Based on observation, interview and record review the facility failed to provide assistance/cueing for 1 of 3 residents (R11) reviewed for meal assistance in the sample of 36. Finding include: 1. On 1/13/2025 at 12:24PM R11 observed sitting at table in dining room asleep. R11's green beans are in bowl, with a roll in it. R11's spaghetti is in a bowl with a built up handled fork in spaghetti. On 1/13/2025 at 12:32 PM V21, Licensed Practical Nurse (LPN) asked R11 who was sleeping if R11 was getting enough to eat. R11 had not touched his food. V21 LPN did not cue R11 to eat. On 1/13/2025 at 12:37PM V21, LPN did place R11's drink in front of R11. At 12:40PM R11 observed drinking hot chocolate from cup and pouring it down his shirt. 12:42PM R11 got bowl of spaghetti and holds in left hand while scooping spaghetti with fork and spilling it on clothes. R11 then starts eating spaghetti out of bowl with his hands. At no time does staff provide cueing or assistance to R11. At 1:11 PM V21, LPN asks R11 if wants dinner roll and places in R11's hand. R11 eats 100% of dinner roll. R11 is never provided assistance with green beans or eats green beans. On 1/13/2025 at 1:20 PM V21, LPN sits at table with R11, working on meal tickets, but never cues R11 to eat. R11's Face Sheet dated 1/14/2025 documents in part a diagnosis of qualified visual loss both eyes. R11's Care Plan dated, revised 11/2023 documents R11 has a self care deficit as evidenced needs assistance wit ADSl's related to blindness. R11 Care plan documents the following interventions; eating set up only /cueing required 5/6/2021. The facility policy Meal Assistance dated, revised 2/17/20 documents residents shall received assistance with meals in a manner that meets the individual need of each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to prevent hair contamination for 2 of 24 residents (R7, R23) reviewed for Dietary Services, in the sample of 36. Findings include: 1. On 1/14/2025 at 10:10 AM, R7 stated, I found a hair in my mashed potatoes about a month ago. I love mashed potatoes and gravy and I'm trying to gain weight. I didn't finish eating them. I told someone, I don't know who, someone in the kitchen. R7's Minimum Data Set (MDS) dated [DATE] documents R7 is cognitively intact. 2. On 1/14/2024 at 10:15 AM R23 stated, I've also had hairs in my food. I felt something in my mouth and there was a hair on my hamburger. It wasn't a short one like mine, it was long. They (Dietary staff) wear hairnets but it still happens occasionally. R23 stated she did not finish eating her hamburger because she lost her appetite. On 1/15/25 at 3:24 PM, V1, Administrator stated she was unaware of complaints of hair in food but she would look into it. The Facility's Safe Food Handling Policy dated 9/1/2021 documents, Dining Services staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the Facility failed to ensure food was served at an appealing temperature for 7 of 24 residents (R7, R23, R32, R38, R66, R73, and R283) reviewed for dietary services in the sample of 36. Findings include: 1. On 1/14/2025 at 10:10 AM, R7 stated she eats her meals in her room and the food is cold 99% of the time. It won't even melt butter. Yesterday I only ate half of my spaghetti. Every bite was gross because it was cold. R7's Minimum Data Set (MDS) dated [DATE] documents R7 is cognitively intact. 2. On 1/14/2024 at 10:15 AM, R23 stated, Most of the time it's cold (the meals). I usually get cold eggs but I eat them. I just cover them with mayo. R23's MDS dated [DATE] documents R23 is cognitively intact. The Facility's Resident Council Meeting Minutes dated 10/25/2024 documents residents had dietary concerns of the food temperatures and Some residents' food is still cold- on the hall. 3. R66 was admitted to the facility on [DATE] with diagnosis of, in part, cirrhosis of the liver, hepatic encephalopathy, and type two diabetes mellitus. R66's Minimum Data Set (MDS) dated [DATE], documented she is cognitively intact. On 1/13/25 at 9:32 AM, R66 stated the food is cold when it gets to her room, and she has told staff she refuses to eat her food cold. R66 stated she often will leave her cold meal uneaten on the bedside table. R66 stated she will purchase food to keep in her room to eat. 4. R38 was admitted to the facility on [DATE] with diagnosis of, in part, congestive heart failure (CHF), type two diabetes mellitus, and depression. R38's MDS dated [DATE], documented she is cognitively intact. On 1/13/25 at 11:37 AM R38 stated the food is cold whenever she eats in her room, so she tries to make it to the dining room to eat if she can. 5. R73 was admitted to the facility on [DATE] with diagnosis of, in part, osteomyelitis, closed fracture of left tibia and fibula, and type two diabetes mellitus. R73's MDS dated [DATE], documented she is cognitively intact. On 1/13/25 at 9:50 AM, R73 stated she eats in her room because it is really hard to get up and with her hardware in her leg, she prefers not to go to the dining room. R73 stated her food is always cold when it gets to her. 6. R283 was admitted to the facility on [DATE] with diagnosis of, in part, chronic respiratory failure, chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disease (GERD) and pneumonia. R283's MDS dated [DATE], documented he is cognitively intact. On 1/13/25 at 10:05 AM, R283 stated the food is usually cold when it gets delivered to his room. 7. R32 was admitted to the facility on [DATE] with diagnosis of, in part, nonrheumatic mitral valve disorder, type two diabetes mellitus, and malignant neoplasm of prostate. R32's MDS dated [DATE], documented he is cognitively intact. On 1/13/25 at 10:05 AM, R32 stated the food is always cold when it gets to his room. R32 stated he is a bit of a loner and prefers to eat in his room. R32 stated he sees the tray warmers being brought down the hall without being plugged in to stay warm and thinks the staff don't know how to use it properly. On 1/14/25 at 11:45 PM, lunch was put onto the steam table in the kitchen. At 12:06 PM, while serving the dining room lunch, V14, kitchen staff, heated up chicken noodle soup for a resident in the microwave, then placed it on a tray to be served. V14 stated he did not check the temperature of the soup. This surveyor checked the temperature of the soup, and it was 101.9 degrees Fahrenheit. V15, kitchen staff, continued to serve the soup when this surveyor notified V13, Regional Dietary Manager, of the temperature. V14 told V13 not to serve the soup. V13 asked V14 how he checked to see if the soup was warm enough to serve. V13 stated it felt warm. On 1/14/25 at 12:50 PM, the south food cart left the kitchen to be served to the remaining residents in their rooms. The tray warmer was not plugged in for the last 4 trays being served. The last food tray to be served was at 1:11 PM. The food on the last tray had temperatures as follows: Lo Mein Noodles 113.9 degrees Fahrenheit, and Sweet and Sour Chicken 123.4 degrees Fahrenheit. On 1/15/2025 at 11:25, V1, Administrator, stated the cold meals has been a complaint in the past but there hasn't been as much lately. V1 stated we do need to do better, and that she will work with staff to improve that. The facility's Safe Food Handling Policy dated 9/1/2021, documented the dining services director will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 degrees Fahrenheit and/or less than 135 degrees Fahrenheit, or per state regulation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the Facility failed to ensure the Illinois Department of Public Health deficiencies findings were readily available for review, as well as post signage indicating where the report was located. This failure has the potential to affect all 81 residents residing in the Facility. Findings include: On 1/14/2025 at 10:15 AM, R7, R8, R12 and V23 stated they were unaware where to locate the survey results binder or what the results of the last survey were. R7's Minimum Data Set (MDS) dated [DATE] documents R7 is cognitively intact. R8's MDS dated [DATE] documents R8 is mildly cognitively impaired. On 1/15/2025 at approximately 11:00 AM, V19, MDS coordinator stated R8's cognition has improved since her last MDS assessment. R12's MDS dated [DATE] documents R12 is cognitively intact. R23's MDS dated [DATE] documents R23 is cognitively intact. On 1/14/2025 at approximately 11:00 AM V22, Medical Records, was asked where the survey results binder was located. V22 opened a cabinet in the front lobby and provided a binder. Upon review, the last survey results included in the binder were from 2020. On 1/14/2025 at 3:45 PM, V1, Administrator, stated the posting with the location of the survey binder should be posted on the bulletin board by the employee break room. At this time, the posting was not observed to be posted on the bulletin board. On 1/15/2025 V1 confirmed there was no signage or posting to notify residents or visitors where the survey results binder was located. V1 continued to state that the Facility does not have a policy on posting/survey results, but she would expect the regulation to be followed. The Facility's CMS (Central Management Services) Form 671 dated 1/13/2025 documents there are 81 residents residing in the Facility.

2. On 01/13/25 at 09:45 AM South hall medication cart checked with V4, Licensed Practical Nurse (LPN) Two separate medication cups inside top drawer of cart with opened medication s in each cup. One medication cup had R286's last name written on outside of cup with 8 medications in the cup. The second medication cup contained 7 medication with R68's last name written on cup. V4 initially stated both residents were in therapy and then later stated R68 at dialysis. On 1/15/2025 at 2:30PM V2, Director of Nursing (DON) stated medications are to not be stored in medication cups. The Facility Policy Medication Storage dated, revised 8/23/2022 documents the facility stores all drugs and biological's in a safe, secure, and orderly manner and in accordance with state and federal regulations. The policy documents drugs and biological's are stored in the packaging, containers, or dispensing systems in which they are received. The policy documents the nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Based on observation, interview, and record review, the Facility failed to properly store medications and ensure timely disposal of a multi dose vial. This failure has the potential to affect all 81 residents residing in the Facility. Findings include: 1. On 1/13/2025 at 1:34 PM, the North Hall medication storage room was inspected with V20, Licensed Practical Nurse (LPN). There was a medication refrigerator that contained an open vial of Apilisol (A solution used to adminster TB skin tests) that had an open date of 11/20/2024. The sticker on the vial documented, Discard in use vials after 30 days. On 1/16/2024 at approximately 9:45 AM, V2, Director of Nursing stated V3, Assistant Director of Nursing (ADON) administers the TB skin tests. On 1/16/2025 at 10:19 AM, V3 verified the Apilisol vial observed in the medication storage room refrigerator was the only vial at the Facility on 1/13/2025 but they had since discarded it and ordered 2 more vials, one for each medication room. The document provided by V2, titled Aplisol- Tuberculin Purified Protein Derivative, Diluted [Stabilized Solution] documents, Storage- Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. The Facility's CMS (Central Management Services) Form 671 dated 1/13/2025 documents there are 81 residents residing in the Facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to properly monitor personal food storage for four of four residents (R25, R63, R65, and R17) reviewed for environment in the sample 35. 1. R25's face sheet, dated 1/31/24, documented that R25 was admitted to the facility on [DATE] with diagnosis of hypertensive heart disease with heart failure, Osteomyelitis, chronic obstructive pulmonary disease, neuromuscular dysfunction of bladder, paroxysmal atrial fibrillation, cardiomyopathy, anxiety disorder, osteoarthritis, and chronic gout. R25's MDS (Minimum Data Set), dated 1/16/24, documented that R25 is severely cognitively impaired. On 1/29/24 at 9:15 AM, R25 was observed resting in bed. R25 had a small refrigerator sitting on his nightstand. The nightstand was within reach of R25. The refrigerator had a thermometer that read 78 degrees. The contents in the refrigerator included a gallon of chocolate milk that was half full and warm to touch, individually wrapped homemade caramels, a jar of pickles that had been partially consumed, condiments, and cans of V8. There was food debris and water on the bottom shelf. The refrigerator had a foul sour odor coming from it and multiple gnats were observed flying around the refrigerator and throughout the room. On 1/30/24 at 9:40 AM, the refrigerator thermometer read 80 degrees and the same ingredients were observed within the refrigerator. There was a foul odor coming from the refrigerator and multiple gnats were observed flying around the refrigerator and throughout the room. On 1/30/24 at 9:50 AM, V1 Administrator presented a refrigerator temperature log for R25's refrigerator dated January 2024. V1 stated that the housekeeping department was responsible for checking the refrigerators everyday and for monitoring the temperatures. The January 2024 temp log documented that R25's refrigerator temperature was 40 degrees on 1/29/24 and 40 degrees on 1/30/24. 2. R63's face sheet, dated 1/31/24, documented that resident was admitted to the facility on [DATE] with diagnosis of osteoarthritis, type 2 diabetes, bipolar disorder, anxiety disorder, hyperlipidemia, gastro-esophageal reflux disease, and restless leg syndrome. R63's MDS, dated [DATE], documented that resident is cognitively intact. On 1/30/24 at 9:22 AM, R63 was sitting in his recliner in his room. R63 stated that he uses his refrigerator every day, and he could not recall the last time it had been cleaned or inspected. The refrigerator had a large amount of food debris on the bottom shelf. There was no thermometer in the refrigerator. The refrigerator contained an open package of lunch meat that did not have a date of when it was opened. The refrigerator also contained cheese, applesauce, and condiments. On 1/30/24 at 9:50 AM, V1 Administrator presented a refrigerator temperature log for R63's refrigerator dated January 2024. The January 2024 temperature log documented that R63's refrigerator temperature was 40 degrees on 1/29/24 and 40 degrees on 1/30/24. 3. R65's face sheet, dated 1/31/24, documented that R65 was admitted to the facility on [DATE] with diagnosis of metabolic encephalopathy, chronic obstructive pulmonary disease, type 2 diabetes, Parkinson's disease, dementia, hypertension, and peripheral vascular disease. R65's MDS, dated [DATE], documented that R65 is moderately cognitively impaired. On 1/30/24 at 9:28 AM, R65 was observed resting in bed. There was a small refrigerator next to his bed within his reach. The refrigerator did not have a thermometer in it. There was a jar of salad dressing that was half full. The refrigerator contained a package of opened ham with no opened date. The refrigerator also contained nutritional shakes and soda. On 1/30/24 at 9:50 AM, V1 Administrator presented a refrigerator temperature log for R65's refrigerator dated January 2024. The January 2024 temperature log documented that R65's refrigerator temperature was 40 degrees on 1/29/24 and 40 degrees on 1/30/24. 4. R17's face sheet, dated 1/31/24, documented that R17 was admitted to the facility on [DATE] with diagnosis of emphysema, chronic kidney disease, major depressive disorder, anxiety disorder, hypertension, and dementia. R17's MDS, dated [DATE], documented that R17 is cognitively intact. On 1/30/24 at 9:35 AM, R17's room had a small refrigerator sitting on the floor. The refrigerator had soda spilled on the bottom shelf. There was an undated and unlabeled disposable cup containing a liquid substance with a straw in the refrigerator. R17 stated that he did not know what was in the cup. There was no thermometer in the refrigerator. On 1/30/24 at 9:50 AM, V1 Administrator presented a refrigerator temperature log for R17's refrigerator dated January 2024. The January 2024 temperature log documented that R17's refrigerator temperature was 40 degrees on 1/29/24 and 40 degrees on 1/30/24. Facility Food and Nutrition policy dated 9-1-21 documents in part, The use and storage of food brought to residents by family and other visitors must be monitored to ensure safe and sanitary storage, handling, and consumption. Guidelines. 1. Temperature records or each cold storage unit maintained to ensure temperatures remain at or below 40 degrees for refrigerator . 2. Daily temperatures will be recorded. 3. An accurate thermometer will be kept in each refrigerator and freezer .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the Facility failed to provide a baseline Care Plan that addressed all of a resident's care needs for 1 of 18 residents (R274) reviewed for baseline care plans in the sample of 41. Findings include: R274's admission Record, dated 3/1/23, documents that R274 was admitted to the facility on [DATE]. R274's Electronic Medical Record, documents that R274's Diagnoses include respiratory failure, dementia, cardiac murmur, Alzheimer's disease, and aortic valve stenosis. R274's Baseline Care Plan, dated 2/23/23, documents (R274) is at risk for falls and injuries related to Medications: Psychotropic Meds/ Diuretic Meds/ Cardiovascular Meds/ Pain Meds/ Other Medications. There were no documented interventions in R274's Care Plan related to falls. There was no care plan about R274's risk for elopement. R274's Fall Risk Assessment, dated 2/23/23, documents that R274 is a low fall risk with a score of 6.0. A score of 10 or higher indicates the resident is at risk. R274's Elopement Risk Assessment, dated 2/23/23, documents that R274 is a High Elopement Risk with a score of 10. A score of 10+ means a Resident is considered at High risk for elopement. Document IDT's determination if ankle alarm bracelet (elopement risk) or other intervention is appropriate and update care plan as necessary. If IDT determines ankle alarm bracelet is appropriate, complete Physical Restraint Assessment and obtain consent. If facility does not have an ankle alarm bracelet system, place on 1:1 monitoring. Document contact with responsible party to discuss options for placement in a secure unit or other appropriate facility. On 2/27/23 at 9:12 AM, R274 was seen sitting on the side of her low bed with the side rails up X 2. R274 had an ankle alarm bracelet on her right lower leg and regular socks on and did not have non-slip socks on. On 2/27/23 at 10:45 AM, R274 was seen ambulating in/out of other resident's rooms. Staff assisted her to the dining room to sit at a table. On 2/28/23 at 9:12 AM, R274 was seen wandering in/out of several resident's rooms. Staff noticed her and assisted her to the dining room for activities. On 3/1/23 at 8:55 AM, R274 was sitting in a chair by the front nurse's desk holding a stuffed animal and mumbling incoherently. R274 had an alarm bracelet on her right ankle. On 3/2/23 at 10:50 AM, V24, Registered Nurse (RN), stated (R274) has tried a few times that I know of, to get out the front doors. She wears the ankle bracelet that goes off when she tries to get out. I guess we are just keeping a close eye out on her, keeping her close to the nurses' desk, and taking her to activities. It should be in her Care Plan. I see that there is nothing in the Care Plan about her elopement. The Facility's Wandering/Elopement Policy, dated 10/18/22, documents The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. 1. If identified is at risk for wandering or elopement; the resident's care plan will include strategies and interventions that shall in implemented to maintain the resident's safety, including but not limited to, electronic monitoring device, room placement, frequent checks, etc.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to review and revise Care Plans for individual needs and conditions; and failed to put appropriate interventions into place for 1 of 1 resident (R40) reviewed for care plan revision in a sample of 41. Findings include: R40's admission Record, with a print date of 03/02/23, documents R40 has diagnoses of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and osteoarthritis. R40's Minimum Data Set (MDS), dated [DATE], documents R40 is severely cognitively impaired and requires extensive assistance, 2 plus person physical assist with bed mobility, transfer, toileting, and personal hygiene. R40's MDS documents R40 is also always incontinent of bowel and bladder. It also documents R40 is not steady on her feet and unable to stabilize without assistance from staff. R40's Care Plan, with initiation date of 03/07/22, documents R4 is at risk for falls related to use of psychotropic medications/cardiovascular medications. R40's Care Plan documents Medical Factors: Depression, anxiety, Osteoarthritis, and dementia. The documented care plan goal for R40 is to decrease risk of falls and/or minimize injuries from falls times (x) 90 days. R40's Care Plan interventions document to encourage use of call light and keep call light within reach both initiated on 03/07/22. It further documents that on 03/07/22 to keep all belongings within reach, and on 12/27/22 it documents move night stand away from bed. R40's Incident Report, dated 09/19/22 at 11:53 PM, documents R40 had an unwitnessed fall in her room. The Report documented R40 was found by staff sitting upright with her back against the bed and legs outstretched in front of her on the floor mat. If further documents R40 didn't know what happened. The Report documented Immediate action taken was a skin assessment, pain assessment, Power of Attorney (POA) called, Primary Care Physician (PCP) notified. The Report did not document that any new immediate interventions were put into place after this intervention. A new intervention was not put into place on the care plan until 09/20/22 which was therapy to assess for strengthening. R40's Incident Report, dated 11/01/22 at 3:15 AM, was reviewed and documents R40 had a witnessed fall in her room. The Report documented a Certified Nurse's Assistant (CNA) was restocking the cart and witnessed R40 sliding out of bed and on to the floor mat. The Report documented VS (Vital Signs) obtained, resident assessed for injury, none noted, resident assisted back to bed. The Report had no documentation that any immediate interventions were put into place after this fall. The Report documented, on 11/01/22 IDT (Interdisciplinary Team) reviewed incident. Resident was in bed and CNA was in hallway and observed resident slid out of bed before she could get to her. Continue with all fall interventions. Added scoop mattress to bed to assist with defining bed parameters. R40's Incident Report, dated 11/23/22 at 6:45 PM, was reviewed and documents R40 had an unwitnessed fall in her room. The Report documented R40 was found by the CNA sitting on her buttocks beside her bed. The Report documented the immediate action taken was VS obtained, resident assessed for injury, assisted back to bed, ROM (Range of Motion) WNL (Within Normal Limits), and denies pain. No new immediate interventions were put into place. The notes section of the incident report document on 11/25/22 intervention put into place is toileting program at night due to incontinence at time of fall. The care plan documents no new intervention was put into place until 11/25/22. R40's Incident Report, dated 12/25/22 at 12:26 AM, was reviewed and documents R40 had an unwitnessed fall in her room. The Report documented CNA found R40 with her upper body by the nightstand and R40 was yelling for help. The Report documented when the nurse entered the room R40 was lying on her back, her right eye was swelling, and bottom lip had a little blood on it. The Report documented Immediate action taken were ROM WNL, no signs of pain, neuro checks initiated. No new immediate interventions were put into place. In the note section of the incident report, it documents on 12/27/22, IDT team reviewed the incident. Resident was confused and disoriented at the time of incident. Resident thought she was fighting someone and attempted to get out of bed. Urinalysis (UA) completed, and side table removed from next to bed. Medication review requested from MD (Medical Doctor). The care plan documents that on 12/27/22 it was updated with the new intervention. On 03/06/22 at 10:30 AM, R40's Electronic Medical Record (EMR) does not have any documentation from the doctor that he reviewed R40's medications. On 03/06/23 at 12:05 PM, V2, Director of Nursing (DON) stated there was no doctor note made on R40. She said the doctor did review her medications, and the only thing he did was order a UA to be done. On 03/06/23 at 09:43 AM, V26, Licensed Practical Nurse (LPN) stated R40 isn't really able to use her call light, and if she does use it, she doesn't really know what she wants when she puts it on. On 03/06/23 at 09:45 AM, V19, LPN stated R40 is pretty confused, and she usually doesn't use her call light. On 03/06/23 at 09:50 AM, V22, Certified Nursing Assistant (CNA) stated R40 will drop her call light a lot. She said she will use her call light but doesn't know what she wants when she uses it. V22 stated R40 doesn't really know what the call light is for. On 03/06/23 at 11:50 AM, V20, MDS Coordinator stated if someone is severely cognitively impaired, they will usually put in the basic interventions for them such as clutter free room, keep things close to them, and call light within reach, because even if they are cognitively impaired maybe they will have a good day and use it. On 03/06/23 at 12:20 PM, V20 stated R40 has a bowel and bladder task that should be done every shift. V20 stated the toileting task is for how much assistance she needs. V20 stated the CNAs should be documenting on it every shift if she goes to the bathroom. When V20 was questioned if a toileting program is appropriate for R40, he stated it was more to make sure she had not been incontinent they could try to take her or ask her if she needs to go to the bathroom and if she is already incontinent, they could clean her up before she tries to get up out of bed. He stated it's probably not a good intervention because she (R40) doesn't really know when she has to go to the bathroom. He stated if it's not working, they should probably take it off. The facility's Care Plan policy, revision dated of 01/11/23, documents Purpose: To provide guidance to the facility in developing, implementing, and communicating the individualized plan of care of resident. Policy: Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident.

Based on interview and record review, the Facility failed to ensure the menu was followed and notify residents prior to changes being made for 1 of 1 resident (R61) reviewed for dietary menu in the sample of 41. Findings include: On 2/28/2023 at 10:00 AM, R61 stated, Once in a while they change what is being served and we would like to know ahead of time. On 3/6/2023 at 11:55 AM, V16 Dietary Manager stated, I would expect for the menu to be followed but sometimes I have to tweak the menu. The Facility's Resident Council Meeting Minutes dated 12/2/2022 documents, Concerns regarding when meals change. Would like to be notified in advance. Facility's Grievance Summaries dated 2/6/2023 documents, Residents want to be informed when the meal is changed before it is served. It continues to document Summary of Findings: Sometimes food won't be on the order when sent. It continues, Will start notifying residents sooner than serving time if the menu item isn't available. The Facility's Resident Council Meeting Minutes dated 2/6/2023 documents, Old business: Concerns regarding not being informed when meals change. It further documents, New business: Everyday substitute items on the menu are not always available.

Based on interview and record review, the Facility failed to ensure food was served at palatable temperatures for two of two residents (R7 and R22) reviewed for palatable food temperatures in the sample of 41. Findings include: On 2/28/2023 at 10:00 AM, R22 stated she eats in her room and the food is cold when it comes, and it is late sometimes. R7 stated, They heat tomato soup in the microwave. The bowl gets hot, but the soup doesn't. They should put it in a pot on the stove. It's freezing ice cold. I hate being a pain, but I can't eat soup cold. The Facility's Resident Council Meeting Minutes dated 12/2/2022 documents, Concerns with brownie temperature on 11/1/2022. It continues, Residents would prefer cottage cheese not be kept in the hot cart. The Facility's Resident Council Meeting Minutes dated 1/4/2023 documents, Old Business: Residents stated most were resolved except the coldness of food in hall cart. The Facility's Resident Council Meeting Minutes dated 2/6/2023 documents, Old business: Concerns regarding temperature of food on the hall carts. On 3/6/2023 at 12:05 PM, V16, Dietary Manager, stated, We did have an ongoing problem. We have hot carts that have to be plugged in to keep hot. We have more carts now. Our carts are not geared for the type of service we do.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R34's admission Record, dated 3/1/23, documents that R34 was admitted to the facility on [DATE]. R34's Electronic Medical Record documents that R34's diagnoses include Hemiplegia, COVID-19, Cerebral Aneurysm, Osteoarthritis, HTN (Hypertension), Major Depressive Disorder, Dysphagia, Orthopnea. R34's Care Plan, dated 11/18/22, documents (R34) At risk for falls and injuries related to Medications: Psychotropic Meds/ Diuretic Meds/ Cardiovascular Meds/ Pain Meds/ Other Medications. Medical Factors: Interventions: 11/18/21 Toileting program added. 11/25/21: Therapy to screen for wheelchair positioning. 2/20/23 Bolster cover to bed to assist with defining bed parameters. 2/24/22 Staff to supply body pillow to assist with positioning for comfort. Encourage use of call light. Fall 12/6/22: Bariatric bed to provide resident with more space in bed. Keep call light within reach. Keep environment clutter free. Keep personal belongings within reach. Low bed. Mat at bedside when in bed. Provide adequate lighting. Resident known to lay in incorrect positions in the bed. R34's MDS, dated [DATE], documents that R34 has a moderate cognitive impairment with a BIMS (Basic Interview for Mental Status) of 7. R34 MDS documents R34 requires extensive assistance from two staff members for all of her Activities of Daily Living and is always incontinent of both bowel and bladder. R34's Progress Note, dated 2/19/23, documents Resident yelling out with pain to left upper leg and left hip due to normal leg contractures. Unable to do neuro check to lower extremities. Resident yells out in pain when writer touched her upper leg and hip area no distention noted to hip or upper leg area. Resident states 'I rolled over and rolled out of bed onto floor.' Neuro-check completed to upper extremities WNL (within normal limits) to upper extremities. Resident states 'I didn't hit my head.' No c/o (complaint of) back pain or neck pain resident transferred to (local hospital) for evaluation due to severe pain to left upper leg and hip area. R34's Progress Note, dated 2/20/23 at 00:42 AM, documents Returned to facility from (local hospital) per ambulance no factures per (local hospital) ER (emergency room) per report from (local hospital) ER resident given Fentanyl 50 MCG (microgram) per IV (intravenous) in ambulance when enroute to (local hospital) ER Morphine 4 MG (milligram) per IV given at 11:17 PM in ER and Norco 5-325 MG given PO (orally) before being transferred back to facility and Lidocaine patch to hip area POA (Power of Attorney) was at (local hospital) ER and is aware of results and treatment of pain meds, resident Orientated X 2 able to make needs known skin warm and dry color WNL (within normal limit) states only her left leg only hurts a little now, denies back neck or headache, neuro check WNL, bed in low position, mat next to bed, call light in reach, reminded resident to use call light if she needs to turn, not to roll by herself, staff needs to assist her, she said she understands. On 2/27/23 at 9:15 AM, R34 was sitting in wheelchair watching TV, (full body mechanical lift device) sling under her, a fall mat sitting on the floor by the side of her bed. R34 had mattress with bolsters. On 2/28/23 at 8:46 AM, R34 was brought back to her room from dining room, sitting in wheelchair with a pair of regular fuzzy socks on and did not have the non-slip socks on. A fall mat was on the floor by the side of her bed. R34 was sitting at foot of her bed with her call light tied to her bed rail by the head of her bed and was not reachable. On 3/1/23 at 8:38 AM, R34 sitting in her wheelchair with her tray table and drink sitting next to her. R34 now has non-skid socks on, call light sitting in her lap, fall mat on the floor. R34's wheelchair was half on and half off the mat, causing her wheelchair to tilt. On 3/2/23 at 10:52 AM, V24, Registered Nurse (RN), stated (R34) usually sits in her wheelchair towards the foot of her bed to watch her television. We usually stretch the call light over to her chair. Her fall mat should be folded up if she is out of bed to keep it from being a hazard. If she is out of bed, she should have the non-slip socks on and not fuzzy socks. On 3/2/23 at 12:55 PM, V2 stated I would expect the staff to keep the resident's call light within reach at all times. 4. R56's admission Record, dated 3/1/23, documents that R56 was admitted to the facility on [DATE]. The Record documents R56's has the following diagnoses: Complete lesion of unspecified level of lumbar spinal cord, Osteomyelitis, Emphysema, Type 2 DM (Diabetes), COPD (Chronic Obstructive pulmonary disease), Malignant Neoplasm of Prostate, Dementia, Pathological Fracture in Neoplastic Disease - shaft of humerus left arm, Anxiety Disorder, Wedge fracture of lumbar vertebra, Aortic Valve Stenosis, Fracture of Sacrum, Disorder of Kidney and Ureter, HTN (hypertension), Mild Cognitive Impairment, Obstructive and reflux uropathy, Anemia, Kidney Failure. R56's Care Plan, dated 2/14/23, documents (R56's) Care Plan, dated 2/14/23, documents (R56) is at risk for falls and injuries related to Medications: Pain Meds. Medical Factors: Compression fractures, impaired mobility, weakness. Interventions: 1/27/22 Provide adequate lighting, keep personal belongings within reach, keep environment clutter free, keep call light within reach, Encourage use of call light, 8/2/22 Bed and Chair alarm. 8/3/22 Offer toileting in the morning upon waking, before and after meals, and at bedtime, assess toileting needs. 11/9/22 Hospice to provide bolsters and low bed. 11/10/22 Low Bed. 1/27/23 Dycem in the bed. R56's MDS, dated [DATE], R56 has a severe cognitive impairment with a BIMS of 4. R56 MDS documents R56 requires extensive assistance from two staff members for most of his ADL's. R56's MDS documents R56 requires extensive assistance from one staff member for bathing and personal hygiene and has urinary catheter and is frequently incontinent of bowel. R56's Fall Risk Assessment, dated 1/27/22, documents that R56 is a low fall risk with a score of 2. A score of 10 or higher indicates that the resident is at risk for falls. R56's Fall Risk Assessment, dated 7/13/22, documents that R56 is a High Fall Risk with a score of 13. A score of 10 or higher indicates that the resident is at risk for falls. R56's Progress Note, dated 11/9/22 at 2:56 PM, documents Resident slid out of bed trying to roll over. Resident complaining of some side pain. Called hospice and requested x-rays and bolsters, and a bed for resident. They are sending out a nurse to evaluate him. R56's Physician order, dated 12/28/22, documents Chair/Bed alarm. Monitor for proper functioning. R56's Progress Note, dated 1/26/23 at 7:23 AM, documents Writer called to resident's bedside by resident's roommate where he was noted to be lying on the floor next to his bed without his alarm sounding. Skin tear noted to left elbow. Alarm not sounding as it was not turned on. Resident was assessed and then assisted back into bed by staff. Physician and POA notified of the incident. Hospice CNA and nurse notified as well. On 2/27/23 at 9:50 AM, R56 was lying in bed with his call light hanging on rail and down to the floor. R56's bed/chair alarm hanging on rail but not clipped to R56 as the alarm box was secured to bedrail with the cord hanging on floor. R56 had a fall mat on the floor side of bed, a Call-Don't Fall sign on the wall, and bolsters on his mattress. On 2/28/23 at 9:17 AM, R56 was lying in bed with the bed in lowest position, a fall mat lying on the floor on the side of his bed, a Call-Don't Fall sign on the wall, the call light hanging on his bedrail dangling to the floor, and his bed alarm was attached to R56's shirt and secured to the bedrail. On 3/1/23 at 8:50 AM, R56 was sitting up in his bed with his tray table over the bed while he was eating breakfast. R56's call light was seen hanging over bedrail and down to the floor. R56's bed alarm was attached to a bedrail with the cord hanging to the floor and not to R56. R56's fall mat was folded and sitting by the head of his bed. On 3/2/23 at 10:45 AM, R56 was lying in bed with his call light hanging off his bedrail and to the floor. R56's bed alarm was attached to the bedrail with the cord hanging to the floor and not attached to R56. On 3/2/23 at 10:55 AM, V24, RN, stated (R56) should always have his tag alarm attached to him at all times, in his bed and in his chair. On 3/2/23 at 12:55 PM, V2, DON, stated I would expect the staff to keep the resident's call light within reach at all times. If a resident has a bed or chair alarm, I would expect the staff to keep that alarm attached to the resident for their safety. I would expect the nurses providing wound care to maintain cleanliness, hand hygiene, and appropriate procedures for wound care. The Facility's Fall Prevention Program/Protocol Policy, dated 2/1/23, documents Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. It continues 1. The interdisciplinary will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk (based on the falls assessment results) or with a history of falls. 5. If falling recurs despite initial interventions, staff will implement additional or different interventions, discontinue ineffective interventions or indicate why the current approach remains relevant. 6. If underlying causes cannot be readily identified or corrected, the team will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. The resident and/or responsibility, the physician and therapy department may be involved in the process for a holistic evaluation. 7. The team shall identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. 8. Position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner. It continues Early prevention and fall risk detection: 3. Rounds shall be completed at least daily to ensure fall interventions remain in place. 4. Resident's individualized fall interventions shall be accessible to all staff for quick review. Monitoring subsequent falls and fall risk: 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 4. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. 5. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. The Facility's Fall Prevention Program/Protocol dated 2/1/23, documents Fall Risk Factors: 1. Environmental factors that may contribute to the risk of falls include: f. Footwear that is unsafe or absent. 2. Resident condition s that may contribute to the risk of falls include: c. Delirium and other cognitive impairment, e. Lower extremity weakness, f. Poor grip strength, g. Medication side effects, i. Functional impairments, k. Incontinence. 3. Medical factors that may contribute to the risk of falls include: a. Arthritis, d. Neurological disorders, e. Balance and gait disorders. 5. R274's admission Record, dated 3/1/23, documents that R274 was admitted to the facility on [DATE]. R274's Electronic Medical Record, documents that R274's diagnoses include Respiratory Failure, Dementia, Cardiac Murmur, Alzheimer's Disease, and Aortic valve stenosis. R274's Baseline Care Plan, dated 2/23/23, documents (R274) is at risk for falls and injuries related to Medications: Psychotropic Meds/ Diuretic Meds/ Cardiovascular Meds/ Pain Meds/ Other Medications. Interventions: There are no interventions placed in R274's Care Plan for falls and there was nothing in R274's Care Plan about her Elopement Risk. R274's MDS, has not been completed yet. R274's Fall Risk Assessment, dated 2/23/23, documents that R274 is a low fall risk with a score of 6.0. A score of 10 or higher indicates the resident is at risk. R274's Elopement Risk Assessment, dated 2/23/23, documents that R274 is a High Elopement Risk with a score of 10. A score of 10+ means a Resident is considered at High risk for elopement. Document IDT's determination if ankle alarm bracelet (elopement risk) or other intervention is appropriate and update care plan as necessary. If IDT determines ankle alarm bracelet is appropriate, complete Physical Restraint Assessment and obtain consent. If facility does not have an ankle alarm bracelet system, place on 1:1 monitoring. Document contact with responsible party to discuss options for placement in a secure unit or other appropriate facility. On 2/27/23 at 9:12 AM, R274 was seen sitting on the side of her low bed with the side rails up X 2. R274 had an ankle alarm bracelet on her right lower leg and regular socks on and did not have non-slip socks on. On 2/27/23 at 10:45 AM, R274 was seen ambulating in/out of other resident's rooms. Staff assisted her to the dining room to sit at a table. On 2/28/23 at 9:12 AM, R274 was seen wandering in/out of several residents' rooms. Staff noticed her and assisted her to the dining room for activities. On 3/1/23 at 8:55 AM, R274 was sitting in a chair by the front nurse's desk holding a stuffed animal and mumbling incoherently. R274 had an alarm bracelet on her right ankle. On 3/2/23 at 10:50 AM, V24, RN (Registered Nurse), stated (R274) has tried a few times that I know of, to get out the front doors. She wears the ankle bracelet that goes off when she tries to get out. I guess we are just keeping a close eye out on her, keeping her close to the nurse's desk, and taking her to activities. It should be in her Care Plan. I see that there is nothing in the Care Plan about her elopement. The Facility's Wandering/Elopement Policy, dated 10/18/22, documents The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. 1. If identified is at risk for wandering or elopement; the resident's care plan will include strategies and interventions that shall in implemented to maintain the resident's safety, including but not limited to, electronic monitoring device, room placement, frequent checks, etc. 2. R40's admission Record, dated 03/02/23, documents she has diagnoses of Unspecified Dementia, Unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and osteoarthritis. R40's MDS, dated [DATE], documents R40 is severely cognitively impaired and requires extensive assistance, 2 plus person physical assist with bed mobility, transfer, toileting, and personal hygiene. R40's MDS documents R40 is always incontinent of bowel and bladder. It also documents R40 is not steady on her feet and unable to stabilize without assistance from staff. R40's Care Plan, with an admission date of 03/07/22, documents R40 is at risk for falls and injuries related to (r/t) Medications: Psychotropic Medications (Meds)/Cardiovascular Meds. Medical Factors: Depression, anxiety, osteoarthritis, and dementia. R40's Incident Report, dated 09/19/22 at 11:53 PM, was reviewed and documents R40 had an unwitnessed fall in her room. The Incident Report documents R40 was found by staff sitting upright with her back against the bed and legs outstretched in front of her on the floor mat. It further documents R40 doesn't know what happened. The Report documented Immediate action taken was a skin assessment, pain assessment, Power of Attorney (POA) called, Primary Care Physician (PCP) notified. There was no documentation that new immediate interventions were put into place to ensure that R40 did not fall again. A new intervention was not put into place on the care plan until 09/20/22 which was therapy to assess for strengthening. R40's Incident Report, dated 11/01/22 at 3:15 AM, was reviewed and documents R40 had a witnessed fall in her room. R40's Report documents a Certified Nurse's Assistant (CNA) was restocking the cart and witnessed R40 sliding out of bed (OOB) and on to the floor mat. The Report documented Immediate action taken was Vital Signs (VS) obtained, resident assessed for injury, resident assisted back to bed. No new immediate interventions were put into place at the time of the fall. It documents in the notes section, on 11/01/22 IDT (Interdisciplinary Team) reviewed incident. It documents Resident was in bed and CNA was in hallway and observed resident slid out of bed before she could get to her. Continue with all fall interventions. Added scoop mattress to bed to assist with defining bed parameters. Care plan documents it was updated on 11/01/22 but there was no time noted. R40's Incident Report, dated 11/23/22 at 6:45 PM, was reviewed and documents R40 had an unwitnessed fall in her room. The Report documented R40 was found by the CNA sitting on her buttocks beside her bed. The Report documented Immediate action taken was vital signs (vs) obtained, resident assessed for injury, assisted back to bed, Range of Motion (ROM) Within Normal Limits (WNL), and denies pain. No new immediate interventions were put into place to ensure that R40 did not fall again. The notes section of the incident report document on 11/25/22 intervention put into place is toileting program at night due to incontinence at time of fall. The care plan documents no new intervention was put into place until 11/25/22. R40's Incident Report, dated 12/25/22 at 12:26 AM, was reviewed and documents R40 had an unwitnessed fall in her room. The Report documented a CNA found R40 with her upper body by the nightstand and R40 was yelling for help. The Report documented when the nurse entered the room R40 was lying on her back, her right eye was swelling, and bottom lip had a little blood on it. The Report documented Immediate action taken documents ROM WNL, no signs of pain, neuro checks initiated. No new immediate interventions were put into place. In the note section of the incident report, it documents on 12/27/22, IDT team reviewed the incident. Resident was confused and disoriented at the time of incident. Resident thought she was fighting someone and attempted to get out of bed. Urinalysis (UA) completed, and side table removed from next to bed. Medication review requested from MD (Medical Doctor). The care plan documents that on 12/27/22 it was updated with the new intervention. On 03/06/23 at 11:50 AM, V20, Minimum Data Set (MDS) coordinator stated the nurse should put an immediate intervention into place when someone has a fall, they are supposed to do something right away.Based on observation, interview and record review, the Facility failed to implement progressive interventions to prevent falls and elopement for 5 of 8 residents (R33, R34, R56, R40, R274) reviewed for supervision to prevent accidents in the sample of 41. Findings include: 1.R33's Minimum Data Set (MDS) dated [DATE] documents R33 requires supervision of one staff member and one-person physical assistance for walking in her room. R33's Care Plan, initiated 4/5/22, documents R33 is at risk for falls and injury due to medications, arthritis, weakness, and hospice/end of life care. The Facility's Incidents by Type Log dated 2/27/2023 documents R33 had two falls on 10/21/2023. The Facility's untitled document dated 10/21/2022 at 3:15 (AM) documents R33 had an unwitnessed fall in her room. It documents, Heard a noise and went into resident room. Resident was on the floor laying on left side with feet towards the door. Reports hitting head off metal bed frame. It further documents R33 stated, I was trying to go to the bathroom. It continues, Immediate Action Taken: Full head to toe assessment completed. ROM (Range of Motion) WNL (within normal limits). Resident does have a goose egg on the back left side of head. Ice pack applied and vital (signs) obtained. Denies any other injuries or pain. Injuries Observed at Time of Incident: Hematoma: back of head. Level of consciousness: Lethargic (Drowsy) Mobility: Ambulatory with assistance. It continues to document, 10/21/2023- IDT (Inter Disciplinary Team) reviewed incident. Resident was in bed and attempted to self-transfer to WC (Wheelchair) to go to bathroom. Call light was not activated. Resident states her leg gave out on her when transferring. Nonskid strips next to bed. Encourage bed in lowest position. Transfer changed to assist x (times) 1 from independent. R33's Progress Notes dated 10/21/2022 at 1:19 PM documents, Physician's office to request x-ray, got orders to right foot and hip. R33's Progress Notes dated 10/21/2022 at 1:45 PM documents, Called (hospice) to request a floor mat and an alarm. Inform(ed) them of bruising and pain in foot and x-rays are ordered. R33's Progress Note dated 10/21/2022 at 2:16 PM documents, Mistaken Entry- Nurse returned called and stated that alarm and mat are ordered, and alarm will be here on Tuesday since they are waiting for them to be delivered. R33's Progress Notes dated 10/21/2022 at 2:18 PM documents, Hospice nurse returned call and stated that they will get floor mat and alarms ordered for resident. Informed them of fall and x-ray as well. R33's Progress Notes dated 10/21/2022 at 3:43 PM documents, Resident continues hospice care. Resident has declined and has increased confusion. Resident is now an assist of 1 instead of independent. Resident fell last night. Monitoring her for that. Resident complaining of pain in foot awaiting x-rays. Vitals remain within normal limits. Will continue to monitor. The Facility's untitled document dated 10/21/2023 at 16:49 (4:49 PM) documents R33 had another unwitnessed fall. It documents, Writer called into room by (nurse) who found resident lying on floor. When writer approached resident was confused and stated that foot and hip hurt. Writer found resident laying on L (left) side with head towards bed and feet towards the bathroom. Resident has co (complaints of) pain to R (Right) foot and R hip from previous fall. Resident also has a hematoma to back of head from previous fall. Resident toileted by (nurse) and writer approximately hour prior. ROM to all extremities except R foot. Resident is able to move ankle. Immediate Action Taken: Pain/Skin assessment, VS (vital signs). Resident had grip sock on bilateral feet. Strips are in place at bedside and bed is in low position. Pressure alarm in place and in working condition. Notes: Resident has a pain of 7 (on a 1-10 scale, 10 being excruciating) due to previous fall injuries to foot, right hip and hematoma to back of head. No new injuries at this time. It continues to document, 10/24/2022 IDT reviewed incident. Resident noted to attempt to get out of bed per self. Call light not activated. Resident alert and able to voice needs. General decline due to Dx (diagnosis). Currently on hospice care. Continue with low bed. Strips at bedside. Continue assist for transfers and toileting. Alarm placed after fall. R33's Progress Notes dated 10/22/2022 at 22:09 (10:09 PM) documents, Resident continues with hospice and has had a recent decline in condition. Resident is unable to self-ambulate, requires assist of 2. Resident requires assistance completing all ADLS (Activities of Daily Living). Resident receives scheduled morphine effective for pain management. Post fall observation continues. (Portal x-ray) present this evening to obtain x-ray of right foot and right hip. Results have been returned showing right metatarsal fracture. On 3/01/23 at 11:28 AM, V20, Minimum Data Set (MDS) Coordinator stated, We go over falls in our morning meetings and come up with an intervention. There should be an immediate invention, like offering to take her to the bathroom every 2 hours. On 2/28/2023 at 9:45 AM, R33 was observed in her room, ambulating from the bathroom to her bed independently. There was no alarm sounding. On 3/1/2023 at 10:06 AM, V2, Director of Nursing (DON) stated, One of her (R33's) falls was early morning. She was trying to go to bathroom and had been independent prior. She still thinks she's capable and she is very anxious. We changed her to assist of one. That was the one (fall) where she had the hematoma. Neither falls were witnessed. (R33) is one who just tends to do what she wants. Later that evening she was found sitting on the floor next to bed. She said she didn't remember what she was doing. We continued with the prior interventions and assist with transfers. The nurse placed an alarm on her then. She is currently still a one assist and does have the alarm. On 3/1/2023 at 10:57 AM, V26, Licensed Practical Nurse (LPN) stated, (R33) gets up by herself. She transfers to the wheelchair to go potty (by herself). She doesn't need help. On 3/1/2023 at 11:00 AM, V14, Certified Nursing Assistant (CNA) stated, (R33) ambulates independently but not too far, mostly from wheelchair to bed or to the bathroom. She has an alarm so if we hear it, we go down there. On 3/01/23 at 1:41 PM V2 stated, They made her (R33) a one assist. That is no different than a resident who is confused. We still have to check on them every 2 hours. Staff knew she was a one person assist. She just gets up without assist. She is still supposed to be a one assist. Residents can still fall even when they are one assist. She was found sitting next to the bed.

Based on observation, interview, and record review, the facility failed to perform hand hygiene and don/doff gloves appropriately for 5 of 5 residents (R9, R20, R36, R45, R56) reviewed for infection control in the sample of 41. Findings include: 1. On 2/28/23 at 8:55 AM, V4, Licensed Practical Nurse (LPN), passed medications to R36. V4 did not perform hand hygiene before or after the medication pass and hand hygiene was not done in between residents. 2. On 2/28/23 at 9:07 AM, V4, LPN, passed medications to R20. V4 did not perform hand hygiene before or after the medication pass and hand hygiene was not done in between residents. 3. On 2/28/23 at 10:49 AM, V8, Certified Nurse Assistant (CNA), and V10, CNA, performed Peri Care for R9. V8 used a washcloth with a no-rinse foam cleanser on the cloth to cleanse R9's front peri area. R9 was turned over to her right side. V8 used the same gloves and a new cloth with foam cleanser to cleanse R9's buttocks and rear peri area. V8 used the same pair of gloves and obtained a clean incontinence brief and placed it under R9. V8 doffed her gloves, tied trash bag with soiled linen, then washed her hands. The Facility's Incontinence Care Policy, dated 5/16/23, documents 5. Wash hands, apply gloves. 4. On 02/28/2023 at 1:18 PM, V13, Wound Care Nurse, and V3, Assistant Director of Nurses (ADON), provided wound care to R56's coccyx wound. V13 performed hand hygiene in the hallway in front of the resident's doorway. V13 placed both hands in her pockets of her scrub jacket, then into the treatment cart to retrieve supplies (hand towel in the right hand, gauze, scissors in the left hand). V13 entered the room. V3 sanitized the overbed table with a sanitary wipe, however, she had not cleaned the entire table (in the middle of the table was a rounded dry spot). V13 placed the hand towel on the overbed table along with the gauze and scissors. The table was still wet when V13 placed the hand towel and supplies on the table. (Same supplies that were held by both contaminated hands). Using her bare contaminated hands, V13 opened the Calcium Alginate and the 4X4 dressing packaging and left them lying on towel. V13 washed her hands in the sink, donned gloves and removed the old dressing. V13 proceeded to cleanse the wound area with the cleansing spray. V13 doffed gloves, hand sanitizer used, donned clean gloves, sprayed wound cleanser on a 4X4. V13 then dabbed the middle of the wound with the cleansed gauze, dabbed the outer area from the middle, and then did not rotate the gauze completely as to not re-wipe the cleansed area of the wound with the contaminated part of the gauze. V13 doffed gloves, hand sanitizer used, donned clean gloves, held the sterile Calcium Alginate dressing outside the package used a pair of scissors that were taken out of procedure cart to cut the Calcium Alginate with Silver and then placed that piece in the bed of the wound, the Calcium Alginate sheet did not fill the entire wound bed. A dry gauze was then placed over the wound. V13 did not clean the scissors prior to or after the wound care treatment. The Facility's undated Dressings, Dry/Clean Policy/Procedure documents, Steps in the procedure: 1. Establish a clean field. 2. Place the clean equipment on the clean field. Arrange the supplies so they can be easily reached. It continues, 5. Perform hand hygiene. 6. Put on clean gloves. Loosen tape and remove soiled dressing. 7. Pull glove over dressing and discard into plastic or biohazard bag. 8. Perform hand hygiene. 9. Open dressing equipment using clean technique. 10. Label tape or dressing with date, time and initials. Place on clean field. 11. Perform hand hygiene. 13. Put on clean gloves. It continues, 15. Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually, from the center outward). It continues, 19. Remove disposable gloves and discard into designated container. 20. Perform hand hygiene. 5. On 02/28/2023 at 12:10 PM, V4, LPN, without benefit of hand hygiene, got Humalog insulin out of the drawer for R45. V4 did not cleanse the top of the Humalog vial prior to drawing up 2 units for R45. She then entered R45's room, without benefit of hand hygiene nor did she don gloves, administered the insulin to R45's abdominal area. On 3/2/23 at 12:52 PM, V2, DON, stated, I would expect the nurses to perform hand hygiene before medication administration, after medication administration, and in between residents receiving medications. The facility's policy, Handwashing/Hand Hygiene, undated, documented, 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: It continues, B. Before and after direct contact with residents; C. before preparing or handling medications; D. Before performing any non-surgical invasive procedures. It continues, G. Before handling clean or soiled dressing, gauze pads, etc.; H. Before moving from a contaminated body site to a clean body site during resident care; I. After contact with blood or bodily fluids; J. After handling used dressings, contaminated equipment, etc., K. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; L. After removing gloves. It continues, 9. Single-use disposable gloves should be used: a. Before aseptic procedures; b. When anticipating contact with blood or body fluids;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the Facility failed to ensure that proper Nurse skills were provided according to standard of practice related to wound care. This has the potential to affect all 75 residents in the facility. Findings include: R56's admission Record, dated 3/1/23, documents that R56 was admitted to the facility on [DATE]. R56's Diagnosis: Complete lesion of unspecified level of lumbar spinal cord, Osteomyelitis, Emphysema, Type 2 DM (Diabetes Mellitus), COPD (Chronic Obstructive Pulmonary Disease), Malignant Neoplasm of Prostate, Dementia, Pathological Fracture in Neoplastic Disease - shaft of humerus left arm, Anxiety Disorder, Wedge fracture of lumbar vertebra, Aortic Valve Stenosis, Fracture of Sacrum, Disorder of Kidney and Ureter, HTN (Hypertension), Mild Cognitive Impairment, Obstructive and reflux uropathy, Anemia, Kidney Failure. R56's Care Plan, dated 2/14/23, documents (R56) has an Actual Pressure Ulcer; Site(s): coccyx. Requires assist with turning and repositioning, two assist, Acquired, Poor Nutritional status. Interventions: 9/20/22 Treatment Ordered: See current treatment order in EHR (electronic health record) orders, Monitor for pain indicators, Pain medication prior to wound care if indicated, Check dressing placement q shift, Monitor for s/s (signs/symptoms) of infection daily-increased warmth of surrounding tissue, redness, swelling, pain, purulent drainage, foul odor. Notify MD (Medical Doctor) if identified, Assess pressure ulcer weekly by licensed nurse, Notify MD as needed if ulcer fails to shows progress in healing, Provide off loading of ulcer site, Monitor incontinence and provide peri-care after each incontinent episode, Medications as ordered, Shower 2x/week, Encourage PO (oral) meal intake, Encourage fluid intake, Diet as ordered, Encourage (R56) to reposition as able, Repositioning every two hours and PRN (as needed), Provide pressure redistribution therapeutic device as ordered, Low Air Loss Mattress. 10/13/22 Supplement. R56's Minimum Data Set (MDS), dated [DATE], R56 has a severe cognitive impairment with a BIMS (Brief Interview for Mental Status) of 4. R56 requires extensive assistance from two staff members for most of his ADL's (Activities of Daily Living). R56 requires extensive assistance from one staff member for bathing and personal hygiene. R56 has urinary catheter and is frequently incontinent of bowel. On 2/28/23 at 9:17 AM, R56 stated I have had a sore on my butt for a long time. It flares up from time to time and they put some medicine and bandages on it. I turn myself while I'm in bed whenever I need to. R56's Physician Order, dated 1/6/23, documents Sacrum: cleanse area with wound cleanser. Apply calcium alginate with silver to wound bed. Monitor for s/s of infection. Every shift for treatment and as needed for soiled. R56's Physician Order, dated 12/8/22, documents Low air loss mattress. R56's Physician Order, dated 12/5/22, documents Morphine Sulfate (Concentrate) Solution 20 MG (milligram)/ML (milliliter). Give 0.5 ML by mouth every four hours as needed for pain. R56's Physician Order, dated 8/1/22, documents Hydrocodone-Acetaminophen Tablet 5-325 MG. Give 1 tablet by mouth every six hours as needed for mild to moderate pain. R56's Wound Physician Note, dated 2/24/23, documents Wound Sacrum, Stage 4, at least 125 days duration, Moderate Serous Exudate. Wound size 3 CM (centimeters) X1.7 CM X1.8 CM with surface area 5.10 CM, Undermining 0.5 CM at 5 O'clock, 100% granulation, Wound progress improved. 2/28/23 at 1:18 PM, V13, Wound Nurse, and V3, ADON (Assistant Director of Nurses), in R56's room to provide wound care to R56's coccyx wound. V13 did hand hygiene, then walked to the door, where wound supply cart was located, put her clean hands in her pocket and pulled out her keys, then opened the cart and gathered supplies. V13 came back into the room and had V3 wipe off the bedside table with a wet wipe, while V13 held the dressings, Derma Cleanse wound cleanser, and a clean towel in her now contaminated hands. Before letting the table dry, V13 spread the towel over the bedside table and laid the supplies on top of it. Using her bare contaminated hands, V13 opened the Calcium Alginate and the 4X4 dressing packaging and left them lying on towel. V13 then stated she needed to wash her hands and went into restroom and washed her hands. V13 donned gloves as V3 rolled R56 to his left side with R56 moaning of pain and stated, Be careful while moving me, that hurts. V13 removed an old dressing dated 2/28/23 which had slight amount of oozing noted. R56 has a large open wound which appears to have a center hole. V13 doffed gloves, hand sanitizer used, donned clean gloves, sprayed wound cleanser on a 4X4 and gently patted wound by first touching the center of the wound and then patting a few times around the wound. V13 doffed gloves, hand sanitizer used, donned clean gloves, held the sterile Calcium Alginate dressing outside the package used a pair of scissors that were taken out of procedure cart and was not seen cleaned, to cut the Calcium Alginate and then placed that piece onto the open wound and was not packed inside the wound. V13 doffed gloves, used hand sanitizer, donned clean gloves, and then placed an occlusive dressing over the wound site. V13 did not date/time/initial the dressing before V3 attached R56's incontinence brief and rolled him back over. Neither nurse asked R56 if he needed pain medication prior to the dressing change. R56's MAR and progress notes do not show any pain medication administered to R56 up to this procedure time. On 3/2/23 at 10:55 AM, V24, RN, stated (R56) does turn and position himself when he needs to. He can actually get himself up to his chair if he wants to. I have change (R56's) dressing before and I don't recall him complaining of any pain during the procedure. He will occasionally complain of pain and can get pain medication, but he really doesn't complain much. On 3/2/23 at 1:00 PM, V2, DON, stated I would expect the nurses providing wound care to maintain cleanliness, hand hygiene, and appropriate procedures for wound care. I would expect the staff to perform hand hygiene before, during, and after resident care. I would expect the staff to change gloves when going from dirty to clean areas during resident care. The Facility's Dressings, Dry/Clean Policy/Procedure, undated, documents Steps in the procedure: 1. Establish a clean field. 2. Place the clean equipment on the clean field. Arrange the supplies so they can be easily reached. It continues, 5. Perform hand hygiene. 6 Put on clean gloves. Loosen tape and remove soiled dressing. 7. Pull glove over dressing and discard into plastic or biohazard bag. 8. Perform hand hygiene. 9. Open dressing equipment using clean technique. 10. Label tape or dressing with date, time and initials. Place on clean field. 11. Perform hand hygiene. It also documents, 13. Put on clean gloves. 14. Assess the wound and surrounding skin for edema, redness, drainage, tissue healing progress and wound. 15. Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually, from the center outward). 16. Use dry gauze to pat the wound dry. 17. Apply the ordered dressing and secure with tape or bordered dressing per order. Label with date and initials to top of dressing. It further documents, 19. Remove disposable gloves and discard into designated container. 20. Perform hand hygiene. Documentation: The following information should be recorded in the resident's medical record, treatment sheet or designated wound form. 1. The date and time the dressing was changed. 2. The name and title (or initials) of the individual changing the dressing. 3. The type of dressing used, and wound care given. 4. Any problems or complaints (e.g., pain or discomfort) made by the resident related to the procedure. The Resident Census and Conditions of residents, CMS 672, dated 2/27/2023 documents that the facility has 75 residents living in the facility.

Based on observation, interview and record review, the Facility failed to ensure food items are stored in a manner that prevents food borne illness and potential contamination. This has the potential to affect all 75 residents in the facility. Findings include: 1. On 2/27/2023 at 9:37 AM, V16, Dietary Manager, stated, Excuse the mess. At this time, there was a large pan covered with aluminum foil. There was no label or date on the pan or foil. V16 stated, That's the cake I told her to label. Did she? Nope. I was using it for snacks. There was also a plastic bag of salad. It was open, not entirely sealed, only wrapped partially with saran wrap. The salad inside the bag was wilted and some pieces were brown. There was no date to indicate when the bag was opened. The bag had an expiration date of 2/25/2023. There was also a clear container, unlabeled and undated, with a yellow fluffy substance in it. V16 stated they were eggs from the previous day. There were 3 bags of peas in the refrigerator that were thawed and sweating. On the bag it was printed Keep frozen until ready to use. On 2/27/2023, V16 verified it was Day 23-Week 4 on the Week at a Glance menu. On 3/2/2023 at 10:20 AM, an unknown staff member was telling residents peas were being served for dinner. On 3/4/2023 at 12:05 PM, V16 stated she would expect all items in the refrigerator to be labeled and dated when opened. V16 also stated pea salad was served for Residents Choice supper on Day 26 (Three days after 3 bags of frozen peas were observed thawing in the refrigerator). The Resident Census and Conditions of Residents, CMS 672, dated 2/27/2023 documents that the facility has 75 residents living in the facility.

Based on interview and record review, the facility failed to identify falls as a facility issue for their Quality Assurance Performance Improvement (QAPI) program. This failure has the potential to affect all 75 residents living in the facility. Findings include: On 03/02/2023 at 10:28 AM, V2, Director of Nurses (DON), stated that Quality Assurance was working on Wounds. She continued to state that everyone on the committee is invited and if they are unable to attend in person they can call in or if they can't make it, they are given the report. Sometimes they have an extra meeting like for wounds this past month. 03/02/23 10:36 AM, V1, Administrator, stated they meet quarterly and go over all grievances and facility issues. The facility's QAPI Program Meeting Verification, dated 01/11/2023, does not document any issues with fall prevention or management. The facility's Quality Assurance Performance Improvement (QAPI) Charter, dated 02/15/2023, documented, Quality Issues Identified: Increase in acquired pressure ulcers. It did not document any issues with falls. The facility's Quality Assurance and Performance Improvement (QAPI) Policy and Procedure, dated 2019, documented, C. Program activities. It continues, ii. The activities will track medical errors and adverse resident events, analyze their causes, and implement preventive action and mechanisms that include feedback and learning throughout the facility. The Resident Census and Conditions of residents, CMS 672, dated 2/27/2023 documents that the facility has 75 residents living in the facility.

Based on interview and record review, the facility failed to conduct ongoing review of antibiotic use to ensure residents are prescribed the appropriate antibiotic. This has the potential to affect all 75 residents living in the facility. Findings include: 1. The facility's Monthly Infection Control Log, dated 02/01/2023 to 02/28/2023, documented that R38 did not meet infection criteria for being placed on an antibiotic. R38's Physician's order, dated 2/9/2023 documented, Obtain UA (urinalysis) one time only for UA for 1 day. R38's Progress note, dated 02/09/2023 at 8:36 PM, documented, (V28, R38's Doctor) was here to see resident and ordered labs, UA, and a chest xray to be done. R38's Progress note, dated 02/16/2023 at 5:31 PM, documented, (Office worker from V28's office), office called after reviewing UA and started resident on Cipro (antibiotic) 500 BID (2 times a day) for 7 days. R38's Progress note, dated 02/17/2023 at 9:52 AM, documented, dr. notified that antibiotic needed to be changed for his UTI (urinary tract in, he ordered Macrobid 100mg (milligrams) bid for 7 days, order has been put in the computer and resident notified of this. 2. The facility's Monthly Infection Control Log, dated 02/01/2023 to 02/28/2023, documented that R49 did not meet infection criteria for being placed on an antibiotic. R49's Progress notes, dated 02/17/2023 at 9:12 AM, documented, resident has a (indwelling urinary catheter) and it is draining yellow colored urine, she has no issues with it at this time. R49's Progress notes, dated 02/21/2023 at 10:35 AM, documented, Resident has a (indwelling urinary catheter), it is draining dark colored urine, she is having no complaints with at this time. R49's Physician Order, dated 02/28/2023, documented, Piperacillin Sod-Tazobactam So (antibiotic) Solution Reconstituted 4-0.5 GM. Use 4.5 gram intravenously (IV) three times a day for UTI for 10 Days 3. The facility's Monthly Infection Control Log, dated 02/01/2023 to 02/28/2023, documented that R15 did not meet infection criteria to be placed on antibiotic. R15's Physicians Order, dated 02/23/2023, documented, Obtain UA with C&S (culture & sensitivity) if indicated. R15's Progress note, dated 02/23/2023 at 1:05 PM, documented, Writer approached by (R15's son) whom requests for orders to be obtained for UA with C&S if indicated, he feels she is more confused than her usual. Order obtained from nurse at (V27, Medical Director) office. R15's Progress note, dated 02/24/2023 at 10:15 AM documented, MD (physician) nurse called at 0915 with new orders on UA that was obtained and sent to (hospital), MD wants IV Ertapenem (antibiotic) 1gram daily x 10 days. Writer placed 22g (gauge) peripheral IV in posterior right hand, attempt x 1, tolerated well, flushes without difficulty. Ertapenem pulled from cubex (automated dispensing smart cabinets for medications) and IV abt (antibiotic) started. IV running without issues at this time. Call was placed to POA (power of attorney) to updated on new orders, no answer at this time, message left. 4. The facility's Monthly Infection Control Log, dated 01/01/2023 to 01/31/2023, documented that R7 did not meet infection criteria for use of antibiotics. R7's Progress note, dated 01/03/2023 at 3:30 AM, documented, .Resident voices discomfort around (Gastrostomy Tube) site related to tubing stitched close to skin. Split gauze sponge placed between skin and (Gastrostomy Tube) for comfort. Resident is permitted to eat a regular diet as tolerated. Resting comfortably in bed at this time with call light in reach. Will continue to monitor. R7's Progress note, dated 01/04/2023 at 2:46 PM, documented, . (Physician Assistant) here to see resident today and ordered wound culture of g-tube site, begin Keflex (antibiotic) 500mg QID (4 times a day) x7 days and continue to provide dressing cares to site. Culture obtained and sent to (hospital) lab for testing. First dose of po (oral) ABT administered with lunch today. R7's Physician order, dated 01/04/2023, documented, Keflex Capsule 500 MG (Cephalexin) Give 1 capsule via G-Tube four times a day for drainage from g-tube insertion site for 7 Days. R7's Physician order, dated 01/07/2023, documented, Ertapenem Sodium Injection Solution Reconstituted 1 GM (Ertapenem Sodium) Inject 1 gram intramuscularly one time a day for Infection Mix with Lidocaine. On 03/02/2023 at 02:08 PM, V2, Director of Nurses (DON), stated that R49 did not meet McGeer Criteria and that their next step would be to let the doctor know. As per the facility's Antibiotic Stewardship Protocol, dated 08/10/2022, when asked where are the policies that have been written and revised according to Action- Policies shall be written, monitored and revised as needed to improve the proper antibiotic usage within the facility V2 stated that she will have to ask. On 03/02/2023 at 2:13 PM, V2, DON stated that McGeer Criteria is used when tracking and analyzing infections for Antibiotic Therapy Stewardship and when there is a N on the Monthly Infection Control Log it means that the resident did not meet the criteria for an infection needing antibiotics. V2 continued to state that they have trouble with the doctors and the Medical Director adhering to the Antibiotic Stewardship and that the Medical Director has told her that he knows his residents best and he continues to order Urinalysis and treat with antibiotic even though the residents do not meet the criteria and that he is aware of the regulation. V2 continued to state that the Medical Director does QAPI (Quality Assurance and Performance Improvement) and review the pharmacy and lab reports related to infections and antibiotic use but does not follow the Antibiotic Stewardship program. She stated that the doctor is aware that R49 appears to be colonized for ESBL (extended-spectrum beta-lactamases) and that he still orders antibiotics for her. V2 stated that she would have to look for any documentation from the Medical Director or the Medical Doctor as to why they are not following the antibiotic stewardship program and that the only tracking document she has was the monthly infection tracking log. On 03/06/2023 at 09:05 AM, V27, Facility Medical Director, stated that McGeer Criteria is good but hasn't been updated since like 2009. They (him and the facility) will try and talk during their meetings about antibiotic stewardship in the future, but McGeer is not the only method the facility uses. They have residents that get septic very quickly and they try and safeguard those residents. For example, (R15) she has been known to go septic quickly and Ertapenem works for her. He continued to state that yes, he knows his residents best and that is why he automatically prescribes an antibiotic before cultures come back. The facility's Antibiotic Stewardship Policy, dated 08/10/2022, documented, Leadership Commitment- antibiotic use shall be appropriately administered. 1. Diagnostics shall be obtained, as appropriate, prior to administration of antibiotics. 2. Infections shall be evaluated (through s/sx [signs and symptoms], McGeer's criteria, lab results, diagnostics, etc.) to determine if infection meets criteria of a 'true' infection. 3. Physicians shall be notified of findings of those results. Education may be provided where appropriate. It continues under Accountability, 3. Discuss with medical director and /or facility physicians the importance of the antibiotic stewardship program. It continues, Tracking- Surveillance shall be on-going to monitor the successful use or and the outcome of the use of antibiotics within the facility. It continues, 3. QAPI plan shall be initiated when trend is identified. The Resident Census and Conditions of residents, CMS 672, dated 2/27/2023 documents that the facility has 75 residents living in the facility.