**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility document review, and staff interviews, the facility failed to ensure one resident (Resident (R) 25) was provided mental health services after sexual abuse which involved Housekeeper 1. This failure had the potential for R25 to suffer potential psychological stress after the event.Findings included: A review of a document provided by the facility titled Job Description, dated 2/3/2024, indicated the Social Worker was responsible for planning, organizing, and directing the overall operation of the Social Services Program to provide for the psychosocial needs of the patients and families served by the center.A review of a document provided by the facility for R25 titled Face Sheet indicated the resident was admitted to the facility on [DATE].A review of the annual Minimum Data Set (MDS) assessment for R25 with an Assessment Reference Date (ARD) of 9/11/2024 indicated the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15, which indicated the resident was moderately cognitively impaired.A review of an untitled document provided by the facility (referred to as a follow-up to the initial State Survey Agency incident), dated 9/20/2024, indicated that on 9/13/2024, R25 was kissed by Housekeeper 1. The police were notified, and Housekeeper 1 admitted that he kissed R25 and touched her hand.A review of a document provided by the facility for R25 titled Care Plan failed to address the sexual assault by Housekeeper 1, and that the resident, at the time of the incident, was unable to consent to the act.A review of R25's electronic medical records (EMR) failed to address psychological services after an incident of being kissed by Housekeeper 1.During an interview on 8/6/2025 at 10:43 AM, the Administrator stated a psychological visit would be made by the Social Worker (SW) if there was an allegation of abuse/neglect. The Administrator stated based on the SW's assessment, the resident would then be seen by psychological services, and then care would be planned after the event. The Administrator stated the care plan would need to be developed so the staff could monitor the resident for any associated behaviors. The Administrator stated this would be completed by the SW.During an interview on 8/6/2025 at 11:49 AM, SW1 stated she was not employed by the facility at the time R25 was kissed by Housekeeper 1. SW1 stated the resident would need to be assessed by the SW and a referral made for mental health evaluation. SW1 stated it was important to then update the resident's care plan so staff could monitor any associated psychological stress related to the incident. (Refer to F600)

Based on observation, staff interviews, record reviews, and review of the facility procedural guideline titled, Pharmacy Services Infusion Therapy Product Labels, the facility failed to ensure medications were labeled in accordance with standard requirements for one of one Residents (R) (R271) sampled for intravenous (IV) medication administration. Specifically, the date and time administration of the IV medication began and the nurse's initials that administered it were not written on R271's IV label. Findings include: Review of the facility procedural guideline titled, Pharmacy Services Infusion Therapy Product Labels dated 2019 revealed the intent was that infusion therapy products are labeled in accordance with center requirements and applicable state and federal laws. The label includes sufficient additional information as required to assure safe and efficient administration to patients. The Guidelines section included infusion products are labeled in the pharmacy with the date started, time, and RN (registered nurse) initials. Review of the clinical record for R271 revealed resident was admitted with diagnoses including but not limited to streptococcal sepsis. Review of the physician orders revealed an order dated 9/23/2023 for cefazolin 2 grams (gm) (a medication used to treat serious bacterial infections) in 50 milliliter (ml) dextrose IV piggyback (small IV bag with antibiotic), one piggyback IV every eight hours for 38 days. Review of the care plan included a problem area of vascular access related to receiving antibiotics. The goal was that the resident will experience no complications from vascular access during the review period. Interventions included administering medications as ordered, assessing signs and symptoms of infection. Observation on 10/3/2023 at 4:20 pm of R271 revealed one 50 ml bag of cefazolin 2 gm and dextrose connected to an IV infusion pump. The medication had completed infusing. The pump was on, and the alarm was audible. Further observation revealed Licensed Practical Nurse (LPN) AA entered the room and turned the IV pump off. Observation of the bag of cefazolin 2 gm and dextrose IV medication revealed it was not labeled with a date or time of administration or a nurse's initials on the bag. Interview on 10/3/2023 at 4:30 pm with LPN AA revealed she had administered the IV cefazolin 2gm in 50ml of dextrose solution. She stated she was aware she should label the IV medication bag with the administration date and time, and her initials when she began the administration, and she must have forgotten. Observation of the empty bag of cefazolin with LPN AA revealed the bag did not have a date, time, or initials on it. She verified she did not label the bag prior to administration. Interview on 10/4/2023 at 2:15 pm with Registered Nurse (RN) BB revealed when administering an IV medication, the medication should be labeled with the date and time administration of the medication began and the nurse's initials that administered it. Interview on 10/4/2023 with LPN CC revealed IV medications should be labeled with the date and time administration of the medication began and the nurse's initials that administered it. Interview on 10/5/2023 at 11:00 am with LPN DD revealed her to state the nurse administering IV medications should label the infusion bag with the date and time of administration and the nurse's initials when the medication administration was started. Interview on 10/5/2023 at 11:30 am with the DON revealed IV medications arrived at the facility with a pharmacy label that contained the medication information, and the nurse did not need to place the date and time of administration or the nurse's initials on the label when the medication administration was started. She stated the nurse documented the date and time of administration and the initials on the medication administration record (MAR) therefore it was not required for the information to be placed on the container of medication.

Based on observations, staff interviews, record review, and review of the facility procedural guideline titled, Pharmacy Services Safe Administration of Infusion Therapy Products, the facility failed to ensure infection control practice was followed during the flush procedure for a resident receiving medication via a peripherally inserted central catheter (PICC) line (a vascular access device used to safely administer medication into the bloodstream) for one of one Residents (R) (R271) sampled for intravenous (IV) medication administration. This failure had the potential of exposing R271 to infections due to cross contamination. Findings include: Review of the facility procedural guideline titled, Pharmacy Services Safe Administration of Infusion Therapy Products dated 2023 revealed the intent was to promote safe and effective administration of infusion therapy products. The Procedure section included a procedure of: The licensed nurse responsible for changing an intravenous solution is expected to follow appropriate standards of nursing practice in protecting against contamination. Review of the clinical record for R271 revealed resident was admitted with diagnoses including but not limited to streptococcal sepsis. Review of the physician orders revealed an order dated 9/23/2023 for cefazolin 2 grams (gm) (a medication used to treat serious bacterial infections) in 50 milliliter (ml) in dextrose IV piggyback, one piggyback IV every eight hours for 38 days; and an order dated 9/23/2023 for midline catheter non-valved with saline, antibiotic, saline, heparin (SASH) flush before and after medication administration intravenously every eight hours for 25 days. Review of the care plan revealed a problem area of IV therapy required due to diagnosis of sepsis. The goal was that R271 will experience no complications of IV therapy. Interventions included assessing the catheter site for signs and symptoms of infection. Observation on 10/3/2023 at 4:20 pm of R271 with one 50 ml bag of cefazolin 2 gm and dextrose connected to an IV infusion pump revealed the medication had completed infusing. The pump was on, and the alarm was audible. Further observation by two surveyors revealed Licensed Practical Nurse (LPN) AA entering R271's room and turning the pump off. She disconnected the IV tubing from the PICC line access site located in the resident's right antecubital (inner arm at elbow) area. She then cleaned the needleless connector of the PICC with an alcohol wipe, allowed the uncapped needleless connector to lie on and touch the bed linen while preparing the heparin flush, picked it up and flushed it with the heparin flush without sanitizing it. She then disconnected the heparin flush syringe and connected a disinfection cap to the needleless connector. Interview on 10/3/2023 at 4:30 pm with LPN AA revealed she was unaware that she had allowed the PICC line needleless connector to touch the bed linen prior to administering the heparin flush and after she had sanitized the connector end. She stated the needleless connector should have been sanitized just prior to administering the flush solution. She stated she had received education on infection control and IV medication administration but could not recall the date of the education. She stated her intentions with resident care were to prevent cross contamination which could potentially cause a resident's condition to worsen. Interview on 10/4/2023 at 2:15 pm with Registered Nurse (RN) BB revealed her to state when administering an IV medication or fluids, the needleless connector of the IV line should never touch an unclean surface without the cap attached to it. Interview on 10/4/2023 with LPN CC revealed she had received recent education on administering IV medications via an online platform. She could not verify the date of the education. She stated when administering an IV medication or fluids, the needleless connector of the IV line should never touch an unclean surface without the cap attached to it. Interview on 10/5/2023 at 11:00 am with LPN DD revealed her to verbalize steps taken during disconnection of IV medication administration. She stated she would disconnect the needleless connector from the IV tubing hub, would hold the needleless connector in her hand, clean the end of it, administer the flush solution, and place the protective cap onto the needleless connector. She stated the end of the needleless connector should not be allowed to touch a surface and if it did, it should be cleaned with an antiseptic wipe just prior to administering flush solution and prior to placing the protective cap on it. Interview on 10/5/2023 at 11:30 am with the DON revealed she didn't think the PICC line needleless connectors were long enough to come into contact with a surface. She stated if it did, the nurse should sanitize it prior to placing the protective cap on it and prior to administering any solution into it. She stated her expectations were for the needleless connector to be sanitized with a sanitizing wipe prior to administering any solution into it and for it to have a protective cap on it when not in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to follow the care plan related to a prescribed diet as ordered for one resident (R) (R#85) of 39 sampled residents. Findings include: Resident R#85 was admitted to the facility on [DATE] with a diagnosis of diabetes, and below the knee amputation (BKA). Review of the Quarterly Minimum Data Set (MDS) Assessment on 11/25/21 revealed that R#85 had a Brief Interview for Mental Status (BIMS) of 15, meaning that R#85 is cognitively intact. Review of the January 2022 Physician Orders revealed that R#85 was to receive large portions of vegetables which was originally ordered 11/5/21. Review of R#85's care plan, originally dated 6/15/21, revealed that R#85 was at risk for altered nutrition status related to food preferences. Interventions were to provide diet as prescribed. During lunch observation on 1/4/22 at 1:13 p.m., R#85 was sitting up in her room eating her lunch. She was observed to be served a baked potato and a bowl of chili. She stated that the food was not good, had no flavor and was cold. During observation, she stated that she loved vegetables and that she did not get any vegetables on her tray. No vegetables were observed on the resident's lunch tray. R#85 said that she does not eat chili due to it giving her heartburn. She said that when she asks staff for an alternate, she would usually just get a sandwich. During lunch observation and resident interview on 1/5/22 at 1:22 p.m. with R#85, the resident was sitting up in her wheelchair in her room eating lunch. She was observed to have been served a small amount of chopped meat and mashed potatoes with brown gravy. There were no vegetables observed on R#85's tray. During a review of the meal ticket placed on R#85's tray, it was noted that she was supposed to receive large portions of vegetables. R#85 said that she does not get vegetables, but she loved them. She stated that the meat was a mystery meat, that it does not look like meat loaf. R#85 ate approximately four to five bites of the meat but no mashed potatoes. During lunch observation on 1/6/22 at 1:20 p.m., R#85 was sitting up in her room eating lunch. She was served a small ear of corn, half of sweet potato, a slice of red velvet cake, a roll, and a small piece of chicken breast, which appeared to be dry and hard. She said that the chicken looked so tough. R#85's meal ticket was reviewed and revealed that she was supposed to receive large portions of vegetables were to be served. Interview with Certified Nursing Assistant (CNA) BB on 1/6/22 at 1:25 p.m., she confirmed that resident did not have large portions of veggies on her tray. During an interview with the Food Service Manager (FSM) AA on 1/6/22 at 1:32 p.m., she said that a large portion of vegetables could be a bigger portion of the regular and/or additional extra vegetable. She confirmed that R#85 did not like peas, so if peas were served, then R#85 would not get a vegetable at all. She further added it would depend on what else was on the tray line, what was already prepared, and what R#85's preferences were. She did state that green peas were served on Tuesday for lunch and field peas on Wednesday for lunch. The FSM confirmed that the staff should be following the Physicians order related to the residents diet. Interview with the Director of Nursing (DON) on 1/6/22 at 2:00 p.m., when asked about large portions of vegetables for R#85, she said that she would think it would mean an extra scoop of vegetables. During a telephone interview with the Corporate Certified Dietary Manager (CDM) DD on 1/6/22 at 5:23 p.m., she stated that they were resident-centered, meaning that they honor the preferences of the resident. When asked about the nutritional value of the food when substituting vegetables (when a resident did not like what was served and the kitchen was aware of this dislike), she confirmed there should be something of the same nutritional value served in the place of what the resident did not like. In an interview with the Registered Dietitian (RD) on 1/7/22 at 9:20 a.m., she confirmed that a large portion of vegetables would be extra or additional vegetables and stated that if there was a vegetable that was being served that a resident did not like, then it should be substituted for another vegetable. The RD stated she expected that all residents are to get what was on the dietary spreadsheet for a meal (meat, starch, and vegetable). Review of the Diet Spreadsheet with approval date of 1/4/22 revealed that a regular diet for lunch was to receive an eight-ounce ladle of chili, one baked potato, a four-ounce (serving) of green peas, a roll, and one slice of pound cake. Review of the Diet Spreadsheet with approval date of 1/5/22 revealed that a regular diet lunch was to consists of a three-ounce slice of meat loaf, a four-ounce (serving) of mashed potatoes, a four-ounce (serving) of purple hull peas, choice of roll, and one serving of a cookie or ice cream. Review of the Diet Spreadsheet with approval date of 1/5/22 revealed that a regular diet for lunch was to be served one breast of Italian baked chicken, one-half of a baked sweet potato, one-half of corn on the cob, a roll, and red velvet cake. Review of Tray ticket dated 1/7/22 revealed that R#85 was to get large portions of vegetables, and that R#85 dislikes peas, and carrots.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, review of policy facility titled Menus and interviews, the facility failed to ensure that one resident (R) (R#85) of 39 sampled residents received a diet that was well-balanced and followed physician orders. Findings include: Review of facility policy titled Menus with copyright date of 2020 revealed that it is the intent of the facility to provide meals based on a menu following established national guidelines. Further review revealed that menu items will be nutritionally adequate, attractively served, palatable, at a safe and appetizing temperature, and within cost or budget projections. The menu alternates of similar nutritive value will be offered to patients daily and as needed. Record review revealed that R#85 was admitted to the facility on [DATE] with a diagnosis of diabetes, and below the knee amputation (BKA). Review of the Quarterly Minimum Data Set (MDS) Assessment on 11/25/21 revealed that R#85 had a Brief Interview for Mental Status (BIMS) of 15, meaning that R#85 is cognitively intact. Review of the January 2022 Physician Orders revealed that R#85 was to receive large portions of vegetables with meals. (Originally ordered 11/5/21.) Review of the Diet Spreadsheet with approval date of 1/4/22 revealed that a regular diet for lunch on Tuesday (1/4/22) was to receive eight-ounce (serving) of chili, one baked potato, four-ounce (serving) of green peas, one roll, and one slice of pound cake. Review of the Diet Spreadsheet with approval date of 1/5/22 revealed that lunch on Wednesday (1/5/22) was to receive (regular diet) three-ounce slice of meat loaf, four-ounce (serving) of mashed potatoes, four-ounce (serving) of purple hull peas, choice of roll, and one serving of a cookie or ice cream. Review of the Diet Spreadsheet with approval date of 1/5/22 revealed that a regular diet for lunch on Thursday (1/6/22) was to be served one breast of Italian baked chicken, half of baked sweet potato, half of corn on the cob, roll, and red velvet cake. Review of Tray ticket dated 1/7/22 revealed that R#85 was to get large portions of vegetables, and that R#85 disliked peas and carrots. During lunch observation on 1/4/22 at 1:13 p.m., R#85 was sitting up in her room eating her lunch. She was observed to be served a baked potato and a bowl of chili. She stated that the food was not good, had no flavor and was cold. During observation, she stated that she loved vegetables and that she did not get any vegetables on her tray. No vegetables were observed on the resident's lunch tray. R#85 said that she does not eat chili due to it giving her heartburn. She said that when she asks staff for an alternate, she would usually just get a sandwich. During lunch observation and resident interview on 1/5/22 at 1:22 p.m. with R#85, the resident was sitting up in her wheelchair in her room eating lunch. She was observed to have been served a small amount of chopped meat and mashed potatoes with brown gravy. There were no vegetables observed on R#85's tray. During a review of the meal ticket placed on R#85's tray, it was noted that she was supposed to receive large portions of vegetables. R#85 said that she does not get vegetables, but she loved them. She stated that the meat was a mystery meat, that it does not look like meat loaf. R#85 ate approximately four to five bites of the meat but no mashed potatoes. During lunch observation on 1/6/22 at 1:20 p.m., R#85 was sitting up in her room eating lunch. She was served a small ear of corn, half of sweet potato, a slice of red velvet cake, a roll, and a small piece of chicken breast, which appeared to be dry and hard. She said that the chicken looked so tough. R#85's meal ticket was reviewed and revealed that she was supposed to receive large portions of vegetables were to be served. In an interview with Certified Nursing Assistant (CNA) BB on 1/6/22 at 1:25 p.m., she confirmed that R#85 did not have large portions of vegetables on her tray. She said that staff are to look at the resident's tray ticket before giving resident a tray to ensure the resident received what was ordered. During an interview with the Food Service Manager (FSM) AA on 1/6/22 at 1:32 p.m., she said that a large portion of vegetables could be a bigger portion of the regular and/or additional extra vegetable. She confirmed that R#85 did not like peas, so if peas were served, then R#85 would not get a vegetable at all. She further added it would depend on what else was on the tray line, what was already prepared, and what R#85's preferences were. She did state that green peas were served on Tuesday for lunch and field peas on Wednesday for lunch. The FSM confirmed that the staff should be following the Physicians order related to the residents diet. During a telephone interview with the Corporate Certified Dietary Manager (CDM) DD on 1/6/22 at 5:23 p.m., she stated that they were resident-centered, meaning that they honor the preferences of the resident. When asked about the nutritional value of the food when substituting vegetables (when a resident did not like what was served and the kitchen was aware of this dislike), she confirmed there should be something of the same nutritional value served in the place of what the resident did not like. Interview with the Registered Dietitian (RD) on 1/7/22 at 9:20 a.m., she confirmed that a large portion of vegetables would mean an extra serving of vegetables and stated that if there was a vegetable that was served that a resident did not like, then it should be substituted out for another vegetable. She said that she expected that all residents were to get what was on the dietary spreadsheet for a meal (meat, starch, and vegetable).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with residents and staff, and record review, the facility failed to ensure the dietary services department response to grievances filed by the Resident Council Group and residents for two residents (R) (R#48 and #85) of 39 sampled residents. Findings include: 1. Record review revealed that R#85 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS) Assessment on 11/25/21 revealed that R#85 had a Brief Interview for Mental Status (BIMS) of 15, meaning that R#85 is cognitively intact. Review of the January 2022 Physician Orders revealed that R#85 was to receive large portions of vegetables with meals. (Originally ordered 11/5/21.) During lunch observation on 1/4/22 at 1:30 p.m., R#85 was observed sitting up in her wheelchair in her room, eating off a Styrofoam-style take out tray. She said that the food was not good. She stated that it did not have a taste and was cold. She said that she loved vegetables and did not get any on her tray. No vegetables were observed on resident's lunch tray. R#85 stated that she had written on her tray ticket what she liked and didn't like, but it didn't do any good (e.g., no changes were made in food served to support her preferences). She further stated that she had spoken with the kitchen staff, and it does no good. During lunch observation and resident interview on 1/5/22 at 1:22 p.m. with R#85, the resident was sitting up in her wheelchair in her room eating off Styrofoam-type take out trays with a small amount of chopped meat, and mashed potatoes with brown gravy; however, no vegetables were noted on R#85's tray. During observation, R#85's tray ticket was reviewed, and revealed large portions of vegetables were to be served. R#85 said that she does not like eating off Styrofoam and was unsure how long she had been eating with plastic silverware. R#85 said that she does not get vegetables, but she loved them. She stated that the meat was a mystery meat, that it does not look like meat loaf. R#85 ate approximately four to five bites of the meat but no mashed potatoes. Review of the Diet Spreadsheet with approval date of 1/4/22 revealed that a regular diet for lunch on Tuesday (1/4/22) was to receive eight-ounce ladle of chili, one baked potato, four-ounce (serving) of green peas, one roll, and one slice of pound cake. Review of the Diet Spreadsheet with approval date of 1/5/22 revealed that lunch on Wednesday (1/5/22) was to receive (regular diet) three-ounce slice of meat loaf, four-ounce (serving) of mashed potatoes, four-ounce (serving) of purple hull peas, choice of roll, and one serving of a cookie or ice cream. Review of Tray Ticket dated 1/7/22 revealed that R#85 was to get large portions of vegetables, and that R#85 disliked peas and carrots. 2. During an interview on 1/4/2022 at 12:28 p.m., Resident (R) #48 stated that meals were not what they should be. There was no milk for breakfast, and they can't get milk when they choose cereal for breakfast. R#48 stated the Resident Council had made many complaints about the food during the meetings, but no one from the kitchen had come to address their concerns with them. A review of the Skilled Inpatient Services Grievance/Concern Guideline for Patients dated 2020, showed that grievances may be filed with the center or other entities the patient chooses. It was also the intent of the center to support each patient ' s right to voice concerns and to assure that after receiving a concern/grievance, the facility will actively seek a resolution and keep the patient (or representative) apprised of the progress toward resolution. A review of the Resident Council Meetings Minutes from January 2021 to December 2021 revealed the following: On 4/7/21 residents had concerns about food presentation. Residents stated sometimes they could not tell what the meal was supposed to be by looking at the food presented on the tray. Residents reported that soups and drinks tasted watered down, and bread-type foods with breakfast were soggy. On 4/13/21 residents stated the above concerns, but additionally stated the eggs served during breakfast were watery. It was noted that the Dietitian discussed food concerns with group members. On 4/21/21 residents discussed food concerns to include meat being too tough to cut at times, food presentation, eggs, and watery juice. Food Service Manager (FSM) made a visit to the meeting and discussed food preferences and food portions. On 5/20/21 residents discussed food quality at the Resident Council meeting. On 6/10/21 residents discussed food presentation at the Resident Council meeting. On 7/8/21 residents requested baked potatoes to be placed on the menu and how they disliked diced potatoes as served on the menu. On 9/15/21, residents discussed that breakfast breads were soggy when served on plates and requested that breads served at breakfast time be placed in plastic bags. On 10/07/21 residents discussed the grits and oatmeal were served cold and hard, and portion sizes were too small. Residents requested cabbage greens to be served more often and staff was forgetting to serve condiments with their meals. The FSM was noted to have attended this meeting to respond to food service requests. On 11/4/21 residents discussed that potatoes were not fully cooked. Residents stated that they understood that kitchen did not have some foods but requested that if kitchen staff could do better with the foods that they did have it would be appreciated. Residents also discussed that pizza was a blob of dough and did not resemble pizza at all. [NAME] did not resemble rice in appearance. Chili was cold as if it had been refrigerated and not heated thoroughly. Residents further discussed that they had not had soup in a while, there were no tops or straws for cups, and the food was awful at best. Residents also stated that they would like cereal to be added to the regular breakfast and portion sizes of meats are too small and/or too difficult to eat. On 12/9/21 residents discussed that grits and oatmeal was inedible and they would like cereal instead since the breakfast was always cold. Residents approved to begin to request department managers be invited to the Resident Council meetings. Residents also discussed that the grill cheese was always burned as well as pizza. Residents further discussed not receiving soups or vegetables. Residents also discussed that weekend meals are terrible. The Administrator discussed a convenience menu to residents. This menu consisted of sandwiches such as ham, peanut butter and jelly, and grilled cheese. A review of the Resident Council Meeting Minutes showed that old business was discussed during each meeting, but there was no resolution documented to the concerns related to the facility food. During an interview on 1/06/2022 at 4:36 p.m., FSM AA stated that she attended the Resident Council meetings and the few complaints that she was aware of had been addressed. FSM AA stated that she would provide documentation of when concerns were addressed. Documentation was requested twice and was not provided. During an interview on 1/07/2022 at 9:48 a.m., Registered Dietitian (RD) EE stated that the expectation was the food should be warm and palatable when served to residents. RD EE stated if foods were not warm when served, then the nursing staff was expected to warm the food in the microwave in the nurse pantry and take the temperature of the food prior to service. RD EE stated in regard to food that was not served tender enough to cut with a plastic knife, from that point forward, the dietary department would monitor residents who need more assistance. During an interview on 1/7/2022 at 12:08 p.m., Activities Director (AD) JJ stated that the process for informing the appropriate department manager about the information discussed during the Resident Council meetings was when a subject was brought up in the meeting, she would invite the manager to that current meeting if the manager was available. If the manager was not available, then the issues would be brought up in the morning meetings. AD JJ stated the manager would be informed verbally, and the grievance would be documented in TSI Service Recovery Opportunity (SRO) which is an internal system for grievances which was accessed by the department managers. AD JJ stated that managers had a certain amount of time to respond to the grievance. AD JJ stated that managers would respond in TSI, speak with residents one on one and or follow up at the next meeting. AD JJ stated that the last time there was a concern for the dietary department was November 2021. During an interview on 1/7/2022 at 12:50 p.m., Social Services Director (SSD) II stated all department managers had access to SRO. If there was a concern for a department, the concern would be assigned to that the department and the manager received an email about the grievance. During an interview on 1/07/2022 at 2:05 p.m., the Administrator stated that it was her expectation that staff documented grievances voiced by the residents. The grievances were to be delegated to the appropriate department, the grievance was to be investigated, a correction plan completed, and the resolution reported to the person who filed the grievance. The Administrator further stated that it was an expectation that the dietary manager was to review the grievances filed for the dietary department and respond appropriately to the grievances filed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews the facility failed to provide meals that were prepared by methods that conserve nutritive value, flavor, and appearance and provide meals that were palatable, attractive, and at a safe and appetizing temperature for six residents (R) (R#48, #32, #296, #67, #85, and #44) of 39 residents sampled residents. Findings include: 1. Record review revealed that R#48 was admitted to the facility on [DATE]. A review of the Quarterly Minimum Data Set (MDS) dated [DATE] for R#48 revealed a Brief Interview for Mental Status (BIMS) score of 15, meaning that R#48 is cognitively intact. During an interview on 01/04/22 12:28 p.m., R#48 stated that the Resident Council had a meeting last month. R#48 stated that the biggest complaint in the past meetings was about the food. R#48 stated that the residents have requested to have cereal and milk in the mornings for breakfast, but it has not happened. 2. Record review revealed that R#32 was admitted to the facility on [DATE]. A review of the Annual MDS dated [DATE] for R#32 revealed a BIMS score of 13, indicating mild cognitive impairment. On 1/04/22 at 1:29 p.m. R#32 was observed eating her lunch. She stated that food was not good; the food was cold and that the meat was tough. She stated that the taste overall was just not good. On 1/05/22 at 2:35 p.m. R#32 stated that she had chicken for lunch and that it was tough and dry, and the potato was not cooked well. 3. Record review revealed that R#296 was readmitted to the facility on [DATE]. A review of the Annual MDS dated [DATE] for R#296 revealed a BIMS score of 13, indicating mild cognitive impairment. Review of R#296's medical record revealed no evidence of her likes and/or dislikes. Review of the meal ticket for R#296 dated 1/7/22 revealed NAS diet with no evidence of dislikes or preferences listed. During an interview with R#296 on 1/4/22 at 10:10 a.m., she stated that the food was cold (all meals), she was served items that she cannot eat (bacon, ham), and that the meals were served on Styrofoam-like take out trays with plastic silverware for all meals. She said that she did not like this, and that she did not even go to restaurants that serve on Styrofoam-like containers. During lunch observation on 1/4/22 at 1:15 p.m., R#296 was served chili, peas and a baked potato. Resident said she did not like chili (gives her heartburn). Reviewed R#296's lunch meal ticket which only listed her name, room number with diet ordered; however, no likes and/or dislikes listed. During breakfast observation on 1/5/22 at 9:13 a.m., R#296's meal ticket was observed to be blank other than diet listed. She was served on Styrofoam-like carry out tray. She was served grits, which appeared to be thick and pasty white colored. During interview with R#296 on 1/5/22 at 9:18 a.m., she said that she did not like grits and that nobody from dietary had spoken with her about her dislikes. During observation and interview with R#296 on 1/5/22 at 1:32 p.m., her lunch tray observed with one roll, unknown substance of ground meat which appeared hard on top with gravy, mashed potatoes with gravy, and a dark gray colored unknown type of beans serving. The resident said that the tea was kind of sweet but that she liked unsweet tea. She said, What does not kill you, makes you stronger. Resident stated, while pointing to the unknown substance of ground meat, that it looked very hard. During observation of breakfast on 1/6/22 at 9:30 a.m., R#296 was sitting up in her bed, eating approximately her meal. The tray had grits on it which the resident did not touch. Her meal ticket remained without preferences. During observation of lunch on 1/6/22 at 1:30 p.m., R #296 was sitting up in her wheelchair, served her lunch tray which contained sweet tea, a small corn on the cob, half of sweet potato, and a small piece of chicken breast. She said that the food was lukewarm and that the sweet tea would have to be diluted with water. 4. Record review revealed that R#67 was re-admitted to the facility on [DATE]. Review of R#67's admission MDS assessment dated [DATE] revealed a BIMS score of 15, meaning that R#67 is cognitively intact. Review of the meal ticket for R#67 dated 1/7/22 revealed regular diet with dislikes for eggs and grits. During initial tour of the facility on 1/4/22 between 10:00 a.m.-11:00 a.m., R#67 stated that the facility food was not good (cold food). During observation and resident interview on 1/4/22 at 1:30 p.m., R#67 said that she ate only the vegetable and bake potatoes for lunch due to the chili giving her heartburn. During lunch observation on 1/6/22 at 1:15 p.m., revealed R#67 sitting up in her recliner, finishing her lunch, in which she was served a small corn on the cob, half of a sweet potato, red velvet cake, yogurt, and chicken. The resident stated that she did not enjoy the chicken, that it was hard to cut, so she did not eat it. The chicken was observed and appeared to be dry. 5. Record review revealed that R#85 was admitted to the facility on [DATE] with a diagnosis of diabetes, and below the knee amputation (BKA). Review of the Quarterly MDS assessment dated [DATE] revealed that R#85 had a BIMS of 15, meaning that R#85 is cognitively intact. Review of the January 2022 Physician Orders revealed that R#85 was to receive large portions of vegetables with her meals. (Originally ordered 11/5/21.) Review of the tray ticket dated 1/7/22 revealed that R#85 was to receive large portions of vegetables, and that R#85 disliked peas and carrots. During lunch observation on 1/4/22 at 1:13 p.m., R#85 was sitting in her room eating her lunch off a Styrofoam-like take out tray. She stated that the food was not good, had no flavor and was cold. During observation, she said that she loved vegetables and that she did not get any vegetables on her tray. No vegetables were observed on her lunch tray. She stated that she does not eat chili, which was served for lunch, due to it giving her heartburn. She said that when she asks for an alternate vegetable, she received a sandwich. During lunch observation and resident interview on 1/5/22 at 1:22 p.m., R#85 sitting in her wheelchair in her room eating lunch from a Styrofoam-type take out tray. The tray contained a small amount of chopped meat, and mash potatoes with brown gravy; however, no other vegetables were noted on R#85's tray. During observation, R#85's tray ticket was reviewed, and revealed large portions of vegetables were to be served. R#85 said that she did not like eating off Styrofoam and was unsure how long she had been eating with plastic silverware. R#85 said that she did not get large portions of vegetables, but she loved them. She further stated that the meat was a mystery meat, that it does not look like meat loaf. During lunch observation on 1/6/22 at 1:20 p.m., R#85 was sitting in her room eating lunch from a Styrofoam-like take out tray. The tray contained a small ear of corn, half of a sweet potato, red velvet cake, a roll, and a small piece of chicken breast, which appeared to be dry and hard. The resident said that the chicken looked so tough. R#85's tray ticket review revealed large portions of vegetables. 6. Record review revealed that R#44 was admitted to the facility on [DATE]. Review of the Quarterly MDS assessment dated [DATE] revealed that R#44 had a BIMS of 15, meaning that R#44 is cognitively intact. On 1/4/22 at 11:27 a.m. in an interview with R#44, he stated the food wasn't consistent. He stated that he was on a diet and was told he can't have fried chicken, but he receives fried fish some days. He stated the kitchen is constantly saying they don't have some items. During an observation and interview with R#44 on 1/4/22 at 12:29 p.m. he was served chili and half of a baked potato for lunch. He stated that he doesn't really eat chili, so he requested a second baked potato. He was served an additional baked potato but was told by staff that he couldn't get any extra butter because there wasn't any left. Review of facility policy titled Menus with copyright date of 2020 revealed that it was the intent of the facility to provide meals based on a menu following established national guidelines. Further review revealed that menu items will be nutritionally adequate, attractively served, palatable, at a safe and appetizing temperature, and within cost or budget projections. The menu alternates of similar nutritive value will be offered to patients daily and as needed. A review of the Resident Council Meetings Minutes from January 2021 to December 2021 noted the following: On 4/07/21 residents had concerns about food presentation. Residents stated sometimes they could not tell what the meal was supposed to be by looking at the food presented on the tray. Residents reported that soups and drinks were watered down, and breaded food with breakfast was soggy. On 4/13/21 residents stated the above concerns, but additionally stated that the eggs served during breakfast were watery. It was noted that Dietician discussed food concerns with group members. On 4/21/21 residents discussed food concerns to include meat being too tough to cut at times, food presentation, eggs, and watery juice. Food Service Manager made a visit to the meeting and discussed food preferences and food portions. On 5/20/21 residents discussed food quality. On 6/10/21 residents discussed food presentation. On 7/08/21 residents requested baked potatoes to be placed on the menu and how they disliked diced potatoes served on the menu. On 9/15/21, residents discussed that breads were soggy when served on places and requested that breads served at breakfast time be placed in plastic bags. On 10/07/21 residents discussed that grits and oatmeal were served cold and hard, and portion sizes were too small. Residents requested cabbage greens to be served more often and staff was forgetting to serve condiments. Food Service Manager was noted to have attended the meeting to respond to food service requests. On 11/04/21 residents discussed that potatoes were not fully cooked. Residents stated that they understood that kitchen did not have some foods but requested that if kitchen staff could do better with the foods that they did have it would be appreciated. Residents also discussed that pizza was a blob of dough and did not resemble pizza at all. [NAME] did not resemble rice. Chili was cold as if it had been refrigerated. Residents further discussed that they had not had soup in a while, there were no tops or straws for cups, and the food was awful at best. Residents also stated that they would like cereal to be added to regular breakfast and portion sizes of meats are too small or too difficult to eat. On 12/09/21 residents discussed that grits and oatmeal was inedible and they would like cereal instead since the breakfast was always cold. Residents approved to begin to request department managers into the resident council meetings. Administrator discussed convenience menu to residents. Residents also discussed that the grill cheese was always burned as well as pizza. Residents further discussed not receiving soups or vegetables. Residents also discussed that weekend meals are terrible. A test tray observation was started on 1/06/22 at 1:00 p.m. During this observation the meal was placed on the cart at 1:00 p.m. After all trays on the cart were passed to residents, the test tray was removed and sampled by anonymous staff at 1:28 p.m. They stated that the sweet potato was a little under cooked, the corn was dry and cooked too long. Staff stated that the chicken was okay but missing something. Staff reported that food was better than it had been in the past but that residents still complained about the food all the time. During an interview on 1/06/22 at 4:36 p.m., Food Service Manager (FSM) AA stated that she attended the Resident Council Meetings and the few complaints that she was aware of had been addressed. FSM AA stated that she would provide documentation showing concerns were addressed. The information was requested twice, but no documentation was provided. During an interview on 1/07/22 at 9:48 a.m., Registered Dietitian (RD) EE stated the expectation was the food should be warm and palatable when served to residents. RD EE stated that if foods were not warm when served, then the nursing staff was expected to warm the food in the microwave in the nurse pantry and take the temperature of the food prior to service. RD EE stated in regard to food that was not served tender enough to cut with plastic knife, from this point forward, the dietary department would monitor residents who needed more assistance. During an interview on 1/07/22 at 2:05 p.m., the Administrator stated that it was her expectation that staff would document grievances that were voiced by residents. The grievances were to be delegated to the appropriate department, the grievance would be investigated, a correction plan would be completed, and the resolution would be reported to the person who filed the grievance. The Administrator further stated that it was the expectation that the dietary manager was to review the grievances filed for the dietary department and respond appropriately to the grievances filed.