**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, staff interviews, and policy review, the facility failed to respect resident dignity throughout all care provided and in speaking to them for 2 out of 6 residents reviewed (Residents #3 & #6). The facility reported a census of 39 residents. Findings include: 1. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified the diagnoses of Parkinson's, muscle wasting right and left lower legs, abnormal mobility, & repeated falls, and a Brief Interview for Mental Status score of 4 suggesting severely impaired cognition. The Care Plan identified Resident #3 was dependent on staff for ambulation, required assistance with a wheeled walker, gait belt, and to be followed with a wheelchair. The Progress Note for Resident #3 dated 4/1/25 at 6 PM revealed: 1. An annual wellness visit was completed with an assessment by the provider. 2. An increased fall risk and non-compliance of healthcare plan. 3. Cognitively does not understand important safety measures with use of call light or waiting and asking for help. 4. The patient may become agitated due to lack of comprehension and behavior may lead the patient to become noncompliant. 5. A diagnoses of dementia, psychotic disturbance, mood disturbance, anxiety, and had behaviors on and off. 6. The patient was seen by psych services. During an observation on 4/8/25 at 10:52 AM, Resident #3 was assisted by a CNA to a recliner in the small living room. She was alert and had bruises to her left side of her face above her ear and left forehead in her hair line, both were yellow in color. Resident #3's hair was clean with small braids and her body had involuntary movements. During an interview on 4/8/25 at 10:52 AM, Resident #3 said she falls often and had hit her head this last time. She said the staff treat her well here. A document titled Unwitnessed Fall dated 4/1/25 at 23:30 for Resident #3 documented by the Director of Nursing (DON) on 4/2/25 revealed: 1. A CNA saw Resident #3 lying on the floor. 2. The nurse assisted the resident off the floor by one staff member and placed in a chair. 3. No injuries observed at the time of incident. 4. Pain level, mental status was not documented. 5. Predisposing physiological factors listed were gait imbalance, impaired memory and weakness/faints. 6. Predisposing situation factors were listed as ambulating without assistance. 7. No statement found. 8. The physician was notified on 4/2/25 at 10:30 am. 9. The guardian was notified on 4/2/25 at 10:58 am. During an interview on 4/8/25 at 2:20 PM, Staff J, Certified Medication Assistant (CMA) stated on 4/1/25 during the 2-10 PM shift, Resident #3 fell and Staff B, Registered Nurse (RN) watched her fall and did not assess her or do vitals. Staff J stated Staff B picked Resident #3 up off the floor under her arms, put her back into the wheelchair and told her that he was tired of her shit and she knew better. Staff J stated Resident #3 had severe dementia and thought she had to go to work, she was a nurse, and she thought she needed to do someone's vital signs. During an interview on 4/8/24 at 2:47 PM Staff D, Certified Nursing Assistant (CNA) stated she had worked the night that Resident #3 fell on 4/1/25. Staff D stated she saw Resident #3 on the floor on her right hip and she was crying, Staff B, Registered Nurse (RN) was facing the computer in the nurses station, not paying attention. Staff D stated she notified Staff B that Resident #3 was on the floor and he said, Oh Jesus and he picked her up cursing, this is fucking ridiculous and (name) Administrator was not taking care of this, we don't have the staff for this shit. Staff D stated Staff B didn't count it as a fall and did not assess her. Staff D stated she left the area to find Staff K, CMA and they found Resident #3 was on the floor again and Staff B picked her up again, put his hands under her arm pits and dragged Resident #3 back to the recliner. Staff D stated Staff K joined her, went to a room to talk since Staff B manhandled her, second fall in 5 minutes and did not conduct assessments. Staff D stated she heard Staff B saying (Resident #3) I'm [AGE] years old and I'm sick of this shit. Resident #3 said she was [AGE] years old too, was crying a bit and she looked really uncomfortable. Staff D and Staff K moved Resident #3 to her room and stayed with her. Staff D stated Staff K called the DON at shift change to report the incident, and the DON called Staff D at home. Staff D stated they were scared and were not sure if management was going to take them seriously since Staff B was a nurse. Staff D stated Staff B had been rude and weird toward Resident #3 because she falls often and rude to coworkers about sexist things and that was not ok. During an interview on 4/10/25 at 7:33 AM, Staff K, CMA stated on 4/1/25 about 9:30 PM she was at the medication cart directly in front of Staff B, RN and Resident #3 was on the opposite side of the nurses station in a wheelchair and she tried to stand two times when Staff B told her to sit down. Staff K stated Resident #3 tried to stand up and Staff B ran over to her and verbally reprimanded her. Staff B got a recliner and Staff K stated she transferred Resident #3 and Staff B said sorry I should have not lost my temper, but did not apologize to Resident #3. Staff K stated she situated Resident #3 with a color book and she calmed down. Staff K stated she went to answer a call light when Staff D, CNA stated Resident #3 was on the floor and Staff B was on his phone but helped her up. Staff K stated when they exited that room, they saw Resident #3 on the floor again and Staff B picked her up under her arms saying stuff to her and drug her away both of her feet dragging the ground and her knees bent Staff K stated he didn't have Resident #3 up high enough for her to walk and her feet flipped backwards and he dragged her about 5-10 feet, out of line of sight. Staff K stated both her and Staff D were moving quickly and found Resident #3 visibly shaking at that point and wanting to separate the situation, they put her in a wheelchair and took her to her room. Staff K stated they were shaken up. Staff K stated she sat with Resident #3 for 45 minutes until she was asleep. Staff K stated Resident #3 was so intelligent, a nurse who thinks she was doing rounds. Staff K stated Staff B verbally said he was not going to document her falls and in the morning, her falls were not mentioned during the report. Staff K stated she stepped out of the nursing station and called the DON at 8:54 AM, aware it was more than 2 hours and she told me to write a statement. On 4/9/25 at 11:14 AM, Staff B, RN declined to be interviewed. 2. The MDS dated [DATE] for Resident #6 revealed diagnoses of muscle weakness & dementia, and required total assistance from staff for dressing, toileting, personal hygiene, and transfers from bed to chair. Not attempted to stand or walk. Resident #6 had a BIMS score of 3 which suggested severe cognitive impairment. The Care Plan for Resident #6 identified she was non ambulatory and directed staff to utilize a mechanical lift with the assistance of 2 staff for transfers. Progress Notes for Resident #6 dated 4/5/25 incident, nurse was notified that resident had bruising to bilateral upper extremities (BUE), observed bruising to right outer forearm and left outer forearm. The resident denied pain, confused and forgetful and unable to verbalize how bruising occurred, no further injuries identified. A document titled wound assessment evaluated 4/5/25 at 22:07 Resident #6 identified a bruise to the right outer forearm, a new in-house acquired, no measurement. The picture revealed a dark purple bruise to the right forearm that started from above the right elbow to wrist. The practitioner was notified. A document titled wound assessment evaluated 4/5/25 at 22:13 for Resident #6 identified a bruise to the left outer forearm, a new in-house acquired measured area 7.03 centimeters (cm), 3.51 cm long and 2.65 cm wide. The picture revealed a dark purple bruise to the left forearm, above the wrist. The practitioner was notified. A document titled incident report dated 4/5/25 at 21:56 for Resident #6 revealed: 1. The nurse was notified Resident #6 had bruises on BUE. 2. The nurse observed bruising to the right outer forearm and left outer forearm. 3. Resident #6 denied pain, confused, forgetful, unable to verbalize how the bruising happened. 4. No further injuries identified. 5. No predisposing situation factors. 6. The resident was agitated, swinging arms at staff. 7. The physician was notified on 4/5/25 at 22:58. 8. The Director of Nursing was notified on 4/5/25 at 21:46. 9. The guardian was notified on 4/5/25 at 22:26. During an interview on 4/9/25 at 9:16 AM Staff F, CNA stated on Saturday, 4/5/25, she was at the nurses station with Staff M, CNA and heard Resident #6 screaming, what are you doing to me, you're hurting me, why are you doing this to me. Staff F stated she opened the door and found Staff G, CNA in front of Resident #6, her bottom was barely on the wheelchair without a mechanical sling or lift on site. Staff F stated Resident #6 was shaken up and Staff G would not let her help as she went to the back of the chair and grabbed Resident #6 by her pants and roughly pulled her back into the wheelchair. Staff F stated Resident #6 was [AGE] years old and looked fearful, shaking, compared to her normal self. She kept saying what are you doing to me? Staff F stated Resident #6 did get worked up during transfers but she had never heard her scream like that. Staff F stated Resident #6 normally transfers with a Hoyer lift per the Care Plan. Staff F stated Staff M left to get the nurse since Staff G refused to let them do anything to help and Staff L, RN stood by the door. Staff F stated both her and Staff M voiced their concerns and felt that Staff G should not have hands on other residents after that to Staff L, who called the DON. Staff F stated Staff G was sent home after 6 PM but was allowed to return the next afternoon, the Administrator stated she was allowed to work. Staff F stated she and Staff M made sure they took care of the cognitively impaired residents including Resident #6, and Staff G was allowed to take care of the people who could defend themselves. During an interview on 4/8/25 at 2:20 PM, Staff J, CMA stated she was passing medication and heard Resident #6 yelling, you're hurting me, stop. Staff G, CNA was providing care and transferred Resident #6 without a mechanical lift. Staff J stated Resident #6 looked frightened, eyes wide and did not want anyone to touch her, and at bed time, found bruises all the way up her right arm. Staff J stated the DON was notified by Staff L, RN. Staff J stated Staff G continued to work the next day. During an interview on 4/10/25 at 7:33 AM, Staff K, CMA stated she was told in report on 4/5/25 that Staff G, CNA transferred Resident #6 without a mechanical lift and at 10 PM found bruises to both arms when her sweater was removed. Staff K stated the nurse was notified, made an assessment, and notified the DON. During an interview on 4/8/25 at 3:32 PM Staff L, RN stated that on 4/5/25, Staff M, CNA and Staff F, CNA told her they were concerned as they could hear Resident #6 screaming, and Staff F went into the room and the resident was sitting on the edge of the wheelchair and Staff G, CNA roughly sat the resident back into the wheelchair. Staff L asked Staff G if she had transferred Resident #6 without the mechanical lift and she said yes, and she was educated not to do that again. During a follow up interview on 4/9/25 at 9:55 AM, Staff L, RN stated on 4/5/25, Staff M, CNA and Staff F, CNA continued to say that they had concerns about Staff G, CNA and Staff L stated she believed them due to the inability to locate Staff G earlier in the shift, found in a resident's room, on her phone. Staff L stated Resident #6 screaming and over heard things falling in the room, the unsafe transfer and Resident #3 getting her fingers in the brakes on her wheelchair when Staff G was pushing her. Staff L stated she felt too much had happened and called the DON and sent Staff G home at 6:30 PM for the day. During an interview on 4/14/25 at 8:52 AM, Staff G, CNA stated she had only worked at the facility for 2 months and only had 2 days of training before she had to work on her own. Staff G stated she usually gets Resident #6 up for supper, it was hard, she was [AGE] year and would hit, pinch or grab at staff. Staff G stated she would scream at staff. Staff G stated she got Resident #6 dressed, was hitting her hard and when she nudged Resident #6 over to the wall to pull up her brief, Resident #6 hit the wall. Staff G stated she turned the call light on for 2 minutes but no one came so she went to look for another CNA to help. Staff G stated she could not find any staff so she returned to Resident #6's room, it was about 5:20 PM, put the gait belt on, put the wheelchair close to the bed and did a pivot transfer. Staff G stated Resident #6 could not stand so she body lifted her, Staff F, CNA entered the room as she was pulling Resident #6's pants up. Staff G stated that Staff F asked if she needed help and replied she was already done by that time. During an interview on 4/14/25 at 10:47 AM, the DON stated that the CNA should call if they are not comfortable with the nurse. The DON stated a couple of CNA's had mentioned that Staff B, RN had inappropriate conversations with staff and I told him that was not appropriate. The DON stated that her expectation was that the nurses should treat every one with respect, talk appropriately with residents and appropriate conversations at the nurses station as residents are listening. The expectation of falls was the CNA gets a nurse, an assessment completed and transfers the resident with a gait belt to get them off the floor. The DON stated if the staff notice other things that are different, tell the nurse again, or notify her as she was on call 24/7. Policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revealed: Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including facility staff. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, resident and staff interviews, the facility failed to appropriately provide an assessment for Resident #2 after a fall that inadvertently pulled out the resident's suprapubic urinary catheter from a surgical opening in her abdomen and failed to provide an intervention for 7 hours for a transfer to the hospital for the catheter to be replaced. The facility reported a census of 39 residents. Findings include: Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified the diagnoses of diabetes mellitus, retention of urine, & chronic kidney disease, dependent upon staff for transfers, personal hygiene, and toileting and a Brief Interview for Mental Status (BIMS) score of 14 indicating intact cognition. The Care Plan identified a suprapubic catheter and directed staff to provide catheter care every shift. The Care Plan failed to provide direction for staff if the catheter was pulled out. During an interview on 4/8/25 at 10:16 AM, Resident #2 stated she remembered that she had a catheter in her stomach and the staff cleaned it. Resident #2 stated she could not remember the specifics about the fall on 1/2/25, just that she did not feel well, an out of body feeling. She stated she gave the Emergency Medical Technician's (EMT) a hard time, that she didn't want to go to the hospital, but her abdomen felt full and the facility staff encouraged her to go. Resident #2 stated EMT's returned, transported her to the hospital, where she refused to be admitted and have the catheter replaced into her abdomen but agreed to a Foley catheter placement. During an interview on 4/9/25 at 10:09 AM, Staff C, Certified Nursing Assistant (CNA) stated she had provided care for Resident #2 on 1/2/25 2 PM to 10 PM shift. Resident #2 was weak, unable to stand and Staff A, Registered Nurse (RN) assisted with the mechanical lift transfer to a commode, the catheter was in her abdomen at that time, then she was transferred to the recliner. Staff C stated within 15 minutes, she heard Resident #2 screaming and found her on the floor. Staff C stated that Staff D, CNA notified Staff A and Staff E, CNA assisted as it took 4 staff to assist Resident #2 off the floor and into the recliner. Staff C stated that she and Staff D noticed the suprapubic catheter was not in Resident #2's abdomen and reported this to Staff A. Staff C stated the CNA's began assisting other residents and when it was time to assist residents to bed, Resident #2 was bleeding from her abdomen and she notified the 3rd shift nurse Staff B, RN who said he was unaware that the suprapubic catheter was missing. Staff C stated that Staff B did not call for the EMT's until after 10 PM and Resident #2 refused to go, but within an hour, she agreed to go to the hospital. During an interview on 4/8/25 at 2:47 PM Staff D, CNA stated she worked on 1/2/25 when Resident #2 fell, she had been confused and agitated for a few days. Staff D stated Staff C, CNA was with her and heard Resident #2 yelling for help, found her on the floor and called for Staff A, RN. Staff D stated after they got the resident up and the bowel movement cleaned off, she noticed the suprapubic catheter was missing. Staff D notified Staff A but did not witness her assess Resident #2. Staff D stated later in the shift, after 6 PM, when Staff B, RN was in charge, she asked why Resident #2 was not being treated, it was a suprapubic catheter and it was emergent. Staff D stated Staff B was mad as he was not informed of that in report and assessed Resident #2 but did not call the EMT's until after 10 PM. Staff D stated that she and her coworkers were confused, it fell out at 2:30 PM and it was 7 hours before she was treated by a nurse. The Skilled Progress Note on 1/2/25 at 8:51 AM revealed an assessment that identified Resident #2 was alert, experienced weakness, lethargic at most times, poor food and drink intake and active bowel sounds, completed by Staff A, RN. The next Progress Note, unusual occurrence note, dated 1/2/25 at 7:51 PM revealed that a CNA informed the nurse that the suprapubic catheter came out around 2 PM and the previous nurse was informed. The note was completed by Staff B, RN, During an interview on 4/9/25 at 2:22 PM, Staff A, Registered Nurse (RN) stated Resident #2 had a mental status change on 1/2/25 and the CNA's informed her that the resident fell. Staff A stated she completed a fall assessment, assisted the resident off the floor but was unaware that the suprapubic catheter was pulled out and did not include that in the report to the 6 PM nurse. During an interview on 4/9/25 at 11:14 AM, Staff B, RN stated that on 1/2/25 he came to work at 6 PM and did not remember if he was told in report that Resident #2 fell. Staff B stated that the CNA's told him that Resident #2's catheter came out at 2 PM, he assessed the resident, called the physician and received an order to transport the resident to the hospital. Staff B stated that Resident #2 refused to go with the EMT's, then later agreed to go to the hospital and the EMT's returned. Staff B stated the opening into the abdomen (stoma) was not leaking urine and felt the catheter was out for so long, that the stoma may have closed. During an interview on 4/7/25 at 2:02 PM, Staff H, EMT stated that he and the ambulance driver, Staff I, EMT, responded to a call for a sick person on 1/2/25 at 9:30 PM. Staff H stated that when they entered the facility, they were met by Staff B, RN who reported Resident #2 fell about 2 PM and the suprapubic catheter had been pulled out. Staff H stated Resident #2's room smelled of urine and her clothes were wet from urine leaking from the abdominal opening. Staff H stated when they loaded Resident #2 to the cot, she refused to go to the hospital and she was alert and oriented so they could not take her. Staff H stated he contacted the Director of the Emergency Medical Services (EMS) and the Medical Director of the EMS who spoke with Resident #2, who notified her of the consequences of not receiving treatment. Resident #2 continued to refuse and the EMT's returned to base. Staff H stated one hour later at 11:30 PM, they received another call for Resident #2, she had agreed to be transported to the hospital. Staff H stated that during transport, Resident #2 stated the facility staff was not taking care of her catheter today, she was confined to a bed for 8 hours, leaking urine, with no one providing care. Staff H stated Resident #2 was alert, oriented and hypertensive (high blood pressure) 200/80. A document titled ED (Emergency Department) Provider Notes for Resident #2 revealed: 1. Resident #2 was alert and oriented x 3 (person, place, and time). 2. Assessment in regard to a fall and no fractures were identified. A concern for a possible syncope (temporary loss of consciousness) vs TIA (transient ischemic attack, a mini stroke). 3. The suprapubic catheter was displaced for too long and was unable to replace it. 4. A plan to admit to the hospital for further evaluation that the resident declined against medical advice. 5. A Foley catheter was placed. During an interview on 4/14/25 at 10:47 AM, the Director of Nursing (DON) stated that if the CNA was not getting what they needed from the nurse, they should call her as she was on call 24/7. The DON state the facility nursing staff are to send the residents who have a suprapubic catheter to the hospital for replacement due to the nurses training not including replacing those catheters.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and staff interviews, the facility failed to safely transfer 1 of 1 residents (Resident #6) according to the Care Plan resulting in bruising injuries to the resident's arms. The facility reported a census of 39 residents. Findings include: The MDS dated [DATE] for Resident #6 revealed diagnoses of muscle weakness & dementia, and required total assistance from staff for dressing, toileting, personal hygiene, and transfers from bed to chair. Not attempted to stand or walk. Resident #6 had a Brief Interview for Mental Status (BIMS) score of 3 which suggested severe cognitive impairment. The Care Plan for Resident #6 identified she was non ambulatory and directed staff to utilize a mechanical lift with the assistance of 2 staff for transfers. Progress Notes for Resident #6 dated 4/5/25 incident, nurse was notified that resident had bruising to bilateral upper extremities (BUE), observed bruising to right outer forearm and left outer forearm. The resident denied pain, confused and forgetful and unable to verbalize how bruising occurred, no further injuries identified. A document titled wound assessment evaluated 4/5/25 at 22:07 Resident #6 identified a bruise to the right outer forearm, a new in-house acquired, no measurement. The picture revealed a dark purple bruise to the right forearm that started from above the right elbow to the wrist. The practitioner was notified. A document titled wound assessment evaluated 4/5/25 at 22:13 for Resident #6 identified a bruise to the left outer forearm, a new in-house acquired measured area 7.03 centimeters (cm), 3.51 cm long and 2.65 cm wide. The picture revealed a dark purple bruise to the left forearm, above the wrist. The practitioner was notified. A document titled incident report dated 4/5/25 at 21:56 for Resident #6 revealed: The nurse was notified Resident #6 had bruises on BUE. The nurse observed bruising to the right outer forearm and left outer forearm. Resident #6 denied pain, confused, forgetful, unable to verbalize how the bruising happened. No further injuries identified. No predisposing situation factors. The resident was agitated, swinging arms at staff. The physician was notified on 4/5/25 at 22:58. The Director of Nursing was notified on 4/5/25 at 21:46. The guardian was notified on 4/5/25 at 22:26. During an observation on 4/8/25 at 2:47 PM Staff D, Certified Nursing Assistant (CNA) was assisting Resident #6 to her room and removed her sweater and the coverings to both arms to reveal Resident #6's right arm, from above her elbow, mid upper arm, to her right wrist, was a dark purple bruise. The left lower arm above her wrist had a circular dark purple bruise. During an interview on 4/8/25 at 2:20 PM, Staff J, CMA stated she was passing medication and heard Resident #6 yelling, you're hurting me, stop. Staff G, CNA was providing care and transferred Resident #6 without a mechanical lift. Staff J stated Resident #6 looked frightened, eyes wide and did not want anyone to touch her, and at bed time, found bruises all the way up her right arm. Staff J stated the DON was notified by Staff L, RN. Staff J stated Staff G continued to work the next day. During an interview on 4/9/25 at 9:16 AM Staff F, CNA stated on Saturday, 4/5/25, she was at the nurses station with Staff M, CNA and heard Resident #6 screaming, what are you doing to me, you're hurting me, why are you doing this to me. Staff F stated she opened the door and found Staff G, CNA in front of Resident #6, her bottom was barely on the wheelchair without a mechanical sling or lift on site. Staff F stated Resident #6 was shaken up and Staff G would not let her help as she went to the back of the chair and grabbed Resident #6 by her pants and roughly pulled her back into the wheelchair. Staff F stated Resident #6 was [AGE] years old and looked fearful, shaking, compared to her normal self. She kept saying what are you doing to me? Staff F stated Resident #6 did get worked up during transfers but she had never heard her scream like that. Staff F stated Resident #6 normally transfers with a Hoyer per the care plan. Staff F stated Staff M left to get the nurse since Staff G refused to let them do anything to help and Staff L, RN stood by the door. Staff F stated both her and Staff M voiced their concerns and felt that Staff G should not have hands on other residents after that to Staff L, who called the DON. Staff F stated Staff G was sent home after 6 PM but was allowed to return the next afternoon, the Administrator stated she was allowed to work. Staff F stated she and Staff M made sure they took care of the cognitively impaired residents including Resident #6, and Staff G was allowed to take care of the people who could defend themselves. During an interview on 4/10/25 at 7:33 AM, Staff K, CMA stated she was told in report on 4/5/25 that Staff G, CNA transferred Resident #6 without a mechanical lift and at 10 PM found bruises to both arms when her sweater was removed. Staff K stated the nurse was notified, made an assessment, and notified the DON. Staff K stated the mechanical lift sling it was in the recliner, Staff M, CNA and Staff F put it under her when they put her back to bed. During an interview on 4/8/25 at 3:32 PM Staff L, RN stated that on 4/5/25, Staff M, CNA and Staff F, CNA told her they were concerned as they could hear Resident #6 screaming, and Staff F went into the room and the resident was sitting on the edge of the wheelchair and Staff G, CNA roughly sat the resident back into the wheelchair. Staff L asked Staff G if she had transferred Resident #6 without the mechanical lift and she said yes, and she was educated not to do that again. During a follow up interview on 4/9/25 at 9:55 AM, Staff L, RN stated on 4/5/25, Staff M, CNA and Staff F, CNA continued to say that they had concerns about Staff G, CNA and Staff L stated she believed them due to the inability to locate Staff G earlier in the shift, found in a resident's room, on her phone. Staff L stated Resident #6 screaming and over heard things falling in the room, the unsafe transfer and Resident #3 getting her fingers in the brakes on her wheelchair when Staff G was pushing her. Staff L stated she felt too much had happened and called the DON and sent Staff G home at 6:30 PM for the day. During an interview on 4/14/25 at 8:52 AM, Staff G, CNA stated she had only worked at the facility for 2 months and only had 2 days of training before she had to work on her own. Staff G stated she usually gets Resident #6 up for supper, it was hard, she was [AGE] year and would hit, pinch or grab at staff. Staff G stated she would scream at staff. Staff G stated she got Resident #6 dressed, was hitting her hard and when she nudged Resident #6 over to the wall to pull up her brief, Resident #6 hit the wall. Staff G stated she turned the call light on for 2 minutes but no one came so she went to look for another CNA to help. Staff G stated she could not find any staff so she returned to Resident #6's room, it was about 5:20 PM, put the gait belt on, put the wheelchair close to the bed and did a pivot transfer. Staff G stated Resident #6 could not stand so she body lifted her, Staff F, CNA entered the room as she was pulling Resident #6's pants up. Staff G stated that Staff F asked if she needed help and replied she was already done by that time. Staff G stated she was aware that Resident #6 required the use of a mechanical lift and 2 person assist due to watching others as she did not know how to access a resident's Care Plan. A document titled Education given to Staff G, CNA dated 4/5/25 revealed: 1. Make sure to follow the Care Plan for each resident. If you don't know how someone transfers, ask another staff member. 2. Never transfer a resident that needs a Hoyer without 2 people. Make sure if no one comes to help with a transfer, you make sure the resident is safe and go and find a 2nd person. 3. Also, educated by the nurse on duty on that shift. Signed by Director of Nursing. During an interview on 4/14/25 at 10:47 AM, the DON stated that the CNA should call if they are not getting what they need or not comfortable with the nurse. The DON stated the CNA's get a packet to train with their mentor, to include transfers and mechanical lifts. The DON stated they try to provide 5-6 days of training and if they feel they need more, then we give them more time, more if they are new CNA. The DON stated Staff D was the mentor on the 2-10 shift and she informed her that Staff G was lazy, hiding, but no one told me she was unsafe. The DON stated Staff G did not tell me or others that she did not know how to access a Care Plan. The DON stated if the staff notice other things that are different, tell the nurse again, or notify her as she was on call 24/7.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, and staff, resident and resident responsible party interviews, the facility failed to assess a resident's decline in condition, and failed to complete and document assessments imperative for the resident's condition/care required over a 3 day period for 1 of 4 resident records reviewed (Resident #2). The facility reported a census of 43 residents. Findings include: The Minimum Data Set (MDS) Assessment tool dated 9/20/24 revealed Resident #2 scored 8 out of 15 points possible on the Brief Interview for Mental Status (BIMS) cognitive assessment, that indicated moderate cognitive impairment with symptoms of delirium present, always able to make himself understood and understood others, had diagnoses that included diabetes, non-Alzheimer's dementia, and muscle weakness, weighed 122 pounds, without weight gain or loss in the 6 months that preceded the assessment and had no identified skin conditions. The Assessment revealed the resident required substantial staff support to reposition in bed, transfer to and from bed and chair, dressing, toileting, bathing, and personal hygiene, and required moderate staff assistance for eating. Weights recorded in the resident's record revealed: 8/13/24 123.0 pounds (#) 8/15/24 124.0 # 8/20/24 123.5 # 8/22/24 123.0 # 8/27/24 119.5 # 8/29/24 121.5 # 9/3/24 122.0 # 9/5/24 120.0 # 9/10/24 123.0 # 9/12/24 121.5 # 9/17/24 121.5 # 9/19/24 122.5 # 9/26/24 120.5 # 10/1/24 120.0 # 10/15/24 109.5# A problem labeled I use hypoglycemic medications related to diabetes initiated 4/12/23 on the Nursing Care Plan, directed staff with interventions that included: a. Administer diabetic medications as ordered by physician, initiated 4/12/23, revised 10/15/24. b. Monitor blood glucose as ordered, initiated 4/12/23, revised on 10/15/24. c. Monitor for side effects (low blood sugar, headache, weakness, sweating and fainting) and effectiveness, initiated 4/12/24, revised on 10/15/24. Another problem labeled I have PRN (apply as needed) oxygen therapy related to Covid respiratory illness, initiated 10/15/24 on the Nursing Care Plan, with 1/22/25 goal date, the resident would not have signs and symptoms of poor oxygen absorption, directed staff: a. Administer oxygen as ordered, initiated 10/15/24. b. Ensure that oxygen supply is available at all times, initiated 10/15/24. c. Monitor for signs and symptoms of respiratory distress and report to physician as needed: respirations, pulse oximetry, increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, hemoptysis (blood-tinged or bloody mucous produced with cough) cough, pleuritic pain (pain associated to the chest wall), accessory muscle usage (actions in attempts to draw more air into the chest during respirations, that include sitting upright with chest leaned forward, using muscles in the neck not normally used during respirations) and skin color, initiated 10/15/24. d. Oxygen settings: Oxygen via nasal cannula at 2 liters per minute PRN, humidified, initiated 10/15/24. The resident's recorded food intake, recorded by percentage at the breakfast, lunch and supper meals, and fluid intake, recorded in milliliters (ml) at each of the 3 daily meals revealed the following: Food Fluid 10/7/24 0-25% 120 0-25% 60 0-25% 240 420 total, or 14 ounces 10/8/24 0-25% 50 Refused 0-25% 240 290 total, or just under 10 ounces 10/9/24 0-25% 0-25% 20 0-25% 25 45 total, or 1 and 1/2 ounces 10/10/24 0-25% 120 Refused 120 0-25% 50 290 total, or just under 10 ounces 10/11/24 0-25% 60 0-25% 80 0-25% 120 240 total, or 8 ounces 10/12/24 Refused 0-25% 60 26 - 50% 120 180 total, or 6 ounces 10/13/24 0-25% 120 0-25% 120 76 - 100% 340 580 total, or just over 19 ounces 10/14/24 0-25% 50 Refused 100 0-25% 0 150 total, or 5 ounces 10/15/24 26 - 50% 110 0-25% 0 0-25% 60 170 total, or just under 6 ounces 10/16/24 0-25% 240 0-25% 120 0-25% 0 360 total, or 12 ounces Physician orders directed staff: 1. Administer Metformin (an oral anti-diabetic medication that helps reduce blood sugar) 500 milligrams (mg) oral 2 times daily, ordered 9/17/24. 2. Administer Mucinex 600 mg Extended Release (ER), 1 tablet oral every 12 hours as needed, ordered 10/8/24. This order was changed later on 10/8/24 to 2 ER tablets (1200 mg) administered oral twice daily for 14 days. 3. Administer Albuterol 2.5 mg in 3 milliliter (ml) solution via inhalation nebulizer every 6 hours as needed, ordered 10/8/24. This order was discontinued later on 10/8/24 and changed to administer DuoNeb, (Ipratropium-Albuterol 0.5-2.5 mg in 3 ml, inhaled via nebulizer 4 times daily for 14 days. 4. Prednisone (a steroid used to reduce swelling and treat infection) 40 mg administered oral daily for 5 days, ordered 10/8/24 to start 10/9/24. The facility's daily nursing schedules revealed the following nursing staff assigned: 10/12/24 6:00 a.m. to 2:00 p.m. Director of Nursing (DON) 2:00 p.m. to 6:00 p.m. DON 6:00 p.m. to 6:00 a.m. on 10/13/24 Staff C, Licensed Practical Nurse (LPN) 10/13/24 6:00 a.m. to 2:00 p.m. DON 2:00 p.m. to 10:00 p.m. Staff D, LPN 10:00 p.m. to 6:00 a.m. on 10/14/24 Staff C, LPN 10/14/24 6:00 a.m. to 2:00 p.m. Staff A, LPN 2:00 p.m. to 10:00 p.m. Staff E, LPN 10:00 p.m. to 6:00 a.m. on 10/15/24 Staff B, RN 10/15/24 6:00 a.m. to 2:00 p.m. Staff A, LPN 2:00 p.m. to 10:00 p.m. Staff D, LPN 10:00 p.m. to 6:00 a.m. on 10/16/24 Staff B, RN 10/16/24 6:00 a.m. to 2:00 p.m. Staff A, LPN 2:00 p.m. go 10:00 p.m. DON Nursing Progress Note entries included the following: 10/2/2024 at 2:53 p.m., Staff A, Licensed Practical Nurse (LPN): Resident with cold symptoms including runny nose, cough, voice change, chest congestion. Covid test completed and positive. Notified provider, order for Molnupiravir (an anti-viral medication used to treat Covid) 800 milligrams (mg) administered oral twice daily for 5 days. 10/8/2024 at 2:15 a.m., Staff B, Registered Nurse (RN): Contacted provider, physician order for 2 view portable chest X-Ray for congested lung sounds, low oxygen saturation, and positive for Covid. Order to administer Mucinex (an expectorant that loosens and thins mucous/congestion) 600 mg oral every 12 hours as needed, apply Oxygen at 2 liters per nasal cannula as needed to keep oxygen saturation above 90%, and 1 vial Albuterol (a potent bronchodilator, used for emergency relief during airway constriction and asthma attacks) administered by nebulizer inhalation 4 times a day as needed. 10/8/2024 at 6:33 a.m., Staff B, RN: Changes in condition with congestion. Vital signs: T: 97.9, P: 67, R: 18, BP: 121/87, Oxygen saturation (O2 Sat): 85%, lung sounds congested. Applied Oxygen, notified Director of Nursing (DON) then on-call provider with orders received as noted. 10/8/2024 at 4:28 p.m., Staff A, LPN: Provider in facility and clarified Mucinex and nebulizer orders given by on call provider last evening. Orders changed to DuoNeb (mixture of Albuterol and Ipratropium, bronchodilator and a mucous expectorant) administered by inhalation 4 times daily for 14 days, and Mucinex increased to 1,200 mg administered oral twice daily for 14 days. 10/8/2024 4:50 p.m., Staff A, LPN: Resident continues on Oxygen and doesn't show any signs or symptoms of distress. He doesn't communicate well and just rests with his eyes closed. Chest X-ray completed earlier this shift, orders received, see previous documentation for details. Resident states he just feels tired. 10/9/2024 4:44 p.m., Staff B, RN: Resident is tolerating anti viral medication without noted or reported adverse reactions. Resident's appetite or fluid intake at baseline. Resident continues on Oxygen and doesn't show any signs or symptoms of distress. Vital signs within normal limits. Will continue to monitor per protocol. 10/10/2024 at 3:14 a.m., Staff C, LPN: Monitoring for positive COVID. O2 Sat level has come up to 93% on room air. Lungs clear bilaterally, diminished throughout. Denies shortness of breath, afebrile. Will continue to monitor. 10/11/2024 at 2:00 a.m., Staff C, LPN: Monitoring for positive COVID. O2 level has come up to 93% on room air. Lungs clear bilaterally, diminished throughout, some upper chest/throat congestion noted that clears with cough. Occasional dry cough reported. Denies shortness of breath, denies pain. Afebrile. Will continue to monitor per protocol. 10/11/2024 5:25 p.m., Staff A, LPN: Resident currently being monitored as he is Covid positive and currently in isolation. He is tolerating anti viral medication without noted or reported adverse reactions. Resident's appetite or fluid intake decreased today. Resident's O2 Sat's adequate on room air and doesn't show any signs or symptoms of distress. Resident did have a large loose stool this shift and was noted to have redness to his right medial heel that resolved when pressure was relieved. Heel boots applied and feet floated on a pillow as well. Vitals within normal limits. Will continue to monitor per protocol. 10/12/2024 at 11:45 p.m., recorded as a Late Entry, actually recorded on 10/13/24 at 7:47 a.m. by Staff C, LPN: Monitoring for positive COVID. Lungs congested bilaterally, diminished throughout. O2 Sat 86% on room air. No cough noted. Denies shortness of breath, denies pain. Afebrile. Will continue to monitor per protocol. 10/12/2024 at 11:50 p.m., recorded as a Late Entry, actually recorded on 10/16/24 at 8:47 a.m. by the Director of Nursing (DON): Oxygen applied, O2 Sat 96% with Oxygen at 2 liters per minute per nasal cannula. Resident denies concerns, call light in reach upon exit. 10/13/2024 at 12:00 a.m., Staff C, LPN: Recheck O2 Sat 93% on Oxygen at 2 Liters per nasal cannula. There were no other entries recorded in the resident's medical record until this entry, recorded by the facility's Registered and Licensed Dietician (RDLD), who wrote: 10/16/2024 at 7:55 a.m. Resident with rapid significant weight loss. Nutrition focused physical exam (NFPE) performed with severe fat loss noted to orbital sockets and triceps. Severe muscle loss to temporalis, clavicle, shoulder and calf. Resident is not interested in any food or supplements. No appetite. Hospice level of care recommendable from dietary perspective. The next entry, recorded by the DON, stated: 10/16/2024 at 8:10 p.m., Resident not answering questions, hard to respond. Family visited an hour prior. Power of Attorney (POA) notified of current events and said they will be up to visit. Vital signs within normal limits, call light within reach, will continue to check frequently. 10/16/2024 at 8:32 p.m., the DON stated: Resident unresponsive, with [NAME] Stokes breathing noted (a breathing pattern that involves alternating periods of deep, rapid breathing with shallow breathing, and sometimes pauses in breathing or apnea, and usually associated with imminent death.) Order obtained from provider on call for transfer to hospital by ambulance. Resident remains full code, paramedics arrived and transferred resident to hospital. The last recorded vital signs recorded in the resident's record were: 10/8/24 at 7:12 a.m., T 97.9, B/P 121/87, P 67, by Staff B, RN. 10/12/24 at 11:45 p.m., R 20, by Staff C, LPN. 10/12/24 at 11:45 p.m. O2 Sat 86% on room air, 10/13/24 at 12:00 a.m. O2 Sat 93% on Oxygen at 2 liters via nasal cannula, by Staff C, LPN. There was no documentation of any physical assessment of the resident between 10/13/24 and 10/16/24, until the assessment by the dietician on the morning of 10/16/24. The DON's documentation on 10/16/24 revealed the resident's vital signs were stable, however there was no documentation of vital signs or assessment of the resident other than when found unresponsive, with [NAME] Stokes respirations. The resident's record did not reveal any documentation that the physician was notified of the resident's limited and sometimes refused oral intake. The last recorded blood sugar in the record was obtained on 4/19/23, 145 mg/dl (milligrams per deciliter). The resident arrived at the nearest hospital's emergency room (ER) at approximately 9:00 p.m. on 10/16/24, minimally responsive, in a metabolic crisis with blood sugar of 667 mg/dl obtained at 9:07 p.m. (normal range 70 to 110 mg/dl). The resident was treated for Hyperosmolar Hypoglycemic State, or HHS, a life-threatening emergency manifested by marked elevation of blood glucose and hyperosmolarity (high blood sugar with high sodium level) with little or no ketosis (when the body burns fat instead of blood sugar for energy), usually caused by an infection, left lower lobe pneumonia, dehydration and acute renal failure. The resident required transfer to a larger hospital within 3 hours due to the critical nature of his condition and care requirements, hospitalized in the Intensive Care Unit for 4 days, and discharged to the facility from the hospital on [DATE]. The facility's Change in a Resident's Condition or Status policy, dated as revised February, 2021, directed staff: 1. Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. 2. The nurse will notify the resident's attending physician when there has been a significant change in the resident's physical/emotional/mental condition, or need to alter the resident's medical treatment significantly. 3. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; and requires interdisciplinary review and/or revision to the care plan. 4. Prior to notifying the physician, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including information prompted by the Interact SBAR Communication Form. 5. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status. The resident's POA, interviewed 10/29/24 at 9:34 a.m. stated they had not seen the resident since before he had Covid due to their own health issues, the facility would usually call when he was sick, but had not notified them of the bruise/sore on his left heel, and the first they knew of the resident being so sick was on 10/16/24 when staff called at 4:42 p.m. and said he wasn't responding like he normally did and asked them to come to the facility. The POA directed the facility to notify a family member who lived closer to come, as the POA lived over an hour away. The POA didn't hear anything more until 8:50 p.m., when the facility called and said the resident was non-responsive and asked what they should do. The POA directed the staff to call the doctor and take the resident to the hospital. The POA drove to the hospital where she saw the resident and spoke to the doctor, the doctor told them he was in critical condition and had to go to a larger hospital as they couldn't provide the care he needed there, and the doctor warned that he may not make it to the next hospital as he was that sick and dehydrated, his blood sugar was over 650. The resident's family member, interviewed 10/30/24 at 12:02 p.m. stated they visited the resident on the afternoon of 10/16/24 and hadn't seen the resident since before he had Covid. They didn't know exactly what to expect, the resident slept throughout most of the visit and they thought he was tired from having Covid, didn't realize he was so sick and would have to go to the hospital that evening. The resident stayed in bed, he didn't want to get up. At one time the resident said he was so tired and just wanted to sleep, the family member thought that's what the resident needed and stayed near the resident as he slept, then had to leave around supper time. Staff interviews revealed: 10/29/24 at 10:14 a.m., Staff H, Certified Medication Aide (CMA), stated she administered breathing treatments to residents and had administered them to the resident before he went to the hospital, there wasn't anything in the directives that she had that told her the nurse had to assess the resident when she gave the breathing treatments, like when she gave a pain medication and the nurse had to assess the resident for that. 10/29/24 at 10:17 a.m., Staff J, RN, Assistant Director of Nursing (ADON) stated if a resident had breathing treatments ordered, the nurse should assess the resident's breath sounds at least daily, if the resident had abnormal breath sounds, or had a cough, or mucous production with a cough the nurse should check the resident's breath sounds before and after their breathing treatments, and other assessments as indicated such as O2 Sat, vital signs, how the resident was feeling. 10/29/24 at 12:07 p.m., the facility's RDLD stated she had last seen the resident about a month before she saw him on 10/16/24. On 10/16/24 he definitely appeared malnourished, had no interest in food, he was seated in a wheelchair in the Dining Room when she saw him. He wouldn't eat even with much staff encouragement. Over the last 3 to 4 months he didn't have much interest in food, but that got much worse when he had Covid. She had put several dietary interventions in place, with quite a variety offered, but the resident just didn't want to eat. 10/29/24 at 1:03 p.m. Staff A, LPN, stated the resident had not been eating or drinking, even before he had Covid, but did better with drinks, staff could usually get him to drink something. She worked on 10/16/24, when she left work that day the resident was talking, he was more tired and told his family he was worn out, but he did respond to questions. There had not been any change in his breath sounds, she had not heard him coughing or wheezing. Staff A stated she documented breath sounds in the Nursing Progress Notes when she assessed them. 10/29/24 at 2:08 p.m. Staff F, a DON at a different facility owned by the same corporation and who was at the facility during the facility's DON's absence stated if a resident had an order for Oxygen to maintain O2 Sat's at a certain level, and had to have the Oxygen in order to do that, the nurse should assess the resident's O2 Sat at least daily and as needed. Staff should assess resident breath sounds when they had breathing treatments ordered to treat respiratory conditions, before and after the breathing treatments, continue to make the assessments until the resident's breath sounds were normal, and the assessments should be documented in the resident's record. Staff should continue to assess the breath sounds as needed with the resident's condition, and document the findings in the record. 10/30/24 at 9:36 a.m., the facility DON, Staff G, stated the resident wasn't doing well on 10/16/24, she had to work as the nurse that evening because the facility was having their annual survey by the State (Iowa Department of Inspections, Appeals, & Licensing) and nobody wants to work then. The RDLD had seen the resident that day and they were trying to make a referral to Hospice due to his decline, but could not describe any actions that were taken to initiate the referral at that time. The DON stated the girls said there was something different, the girls referring to facility staff. The DON stated the ADON had gone into assess him and said his vital signs were lower, so she went in to assess him then and he was non-responsive. She notified the POA, they said to send him to the hospital, the ambulance came and they asked what they were supposed to do because he was dying. The DON stated she gave the ambulance staff report and directed them the resident was a full code and was to be taken to the hospital. When asked if she had called report to the hospital (a standard of practice) the DON stated no, she gave report to the Emergency Medical Technicians (EMT's) that worked on the ambulance. The DON acknowledged the resident received breathing treatments, was on oxygen to keep his saturations up, she had not assessed his breath sounds that day, on days prior they were diminished, cleared when he coughed if she remembered correctly. When asked where her assessments would be documented, the DON stated in the Nursing Progress Notes, and staff should check breath sounds if they were abnormal, or if they were on breathing treatments and record the findings in the record. She checked his O2 Sat when he was non-responsive and it was 94% with the oxygen on. When asked if she had checked his blood sugar, or knew that it was 667 upon his arrival to the ER, the DON stated the resident had not been eating when he had Covid and didn't understand why his blood sugar was so high. 10/29/24 at 1:18 p.m., Staff I, Certified Nursing Assistant (CNA) stated when the resident had Covid, he didn't have an appetite at all, and wouldn't eat even with a lot of encouragement and support by staff. He did better with liquids/supplements, and even that took a lot of coaxing in order to get the resident to drink. Staff I stated she would tell the nurse when the resident refused to eat anything.

Based on observation and resident interview the facility failed to provide a resident room tray until early afternoon for 1 resident (Resident #5) and when the tray was served the facility failed to provide metal eating utensils. The facility reported a census of 37 residents. Findings include: During an observation on 10/15/24 at 12:33 PM the administrator approached Resident #5's room to ask if she was coming to the dining room. Resident #5 requested a room tray. The resident's tray was delivered to her room at 1:38 PM. When her tray was delivered she was given plastic eating utensils. During an interview on 10/15/24 at 1:47 PM the resident stated she wished the facility would have given her regular eating utensils, not the plastic.

Based on interviews, personal health record reviews and pharmacy recommendation reviews, the facility failed to have a provider respond to a monthly pharmacy recommendation in July and in August for 1 of 5 residents reviewed (Resident #8). The facility reported a census of 37 residents. Findings include: A Physician Recommendation dated 7/10/24 and A Physician Recommendation dated 8/7/24, sent from the Consultant Pharmacist to the provider both requested the provider consider a reduction in Sertraline (antidepressant medication) to 150 milligrams (mg). These 2 recommendations went without a provider response. A Physician Recommendation dated 9/9/24, documented this was the third request and requested the provider consider a reduction in Sertraline (antidepressant medication) to 150 mg. The response from the Mental Health Nurse Practitioner documented the patient had been stable and a dose reduction in therapy may impair function and/or cause patient distressed behavior or to be of psychiatric instability by exacerbating this resident's psychiatric disorders. This response was dated 9/18/24. On 10/16/24 at 4:40 p.m., the DON brought the 9/18/24 response to Sertraline. She did not have responses to GDR (Gradual Dose Reduction) requests from 7/10/24 or 8/7/24. The DON stated that the Nurse Practitioner who follows his psychiatric medications doesn't see him as often and she was the one who responded on 9/18/24. A 9.1 Medication Regimen Review policy revised on 3/30/20, directed the following: This Policy 9.1 sets forth procedures relating to the medication regimen review (MRR). The Consultant Pharmacist will conduct MRR's if required under a Pharmacy Consultant Agreement and will make recommendations based on the information available in the residents' health record. Facility should encourage Physician/Prescriber or other Responsible Parties receiving the MRR and the Director of Nursing to act upon the recommendations contained in the MRR. For those issues that require Physician/Prescriber intervention, Facility should encourage Physician/Prescriber to either accept and act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. If the attending physician has decided to make no change in the medication, the attending physician should document the rationale in the residents' health record. Facility should alert the Medical Director where MRR's are not addressed by the attending physician in a timely manner.

Based on observation, document review, and resident and staff interview the facility failed to maintain hot foods above 135 degrees Fahrenheit and cold beverages below 41 degrees Fahrenheit for 1 of 1 test trays. The facility failed to address the food temperatures on room trays despite residents voicing their concerns about cold food during Food Council Meetings on 2/20/24, 3/12/24, 4/15/24, 5/21/24 and 1 undated meeting. The facility reported a census of 37 residents. Findings include: During an interview on 10/14/24 at 2:30 PM, Resident #5 explained her food was sometimes cold when she got her room trays. During the lunchtime meal service, a test tray was temperature checked immediately following the last room tray served on the 100 hall. The food temperatures included fish at 149.0 degrees Fahrenheit, rice at 133.7 degrees Fahrenheit, peas at 121.0 degrees Fahrenheit. The chocolate milk temped at 46.6 degrees Fahrenheit and the juice temped at 43.2 degrees Fahrenheit. Staff A explained hot food should be 165 degrees Fahrenheit and cold food and drinks should be below 40 degrees Fahrenheit. She stated that's not good when the milk was temped. Food items were tasted by the surveyor. The fish and rice tasted lukewarm and the peas tasted cold. The milk and juice were not sampled for temperature and palatability. The Food Council minutes for February, March, April, May, and 1 undated report all documented food temperatures, specifically food being cold or warm, not hot. The February, March, April, and May Food Council minutes were signed by facility staff. The undated Food Council minutes report was unsigned.

Based on observations, interviews, and record review, the facility failed to obtain a doctor's order for a change in diet for 1 of 6 resident's reviewed (Resident #16). Speech Therapy recommended a diet change from pureed to mechanical soft. A Doctor's/Provider's order was not obtained for a diet change and the facility served a mechanical soft diet to the resident without the order. The facility reported a census of 37 residents. Findings include: A Diet Type Report dated 10/14/24 at 12:38 p.m., documented that 2 residents were to receive a pureed textured diet. Resident #16 was one of the 2 residents. A physician's diet order dated 9/19/24, documented that Resident #16's diet was to be pureed texture. On 10/15/24 at 9:35 a.m., the Dietary Manager (DM), stated serving started at 11:45 a.m. The DM stated they only had one resident that was on a pureed diet and that resident had asked for broth for lunch. A Therapeutic Spread Report-Spring/Summer Menu '24 signed as approved by the Regional Dietitian on 4/8/24, documented the following for week 1 Tuesday's lunch: Regular diet: baked fish 3 ounces, rice pilaf ½ cup, green peas ½ cup, apple crisp ½ cup and 1 slice of whole wheat bread with margarine. Mechanical Soft diet: 3 ounces of ground fish, rice pilaf ½ cup, wax beans ½ cup, apple crisp ½ cup and 1 slice of whole wheat bread with margarine. Pureed: baked fish 3 ounces pureed, rice pilaf pureed 1 serving, wax beans pureed 1 serving, whole wheat bread pureed 1 serving, and apple crisp pureed 1 serving. On Tuesday, 10/15/24 at 11:57 a.m., Staff B, Cook, took temperatures on the following food prior to the start of lunch service: fish patties 176 Fahrenheit (F), peas 168 F, waxed beans 175.8 F, apple crisp 176.4, rice pilaf 209.2 F and mechanical soft rice 205 F (no almonds). There was no food altered into puree texture. On 10/15/24 at 11:59 a.m., the kitchen started serving their first trays. When it came time to serve Resident #16, Staff B, Cook, placed on her plate bread and butter, a fish patty, waxed beans, and rice. When asked about Resident #16 having an order for a pureed texture diet, the Dietary Manager stated they were trialing a mechanical soft diet for Resident 16. The Registered Dietitian stated that on her list it showed Resident #16 was to receive pureed. The Dietitian asked 'when did it change to a trial?' The DM stated that she would go and check. The DM then left the kitchen and brought back a Nursing/Therapy communication. A Nursing/Therapy communication dated 10/8/24 at 1:00 p.m., documented the following: therapy to nursing. Problem and/or change in diet texture. Recommending upgrade to mechanical soft. Continue thin liquids. Assist with feeding as needed. A physician's diet order dated 10/15/24 at 12:32 p.m, documented that Resident #16's diet was to be mechanical soft texture. The previous physician's order for pureed texture was discontinued on 10/15/24 at 12:30 p.m., with a note that diet was upgraded. On 10/15/24 at 03:10 p.m., the Administrator and the Nurse Consultant acknowledged the concern with Resident #16's diet order not being obtained for an upgrade from pureed to mechanical soft until today 10/15/24. The Administrator and the Nurse Consultant acknowledged the recommendation was given by Speech Therapy on 10/8/24. She stated that the kitchen should not have changed the diet without an order. The Director of Nursing (DON) stated that they were trialing the mechanical soft diet first. The Nurse Consultant stated that a trial could be done but could not last longer than 3 days and this had gone on longer than 3 days. An Interdepartmental Notification of Diet (Including Changes and Reports) policy revised 10/2017, directed the following: Nursing services shall notify the food and nutrition services department of a resident's diet orders, including changes in the resident's diet, meal service and food preferences. A Therapeutic Diets policy revised on 10/2017, directed: Therapeutic diets are prescribed by the Attending Physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. A 'therapeutic diet' is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet. The dietitian, nursing staff, and attending physician will regularly review the need for, and resident acceptance of, prescribed diets.

Based on observations, interviews, and policy review, the facility failed to safely handle food when preparing sandwiches. The staff put on gloves then touched other items with gloved hands prior to touching bread with the same gloved hands. The facility reported a census of 37 residents. Findings include: On 10/15/24 at 1:05 p.m., Staff B, Cook, dumped a slice of bread out of the bread bag on to a plate then moved it more center on the plate with his fingers. Staff B put peanut butter on the bread while holding it with his fingers. Staff A, Dietary Manager for another facility, had Staff B start over. Staff B then put 2 gloves on his right hand. He then took one glove off and grabbed bread and spread peanut butter on it. Staff B then opened cupboard doors with both hands, took a plastic knife out then grabbed the slice of bread with his left hand and held it while he put butter on. On 10/15/24 at 1:16 p.m., Staff D, Cook, put gloves on and spread butter on bread, he then touched the plate and after touching the plate spread butter again on to bread while grabbing bread to make a grilled cheese. On 10/15/24 at 1:19 p.m., Staff B had gloves on and touched the peanut butter container then the jelly container then a plate. He then picked up bread and put the peanut butter and jelly on bread to make a sandwich while wearing the same gloves. Staff B then touched a potato chip bag, reached into the bag grabbed chips and placed in bowl all while wearing the same gloves. On 10/15/24 at 3:10 p.m., the Administrator and the Nurse Consultant acknowledged the issue with using gloved hands and touching food after touching other objects with the same gloved hands. A Preventing Foodborne Illness - Food Handling policy revised on 7/2014, directed the following: Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. 1. This facility recognizes that the critical factors implicated in foodborne illness are: a. Poor personal hygiene of food service employees; b. Inadequate cooking and improper holding temperatures; c. Contaminated equipment; and d. Unsafe food sources. 2. With these factors as the primary focus of preventative measures, this facility strives to minimize the risk of foodborne illness to our residents. 3. All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents.

Based on observations, interviews, and record review, the facility served 1 resident the wrong diet (Resident #27) and failed to initially set up the appropriate diets for 4 other residents with the intention to serve them prior to the Dietician stopping the kitchen staff from serving the wrong diets (Residents #12, #18, #26 and #28). The facility served 37 residents on the day of kitchen observation. The facility reported a census of 37 residents. Findings include: 1. A physician's diet order dated 2/20/24, documented that Resident #12's diet was to be mechanical soft texture. 2. A physician's diet order dated 10/1/21, documented that Resident #18's diet was to be mechanical soft texture. 3. A physician's diet order dated 12/12/23, documented that Resident #26's diet was to be mechanical soft texture. 4. A physician's diet order dated 3/12/24, documented that Resident #27's diet was to be mechanical soft texture. 5. A physician's diet order dated 5/7/24, documented that Resident #28's diet was to be mechanical soft texture. A Therapeutic Spread Report-Spring/Summer Menu '24 signed as approved by the Registered Dietitian on 4/8/24, documented the following for week 1 Tuesday's lunch: Regular diet: baked fish 3 ounces, rice pilaf ½ cup, green peas ½ cup, apple crisp ½ cup, and 1 slice of whole wheat bread with margarine. Mechanical Soft diet: 3 ounces of ground fish, rice pilaf ½ cup, wax beans ½ cup, apple crisp ½ cup, and 1 slice of whole wheat bread with margarine. On Tuesday, 10/15/24 at 11:57 a.m., Staff B, Cook, took temperatures on the following food prior to the start of lunch service: fish patties 176.0 Fahrenheit (F), peas 168.0 F, waxed beans 175.8 F, apple crisp 176.4 F, rice pilaf 209.2 F and mechanical soft rice 205.0 F (no almonds). On 10/15/24 at 11:59 a.m., Staff B set up Resident #27's tray to be delivered to his room. Staff B placed a whole fish patty, waxed beans, rice without almonds, and apple crisp on a paper plate. This was sent out to Resident #27's room. On 10/15/24 at 12:41 p.m., the Registered Dietitian told Staff B to grind up Resident #26's fish patty that was already on the plate and ready to be served. When the Registered Dietitian was asked if all residents with mechanical soft diets should have their fish ground, this Dietitian answered yes. When told that Resident #27 was served regular fish, this Registered Dietitian acknowledged this and stated she was going to go check on Resident #27. On 10/15/24 at 12:44 p.m., Staff B ground up 3 more fish patties. He then placed the ground fish on plates with peas and rice with no almonds. Staff B then placed the plates on a cart to send out to the dining room for service. When asked about the peas Staff B stated he should have put waxed beans on the plates. Staff B then changed all three plates out by removing the peas and adding waxed beans. These plates were for Resident #12, Resident #18 and Resident #28. On 10/15/24 at 12:48 p.m, the Dietary Manager stated that Resident #27 had not eaten his meal yet as he needed assistance, so Resident #27 hadn't eaten the fish. On 10/15/24 at 12:55 p.m., the Dietary Manager came back in to the kitchen and said she was mistaken, and that Resident #27 had eaten. This Dietary Manager brought Staff C, Certified Nurse Aide (CNA), along and stated that Staff C had assisted Resident #27 to dine. Staff C stated she cut the fish up in to small pieces and mixed It with tartar sauce. On 10/15/24 at 3:10 p.m., the Administrator and the Nurse Consultant acknowledged that Resident #27 was served a whole fish patty from the kitchen when it should have been ground, that Staff B was going to serve Resident #26 a whole fish patty and would have served it if the Dietitian would not have intervened, and that Staff B was going to serve Resident #12, Resident #18, and Resident #28 peas instead of waxed beans. The Administrator and the Nurse Consultant acknowledged that all 5 of these residents were to receive a mechanical soft altered diet and whole fish patties and peas should not have been served to residents who were on a mechanical soft diet. On 10/16/24 at 10:32 a.m, the Registered Dietitian stated she had consistent communication with the Dietary Manager. She stated she was in the building 1-2 times a month and then they communicate weekly through phone calls and emails. She stated she came to the facility on this morning and implemented a Nutrition Management program available through their electronic health records that prints off each resident's diet slip. She stated they utilized the strips this morning and it worked well and this is what they will be using from here on out. This will ensure all residents receive a meal and receive the appropriate diet. When asked about the wrong diets being served up on to plates and the fish not being ground, the Dietitian stated she had never seen that before at this facility. A Therapeutic Diets policy revised on 10/2017, directed: Therapeutic diets are prescribed by the Attending Physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences. A 'therapeutic diet' is considered a diet ordered by a physician, practitioner or dietitian as part of treatment for a disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet. The dietitian, nursing staff, and attending physician will regularly review the need for, and resident acceptance of, prescribed diets.

Based on clinical record reviews, staff and resident interviews, observations, and review of dietary spread sheets/menus the facility failed to prepare and serve the correct amount of food for 2 of 3 dining observations. The facility failed to provide education for dietary staff prior to working independently. The facility reported a census of 39 residents. Findings included: Observation on 2/19/24 at 12:00 pm revealed Staff H, [NAME] getting ready to start serving the noon meal. Staff H, [NAME] picked up a pair of silver tongs and dished up a mixture of spaghetti noodles mixed with red sauce and ground beef. Staff H grabbed the mixture with the tongs and placed it on a dinner plate, failing to measure the amount given to the residents. He placed the rest of the meal on the plate and served it to the residents, each resident received an unmeasured serving of the spaghetti mixture for the noon meal. Review of the dietary spread sheets for 2/19/24 noon meal directed the cook to serve each resident on a regular diet: a. 6 ounce ladle of meat sauce b. 4 ounce spoodle of spaghetti noodles c. 1/2 cup of broccoli d. 1 slice of garlic bread e. 1/2 cup of sherbet. Observation on 2/19/24 at 12:45 pm Staff H, [NAME] finished serving the noon meal, Staff F, Dietary Manager asked to remove the last plate of food that was to be delivered to a resident and measure the amount of spaghetti mixture. Staff F measured a total amount of 6 ounces of spaghetti mixture, the amount the cook served to each resident. Staff F stated the [NAME] did not serve it correctly and did not serve the correct amount of food. Observation at the completion of the serving revealed at least 1/2 of the prepared spaghetti mixture remained on the steam table, not served to the residents. Staff F prepared each resident a 1/2 cup of cottage cheese stating they did not receive enough protein so I will supplement the meal with the cottage cheese. Observation on 2/19/24 at 12:50 revealed Staff F re-educated Staff H, [NAME] on the appropriate serving scoops and how to read the spread sheets. Staff H stated he has never seen the dietary spread sheets before and hasn't used them. Staff H, [NAME] stated he made approximately 40 servings of spaghetti and meat sauce for the noon meal. Staff H, [NAME] stated he was oriented for 3 days and then thrown in to work alone because they were short staffed. Staff H indicated he as been employed at the facility approximately for 3 weeks. Observation on 2/20/24 at 11:00 am revealed Staff I, [NAME] preparing to puree 3 servings of pears for the noon meal. Staff I opened a can of diced pairs and measured 3 servings, 1/4 cup each, into a Robo coupe blender. Staff I stated she will serve only pears to the residents with pureed diets as per the spread sheet for the noon meal. Staff F, CDM present at this time did not recognize the [NAME] used a 1/4 cup measure instead of a 1/2 cup measure. Surveyor stopped the [NAME] and informed her she used the wrong scoop size for the pureed pears. Staff I, [NAME] stated she always uses that scoop, that was how she was trained to do it. Review of the dietary spread sheet for 2/20/24 noon meal directed the cook to puree 1/2 cup of lime pear square. During an interview on 2/19/24 at 1:00 pm with Staff A, Business Office Manager, stated she cannot find any dietary training for Staff H, [NAME] and Staff I, [NAME] in their employee files. During an interview with Staff B, Administrator on 2/19/24 at 2:10 pm revealed the facility has not had a Certified Dietary Manager since 12/31/23. Staff B stated the facility had many dietary problems, they cannot get staff, the staff are then not trained as they should be. Staff B stated it had been a ongoing problem.

Based on clinical record review, staff interviews, and observations the facility failed to employ a full time Director of Nurses since 1/26/2024. The facility reported a census of 39. Findings include: During an interview with Staff B, Administrator on 2/19/24 at the start of the survey, Staff B stated the former Director of Nurses (D.O.N.) left facility employment on 1/26/24 after working in facility for approximately 1 year. Staff B provided the surveyor a staff list which identified the D.O.N. as Staff E. Staff E is the full time D.O.N. from one of the corporation's sister facilities. Staff B stated Staff E was interim until a replacement for the former D.O.N. could be found and then stated Staff E will be transferring to this facility. The Administrator stated Staff C, LPN Assistant Director of Nurses transferred to the facility from another facility on 2/7/24. During an interview with Staff B, Administrator on 2/20/24 at 1:40 pm, Staff B stated Staff E will not be coming to the facility to serve as the Director of Nurses instead is the interim Director of Nurses. Staff B stated they are currently looking for a Director of Nurses but do not have any prospects. During an interview with Staff E, D.O.N. on 2/22/24 at 11:00 am, Staff E stated she is not transferring to this facility. She stated she did come to the building last Thursday, 2/15/24 and again today 2/22/24 to assist. During an interview with Staff A, Business Office Manager on 2/19/24 at 1:00 pm, Staff A stated the former D.O.N. left employment on 1/24/24 and currently there are no prospects for the D.O.N. position. Staff C, LPN/Assistant Director of Nurses did transfer to this facility to help fill the D.O.N. void.

Based on clinical record review, staff and resident interviews, observations, and dietary schedules the facility failed to employ a full time Dietary Manager since 12/31/23. The facility reported a census of 39. During an interview with Staff B, Administrator on 2/19/24 at the start of the survey, Staff B stated the former Food Service Supervisor left facility employment on 12/31/23. Staff B provided a staff list which failed to identify a Dietary Manager. Staff B stated the Certified Dietary Manager from a sister facility is providing coverage. Staff B acknowledged the facility does not have a Certified Dietary Manager at this time. Staff B stated the Certified Dietary Manager who has been covering occasionally at the facility did not obtain her certification until Feb. 4, 2024. During an interview with Staff F, Certified Dietary Manager from a sister facility on 2/19/24 at 12:20 pm stated the former CDM left on 12/31/23 and she has been coming to the facility 1 time weekly for the past month. During an interview with Staff G, Registered Dietician on 2/20/24 at 8:52 am revealed Staff G comes to facility 1 time a week since the former Dietary Manager left her employment. Staff G stated training has been an issue since the Dietary Manager left.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and observations the facility failed to employ an Assistant Administrator to provide Administrator coverage due to the Administrator being responsible for 2 facilities at the same time. The facility reported a census of 39 residents. Findings include: During an interview with Staff B, Administrator on 2/20/24 at 1:40 pm revealed she is the official administrator for 2 buildings, [NAME] and a sister facility which is 42.9 miles from [NAME]. Staff B stated she does not have an Administrative Assistant in either building. During an interview with Staff A, B.O.M on 2/19/24 at 1:00 pm, Staff A stated the Administrator is responsible for 2 facilities, this facility and a sister facility south of here. During an interview with Staff C, A.D.O.N. on 2/22/24 at 10:00 am, Staff C stated she recently worked with Staff B, Administrator at a sister facility where she has been the administrator for approximately 2 years. Staff C stated in the facility she recently left to come to [NAME] Speciality Care they did not have an Assistant Administrator and they do not have one in this building. Staff C stated if she felt the Administrator needed to know information and was not in the building she would call her. Staff C stated Staff B, Administrator had been running both buildings by herself for the past several years.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, policy review, and staff interviews, the facility failed to ensure clear direction of a resident's wishes regarding code status for 1 of 16 residents reviewed for advanced directives(Resident #43). The facility reported a census of 42 residents. Findings included: The Minimum Data Set (MDS) Assessment Tool, dated [DATE], listed diagnoses for Resident #43 which included diabetes, weakness, and cellulitis (inflammation of the tissue). The MDS listed the residents Brief Interview for Mental Status (BIMS) score as 11 out of 15, indicating moderately impaired cognition. The facility policy Cardiopulmonary Resuscitation and Do Not Resuscitate Orders, dated [DATE], directed staff to input the code status order into the Electronic Health Record (EHR), scan the declaration form into the EHR, and place it into the Code Status Binder at the nursing station. The Clinical Physician Orders, viewed in the EHR on [DATE] at 10:07 a.m., listed a [DATE] order for Cardiopulmonary Resuscitation (CPR). The Cardiopulmonary Resuscitation and Do Not Resuscitate (DNR) Order Declaration Form, located in a facility binder at the Nursing Station and dated [DATE], stated the resident wished to be a DNR status. On [DATE] at approximately 10:00 a.m., the Director of Nursing (DON) stated staff could look in the EHR or the paper document to determine a resident's code status. She stated both of the sources should match. On [DATE] at 11:33 a.m., the DON stated the code status order in the EHR was inaccurate and she corrected this. On [DATE] at 2:24 p.m. the Administrator stated staff could check code status in the EHR or in the Code Status Book. She stated both sources should match.

Based on observation, clinical record review, policy review, and staff interview, the facility failed to follow physician orders during the administration of a tube feeding for 1 of 1 residents reviewed receiving tube feedings (Resident #9). The facility reported a census of 42 residents. Findings Include: The Minimum Data Set (MDS) Assessment Tool, dated 5/16/23, listed diagnoses for Resident #9 which included multiple sclerosis, dysphagia (difficulty swallowing), and gastrostomy (G-tube-a tube inserted surgically into the stomach to provide nutrition, fluids, and/or medications) status. The MDS listed the resident's Brief Interview for Mental Status (BIMS) score as 9 out of 15, indicating moderately impaired cognition. On 7/18/23 at 3:30 p.m., Staff F, Licensed Practical Nurse (LPN) flushed the resident's G-tube with water, instilled 237 milliliters (mls) of Promote Nutrition, and then flushed with water. Staff F did not mix the Promote with water. Staff F did not ask the resident if he could mix the feeding with water. The facility policy Medication Orders, revised November 2014, directed staff to specify the type of feeding, amount, and frequency when inputting enteral orders. The policy directed staff to include the amount of flush following the feeding. The policy did not address the mixing of water with nutritional feedings. The Medication Administration Record (MAR) listed a 4/7/21 order for Nutrition Promote 237 ml mixed with 150 ml water twice daily. A Care Plan entry, revised 4/27/23, stated the resident received Promote 237 mls per G-tube mixed with 150 ml of water. On 7/20/23 at 12:23 p.m., the Director of Nursing (DON) stated she spoke to the Nurse Practitioner (NP) regarding mixing the resident's feeding with water. The DON stated the NP would update the order so this was not required and stated the resident was particular about his feedings because he completed them himself for several years. On 7/20/23 at 2:24 P.M., the Administrator stated she expected staff to follow physician orders.

Based on clinical record review, resident and staff interviews, and facility policy review, the facility failed to provide ordered nutrition supplements or contact the Dietician or provider for alternate options for 1 of 2 residents reviewed for nutrition (Resident #7). The facility reported a census of 42. Findings Include: The Quarterly Minimum Data Set (MDS) Assessment Tool, dated 7/5/23, listed diagnoses for Resident #7 which included malnutrition, abnormal weight loss, and disorientation. The MDS documented the resident required supervision and set up for eating and listed the resident's Brief Interview for Mental Status (BIMS) as 14 out of 15, which indicated intact cognition. A focus area of the Care Plan, revision dated 7/7/23, indicated Resident #7 provided with a diet order for small portions, regular texture, and thin liquids. The focus area included diagnoses of potential nutrition risk related to (R/T) the diagnoses of Congestive heart failure (CHF), Depression, Anxiety, gastro-esophageal reflux disorder (GERD), significant weight loss, diuretic use, varied intake, underweight, and at risk of malnutrition per the Mini Nutritional Assessment (MNA). A Care Plan intervention, revised on 7/19/22, indicated the resident wanted supplements provided as ordered. A policy titled Medication Orders, revised November 2014, revealed a current list of orders must be maintained in the EMR of each resident and commercial dietary supplement orders must specify the type, amount, and frequency. A Dietary Note, dated 7/7/23, indicated a Nutritional Assessment completed and included Supplements: House supplement 2 oz BID (twice per day). With Resident #7's weights listed as: a. On 7/6/23 89 pounds (lbs) b. on 6/11/23 90 lbs. c. On 4/2/23 90 lbs. d. On 1/6/23 94 pounds. BMI: 16.7 - underweight for age A Dietary Note, dated 7/7/23, indicated the MNA score of 11, at risk of malnutrition. The June 2023 Medication Administration Record (MAR) showed the ordered supplement was not available twice on 6/13/23, twice on 6/14/23, 6/19/23, 6/20/23, 6/27/23, and twice on 6/28/23. The July 2023 Medication Administration Record (MAR) indicated the ordered supplement was not available 7/10/23 and 7/11/23. Progress Notes, dated 6/13/23, 6/14/23, 6/19/23, 6/20/23, 6/27/23, 6/28/23, 7/10/23, and 7/11/23, lacked documentation regarding contact with the Dietician or provider for alternate nutrition supplementation when the House Supplement was not available. Progress notes, dated 6/13/23, 6/14/23, 6/19/23, 6/20/23, 6/27/23, 6/28/23, 7/10/23, and 7/11/23, lacked documentation regarding alternate nutritional support offered to the resident. Point of Care Task Nutrition Amount Eaten indicated that Resident #7 consumed the following: a. On 7/10/23, 0% to 25% of breakfast. b. On 7/10/23, 75% to 100% of lunch. c. On 7/10/23, 0% to 25% of dinner. d. On 7/11/23, 0% to 25% of breakfast. e. On 7/11/23, 25% to 50% of lunch. f. On 7/11/23, 0% to 25% of dinner. On 7/19/23, at 1:26 PM, the Administrator stated the expectation for nursing was to notify the Dietician for alternate options. The Administrator stated ordering responsibilities depended on the type of supplement, and Dietary ordered the House Supplement. On 7/19/23 at 2:05 PM, Staff C, Certified Medication Aide (CMA), confirmed that 'N/A' in Resident #7 progress notes meant not available. She stated the facility ran out of the house supplement a lot. On 7/20/23 at 09:14 AM, Resident #7 indicated she drank hot chocolate and milk for breakfast. The resident was unable to recall if she had the House Supplement today. Resident was unable to recall if there were days the supplement was missed.

Based on observation, record review, and staff interview, the facility failed to store and prepare foods under sanitary conditions for 2 of 2 kitchen observations. The facility reported a census of 42 residents. Findings Include: 1. The initial kitchen observation on 07/17/23 at 8:54 AM revealed the following: a. Expired food items, located in the dry storage room and refrigerator: 1. Browning, slimy celery, date unclear. 2. Browning lettuce, dated 7/13/23. 3. Lemon pudding, dated 7/11/23. 4. Hamburger buns, expiration date 7/15/23. 5. Hot dog buns, expiration date 6/22/23. b. A large bowl of mixed fruit was covered with saran wrap in the refrigerator. Approximately one inch of a clear liquid rested on the surface of the saran wrap. More liquid was observed dripping from the shelf above. c. At 9:11 AM, Staff D, Dietary Manager, washed her hands with soap and dried them with paper towels. She lifted the lid to the garbage can near the Handwashing Station with her bare left hand to throw away the towels and then entered the clean kitchen area and opened the refrigerator. d. At 09:21 AM, the floor on the clean side of the kitchen was sticky with staff's shoes making noise when lifting them off of the tile. e. At 9:30 AM, the temperature dial for the dishwasher was obstructed due to lime deposits. Staff D knelt to read the dial and stated it read between 125 and 130. Staff D attempted three different strips to monitor chlorine. Two of the strips did not register and the third indicated insufficient chlorine. 2. The second kitchen observation on 07/18/23 revealed the following: a. At 11:07 AM, food was located in the Handwashing Sink below a sign that read, There should be no food in this sink This is for hand washing-you know this!' Items included corn and chunks of a white substance. b. At 11:09 AM, the floor on the clean side of the kitchen was sticky and shoes made noise when lifting them off of the tile. c. At 11:21 AM, Staff D threw trash in the garbage by lifting the lid with her bare left hand and failed to complete hand hygiene after touching the lid. d. At 11:47 AM, Staff E, Dietary Aide, washed her hands with soap, dried her hands with a paper towel, and lifted the garbage lid with her bare left hand. She then touched a food delivery cart and a carton of milk. A policy titled Refrigerators and Freezers, revised December 2014, revealed supervisors are responsible for ensuring food items in the pantry and refrigerators are not expired or past perish dates. Supervisors will inspect refrigerators monthly for gasket condition, fan condition, presence of rust, and excess condensation. A policy titled Food Receiving and Storage, revised October 2017, indicated that functioning of the refrigerator will be monitored at designated intervals throughout the day. Food Services or other designated staff will maintain clean food storage areas at all times. A policy titled Handwashing/Hand Hygiene, revised August 2019, showed that all personnel shall be trained on the importance of hand hygiene. On 07/17/23 at 8:54 AM, Staff D indicated she was aware of the clear liquid on the fruit and indicated that maintenance would be notified. On 7/17/23 at 9:34 AM, Staff D established that the facility policy is to throw away expired foods and open items in the refrigerator should be no more than 3 days old. On 07/17/23 at 9:36 AM, Staff E, Dietary Aide indicated they were aware of issues with the dishwasher, stating the dishwasher servicing company was supposed to come fix it but they haven't been here for a while. On 7/17/23 at 9:51 AM, Staff D stated the dishwasher and refrigeration companies were contacted. On 7/17/23 at 11:59 AM, Staff D shared that the dishwasher company repaired the unit in time for lunch. On 7/20/23 at 2:13 PM, Staff A, Administrator confirmed Staff D was supervised by the Administrator and that kitchen staff are expected to follow facility hand washing policies and throw away expired items. The company that repaired the dishwasher usually followed a regular schedule.

Based on observation, clinical record review, policy review, and staff interviews, the facility failed to revise Resident Care Plans after each assessment for 1 of 12 residents (Resident #5). The facility reported a census of 40 residents. Findings Include: 1. The Minimum Data Set (MDS) Quarterly Assessments, dated 2/22/22 and 5/18/22 listed diagnoses for Resident #5 that included Huntington's Disease, dysphagia, and dystonia, unspecified. The MDS stated the resident required extensive assistance of two staff for bed mobility, transfers, and use of the toilet, with walking not assessed, total dependence for locomotion on and off the unit. The MDS listed the resident's Brief Interview Interview for Mental Status (BIMS) score as 2 out of 15, indicating severe cognitive impairment. The Care Plan dated 2/4/22 stated the resident required a one person assist with transferring, and use of the toilet. A Physical Therapy (PT) Evaluation and Plan of Treatment signed by the facility Physical Therapist on 12/6/21, and on 12/29/21 by the provider certifying the medically necessary services furnished under the Treatment Plan assessed the resident required an assist of two staff for all transfers, and at baseline is non-ambulatory. Observation on 5/23/22 at 4:12 PM, revealed the resident in bed with his feet up to mid calf dangled over the edge of the bed. He requested help to go to the bathroom. Staff F, Temporary Nurse Aide, entered the room and placed a gait belt around the residents waist. Staff F then with a one person physical assist stood the resident up and walked him to the bathroom. Staff F held onto the waist of the residents pants without use of the gait belt. The resident repeatedly stated I am gonna fall. Observation on 5/24/22 at 11:33 AM, revealed Staff G, Certified Nursing Assistant (CNA) and Staff H, CNA secured a gait belt around the residents waist prior to transfer. Both CNA's stood on each side of the resident, grabbed hold of the gait belt prior to standing and pivoting him to the wheelchair. The resident did not voice concern of falling. During an interview on 5/24/22 at 11:45 AM, Staff G, CNA stated the resident does not walk, and she would not transfer him herself as he sometimes jerks and it is not safe for one person to transfer him. During an interview on 5/25/22 at 2:03 PM, Staff C, Licensed Practical Nurse (LPN)/ Charge Nurse, stated Resident #5 is a one person transfer, however most CNA's usually transfer him with a second person. Staff C stated she would need to complete a record review to determine why the Care Plan directed staff to transfer the resident with one person, while the MDS and PT evaluation assessed a two person physical assistance is needed. Staff C stated she last transferred the resident three days ago and would not feel safe walking him On 5/31/22 at 9:02 AM, the facility supervising Physical Therapist (PT) stated the resident required two people with a gait belt for all transfers. The PT stated that prior to 5/23/22 the resident had not walked. She stated if the resident attempted to walk for the first time she would expect staff to immediately transfer him to his wheelchair and then assist him to the bathroom. The PT stated she did not recommend the use of a resident's clothing as the sole means of support when assisted with a transfer or walking. The PT added she walked the resident and he is not safe to walk with one person. During an interview on 5/31/22 at 10:31 AM, the Director of Nursing (DON) stated she is not able to explain the discrepancy between the resident's MDS, PT Evaluation and Care Plan. She stated there had been multiple people completing the MDS assessments until recently. She stated that she started an audit on Care Plans and MDS but has yet to get that task completed. The DON stated her expectation would be for staff to transfer and walk Resident #5 with a gait belt and two person assist. The DON stated she completed Safe Transfer Training the week of May 23, 2022. A facility policy, dated January 2015, titled Care Plan Process stated the purpose of the Care Plan is to develop care directives to maintain the optimum health status when dependent on staff for needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, Physician Orders review, and staff interviews, the facility failed to carry out Physician's Orders for 1 of 12 residents reviewed (Resident #5). The facility reported a census of 40 residents. Findings Include: 1. The Minimum Data Set (MDS) Quarterly Assessments, dated 2/22/22 and 5/18/22 listed diagnoses for Resident #5 that included Huntington's Disease, dysphagia, and dystonia, unspecified. The MDS stated the resident required extensive assistance of two staff for bed mobility, transfers, and use of the toilet, with walking not assessed, total dependence for locomotion on and off the unit. The MDS listed the resident ' s Brief Interview Interview for Mental Status (BIMS) score as 2 out of 15, indicating severe cognitive impairment. The resident's January 2022 signed Physician Orders directed the resident to have a Speech Evaluation. The record lacked documentation that the evaluation had been completed. During an interview on 5/25/22 at 1:55 PM, Staff C, Licensed Practical Nurse (LPN)/Charge Nurse stated the resident did not have a Speech Evaluation completed since his admission on [DATE]. During an interview on 5/31/22 at 10:31 AM, the Director of Nursing stated that her expectations are Physician Orders are in place as soon as possible, and Therapy Orders are started within 48 hours. The facility lacked a policy regarding Physician Orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review and staff interviews, the facility failed to meet the nutritional well being of residents by serving less than the specified serving sizes of ground meat for 3 of 3 residents, cauliflower for 3 of 38 residents, sweet potatoes for 5 of 38 residents, and the special dietary needs for 1 of 1 resident (Resident #5) The facility reported a census of 40 residents. Findings Include: 1. Review of the 5/23/22 Facility Dinner Menu directed staff to serve two honey glazed chicken strips, half a cup of cauliflower (half a cup equals 4 ounces), and half a cup of sweet potatoes. The facility reported three residents required a mechanical soft diet (chopped, ground or soft foods that break apart without a knife). Observation on 5/23/22 at 5:05 PM, revealed Staff D, [NAME] prepared the ground chicken using 2 chicken strips for each resident, for a total of six strips. Staff D transferred the ground chicken from the Robot Coupe (kitchen appliance to ground the food) to a plate. After the portions were plated, ground chicken remained in the serving bowl. The remaining ground chicken measured out to be 16 ounces and was not divided out to the portions plated. Observation on 5/23/22 at 5:51 PM, revealed Staff D, [NAME] served 38 residents sweet potatoes. Five of the 38 servings failed to fill the four ounce scoop as directed by the menu. Observation on 5/23/22 at 5:59 PM, revealed Staff D, [NAME] served 38 residents cauliflower. The last 3 servings failed to fill the four ounce scoop as directed by the menu. Staff D stated he could not fill the scoop as the cauliflower disintegrated. The facility provided a Weekly Menu titled Week at a Glance- Spring/Summer Menu, week 1, and a Diet Type Report dated May 24, 2022 in response to requested policies for mechanical soft process. The documents lacked direction on how to prepare ground meat, and to ensure directed menu portions served correctly. During an interview on 5/25/22 at 9:47 AM, Staff E, covering Dietary Manager stated a mechanical soft diet should be prepared by using the menu directed portion times the number of residents with the diet order. Staff E stated she would then expect the cook to divide the ground meat out evenly between all plates. Staff E stated she would not expect any leftovers of six chicken strips were used to prepare mechanical soft texture for three residents. The facility lacked a policy on mechanical soft texture preparation. 2. The Minimum Data Set (MDS) admission Assessment Tool, dated 11/23/21, listed diagnosis for Resident #5 including Huntington's Disease, dysphagia, and dystonia, unspecified. The MDS stated the resident required total dependence of one person to eat and drink. The MDS listed the resident ' s Brief Interview Interview for Mental Status (BIMS) score as 2 out of 15, indicating severe cognitive impairment. Resident #5 was admitted to the facility from the hospital on [DATE] after treatment for aspiration pneumonia. On 11/19/21, the facility provider entered an order for a mechanical soft texture, and level 2 mildly thick (nectar) consistency liquids. On 11/21/21, a Nursing Progress Note stated the resident choked on bread and liquid. On 11/24/21, a Dietary Note completed by the facility Registered Dietician (RD) noted the resident's history of aspiration pneumonia and a pureed diet order while in the hospital. The RD questioned if the resident would benefit from an Occupational Therapy (OT)) consult for positioning, and/or Speech Therapy (ST) related to the choking on bread and liquids noted on 11/21/21. On 11/25/21, a Progress Note stated the resident had a fever, and was treated with Tylenol On 11/26/21, the Electronic Health Record (EHR) vitals section noted the resident had a temperature of 99.1. On 12/3/21, a Progress Note entitled SPN -Nursing/Therapy Communication stated the resident had a change in condition in the following areas: bathing, dressing, personal hygiene, transfers, positioning/bed mobility, general physical decline, eating/swallowing, wheel chair (W/C) positioning/mobility. On 12/3/21, the facility provider ordered Physical Therapy and Occupational Therapy Evaluations and Treatment. On 12/10/21 at 2:42 PM, a Nurse's Note in the EHR stated the resident became weak and more tired as the shift went on. It stated the resident ate well at breakfast, but had more trouble with muscles and swallowing at lunch, he coughed and choked with the mechanical soft meat. The resident was noted to have increased respiratory effort, coughing, and a dusky color. He was assisted to bed, and later had an emesis. On 12/10/21 at 4:19 PM, a Nurse's Note in the EHR stated a three day trial of a pureed diet was initiated On 12/10/21 at 5:45 PM, a Nurse's Note in the EHR stated the resident became pale and lethargic, with auditory wheezes noted. The resident acknowledged having pain. His oxygen saturation (level of oxygenation in blood, a normal level is 91% to 100%) was 84%, and had a temperature of 101.6 degrees. On 12/10/21 at 5:55PM, the facility provider gave orders to send the resident to the emergency room (ER) for evaluation and treatment. On 12/10/21 at 11:55 PM, a Nurse's Note in the EHR stated the resident had been admitted to the hospital for pneumonia and received intravenous (medication delivered into the bloodstream) antibiotic treatment. During an interview on 5/25/22 at 1:11 PM, the Registered Dietician (RD) stated after an assessment is completed, she would enter recommendations on the facility Diet Recommendations List. She stated she would then discuss the recommendation with the Administrator, Director of Nursing and Dietary Manager. The RD explained if the team agreed with a recommendation she would then fax the request to the provider. The RD stated she does not recall what happened after the 11/24/21 Dietary Assessment as she was not informed of any other concerns after the 11/21/21 choking incident. The RD stated she saw in the record the resident had a change of condition noted on 12/3/21, but is not sure what happened afterwards. During an interview on 5/31/22 at 10:31 AM, the Director of Nursing (DON) stated if a resident has a history of aspiration pneumonia, and experienced an episode of choking, her expectation would be the concern be addressed within 48 hours. The DON stated she was not working at the facility in early December 2021 but is shocked at the time it took for Resident #5 to have a diet order change given his history and the progressive nature of Huntington ' s disease. The facility policy, dated February 2016, titled Diets Texture Modification/Therapeutic Diets stated altering the consistency of foods can greatly relieve eating problems related to chewing, managing food in the mouth, and swallowing. It is important that this be evaluated on an individual basis by an Interdisciplinary Team consisting of a Speech Therapist, Dietician, Nurse and Doctor.

Based on observation, policy review, and staff interviews the facility failed to provide a sufficient number of Dietary Staff to safely and effectively prepare 4 of 12 meals. The facility reported a census of 40 residents. Findings Include: Observation on 5/22/22 at 12:45 PM, revealed the Social Services Coordinator (SSC) prepared lunch. The SSC stated the Dietary Manager had been scheduled to cook, but had been a no call, no show for two days. During an interview on 5/22/22 at 1:00 PM, the Business Officer Manager (BOM) stated she had cooked breakfast. The Dietary Schedule for May 2022 listed day cooks needed for May 1, 6, 7, 9, 14, 15, 20, 23, 28, and 29. Evening cooks needed for May 2, 13, 16, 30. The Dietary Manager was scheduled as the day cook on May 22, 24, 25, 26, 27, 30, and 31. During an interview on 5/25/22 at 9:47 AM, Staff E, covering Dietary Manager stated three competencies are required for non dietary staff to fill in as cook. The three competencies are Modified Diets, Food Safety, and Sanitation Training. During an interview on 5/25/22 at 10:05 AM, the BOM stated she had not completed any competencies to act as a fill-in cook. The BOM stated she had cooked breakfast on 5/22/22, 5/23/22, and on 5/24/22. During an interview on 5/25/22 at 10:07 AM, the SSC stated she had not completed any competencies to act as a fill-in cook. The SCC stated she cooked lunch on 5/22/22. The facility policy, dated February 2016, titled Orientation/Training of Dietary Services Personnel stated all Dietary Employees must complete a Food Sanitation Course, those responsible for food preparation must complete a Modified Diet Training.

Based on observation, Menu review, Training Form review, and staff interviews, the facility failed to follow the Planned Menu for 3 out of 38 meals. The facility reported a census of 40 residents. Findings Include: On 5/23/22 the Dinner Menu directed staff to prepare mashed sweet potatoes. The recipe specified ingredient amounts for 10, 25, 50, 75, 100 and 125 residents. For 38 residents the recipe for 50 residents would be followed. The recipe for 50 residents directed staff to use two #10 cans of sweet potatoes, ½ cup of margarine, and 1 ½ cups of brown sugar. Observation on 5/23/22 at 5:51, revealed the mashed sweet potatoes prepared would not provide 38 required portions. Staff D, [NAME] stated he used two #10 cans and that should have been enough. Staff D, [NAME] prepared additional mash sweet potatoes by heating up a #10 can of sweet potatoes on the stove to the appropriate temperature, and then served them to three residents. Staff D did not add additional ingredients to the sweet potatoes as directed by the recipe. The recipe for 10 residents directed staff to add ¼ cup of margarine, and one cup and ¼ cups of brown sugar to one #10 can of sweet potatoes. During an interview on 5/25/22, Staff E, covering Dietary Manager stated if additional portions of a menu item needed to be prepared during the meal she would expect all ingredients be added as directed by the recipe. A Training Form, dated February 2016, titled Dietary Employee Orientation for Cooks/Dietary Aides directed training for standard food preparation and service which included: menus, standardized recipes, scales, weights, and measuring tools, portion control; scoops, spoodles, tongs and food tasting.