**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and facility policy review the facility failed to notify the ombudsman office of a discharge to the hospital for 2 of 2 residents (Residents #8, #17) reviewed for hospitalizations. The facility reported a census of 18 residents. Findings include: 1. Resident #8's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMs) score of 04, indicating severely impaired cognition. Resident #8 ' s MDS included diagnoses of coronary artery disease, heart failure, transient cerebral ischemic attack (TIA/mini stroke) and non-Alzheimer ' s dementia. Review of Census and Progress Note dated 3/22/25 revealed Resident #8 was admitted to the hospital for pneumonia and respiratory syncytical virus (RSV). The facility form titled Notice of Transfer Form to Long Term Care Ombudsman used to track discharges and notify the Ombudsman of a discharge revealed Resident #8 was not listed on the forms for March or April 2025. 2. Resident #17's Minimum Data Set (MDS) dated [DATE] assessment identified a Brief Interview for Mental Status (BIMs) score of 12, indicating moderately impaired cognition. Resident #17's MDS included diagnoses of diabetes mellitus, arthritis, non-Alzheimer's dementia, and presence of right artificial hip joint. Review of Census and Progress Note dated 2/24/25 revealed Resident #17 was admitted to the hospital due to a fracture of the right hip. The facility form titled Notice of Transfer Form to Long Term Care Ombudsman used to track discharges and notify the Ombudsman of a discharge revealed Resident #17 was not listed on the forms for February or March 2025. On 6/3/25 at 3:35 PM, the Administrator reported she was responsible for completing the notifications to the Ombudsman and was not aware that hospitalizations were required to be reported. She said she notified the Ombudsman of transfers that included discharges to home or to another facility. A facility policy titled Ombudsman Notification Process revised January 2023 documented the facility was responsible for notifying the Long Term Care Ombudsman of all transfers and discharges from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to serve food in a form to meet individual needs for 2 of 2 residents reviewed (Resident #17 and #13). The facility reported a census of 18 residents. Findings include: 1) According to the Minimum Data Set (MDS) assessment dated [DATE], Resident #17 scored 12 on the Brief Interview for Mental Status (BIMS) indicating moderate cognitive impairment. The resident required partial/moderate assist assistance with eating. The resident had diagnoses including diabetes and non-Alzheimer's dementia. The Care Plan revised 4/16/25 identified the resident had dementia and diabetes. Speech Therapy (ST) recommended nectar thick liquids - which the resident refused. The resident had been on a mechanically altered texture diet in the past. The interventions included staff would cut up the resident's meat and cut sandwiches in half or fourths as the resident desired per therapy recommendations revised 5/10/25. A Diet Roster report printed 5/13/25 documented the resident had a Doctor's order for a regular diet with additional directions for cut up meat. A Rehab Communication dated 3/10/25 documented Speech Therapy recommended a diet upgrade to regular solids, and please cut all plated meats into bite size pieces, and cut sandwiches into half or fourth for resident to hold. 2) According to the MDS assessment dated [DATE], Resident #13 scored 14 on the BIMS indicating moderate cognitive impairment. The resident required set up/cleanup assist assistance with eating. The resident had diagnoses including non-Alzheimer's dementia. The Care Plan revised 7/10/24 identified the resident had a potential alteration in nutrition related to her dementia diagnosis, vision status as evidenced by the need of set-up assistance with meals, fair to poor meal intake, and slow weight loss. The interventions included the resident was on a regular diet, and cut-up foods to aid in self-feeding. A Diet Roster report printed 5/13/25 documented the resident had a Doctor's order for a regular diet with additional directions for cut up meats. During observation and concurrent interview on 6/4/25 during the noon meal service a white board in the kitchen had 3 residents listed that would get their meat cut up (including Resident #17 and #13). It didn't indicate how it would be cut up. Staff A [NAME] cut the cheddarwurst up in very large chunks for the 3 residents listed. During interview with the Dietary Manager (DM) she confirmed that they should be bite-size pieces, and they were not bite sized. In an email on 6/4/25 at 2:28 p.m. the Administrator wrote she could not find a policy on diet orders, but the DM said that they went by what the nurse told them and the care plan.

Based on observation, record review, and staff interview, the facility failed to hold hot foods at 135 degrees during 1 meal service. The facility reported a census of 18 residents. Findings include: The noon menu for 6/4/25 included a cheddarwurst on a bun with peppers and onions and a hashbrown patty. During a combined observation and interview on 6/4/25 at 11:43 a.m. Staff A Cook, temped all of the food, and all hot food greater than 165 degrees. During the meal service, Staff A served the peppers and onions from a pan on top of the stove. He removed a pan of the hashbrown patties from the oven and sat on top of stove. The oven doors remained open during the service. Right after the meal service Staff A temped the food. The cheddarwursts were above holding temperature (135 degrees), the hashbrown patties only reached 131 degrees, and the peppers and onions only reached 91 degrees. The Dietary Manager stated it was hard to keep things hot, which was why she served out of the oven rather than putting hot food on top. The undated facility policy, Food Temperatures, documented all hot foods must be cooked to appropriate internal temperatures and held at a temperature of at least 135 degrees.

Based on observation and staff interview, the facility failed to serve food in accordance with professional standards of quality for 1 meal. The facility reported a census of 18 residents. Findings include: During an observation and concurrent interview 6/4/25 at 11:59 a.m. Staff B, Dietary Aide (DA) was in and out of the kitchen several times taking fluids to residents, getting in and out of the refrigerator and opening and closing the door to the kitchen without washing her hands. Staff A, [NAME] washed his hands prior to the meal service. Staff A plated food placing his thumbs into the plate on both sides and then putting the food on the plate. Staff A placed several of the utensils with the handles on a cutting board, and then used the same cutting board to cut up hot dogs for residents. During the meal service Staff A also touched his face and his ear with his hand and did not wash his hands. He did not handle food, but he did handle the utensils including those on the cutting board. The Dietary Manager stated stated she should have been observing the dietary staff closer to ensure the were washing hands when needed, and not putting hands on the eating surface of the plates. It was Staff A's first survey, and he was nervous. On 6/5/25 at 8 a.m. the Administrator stated they did not have a hand washing policy specific to the kitchen. The facility policy Hand Hygiene updated 7/29/21 indicated hand washing should be performed by all staff as necessary to prevent cross contamination. The 2022 Food Code 2-301.14 directed when to wash hands included after touching bare human body parts other than clean hands and clean, exposed portions of arms.

Based on the Center of Medicare and Medicaid Services (CMS) Payroll Based Journal (PBJ) Staffing Data Report (October 1st- December 31), facility staffing assignments/schedules and staff interviews, the facility failed to submit accurate staff data for the PBJ Staffing Data Report. The facility reported a census of 18 residents. Findings include: The PBJ Staffing Data Report run date 5/28/2025 triggered for failure to have licensed nurse coverage 24 hours/day on the following infraction dates: 11/8, 11/17, 12/28, and 12/29. Review of the Facility Nursing Assignments/Schedules for the infraction dates reflected that the DON (Director of Nursing) covered the nursing shifts. A facility report titled 1702D Report from CMS revealed the DON's hours on 11/8, 11/17, 12/28 and 12/29 were not submitted to PBJ. On 6/3/25 at 10:30 AM, the Administrator verified the DON had covered nursing hours on 11/8, 11/17, 12/28, and 12/29. The Administrator reported the DON hours should have been reported to PBJ. She said the facility used an old system back then to report the PBJ hours and that the facility has a different system now. On 6/3/25 at 11:31 AM, the Administrator verified the DON's hours were not submitted to PBJ on 11/8, 11/17, 12/28 and 12/29. On 6/3/25 at 3:47 PM, the Administrator reported she recognized that with the old system the facility was having company wide errors so switching to the new system will allow to track PBJ hours monthly instead of quarterly. An undated facility procedure titled Getting Started with SimplePBJ documented the following steps for PBJ compliance: 1. Assemble data- gather data from payroll and/or timekeeping system, agencies, and contractors to load to SimplePBJ. 2. Validate data- Analyze for issues, review potential errors, and easily make changes to the PBJ data. 3. Predict five-star staff rating. 4. Submit data- create PBJ report and submit directly to CMS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, document review, resident and staff interviews, the facility failed to revise the care plan to accurately reflect the risks of utilizing high-risk medications for 2 of 5 residents sampled for medication management, (Resident #11 and #16). The facility reported a census of 18 residents. Findings include: 1.The Minimum Data Set (MDS) Assessment for resident #11 dated 3/30/23 showed a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. The MDS documented Resident #11 received an anticoagulant medication (a medication that carries a risk of increased bleeding potential) during the 7 day MDS look back period. The Hospital discharged Instructions electronically signed by the physician on 3/24/23 documented a physician order for Apixaban 2.5 mg oral tablet give 4 tablets every 12 hours for 1 week then 5 mg twice a day. A review of the Resident's March and April 2023 Medication Administration Records (MARs) completed on 4/11/23 documented Resident #11 received an apixaban oral tablet 2.5 milligrams (mg) give 4 tablets by mouth two times a day from 3/24/23 - 4/11/23. The Resident also received aspirin (medication to minimize blood clotting) enteric coated tablet delayed release 81 mg, give 1 tablet by mouth one time a day for cardiac prevention related to non-st elevation (NSTEM) myocardial infarction from 3/9/21 - 3/21/23, 3/25/23 - 4/11/23. A review of the Care Plan with a revised date of 4/11/23 lacked documentation related to the use of anticoagulant medication (Apixaban) and risk factors for use. During an interview on 4/11/23 at 2:20 p.m. Resident #11 reported she is on a blood thinner due to having blood clots. An interview with the MDS Coordinator on 4/11/23 at 3:06 p.m., reported she updates the care plan according to the changes on the MDS. If a new order comes in and the MDS had recently been completed then she would add the changes to the care plan before the next review. During an interview on 4/11/23at 3:09 p.m. with Staff A, Registered Nurse, reported the care plan would have interventions and things to look for regarding medications. An interview with the DON on 4/11/23 at 3:12 p.m., verbalized the initial orders go into a folder that she keeps in her office. She gives the folder to the MDS Coordinator to insure the care plans are updated in the computer. During an interview on 4/11/23 at 3:18 p.m. the DON reported the facility does not have a care plan policy. 2. The MDS assessment dated [DATE] for Resident #16 showed a BIMS score of 15 indicating intact cognition. The MDS identified Resident #16 received an antidepressant medication (a medication that can carry side effects of dizziness, loss of appetite, insomnia and can alter mood status) during the 7 day MDS look back period. An Office Clinic Note dated 3/22/23 documented a diagnosis of anxiety and depression in which the Lexapro would be used to treat both conditions. A review of the Care Plan with a revised date of 4/3/23 lacked documentation related to the use of an antidepressant medication (Lexapro), the diagnoses of anxiety and depression, side effects to monitor for and psychosocial resident needs. A review of the Resident's March and April 2023 Medication Administration Record (MAR) completed on 4/11/23 revealed the Resident received the Lexapro 10 mg by mouth one time a day for generalized anxiety disorder from 3/1/23 - 4/1/23. The MAR further showed the Lexapro antidepressant medication had a start date of 11/24/22. During an interview on 4/11/23 at 2:30 p.m. Resident #16 reported that she recently started on a medication to help with her depression.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, policy review and staff interview, the facility failed to minimize the risk of infection during the provision of catheter care for 1 of 1 resident reviewed, (Resident #12). The facility identified a census of 18 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. Resident #12 required extensive assistance with bed mobility, transfer, dressing, personal hygiene and toileting. The MDS listed a diagnoses of malignant neoplasm of the prostate and identified Resident #12 utilized an indwelling urinary catheter (a catheter that remains in place in the bladder that drains urine from the bladder into a bag outside of the body). A Physician Order Report signed by the Provider on 1/9/23 documented the following physician orders: a. Replace the Foley catheter every 30 days with a 16 French catheter with a 10 cubic centimeters (cc) bulb one time a day every 30 day(s) for infection control related to malignant neoplasm of the prostate and as needed. Active date 1/10/23. b. Change the catheter drainage bag every 15 days and as needed one time a day every 15 day(s) for infection control and as needed. Active date 1/10/23. A Care Plan Focus revised 11/11/22 by the DON documented Resident #12 had a catheter due to prostate cancer. The Care Plan directed the C.N.A.'s to provide catheter care twice a day and as needed with a care plan goal that Resident #12 would not develop a urinary tract infection due to the catheter use. During an observation on 4/11/23 at 7:32 a.m. the Director of Nursing (DON) assisted Staff B, Certified Nursing Assistant (C.N.A.) with catheter care. The DON stood by the head of the bed. She kicked the trash can toward the bed with her left foot, then bent down and used her right gloved hand to grasp the 1/2 full garbage can by the rim with her gloved thumb, index finger and middle finger to move the trash can by the bed. Observation revealed used Kleenex in the garbage can. The DON directed Staff B to do the catheter care because she had clean gloves on. The DON picked up a package of disposable wipes in her left gloved hand and used her right gloved thumb, index and middle finger to pull a disposable wipe from the package and handed the wipe to Staff B who used the wipe to cleansed around the urinary meatus (tip of penis) head at the catheter insertion site The DON pulled another disposable wipe with the gloved right hand, handing the wipe to Staff B. Staff B took the second disposable wipe and cleansed around the urinary meatus again. The DON pulled two more disposable wipes out of the package with her gloved right hand and handed to Staff B so she could cleanse the left and right groin folds with the disposable wipes. The DON then pulled another disposable wipe from the package with her right gloved hand handing the wipe to Staff B so she could cleanse from the catheter insertion site four inches down the catheter. The DON repeated the process a second time so Staff B could cleanse down the catheter one more time. Both Staff removed their gloves upon completion of the catheter care. During an interview on 4/11/23 at 2:51 p.m. Staff C, C.N.A. reported she had received training on catheter care. She reported she is to use clean gloves to provide catheter care. If she touched something dirty, she would have to change her gloves and do hand hygiene prior to performing catheter care. During an interview on 4/11/23 at 3:33 p.m. Staff D, Registered Nurse (RN) reported she would expect if gloves become contaminated prior or during catheter care, the gloves should be changed. During an interview on 4/12/23 at 11:40 a.m. the DON reported she expected staff to change gloves if gloves become contaminated and perform catheter care with clean gloves. The Hand Hygiene Policy updated 6/21/21 directed staff should always complete hand hygiene before and after putting on and taking off of gloves and after handling contaminated items and equipment such as dressings, secretions and excretions from residents. The Catheter Care Policy updated 6/21/21 documented a purpose to prevent infection and reduce irritation. The Policy directed to use peri wash, washcloths, towel, gloves and a surface barrier for equipment supplies. The Procedure documented the following steps: a. Wash hands, gather equipment and take to the bedside. b. Provide privacy and explain the procedure to the resident. c. Apply gloves. d. Clean the area at the catheter insertion. Do one side of the area and then using the clean area of the wash cloth do the other side. Be careful not to pull on the catheter or advance it further into the urethra. Make sure all debris is removed from the catheter insertion site. Always clean from the front to the back. For male residents retract the foreskin for thorough cleansing, making sure to pull the foreskin back down when finished. e. Gently pat dry. f. Discard equipment properly. g. Position the resident comfortably with the call light within reach. h. Wash hands. The Catheter Care Policy failed to direct the staff on when to change to clean gloves if gloves become contaminated by other environmental surfaces. The Standard Precautions Policy updated 6/21/21 directed gloves should be worn when touching blood, body fluids, secretions, excretions, and contaminated items. Gloves should be removed promptly after use and before touching non-contaminated items and environmental surfaces and before going to another resident. Hand washing should be completed after gloves are removed. The Policy indicated Standard Precautions are indicated for all residents. The Policy directed to handle Resident- Care equipment soiled with blood, body fluids, secretions, or excretions to prevent skin and mucous membrane exposure, contaminating of clothing and the transfer of microorganisms to other residents and environments. The Policy direct to clean reusable equipment and discard disposables.