**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4) A record review on 10/14/24 09:19 AM revealed that Resident#1 was admitted to the facility on [DATE] with diagnoses that included Agitation, Anxiety, Depressive disorder, Mental disorder, Dysphagia, GERD, Intracerebral hemorrhage, Psychosis, Seizures, and Unspecified cerebral artery occlusion with cerebral infarction. The Brief Interview for Mental Status (BIMS) score was 0 on the Minimum Data Set (MDS) assessment Quarterly assessment dated [DATE]; this indicated that Resident #1 had severe cognitive impairment. This MDS assessment also showed that Resident #1 was administered antipsychotics on a routine basis for anxiety and depression. According to Resident #1's Physician's orders, she was on Diazepam since 09/17/24 (5 mg twice a day for anxiety), Mirtazapine since 02/06/24 (30 mg at bedtime for depressive disorder), and Quetiapine since 02/06/24 (50 mg every 8 hours for Depression). These are psychotropic medications. Resident #1's care plan dated 08/08/24 stated that Resident #1 was at risk for adverse side effects related to use of psychotropics. The interventions for that problem included to monitor for confusion and sedation, and to monitor for moods and behavioral patterns. The MD (Medical Doctor) was to be notified of any significant changes. In addition, the care plan stated that Resident #1 has a history of periods of agitation and resistance of care at times. The specified goal was that the resident's mood state would not interfere with daily life functioning. The interventions included to monitor mood state and to report changes to appropriate disciplines. Another care plan for Resident #1 stated that the resident had the potential for symptoms of mood disorders; the interventions included to monitor mood state and to report the changes to the appropriate disciplines. A review of the Behavior Monitoring for Psychotropic Meds report beginning 09/01/24 and ending 10/13/24 showed no documentation of behavior monitoring on 09/03/24, 09/10/24, 09/11/24, 09/16/24, 09/18/24, 09/24/24, 09/25/24, 09/27/24, 09/28/24, 09/29/24, 09/30/24, 10/05/24, 10/06/24, 10/08/24, 10/09/24, and 10/11/24. Photographic evidence obtained. 3) Record review for Resident #73 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Coronary Artery Disease; Diabetes Mellitus, type II; Venous Insufficiency; Vertigo. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #73 had a Brief Interview for Mental Status (BIMS) of 13, which indicated that he was cognitively intact. Review of Section N revealed that Resident #73 was on an antidepressant. Review of the Physician's Orders showed that Resident #73 had an order dated 08/22/24 for Cymbalta (Duloxetine) capsule 20mg for Depression. Review of the Physician's Orders showed that Resident #73 had an order dated 09/09/24 for Remeron (Mirtazapine) tablet 7.5mg for Appetite loss. Review of the Physician's Orders for Resident #73 did not include orders for side effects monitoring and no orders for behavior monitoring for psychotropic medications. Review of the Care Plan dated 08/27/24 documented that Resident #73 is at risk for adverse side effects related to (r/t) use of psychotropic medication due to diagnosis: Depression and Adjustment Disorder with Anxiety. The goal for the resident was to have no injury related to the medication usage and/or side effects through the review date. The interventions included: Administer medication as ordered; Report any negative observation to MD; Monitor for confusion and sedation; Monitor moods and behavioral patterns; Gradual dose reduction as needed. Review of the Nursing Note/assessment dated from 08/22/24 to 10/08/24 revealed no documentation of side effects or behavior being monitored for Resident #73. An interview conducted on 10/11/24 at 10:15 AM with DON. She stated residents on psychotropic medications are monitored for behaviors only if the behavior is observed, and then documented by the nursing management under the Behavior Monitoring Flow Sheet (BMFS) in the computer system. She also stated if the resident has not shown any behavior changes, there will not be a BMFS in the resident's chart. 2) Record review for Resident #79 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Paraplegia, Intracranial Injury with Loss of Consciousness, and Sequela. Review of the Minimum Data Set for Resident #79 dated 10/03/24 documented in Section C a Brief Interview of Mental Status score of 15 indicating a cognitive response. Review of the Nurse Progress Notes for Resident #79 from 09/01/24 to 10/14/24 revealed no documentation of behaviors being monitored. Review of the Behavior Monitoring Flow Sheet for Resident #79 from 09/01/24 to 10/14/24 revealed no Behavior Monitoring Flow Sheet. Review of the Physician's Orders for Resident #79 revealed an order dated 06/27/24 for Mirtazapine (Remeron) 15 mg oral at bedtime for Major Depressive Disorder. Review of the Care Plan for Resident #79 dated 10/04/24 with a problem of resident is at risk for adverse side effects related to use of psychotropic medication Diagnoses Anxiety and Depression. The goal was for the resident to have no injury to medication usage/side effects through next review date. The interventions included monitor for confusion and sedation, Monitor moods and behavioral patterns. Notify MD of any significant changes. Gradual dose reduction as needed. During an interview conducted on 10/14/24 at 9:25 AM with the Director of Nursing who stated she has worked at the facility for 6 years. When asked about behavior monitoring for residents on psychotropic medications, she stated If resident is receiving a psychotropic medication, the resident would be monitored for behaviors, and this would be documented on the behavior monitoring flow sheet or it could be documented in the nursing progress notes. They only document if the resident is having behaviors, they do not document if the resident has no behaviors. They chart by exception. When asked about monitoring behaviors for Resident #79 the DON acknowledged there was no Behavior Monitoring Flow Sheet for the resident. The DON also acknowledged there were no Nursing Progress Notes for the resident that document with information specifically pertaining to behaviors. When asked if they have any facility policy indicating they document by exception, she said no. During an interview conducted on 10/14/24 10:44 AM with Staff D Consultant Pharmacist, since May 2024. When asked when a resident is on psychotropic medication, does he check if the resident is being monitored for behaviors, he stated yes, he does, he believes they chart by exception. If they have no Behavior Monitoring Flow Sheet, he would assume the resident is not having any behaviors. When asked about an example of a Behavior Monitoring Flow Sheet for Resident #79 which documented an outcome code as same, and then improved and was asked what this indicates, he said I would not know. It was noted that this improved behavior documentation did not specify which behavior this resident experienced and what had improved. During an interview conducted on 10/14/24 at 11:22 AM with Staff E, Registered Nurse who stated she has worked at the facility for 2.5 years. Staff E was asked if a resident is receiving a psychotropic medication does she document for behaviors. She stated yes, if resident is screaming or fighting with staff, she would document this on the note (Nursing Progress Note) for the day. When asked about documenting on a behavior monitoring flow sheet, she said no she does not use this. Based on observations, interviews, and record review, the facility failed to monitor the behaviors of residents who are receiving psychotropic medications for 4 of 5 sampled residents reviewed for unnecessary medication (Resident #94, Resident #79, Resident #73, and Resident #1). The findings included: A review of the facility ' s policy titled Use of Psychotropic Medication revised in October 2022 revealed the following: Resident are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnoses and documented in the clinical record, and medication is beneficial to the resident, as demonstrated by monitoring and documentations of the resident ' s response to the medications. 1) Record review revealed that Resident #94 was admitted to the facility on [DATE] with diagnoses of Mild Dementia, Major Depressive Disorder, and Type 2 Diabetes. The Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #94 has a Brief Interview of Mental Status (BIMS) score of 11, indicating moderately cognitively impaired. A review of a Physician 's order revealed an order for Zoloft (antidepressive medication) 25 milligrams daily, which was dated 09/03/24. In an interview conducted on 10/11/24 at 1:00 PM with Resident #94, it was revealed that she did not remember seeing a psychologist for her anxiety and depression. She is currently not having any symptoms of anxiety and anxiousness. Review of the care plan, which started on 09/10/24, revealed the following: Resident #94 had psychosocial anxiety with the goal of not having the anxiety interfere with daily life functions. Interventions are in place to administer appropriate medications as ordered and monitor for effectiveness of medications-a care plan for psychosocial behaviors with interventions to monitor for changes/severity of behavioral symptoms. Further review revealed a care plan, which started on 09/10/24, for psychosocial-mood documented, with interventions in place: Monitor mood state and report changes to appropriate disciplines. Administer medications as ordered. Monitor the effectiveness of medications. A review of the Behavior Monitoring Flow Sheet did not show that any behavior monitoring was done for Resident #94 since admission on [DATE]. Record review revealed that Resident #94 was seen by a psychologist on 10/9/24 for situational depression and major depressive disorder. A review of the progress notes completed by nursing did not show any documentations regarding behavior monitoring. In an interview conducted on 10/11/24 at 1:05 PM with Staff C, a Registered Nurse (RN) she stated that any behaviors observed of the residents are documented in the progress notes for every medication that was administered to them. This included behavioral examination and observation of the patient for any signs of agitation, anxiety, and extreme depression that she defined as being quiet and sleepy. She further reported that if no behaviors are observed she documents as stable. In this interview, Staff C did not mention any Behavior Monitoring Flow Sheet. In an interview conducted on 10/11/24 at 1:15 PM with Staff A, RN, she stated that residents on psychotropic medications are being monitored for behaviors and documented on a specific behavior flow sheet that she created herself. Nursing supervisors fill out that particular behavior flow sheet, but the bedside nurse observes. In an interview conducted on 10/11/24 at 1:20 PM with the facility's Director of Nursing, the director stated that the behavior flow sheet is completed only when a resident has a present behavior. When behaviors are present, they are documented in the progress notes (narrative) and noted as stable. In an interview conducted on 10/11/24 at 1:23 PM with Staff A, she acknowledged that Resident #94 did not have a completed behavioral flow sheet since admission on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and chart review, the facility, failed to provide the correct diet consistency, for the Pureed diet observed during 2 of 2 observations for Resident #34. This had the potential to effect 10 residents on a Pureed diet. The findings included: A review of the International Dysphagia Standardization Initiate (IDDSI) Descriptions provided by the facility's Speech Therapy Pathologist revealed the following: Pureed diet level 4: falls off the spoon when tilted. It continues to hold its shape in a plate. It cannot be drunk from a cup or sucked from a straw. It can be molded and does not require chewing. It has no lumps or stickiness. A chart review showed that Resident #34 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Bipolar Disorder, and Depression. The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score indicating Resident #34 is rarely understood. In an observation conducted on 10/07/24 at 12:43 PM, Resident #34 was observed eating her lunch meal in her room. The meal ticket was noted to have the following: pureed chicken, mashed potatoes, pureed broccoli, pureed bread, and pureed cobbler. The meal plated was noted with pureed chicken, mashed potatoes, pureed broccoli, pureed cobbler, and pureed bread, noted with lumpy pieces and not having one uniform consistency (photographic evidence obtained). In an observation conducted on 10/08/24 at 8:43 AM, Resident #34 was eating her breakfast tray in the room. The breakfast tray consisted of pureed fortified oatmeal, pureed cheese omelet, pureed ham, and pureed bread, which was noted to have lumps and not one uniform consistency (photographic evidence obtained). In an interview conducted on 10/14/24 at 8:25 AM with Staff B, the Speech-Language Pathologist, it was stated that the pureed diet should be smooth and creamy with no solid particles. It should not have any lumps or pieces. According to Staff B, most of the pureed foods are bought by an outside company, and only certain food items are prepared in-house. In an interview conducted on 10/14/24 at 9:10 AM, the Food Service Director stated that Pureed bread is not bought from an outside company and is made in-house. She further said that 10 residents are on a pureed diet. When photographic evidence of the pureed diet was shown, she acknowledged that it was not within the guidelines of a pureed diet consistency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to ensure a resident's wound dressings were changed timely and as per physician orders for 1 of 1 sampled residents reviewed for skin conditions (Resident #5). The findings included: Review of the facility's policy titled Skin Integrity-Skin Tears implemented on 01/09/23 with no revision date documented, it is the policy of this facility to provide proper treatment and care to maintain skin integrity .licensed nurses will conduct skin assessments .RNs (Registered Nurses) and LPNs (Licensed Practical Nurses) will participate in the management of skin tears .by following physician orders, assessment of residents . Review of Resident #5's clinical record documented an admission date to the facility on [DATE] with no readmissions. The resident diagnoses included Renal Insufficiency, Hypertension, Metabolic Encephalopathy, Chronic Kidney Disease, Anemia, Atrial Fibrillation, Congestive Heart Failure, and Infection of the skin- subcutaneous tissue. Review of Resident #5's Minimum Data Set (MDS) annual assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 15, indicating that the resident had no cognition impairment. The assessment documented under Functional Status that the resident needed extensive assistance with most of his Activities of Daily Living and total assistance from the staff with transfers via a mechanical lift. Review of Resident #5's physician order dated 07/16/23 documented wound care orders dressing /ointment type: dry dressing: wound location and care instructions: cleanse healing skin tear left lower leg and right lower leg with normal saline, pat dry, apply xeroform gauze, cover with dry dressing every third day and as needed (prn) until resolved. Review of Resident #5's care plan titled, Resident's skin will remain without skin integrity compromise initiated on 04/05/23 and revised date on 07/05/23 documented an intervention that read .assess skin daily .monitor skin during care for red or open areas and notify the nurse . The care plan did not address actual wounds. On 07/24/23 at 12:10 PM, an interview was conducted with Resident #5 in his room who stated no concerns with the care provided. The resident was accompanied by an aide and were playing a table game. Resident #5 stated that the aide was his private aide (PA) who had been with him for two years. Observation revealed a dressing on the resident's right leg dated 07/19/23, and a dressing on his left lower leg. The surveyor was unable to see the left leg dressing date because he was sitting and facing the aide. The resident stated that he was taking blood thinners and his skin was thin from the blood thinners. The PA stated the resident loves to put bandages on his skin. The PA was asked to state the date on the resident's left lower leg and stated it was dated 07/19/23. On 07/26/23 at 9:33 AM, observation revealed Resident #5 in bed and he continued to have a right leg dressing dated 07/19/23 and had a dressing on his left lower leg dated 07/25/23. Subsequently, a joint interview was conducted with the resident and his PA. The PA stated that the nurse changed the resident dressing on his left leg but did not see the dressing on the right leg. During the interview, Staff E, Licensed Practical Nurse (LPN) came into Resident #5's room and stated she was there to say hello to the resident. Consequently, an interview was conducted with Staff E who stated that she did not do the resident's dressing change on 07/25/23. Staff E was apprised of the right leg dressing dated 07/19/23 and stated that the dressing was for protection maybe and offered to remove it. Observation revealed Staff E performed hand hygiene, donned gloves, and removed Resident #5's right leg dressing dated 07/19/23. Staff E, LPN stated the skin tear was healed. Observation revealed a small scratch like skin mark. The removed dressing had a piece of xeroform gauze in it. Staff E confirmed that the piece of xeroform gauze was in the dressing removed. 0n 07/26/23 at 9:43 AM, an interview was conducted with Staff B, Registered Nurse (RN) who stated there was nothing on Resident #5's right leg and added that all that the nurse needed to do was remove the dressing and discontinue the order. Staff B was apprised that the dressing on his right upper leg (thigh) and left lower leg, were dated 07/19/23 when the observation was made on 07/24/23. On 07/26/23 at 9:52 AM, a joint interview was conducted with Staff B, RN, Staff E, and the Assistant Director of Nursing (ADON). The ADON confirmed that Resident #5's physician order's frequency for the right leg and left leg was to be changed every third day and should have been changed on 07/22/23. Staff E confirmed that the right leg dressing was dated 07/19/23 and the left leg dressing was dated 07/25/23. The ADON was apprised that the right leg dressing was on for 7 days and the left leg dressing was changed 6 days rather than every third day as ordered. On 07/26/23 at 10:08 AM, a side by side review of Resident #5's clinical record was conducted with Staff B, RN/Unit Manager. Staff B confirmed that the resident's physician orders dated 07/16/23, included wound care orders dressing /ointment type: dry dressing: wound location and care instructions: cleanse healing skin tear left lower leg and right lower leg with normal saline, pat dry, apply xeroform gauze, cover with dry dressing every third day and prn (as needed) until resolved. Continued review revealed that Resident #5's wound care documentation for 07/22/23 documented skipped by the nurse on duty for the day. Staff B stated that the dressing change was not done on 07/22/23. Further review revealed that the resident's dressing changed on 07/25/23 was not documented. On 07/26/23 at 10:27 AM, an interview was conducted with Staff E, LPN who stated she took the physician orders for Resident #5's wound care for the right and the left leg, but that somehow did not prompt the nurses to do it. On 07/26/23 at 3:09 PM, an interview was conducted with the MDS Coordinator who stated that Resident #5's annual assessment dated [DATE] documented that the resident had skin tear (s) during the review. On 07/27/23 12:03 PM, surveyor was approached by the Director of Nursing (DON) who stated that the facility did meet with the managers and the wound care nurse, and that they were addressing the dressing change problem. The DON was apprised that Resident #5's dressing on both legs were in place for over 6 days and the physician orders were to change it every third day. The DON was informed that the dressings were dated 07/19/23 for both legs, and the left leg dressing was changed on 07/25/23 but the right leg dressing was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide the tube feeding regimen according to the Physician ' s orders for 1 of 2 sampled residents reviewed for tube feeding (Resident #66). The findings included: In an observation conducted on 07/25/23 at 7:30 AM, Resident #66 was noted with the tube feeding Isosource 1.5 (tube feeding formulary) running at 55 ml (milliliters) an hour. Closer observation showed that the tube feeding was started at 4:00 PM, the night before and was at the 800 ml mark out of a 1500 ml capacity bag. The tube feeding mark showed that 700 ml of tube feeding was infused during the night. In an observation conducted on 07/25/23 at 8:07 AM, the breakfast tray was brought into Resident #66's room. The breakfast tray showed a sliced cheese omelet, ground ham, white toast, and grits. Closer observation showed that the tube feeding was still running with Isosource 1.5 (tube feeding formulary) at 55 ml (milliliters) an hour. In this observation, Resident #66 said, I am not hungry. Upon continued observation at 8:18 AM, Resident #66's tube feeding was still running with Isosource 1.5 at 55 ml an hour. The breakfast tray was noted to be 100% untouched. At 8:50 AM, the tube feeding was still running in the room while Resident #66 was trying to eat her breakfast tray. Resident #66 ate a few bites of her breakfast tray. In an observation conducted on 07/26/23 at 8:13 AM, Resident #66 was trying to eat her breakfast tray in her room. Closer observation showed the tube feeding was still running at 55 ml an hour. The tube feeding bag was at the 800 ml mark out of a 1500 ml capacity bag. This showed that 700 ml of formulary was given instead of the 880 ml as ordered by the Physician. Continued observation at 8:22 AM showed that the tube feeding was turned off, and Resident #66 did not eat anything on her breakfast tray. At 8:40 AM, the breakfast tray was still 100% untouched. A record review showed that Resident #66 was readmitted on [DATE] with severe malnutrition and respiratory failure diagnoses. An order was noted for tube feeding continuously every 16 hours to start at 4:00 PM and stopped at 8:00 AM to provide 880 ml dated 07/14/23-diet order for mechanical soft ground dated 03/30/23. A nutrition progress note dated 06/06/23 showed that the tube feeding order meets 74% (percent) of Resident 66's daily caloric needs and 78% of Resident #66's daily protein needs. Resident #66 ' s estimated caloric requirements range between 1785 to 2024, and estimated protein needs range between 77 to 102 grams of protein. The care plan showed that Resident #66 is at risk of unintended weight loss in nutrition parameters due to total dependence on Enteral Feeding (delivering nutrition straight to your stomach or small intestines) for fluids and hydration. A caloric daily intake was conducted on 04/04/23 for the three daily meals, which showed that Resident #66 was eating 30% of her caloric needs and 38% of her protein needs. In an interview conducted on 07/26/23 at 12:10 PM with Staff A, Registered Nurse (RN), it was stated that Resident #66 tolerates her tube feeding well. The tube feeding runs from 4:00 PM the night before until 8:00 AM the next day for 16 hours. When asked why the tube feeding was running past 8:00 AM while Resident #66 was eating her meals, she said that the tube feeding pump would beep when it was done, and that is when she turned the tube feeding off. Staff A further reported that it is okay for the tube feeding to run while the Resident eats her meals. In an interview conducted on 07/26/23 at 12:20 PM, Staff B Registered Nurse (RN) stated that it is not best practice to run tube feeding while a resident eats. She further said that the tube feeding should have stopped while Resident #66 was eating her lunch meals. In an interview with Staff D, Registered Dietitian, on 07/27/23 at 8:45 AM, stated that Resident #66 Tube feeding runs 16 hours starting at 4:00 PM and stopping at 8:00 AM running at 55 ml an hour. She adjusts the tube feeding based on how well the Resident eats, and Resident #66 sometimes fluctuates. She was only eating 10% to 30% of her meals for a while. This is why she based her needs from the tube feeding on the higher end of needs. She further stated that you should run the tube feeding at a different time than Resident #66 is eating her meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide food accommodating resident preferences, choices, and tolerances. The facility did not follow its menu regarding food portion sizes during multiple dining observations for Resident #74, Resident #148, Resident #14, Resident #55, Resident #20, and Resident #71. The findings included: A review of the facility's 4-week menu cycle revealed the following: Tuesday's menu showed lunch served was had roast beef (3 ounces), gratin potatoes, green beans, and a soft roll. For Wednesday, the menu showed lunch served was glazed pork loin, baked potato, and mixed vegetables. 1. Resident #74 was admitted to the facility on [DATE] with a diagnosis of Stroke and Hypertension. The Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview of Mental Status (BIMS) score of 09, indicating mild to severe cognitive impaired. The diet order showed a mechanical soft cardiac heart healthy dated 10/2/122. In an observation conducted on 07/25/23 at 8:07 AM, Resident #74 was eating his breakfast meal. Closer observation revealed a meal ticket, documenting 6 ounces of grits, 2 ounces of eggs, ground ham, and a slice of white bread. Further observation revealed Resident #66's tray did not have the 6 ounces of grits as noted on his meal ticket. 2. Resident #148 was admitted to the facility on [DATE] with a diagnosis of Diabetes and Severe Obesity. The MDS assessment dated [DATE], showed a BIMS score of 15, indicating cognitively intact. Diet order noted for cardiac heart-healthy carbohydrate control dated 07/24/23. In an observation conducted on 07/25/23 at 8:44 AM, Resident #148 was in his room with a breakfast tray. His meal ticket showed a diet for cardiac carbohydrates controlled with eggs, white toast, coffee, and sugar packets. In this observation, Resident #148 stated that they gave him sugar packets on his tray and that he has diabetes. A review of the facility's week-at-a-glance menu breakdown showed that on the carbohydrate-controlled diet, sugar substitutes would be provided instead of sugar packets. 3. Resident #14 was admitted to the facility on [DATE] with diagnoses of Dementia and Parkinson's disease. The MDS dated [DATE] lacked documentation of a BIMS score. The order noted for regular diet dated 03//02/22. In an observation conducted on 07/24/23 at 12:15 PM, Resident #14 was noted with a lunch tray. Closer observation showed a regular diet meal ticket with 3 ounces of roast beef. The lunch plate was noted with two round slices of roast beef. In an interview conducted on 07/25/23 at 3:50 PM, Staff C, Registered Dietitian, stated that for the lunch menu, the roast beef is sliced and placed on the scale to ensure that each slice is 3 ounces. When asked by the surveyor of why some residents received two round pieces of roast beef and some residents received one portion, she said that they might be less than 3 ounces, and if they looked smaller, they would provide two pieces. 4. Resident #55 was admitted to the facility on [DATE] with a diagnosis of Anemia and Diabetes. The MDS assessment dated [DATE] with a BIMS score of 14, which is cognitively intact. Diet order for cardiac, carbohydrate controlled dated 03/01/22. In an observation conducted on 07/24/23 at 12:10 PM, Resident #55 was noted with her lunch tray. Closer observation showed a lunch plate that consisted of 1 slice of round roast beef and potatoes. The meal ticket showed Resident #55 has a cardiac carbohydrate-controlled diet with 3 ounces of roast beef. 5. Resident #20 was admitted to the facility on [DATE] with diagnoses of Diabetes and Hypertension. The MDS assessment dated [DATE] with BIMS score of 13, indicated the resident cognitively intact. Diet order noted for carbohydrate control diet dated 03/01/22. In an observation conducted on 07/24/23 at 12:13 PM, Resident #20 was noted with her lunch tray. Closer observation showed a lunch plate that consisted of 1 slice of round roast beef. The meal ticket showed that Resident #20 has a carbohydrate-controlled diet with 3 ounces of roast beef. Another observation was conducted on 04/26/23 at 8:12 AM, Resident #20 was eating her breakfast meal. The meal ticket showed a diet for carbohydrate control with 4 ounces of juice and sugar substitute. Closer observation showed 4 ounces of juice on the breakfast tray and 8 ounces of regular hot chocolate. 6. Resident #71 was admitted to the facility on [DATE] with a diagnosis of Dementia and Kidney Stones. The MDS assessment dated [DATE] has a BIMS score of 08, indicating moderate to severe cognitive impairment. Diet order noted for a regular diet; send side gravy/sauce with the meal and omit the baked ham and roast pork dated 02/11/23. In an observation conducted on 07/25/23 at 12:25 PM, Resident #71 was noted in the room with his lunch tray. The tray showed a tuna sandwich and one soft roll. Closer observation showed a meal ticket for a tuna salad sandwich, soft roll, and ½ cup of mixed vegetables, which was not on the tray. In an interview conducted on 07/25/23 at 3:50 PM with Food Service Director, it was stated that there is one staff member that is assigned to the tray line to ensure that the appropriate food items are placed on the correct diet trays. Any food items listed on the meal ticket will be on the tray unless the resident request something different it will write in pen on the meal ticket.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 1 (South Wing) of 2 residential wings. The findings included: During the Environment Tour conducted on 03/21/22 at 8 AM, and 03/22/22 at 3 PM, accompanied with Administrator, and Infection Control Perfectionist, the following were noted: room [ROOM NUMBER]: (a) Window Shade (1 of 2) - noted to be heavily soiled with large areas dried red/matter. (b) Window (1 of 2) - noted the window film was peeling off the entire surface area . (c) Room Clock- located on wall, noted not to be working - time on clock was 9 AM. (d) Bathroom - noted emergency call cord was wrapped around wall hand rail . Could not be activated when attempting to activate due to the cord wrapping. (e) Bathroom - noted large soaked towel on floor - no staff noted in the room. (f) Above bed wallboard - noted wall board located over B-bed to have large areas of dried tape. (g) Ceiling tiles (2) - located in center of room was noted to have large areas of stained/dried red/brown matter. (h) Room Walls - areas of peeling paint and unknown areas of dried matter. room [ROOM NUMBER] - Noted bathroom floor area around the toilet was in disrepair and heavily worn. room [ROOM NUMBER] - Noted bathroom floor area around the toilet was in disrepair and heavily worn. Full urinal located on overbed table next to breakfast tray. room [ROOM NUMBER] - The over bed light cord was out of reach for the resident residing in the B-bed due to the position of the bed. The bathroom emergency call cord was wrapped twice around the wall hand rail. The light could not be activated due to the cord wrapping. Photographic evidence obtained for all examples.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide fingernail grooming for 1 of 1 sampled residents reviewed for activities of daily living (Resident #38). The findings included: Review of the facility's policy titled, Providing Nail Care, revised on 01/12/21, documented the following: Assessments of resident nails will be conducted on a regular basis to determine condition of the resident's nail condition, needs, and preferences for nail care, if possible. Routine cleaning and inspection of nails will be provided during activities of daily living (ADL) care on an ongoing basis. Routine nail care, to include trimming and filing, will be provided on a regular schedule. Nail care will be provided between scheduled occasions as the need arises. Review of the Certified Nurse Assistant (CNA) job description documented that CNAs were to assist patients with tending to personal care and activities of daily living, including bathing, grooming and eating. Review of the record documented that Resident #38 was admitted to the facility on [DATE] with diagnoses which included: Atrial Fibrillation, Hyperlipidemia, Hypertension, and Pulmonary Fibrosis. Review of Section C of the admission Minimum Data Set (MDS) dated [DATE] documented that Resident #38 had a Brief Interview for Mental Status score of 15, which indicated that he was cognitively intact. Review of Section G of the admission MDS dated [DATE] documented that Resident #38 required limited assistance with one person physical assist for personal hygiene. Review of the Care Plan dated 01/19/22 documented that Resident #38 required limited assistance with personal hygiene related to muscle weakness. Goals were for Resident #38 to be cleaned, groomed, and free of odor daily. Interventions were to assist him with ADLs and shower three times a week. During an observation conducted on 03/21/22 at 11:46 AM, Resident #38 was observed with long fingernails that were about 1/4 inch past the tips of his fingers. Closer observation showed that there was black residue underneath his fingernails. When asked about his fingernails, Resident #38 stated, I want them cut. I have asked them so many times but they don't cut them. During an observation conducted on 03/21/22 at 2:04 PM, Resident #38 was still observed with long fingernails that were about 1/4 inch past the tips of his fingers. Closer observation showed that there was still black residue underneath his fingernails. When asked about his fingernails, Resident #38 stated No one came to do anything. During an observation conducted on 03/22/22 at 8:40 AM, Resident #38 was still observed with long fingernails that were about 1/4 inch past the tips of his fingers. Closer observation showed that there was still black residue underneath his fingernails. Resident #38 asked the surveyor to ask a staff member to come cut his fingernails During an observation conducted on 03/22/22 at 2:44 PM, Resident #38 was still observed with long fingernails that were about 1/4 inch past the tips of his fingers. Closer observation showed that there was still black residue underneath his fingernails. During an observation conducted on 03/22/22 at 5:49 PM, Resident #38 was still observed with long fingernails that were about 1/4 inch past the tips of his fingers. Closer observation showed that there was still black residue underneath his fingernails. During an observation conducted on 03/23/22 at 8:56 AM, Resident #38 was still observed with long fingernails that were about 1/4 inch past the tips of his fingers. Closer observation showed that there was still black residue underneath his fingernails. Resident #38 stated that he still wanted his fingernails cut and asked the surveyor if staff were going to cut his fingernails. During an observation conducted on 03/23/22 at 11:21 AM, Resident #38 was still observed with long fingernails that were about 1/4 inch past the tips of his fingers. Closer observation showed that there was still black residue underneath his fingernails. Resident #38 stated that he still wanted his fingernails cut. During an interview conducted on 03/23/22 at 11:32 AM, Staff A, CNA, stated that all CNAs were responsible for cutting/cleaning residents' fingernails. She further stated, If they are in your assignment, then you're responsible for cutting their nails. Staff A stated that she checked fingernails once a week to see if they needed to be cleaned/cut. She further stated that if a resident asked to have their fingernails cut, she would cut them and if she was busy, she would tell the resident that she would come back later in the day to cut their fingernails. According to her, no residents had asked for their nails to be cut. When asked about Resident #38, she stated that he had not asked for his nails to be cut. Staff A then accompanied the surveyor to look at Resident #38's fingernails. Staff A acknowledged that they were long and stated, Yes, they need to be cut. During an interview conducted on 03/23/22 at 12:18 PM, the Director of Nursing (DON) stated that CNAs were responsible for cleaning/cutting fingernails. She stated that documentation of fingernail care refusal was kept at the nursing station on a census. The DON then accompanied surveyor to ask Staff B, Registered Nurse/Unit Manager, for documentation of fingernail care refusal. Staff B stated that she did not have it and that she gave it to the Assistant Director of Nursing (ADON). During an interview conducted on 03/23/22 at 12:40 PM, the ADON reviewed the Nail Care Audit dated 03/08/22 with the surveyor which showed that there was no documentation that Resident #38 refused fingernail care. The surveyor informed the ADON of the findings and the ADON stated that Resident #38 will sometimes refuse fingernail care. When asked for documentation of fingernail care refusal, the ADON stated that the Nail Care Audit dated 03/08/22 was the only form that she had and that if Resident #38 had refused, staff should have documented it on there. Review of all notes under the Notes tab in Epic (electronic charting system) dated 03/01/22 - 03/23/22 showed that there was no documentation of Resident #38 refusing fingernail care. During an interview conducted on 03/23/22 at 12:57 PM, the DON stated that she did not have any notes at this time showing that Resident #38 refused fingernail care. During an interview conducted on 03/23/22 at 2:16 PM, the DON stated that that she did not have any notes at this time showing that Resident #38 refused fingernail care. On 03/24/22 at 8:30 AM, the DON approached the surveyor and provided the surveyor with a handwritten form which documented that Resident #38 refused nail care on Sunday. Closer observation showed that there was no date to indicate on which Sunday nail care was refused. During an interview conducted on 03/24/22 at 8:53 AM, Resident #38 was asked if he refused nail care on Sunday (03/20/22). Resident #38 stated, I actually asked them to cut my nails on Sunday. I didn't refuse. When asked if he refused fingernail care over the weekend, Resident #38 stated that he did not refuse nail care over the weekend and that he has never refused fingernail care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and review of policy and procedure, it was determined that the facility failed to 1) ensure that it dated and properly labeled the oxygen tubing for 3 of 3 sampled residents observed receiving oxygen therapy (Resident #20, Resident #80 and Resident #52. And, 2) failed to ensure that it properly administered ordered oxygen therapy as per physician order for 1 of 3 sampled residents observed, Resident #20. The findings included: Review of the facility policy and procedure on 03/24/22 at 10:45 AM for Standard Practice Oxygen Therapy Techniques provided by the Director of Nursing (DON) reviewed February 2021 indicated Policy: Oxygen therapy devices will be set-up and used under the following guidelines. Purpose: to provide safe, effective Oxygen therapy in an effort to therapeutically raise arterial oxygen tension Aerosol Devices. Indications 1) Aerosol devices are employed to deliver a particulate mist to the tracheobronchial tree in an attempt to correct a humidity deficit 11) All aerosol devices from flowmeter to, and including resident connector will be changed once a week. Aerosol device and drainage bag are to be dated when changed Review of the facility policy and procedure on 03/24/22 at 10:51 AM for Medication Administration (Oxygen as a medication for administration) provided by the (DON) effective July 2015 indicated Policy---to administer medications in a safe and effective manner . Review of the facility policy and procedure on 03/24/22 at 11:13 AM for Standard Practice Oxygen Therapy provided by the (DON) updated March 2021 indicated Policy: Oxygen therapy will be provided by the Respiratory Therapy Department to residents in Memorial Manor in response to verbal or written orders from attending physicians under the following guidelines. Purpose: to describe the routine methods of delivery of oxygen and the goals of the Respiratory Therapy Department for providing safe, effective therapy. Procedure: 1. orders for Oxygen therapy must comply with accepted standards set by the policy concerning physicians orders of Respiratory Therapy 3. All aerosol devices will be changed on Monday by the 7-3 shift personnel. Review of facility licensed Respiratory Therapist job description on 03/24/22 at 11:26 AM dated 09/15/21 indicated for patients with Cardiopulmonary Disorders. Responsibilities: delivers and assesses response to ordered therapy per plan of care. Monitors, documents and communicates patient condition as appropriate. Evaluates respiratory care policies and procedures based on patient outcomes, current research, and best practices Assesses patient condition and delivers appropriate treatment. Review of facility licensed Unit Manager Nurse job description on 03/24/22 at 11:47 AM indicated that they manage the daily operations of the assigned departments. Job responsibilities: Assesses the quality of patient care delivered. Evaluates needs of patients and families and provides patient and family centered care . Review of facility licensed nurse job description on 03/24/22 at 12:07 PM revealed a Job Summary: Provides direct resident care using the nursing process in or/as supervised and delegated by a registered nurse, provides direct resident care in accordance with applicable scope and standards of practice and with the policies, values and mission of the organization. Job responsibilities: plans, implements and evaluates resident care based on assessment to optimize outcomes and maximizes available resources. Monitors, records and communicates resident condition as appropriate or contributes to the assessment of patients by collecting data for analysis. Performs plan of car interventions .Performs treatments and administers medications in accordance with established policies and procedures. Collaborates as needed across disciplines to coordinate resident care .Administers medications .and all treatments in accordance with established policy and procedure. 1) During an observational screening tour conducted on 03/21/22 at 12 PM Resident #20 was noted to have oxygen infusing at two (2) liters per minute via oxygen concentrator, but there was no label or date noted on the oxygen tubing as to when it was last changed by facility staff. Photographic evidence obtained of Resident #20's oxygen tubing with no label or date noted. Resident #20 was admitted to the facility on [DATE] with diagnoses which included Dementia, Coronary Artery Disease and Hypertension. She had a Brief Interview Mental Status (BIM) score of 0. (severely impaired). On 03/21/22 at 1:59 PM, Resident #20 was noted to have oxygen infusing at two (2) liters per min via oxygen concentrator, but there was still no label or date noted on the oxygen tubing as to when it was last changed. On 03/22/22 at 10:14 AM, Resident #20 was noted to have oxygen infusing at two (2) liters per min via oxygen concentrator, but there was still no label or date noted on the oxygen tubing as to when it was last changed. On 03/22/22 at 2:36 PM, Resident #20 was noted to have oxygen infusing at two (2) liters per min via oxygen concentrator, but there was still no label or date noted on the oxygen tubing as to when it was last changed. On 03/23/22 at 9:52 AM, Resident noted to have oxygen infusing at 2 liters per min via oxygen concentrator, but there was still no label or date noted on the tubing as to when it was last changed. On 03/23/22 at 10:02 AM, a computerized record review conducted of the Resident #20's current physician's orders dated 11/26/21 which indicated Oxygen therapy routine method of oxygen administration: Nasal cannula administer two (2) liters/minute; keep oxygen saturation % greater than 92% continuous. On 03/23/22 at 10:24 AM, record review of Resident #20's nursing care plan dated 10/01/19 indicated Problem: the resident was at risk for respiratory difficulties related to limited mobility. Interventions: Administer oxygen as needed. Medications as ordered. Goal: resident will be managed with interventions in place through next review date. 2) During an observational screening tour conducted on 03/21/22 at 12:04 PM Resident #80 was noted to have oxygen infusing at two (2) liters per min via oxygen concentrator, but there was no label or date noted on the oxygen tubing as to when it was last changed by facility staff. Resident #80 was admitted to the facility on [DATE] with diagnoses which included Traumatic Brain Injury, Hemiplegia/Hemiparesis, Seizures and Bipolar Disorder. She had a Brief Interview Mental Status (BIM) score of 15 (cognitively intact). Photographic evidence obtained of Resident #80's oxygen tubing with no label or date noted on it. On 03/21/22 at 2:01 PM Resident #80 was noted to have oxygen infusing at two (2) liters per min via oxygen concentrator, but there was still no label or date noted on the oxygen tubing as to when it was last changed. On 03/22/22 at 10:15 AM Resident #80 was noted to have oxygen infusing at two (2) liters per min via oxygen concentrator, but there was still no label or date noted on the oxygen tubing as to when it was last changed. On 03/22/22 at 2:38 PM Resident #80 was noted to have oxygen infusing at two (2) liters per min via oxygen concentrator, but there was still no label or date noted on the oxygen tubing as to when it was last changed. On 03/23/22 at 9:57 AM Resident #80 was noted to have oxygen infusing at two (2) liters per min via oxygen concentrator, but there was still no label or date noted on the oxygen tubing as to when it was last changed. On 03/23/22 at 10:07 AM, Resident #80's current physician's orders dated 11/26/21 which indicated Oxygen therapy routine method of oxygen administration: Nasal cannula administer two (2) liters/minute; keep oxygen saturation % greater than 92% continuous. On 03/23/22 at 10:32 AM, record review of Resident #80's nursing care plan dated 10/01/19 indicated Problem: the resident was at risk for respiratory difficulties related to limited mobility. Interventions: Administer oxygen as needed. Medications as ordered. Goal: resident will be managed with interventions in place through next review date. On 03/23/22 at 12:36 PM, an interview was conducted with Staff C, a Licensed Practical Nurse (LPN) and with Staff B, a Registered Nurse (RN)/Unit Manager (UM), regarding the Resident #20 and Resident #80's oxygen tubing undated/unlabeled and they both acknowledged that the resident's oxygen tubings should have been labeled and dated as to when they were last changed by staff; this was not done. 3) During an observational screening tour conducted on 03/21/22 at 12:38 PM Resident #52 was receiving oxygen at two (2) liters via oxygen concentrator, but with no label or date noted as to when the oxygen tubing was last changed by facility staff. Resident #52 was admitted to the facility on [DATE] with diagnoses which included Intracerebral Hemorrhage, Psychosis, Agitation, Anxiety and Depressive Disorder. She had a Brief Interview Mental Status (BIM) of (severely impaired). Photographic evidence obtained of Resident #52's oxygen tubing with no label or date noted on it. On 03/22/22 at 12:22 PM, Resident #52 was receiving oxygen at two (2) liters via oxygen concentrator, but still with no label or date noted as to when the oxygen tubing was last changed. On 03/22/22 at 3:20 PM, Resident #52 was receiving oxygen at two (2) liters via oxygen concentrator, but still with no label or date noted as to when the oxygen tubing was last changed. On 03/23/22 at 10:28 AM, Resident #52 was receiving oxygen at two (2) liters via oxygen concentrator, but still with no label or date noted as to when the oxygen tubing was last changed. On 03/23/22 at 11:18 AM, an interview was conducted with the facility's Respiratory Therapy Director, regarding the Resident #52's oxygen tubing should be changed every week and he further acknowledged that none of the resident's oxygen tubings had dates on them to directly indicate exactly when they had been changed by Respiratory staff; this was not done. On 03/23/22 at 11:24 AM Resident #52's current physician's orders dated 11/26/21 which indicated Oxygen therapy routine method of oxygen administration: Nasal cannula administer two (2) liters/minute; keep oxygen saturation % greater than 92% continuous. On 03/23/22 at 11:36 AM, record review of Resident #52's nursing care plan dated 10/01/19 indicated Problem: the resident was at risk for respiratory distress due to shortness of breath/wheezing/cough. Interventions: assess respiratory status. Ongoing oxygen and respiratory treatments as needed per medical doctor (MD) order. Goal: will have no respiratory distress through next review date. On 03/23/22 at 12:40 PM, an interview was conducted with Staff E, a Registered Nurse (RN) and with Staff B, a Registered Nurse (RN)/Unit Manager (UM), regarding the Resident #52's oxygen tubing undated/unlabeled and they both acknowledged that the resident's oxygen tubing should have been labeled and dated as to when it was last changed by staff; this was not done. 4) During an observational screening tour conducted on 03/22/22 at 10:14 AM Resident #20's oxygen was not noted to be infusing into the resident as ordered. The end of the resident's oxygen tubing was not attached/connected to the oxygen concentrator to allow the resident to receive her ordered infusion of oxygen therapy from the machine, which was on and currently running. On 03/22/22 at 02:36 PM, Resident #20 was noted to not be receiving her ordered oxygen. The end of the resident's oxygen tubing was still not attached/connected to the oxygen concentrator machine to allow the resident to receive her ordered infusion of oxygen therapy from the machine which was still on and currently running. On 03/23/22 at 10:02 AM, a computerized record review conducted of the Resident #20's current physician's orders dated 11/26/21 which indicated Oxygen therapy routine method of oxygen administration: Nasal cannula administer two (2) liters/minute; keep oxygen saturation % greater than 92% continuous. On 03/23/22 at 10:24 AM, record review of Resident #20's nursing care plan dated 10/01/19 indicated Problem: the resident was at risk for respiratory difficulties related to limited mobility. Interventions: Administer oxygen as needed. Medications as ordered. Goal: resident will be managed with interventions in place through next review date. On 03/23/22 at 10:50 AM, an interview was conducted with the facility's Respiratory Therapy Director, regarding Resident #20's oxygen therapy tubing not connected and not being infused as ordered and he acknowledged that the resident's oxygen should have been connected and administered as ordered by Respiratory staff; this was not done. On 03/23/22 at 11:15 AM, an interview was conducted with Staff C, a Licensed Practical Nurse (LPN) and with Staff B, a Registered Nurse (RN)/Unit Manager (UM), regarding Resident #20's oxygen therapy tubing not connected and not being infused as ordered and they both acknowledged that the resident's oxygen should have been connected and administered as ordered; this was not done. It was noted that Resident #20's ordered oxygen therapy had been off/disconnected/not infusing for more than a minimum of four (4) hours that day, during the survey. The Director of Nursing (DON) further acknowledged that all of the resident's oxygen tubing should have been labeled and dated as to when it was last changed by staff and that the resident's oxygen should have been connected and administered as ordered; this was not done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of policy and procedure, it was determined that the facility failed to 1) ensure that it secured over-the-counter (OTC) topical medications for 3 of 27 sampled residents observed, (Resident #297, Resident #9, and Resident #61) and 2) failed to discard resident's expired OTC topical medication left at bedside for 1 of 27 sampled residents observed Resident #297. The findings included: Review of the facility policy and procedure on [DATE] at 2 PM for Storage of Medications provided by the Director of Nursing effective [DATE] indicated that Medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications Outdated, contaminated or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal. 1) On [DATE] at 10:21 AM during observational room rounds, it was noted that on Resident #297's bedside dresser there was a used tube of (OTC) topical Menthol 0.44% and Zinc Oxide Ointment 20.625% with an expiration date of 07/21; it was visible, accessible and unsecured, to other residents, staff members and visitors. Photographic evidence obtained of tube of (OTC) topical Menthol 0.44% and Zinc Oxide Ointment 20.625%. Resident #297 was re-admitted to the facility on [DATE] with diagnoses which included Stroke with left hemiplegia, Morbid Obesity and Depression. She had a Brief Interview Mental Status (BIM) score of 15 (cognitively intact). On [DATE] at 11:34 AM, it was noted that on Resident #297's bedside dresser there was a used tube of (OTC) topical Menthol 0.44% and Zinc Oxide Ointment 20.625% with an expiration date of 07/21; it was visible, accessible and unsecured, to other residents, staff members and visitors. Record review of the resident's Medication Administration Record (MAR) revealed that Resident #297 had previously been prescribed (OTC) Menthol 0.44% -Zinc Oxide 20.625% (Calmoseptine) ointment one (1) topical application to sacrum/buttock daily and as needed (PRN) for redness starting [DATE]. However, it was noted that there were currently no scheduled doses. 2) On [DATE] at 10:47 AM, during observational room rounds, it was noted on the Resident #9's bedside table that there was a used tube of (OTC) tube of topical Muscle Rub with an expiration date of 03/23; it was visible, accessible and unsecured, to other residents, staff members and visitors. Resident #9 was admitted to the facility on [DATE] with diagnoses which included Paraplegia, Depression and Neurogenic Bowel and Bladder. He had a Brief Interview Mental Status (BIM) score of 14 (cognitively intact). Photographic evidence obtained of tube of (OTC) tube of topical Muscle Rub. On [DATE] at 1:51 PM, it was noted on Resident #9's bedside table that there was a used tube of (OTC) tube of topical Muscle Rub with an expiration date of 03/23; it was visible, accessible and unsecured, to other residents, staff members and visitors. Record review revealed that Resident #9 was currently prescribed (OTC) Methly Salicylate 15% and Menthol 10% one (1) topical application twice daily. 3) On [DATE] at 3:04 PM, during observational room rounds, it was noted that on Resident #61's bedside dresser there was a small round used container of (OTC) topical Menthol 0.44% and Zinc Oxide Ointment 20.6% with no expiration date noted; it was visible, accessible and unsecured, to other residents, staff members and visitors. Photographic evidence obtained of (OTC) topical Menthol 0.44% and Zinc Oxide Ointment 20.6%. Resident #61 was admitted to the facility on [DATE] with diagnoses which included C2 Spinal Cord Injury, Diabetes Mellitus Type II and Major Depressive Disorder. He had a Brief Interview Mental Status (BIM) score of 14 (cognitively intact). On [DATE] at 11:07 AM, during a Wound Care Observation conducted with the Wound care nurse for Resident #61, it was noted that there was a thirty-two (32) oz. bottle of liquid Hydrogen Peroxide located in a basket at the bedside, on his bedroom dresser tabletop. Further record review revealed that Resident #61 was currently prescribed (OTC) Methly Salicylate 15% and Menthol 10% one (1) topical application twice daily. However, there was no order noted for the liquid Hydrogen Peroxide. On [DATE] at 12:31 PM an interview was conducted with Staff C, a Licensed Practical Nurse (LPN), regarding the (OTC) topical Menthol 0.44% and Zinc Oxide Ointment 20.625% with an expiration date of 07/21 for Resident #297 and the (OTC) tube of topical Muscle Rub for Resident #9, left unattended and unsecured at both of the resident's bedsides. She acknowledged that the medications should not have been there and should have been properly secured or discarded, if expired; this was not done. On [DATE] at 12:45 PM an interview was conducted with Staff D, an (LPN), regarding (OTC) topical Menthol 0.44% and Zinc Oxide Ointment 20.6% with no expiration date for Resident #61, left unattended and unsecured at both of the resident's bedsides and she acknowledged that the medication should not have been there and should have been properly secured; this was not done. On [DATE] at 1 PM an interview was conducted with Staff B, a Registered Nurse (RN)/Unit Manager (UM), regarding the (OTC) topical Menthol 0.44% and Zinc Oxide Ointment 20.625% with an expiration date of 07/21 for Resident #297 and for Resident #61 and the (OTC) tube of topical Muscle Rub for Resident #9, all left unattended and unsecured at each of the resident's bedsides. She further acknowledged that the medications should not have been there and should have been properly secured or discarded, if expired; this was not done. There was no assessment performed for any of these residents to ensure that they were able to administer their own medications at the bedside; the facility administers the medications for them, per Staff B, a Registered Nurse (RN)/Unit Manager (UM). Further review revealed none of three residents were assessed by the facility, as being able to safely and responsibly, self-administer their own medications. Furthermore, the unattended/unsecured OTC medications were removed from the resident's bedsides, after surveyor intervention. The Director of Nursing (DON) further acknowledged and recognized that Resident #297, Resident #61 and Resident #9's, unattended and unsecured medications should not have been left at their bedsides and should have been properly secured or discarded, if expired; this was not done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of policy and procedure, it was determined that the facility failed to provide dental care services to meet the needs of the resident by not making appointments and arranging for transportation to and from the dental services location for 1 of 1 sampled residents reviewed for dental care (Resident #28). The findings included: Review of facility policy and procedure for Dental Services provided by the Director of Nursing (DON) reviewed May 2016, indicated that Policy: in order to promote good oral hygiene and mouth care to the residents of Memorial Manor, dental services will be made available. Procedure: 1. Residents have the right to use their own community dentist. 2. Residents who have Medicaid Managed Assistance Plans have dental coverage and will be able to receive care and services in accordance with their plan .6. The nursing staff will perform oral assessments. Review of facility licensed Unit Manager Nurse job description on 03/24/22 at 11:47 AM, indicated that manages the daily operations of the assigned departments. Job responsibilities: Assesses the quality of patient care delivered. Evaluates needs of patients and families and provides patient and family centered care . Review of facility licensed nurse job description on 03/24/22 at 12:07 PM, indicated that Job Summary: Provides direct resident care using the nursing process in or/as supervised and delegated by a registered nurse, provides direct resident care in accordance with applicable scope and standards of practice and with the policies, values and mission of the organization. Job responsibilities: plans, implements and evaluates resident care based on assessment to optimize outcomes and maximizes available resources. Monitors, records and communicates resident condition as appropriate or contributes to the assessment of patients by collecting data for analysis. Performs plan of car interventions .Performs treatments and administers medications in accordance with established policies and procedures. Collaborates as needed across disciplines to coordinate resident care .Administers medications .and all treatments in accordance with established policy and procedure. Review of facility policy and procedure on 03/24/22 at 12:19 PM for Social Worker Job Description provided by the (DON) indicated that Job Summary: Provides assessment, planning, counseling and education to patients. Job Responsibilities: .Interviews and assesses patients and/or patient's family, caregivers and/or legal representatives. Determines prioritizes, provides and/or arranges for needed internal and external services/interventions During observational room rounds conducted on 03/21/22 at 12:26 PM of Resident #28, it was observed that he only had approximately eleven (11) portions/remnants of his normally occurring thirty-two (32) full-sized adult teeth, in his mouth. Photographic evidence obtained. A brief interview was conducted with Resident #28, in which he conveyed to this surveyor that he had not been seen by a dentist in over two (2) years and would like to follow-up with one. He added that sometimes when he chews it does hurt. He elaborated by stating that he recalls mentioning this to one of the facility staff members sometime ago, but nothing ever happened. Resident #28 was re-admitted to the facility on [DATE] with diagnoses which included Deep Vein Thrombosis (DVT), Gastroesophageal Reflux (GERD), Neurogenic Bladder, Hyperlipidemia, Paraplegia, Depression and Anemia. He had a Brief Interview Mental Status (BIM) score of 15 (cognitively intact). During an interview conducted on 03/23/22 at 2:21 PM with Staff D, a Licensed Practical Nurse (LPN) for Resident #28, she acknowledged that the resident had dental issues that need to be addressed; this was not offered to him by her. And, she added that he has not been to see a dentist, to her knowledge. Further review revealed there were no physician's orders related to/regarding dental services for this resident. Review of the Annual MDS (Minimum Data Set) assessment dated [DATE], revealed the assessment did not indicate whether or not Resident #28's natural teeth or tooth fragments-edentulous, were assessed. The resident's facility computerized quarterly care plan dated 10/11/21 documented to provide resident with necessary dental care on a regular basis and as needed and Problem: Resident #28 is at risk for dental problems due to some missing teeth. Interventions: assist resident with dental hygiene needs, monitor resident's oral cavity for redness, swelling, bleeding, pain, difficulty chewing/eating .Dental evaluation and follow-up as needed (PRN); this was not done. Record review of Resident #28's two (2) most recent Interdisciplinary Team (IDT) meetings dated 10/21/21 and 01/20/22, did not identify or make any references to the resident's current/on-going dental status/ issues, nor whether this was being addressed or discussed, at any point during his facility stay. An interview was conducted with the Social Services Director on 03/23/22 at 1:15 PM regarding the resident's dental insurance coverage and his last dental appointment and she stated that she does not take care of this; she said that the North wing Unit Manager handles this for the residents on her unit. There was no Social Services documentation nor any nursing notes documentation in the record to reflect that Resident #28 had received any dental care/visits during his two and one-half (2.5) year facility stay. On 03/23/22 at 2:20 PM, an interview was conducted with Staff B, a Registered Nurse (RN)/Unit Manager (UM), regarding the Resident #28's dental consults and she indicated that the Resident #28 has not been seen by a dentist during his 2.5- year facility stay. She acknowledged that the resident had dental issues that need to be addressed; this was not offered to him by her. And, she added that he has not been to see a dentist, to her knowledge, since he has been residing in the facility and she also stated that she is responsible for scheduling all of the resident's dental appointments on her unit. Record review of Resident #28's eligibility verification request documentation revealed that Resident #28 has currently had Full-Medicaid insurance coverage effective ever since 03/01/22. An appointment was not scheduled for the resident until April 2022, after surveyor intervention. The (DON) further acknowledged and recognized that dental care and services were to be provided to the resident during his facility stay; this was not done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain food safety requirements with storage, preparation, and distribution in accordance with professional standards for food service safety which included: failure to maintain sanitary conditions and failure to maintain adequate holding temperatures. The findings included: 1. During the initial tour of the kitchen conducted on 03/21/22 at 8:45 AM, accompanied by the Executive Chef and Operations Manager, the following were noted: a. A lanyard with about 10 keys was stored on top of the food preparation table. The Executive Chef acknowledged that the keys should not have been stored on top of the food preparation table. b. In the Victory reach-in refrigerator, one plastic container with about 40 hotdogs was missing a label with a use by date. c. In the reach-in cooler, one opened package of Swiss cheese had an open date of 03/03/22. The Executive Chef stated that opened products were to be used within 7 days after opening and that the Swiss cheese should have been discarded. d. In the dry storage area, a coat was stored on top of the shelving racks containing food products. e. In the dry storage area, one 15 ounce can of Gandules Verdes was observed with a dent. f. In the dry storage area, one 18-quart plastic storage bin of dried northern beans was missing a label with a use by date. g. In the walk-in refrigerator, one 6-quart plastic container of peach slices was observed with a use by date of 03/19/22. h. In the walk-in freezer, one package of oven ready whole grain breaded Alaska [NAME] fillet portions was left open and uncovered. The Executive Chef acknowledged that this put the fillet portions at risk of contamination. i. In the paper goods dry storage area, one rolling cart containing clean aprons was stored over a puddle/drain. Closer observation showed that the strings of the clean aprons were hanging out of the cart and laying in the puddle. The Executive Chef acknowledged that this contaminated the clean aprons. j. One light bulb was out over the dishwashing machine. 2. During a tour of the South Wing Nourishment Room conducted on 03/21/22 at 9:15 AM, the flooring underneath the shelving was observed with a moderate amount of debris. In an interview conducted on 03/23/22 at 4:19 PM, the Food Service Director was informed of the findings and acknowledged all findings. 3) During a follow-up observations of the kitchen/Food Service Department on 03/22/22 at 7:30 AM and 03/23/33 at 11:30 AM, the temperatures of the hot and cold foods on the lunch tray assembly line were taken by the use of the facility's calibrated bayonet food thermometer. The temperature testing results noted that hot foods were not being held and the regulatory requirement of 135 degrees F or greater and cold foods were not being held at the regulatory requirement of 41 degrees F or below, as per the following: Fried Eggs (3) = 130 degrees F Dannon Yogurt - (5 individual) = 45 degrees F Hamburger Patties (3) = 120 degrees F Chefs Salad (3) - including ham,turkey, and egg = 50 Degrees F Beet & Onion Salad (28 individual) = 51 degrees F