**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of allegations of abuse, neglect, exploitation, or mistreatment for one (Resident #113) of three sampled residents. Findings included: On 08/21/2023 at 9:00 a.m., Resident #113 was observed laying in bed holding his arm, with his covers halfway on his body. Resident # 113's arm was observed with a laceration. On 08/22/2023 at 11:00 a.m., Resident #113 was observed laying in bed with his covers on top of him. Resident # 113 arm was observed with an dirty bandage on his arm, next to the open laceration. A review of the admission record showed Resident # 113 was admitted to the facility on [DATE], with diagnoses to include but not limited to Muscle Wasting and Atrophy, Not Elsewhere Classified, Multiple Sites, Metabolic Encephalopathy, Other Toxic Encephalopathy, Malignant Neoplasm of Peritoneum, and Uncomplicated, Chronic Kidney Disease, Stage 3A. A review of the order summary report dated 08/22/2023 showed treatment as follows: cleanse left arm areas with normal Saline, apply skin prep to periwound skin and adhesive contact areas. Further review of the order summary showed treatment as follows: cleanse left forearm with Normal Saline apply skin prep to periwound skin and adhesive contact areas, order date 08/23/2023. A review of the progress note dated 08/15/2023, signed by Staff M, Registered Nurse, Unit Manager, showed Staff M received a call from [local hospital] saying when they received Resident #113, he had skin tears on his knee. They offered to take him to the emergency room but Resident #113 said he was not in pain. Staff M noted that per [local hospital] they reported the transportation people to their supervisor. A review of the Weekly Skin Check dated 08/12/2023, showed No New Areas of Skin Impairment. A review of the electronic medical record showed a skin check was not conducted on 08/15/2023 when Resident #113 arrived back to the facility. A review the Weekly Skin Check dated 08/19/2023, showed No New Areas of Skin Impairment. During an interview on 08/ 23/2023 at 10:08 a.m., the Director of Nursing said she was not notified of any incident that occurred on 8/15/2023 with Resident # 113, it was just brought to her attention 8/22/2023. The DON said after she was notified about the incident, she conducted her investigation and found out Resident # 113 had an incident outside of the facility with his transport service. She said a nurse at [local hospital] reported to Staff M, the unit manager, that when Resident #113 arrived at his appointment with transportation service, she pulled the resident's covers off of him and noticed blood on his covers and skin tears on his legs and knees. During an interview on 8/23/2023 at 2:00 p.m., Staff M said she received a call from the nurse at [local hospital] on 8/15/2023 to inform the facility that Resident #113 was left in the front lobby by someone from the transportation service. She said the nurse reported she noticed blood on the resident's sheet when he arrived so she conducted an assessment on the resident and found big abrasions on his legs and arms. She said the nurse told her she immediately reported Resident #113's condition to her supervisor and was informed by her supervisor to notify the nursing facility. Staff M said the nurse reported to her that they offered to send Resident #113 to the emergency room (ER) but he refused to go. Staff M said, when the resident arrived back to the facility, they did not conduct an skin assessment on him. She was not aware of the skin tears on the resident's arms until later on. She said she did not report the information that was given to her by the nurse at [local hospital] to the Director of Nurses (DON) and the Risk Manager (RM), she only reported the information to the floor nurse who took care of the resident when he came back to the facility. Staff M said she knew she should have made sure that an skin assessment was done and that she should have reported the information to her supervisor/ DON. During an interview on 8/23/2023 at 1:30. p.m., the Nursing Home Administrator (NHA)/RM said she was not notified that Resident #113 had an incident on 8/15/2023 until [this writer] brought it to her attention. She said after she was notified, she conducted an investigation and found out by another resident that Resident #113 was dropped on the floor on 8/15/2023 by the transport service. The NHA/ RM said the resident across the hall reported to her he watched the transport service drop Resident #113 on the floor while trying to transfer him onto their stretcher. He also reported he watched them clean up the blood from the resident off the floor, then left the room with Resident #113 on their stretcher. The NHA/ RM said she reached out to the transportation services to further investigate the situation. The transportation service reported Resident #113 was sitting on the edge of his bed and fell off the bed and scraped his knee according to their driver. They reported when they asked the resident if he was okay, the resident replied, Yes, so they picked him up off the floor, placed him on their stretcher and left the facility to take the resident to his appointment without telling anyone at the facility what happened. The NHA/ RM said a nurse from [local hospital] called the unit manager to report to her the condition Resident #113 was in when he arrived at their facility. The unit manager followed up by notifying Resident #113's doctor to obtain an order for his left knee, but she did not notify the RM and the DON about Resident #113's condition. The NHA/ RM said the nurse did everything she was supposed to do. She felt like the only thing the nurse did not do was an event report, but all other protocols were followed. A review of the facility Risk Management Manual titled, Abuse Prevention Program, Change date, August 2022. Policy: The facility has designated and implemented processes, which strive to reduce that risk of abuse, neglect, exploitation, mistreatment, and misappropriation of resident's property. These policies guide the identification, management and reporting of suspected, or alleged, abuse, neglect, mistreatment, and exploitation. It is expected that these policies will assist the facility with reducing the risk of abuse, neglect, exploitation, and misappropriation of resident's property through education if staff and residents, as well as early identification of staff burn out, or resident behavior which may increase the likelihood of such events. Definition: Alleged Violations A situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not been investigated and if verified, could be noncompliance with Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries or unknown, and misappropriation of resident property. Procedure: The facility has implemented the following procedures in an effort to provide residents, visitors, and staff with a safe and comfortable environment. The Administrator, DON, and/ or designated individual are responsible for the investigation and reporting of suspected, or alleged, abuse, neglect, exploitation and misappropriation. Identification: Events of injuries of unknown origin/ source, such as suspicious bruising occurrences, patterns, & trends or other resident injury that may constitute abuse, neglect, or mistreatment are identified ad thoroughly investigated, with appropriate reporting as indicated. Event report is initiated upon identification of actual, suspected, and/ or abuse. Investigation: An event report is initiated. NHA or designee is notified and will initiate and conclude a complete and thorough investigation within the specified timeframe. Reporting: The facility will follow Federal regulations and State specific reporting requirements. DCF will be notified promptly. The administrator of the facility and/ or designee will be notified immediately. Photographic evidence obtained.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview, the facility failed to confirm the accuracy of a Pre-admission Screening and Resident Review (PASRR) and to correct the document for seven (Residents #172, #205, #28, #81, #82, #110 and #130) of forty residents sampled when mental illness or suspected mental illness diagnoses were identified and added to the resident's medical diagnoses . Findings included: 1. Review of Resident #172's admission Record identified an original admission date of 8/27/21 and a recent admit date of 8/9/22. The review of Resident #172's Pre-admission Screening and Resident Review (PASRR), dated 8/25/21, showed the diagnoses of bipolar disorder, psychotic disorder, and substance abuse. The PASRR revealed the resident had had the following characteristics of difficulty of interpersonal functioning, concentration, persistence, and pace, and adaptation to change, recent treatment for mental illness, and exhibited actions or behaviors that may make them a danger to themselves or others. The PASRR showed the resident may not be admitted to an [sic] Nursing Facility and that a Level II PASRR evaluation would have to be requested due to the diagnosis or a suspicion of a Serious Mental Illness. The admission Record for Resident #172 showed diagnoses not included on the residents PASRR: dementia in other disease classified elsewhere unspecified severity with other behavioral disturbance, unspecified schizophrenia, unspecified recurrent major depressive disorder, and unspecified mood (affective) disorder. A review of Resident #172's clinical record did not include a Level II PASRR determination. The facility did not provide the resident's Level II PASRR determination. On 8/24/23 at 2:13 p.m., Staff Q, Assistant Director of Nursing (ADON), reviewed the PASRR and confirmed Resident #172's PASRR should have been redone due to the addition of diagnoses. 2. Review of Resident #205's admission Record showed an admission date of 7/20/23 and included diagnoses of unspecified severity unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified psychosis not due to a substance or known physiological condition, and generalized anxiety disorder. A review of Resident #205's Pre-admission Screening and Resident Review (PASRR) did not show the resident had any diagnosis of mental illness (MI) or suspected MI. On 8/24/23 at 2:09 p.m., an interview was conducted with the Admissions Coordinator and Staff Q. The Coordinator stated that Admissions department ensured the PASRR obtained prior to admission and was reviewed for accuracy, if inaccurate the Nursing Home Administrator (NHA) and Social Services (SS) review if the Level II was necessary then gets back in contact with the case manager (hospital). Staff Q stated that the SS and NHA have been auditing PASRR's for the last two weeks. 3. Review of Resident #81's face sheet showed the resident was admitted to the facility on [DATE] and re-admitted on [DATE]. The Face sheet indicated a list of secondary diagnoses that included the following: -Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety with onset date of 7/19/19 -Major depressive disorder, Recurrent, with onset date of 6/5/18 -Schizophrenia, unspecified, with onset date of 5/16/14. Review of the PASRR Level I Screen completed, signed and dated by a facility nurse on 2/11/2020 showed the resident had mental illness identified as Depressive Disorder and Schizophrenia. Review of the resident record showed there was no level II PASRR available for review. In an interview on 08/24/23 at 02:00 p.m. with Staff Q, she stated the social worker reviewed the PASRR for accuracy and if it was warranted a request for a Level II screen would be made. She indicated for Resident #81 once new diagnoses of dementia and mental illnesses were identified a request for a level II PASRR should have been made. 4. Review of Resident #82's Level I PASRR dated 2/11/20, showed a mental illness diagnosis of Anxiety Disorder, Depressive Disorder, and Schizophrenia and indicated the resident did not have a primary or secondary diagnosis of dementia or related neurocognitive disorder. A review of Resident #82's diagnosis list in the electronic record showed a diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety dated 4/1/20 as a secondary diagnosis. A review of the residents care plan related to PASRR Level II Resident has or is suspected to have a Serious Mental Illness (SMI), Intellectual Disability (D) or other related conditions that require a a PASRR Level II, This plan was initiated on 5/11/21. A review of the quarterly Minimum Data Set (MDS) dated [DATE] showed the resident had non-Alzheimer's Dementia, Seizure disorder, Anxiety Disorder, Depression other than Bipolar. A review of the Psychiatric note dated 6/16/23 indicated the reason for the visit was to address Major depressive disorder, anxiety disorder, pseudobulbar affect, Vascular dementia. An interview on 08/24/23 at 2:00 p.m. with Staff Q revealed she, along with the social worker, reviewed the PASRR when the resident was admitted and if there were errors, the PASARR would be re-done and if a level II was needed all required documents would be sent for the review. 5. A review of the admission Record for Resident #110 showed he was admitted on [DATE], with diagnoses included but not limited to Schizophrenia, Unspecified, Psychotic Disorder with Delusions Due to known Physiological Condition, Major Depressive Disorder, Recurrent, Unspecified, Generalized Anxiety Disorder, Post - Traumatic Stress Disorder, Chronic, Abuse of Other Non- Psychoactive Substance. A review of the quarterly Minimum Data Set (MDS) dated [DATE], Section C, Cognitive Patterns, showed a Brief Interview for Mental Status, (BIMS) score of 02, which indicated severe cognitive impairment. A review of the Preadmission Screening and Resident Review (PASRR), Level I Screen, showed Section 1, PASRR Screen Decision Making, not completed. During an interview on 8/24/2023 at 3:00 p.m., Staff Q stated she was responsible for ensuring Level II PASRR's were obtained for residents at the facility who were eligible for a Level II. Staff Q, ADON, confirmed she did not follow up to obtain a Level II PASRR for Resident # 110. 6. On 08/21/23 at 10:00 a.m., Resident #28 was observed in bed repeatedly hitting her head with her fist. The admission Record for Resident #28 showed she was initially admitted on [DATE] with diagnoses of major depressive disorder and generalized anxiety disorder. The admission Record revealed new diagnoses of vascular dementia, unspecified severity, with other behavioral disturbance documented on 10/01/22, dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance documented on 10/01/22, schizophrenia documented on 05/18/22, anxiety disorder documented on 04/15/21, and unspecified psychosis not due to a substance or known physiological condition documented on 04/03/20 and the resident was not assessed for PASRR Level II. Section C Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] showed Resident #28 had a BIMS score of 03 out of 15 which indicated severe cognitive impairment. Section I Active Diagnoses showed diagnoses of anxiety disorder, depression, psychotic disorder, and schizophrenia and the resident was not assessed for PASSAR Level II. A review of Resident #28's PASRR Level I Assessment, dated 08/27/19 showed diagnoses of anxiety disorder and depressive disorder and no PASRR Level II was required. Review of the medical record showed the resident was not assessed for PASRR Level II. 7. The admission Record for Resident #130 showed he was initially admitted on [DATE] with a diagnosis of schizophrenia. The admission Record revealed new diagnoses of dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance documented on 10/01/22, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety documented on 04/04/22, depression documented on 04/04/22, and the resident was not assessed for PASRR Level II. Section C Cognitive Patterns of the MDS dated [DATE] showed Resident #130 had a BIMS score of 03 out of 15 which indicated severe cognitive impairment. Section I Active Diagnoses showed diagnoses of anxiety disorder and depression and the resident was not assessed for PASRR Level II. Review of Resident #130's PASRR Level I Assessment, dated 02/01/21 revealed no qualifying mental health diagnosis and that no PASRR Level II was required. Review of the medical record revealed the resident was not assessed for PASRR Level II. On 08/24/23 at 1:50 p.m., Staff Q said she completed and submitted the PASRRs. The Social Services Director and Administrator reviewed the PASRRs for accuracy. She looked at medications and diagnoses to determine what should be checked on the PASRR. Staff Q confirmed diagnoses were not indicated on the Level I PASARR for Resident #28 and #130. She stated the forms should have been corrected and resubmitted to Kepro for a Level II PASRR. Review of the facility's policy titled PASRR Requirements Level I and Level II- Florida effective February 2021 revealed A resident review must be completed when there has been a significant change in a resident mental or physical condition resident review is also required if a resident is transferred to a hospital for care and the stay last longer than 90 consecutive days prior to readmission. 2. Written notification requirement for Level II referral: upon completion of the Level I PASRR screen, if the resident has a diagnosis of or suspicion of having a Serious Mental Illness (SMI), Intellectual Disability (ID) or both the screener must send the resident or legal representative written notice stating the individual has a diagnosis of, or is suspected of having an SMI, ID, or both and is being referred for a Level II evaluation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure two (Residents #26 and #215) of 59 residents received treatment and care in accordance with professional standards of practice related to not obtaining orders for the use of a skin cream and accurately completing skin assessments for Resident #26 and not following hospital discharge orders related to a catheter and wound vac for Resident #215. Findings included: On 08/22/23 at 11:07 a.m., Resident #26 was observed in bed. A red rash was observed around her nose and on her forehead. Resident #26 stated the rash itched and staff was putting cream on it. On 08/23/23 at 9:25 a.m., Resident #26 was observed in the hallway, dressed for the day, and wearing shoes. A red rash was observed around her nose and on her forehead. Staff U, Registered Nurse (RN), was observed at the medication cart. She stated Resident #26 had dermatitis and she had a cream for it. A review of the admission Record showed Resident #26 was initially admitted into the facility on [DATE] with a primary diagnosis of multiple sclerosis. A review of Section C Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] showed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 which indicated moderate cognitive impairment. A review of the Order Summary Report with an order date range of 08/01/23 to 08/31/23 revealed no orders for a skin cream. A review of the Skin Check Weekly & PRN (as needed) forms revealed the following: 08/23/23- No new areas of skin impairment. 08/16/23- No new areas of skin impairment. 08/09/23- No new areas of skin impairment. 08/02/23- No new areas of skin impairment. The red areas were not noted on the Skin Check Weekly & PRN forms. A review of the Skin Observation task showed Resident #26 did not have any scratches, red areas, discoloration, skin tears, or open areas within the last 30 days. The red areas were not noted on the Skin Observation task. There were no progress notes related to the skin condition. The care plan revealed a focus area of impairment to skin integrity related to dermatitis to the face. Interventions included administering medications as ordered, treatment as ordered, report changes in discoloration area, pain location, type frequency, and intensity. On 08/23/23 at 2:15 p.m., Staff U, RN, stated the resident had a cream for 14 days and she was done with it. Staff U, RN, stated Resident #26 finished the cream about a week ago. The nurse reviewed the electronic medical record for Resident #26 and could not find the completed order for the cream. Staff U, RN, stated the resident had an order for Ketoconazole. She then stated it was probably hydrocortisone. Staff U, RN, could not find a completed or discontinued order for the creams in the month of August. On 08/24/23 at 1:07 p.m., the Director of Nursing (DON) stated nurses should not be administering a cream without an order. On 08/24/23 at 11:00 a.m., Staff P, Regional Nursing Consultant, stated Resident #26 had a cream for the rash in January and February. She confirmed that she did not have a recent order for a cream. ` The policy and procedure provided by the facility Weekly and PRN Skin Check effective October 2021 revealed the following: The nurse will conduct weekly skin check and /or a PRN check when applicable as a proactive measure to identify impairment or suspected impairment timely to reduce the risk of further decline in skin integrity. If a new area of impairment is identified during or between scheduled checks, it should be documented on the weekly and PRN Skin Check and the appropriate skin grid initiated depending on the cause. A review of the admission Record for Resident #215 revealed he was admitted into the facility on [DATE] with diagnoses that included anoxic brain damage, persistent vegetative state, encephalopathy, pressure ulcer of sacral region stage 4, chronic kidney disease, altered mental status, unspecified injury of unspecified kidney, tracheostomy status, and gastrostomy status. A review of the Medical Certification for Medicaid Long Term Care Services and Patient Transfer Form from a local hospital showed Resident #215 had a wound vac and he was incontinent. The comments section indicated the resident had a wound vac with black foam and to change the dressing on Monday, Wednesday, and Friday. A review of the Admission/readmit: Data Collection and Baseline Care Plan with an effective date of 07/18/23 showed the resident had a condom catheter. The care plan related to the catheter revealed a focus area of the resident uses a urinary catheter with risk for infection and/or complications. Interventions included review with physician for possible removal of catheter. The resident was admitted with a coccyx pressure wound. Interventions included treatment as ordered. A review of the Order Summary Report for completed and discontinued orders did not show any orders for a catheter, catheter care, or a wound vac. A review of the Advance Wound Care form did not reveal an order to discontinue the wound vac. On 08/24/23 at 1:10 p.m., the DON stated Resident #215 was admitted with a condom catheter from the hospital but did not have a catheter during his stay in the facility. His family was adamant about him having a catheter. The DON stated you must have a specific diagnosis to have a condom catheter. The DON stated she would check to see if Resident #215 needed a wound vac, but did not follow up.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure appropriate treatment and services to prevent further decrease in range of motion for one (Resident #3) of three sampled residents. Findings included: On 8/21/2023 at 10:12 a.m., 11:45 a.m., 12:50 p.m., and 1:55 p.m., Resident #3 was observed in her room, lying flat in bed and with her head on a pillow. One quarter bed rails on both sides of the bed were up. Resident #3 had eyes closed and with the bed linen over her and covering the lower part of her body. She was not presenting with any behaviors, pain or discomfort during all observed times. Further observations revealed both of her upper extremities (hands) were contracted. Her hands were positioned and leaning on bed rails in a manner that appeared uncomfortable. Resident #3 was not interviewable. The resident was observed not wearing any splints or braces on either of her hands. On 8/22/2023 at 7:06 a.m. and 8:20 a.m., the resident was observed in bed in a flat position with both bed rails up. Both of her hands were positioned and leaning on the metal bars of the bed rails and appeared to look uncomfortable. She was not observed wearing any splints or braces on either of her hands during all observed times. On 8/22/2023 at 12:15 p.m., the Resident #3 was observed out of bed and in a reclining chair, positioned next to her bed. She had covers and a blanket over her with her eyes closed and resting comfortably. She was not observed presenting with any behaviors, pain or discomfort. Resident #3's hands could not be observed as they were placed beneath the blanket/linen. The side of the blanket/linen was lifted slightly to observe her hands. Both hands were observed without any splints or hand devices. On 8/23/2023 at 7:10 a.m., Resident #3 was noted in bed, lying flat and under the covers. Both bed rails were up. Both of the resident's arms and hands were out from the bed linen/covers and positioned on her sides. Both of the resident's hands were noted without any splints or braces on. She was also observed at 8:01 a.m., 8:30, and 9:45 a.m. lying in bed with no splints or braces on either of her hands. On 8/23/2023 at 10:10 a.m. an interview with Staff F, Certified Nursing Assistant (CNA) was conducted. She said she had the resident on her normal working assignment and had her on a regular basis. Staff F said she was knowledgeable of the resident and her care. Staff F revealed the resident had been at the facility for a very long time and she needed total care with all of her Activities of Daily Living (ADL). Staff F confirmed Resident #3 had contractures on both of her hands. Staff F was asked if the resident utilized splints or guards. Staff F said the resident did but she had not placed them on her yet. She was asked if there were special tasks regarding palm guard/splints and she confirmed there was and it was noted in the CNA [NAME] [daily task plan]. She confirmed the palm guard/splints were to be positioned and placed during the day at the start of the 7:00 a.m.-3:00 p.m. shift. Staff F confirmed she had not gotten to it yet and was going to place them on the resident shortly. She confirmed the resident did not refuse to wear the palm guards/splints. When asked how Staff F documented the palm guards/splints were placed on each day, she revealed there was no check list for that but if there were any problems with the palm guards/splints and if the resident were to refuse, she would tell either the unit nurse or the unit manager. Staff F confirmed she worked on 8/22/2023 as well and believed she put the palm guard/splints on but was not sure. She had no documentation to support the palm guard/splints were on that day. A review of the medical record showed Resident #3 was admitted to the facility on [DATE], and was readmitted on [DATE]. Review of the diagnosis sheet revealed diagnosis sheet revealed current diagnoses to include but not limited to: Dysphagia, Contracture, unspecified joint, Contracture, unspecified hand, Epilepsy, and Intellectual Disability. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed: (Cognition/Brief Interview Mental Score or BIMS score - Not score, but indicated resident had short term/long term memory problem and with severely impaired decision making skills); (ADL - BED MOBILITY = Total Dependence, TRANSFER = Total Dependence, DRESSING = Total Dependence, TOILET USE = Total Dependence, PERSONAL HYGIENE = Total Dependence); (Upper Extremity - Impairment both sides, Lower extremity - Impairment on both sides, Mobility device - None). A review of the current Physician's Order Sheet (POS) dated for the month of 8/2023 showed: - Monitor pain every shift and record pain number on a 0-10 scale x shift. - Resident to wear bilateral palm guards on in a.m. , and off in p.m., as tolerated. May remove for care and inspection of skin integrity x day shift (order date 4/6/2023). A review of the Care Plan Interdisciplinary Team (IDT) note dated 5/30/2023 showed - Care plan meeting held today with resident/[family member] in facility. IDT members information given [by] UM [unit manager], CNA, Activities Director and MDS. Discussed [NAME], medication and treatment. She uses Bilateral palm guards and is on pain meds. [Family member] says she is happy when everything is good. Plan of care will continue. A review of the all nursing notes dated from 11/25/2022 through to current 8/23/2023 did not show documentation to support Resident #3 had ever refused the use of the palm guards or hand splints. A review of the Certified Nursing Assistant (CNA) tasks/[NAME] document, showed a section for : Splint task splint type - Bilateral palm guard apply to: Splint bilateral palm guards on in am care (during day) off pm care (at night). May remove for skin sweep on 7-3, as tolerated. This task was noted assigned to CNA and RNA (Restorative Nursing Assistant). The task history for this device noted the same direction on 4/5/2021, 10/29/2021, and 1/16/2021. There were no device notes since 1/16/2023. A review of the care plans with next review date 11/15/2023, showed the following problem areas: a. Cognition - Has impaired cognitive function/dementia or impaired thought process r/t Severely impaired BIMS score of 0-7, Disease process, with interventions in place as reviewed and observed. b. Resident has a problem with communication: Rarely or never understood - unable to express ideas or want, Rarely/never understands, with interventions in place as reviewed and observed. c. Has an ADL Self Care Performance Deficit as evidence by: Cannot complete ADL tasks independently and requires individualized interventions to maintain because; Weakness, Impaired cognition, with interventions to include but not limited to: Range Of Motion - Limitations to Lower and Upper extremities encourage/provide passive/active with routine care and within physical capacity; Side Rails - Left and Right ¼ rails up as mobility aid and/or for safety during care provision and is medically appropriate for use because of weakness. d. Range of Motion: Resident has a risk or actual limitations in Range of Motion as evidenced by: Impairment on both side hands bilateral palm guards, with interventions to include but not limited to: Splint task, Splint type: Bilateral palm guard apply to: blank no information; Splint to bilateral palm guards on in am care (during day) off pm care (at night). May remove for skin sweep on 7-3, as tolerated; Observe and Report decline in ROM. e. Skin Integrity risk - Resident has potential/actual impairment to skin integrity r/t keloids all over her back, with interventions to include but not limited to: Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surfaces. On 8/24/2023 at 8:40 a.m., an interview with Staff A, Licensed Practical Nurse (LPN) showed during her shift she would make rounds and ensure her staff were implementing care plan interventions per the [NAME] and care plan problem areas. She confirmed Resident #3 had contractures on both of her hands and she was to wear splints/palm guard devices on both hands during the day to include all of the 7:00 a.m. - 3:00 p.m. shift. Staff A said the assigned aide for the day was responsible for applying the splint/palm guard daily but there was no documentation to support if the splints/palm guards were placed on or not. Staff A also said the aides did not put the splint/palm guards on, then she would do it. She confirmed as far as the donning and doffing of the splints/palm guard, the restorative staff were not responsible to do that. On 8/24/2023 at 12:30 p.m., an interview with the 100 Unit Manger Staff E confirmed the resident had a long standing of contractures on both her right and left hands. Staff E said Resident #3 had resided at the facility for many years and she required and used palm guards on both of her hands on a daily basis to reduce further contracture. Staff E was not aware Resident #3's palm guards were not applied on 8/21/2023, 8/22/2023, and the morning of 8/23/2023. She said all staff were aware to look at their [NAME] daily care plans and were to follow each intervention. She said the floor nurse as well as herself made rounds to ensure all interventions were in place, per each assignment. Staff E could not provide any documentation to support palm guards were placed and positioned each day, or if the palm guards were ever refused. Staff E said, to her knowledge, Resident #3 had never refused the use of the palm guards. During an interview on 8/24/2023 at 2:00 p.m. with the Nursing Home Administrator, she said the facility did not have a specific Contracture Management policy and procedure for review.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide enteral nutrition for one (Resident #150) out of six residents sampled for tube feeding as evidence by staff stopping the nutrition prior to the prescribed amount being infused. Findings included: On 8/21/23 at 12:50 p.m., Resident #150 was observed lying in bed with a enteral pump on an infusion pole next to the bed. The observation showed that no nutrition bottle was hanging on the pole and the pump was not running. On 8/22/23 at 11:04 a.m., Resident #150 was observed without a bottle of nutrition hanging from the infusion pole and the nutrition pump was not running. (Photographic Evidence Obtained) Review of Resident #150's admission Record revealed the resident had been admitted on [DATE] with diagnoses that included but not limited to oropharyngeal phase dysphagia, unspecified protein-calorie malnutrition, and gastrostomy status. Review of Resident #150's physician orders, completed on 8/22/23 at 1:48 p.m., revealed an order started on 6/19/23 for Enteral Feed - every shift Enteral Feed: Glucerna 1.2 Cal Continuous via tube to infuse at a rate of 50 mL/hour (hr). Total volume of 1200 mL infused in 24 H (hour). May turn off for care/services. Start at 2 p.m. Verify infusing every (Q) shift. Clear pump when total volume has infused. The above order identified that Resident #150's enteral nutrition would have to run for 24 hours or more depending on care times to infuse 1200 mL's at 50 mL/hr (24 hours x 50 mL/hr = 1200 mL). During an interview on 8/22/23 at 11:12 a.m. Staff K, Licensed Practical Nurse (LPN) stated the Resident #150's nutrition had been taken down at 10-ish (10:00 a.m.) and goes back up at 2:00 p.m., I believe. The staff member reviewed the enteral feed order and confirmed that the resident was to have 1200 milliliter (mL's) of Glucerna infused. Staff K calculated the time that it would take to infuse 1200 mL at 50 mL/hour (as ordered) and confirmed it would be 24 hours or longer due to the stopping of nutrition during care. The staff member confirmed the order did not allow for taking the nutrition down at 10:00 a.m., then stated the bottle was empty. On 8/22/23 at 11:26 a.m., an observation of Resident #150 showed that no nutrition was infusing. On 8/22/23 at 11:40 p.m., an observation was conducted of Resident #150's nutrition delivery system delivering 50 mL/hr and 936 mL had been infused. A full bottle that contained 1000 mL's of Glucerna 1.2 was hanging from the pole. Staff K confirmed that 935 mL's had been infused not the ordered 1200 mL's. The Nutritional Risk Evaluation Monthly, effective 8/14/23 at 2:04 p.m. for Resident #150 showed Glucerna 1.2 @ 50 mLs/hr until 1200 mLs, 100 mLs q4hrs. The evaluation showed the resident's current weight was 96.4 pounds with no weight change and a nothing by mouth (NPO) diet. A review of Resident #150's Medication Administration Record, printed on 8/22/23 at 5:53 p.m., did not show that staff were to stop the infusion of the resident's nutrition at 10:00 a.m., per Staff K's interview. It did identify that staff verified the infusion every shift (Q shift). The care plan for Resident #150 showed the resident was receiving enteral nutrition through tube feeding and the goals were to Will obtain adequate nutrition and (&) hydration and interventions included Administration of enteral nutrition as ordered (Refer to MD orders for current orders). Review of the policy: Nutrition - Enteral/Parental Nutrition & Hydration, effective October 2021, included Optimizing nutritional status to delay decline will be an appropriate goal only if in accordance with resident/patient or legal guardian's wish. An interview was conducted with the Director of Nursing on 8/24/23 at 2:31 p.m. The DON reviewed the order for Resident #150's enteral feeding and said the expectation would be that the order for nutrition be followed and that continuous (infusion) would be continuous except for care periods.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to follow physician orders related to side effect monitoring for psychotropic medications for one (Resident #161) out of five sampled residents. Findings included: The admission Record showed Resident #161 was initially admitted on [DATE] with diagnoses to include unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, depression, generalized anxiety disorder, and altered mental status. Section C Cognitive Patterns of the Minimum Data Set (MDS) dated [DATE] revealed Resident #161 was rarely/never understood. Section N Medications indicated the resident took antianxiety and antidepressants for 7 days. The Order Summary Report with active orders as of 08/24/23 revealed the following orders: side effect monitoring; Ativan oral tablet 0.5 MG- Give 1 tablet by mouth (po) at bedtime for anxiety; buspirone HCL oral tablet 10 MG- Give 1 tablet po three times a day related to generalized anxiety disorder; divalproex sodium oral capsule delayed release sprinkle 125 MG- Give 2 capsule po three times a day for mood disorder; mirtazapine oral tablet 7.5 MG- Give 1 tablet po at bedtime for depression; and sertraline HCL oral tablet 25 MG- Give 1 tablet po at bedtime for depression. A review of the Medication Administration Record (MAR) and Treatment Medication Record (TAR) for June 2023, July 2023, and August 2023 revealed side effects were not monitored as ordered. The care plan initiated 04/17/23 showed a focus area of the use of psychotropic medications related to antidepressants to manage depression and anxiety. Interventions included antidepressant side effect monitoring and psychotropic side effect monitoring. On 08/24/23 at 1:20 p.m., the Director of Nursing (DON) stated she would have to check on the order related to side effect monitoring but did not follow up.

Based on observations, record reviews, and interviews the facility failed to ensure the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed and two errors were identified for two (#87 and #106) of six residents observed. These errors constituted a 8% medication error rate. Findings included: 1. On 8/22/23 at 8:55 a.m., an observation of medication administration with Staff H, Licensed Practical Nurse (LPN), was conducted with Resident #87. The staff member dispensed the following medications: - Acidophilus Probiotic 1 billion over-the-counter (OTC) capsule - Retrieved from medication refrigerator. - Amlodipine Besylate 2.5 milligram (mg) tablet - Baclofen 20 mg tablet - Vitamin D 25 microgram (mcg) - 2 tablets OTC - Loratadine 10 mg tablet OTC - Vitamin B-12 1000 mcg - 2 tablets OTC - Praxada 150 mg capsule - Potassium chloride Extended Release 20 milliequivalent (meq) - Furosemide 20 mg tablet - Gabapentin 100 mg - 2 capsules - Tamsulosin 0.4 mg capsule - Lubiprostone 24 mcg capsule - Metformin 500 mg tablet Review of Resident #87's Order Summary Report revealed an order for Acidophilus Oral Capsule (Lactobacillus) - Give 2 capsule by mouth two times a day for GI Probiotic. The review of Resident #87's August Medication Administration Record (MAR) showed Staff H had documented 2 capsules of Acidophilus had been administered. The observation of Staff H dispensing Resident #87's oral medications and the confirmation from Staff H that 16 tablets/capsules had been dispensed verified the resident did not receive 2 capsules of the probiotic. 2. On 8/22/23 at 9:19 a.m., an observation of medication administration with Staff I, Licensed Practical Nurse (LPN), was conducted with Resident #106. Staff I dispensed the following medications: - Docusate Sodium 100 milligram (mg) capsule over-the-counter (OTC) - Folic acid 400 microgram (mcg) - 2 tablets OTC - Lactulose 10 gram/15 milliliter (mL) - 15 mL's - Tamsulosin 0.4 mg capsule - Vitamin D3 50 mcg (2000 international unit (iu)) OTC Staff I confirmed 5 tablets/capsules and one liquid medication had been dispensed. Staff I administered the medications to Resident #106. Review of Resident #106's August Medication Administration Record (MAR) showed the resident was scheduled at 9:00 a.m. to receive 17 grams of Polyethylene Glycol powder mixed with 8 ounces of water one time a day for constipation along with the above dispensed medications. The MAR showed Staff I had administered the Polyethylene Glycol. The observation did not show the resident had received Polyethylene Glycol. On 8/24/23 at 9:08 a.m., the Director of Nursing (DON) and Staff P, Regional Nurse Consultant (RNC) were notified of the medication errors observed. Review of Medication Administration, dated 09/18, revealed that Medications are administered as prescribed in accordance with manufacturer's specifications, good nursing principles and practices, and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. The procedure instructed that Prior to administration, review and confirm medication orders for each individual resident on the Medication Administration Record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure 1. one (secured 400-hall) out of five treatment carts were locked while unattended by authorized personnel on two separate occasions, 2. a tube of medicated topical ointment prescribed for a resident was not left on the dresser in a room that the resident did not reside, and 3. one (2-High) out of eight medication carts did not contain an unopened vial of Insulin Lispro. Findings included: 1. On 8/21/23 at 9:28 a.m., an observation was conducted on the secured behavioral 400-hall of a treatment cart parked behind the nursing desk next to a dining/common area. The area did not have a latched gate or door and was accessible to residents, unauthorized personnel, and visitors. The observation revealed the first drawer of the treatment cart held 2 bottles of Thick Hand Sanitizer, a box that indicated it contained a tube of Hydrocortisone cream, multiple packages of denture cleanser, and a bottle of a reddish-brown liquid. The second drawer held multiple tubes of prescribed medicated ointments, the third drawer held sterile packages of wound care supplies, a spray bottle of a liquid, and a bottle of body cleanser, the fourth drawer contained sterile packages and two bottles that contained unknown substances, and the bottom drawer contained multiple items including unpackaged cigarettes and a bottle of hair cleanser. (Photographic evidence obtained) An interview was conducted on 8/21/23 at 9:32 a.m., with Staff L, Licensed Practical Nurse (LPN). Staff L arrived to the nursing desk area from assisting with the passing of breakfast trays to residents in their rooms and confirmed the treatment cart was unlocked. Staff L stated the residents of the secured behavioral unit couldn't go through the cart then stated residents shouldn't (go through the cart). 2. On 8/22/23 at 11:12 a.m., an observation was conducted with Staff K, LPN, of a tube of medicated ointment on a dresser of a 4-bed room (room [ROOM NUMBER]) that was currently under Enhanced Barrier Precautions and where 4 residents did reside. The staff member confirmed the observation and said the medication was prescribed to a resident that did not reside in the room and stated she must have grabbed the wrong tube. Staff K confirmed the medicated topical ointment should not have been left in the room. (Photographic evidence was obtained) 3. On 8/24/23 at 10:54 a.m., a review of the 2-High medication cart was conducted with Staff M, Registered Nurse (RN)/Unit Manager (UM). The observation identified an unopened vial of Humalog (Insulin Lispro). The pharmacy label instructed Refrigerate until opened then store at room temperature. Staff M confirmed the resident had an opened vial of the same insulin that was almost full and that the unopened vial should be refrigerated. Review of the policy - Medication Storage, dated 09/18, revealed that Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medication (such as medication aides) are allowed access to medication carts. Medication rooms, cabinets, and medication supplies should remain locked when not in use or attended by persons with authorized access. The procedure revealed that Insulin products should be stored in the refrigerator until opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that one (Resident #37) of one resident reviewed for dental services was provided with dental follow-up for missing dentures. Findings included: An interview with Resident #37 on 08/21/23 at 10:17 a.m. revealed he had broken upper and lower teeth. The resident said he had dentures and lost them. He said he thought someone was working on getting new ones, but he was not sure who was working on it. Review of the annual Minimum Data Set (MDS) dated [DATE] indicated the following: -No broken or loose fitting dentures -No cavity or broken natural teeth Review of the Nutrition Evaluation dated 6/28/23 indicated the following: -chewing problems -dysphagia A review of Resident #37's care plan showed has potential oral/dental problem dated 9/26/18. The care plan, including the interventions, had no mention of the use of dentures. A review of the dental vendor Patient Progress report dated 4/19/23 showed that Patient presents for evaluation. Top denture and lower partial fit ok. No follow up needed Observations of Resident #37 on 08/24/23 at 8:44 a.m. revealed the resident lying in bed and noted to have no missing upper teeth. During an interview with the resident at this time, he reported that he had his top dentures but his bottom dentures were lost. The resident showed his mouth which reflected his upper dentures present and his lower dentures not present. During an interview on 08/24/23 at 8:46 a.m. with Staff S, Certified Nursing Assistant (CNA), she located the resident's denture cup from his nightstand which was empty and voiced his upper dentures was present at the end of her shift last evening. The resident took his upper denture from his mouth and then placed it in the cup, Staff S reported the resident was transferred from another unit with only the top dentures which he used daily. She said she was not aware of the resident having bottom dentures while on this unit. An interview on 08/24/23 at 8:52 a.m. with Staff I, Licensed Practical Nurse (LPN), revealed the resident transferred from the 300 unit and only had upper dentures since being on the 400 unit. She said Social Services was responsible for dental follow-up. An interview on 08/24/23 at 8:55 a.m. with Staff T, Social Service Director, revealed she was not aware of the resident having missing dentures. She said nursing would usually tell Social Services if there was a dental problem, and would then schedule an appointment for the resident to be seen by the dental vendor. She said she was not sure when then resident was last seen by the dental vendor. Review of the facility policy titled Dental Services Policy indicated the following: The facility will assist residents in obtaining routine care, 24-hour emergency dental care and denture replacement in the case of loss, damage, or ill-fitting dentures.

Based on record review and interview, the facility failed to ensure all residents/representatives was appropriately informed and provided consent for Pneumococcal and influenza vaccinations for four (Resident #59, #81, #82, #141) of five residents reviewed for immunizations. Findings included: 1. Review of Resident #59's record showed a form titled Pneumococcal & Influenza Vaccination Information & Request was present in the file. The form showed the resident requested the Pneumococcal vaccination and the annual influenza. Further review of the form indicated the form was signed by a facility representative on 10/14/22. There was no signature present from the resident or responsible party. 2. Review of Resident #81's record showed a form titled Pneumococcal & Influenza Vaccination Information & Request was present in the file. The form showed the resident declined the Pneumococcal vaccination and the annual influenza. Further review of the form showed the form was signed by a facility representative on 6/19/23. There was no signature present from the resident or responsible party. 3. Review Resident #82's record showed a form titled Pneumococcal & Influenza Vaccination Information & Request was present in the file. The form showed the resident declined the Pneumococcal vaccination and the annual influenza. Further review of the form showed the form was signed by a facility representative on 4/27/23. There was no signature present from the resident or responsible party. 4. Review Resident #141's record showed a form titled Pneumococcal & Influenza Vaccination Information & Request was present in the file. The form indicated the resident declined the Pneumococcal vaccination and the annual influenza. Further review of the form indicated the form was signed by a facility representative on 8/3/23. There was no signature present from the resident or responsible party. An interview on 08/24/23 at 2:22 p.m., with the Director Of Nursing (DON) revealed she did not know why consents were not signed by the resident/representative, she indicated the consents might have been by phone but confirmed that should have been reflected on the form. A request was made of the facility for a policy on immunization consents, but not provided.

Based on observation, staff interview, and record review, the facility failed to ensure 1. One of one walk in freezer unit was maintained in a manner to prevent frosting and heavy ice build up on shelving and packaged food items and 2. Failed to ensure one of one dish washing machine was operating within wash and rinse water temperature specification requirements. Findings included: 1. On 8/21/2023 at 9:15 a.m., an interview was conducted with Staff B, Dietary Manager and Staff C, Registered Dietician. Staff B said he had only been working at the facility for a couple of weeks. Staff C said she too was new to the facility and was only a Traveling Dietician. Staff B and Staff C confirmed there was a full time Dietician for the facility that was currently in the hiring process. An initial kitchen tour was conducted with Staff B and Staff C. During the tour, they said the dish machine did not normally operate until 10:00 a.m. as the facility is very large and each meal service took some time to complete. On 8/21/2023 at 10:18 a.m., a second kitchen tour was conducted with Staff B. Staff R, Dietary Aide was operating the dish washing machine. Staff B and Staff R both said the dish washing machine was a Low Temperature machine and that it had been operating properly with no issues. Both said the Wash and Rinse temperatures had been optimal and reached the machine specifications requirement. Staff B and Staff R pointed out on the machine a specifications plate that showed the machine's requirements, and showed the machine operated at low temperature with a chemical sanitizer. Staff R revealed the Wash cycle temperatures should reach about 120 degrees F (Fahrenheit) and the Rinse cycle should reach at least 130 - 135 degrees F. Staff B. confirmed this as well. A review of the specifications plate on the machine showed Wash cycle should reach at least 120 degrees F. and the Rinse cycle should reach at least 120 degrees F. Staff R and Staff B were asked what the chemical sanitizer range should reach and how they identified that. Staff B said he utilized the litmus paper test strips to test the sanitizer during each meal service, and on a daily basis to test the sanitizer output. He was then asked what the Parts Per Million (PPM) range should read. He said the range should be 150 - 400 PPM. A review of the machine specifications plate with Staff R and Staff B revealed the PPM should be in range between 50 and 100 PPM. There was signage hanging on the wall that indicated PPM range between 50 and 150 PPM. Staff B confirmed the machine should be operating with PPM between 50 and 150 PPM. Staff R was not sure what the PPM range should be with the sanitizer component of the machine. Prior to demonstrating the machine use and temperature requirements, both Staff B and Staff R said there had not been any concerns with the machine and the maintenance company had been out to check the machine and provided routine maintenance on it with no concerns. Staff B provided the Dish Machine Log for months 8/2023, 7/2023, and 6/2023 for review. It was determined through review of all three months logs, and for each day and each meal service, that the Wash temperatures were documented at 125 degrees F and above, the Rinse temperatures were documented at 125 degrees F. and above, and the PPM sanitizer was documented at 100 PPM. At 10:22 a.m. Staff R along with Staff B, demonstrated the use of the dish washing machine. The first demonstration of the machine at 10:22 a.m. revealed; The Wash gauge reached around 100 - 105 degrees F. The Rinse gauge when the rinse cycle started and finished, only reached 105 degrees F. The gauge face was observed fogged up and almost unreadable. However, after using a bright light, the gauge could then be read more clearly. At 10:24 a.m. a second crate of dishes was run through and again the Wash temperature reached 100 - 105 degrees F. and the Rinse temperatures reached 108 degrees F. Both the Wash and Rinse cycle were confirmed by Staff B, Staff C and the Dietician. At 10:30 a.m. Staff B said the dish washing machine was working appropriately when first started this morning and had been working fine prior to that. He confirmed the temperature gauge was very hard to read and he would need to call the maintenance department and ask how the water heater boosters were and if they needed to be adjusted. Staff B revealed he would call the dish machine maintenance company to have them come out and look at the machine and see about getting a new temperature gauge. He said would use paper and plastic until the machine was fixed. On 8/23/2023 12:00 p.m., during an interview with the Dietary Manager and the Maintenance Director, both had indicated the facility's water heater booster had to be adjusted to a higher temperature, so the required heating temperatures reached the dish machine. It was confirmed that the kitchen and laundry room shared the same water heater booster. The Nursing Home Administrator also provided the Dish Machine Temperature Log policy and procedure with an effective date of 1/2021 for review. The Policy revealed; To monitor dish machine temperatures and chemical saturation (parts per million PPM), for both high and low temperature machines at each meal prior to dishwashing to assure proper cleaning and sanitizing of dishes. The Procedure section revealed; #1 Record month and year at the top of the form #2 Send an empty dish rack through the dish machine prior to recording temperature. a. This allows the water to reach appropriate temperatures. b. May take 3-4 times. 2. During the initial kitchen tour on 8/21/2023 at 9:15 a.m., both the walk in refrigerator and walk in freezer were observed. Upon walking in the refrigerator, there was a door in the back of the unit that lead to the inside of the walk in freezer. The analog thermometer in the walk in refrigerator that was hanging on one of the shelves in the unit read 40 degrees F. Staff B said they had just had the door open while bringing in packages of food items. After the temperature for the walk in refrigerator was read, the door to the walk in freezer unit was observed closed, but the above the door hinge and arm was not clicked in to indicate the door was completely shut. The door pulled open easily. Upon walking into the freezer unit, the back wall appeared with a double fan motor unit and with a shelving system below the motor unit. The back wall of the unit had a three tiered shelving unit with the top shelf approximately one foot below the motor unit housing. Further observations revealed packages of food items to include packaged spinach x 3 with heavy built up ice. There were clumps of ice built up on these packs of food items measuring from five inches across and six to eight inches high. The packaged food items were positioned on the top shelf, and directly below the motor unit housing. There was also very heavy ice built up on the top shelf measuring approximately six to ten inches across to five to eight inches high. There was was heavy ice built up on the floor of the unit, behind the bottom shelf. Staff B confirmed the observations. He was not sure why so much heavy ice was built up but confirmed that none of the packaged food items should have ice build up. Photographic evidence was obtained On 8/24/2023 the Nursing Home Administrator confirmed they did not have a specific Dish Machine operations policy and procedure. She provided the Safety Policy and Procedure, with and effective date of 1/2021, for review. The Policy revealed; The facility promotes an optimal safe work environment in daily work routines and equipment operations. The procedure section revealed; #2 Follow manufacturer directions for each piece of equipment for property safety procedures. #4 Maintain equipment in proper working order. Report malfunctions immediately to the Maintenance Department. The Nursing Home Administrator revealed that the above policy and procedure is an interpretation of the facility's Dish Washing Machine and it's use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to obtain laboratory results timely and report timely to the physician, resident and/or their families for three residents (#3, #4, #5) of three sampled residents. Findings included: 1. Review of the admission Record showed Resident #3 was admitted on [DATE] and readmitted on [DATE]. Resident #3's diagnoses included but were not limited to cerebral vascular accident with hemiplegia (CVA), aphasia, seizures and depression. Review of the Annual Minimum Data Set (MDS), dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 99 (resident was unable to complete the interview). Section G Functional Status showed she needed extensive assistance of one for bed mobility and was totally dependent on two for transfers and toileting. Review of the current physician orders and June 2023 Treatment Administration Record (TAR) showed an order for a urinalysis (U/A) and culture and sensitivity (C and S) on 06/11/2023 and performed on 06/12/2023; an order for a U/A and C and S on 06/17/2023 and performed on 06/19/2023; an order for Cipro 500 mg (milligrams) for a Urinary Tract Infection (UTI) as of 06/20/2023. Record review of the Urinalysis and C and S results, dated 06/12/2023, were as follows: Appearance slight cloudy or abnormal Blood 50-150 or abnormal Protein 15-30 or abnormal Leukocytes 25.0 or abnormal Bacteria 2+ or abnormal Amorphous crystals few or abnormal. C and S dated 06/12/2023 showed: Organism Proteus Mirabilis Colony Count over 100,000. Record review of the progress notes starting on 06/01/2023 showed no progress notes documented regarding the U/A and C &S until 06/20/2023: On 06/20/2023 at 15:25 (3:25 p.m.) showed the result for U/A, C &S received and physician office updated. See new order per physician office to start Cipro 500 milligrams (mg) twice a day for 5 days. On 06/20/2023 at 23:39 (11:39 p.m.) showed resident was on by mouth antibiotic, Cipro 500 mg two times a day for UTI. Dose was given and no signs and symptoms (S/S) of side effects was noted. Oncoming nurse was aware. On 06/21/2023 at 16:04 (4:04 p.m.) showed resident was afebrile (not feverish). Antibiotic for UTI in progress, no adverse effect noted. On 06/22/2023 at 23:23 (11:23 p.m.) showed resident continues with by mouth antibiotic for UTI, resident denies pain or discomfort. No s/s of acute distress noted. On 06/23/2023 at 16:13 (4:13 p.m.) showed resident was afebrile, Antibiotic ongoing for UTI. No adverse effect noted. Review of care plans showed an antibiotic care plan related to antibiotic therapy related to infection for UTI. Interventions included but were not limited to administer medications as ordered. Care plan related to incontinence. Interventions included but not limited to observe for foul smelling, cloudy urine, change in urinary output, mental status change. Care plan related to Seizure disorder showed interventions included but not limited to monitor labs and report any sub therapeutic or toxic results to physician, obtain and monitor lab/diagnostic work as ordered. Report results to physician and follow up as indicated. The labs ordered on 06/17/2023 and performed on 06/19/2023 were not located by the facility. 2. Review of the admission Record showed Resident #4 was admitted on [DATE] and readmitted on [DATE]. Resident #4's diagnoses included but were not limited to fractured right femur, hypertension, anemia, kidney failure. Review of the Quarterly MDS, dated [DATE], showed a BIMS score of 10 (moderately impaired). Section G, Functional Status showed he needed supervision for bed mobility, transfers, and limited assistance for toileting. Review of the current physician orders and June 2023 Treatment Administration Record (TAR) showed an order for a Vitamin D level on 06/24/2023 performed on 06/24/2023. Review of the lab results dated 06/24/2023 showed Vitamin D-3 level of 23 or low. Record review of the progress notes showed on 06/24/2023 at 06:27 (6:27 a.m.) blood drawn for Vitamin D labs this morning. No further documentation was provided. Review of the Nutritional care plan showed to obtain and review lab/diagnostic work as ordered. Report results to physician and follow up as indicated. 3. Resident #5 was admitted on [DATE] and readmitted on [DATE]. Resident #5's diagnoses included but not were not limited to osteomyelitis of sacral vertebra, weakens, dysphagia, pressure ulcer left heel, fibromyalgia, anemia, diabetes, morbid obesity, asthma, and hypertension. Review of the Quarterly MDS, dated [DATE], showed a BIMS score of 14 (cognitively intact). Section G, Functional Status showed he was totally dependent on two persons for bed mobility, transfers, and toileting. Review of the current physician orders and June 2023 TAR showed an order for CBC (Complete Blood Count), BMP Basic Metabolic Panel), U/A, C&S ordered on 06/24/23. Review of the labs, dated 06/24/2023, showed the following as abnormal: CBC showed: RBC (Red Blood Count) 4.29 or low Hemoglobin 12.0 or low Hematocrit 37.3 or low RDW (Red Cell Distribution Width) (used to help diagnose anemia) 16.1 or high. BMP showed: BUN (Blood Urea Nitrogen) (shows kidney function) 26 or high. Record review of the progress notes showed: On 06/24/2023 at 06:27 blood drawn for CMP, BMP, urine collected for urinalysis, urine culture and sensitivity this morning. On 06/24/2023 at 06:28 (6:28 a.m.), chest x-ray done. Waiting for results. The oncoming nurse will be made aware. There was no reference to the lab results in the progress notes. Review of the Nutritional care plan showed to obtain and review lab/diagnostic work as ordered. Report results to physician and follow up as indicated. During interview on 06/26/2023 at 3:20 p.m. with Staff A, Registered Nurse/Unit Manager (RN/UM) she stated the lab process was for either the UM or the floor nurse to access the lab results from the lab computer site. The results were to be printed off. The results were then placed into the physician's notebook for review. The lab results, after the physician reviews, were then filed into the resident's hard chart. Staff A looked in the physician's notebook and in hard charts for Resident #3, #4, and #5 and was unable to find the lab results. Staff A, RN/UM then went to the computer, onto the lab's website and printed all three of the resident's labs. She verified that Resident #4 had labs ordered on and performed on 06/20/2023 and it was documented in the resident's e-chart that there were no new orders as of 06/22/23. He also had labs performed on 06/24/2023, which there was no documentation in the e-chart that the physician had been notified of the results. Staff A stated if the labs were normal, they place the results in the physician's notebook and the physician will look at them on Monday. When asked if they were reviewed today (Monday), she stated the APRN (Advanced Practice Registered Nurse) did not come in today. Staff A then verified Resident #5 had labs performed on 06/24/2023 for urinalysis and BMP. She again was unable to find the results in the physician's notebook nor in the hard chart. She printed them from the lab's computer site. She verified there was no documentation the physician or family was called with the results. Then Staff A reviewed Resident #3's labs and progress notes and verified the labs were performed on 06/12/2023 but the antibiotic was not ordered until 06/20/2023. She stated that she did not know why there was such a delay in reporting to the physician. During an interview on 06/26/2023 at 3:59 p.m. the Director of Nursing (DON) stated they were to get an order and follow that order. They insert the order into the e-chart. Once the labs have been drawn or picked up, they would advise the physician of the pick-up time and date, if it was going to be delayed. The nurse was then to look for the results on the lab's website. They were to use the nurse-to-nurse report to let the next nurse know of the labs. Each nurse was to follow-up during their shift until the lab results were obtained. She stated a C & S result could take up to three or four days. They were to check on the lab's website in the computer. They were to print the results. She stated sometimes the lab will fax over the results. The nurse should then notify the physician and obtain orders as needed. If the resident was their own person, the nurse can notify the resident of the results. If they aren't then the families are to be notified of the lab results and any changes in orders. Some of the families want to know everything and if the resident was okay with that, then they are told. They follow the wishes of the resident. The nurse should document in the chart they notified the physician and resident and/or family of the results. The lack of following up on the lab results and informing the physician could result in a negative outcome they could miss something; they could miss a critical lab result. Record review of the facility's policy titled, Laboratory Services, effective January 1, 2020, showed the facility will provide or obtain laboratory services to meet the needs of its residents/patients. The facility will be responsible for the quality and timeliness of services whether provided by the facility or an outside agency. Procedure: 1. Assure laboratory tests or completed results provided to the facility within timeframes normal for appropriate intervention. 2. Provide or obtain laboratory services only when ordered by a physician. 3. Assure Nursing notifies the physician promptly of the findings. 5. Assure the laboratory reports submitted by the laboratory are filed in the resident/patient's clinical record contain at least the following: a. Date b. resident/patient name c. name and address of the testing laboratory. 6. Monitor services, timeliness, and quality through the Quality Assurance Committee. Record review of the facility's policy titled, Resident Rights, effective February 2021, showed the facility strives to assure that each resident has a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility. The facility will protect and promote the rights of each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to ensure that two (#36 and #68) out of five residents on one of the two secured units who required extensive assistance with eating were identified in a dignified manner. Findings included: On 8/10/2021 at 12:11 p.m., Staff Member G, 300-unit Registered Nurse/Unit Manager (RN/UM), was observed removing trays from the meal cart on the 300-secured unit and passing them to staff members who were assisting residents with the set up of their lunch meal. The RN/UM removed one tray from the cart, while an aide waited for her to pass the tray, then placed it back on the cart while identifying that Resident #36 is a feeder. The Unit Manager was observed delivering a tray into room [ROOM NUMBER], returning with the tray and stated that Resident #68 is a feeder. Staff Member G stated, on 8/10/21 at 12:26 p.m., that both Resident #36 and Resident #68 required 1:1 assistance with eating. She confirmed that she did call Resident #36 and Resident #68 feeders and that she should not have referred to them in that manner. The admission Record identified that Resident #36 was admitted on [DATE] and diagnoses were not limited to unspecified dementia without behavioral disturbance and oropharyngeal phase dysphagia. Resident #36's Comprehensive Assessment, dated 5/12/2021, indicated the resident required extensive assistance from one-person for the task of eating. The admission Record identified that Resident #68 was admitted on [DATE] and diagnoses were not limited to unspecified dementia without behavioral disturbance and oral phase dysphagia. The Quarterly Comprehensive assessment, 5/25/2021, indicated the resident required extensive assistance from one-person for the task of eating. On 8/12/2021 at 6:17 p.m., the Director of Nursing (DON) stated that staff should know the residents who needed assistance with eating and that residents should not be identified as feeders if they required assistance with eating. During a continued interview, at 6:32 p.m. on 8/12/2021, the DON stated she was disheartened that staff had referred to the residents as feeders. The policy, Dining Program, effective January 2021, indicated that the facility promotes quality meal service to allow the residents a dignified and pleasurable dining experience. The policy did not identify how staff were to refer to residents in regards to the assistance required during the meal service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to ensure that each resident was afforded the right to personal privacy for one (Resident #168) of 59 sampled residents. Findings include: Observations of Resident #168's room on 8/10/21 at 11:28 a.m., revealed the resident lived in a 4 bed room and occupied the bed next to the window. It was noted that there were multiple broken and bent blinds at the window not allowing for privacy. Observations on 8/11/21 at 10:18 a.m., revealed that the window blinds next to Resident #168 bed were bent, broken, and not allowing for privacy. Observations on 8/12/21 at 9:27 a.m., revealed that Resident #168 was asleep in her bed and the window blinds on the window next to her bed were bent, broken, and not allowing for privacy Observations on 8/13/21 at 7:47 a.m., revealed Resident #168 lying in bed sleeping in her bed next to the window. The window blinds were bent, broken, and not allowing for privacy. Review of Resident #168's quarterly Minimum Data Set (MDS) dated [DATE], revealed that this resident had a Brief Interview For Mental Status (BIMS) score of 03 (Severe Cognitive Impairment), and required extensive physical assistance of 2 persons for dressing and personal hygiene. Review of the Resident #168's care plan dated 5/7/16, revealed that the resident was unable to complete activities of daily living (ADL) tasks independently and required individualized interventions. An interview on 8/13/21 at 7:50 a.m., with Staff B, RN Unit manager revealed that the window blinds should not be like that. He reported that the window looked out to a courtyard and with other windows across on the other side of courtyard, it was possible for someone to see into the room. He reported that he was not aware of the condition of the window blinds and that this resident required total care. He said the aides who provide care daily to the resident should have reported the blinds. An interview on 8/13/21 at 8:00 a.m., with the Maintenance Director revealed that the system in place was that if staff notice a concern they should complete a work request and place it in the wall file located on each unit. He reported that every day he collected the work requests from the wall files on each unit, but had not seen anything related to the window blinds in this room. He reported in addition to the staff making work request, he did a daily walk-through and must have missed the window blinds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide a complete written notification of a Transfer & Discharge notice to the Resident representative and the Ombudsman for one (Resident #81) of five residents sampled for discharge. Findings included: Resident #81 was admitted to the facility on [DATE] according to the admission Record. On 8/11/21 at 10:11 a.m., Resident #81 was observed lying in bed. The resident was unable to speak or answer any questions related to care and was bed bound. A review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS) was unable to be conducted due to Resident #81 being rarely/never understood. A review of the progress notes, dated 6/1/21 at 11:15 a.m., revealed Resident #81 had episodes of vomiting projectile coffee ground emesis times 4. The physician was notified, and the Advanced Registered Nurse Practitioner (ARNP) ordered the nurse to send the resident to the emergency room for evaluation and treatment. A follow up note from nursing, dated 6/1/21 at 11:15 p.m., indicated Resident #81 was admitted with a diagnosis of gastrointestinal bleeding. A review of the order summary for Resident #81 revealed a physician's order to transfer the resident to the emergency room for nausea, vomiting and coffee ground emesis dated 6/1/21. According to the admission record, the resident returned to the facility on 6/4/21. A review of the nursing home transfer/discharge notice form provided by facility revealed the front of the form to be typewritten and indicated the resident's needs could not be met at the facility. The back of the form was only signed by a nurse and dated 6/1/21. There was no signature from the resident/resident representative on the form, and no indication of notice to the Ombudsman was on the form. A review of the monthly transfer/discharge list for the facility did not indicate Resident #81 had been transferred to the hospital on 6/1/21. On 8/13/21 at 1:49 p.m., an interview was conducted with the Medical Records Manager and the Regional Registered Nurse (RN). The Manager stated she was not aware that transfer/discharge notices had to go out in writing to the resident representative. The Regional RN stated she was aware of the process, but she was not able to verify the transfer/discharge notice, and ombudsmen notification had been sent to the Resident Representative for Resident #81. The Manager stated the process had been for the nurse to initiate the documents and send the record to the medical records department where the paperwork was checked for accuracy and provided the notification. The Manager verified this process was now in place and they, medical records, would be sending the notifications out as required in the future. On 8/13/21 at 1:55 p.m., an interview was conducted by telephone with the Resident Representative for Resident #81. The Representative stated she did receive a phone call from the facility when the resident was sent out for care, and did not recall receiving any documents in the mail related to the transfer. The Representative stated she was not aware that she was to receive any documents in writing at the time of a transfer or discharge. The Representative stated she was the only designated person responsible for the care of Resident #81. A review of the policy entitled Bed hold and in-house transfer- Florida with a revised date of February 2021, revealed the following : Policy: In-house transfer: Residents that are transferred, planned or unplanned will receive the Nursing Home Transfer and Discharge Notice AHCA Form 3120. Purpose: 5. In cases of emergency transfer, notice at the time of transfer means the family, surrogate, or representative are provided with written notification within 24 hours of the transfer. Emergency transfers: When a resident is temporarily transferred on an emergency basis to an acute care facility, notice of the transfer may be provided to the resident and resident representative as soon as practicable. Copies of notices for emergency transfers must also still be sent to the ombudsman, but may be sent when practicable, such as in a list of residents on a monthly basis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to provide written notification of the facility Bed Hold Policy to the Resident representative for one (Resident #81) of five residents sampled for discharge. Findings included: A review of the facility bed hold policy (dated 6/1/21) revealed a stamp on the document stating a copy was sent with Resident #1 and a copy was mailed to the patient representative. Unable to sign was written on the document and dated by nursing on 6/1/21. A review of the policy entitled Bed hold and in-house transfer- Florida with a revised dated of February 2021, revealed the following: Policy: The facility provides the resident/resident representative notice of bed-hold in advance of transfer. An additional notice, which specifies the duration of the bed-hold, will be provided upon transfer to the hospital or prior to the therapeutic leave. The bed hold form provided at the time of discharge or therapeutic leave will be written and shall specify the duration for the bed-hold. Resident hospitalization or therapeutic leave days that exceed the bed-hold period under the State's plan, 8 days for hospitalization and 16 days for therapeutic leave, will be readmitted to the facility upon the first availability of the bed in a semi-private room if the resident requires the services provided by the facility; and is eligible for Medicaid nursing facility services A review of the monthly transfer/discharge list for the facility did not indicate Resident #81 had been transferred to the hospital on 6/1/21. On 8/13/21 at 1:49 p.m., an interview was conducted with the Medical Records Manager and the Regional Registered Nurse (RN). The Manager stated she was not aware that transfer/discharge notices and bed hold policies had to go out in writing to the resident representative. The Regional RN stated she was aware of the process, but she was not able to verify the bed hold policy had been sent to the Resident Representative for Resident #81. The Manager stated the process had been for the nurse to initiate the documents and send the record to the medical records department where the paperwork was checked for accuracy and provide the notification. The Manager stated that this process was now in place and they, medical records, would be sending the bed holds out as required in the future. On 8/13/21 at 1:55 p.m., an interview was conducted by telephone with the Resident Representative for Resident #81. The Representative stated she received a phone call from the facility when the resident was sent out for care, did not recall receiving any documents in the mail related to the transfer. The Representative stated she was not aware that she was to receive any documents in writing at the time of a transfer or discharge. The Representative stated she was the only designated person responsible for the care of Resident #81. Resident #81 was admitted to the facility on [DATE] according to the admission Record. On 8/11/21 at 10:11 a.m., Resident #81 was observed lying in bed. The resident was unable to speak or answer any questions related to care. The resident was bed bound. A review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS) was unable to be conducted due to Resident #81 being rarely/never understood. A review of the order summary for Resident #81 revealed a physician's order to transfer the resident to the emergency room for nausea, vomiting and coffee ground emesis dated 6/1/21. According to the admission record, the resident returned to the facility on 6/4/21.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that resident assessments reflected the resident's status accurately for two (#29, #32) of 59 sampled residents. Findings included: 1. Observations on 8/10/21 at 11:55 a.m., revealed that Resident #29 was noted with his lower mouth sunken in. The resident opened his mouth to show his upper dentures in place and reported that his lower dentures were in the night stand top draw and that staff assist him in putting it in daily but no one had done it today. Observations of Resident #29 on 8/11/21 at 12:15 p.m., revealed the resident with his midday meal. It was noted that he did not have in his lower dentures. Observations on 8/12/21 at 9:24 a.m., revealed Resident #29 seated in the hallway by a window looking out. He reported that he had his breakfast already but that his dentures were still in his room in the drawer. He reported that he did not get any assistance with getting his dentures put in for his meal. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed that the resident had no dental concerns. Review of the annual MDS dated [DATE], revealed that the resident had no dental concerns. The assessment indicated that this resident required extensive assistance of one person to complete personal hygiene Review of the Nursing quarterly and PRN Data collection dated 7/29/21, indicated that the resident has natural teeth and did not have dentures. Review of the Nursing quarterly and PRN Data collection dated 4/29/21, indicated that the resident did not have natural teeth and did not have dentures. Review of the Nursing quarterly and PRN Data collection dated 1/29/21, indicated that the resident did not have natural teeth and did not have dentures. Review of the Nursing quarterly and PRN Data collection dated 10/29/20, indicated that the resident did not have natural teeth and did not have dentures. Review of the Nursing quarterly and PRN Data collection dated 7/29/20, indicated that the resident had natural teeth and did not have dentures. An interview with Resident #29 on 8/12/21 at 12:35 p.m., revealed that he did not get assistance with his lower dentures. He said that he would like to wear them but they did not fit, and had not fit for a long time. Interview on 8/12/21 at 12:36 p.m., with Staff A, CNA revealed that the resident did have dentures and that she asked him daily if he wanted them in and he refused. When asked if the dentures fit, she replied that she was unsure but that could be why he refused them. In an interview on 8/12/21 at 12:46 p.m., with Staff B, Unit 4 manager, he reported that he was not aware of a problem with Resident #29's dentures. He was not aware that they were not being worn. He reported that he would contact Social Services and get the resident on the list to be seen by dental services. 2. Resident #32 was admitted to the facility on [DATE] and had diagnoses that included Parkinson's Disease; Contracture of Right Hand; Contracture of Left Hand; Osteoarthritis, unspecified site. Observations of Resident #32 on 8/10/21 at 11:08 a.m., revealed the resident lying in her bed with bilateral palm splints in place. Observations on 8/10/21 at 11:11 a.m., revealed the resident lying in bed. She was noted to be wearing bilateral hand splints. Observations on 8/10/21 at 1:52 p.m., revealed the resident with bilateral hand splints. Observations of Resident #32 on 8/11/21 at 10:54 a.m., revealed the resident wearing bilateral hand splints. Observations on 8/12/21 at 11:55 a.m., revealed the resident with bilateral hand splints on. Observations on 8/13/21 at 7:46 a.m., revealed the resident lying in bed, she was noted to not be wearing bilateral hand splints. An interview on 8/13/21 at 7:50 a.m., with Staff B, RN revealed that the resident needed total care and that she had some contractures of both her hands and used bilateral hand splints. Review of the Nursing Quarterly and PRN data collection dated 6/6/21 revealed that the resident did not have contractures of the right and left upper extremities, but did have contractures of right and left lower extremity. Review of the Nursing Quarterly and PRN data collection dated 3/6/21 revealed that the resident did not have contractures of the right and left upper and lower extremities. Interview on 8/13/21 at 1:59 p.m. with the Director of Nursing (DON) confirmed that Resident #32 did have contracture's of her right and left upper extremities. She reported that nursing completes the nursing assessments which should be accurate. 3. A policy was requested from the facility related to the accuracy of assessments. This policy was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to revise the care plan for one (#153) out of fifty-nine sampled residents in related to the implementation of positioning devices while the resident was in bed. Findings included: Resident #153 was observed, on 8/11/21 at 9:25 a.m., lying in bed with the head of the bed raised and bilateral floor mats. During the observation, the mattress appeared to have bilateral bolsters on each side of the resident. On 8/12/21 at 4:10 p.m., the resident was observed lying in bed with bilateral mattress bolsters and no side rails were attached to the bed frame. On 8/12/21 at 5:28 p.m., an observation of Resident #153 was conducted with the Director of Nursing (DON) and the Assistant DON (ADON). The DON confirmed that the blue wedge on the left-side of the bed was removable from the mattress and not attached to the bed frames and that the rectangular bolster on the right-side of the bed was not attached to either the mattress or bed frame. On 8/13/21 at 10:00 a.m., an observation of the resident indicated that the resident was lying in bed with both the rectangular and wedge bolster on either side of the resident. The admission Record of Resident #153 indicated that the resident was admitted on [DATE]. The record included diagnoses not limited to other seizures, unspecified extrapyramidal and movement disorder, and dementia in other disease classified elsewhere without behavioral disturbance. A review of Resident #153's care plan indicated that the resident had a Focus for a seizure disorder, with an initial date of 10/04/16. The interventions related to the resident's seizure disorder did not indicate any safety devices were used for the resident. The care plan had a Focus that the resident was at risk for falls, with an initial date of 10/04/16. The interventions indicated that floor mats and a low/platform bed were to be used while the resident was in bed but did not indicate that bolsters were in use. The interventions of Resident #153's care plan did not identify that bilateral positioning devices were utilized for the resident. A review of Resident #153's physician orders, active as of 8/12/21, did not include an order for the use of any positioning devices while the resident was in bed. On 8/13/21 at 2:15 p.m., Staff Member H, Certified Nursing Assistant (CNA), stated Resident #153 had the wedges (bolsters) on the mattress for about one week. The staff member identified that the Registered Nurse/Unit Manager (RN/UM) had put the devices on the resident's bed. On 8/13/21 at 2:25 p.m., Staff Member G, Registered Nurse/Unit Manager (RN/UM), confirmed that she had placed the positioning devices on Resident #153's bed one or two weeks ago. She stated she had meant to implement a care plan but had not. She stated that the responsible party had been notified. She reviewed the progress notes and stated that she had not documented that the responsible party was notified. She stated that the resident had extrapyramidal movements and had the tendency to turn in the bed and its not safe. The RN/UM reviewed the clinical record and confirmed that therapy had not been notified to evaluate the resident for positioning devices. She stated she normally did refer to therapy and had meant to send the referral. The Unit Manager reported that the procedure for placing devices next to the resident was to have a therapist evaluate the resident then let the doctor know of therapy recommendations. She confirmed that the last Therapy Referral on 7/7/21 was not for an evaluation of positioning devices. The Director of Nursing (DON) stated, on 8/12/21 at 5:17 p.m., staff did not need a physician order for the bolsters but the bolsters should be care planned. She stated that the resident utilized the bolsters for positioning. The DON reviewed the care plan for Resident #153 and confirmed that it did not identify bolsters were utilized. On 8/13/21 at 8:54 a.m., the DON stated that the wedges were placed by nursing this week as a nursing judgement. On 8/13/21 at 1:31 p.m., the Clinical Reimbursement Coordinator stated that changes to the care plan were done as things change for the residents. The Clinical Reimbursement department was notified of changes during morning meetings, and the unit managers and nurses notify them of changes daily. The policy and procedure, Care Plan Interdisciplinary Plan of Care from Interim to Meeting, effective March 2017, indicated that The facility shall support that each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing, in accordance with the comprehensive assessment and plan of care. The policy indicated that Daily updates to care plans are added by a member of the Interdisciplinary Team (IDT) at the time of the change is implemented, the interventions needed, or other care plan revision in indicated. Accuracy of the care plan is validated by the IDT during the daily clinical meeting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide prompt dental service when a residents dentures do not fit appropriately for one (Resident #29) of 59 sampled residents. Findings included: Observations on 8/10/21 at 11:55 a.m., revealed that Resident #29 was noted with his lower mouth sunken in. The resident opened his mouth to show his upper dentures in place and reported that his lower dentures were in the night stand top draw and that staff assist him in putting it in daily but no one had done it today. Observations of Resident #29 on 8/11/21 at 12:15 p.m., revealed the resident with his midday meal. It was noted that he did not have in his lower dentures. Observations on 8/12/21 at 9:24 a.m., revealed Resident #29 seated in the hallway by a window looking out. He reported that he had his breakfast already but that his dentures were still in his room in the drawer. He reported that he did not get any assistance with getting his dentures put in for his meal. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed that the resident had no dental concerns. Review of the annual MDS dated [DATE], revealed that the resident had no dental concerns. The assessment indicated that this resident required extensive assistance of one person to complete personal hygiene Review of the Nursing quarterly and PRN Data collection dated 7/29/21, indicated that the resident has natural teeth and did not have dentures. Review of the Nursing quarterly and PRN Data collection dated 4/29/21, indicated that the resident did not have natural teeth and did not have dentures. Review of the Nursing quarterly and PRN Data collection dated 1/29/21, indicated that the resident did not have natural teeth and did not have dentures. Review of the Nursing quarterly and PRN Data collection dated 10/29/20, indicated that the resident did not have natural teeth and did not have dentures. Review of the Nursing quarterly and PRN Data collection dated 7/29/20, indicated that the resident had natural teeth and did not have dentures. An interview with Resident #29 on 8/12/21 at 12:35 p.m., revealed that he did not get assistance with his lower dentures. He said that he would like to wear them but they did not fit, and had not fit for a long time. Interview on 8/12/21 at 12:36 p.m., with Staff A, CNA revealed that the resident did have dentures and that she asked him daily if he wanted them in and he refused. When asked if the dentures fit, she replied that she was unsure but that could be why he refused them. In an interview on 8/12/21 at 12:46 p.m., with Staff B, Unit 4 manager, he reported that he was not aware of a problem with Resident #29's dentures. He was not aware that they were not being worn. He reported that he would contact Social Services and get the resident on the list to be seen by dental services. Review of the facility policy titled Dental Services with an effective date of February 2021 revealed that The facility will assist residents in obtaining routine care, 24-hour emergency dental care and denture replacement in the case of loss, damage, or ill-fitting dentures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to honor resident's rights related to their choice of food preferences for five (Residents #37, #122, #160, #171, #193) of 59 sampled residents. Findings included An interview on 8/13/21 at 12:48 p.m., with Resident #160 revealed that she was on a regular diet and loved hot dogs and missed eating hot dogs. She reported that she did not know why she could not have a hot dog. She reported that the facility said that it was a safety hazard. She said, her mother brought her some hotdogs thinking that the facility would cook them but they would not, she was told that she could buy ready cooked hotdogs from outside the facility. Review of Resident #160's record revealed that she was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS) dated [DATE], revealed that she had a Brief Interview for Mental Status (BIMS) score of 13 (Cognitively intact), did not require her food to be mechanically altered, and had no difficulty chewing. Review of Resident #160's Nutrition Evaluation dated 7/6/21, revealed that the resident had no difficulty chewing or swallowing. During a meeting of four alert and oriented Residents (#37, #122, #171, #193) on 8/12/21 at 10:30 a.m., the group reported that they were told that due to a child choking on a hotdog at a day care center, they are not allowed to have hot dogs. The group reported that they do not understand why those who are not capable of handling a hot dog should be addressed on an individual bases and allow those residents who could and want hot dogs to have them. The group reported that this rule affects hot dogs, kielbasa, and link sausages. The group reported that this was not fair. Review of resident #37's record revealed that he was admitted to the facility on [DATE] . Review of the MDS dated [DATE], revealed that he had a BIMS score of 11 (Moderate impairment), Did not require her food to be mechanically altered and had no difficulty chewing. Review of Resident #37's Nutrition Evaluation dated 5/13/21, revealed that the resident had no difficulty chewing or swallowing. Review of Resident #122's record revealed that she was admitted to the facility on [DATE]. Review of the MDS dated [DATE], revealed that she had a BIMS score of 15 (Cognitively intact), did not require her food to be mechanically altered, was not on a therapeutic diet and had no difficulty chewing. Review of Resident #122's Nutrition Evaluation dated 6/23/21, revealed that the resident had no difficulty chewing or swallowing. Review of Resident #171's record revealed that she was re-admitted to the facility on [DATE]. Review of the MDS dated [DATE], revealed that she had a BIMS score of 15 (Cognitively intact), did not require her food to be mechanically altered, was not on a therapeutic diet and had no difficulty chewing. Review of Resident #171's Nutrition Evaluation dated 7/15/21, revealed that the resident had no difficulty chewing or swallowing. Review of Resident #193's record revealed that she was re-admitted to the facility on [DATE]. Review of the MDS dated [DATE], revealed that she had a BIMS score of 15 (Cognitively intact), did not require her food to be mechanically altered and had no difficulty chewing. Review of Resident #193's Nutrition Evaluation dated 7/19/21, revealed that the resident had no difficulty chewing or swallowing. An interview on 8/13/21 at 12:11 p.m., with the Nursing Home Administrator (NHA) revealed that it was the rule of the facility that hotdogs and other sausages could not be served. He reported that this rule had been put in writing in the form of an email from the Director of Nutrition Services dated February 10, 2021, and this was what he went by. He reported that the facility did not have a policy related to serving hotdogs/sausages. An interview on 8/13/21 at 12:35 p.m., with the Registered Dietician (RD) revealed that about one year ago all cylindrical meats were removed from the purchase guide and menus for the safety of the residents. She reported that no assessments were completed on any resident as to their ability to consume hotdogs safely. She reported that the first time she heard of a concern about hotdogs was this week when a resident consulted with her and wanted hotdogs. A phone interview on 8/13/21 at 1:27 p.m., with the Director of Nutrition Services revealed that cylindrical meats were not on the menu and not on the order guides. She reported that the order guides accommodate only meals that were in the order guide. She reported that she had been with the company for about one year and ordering outside of the order guide had never been done. She reported that typically residents were not assessed as to their ability to consume certain foods unless there was an issue. She reported that all residents had the ability to request resident choice meals, but could only get the item if it was on the order guide. She reported that there was no policy related to not serving cylindrical meats. A review of an email dated February 10, 2021, from the Director of Nutrition Services revealed that this email included the following: Just a reminder that we do not serve any cylindrical meats at our facilities (no hot dogs, no cylindrical sausages). These are not on our order guide and also should not be purchased from outside vendors. Review of the facility policy titled Resident Rights with an effective date of January 2017 revealed the following: The facility will protect and promote the rights of each resident. The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #147 was observed on 10/07/2019 eating lunch with assistance in the restorative dining room. Her meal ticket reflected a regular puree diet and her tray revealed pureed foods. On 10/09/2019 at 12:47 PM Resident #147 was, again, observed eating lunch with assistance in the restorative dining room and her meal ticket reflected a regular puree diet and her tray revealed pureed foods that matched the ticket. Photographic evidence was obtained. A review of the medical record for Resident #147 found that she was admitted to the facility on [DATE] with diagnoses that included dysphagia. A review of the active physician orders revealed an order for Regular diet, Puree texture, Regular (Thin) consistency, with a start date of 03/12/2019. The most recent completed MDS, dated [DATE], revealed in section K, Swallowing/Nutritional Status, an entry of 0. Not checked (No) for whether the nutritional approach of a mechanically altered diet such as pureed food had been performed while the resident was residing in the facility within the last 7 days. The entry was signed and dated 9/16/2019 at 11:22:37 PM. Photographic evidence obtained. Staff M, Registered Dietician (RD) was interviewed on 10/10/2019 at 12:08 PM. He stated he had been covering at the facility for eight days and was familiar with the resident, and that she was on a mechanically altered pureed diet. Staff C, Registered Nurse (RN), Unit Manager (UM) was interviewed on 10/10/2019 at 2:30 PM and stated, she's on a puree diet. On 10/10/2019 at 6:50 PM an interview was conducted with Staff R, RN, Clinical Reimbursement Specialist (CRS) who reported that there were three personnel in the facility who completed Minimum Data Set (MDS) assessments but that one was out on leave and that she [Staff R] was the main person responsible for MDS assessments currently. Staff R was asked to pull up section K for the MDS dated [DATE] for Resident #147 and she confirmed that she was the one that signed the entry and confirmed that the entry revealed that the resident was not on a mechanically altered diet. She stated, I don't know what happened here .I guess it's another one we'll have to modify. When asked whether the entry was inaccurate staff R stated, I'm not going to say that .I need more time to look into that. Staff R was offered more time to investigate and report back and in follow up continued to decline answering whether the entry in the MDS section K dated 09/01/2019 that reflected that Resident #147 was not on a mechanically altered diet was accurate or inaccurate. The Administrator was interviewed on 10/10/2019 regarding the accuracy of the MDS assessments in the facility. He responded that there had been no issues and that the facility received a monthly report from an MDS consultant but they've [facility MDS assessments] been pretty much on target for the last 8 months. It was revealed to the Administrator what had been discovered in investigation and he stated it would be addressed at the next Quality Assurance and Performance Improvement (QAPI) committee meeting. 2. Resident #215 was admitted on [DATE]. The admission Record included diagnoses not limited to other sequelae following unspecified cerebrovascular disease, Chronic Obstructive Pulmonary Disease with acute exacerbation, and Type 2 Diabetes Mellitus with complications. The AHCA (Agency for Healthcare Administration) Form 5000-3008, dated 5/30/17, indicated Resident #215 was transferred to the facility with a stage IV coccyx wound. The skin/wound notes for the resident included the following: On 2/4/19 at 12:31 p.m., Resident #215 was admitted in 2015 with a stage IV coccyx wound, which the facility resolved on 7/28/17. The facility noted the original wound had reopened and the area noted as a stage II was a healing stage IV as previously noted on admission. The notes from 2/15, 2/23, and 3/1/19 indicated the coccyx wound was a stage II. A note of 3/8/19 at 14:56 (2:56 p.m.) revealed a previously stage IV coccyx wound was a stage II. The notes on 3/15, 3/22, 3/29, 4/5, 4/11, 4/19, and 4/26/19 documented a previously staged IV was a stage II coccyx wound. The notes on 5/3, 5/10, 5/17, 5/24, 5/31, 6/7, 6/14, 6/21, 6/28/19 indicated a healing stage IV appeared to be a stage II coccyx wound. A note of 7/5/19 at 13:34 (1:34 p.m.) indicated a healing stage IV coccyx wound. The notes on 7/11, 7/19, 8/2, 8/9, 8/16, 8/23, 8/30, 9/6, 9/13, 9/19, 9/27, and 10/4/19 indicated a healing stage III coccyx wound. The Wound Care physicians' notes revealed the following information: Visit date 1/17/19 revealed a Stage III coccyx wound that was not present at the time of admission. A note from the visit on 3/21/19 indicated a coccyx wound, which was not present at the time of admission, was a stage III. The note, dated 4/18/19, identified a stage III coccyx wound, which was not present at the time of admission. The 5/23/19 visit note revealed a stage III coccyx wound, which was not present upon admission. A note from the visit date 8/14/19 identified a stage III coccyx wound, which was not present at the time of admission. The note, dated 9/19/19, indicated a stage III coccyx wound, which was not present at the time of admission. A review of Resident #215's Minimum Data Set assessments revealed the following information: The Quarterly, dated 1/4/19, indicated the resident had a stage II pressure ulcer, which was not present upon admission/entry or reentry. The Quarterly, dated 4/1/19, identified a stage II pressure ulcer which was not present upon admission/entry or reentry. Documentation from the wound care nurse indicated that Resident #215's coccyx wound was previously a stage IV and the Wound Care physician identified a stage III coccyx wound. The Quarterly, dated 6/27/19, revealed a stage II pressure ulcer which was not present upon admission/entry or reentry. Resident #215's clinical record identified a previously stage IV coccyx wound (from wound care nurse) and the Wound Care physician documented a stage III coccyx wound. The Annual, dated 9/24/19, identified a stage III pressure ulcer which was not present upon admission/entry or reentry. The wound care nurse documented Resident #215's coccyx wound has a previously stage IV coccyx wound and a stage III coccyx wound. During an interview, on 10/10/19 at 2:59 p.m., Staff Member D, Wound Care Registered Nurse (RN), stated Resident #215's coccyx wound had reopened. The staff member identified the resident's wound was currently a stage III and to her knowledge, it (the wound) had been a stage III, I don't know what it was before but since I took over it was a stage III. Staff Member D stated when Resident #215 arrived at the facility the wound may have been a stage IV. The staff member reviewed the progress note, dated 10/22/15, and stated she should have clearly gone back that far to stage the wound. The wound care nurse confirmed a pressure ulcer could not be downgraded, if a stage IV wound was healing, the wound did not become a stage III. At 3:31 p.m. on 10/10/19, Staff Member C, RN, confirmed (twice) Resident #215's coccyx wound opens and closes, always the same one. The staff member stated the resident's coccyx wound was a stage IV upon admission. The Center of Medicare and Medicaid Services (CMS) indicated, in 2004 at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/IRF-Quality-Reporting/Downloads/IRF-QRP-Training---PrU-Staging-May-12-2014-.pdf, pressure ulcer stages were not to be reversed, the initial pressure ulcer stage does not change despite healing. The National Pressure Ulcer Advisory Panel (www.npuap.org) indicated if a pressure ulcer re-opens the ulcer resumes the previous stage, once a stage IV always a stage IV. The care plan identified Resident #215's had an actual wound, initiated and revised on 11/19/18, located at the coccyx, and was related to pressure, impaired mobility, incontinence or increased moisture. The interventions, initiated on 11/19/18, instructed staff to monitor wound weekly of location, highest stage, &/or visual stage. Based on observation, interview, record review and review of facility policy and procedure, it was determined that the facility failed to ensure the accuracy of assessments for three of sixty-one sampled residents (#115, # 147 and # 215). Findings included: 1. Review of the record for Resident #115 revealed that she was admitted to the facility on 11/30, with diagnoses which included Tracheostomy Status. Review of Physician's orders for Resident #115 revealed an order, dated 11/5/17, for Suction trach every shift as well as PRN. Review of an Annual MDS assessment, dated 9/24/19, revealed under the section for Special Treatment and Procedures, a response of No for Suctioning. An interview was conducted with Staff S Clinical Reimbursement Specialist, on 10/9/19 at 6: 54 p.m. She reviewed the physician's orders and the Medication Administration and Treatment Administration records for Resident # 115 which found documentation of daily suctioning and stated that she didn't pick up the suctioning and missed it on the annual MDS.

Based on observations, interviews, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed, and four errors were identified for three (#202, #173, and #165) of ten residents observed. These errors constituted a 16.00% medication error rate. Findings included: 1. On 10/8/19 at 4:05 p.m., an observation of medication administration with Staff Member N, Licensed Practical Nurse (LPN) was conducted with Resident #202. The LPN was observed administering the following medications: --Risperidone 0.25 milligrams (mg) via g-tube (gastrostomy) --Buspirone HCl 5mg via g-tube Staff Member N prepared the medications by placing both tablets into one plastic crushing envelope, crushed the medications together, and placed the crushed tablets into a plastic cup, poured 30 milliliters (mL) of water in the cup. Staff Member N took the medications into Resident #202's room, disconnected the enteral nutrition, with a 60 mL syringe placement was auscultated. The staff member flushed the g-tube with greater than 30mL of water, administered the medications, then flushed the tube with 50mL of water. The staff member disconnected the syringe and connected the nutrition tubing to the tube. A review of the physician orders for Resident #202 revealed the following medications orders: - Enteral Feed Order every shift. Dilute each crushed/sprinkles/powdered med with at least 15 mL of water and rinse the cup with 5 to 15 mL to ensure all residue is out of the cup. - Flush feeding tube with 5 mL of water between meds, every shift for maintain patency. - Risperidone tablet 0.25 mg - Give one tablet by mouth two times a day for schizo. - Buspirone HCl 5mg - Give one tablet by mouth three times a day for anxiety. 2. On 10/8/19 at 4:48 p.m., an observation of medication administration with Staff Member N, Licensed Practical Nurse (LPN) was conducted with Resident #173. Staff Member N cleansed the right ring finger of Resident #173, lanced the finger, and obtained a blood glucose of 335. The staff member returned to the medication cart and obtained the following medication: - Novolog 100 units/mL - drew up 9 units into the syringe. Staff Member N cleansed the Left Upper Quadrant (LUQ) of Resident #173's abdomen and administered the 9 units of Novolog. A review of the October Medication Administration Record for Resident #173 revealed the following medication orders: - Novolog Solution 100 unit/mL (Insulin Aspart) - Inject as per sliding scale: if 150-200 = 3 units, 201 - 250 = 6 units, 251 - 300 = 9 units, 350 - 400 = 12 units. If greater than 400 cover with 12 units and call MD, subcutaneously before meals for diabetes. On 10/8/19 at 5:52 p.m., Staff Member N confirmed Resident #173 had been administered 9 units of Novolog. At 5:58 p.m. on 10/8/19, Staff Member J, Registered Nurse/Unit Manager (RN), reviewed the Novolog order for Resident #173 and confirmed the order did not include the amount of insulin that should be administered for the blood glucose range of 301 - 349. The Unit Manager stated the mistake was his fault, he took the order from the endocrinologist on Friday (October 4, 2019) and the endocrinologist wanted a mid-high sliding scale. Staff Member J stated he was going to change the order to include 301-349 units. 3. On 10/9/19 at 5:34 p.m., an observation of medication administration with Staff Member O, Registered Nurse (RN), was conducted with Resident #165. The RN was observed dispensing the following medications: - Gabapentin 100mg 1cap - Gabapentin 400mg 1 cap - Tizanidine Hcl 2mg tab - Metformin HCll 500mg tab - Docusate Sodium 100mg 1 tab The RN entered Resident #165's room, handed the medication cup to the resident. The writer asked the RN to retrieve the medication cup from Resident #165 and to review the physician orders. Staff Member O reviewed the electronic Medication Administration Record and confirmed the medication cup contained a 100 mg tablet of Docusate Sodium. The review indicated the resident was to be administered one tablet of Senna S 8.6-50 mg. The RN retrieved a bottle of Senna 8.6 mg laxative and stated it was not it either. Staff Member Q, RN Supervisor, arrived at the cart and confirmed Docusate Sodium was not the same as Senna S but stated Senna S did contain Docusate and the facility process was that if a resident came in with a Senna S order, the order would be separated to one tablet of Senna 8.6 mg and one of these, indicating the bottle of Docusate 100 mg. The RN Supervisor stated he would contact the physician. Staff Member O took the medication cup containing the medications, and flushed them in the nursing station bathroom. The staff member returned to the medication cart, poured the following medications: -Gabapentin 100 mg -Gabapentin 400 mg -Tizanidine HCl 2mg -Metformin HCl 500 mg - Senna 8.6 mg Staff Member Q informed Staff O that the provider had been contacted and it was okay. The staff member administered the medications to Resident #165, returned to the medication cart and stated he did not know whether the order was for Senna or Docusate. The October Medication Administration Record indicated the following orders for 10/9/19 for 5:00 and 6:00 p.m.: - Metformin HCl 500 mg - Senna-S 8.6-50 mg (Staff Member O indicated the medication was administered) - Gabapentin 100 mg - Gabapentin 400 mg - Tizanidine HCl 2mg The physician orders indicated Docusate Sodium 100 mg - Give 1 tablet by mouth two times a day for constipation, ordered 10/9/19, to start on 10/10/19 and Senna Lax tablet - Give one tablet by mouth two times a day for Constipation OTC (over-the-counter), ordered 10/9/19 and to start on 10/10/19. On 10/10/19 at 8:45 p.m., the Director of Nursing stated it was a nursing judgement whether medications could be crushed together, unless there was a contraindication. She stated her expectation would the staff member ask if her unsure if medications could be crushed together. The DON stated Resident #202 had a standing order to change the form of medications to liquid or oral depending on the condition of the resident. The DON explained that Staff Member N had informed her of the insulin administration, told her the accu-check was 340-something and the nurse did not question the order but Staff Member J had admitted to the transcription of the order. She stated her expectation would be if any question (of physician order) the staff should ask. When the administration of medications with Staff O was described, she stated staff had already told her about it and the staff had already gotten an order for it. The policy titled, Medication Administration - General Guidelines, dated 12/12 - Section 7.1, identified medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices, and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. #3 of the medication preparation indicated prior to administration the orders are reviewed and confirmed on the Medication Administration Record. The Medication Administration section of the policy identified medications are administered in accordance with written orders of the prescriber. According to Preventing Errors When Drugs Are Given Via Enteral Feeding Tubes (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3875244/ ); October 2013, errors occur more frequently when administering medications through a feeding tube. The described errors included not preparing the medications properly. The errors can result in feeding tube occlusions, reduced drug effect, and drug toxicity. In the section: Wrong Administration Technique, it described the most common improper technique was mixing multiple drugs together and administering at the same time. The safe practice recommendations included administering each drug separately. The article reiterated medications should be prepared and administered separately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident centered activities program was implemented based on the comprehensive assessment, care plan, and resident interests for the purpose of supporting physical, mental, and psychosocial well-being for nine (#172, #216, #54, #41, #36, #115, #214, #202, and #204) out of sixty-one sampled residents. Findings included: 1. The facility's calendar of activities was reviewed and revealed the following schedule for the dates of the survey: 10/07/19 8:30 Daily Chronicle, 10:00 Coffee Social, 10:00 Exercise & Meditation, 1:00 Activity Cart, 2:00 Bingo; 10/08/19 8:30 Daily Chronicle, 10:00 Morning Social, 10:30 Who Am I?, 1:00 Activity Cart, 2:00 Culinary Arts; 10/09/19 8:30 Daily Chronicle, 10:00 Bingo, 1:00 Activity Cart/1:1 Visits, 2:00 Nail Art; 10/10/19 8:30 Daily Chronicle, 10:00 Coffee Social; 1:00 Activity Cart; 2:00 Happy Hour w/ Cowboy [NAME] [live musical entertainment]. (Photographic evidence obtained) Multiple observations were made of Resident #172: 10/07/19 at 10:50 a.m. observed seated in her room in her wheelchair once the closed door was opened, roommates were present, one of whom was making loud verbalizations; 10/07/19 at 12:15 p.m. observed side-lying in bed, awake, with the bed in low position; 10/08/19 at 9:17 a.m. observed in her room seated in wheelchair; 10/08/19 at 12:32 p.m. observed in her room seated in her wheelchair grinding her teeth loudly and staring in an unfocused manner although television was on; 10/08/19 at 4:05 p.m. observed side-lying in bed, lights off, right arm draped over the side of the bed rail, grinding her teeth and mumbling; 10/09/19 at 9:40 a.m. observed asleep in bed; 10/09/19 at 11:48 a.m. observed reclined in wheelchair in hallway on unit lined up next to the wall in a single file row with other residents; 10/09/19 at 2:06 p.m. observed seated in her wheelchair in her room, door closed, lights off; 10/10/19 at 11:36 a.m. observed seated in wheelchair in her room, lights off; 10/10/19 at 2:30 p.m. music group activity was observed in progress in main dining room, however resident was found in her room seated in her wheelchair with the lights off. A review of the admission & medical record for Resident #172 revealed that she was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, aphasia, dementia, major depressive disorder, generalized anxiety disorder, and schizophrenia. The most recent completed Minimum Data Set (MDS) dated [DATE] for Resident #172 revealed short and long-term memory problems, severely impaired cognitive skills for daily decision making, total dependence for mobility and Activity of Daily Living (ADL) performance. An interview for activity preferences that documented answered by family or significant other and rated all items as somewhat important. Task documentation for group events and individual activity revealed no progress notes for the last 6 months (May 2019 - October 2019). Resident #172's active care plan revealed a focus area for Activities, initiated on 7/19/16 and with a revision date of 6/5/18 described as, [Resident] requires Staff assistance with involvement of Activities related cognitive deficits. Resident chooses to relax in the comfort of her room. The goals revealed, Will participate in activities, and Will participate in 1:1 visits, both with target dates of 12/18/19. Interventions included, Prefers/would benefit from small group, the resident needs assistance/escort to and/or from activity functions. Staff F, Certified Nursing Assistant (CNA) was interviewed on 10/09/19 at 4:28 p.m. and reported that Resident #172 and Resident #41 did attend facility activities depending on what was offered and stated, When there are activities, everyone in the room is taken. Regarding Resident #172, Staff F was unable to identify an activity that the resident had participated in that week and confirmed that Resident #172 was dependent on staff to initiate and transport her to a group activity. 2. Multiple observations were made of Resident #216: 10/07/19 at 12:23 p.m. - observed in reclined position in specialized chair positioned in her room at the end of her roommate's bed, legs drawn up in a flexed position, repetitive mouth motor movements, not responsive to greeting or attempts to engage; 10/08/19 observed in bed, bed was in a low position, room was dark, TV on, Resident's eyes were open, Resident was not responsive; 10/09/19 8:39 a.m. observed reclined in specialized chair positioned at the foot of her roommate's bed, had slid down in the chair, bilateral legs with observable tremor; 10/09/19 1:13 p.m. observed in her room reclined in specialized chair positioned at the foot of roommate's bed; 10/10/19 11:30 a.m. observed asleep in her bed in her room; 10/10/19 2:39 p.m. group music activity observed in progress, however resident was observed in her room reclined in specialized chair, awake and lights were off. A review of the admission & medical record for Resident #216 revealed that she was admitted to the facility on [DATE] with diagnoses that included schizophrenia, dementia, and bipolar disorder. The most recent completed MDS dated [DATE] revealed short and long-term memory problem and severely impaired cognitive skills for daily decision making. An interview for activity preferences was documented as Interview could not be completed by resident or family/significant other. A review of the most recent Nursing Quarterly and PRN (as needed) Data Collection form dated 10/01/19 revealed the functional status of dependent for ADLs (activities of daily living) and extensive assistance required for mobility. Resident #216's active care plan revealed a focus area of Activities, initiated on 10/7/16 and revised on 4/4/19 described as, The Resident requires Staff assistance with involvement of Activities related to Cognitive deficits. Resident chooses the comfort of her room relaxing and listening to music. The goals included, Will participate in 1:1 visits. The interventions included: Prefers/would benefit from small group, and the resident needs assistance/escort to and/or from activity functions. Staff C, RN/UM was interviewed on 10/10/19 at 2:00 p.m. and reported that the activities staff do bedside activities with Resident #216 or, We'll take her when there's music going on or we'll take her outside. 3. Multiple observations were made of Resident #54: 10/07/19 at 12:49 p.m. observed in her room seated in her wheelchair; 10/08/19 at 9:32 a.m. observed seated in her wheelchair in the hallway near the nurse's station lined up against the wall with other residents; 10/08/19 at 4:10 p.m. observed seated in her wheelchair in the hallway near the nurse's station lined up against the wall with other residents; 10/09/19 at 10:03 a.m. observed seated in her wheelchair in the hallway near the nurse's station lined up against the wall with other residents; 10/10/19 at 11:37 a.m. observed seated in her wheelchair in the hallway near the nurse's positioned underneath the television facing away from it and toward line of residents against opposing wall. A review of the medical record for Resident #54 revealed that she was admitted to the facility on [DATE] with diagnoses that included dementia, schizophrenia, major depressive disorder, and generalized anxiety disorder. A review of the most recent completed MDS for Resident #54 dated 7/28/19 revealed the following: A Brief Interview for Mental Status (BIMS) score of 4, which meant that the resident was severely cognitively impaired. An interview for daily preferences documented the resident as the primary respondent and a coding of very important in response to rating importance of doing favorite activities. The most recent Nursing Quarterly and PRN Data Collection form dated 8/4/19 with a lock date of 9/05/19 revealed a functional status of requiring extensive assistance for ADLs and mobility. Resident #54's active care plan revealed a focus area for Activities, initiated on 5/17/17 and revised on 2/5/19 documented, [Resident #54] requires Staff assistance with involvement of Activities related to reminders and invitations . Interventions included: Encourage to participate with activities of choice, Prefers/would benefit from Large Group and the resident needs assistance/escort to and/or from activity functions. Staff J, Registered Nurse (RN)/Unit Manager (UM) was interviewed on 10/08/19 at 9:33 a.m. about why Resident #54 was lined up with other residents in their wheelchairs in the hallway by the nurse's station for portions of the day. He reported that it was the rest spot and place where they were watching television (TV). He stated that most of the group activities took place in the main dining room. Staff I, CNA was interviewed on 10/09/19 at 3:13 p.m. and reported that Resident #54 was not really involved in activities. She stated that she sometimes took Resident #54 outside, that Resident #54 liked to hold her doll, and that the unit positions her in the hall near the nurse's station so they could supervise so she didn't try to get up and fall. 4. Multiple observations were made of Resident #41: 10/07/19 at 12:15 p.m. observed in room in bed, bed was in low position, making loud verbalizations; 10/08/19 at 12:33 p.m. observed in her room in bed, bed was in low position, door was closed prior to entry into room, making loud verbalizations; 10/08/19 at 4:15 p.m. observed lying in bed, bed was in low position, lights were off, making loud verbalizations; 10/09/19 at 11:52 a.m. resident observed seated in wheelchair in hallway of unit with other residents who were lined up single file against the wall; On 10/09/19, Resident # 41 was also observed lying on bed, bed was in low position, lights off, making loud verbalizations; On 10/10/19 at 2:38 p.m., a group music activity was observed in progress, however, Resident # 41 was observed in her room sitting at the edge of the bed, lights off, door closed, making loud verbalizations. A review of the admission & medical record for Resident #41 revealed that she was admitted to the facility on [DATE] with diagnoses that included dementia, schizophrenia, anxiety disorder, and major depressive disorder. The MDS completed on 1/26/19 for Resident #41 revealed the following for Section F Preferences for Customary Routine and Activities: an interview for activity preferences was documented as Interview could not be completed by resident or family/significant other. The most recent Nursing Quarterly and PRN Data Collection form, dated 10/05/2019, revealed the functional status of requiring extensive to total assistance with ADL, and total dependence for locomotion on and off unit. The Activities Task documentation for self-directed activity revealed one entry on 9/27/19 for Activity Bins. Resident #41's active care plan revealed a focus area for Activities, initiated on 1/28/13 and revised on 4/28/17, documented as, [Resident #41] requires Staff assistance with involvement of Activities related to Cognitive deficits. Resident chooses to relax in the comfort of her room and listening to music. The interventions included: Prefers/.would benefit from small group, and the resident needs assistance/escort to and/or from activity functions. An interview on 10/10/19 at 6:00 p.m. with the Activities Assistant, found that she had been an activities assistant at the facility for 5 years and was currently acting as the Activities Director while the regular Activities Director was on medical leave. The Activities Assistant, who was acting as the Activity Director, reported that there were two other activities assistants in the department. When asked how often the activities staff was engaging residents in programming she responded, I'd like to think it's on a daily basis. She defined 1:1 (one to one) activity programing as an activities staff person taking the activity cart on the units and to individual rooms and engaging residents. She stated that a 1:1 activity for Resident #172 might be hand massaging. She stated that most of the time residents who receive 1:1 programming were in bed or a [specialized chair] or nonverbal. She reported that, Most of our programs are in the main dining room, and that when residents were sitting in hallways such as what had been observed with Resident #54, she considered that their leisure time and not an activity. She was asked to explain how Resident #172, Resident #216, and Resident #41 were assessed for the preference for relaxation in their rooms which was documented in each of their care plans. She responded, It's how I was taught to do care planning .I guess I just got comfortable in the habit of writing that. She confirmed that Resident #216 would not be able to communicate that preference stating, If a resident is not appearing in discomfort or can't get up or is nonverbal and in a [specialized chair] but don't look in discomfort, then I make that determination that they are comfortable in their own room; but I guess it's bad to assume someone is enjoying watching TV in their room just because I observe them doing that. She was asked to reveal documentation for assessment of residents, group attendance and 1:1 programming and for specifics on Resident #54, Resident #172, Resident #41, and Resident #216. She reported that they document on the Task List in the Kardex and, If we're on top of it that day, we try and click in the tablet .I don't know if it's happening to a tee .I should be more on top of them [the activities staff]. She went on to say that the accuracy of documentation was based on floor assignments and, Sometimes I'm a little blurry on 3 and 4 [units where Residents #172, #54, #216, and #41 resided]. If we're having a busy day .we all [activity staff] try and share the documentation. She was questioned about the documentation in the Activity Task List in the Kardex that Resident #172 attended the music activity on 10/10/19, since the resident was observed in her room during that activity. She responded, I think she (Resident #172) was there, but stated she couldn't be sure and that sometimes there was miscommunication among the team about what programming had occurred. She revealed that there were binders kept with activities assessments and provided copies of assessments for Residents #172, #54, #216, and #41. The hand-written assessments were reviewed for each resident following the interview. The assessments had responses to activity questions, however it did not have any date on them other than each resident's date of admission. The Administrator was interviewed regarding the facility activity programming on 10/10/19 at 8:45 p.m. He reported that because the Activities Director was out on medical leave, arrangements had been made for an activities consultant to start next week and that they would be at the facility twice a week to help with programming and to direct things in the department. He stated that there was not currently a Performance Improvement Plan (PIP) for activities, but that once the consultant was able to make their assessment a PIP could be developed if needed. 8. Resident #202 was admitted on [DATE]. The admission Record included diagnoses not limited to malignant neoplasm of unspecified site of right female breast, other seizures, sequela traumatic subdural hemorrhage with loss of consciousness of unspecified duration, and unspecified dementia without behavioral disturbance. An observation of Resident #202, on 10/8/19 at 9:47 a.m., revealed an elderly resident lying in bed, head of bed raised, and the resident was able to reposition self-minimally. An observation during the mandatory task of Medication Administration, on 10/8/19 at 4:05 p.m., revealed Resident #202 lying in bed, receiving enteral feeding, a prosthetic right eye, and responded verbally to nurse. On 10/9/19 at 3:12 p.m., the resident was observed lying in a specialized chair, under the TV at the end of the 400-unit with other residents and a family member. On 10/10/19 at 12:25 p.m., Resident #202 was lying in a specialized chair, with a 22 television (hanging on the wall opposite of beds B and C), the resident of bed D also had a radio playing music. The 5-day Minimum Data Set (MDS), dated [DATE], in Section B: Hearing, Speech, and Vision, indicated Resident #202 had unclear speech, was rarely/never understood or able to make self-understood, rarely/never understood others, had highly impaired vision, and no Brief Interview of Mental Status due to being rarely/never understood. The admission MDS, dated [DATE], identified the family member of Resident #202 indicated the following activity preferences for the resident as somewhat important: - reading material - listen to music - be around animals - keep up with the news - do things with groups of people - do favorite activities - go outside to get fresh air - participate in religious services The activity questionnaire for Resident #202, undated and received from the facility, indicated staff were to push wheelchair, resident was to receive the activity cart (everyone), attend group activity, party and socials, music and entertainment, bingo-games, and favorite activity was resting and spending time with time. The questionnaire did not indicate any adaptions for the resident's vision deficit. The Activity Assessment, effective 6/24/19, indicated a family member was involved with the assessment and indicated afternoon was the preferred activity time, in-room, and the general activities program, and the passive activities enjoyed were watching movies and listening to music. The family described Resident #202's favorite activities as music and social events. The Individual Activity task for 30 days indicated Resident received current events on 9/11/19 at 12:23 p.m., and an in-room visit on 9/30 (2:59 p.m.) and 10/10/19 (1:23 p.m.). The Group Event activity task for 30 days indicated Resident #202 received current events on 9/11/19 at 12:23 p.m., the activity bin on 9/16/19, and attended, on 10/8/19 at 10:48 a.m., the coffee hour/clutch. The physician orders indicated Resident #202 had an NPO (nothing by mouth) diet and multiple observations were made of resident receiving Diabeta Source via gastromy tube at 80 mL/hr (milliliters/hour). On 10/10/19 at 6:24 p.m., the Activities Assistant stated the documentation of Resident #202 attending the coffee clutch/hour on 10/10/19 was a mistake. The Activities care plan, initiated 6/24/19 and revised 6/24/19, indicated Resident #202 required staff assistance with involvement of Activities related to physical assistance to and from activities. The interventions included: - provide activities calendar monthly. - prefers/would benefit from in-room. - preferred morning activity time. - provide resident with materials for individual activities as indicated. 9. Resident #204 was admitted on [DATE] and 9/27/19. The admission Record included diagnoses of sequelae following unspecified cerebrovascular disease, other seizures, paraplegia (paraparesis) and quadriplegia (quadriparesis), dementia in other disease classified elsewhere without behavioral disturbance, and unspecified schizophrenia. The 5-day Minimum Data Set (MDS), dated [DATE], did not include a Brief Interview for Mental Status as the resident was rarely/never understood. An observation, on 10/8/19 at 9:52 a.m., revealed an elderly, frail resident lying in bed. During the observation, Resident #204 did not respond verbally to this writer, he did follow with his eyes, and was wearing a nasal cannula delivering 3Lpm (liter per minute) of oxygen via concentrator. On 10/10/19 at 12:28 p.m., Resident #204 was observed lying in bed with eyes closed. The MDS (9/30/19) indicated Resident #204 had no speech, was rarely/never understood, was rarely/never understood to understand others, and had highly impaired vision. The MDS indicated the resident required total assistance from one-person for bed mobility, locomotion on/off unit, dressing, and eating, total assist from two persons for transfers, and walking in room/corridor did not occur. The Significant Change in Status MDS, dated [DATE], indicated the interview for daily and activity preferences should be conducted however could not be completed by the resident or family/significant other. Section F: Preferences identified the daily preference interview, which could not be conducted with the resident or representative, there was no response or was non-responsive. The staff assessment for Resident #204's preference indicated the resident preferred reading material, listening to music, keeping up with the news, doing things with groups of people, and participating in favorite activities. The Activity Assessment, effective 8/25/19, indicated the resident's preference for activities was morning activities, small, large, and general activities program. The assessment did not indicate any passive or creative activities and favorite activities were unknown but does spend majority of his time choosing the comfort of his room. The Individual Activity task indicated an in-room visit was completed on 9/16, 10/8 (10:46 a.m.), and 10/10/19 (1:26 p.m.), and the resident participated in current event activity on 10/7/19 and had unknown individual activities on 9/24 and 10/1/19. The resident participated in unknown group events on 9/24 and 10/1/19 and current events on 10/7 and 10/8/19. The Individual and Group Activity tasks indicated Resident #204 participated in activities ten (10) times in 30 days. The activities on 9/24 at 10:53 a.m., 10/1 at 10:02 a.m., and 10/7/19 at 10:07a.m. were included in both individual and group activities. The Activities care plan, initiated 1/30/14 and revised 2/5/18, for Resident #204 revealed the resident required staff assistance with activities related to cognitive deficits, chooses the comfort of room relaxing and listening to music, The activity interventions included to provide activities calendar monthly, encourage participation with activities of choice, and provide the resident with materials for individual activities as indicated. On 10/10/19 at 1:33 p.m., Staff P, CNA, identified self as the staff member assisting and caring for Resident #204. The staff member stated Resident #204 was once on the secure unit, stopped walking about four months ago, did not get out of bed, and did not participate in activities. 5. Review of the medical record for Resident #36 revealed that she was admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy, unspecified dementia without behavioral disturbance and unspecified sequelae of cerebral infarction. Multiple observations of Resident #36 revealed the following: On 10/7/19 from 11:26 a.m. to approximately 2:00 p.m., Resident #36 was observed to be asleep in bed in her room with no music, TV, or external stimulation. On 10/8/19 at approximately 2:00 p.m., the Resident was observed in her room, up in a specialized chair, eyes were closed and appeared to be asleep, with no music or TV, and no external stimulation. On 10/10/19 at 11:55 a.m., the Resident was observed in bed with her eyes closed, with no music or TV, and no external stimulation. Review of a Significant Change MDS assessment, dated 1/25/19, revealed that the resident interview for preferences for activities could not be completed due to no response or non-responsive. The staff assessment for daily and activities preferences indicated that the resident preferences were, choosing clothes to wear, reading books/newspapers or magazines, listening to music, keeping up with the news, and participating in favorite activities. The Significant Change assessment (1/25/19) revealed that the resident was rarely/never understood, had short- and long-term memory problems, severely impaired cognitive skills for daily decision making and was totally dependent on staff for activities of daily living. Review of a quarterly MDS assessment, dated 7/20/19, revealed that the resident was rarely/ never understood, had short- and long-term memory problems, no recall, severely impaired cognitive skills for daily decision making and was totally dependent on staff for activities of daily living. Review of the active care plans for Resident #36 revealed focus areas of: Cognition (Initiated 11/9/16, revision on 7/4/17): Has impaired cognitive function/dementia or impaired thought processes reference to severely impaired. Communication (Initiated 7/4/17): Has a problem with communication rarely or never understood- unable to express ideas or wants. Rarely/ never understands. Activities (Initiated 11/9/16 revision on 2/4/19): Focus: The resident requires staff assistance with involvement of activities related to cognitive deficits. May not stay for the entire activity. Resident requires staff assistance to and from programs. Resident chooses the comfort of her room relaxing and watching TV. Goal: Will participate in activities, Will participate in 1:1 visits. Interventions: Provide activities calendar monthly, resident prefers family significant other involvement in care decisions, encourage to participate with activities of choice, prefers would benefit from passive/active room activity prefers would benefit from small group, preferred activity times afternoons. The resident needs assistance/escort to and/or from activity functions, thank the resident for attendance at activity function. Inform of may leave activities at any time, and not required to stay for entire activity, invite/encourage the resident's family members to attend activities with resident in order to support participation. An untitled and undated form with Resident # 36's name on it was provided by the Director of Nursing (DON) on 10/10/19. The form indicated, She enjoys flowers; Self Directs: No. 1:1 visits. Requires physical assistance with activities, afternoon activities. An interview was conducted on 10/10/19 at 12:00 p.m. with Staff A, Licensed Practical Nurse (LPN), who provided care regularly to Resident #36, stated that Resident #36 does not go out of her room, staff do get her up to her specialized chair in her room and she yells and screams out on occasions. An interview was conducted on 10/10/19 at 2:20 p.m. with Staff E, CNA, who provided care to Resident #36, and stated that Resident #36 gets up to specialized chair three times a week. She stated that sometimes staff take her to activities, but when the noise of activities bothers her (Resident #36) they bring her back to her room. Review of Resident #36's record revealed an Activity Assessment, dated 7/9/19, which was crossed through and stated incomplete, assessment not required. An activity Assessment was found for 4/19. This activity assessment indicated that Resident #36 participated in one to one and small group activities, family stated she enjoyed flowers and there were no responses for interests. An interview was conducted with the Activity Assistant, who was acting as the Activity Director, on 10/10/19 at 6:11 p.m. She stated that she included watching TV in Resident #36's care plan because the TV was on in her room and she was lying in the bed. She stated that she does come out of her room, but she has not seen her in an activity program in a while. She stated she does come into the room and provides hand massages and when she is talking to all three residents in B bed (#36), C bed (#214) and D bed (#115) that she considered that a group activity. Review of the activity documentation under the Task Section of the record for 9/27/19 through 10/9/19 revealed a check mark in the box for Not Applicable for Individual Activities and Group Activities for Resident #36. On 10/10/19, after the exit conference, the Director of Nursing (DON) provided a printed copy of the ADL documentation for Resident #36 from 9/27/19 to 10/9/19 with nail care checked daily in addition to Not Applicable checked daily. The activity of daily living of nail care being checked was to indicate that activities were being provided. 6. Review of the medical record for Resident #115 revealed that she was admitted to the facility on [DATE] with diagnoses that included cerebral palsy and developmental disability. Multiple observations of Resident #115 revealed the following: On 10/08/19 at 10:45 a.m., 11:30 a.m., 12:06 p.m., 1:16 p.m., Resident # 115 was in the hall of the 100 Unit, against right side of wall covered with a blanket and sheet. The resident's eyes were open and moving around and the Resident remained in this same position for all four observations. On 10/10/19 at 9:35 a.m., the Resident was in bed asleep, on her back. On 10/10/19 at 11:55 a.m., the Resident was in bed lying on her back, asleep. A small 22-inch TV was on and located in the middle of the room high up on the wall. The TV was not within view of Resident #115 from her bed and not audible while standing next to her bed. On 10/10/19 at 1:09 p.m., the Resident was in bed, on her back asleep. The TV was on and the sound was unable to be heard from Resident's bed, and TV was far outside of her visual field. Resident #115 was observed to be severely contracted in her upper limbs and hands. Review of an annual MDS, dated [DATE], revealed that Resident #115 was rarely/never understood, rarely/never understands, had severely impaired vision and was not able to complete the Brief Interview for Mental Status. The staff assessment for mental status indicated short- and long-term memory problems, no recall and severely impaired cognitive skills for daily decision making. Under Section F for Preferences for Customary Routine and Activities, it was documented that family or significant other was the primary respondent. Activity preferences indicated that it was somewhat important to have books, newspapers and magazines to read, listen to music, keep up with the news, do things in groups of people, go outside for fresh air and participate in religious services or practices and very important to do favorite activities. The functional status indicated that Resident #115 was totally dependent on staff for activities of daily living and had impairment on both sides of upper and lower extremities. Review of active care plans for Resident #115 found: Communication: Has a communication problem, rarely or never understood - unable to express ideas or wants. Rarely/never understands (Initiated 3/5/13, revision on 6/19/17). Vision (initiated 3/5/13, revision 6/19/18): Has impaired visual function reference to highly impaired. Eyes follow objects, if the resident's ability to identify objects in his or her environment is in question, but resident's eye movements appear to be following objects (especially people walking by), also has impaired cognition. The goal of this care plan was will feed self with assistance of 1 through next review date. Activities (initiated 2/27/13, and revision on 8/3/17): Requires staff assistance with involvement of activities related to cognitive deficits. Resident requires assistance to and from activities. Resident chooses to relax in the comfort of her room. Goal will participate in appropriate group activities. Will participate in 1:1 sensory visits initiated 2/27/13, revised 3/5/18 target date 11/18/19. Interventions: provide activities calendar monthly, resident prefers family or significant other involvement in care decisions, encourage to participate with activities of choice. Prefers/would benefit from general activities program preferred times: afternoon, the resident needs a[TRUNCATED]

Based on observation, staff interview and facility policy review, the facility failed to ensure that food items were held at required food holding temperatures during one (10/09/2019 lunch meal) of two meal services observed, and failed to ensure that food was not served after temperatures did not meet required temperatures for 1 out of 6 units, related to a cold food held at a temperature above 41 degrees F. Findings included: On 10/09/19 at 11:20 am a follow up visit was made to the kitchen for lunch meal temperature purposes, specifically for food holding temperatures. The Regional District Manager (RDM), Certified Dietary Manager (CDM) and the Registered Dietician (RD) were present to conduct the meal temperatures. The CDM stated I have not done temperatures yet, so I will be doing them along with you. She stated that the thermometer was electronic and that it did not need to be calibrated. The CDM stated that the residents will be coming in shortly to be served at 12:00 pm and that they loved the egg salad that was to be served today. She also confirmed that all the food items were set up and ready to be served to residents at this time. The CDM stated the food items were on beds of ice to keep them cool while serving. The first food item temperature was taken with a digital thermometer, without calibration: 1. Egg salad 57 degrees F and held. At 11:25 am, the RDM stated that she would normally calibrate the thermometer with ice and water. The CDM stated Let me get a cup of ice with water. The Regional also got an additional thermometer to use for calibration and food temperature purposes. The following food item temperatures were demonstrated with the same digital thermometer after calibration: 1. Egg salad at 51 degrees F., 2. Puree Egg salad at 49 degrees F. The RDM suggested the regular egg salad be placed in a shallow pan and placed back in the refrigerator, the morning cook assisted her. At 11:30 am The CDM went back to calibrating the thermometer and once it reached the temperature of 32 degrees F the RD took the thermometer from the CDM and began, for a third time taking food temperatures. 1. The Puree Egg salad held at 40 degrees F. 2. Macaroni salad temperature was held at 62 degrees F. At 11:35 am the CDM stated if you could give me about 10 minutes, we will be ready again for you. On 10/09/19 at 11:50 am a second visit to the kitchen was conducted. The CDM stated I have done the temperatures and they're okay now. The following food item temperatures were taken: 1. Egg salad at 53 degrees F, 2. Sliced Ham at 40 degrees F., 3. Cucumber Salad at 38 degrees F., 4. Macaroni salad at 40 degrees F., 5. Pureed veggies at 39 degrees F., 6. Pureed egg at 38 degrees F., 7. Milk 40 degrees F. The CDM revealed the alternative meat would be sliced ham and that some were already pulled to be served but the rest could also be prepared to replace the egg salad. At 11:58 am The CDM stated the residents will be having ham and cheese with lettuce and tomatoes sandwiches instead of the egg salad sandwich. The regular egg salad will not be served. On 10/10/19 beginning at 12:20 p.m. an observation of the 300 secured unit dining area for lunch was conducted. An interview was conducted with Staff B, LPN who confirmed Resident #228 had eaten an egg salad on a croissant and then he wanted something else so she got him the alternate meal. The Unit Manager Staff C also confirmed the observation. On 10/9/19 at 12:39 p.m. an observation on the 300 secured unit was conducted by two surveyors of Resident #55's lunch tray in his room. The resident's meal ticket indicated he was served an egg salad sandwich, which he had consumed. On 10/9/19 at 12:45 p.m. two surveyors observed Resident #58 seated in the dining area of the 300 secure unit with a partially eaten sandwich on his tray. The resident had been served an egg salad sandwich. (Photographic Evidence obtained) On 10/09/19 at 12:45 pm an interview was held with the CDM who restated there were only three regular egg salads served by her from the ready to serve area, to three residents that were in the restorative dining area. The CDM continued and stated I am not sure how the other residents got the sandwiches on the 300 unit. We looked on 400 and no issues there. On 10/09/19 at 02:18 pm the Administrator was made aware of the visit to the kitchen and the concern with the holding temperatures and the residents being served a food that was not at the proper holding temperature. The Administrator stated that the identified residents would be monitored and that an action plan was going to be put in place immediately. A policy was provided by the facility titled Food: Preparation policy and procedure for review, which was dated and revised as of 9/2017. Under the procedure section of the policy and procedure, #4, it revealed The dining services director/cook(s) will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 degrees F. and less than 135 degrees F., or per state regulation. An additional policy was provided by the facility titled Meal Distribution HCSG Policy 013, Dining Services Policy and Procedure Manual, Original 5/2014, Revised 9/2017. Under the Procedures section of the Policy and procedure #13, it revealed All foods will be held at appropriate temperatures, greater than 135 degrees F for hot holding, and less than 41 degrees F for cold food holding.