Based on observation, record review and interview, the facility failed to protect residents' healthcare information on 3 out of 7 medication carts reviewed as evidenced by electronic health record screen were observed open and unattended. There were 172 residents residing in the facility at the time of the survey. The findings included: On 07/15/24 at 08:40 AM on the third floor an observation revealed an open electronic health record computer screen open and unattended with residents' information visible, on the [NAME] medication cart. On 07/15/24 at 08:44 AM Staff A, Licensed Practical Nurse (LPN) exited a resident's room and returned to the [NAME] medication cart and was approached by surveyor. Staff A, LPN stated: The computer has been having issues and when I walked away it was off but maybe when I plugged it in the screen came back on while; I was away from cart. I am supposed to lock my screen when I am away from the medication cart. On 07/16/24 at 9:26 AM; observation on the third floor the East medication cart was noted unattended, and the computer screen was open with residents' electronic health records information visible. On 07/16/24 at 9:35 AM Staff B, Registered Nurse (RN) exited a resident's room and returned to the East medication cart and was approached by surveyor. Staff B, RN stated: I have been employed at this facility for three months. The facility gives us training on the proper procedure concerning protecting residents' information by closing the computer screen when walking away from the medication cart. It was not locked because I went to check on a resident and didn't realize I left it open. On 07/17/24 at 9:51 AM; on the third-floor East medication cart, a medication administration observation was done with Staff C, LPN and an observation was made of an open electronic health record computer screen left open and unattended with residents' information visible. Staff C, LPN returned to cart stated: It is not okay to leave screen open when I am away from the medication cart. On 07/18/24 at 2:26 PM the Director of Nursing (DON) stated: The electronic medication administration screen should be closed when staff is away from the cart to protect residents' personal information. Record review of The facility's Policy HIPPA Security Measure dated 5/2024. Policy: It is the facility's policy to implement reasonable and appropriate measures to protect and maintain the confidentiality, integrity, and availability of the resident's identifiable information and or records that are in electronic format. 10. Technical safeguards will be implemented to allow access of EPHI only to those employees or software programs that have been granted access rights. C. Automatic logoff: electronic sessions will be terminated after a predetermined time of inactivity depending on the systems housed on the workstation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview facility failed to coordinate with the appropriate State authority to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) was completed in a timely manner for one resident (Resident #46) with a major mental disorder out of nine residents sampled as evidenced by Level I PASRR dated 2/19/24 omitted diagnosis of Schizophrenia, Bipolar disorder and Anxiety. There were 172 residents residing in the facility at the time of survey. The findings included: Record review of Preadmission Screening and Resident Review (PASRR) dated 2/19/24 Section I: PASRR Screen Decision-Making: Depressive Disorder and Psychosis was checked, Section IV: PASRR Screen Completion: No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required, signed on 2/19/24 by DON at the facility Record review of demographic sheet for Resident #46 revealed an admission date of 2/19/24 with diagnoses that included Major Depressive disorder, Psychosis, Bipolar, Anxiety, and Schizophrenia. Record review of admission Minimum Data Set (MDS) dated [DATE] Section A (Identification) revealed No level II PASRR Is the resident currently considered by the State process to have serious mental illness and/or intellectual disability or a related condition. Preadmission Screening and Resident Review (PASRR). Section I (active diagnosis) revealed Depression and Psychotic disorder. Further record review of electronic health record revealed a Significant Change MDS dated [DATE], Section I showed Anxiety disorder, Depression (other than bipolar), Bipolar Disorder, Psychotic disorder, and Schizophrenia. Section N indicated Antidepressant and Antipsychotic medications were received in the last 7 days. Section O indicated Psychological Therapy with total minutes of zero. Record review of Care Plan date initiated on 2/19/24 indicated R#46 was at risk for drug related side effects due to use of psychotropic meds for the diagnosis of Major Depressive Disorder and Psychosis. Interventions included: Notify Social Worker about any change in behavior pattern. Record review of physician orders revealed orders dated 4/26/24 for Quetiapine Fumarate Tablet 50 MG (milligrams) one tablet by mouth two times a day related to Psychosis and an order dated 6/18/22 for Lorazepam Tablet 0.5 MG one tablet by mouth every 12 hours for Anxiety. Record review of a Psychiatric Consult dated 2/19/24 revealed diagnosis of Major depression disorder. On 07/18/2024 at 11:24 AM, the Social Services Director stated, the process for completing PASSR is to evaluate all diagnosis upon admission, discuss in the morning meeting, and review current Level I to determine need for Level II. For residents who are currently residing in the facility we complete a resident review that includes clinicals and a Level I to determine if there is a need for a Level II to be sent to Kepro. The nurses are to update me about any new behaviors so I can ensure an accurate PASRR. For [Resident #46] I was notified last week by the resident's previous case worker via email about new diagnosis last week. I immediately completed a new PASSR and submitted it to Kepro for Level II determination on 7/16/24. Record review of an email given to the surveyor by the Social Services Director revealed a date of 4/8/2024 from case worker from a healthcare company regarding Resident #46, revealed a comprehensive care plan dated 4/1/24 that included diagnoses of Schizophrenia, Bipolar and Attention Deficit Hyperactivity Disorder Anxiety and Depression. Record review of the facility's Policy for PASRR dated 3/2021 Policy: It is the of the facility to assure that all residents admitted to the facility receive a Pre-admission Screening and Resident Review, in accordance with State and Federal Regulations. Procedure: 5. A nursing facility must notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has a mental illness or intellectual disability for resident review.

Based on observations and interviews, the facility failed to accurately reconcile two controlled medications on one medication cart out of seven medications carts reviewed. There were 172 residents residing I the facility at the time of survey. The findings included: On 07/17/24 at 12:52 PM on the 4th floor cart a controlled medication count was completed with Staff E, Licensed Practical Nurse (LPN) on the East medication cart. Two Medication Monitoring/ Control Records were inaccurate when compared to the corresponding bingo card. (photo evidence) On 07/17/24 at 12:52 PM Staff E, LPN stated: The correct procedure for signing out narcotics is to sign out the narcotic at the time it was given. I administered the medication to the resident but did not sign due to getting busy with other nursing tasks. On 07/18/24 at 2:26 PM the Director of Nursing (DON) stated: Nurses are to sign out controlled medications once it is popped out of the bingo card. Record review of the facility's policy: Controlled Substance Administration and Accountability date implemented June 2021. Policy: It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure. Policy Explanation and Compliance Guidelines: h. The Controlled Drug Record (or other specified form) serves the dual purpose of recording both narcotic disposition and patient administration.

Based on observations and interview the facility failed to properly store and label medications in one medication room and one medication cart out of three medication rooms and seven medication carts reviewed as evidenced by an observation of an unlabeled vial and medication left unattended. There were 172 residents residing I the facility at the time of survey. The findings included: On 07/16/24 at 4:35 PM a review of a medication storage room on the second floor revealed a vial Labeled Lorazepam injection with no open date observed on the vial. On 07/16/24 at 4:45 PM Staff D, Registered Nurse (RN) stated: I counted the controlled medications with the off going nurse. I received the Ativan in the fridge. I did not notice there was not an open date. The vial should be labeled with an open date. On 07/17/24 at 8:47 AM on the second floor an observation was made of crushed medication in a transparent medicine cup unattended, on top of the middle medication cart. (photo evidence) 07/17/24 08:52 AM Staff F, Registered Nurse (RN) returned to medication cart and stated: It is not okay to leave the medication on top of the cart. The reason I left the medication unattended was because I went to call the other nurse to open the fridge. On 07/18/24 at 2:26 PM the Director of Nursing (DON) stated: All open vials of medications should be labeled with an open and expiration date. No medication should be left unattended. Record review of the facility's policy Labeling of Medications Storage of drugs and Biologicals dated 11/28/2019. Policy: It is the policy of this facility to ensure that all medications and biologicals used in the facility will be labeled and stored in accordance with current state, federal regulations. Policy Explanation and Compliance Guidelines: 9. Labels for multi-use vials must include: a. The date the vial was initially opened or accessed (needle-punctured); with specified timeframes for usage once opened that are outside of the manufacturers expiration date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and Interview the facility failed to follow infection prevention protocol for one resident (Resident #118) out of seven sampled as evidenced by; the wound care nurse not wearing gown while providing wound care to Resident #118 who is under enhanced barrier precaution. There were 172 residents in the facility at the time of survey. The findings included: On 07/17/24 at 10:40 AM, during a wound care observation with the wound care nurse. The Licensed Practical Nurse (LPN wound care nurse performed wound care for Resident#118. Prior to wound care, the LPN wound care nurse donned gloves. Record review of demographic sheet for Resident #118 revealed an admission date of 7/4/2022 and readmission date of 9/29/2022 with diagnosis that included: Stage 4 Pressure Ulcer of right buttock and other site. Record review of Quarterly Minimum Data Set (MDS) dated [DATE] Section C (cognitive status) revealed a Brief Interview for Mental Status score of score 13 out of 15 indicated cognition was intact, Section GG (Functional status) revealed Resident #118 dependent for ADLs. Section H (bowel and bladder) revealed Resident #118 had an indwelling catheter. Section M (skin) revealed the resident had a 1 Stage IV unhealed pressure ulcer. Record review of CARE PLAN start date 10/16 /23 and revision date 5/10/24 revealed Resident #118 had a pressure injury on admission [DATE] and interventions included: Enhanced based precaution (EBP) due to wounds and wound care as ordered. On 07/17/24 at 1:37 PM the LPN wound care nurse stated: [Resident #118] is under EBP due to his wound and catheter, and I did not wear a gown while performing wound care and that was a mistake. According to Protocol for EBP I should wear a disposable gown during wound care. Record review of the facility's Policy Enhanced Barrier Precautions issued 8/16/2022 revised 4/1/2024 Enhanced Barrier Precautions dated 8/16/2022 revised 4/1/2024 Policy: It is the policy of this facility that Enhanced Barrier Precautions, in addition to Standard and Contact Precautions will be implemented during high-contact resident care activities when caring for residents that have an increased risk for acquiring a multidrug resistant organism (MDRO) such as a resident with wounds, indwelling medical devices or residents with infection or colonization with an MDRO. Enhanced Barrier Precautions (EBP) consists of the use of gowns and gloves for high contact care activities which include but may not be limited to wound care: any skin opening requiring a dressing.

Based on observation, interview and record review the facility failed to ensure lint screens were cleaned for two out of three dryers as evidenced by two out of three dryers lint screens observed full of lint. There were 172 residents residing in the facility at the time of the survey. The findings included: On 07/18/24 at 1:25 PM a Laundry Tour was conducted with the Housekeeping Director. The clean room contained three 87-pound capacity dryers. Two dryers were in progress and the lint screens were filled with lint. (photo evidence) When asked to view the lint log, the Housekeeping Director responded that the lint log was upstairs. On 07/18/2024 at 3:15 PM the surveyor was approached by the Housekeeping Director and given a lint log. Review of the Lint Log revealed July 18: 1:00 AM, 3:00 AM and 5:00 AM the log was not signed. The Housekeeping Director stated: The staff will sign for 1:00 AM, 3:00 AM and 5:00AM July 18 on July 19 overnight shift. Record review of the facility's Laundry Policy date implemented July 2020 Policy: The facility launders linens and clothing in accordance with current CDC guidelines to prevent transmission of pathogens. 10. Dryer filter will be checked, and lint removed every three hours while being used and PRN (as needed).

Based on observation, interview and record review the facility failed to maintain an effective pest control program so that the environment is free of flies. This was evident throughout the facility in the kitchen, conference room, second floor, third floor and fourth floor where resident's reside. This has the potential to affect the entire resident population (one-hundred and seventy-two residents) residing in the facility at the time of this survey. The findings included: Record review of the facility's policy titled Pest Control (issued date 3/2020) documented: Policy-It is the policy of the facility to maintain an effective pest control program that eradicates and contains common household pests and rodents; Definition of an Effective pest control program is defined as measures to eradicate and contain common household pests (flies); Policy Explanation and Compliance Guidelines: 1) Facility will maintain a written agreement with a qualified outside pest service to provide comprehensive pest control services on a regular and scheduled basis and 3) Facility will report issues that may arise in between scheduled visits with the outside pest service and treat as indicated. Observation of the facility's conference room on 7/15/24 at 7:35 AM revealed a swarm of flies in the conference room, flying around and landing on the tables. A fly repellent with a blue light was noted in the conference room. Observation during the initial kitchen tour on 7/15/24 at 8:08 AM with the Dietary Supervisor and the Registered Dietitian (RD) revealed flies were noted flying around the kitchen around the steam table and throughout the kitchen. A fly repellent with a blue light was noted in the kitchen. On 7/15/24 at 8:09 AM, interview with the Dietary Supervisor confirmed the flies in the kitchen. Observation of the second floor nurses' station on 7/16/24 at 8:58 AM revealed flies were flying and landed on the nurses' station. (Photographic evidence submitted) Observation of the second floor nurses' station on 7/17/24 at 7:35 AM revealed flies were flying and landed on the nurses' station. During observation of the lunch tray line on 7/17/24 at 11:39 AM revealed flies were noted in the kitchen, flying around the tray line. The flies were noted on top of the shelf on tray line and on the plate warmers. Dietary staff were observed fanning the flies away while on the tray line. (Photographic evidence submitted) On 7/17/24 at 11:41 AM, interview with the Dietary Supervisor confirmed the flies in the kitchen. On 7/17/24 at 2:05 PM, interview with the Regional Director of Maintenance. He stated, We are aware of the flies and have had the pest control company come out. On 7/17/24 at 2:28 PM, interview with the Administrator. She confirmed that the facility has a pest control contract and that the pest control company comes on a regular basis to the facility. On 7/17/24 at 2:47 PM, interview with the Director of Maintenance via Spanish translator. He revealed the pest control company comes to the facility every single week. They fumigate the whole building and when they come they do a specific area. Review of the Pest Control contract documented dated and signed on 6/05/24, with an effective date of 5/01/24; Contract covers American Roaches, [NAME] Banded Roaches, Oriental Roaches, Smoky [NAME] Roaches, German Roaches, House Ant, Rat/Mice. The contract did not list flies as a part of the interior pest control treatment. Review of the Pest Management Invoices dated from 1/02/24-6/04/24 revealed the facility had received pest control treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to implement their abuse and neglect policy as evidenced by staff failure to notify law enforcement that a crime had occurred against a resident this involved two (Resident #1, Resident #2) out of six residents sampled during the time of this survey. The findings included: Record review of the facility's policy titled, Abuse, Neglect and Exploitation protocol implementation date was on 10/2019, the policy documented: The facility will provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect and exploitation. Abuse means the infliction of injury with resulting physical harm, pain or mental anguish. Law enforcement is the full range of potential responders to elder abuse, neglect and exploitation including police sheriffs, detectives and public safety officers. A prompt thorough investigation will be conducted by the facility immediately. Policy Explanation and Compliance Guidelines: 1) The facility will develop and implement written policies and procedures that: a) Prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident property. VII. Reporting/Response of Abuse, Neglect and Exploitation: When abuse, neglect or exploitation is suspected: Immediately report all alleged violations to the Administrator, state agency, adult protective services and all other required agencies (law enforcement) within specified timeframes. Review of the Demographic Face Sheet for Resident #1 documented the resident was admitted on [DATE] with a diagnosis of chronic obstructive pulmonary disease, respiratory failure, anxiety disorder, major depressive disorder, schizophrenia, hypertension, emphysema, insomnia and blindness one eye. The resident was discharged from the facility on 4/10/23. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] for Resident #1 documented the resident's Mental Status (BIMS) Summary Score was 15, indicating no cognitive impairment and he was able to make his needs known and he required supervision with setup help only for adls (activities daily living). Review of the Physician's Order Sheets (POS) and Medication Administration Records (MAR) dated February 2023 for Resident #1 documented the resident was receiving the following medications: Quetiapine Fumarate 100mg (milligrams) tab (tablet) 200mg PO (by mouth) HS (at night) for schizophrenia; Zolpidem Tartrate 10mg tab 1 tab PO HS for insomnia; Percocet 5-325mg tab 1 tab PO every 8 hours PRN (as needed) for pain; -Trazodone HCL (hydrochloride) 50mg tab 1 tab PO HS for major depressive disorder and Divalproex Sodium DR (delayed release) 500mg tab 1 tab PO BID (twice a day) for other seizures. Review of Resident's #1 Psychotropic meds care plan dated 12/03/22 documented the resident was at risk for drug related side effects due to use of psychotropic meds for the diagnosis of: Depression, Insomnia, Schizophrenia, Psychosis; Goal: Resident will remain free of drug related side effects through next review date and Interventions: Medicate as ordered; Monitor behavior and mood changes. Review of the Demographic Face Sheet for Resident #2 documented the resident was admitted on [DATE] with a diagnosis of encephalopathy, diabetes mellitus, cerebral infarction, major depressive disorder, bipolar disorder, glaucoma, hypertension, anxiety disorder and psychosis. Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] for Resident #2 documented the resident's Mental Status (BIMS) Summary Score was 03, indicating severe cognitive impairment and he required supervision with setup help only for adls (activities daily living). Review of the Physician's Order Sheets (POS) and Medication Administration Records (MAR) dated February 2023 for Resident #2 documented the resident was receiving the following medications: Divalproex Sodium DR 500mg tab 2 tabs PO HS for seizures; Risperidone 0.5mg tab 1 tab PO BID for psychosis; Haloperidol 0.5mg tab 1 tab PO in the morning for psychosis and Mirtazapine 7.5mg tab 1 tab PO HS for depression. Review of Resident's #2 Psychotropic meds care plan dated 7/14/22 documented the resident was at risk for drug related side effects due to use of psychotropic meds for the diagnosis of: Anxiety, Major Depressive Disorder, Bipolar Disorder, Psychosis; Goal: Resident will remain free of drug related side effects through next review date and Interventions: Medicate as ordered; Monitor behavior and mood changes. Review of Federal Immediate Report dated 2/15/23 documented the following: Date/Time of Incident: 2/15/2023 3:15 PM; Type of Incident: Abuse; Who has been notified: Resident Representative, Abuse Registry; Law enforcement not notified; Description of Incident: On 2/15/23 at 15:20 a resident who is alert and oriented times three reported to staff when passing by room [ ] he observed [ ] Resident #2 on top of resident [ ] Resident #1 hitting him in his face. Residents were immediately separated from each other and placed on one to one supervision. [ ] Resident #2 states that he hit his roommate because he called him a [ ] and this made him upset. [ ] Resident #1 said he gave [ ] Resident #2 the tv remote control and he was called a [ ]. [ ] Resident #1 told to not call him a [ ] and went to his bed. [ ] Resident #2 climbed on top of [ ] Resident #1 and hit him. [ ] Resident #2 suffered no injuries and [ ] Resident #1 has scratches on his face with minimal bleeding. First aide was given. [ ] Resident #1 voiced no concerns for his safety and exhibits no change in behavior related to the incident. Administrator was notified. Residents placed on a one to one. On 10/03/23 at 11:55 AM attempted to interview Resident #2 but the resident did not answer. On 10/03/23 at 1:10 PM interview with the Administrator/Abuse Coordinator. She stated, They were roommates at the time. [ ] Resident #1 called [ ] Resident #2 a [ ]. [ ] Resident #2 was on top of [ ] Resident #1 and started hitting him. Staff was walking by their room and saw them in action and broke them up. [ ] Resident #2 said he slapped the guy because he don't like the word. [ ] Resident #2 was sent to the hospital for aggressive behavior. [ ] Resident #1 said he didn't have any hard feelings but if he came back that he didn't want him to be his roommate. When [ ] Resident #2 came back they were placed in different rooms. [ ] Resident #1 was discharged to an ALF (assisted living facility). The Administrator/Abuse Coordinator reported I report abuse when I get them. Abuse is supposed to be reported in two hours. This was not reported to Law Enforcement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to report an alleged abuse incident to the abuse registry for allegation of abuse for one (Resident #1, Resident #2) out of six residents reviewed for abuse. The findings included: Record review of the facility's policy titled, Abuse, Neglect and Exploitation protocol implementation date was on 10/2019, the policy documented: The facility will provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect and exploitation. Abuse means the infliction of injury with resulting physical harm, pain or mental anguish. Law enforcement is the full range of potential responders to elder abuse, neglect and exploitation including police sheriffs, detectives and public safety officers. A prompt thorough investigation will be conducted by the facility immediately. Policy Explanation and Compliance Guidelines: 1) The facility will develop and implement written policies and procedures that: a) Prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident property. VII. Reporting/Response of Abuse, Neglect and Exploitation: When abuse, neglect or exploitation is suspected: Immediately report all alleged violations to the Administrator, state agency, adult protective services and all other required agencies (law enforcement) within specified timeframes. Review of the Demographic Face Sheet for Resident #1 documented the resident was admitted on [DATE] with a diagnosis of chronic obstructive pulmonary disease, respiratory failure, anxiety disorder, major depressive disorder, schizophrenia, hypertension, emphysema, insomnia and blindness one eye. The resident was discharged from the facility on 4/10/23. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] for Resident #1 documented the resident's Mental Status (BIMS) Summary Score was 15, indicating no cognitive impairment and he was able to make his needs known and he required supervision with setup help only for adls (activities daily living). Review of the Physician's Order Sheets (POS) and Medication Administration Records (MAR) dated February 2023 for Resident #1 documented the resident was receiving the following medications: Quetiapine Fumarate 100mg (milligrams) tab (tablet) 200mg PO (by mouth) HS (at night) for schizophrenia; Zolpidem Tartrate 10mg tab 1 tab PO HS for insomnia; Percocet 5-325mg tab 1 tab PO every 8 hours PRN (as needed) for pain; -Trazodone HCL (hydrochloride) 50mg tab 1 tab PO HS for major depressive disorder and Divalproex Sodium DR (delayed release) 500mg tab 1 tab PO BID (twice a day) for other seizures. Review of Resident's #1 Psychotropic meds care plan dated 12/03/22 documented the resident was at risk for drug related side effects due to use of psychotropic meds for the diagnosis of: Depression, Insomnia, Schizophrenia, Psychosis; Goal: Resident will remain free of drug related side effects through next review date and Interventions: Medicate as ordered; Monitor behavior and mood changes. Review of the Demographic Face Sheet for Resident #2 documented the resident was admitted on [DATE] with a diagnosis of encephalopathy, diabetes mellitus, cerebral infarction, major depressive disorder, bipolar disorder, glaucoma, hypertension, anxiety disorder and psychosis. Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] for Resident #2 documented the resident's Mental Status (BIMS) Summary Score was 03, indicating severe cognitive impairment and he required supervision with setup help only for adls (activities daily living). Review of the Physician's Order Sheets (POS) and Medication Administration Records (MAR) dated February 2023 for Resident #2 documented the resident was receiving the following medications: Divalproex Sodium DR 500mg tab 2 tabs PO HS for seizures; Risperidone 0.5mg tab 1 tab PO BID for psychosis; Haloperidol 0.5mg tab 1 tab PO in the morning for psychosis and Mirtazapine 7.5mg tab 1 tab PO HS for depression. Review of Resident's #2 Psychotropic meds care plan dated 7/14/22 documented the resident was at risk for drug related side effects due to use of psychotropic meds for the diagnosis of: Anxiety, Major Depressive Disorder, Bipolar Disorder, Psychosis; Goal: Resident will remain free of drug related side effects through next review date and Interventions: Medicate as ordered; Monitor behavior and mood changes. Review of Federal Immediate Report dated 2/15/23 documented the following: Date/Time of Incident: 2/15/2023 3:15 PM; Type of Incident: Abuse; Who has been notified: Resident Representative, Abuse Registry; Law enforcement not notified; Description of Incident: On 2/15/23 at 15:20 a resident who is alert and oriented times three reported to staff when passing by room [ ] he observed [ ] Resident #2 on top of resident [ ] Resident #1 hitting him in his face. Residents were immediately separated from each other and placed on one to one supervision. [ ] Resident #2 states that he hit his roommate because he called him a [ ] and this made him upset. [ ] Resident #1 said he gave [ ] Resident #2 the tv remote control and he was called a [ ]. [ ] Resident #1 told to not call him a [ ] and went to his bed. [ ] Resident #2 climbed on top of [ ] Resident #1 and hit him. [ ] Resident #2 suffered no injuries and [ ] Resident #1 has scratches on his face with minimal bleeding. First aide was given. [ ] Resident #1 voiced no concerns for his safety and exhibits no change in behavior related to the incident. Administrator was notified. Residents placed on a one to one. Review of the Abuse Log dated February 2023-October 2023 documented the following: Dated 2/15/23, APS ID Date Called Time Called: 2/15/2023 6:15?, Accepted/Rejected: Answer Blank, Allegations: Resident to Resident. The abuse log dated for the incident on 2/15/23 documented the date, the time it was reported had a question mark and if the report was accepted or rejected, the answer was blank. All other abuse allegations on the abuse log were completed with the date, time, the person's name and ID (identification) number who took the report of the abuse and if the abuse report was accepted or rejected at the abuse registry. On 10/03/23 at 11:05 AM, interview with the Administrator/Abuse Coordinator. She stated, I called the abuse in because the abuse registry online was down. I don't have proof that the call was made. On 10/03/23 at 11:55 AM attempted to interview Resident #2 but the resident did not answer. On 10/03/23 at 12:13 PM via telephone with Administrator and local state abuse registry agency representative #1. She stated, I can't confirm or deny whether a call was received for abuse. I will transfer you to my supervisor. On 10/03/23 at 12:18 PM via telephone with Administrator and local state abuse registry agency supervisor representative #2. She stated, I can't confirm or deny whether a call was received for abuse. If an abuse report is accepted or rejected, it is put into the system. The Administrator was asked by the local state abuse registry agency supervisor representative #2 did she write down the person's name and ID number who took her report over the phone, and she stated, No, I didn't. On 10/03/23 at 1:10 PM interview with the Administrator/Abuse Coordinator. She stated, They were roommates at the time. [ ] Resident #1 called [ ] Resident #2 a [ ]. [ ] Resident #2 was on top of [ ] Resident #1 and started hitting him. Staff was walking by their room and saw them in action and broke them up. [ ] Resident #2 said he slapped the guy because he don't like the word. [ ] Resident #2 was sent to the hospital for aggressive behavior. [ ] Resident #1 said he didn't have any hard feelings but if he came back that he didn't want him to be his roommate. When [ ] Resident #2 came back they were placed in different rooms. [ ] Resident #1 was discharged to an ALF (assisted living facility). The administrator/abuse coordinator reported, I report abuse when I get them. Abuse is supposed to be reported in two hours. This was not reported to Law Enforcement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review and policy review, the facility failed to provide adequate pain control management for 1 (Resident #102) out of 1 sampled resident for pain management. The findings included: The facility's policy Pain Management issued 03/2020 reveals The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. On 02/20/2023 at 10:12 AM during the initial observation and interview Resident #102 stated he had pain in his right hip and left shoulder. He stated he had a patch on his left shoulder, but the shoulder especially was hurting. During observation and interview on 02/21/2023 at 9:00 AM, Resident #102 again stated he had pain in his left shoulder. Resident #102 was initially admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease, Pain in Left Shoulder, and Hyperlipidemia. The quarterly Minimum Data Set (MDS) with an assessment reference date of 01/11/2023 revealed a Brief Interview of Mental Status (BIMS) score of 14 out of 15 which indicated intact cognition. Review of the resident's care plan revealed Resident #102 has potential for alteration in comfort related to (r/t) limited mobility, Left Shoulder pain. Care plan with revised date of 10/27/2022 with an intervention of observe for effectiveness of pain intervention, report acute pain or pain that is not relieved with intervention to MD (Medical Doctor) as needed. A review of the Electronic Health Record (EHR) revealed the resident was being seen by a pain management nurse practitioner since 05/08/2021. Percocet 5/325 milligrams (mg) every 8 hours as needed (PRN) for pain had been on the Physician's orders as far back as 12/11/2020 when the EHR began on this resident. The most recent pain management note in the EHR which was dated 01/26/2023 revealed follow up pain management chronic pain Plan 1. Percocet 5/325 mg po (by mouth) q (every) 8 hours PRN 2. will continue to follow patient seen and examined by . A review of the resident's medications was done and there was no Physician order for Percocet. The Percocet was discontinued on 01/10/2023. Resident #102 has an order for acetaminophen 325 mg give 2 tablets orally every 6 hours as needed for temperature above 100 degrees/mild pain. Use for pain scale 1-3. On 02/23/2023 at 10:35 AM an interview was conducted with the Director of Nurses (DON). The DON stated the Percocet was discontinued because it was a pharmacy recommendation on 12/27/2022 to discontinue Oxycodone PRN because he did not use the medication and it did not have a stop date on it. The primary physician's nurse practitioner (NP) was consulted to discontinue the medication, not the pain management NP so the pain management NP was unaware that it was discontinued. Additional interview with Resident #102 on 02/23/2023 at 10:41 AM revealed the resident had pain in the left shoulder and the patch was not really helping. He stated he told the nurse the pain was a level 4. Interview with Staff A, Registered Nurse, on 02/23/2023 at 10:45 AM revealed she gave him Acetaminophen 325 mg, 2 tablets earlier for a pain level of 4, but has not had a chance to follow up with him yet to see if it relieved the pain. On 02/23/2023 at 10:50 AM an interview was conducted with DON which revealed the resident had no medication available for a pain level of 4.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide physician ordered adaptive equipment for 1 out of 35 sampled residents (Resident #17). The findings included: Review of the facility's policy titled, Restorative Dining with a revised date of 10/2022 included: Assistive eating devices are utensils people use when they have difficulty eating or drinking independently. These devices are typically used for people with disabilities or people that have low dexterity. The device is placed on each tray or table setting and is available for the resident to use when eating. Record of Resident #17's clinical records revealed the resident was originally admitted to the facility on [DATE] with the most recent readmission date of 10/05/2022; clinical diagnoses included but not limited to Parkinson's Disease and feeding difficulties. Review of Section C for cognitive pattern on the Minimum Data Set (MDS) dated [DATE] revealed that Resident #17 had a Brief Interview for Mental Status of 13, which indicated that she had an intact cognitive response. Review of Section G for functional status of the MDS revealed that Resident #17 had a bed mobility, transfer self-support of limited assistance with support of one-person physical assist, dressing self-performance of extensive assistance with support of one-person physical assist, eating self-performance of supervision with support of setup help only. Review of the Physician's Orders revealed that Resident #17 had an order dated for 10/11/2022 for patient to use double handled sippy cup, weighted utensil, and scoop plate during meals in order to facilitate self-feeding skills. Review of the Care Plan for Resident #17 dated 01/17/2023 revealed a care plan with a focus on the resident is at risk for nutritional and or hydration deficits as evidenced by: at risk for weight loss, due to fair intake of meals and skipping meals. Goals were to meet 75-100% of nutritional and hydration needs over the next review date. Interventions included: Assess/record nutritional status. Encourage/assist to eat as needed. Observe meal consumption. During an observation conducted on 02/20/2023 at 12:30 PM, Resident #17 was in the 4th floor dining room having lunch. On her lunch tray was a scoop plate, and weighted utensils. There was no sippy cup provided to resident with lunch tray, nor did staff offer to obtain a sippy cup for the resident. During an interview conducted on 2/20/2022 at 12:40 PM with Resident #17 when asked about her adaptive equipment for meals, she stated she has Parkinson's and shakes a lot, so they send me a scoop plate and weighted utensils with each meal. She then stated they are supposed to send me a sippy cup, but they don't always send the sippy cup. When asked how often they send the sippy cup, she said less than 50% of the time. During an interview conducted on 02/20/2023 at 12:45 PM with Staff E Licensed Practical Nurse (LPN) when asked if Resident #17 is supposed to have a sippy cup provided with her meals, she replied only if it is ordered for the resident. Staff E verified the meal ticket that revealed Adaptive Devices: Scoop Plate, Sippy Cup, Weighted Utensils. Staff E stated that she would call the kitchen to have a sippy cup sent up for the resident to use with her lunch.

During the QAPI review and interview on 02/23/23 at 10:11 AM it was revealed that the QAPI meeting is conducted on the third Friday of the month. The risk manager is the Administrator. The QAPI members are committee chairperson, administrator, Director of Nursing, Medical Director, Dietary, Pharmacy representative, Social Service, Activities, Environmental representative, Infection control, Rehab, Staff Development, Safety representative and Medical records representative. Based on record review, observations, and interview it was determined that the facility's Quality Assurance and Performance Improvement Activities (QAPI/QAA) failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area as evidenced by repeated deficient practices for F 812- Food Procurement, Store/Prepare/Serve-Sanitary and F 908- Essential Equipment, Safe operating condition. There were 178 residents residing in the facility at the time of this survey. The findings include: Review of the facility's survey history revealed during the recertification and relicensure survey with exit dated 10/29/2021 the facility was cited F 812 and F 908 due to the facility's failure to ensure the proper washing of the dishes and utensils by not having an operable wash tank temperature gauge on the high temperature dish machine. This had the potential to affect 141 out of 169 residents who eat orally residing in the facility at the time of the survey. During this survey with exit dated 02/23/2023 the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by failure to maintain the refrigeration/freezer units in proper working order, failure to properly clean and sanitize food preparation and serving equipment, and failure to hold hot and cold foods at regulatory temperatures. (Reference: F 812 and F 908)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews conducted the facility failed to provide a safe, clean, comfortable, and homelike environment, as evidenced by unclean, disrepair, unkempt environment to include floors, ceilings, bathrooms and furniture. There were 178 residents residing in the facility at the time of the survey. The findings included: During the environment tour conducted on 02/21/2023 at 1:00 PM with the Administrator, Director of Housekeeping, and Corporate Maintenance Director, the following were noted: First Floor: Observation of the main hallway to the Smoking Area, revealed approximately 20 feet of the handrails located on the south side were noted to be loose and falling from the wall. Observation of elevator #2 revealed a large hole in the floor that could be a potential trip hazard to residents and anyone entering the elevator. Second Floor: Observation revealed the entire floor around and behind the second-floor nurses' station to be soiled, stained, and black in color. Observation of the second floor East Wing: The ceiling frame was noted to be rust laden. The second floor dining room had six large windows that were clouded over with a waxy substance and view to outside could not be seen by residents. Observation of the second floors' Community Shower room [ROOM NUMBER]: The toilet seat was detached and falling off the toilet bowl, and the shower stall grout was stained and black in color. Observation of Community Shower room [ROOM NUMBER]: The metal ceiling frame was rust laden, and the floor was soiled and stained. Observation on the second floor Hallway revealed the handrails were detached from the walls between rooms #225 to #227. Observation of room [ROOM NUMBER] revealed the exterior of the 2 room chairs were heavily worn. The room floor was soiled and stained, the privacy curtain (A bed) was soiled and stained, and 1 of 2-bathroom lights was not working. Observation of room [ROOM NUMBER] revealed the Room floor was soiled and stained. During observation of room [ROOM NUMBER], it was noted that the room floor was soiled and stained, the exterior of the 2 overbed tables were worn and wood exposed, and the privacy curtain (A bed) was soiled and stained. Observation of room [ROOM NUMBER] revealed the floor soiled and stained, a large area of the vinyl floor was becoming detached from floor. Observation of room [ROOM NUMBER]: The exterior of the tube feeding pole (A bed) was noted to be soiled and stained, the exterior of the 2 overbed tables were heavily worn with wood exposed, there was a large hole in the wall behind B bed, the room chair exteriors were heavily worn. Observation of room [ROOM NUMBER] revealed the footboard (A bed) was heavily worn with sharp wood exposed and the exteriors of the 2 overbed tables were worn and in disrepair. Observation of room [ROOM NUMBER] revealed the privacy curtain (A bed) was soiled and stained, the vinyl room floor was detached from the floor, and the exterior of the bathroom entry door was damaged and in disrepair. Observation of room [ROOM NUMBER]: The base boards were detached from the room walls, the exterior of the 2 room chairs were heavily worn, and the exterior of the entry door for the bathroom was damaged and in disrepair. Observation of room [ROOM NUMBER]: The privacy curtain (A bed) was soiled and stained, the base boards were falling off from the room walls, the exterior of the bathroom door was damaged and in disrepair, and 1 of 2-bathroom lights not working. Observation of room [ROOM NUMBER]: The armrest of the electric wheelchair (A bed) was heavily worn and torn and in need of replacement (resident requested replacement), the exterior of bathroom entry door was damaged and in disrepair, the base boards in the room were detached from the room wall, and there was no overbed light cord (B bed). Observation of room [ROOM NUMBER]: The privacy curtain was soiled and stained and the exterior of the overbed table (1) was heavily worn, and wood exposed. Observation of room [ROOM NUMBER]: The privacy curtain (1) was soiled and stained, the overbed table was heavily worn wood exposed. Observation of room [ROOM NUMBER]: The privacy curtain (a bed) was too short to flow around the bed and could not ensure privacy. Observation of room [ROOM NUMBER]: A large area of the ceiling in the room had peeling paint and was in disrepair. Observation of room [ROOM NUMBER]: The exterior of the 2 overbed tables were rust laden, and no television cable reception for A bed. Third Floor: Observation of the third-floor dining room revealed six large windows that were clouded over with a waxy substance and view to outside could not be seen by residents. Observation of the third-floor community shower room [ROOM NUMBER], noted the toilet seat not secured to toilet, and 1 of 3 room lights mot working. Observation of the third-floor community shower room [ROOM NUMBER]: The bathroom handrail was detached and falling from the wall in the shower stall, and the room entry door was noted to have large bolts protruding through door that could cause potential injury to residents. Fourth Floor: Observation of the fourth-floor dining room revealed, six large windows that were clouded over with waxy substance and view to outside could not be seen by residents. Observation of room [ROOM NUMBER]: The room floor was soiled and stained, the bathroom floor was soiled and stained, there was a large bolt protruding from the bottom of the bathroom door that was a potential accident hazard to the residents. Observation of room [ROOM NUMBER]: Bathroom light 1/2 was not working, the privacy curtain (A bed) was soiled and stained, and the exterior bathroom door was damaged and in disrepair, Observation of room [ROOM NUMBER]: The exterior of room entry door was damaged and in disrepair, the exterior of the bathroom door was damaged and in disrepair, the 2 overbed tables were heavily worn with wood exposed. On 02/21/2023 at approximately 2:00 PM following the environment tour the findings were again confirmed with the Administrator. It was stated that staff are failing to report the housekeeping/maintenance issues on the Maintenance Logbook that are located at all 3 nurses stations.

Based on observation, interview, and record review, it was determined that the facility failed to follow the approved menu for Regular Diets (94 residents), Mechanical Soft Diet (47 residents), No Added Salt Diet (26 residents), and Low Concentrated Sweets Diet (15 residents), and Pureed Diet (21 residents). The findings included: During the review of the approved menu for the lunch meal of 02/20/2023, the following were documented to be served: 1 Slice Bread and 1 teaspoon Margarine - Regular Diet, Mechanical Soft Diet, No Added Salt Diet, and Low Concentrated Sweets Diet and for Pureed Diets-(2 ounces) Scoop of Pureed Bread and 1 teaspoon Margarine. During the observation of the lunch meal in the second-floor dining room on 02/20/2023 at 12:00 PM, it was noted that bread, pureed bread, and margarine were not served to the 20 residents. Observation of the second and third floor dining rooms noted again that no bread, pureed bread, or margarine were included on the resident lunch trays. The concerns observed during the lunch meal was discussed with the facility's Registered Dietitian and Administrator for their review. Upon review by the facility's Registered Dietitian and Administrator, it was revealed that the bread and margarine were available to any residents however, dietary staff failed to serve the bread, pureed bread, and margarine as per the approved menu to the residents for the meal on 02/20/2023. During the review of the approved menu for the Breakfast meal on 02/21/2023 the following was documented to be served. 4 ounces (#8 scoop) Pureed Cream of [NAME] Cereal 4 ounces (#8 scoop) Pureed Pancakes 4 ounces (#8 scoop) Pureed Scrambled Eggs with Ham During the observation of the breakfast meal conducted in the main kitchen on 02/21/2023 at 7:15 AM it was noted that the steam table did not contain prepared portions of Pureed Cream of [NAME] Cereal, Pureed Pancakes, and Pureed Scrambled Eggs with Ham. Interview with the Food Service Supervisor at the time of the observation revealed that the cook (Staff C) failed to review the approved breakfast menu and the pureed foods were not prepared as per the approved breakfast menu. A review of the facility's diet census for 02/21/2023 noted that there were currently 11 residents with physician ordered Pureed Diets which included sampled Resident #2, Resident # 22, Resident #33, Resident #42, # Resident 79, Resident #80, and Resident #89. During review of the approved menu for the lunch meal on 02/23/2023 the following foods were documented to be served: 4 ounces (#8 scoop) Ground Turkey (Mechanical Soft Diet) 3 ounces Hot Dogs (Alternate Entree) During the observation of the lunch meal in the Main Kitchen on 02/22/2023 at 11:30 AM the following were noted: 2 ounce (#16 scoop) was served for Mechanical Soft Diets 1-ounce Hot Dog was served as the alternate entree Interview with the Registered Dietitian and Food Service Supervisor on 02/22/2023 at 11:45 AM during the time of the lunch meal observation it was revealed that staff were to review the approved menu and were unaware the approved menu documented a 4-ounce serving of Ground Turkey for Mechanical Soft Diet. It was also noted that the alternate entree of Hot Dog was to be a 3-ounce portion.

Based on record review, observation, and interview it was determined that food was not prepared by following standardized recipes to ensure nutritive value, flavor, and appearance for Regular Diet, Mechanical Soft Diet, No Added Sugar Diet, No Concentrated Sweet Diets (141 facility residents) and Pureed Diet (21 Residents) to include sample Resident #2, Resident #22, Resident #32, Resident #42, Resident #79, Resident #80, and Resident #89. The findings included: Review of Standardized Recipe for Scrambled Egg with Ham noted ingredients: 4 gallons, 2 cups of frozen scrambled eggs 1 gallon, 1/2 cup of 2% milk. 1 gallon, 1/2 cup of diced ham. Approved Portion Size = #8 scoop During observation of the breakfast meal in the Main Kitchen on 02/21/2023 at 7:15 AM, it was noted that portions of the entree contained ham pieces while other portions did not contain ham. The scrambled eggs with ham was observed in the steam table and it was noted that there were large/whole pieces of ham and no ground ham. When portioned some of the entree contained large ham pieces while others contained no ham. Interview with the [NAME] (Staff C) at the time of the observation revealed that she did not prepare the entree by use of the standardized recipe and did not utilize ground ham. The cook utilized whole pieced of ham and was not aware that each portion must contain a minimum 2 ounces of ground ham. Additional interview with the Food Service Supervisor also revealed that she was unaware of the recipe and that ground ham must be used for the preparation of the scrambled eggs with ham. Review of the Pureed Frosted Chocolate Cake recipe documented the following ingredients: Frosted Chocolate Cake (21 pieces) and 30 ounces of 2% Milk. During the observation of the lunch meal in the Main Kitchen on 02/22/2023 at 11:30 AM, accompanied by the Food Service Supervisor and Registered Dietitian, the surveyor requested to observe the pureed frosted cake. Upon opening the pureed cake was noted to be in a total liquid form. Interview with the Diet Aide (Staff D) who stated she prepared the cake, reported that she added too much water to the cake mix prior to pureeing. The surveyor asked if she reviewed the recipe for the cake that documented 30 ounces of 2 % milk and Staff D answered no. The Supervisor and Dietitian at the time of the observation stated that the pureed cake was too thin and would not be palatable for residents receiving pureed diet. A review of the Diet Census for 02/22/2023 revealed that there were currently 21 residents with physician ordered Pureed Diet. The 21 residents included sampled Resident #2, Resident #22, Resident #32, Resident #42, Resident #79, Resident #80, and Resident #89.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to follow food preferences for 4 (Resident #12, Resident #33, Resident #104, and Resident #69) out of 12 residents reviewed for nutrition. The findings included: Review of the facility's policy titled, Nutrition and Hydration with a revised date of 06/2021, revealed: The facility will provide a therapeutic diet taking into account the resident's clinical condition and preferences. 1) Review of Resident #12's clinical records revealed the resident was admitted on [DATE] with the most recent readmission dated 02/05/2020. Clinical diagnoses include but not limited to: Type 2 Diabetes Mellitus with Hyperglycemia, Anemia in other Chronic Diseases Classified Elsewhere, and Gastro-Esophageal Reflux Disease without Esophagitis. Review of Section C for cognitive pattern on the Minimum Data Set (MDS) dated [DATE] revealed that Resident #12 had a Brief Interview of Mental Status score of 15, indicating an intact cognitive response. Review of the Section G for functional status revealed that Resident #12 for bed mobility and dressing both had a self-performance of extensive assistance with support of one-person physical assist, eating had a self-performance of supervision with support of setup help only. Review of the Physician's orders for Resident #12 revealed an order dated 10/01/2020 for NAS/NCS (No Added Salt/No Concentrated Sweets) diet, regular texture, regular/thin consistency. Review of Care Plan for Resident #12 revealed a care plan dated 07/19/2021 with a focus indicating the resident has nutritional problem or potential nutritional problem related to non-compliant with NCS, NAS diet, Obesity, no significant weight change, BMI (Body Mass Index) 44.4, morbidly obese. not compliant with NAS, NCS diet, Buying food from outside. Resident continues to order food from outside frequently, complains about facility meals despite interventions to accommodate his food preferences, reports poor appetite. Goals included resident will not develop complications related to obesity, including skin breakdown, ineffective breathing pattern, altered cardiac output, diabetes, impaired mobility through review date. Interventions included: Monitor weights monthly, provide and serve NAS, NCS diet as ordered. Review of the Reaction Note for Resident #12 dated 02/01/2023 included: food allergy with Fish and Strawberries both give resident upset stomach. Review of the Dietary Consult Note for Resident #12 dated 07/08/2022 included: Resident reported he does not care for facility meals and at times will eat maybe one meal a day. Resident visited by dietary representative for meal preferences, however still verbalized dissatisfaction with meals. Staff reported that resident orders food from outside source. Resident reported he has not been doing that lately as he has no funds. Review of the Nutrition/Dietary Note for Resident #12 dated 10/25/2022 included: Visited resident, got grilled cheese sandwich from the kitchen for lunch, said that it is the only thing that he likes eating at the facility, reported that food is not appetizing, gives him diarrhea, orders food from outside frequently. Will speak with dietary and try to accommodate his food preferences as best as possible. During an interview conducted on 02/20/2023 at 3:40 PM with Resident #12, he stated he does not like a lot of the food the facility provides and often wants a cheeseburger, but the facility will not provide one, so he asks for a grilled cheese sandwich with a burger on it, but rarely gets what he asks for. Resident #12 stated that when he asks for the grilled cheese sandwich with a burger they tell him that they do not have any hamburgers, or they cannot make his request. During an observation conducted on 02/21/2023 at 12:53 PM, Resident #12 received 2 grilled cheese sandwiches with hamburger in each grilled cheese sandwich. During an interview conducted on 02/22/2023 at 2:00 PM with Staff B Dietary Supervisor, who stated she was promoted to Dietary Supervisor position from kitchen aid 1 year ago. Staff B stated she does the ordering for the facility twice weekly for delivery on Mondays and Wednesdays. She stated that the facility was always able to provide a hamburger to the residents, they have frozen hamburger patties or fresh hamburger and can make a hamburger patty. 4. During the resident council meeting on 02/21/23 at 03:05 PM, Resident #69 expressed that he asks for a fruit plate, and it is never available. There were 15 residents in attendance and 7 of the 15 agreed that they would like fresh fruit plates. An interview was conducted with the Registered Dietician (RD) on 02/22/23 at 10:23 AM. She stated that they do have fresh fruit plates, and it is on the substitute menu. There are different fruits which depend on the availability of obtaining the fruits from the vendor. They will get watermelon, honey dew, bananas, oranges, and/or strawberries. Upon review of the substitute list for dining, the choice documented indicated a cottage cheese fruit plate. On 02/22/2023 at 2:03 PM the Dietary Supervisor (Staff B) stated that they do not have the cottage cheese available unless a resident asks for a fruit plate before 10:00 AM, then someone can run to the store and buy cottage cheese. The RD and Staff B were asked if they ever attended Resident Council meetings and if they were aware that the residents would like more fresh fruit available. They stated that they were attending meetings for 3 months and were aware. 2) During observation of the lunch meal on 2/20/2023 at 12:00 PM in the third floor dining room, it was noted that Resident #33 was being fed by staff. Further observation noted that the resident's food plate contained only 2 servings of pureed spaghetti, 1 serving of mashed potatoes and 1 serving of pureed carrots. Further observation noted that there was no pureed entree (pureed meatballs) on the main plate. A review of the resident's tray card noted documentation of No Red Meats. During an interview with the Food Service Supervisor on 02/21/2023 at 11:45 AM it was revealed that only the entree stated on the approved pureed menu is prepared and no additional pureed entrees are prepared for the resident's personal preferences. On 02/22/2023 during an interview at 11:45 AM the facility's Registered Dietitian revealed that she was unaware that the resident personal preferences for 'No Red Meats was not followed and further stated that additional pureed entree should be available at all meals to follow residents food preferences. 3) During the lunch meal observation conducted in the main kitchen on 02/22/2023 at 11:30 AM and accompanied with the Food Service Supervisor and Registered Dietitian, it was noted that the lunch tray for Resident #104 did not contain a pureed turkey entrée. The resident was being served only pureed vegetable and mashed potatoes. A review of the resident's tray card documented food preference of no turkey. On 02/22/2023 at 11:30 AM during the lunch meal observation in the main kitchen, the cook (Staff C ) revealed that only the entree listed on the approved menu for pureed diet was prepared. It was further revealed that additional pureed entrees are not prepared for meals to meet resident's personal food preferences. The facility's Registered Dietitian at the time of the observation revealed that she was unaware that the resident was not going to receive a pureed entree of preference and unaware that an additional pureed entree was not being prepared for all meals to meet residents' personal food preferences.

Based on observation, interview, and record review, it was determined that the facility failed to follow physician ordered Double Portion Diet that were a nutrition intervention for weight loss for 17 out of 17 facility residents that included sampled Resident #20, Resident #80, Resident #124, Resident #137, and Resident #166. The findings included: During the observation of the lunch tray assembly line in the main kitchen on 02/22/2023 at 11:30 AM, accompanied by the facility's Registered Dietitian and Food Service Supervisor, it was noted that residents with physician ordered Double Portion Diet were not receiving a double portion of Oven Roasted Turkey (6 ounces protein), Mashed Potatoes, and Carrots. Specifically, the only double portion included on the main plate was a double portion of mashed potatoes. The turkey (3 ounces) and carrots (4 ounces) were all noted to only be a single portion. An interview at 02/22/2023 at approximately 11:35 AM with the cook (Staff D) at the time who was serving the foods on the tray line stated that she thought the only double portion to be served was the mashed potatoes. Staff D further stated that she had not been trained/in-serviced on the serving of Double Portion Diet. Interview with the facility's Registered Dietitian on 02/22/2023 at at approximately 11:38 AM at the time of the meal observation stated that the Double Portions are ordered for residents with weight loss (high calorie, high protein). The Registered Dietitian further stated that the Double Portion Diet included 2 portions of entree, 2 portions of starch, and 2 portions of vegetables for all lunch and dinner meals. The Registered Dietitian also stated that she was unaware that the only double portion being served for lunch and dinner meals was the was the starch portion. A review of the facility's Diet Census for 02/22/23 documentation noted there were currently 17 facility residents with physician ordered Double Portion Diet' that included 5 sampled residents that had nutrition risk/weight loss Resident #20, Resident #80, Resident #124, Resident #137, and Resident #166.

. Based on observations and interviews the facility failed to maintain refrigeration/freezer units in proper working order The findings include: During the initial kitchen/food service observation tour conducted on 02/20/23 at 9:00 AM, accompanied with the Food Service Supervisor (FSS), the following were noted: (a) Observation of the walk-in freezer noted the entrance frame to have black organic matter and rust laden, and the door gasket was heavily torn. The door was also noted to have a heavy build-up of ice. Upon entering it was noted that the motor and fan were encased in ice. The motor was noted to be spraying ice throughout the unit. Cases of unidentifiable foods were noted to be covered and encased in ice. The surveyor requested to the FSS that foods be removed from the freezer and be located in alternate refrigeration units and requested that a licensed refrigeration vendor assess the refrigeration issue. (b) During the observation of the walk-in refrigerator it was noted that the internal motor unit was dripping condensation heavily onto foods located below the motor. It was also noted that the motor was spewing condensation onto other foods stored within the unit. Cases of foods were noted to be drenched in condensation. The surveyor informed the FSS that the foods located within the unit were becoming contaminated by the condensation. The surveyor requested to the FSS that foods be removed from the freezer and be located in alternate refrigeration units and requested that a licensed refrigeration vendor assess the refrigeration issue. (c) Observation of reach-in #1 refrigerator noted that the interior of the unit was pitting and the motor dripping condensation heavily. Foods located within the unit were noted to be wet with the dripping condensation. The surveyor requested that the unit not be utilized until repairs could be made. During a second observation tour of the main kitchen on 02/21/23 at 7:00 AM, accompanied with the FSS; it was noted that the walk-in freezer, walk-in refrigerator, and reach in refrigerator continues to drip condensation and spray and spew condensation and ice throughout the units.

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 as evidenced by failure to maintain refrigeration/freezer units in proper working order, failure to properly clean and sanitize food preparation and serving equipment, and failure to hold hot and cold foods at regulatory temperatures. The findings included: During the initial kitchen/food service observation tour conducted on 02/20/23 at 9:00 AM, accompanied with the Food Service Supervisor (FSS), the following were noted: (a) Observation of the walk-in freezer noted the entrance frame to have black organic matter and rust laden, and the door gasket was heavily torn. The door was also noted to have a heavy build-up of ice. Upon entering it was noted that the motor and fan were encased in ice. The motor was noted to be spraying ice throughout the unit. Cases of unidentifiable foods were noted to be covered and encased in ice. The surveyor requested to the FSS that foods be removed from the freezer and be located in alternate refrigeration units and requested that a licensed refrigeration vendor assess the refrigeration issue. (b) During the observation of the walk-in refrigerator it was noted that the internal motor unit was dripping condensation heavily onto foods located below the motor. It was also noted that the motor was spewing condensation onto other foods stored within the unit. Cases of foods were noted to be drenched in condensation. The surveyor informed the FSS that the foods located within the unit were becoming contaminated by the condensation. The surveyor requested to the FSS that foods be removed from the freezer and be located in alternate refrigeration units and requested that a licensed refrigeration vendor assess the refrigeration issue. (c) Observation of reach-in #1 refrigerator noted that the interior of the unit was pitting and the motor dripping condensation heavily. Foods located within the unit were noted to be wet with the dripping condensation. The surveyor requested that the unit not be utilized until repairs could be made. (d) Observation of food preparation skillets (frying pans = 9) were noted to be covered in a thick layer of carbon. The surveyor informed the FSS that the carbon could possibly result in food contamination when the pans a heated. The surveyor requested that the skillets/pans be discarded as soon as possible. (e) Observation of the [brand] industrial food chopper and blender was reported by the FSS to be clean and ready for use however, further observation noted approximately an inch of fluid in the bottom of the unit. The surveyor informed the FSS that the unit must be turned upside down after cleaning/sanitizing and air dried prior to next use. The surveyor requested that the unit not be used until it is properly cleaned, sanitized, and internal dried. (f) Observations of the kitchen noted 3 cleaning rags left on food preparation and serving surfaces. The surveyor requested that the rags be store in a chemical sanitizing solution when not in use. (g) A container located within the reach-in #2 refrigerator was noted to have a yellow food substance. The container was dated 02/15/2023 and did not contain documentation of what the food was. The FSS stated that she thought the food was pudding, however, should have been discarded with 72 hours. (h) The utility drawer observed contained food portioning equipment. Further observation noted that the serving spoons and scoops were placed in all directions and not placed in a sanitary manner to ensure that staff would handle only by the handles. The surveyor requested that the serving utensils be rewashed and sanitized and placed in the drawer in a sanitary manor. (i) Observation revealed Staff G had three packed bags on foods. Upon further investigation it was revealed that the 3 bags contained sandwiches for residents leaving the facility for medical appointments. The bags were noted to contain egg salad sandwiches (2) and cheese sandwich (1) It was revealed that the perishable sandwiches were to be transported with the residents were not in an insulated container with commercial ice packs to ensure that the sandwiches maintained the regulatory 41 degrees F or below. Staff G stated that the sandwiches would be transported at room temperature in a zip lock bag. (j) Observation of the commercial slicer revealed the unit was not properly cleaned after the last use. The unit was noted to have areas of dried food matter around the blade's exterior and base. The surveyor requested that the unit be properly cleaned and sanitized prior to the next use. 2) During a second observation tour of the main kitchen on 02/21/2023 at 7:00 AM, accompanied with the FSS, the following were noted: (k) Food temperatures were taken by the Food Service Supervisor with the facility's calibrated bayonet food thermometer. The results of the temperature testing revealed that hot foods were not being held at the regulatory temperature of 135 degrees Fahrenheit (F) or higher and cold foods were not being held at the regulatory temperature of 41 degrees F or below. The following was noted: Waffles (40 portions) = 110 degrees F Pancakes (40 portions) = 115 degrees F Orange Juice (50 - 4-ounce portions) = 55 degrees F Thickened Orange Juice (10 - 4-ounce portions) = 50 degrees F (l) During the observation it was noted that the walk-in freezer, walk-in refrigerator, and reach in refrigerator continues to drip condensation and spray and spew condensation and ice throughout the units.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement comprehensive care plans related to falls for one resident ( Resident #47) and impaired skin integrity for one resident ( Resident # 123) out of fourteen residents whose care plans were reviewed. There were 169 residents admitted to the facility during the survey. The findings Included: 1. Record review revealed, Resident #47 was admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses to include but were not limited to: Parkinson's disease, history of falling, altered mental status, unspecified, age-related nuclear cataract unspecified eye, insomnia unspecified, presence of intraocular lens, and unspecified disorder of refraction During observation on 10/26/21 at 08:11 AM Resident#47 was in low positioned bed, the call light was on the bed and bilateral floor mats noted under the bed. On 10/27/21 at 09:24 AM Resident #47 was observed in the bathroom receiving AM care being performed by Certified Nursing Assistant (CNA) Staff A. The bilateral floor mats were observed partially under the bed (Photo Obtained). On 10/28/21 at 08:04 AM, Resident #47 was observed laying on the right side of bed, attempting to get out of bed. The bed was in low position and the bilateral floor mats were partially under the bed (photo obtained). Staff A, CNA was present in the room and stated that Resident #47 does that when she is ready to go to the bathroom. Staff A, CNA then assisted Resident #47 to the bathroom. On 10/29/21 at 08:05 AM Resident #47 was observed in bed. The bed was in the lowest position and bilateral floor mats present on sides of bed. Review of Resident # 47's Minimum Data Set (MDS) quarterly assessment dated [DATE]: Section C-for cognitive pattern documented a Brief Interview of Mental Status (BIMS) Score of 7 out of 15 indicating Resident #47 is severely cognitively impaired. Section E- Behavior, documented no behavior symptoms present, no indicators of psychosis. Section G-for functional status indicated limited assistance with one person assistance for Activities of Daily Living (ADL). Section H- Resident #47 always continent of bowels and occasionally incontinent of bowels. Section J-Health conditions indicate no presence of pain, Received no scheduled pain medication regimen within the past five days. Section O- Resident received Occupational therapy from 11/7/2021-11/20/2021 and Physical therapy from 7/27/21 to currently. Section P-No restraints used on resident. Review of Resident # 47's Care Plan dated 7/9/21 revealed the focus to be: Resident is at risk for falls related to impaired mobility, unsteady gait and decline in visual status. Goals: Resident will be free of fall related injuries by next review date. Interventions: Assist resident with transfers and mobility, bilateral floor mats, call light in reach while in room, check at frequent intervals to monitor for unsafe actions and intervene promptly, clutter free environment, ensure proper footwear, keep bed in lowest position, Instruct/ remind to call for assistance with all transfers, pharmacy to review medications and re-educate resident on the importance of using the call bell. Review of the facility's incident log dated 10/26/21 revealed Resident #47 had falls on 7/20/21, 8/6/21, and 9/19/21. Review of Resident's #47 nurses' progress notes revealed on 9/19/21-Resident #47 was found on floor sitting upright next to bed with right arm leaning on bed. Resident # 47 was placed back into bed, no injuries noted, Full range of motion. no open skin, bleeding or deformity noted. Further review of documentation revealed Resident #47's primary physician was called, and voicemail left. Resident # 47's Nurse Practitioner was called, and new orders were given for bilateral hip X rays and neurological checks to be done. Resident #47 family member was informed about the resident's condition. Documentation dated 8/6/21 for the 7:00 AM to 3:00 PM shift note Resident awake and alert out of bed to chair no complains heard at this time no signs of acute distress noted. Resident refuse to stay in one place, kept moving around, Resident was placed at the nursing station for close supervision. 2:00 PM Resident #47 went back to her room, PM care given, and snacks offered, Resident #47 ate 100%. 3 PM -11 PM around 4:30 PM while in the hallway I heard a sound at the nursing station it was Resident #47 on the floor at the nursing station. Some old bruises all over the body no new finding noted able to move all extremities. Resident help back to chair with help. Resident's Nurse Practitioner was present, Nurse Practitioner assessed resident #47 and ordered X-ray of left arm. 8:30 PM x-ray completed, awaiting the result, Resident #47 help back to bed, no complains, no signs of acute distress noted. On 7/20/21 when taking Resident #47 blood pressure, several bruises were observed on Resident #47's left upper arm, left breast, and right hip. Resident's Nurse Practitioner was called, and an order was received for an x-ray, family notified Interview on 10/29/21 at 08:06 AM with Registered Nurse, Fourth Floor Unit Manager, (Staff C). Staff C states she is aware that resident has fallen at least one time in a couple of weeks. Staff C reported that she is an as needed employee and is not usually in the facility every day and was aware that the resident has to have bilateral floor mats and bed in lowest position while in bed. Staff C explained that usually when Resident #47 is not in bed the resident is monitored at the nursing station. On 10/29/21 at 08:13 AM during an interview regarding the resident's plan of care, Resident #47's primary nurse, Licensed Practical Nurse (LPN), Staff B reported that; Resident #47 requires total care, usually answers to her name and is usually trying to get out of bed. Staff B, LPN stated : we take her to activities or to the nursing station to be watched and the CNAs rotate monitoring her every thirty minutes depending on their assignments. I am aware that she fell maybe a month ago, I believe she fell out of bed on the floor mats, she did not have any injuries and she had x-rays, she has bilateral floor mats in her room and her bed is always supposed to be in the lowest position when she is bed. Sometimes she listens when you tell her to stay in bed to be safe and you stay with her a little bit. During an interview on 10/29/21 at 08:26 AM, Staff A, CNA was asked about the Resident #47's plan of care. Staff A stated: I am aware that the resident is at risk for falls, and I know she fell in the past, I was not here, I heard she fell so when I work, once I finish with her breakfast and do AM care I put her in her Geri chair and bring her to the nursing station, when she is in bed I know that she has to have floor mats on both side of the bed and her bed has to be in lowest position, the resident is very active, likes to read and color but she is not stable on her feet, when we do put her at the nurses station and give her something to do, she does very well. Review of the facility's policy on Reporting Accidents and Incidents dated 3/2020 revealed: The facility will identify each resident at risk for accidents and/or falls and adequately plan care and implement procedures to prevent. 2. During observation of Resident #123's bilateral feet wound dressings on 10/29/21 at 2:50 PM, Staff F, a Certified Nursing Assistant was asked to lift the resident's sheet so the dates on the dressings could be observed. The dressings were observed to be dated 10/27/2021. It was observed that the residents feet were directly on the residents sheet and mattress. The residents feet were not on a pillow or off loaded with another device. During the record review, it was noted that the resident was admitted to the facility on [DATE] with diagnoses that included, Cerebral Infarction, Hemiplegia, Hemiparesis and Contractures. The residents care plans documented, that the resident was at risk for impairment to skin integrity due to immobility, decreased mobility, fragile skin, contractures, hemiplegia, weakness, anemia, acute kidney failure and dermatitis. The last date on the care plan was 08/13/2021. The goal was for the resident not to develop any alteration in skin integrity through the next review date unless unavoidable due to multiple predisposing risk factors and clinical conditions. The care plan interventions included: Float/offload heels. The care plan was not followed as demonstrated during the 10/29/2021, 2:50 PM observation. On 10/29/2021 at 3:00 PM, the Director of Nurses was notified about the finding.

Based on observations, interviews and policy review the facility failed to assure the garbage and refuse area was clean and expired water jugs were properly disposed and contained on the facility grounds. The findings included: Record review of the Dietary-Disposal of Garbage and Rubbish Policy and Procedure dated 3/01/21 documented: Policy-It is the policy of the facility to provide care and services related to the disposal of garbage and rubbish in accordance with State Requirements; Procedures-2) Garbage should be disposed of in rubbish containers, which have plastic liners and lids; 7) Dumpsters should be emptied according to the facility contract; garbage should not accumulate or be left outside the dumpster. Observation of the garbage and refuse area with the Food Service Director/Consultant on 10/27/21 at 7:52 AM. The area had three garbage bins with two used for garbage and one for recyclables. There were 60 crates with two one gallon jugs of expired water in each on the ground. The date 11/01/21 was printed on the water jugs and were soon to be outdated. The crates were scattered on the ground. The expired waters were not contained in a garbage bin. Photographic evidence submitted. On 10/27/21 at 7:53 AM, interview with the Food Service Director/Consultant. She stated, The Maintenance Director put these crates out here on yesterday. The new water was rotated and the expired water was brought out here. The crates should not have been on the ground. They should have been in the garbage bin. On 10/27/21 at 7:55 AM, interview with the Maintenance Director. He stated, This is garbage. This is not supposed to be on the ground. I put it out here on yesterday. I will get rid of it.

Based on observations, interviews and record review the facility failed to ensure the proper washing of the dishes and utensils by not having an operable wash tank temperature gauge on the high temperature dish machine. This has the potential to affect 141 out of 169 residents who eat orally residing in the facility at the time of the survey. The findings included: Record review of the manufacturer temperatures for high temperature dish machine operating temperatures were documented: Wash 150-160 degrees Fahrenheit (F); Pumped Rinse 160 degrees F and Final Rinse 180-195 degrees F. Observation of the high temperature dish machine on 10/28/21 at 9:23 AM with Staff H [NAME] and the Food Service Director/Consultant revealed wash dial was at 110 degrees F and the final rinse dial was at 180 degrees F. Staff H [NAME] revealed the wash temperature should be at 160 degree F. Staff H [NAME] placed several more trays with cups and dishes to be washed through the dish machine and the wash dial did not move, it stayed at 110 degrees F and the final rinse dial was at 180 degrees F. Several more cycles were conducted and the wash dial stayed at 110 degrees F and the final rinse dial was at 180 degrees F. The Food Service Director/Consultant revealed the wash temperature should be at 160 degrees F. The Food Service Director/Consultant immediately stopped the dish machine and called the service tech company to come to the facility and service the dish machine. Review of the Dish Machine Temperature Log documented for the month of October 2021 documented the wash temperature was 160 degrees F and the final rinse was 180 degrees F for breakfast, lunch and supper. On 10/28/21 at 11:42 AM, the Food Service Director/Consultant notified the surveyor that the dish machine wash dial was now at 130 degrees F. Observation of the high temperature dish machine on 10/28/21 at 11:56 AM, revealed the wash dial was still at 110 degrees F. The Food Service Director/Consultant revealed that she had the dietary staff wash all the dishes, cups, silverware in the 3 compartment sink by hand. She did not want to serve the lunch meal on disposable because the resident's preferred the food to be hot, hot and the disposable did not keep the food as hot. Observation and interview on 10/28/21 at 12:01 PM, with the dish machine tech. He was observed servicing the dish machine. He stated, The heaters are blown on the machine. I was here a week and half ago and the serviced the dish machine. I will need to replace the heater. It should be done by later this afternoon. Refer to photographic evidence. Review of the Dish machine Repair Company Invoice dated 10/28/21 documented the following: Dish machine was check. Elements for the wash tank are blown. All use of the dish machine needs to be stop, till further notice. A replacement part will be order. ASAP (as soon as possible). Observation and interview on 10/29/21 at 7:57 AM, with the Food Service Director/Consultant. The dish machine was not in operation. She stated, The part for the dish machine had to be ordered on yesterday and is supposed to be delivered this morning. The tech will be coming later this morning to install the part. We have decided to use disposable wear for meals instead of washing everything in the 3 compartment sink. I in-serviced the staff on yesterday on how to properly use the dish machine. Subsequent interview with the Food Service Director/Consultant at 12:26 PM revealed the part for the dish machine had not been delivered and would be coming from another state. Meals would continue to be served on disposable wear until the new part is installed in the dish machine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure complete and accurate medical records for one (Resident #17) out of thirty five residents whose records were reviewed as evidenced by failure to ensure documentation of medication administered was complete and accurate in the resident Medication Administration Record (MAR). The findings included: Interview with Resident # 17 on 10/28/21 at 12:20 PM revealed the her problem with the medications has to do with her blood pressure medications. Resident #17 reported an incident in May and another in August when they held her blood pressure medications and told her blood pressure was too low. Resident # 17 stated, I think they just did not have the medication and this is the reason I did not get it. Record review of the census record revealed Resident #17 was admitted to the facility on [DATE] with multiple diagnoses including Hypertension. Record review of Resident #17's Minimum Data Set (MDS) dated [DATE] revealed her BIMS (Brief Interview for Mental Status) score was 13 out of 15 which reflects intact cognitive status. Record review of the physician's orders revealed Resident #17 orders for blood pressure medications included Verapamil 120 (milligram) SR (slow release) capsule every 12 hours, Metoprolol 50 mg ER (extended release) tablet once daily, and Clonidine 0.1 mg tablet three times per day. Record review of Resident #17 'S MAR for May 2021 revealed the Metoprolol ER was signed off as given every day in May 2021. The MAR was not initialed to indicate the medications were all administered on 5/2/21 and 5/9/21. This included the 2100 dose of Verapamil and the 1700 dose of Clonidine. Further review of the May 2021 MAR revealed Resident # 17 did not receive any of her medication ordered during the 3:00 PM to 11:00 PM shift on 5/2/21 an 5/9/21. Review of the MAR for August 2021 indicated Resident # 17 received all of her medications a ordered. Interview with Licensed Practical Nurse (LPN), Staff G on 10/29/21 at 9:34 AM revealed there should be a note in the nursing progress note to indicate the reason the resident did not receive the medication and that the system prompts the nurse to write a progress note any time a medication is not administered. Record review of the nursing progress notes for May 2021 revealed no notes to indicate why the medications were not administered as ordered. Interview with the Director of Nursing (DON) on 10/29/21 at 2:30 PM revealed, I was able to speak to the nurse who was scheduled to work 5/2/21 and 5/9/21. She worked a double shift on 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shifts on 5/2/21 and 5/9/21 she signed off all of Resident # 17 'S medication on the 7:00 AM to 3:00 PM shift, but she failed to sign off the medications administered on the 3:00 PM to 11:00 PM shift. She did report to me that there is no way Resident # 17 would ever go to bed without getting her medications, she would be looking for me and she would refuse to go to bed without making sure she took her medication. She keeps close track of all of her medications. The LPN stated she failed to sign off on the MAR for the medications administered on the 3:00 PM to 11:00 PM shift. Review of the facility policy and procedure titled Documentation in the Medical Record dated 6/2020 revealed: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate and timely documentation . Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. Documentation shall be completed at the time of the service, but no later than the shift in which the assessment, observations, or care service occurred.

Based on observations, interviews and record review the facility failed to ensure the high temperature dish machine wash cycle was working properly. This has the potential to affect 141 out of 169 residents who eat orally residing in the facility at the time of the survey. The findings included: Record review of the manufacturer temperatures for high temperature dish machine operating temperatures were documented: Wash 150-160 degrees Fahrenheit (F); Pumped Rinse 160 degrees F and Final Rinse 180-195 degrees F. Observation of the high temperature dish machine on 10/28/21 at 9:23 AM with Staff H [NAME] and the Food Service Director/Consultant revealed wash dial was at 110 degrees F and the final rinse dial was at 180 degrees F. Staff H [NAME] revealed the wash temperature should be at 160 degree F. Staff H [NAME] placed several more trays with cups and dishes to be washed through the dish machine and the wash dial did not move, it stayed at 110 degrees F and the final rinse dial was at 180 degrees F. Several more cycles were conducted and the wash dial stayed at 110 degrees F and the final rinse dial was at 180 degrees F. The Food Service Director/Consultant revealed the wash temperature should be at 160 degrees F. The Food Service Director/Consultant immediately stopped the dish machine and called the service tech company to come to the facility and service the dish machine. Review of the Dish Machine Temperature Log documented for the month of October 2021 documented the wash temperature was 160 degrees F and the final rinse was 180 degrees F for breakfast, lunch and supper. On 10/28/21 at 11:42 AM, the Food Service Director/Consultant notified the surveyor that the dish machine wash dial was now at 130 degrees F. Observation of the high temperature dish machine on 10/28/21 at 11:56 AM, revealed the wash dial was still at 110 degrees F. The Food Service Director/Consultant revealed that she had the dietary staff wash all the dishes, cups, silverware in the 3 compartment sink by hand. She did not want to serve the lunch meal on disposable because the resident's preferred the food to be hot, hot and the disposable did not keep the food as hot. Observation and interview on 10/28/21 at 12:01 PM, with the dish machine tech. He was observed servicing the dish machine. He stated, The heaters are blown on the machine. I was here a week and half ago and the serviced the dish machine. I will need to replace the heater. It should be done by later this afternoon. ( Refer to photographic evidence). Review of the Dish machine Repair Company Invoice dated 10/28/21 documented the following: Dish machine was check. Elements for the wash tank are blown. All use of the dish machine needs to be stop, till further notice. A replacement part will be order. ASAP (as soon as possible). Observation and interview on 10/29/21 at 7:57 AM, with the Food Service Director/Consultant. The dish machine was not in operation. She stated, The part for the dish machine had to be ordered on yesterday and is supposed to be delivered this morning. The tech will be coming later this morning to install the part. We have decided to use disposable wear for meals instead of washing everything in the 3 compartment sink. I in-serviced the staff on yesterday on how to properly use the dish machine. Subsequent interview with the Food Service Director/Consultant at 12:26 PM revealed the part for the dish machine had not been delivered and would be coming from another state. Meals would continue to be served on disposable wear until the new part is installed in the dish machine.