**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, and record review, the facility failed to provide staff assistance with activities of daily living for one of four residents (Resident (R) 244) reviewed for activities of daily living out of a total sample of 24 residents. This failure had the potential to lead to a decline in activities of daily living. Findings include: Review of R244's admission Record located under the Profile tab in the electronic medical record (EMR), revealed R244 was initially admitted on [DATE] with diagnoses including acute respiratory failure, epilepsy, cerebral palsy, cognitive communication deficit, bipolar, and intellectual disabilities. The resident went out to the hospital on 2/28/29, readmitted on [DATE], and discharged on 03/15/25. Review of R244's Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Reference Date (ARD) of 02/28/24 revealed the resident was unable to complete a Brief Interview of Mental Status (BIMS) assessment. A Staff Assessment for Mental Status was conducted and determined that the resident's cognitive skills for daily decision making was severely impaired. The MDS also indicated R244 required substantial/maximal assistance to complete bathing. Review of R244's Baseline Care Plan located in the EMR under the Assessments tab revealed the resident required the assistance of one person for bathing. Review of R244's Documentation Survey Report - Feb-24 located under the Reports tab in the EMR revealed there was no documentation that the resident was bathed from 02/23/24 through 02/28/24. The resident was scheduled to be bathed on 02/27/24 but was not marked as completed. During an interview on 04/17/25 at 4:50 PM, Certified Nursing Assistant (CNA) 6 stated, There is a bath sheet at nurses desk indicating when residents are scheduled to be bathed. We, then, documented in EMR. If a resident refuses their bath/shower, we ask them three times and then notify the nurse. We then document the refusal in the EMR and select refused. If a resident wants to be bathed the next day, then we would bathe them the next day. New admissions would be scheduled on the bath sheet as soon as they are admitted . If a resident was admitted on Tues, then they would be scheduled for one on the next day. Residents are scheduled either Monday, Wednesday, Friday, or Tuesday, Thursday, Saturday. If a resident needs a bath when they are admitted , then they would get one right away. I do not recall a resident by the name of [R244]. During an interview on 04/17/25 at 5:00 PM, CNA5 stated, A list of the residents' bath schedule is at the nurses' desk. We look at the list when we come in each day. Residents are scheduled either Monday, Wednesday, Friday or Tuesday, Thursday, Saturday. Baths would be scheduled between day, evening, and night shift depending on the resident's preference. Residents who refuse are reapproached three times, then we notify the charge nurse. I document in EMR the refusal. I note it on the bath list and notify the nurse. The nurse also documents the refusal in the chart. New admissions would be scheduled either the same day or the next day. I do not recall a resident by name of [R244]. During an interview on 04/17/25 at 5:10 PM, the DON stated. New admissions are scheduled by the nurse manager for Monday, Wednesday, Friday or Tuesday, Thursday, Saturday and based on the resident's preference for the time of day. The expectation is that residents receive a bath immediately if needed or the next day. [R244] was admitted on [DATE]. The expectation was that [R244] should have been scheduled for a bath on 02/24/24. The CNAs that worked then have retired and no longer work here. The CNA scheduled that day did not document any baths in the chart for the day. There was no documentation that the resident was offered a bath or refused. [R244] was scheduled for baths beginning 02/27/24. The documentation for bathing was blank on 02/27/24. No documentation would mean that the task was not completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, and staff interviews, the facility failed to ensure physician orders were followed related to laboratory monitoring for one of one (Resident (R)45) residents reviewed for laboratory services. Specifically, the facility failed to ensure that R45's HbA1c (blood test measuring average blood sugar levels over the past two to three months) labs were drawn in October 2024 and January 2025. Findings included: Review of R45's admission Record located in the Electronic Medical Record (EMR) under the Profile tab, showed an admission date of 12/15/20 with a primary medical diagnosis of hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side. Review of R45's Care Plan revised 04/11/25 located in the EMR under the Care Plan tab included diabetic status and .labs as ordered . Review of R45's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Review Date (ARD) of 01/07/25 revealed a Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicating that he was moderately cognitively impaired. Review of R45's Order Summary Report located in the EMR under the Orders tab included an order, dated 03/13/24, for HbA1c to be drawn quarterly in January/April/July/October. Review of R45's HbA1c results located in the EMR under the Results tab revealed the most recent HgA1c was drawn on 03/19/24 at the facility. The resident was hospitalized [DATE] and had HgA1c drawn while hospitalized . No HgA1c was collected for October 2024 or January 2025. Review of Pharmacy Progress Notes, dated 11/05/24, located in the EMR under the Progress Notes tab included a recommendation to update HbA1c lab monitoring. Review of Pharmacy Progress Notes, dated 02/03/25, located in the EMR under the Progress Notes tab included a recommendation to update HbA1c lab monitoring. During an interview on 04/16/25 at 4:07 PM with the Director of Nursing (DON) stated that the expectation was for labs to be drawn as ordered by the physician. The expectation for pharmacist review recommendations was for the physician or the nurse practitioner to bring back any signed recommendations or new orders that resulted from the pharmacist reviews. The DON confirmed that she was unable to locate proof of HgA1c being drawn in October 2024 or January 2025. Additionally, the Unit Managers receive a list of which residents are due for labs from Clinical Laboratory Services (CLS) which generates from standing orders. The DON showed this surveyor an email that she received for October 2024 and January 2025 which did not include R45 for HgA1c. The DON did not know why the order did not trigger with the pharmacy, and the facility had no protocol in place to ensure laboratory monitoring was in place. The DON stated that the facility did not have a policy related to following physician orders or laboratory monitoring. During an interview on 04/17/25 at 2:28 PM with Corporate Compliance Nurse (CCN) confirmed that R45 had orders for HbA1c to be drawn January/April/July/October. CCN confirmed that lab results could not be located to confirm that HbA1c was drawn in October 2024 or January 2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to maintain a complete and accurate medical record for one of 31 sampled residents (Resident (R) 8). Specifically, the facility failed to include the physician order for metoprolol tartrate 25 milligrams (mg) into the electronic medical record (EMR) following a readmission after hospital discharge. This failure had the potential to cause a medication error that could be harmful to the resident. Findings include: Review of R8's admission Record located in the EMR under the Profile tab indicated R8 was readmitted to the facility on [DATE] with a primary diagnosis of encounter for surgical aftercare following surgery on the circulatory system. Review of R8's Order Summary Report, dated 04/17/25, did not include orders for metoprolol 25mg tablets. An order for gabapentin 100mg capsule, give 2 capsules by mouth twice daily for neuropathy was ordered 08/01/24 and atorvastatin 20mg tablet, give one tablet by mouth every evening for hyperlipidemia was ordered 02/04/25. Review of R8's .Discharge to Acute/Chronic Medical Facility Medication Orders, dated 04/12/25, included metoprolol 25 mg, one tablet to be given by mouth twice daily. During an observation and interview on 04/16/25 at 4:38 PM with Licensed Practical Nurse (LPN) included administration of metoprolol tartrate 25mg. The medication was delivered by the pharmacy in a packet, dated 04/16/25, which included atorvastatin, gabapentin, and metoprolol. LPN1 stated that the resident was recently hospitalized and was on multiple cardiac medications and she knew that R8 had been on metoprolol for a long time. LPN1 stated she would let her Unit Manager (LPN4) know that the medication order was not in the EMR. LPN1 administered metoprolol 25mg without having active orders for the medication. Administration of the medication was not documented in the EMR due to no order triggering documentation after administration. During an interview on 04/17/25 at 10:55 AM with LPN4 confirmed that R8 was recently hospitalized and that the hospital sends the pharmacy the medication orders for packaging and delivery. The hospital sends Discharge to Acute/Chronic Medical Facility Medication Orders document to the facility. LPN4 stated that the protocol was for the nurse readmitting the resident to review the hospital discharge orders, review with the physician, and then transcribe the orders into the EMR. During an interview on 04/16/25 at 5:48 PM with Director of Nursing (DON) stated that R8 recently went to the hospital and was prescribed metoprolol tartrate 25mg oral tablets, give one tab by mouth twice daily, she was discharged from the hospital 04/12/25. Her expectation was for the Unit Manager to fax the pharmacy the medication orders and then the nurse that re-admits the resident puts the orders in the EMR. The DON stated that it appeared that the nurse that did the re-admission failed to add the metoprolol order but should have. During an interview on 04/17/25 at 6:06 PM the DON stated the facility did not have a policy related to complete/accurate medical records

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and facility policy review, the facility failed to ensure infection control was maintained for five of 31 sampled residents (Resident (R) 17, R53, R59, R61, and R84). Specifically, the facility failed to ensure that hand hygiene was completed during medication administration, meal service, and housekeeping tasks. Additionally, a personal drink was on top of the medication cart during medication pass which increased the risk for cross contamination and infections. Findings include: Review of the facility policy titled, Handwashing/Hand Hygiene provided by the facility and revised 08/2019 indicated, This facility considers hand hygiene the primary means to prevent the spread of infections .Use an alcohol-based hand rub .before preparing or handling medications .before handling clean or soiled dressings .after handling used dressings, contaminated equipment .after contact with objects (e.g., medical equipment) in the immediate vicinity of the resident . 1. During an observation and interview of medication administration on 04/16/25 at 4:26 PM Licensed Practical Nurse (LPN1) 1 had an open can of soda on top of the medication cart for D Hall. LPN1 confirmed that the soda was hers and that it should not be on top of the medication cart at any time. She said that she just got braces yesterday and her mouth was very sore and dry and that's why she had her drink on the cart. 2. Observation of medication administration pass on 04/16/25 from 5:20 to 5:30 PM with LPN2 revealed the following: At 5:20 PM, LPN2 provided medication to R59 and did not perform hand hygiene after medication administration. At 5:24 PM, LPN2 prepared and administered medications for R84. LPN2 did not perform hand hygiene after administration of medications to R84. At 5:28 PM LPN2, prepared and administered medications for R53. LPN2 did not perform hand hygiene after administration of medications to R53. During an interview on 04/16/25 at 5:30 PM with LPN2, she confirmed that she had not performed hand hygiene between residents receiving medications and should have. She did not give a reason why hand hygiene was not performed. Review of R53's admission Record located in the Electronic Medical Record (EMR) under the Profile tab, showed an admission date of 05/20/21 with a primary medical diagnosis of alcohol dependence with alcohol-induced persisting dementia. Review of R53's quarterly Minimum Data Set (MDS) located in the EMR under the MDS tab with an Assessment Review Date (ARD) of 03/01/25 revealed a Brief Interview for Mental Status (BIMS) score of three out of 15 indicating that he was severely cognitively impaired. Review of R59's admission Record located in the EMR under the Profile tab, showed an admission date of 12/05/23 with a primary medical diagnosis of chronic pancreatitis. Review of R59's annual MDS located in the EMR under the MDS tab with an ARD of 15 revealed a BIMS score of 15 out of 15 indicating that he was cognitively intact. Review of R84's admission Record located in the EMR under the Profile tab, showed an admission date of 12/04/24 with a primary medical diagnosis of urinary tract infection. Review of R45's quarterly MDS located in the EMR under the MDS tab with an ARD of 0/13/25 revealed a BIMS score of nine out of 15 indicating that he was moderately cognitively impaired. During an interview on 04/17/25 at 5:05 PM with the Director of Nursing (DON) stated that her expectation was for the nurse to perform hand hygiene before medication administration, between residents, and at completion of medication pass. Additionally, staff are not allowed to have personal beverages on the medication cart or at the nurses' station. All food and drinks are to be consumed in the staff break room. The DON stated the facility did not have a policy regarding personal beverages on the medication carts. 3. Review of R61's admission Record found under the Profile tab of EMR revealed R6 was admitted to the facility on [DATE]. Review of the annual MDS assessment with an ARD of 11/10/24, documented R61 had a score of 15 out of 15 on the Brief Interview for Mental Status and had multiple diagnoses on admission, which included an unstageable chronic wound. Review of the Care Plan, dated 01/10/25, indicated the resident was on Enhanced Barrier Precautions. The posting on the door indicated all staff who enter the room should complete hand hygiene when entering and before leaving the room. Review of the R17's admission Record revealed an admission date of 05/25/15. Review of the annual MDS assessment with an ARD date of 11/10/24, indicated the resident was admitted to the facility with a progressive neurological disease, and needed assistance from staff with the Activities of Daily Living (ADL's I.e. Dressing, grooming, hygiene, transfers and eating), but had independent mobility after being transferred to a motorized wheelchair. Review of the Care Plan, dated 01/10/25, indicated the resident was on Enhanced Barrier Precautions. On 04/16/25 at 10:00 AM, Housekeeper (HK) 1, was observed in R61's room cleaning the floor with a floor mop, after completing the task HK1 exited the room, wearing gloves. After placing the mop on the cart, the staff removed the gloves, and obtained another pair of clean gloves, and placed them on. HK1 then obtained a cleaning cloth from a locked cupboard on the cart and a spray bottle. After spraying the cleaning solution on the cloth HK 1 then entered R17's room and begin cleaning the bathroom. Although a sign was hung on R61's door directing any staff that entered the room to complete hand hygiene prior to leaving the room, HK1 did not wash her hands or sanitize them prior to exiting the room. On 04/1625 at 10:10 AM, HK1 was interviewed. When asked about hand hygiene after removing the gloves, she acknowledged the error. On 04/16/25 at 3:20 PM, Licensed Practical Nurse (LPN) 5 was observed preparing to provide wound care for R61. After placing the Personal Protective Equipment (PPE's) on to provide wound care (a gown and gloves), LPN 5 stated he had forgotten supplies. The LPN5 removed the PPE's, exited the room, closed the door, then returned to the room with additional supplies. The staff entered the room, placed a new gown and gloves on without completing hand hygiene, and then completed the dressing change. On 04/16/25 at 5:50 PM, during a follow up interview, LPN5 acknowledged the error and explained hand hygiene should have been completed after reentering R61's room, but it was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and policy reviews, the facility failed to ensure five of 10 residents and their representatives (Resident (R) 8, R7, R23, R45, and R74) reviewed for facility initiated emergent hospital transfer from a total sample of 31 were provided with written transfer/discharge notice that stated the reason for transfer, the place of transfer, and other information regarding the transfer. This failure had the potential to affect the residents and their Resident Representative (RP) by not having the knowledge of where and why a resident was transferred, and/or how to appeal a transfer, if desired. Findings included: Review of the facility policy titled, Transfer or Discharge, Facility Initiated, dated 10/2022, revealed, .Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy .Notice of Transfer is provided to the resident and representative as soon as practicable .notices are provided in a form and manner that the resident can understand .Upon notice of transfer or discharge, the resident will be provided with a statement of his or her right to appeal the transfer or discharge . 1. Review of R8' s, admission Record (AR) under the Profile tab in the Electronic Medical Record (EMR) revealed an admission date 12/22/21. Review of the significant change Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/08/24 identified the R8 experienced a significant change in condition and experienced a decline in the ability to participate in walking, toileting, and transfers after sustaining a fracture of her lower leg. Review of the Nursing Progress Note dated 04/06/25 at 2:00 PM, documented R8, refused breakfast and lunch. The entry noted R8 stated she .did not feel well, and was hurting all over. The entry noted the staff contacted the physician, who ordered the resident to be transferred to the emergency room (ER) for further evaluation, the entry documented the family was contacted to notify them of the transfer, however there was no documentation the reason behind the transfer was provided with the discharge paperwork. Review of the Notice of Transfer or Discharge dated 04/06/25, did not identify the reason for the discharge. Review of the Situation Change In Condition note sent to the physician, documented the R8 had low and/or high Blood Pressure, heart rate, respiratory rate, weight change, and a change in her level of consciousness. However, there was no evidence, the reason for the transfer was provided in writing to R8 or family member. 2. Review of R7's admission Record under the Profile tab in the EMR revealed R7 had an admission date was 03/08/24. Review R7's last discharge MDS assessment, with an ARD of 11/08/24, identified multiple diagnoses, including a non-traumatic brain injury and was dependent on staff for most Activities of Daily Living (ADL i.e, dressing, grooming, hygiene, toileting transfers and mobility.) Review of the Notice of Transfer or Discharge dated 11/08/24, revealed the resident was transferred to the hospital but did not identify the reason for the transfer. The reason for the transfer was not identified in writing and provided to the R7 or the family member. Review of a Nursing Progress Note, dated 11/08/24, documented Licensed Practical Nurse (LPN) 5 contacted the Physician after identifying swelling in scrotum. The resident received order to send patient out to ER for further evaluation, for enlarged left testical (sic) with pain upon touch. 3. Review of R23's admission Record located in the EMR under the Profile tab, showed an admission date of 12/24/21 with a primary medical diagnosis of chronic pulmonary edema. Responsible Party (RP)1 was the emergency contact/RP for R23. Review of R23's discharge MDS Assessment was not completed for this transfer/discharge to the hospital. Review of R23's Notice of Transfer or Discharge document provided by the facility and dated 01/23/25 revealed the resident was transferred to an unknown hospital for an unknown reason. A phone call was made to the RP on 01/23/25 at 6:00 AM. No documentation was located to confirm complete information was provided to the RP regarding the transfer to the hospital. Review of R23's Progress Notes located in the EMR under the Progress Notes tab did not indicate written notification was sent to the RP regarding transfer/discharge. During an interview on 04/15/25 at 11:31 AM RP1 stated that when R23 had to be sent to the hospital the facility calls to notify her of the transfer, but does not send any documents explaining where/why R23 was being sent. During an interview on 04/16/25 at 9:00 AM with R23 stated that her granddaughter handles her paperwork and wasn't sure if the facility sent Notice of Transfer or Discharge. R23 confirmed that the facility did not provide her with any documentation related to hospital transfer/discharges. 4. Review of R45's admission Record located in the EMR under the Profile tab, showed an admission date of 12/15/20 with a primary medical diagnosis of hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side. Review of R45's discharge MDS Assessment, with an ARD of 09/09/24, indicated the resident was discharged to a short-term general hospital. Review of R45's Notice of Transfer or Discharge document provided by the facility and dated 09/09/24 revealed the resident was transferred to an unknown hospital for an unknown reason. A phone call was made to the RP on 01/23/25 at 12:00 AM. No documentation was located to confirm complete information was provided to the RP regarding the transfer to the hospital. Review of R45's Progress Notes located in the EMR under the Progress Notes tab did not indicate written notification was sent to the RP regarding transfer/discharge. During an interview on 04/14/25 at 12:47 PM stated that he did not recall going to the hospital on [DATE] and had not received any documents related to a hospital visit. 5. Review of R74's admission Record located in the EMR under the Profile tab, showed an admission date of 01/20/25 with a primary medical diagnosis of emphysema. Review of R74's discharge MDS Assessment with an ARD of 02/14/25, indicated the resident was discharged to a short-term general hospital. Review of R74's Notice of Transfer or Discharge document provided by the facility and dated 02/14/25 revealed the resident was transferred to an unknown hospital for an unknown reason. A phone call was made to the RP on 02/14/25 at 9:00 AM. No documentation was located to confirm complete information was provided to the RP regarding the transfer to the hospital. During an interview on 04/15/25 at 3:48 PM, the Interim Administrator and Corporate Compliance Nurse (CCN) stated that the nurse on duty fills out a Notice of Transfer or Discharge which accompanies the resident to the hospital. The nurse on duty fills out a Bed Hold form that is to be mailed to the RP. No other forms are mailed to the RP and the Administrator/CCN stated they were not aware of the requirement to provide written transfer/discharge notice that stated the reason and location of the transfer. During an interview on 04/17/25 at 4:21 PM with LPN3 stated that when the nurse sends a resident out to the hospital, they call the RP to let them know the resident had been sent out, Notice of Transfer or Discharge document is filled out and is sent with the resident to the hospital. The packet also includes current orders, advance directives, face sheet, and the Notice of Transfer or Discharge. The Notice of Transfer or Discharge form is not sent to the RP and does not include a reason for transfer/discharge. Additionally, the facility had not been sending a copy of this notification to the resident/RP and was not aware that the facility needed to do so. During an interview on 04/15/25 at 4:40 PM with the Director of Nursing (DON) stated that the Notice of Transfer or Discharge was one of the forms that was to be sent with the resident to the hospital, this form was not sent to the RP. She was not aware that the Notice of Transfer or Discharge form did not include an area for the nurse sending the resident to the hospital to indicate the reason for the hospitalization/discharge. The DON stated that she was not aware of this requirement.

Based on observations, staff interview, and record review, the facility failed to ensure that the preplanned menu portion serving sizes and standardized recipes were followed. Failure to meet these requirements altered the intended calorie and nutritional content of the meal offered and could place residents at risk for weight loss and health complications associated with malnutrition. The deficient practice had the potential to affect all residents who receive an oral diet from the kitchen. Findings include: On 04/15/25 at 4:45 PM, [NAME] (C) 3 was observed setting up the tray line for the meal service. After removing the main entrée from the oven, C3 tested the temperature, and stated the menu included chicken pot pie, and could be served without any alteration to the residents with altered textured diets. C3 then stated he needed to prepare the casserole for puree foods. When asked if a standardized recipe was used to prepare the casserole, C3 explained he had added cheese to the recipe and provided assurance the resident really liked it. It was also noted that biscuits had been placed on the top of the pot pie while baking. C3 then used a gray handled scoop (which held a four (4) ounce serving) to place four scoops of the pot pie into the blender, added a liquid and blended the food to a smooth texture. After placing the puree on the steam table in the pan, C3 began to plate foods for residents sitting in the dining room. After serving approximately 10 plates to residents, the Dietary Manager (DM) was asked about the portion serving size used for the entree. The DM stated the scoop was not the right portion size, and advised C3 the portion size should be six ounces, she then obtained a six-ounce scoop and provided it to C3. Which was the portion serving size identified on the spread sheet for the entree. Review found the standardized recipe, provided by the facility, revealed the recipe did not include any cheese. In addition, the recipe included a pie crust being cooked on top of the casserole, the recipe was not followed and changed the calorie and nutrient value of the meal. During a follow-up interview with the DM on 04/16/25 at 10:30 am the following day, a copy of the diet count was provided. The diet count showed the eight residents had physician orders for puree diet. When asked how 16 ounces (four scoops) of the casserole prepared in a blender with liquid met the nutritional needs for the eight puree diets, she stated she did not know. The menu extension verified a six-ounce portion serving size was intended portion to be served the puree diets.

Based on observations, staff interviews, and record review, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions; as evidenced by failure to ensure food preparation equipment was stored under sanitary conditions; and ensure food storage areas were kept clean and sanitary. In addition, the facility failed to ensure foods were cooked to the appropriate temperature before placing them in a warmer (a low temperature oven intended to hold hot food), and failure to ensure ready to eat foods were handled in a manner that prevented contamination. The deficient practice increased the risk for all residents residing in the facility who receive a diet from the kitchen could experience a food borne illness. Findings include: On 04/14/25 at 9:20 AM, during the initial tour of the kitchen, the following observations for food preparation equipment, and food storage areas were kept in a clean and sanitary manner. The floor in the kitchen was soiled with food crumbs, and particulate matter, broken linoleum tiles were observed exposing the sub-floor. Food particulate matter was adhered to the cracked and broken edges of the tiles. The doors and handles on the reach in refrigerators were visibly soiled with food splash and spills. A deep fryer had splash guard that was heavily soiled with food spills and crumbs. The Dietary Manager (DM) stated it was used the previous day and should have been cleaned after use. The microwave handle was soiled and the interior had food crumbs inside. A juice dispenser machine was observed on the counter, the DM reported the dispenser spigots are cleaned weekly. The steam table wells had food spills and splash inside the water. When asked how often the water was changed, the DM responded it should have been emptied and cleaned the previous day and appeared that it was not completed. On 04/14/25 at 9:20 AM, the DM stated the cleaning schedule was being revised to meet the facility's needs, and stated a new contractor had just taken over the food service department that week. On 04/15/25, at 4:45 PM, [NAME] (C)3 observed preparing and setting up for meal service. C3 removed a deep steamtable pan from the oven containing chicken pot pie. C3 obtained a blender, prepared the pureed entrée, and placed it in the steam table for service. C3 began serving plates using utensils to plate hot foods, and then placed a biscuit on the plate using gloves (which had touched multiple surfaces throughout the kitchen) and could contaminate the ready-to-eat food. C3 served several plates and then obtained a pair of tongs to serve the biscuits, stopped handling them with the gloves. On 04/16/25 at 10:55 AM, several pans of food were observed in the warming oven (intended for hot holding). The thermometer inside the unit displayed a temperature of 200 degrees Fahrenheit (F). When asked to test the temperature of the pureed meat, the thermometer reading was below 100 F. When asked how long the item had been in the warming oven, the DM asked the staff, who responded it was just prepared and placed in the warmer. When asked about the facilities practice for heating foods, the DM explained food should be heated to 165 F prior to placing the item in the warmer. On 04/16/25 at 2:45 PM, during a follow up interview with the DM, when asked about the manufacturers' recommendations for a clean the juice machine, she revealed the instructions were found on the interior of the door, the recommendation was to clean and sanitize the spigots daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the facility policy titled, Discharging the Resident the facility failed to complete a recapitulation of stay and discharge summary for one resident (R) R#92 of 11residents discharged from the facility in the last three (3) months. The deficient practice had the potential to affect the continuance of care for R#92 after being discharged from the facility. Findings include: Review of the facility policy titled; Discharging the Resident revised 10/2010 revealed: Documentation-The following information should be recorded in the resident's medical record: 1. The date and time the discharge was made. 2. The name and title of the individuals who assisted in the discharge. 3. All assessment data obtained during the procedure, if possible. R#92 was discharged from the facility on 9/14/2022 with return not anticipated. Diagnoses included but not limited to hypertension, COVID-19, diabetes, chronic kidney disease and dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C- Cognitive Pattern: Brief Interview of Mental Status (BIMS) score of 3 indicating very poor cognition; Section G-Functional Status: resident required supervision with bed mobility, transfers, walking, eating and locomotion; extensive assistance with dressing, toileting, personal hygiene, and bathing. Review of R#92's care plans revealed resident will be long term. Review of the electronic medical record (EMR) Department Notes revealed a note dated 9/14/2022 at 8:53 a.m. indicating R#92 left facility via transport with belongings and medications. Review of the EMR Department Note dated 9/8/2022 revealed the Social Worker (SW) started discharge planning with the residents' daughter. Review of the EMR and the physical paper chart revealed no order to discharge resident, no recapitulation of stay and no discharge summary. The Director of Nursing (DON) later produced a Telephone Order dated 9/14/2022 that revealed Discharge resident to another facility, continue medications and treatments as ordered. An interview on 12/14/2022 at 10:52 a.m. with the DON revealed she verified the EMR, and the physical paper chart did not contain a recapitulation of stay or a discharge summary. She indicated the nurses are responsible for writing an order to discharge a resident. She indicated they do not do a recapitulation of stay or a discharge summary. An interview on 12/15/2022 at 11:46 a.m. with the facility SW and the Administrator both revealed they do not do a recapitulation of stay or a discharge summary. The SW indicated she chart notes in the medical record indicating discharge planning and she makes a follow up call after discharge.

Based on observations, record review, staff interviews and review of the facility policy titled, Medication Monitoring and Management, the facility failed to ensure that a psychotropic medication was not ordered as needed (PRN) for more than 14 days unless clinically indicated for one (1) resident (R) R#33 of five (5) residents reviewed for unnecessary medications. Specifically, the facility failed to ensure that there was a stop order date for Klonopin prescribed for R#33. Finding include: Review of the facility policy titled, Medication Monitoring and Management effective 5/1/2020 revealed: A. 6) As needed (PRN) orders include an indication for use. a. If the PRN medication is used to modify behavior, the indication for use is clearly defined in objective terms, what specific symptom is being addressed. b. The resident is monitored for the effectiveness of the medication or possible adverse consequence. the results are documented in the medical record. Diagnoses for R#33 included but not limited to upper respiratory infection, ortho aftercare, weight loss, atrial fibrillation, left knee osteoarthritis and dementia. Review of the Annual Minimum Data Set (MDS) for R#33 dated 10/26/2022 revealed Section C-Cognitive Pattern: Brief Interview of Mental Status (BIMS) score of three (3) indicating poor cognition; Section D-Mood: Mood score of 1; Section E-Behavior: behaviors not directed to others: Section N-Medications: resident received an antipsychotic, antidepressant, antianxiety seven (7) during the 7-day look back period. Review of the Care Plan for R#33 dated 10/31/2022 revealed (partial list): Dementia-At risk for side effects related to use of psychotropic medications Resident is at risk for altered cognition related to diagnosis of dementia with behaviors, agitation, and restlessness. Resident is at risk for mood state issues related to dementia with behaviors, agitation, and restlessness. Resident exhibits inappropriate behaviors due to cognitive loss, poor insight and decreased judgement related to diagnosis of dementia with behaviors, agitation, and restlessness. Resident is at risk for side effects and complications related to the use of psychotropic medications. Review of R#33's December 2022 Physician Orders (partial list) revealed an order for: Klonopin (clonazepam) 0.5 milligrams (MG) tablet give 1 tablet by mouth (PO) at bedtime (HS) PRN, ordered 11/14/2022. Order did not include a diagnosis, indication for use or a stop date. Observations made of R#33 throughout the Recertification /survey revealed no behavioral concerns. An interview held on 12/15/2022 at 11:09 a.m. with the Director of Nursing (DON) revealed the Pharmacist comes to the facility monthly. He makes recommendations. Those recommendations are reviewed by the Nurse Practitioner (NP). After she reviews the recommendations, she will write an order if changes are made. She verified the Klonopin order did not have an indication for use or a stop date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of medical record for R#21 revealed diagnosis of acute chronic respiratory failure and chronic obstructive pulmonary disease (COPD). The Minimum Data Set annual assessment dated [DATE] section O revealed oxygen therapy. Record review of the medical record revealed a care plan for R#21 being at risk for ineffective breathing due to COPD and acute chronic respiratory failure with an intervention that included oxygen as ordered. There was no Physician's order for oxygen. During observations on 1/27/2020 at 3:17 p.m., 1/28/2020 at 4:28 p.m., and 1/29/2020 at 8:45 a.m. R# 21 was observed wearing oxygen. During an interview with Licensed Practical Nurse (LPN) CC on 1/29/2020 at 1:40 p.m. she confirmed that R#21 wears oxygen but was unable to find the orders for oxygen. Based on observation, record review, and staff interviews the facility failed to follow the care plan for two of 24 residents (R#82, R#21) reviewed for care plans. Findings include: 1. Record review revealed that R#82 was admitted to the facility with diagnoses that included: sepsis and paroxysmal atrial fibrillation. A review of the Physician Orders for R#82 revealed an order for oxygen at 3 LPM via nasal cannula as tolerated by the resident. A review of the care plan revealed that R#82 was at risk for ineffective breathing pattern related to requiring oxygen with an intervention to follow the physician orders. An observation on 1/27/2020 at 11:51 a.m. revealed that portable oxygen for resident (R)#82 was set at 2 liters per minute (LPM) and the resident was up in a wheelchair. The observation revealed that the oxygen concentrator was also on and was set at 2.5 LPM. An observation on 1/28/2020 at 10:03 a.m. revealed that R#82 was in bed with oxygen on. The oxygen concentrator was set at 2.5 LPM. An observation on 1/29/2020 at 12:49 p.m. revealed that R#82 was in bed with oxygen on and the oxygen concentrator was set at 2.5 LPM. An interview and observation on 1/29/2020 at 2:16 p.m. with the Licensed Practical Nurse (LPN) AA of R#82 in Room B5-A confirmed the oxygen concentrator was set at 2.5 LPM. LPN AA also confirmed that the Physician Order documented the oxygen was to be set at 3 LPM. An interview on 1/29/2020 at 2:36 p.m. with the Director of Nursing (DON) revealed that her expectation was that oxygen was to be administered as ordered by the Physician. The DON confirmed that the oxygen for R#82 was ordered at 3 LPM. An interview on 1/30/2020 at 2:58 p.m. with the DON confirmed that R#82 and R#21 both have interventions on their care plan to administer oxygen as ordered and that her expectation was that the care plan was to be followed. An interview on 1/30/20 at 3:06 p.m. with the Nurse Consultant revealed that the facility used the RAI guidelines as their care plan policy.

2. Oxygen Administration - revised 2010 1. Verify that there is a Physician's order for this procedure. Review the Physician's orders or facility protocol for oxygen administration. Review of medical record for R#21 revealed diagnoses of acute chronic respiratory failure and chronic obstructive pulmonary disease. During observations on 1/27/2020 at 3:17 p.m., 1/28/2020 at 4:28 p.m., and 1/29/2020 at 8:45 a.m. R# 21 observed wearing oxygen. Record review revealed that that there was not any evidence of documentation that the resident had a Physician order for oxygen. Review of 11/12/19 visit with the medical doctor revealed resident is oxygen dependent. During an interview with Licensed Practical Nurse (LPN) CC on 1/29/2020 at 1:40 p.m. she confirmed that R#21 wears oxygen but was unable to find the orders for oxygen. LPN CC revealed that the admitting nurse is responsible for uploading orders in the electronic medical record. During an interview with the Director of Nursing (DON) on 1/29/2020 at 2:33 p.m. she reported that her expectation is that oxygen will be administered as ordered. The DON further revealed that the admitting nurse is responsible for putting in orders for residents and more than one person will have to check to ensure that orders are in place going forward. Based on observation, staff interviews, record review, and review of the facility policy titled, Oxygen Administration the facility failed to ensure that the Physician's order for oxygen administration was followed for one resident (R#82) and failed to obtain an order for oxygen administration for one resident (R#21) for 18 residents reviewed for oxygen administration. Findings include: 1. A review of the policy titled, Oxygen Administration under subtitle 1. Preparation reveals that there was to be verification of the Physician's order. Record review revealed that R#82 was admitted to the facility with diagnoses that included: sepsis and paroxysmal atrial fibrillation. A review of the Physician Orders revealed an order for oxygen at 3 LPM via nasal cannula as tolerated by the resident. An observation on 1/27/2020 at 11:51 a.m. revealed that portable oxygen for resident (R)#82 was set at 2 liters per minute (LPM) and the resident was up in a wheelchair. The observation also revealed that oxygen concentrator was on and was set at 2.5 LPM. An observation on 1/28/2020 at 10:03 a.m. revealed that R#82 was in bed with oxygen on. The oxygen concentrator was set at 2.5 LPM. An observation on 1/29/2020 at 12:49 p.m. revealed that R#82 was in bed with oxygen on and the oxygen concentrator was set at 2.5 LPM. An interview and observation on 1/29/2020 at 2:16 p.m. with the Licensed Practical Nurse (LPN) AA of R#82 in Room B5-A confirmed the oxygen concentrator was set at 2.5 LPM. LPN AA also confirmed that the Physician Order documented the oxygen was to be set at 3 LPM. An interview on 1/29/2020 at 2:36 p.m. with the Director of Nursing (DON) revealed that her expectation was that oxygen was to be administered as ordered by the Physician. The DON confirmed that the oxygen for R#82 was ordered at 3 LPM.

Based on observation, record review, staff interview, and review of the policy titled, Important Dietary Instruction Guide: Labeling and Dating, the facility failed to ensure opened and canned food items in the dry storage area were properly labeled and dated. This had the potential to affect 111 out of 120 residents receiving an oral diet. Findings include: 1. Review of the facility policy titled Important Dietary Instruction Guide: Labeling and Dating, revealed All Foods Must Have a Date Grocery truck opened times: Any items that have been opened but will be used again. During the initial tour on 01/27/2020 at 11:10 a.m. with the Dietary Manager revealed the following: (3) gallon-sized cans of ketchup not labeled for receiving date, (2) gallon-sized cans of whole kernel corn not labeled for receiving date, (7) gallon-sized cans of beets not labeled for receiving date, (1) gallon-sized can of apple sauce not labeled for receiving date, (1) 16 oz. bag of marshmallows opened with no opening date, (1) 16 oz. container of All Spice Seasoning opened with no opening date, and (1) 16 oz. container of Pumpkin Pie Spice opened with no opening date. An interview with the Dietary Manager on 12/17/19 at 8:15 a.m. revealed that that it is the expectations of everyone to label all food items with date item was received, opened, and expires. The DM explained that they receive supplies each week and supplies are to be labeled upon arrival.

Based on observation, staff interview, and review of the facility policy titled, Ice Machine and Ice Storage Chests the facility failed to provide a sanitary ice scoop for an ice machine serving five of five halls and failed to ensure a soap dispenser was working in one of three shower rooms. Findings include: Review of the Ice Machine and Ice Storage Chests policy dated January 2012 revealed to keep ice scoop/bin in a covered container when not in use. During an interview on 1/30/2020 with the Maintenance Assistant he reported that the ice scoop should be kept on the outside of the ice machine. During an observation on 1/27/2020 at 11:20 a.m. of the ice machine on the F hall there was a blue scoop inside of the ice machine. During an observation on 1/27/2020 at 11:57 a.m. in the shower room on F hall the hand soap dispenser was not functioning. During an observation and interview on 1/30/202 at 11:45 a.m. Licensed Practical Nurse DD confirmed there was a scoop hanging in the ice machine. LPN DD also revealed that the ice scoop should be kept in the ice machine to keep residents from getting it. LPN DD reported that she is unsure of who is responsible for cleaning the ice machine or how frequently the ice machine is cleaned. During an observation and interview on 1/30/2020 at 12:04 p.m. Certified Nursing Assistant (CNA) FF was present at the ice machine on the F hall and was filling cooler with ice. CNA FF revealed that the ice scoop should be kept inside of the ice machine. During an interview and observation with the Maintenance Director on 1/30/2020 at 12:12 p.m. who confirmed that the scoop was in the ice machine. The Maintenance Director reported that the scoop should be stored on the outside of the ice machine.