**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and facility document review, the facility failed to ensure an effective pest control program was in place in three rooms (124 B, 126 B and 204 A/B) out of 11 rooms observed.Findings included:During an observation of room [ROOM NUMBER] B on 6/16/2025 at 08:46 A. M., there were three black live insects on the resident's overbed table near the resident's bed. In an immediate interview, the resident stated ants are always in her room, and that they never leave. She states she complains to the staff daily about issues including ants. She states she has seen big bugs in the facility as well. During a tour of room [ROOM NUMBER] on 06/17/2025 at 11:04 A. M., an observation of the bathroom revealed a live brown colored insect crawling on the wall under the sink, in the bottom right corner near where the floor tile meets the wall. In an interview with the resident explained there were insects in the facility and stated a roach was seen earlier crawling across the wardrobe header. The resident stated it went down to the side of the wardrobe cabinet and to the right on the floor. On 06/17/2025 at 11:07 A. M., an interview was conducted with Staff D, Licensed Practical Nurse (LPN)/Unit Manager. She stated that she had not seen any insects, but the residents had complained to her about ants. During an interview on 06/17/2025 at 11:11 A. M., with a random resident, he stated he saw flies on 06/16/2025. He stated that he didn't tell staff because it was a waste of time. During an interview with a random resident on 06/17/2025 at 02:03 P. M., he stated he saw a bug in the 100 hallway near room [ROOM NUMBER]. He stated he sighted it a week prior. The resident stated he notified staff, and the staff proceeded to smash the bug, by stomping on it.An observation of room [ROOM NUMBER] Bed B on 06/18/2025 at 08:07 A. M., revealed the room had a food tray with two small live insects on the table near the resident's bed. The resident confirmed that this was their breakfast tray. Observations of a cubby counter space in between the wardrobe section of the room showed a food tray. The observations revealed ants were on the tray with a tea bag and other items. There was a food plate from the prior day's dinner with no food on it. The plate had approximately forty to fifty live small insects crawling over the plate. An interview was conducted on 06/18/2025 at 08:09 A. M., with Staff C, Registered Nurse (RN)/UM, in 126 B. Staff C UM RN confirmed she saw the live ants on the overbed table and the wardrobe cubby. She stated that she would speak with maintenance. During a tour on 06/18/2025 at 08:22 A. M., observations of room [ROOM NUMBER] B revealed approximately five live small crawling insects, on a counter in a cubby in the wardrobe section connected to the wall near the window. The resident had items on the counter, including a plastic bag that the ants were crawling on. An interview on 06/18/2025 at 08:21 A. M., with Resident #16, he stated that ants are all over the room, on the floor, under the AC, and in the bathroom. He said that it was a waste of time to inform staff. On 06/18/2025 the nursing home administrator (NHA) provided the facility's Service Agreement for Commercial Pest Management, which revealed the facility has a signed service agreement with a pest control maintenance company. The service agreement was signed and dated 04/11/2024. The service agreement details that the service frequency is monthly. The service type was interior. The service for included Fly control. The service agreement shows a three-step process: 1. Inspect to pinpoint pest issues.2. Identify not only the pest, but the true cause of the problem.3. Treat in the most environmentally responsible way to eliminate/prevent any issues.Review of the facility's Pest Sighting Log for April, May, and June of 2025 revealed sightings of roaches, bugs and ants in hallways and resident's rooms.An interview was conducted on 6/18/2025 at 01:12 P. M., with the director of Maintenance (DOM). He stated the facility has a pest control company. He stated he makes sure that the company does what needs to be done and that he requests treatment for specific rooms as necessary. He stated he tries to ensure the company does not miss areas that staff has been alerted of need for treatment. He stated he is alerted about pest issues via staff, logs, and work book/orders. He stated that sometimes the roaches are gone when he checks for them. The DOM stated a specialized visit had been requested on 06/18/2025, but they had not been in yet. He stated the pest control company treats the exterior and the interior twice a month and does not go into resident rooms unless requested. He stated he had not heard reports of ants. Review of the facility's policy dated 11/30/2014, titled Pest Control revealed: The facility will maintain a pest control program, which includes inspection, reporting, and prevention.Procedure:1. A pest control contract will be maintained with a licensed exterminator.2. The contract will include routine quarterly inspections. 3. Treatment will be rendered as required to control the insects and vermin.4. Any unusual occurrence or sightings of insects should be reported immediately to the supervisor (See Policy - Maintenance Repair Request Form). Proper action will be taken.5. A copy of the company's Safety program, including MSDS (material safety data sheet) forms and certification of insurance will be on file in the facility.(Photographic evidence obtained)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure dignity was maintained for two (Residents #16 and #32) of 2 residents sampled for dignity out of of 61 total residents sampled. Findings included: 1. An observation was conducted on 6/9/24 at 1:00 p.m. of Resident #16 going to the smoking patio in a wheelchair wearing a hospital gown with one sock on. The resident's skin was visible from the top center of her back to the top of her buttocks. Her hair was also observed to be matted and unkempt. Review of the admission Record showed Resident #16 was admitted on [DATE] with diagnoses including mechanical loosening of internal left hip prosthetic joint and chronic pain syndrome. Review of Resident #16's Minimum Data Set (MDS) assessment, dated 05/25/2024, Section C - Cognitive Patterns showed her Brief Interview for Mental Status (BIMS) score was 14, indicating she was cognitively intact. An interview was conducted on 6/9/24 at 4:19 p.m. with Resident #16. She stated she had not had clothes in three weeks. She said she had no family to assist her and did not come to the facility with clothes. An observation conducted on 6/10/24 at 4:10 p.m. showed Resident #16 still in a hospital gown, with matted unkempt hair. She was on the smoking patio with 12 other residents and one staff member. A follow-up interview was conducted on 6/11/24 at 10:20 a.m. with Resident #16. She said she had asked for clothes; they gave her a dress that belonged to another resident who wanted it returned. She stated the night gown she was wearing currently; they gave her on 6/10/24. The resident said, It's embarrassing to go into public areas in a hospital gown with my butt hanging out. The resident also said that she had not had a shower and it makes me feel gross. She said the first time they provided her with clothes to wear was yesterday when she was supposed to leave the facility for an appointment. An interview was conducted on 6/11/24 at 2:46 p.m. with Staff U, Social Services Assistant. She said she was aware of three residents that wear gowns regularly throughout the day, that included Resident #16. Staff U said she gave Resident #16 extra clothes from the laundry room on 6/10/24. She also stated Resident #16 had funds that could be used for clothing. An interview was conducted on 6/11/24 at 11:28 a.m. with Staff T, Account Manager, who stated laundry generally had extra or donated clothing available. He stated if there was a situation where they could not help accommodate a resident's needs with laundry, he would notify the Nursing Home Administrator (NHA). During an interview conducted on 6/11/24 at 10:55 a.m. with Staff P, Registered Nurse (RN), Staff P stated they had donated items in laundry to provide clothing to residents when needed. She stated she had access to get resident items from donations or she would notify social services if there was a situation she could not address. During an interview conducted on 6/11/24 at 3:19 p.m., the Director Of Nursing (DON) stated she would expect if a resident had clothing needs it would be brought to her attention. She stated she had not been notified of anyone with clothing needs that the facility could not accommodate. She stated she was not aware of a resident who had been in a hospital gown for 3 weeks, who came in without any personal clothing. 2. An observation was conducted on 6/10/24 at 11:26 a.m. of Resident #32 in her bed. She was noted to have on a hospital style gown and five wrist bands on her right arm and one wrist band on her left arm. The arm bands were from the hospital; there was a band labeled with her name, age, birthday, medical records number, a DNR (Do Not Resuscitate) band, a Fall Risk band, an allergy band, and a band with just her name on it. (Photographic evidence obtained.) An observation and interview was conducted on 6/11/24 at 2:14 p.m. with Resident #32. The resident was observed to still have the five wrist bands on her right arm and one wrist band on her left arm. She also remained in the same hospital style gown. The resident said the arm bands were aggravating on her arm. Review of admission Record for Resident #32 showed she was admitted on [DATE] with diagnoses including anemia, dementia, and anxiety disorders. Review of Resident #32's Minimum Data Set (MDS) Section C, Cognitive Patterns, showed her Brief Interview for Mental Status (BIMS) score was not completed. Section C did note Resident #32 was severely impaired cognitively. An interview was conducted on 6/12/24 at 4:30 p.m. with Staff X, Licensed Practical Nurse (LPN)/Unit Manager (UM). She was observed going to Resident #32's room and looking at her arm bands. Staff X said she would have taken the arms bands off if she had seen them. She said she could also see a concern with them being irritating to the resident's skin. An interview was conducted on 6/12/24 at 4:38 p.m. with the DON. When notified Resident #32 had 6 wrist bands from the hospital still on her arms after being in the facility three weeks, she agreed it was a concern and said the bands should have been removed on admission. She said they would be removed immediately. On 6/12/24 at 5:06 p.m. the DON said the facility did not have a policy on Dignity. Review of the Bill of Rights for resident of nursing homes posted on the facility wall showed: You, as a long-term care resident, have the right to: -Be treated courteously, fairly, and with the fullest measure of dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident had use of personal belongings for one (Resident #43) of five residents reviewed for personal property. Findings included: During an observation and interview on 06/09/24 at 10:20 a.m., Resident #43 stated she had been readmitted to the facility following a recent hospitalization. The resident stated she had been at the facility for 2 days and did not have her personal belongings. The resident was observed wearing a hospital gown. She stated she did not have her clothes. She stated she had asked staff, and everyone said, Okay, but they did not bring her clothes. The resident stated at her previous room she had all her personal items, stuffed animals and family pictures. She stated she had an air mattress to relief pressure because of wounds. She stated she had fall mats following previous falls. The resident said, most importantly, my glasses are missing. I cannot see without them. I have been asking staff for 2 days. Review of the admission Record revealed Resident #43 was originally admitted to the facility on [DATE] and re-admitted on [DATE]. Review of Resident #43's Annual Minimum Data Set (MDS), dated [DATE], revealed in Section C-Cognitive and Patterns a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. An interview on 06/09/24 at 10:20 a.m. with Staff I, Licensed Practical Nurse (LPN), revealed she did not know Resident #43 did not have her personal belongings. She stated she had not noticed. She stated Staff F, Registered Nurse went to look for the fall mats. An interview on 06/09/24 at 1:48 p.m. with Staff E, Certified Nursing Assistant (CNA) revealed they were still looking for the resident's glasses. He confirmed the resident did not have an air mattress at this time. He stated these items should be in the resident's old room. He stated he did not know why the resident did not go back to that room. On 06/10/24 at 1:42 p.m., an interview was conducted with Resident #43. She stated her daughter had brought her an old pair of glasses. She stated she still had not heard from the facility regarding her other pair of glasses. She stated an aide brought her clothes this morning. The resident stated the facility had misplaced her glasses and she still did not have her air mattress. An interview on 06/10/24 at 1:58 p.m. with Staff K, Therapy assistant revealed on-going concerns post hospitalization. She stated if a resident returned from the hospital within a short period, they should normally resume the current care plan. She stated fall mats should be replaced. She stated if a resident was using pressure relieving mattress it should be provided upon return. An interview on 06/10/24 at 2:19 p.m. was conducted with the Assistant Social Services Director (ASSD) and Regional SSD. The ASSD stated the process was to box a resident's items and inventory them accordingly when they were transferred out. She stated when a resident is re-admitted , they should receive their personal items right away. They should be placed in the room as soon as the resident was admitted , if not prior to their arrival. An interview was conducted on 06/10/24 at 3:52 p.m. with the Director of Nursing (DON) and the Nursing Home Administrator (NHA). The NHA stated when a resident was admitted to the hospital, they packed the resident's room up. She stated they inventory the resident's belongings and store them in a locked area. She stated once they knew the resident was coming back or had re-admitted , the CNA should go to the storage room and retrieve the belongings. She stated she did not know why Resident #43 did not receive her personal belongings. She stated they had recently hired a concierge to help assist with admissions. The DON stated upon readmission a nurse should assess the resident and if they were still at risk for falls, the fall mats should be placed in the room per orders. She stated for air mattresses, it was tricky because some residents did not own these items. She stated they would contact DME (Durable Medical Equipment) to obtain the equipment as soon as orders were in place An interview on 06/11/24 at 5:01 p.m. with the SSD revealed they were still looking for the resident's glasses. He stated they had called the hospital, and the glasses could not be found. He stated he had added her to the list to be seen the next time the physician was at the facility. Review of a document titled, INVENTORY OF PERSONAL EFFECTS, showed on discharge/move-out, personal items are sent with resident/patient or picked up responsible party. Upon transfer, personal items are to be boxed and placed in designated storage area for safe keeping (or handling per facility/community/center policy). Review of a facility policy and procedure titled, Personal Property - loss or theft, dated 07/24/17 showed the center has a process to minimize the risk of loss or theft of patient's personal property.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the facility's policy Abuse, Neglect, Exploitation & Misappropriation, the facility failed to ensure protection from repeated incidents of verbal abuse by Resident #96 towards one (Resident #34) of three residents reviewed for abuse. Findings included: During an interview on 06/11/24 at 12:50 p.m., Resident #34 stated he was receiving his medications at the nursing station around 7:00 a.m. this morning with Staff A, Licensed Practical Nurse (LPN). Resident #34 stated while taking his medication Resident #96 came to the nurses station and verbally assaulted me calling me a fat ass and using the F word. Resident #34 stated Staff A Licensed Practical Nurse (LPN) heard everything and all she did was apologize to me for his behavior. Resident #34 stated Staff B Licensed Practical Nurse (LPN), Unit Manager (UM) also came to speak with him and apologized for Resident #96's behavior towards him. Resident #34 stated this was not the first time this had occurred and he was getting tired of everyone always apologizing for Resident #96's behavior and not doing anything about it. Resident #34 stated everyone told me to just stay away from him but Resident #96 was the one who seeks me out most of the time and these verbal attacks on me need to stop. Review of the admission Record showed Resident #34 was admitted to the facility on [DATE] with diagnoses that included but not limited to Unspecified Sequela of unspecified Cerebrovascular disease, recurrent depressive disorder, difficulty walking, weakness, type II diabetes mellitus and osteoarthritis. The quarterly Minimum Data Set (MDS) dated [DATE], Section-C-Cognitive Patterns showed Resident #34 had a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognition. Review of the admission Record showed Resident #96 was admitted to the facility on [DATE] with diagnoses that included but not limited to Schizophrenia, Encephalopathy, difficulty walking, pancytopenia, alcohol abuse uncomplicated and muscle weakness. Review of the the quarterly MDS dated [DATE], Section-C-Cognitive Patterns showed Resident #96 had a Brief Interview for Mental Status (BIMS) of 15, which indicated intact cognition. During an interview on 06/11/24 at 12:58 p.m., Staff A Licensed Practical Nurse (LPN) stated there was a verbal altercation between Resident #34 and Resident #96 this morning. Staff A LPN stated Resident #34 was at the medication cart getting his blood pressure taken when Resident #96 approached the nurses station and began cussing at Resident #34. Staff A LPN stated that Resident #34 did not engage in the verbal altercation and Staff B LPN, Unit Manager (UM) heard Resident #96 yelling and came out of her office and took care of the issue. Staff A LPN confirmed this was not the first encounter between Resident #34 and Resident #96 and stated they have a history and did not like each other. During an interview on 06/11/24 at 1:01 p.m., Staff B LPN,UM stated she heard an altercation this morning and came out of her office to see what was going on. Staff B LPN, UM stated she was aware of Resident #96's mental health issues, so she immediately went out the verbal altercation and told Resident #96 to cut it out and told Resident #96 to take a walk. Staff B LPN, UM stated Resident #96 then walked down the hall allowing separation between both Resident #34 and #96. Staff B LPN, UM stated Resident #34 and Resident #96 did not like it each other. During an interview on 06/11/24 at 1:08 p.m., the Administrator stated she was also the Risk Manager. The Administrator stated that nothing had been reported regarding any abuse or resident to resident altercation today. The Administrator stated that she had heard nothing about the verbal altercation between Resident #96 and Resident #34 from this morning, 06/11/2024. The Administrator stated if a Resident to Resident altercation occurred she would have expected Staff B LPN, UM to have reported it to her right away so she could have filed a report within the appropriate timeframe and per policy. The Administrator stated that she would report this altercation immediately and start an investigation now. During an interview on 06/11/24 at 1:12 p.m., Resident #96 stated that he did not like Resident #34 and he did tell him off. Resident #96 stated that Resident #34 was also trying to mess with his life and get him in trouble. Review of the facility's policy Abuse, Neglect, Exploitation & Misappropriation revised date 11/16/22 showed, Verbal Abuse may be considered a form of mental abuse. Verbal abuse includes the use of oral, written or gestured communication, or sounds, to resident within hearing distance regardless of age ability to comprehend or disability. 7. Reporting/Response: Any employee or contracted service provider who witnessed or has knowledge of an act of abuse or an allegation of abuse, neglect, exploitation or mistreatment, including injuries of unknown sources misappropriation of resident property, to a resident, is obligated to report such information immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later then 24 hours if the event that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator and to the other officials in accordance with State law.

Based on record review, staff interviews, and review of the facility's policy titled Resident Assessment-Coordination with PASARR Program, the facility failed to complete the Level II Preadmission Screening and Resident Review (PASARR) documentation for one (#118) of six residents sampled for PASARRs. Findings included: Review of the admission record for Resident #118 revealed an admission date of 04/17/24 with diagnoses of Alzheimer's disease, primary, depression, and unspecified mood affective disorder. Review of the medical record showed a Level I PASARR was not conducted upon admission. Review showed it was initiated on 05/26/24. Review of Resident #118's Level I PASARR dated 05/26/24 showed diagnoses of Depressive Disorder, other Mood Disorder and Alzheimer's Disease were indicated. The Level I PASARR showed the resident had exhibited behaviors that made them a danger to themselves or others. Level II evaluation section showed Resident #118 had documented behavioral observations, has interpersonal functioning problems, concentration persistence and pace problems, and difficulty adapting to change. On 06/10/24 a level II PASARR was initiated. The requested documents were not submitted. On 06/11/24 at 2:40 p.m., the Regional Social Services Director (SSD) stated she had just submitted the Level II documentation today. She said, I cannot speak of the timing. I don't know why it had not been submitted. She stated nursing should have submitted the paperwork for the Level II recommendation. An interview was conducted with the Director of Nursing (DON) on 06/11/24 at 3:48 p.m. She stated she had initiated the Level I PASARR on 05/26/24. She confirmed Resident #118 did not have a level I PASARR in place upon admission. She said, I have been the only one reviewing PASARRs. Admissions should have initiated a Level I prior to admission or upon admission. She stated upon review of the Level I, she initiated the Level II, but did not submit the required paperwork. She stated she was the only one catching up on PASARRs at that time. She stated the Social Services Department did not have qualified personnel, but they do now. Review of a facility policy titled, Preadmission Screening and Resident Review, dated 11/08/2021, showed The center will assure that all Serious Mentally Ill (SMI) and Intellectually Disabled (ID) residents receive appropriate pre-admission screenings according to the Federal/State guidelines. The purpose is to ensure that the residents with SMI or are [sic] ID receive the care and services they need in the most appropriate setting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Activities of Daily Living (ADLs) were appropriately provided for two (Residents #32, and #68) of five residents sampled for ADLs. Findings included: 1. An observation and interview was conducted on 6/10/24 at 11:27 a.m. with Resident #32. She was observed in a hospital style gown with hospital arm bands on her wrist. The resident said she did not get showers, and no one got her out of bed. Review of the admission Record for Resident #32 showed she was re-admitted on [DATE] with diagnoses including anemia, dementia, morbid obesity, overactive bladder, and anxiety disorders. Review of Resident #32's Minimum Data Set (MDS) Section C, Cognitive Patterns, showed her Brief Interview for Mental Status (BIMS) score was not completed. Section C did note Resident #32 was severely cognitively impaired. Review of Resident #32's task documentation by the Certified Nursing Assistants (CNAs) showed the resident had two showers (6/3 and 6/10/24) and two bed baths (5/30 and 6/6/24) since her re-admission on [DATE]. Although documentation showed Resident #32 had a shower on 6/10/24 at 1:28 p.m., the resident was observed to be in the same hospital style gown on 6/10/24 at 3:34 p.m. An interview was conducted on 6/10/24 at 3:34 p.m. with Resident #32. The resident said she had not been out of bed all day and had not showered. An interview and observation was conducted on 6/10/24 at 3:37 p.m. with Staff Y, Registered Nurse (RN). She was observed going to Resident #32's room and looking at the resident. She said the resident had been in the same gown all day. She was observed checking the daily shower sheets and said she had not received one for Resident #32. She said the CNAs should document under tasks and fill out a shower sheet when they gave a resident a shower or bed bath. Staff Y reviewed Resident #32's task documentation and confirmed it showed the resident was scheduled for showers on Monday and Thursday on the 7:00 a.m. to 3:00 p.m. shift and a shower had been documented as done that day. She said additional shower sheets would be in the Unit Manager's office. On 6/12/24 Staff X, Licensed Practical Nurse (LPN)/Unit Manager (UM) provided all the shower sheets she had for Resident #32. The only shower sheet since the resident was re-admitted was on 5/28/24. That shower sheet showed the resident had a shower and noted redness to the pubic area. Resident #32 was observed to remain in the same position in bed with the same gown on throughout the days of 6/10 and 6/11/24. An interview was conducted on 6/11/24 at 11:55 a.m. with Staff W, RN. She confirmed she provided wound care to residents. She said Resident #32 did not currently have any wounds but did have redness and irritation on her buttocks and was getting zinc barrier cream applied. 2. An interview was conducted on 6/9/24 at 4:21 p.m. with Resident #68. She said she did not get showers, she said she only got cleaned up. She said it took at least 30 minutes to get cleaned up after she pushed her call light, then staff came in with an attitude. Review of admission Records showed Resident #68 was re-admitted on [DATE] with diagnoses including sepsis due to Methicillin Resistant Staphylococcus Aureus (MRSA), fracture of right patella, depression, and anxiety. Review of Resident #68's MDS, Section C, Cognitive Patterns, showed her BIMS score was a 15, which indicated she was cognitively intact. Review of Resident #68's care plan for ADL care showed she required an assist of one staff member for bathing/showering. Review of Resident #68's task documentation by the CNAs showed the resident had five showers (5/30, 6/1, 6/2, 6/9, and 6/11/24) and seven bed baths (6/3, 6/4, 6/5, 6/6, 6/7, 6/8, and 6/9/24) in the past two weeks. On 6/12/24 Staff X, LPN/UM was unable to provide any shower sheets for Resident #68. She said she did not know why there were not any. A follow-up interview was conducted on 6/12/24 at 3:14 p.m. with Resident #68. The resident said she absolutely did not have showers on 6/9 and 6/11/24. She said she had not even had a good bed bath in weeks. She said the only thing that was done was that her private area was cleaned up when her brief was soiled. She said not even her back had been washed. An interview was conducted on 6/12/24 at 3:42 p.m. with the Staffing Coordinator. She said she was also a CNA and worked shifts on the floor. She said resident showers were always documented in tasks and a shower sheet was filled out. She said CNAs should only document what they did. An interview was conducted on 6/12/24 at 3:47 p.m. with Staff X, LPN/UM. She said call lights should be answered and briefs changed immediately if needed. She said showers should be documented by CNAs in tasks and on a shower sheet. She said a shower should absolutely not be documented if it was not done. An interview was conducted on 6/12/24 at 4:38 p.m. with the Director of Nursing (DON). The DON said she would expect a resident to receive a shower if they wanted one. She said it was not up to the CNAs to decide if a resident got a shower or bed bath. The DON said a shower should be documented under tasks in the medical record if and only if a resident received the shower, and a shower sheet should be filled out. On 6/12/24 at 5:06 p.m. the DON said the facility did not have a policy on ADLs or Showers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure residents unable to carry out ADL (Activities of Daily Living) received assistance related to hair care for one (Resident #117) of five residents reviewed for ADLs. Findings included: An observation and interview was conducted on 06/09/24 at 2:14 p.m. with Resident #117. The resident was observed with matted, tangled clumps of hair. She stated she had asked staff for help. She said, I need help with my hair. The staff are not available to help. They are too busy. There is not enough time for me. It will take time to untangle. No one has the time. The resident stated she had been begging staff to help her with her hair since admission. She stated she did not like looking like a bird's nest. She said, it is embarrassing. I would like to brush my hair again. Review of the admission Record for Resident #117 showed an admission date of 04/15/24, with diagnoses to include partial traumatic metacarpophalangeal amputation of unspecified finger and need for assistance with personal care. Review of Resident #117's admission Minimum Data Set (MDS), dated [DATE], in Section C-Cognitive and Patterns, showed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. On 06/11/24 at 02:45 p.m., Resident #117 stated a CNA was supposed to help her last night. She never came back this happened all the time. The Resident said, I have not washed my hair since I was admitted because if I wash it, it will be stinky because it will not dry. It is already matted. The resident stated she had been at this facility for almost 2 months. Review of a care plan with a focus ADL-self-care, dated 04/25/24 showed the resident had a self- care deficit related to activity intolerance, fatigue, impaired balance, limited mobility, and trauma to Right hand. Interventions for personal hygiene, bathing/showering showed the resident required assistance by staff for personal care and bathing/showering. An interview on 06/11/24 at 3:05 p.m. with Staff L, Certified Nursing Assistant (CNA) confirmed the resident was admitted with matted hair following a lengthy hospitalization. She stated some CNA's had started helping the resident untangle the hair. She stated, It just takes a while. I know, two months is a long time to wear your hair like that. We have to keep trying. We just don't have the time among the other duties. Staff L stated the resident would not be able to untangle the hair herself. She confirmed the resident needed staff's assistance. An interview was conducted on 06/11/24 at 3:10 p.m. with the Director of Nursing (DON). She stated she just heard about the resident with matted hair. The DON stated residents who were dependent on staff should receive care as needed. She stated they had to prioritize care. She said, We are trying. I understand it's a dignity issue. We hired a concierge two weeks ago. She spent an hour helping her. The DON stated there was only so much they could do because the staff had to attend to higher care needs. She said, I know she is dependent. It is just not a priority for nursing staff. The DON stated the resident refuses to cut her hair. An interview on 06/11/24 at 4:34 p.m. with the Nursing Home Administrator (NHA) revealed they did not have someone to do hair. She stated they had a salon, but it was currently closed. She stated they had recently hired a concierge who would be helping with things like this. On 06/11/24 at 05:22 p.m., the NHA stated they did not have a policy on ADLs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident received proper treatment to maintain communication abilities for one (Resident #280) of three residents sampled. Findings included: Review of the admission Record for Resident #280 revealed an original admission date of 04/29/24 and a re-admission date of 06/03/24 with diagnoses to include Deaf non-speaking. During an observation on 06/09/24 at 9:30 a.m., Resident #280 was laying on his bed staring at the Television which was turned off. The resident did not respond to the interview. The resident looked at this surveyor and initiated hand movements, signaling he communicated via sign language. A look around the room revealed there were no personal effects and there were no communication assistive devices, or anything indicating the resident required assistance to communicate with others. Review of an admission Minimum Data Set (MDS) dated [DATE] showed in section B0200 - Hearing, Speech, and Vision, the resident was highly impaired related to absence of useful hearing. B0700 showed the resident is sometimes understood and his ability to make concrete requests was limited. B0800 the resident sometimes understands others. Under B1000 - vision, the resident is highly impaired. Under Health literacy B1300, the resident always needed to have someone help him when he read . written material. Section C - Cognitive Patterns revealed a BIMS (Brief Interview for Mental Status) score of 00, meaning the resident was unable to complete the interview. Review of a care plan initiated on 04/30/24 showed Resident #280 was care planned for a communication problem related to hearing deficit/deaf and partial blindness. Interventions showed to anticipate and meet needs. Be patient with resident as he is deaf and has poor vision. Resident requires assistance with communication. Provide translator as necessary to communicate with the resident. The resident is able to communicate by gesture sign language/translator. Use ASL (American Sign Language) to communicate with patient as deemed appropriate. An interview on 06/09/24 at 9:39 a.m. with Staff D, Certified Nursing Assistant (CNA) revealed the resident was deaf. She stated the resident communicated via sign language and she communicated with him by trying to guess what he needed. She stated the resident was new to this part of the building and she was getting to know him. Staff D, CNA stated the resident stayed in his room most of the time. She stated if he was out, he watched television and did not engage easily with others due to communication disability. On 06/10/24 at 1:54 p.m., an interview was conducted with Staff E, CNA. He stated this resident was deaf. He stated he communicated with him by asking Yes, or NO questions. The CNA stated he tried to guess what the resident was trying to say. He stated he would ask the nurse if he could not figure out what the resident was saying. He stated he did not know any sign language and he was not aware if any of the staff were able to sign. An interview on 06/10/24 at 2:30 p.m. with Staff G, Registered Nurse (RN) revealed she did not know much about this resident. She said, When I walked in earlier, he did not respond to me. I called out to him. His eyes were open. I walked to him and tapped his shoulder. I placed the medication cup in his hand. He knew that meant he should take his medications. Staff G stated she did not know if he was deaf. She stated the resident was new to her and she would review his care plan to know how he communicated. During this interview, this surveyor and nurse walked into the resident's room. He did not have any signs posted to let someone know his preferred method of communication. The room was noted very warm, the temperature on the unit showed it was on heat settings and a reading of 78 degrees was noted. The Nurse stated she did not know if it was the resident's preference to have the heat on during hot summer months. She said, I am not sure if this was his preference. You know there is a language barrier. The nurse attempted to interact with the resident. The resident signed back in response, which the nurse did not understand. Staff G stated she would have to find out what he was trying to say. In an interview on 06/10/24 at 2:45 p.m. with Staff H, RN/ MDS and the Regional MDS, they stated staff should know how to communicate with the resident. The Regional MDS stated the nursing staff could review the [Brand Name of a filing system used in nursing homes] to identify the resident's communication needs. She stated for other people without access, there should be a sign directing them to see nurse posted on the door. She stated they had a care plan with interventions to reach out to the resident's family member for assistance. The Regional MDS stated there should be a number to call for ASL assistance. She stated she would update the care plan to include a communication board or cards with familiar phrases. An observation on 06/11/24 at 9:14 a.m. to 06/11/24 at 12:04 p.m., revealed Resident #280 in a Broda chair positioned in front of the television in the common/dining area in hall 300. This resident was not observed participating in any activities or engaging with staff or residents. During this time period, other residents were observed participating in various activities such as puzzles, cards, making phone calls and engaging with each other and staff in conversations. Resident #280 had his back turned to the other residents the entire time. The resident was unable to initiate any interaction with staff or other residents. Review of a facility policy subject, Reasonable Accommodation of Hearing Impaired, revised 09/05/2017, showed upon admission the charge nurse will determine the level of hearing impairment. If a hearing impairment is noted staff will consult with the resident and if applicable family members to determine what auxiliary aids may be needed to ensure effective communication. If hearing impairment exists, then the following interventions may be implemented as deemed appropriate. Personnel to directly face resident when speaking to him or her. Allow resident to see facial expression to help lip reading. Provide pencil and paper to communicate in writing in cases of totally deaf. Determine residents awareness of hearing loss. Should a qualified interpreter be needed, the family should consult with social services to identify local resources.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure proper care to prevent the worsening of pressure wounds for two (Residents #74 and #12) of four residents sampled for pressure wounds. Findings included: An observation was conducted on 6/11/24 at 11:48 a.m. of Resident #74 lying in bed with his legs exposed crying out for assistance. He said his feet hurt and he needed help moving his leg. The resident was observed to have bandages on both heels and his feet were propped up on a plastic pack of disposable briefs. (Photographic evidence obtained with resident permission.) An observation and interview was conducted on 6/11/24 at 11:50 a.m. of Staff V, Certified Nursing Assistant (CNA) entering Resident #74's room and assisting to reposition his leg. Staff V confirmed the resident's heels were being offloaded with a pack of briefs. She said his pressure relieving boots were in the laundry so someone must have put those there. Staff V said the resident had wound care that morning and maybe they put the briefs under his heels. Review of admission Records showed Resident #74 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, muscle weakness and difficulty walking. The resident was listed as his own responsible party. Review of Resident #74's Minimum Data Set (MDS), dated [DATE], Section C, Cognitive Patterns, showed the resident had a Brief Interview for Mental Status (BIMS) score of 2, indicating severely impaired cognition. Review of Resident #74's physician orders showed: -Encourage offloading bilateral heels while in bed. Every shift for unstageable bilateral heels as tolerated. Date 6/4/24. Review of wound care provider notes showed the resident had right and left heel wounds. On 5/6/24 the wound etiology was noted to be pressure, unstageable, and offloading boots were in place. On 5/15/24 the left and right heel wounds were changed to stage 4. An interview was conducted on 6/11/24 at 11:53 a.m. with Staff W, Registered Nurse (RN). She confirmed Resident #74 had stage 4 pressure wounds on both heels that were in house acquired. She said the resident had boots to offload his heels while he was in bed. Staff W reviewed the photo of Resident #74's heels propped on a pack of briefs. She said that was totally inappropriate. She said she would never put briefs under someone's feet to offload them. She said had she seen that she would have fixed it immediately and educated staff. An interview was conducted on 6/11/24 at 12:31 p.m. with the Director of Nursing (DON). She reviewed the photo of Resident #74's heels offloaded with the pack of briefs. The DON said that was not at all appropriate and she could not believe someone would have used briefs to prop his heels on. She said it should not have happened and she would investigate. Review of the admission Record showed Resident #12 was originally admitted to the facility on [DATE] with diagnoses that included but not limited to multiple sclerosis, restless leg syndrome, polyneuropathy, and Parkinson's disease with dyskinesia without mention of fluctuations. Review of the quarterly Minimum Data Set (MDS) dated [DATE] Section-C-Cognitive Patterns showed Resident #12 had a Brief Interview for Mental Status (BIMS) of 15 (Cognitively Intact). Review of Resident #12's care plan showed a focus [Resident #12] has a pressure injury to the right heel. The goal showed, The resident's pressure injury will show signs of healing and have minimal risk of infection by/through the review date. The interventions included but not limited to: Administer treatments as ordered and monitor for effectiveness, assess/record/monitor wound healing, and monitor dressing to ensure it is intact and adhering report loose dressing to the nurse An additional focus showed, [Resident #12] has an arterial ulcers to: left dorsal 2nd toe, left lateral malleous, left dorsal 3rd toe, left lateral foot and left dorsal 4th toe. The goal showed, The resident will be free from infection or complications related to arterial ulcer through review date. The interventions included but not limited to Monitor/document wound document progress in wound healing on an ongoing basis, wound medical doctor visit at [local] medical weekly as ordered, WOUND/DRESSING change the dressing and record observations of site. Review of Resident #12's current orders showed wound care orders as followed: - Consultation with wound care provider dated 06/01/24 - Consult with Wound Care [as needed] PRN dated 05/06/24 - [Brand name for a strong topic antiseptic] (1/4 strength) External Solution 0.125% (Sodium Hypochlorite) - Apply to left dorsal 2nd toe topically as needed for unstageable if soiled dated 05/06/24. - [Brand name for a strong topic antiseptic] (1/4 strength) External Solution 0.125% (Sodium Hypochlorite) - Apply to left dorsal 3rd toe topically every day shift for unstageable. Use [Brand name for a strong topic antiseptic] Solution, wet gauze, and apply to wound bed for 10 mins prior to dressing application, use wound cleanser, pat dry, apply Aquacel AG hydrofiber cleanser with silver (cut to size of wound bed as directed), apply ABD Pad, cover with kerlix dated 05/06/24. - [Brand name for a strong topic antiseptic] (1/4 strength) External Solution 0.125% (Sodium Hypochlorite) - Apply to left dorsal 4th toe topically as needed for unstageable if soiled dated 05/06/24. - [Brand name for a strong topic antiseptic] (1/4 strength) External Solution 0.125% (Sodium Hypochlorite) - Apply to left dorsal 4th toe topically every day shift for unstageable. Use [Brand name for a strong topic antiseptic] Solution, wet gauze, and apply to wound bed for 10 mins prior to dressing application, use wound cleanser, pat dry, apply Aquacel AG hydrofiber cleanser with silver (cut to size of wound bed as directed), apply ABD Pad, cover with kerlix. dated 05/06/24. - [Brand name for a strong topic antiseptic] (1/4 strength) External Solution 0.125% (Sodium Hypochlorite) - Apply to left dorsal 2nd toe topically every day shift for unstageable. Use [Brand name for a strong topic antiseptic] Solution, wet gauze, and apply to wound bed for 10 mins prior to dressing application, use wound cleanser, pat dry, apply Aquacel AG hydrofiber cleanser with silver (cut to size of wound bed as directed), apply ABD Pad, cover with kerlix. dated 05/06/24. - [Brand name for a strong topic antiseptic] (1/4 strength) External Solution 0.125% (Sodium Hypochlorite) - Apply to left lateral foot topically as needed for unstageable if soiled dated 05/06/24. - [Brand name for a strong topic antiseptic] (1/4 strength) External Solution 0.125% (Sodium Hypochlorite) - Apply to left lateral malleous every day shift for unstageable. Use [Brand name for a strong topic antiseptic] Solution, wet gauze, and apply to wound bed for 10 mins prior to dressing application, use wound cleanser, pat dry, apply Aquacel AG hydrofiber cleanser with silver (cut to size of wound bed as directed), apply ABD Pad, cover with kerlix. dated 05/06/24. - [Brand name for a strong topic antiseptic] (1/4 strength) External Solution 0.125% (Sodium Hypochlorite) - Apply to left lateral malleous topically as needed for unstageable if soiled dated 05/06/24. - [Brand name for a strong topic antiseptic] (1/4 strength) External Solution 0.125% (Sodium Hypochlorite) - Apply to right medial calcareous topically as needed for unstageable if soiled dated 05/06/24. - [Brand name for a strong topic antiseptic] (1/4 strength) External Solution 0.125% (Sodium Hypochlorite) - Apply to right medial calcareous every day shift for unstageable. Use [Brand name for a strong topic antiseptic] Solution, wet gauze, and apply to wound bed for 10 mins prior to dressing application, use wound cleanser, pat dry, apply Aquacel AG hydrofiber cleanser with silver (cut to size of wound bed as directed), apply ABD Pad, cover with kerlix. dated 05/06/24. Review of the Treatment Administration Record dated May 2024 showed Resident #12 missed wound treatments on the following dates: - 05/12/24 -05/14/24 -05/17/24 -05/19/24 -05/21/24 -05/23/24 -05/24/24 -05/27/24 -05/30/24 -05/31/24 Review of the Treatment Administration Record dated June 2024 showed Resident #12 missed wound treatments on the following dates: - 06/08/24 -06/09/24 During an interview on 06/11/24 at 12:32 p.m., the Director of Nursing (DON) stated the TAR did look like the wound treatments were not completed but needed to look into this more because she wondered if it was more of a documentation error than the nurses not providing wound treatment. During an interview on 06/11/24 at 12:40 p.m., Resident #12 stated that no one provided wound treatment to her feet this weekend. Resident #12 stated that she went to the wound care clinic every Wednesday but the nurses at the facility were to provide wound care to her all other days. During an interview on 06/11/24 at 5:50 p.m., The Director of Nursing (DON) stated that she spoke with some of her nurses and they informed her the wound treatment was completed they just forgot to document they completed the treatment. The DON stated that she would have expected the nursing staff to document when they provided the wound treatment for Resident #12 but did not. Review of the facility's policy Non-pressure skin Condition Record revision date 04/01/17 showed, Policy: To document the presence of skin impairments/new skin not related to pressure when first observed and weekly thereafter. This includes skin tears, surgical sites, etc. One site will be recorded per page. Review of the facility's policy Clinical Guidelines Skin & Wound effective date 04/01/2017 showed, To provide a system for identifying skin at risk, implementing individual interventions including evaluation and monitoring as indicated to promote skin health, healing and decrease worsening of/prevention of pressure injury. Review of the facility's policy Physician Orders revision date 03/03/21 showed, Policy: The center will ensure that Physician orders are appropriately and timely documented in the medical record. Review of the facility's policy Pressure Injury Record revision date 04/01/2017 showed, Policy: To document the presence of skin impairment/new skin impairment related to pressure when first observed and weekly thereafter until the site is resolved. Once site will be recorded per page. Review of the facility's Clinical Nurse 1 LPN Job Description showed Duties and Responsibilities that included but not limited to 6. Comply with evaluation, treatment, and documentation of the company guidelines. 7. Complete required documentation in an accurate and timely manner. Review of the facility's Clinical Nurse 1 RN Job Description showed Duties and Responsibilities that included but not limited to 6. Comply with evaluation, treatment, and documentation of the company guidelines. 8. Complete required documentation in an accurate and timely manner. 14. Monitor compliance with resident record documentation, as directed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to monitor behaviors of side effects of psychotropic medications for two residents (Resident #36 and #77) out of the sampled five residents. Findings included: A review of the admission Record showed Resident #36 was initially admitted to the facility on [DATE] with a primary diagnosis of unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and other diagnoses to include schizoaffective disorder, bipolar type, major depressive disorder, and anxiety disorder. Section I- Active Diagnoses of the Minimum Data Set (MDS) dated [DATE] showed the resident had diagnoses of non-Alzheimer's Dementia, anxiety disorder, depression, and schizophrenia. The Order Review Report dated 06/01/24-06/30/24 revealed the following orders: 02/14/24 Cymbalta Oral Capsule Delayed Release Particles 60 MG- Give 1 capsule by mouth one time a day related to major depressive disorder; 03/06/24 Risperdal Oral Tablet 0.5 MG- Give 1 tablet by mouth one time a day related to schizoaffective disorder, bipolar type 03/04/24 Seroquel Oral Tablet 200 MG- Give 200 MG by mouth at bedtime related to schizoaffective disorder, bipolar type 02/14/24 Wellbutrin XL Oral Tablet Extended Release 24 Hour 300 MG- Give 1 tablet by mouth one time a day related to major depressive disorder. The Medication Administration Record (MAR) for April, May, and June 2024 did not show behaviors and side effects were monitored for psychotropic medications. A review of the admission Record for Resident #77 showed the resident was initially admitted to the facility on [DATE] with diagnoses to include unspecified psychosis not due to a substance or known physiological condition and major depressive disorder. Section I- Active Diagnoses of the MDS dated [DATE] showed the resident had diagnoses to include depression and psychotic disorder. The Order Summary Report with active orders as of 04/30/24 showed the following orders: 04/15/24 Amitriptyline HCL Oral Tablet 75 MG- Give 1 tablet by mouth at bedtime for depression. 04/24/24 Buspirone HCL Oral Tablet 10 MG- Give 1 tablet by mouth two times a day for anxiety. The Medication Administration Record (MAR) for April, May, and June 2024 did not show behaviors and side effects were monitored for psychotropic medications. The care plan with a focus area related to anxiety initiated on 04/10/24 showed interventions to include monitor for anxiety type related behaviors and monitor for signs and symptoms of side effects from medication. The care plan with a focus area related to antidepressant medications initiated on 06/07/23 showed interventions to include monitor/document side effects and effectiveness every shift. On 06/11/24 at 5:27 p.m., the Director of Nursing (DON) stated there should be an order for behavior and side effect monitoring for psychotropic medications and it should be done per order. The policies and procedures provided by the facility Medication Management- Psychotropic Medications revised on 10/24/22 showed the following: 4. Monitor behavior and side effects every shift utilizing the Behavior Monitoring Flow Record (BMFR) or electronic equivalent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide food to accommodate preferences for one (Resident #59) out of six residents sampled for food. Findings included: On 06/09/24 at 11:34 a.m., Resident #59 reported the facility was no longer serving chef salads. She stated she needed to eat the chef salads because she wanted to lose weight. On 06/09/24 at 1:48 p.m., the resident was observed in the room with the meal tray in front of her. The tray consisted of mashed potatoes, green beans, and chicken broth. The resident reported she wanted to eat chef salads because she needed to lose weight. She carried a lot of weight and had pain in her back, she had diabetes, and needed to lose 40 pounds. She needed protein on her tray and was not getting any protein. She sent messages to speak with the Kitchen Manager, but she never came On 06/12/24 at 1:00 p.m., Resident #59 reported every day they gave her chicken broth, and it was too salty. They never gave her crackers with the soup. She used to get chef salads with lettuce, tomato, turkey, ham, chopped cheese, and dressing. She was told by the kitchen staff only certain people could get the chef salads. The resident asked how could she be one of the certain people. She wanted more protein and fiber for weight loss. She never got any protein. A review of the menu during the week of the survey showed chef salads were not listed on the menu. A review of the always available menu showed chef salad was not listed on the menu. A review of the meal tickets for Resident #59 showed a chef salad was not listed on the meal ticket. A review of the admission Record for Resident #59 showed the resident was initially admitted to the facility on [DATE] with a diagnosis to include atherosclerosis heart disease of native coronary artery without angina pectoris. Section C-Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] showed Resident #59 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated intact cognition. Section K-Swallowing/Nutritional Status showed the resident weighed 224 pounds. A review of the Order Summary Report with active orders as of 06/12/24 showed a regular diet, regular texture, regular/thin liquid consistency diet that started on 04/03/23. The care plan related to nutrition initiated on 08/29/19 showed a focus area to include a desire to lose weight. On 06/12/24 at 11:59 a.m., the Kitchen Manager stated she set up the meetings for the Food Committee. The residents had voiced concerns with foods that were no longer available on the always available menu such as chef salads and cold food. They had lettuce available all the time, but they did not have eggs, turkey, or ham all the time. They only had foods that were listed on the menu. The alternate meal today was chicken salad, broccoli, and she only had one order for chicken. The main course was the darker color, and the alternate was the lighter color on the menu. The always available options were soup, chicken salad sandwich, chicken salad, and hamburger. A review of the Food Committee Meeting Minutes dated 03/18/24 showed there were requests for more chef salads. On 06/12/24 at 12:58 p.m., the Kitchen Manager stated Resident #59 did not like pork, chicken, turkey, beef, fish, or shellfish. She stated corporate changed the menu and they no longer offer chef salads. On 06/12/24 at 11:24 a.m., the Administrator stated she would have to check to see why Resident #59 could not get a chef salad.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the grievance policy was followed to include documentation, resolution, and follow-up for 11 of 13 residents attending the resident council meeting and seven (#40, #70, #59, #39, #58, #25, and #97) of 61 total residents sampled. Findings included: Review of the facility's policy and procedures titled Complaint/Grievance with an effective date of 11/30/2014 and a revised date of 10/24/2022, revealed: Policy - The center will support each resident's right to voice a complaint/grievance without fear of discrimination or reprisal. The center will make prompt efforts to resolve the complaint/grievance and informed the resident of progress towards resolution. Procedure: 1. An employee receiving a complaint/grievance from a resident, family member and/or visitor will initiate a complaint/grievance form. * Complaint/grievance forms will be available 24 hours per day seven days a week in an unsecured common area. *Accommodations will be made to ensure residents have the opportunity regardless of their physical abilities or limitations. 2. Original grievance forms are then submitted to the grievance officer/designee for further action. 3. The grievance officer/designee shall act on the grievance and begin follow up of the concern or submit it to the appropriate department director for follow up. 4. The grievance follow-up should be completed in a reasonable time frame; This should not exceed 14 days. 5. The findings of the grievance shall be recorded on the complaint/grievance form. 6. The results will be forwarded to the executive director for review and filing. 7. The grievance official will log complaints/grievances and monthly grievance log. 8. The individual voicing the grievance will receive follow up communication with the resolution, a copy of the grievance resolution will be provided to the resident upon request. 1. During a Resident Council (RC) Meeting on 06/10/24 at 3:15 p.m., residents voiced the following concerns: • 11 of 13 residents present stated they had an unresolved grievance about frequently receiving their meals cold for months. The residents stated they were told the facility was going to get tray warmers but the food continued to be cold. Ten of thirteen residents present at the meeting voiced dissatisfaction with the dietary service offered by the facility. • Resident #40 stated residents could report a grievance and the facility accepted the grievance, but the breakdown in the process was a resolution. There was never a resolution. • Resident #70 stated the facility used to provide the resident with a copy of the grievance when they placed grievances, but we are no longer allowed to have a copy of the grievance we complete. I asked for a copy of a grievance I wrote and was told no. The facility starts to take steps to correct the grievance but generally fall short. Interview on 06/09/24 at 11:34 a.m. with Resident #59 revealed the food was always cold and had informed the facility of this concern. A review of the admission Record for Resident #59 revealed she had resided in the facility for over 5 years. Review of Resident #59's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status score of 15 out of 15, indicating intact cognition. Review of the Grievance Log revealed: Resident #39 filed a grievance on 05/24/24 related to cold breakfast. The findings of the investigation showed the hot pellet warmer had not been working for a long period of time. Maintenance had been working to fix it. The plan to resolve the complaint/grievance indicated waiting for the hot pellet warmer to be fixed. The expected results of action taken was to fix the pellet warmer. The post investigation follow up showed the resident understood the pellet warmer was down right now, and staff would try to pass trays out in a timely manner. Resident was understanding and would keep her updated during guardian angel rounds. Resident #58 filed a grievance on 05/24/24 related to cold food. The findings of the investigation showed the hot pellet warmer had not been working for a long period of time. Maintenance had been working to fix it. The post investigation follow up documented explained to the resident the pellet warmer was down and maintenance was fixing it. Resident was understanding and would keep her updated during guardian angel rounds. Resident #25 filed a grievance on 05/29/24 related to cold food. The findings of the investigation showed the hot plates were used with hot food. The plan to resolve the issue was to ensure meals were sent to the floor timely. A review of the Resident Council Meeting Minutes from 01/02/24 to 05/31/24 showed no concerns related to cold food; however, a grievance filed by the Resident Council on 05/24/24 related to cold food. The findings of the investigation showed the hot pellet warmer had not been working properly and maintenance was aware of the situation. A steam table was approved and when it comes, staff will put in place. Residents were thankful that the facility was working on a steam table to ensure meals were hot. Review of the Food Committee Meeting Minutes dated 01/05/24 showed there was a concern about cold food. The pellet warmer was not working. Review of the Food Committee Meeting Minutes dated 05/24/24 showed there were concerns about cold food. On 06/12/24 at 11:53 a.m., the Kitchen Manager reported she reports concerns voiced during the Food Committee Meetings to her boss and the Administrator via email. On 06/12/24 at 11:59 a.m., the Kitchen Manager stated she had not been invited to the Resident Council Meetings. She sets up the meetings for the Food Committee. She reported the facility does not have food delivery carts with warmers. The Kitchen Manager stated the pellet warmer was not working, and this had been an issue prior to her being employed here. Review of the background screening log revealed the Kitchen Manager had a hire date of 4/30/2024. The pellet warmer was leaving the kitchen today stated the Kitchen Manager. She had done audits on food temperatures, and she found that the Certified Nursing Assistants (CNAs) were not delivering the trays timely. There had been some education done. On 06/12/24 at 10:19 a.m., the Social Services Director (SSD) reported anyone can write a grievance. When he receives a grievance related to dietary, he makes a copy of the grievance, put it on the Grievance/Concern Log, and takes the grievance to the Kitchen Manager. The Kitchen Manager conducts the investigation. After the investigation was complete, he would close it out and follow up with the resident and make sure the resident signs the grievance. The SSD reported he had received a lot of dietary grievances related to cold food. Dietary has been a trend, stated the SSD. The SSD stated there had been issues with cold food because they had to order a part for a piece of equipment. On 06/12/24 at 11:05 a.m., the Administrator stated she hadn't heard any concerns regarding cold food since the last grievance was received on 05/24/24. The resolution was more so explaining to the residents what was going on with the pellet warmer in the kitchen. The wire was not functioning properly. It was fixed but went down again, and they had to order another part. She stated right now it does not get super-hot. On 06/12/24 at 11:48 a.m., the Administrator reported the pellet warmer had been fixed before and provided documents related to the work orders. -An invoice dated 01/26/24 showed the plate warmer was not working. Replaced the high limit and thermostat. Tested the unit for proper operation and unit was working properly. -An invoice dated 03/22/24 showed 2 or 3 bins on the plate warmer not heating. They took the plates out and checked all wires, adjusted the thermostat, and then tested the unit for proper operation. -An invoice dated 05/15/24 showed the hot food steam table had power issues. The technician arrived onsite and determined parts needed, however the unit was made in 1998 and parts are obsolete, provider was recommending replacement as they cannot locate parts. -An invoice dated 06/06/24 showed pending work was in progress for the pellet warmer to replace 20 dispenser springs, replace thermostat, and replace high limit. The replacements had not been approved. 2. During an interview on 6/12/2024 at 9:09 AM, Resident #40 stated he was having concerns regarding missing clothing and a broken TV since returning from the hospital in April 2024. The resident stated when he returned from his hospitalization his room had been changed and that's when he discovered the missing items and the TV was not working right. Resident #40 stated the concerns were not being followed up on, and Resident #40's responsible party contacted the Ombudsman. Resident #40 reported the Ombudsman came to the facility and spoke with him. Resident #40 stated the Ombudsman would speak with the administration and follow back up. Resident #40 has not had any further follow up. A review of the Grievance Logs from February 2024 to current, revealed one grievance in regard to missing clothing from March, 18, 2024. No other grievances were found related to Resident #40. On 6/12/2024 at 9:43 AM, the Social Service Director (SSD) reviewed the grievance process. The SSD reported once the grievance was received, it was logged in by social services. A decision of who was responsible for investigating the grievance was made. Then the department manager was responsible to investigate, determine resolution and follow up with the resident/responsible party. Once completed, the grievance form was returned to social services. The SSD stated, we like to get them back in three to five days. The SSD stated the Administrator (NHA) and SSD meet weekly to discuss grievances. The SSD was not aware of the Ombudsman visit for Resident #40 and stated a grievance would need to be completed if the visit was related to a concern. The SSD confirmed Residents #40's only grievance on file related to missing clothing in March of 2024. Interview on 6/12/2024 at 11:04 AM with the Nursing Home Administrator (NHA) revealed she was aware of Resident #40's concerns regarding the issues with the TV and the Ombudsman visit. The NHA stated a grievance was completed but never provided any documentation of the grievance. 3. During an interview on 6/12/2024 at 9:28 AM, Resident #97 stated the facility requested he complete a room change in April of 2024. Resident #97 stated he agreed to the move and while he was at dialysis, the facility packed up his belongings and moved them to the new room. The resident reported that his good clothing that were in the closet in the previous room missing upon his return. Resident #97 stated he told the NHA his good clothing was missing. Resident #97 stated he never received any follow up in regards to the missing clothing. During an interview on 6/12/2024 at 9:43 AM with the SSD. The SSD confirmed no grievances were filed for Resident #97.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the admission Record for Resident #280 revealed an original admission date of 04/29/24. Review of the contact information section revealed the resident was his own Responsible Party. The resident had an emergency contact listed. Review of a document titled, NURSING HOME TRANSFER AND DISCHARGE NOTICE, signed on 05/23/24 showed the resident was transferred to a local medical center. The reason for Discharge or Transfer was not completed. The notice section showed the form was presented by a staff member and dated 05/23/24. The area to list the Resident or Representative's name was blank. The signature line/date for the Resident or Representative to acknowledge the document was received line was blank. The area to date that the notice was provided to the Local Long Term Care Ombudsman Council was blank. Review of a document titled, NURSING HOME TRANSFER AND DISCHARGE NOTICE, signed on 05/18/24 showed the resident was transferred to a local medical center. The notice section showed the form was presented by a staff member and dated 05/18/24. The area to list the Resident or Representative's name was blank. The signature line/date for the Resident or Representative to acknowledge the document was received line was blank. The area to date that the notice was provided to the Local Long Term Care Ombudsman Council was blank. 3. Review of the admission Record for Resident #427 revealed an original admission date of 12/19/22. A review of a change in condition form revealed Resident #427 was transferred to the hospital on [DATE] and did not return. Review of the contact information section of the admission Record revealed the resident was his own Responsible Party. A Nursing Home Transfer and Discharge Notice could not be located and no documentation could be found to show the Ombudsman was notified of the transfer/discharge. The record did not show any discharge paperwork was provided to the resident. On 06/11/24 at 11:31 a.m., the Assistant Social Services Director (ASSD) reviewed Resident #427's medical record. The ASSD could not locate the transfer forms in the record. She stated upon discharge all paperwork should be filed in the resident's chart. She stated the expectation was for the nurse who was sending the resident out to initiate the paperwork. She stated if the resident was their own person they would sign, and if the resident was not able to sign, the nurse will write unable to sign and send a copy with the resident to the hospital. If a responsible party was notified of the transfer, it should be documented notification was conducted via phone. An interview was conducted on 06/11/24 at 1:35 p.m. with the Social Services Director (SSD), Regional SSD, and the Nursing Home Administrator (NHA). The Regional SSD confirmed the records she reviewed for Resident #280 and #427 did not show the resident/representative were notified of the transfers. The Regional SSD confirmed the Nursing Home Transfer and Discharge Notices for the two Nursing Home Transfer and Discharge Notices for Resident #280 were incomplete. The SSD confirmed it should be documented if the residents were unable to sign. The SSD stated she faxes the notifications of transfer/discharge to the Ombudsman. She stated if the Ombudsman was notified, it should be documented. The NHA stated they should be keeping a fax as evidence the ombudsman was notified. Review of a facility policy and procedure document titled, Transfer/Discharge Notification and Right to Appeal, Revised 10/14/22, showed transfer and discharges of residents, initiated by the center (facility initiated) will be conducted according to federal and/or state regulatory. When the center transfers or discharges a resident under any of the circumstances listed above [emergency transfers to acute care], the facility will ensure that the transfer or discharge is documented in the residents medical record and appropriate information is communicated to the receiving healthcare institution or provider. Review of Notice before transfer showed: Before a center transfers or discharges a resident, the center must: Notify the resident and resident representative of the transfer or discharge and the reasons for the move in writing (in a language and manner they understand). The center must send a copy of the notice to a representative of the office of the state Long-Term Care Ombudsman. Record the reasons for the transfer or discharge in the resident's medical record. Notice must be made as soon as practicable before transfer or discharge. Based on record review and interviews, the facility failed to notify the resident and/or resident representative in writing of the transfer/discharge and reason and send a copy of the notice to the State Long Term Care Ombudsman's Office for three (#177, #280, and #427) of four residents reviewed for hospitalization. Findings included: 1. A review of the admission Record showed Resident #177 was admitted to the facility on [DATE]. A review of a change in condition form revealed she was transferred to the hospital on [DATE] for altered mental status and did not return to the facility. Review of the medical record revealed no 'Nursing Home Transfer and Discharge Notice could be located and no documentation to indicate the Ombudsman was notified of the transfer/discharge. On 06/11/24 at 5:48 p.m., the Administrator confirmed they could not find any documentation to show the Ombudsman was notified of the discharge, and they did not have the Nursing Home Transfer and Discharge Form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the admission Record for Resident #280 revealed an original admission date of 04/29/24. Review of the contact information section revealed the resident was his own Responsible Party. The resident had an emergency contact listed. Review of a Nursing Home Transfer and Discharge Notice revealed the resident was transferred to the hospital on [DATE]. Review of the bed-hold notice revealed Resident #280's name was filled in and his representative's name was filled in on 05/23/24 to indicate the bed-hold notice was provided; however, below the names of the resident/resident representative was the following statement: By signing below the staff member attest to providing the written bed hold notice to the resident and resident representative if applicable The signature/title line was not completed to attest that the notice was provided. 3. Review of the admission Record for Resident #427 revealed an original admission date of 12/19/22 and transfer to the hospital on [DATE]. Review of the contact information section revealed the resident was his own Responsible Party. Review of the medical record revealed no evidence that the resident received the bed-hold notice at the time of transfer. On 06/11/24 at 11:31 a.m., the Assistant Social Services Director (ASSD) reviewed the medical record for Resident #427. She confirmed that no bed hold notification paperwork was present. She stated the expectation was for the nurse who was sending the resident out to initiate the paperwork. She confirmed the staff sending the resident out should sign the bed-hold form confirming they provided the bed hold information. An interview was conducted on 06/11/24 at 1:35 p.m. with the Social Services Director (SSD), Regional SSD, and the Nursing Home Administrator (NHA). The Regional SSD confirmed the records she reviewed for Residents #280 and #427 did not show the resident/representative were notified of the facility's bed hold policy. Review of the August 2018 policy and procedure titled, BED HOLD NOTICE showed in accordance with state and federal law the center provides written notice of its bed hold information to each resident and resident representative, if applicable, regarding the duration of the state bed-hold policy, during which the resident is permitted to return and resume residence in the nursing facility and the reserve bed payment policy in state plan. Based on record review and interview, the facility failed to notify the resident and/or resident representative of the facility policy for bed-hold for three (#177, #280, and #427) of four residents reviewed for hospitalization. Findings included: 1. A review of the admission Record showed Resident #177 was admitted to the facility on [DATE]. She was discharged to the hospital on [DATE]. Additional review of the Electronic Medical Record and the Resident's 'Hard Chart' revealed no 'Bed Hold Policy'. On 06/11/24 at 5:48 p.m., the Administrator reported they could not find a bed hold policy for Resident #177. A review of the admission Record showed Resident #177 was admitted to the facility on [DATE]. A review of a change in condition form revealed she was transferred to the hospital on [DATE] for altered mental status and did not return to the facility. Review of the medical record revealed no evidence of a bed-hold notice at the time of transfer. On 06/11/24 at 5:48 p.m., the Administrator confirmed they could not find any documentation to show the resident and the resident representative received written notice of the bed-hold upon transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility's policy, the facility failed to ensure residents received an accurate Level I Preadmission Screening and Resident Review (PASARR) for four (Residents #20, #36, #42, and #96) of six residents reviewed for PASARR. Findings included: 1. Review of the admission Record showed Resident #20 was initially admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, schizophrenia and mixed anxiety disorder. Review of Resident #20's PASARR dated 01/15/24 Section A. MI or suspected MI (check all that apply) showed the check boxes next to Anxiety Disorder and Schizophrenia were not marked. 2. Review of the admission Record showed Resident #96 was initially admitted to the facility on [DATE] with diagnoses that included schizophrenia unspecified, other seizures and alcohol abuse, uncomplicated. Review of Resident #96's PASARR dated 12/22/23 Section A. MI or suspected MI (check all that apply) showed the check boxes next to Schizophrenia and Substance Abuse were not marked. On 06/11/24 at 3:35 p.m., the Director of Nursing (DON) stated she had been working in the facility for two months. The DON stated when she was first hired there was no one in the facility to review PASARRs. The DON stated that the facility had identified PASARRs that were incorrect and there was a list of PASARRs that need to be corrected, but she was the only person completing this task. The DON stated she would continue to work on them when she could. 3. A review of the admission Record showed Resident #36 was initially admitted to the facility on [DATE] with a Principle/Primary diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Section I- Active Diagnoses of the Minimum Data Set (MDS) dated [DATE] showed the resident had diagnoses of non-Alzheimer's Dementia, anxiety disorder, depression, and schizophrenia. Review of Resident #36's PASARR dated 08/28/18 showed the resident was marked no for a primary diagnosis of Dementia. 4. A review of the admission Record showed Resident #42 was initially admitted to the facility on [DATE] with diagnoses present on admission to include bipolar disorder, major depressive disorder, and post-traumatic stress disorder. An additional diagnosis of anxiety disorder, unspecified with an onset date of 10/12/2023 was also listed. Section I- Active Diagnoses of the MDS dated [DATE] showed diagnoses of anxiety disorder, depression, bipolar disorder, and post-traumatic stress disorder (PTSD). Review of the PASARR dated 05/25/23 showed the resident had diagnoses of bipolar disorder and PTSD. The resident's PASARR was not updated to reflect the new anxiety diagnosis that occurred during the resident's stay. On 06/11/24 at 5:27 p.m., the Director of Nursing (DON) stated she would expect to see all the diagnoses listed on the PASARR and if a resident had a primary diagnosis of dementia, a Level II should be completed.

Based on observation, interview, and record review, the facility failed to ensure nine residents (Residents #19, #48, #76, #79, #96 #106, #107, #117 and #279) of twenty three residents reviewed for smoking returned smoking materials to staff after the designated smoking times and when returning back from leave of absence (LOA). Findings included: On 06/09/24 at 1:00 p.m., a total of thirteen residents were observed smoking in the designated smoking area. Staff O, Concierge was observed only providing one resident their cigarettes and lighter. The twelve other residents were observed to have their cigarettes and lighters already in their possession. During an interview on 06/09/24 at approximately 1:00 p.m., Staff O, Concierge stated she only had to assist one resident during this smoke break as the other twelve residents had their cigarettes and lighters already in possession and smoked without assistance. During an interview on 06/09/24 at 1:25 p.m., Resident #117 stated she smokes. Resident #117 stated she kept her cigarettes with her at all times so no one would steal them. During an observation on 06/09/24 at 4:00 p.m., nineteen residents were observed smoking. Nine of Nineteen residents were observed to have either cigarettes, lighters or both in their possession. Observations included: - Resident #76 was observed pulling out a cigarette and in possession of the cigarette. - Resident #96 was observed pulling out a lighter from his pocket. Resident #96 was then observed taking a cigarette from Resident #76. Resident #96 then lit Resident #76's cigarette and his cigarette before Staff M, Certified Nursing Assistant (CNA) even began passing out cigarettes and lighting cigarettes for other residents waiting. - Resident #107 was observed pulling a pack of cigarettes from his pocket and smoking with the assistance of Resident #96 who lit his cigarette. - Resident #19 was observed coming out to the designated smoking area and pulled out a cigarette and lighter. - Resident #117 was observed with 2 cigarettes in hand and giving those cigarettes to Resident #107 to add to his pack of cigarettes. Resident #107 was observed adding those 2 cigarettes to the pack in his possession and put the pack back in his pocket. - Resident #279 received a cigarette from Resident #106. Resident #279 was holding the cigarette in his hand and Resident #106 stated, do you need a light? Resident #279 stated no I am saving it for the 9 p.m. smoke break. Resident #106 said then hide it. Resident #279 was observed putting the cigarette under his shirt and taking the cigarette back into the facility. - Resident #76 was observed throwing cigarettes down into the rocky yard décor. (Photographic evidence obtained.) During an interview on 06/09/24 at 4:30 p.m., Staff M, Certified Nursing Assistant (CNA) stated she had a great relationship with the residents who smoke. She stated she ensured she took all unused cigarettes and lighters before residents entered the facility and placed them in the lock box, per policy. Review of the facility's Resident Council Meeting notes dated 05/31/24 showed, Administration addressed Smoker's not following policy, Leave of Absent Policy Issues and Actions: Administrator addressed concerns about smokers following policy. Making sure they turn in their smoking articles when they go out on LOA to purchase them and when family brings them in to turn into nurse. During an interview on 06/10/24 at 10:00 a.m., Resident #40 stated during the last Resident Council Meeting staff spoke to us regarding the smoking policy. Resident #40 stated that staff told us that they would be cracking down a lot more on residents having their cigarettes and lighters. Resident #40 said the main problem was when the residents who smoke go out on LOA and go smoke to the side of the facility under the trees and throw their cigarette butts on the dry ground. Resident #40 stated the ladies who smoke stated they put their cigarettes and lighters in their bra to keep their smoking materials. Resident #40 stated the guys who smoke put their smoking materials in their pockets or under their shirts. Resident #40 stated most of the smokers have their own stash. Resident #40 stated last night around 10:00 p.m. the nurse had to stop giving me my medications to let a smoker out the side door to smoke. Resident #40 reported the designated smoking time was 9:00-9:30 p.m. During an interview on 06/10/24 at 10:10 a.m., Resident #97 stated at the last resident council meeting the Social Services and the Activity Director stated the non-smokers do not need to worry about the smokers in the facility as staff was going to crack down on the smoking materials in the facility. Resident #97 stated it truly meant nothing because staff had been saying they were going to take control of the smoking materials for awhile now and nothing had been done. Resident #97 stated look out the window. Resident #107 was observed leaving the side of the facility where the trees were and coming back into the facility. Resident #97 stated the smokers smoke under the tree area at the side of the facility all the time. An observation of 06/10/24 at 10:23 a.m., revealed a pathway to the side of the facility with trees and bushes. Further observation showed multiple cigarette butts in this area with no proper safety equipment to dispose of cigarettes to prevent an accident hazard. The observation of the used cigarettes in this area showed multiple cigarette used butts that laid in the dry leaves and around the grass underneath the trees. Photographic evidence obtained. During an interview on 06/10/24 at 10:52 a.m., the Administrator stated a smoking concern had been going on since January 2024 when all the smokers walked out of the resident council meeting and refused to go back due to the smoking policy. The Administrator stated she had to call the Ombudsman to come in and talk with the Resident Council regarding resident rights for the February 2024 Resident Council Meeting. The Administrator stated residents who smoke signed themselves out on LOA and were not supposed to smoke on property. The Administrator stated those residents who go on LOA to smoke were required to go to the city sidewalk to smoke off property. The Administrator stated smokers would be required to obtain their smoking materials from the nurse prior to going on LOA and then return the smoking materials once they returned to the facility from LOA. The Administrator stated that was where the problem was as not all residents returned their smoking materials. During an interview on 06/09/24 at 12:03 p.m., the Ombudsman stated, I was invited to the facility to discuss how to set up a Resident Council Meeting and bylaws. The Ombudsman stated, I know there is a smoking concern there at the facility. The Ombudsman stated she spoke with the Administrator regarding not having control of smoking materials. The Ombudsman stated there was a resident in the facility who was concerned about smoking and his safety regarding fire. The Ombudsman stated that particular resident had a room next to the exit door because of his concern. The Ombudsman stated that resident reported residents were going outside to smoke at 2:00 a.m., and then coming back in to the facility and not turning in their smoking materials. The Ombudsman stated that resident reported there has been no change with these concerns for awhile. The Ombudsman stated she talked with the Administrator about smoking materials. The Administrator's responded, It's LOA, can't do anything about it and stated, my hands are tied. The Ombudsman stated in February 2024 the Administrator was supposed to put out a letter to residents and family that explained they can't have lighters and cigarettes in rooms or in the facility per policy and if they do break the policy then they will be issued a discharge notice. The Ombudsman stated she was unsure if that letter was ever sent out. An observation of smoking on 06/10/24 at 1:00 p.m., revealed eighteen residents smoking with four Residents who supplied their own material. - Resident #48 was observed coming out of the facility to the smoking area past the locked box of resident smoking materials and pulled out a cigarette and lighter in her possession. - Resident #96 was observed coming out of the facility to the smoking area past the locked box and pulled a pack of cigarettes out of his pocket with a lighter and began smoking without assistance. - Resident #106 was observed coming out of the facility to the smoking area and pulled a pack of cigarettes out of his pocket. Resident #106 began distributing cigarettes to Resident #6 and Resident #102. - The Administrator was outside and following around the residents smoking showing them the smoking policy. - After the smoking break, Resident #106 refused to give his pack of cigarettes to the Social Services Director (SSD) at first and re-entered the facility. Resident #106 then turned around and threw his cigarettes at the SSD and stated if even one cigarette comes up missing, he won't give them up again for staff to keep them again. During an observation on 06/10/24 at 1:20 p.m., the Administrator was speaking with Resident #48 with the smoking policy in hand. Resident #48 stated to the Administrator, this is ridiculous, I can't even get my meds and your worried about my cigarettes. The Administrator continued to review the smoking policy with Resident #48. An observation on 06/10/24 at 1:35 p.m. revealed Resident #79 had a pack of cigars and a pack of cigarettes stored in the nightstand beside his bed. (Photographic evidence obtained) During an interview on 06/11/24 at 9:12 a.m., Staff N, Director of Maintenance (DOM) stated the property line ends at the white picket fence in front of the facility. The DOM stated that he came out and informed residents about smoking under the tree and educated the residents that it was a fire safety risk throwing all their cigarettes in the dry leaves and grass area, as there was a burn ban in the county. He stated that when he directed the residents to go further to the city sidewalks the residents pulled up the facility blueprint on the county website and said this land belongs to the county. Staff N, DOM stated he went to the facility's blueprints and discovered the property ends at the white picket fence. Staff N, DOM stated that he did see an accident hazard and even a fire risk with residents throwing their used cigarettes into the dry leaves and on the ground. Staff N, DOM stated it was the facility's responsibility to keep this area of land clean but it was owned by the county not the facility. Staff N, DOM stated that he would call the County Fire Department today as he was sure the county does not know the residents are throwing their used cigarettes out into the dry leaves and ground causing a fire safety risk. During an interview on 06/11/24 at 9:40 a.m., the Administrator stated that all residents are expected to follow the Smoking Policy. The Administrator stated that she gave one resident a 30 day notice yesterday for not following the policy and having smoking materials on her possession. The Administrator reviewed the photographic evidence obtained from the non designated smoking area. The Administrator confirmed residents throwing their used cigarettes down in dry grassy areas and leaves was a safety hazard. The Administrator stated maybe they could look at providing a cigarette receptacle out near that area to try to eliminate the accident hazard. An observation on 06/12/24 at 12:00 p.m., revealed Resident #79 continued to have cigars stored in the nightstand at the bedside. Review of the Smoking Agreement/Notice of Policy dated 01/2020 showed, Smoking is allowed by the Center to accommodate those who wish to smoke. However, for the safety of all residents and staff the center has promulgated a safe smoking policy. All resident who wish to smoke at the center will abide by the center's smoking policy. Resident's electing to smoke will be provided a safe smoking assessment to determine and evaluate each resident's ability to safely smoke. Because violations of the smoking policy can lead to catastrophic consequences, the smoking policy will be vigorously applied without exception. Violations of the policy will result in remedial action based upon the nature of the infraction. Remedial action includes but is not limited to to warning, revocation of smoking privilege's, police intervention, and/or discharge. The agreement represents your acknowledgement that the center has provided you a copy of the center's smoking policy and your agreement to abide by the team set forth in the policy. Review of the facility's policy Smoking-Supervised revised 02/07/2020, revealed The center will provide a safe, designated smoking area for residents. For the safety of all residents the designated smoking area will be monitored by staff during the authorized smoking times. The center will have safety equipment available in designated smoking areas including: smoking blankets, smoking aprons, a fire extinguisher and non-combustible self-closing ashtrays. The center will retain and store matches, lighters, etc, for all residents. All residents who wish to smoke will sign an agreement attesting to abide by the smoking policies and procedures. Residents will be advised upon admission that violation of the smoking policy may result in revocation of smoking privileges, discharge, and/or being reported to law enforcement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food was prepared and served at safe and appetizing temperatures for two (Resident #7 and #73) of six residents sampled for food. Findings included: During an interview on 06/09/24 at 10:38 a.m., Resident #73's family member stated he had filed grievances on her behalf related to food and care. He stated on May 5th, 2024, while he was visiting with Resident #73, the residents were served raw chicken. The family member stated a resident who was sharing the table with Resident #73 ate the whole thing. He stated he had taken a photo which he showed this surveyor, of red meat on the plate that the resident ate. He said, I told the nurse. I said if anyone gets sick, it is their fault. Review of Resident #73's admission Record revealed she was admitted to the facility on [DATE] with diagnoses to include dementia. The record showed the family member was the Responsible Party. An interview on 06/12/24 at 11:30 a.m., revealed Resident #7 was frustrated because the food was not served at the right temperatures. Resident #7 showed this surveyor photos with dates and times when he was served raw chicken. He confirmed the dates of 05/05/24 and 06/02/24. The resident stated on 05/10/24, the residents were served grilled cheese sandwiches. He said, it was black and hard as a rock. He stated he had voiced grievances related to food, but they were never resolved. Review of Resident #7's admission Record revealed he was admitted to the facility on [DATE]. Review of Resident #7's quarterly Minimum Data Set (MDS), dated [DATE], revealed in Section C-Cognitive and Patterns a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. Review of facility menus confirmed the following: On 5/5/24 for lunch the residents were served fried chicken. On 5/10/24 for dinner the residents were served Grilled cheese sandwiches. On 6/2/24 for lunch the residents were served fried chicken. On 06/10/24 at 4:08 p.m. an interview was conducted with the facility's Certified Dietary Manager (CDM) and the Regional Dietary Manager. The CDM stated she had received grievances related to chicken being served raw. She stated a resident had shown her a photo of the raw chicken. She said, We did not serve the chicken at the right temperature. It should not have been served like that. The CDM stated in response to the incident on 05/05/24, she did an in-service. She stated the in-service was to ensure chicken was cooked until internal temperatures reached 165 degrees. During a follow-up interview on 06/12/24 at 1:53 p.m., the CDM stated she became aware there was a second incident of chicken served raw in June. She stated that was not acceptable. She said as a chef, I would know the meat closer to the bottom does not cook all the way. She stated it would be up to nursing staff to stop a vulnerable resident from eating raw meat. She stated nonetheless, it should not have gone out like that. The CDM reviewed a photo of a grilled cheese served to a resident, noted black in color. She said, yes, that is burnt. It should not have been sent out like that. She stated their expectation was to check the food temperatures after cooking, and to confirm it was thoroughly cooked prior to service. She stated the [NAME] should be utilizing a meat thermometer. She stated food should not leave the kitchen if it was not palatable. Review of a facility policy tilted, Food: Preparation, revised 02/2023, showed a policy statement that all foods are prepared with the FDA (Food and Drug Administration) Code. 10. Time/Temperature Control (TCS) hot food items will be cooked to a minimum internal temperature as follows; All poultry and stuffed foods 165 degrees Fahrenheit.

Based on observation, record review, and interview, the facility failed to ensure food was labeled and dated, the floor in the walk in freezer was clean, and personal belongings were stored appropriately in one of one kitchen. Findings included: On 06/09/24 at 9:31 a.m., an initial tour of the kitchen was conducted. Two bags of opened pasta were observed with no date. There was a clear container of brown liquid in the walk-in cooler with no date. Pieces of paper and other trash were observed on the floor in the walk-in freezer. The Kitchen Manager confirmed the floor was dirty and stated today was cleaning day. There was an unknown food wrapped in plastic wrap with no label or date in the walk-in freezer. There was a container of cereal observed underneath the prep table in the food prep area with no date. A jacket was observed hanging from a dish rash where clean dishes were stored. On 06/12/24 at 11:59 a.m., the Kitchen Manager stated food should be labeled and dated as soon as items are put in a container or opened. She stated they have hangers for jackets. The Labeling and Dating Inservice undated provided by the facility revealed the following: Importance of Labeling and Dating Proper labeling and dating ensures that all foods are stored, rotated, and utilized in a First In First Out manner. This will minimize waste and ensure that items that are passed their due dates are discarded. Guidelines for Labeling and Dating All foods should be dated upon receipt before being stored. Leftovers must be labeled and dated with the date they are prepared and the use by date.

Based on observation and interviews, the facility failed to ensure resident council meeting concerns were documented and responded to for three of three months of Resident Council meetings and Food Committee meetings for five (Residents #2, #3, #5, #6 and anonymous resident) who reported concerns pertaining to food and inadequate staffing concerns of eleven sampled residents. Findings included: A review of the facility's Resident Council Meeting Minutes for 12/22/2023, 01/18/2024, and 02/22/2024 revealed the following: On 12/22/2023, for Nursing, No concerns at this time but turnover is a problem. No further issues with staffing and the Dietary subject was blank. On 01/18/2024, for the Nursing subject, it was blank. For Dietary: N/A (not applicable). On 02/22/2024, for the Nursing subject, it was blank. For Dietary: N/A. On 02/28/2024, the facility provided Food Committee notes, dated 11/03/2023, 12/08/2023, and 01/05/2023. The notes documented no concerns with food. On 02/28/2024 at 9:27 a.m., an interview was conducted with Resident #2, she stated for food, there is just not enough. I have had weight loss, sometimes I go hungry. When asked if she felt the facility had enough staff to help her with her care and services in a timely manner, she stated, no, not enough staff. When asked why, she stated, I find it hard to explain. They will ignore you, the aides. On 02/28/2024 at 9:30 a.m., an interview was conducted with Resident #3. Resident #3 was observed in her room, sitting in a wheelchair, dressed and groomed, personal items on her bedside table in front of her, with her television on. She stated, for food, once in a while, she will receive a full portion. I have not gone hungry, but the portions are light. The quality of the food, well, it is cooked, clean, and um, average. On 02/28/2024 at 9:50 a.m., an interview was conducted with Resident #5, he confirmed he attended resident council meetings on a regular basis. He stated the food products on the plate do not match meal ticket that lists the meal to be served. He stated alternate foods were provided with no notice. The quality of the food could be better. He stated for the resident council, we might have the meeting, but there was no consistency of response to the concerns. For staffing, he stated not enough. Might be enough, but they are sitting at the desk. Yes, there had been complaints about the food. The facility was not responding. For the past two months, we were supposed to have a food committee meeting, but we did not. On 02/28/2024 at approximately 9:55 a.m., an interview was conducted with Resident #6, he stated food served does not match the meal ticket sometimes. It was industrial food, poor quality, and a lot of the same things. He said We have resident council, but it is a waste of time. Nothing comes of it. On 02/28/2024, a resident who wished to remain anonymous stated, for call bell light response, he/she stated, the 2nd and 3rd shift are the worst. It can take 90 minutes for them to help you. I sit here and I watch the clock. They have been shorthanded

Based on record review, observation, interviews and photographic evidence, the facility failed to ensure the provision of a therapeutic diet for one (Resident #2) of eleven sampled residents. Findings included: On 02/28/2024 at 9:27 a.m., Resident #2 was observed in her bed, eyes open, clean, groomed, and comfortable. She agreed to an interview. She stated she had resided in the facility for more than one year. She stated she ate her meals in her room. She confirmed she received three meals a day. She said the food taste was ok, there was just not enough. She stated, Yes, I have had weight loss. I eat independently. Sometimes not enough, sometimes I go hungry. A review of Resident #2's clinical record, the admission Record, documented an admission of 05/03/2023 with readmission of 02/19/2024. Her diagnosis information included: Chronic obstructive pulmonary disease, unspecified severe protein-calorie malnutrition, and ulcerative colitis. A review of Resident #2's Minimum Data Set, a 12/18/2023 PPS (Prospective Payment System) Part A Discharge assessment, Section C, documented a Brief Interview for Mental Status score of 13 out of 15, which meant the resident's cognition was intact. A review of a Nutrition Evaluation, dated 02/21/2024, documented Resident #2 had significant weight change, weight loss is significant, unplanned, and undesirable within x 3, and x 6 months. A review of Resident #2's weight history reflected the following: 08/09/2023, 77 pounds (lbs) 09/28/2023, 74 lbs. 10/09/2023, 72.2 lbs. 11/13/2023, 79.8 lbs. 12/27/2023, 69.2 lbs. 01/18/2024, 67.2 lbs. 02/26/2024, 67.5 lbs. A review of Resident #2's Care Plan, reflected a Focus area: Resident has potential nutritional problem .Weight: severely underweight, initiated 05/09/2023, last revised, 02/21/2024. Interventions included: Provide, serve diet as ordered. An observation was conducted on 02/28/2024 at approximately 12:22 p.m. of Resident #2's meal delivered to her room with her meal ticket. (Photographic evidence obtained). Review of the meal ticket, documented the following: Regular-Dysphagia Advanced #8 SCP (scoop)-ground homestyle meatloaf with ketchup glaze. 2 OZ (ounces)-brown gravy ½ cup-seasoned green peas ½ cup-fortified mashed potatoes, extra gravy ½ cup chocolate pudding 1-dinner roll/bread 1-margarine 1 square-caramel apple upside down cake 6 OZ-juice of choice 6 OZ-tea of choice An observation of the meal provided to the resident, revealed she had a portion of meatloaf with ketchup glaze, no brown gravy was observed on the meatloaf; a scoop of mashed potatoes, no gravy was observed on the potatoes; and a portion of peas. A dinner roll, but no margarine was present; a small dish of fruit with cinnamon sprinkled on top. No chocolate pudding was observed. An interview was conducted with Resident #2 at this time, she confirmed her meal had not included brown gravy, chocolate pudding, or margarine. She stated she did want those products. She stated the fruit in the cup looked like apples and not an upside-down cake. She stated no tea had been provided, but that was ok, she did not want the tea. A review of the facility's cycle menu for the 02/28/2024 lunch meal, documented the following meal products to be served: Homestyle meatloaf with ketchup glaze, 4 OZ (ounces) Au Gratin potatoes, ½ cup. Seasoned [NAME] Peas, ½ cup. Dinner Roll/ Bread, 1 each. Carmel Apple Upside Down cake 1 square. On 02/28/2024 at 12:37 p.m. an interview was conducted with the facility's Registered Dietitian. He reported Resident #2 had just come back from the hospital. He stated his goal for her was to maintain her weight and if possible, to increase. Her current weight was about 67.5 lbs. He confirmed Resident #2 was at risk for weight loss. He stated, yes, it was the expectation the resident would receive the menu items that corresponded to the menu. During the interview, he reviewed the photo of Resident #2's lunch meal. He confirmed a brown gravy was to be served over the meatloaf and the potatoes. In addition, the resident should have received chocolate pudding and margarine.

Based on observations, record review, and interview, the facility failed to ensure each resident received a diet that met their dietary needs for four (#2, #7, #9, #10) of eleven sampled residents. Findings included: A review of the food committee meeting minutes for the past 6 months revealed that each meeting minutes recorded the date and time but did not record the names of the residents in attendance and did not record any concerns. An interview on 2/28/24 at 10:44 a.m. with the Certified Dietary Manager (CDM) revealed there was a food committee meeting the 1st Friday of each month. He said there were a variety of concerns, with ongoing concerns from some of the residents wanting double and triple portions. When asked why residents were asking for double and triple portions, the CDM reported Because people like to eat. He said they (the dietary department) try to accommodate resident's requests. Observations on 2/28/24 at 11:31 a.m., of the midday meal tray-line, revealed Staff A, [NAME] cutting the meat loaf into small squares using a flat spatula and then started plating each dish with Staff B, Dietary Aide, calling out each resident's food order per meal ticket and placing dessert and liquids on tray. Review of the menu revealed that the following was to be served: Meal for regular diet Homestyle meatloaf with ketchup glaze 4 oz (ounces) Au gratin Potatoes (substituted with Mashed potatoes) ½ cup Seasoned [NAME] Peas ½ cup Dinner Roll/Bread 1 each Caramel Apple Upside Down Cake (Substituted with steamed cinnamon apple) 1 square During continued observations of the tray line, the following serving utensils were noted to be in use: Green scoop #12 (2.66 oz)- Rice, mashed potatoes Yellow scoop #20 (1.63 oz)-Puree meat, Mech meat, puree bread Red scoop #24 (1.33 oz)-, puree vegetables Yellow ladle (1.0 oz)-ketchup Green ladle (4.0 oz)- Spinach, Soup White Ladle (3.00 oz)- [NAME] peas Resident #2's tray was noted to be plated per the meal card -Regular-Dysphagia Advanced -should have received #8 (4.0 oz) scoop of meatloaf- actually received #20 scoop (1.63 oz) -Should have received ½ cup of green peas-actually received white ladle (3.0 oz) -Should have received ½ cup of mashed potatoes-Actually received #12 scoop (2.66 oz) -Resident was to receive 2.0 oz plus extra brown gravy- Actually received no gravy. Resident #7's tray was noted to be plated per the meal card-Regular Double Protein & Vegetable -Should have receive 4 oz of meatloaf x 2-actually received 2 visibly small squares of meatloaf. -Should have received ½ cup vegetable x 2-actually received 1 heaped green ladle (4.0 oz) Resident #9's tray was noted to be plated per the meal card -Regular-Dysphagia Puree -should have received #8 (4.0 oz) scoop of meatloaf- actually received #20 scoop (1.63 oz) -Should have received #10 scoop (3.25 oz) of green peas-actually received white ladle(3.0 oz) -Should have received #8 scoop (4.0 oz) of mashed potatoes-Actually received #12 scoop (2.66 oz) -Should have received #16 scoop (2.00 oz) of pureed dinner roll-Actually received #20 (1.63 oz) scoop. -Resident was to receive 2.0 oz of brown gravy- Actually received no gravy. Resident #10, tray was noted to be plated per the meal Card-Consistent Carbohydrate (CCD) Dysphagia Advanced -should have received #8 (4.0 oz) scoop of meatloaf- actually received #20 scoop (1.63 oz) -Should have received ½ cup of green peas-actually received white ladle(3.0 oz) -Should have received ½ cup of mashed potatoes-Actually received #12 scoop (2.66 oz) -Resident was to receive 2.0 oz brown gravy- Actually received no gravy. An interview with Staff A, [NAME] at this time revealed she was providing each resident with the appropriate amount of food. Staff A was unable to verbalize how much each scoop was and reported she did not know the amount. Staff A left the tray-line and went to a posting on the wall and provided posting and said these are the scoop sizes. Staff A continued to verbalize she did not know if she was using the right scoops and continued plating. Staff A was asked how much each square of meatloaf weighed, Staff A reported she did not know how much each slice was, that she just cut it into squares to serve. She was unable to verbalize how she could determine the weight of each slice of cooked meatloaf. An interview with the CDM at this time revealed that all the serving ladles and scoops have different sizes and could be found on the utensils, additionally they were color coded which was universal and each scoop color represented a number and the measurement that it held. He provided the scoop chart off the wall. He confirmed the wrong scoops and ladles were in use. He reported he did not know how much each slice of meat loaf weighed because he did not have a scale, so the staff just estimate. During a continued observation of the tray-line on 2/28/24 at 11:51 a.m., the CDM obtained a gray scoop and a white ladle from the draw and placed the gray scoop into the mashed potatoes and white ladle in the rice. At this time, it was noted the first 100 hall cart minus 4 trays was full. No attempts were made at supplementing the trays that were already plated including trays for residents #2, #7, #9, #10. An interview on 2/28/24 at 12:05 p.m. with the CDM revealed there were three cooks and all cooks should know the measurements of all scoops and ladles and should use them accordingly. He reported the cooks should be independent in the use of the appropriate scoops and ladles when plating resident meals to ensure that each resident receives the meals as ordered. He said he was not sure if Staff A, Cook, had been trained in the use of the appropriate scoops and ladles. The CDM said for those residents who were requesting double and triple portions he encouraged heftier portions. He reported that today's, 2/28/24, meatloaf portion was average but could not be sure because the kitchen had no scale. During an interview on 2/28/24 at 12:37 p.m., the Registered Dietician (RD) revealed he was at the facility 32 hours weekly 4 days a week. He reported he monitored for accuracy of meals and appropriate substitutes. He reported he did not do anything in the kitchen and that he only did the clinical side, completed assessments, and reviewed for weight loss. He reported the residents should get their meals as ordered. Review of the facility policy titled Therapeutic Diets with an original date of 5/2014 and a revised date of 9/2017 revealed the following: All residents have a diet order, including regular, therapeutic, and texture modifications, that is prescribed by the attending physician, physician extender, or credentialed practitioner in accordance with applicable regulatory guidelines.

Based on observations, record review, and interview, the facility failed to employ dietary staff that displayed appropriate competencies to meet the resident's nutritional needs related to one (Staff A) of three cooks and the Certified Dietary Manager. Findings included: Review of the Dining Services Director/Account Manager job description revealed the following: -Provides leadership, support and guidance to ensure that food quality standards, inventory levels, food safety guidelines and customer service expectations are met. -Training, quality control and in-servicing staff to HCSG standards is an essential part of the Manager's responsibility and includes touring kitchen several times per day to assess work quality using QCIs for documentation purposes. Review of the [NAME] job description revealed the following: -Plates appropriate foods to resident meal trays. -Inspect special diet trays to ensure that the correct diet is served to the resident. -Adhere to menus and portion control standards, including those for special diets when preparing and serving meals. -Review tray card to assure that current food information is consistent with foods served. An interview on 2/28/24 at 10:44 a.m. with the Certified Dietary Manager (CDM) revealed there was a food committee meeting the 1st Friday of each month. He said there were a variety of concerns, with ongoing concerns from some of the residents wanting double and triple portions. When asked why residents were asking for double and triple portions, the CDM reported Because people like to eat. He said they (the dietary department) try to accommodate resident's requests. Review of the food committee meeting minutes for the past 6 months revealed that each meeting minutes recorded the date and time but did not record the names of the residents in attendance and did not record any concerns. Observations on 2/28/24 at 11:31 a.m., of the midday meal tray-line, revealed Staff A, [NAME] cutting the meat loaf into small squares using a flat spatula and then started plating each dish with Staff B, Dietary Aide, calling out each resident's food order per meal ticket and placing dessert and liquids on tray. Review of the menu revealed that the following was to be served: Meal for regular diet Homestyle meatloaf with ketchup glaze 4 oz (ounces) Au gratin Potatoes (substituted with Mashed potatoes) ½ cup Seasoned [NAME] Peas ½ cup Dinner Roll/Bread 1 each Caramel Apple Upside Down Cake (Substituted with steamed cinnamon apple) 1 square During continued observations of the tray line, the following serving utensils were noted to be in use: Green scoop #12 (2.66 oz)- Rice, mashed potatoes Yellow scoop #20 (1.63 oz)-Puree meat, Mech meat, puree bread Red scoop #24 (1.33 oz)-, puree vegetables Yellow ladle (1.0 oz)-ketchup Green ladle (4.0 oz)- Spinach, Soup White Ladle (3.00 oz)- [NAME] peas Resident #2's tray was noted to be plated per the meal card -Regular-Dysphagia Advanced -should have received #8 (4.0 oz) scoop of meatloaf- actually received #20 scoop (1.63 oz) -Should have received ½ cup of green peas-actually received white ladle (3.0 oz) -Should have received ½ cup of mashed potatoes-Actually received #12 scoop (2.66 oz) -Resident was to receive 2.0 oz plus extra brown gravy- Actually received no gravy. Resident #7's tray was noted to be plated per the meal card-Regular Double Protein & Vegetable -Should have receive 4 oz of meatloaf x 2-actually received 2 visibly small squares of meatloaf. -Should have received ½ cup vegetable x 2-actually received 1 heaped green ladle (4.0 oz) Resident #9's tray was noted to be plated per the meal card -Regular-Dysphagia Puree -should have received #8 (4.0 oz) scoop of meatloaf- actually received #20 scoop (1.63 oz) -Should have received #10 scoop (3.25 oz) of green peas-actually received white ladle(3.0 oz) -Should have received #8 scoop (4.0 oz) of mashed potatoes-Actually received #12 scoop (2.66 oz) -Should have received #16 scoop (2.00 oz) of pureed dinner roll-Actually received #20 (1.63 oz) scoop. -Resident was to receive 2.0 oz of brown gravy- Actually received no gravy. Resident #10, tray was noted to be plated per the meal Card-Consistent Carbohydrate (CCD) Dysphagia Advanced -should have received #8 (4.0 oz) scoop of meatloaf- actually received #20 scoop (1.63 oz) -Should have received ½ cup of green peas-actually received white ladle(3.0 oz) -Should have received ½ cup of mashed potatoes-Actually received #12 scoop (2.66 oz) -Resident was to receive 2.0 oz brown gravy- Actually received no gravy. An interview with Staff A, [NAME] at this time revealed she was providing each resident with the appropriate amount of food. Staff A was unable to verbalize how much each scoop was and reported she did not know the amount. Staff A left the tray-line and went to a posting on the wall and provided posting and said these are the scoop sizes. Staff A continued to verbalize she did not know if she was using the right scoops and continued plating. Staff A was asked how much each square of meatloaf weighed, Staff A reported she did not know how much each slice was, that she just cut it into squares to serve. She was unable to verbalize how she could determine the weight of each slice of cooked meatloaf. An interview with the CDM at this time revealed that all the serving ladles and scoops have different sizes and could be found on the utensils, additionally they were color coded which was universal and each scoop color represented a number and the measurement that it held. He provided the scoop chart off the wall. He confirmed the wrong scoops and ladles were in use. He reported he did not know how much each slice of meat loaf weighed because he did not have a scale, so the staff just estimate. During a continued observation of the tray-line on 2/28/24 at 11:51 a.m., the CDM obtained a gray scoop and a white ladle from the draw and placed the gray scoop into the mashed potatoes and white ladle in the rice. At this time, it was noted the first 100 hall cart minus 4 trays was full. No attempts were made at supplementing the trays that were already plated including trays for residents #2, #7, #9, #10. An interview on 2/28/24 at 12:05 p.m. with the CDM revealed there were three cooks and all cooks should know the measurements of all scoops and ladles and should use them accordingly. He reported the cooks should be independent in the use of the appropriate scoops and ladles when plating resident meals to ensure that each resident receives the meals as ordered. He said he was not sure if Staff A, Cook, had been trained in the use of the appropriate scoops and ladles. The CDM said for those residents who were requesting double and triple portions he encouraged heftier portions. He reported that today's, 2/28/24, meatloaf portion was average but could not be sure because the kitchen had no scale. During an interview on 2/28/24 at 12:37 p.m., the Registered Dietician (RD) revealed he was at the facility 32 hours weekly 4 days a week. He reported he monitored for accuracy of meals and appropriate substitutes. He reported he did not do anything in the kitchen and that he only did the clinical side, completed assessments, and reviewed for weight loss. He reported the residents should get their meals as ordered. Review of the facility policy titled Professional Staffing with an original date of 5/2014 and a revised date of 9/2017 revealed the following: The Dining Services department will employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the resident population.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review, resident and staff interview and observation, it was determined the facility failed to ensure reasonable accommodations were made to ensure one (#3) of seven residents reviewed was able to get up to a wheelchair instead of remaining bedbound for one month due to the facility's loss of wheelchair leg rests. Findings Included: An interview was conducted with Resident #3 on 11/1/22 at 3:30 p.m. Resident #3 was observed in his bed, and a. wheelchair was observed next to the bed without leg rests. There were no leg rests observed in the room. Resident #3 stated he was evacuated to another facility on or around 9/27/22 due to an impending hurricane and he was told his customized wheelchair was placed in the storage compartment of the bus used for evacuation. He stated the wheelchair did not arrive at the evacuation facility and he did not have it there. The resident stated when he was brought back to this facility his wheelchair was not found immediately. Resident #3 said his wheelchair was eventually located and returned to him; however, the leg rests were not found. He stated he had purchased the wheelchair himself and his name was marked on the leg rests with a permanent marker. Resident # 3 stated he must have the leg rests on his wheelchair in order to have normal mobility due to issues with his legs. He stated he has been a prisoner in his bed for a month now due to having severe foot drop and Multiple Sclerosis as the leg rests support his legs and feet. Resident #3 stated he spoke with several people at the facility, but they have not found the leg rests or replaced them. Resident #3 stated he provided an invoice for the leg rests to the Social Service Director for the facility to replace the leg rests; however, he was told that the facility was not responsible for the loss and would not replace them. Review of the medical record for Resident #3 revealed he was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, and muscle weakness. Review of a quarterly Minimum Data Set (MDS) assessment, dated 10/5/22, revealed a score of 13 on the Brief Interview for Mental Status (BIMS) assessment, indicating the resident was cognitively intact. Functional Status on the MDS assessment indicated Resident #3 required two-person physical assist for transfer and locomotion on and off unit. Balance during transition and walking indicated Activity did not occur, Functional limitation and range of motion indicated lower extremity impairment on both sides and mobility devices utilized was checked for wheelchair. A care plan for Activities of Daily Living (ADL) self-care performance deficit, initiated 7/6/21 and revised 8/1/22, indicated Resident #3 was totally dependent on two staff for transfer. A review of the facility grievance log for September and October 2022 revealed no grievances for Resident #3. Further review of Resident #3's medical record, from 9/27/22 to 10/28/22, revealed no documentation related to missing wheelchair leg rests. An interview was conducted with the Social Service Director (SSD), on 11/1/22 at 3: 49 p.m. The SSD confirmed Resident #3 informed him when he came back from evacuation his wheelchair leg rests were missing. The SSD stated, everything was coming back from five buildings, five buses, two cargo trucks and therapy was trying to match the wheelchairs with the residents as the labels were lost. He confirmed he did not write a grievance related to Resident #3's report of missing leg rests. The SSD stated, I told him if the leg rests were not back in a week or so to give me a call. I didn't hear back from him. He said he did not follow-up with Resident #3 to determine if the leg rests had been located, stating No I didn't follow up with him, he was supposed to call me. The SSD stated there were seven or eight residents who had missing wheelchairs and other items and everyone else called me back, he's the only one who didn't call me back. The SSD stated the Ombudsman called yesterday about the leg rests so I wrote up a grievance about it yesterday. He said Resident #3 gave him an estimate for the specialty leg rests and stated, but he's probably not going to get those, he'll get whatever leg rests we have. An interview was conducted with the Director of Therapy, on 11/1/22 at 4: 12 p.m. She stated when the facility evacuated, all wheelchairs were labeled and came back from evacuation unlabeled. She stated it took two long days to get everything back to the residents; however, she never heard that Resident #3 did not have his leg rests until a week or so after the return from evacuation. She stated Resident #3 told her about the leg rests about five days or so after we came back. She stated she reached out to the facility he was evacuated to and asked the therapy director there to keep an eye out for them, and she spoke with Resident #3 twice to let him know she was hoping they would be found. The Director of Therapy confirmed Resident #3 did have severe foot drop, cannot hold his legs up to be pushed, and cannot have his legs on a regular leg rest. She stated he had purchased the wheelchair himself. She stated he does not get up out of bed often, but now he cannot get up at all without the correct leg rests. The Director of Therapy stated she spoke with the SSD about two weeks ago and told him to let her know if he needed to know what type of leg rests to order to replace them, and she would look the information up for him. She stated she did not hear back from the SSD. An interview was conducted with the Nursing Home Administrator (NHA), on 11/2/22 at 10: 00 a.m. She stated she found out about the wheelchair leg rests last week when the Ombudsman called her. She said she told the SSD to write a grievance and stated, which he did not do until 11/1/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to maintain a safe, comfortable, and homelike environment related to dirty and stained linen, medical equipment in hallways, and maintenance/repairs not completed in three out of three units and outdoor spaces. Finding included: An observation was made on 11/1/22 at 10:39 a.m. of room [ROOM NUMBER]. On the wall next to the air conditioner there was an approximate 24 x 4 gouge in the sheetrock. The bed nearest the door was also observed to have a footboard and metal grab bar lying on top with the bed not made. Two bags of dirty linen were also observed on the floor in the bathroom. (Photographic evidence obtained) On 11/1/22 at 10:55 a.m. an interview was conducted with Resident #14. He expressed he was not happy because maintenance did not do what they are supposed to do. He pointed out the view from his window. He stated the lawn had not been mowed in a month and the facility is unkept. His view was observed to be overgrown grass and weeds. On 11/1/22, 11/2/22, and 11/3/22 the view from windows and doors in multiple hall and resident rooms showed an overgrown lawn with weeds that had not been cared for. (Photographic evidence obtained) On 11/1/22 at 11:02 a.m. dirty linens were observed to be on the floor inside the door of room [ROOM NUMBER]. No staff members were in the room at that time. (Photographic evidence obtained) On 11/1/22 at 11:04 a.m. a ladder was observed to be lying flat on the ground in the resident courtyard. No staff members were present, and one resident was in the courtyard. At 12:45 p.m. the ladder remained on the ground in the courtyard and two residents were present with no staff members. At 12:50 p.m. the Director of Nursing (DON) was notified of the ladder in the courtyard. He stated only one resident comes out to the courtyard regularly. The DON called maintenance who stated he had been up on the roof and had not brought the ladder back in yet. The doors to the courtyard were unlocked and the courtyard was accessible to residents. (Photographic evidence obtained) On 11/1/22 at 11:15 a.m. a partially eaten sandwich was observed sitting on a bedside tray table in the hall outside of room [ROOM NUMBER]. (Photographic evidence obtained) On 11/1/22 at 11:06 a.m. a mattress was observed in the 300-hall leaning against the wall. At 11:13 a.m. a mattress was observed leaning against the wall in the 200-hall. On 11/2/22, and 11/3/22 there continued to be multiple mattresses and beds observed to be in the hall of the 100, 200, and 300 units. (Photographic evidence obtained) On 11/1/22 at 3:29 p.m. trash including plastic lids, a box, and paper were observed on the ground in the resident courtyard. The same trash remained on the ground in the courtyard on 11/2/22 at 5:00 p.m. (Photographic evidence obtained.) On 11/2/22 at 2:30 p.m. during an interview, three members of the resident council (Residents #5, #6, and #7) expressed their concerns about dirty linens. They stated one resident had received linen that had what appeared to be feces on it. On 11/2/22 at 5:00 p.m. two oxygen concentrators, a bedside tray table, a box fan and a ripped chair were observed to be in the hall leading to the resident dining and activities room. These items remained in the hall on 11/3/22. (Photographic evidence obtained) On 11/2/22 at 5:05 p.m. the resident dining room was observed to have eight dirty food trays stacked up on the counter with tray cards noting there were from that day's lunch service. These trays were observed from the main hall and the door was propped open. There was a plastic container containing pieces of sheetrock, cans, bottles, cardboard, and other miscellaneous trash sitting near the entrance. (Photographic evidence obtained.) On 11/2/22 at 5:15 p.m. a tour of the residential unit's linen closest were conducted. In the 100-unit linen closet one sheet was found that was ripped, one sheet was worn and threadbare, seven other sheets/blankets were found to have miscellaneous stains including some that appeared to be urine stains. In the 200-unit linen closet a sheet was found to have a 1 x 0.5 red tinged stain on it. On 11/2/22 at 5:30 p.m. an interview was conducted with the Nursing Home Administrator (NHA.) She was shown some of the sheets found in the linen closet. She stated those should not have been in the linen closet and should have been removed from use. She agreed it was unacceptable. She stated she was going to speak with laundry. On 11/3/22 at 1:00 p.m. an interview was conducted with the Housekeeping Manager. She stated when staff are folding the laundry, they should remove any linen that is stained or torn. She stated if any is missed, CNAs should remove it. She said stained laundry should be washed a second time to see if stains will come out, if they do not, the linen should be ragged out. She stated she tracks how much is ragged out so she knows how much to order. Regarding the thin worn sheets, she stated the facility did not have enough towels so she ordered cheaper sheets so there was money to buy more towels. She stated the sheets came in very thin and she will not buy those again. She stated she was aware a resident received a dirty sheet a week or two ago. She said she was shown the stained and torn linen found in the linen closet the previous day. She stated the staff started a full house linen audit last night. She stated six or seven bags of stain or torn linen were removed from use and there is still a lot more to take out. On 11/2/22 at 2:30 p.m. an interview was conducted with the Maintenance Director. He stated he walks the entire building himself looking for things that need repair. He stated there are logbooks at the nurses' stations for staff to report issues. He said he checks the logbooks and fixes as much as he can. He stated as far as items in rooms that need repair, he stated the department heads do angel rounds and go room to room. They report what they see at stand down every morning. He stated he is the only person doing maintenance work, he has no assistant. He stated he works all day and has to be on call too for any emergencies. He stated he does what he can to fix things but also must complete daily tasks like temperatures, generator checks, lock checks, etc. He confirmed the lawn has not been mowed in at least two months. He said he has a small push [NAME] that he uses to try to maintain the resident courtyard but cannot do all the grounds work outside and take care of the building too. He said they have not had a lawn contractor in a while but are trying to get one. The Maintenance Director was shown room [ROOM NUMBER]. He stated he was not aware of the large gash in the wall; it had not been reported to him. He stated the footboard that was lying on bed A and the grab bar should not have been there. He stated he would install the bar on the resident's bed nearest the window. He stated the A bed should have been made up, not been used for equipment. Maintenance logs were reviewed. Multiple maintenance requests from September and October were not signed off as completed. An example of the items not marked as completed are the following: 9/16/22 127-A Toilet leaking 10/2/22 226-A needs a new mattress, it stinks and cannot be cleaned 10/6/22 204-A TV not working 10/10/22 206-B Air mattress malfunctioning. Alarm will not silence. 10/10/22 227-B TV Channels missing 10/13/22 207-B Needs longer bed or footboard removed. 10/15/22 Shower room bar needs to be fixed in long term main shower room 10/19/22 310 Bathroom door handle 10/24/22 201-B Bed is low pressure and sinking in Several requests were made for lights, tv, or tv remotes not working that were not signed off as completed. An interview was conducted with the NHA on 11/2/22 at 2:46 p.m. She confirmed angel rounds are done daily and department heads are supposed to be checking every room for being clean, clutter free, having water cup in place and dated, and having no maintenance issues. She stated they should fix and the problem immediately if they are able, if not they should go over the findings in the morning meeting. She stated homework sheets or work orders are done for remaining items that need taken care of. She stated she knows there are issues and maintenance needs help. She confirmed they are working on getting a lawn contractor. A facility policy titled Maintenance, dated 11/30/22 was reviewed. The policy stated the following: Policy: The facility's physical plant and equipment will be maintained through a program of preventive maintenance and prompt action to identify areas/items in need of repair. Procedure: The Director of Environmental Services will perform daily rounds of the building to ensure the plant is free of hazards and in proper physical condition. A facility policy titled Linen Supply/Laundry Pick up, dated 11/20/2014 was reviewed. The policy stated the following: Policy: 1. Assure the linen supply is adequate for the resident needs 7. Soiled linen will not be thrown on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interviews, resident record review, and review of the facility grievance log and grievance policy, it was determined the facility failed to ensure, 1.) a grievance for one (#3) of seven residents was acted upon; and 2.) written grievances included the steps taken to investigate the grievances, a summary of the pertinent findings or conclusion of the investigation, and documentation of appropriate and relevant correction action taken to resolve the grievances for six (#8, #9, #10, #11, #12, #13) of seven resident grievances reviewed from 9/26/22 to 10/15/22. Findings included: 1. An interview was conducted with Resident #3 on 11/1/22 at 3:30 p.m. Resident #3 was observed in his bed, and a. wheelchair was observed next to the bed without leg rests. There were no leg rests observed in the room. Resident #3 stated he was evacuated to another facility on or around 9/27/22 due to an impending hurricane and he was told his customized wheelchair was placed in the storage compartment of the bus used for evacuation. He stated the wheelchair did not arrive at the evacuation facility and he did not have it there. The resident stated when he was brought back to this facility his wheelchair was not found immediately. Resident #3 said his wheelchair was eventually located and returned to him; however, the leg rests were not found. He stated he had purchased the wheelchair himself and his name was marked on the leg rests with a permanent marker. Resident # 3 stated he must have the leg rests on his wheelchair in order to have normal mobility due to issues with his legs. He stated he has been a prisoner in his bed for a month now due to having severe foot drop and Multiple Sclerosis as the leg rests support his legs and feet. Resident #3 stated he spoke with several people at the facility, but they have not found the leg rests or replaced them. Resident #3 stated he provided an invoice for the leg rests to the Social Service Director for the facility to replace the leg rests; however, he was told that the facility was not responsible for the loss and would not replace them. Review of the medical record for Resident #3 revealed he was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, and muscle weakness. Review of a quarterly Minimum Data Set (MDS) assessment, dated 10/5/22, revealed a score of 13 on the Brief Interview for Mental Status (BIMS) assessment, indicating the resident was cognitively intact. Functional Status on the MDS assessment indicated Resident #3 required two-person physical assist for transfer and locomotion on and off unit. Balance during transition and walking indicated Activity did not occur, Functional limitation and range of motion indicated lower extremity impairment on both sides and mobility devices utilized was checked for wheelchair. A care plan for Activities of Daily Living (ADL) self-care performance deficit, initiated 7/6/21 and revised 8/1/22, indicated Resident #3 was totally dependent on two staff for transfer. A review of the facility grievance log for September and October 2022 revealed no grievances for Resident #3. Further review of Resident #3's medical record, from 9/27/22 to 10/28/22, revealed no documentation related to missing wheelchair leg rests. An interview was conducted with the Social Service Director (SSD), on 11/1/22 at 3: 49 p.m. The SSD confirmed Resident #3 informed him when he came back from evacuation his wheelchair leg rests were missing. The SSD stated, everything was coming back from five buildings, five buses, two cargo trucks and therapy was trying to match the wheelchairs with the residents as the labels were lost. He confirmed he did not write a grievance related to Resident #3's report of missing leg rests. The SSD stated, I told him if the leg rests were not back in a week or so to give me a call. I didn't hear back from him. He said he did not follow-up with Resident #3 to determine if the leg rests had been located, stating No I didn't follow up with him, he was supposed to call me. The SSD stated there were seven or eight residents who had missing wheelchairs and other items and everyone else called me back, he's the only one who didn't call me back. The SSD stated the Ombudsman called yesterday about the leg rests so I wrote up a grievance about it yesterday. He said Resident #3 gave him an estimate for the specialty leg rests and stated, but he's probably not going to get those, he'll get whatever leg rests we have. An interview was conducted with the Director of Therapy, on 11/1/22 at 4: 12 p.m. She stated when the facility evacuated, all wheelchairs were labeled and came back from evacuation unlabeled. She stated it took two long days to get everything back to the residents; however, she never heard that Resident #3 did not have his leg rests until a week or so after the return from evacuation. She stated Resident #3 told her about the leg rests about five days or so after we came back. She stated she reached out to the facility he was evacuated to and asked the therapy director there to keep an eye out for them, and she spoke with Resident #3 twice to let him know she was hoping they would be found. The Director of Therapy confirmed Resident #3 did have severe foot drop, cannot hold his legs up to be pushed, and cannot have his legs on a regular leg rest. She stated he had purchased the wheelchair himself. She stated he does not get up out of bed often, but now he cannot get up at all without the correct leg rests. The Director of Therapy stated she spoke with the SSD about two weeks ago and told him to let her know if he needed to know what type of leg rests to order to replace them, and she would look the information up for him. She stated she did not hear back from the SSD. On 11/2/22 at 10:00 a.m. during an interview, the Director of Therapy stated she was going today to a local mobility company to see if they could locate leg rests that will fit the wheelchair as the wheelchair has been discontinued. She stated Resident #3 agreed for her to take the wheelchair with her to the mobility company and also agreed to try a different wheelchair today to see if it would work for him. On 11/2/22 at 1:07 p.m. during an interview, the Nursing Home Administrator (NHA) and Regional Nurse Consultant stated the mobility company was able to locate the correct leg rests and they will be delivered to the facility this afternoon. On 11/3/22 at 1:11 p.m. a follow up interview was conducted with Resident #3. He confirmed the receipt of the leg rests and stated, this should have been taken care of a month ago. The wheelchair with leg rests were observed in Resident #3's room. The SSD provided a copy of the complaint/ grievance report, dated 11/1/22 with a documented resolution date of 11/3/22. The concern was documented as Resident reports he is missing the leg rests to his wheelchair. The staff member(s) assigned responsibility for the investigation were documented as the Director of Housekeeping and the Assistant Director of Nursing. The findings of the investigation were documented as the actions taken on 11/2/22 by the Director of Therapy to locate new leg rests and replace them at the facility's expense. The resolution indicated that Resident #3 was satisfied with the outcome. 2. Six grievances from the September and October 2022 grievance log were selected for review: -A grievance, dated 9/26/22, for Resident #8 was documented as reported to the facility by a family member. The concern was documented as would like to go to back to room where moved from - skin is very dry, furniture dirty, missing pictures, lotions, sketchers (black), needs a haircut. Staff members assigned responsibility for the investigation were listed as the Director of Nursing and the Assistant Director of Nursing Findings of the investigation were documented as: Staff have completed investigation and identified areas where staff can improve quality of patient care and customer service. The plan to resolve the complaint/ grievance was documented as: Staff will complete re- education on providing quality patient care and customer service. The results of actions taken were documented as: Staff have completed re- education on providing quality patient care and customer service. The resolution was documented as: Re- education completed The resolution section indicated the complainant was satisfied, the results and resolutions were reported to the family and the resident. The form indicated confirmed closing of grievance via phone contact with family. There was no documentation on the grievance form that the specific areas of concern were addressed. An interview conducted with the Director of Nursing (DON), on 11/2/22 at 3:20 p.m., revealed he addressed all the issues in the complaint to the satisfaction of the family. Regarding whether there was documentation that he addressed all the areas of concern, the DON responded no. He was not able to state specifically what he did to resolve the areas of concern. -A grievance, dated 9/26/22, for Resident # 9 was documented as reported to the facility by Resident #9's significant other. The concern was documented as call lights wasn't answered, and resident was in her own waste in a timely manner Staff members assigned responsibility for the investigation were listed as the Director of Nursing and the Assistant Director Nursing. Findings of the investigation were documented as: Staff have completed investigation and identified areas staff can improve quality of patient care and customer service. The plan to resolve the complaint/grievance was documented as: Staff will complete re- education on providing quality patient care and customer service. The results of actions taken were documented as: Staff have completed re- education on providing quality patient care and customer service. The resolution was documented as: Re-education completed The grievance form indicated the complainant was satisfied and the investigation results and resolution steps were report the family and resident both verbally and in writing on 10/5/22. There was no documentation on the grievance form that the specific area of concern for Resident #9 was addressed. An interview with the DON, on 11/2/22 at 3:20 p.m., revealed he did call light audits and he would look for them. The SSD stated, they were happy with the education and signed the grievance form. -A grievance, dated 10/5/22, for Resident #10 was documented as reported to the facility on [DATE]. The concern was documented as Resident reported to SW (Social Worker) that on her way back to her room, CNA (Certified Nursing Assistant) (Staff E) tried to hit her with dinner cart. Staff members assigned responsibility for the investigation were listed as the Director of Nursing and Assistant Director of Nursing. The findings of the investigation included Staff member will be transferred to a different area of the building and Staff have completed investigation and identified areas staff can improve quality of patient care and customer service. The plan to resolve the complaint/ grievance was documented as: Staff will complete re- education on providing quality patient care and customer service. The results of actions taken were documented as: Staff have completed re- education on providing quality patient care and customer service. The resolution was documented as: Re- education completed The grievance form indicated that the concern was not reportable to the state agency. There was no documentation as to whether Resident #10 was satisfied with the resolution. The investigation results were documented as reported to the resident both verbally and in writing with a date of 10/24/22 On 11/2/22/ at 3: 20 p.m., the DON stated he did a whole investigation and obtained written statements from Staff and another who witnessed the event. The DON stated Resident #10 was trying to give her roommate liquids that were not thickened, and staff stopped her. He stated Resident #10 reported her attempting to hit her with the cart because she did not like staff stopping her. The DON provided the written statements from the staff and a text message document, dated 10/5/22 from him to the Regional Director of Clinical Services. The text message documented stated (Resident # 10) acknowledged and agreed there was no direct intent by the CNA to run over her with the tray cart and also agreed that those carts are not easy to maneuver and tends to sway to either to the left or right. -A grievance, dated 10/6/22, for Resident #11, was documented as reported to the facility on [DATE] by Resident #11's family member. The concerns was documented as: Has not received a shower this week, needs to be shaved, bed linens are not changed consistently, needs eye drops for dry eyes. Missing golf shirt and pants. Staff Members assigned responsibility for the investigation were listed as the Assistant Director of Nursing (ADON) and the Director of Housekeeping Findings of the investigation were documented as: Staff have completed investigation and identified areas staff can improve quality of patient care and customer service. The plan to resolve the complaint/ grievance was documented as: Staff will complete re- education on providing quality patient care and customer service. The results of actions taken were documented as: Staff have completed re- education on providing quality patient care and customer service. The resolution was documented as: Re- education completed The grievance form indicated the family was satisfied with the resolution and was informed verbally via phone of the resolution on 10/21/22. There was no documentation on the grievance form that the specific areas of concern were addressed. An interview conducted with the DON and ADON, on 11/2/22/ at 3:20 p.m. The DON stated We are doing the showers. There was a breakdown of communication with shower schedule. The ADON stated she told the CNAs to notify the nurse if the resident refuses a shower so it can be documented. There was no responses given by the DON and ADON as to the concerns related to shaving, bed linens, eye drops and missing clothing. -A grievance, dated 10/13/22, for Resident #12, was documented as reported the facility by a family member of Resident # 12. The concern was documented as: Resident admitted at 3:30 no water, no medications, daughter requesting immediate transfer- no one would answer phone, nurse was complaining about shift. Staff Members assigned responsibility for the investigation were listed as the Assistant Director of Nursing and the Director of Nursing. Findings of the investigation were documented as: Staff have completed investigation and identified areas staff can improve quality of patient care and customer service. The plan to resolve the complaint/ grievance was documented as: Staff will complete re- education on providing quality patient care and customer service. The results of actions taken were documented as: Staff have completed re- education on providing quality patient care and customer service. The resolution was documented as: Re- education completed The grievance form indicated the family was satisfied with the resolution and was informed verbally via phone of the resolution on 10/21/22. There was no documentation on the grievance form that the specific areas of concern were addressed. An interview was conducted with the DON and ADON, on 11/2/22 at 3: 20 p.m. The DON stated the concerns were addressed with the family and Resident #12 is still in the facility. -A grievance, dated 10/15/22, for Resident #13 was documented as reported to the facility by a CNA. The concern was documented as: writer was informed by staff, the resident was left unchanged for several hours on the overnight shift. (Name of CNA) was in charge of resident care. Staff members assigned responsibility for the investigation were listed as the Director of Nursing and the Assistant Director of Nursing Findings of the investigation were documented as: Staff have completed investigation and identified areas where staff can improve quality of patient care and customer service. The plan to resolve the complaint/ grievance was documented as: Staff will complete re- education on providing quality patient care and customer service. The results of actions taken were documented as: Staff have completed re- education on providing quality patient care and customer service. The resolution was documented as: Re- education completed The grievance form indicated that the complainant was satisfied with the resolution and the investigation and resolution steps were reported to the family and resident both verbally and in writing on 10/22/22. There was no documentation on the grievance form that the specific area of concern was addressed. The DON and ADON, during an interview on 11/2/22 at 3: 20 p.m., stated care was provided for the resident. The DON stated during an interview on 11/2/22 at 3:30 p.m. that the grievances are assigned to him and the ADON because the facility has no Unit Managers. Regarding the lack of documentation that the specific areas of concern were addressed on the grievances, the DON stated, Unfortunately more documentation on our part is what you are saying, I can see that is a problem. Further review of the grievance forms for Residents #8, #9, #10, #11, #12 and #13 revealed an attached titled Education In-service Attendance record. There was no date on the form as to when the in service was conducted. The Topic of the education was documented as ANE, Customer service and Resident Care, and a summary of the training session indicated customer service resident care, timely care of resident's needs, i.e., medication, answering call lights, incontinent care, documentation in [name of electronic medical record]. During an interview with the DON and SSD, on 11/2/22 at 4: 00 p.m., they stated the education in-service was completed on 10/17/22. The DON provided another copy of the same Education In-service Attendance record form with the date of 10/17/22 written in. There were eleven staff names on the attendance record, seven CNAs and four Licensed Practical Nurses (LPNs). The DON stated he would look to see if any more staff completed this in- service. At 4:30 p.m. on 11/2/22 the DON stated he could not find any more documentation of staff who attended the in service. The DON stated he could provide documentation of other in-service education that he conducted which would demonstrate that the grievance concerns were addressed. The DON provided a call light audit documented for 9/1/22 and education in-service attendance records for the following: -9/14/22 Call lights -9/22/22 Abuse Neglect and Exploitation: summary of training: Abuse Neglect and Exploitation including customer service, providing timely care and attending to resident needs, medication and all MD's (doctors) order upon admissions and during stay at the facility, call light response, grievance and hotline complaint calls. This documentation provided predated the grievances received from 9/26/22 to 10/15/22. In an interview on 11/2/22 at 3:40 pm the SSD described his role in the grievance process. He stated he was the grievance coordinator and he just coordinates the grievances. He stated, pointing to the DON and the ADON, you guys resolve it, you do the education. He continued I don't determine if it was handled to satisfaction, it is whoever is assigned to it who determines that. I collect, coordinate, make sure they get done on time. I am not involved in the micro of it. I tell them hey this happened, address it, hey it's been addressed, we are all happy, it's done. The SSD stated his documentation looks the same because of the way I approach, I say to the resident 'hey were you sitting in your own [vulgar profanity] for three hours', they say yes, I pass it along, they say no, I move on. The SSD stated if there is a bowel and bladder grievance, and an in-service is done on bowel and bladder that would be sufficient to resolve the grievance. During an interview on 11/3/22 at approximately 10:00 a.m., the NHA stated the grievances for Residents #8, #9, #10, #11, #12 and #13 were reviewed and the residents and or families were contacted on the evening of 11/2/22 to determine if these grievances were resolved to their satisfaction. She stated all were resolved to their satisfaction except the family of Resident #8 would like the sketchers and the lotion replaced. She stated they are in the process of replacing those items today. Review of a facility policy and procedure entitled Complaints/ Grievances, with an effective date of 11/30/14 and a revision date of 10/24/22, revealed: Policy: The Center will support each resident's right to voice a complaint/ grievance without fear of discrimination or reprisal. The center will make prompt efforts to resolve the complaint/ grievance and inform the resident of progress toward resolution. Grievances will be reviewed by the Quality Assurance Performance Improvement Committee. Grievances discovered to meet the definition of Abuse, Neglect, Exploitation or Misappropriation will be handled per the facility's Abuse Policy. The center will inform residents of the right to file a grievance orally and in writing, the right to file grievances anonymously, the contact information of the Grievance Officer, a reasonable time frame for completing the review of the grievance, the right to obtain a written decision regarding the grievance and contact information of independent entities with whom grievances may be filed (State agency, Ombudsman, Quality Improvement Organizations). The Executive Director will designate a Grievance Officer at the facility. Procedure: 1. An employee receiving a complaint/ grievance from a resident, family member and/or visitor will initiate a Complaint/Grievance Officer at the facility. Complaint/Grievance forms will be available 24 hours per day 7 days a week in an unsecured common area. Accommodations will be made to ensure residents have the opportunity regardless of their physical abilities or limitations. 2. Original grievance forms are then submitted to the Grievance Officer/ designee for further action. 3. The Grievance Officer /designees shall act on the grievance and begin follow- up of the concern or submit it to the appropriate department director for follow-up. 4. The grievance follow-up should be completed in a reasonable time frame; this should not exceed 14 days. 5. The findings of the grievance shall be recorded on the Complaint/ Grievance Form. 6. The results will be forwarded to the Executive Director for review and filing 7. The Grievance Official will log complaints/ grievances in Monthly Grievance Log. 8. The individual voicing the grievance will receive follow- up communication with the resolution, a copy of the grievance resolution will be provided to the resident upon request.

Based on observations, interviews, and policy reviews, the facility failed ensure menus and always available meal options were provided to five (#14, #3, #5, #6, and #7) out of seventeen sampled residents, and snacks were available to residents on one (11/03/22) of three survey days. Findings included: An interview was conducted with Resident #14 on 11/1/22 at 10:55 a.m. He stated he never knows what the meals are. He said if he wants to know, he must get in his wheelchair and roll to the nurses' station to look at a menu. Then he said if he wants something different, he must roll himself to the dining room to tell someone in the kitchen. He said most of the time, he is told it is too late to change it. Resident #14 stated no one comes to your room to discuss food and he does not like having to do down to the kitchen. He said even when he sees the menu at the nurses' station, it isn't always followed. He is not aware of items that are always available and says he often cannot get snacks. On 11/2/22 at 2:30 p.m. an interview was conducted with three members of the resident council (#5, 6, and 7.) The residents expressed they must go out to the area by the nurses' station and look at a menu posted on the wall to find out what is being served. They stated if they do not want what is posted for the meal and the alternate, they are only aware they can ask for a grilled cheese sandwich. They stated they are not aware of any other options. An interview was conducted with Resident # 3 on 11/3/22 at 1:11 p.m. He stated he does not know what is on the menu each day and does not know what alternatives he can ask for. Resident #3 eats in his room in bed due to diagnoses which include Multiple Sclerosis and weakness according to his clinical record. Throughout the survey days (11/01/22 - 11/03/22) no menus were observed in any resident rooms. Menus were observed to be posted at two nurses' stations and at the door to the dining room. An 'always available' list was not observed in resident rooms, nurses' stations or in the dining room. An interview was conducted with the Certified Dietary Manager (CDM) on 11/3/22 at 12:20 p.m. He stated he hangs menus up at the nurses' stations and outside the dining room and confirmed residents do not get menus in their rooms. When asked how bed bound residents know what the meal and alternates are he stated, I thought their aide would tell them. He stated they have a main meal, an alternate and an always available menu. He said the 'always available' included grilled cheese, peanut butter and jelly, hotdogs, and hamburgers. When asked how residents know what is always available, he stated, I guess I should find a place to post it. The CDM also stated they have a food committee meeting every month. He said it is right before the resident council meeting. He said he doesn't do minutes or write down what they discuss; the concerns are also not filed as grievances. He said there were a lot of concerns, but he thinks he fixed them. He stated when residents want an alternate meal some will call the front desk and be transferred to the kitchen, some will tell staff members, and some residents will come to the kitchen to let them know. He confirmed there was no set system in place, and he thought the nursing staff know they are supposed to notify residents of meal options and let the kitchen know. An interview was conducted with the Dining District Manager on 11/3/22 at 1:30 p.m. She stated the daily menus are posted on each hall and at the dining room. She stated if a resident is unable to make it to the board, their Certified Nursing Assistants (CNA) usually tell them the options. She stated CNAs are aware, but she has never in-serviced them. She said that is just how it has been. She stated snacks are provided three times a day in bulk to the unit refrigerators. She stated it is typically left-over deserts, fruits, pudding, sandwiches, crackers, or apple juice. She confirmed there is a food committee meeting every month and she thought there were minutes taken for them to address concerns. On 11/3/22 at 1:40 p.m. an interview was conducted with Staff H, CNA. She stated she was not taught anything about getting resident alternate meals or changes being made. She stated, my assumption was people in dietary did that. She said she just found out a few minutes ago about residents needing to make changes two hours before a meal. She stated a lot of residents have their own snacks and the facility doesn't always have snacks available for residents. She stated she does not know what meals are always available to residents. On 11/3/22 at 1:45 p.m. a tour was conducted of the 100-unit and 200-unit pantries. One refrigerator (100) had 3 half sandwiches and some apple juice. The second refrigerator (200) had no snacks available. One pantry cabinet (100) had one oatmeal pie. The second pantry cabinet (200) was empty. (Photographic evidence obtained) An interview was conducted with Staff G, Licensed Practical Nurse (LPN) on 11/3/22 at 1:54 p.m. She stated there are sometimes oatmeal pies in the pantry for snacks. She said the kitchen brings snack down. Staff G stated some residents ask what is on the menu and others will come out and look at the board by the nurses' station. She stated the facility used to have residents fill out a card for the meal they chose, but not anymore. An additional interview was conducted with the Dining District manager on 11/3/22 at 2:16 p.m. She stated snacks should be going to the units in bulk at 10 a.m., 2 p.m., and 7 p.m. She stated they used to have staff sign off for receiving snacks but did not do that anymore. She stated maybe they may need to increase the number of snacks going out. The Dietary District Manager provided two in-services she provided to dietary staff on 11/3/22 regarding taking minutes at food committee meetings and ensuring the proper number of snacks are delivered to each unit. A facility policy titled Menus, dated 9/2017 was reviewed. The policy stated the following: 2. Menus will be periodically presented for resident review, including the resident council, menu review meetings, or other review board as indicated by the center. The menu will identify the primary meal, the alternate meal, and any always offered food and beverage items. 8. Menus will be posted in the dining services department, dining rooms, and resident care areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure medical records were complete and accurate according to professional standards of practice for four residents (#1, #15, #16, and #17) out of four skilled care residents sampled. Finding included: A review of admission records indicated Resident #1 was admitted to the facility on [DATE] with diagnoses including pneumonia, sepsis, and chronic obstructive pulmonary disease. Continued reviewed revealed Resident #1 had an order to obtain stool for culture related to diarrhea, with an order date of 10/22/22. A review of the Certified Nursing Assistant (CNA) tasks indicated resident has loose stool/diarrhea on 10/19/22, 10/20/22, 10/21/22, and 10/22/22. A review of Daily Skilled Nursing Notes on 10/17/22, 10/20/22, and 10/22/22 indicated resident had no Gastrointestinal (GI) complaints, soft abdomen, and normal bowel sounds. There was no Daily Skilled Nursing Note on 10/18/22, 10/19/22, or 10/21/22. An interview was conducted with Staff A, Registered Nurse (RN,) on 11/2/22 at 11:52 a.m. She stated Resident #1 was having a lot of loose stools on 10/21/22. She stated she was in the Director of Nursing's (DON) office when Resident #1's power of attorney (POA) came in and voiced concerns to the DON about Resident #1 continuing to have diarrhea. Staff A stated the DON told the POA he would speak to the provider and follow up with her the next day. Staff A said on 10/22/22 Resident #1 was having to be changed about every 20 minutes because he was having so much diarrhea. She said a culture for clostridium difficile (c-diff) was pending. Staff A confirmed there were a few residents with c-diff on the unit at that time. She stated Daily Skilled Nursing notes are done daily, but it is a very busy unit, so I am sure sometimes they get missed. Staff A also compared the daily notes to alarm fatigue. She said if nurses are doing the same notes and assessments all the time, they will just click through the chart and not do the assessment. She stated, I know its's not right, but it happens. An interview was conducted with Staff B, CNA on 11/2/22 at 10:56 a.m. She confirmed Resident #1 was having diarrhea on 10/22/22 and the nurse was aware. She stated he was having to be changed often. An interview was conducted with Staff C, CNA on 11/2/22 at 12:06 p.m. She stated she cared for Resident #1 on 10/21/22 and 10/22/22. She confirmed Resident #1 was having a lot of diarrheas. She stated he just kept going and going. An interview with the DON was conducted on 11/2/22 at 12:24 p.m. He stated the Daily Skilled Nursing note is on the Medication Administration Record (MAR) to be completed by the nurse every shift. He stated he wanted to see all shifts doing the notes. The DON stated the Interdisciplinary Team (IDT) has a Utilization Review (UR) meeting every Wednesday. He stated Daily Skilled Nursing Notes are not reviewed. He stated the Minimum Data Set (MDS) Coordinator should get a notification if the notes are not being completed. He said it is the same for rehab and long-term care. He confirmed completion of Daily Skilled Nursing notes are mandatory. The DON also confirmed he knew some notes were missed. He said it feels like it is agency nurses and there is a communication breakdown. As for Resident #1, he said he was aware the resident was having diarrhea. The DON stated the resident's POA came and spoke to him about her concerns on Wednesday (10/19/22) and he told her he would let the nurse practitioner know about the diarrhea so she could address it on Thursday (10/20/22) when she would be in the facility. He said he promised the POA he would update her the next day. He stated, it's on me. I didn't have a change to give her an update. He confirmed he did not speak to the Nurse Practitioner about Resident #1's diarrhea or the POA's concerns. The DON reviewed Resident #1's medical records and confirmed there were missing Skilled daily nursing notes, there were no progress notes indicating the provider had been contacted about the resident's persistent diarrhea, and the notes that were present indicated normal bowels. Regarding incorrect and mission documentation the DON stated, I can see that is a problem. A review of hospital records showed Resident #1 was transferred back to the hospital on [DATE] and tested positive for C-Diff. A review of admission records indicated Resident #15 was re-admitted on [DATE] with diagnoses including osteomyelitis of vertebra, surgical aftercare, cirrhosis of liver, and intraspinal abscess and granuloma. A review of Daily Skilled Nursing notes from 10/21/22 to current revealed Resident #15 was missing notes from 10/25/22, 10/26/22, 10/28/22, 10/30/22, 10/31/22, 11/1/22 and 11/2/22. A review of admission records indicated Resident #16 was admitted on [DATE] with diagnoses including nondisplaced fracture of greater trochanter of left femur, fracture of rib, chronic obstructive pulmonary disease (COPD,) and type 2 diabetes mellitus. A review of Daily Skilled Nursing notes from 10/21/22 to current revealed Resident #16 was missing notes from 10/22/22, 10/25/22, 10/26/22, 10/31/22, 11/1/22, and 11/2/22. A review of admission records indicated Resident #17 was admitted on [DATE] with diagnoses including atherosclerotic heart disease, COPD, difficult walking, and deep vein thrombosis. A review of Daily Skilled Nursing notes from 10/21/22 to current revealed Resident #17 was missing notes from 10/23/22, 10/25/22, 10/26/22, and 10/28/22 - 11/3/22. An interview was conducted with the MDS Coordinator on 11/2/22 at 1:54 p.m. She stated Daily Skilled Nursing Notes do not trigger on the dashboard or on reports for her or the DON if they are not completed. She stated they do run a 24-hour report for every resident that is reviewed at the morning meeting. She stated the report includes Daily Skilled Nursing notes but does not indicate which residents are receiving skilled care, therefore, they do not notice if a note is missing. As for the nurses completing the Daily Skilled Note, she stated it has become too easy to check the blocks without assessing; you couldn't do that when a narrative note had to be written. An interview was conducted with Staff D, LPN on 11/2/22 at 2:13 p.m. Staff D stated the Daily Skilled Note shows up on the MAR for nurses to complete every shift. She stated they must create the note then go check it off on the MAR, it does not crossover automatically. She stated some people check it off on the MAR without doing the note. She said sometimes agency nurses will say they don't know how to do it, even though they do. Staff D stated she was not educated on the Daily Skilled Note by the facility. Staff D stated, you kind of have to teach yourself. She said she has witnessed nurses just clicking the boxes for the Daily Skilled Note without doing an assessment. A facility policy titled Daily Skilled Nursing Progress Note, dated 9/29/2017 was reviewed. The policy stated the following: -Residents receiving skilled care have progress documented daily in the medical record by the nurse. -Document abnormal findings in a narrative note on the from.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure dignity for one (Resident #73) of twelve residents that had indwelling urinary catheters. Findings included: On 3/29/22 at 12:29 p.m., an interview was conducted with Resident #73. The resident was lying in bed with the urinary drainage bag hanging from the bed frame facing the hallway. The drainage bag was not covered and held approximately 600 milliliter (mL) of concentrated yellow urine. An observation from the hallway was conducted on 3/30/22 at 4:57 p.m., of the resident sitting up in bed, eating dinner. The urinary drainage bag was observed hanging from the bed frame with yellow-colored urine in the bag. On 3/31/22 at 2:50 p.m., an observation was conducted from the hallway with Staff CC, Licensed Practical Nurse (LPN), escorting Resident #73's roommate from the room. Resident #73's urinary drainage bag held yellow-concentrated urine, while hanging from the bed frame. The staff member confirmed, from the hallway, the drainage bag could be seen and that No it should not be. Staff CC stated she would fix it right away. Resident #73 was admitted on [DATE]. The admission Record included diagnoses not limited to unspecified Stage 3 Chronic Kidney Disease, benign prostatic hyperplasia without lower urinary tract symptoms, and unspecified obstructive and reflux uropathy. Resident #73's care plan identified that the resident had an indwelling catheter related to (r/t) skin breakdown, urinary retention, and benign prostatic hyperplasia (BPH). The Regional Clinical Leader (RCL) stated, on 4/1/22 at 9:02 a.m., a residents' urinary drainage bag should not be seen from the hallway without a privacy bag. The RCL provided the following policy. The Policies and Procedures - Resident Rights, effective 11/30/2014, indicated that It is the policy of The Company to: 1. Make residents and their legal representatives aware of residents' rights. 2. Ensure that residents' rights are known to staff. The procedure indicated that Ongoing training on resident rights will be given to staff members as required by state and/or federal regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure two (Residents #73 and #97) of forty-three sampled residents were assessed for self-administration of medications. Findings included: 1. During an observation and interview, on 3/29/22 at 12:33 p.m., with Resident #73, Staff A, agency Licensed Practical Nurse (LPN) sat a medication cup which contained a tablet of medication down on the over-bed table in reach of the resident then left the room. On 3/29/22 at 12:36 p.m., Resident #73 ingested the tablet identifying it as Lisinopril. On 3/29/22 at 12:46 p.m., Staff A reported that he had left Lisinopril with Resident #73. He said the resident was getting it after other hypertensive's due to the resident having low kidney function. A review was conducted on 3/29/22 at 12:55 p.m., of Resident #73's assessments. The review indicated that an assessment to evaluate the resident's ability to self administer medications was not completed. The review of Resident #73's Order Summary Report, active as of 3/30/22, revealed the resident did not have a physician order for the self-administration of medications. Resident #73's care plan did not include a focus area that identified the resident had been assessed for self-administration of medications. The resident's care plan identified, The resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to (r/t) Cognitive deficits, Immobility, (and) Physical Limitations. The quarterly Minimum Data Set (MDS) dated [DATE], identified Resident #73's Brief Interview of Mental Status (BIMS) score of 10, indicative of moderate cognitive impairment. 2. An observation was made on 3/30/22 at 10:35 a.m., of a medication cup with orange liquid, one medication cup with dark green liquid, and a medication cup with at least six medication tablets/capsules sitting on the over-bed table of Resident #97. The observation also identified a medication cup containing one tan-colored capsule and a bottle of Calcium Carbonate Antacid tablets. The resident stated he was legally blind and did not know the tan-colored pill was there. The resident stated the nurse had dropped off the liquids and the cup with multiple pills, as the resident had bad reflux and wanted to eat first. During the interview, on 3/30/22 at 10:58 a.m., with Resident #97, Staff BB, agency Licensed Practical Nurse (LPN) arrived to the resident room and stated she would stay with the resident while he took the medications. She identified the tan-colored capsule as Gabapentin and she had not given it to the resident. A review of the assessments completed for Resident #97 indicated the resident had not been evaluated for the self-administration of medications and a review of the residents' Order Summary Report, active as of 3/30/22 at 3:59 p.m., did not include a physician order for the self-administration of medication. The care plan for Resident #97 identified that the resident had behaviors such as refusing treatment of paracentesis, refusing dialysis, non-compliant with prescribed diets, and refused medications. The interventions regarding the resident's behaviors indicated the staff should Administer medications as ordered and monitor/document for side effects and effectiveness. The 5-day Minimum Data Set (MDS), dated [DATE], identified the resident was cognitively intact and vision was highly impaired. The Regional Clinical Leader (RCL) stated, on 3/30/22 at 3:41 p.m., every resident was assessed at admission for appropriateness of self-administration of medication, a physician order would be obtained, and the resident would be asked what they wanted to do with the medications, if kept at bedside, the facility would provide a locked container. The RCL stated she did not think any resident was able to self-administer but would have to check. The RCL reviewed both Resident #73 and #97's assessments and physician orders and stated neither residents had an assessment completed or a physician order for the self-administration of medication. She reviewed the care plan for Resident #97 and stated there was no focus area related to the resident's ability to self-administer medications. The Policies and Procedures - Self-Administration of Medication at Bedside, effective 11/30/14 and revised 8/22/17, indicated The resident may request to keep medications at bedside for self-administration accordance with Resident Rights. Criteria must be met to determine if a resident is both mentally and physically capable of self-administering medication and to keep accurate documentation of these actions. The procedure identified that staff were to: - Verify physician's order in the resident's chart for self-administration of specific medications under consideration. - Complete Self-administration of Medications Evaluation. - The Interdisciplinary Team will review the evaluation an d will document Section III. Approval granted must be checked yes or no. Interdisciplinary team member sign the evaluation section. If approval is not granted, a statement must be written as to reason for denial. - Self-administration of meds is reviewed by the Care Plan Team with each quarterly review, and when any change in status is noted. - The MAR must identify meds that are self-administered and the medication will need to follow-up with resident as to documentation and storage of medication during each med pass. If kept at bedside, the medication must be kept in a locked drawer. - When a resident is unable to self- administer medication, they will be given by nursing staff until the resident can be reevaluated by the Interdisciplinary Team. The Facility's Pharmacy Services policy - General Dose Preparation and Medication Administration, effective 12/1/07 and revised 5/1/10, 1/1/13, and 1/1/22, indicated in section 5, subsection 5.10 instructed staff Observe the resident's consumption of the medication(s).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility did not ensure physician orders were in place for one (Resident #90) of one sampled resident with an orthopedic device. Findings included: During a facility tour on 03/29/22 at 10:00 a.m., Resident #90 was observed lying on her bed with an abductor pillow in place. Both legs were noted secured with the pillow. Resident #90 stated she wore the pillow all day. Resident #90 stated she was wearing it because she fell and broke her left hip. Resident #90 stated she would like to walk again. Resident #90 stated she did not like wearing the device but was looking forward to her ortho (orthopedic) appointment to evaluate the healing process. Review of an admission record for Resident #90 showed Resident #90 was re-admitted to the facility on [DATE] with a diagnosis of an encounter for orthopedic aftercare, displaced intertrochanteric fracture of unspecified femur and subsequent encounter for closed fracture with routine healing. Review of Resident #90's minimum data set (MDS) dated [DATE] showed a brief interview for mental status (BIMS) of 15, which indicated intact cognition. Section G, functional status showed Resident #90 required extensive assistance for transfers, bed mobility, locomotion on and off unit. Review of electronic medical record (EMR) physician orders for Resident #90 showed there were no orders for the abductor pillow. Review of a care plan for Resident #90 dated 02/14/22 showed a focus area for a pathological bone fracture right femur. The interventions to include: If orthopedic fixation device or traction is present, follow MD (medical doctor) orders for monitoring, maintaining device and providing skin care. The care plan did not show a focus or interventions related to the left hip fracture. On 04/01/22 at 9:55 a.m., an interview was conducted with Staff M, Licensed Practical Nurse (LPN). Staff M stated the therapy department put on the pillow and took it off the resident. Staff M did not know if there was an order or not. Staff M said, therapy should have it. Staff M stated the order should also be in the EMR. An interview was conducted with the Unit Manager on 04/01/22 at 10:00 a.m. The Unit Manager stated if the resident was wearing a device that restricts movement, there should be a physician order. The Unit Manager stated since this was a therapy related device, they [therapy department] should have put in the order. On 04/01/22 at 10:18 a.m., an interview was conducted with Staff N, Physical Therapist (PT). Staff N stated the resident was on case load for therapy post fall. Staff N stated Resident #90 broke her left hip. Staff N stated Resident #90 was discharged from the hospital with the abductor pillow to limit hip movement during healing. Staff N stated the abductor pillow was listed under therapy precautions. Staff N said, Since she came from the hospital, Nursing should have entered the order. On 04/01/22 11:49 a.m., Staff N stated he had called the doctor. Staff N stated the plan was to put an order to use abductor cushion as tolerated, pending clarification from the Orthopedic doctor. Staff N said, The order should have been in the chart. Staff N stated if a resident could not take off a device, it's a restraint. Staff N said, Yes, she should have an order. That's the standard of practice. An interview was conducted on 04/01/22 at 12:06 p.m. with the Regional Clinical Nurse. She stated Resident #90 was not able to independently move with or without the cushion. She said, That does not negate the fact that we should have an order in place. We have put it in now. Review of physician orders for Resident #90 dated 04/01/22 showed new orders for Abductor pillow as tolerated - perform skin integrity every shift. May remove for ADL care as required. (Every shift related to encounter for other orthopedic aftercare) Review of a facility policy titled, physician orders, with a revision date 03/03/21, showed the center will ensure that physician orders are appropriately and timely documented in the medical record. Under procedure for admission orders, the policy showed information received from the referring facility or agency is to be reviewed, verified with the physician, and transcribed to the electronic medical record. The attending physician will review and confirm orders. Confirmation of admission orders requires that the physician sign and date the orders during, or as soon as practicable after it is provided, to maintain an accurate medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure one (Resident #97) out 43 sampled residents received care in accordance with professional standards of practices related to the staff not initiating written physician orders. Findings included: Resident #97 was admitted on [DATE] and readmitted on [DATE]. The admission Record included diagnoses not limited to Type 2 Diabetes Mellitus, Acquired absence of left leg below knee, and End Stage Renal Disease (ESRD). An observation was made of a telephone order flagged in the hard copy of Resident #97's clinical record. The telephone order included the following: - Start patient (pt) on a Vitamin A containing Multivitamin. - Restart Tramadol 50 milligram (mg) by mouth (po) every 6 hours as needed (q6 prn), mod-severe pain. - Wound care consult - Left (L) knee, - Start a triple antibiotic three times a day (TID) to pustular skin lesions x 4 weeks. The telephone order was written and signed by the physician on 3/25/22. The order did not indicate the name of the nurse who had received the order or if the pharmacy was notified. A review of Resident #97's March Medication Administration Record (MAR), printed on 3/31/22 at 5:13 p.m. identified the order for Tramadol 50 mg q6 hours prn was included on the MAR and started at 7:45 a.m. on 3/25/22. The MAR did not include an order for a Multivitamin containing Vitamin A. The March Treatment Administration Record (TAR), printed on 3/31/22 at 5:13 p.m., did not include any treatment for the residents' left knee. On 3/31/22 at 12:27 p.m., Staff F, Licensed Practical Nurse (LPN), stated he had entered the order into the electronic medical record (EMR) for Resident #97's Tramadol then passed the other orders to the nurse who was assigned to the resident. On 3/31/22 at 12:29 p.m., Staff DD, Registered Nurse (RN), stated the process for taking off an order was to make sure the telephone order was legible and if legible, enter the order. The review of the Wound Care Advanced Practitioner Registered Nurse (APRN) progress notes from 3/30/22 identified the following wounds for Resident #97: - Wound #3: Right Heel, Diabetic Ulcer, - Wound #4: Right third toe, Arterial Ulcer, - Wound #5: Right plantar toe, Diabetic Ulcer The note did not include any information regarding a wound to the resident's left knee. A progress note, dated 3/30/22 at 4:17 p.m., reported wound care rounds were done with the APRN and treatment was performed to Resident #97's right heel, right third toe, and right plantar foot. Will continue to follow current plan of care. The note did not indicate the area to the resident's left knee was observed or that a treatment was implemented. A skin/wound note, dated 3/31/22 at 11:18 a.m., identified, Dressing to right heel clean dry and intact. Skin prep applied to right third toe. No complaint of (c/o) pain or discomfort noted during treatment. No signs/symptoms (s/s) of infection noted. Will continue to follow current plan of care. Call light in reach. The note did not indicate staff had identified the area to the residents' left knee. An interview was conducted, on 3/31/22 at 12:57 p.m., with the Regional Clinical Leader (RCL). The RCL reviewed the telephone order written on 3/25/22, and confirmed the orders for triple antibiotic ointment to pustular areas and the Multivitamin were not entered into the electronic record. She stated she had to check with the wound care nurse to see if the wound care provider had seen Resident #97 yesterday when they were in the building. A Non-Pressure Skin Condition, dated 3/31/22 at 1:18 p.m., identified an area on Resident #97's left knee (front) caused by a Trauma wound measuring 4.5 centimeter (cm) in length and 1.7 cm in width with no measurable depth. The evaluation identified there was no drainage, wound edges were Within Normal Limits (WNL), and the peri-wound was red. A progress note, dated 3/31/22 at 1:22 p.m., indicated, This nurse noted an area to the patient's left knee measuring 4.5 cm in length and 1.7 cm in width with no measurable depth. No drainage noted. Wound bed was dark brown in appearance. Received new order to apply oil emulsion and dry dressing every 3 days. No c/o pain or discomfort noted. Patient stated it happened during transfer from dialysis. The following orders were entered into the electronic record: - Order date, 3/31/22 at 1:33 p.m., LEFT KNEE: Cleanse area with Normal Saline (NS). Pat dry. Apply oil emulsion and dry dressing (DD) every (q) 3 days. - Order date, 3/31/22 at 2:30 p.m., Multivitamin-Minerals tablet - Give 1 tablet by mouth one time a day related to End Stage Renal Disease. Use house stock. A Nursing Progress Note, dated 3/31/22 at 2:28 p.m., indicated, Orders dated 3/25/22 were not transcribed. MD and resident are notified, orders are clarified and (&) entered in PointClickCare (PCC). The Facility Assessment 2021, identified that the facility provided the resident support/care needs which included Skin integrity: Pressure injury prevention and care, skin care, (and) wound care (surgical, other skin wounds).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure one (Resident #51) of three residents sampled for positioning received services and equipment to prevent further decrease in range of motion. Findings included: On 03/29/2022 at 12:05 p.m., Resident #51 was observed in his room lying in bed. He was interviewable and his left hand appeared contracted. He was not wearing a splint/brace on his left hand. However, a blue and gray [hook and loop] splint/brace was observed placed on the left side of the bed, on the dresser, and out of his reach. He stated he did not receive therapy services. Photographic evidence obtained. On 03/30/2022 at 12:05 p.m., Resident #51 was observed sitting in his wheelchair. He was noted not wearing his left-hand brace and it was again observed positioned on the left side of the bed on the dresser. It was observed in the same exact position as from the observations the day before (03/29/2022). Photographic evidence obtained. On 03/31/2022 at 10:02 a.m., Resident #51 was observed sitting in the dining/tv room. He was not wearing his left- hand brace. An observation was made on 03/31/22 at 2:34 p.m., Resident # 51's left- hand brace was observed on the left side of the bed on the dresser. Photographic evidence obtained. On 03/31/2022 at 10:35 a.m., an interview was conducted with Staff T, Certified Nursing Assistant (CNA). She stated Resident #51 was able to tell staff if he wanted to wear the left- hand splint. She confirmed she had never seen him wearing the splint and had not observed it on his nightstand. 04/01/22 at 12:27 p.m., Resident #51 was observed sitting in his room, in his wheelchair. He was observed not wearing a splint/brace on his left hand. Review of Resident #51's medical record revealed he was admitted to the facility for long term care on 09/26/18. Review of the admission diagnosis sheet revealed Resident #51 was admitted with contractures of the left hand and wrist. Review of the Minimum Data Set (MDS) assessment dated [DATE], Section C: Cognitive Patterns revealed a Brief Interview for Mental Status score of 12, which indicated Resident #51 had moderately impaired cognition. Section G: Functional Status revealed Resident #51 required extensive assistance of one person for activities of daily living (ADL's) and was impaired on both sides of his upper and lower extremities. Review of the care plans with a last reviewed date of 03/04/22, revealed a focus area for ADL self-care performance deficit related to fatigue, hemiplegia, impaired balance, and limited mobility. Goals were to improve current level of function through the next review date. Interventions included but not limited to, left resting hand/wrist splint to be worn daily as tolerated. A focus area for a contracture of the left hand required him to wear a resting hand splint. Goals were to prevent further contracture. Interventions included but not limited to monitor for skin redness or breakdown and passive range of motion to the left hand after cleansing with warm water and soap. On 04/01/2022 at 12:15 p.m., an interview was conducted with Staff U, Physical Therapist (PT). She confirmed Resident #51 was not on her caseload and his last day on her case load was 02/14/22. She confirmed she had previously worked with him on splint application. She stated he tolerated wearing the splint some days and not as well on others. On 04/01/22 at 12:17 p.m., an interview was conducted with Staff N, PT. He stated when Resident #51 was removed from their caseload, he was put on Restorative Therapy. The facility did not have a restorative aide. He stated the facility was supposed to hire a restorative aide, but it did not happen. When Resident #51 was on case load he was able to remove the splint independently. Staff N confirmed the last active order for splint application was dated 10/05/21 and that was the last time Resident #51 received services from the restorative program. Staff N confirmed the residents at the facility would benefit from having a restorative aide to assist with preventing further decline in functioning. A review of the facility policy titled Contractures and Prevention, revised on 08/22/17 revealed that each resident must be evaluated for need of contracture prevention procedures on admission, readmission and as needed. Procedure: Residents with inactive extremities should have range of motion exercises done to those extremities as part of their daily care. Hand rolls may be placed in any hand that a resident cannot move. Some residents may have braces or splints to prevent or help release contractures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During facility tours on 03/29/22 at 10:25 a.m., 03/30/22 at 11:43 a.m., 03/31/22 at 9:10 a.m., and 04/01/22 at 9:54 a.m., an observation was made of Resident #106's nebulizer stored on top of his nightstand. The nebulizer mask was positioned on top of the machine, exposed to the elements. The nebulizer tubing was hanging on the side of the nightstand, noted partly on the floor. Photographic evidence was obtained. Review of Resident #106 admission record revealed Resident #106 was admitted to the facility on [DATE] with a primary diagnosis of chronic obstructive pulmonary disease (COPD.) An MDS (minimum data set) dated 03/01/22 showed Resident #106 had a brief interview for mental status (BIMS) score of 15, which indicated intact cognition. An interview was conducted on 03/30/22 at 11:43 a.m., with Resident #106. He stated he used the nebulizer every day. He said, I use it to take my medicine. I have COPD. The resident stated he did not know who cleaned his nebulizer or when the mask and tubing were changed. Physician orders for Resident #106 dated 04/01/22, showed an active order dated 12/17/21, to change tubing, mask and / or nasal cannula weekly. May change sooner as needed. Check filter in back of concentrator for cleanliness as needed for hygiene, every night shift, every Friday. A review of the care plan dated 10/23/19, showed a focus area which indicated Resident #106 had COPD. The goal showed Resident #106 would display optimal breathing patterns daily through the review the next review date. Interventions included nebulizer treatments as ordered; Resident may self-administer nebulizer after nurse set up. On 04/01/22 at 09:54 a.m., an interview was conducted with Staff M, Licensed Practical Nurse (LPN.) Staff M observed the nebulizer in Resident #106's room on the nightstand. The mask was exposed to the element and tubing on the floor. Staff M said, The 11pm-7am nurse is supposed to change the cannula weekly. Staff M stated she would change it right away. Staff M said, It should be stored inside a bag, labeled and dated. An interview was conducted on 04/01/22 at 11:16 a.m. with the Regional Clinical. She stated the expectation was for the mask and tubing to be changed weekly and stored in a bag. She said the bag should be dated the day it was changed. The Policies and Procedures - Equipment Change Schedule, effective 11/30/14 and revised 8/28/17, indicated An equipment change schedule provides a schedule for changing disposable equipment at regular intervals as determined by manufacturer's recommendations and standards of practice. Under procedure: Aerosol tubing and aerosol nebulizer to be changed once every seven days. Nebulizer set up, once every seven days along with equipment bag, labeled with name, date and room number. Based on observations, record reviews, and interviews, the facility 1. failed to ensure oxygen therapy equipment was stored in a sanitary manner for two (Residents #97 and #106) of three sampled residents and 2. failed to ensure physician orders were in place for the administration of oxygen therapy one (Resident #97) of three sampled residents Findings included: On 3/30/22 at 10:38 a.m., an observation was conducted of Resident #97's room, between Resident #97's bed and the privacy curtain was an oxygen concentrator with tubing and nasal cannula attached. The nasal cannula was observed lying on floor in front of the concentrator. The resident stated the cannula had probably been there for 2 weeks. The observation identified a Continuous positive airway pressure (CPAP) machine with mask was sitting on top of the bedside dresser beside the resident's bed. The CPAP mask was lying on top of machine, uncovered and undated. On 3/31/22 at 12:51 p.m., an observation was conducted of Resident #97's room with the resident and family members in attendance. The CPAP mask was observed lying on top of the machine and the nasal cannula was observed lying across the oxygen concentrator uncovered and undated. On 4/1/22 at 10:46 a.m., Resident #97 admitted to using the CPAP every night and the oxygen concentrator was running at 3 liters per minute (lpm) while the nasal cannula laid next to the resident in bed. The CPAP mask was lying on top of the machine that was sitting on the bedside dresser. The resident reported using oxygen at times when lying down. A review of Resident #97's Order Summary Report, active as of 3/30/22 at 3:59 p.m., identified the resident did not have a physician orders for oxygen therapy including the use of the CPAP. The 5-day Minimum Data Set (MDS), dated [DATE] did not identify that the resident received oxygen therapy while being a resident. The care plan for the resident did not identify the resident's use of oxygen or CPAP. Resident #97 was admitted on [DATE] and recently readmitted on [DATE]. The admission Record for the resident included diagnoses not limited to End Stage Renal Disease, unspecified heart failure, and unspecified sleep apnea. The clinical record included a progress note, dated 12/23/21, that indicated the Director of Nursing (DON) requested the resident's CPAP to be checked due to not working and the machine was not to be touched by Respiratory Therapist (RT) at (@) the facility. The DON had visualized damage to the CPAP's power cord and included the recommendation for MD write order for CPAP to be set up (s/u) with (c) an appropriate pressure. On 4/1/22 at 10:50 a.m., Staff FF, Licensed Practical Nurse (LPN), reviewed the resident's electronic Medication Administration Record (MAR) and reported that there were no orders to do anything with the CPAP and said, it pains me to say this but I don't see an order for oxygen. The staff member further reviewed the residents' physician orders and stated there was not an order for the CPAP either and both should have an order. The Regional Clinical Leader (RCL) stated, on 4/1/22 at 11:00 a.m., that there should be an order for Resident #97's CPAP and oxygen use. The website medlineplus. gov (https://medlineplus.gov/oxygentherapy.html) identified that oxygen therapy It is only available through a prescription from your health care provider. The website cpaprx.com, located at https://cpaprx.com/cpap-prescriptions-everything-you-need-to-know, indicated that The law regulates the purchase of CPAP machines. The U.S. Food and Drug Administration classifies the machine along with the mask and humidifier as Class II Medical Device. The website identified that CPAP prescriptions also come with pressure settings based on the results of the sleep study.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility, 1. failed to ensure two (Residents #64 and #97) of six residents on dialysis, received a meal and/or snack during Dialysis and 2. failed to ensure one (Resident #97) received pre-dialysis, and post dialysis assessments, which is a standard of care consistent with professional practices. The findings included: 1. On 03/29/22 at 10:30 a.m., an observation and interview were conducted with Resident #64, who indicated the facility did not prepare snacks and/or meals to take to the dialysis center, and said, he was diabetic. Resident #64 revealed he would prefer the facility pack a snack and/or meal to keep his blood sugar stabilized during Hemodialysis. A record review for Resident #64 indicated he was initially admitted on [DATE] with multiple diagnoses that included End Stage Renal Disease and Type 1 Diabetes Mellitus. A review of the Order Summary Report for Resident #64 revealed an active order dated 12/28/2021 for Dialysis every Monday, Wednesday, and Friday, resident to be up and dressed by 09:00 a.m. for chair time at 10:00 a.m. An interview was conducted on 3/31/2022 at 11:00 a.m. with Registered Dietician (RD), and Certified Dietary Manager (CDM). During the interview, the RD revealed she called all the dialysis centers and due to COVID-19, they currently do not want any residents to bring snacks or food to the dialysis centers. On 03/31/2022 at 2:07 p.m., a telephone interview was conducted with the Dialysis Registered Nurse (RN). During the interview she revealed that if it was medically necessary and a resident was diabetic, the center would allow the resident to bring a snack and/or meal and eat it during Hemodialysis. 2. Resident #97 was admitted on [DATE]. The admission Record included diagnoses not limited to End Stage Renal Disease and Type 2 Diabetes Mellitus without complications. The 5-day Minimum Data Set (MDS), dated [DATE], indicated the resident had a Brief Interview of Mental Status (BIMS) score of 15, indicative of intact cognition. The MDS identified the resident received Dialysis treatments prior to being and while a resident of the facility. On Wednesday 3/30/22 at 10:45 a.m., Resident #97 reported leaving for Dialysis on Tuesday, Thursday, and Saturdays at 10:00 a.m. and returned between 4:30 or 5 p.m. The resident stated the facility did not send a lunch or snack to Dialysis and there were times the lunch tray would still be sitting on the over-bed table when he returned from Dialysis. On 3/31/22 at 11:59 a.m., Resident #97 stated after Dialysis he removed the fistula dressing as leaving it on would compromise the site. A physician order indicated Resident #97 was scheduled for Hemodialysis on Tuesday, Thursday, and Saturday and was to be ready for pick up at 10:30 a.m. for a chair time of 11:45 a.m. The care plan for the resident identified the resident exhibited behaviors which included refusing paracentesis, refused Dialysis, did not follow prescribed/recommended diet and refused medications. The Policies and Procedures - Coordination of Hemodialysis Services, effective 11/30/2014 and revised 7/2/2019, indicated Residents requiring an outside End Stage Renal Disease (ESRD) facility will have services coordinated by the facility. There will be communication between the faciltiy and the ESRD facility regarding the resident. The procedure identified: - 1. The Dialysis Communication form will be initiated by the facility for any resident going to an ESRD center for hemodialysis. - 2. Nursing will collect and complete the information regarding the resident to send to the ESRD Center. - 3. The ESRD facility is to review the Dialysis Communication form and either: -- a. Complete the communication form and return with the resident OR -- b. Provide treatment information to the facility. - 4. Upon the resident's return to the facilty, nursing will review the Dialysis Communication form and information completed by the dialysis center OR the information sent by the dialysis center; communicate with the resident's physician and other ancillary departments as needed, implement interventions as appropriate. - 5. Nursing will complete the post dialysis information on the Dialysis Communication form and file the completed form in the Resident's Clinical record. The review of Resident#97's Order Summary Report, active as 3/30/22 at 3:59 p.m., did not include a physician order to assess the resident's Dialysis access site or to remove any dressing from the fistula. A review of Resident #97's Dialysis binder included two recent Dialysis Communication forms: - 3/8/22: the section that was to be completed by the facility prior to Dialysis did not indicate any vital signs, information regarding shunt site, or changes in resident condition since the last visit had been communicated to the center. The section completed upon the residents return from Dialysis which would have included vital signs, access site condition, and if the resident exhibited pain was not completed. The Dialysis Center had documented in the section of the Communication form reserved for them. - 3/12/22: The facility did not document vital signs, shunt condition, or any changes in condition prior to Dialysis or vital signs , pain, and access site condition upon the residents return from Dialysis. The Dialysis Center did complete the section reserved for their evaluation. The census for Resident #97 identified the resident was out of the facility from 3/3 to 3/4/22 and from 3/19 to 3/25/22. According to the census the resident was scheduled for Dialysis and in the facility on Tuesday 3/1, 3/8, 3/15, and 3/29/22, Thursday 3/3, 3/10, 3/17, and 3/31/22, and Saturday 3/5, 3/12, and 3/26/22. A review of the March 2022 Medication Administration Record (MAR) identified that on 3/3 and 3/5/22, the resident refused Dialysis and from 3/19 - 3/25/22 the resident was hospitalized . The MAR indicated that on 3/1, 3/8, 3/10, 3/12, 3/15, 3/17, 3/26, and 3/29/22, the resident received Dialysis, resulting in eight opportunities to complete Dialysis Communication forms. A review of progress notes identified that on 3/8/22 at 6:05 a.m., staff had completed a skilled note for Resident #97 which did not include an assessment of the residents' Dialysis access site. Further progress notes, dated 3/8/22, did not include a post Dialysis assessment of the resident. The progress notes on 3/12/22 did not include assessments for pre- or post- Dialysis condition. A review of progress notes indicated the following notations regarding Resident #97's Dialysis condition: - 3/1/22 at 2:17 p.m., the resident refused Dialysis (not identified on MAR). - 3/2/22 at 5:21 a.m., vascular access was present and Dialysis status was hemodialysis with Left upper extremity shunt and present bruit/thrill. - 3/2/22 at 12:52 p.m., educated on need for Dialysis treatments. The note did not include an assessment of the residents' Dialysis site. - 3/2/22 at 9:21 p.m., Vascular access is not present and Dialysis status is not applicable. - 3/8/22 at 6:05 a.m., Vascular access is not present and Dialysis status is not applicable. - 3/8/22 Dietary notes regarding significant weight loss. - 3/13/22 at 7:02 p.m., Vascular access is not present and Dialysis status is hemodialysis bruit present thrill present. - 3/16/22 at 2:59 a.m., Vascular access is not present and Dialysis status is hemodialysis bruit present thrill present. - 3/17/22 at 4:11 a.m., Vascular access is not present and Dialysis status is not applicable. - 3/25/22 at 2:22 p.m., Vascular access is not present and Dialysis status is hemodialysis bruit present thrill present. - 3/29/22 at 7:11 p.m., Vascular access is not present and Dialysis status is not applicable. - 3/30/22 at 6:50 a.m., Vascular access is not present and Dialysis status is not applicable. - 3/31/22 at 1:58 p.m., identified vascular access was present and Dialysis status is not applicable. - 3/31/22 at 3:49 p.m., Fistula in his leg arm intact Felling(sic) bruit. (writer: Staff DD) On 3/31/22 at 2:42 p.m., Staff Member DD, Registered Nurse (RN), stated he had not documented on Resident #97's access site as he did not have time, you know with all the interruptions. The electronic and paper chart on the unit did not include any other Dialysis Communication forms or any other communication that was received from the Dialysis Center. On 3/31/22 at 10:58 a.m., an interview was conducted with the Registered Dietician (RD) and Certified Dietary Manager (CDM). The RD stated Dialysis Centers were not allowing residents to bring food in from the facilities. She said she had personally called all the centers to confirm food was not to be brought in. On 3/31/22 at 1:54 p.m., an interview was conducted with the Administrator of the Dialysis center where Resident #97 received Dialysis. She stated the resident was allowed to bring a snack due to the diagnosis of diabetes. The Administrator reported the center's policy was for everyone to wear a (face) mask while in the center but due to the diagnoses of diabetes they did allow snacks. She stated the facility usually did send the communication binder if they did not forget it. The Regional Clinical Leader (RCL) stated, on 3/31/22 at 2:26 p.m., the Dialysis center was not real good about filling out the Communication forms and thought the facility had stopped sending the forms. The RCL reported the expectation was if the Dialysis center did not send a printout of what happened during Dialysis the facility should call them and ask for it. On 3/31/22 at 4:30 p.m., the RCL provided Resident #97's Dialysis binder and confirmed the clinical record on the unit did not contain any information received from the Dialysis center.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility did not ensure medications were stored appropriately in four of seven medication carts and in one of three medication rooms. 2. On [DATE] at 10:18 a.m., the 100-low medication cart was observed unlocked and unattended while Staff BB, Licensed Practical Nurse (LPN) was in a resident room. The staff member returned to the medication cart and confirmed the cart was unlocked and unattended. A review of the medication cart located on the 300-hall was conducted with Staff AA, Registered Nurse (RN). An unopened and undated bottle of Latanoprost 0.005% eye drops were observed in the cart. One of the labels on the bottle instructed that the medication Refrigerate Until Opened. The other label instructed staff to discard 42 days after opening. On [DATE] at 12:55 p.m., an observation was conducted with Staff M, LPN, of the 200-high medication cart. The bottom drawer was disorganized and cluttered, the drawer contained an aerosol can of Sanitizing Spray stored in same compartment with tubing, boxes of Albuterol Sulfate Inhalation solutions, box of Triamcinolone Acetonide 0.025% cream, and box of Diclofenac Sodium 1% topical gel. Another drawer of the cart had layers of substances on the bottom of it. The drawer contained over-the-counter medications, an envelope of a medication underneath bottles of liquid medication, and the bottle of Iron Supplement liquid had residual substances on the outside of the bottle. The same compartment contained a box of Pain Relief Lidocaine 4% patches and a box of 1% Hydrocortisone Anti-Itch cream stored with liquid medications. Staff M would leave the medication cart at times and enter the resident room across from the cart. The cart contained an almost empty, undated bottle of Cherry-flavored Sugar Free Pro-Stat. The label of the Pro-Stat indicated that it should be discarded 3 months after opening. Staff M confirmed one Kwikpen of Basaglar insulin was opened and it did not have an opened date, and the label instructed users to Discard 28 days after opening. A bottle of Ofloxacin 0.3% Ophthalmic Solution eye drops was opened, undated, and confirmed by Staff M, The label for Ofloxacin had an area to note the date opened and the date expired. On [DATE] at 1:13 p.m., an observation was conducted with Staff FF, agency LPN, of the Rehab-low medication cart. A review of the cart revealed a container of [brand name]sanitizing wipes stored amongst oral medications, an Insulin Aspart FlexPen was observed in a clear plastic bag without a pharmacy label and the pen was not labeled with an open date, an opened Insulin Aspart FlexPen was undated and the label indicated that the pen was to Discard 28 days after opening. An opened Tresiba Flextouch insulin pen did not have an open date or expiration date and the label instructed users to Discard 56 days after opening. Staff FF confirmed the findings. On [DATE] at 1:18 p.m., an observation of the Rehab unit Medication Preparation Room was conducted with Staff F, LPN. In a top cabinet that had an attached locking mechanism, which was not locked, was a sealed Narcotic Emergency Kit (E-kit) received from the pharmacy on [DATE]. Staff F confirmed that the E-kit had been stored in an unlocked cabinet. On [DATE] at 4:37 p.m., during a telephone interview, the Pharmacist said, Eye drops should be dated, Latanoprost has a shortened life, good practice is to date all eye drops, especially Latanoprost. Medication carts should be organized, clean, and should be locked when unattended . Sanitizing should not be stored in the same compartment with medications. The Pharmacy Services and Procedures - Storage and Expiration Dating Medications, Biologicals, effective [DATE], revised [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE], indicated the following: - 2: Facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding. - 3.1.1: Store all drugs and biologicals in locked compartments, including the storage of Schedule II-V medications in separately locked, permanently affixed compartments, permitting only authorized personnel to have access. - 3.2: Facility should ensure that external use medications and biologicals are stored separately from internal use medications and biologicals. - 3.3: Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart of locked medication room that is inaccessible by residents and visitors. - 3.5: Topical (external) use medications or other medications should be stored separately from oral medications when infection control issues may be a consideration. - 5: Once any medication or biological package is opened, Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication ha a shortened expiration date once opened or opened. -9: Facility should ensure that resident medication and biological storage areas are locked and do not contain non-medication/biological items. - 13.2: After receiving controlled substances and adding to inventory, Facility should ensure that Schedule II-V controlled substances are immediately placed into a secured storage area (i.e., a safe, self-locked cabinet, or locked room, in all cases in accordance with Applicable Law).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility did not ensure garbage and refuse receptacles were covered, the garbage area was maintained in a sanitary manner and the garbage was disposed of in a timely manner. Findings included: During a facility tour on [DATE] at 9:59 a.m., an observation was made of the facility's trash area with a large size dumpster, noted overflowing with trash and refuse. The garbage was not in a covered receptacle. Piles of bags of garbage were observed on the ground next to the dumpster. (Photographic evidence was obtained) An interview was conducted on [DATE] at 9:59 a.m. with the Director of Maintenance (DOM). He stated their contract with the compactor had expired and that was why they rented a dumpster. He stated he had been calling the vendor and the vendor was not responding. Their agreement was that they would pick up every 7 days. The last time trash was picked up was on [DATE]. He expressed frustration with the process and said, Of course this is not acceptable, it is a health hazard. I will keep calling. He stated he was expected to make sure that garbage was picked up in a timely manner. The trash area should be kept clean to keep animals and rodents away. Review of a document titled, open top container timeline, dated [DATE], authored by the DOM showed the container (dumpster) was received on [DATE] with an expectation of a weekly pick up, dump and return. The document showed the trash was last emptied on [DATE]. On [DATE], the DOM documented the container (dumpster) had not been emptied because the hauler was unavailable. An interview was conducted on [DATE] at 11:57 a.m. with the Nursing Home Administrator (NHA). He stated it had been challenging. The vendor had been canceling on them. The NHA said, I know the trash is overflowing, it's a public health concern. I would not disagree with you. He stated he had observed the trash area. He said, I have seen it. It is not okay. An interview was conducted on [DATE] at 10:37 a.m. with the NHA, the DOM, and the Regional Operations [NAME] President (VP.) They were notified of concerns noted during survey. The NHA stated the issue with the trash was addressed. The contract had been renewed with a different company. Review of a facility policy titled, Environment, revised 09/17, showed (6) All trash will be in covered, leak - proof containers that prevent cross contamination. (7) All trash will be properly disposed of on external receptacles (dumpsters) and the surrounding area will be free of debris.

Based on observations, interviews and record review, the facility did not ensure the kitchen was maintained in a clean and sanitary manner, related to sanitation, food storage, and equipment cleaning and maintenance. Findings included: An initial kitchen tour was conducted on 03/29/22 from 9:30 a.m. to 9:57 a.m. with the Certified Dietary Manager (CDM). The CDM stated there were two staff working today, The Dietary Manager in Training (MIT) and Staff R, Dietary Aide. During the tour observations were made of: Ceiling vents noted with dirt, debris in the cooking areas and the dish room. Walls were observed with dust, dirt, and stains. The kitchen floors were observed with food residue, dirt, dust, and debris. Tiles were noted missing by the dish machine with water collected in the hole. The kitchen equipment (stove) was noted with food spills and oil splatters. A vent was noted on the floor with caked-in food remains, dust, dirt, and debris. Kitchen equipment - dish machine, microwave, blender, and dough mixer were noted with brown matter on the surfaces. The CDM stated the kitchen equipment should be cleaned and covered when not in use The ice machine was noted with dust and the vent and filter with debris. Refrigerator surfaces were noted with food marks and food debris. The clean dishes rack was observed with debris and dust. The clean cooking pans were noted resting on the dirty surfaces. The CDM said, That is not sanitary. Cooking spices were observed on a shelf next to the stove, some undated, opened, and exposed to the elements. The CDM stated they should be wiped off after each use, caps should be closed to keep dust off. The CDM stated their policy was to date spices once opened. Three plastic bins were observed stored next to the stove. One of the bins was noted labeled flour the date was illegible. The CDM stated the date on the bin looked like July 2020. The CDM said, It should be changed. The bin in the middle was labeled thickener with a date, 9/22/20. The CDM stated they use up the thickener often. The CDM stated they just keep refilling the bin. The CDM said, The bin should be cleaned out before refilling, new date, and label applied. A third bin did not have any date or label. CDM stated the product was sugar. The CDM stated it should be dated and labeled. An observation was made of the deep fryer with dark brown liquid. The MIT stated he was not sure how often the cooking oil should be changed. The MIT said, No, that does not look good. The MIT stated he did not know how old the oil was. The MIT said, We do not keep track of that. The CDM stated their expectation was to change the oil after each use because they fry different types of food. During a tour of the walk- in cooler, bio growth was observed on the door frame. The surfaces were observed with dirt and dust. The floor surface was observed with food remains, dirt, and debris. The CDM said, It [walk-in cooler] should be maintained in a clean manner. A tour of the freezer was conducted. The freezer was observed with excessive condensation, surfaces covered with ice and icicles. The floor had dirt and ice on it. The CDM stated they were aware there was a problem with condensation. In the dry goods storage area, a blue grocery bag was noted with a food item, unlabeled and undated. The MIT stated the food item was rice. The MIT stated the expectation was to make sure foods were stored in a sealed container and properly dated and labeled. The floors in the dry goods storage area were noted with bio growth around the corners. The CDM stated she did not notice it before. The CDM said, It should be cleaned. An observation was made of a broken sink cabinet in the food service station and water leaking under the sink. The CDM stated this was on the maintenance work order. (Photographic evidence was obtained) An interview was conducted on 03/29/22 at 9:48 a.m. with Staff R, Dietary Aide. Staff R stated they were all expected to clean the kitchen as they go. Staff R stated it did not look good today because they were short staffed. Staff R said, The expectation was for the kitchen to be maintained in a clean manner, all the time. On 03/29/22 at 9: 58 a.m., an interview was conducted with the CDM. The CDM stated she was aware of the identified concerns. The CDM said, I have the same concerns. I agree, the kitchen should not look like that. We will get it cleaned. When asked how they schedule cleaning, the CDM stated that she did not have a cleaning checklist. The CDM stated there was an old checklist that the previous CDM was using, but it was not appropriate. The CDM stated the maintenance department had been notified that the freezer had issues. The CDM stated she thought parts had been ordered. The CDM stated the nursing home administrator (NHA) was aware of the maintenance concerns. The CDM stated the maintenance department was short staffed and they had been told to prioritize what they should address first. On 03/31/22 at 11:35 a.m., an interview was conducted with Staff S, Dietary aide / Cook. Staff S stated everyone was responsible for cleaning and sometimes they used checklists. Staff S said, The problem with the build-up ice in the freezer has been there a long time, probably 2 years. The problem is that the fan is not working, creating a problem with condensation. Staff S stated maintenance had been notified. Staff S stated the facility had switched management many times and there was inconsistency with staffing. Staff S stated that they had been trained to ensure all food items were dated and labeled. Staff S stated maintenance was responsible for cleaning the vents. An interview was conducted on 03/31/22 at 12:05 p.m. with the regional district manager. He stated a vendor had been contacted for the dish machine. The regional manager stated the dish machine needed to be rewrapped to address the rust. The dish machine fan was not working, and this had increased condensation. The regional manager stated the vents would be cleaned today and the tiles in the dish room would be repaired the following day. An interview was conducted on 03/31/22 at 2:50 p.m. with the registered dietician (RD) and CDM. The RD said, The expectation is for all kitchen surfaces to be maintained in a sanitary manner. The RD stated they should have everything on a cleaning schedule to make sure they were reaching all surfaces. The CDM said, The plan is to have a cleaning schedule, we implemented it yesterday. We will conduct daily checks. The RD stated all items in the fridge should be labeled and dated and discarded when out of date. The RD stated they had been addressing the freezer on an on-going basis. The ice build -up had been discussed. The RD said, We have been trying to fix it up. I have discussed it with the [NHA], at least monthly. The RD stated the issue had been documented in her monthly audits. The ice- built up on foods could cause freezer burns and bacteria growth. The RD said, It is not acceptable food storage practice. The CDM stated a vendor had been contacted to fix the bio growth issues and a vendor was coming to install a new gasket. The CDM stated the issues in the kitchen had been discussed with the NHA. Review of a monthly audit form conducted by the RD dated 02/08/22, showed the concerns of significant ice build-up in the walk-in freezer and broken tiles on the floor in the dish room were discussed with the NHA, CDM and Director of Nursing. An interview was conducted on 04/01/22 at 10:37 a.m., with the NHA, the Director of Maintenance (DOM) and the Regional Operations [NAME] President (VP.) They were notified of the concerns noted during the survey. The DOM stated the vents should be cleaned monthly. The VP stated the kitchen equipment had been cleaned. The VP said, the dishwasher needs to be wrapped. The electrician will be out tomorrow. It is not venting out which is causing condensation issues. The VP stated the freezer had been pulled out and the ice was cleaned out, but it was a temporary fix until the root cause could be addressed. The NHA stated he would make sure the cleaning and maintenance orders were completed per their policy and standards. Review of a facility policy titled, Food storage: dry goods, revised 09/17, showed all dry goods will be appropriately stored in accordance with the food and drug administration (FDA) food code. (5) All packaged items will be kept clean, dry, and properly sealed. (6) Storage areas will be neat, arranged for easy identification, and date marked as appropriate Review of a facility policy titled, Food storage: cold foods, revised 04/18, showed all time/temperature control for safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with the guidelines of the FDA. Review of a facility policy titled, Equipment, revised 09/17, showed all food service equipment will be clean, sanitary and in proper working order. Procedures indicated that (1) all equipment will be routinely cleaned and maintained in accordance with the manufacturer's direction. (3) All food contact equipment will be cleaned and sanitized after every use. (4) All food contact equipment will be clean and free of debris. Review of a facility policy titled, Environment, revised 09/17, showed all food preparation areas, food service areas, and dining areas will be maintained in a clean and sanitary condition.

Based on observation, interview, and record review the facility failed to ensure that one (Resident #62) of 40 residents sampled was assessed to self-administer a respiratory (nebulizer) treatment. Findings included: On 01/28/21 at 08:01 a.m., Resident #62 was observed to be sitting in bed watching television, coloring a book, and wearing a nebulizer facemask. The resident's nebulizer machine was running and no staff were present in or around Resident #62's room. An interview was conducted with Staff G, Licensed Practical Nurse (LPN), immediately following the observation. Staff G indicated she performed everything she was told to do by someone who came to her earlier and did not recall the staff member's name. Staff G stated, No one told me I had to stay in the room. I never knew that. A record review of Physician Order dated 12/04/2020 for Resident #62 revealed the following order: Ipratropium Albuterol Solution 0.5-2.5 (3) MG/ML 3 ml inhale orally every 4 hours as needed for (Diagnosis) Acute Respiratory Distress Syndrome (ARDS) Continued review of the record revealed there was no assessment by the interdisciplinary team or care plan for the self administration of medications. On 01/29/21 at 10:38 a.m., an interview was conducted with the Director of Nursing (DON). The DON was informed of the observation and interview with Staff G (LPN). The DON reported that according to facility policy, that Staff G (LPN) was supposed to stay in the room with Resident #62 until the administration of the respiratory treatment was completed. The DON confirmed and further indicated that the resident did not have any assessment to self-administer any type of medication in her room. A review of facility policy titled Nebulizer (Small Volume Nebulizer) Document Name RT-110, with revision date of 03/20/2018, under Procedure, reads Administer treatment until medication is depleted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, and policy review the facility failed to provide respiratory care in accordance with standards of practice and the comprehensive plan of care for four (#30, #51, #62, #66) sampled residents out of 45 facility residents receiving respiratory treatment as evidenced by: 1) the improper storage of respiratory equipment for Resident #51, #62, and #66, and 2) Resident #30 not receiving administration and oversight of a C-PAP (Continuous positive airway pressure ) device. Findings included: 1. On 01/26/21 at 12:19 p.m., observation of Resident #62's room revealed a nebulizer facemask was located in the nightstand's first drawer. Resident #62 was interviewed about the placement of the equipment. Resident #62 indicated she placed the facemask in the top drawer and indicated that the staff don't have time to stay while the treatment is administered. She stated, They [referring to the nursing staff] have no time to do that, they are busy. Clinical record review of the active Physician Order dated 12/04/2020 for Resident #62 revealed she received Ipratropium Albuterol Solution 0.5-2.5 (3) MG/ML 3 ml inhale orally every 4 hours as needed for (Diagnosis) Acute Respiratory Distress Syndrome (ARDS). 2. On 01/26/21 at 10:10 a.m., an observation was conducted of Resident #66's respiratory equipment. The nebulizer facemask was not stored in an appropriate plastic storage bag, and oxygen tubing was hanging over the resident's bed with the nasal cannula portion resting on the floor. A subsequent observation of Resident #66's room was conducted on 01/27/21 at 08:45 a.m. The nebulizer facemask was observed to be wedged in between the nebulizer machine and a paper bag next to a Christmas tree on top of the resident's nightstand. Resident #66 was interviewed and asked about the storage of her respiratory equipment. Resident #66 stated, I just received a respiratory treatment; they were not in the room, and I could not reach the plastic storage bag to put it away in there. Clinical record review of the active Physician Order dated 10/28/2019 for Resident #66 revealed she received Albuterol Sulfate Nebulization Solution (2.5 MG/3ML 0.083% 3ml inhale orally via nebulizer every 6 hours related to Interstitial Pulmonary Disease. 3. On 01/27/21 at 11:02 a.m., Resident #51 was observed to be lying in bed with the nebulizer machine and facemask next to her in bed resting on the bed linens. The resident was interviewed at the time of the observation. She stated that she had just received a nebulizer treatment from the nurse. A repeat observation of Resident 51's room was conducted on 01/27/21 at 12:48 p.m., the facemask and nebulizer machine were in the same spot on the resident's bed with a cover over it. An additional observation was conducted on 1/28/21 at 10:58 a.m. of Resident #51's room. Resident 51's nebulizer facemask and nebulizer machine were in the resident's bed again. Clinical record review of the active Physician Order dated 09/10/2020 for Resident #51 revealed she received Ipratropium Albuterol Solution 0.5-2.5 (3) MG/ML 3 ml inhale orally every 4 hours as needed for (Diagnosis) Shortness of Breath (SOB related to Chronic Obstructive Pulmonary Disease, every 4 hours. On 1/28/21 at 09:20 a.m., an interview was conducted with Staff I, Unit Manager (UM) related to the storage of Resident #51, #62 and #66's respiratory equipment. She was asked about the facility policy and stated, I can't recall, I would have to go find out from my DON [Director of Nursing]. On 01/29/21 at 10:38 a.m., an interview was conducted with the DON related to the observations of Resident #51, #62, and #66's respiratory equipment. The DON confirmed that her nursing staff should be staying in resident rooms until the respiratory treatment was completed, and respiratory nebulizer facemasks and oxygen tubing should be stored in a plastic storage bag, according to their facility policy. A review of facility policy titled Nebulizer (small volume nebulizer) with a revision date of 03/20/2018 revealed: .Disassemble device and rinse the mouthpiece and nebulizer cup with water and air dry. Place entire unit in a bag to be maintained in the resident's room . Photographic evidence was obtained. 4. On 1/27/2021 a medical record review was conducted for Resident#30. He was admitted to the facility in 2019 with multiple diagnosis to include chronic obstructive pulmonary disease, acute chronic respiratory failure, sleep apnea, and insomnia. A review of Resident #30's annual Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS (brief interview for mental status) score of 15 indicating cognition intact. A review of Resident#30 plan of care revealed the following information: The resident has altered respiratory status/difficulty breathing related to sleep apnea date initiated 11/13/2019- Interventions: CPAP (Continuous positive airway pressure) as ordered/needed, encourage sustained deep breaths, position resident with proper body alignment for optimal breathing pattern. The goal for the care plan was for the resident to maintain a normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern through next review date with a target date of 2/18/21. On 01/27/21 at 10:33 AM, Resident #30 was observed with his C-PAP device on and running. He was asked if the nurse had placed the C-PAP on him, monitored his breathing or established a respiratory rate. The resident replied, Are you kidding me. I do this all myself. A second observation was conducted on 01/28/21 at 10:23 AM. Resident#30 was observed with his C-PAP on and running. He was asked again if the nurse had applied the C-PAP. Again he stated, No they never set this machine up. I have to do it myself. An interview was held with Staff A, Unit Manager/Licensed Practical Nurse (LPN), on 1/28/2021 at 10:30 AM. She was asked to review the care plan for this resident along with the surveyor. She confirmed that he was not care planned to set-up the equipment himself and he did not have the ability to establish his own respiratory rate. The Nursing Home Administrator (NHA) walked into the conference room as the interview was in progress and was informed of the current findings. She was not aware that the resident was applying his own C-PAP machine. The NHA provided the facility policy and procedure for the general administration of a CPAP or BIPAP dated 4/1/2019. Under the heading procedure the following was revealed: Review Physicians orders. Gather equipment and proceed to the resident's room. Perform hand hygiene prior to setting up equipment. Assess the resident. Establish baseline respiratory rate, heart rate, and breath sounds. Place the mask over the residents nose and adjust size. Adjust straps until significant leaks are eliminated. Set settings according to physicians orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility did not ensure that one (#314) of 40 sampled residents had medically necessary appointments for the Cardiologist and the Ophthalmologist scheduled in a timely manner and followed through. Findings included: An interview with Resident #314 on 1/27/2021 at 9:30 a.m. revealed that he has been requesting the facility Social Worker to set up an appointment for him to see a Cardiologist as recommended by the dentist to have two of his teeth removed. Resident #314 stated that the facility has not made the appointment for him to see a Cardiologist. The resident stated that his eyesight has been getting progressively worse to the point where he was now legally blind, and he had been requesting a follow up appointment to see the eye doctor for quite a while, but no one was assisting him with the appointment. Medical record review for Resident #314 revealed an original admission date in 2019 and a re-admission date in November of 2020 with multiple diagnosis including chronic obstructive pulmonary disease, heart failure, unspecified protein calorie malnutrition, Type 2 diabetes, major depressive disorder, anemia, and generalized anxiety. A review of Resident's Admissions Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 14 indicating he was cognitively intact. A review of the Social Worker progress note dated 1/30/2020 revealed that an appointment was scheduled for the eye doctor for 2/10/2020, nearly one year ago. A review of the nurses notes dated 10/13/2020 revealed that, a call was received from the eye doctor's office regarding resident appointment for the a.m. The scheduler stated that they attempted to get in touch with resident, but the resident did not respond. A review of nurses notes dated 11/10/2020 revealed that the eye doctor's office called to confirm the resident's appointment, but because the resident was recently hospitalized , he would need a negative COVID-19 test to enter their facility for an appointment. A new appointment was then scheduled for 12/15/2020. During an interview on 1/27/2021 at 1:16 p.m. with the Social Service Director (SSD), she revealed that a dental consult was initiated for Resident #314, but she was not aware of any appointments to see the Cardiologist. She stated that she had made an appointment for him to see the ophthalmologist, but she can't remember why it was not followed up on. An interview with the Director of Nursing (DON) on 1/27/21 at 1:19 p.m., confirmed that appointments were set up for Resident #314 to see the eye doctor and a Cardiologist, but due to COVID-19, and Resident #314's frequent hospitalizations, the appointments were not kept. The DON revealed that if a resident was alert and oriented, the resident may be called by an institution to confirm or verify scheduled appointments. The DON stated that she expected that appointments should be scheduled and set up in a timely manner. A review of an email dated 12/22/2020 at 10:07 a.m. from the dental services company to the Social Service Assistant (SSA) revealed that Resident #314 was scheduled to see the dentist on Tuesday, December 29th, 2020 and was in need of extractions. However, for the dentist to proceed with the extraction .the following information was needed: 1. Medical clearance and 2. Information regarding number of days patient needs to be taken off medication etc . The SSA responded on 12/22/220 at 5:10 p.m. stating that the physician refused to sign medical clearance pending a cardiologist appointment. The form stated that the facility was trying to schedule a cardiologist appointment and continues to try. An interview with the DON on 1/27/2021 at 1:20 p.m. revealed that she was unable to retrieve the resident's primary care physician notes with the recommendation for Resident #314 to see a Cardiologist. She confirmed that the physician refused to sign the consent for extraction of Resident's #314 teeth unless he sees a Cardiologist. On 1/29/2021 at 11:30 a.m., a follow-up interview with the DON related to Resident #314's appointment with the eye doctor scheduled for 12/15/2020 was never kept. Review of the SSD Job description indicated under the heading Purpose of Your Job states: To ensure that the medically related emotional and social needs of the residents are met/maintained on an individual basis. Under the heading Job Functions. It reads, Responsible for providing services to responds to the emotional needs of the residents and their families. Assist with resident admissions and referral process. Further, review under the heading Duties and Responsibilities, States: #5- conduct and document a social services evaluation, including identification of resident's problems/needs. #6-Provide/arrange for social work services as indicated by resident/family needs. #10 - Maintain a current list of community resources to facilitate referrals.

Based on observation, interviews, and policy review, the facility did not appropriately secure medications in six (200 Low, 200 High,100 High, Cart #1, Cart #2, 100 Low) of seven medication carts and failed to ensure controlled substances were stored in a permanently attached container in one (300 hall medication storage room) of two refrigerators sampled. Findings included: Review of facility provided policy titled, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, with a revision date of 07/23/19 revealed under General Storage: 10. Facility should ensure that the medications and biologicals for each resident are stored in the containers in which they were originally received. On 01/29/21 at 10:21 a.m., an observation of the 200 Low Hall medication cart included a ½ and ¼ loose pieces of a tablet in second drawer from the top, and a white ¼ piece of white tablet in the drawer. Staff B Registered Nurse (RN), confirmed the presence of the unsecured tablets and pieces in both drawers. On 01/29/21 at 10:31 a.m., an observation of the 200 Hall High medication cart included in the second drawer ¼ pink pill, and in the fourth drawer 3 white ¼ pieces of loose medications. Staff C, (RN) confirmed the presence of the unsecured tablets. On 01/29/21 at 11:04 a.m., an observation was conducted of the medication on the 100 High Hall that included in the third drawer a ¼ piece of a white tablet, and located on the side third drawer from the top of the medication cart included one (1) white oval loose tablet. Staff D Licensed Practical Nurse (LP), confirmed the presence of the unsecured medications. On 01/29/21 at 11:36 a.m., an observation of medication cart #1 on the 300 Hall included a pink ½ tablet in the second drawer from the top of the medication cart. Staff E (LP) confirmed the presence of the unsecured tablet. On 01/29/21 at 11:45 a.m., an observation of medication cart #2 located on the 300 Hall, included in the front of the second drawer from the top of the medication cart one (1) white round tablet, and in the back of the drawer four (4) white, one (1) green round, one (1) round yellow, two (2) white oval, and two (2) green ½ pieces of loose tablets. Staff HO (LP), confirmed the presence of the 9 total unsecured tablets with two ½ pieces, in the drawer. On 01/29/21 at 11:58 a.m. an observation of the medication cart on 100 Low Hall included a loose white square tablet in the second drawer from the top. Staff F (LPN) confirmed the presence of the unsecured tablet. On 01/29/21 at 11:42 a.m., an observation of the 300 hall medication storage rooms revealed the refrigerator was locked. Staff E (LPN) unlocked the refrigerator to allow for inspection and observed on the second shelf was a brown plastic bag labeled with a resident's name on it. The bag contained Lorazepam (Ativan) 2MG/ML with two (2) unopened vials in it. The scheduled IV medication was not in a separately locked contained, attached to the refrigerator. Staff E, (LPN) confirmed the presence of the medication not being in a separate locked box, and stated I know other units have a separate drawer. According to The United States Drug Enforcement Administration (DEA) drug scheduling alphabetical listing, https://www.deadiversion.usdoj.gov/schedules/orangebook/c_cs_alpha.pdf, Page 11 of 17, Lorazepam (Ativan) DEA number 2885, is a Benzodiazepine, a Schedule IV medication and a considered a controlled substance. A review of the facility policy titled, Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, with a revision date of 10/28/19, revealed: 3. General Storage Procedures 3.1.1 Store all drugs and biologicals in locked compartments, including the storage of Schedule II-V medications in separately locked, permanently affixed compartments, permitting only authorized personnel to have access. On 01/29/21 at 12:11 p.m., the Director of Nursing (DON) stated, My nurses should be checking their medication carts routinely and destroying all medications that are loose. I did not know that there was not a double lock draw in that refrigerator, that was not affixed. Photographic evidence was obtained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and policy review the facility failed to ensure that food items were labeled and dated in three (100, 200, and 300) of three nourishment refrigerators on the units. Findings included: On 1/26/21 at 10:08 a.m., a tour of the kitchen and nourishment areas was conducted with the Certified Dietary Manager (CDM). The nourishment refrigerator on the 200 unit was observed with a brown substance in the bottom of the refrigerator. There was a jar of open cheese that was not dated. There were also containers of unknown food in bags unlabeled and undated. The nourishment refrigerator on the 300 unit was observed with unknown food in bags unlabeled and undated. The nourishment refrigerator on the 100 unit was observed with one bag of food with room [ROOM NUMBER]B written on the bag with a black marker, but the food items were undated. The Certified Dietary Manager (CDM) reported that the unlabeled/undated food in bags probably belonged to staff and confirmed that the items were not labeled and/or dated as they should be. The policy Food Storage: Cold Foods revised on 04/2018 revealed the following: 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination.