**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review an interviews, the facility failed to provide adequate supervision for one (Resident #1) out of three residents sampled for elopement; as evidenced by on 04/05/2025 Resident #1 a vulnerable resident left the facility undetected through the facility's first floor exit/entrance door; Resident #1 was found on the sidewalk several blocks from the facility by the local law enforcement and returned to the facility within twenty (20) minutes after last seen in the facility by staff. There were 139 residents residing in the facility at the time of the survey. The findings included: The facility's location is in a residential neighborhood with busy cross streets and close to a shopping plaza located 0.1 mile from the facility. The temperature on 04/05/2025 was 88 degrees Fahrenheit. according to https://www.accuweather.com. Review of the facility policy titled Elopements revision date 12/2002 states: Staff shall investigate and report on all cases of missing residents. Policy Interpretation and Implementation 1. Staff shall promptly report any resident who tries to leave the premises or is suspected of being missing to the Charge Nurse or Director of Nursing. a. If an employee observes a resident leaving the premises, he/she should: b. Attempt to prevent the departure in a courteous manner. c. Get help from other staff members in the immediate vicinity, if necessary, and instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident has left the premises. Review of the facility policy titled Accidents and Incidents - Investigating and Reporting revision date 07/2017 states: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Record review of the Abuse/Neglect Log from January 2025 to June 2025 revealed the incident occurred on 04/05/25 at 11:39 AM. Record review of the Incident note dated 04/05/25 timestamped 12:20 PM documented: [Resident #1] is alert and oriented x (times) three (3), able to walk, has been admitted since 03/21/2025, today was observed by Police officers near a couple blocks away from facility. The resident was able to provide information about being admitted for therapy and gave them his daughter's phone number. Police officer called facility and let the nurse know that they were going to bring the patient back, as patient knew where he resided. Resident stated that he walked to the therapy department and spoke to the therapist to get some information about therapy scheduled for today. Therapist denied patient having any therapy sessions scheduled for today and resident decided to leave the facility. Assessment was performed, patient able to answer every question asked, very pleasant, no signs of psychological/emotional distress, no injury or skin impairment, vital signs within normal limits. Denies any pain or discomfort. Resident's physician and patient's daughter were made aware. Record review of the nurses' progress note on 04/05/25 timestamped 13:51 (1:51 PM) Documented: Patient has been closely monitored, no signs of any changes on patient state of mind and functioning. Education was provided regarding sign out procedures, also new interventions discussed with patient and daughter. Resident able to make his own decisions, Patient states that he is forgetful at times, and he forget to let the nurse know that he wanted to go out, Resident requested a form that he can use to not occur this episode again. [wander alert device] discussed, patient asked and agreed to use it as a sign to let the nurse know when he is walking around exits doors. Daughter and son-in-law also agreed. [wander alert device] placed. Psychiatric evaluation also was done by Telehealth, Brief Interview for Mental status Score (BIMS) evaluation done. Resident was moved to a room near the nurses' station. Will continue with plan of care. Review of the medical records for Resident #1 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Hypertensive Heart Disease without Heart Failure. Resident #1 was discharged from the facility on 04/18/25 to an Assistant Living Facility. Review of Resident #1's Physician's Orders Sheet for April 2025 orders included but not limited to: 04/05/25 to 04/18/25- [wander alert device] in place-every shift Monitor for placement and functioning. Per Resident and Resident Representative request, resident will transfer to an Assistant Living Facility. 04/18/25- Psychiatrist Evaluation. Record review of Resident #1 's admission Minimum Data Set (MDS) dated [DATE] revealed the resident is cognitively intact. no exhibited no behaviors, for Functional Abilities the resident required partial assistance to walk 10 feet; the resident was receiving antipsychotic, antidepressant, and Antiplatelet medications and no physical restraints or alarms used. Record review of Resident #1's Care Plans Reference Date 04/05/25 revealed: Resident has determined a risk for elopement due to: had an episode of Elopement on 04/05/2025, wanders the unit and wanders near exit doors, ambulates with no devices, had expressed desire to leave. Resident will remain safe and will refrain from leaving facility unsupervised through the next review date. Date Initiated: 04/05/2025. Interventions include-Educate resident / responsible party regarding sign out procedures as needed. Encourage resident to participate in activities of choice, provide one-to-one supervision as needed. Include resident in Elopement Book. Nursing assessment to identify any changes in condition, physically/ mentally/Psychologically. Perform elopement assessments. Perform frequent observations of resident whereabouts every shift. Provide redirection. when observed going towards exit doors. A Psychiatrist evaluation to determine BIMS score, and Psychosocial/Mental distress. Room changed near to nurses' station. Update physician and responsible party if resident elopes. [wander alert device] in place as per resident request. Check placement and functioning every shift. Interview on 06/16/25 at 11:57 AM Certified Nursing Assistant (CNA), (Staff B) via telephone and Spanish Translator revealed on 04/05/2025 she was assigned to Resident #1 she remember giving the resident breakfast, he was given a shower with assistance, supervised the resident dressing himself and then he left his room to go to activities. The last time I saw the resident before the elopement incident was around 11:15 AM in the common room in front of the nursing station on the 500 unit. I was told the resident was missing around 11:30 AM by the Registered Nurse (RN), nursing supervisor (Staff C) that stated the police department found the resident outside the facility. I was at work when the resident was returned to the facility, the resident appeared normal and was in very good condition. Interview on 06/16/25 at 12:06 PM Registered Nurse (RN), Unit Supervisor (Staff C), via telephone with Spanish translator revealed: On 04/05/25 I was the supervisor in charge of the facility, I received a call from the local police department around mid-morning stating they found one of the facility's residents on the sidewalk down the street and will be bringing the resident back to the facility. They were able to identify the resident from the bracelet he had on. The police department stated [Resident #1] was alert but slightly confused. After the phone call with the police department, I checked with the resident's assigned Licensed Practical Nurse (LPN), (Staff D) and CNA (Staff B), they both stated they saw the resident approximately 20-30 minutes ago. At approximately 11:40 AM, I received the resident at the entrance of the facility from the police officers, the resident appeared calm and was alert and oriented to person and place. [Resident#1] was assessed, there were no physical injuries or mental distress noted. [Resident #1] was returned to his room, the Director of Nursing (DON) and Administrator (NHA) were notified after the call from the police department and before the resident was returned to the facility. Interview on 06/16/25 at 12:16 PM via telephone, Licensed Practical Nurse (Staff D stated: I was the assigned nurse for [Resident #1] on 04/05/25 the day of the elopement incident. Around 11:00 AM was the last time I saw the resident in the facility. Staff D revealed the supervisor notified her 20 minutes later that the police department reported they found the resident and was returning him to the facility. On the resident's return to the facility, I assessed the resident, he was alert and oriented, his vital signs were stable, and the resident stated he was trying to go home. I check on my residents at least every hour to an hour and a half to make sure all my residents are doing well during my shift. On 06/16/25 at 12:25 PM, the Administrator (NHA) revealed the Director of Nursing (DON) is the person who conducted the investigation and is currently on vacation. I was informed of all the details of the investigation. I was notified by the DON around 12 noon on 04/05/25 that one of our residents was observed walking on the sidewalk outside of the facility and was returned by the police department. I was informed that the resident was alert and had a Brief Interview for mental status (BIMS) score of 14, he was calm, no injuries or areas of concern, and appeared to be in no physical or emotional distress. We notified the resident's physician, family, and psychiatrist who was able to do a telehealth assessment of the resident on 04/05/25. A [wander alert system] was put in place on 04/05/25 with the resident and family consent. The resident and family were educated on how the [wander alert device] works. All residents with [wander alert devices] were checked for placement, function and active orders, all doors were checked to make sure the wander guard system was in place and working correctly, a head count was completed, all other residents were accounted for in the building. Elopement drills and education were completed immediately with all staff. New hires have been educated upon hire about elopement, elopement drills and code pink for elopement. There is an elopement binder at each nursing station, in the therapy Department, activity department and the reception desk. The elopement binder consists of a photograph of the residents at risk for elopement and their face sheets. We have implemented a lock down of the front entrance/exit door, which is now the only point of entry and put in place the visitor sign in sheet-every visitor that enters the building has to sign in, staff can use their identification badge to enter the building using the electronic door opening system and visitors have to ring the bell to be seen on the camera, in order to be granted access into the facility by the front desk staff. To leave the facility visitors must notify the reception staff to open the door to exit out of the facility or a staff member can escort the visitor to the front door and open the front door using their ID (Identification) badge to access the electronic door opening system.

2) On 04/15/24 at 7:24 AM, Occupational Therapist observed standing while assisting Resident #380 to eat breakfast. Record review of Medicare 5 Day Minimum Data Set (MDS) 4/5/2024 Section C for cognitive status revealed a Brief Interview Mental Status score of six on a scale of zero to ten, indicated severe cognitive impairment. Section GG for functional status revealed Resident #380 was dependent for all Activities of Daily Living (ADL). Review of Resident # 380's care plan initiated 3/27/24 start date 4/10/24; revealed at risk for an alteration in nutrition and or hydration related to Intracerebral Hemorrhage and unable to feed self. Record review of physician orders revealed 3/26/24 a diet order for regular diet, regular texture, thin consistency, maintain aspiration precautions. On 04/15/24 at 7:46 AM the Occupational therapist stated: I was standing while feeding [Resident #380] breakfast, it is okay for me to be standing while assisting this resident to eat because she has weakness and I want to see how much she can do on her own. On 04/18/24 at 9:15 AM the Director of Nursing stated: staff are to be seated next to residents while assisting with meals to provide dignity. The Occupational therapist helps with assisting residents with meals. There is no reason he should be standing while actively assisting a resident with a meal. All staff are aware of this protocol, and we are doing in-services to reinforce this education for staff. I will do a teachable moment with the Occupational therapist. Review of the facility's policy and procedure titled Quality of Life-Dignity revision dated August 2009 indicates: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality. Residents shall be treated with dignity and respect at all times. Review of the facility's policy with revision dated July 2017 titled, Assistance with Meals. Policy Statement: Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Policy Interpretation and Implementation. Dining Room Residents: 3. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: a. Not standing over residents while assisting them with meals; Residents Requiring Full Assistance: 2. Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: a. Not standing over residents while assisting them with meals. Based on observation, interview, and record review the facility failed to promote residents' dignity and respect during dining for two (Resident #62, Resident #380) out of 33 sampled residents. As evidenced by facility staff observed standing while feeding residents who required assistance with meals. The findings included: 1) On 04/17/24 at 01:18 PM during dining observation of residents, surveyor observed the Speech Therapist (Staff A) standing while feeding Resident #62. Speech therapist (Staff A) was asked why he was standing while feeding the resident, Staff A stated he was not aware that he was not allowed to stand and feed the resident, he immediately got a chair that was in the room, placed it close to the resident's bedside and continued to feed the resident. Interview on 04/18/24 at 09:22 AM. The Director of Nursing (DON) stated all staff including the rehabilitation department have been trained and are aware that they are supposed to be sitting down while feeding the residents. Currently I am providing further education and in-service to the staff regarding feeding residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure pharmacy procedures were followed as per facility policy and medication reconciliation procedures were followed for one out of four medication carts observed/reviewed. There were 139 residents residing in the facility at the time of the survey. The findings included: On 04/17/24 at 10:01 AM during routine observation the surveyor observed the 400 Unit Medication Cart # 1, computer screen opened to resident's medication screen and the medication cart was unlocked in the 400-406 hallway, no staff in attendance at the cart; surveyor went looking for the assigned Registered Nurse (Staff C), Staff C was found in front of room [ROOM NUMBER], and stated she was sorry the cart was left unlocked and unattended, and it was her mistake. On 04/17/24 at 11:50 AM During medication cart observation with Registered Nurse (Staff D) assigned to the 500-unit Medication Cart #3. The narcotic count for Resident #87 was incorrect-The count on the bingo card for Resident #87's Dilaudid (Hydromorphone HCl) Oral Tablet 2 Milligrams (MG) was ten (10), the narcotic sheet for the resident documented amount remaining eleven (11) signed out on 4/17/24 at 9:39AM. On 4/17/24 at 11:58 AM Registered Nurse (Staff D) stated she gave two (2) Hydromorphone 2 MG pills to Resident #87 but recorded only one (1) pill given on the resident's narcotic sheet by mistake. Staff D then proceeded to call the Nursing Supervisor for the unit (Staff E) over to the cart, explained to her documentation discrepancy and stated she will be making the correction immediately on the resident's narcotic sheet with the charge nurse (Staff E) as the witness. Interview on 04/17/24 at 10:52 AM. The Director of Nursing (DON) stated: I am going to provide in-service to the Registered Nurse (Staff C) immediately regarding leaving her cart and computer screen unlocked. Interview on 4/18/24 at 10:00 AM; the Director of Nursing (DON) stated she was told what happened with the narcotics on staff D's Medication Cart and is currently providing in-services to all the nursing staff regarding medication reconciliation procedures. Review of the medical records for Resident #87 revealed the resident was admitted to the facility on [DATE] with orders that included: Dilaudid Oral Tablet 2 MG (Hydromorphone HCl)-Give 2 tablets by mouth every 4 hours as needed for moderate pain (scale 4-6) related to low back pain. Review of the facility's policies and procedures titled Reconciliation of Medications revised July 2017 states: The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medication, routes and dosages upon admission or readmission to the facility. Review of the facility's policies and procedures titled Security of Medication Cart revised April 2007 documents: The medication cart shall be secured medication passes. medication carts must be securely locked at all times when out of the nurse's view. Review of the facility's policies and procedures titled Protected Health Information, Management and Protection of revised April 2014 states: Protected Health Information (PHI) shall not be used or disclosed except as permitted by current federal and state laws. It is the responsibility of all personnel who have access to resident and facility information to ensure that such information is managed and protected to prevent unauthorized release or disclosure.

Based on observation, interview, and record review the facility failed to ensure the lint screens for two out of three dryers observed in the laundry room were cleaned as per facility protocol. There were 139 residents residing in the facility at the time of the survey. The findings included: On 04/17/24 at 09:23 AM during an observational tour of the laundry area by two surveyors on the team with the facility's Infection Preventionist (Staff B) and the Director of housekeeping, the lint screens of two out of three clothes dryers were checked and observed covered in a thick layer of lint. Each dryer has a load capacity of 150 pounds and was in working order. On 4/17/24 at 9:40AM, the Director of housekeeping acknowledged that the lint screens for the two dryers were full of lint and was not cleaned, the lint log posted on the wall opposite the dryers documented-the lint screens were last cleaned on 4/17/24 at 9:00 AM. The Director of Housekeeping stated that the dryer lint screens are supposed to be cleaned every hour by the staff on duty. Review of the undated facility policy titled Lint states: All lint screens must be cleaned and brushed every hour and after every single load. If a lint screen is not cleaned out, the air passing through the machine will be blocked, which will raise the temperature in the machine, possibly causing a hazardous situation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain a quiet homelike environment for 1 of 3 sampled residents for oxygen use (Resident #117). The findings included: Resident #117 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment, required extensive one-person assist with activities of daily living, and required the use of oxygen. An observation of the 500 unit was conducted on 12/05/22 at 10:00 AM. A loud humming noise was heard coming from Resident #117's room. Upon entering Resident #117's room, surveyor observed the resident receiving oxygen by nasal cannula. Further observation revealed the loud noise was coming from the oxygen concentrator (device that delivers oxygen). An interview was conducted with Staff G, a Licensed Practical Nurse, on 12/05/22 at 12:00 PM. Surveyor was walking down the 500 unit hallway with Staff G. Staff G acknowledged the loud humming sound heard in the hallway was coming from Resident #117's oxygen concentrator. Staff G stated she did not know why the oxygen concentrator was making such a noise, and would call maintenance and replace the resident's oxygen concentrator. Staff G was observed retrieving a new oxygen concentrator, and replaced the old oxygen concentrator. The new oxygen concentrator was quiet/no sound. Staff G asked Resident #117 if That was better? Resident #117 smiled and nodded her head yes. An interview was conducted with the Maintenance Director on 12/07/22 at 10:00 AM. The director acknowledged the oxygen concentrator that was in Resident #117's room was placed out of service. The Director further acknowledged the loud noise coming from the oxygen concentrator was not normal, and should not have been in Resident #117's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record review, the facility failed to aid during dining for 1 of 1 sampled resident reviewed for Activities of Daily Livings (ADLs) (Resident #111). The findings included: In an observation conducted on 12/06/22 at 8:00 AM, Resident #111 was noted eating her breakfast tray with no staff in the room. At 8:10 AM, Resident #111 was still eating with no assistance from staff and consumed about 50 percent of her breakfast meal. In an observation conducted on 12/06/22 at 12:04 PM, Resident #111 was in the room with the lunch tray at her bedside, and no staff was noted. At 12:15 PM, she ate 10% of her lunch meal, and no staff member was in the room to assist her with her lunch. Continued observation at 12:20 PM showed that she ate 25% of her meal with no staff in the room. (photographic evidence obtained) A chart review showed that Resident #111 was admitted on [DATE] with diagnoses of Dysphagia, Dementia, and Anemia. The MDS (Minimum Data Set) dated 09/05/22 showed that under section C, for Brief Interview of Mental Status (BIMS), Resident #111 had a score of 02 out of 15, which indicate the resident is severely cognitively impaired. Under section G for eating, Resident #111 needs extensive assistance from one person assist. The Speech Therapy Screening Form dated 11/23/22 showed that Resident #111 for on enteral feeding for her main source of nutrition and hydration because of her history of poor intake. It further showed that Resident #111 has poor safety judgment and is to be followed up as needed. In an interview conducted on 12/07/22 at 10:55 AM with Staff C, Staff D, and Staff E, MDS's Coordinators stated that Resident #111 was coded under Section G for eating as needing extensive assistance with one person's assistance. When asked what it meant, they stated that Resident #111 needs someone in the room physically to make sure that Resident #111 is eating. It is not only encouragement to eat but assisting with the meals as well. They also said that they get their information about the residents by looking at the Certified Nursing Assistants' documents, Speech Therapy Assessments, and the Electronic System. In an interview conducted on 12/07/22 at 11:00 AM, Staff A, Certified Nursing Assistant, stated that Resident #111, at times, needs help with her meals. She further revealed that the resdenteats 100% of her meals. The care plan dated 09/07/22 showed that Resident #111 is at risk for an alteration in nutrition and hydration. It further showed to provide cues/encouragement during meals and provide hands-on assistance with eating at meals and as needed. A review of the CNA's (Certified Nursing Assistants) intake of meals from 11/24/22 to 12/07/22 showed that Resident #111 needed the following: 1 documented at independent-no help or staff oversight at any time, five recorded at supervision - oversight, encouragement, or cueing, six reported at limited assistance - Resident highly involved in the activity; staff provides guided maneuvering of limbs or other non-weight-bearing assistance, eight documented at extensive assistance - Resident engaged in the activity, staff provide weight-bearing support, and 20 recorded at total dependence - full staff performance. A review of the facility's policy titled Activities of Daily Living (ADLs), Supporting, revised in March 2018, showed that the following: Appropriate care and services will be provided for residents who are unable to carry out ADLS independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care); b. Mobility (transfer and ambulation, including walking); c. Elimination (toileting); d. Dining (meals and snacks); and e. Communication (speech, language, and any functional communication systems). In an interview conducted on 12/08/22 at 12:30 PM, with the facility's Administrator, she was informed of the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure proper use of splints per physician's order for 2 of 3 residents reviewed for splints (Resident #74 and 122). The findings included: 1) During the initial tour of the facility conducted on 12/05/22 at 9:40 AM, the surveyor noted Resident #74 was wearing splints on both of her hands while lying in bed. Clinical records revealed Resident #74 was admitted to the facility on [DATE]. Resident #74 had a medical history significant for Parkinson's disease, fibromyalgia, depression, anxiety, dementia, and contractures of her hands and ankles. A Quarterly Minimum Data Set (MDS) was done on 09/20/22. This MDS documented Resident #74 had a Brief Interview of Mental Status (BIMS) score of 5, which indicates she had severe cognitive impairment. This MDS also documented Resident #74 required extensive assistance from staff for all activities of daily living. Review of Resident #74's Care Plans revealed there was a care plan in place regarding the contractures and use of splints. Review of Resident #74's physician orders revealed there were orders in place regarding placing splints on her hands and ankles after morning cares and removing the splints before evening cares. There was also an order written on 11/15/22 for Resident #74 to be placed on restorative nursing services. Review of Resident #74's notes revealed there were no notes written regarding Resident #74 refusing to wear or removing splints. Additional observations conducted on 12/06/22, 12/07/22, and 12/08/22 revealed Resident #74 in bed but not wearing her splints. Instead, the ankle splints were observed in the wheelchair and the hands splints were observed on the table under the window in her room. An interview was conducted on 12/08/22 at 10:08 AM with Staff F, Unit Manager. She stated it is the responsibility of the restorative staff to place the splints on the residents and that the nursing staff is supposed to check each resident, based on physician's orders to ensure the splints are being used properly. 2) During the initial tour of the facility conducted on 12/05/22 at 9:45 AM, the surveyor noted Resident #122 was lying in bed and there were splints in a bag on the table under the window in her room. Clinical records revealed Resident #122 was admitted to the facility on [DATE]. Resident #122 had a medical history significant for a traumatic brain injury, diabetes, falls, depression, and contractures of her hands. Review of a Quarterly Minimum Data Set (MDS) dated [DATE]. This MDS documented Resident #122 had a Brief Interview of Mental Status (BIMS) score of 3, which indicates she had severe cognitive impairment. This MDS also documented Resident #122 required extensive assistance from staff for all activities of daily living. Review of Resident #122's Care Plans revealed there were care plans in place regarding a decrease in range of motion, but not for the use of splints. Review of Resident #122's physician orders revealed there was an order in place regarding the use of a splint for her left hand due to decrease in range of motion. Review of Resident #122's notes revealed there were no notes written regarding Resident #122 refusing to wear or removing splints. Additional observations conducted on 12/06/22, 12/07/22, and 12/08/22 revealed Resident #122 in bed or in her chair but not wearing her splints. Instead, the hands splints were observed on the table under the window in her room. An interview was conducted on 12/08/22 at 10:08 AM with Staff F, Unit Manager. She stated it is the responsibility of the restorative staff to place the splints on the residents and that the nursing staff is supposed to check each resident, based on physician's orders to ensure the splints are being used properly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to follow tube feeding orders for 1 out of 7 sampled residents reviewed for tube feeding (resident #58). The findings included: A review of the facility ' s policy titled Enteral Tube Feeding via Continuous Pump, revised in March 2115, showed to position the head of the bed at 30-45 degrees for feeding unless medically contradicted. It further showed to check the label on the enteral formula against the physician's order. A review of the Physician's orders for Resident #58 revealed a Physician's order dated 07/25/22 for tube feeding Osmolite 1.5 (formulary type) at 60 milliliters (ml) per hour for 20 hours via peg tube, held from 8:00 AM to 1:00 PM. Another order dated 06/18/22 to elevate the Head of the bed at least 30-45 degrees while feeding is in progress. In an observation conducted on 12/05/22 at 9:15 AM, Resident #58 was noted in bed. Closer observation showed a tube feeding that was on hold with Osmolite 1.5 at 60 ml an hour and was at the 700 ml mark out of a 1000 ml bottle. Further review showed that the tube feeding bottle was started on 12/05/22 at 12:00 PM. According to the above Physician's orders, the tube feeding should have been at the 520 ml mark out of the 1000 ml capacity bottle. (photographic evidence obtained) In an observation conducted on 12/06/22 at 7:50 AM, Resident #58 was noted in bed. Closer observation showed that the tube feeding was running at 60 ml an hour, and the tube feeding bottle was started on 12/06/22 at 5:00 AM. The tube feeding was noted at the 1000 ml level out of the 1000 ml capacity bottle. Continued observation showed Resident #58 utterly flat on the bed with Staff A, a Certified Nursing Assistant (CNA), providing morning care while the tube feeding was still running. (photographic evidence obtained) A review of the chart showed that Resident #58 was admitted on [DATE] with diagnoses of Parkinson's disease and unspecific severe protein-calorie malnutrition. Review of the Care Plan dated 11/03/22 showed to keep Resident #58's Head elevated at least 30 degrees while tube feeding is infusing and to administer tube feeding formula and flushes as ordered. Progress noted completed on 11/23/22 by the facility's Registered Dietitian revealed that Resident #58 is tolerating her tube feeding well and that the current order provides her protein and calorie needs with Osmolite 1.5 at 60 ml an hour times 20 hours. In an interview conducted on 12/07/22 at 12:36 PM with the facility's Clinical Dietitian, stated on the observation that was conducted on 12/06/22 at 7:50 AM, Resident #58 should have received around 180 ml of a formulary as per the Physician's order. When told of the morning care that was provided by Staff A, without stopping the tube feeding first, she acknowledged the risk for aspiration. In an interview conducted on 12/07/22 at 3:03 PM with Staff B, the Registered Nurse stated that when morning care is provided to the residents, the Certified Nurse Assistant is supposed to call her before to turn off the tube feeding before starting care. She further acknowledged that Staff A did not call her to stop the tube feeding before providing care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to follow Physician's orders and failed to update dialysis care plan for discontinued fluid restrictions for 1 out of resident reviewed for dialysis (Resident #47). The findings included: Review of the facility's policy titled Policy and Procedure: Fluid Restrictions dated 08/07/20, included the following: Fluid restrictions may be utilized to assist in controlling body fluid balance, when a resident's clinical condition warrants. Fluid is only restricted when clinically necessary, and for a limited time, when possible, to preserve resident quality of life. A specific physician's order for the amount of fluids to be provided in a 24-hour period is required. When an order is received for fluid restriction, the dietary manager or dietician confers with the nursing department to determine how much fluid each department is to provide. This is based on the number of medications ordered, as well as the total fluid volume permitted. The Food Service Manager or Dietician visits the resident to obtain preferred fluid information, to make the restriction as acceptable as possible. This is entered into the computer so that the specific fluid amounts are printed on the resident's tray cards. The need for fluid restriction is reviewed periodically by the physician, dietician, and nursing staff. When at all possible, this restriction is liberalized or discontinued, to promote optimal compliance and the highest practicable quality of life. Fluid restrictions are care planned by the interdisciplinary team. Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, with a revised date of December 2016, included the following: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs developed and implemented for each resident. The comprehensive, person-centered care plan will: describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents 'conditions change. The Interdisciplinary Team must review and update the care plan: a) When there has been significant change in the resident's condition; b) When the desired outcome is not met; c) When the resident has been readmitted to the facility from a hospital stay; and d) At least quarterly, in conjunction with the required quarterly Minimum Data Set (MDS) assessment. Review of the facility's policy titled Standards and Guidelines (SG): Hemodialysis with a revised date of 12/2017 included: Standard: It will be the standard of this facility to provide the necessary care and services to those residents receiving hemodialysis while a resident at the facility. Guidelines: If the resident has orders for fluid restriction, they should be clarified as to which shift provides which amount of fluid per shift between nursing and dietary services. The resident will be reviewed by the Interdisciplinary Team (IDT) after admission to determine appropriate orders care plans are addressed with appropriate interventions in place. Record review for Resident #47 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Unspecified Protein-Calorie Malnutrition, Extrarenal Uremia, End Stage Renal Disease, Essential (Primary) Hypertension, and Fluid Overload Unspecified. Review of Section C for cognitive pattern of the Minimum Data Set (MDS) dated [DATE] indicated that Resident #47 had a Brief Interview for Mental Status of 6, which indicated that she was severely cognitively impaired. Review of Section G for functional status of the MDS dated [DATE] documented that Resident #47 had a bed mobility, transfer, dressing, toilet use, and personal hygiene all had a self-performance of extensive assistance with support of one person assist, eating had a self-performance of limited assistance with support of one person assist. Review of Physician's Orders for Resident #47 dated 11/29/21 for Fluid Restriction: 1200 ml/day (mililiters per day). Dietary to provide 720 ml: Breakfast-360 Lunch-240, Dinner-120 Nursing: Day shift - 240 ml Night shift - 240 ml. Exclude supplements from restriction every shift was discontinued on 03/17/22. Review of Physician's Orders for Resident #47 dated 07/05/22 for renal diet, regular texture, thin consistency, pureed Meats, and vegetables, per patient request. Maintain aspirations precautions. Review of Physician's Orders for Resident #47 dated 12/10/21 for dialysis (Monday, Wednesday, Friday) chair time 1:00 PM to 4:30 PM, pick up time 12:15 PM. On 12/06/22 a review of the Care Plan for Resident #47 initiated on 11/29/21 with a focus on the resident has potential for complications related to hemodialysis for treatment of End Stage Renal Disease (ESRD). Shunt site is located: (left upper chest) receives dialysis on Monday, Wednesday, and Friday. Goal was for the resident to remain free from complications related to hemodialysis thru the next review date. Interventions included: Maintain fluid restrictions as ordered; observe for compliance. Complete dialysis communication tool on dialysis days and review upon return from dialysis. Review of the Nutrition Risk Evaluation for Resident #47 dated 11/28/22 included: Fluid needs (in ml/day): 1174-1467. Review of the Nutrition Risk Evaluation for Resident #47 dated 08/30/22 included: Fluid needs (in ml/day): 1180-1475. Review of the Nutrition Risk Evaluation for Resident #47 dated 08/23/22 included: Fluid needs (in ml/day): 1180-1475. Review of the Nutrition Risk Evaluation for Resident #47 dated 05/30/22 included: Fluid needs (in ml/day): 1200. Review of the Dialysis Communication Forms for Resident #47 dated 11/23/22, 11/09/22, 11/04/22, 11/02/22, 10/28/22 all included: under the follow up needed prior to next treatment: fluid restrictions. Review of the Dietary progress note dated 12/07/22 included: Hemodialysis (HD) follow-up: Per Dialysis Center Communication (12/5/22), dry current weight= 126.9 pounds (#). No significant weight changes x 30/90/180 days. Resident with varied oral (PO) intake but tolerating diet well. Case discussed with HD RD on monthly basis. As per nephrologist resident has no need for fluid restriction. Recommend continue current dietary interventions as ordered. Care Plan to be updated as needed (PRN). Review of the Dietary progress note dated 11/15/2022 included: HD follow-up: Per Dialysis Center Communication (10/26/22), dry current weight= 127.6#. Registered Nurse (RN) reported resident presenting varied meal intake but tolerating diet well. Recommend continue current dietary interventions as ordered. Follow prn Review of the Dietary progress note dated 10/27/2022 included: HD follow-up: Per Dialysis Center Communication (10/26/22), dry current weight= 129.3#. Recommend continue current dietary interventions as ordered. Follow prn Review of the Dietary progress note dated 10/13/2022 included: HD follow-up: Per Dialysis Center Communication (10/12/22), dry current weight= 129.8#. Recommend continue current dietary interventions as ordered. Follow PRN ( as needed). Review of the Dietary progress note dated 9/29/2022 included: HD follow-up: Per Dialysis Center Communication (9/27/22), dry current weight= 129.1 pounds. Recommend continue current dietary interventions as ordered. Follow PRN. Review of the Dietary progress note dated 9/13/2022 included: HD follow-up: Per Dialysis Center Communication (9/12/22), dry current weight= 129.8 pounds. Spoke with resident and responsible party. Reported good appetite. Daughter/responsible party requests diet to include puree vegetables and meats since it would be easier for resident to eat. Recommend continue current dietary interventions as ordered. Follow PRN. Review of the Dietary progress note dated 8/11/2022 included: HD follow-up: Per Dialysis Center Communication (8/10/22), dry current weight= 131.5 pounds. Recommend continue current dietary interventions as ordered. Follow PRN. Review of the Dietary progress note dated 07/28/2022 included: HD follow-up: Per Dialysis Center Communication (7/27/22), dry current weight= 132.2 pounds. Recommend continue current dietary interventions as ordered. Follow PRN. Review of the Dietary progress note dated 07/12/2022 included: HD follow-up: Per Dialysis Center Communication (7/11/22), dry current weight= 133.5 pounds. Recommend continue current dietary interventions as ordered. Follow PRN. Review of the Dietary progress note dated 06/30/2022 included: Note Text: HD follow-up: Per Dialysis Center Communication (6/29/22), dry current weight= 131.5 pounds - weight stable. Recommend continue current dietary interventions as ordered. Follow PRN. Review of the Dietary progress note dated 06/14/2022 included: HD follow-up: Per Dialysis Center Communication (6/13/22), dry current weight= 131.7 pounds. - weight stability noted. Recommend continue current dietary interventions as ordered. Will follow PRN. Review of the Dietary progress note dated 05/17/2022 included: HD follow-up: Per Dialysis Center Communication (5/16/22), dry current weight= 131.1 pounds. Recommend continue current dietary interventions as ordered. Review of the Dietary progress note dated 05/3/2022 included HD follow-up: Per Dialysis Center Communication (5/2/22), dry current weight= 129.1 pounds. Recommend continue current dietary interventions as ordered. Review of the Dietary progress note dated 04/12/2022 included: HD follow-up: Per Dialysis Center Communication (4/11/22), dry current weight= 130.9. Recommend continue current dietary interventions as ordered. Review of the Dietary progress note dated 03/29/2022 included: HD follow-up: Per Dialysis Center Communication (3/28/22), dry current weight= 128.4 pounds. Recommend continue current dietary interventions: Review of the Dietary progress note dated 03/17/2022 included: HD follow-up: Per Dialysis Center Communication (3/16/22), dry current weight= 126.7 pounds - resident gained 2 pounds in 1 week. Spoke with HD dietitian and she recommended to discontinue fluid restriction since resident has been stable and there are no concerns. Spoke with resident and daughter/responsible party. New weight and dietary interventions discussed. Recommend continue current dietary interventions: Discontinue fluid restriction In an observation conducted on 12/06/22 at 7:50 AM, Resident #47 was noted in the room with the breakfast tray on her side table. Closer observation showed a meal ticket with the following: 4 ounces of apple juice, fried eggs, 8 ounces coffee, Mighty shake 60 ml and a Renal diet with Fluid restriction of 1200 cc and D:720. The tray consisted of 4 ounces of juice, 8 ounces of milk, and 6 ounces of coffee. Resident #47 was eating on her own in the room with no assistance from staff. Continued observation at 8:10 AM showed that she only ate 20% of her meal with no assistance from staff. In an observation conducted on 12/06/22 at 12:08, Resident #47 was noted in the dining room with the lunch tray. Closer observation showed a meal/tray ticket with the following: Renal, lunch with fluid restriction of 1200 milliliter (ml), dietary (D):720 mls. It showed 120 ml of Apple juice and 120 ml of soup and cream soup or broth only. The tray had 4 ounces of apple juice and 120 ml of soup. During an interview conducted on 12/07/22 at 12:08 PM with the Registered Dietician. When asked about what a renal diet includes as far as restrictions, she stated that a renal diet should be lower in potassium, and we do not add any sodium. She stated that if a resident has a physician's order for fluid restriction, the nurse will verbally inform her of the order and it is her responsibility to break down the total fluid restriction to indicate how much fluids the resident should receive for meals, for nursing and this is further broken down by the shift as well and this is written as an order. Once the order is written for the breakdown of the fluid restriction, she then verbally provides this information to the Certified Dietary Manager (CDM), who in turn ensures that the fluid restriction breakdown is on the meal tickets for the resident. When the RD was asked to explain a meal ticket for Resident #47, she immediately stated that the resident has not been on the fluid restrictions for months. When it was brought to the RD attention that Resident #47 meals/meal tickets are still following the fluid restrictions that were discontinued on 03/17/22, she stated that the fluid restrictions should have been taken off and agreed that Resident #47 has been receiving very few fluids even though the fluid restrictions are not in place at this time. She explained that when nursing receives an order to discontinue fluid restrictions, the nursing staff will inform the RD who turn informs the CDM to remove the fluid restrictions from the meal tickets for the resident. When asked about communication between the facility and the dialysis center, she stated that the facility nursing staff and the dialysis center nursing staff communicate with a Dialysis Communication Form, (these are uploaded into the resident's EMAR) and she does not review any of these documents. She stated that she speaks directly to the dietician at the dialysis center usually every 2 weeks, to discuss weights, labs, diet, and fluid restrictions. She does not always document her discussion that she has with the dietician from the dialysis center, but if she does document the conversation it is documented, under nutrition risk evaluation and a dietary progress note. When the RD was asked care plans being updated, she responded saying the care plans are updated as needed. When asked if the dialysis center staff (including the dietician) attend the care plan meetings for the resident, she stated they do not attend the care plan meetings. MDS Interview 12/07/22 3:30 PM with Staff C Registered Nurse/Minimum Data Set (MDS) Coordinator, Staff D Registered Nurse/Minimum Data Set (MDS) Coordinator, and Staff E Registered Nurse/Minimum Data Set (MDS) Coordinator when asked how are the dietary care plans updated, they all replied dietary does update their own care plans and the person responsible to do the implementing and updating of dietary care plans would be the responsibility of the Registered Dietician. During an interview conducted on 12/07/22 at 3:55 PM with Staff RD when asked if she had updated the care plan for Resident #47, she said yes. When asked what she updated on the care plan for Resident #47, she said she removed the intervention for fluid restrictions. When asked why it was not removed when the order was received to discontinue the fluid restrictions 03/17/22 she said, I made a mistake. When asked who is responsible for updating the dietary care plans, she stated she is the person responsible.

Based on observations, interviews, and record reviews the facility failed to ensure proper storage of medications for Resident #26 and 69. The findings included: Review of the facility policy titled Storage of Medications, revision date 08/2020 revealed the following: Medications and biologicals are stored safely, securely, and properly. Also, Only licensed nurses, pharmacy personnel, and those lawfully authorized to administer medications are permitted to access medications. 1) During the initial tour of the facility conducted on 12/05/22 at 9:25 AM, the surveyor found a bottle of prescription shampoo in the bathroom of Resident #26 (photographic evidence obtained). A review of Resident #26's record revealed a Quarterly Minimum Data Set (MDS) was done on 10/27/22. This MDS documented Resident #26 had a Brief Interview of Mental Status (BIMS) score of 13, which indicates she had mild cognitive impairment. This MDS also documented Resident #26 required extensive assistance from staff members for personal hygiene and transfers-this indicates she was unable to shower herself. Review of Resident #26's physician orders revealed an order was written on 10/20/22 for Ketoconazole Shampoo 2% to be used two days per week for a rash on her scalp. Additional observations made on 12/06/22, 12/07/22, and 12/08/22 revealed the prescription shampoo remained in Resident #26's bathroom for the duration of the survey. An interview and observation was conducted on 12/08/22 at 10:10 AM with Staff F, Unit Manager. She stated she checks the resident's rooms weekly to ensure no medications are left in the rooms. The surveyor showed Staff F the shampoo in Resident #26's bathroom. She admitted the shampoo should not have been left in the bathroom and stated she did not know it had been there for the week. She immediately removed the shampoo from the bathroom. 2) During the initial tour of the facility conducted on 12/05/22 at 9:45 AM, the surveyor found a medication cup containing an unidentified white powder in the bathroom of Resident #69 (photographic evidence obtained). A review of Resident #69's record revealed a Quarterly Minimum Data Set (MDS) was done on 09/30/22. This MDS documented Resident #69 had a Brief Interview of Mental Status (BIMS) score of 99, which indicates she had severe cognitive impairment. This MDS also documented Resident #69 was totally dependent on staff members for all activities of daily living. Review of Resident #69's physician orders revealed no active order for any powdered substance-medication or dietary supplement. Additional observations made on 12/06/22, 12/07/22, and 12/08/22 revealed the medication cup containing the unidentified white powder remained in Resident #69's bathroom for the duration of the survey. An interview and observation was conducted on 12/08/22 at 10:09 AM with Staff F, Unit Manager. She stated she checks the resident's rooms weekly to ensure no medications are left in the rooms. The surveyor showed Staff F the medication cup containing the unidentified white powder in Resident #69's bathroom. She admitted she did not know what the powder was but that it should not have been left in the bathroom and that she did not know it had been there for the week. She immediately removed the medication cup with the powder from the bathroom.

Based on observation and interview, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, including holding cold foods at regulatory temperature and using personal items in the food production area. The findings include the following: In a tour of the central kitchen conducted during lunch tray line observation on 12/07/22 at 11:35 AM, the following was noted: 1. The facility's Certified Dietary Manager was observed using the facility's calibrated thermometer. The temperature of a tossed salad was taken and showed to be at 60.4 degrees Fahrenheit, and another tossed salad showed a temperature of 59.3 degrees Fahrenheit. This had the potential to affect the other 13 tossed salads that were noted in the reach-in refrigerator. (photographic evidence obtained) 2. The facility's Certified Dietary Manager was observed using the facility's calibrated thermometer. The temperature of the fruit salad was taken and showed to be 55.7 degrees Fahrenheit, and another fruit salad showed a temperature of 59.5 degrees Fahrenheit. This had the potential to affect the other 37 fruit salads that were noted in the reach-in refrigerator. In this observation, the facility Certified Dietary Manager stated that the tossed salads and the fruit salads are for some residents who like them for lunch today. He further said that he was aware that they were not meeting the required 40.0 degrees Fahrenheit and below and proceeded to put the fruit salads and the tossed salad in the walk-in refrigerator. (photographic evidence obtained) 3. The facility's Clinical Dietitian was observed near the tray line using her cell phone and putting it back in her pocket, and not practicing hand hygiene after using her cell phone. In an interview conducted on 12/07/22 at 3:45 PM, with the facility's Clinical Dietitian, she acknowledged all findings. In an interview conduced on 12/08/22 at 12:30 PM, with the facility's Administrator she was told of the findings.