**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and a review of the facility policy titled Quality of Care and Quality of Life-Accommodation of Needs, the facility failed to provide dining assistance to one of 13 residents (R) (R38) selected for dining observation. The deficient practice placed R38 at risk for unmet care needs and a diminished quality of life. Findings include: A review of the facility policy titled Quality of Care and Quality of Life-Accommodation of Needs, dated July 8, 2021, revealed the Policy was To define a process to accommodate individual needs and preferences to the extent possible for residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being consistent with residents' assessment and plan of care. The Definitions section included ADLs [Activities of Daily Living]: . Dining, including eating meals and snacks. The Procedure section included Staff Attitudes and Behaviors: 3.1 Accommodate individual needs and preferences; staff attitudes and behaviors must be directed towards assisting the residents in maintaining independence, dignity, and well-being to the extent possible and in accordance with the resident's wishes. A review of the electronic medical record (EMR) for R38 documented she was admitted to the facility with diagnoses including Alzheimer's disease, unspecified dementia, psychotic disturbance, mood disturbance, anxiety, and unspecified psychosis. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of zero (indicating severe cognitive impairment) and section GG (Functional Abilities and Goals) documented that R38 required setup or clean-up assistance for eating - the helper sets up or cleans up and resident completes the activity. A review of the care plan for R38 documented a Focus area initiated on 5/11/2021 and revised on 4/27/2023 for ADLs that stated the resident needs up to limited assistance from one staff member due to CVA [cerebral vascular accident], dementia, and varying cognitive and physical abilities. The Goal, initiated on 5/11/2021 and revised on 5/31/2024, was for the resident to receive assistance with ADLs, to be cleaned and groomed, and to have meals served by staff through the next review date. The Interventions for Eating included the following: 1. One staff member to set up trays and monitors for any choking or difficulty swallowing. 2. Resident can feed herself when OOB [out of bed]. She needs supervision and cues to finish. 3. If a resident is in bed, turn on the soft light and have the resident positioned upright in bed. 4. Set up her tray, cut food, open containers, and have utensils in reach as well as other items. 5. Assist the resident to start feeding herself. If she refuses the tray, offer ice cream from the tray, thicken fluids, and give the resident a cold nutritional beverage. The interventions were initiated on 5/11/2021 and revised on 7/24/2024. Observation of R38 during the dinner meal on 7/24/2024 at 4:52 pm in her room revealed she was positioned upright in bed with her dinner tray on the bedside table across her lap. She was eating ice cream with her right hand fingers. The meal tray held a plate of food with a mechanical soft texture and two juice containers opened with straws inserted. The flatware was still wrapped and inaccessible to R38. In an interview with Unit Support Associate (USA) GG on 7/24/2024 at 5:00 pm in R38's room, he stated he did not deliver the meal tray to R38 and confirmed the flatware was still wrapped, inaccessible to R38, and should have been unwrapped and within the resident's reach as part of the meal setup. In an interview with Licensed Practical Nurse (LPN) HH on 7/24/2024 at 5:05 pm in R38's room, she confirmed the flatware was still wrapped and should have been opened and placed within R38's reach during the meal setup. She unwrapped the flatware. In an interview with Certified Nursing Assistant (CNA) II on 7/24/2024 at 5:20 pm, she stated she delivered the meal tray to R38 and should have unwrapped the flatware and placed it within reach of the resident as part of the meal setup. She stated that if she did not do that, it was simply an oversight.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to provide an environment free from chemical hazards for one of four residents (R) (R91) reviewed for accident hazards. This deficient practice placed R91 at risk for avoidable chemical incidents, injuries, and a diminished quality of life. Findings include: A policy was requested and was not provided. A review of R91's clinical record revealed diagnoses including, but not limited to, unspecified dementia and cognitive communication deficit. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 4 (indicating severe cognitive impairment) and section GG (Functional Abilities and Goals) documented R91 required supervision with ambulation. A review of the care plan revised on 7/17/2024 revealed a focus area of cognitive losses, resident with memory deficit related to diagnosis of dementia. An observation on 7/23/2024 at 11:37 am revealed R91 lying on her bed sleeping. An observation of R91's bathroom revealed a three-tier cart with two cans of disinfectant spray, one container of all-purpose cleaner with bleach, two containers of disinfectant wipes, an aerosol spray can containing an unknown substance, and a spray bottle of air freshener. An observation on 7/24/24 at 5:44 pm revealed R91 sitting in her room in a chair. An observation of R91's bathroom revealed two containers of disinfectant wipes, an aerosol spray can containing an unknown substance, and two cans of disinfectant spray on a three-tier cart. An observation on 7/25/2024 at 10:40 am revealed an aerosol spray can with a blue top containing an unknown substance in R91's bathroom. During an interview and observation on 7/25/2024 at 10:49 am, Wound Care Nurse (WCN) EE confirmed the aerosol spray can with an unknown substance in R91's bathroom, and she removed it. She stated it was not the expectation of the facility for residents to have chemical items in their rooms. She further stated that R91's family brings the items in, places them in the bathroom, and states they feel like R91 knows what to and what not to do with them. She stated when staff finds those items, they remove them from the residents' room and alert the family. An interview with Bath Technician (BT) DD on 7/25/2024 at 10:57 am revealed she had not seen any household chemicals in R91's bathroom. She stated if she were to see any type of household chemicals in a resident's room, she would put them in a higher place so the residents would not be able to reach them. In an interview on 7/25/2024 at 11:26 am, WCN EE revealed chemicals were not allowed in resident rooms. Nurse FF revealed that R91's family was in and out of the facility throughout the day, and staff constantly educated the family on what was allowed in the bathroom. Registered Nurse (RN) FF stated the expectation was for staff to remove chemical items from a resident's room and take them to the nurse. She confirmed the process had not been followed for removing chemical items from the resident's room.

Based on observations and staff interviews, the facility failed to ensure food items in the kitchen cooler were properly stored and labeled with open or discard dates, failed to dispose of expired foods in a resident nourishment pantry, and failed to ensure an ice maker was maintained in a clean and sanitary manner. The deficient practices placed the 106 residents (R) who consumed an oral diet from the kitchen at risk for avoidable foodborne illness. Findings include: The Food Safety policy was requested and was not provided. Observations of the kitchen cooler on 7/23/2024 at 9:15 am revealed the following: One industrial-size cooking sheet containing seasoned chicken was covered with plastic wrap with a light orange substance on the wrap without a label indicating a stored or discard date. Trays of bacon without a label indicating a stored or discard date. Opened condiments, including a wing sauce/glaze, strawberry topping, and salad dressing, without a label indicating a stored or discard date. A pan of green beans without a label indicating a stored or discard date. A pan of unknown food items covered with aluminum foil without a label indicating a stored or discard date. A plastic tub of noodle soup with a cooler stick in it, uncovered and without a label indicating a stored or discard date. Sliced pepperjack cheese, sliced sharp cheese, and cheese cubes without labels indicating a stored or discard date. Observation of the fresh vegetable area in the cooler revealed a clear plastic tub labeled as squash containing a bag of cauliflower, without a label indicating a stored or discard date. Observation on 7/23/2024 at 2:00 pm of a resident nourishment pantry on B Floor revealed a refrigerator/freezer containing an open box of a frozen dessert product without an opened or discard date with a manufacturer's expiration date of 7/1/2024. Observation on 7/23/2024 at 2:16 pm of a resident nourishment pantry on A Floor revealed an industrial ice machine with ice in it. When wiped along the interior of the ice machine with a paper towel, there was a build-up of a dark brown/black substance on the paper towel. Observations of the kitchen cooler on 7/25/2024 at 11:15 am revealed the following: One industrial-size plastic bowl containing seasoned chicken without a label indicating a stored or discard date. Open condiments, including chicken wing sauce, soy sauce, and salad dressing, without labels indicating a stored or discard date. One package of sliced pepper jack cheese without a label indicating a stored or discard date. Observation of the fresh vegetable area in the cooler revealed a clear plastic tub labeled as squash containing long green leafy vegetables, without a label indicating a stored or discard date. In an interview on 7/23/2024 at 9:15 am, the Certified Dietary Manager (CDM) revealed she did not know what the thick orange substance was on the plastic covering the chicken. She stated she was not sure why the staff did not label the open food items and that she was constantly educating them on labeling opened items properly. In an interview on 7/23/2024 at 3:30 pm, the Administrator revealed the ice makers were cleaned weekly and had been cleaned earlier that day around 10:00 am. In an interview on 7/25/2024 at 11:15 am, Sous Chef BB revealed all opened food items should be dated when opened, and it was a continual work in progress to remind and educate staff on dating opened items. In an interview on 7/25/2024 at 12:37 pm, the CDM revealed she continues to educate staff during huddles on labeling and expiration dates. She stated the clear bins should be labeled and dated correctly with the discard date on them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of the facility policy titled, Advance Directive, the facility failed to update the care plan for one of five sampled Residents (R#17) related to code status. Findings include: Record review of the facility policy titled Advance Directive with a revision date of [DATE], revealed under the change in condition, 3.3, initiate a new life-sustaining treatment (RPLST) form and update the care plan to reflect changes, or if no changes have been made, to document the date of review and discussion; Care Plan Review 4.1; all residents will be reviewed at care plan for advance directive and/or RPLST; 4.2 existing RPLST will be reviewed. If there is no change, sign, and date the RPLST form. Record review for R#17 revealed that the resident was admitted to the facility on [DATE]. Diagnosis included but was not limited to encephalopathy, systemic inflammatory response syndrome, the presence of a cardiac pacemaker, and vascular dementia. Record review of the care plan for R#17, revised on [DATE], included Do Not Intubate (DNI) status: Resident to have Cardio-Pulmonary Resuscitation (CPR), no intubation, per new orders [DATE]. Record review of the physician's orders for R#17 revealed a Do Not Resuscitate (DNR) order date of [DATE]. Interview on [DATE] at 6:29 p.m. with the [NAME] Care Coordinator revealed that the code status is reviewed at the quarterly care plan meeting. If there is a change in the code status, order the charge nurse sends an email to the Interdisciplinary team (IDT) team. Interview on [DATE] at 6:29 p.m. with the MDS Coordinator revealed that during the morning meeting, the charge nurse reports information about the residents, including any changes, and the MDS Coordinator will update the care plan in relation to the code status. Interview on [DATE] at 6:45 p.m. with a Registered Nurse (RN) 1 and the Director of Nursing (DON) revealed that the term DNI means Do Not Intubate; the Resident will receive CPR and maybe medications during an emergency but no intubation; the term DNR means Do Not Resuscitate; there will be no CPR, intubation, or medications. The DON and RN 1 confirmed that the physician order on [DATE] was a DNR order, but the code status on the care plan was a DNI.