**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews, the facility failed to maintain dignity for 1 of 17 residents reviewed (Resident#2). The facility reported a census of 52. Findings include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident#2 with a Brief Interview for Mental Status score of 1, which indicated severe cognitive impairment. Diagnoses on the MDS included anxiety, paranoid personality disorder, Alzheimer's Disease, and Parkinson's Disease. The MDS revealed Resident#2 utilized a manual wheelchair independently with staff supervision, but moderate to maximum staff assistance for upper/lower body dressing and bathing. During an observation on 1/23/25 at 8:25 AM, Resident#2 sat in a shower chair, in the hallway, outside of the shower room door. Resident#2 wore a short sleeved top and a blanket over his lower body. The blanket was pulled up to the upper thigh area leaving Resident#2's groin exposed for an unknown amount of time. At 8:33 AM, an unidentified employee checked on Resident#2 and pulled the blanket up to the waist area. In an interview on 1/23/25 at 10:15 AM, Staff B, Certified Nursing Assistant, explained staff will undress and transfer Resident#2 into a shower chair to prep for a shower. This included providing a blanket for the lower body not only for warmth but also for dignity as Resident#2 is not wearing pants or undergarments. Staff B reported Resident#2 preferred to wait outside the shower room until it's time. If waiting in another location, Resident#2 may self-propel out of the area, thus delaying the shower. In an interview on 1/23/25 at 10:30 AM, the Director of Nursing (DON) acknowledged Resident#2 typically waited outside the shower room on. The DON voiced an expectation that Resident#2 should be covered appropriately while in the hallway waiting for his shower.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to accurately code the federally mandated Minimum Data Set (MDS) assessment for 1 of 17 residents reviewed in the sample (Resident#24). The facility reported a census of 52. Findings include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] for Resident#24 indicated the use of a diuretic and an anti-platelet. The MDS did not document the use of an anticoagulant. The Care Plan reviewed/revised on 1/21/25 for Resident#24 included a problem statement documented Resident#24 was prescribed anticoagulant therapy. Interventions included administering anticoagulants as ordered by the physician and to monitor/report labs as ordered by the physician. The Care Plan also included the diagnosis of chronic atrial-fibrillation, which is commonly treated with the use of anticoagulants. The Medication Administration Record for the months of November 2024 and December 2024 revealed Warfarin, a type of anticoagulant, was prescribed and administered to Resident#24 for the entirety of both months. In an interview on 1/23/25 at 2:25 PM, Staff A, Licensed Practical Nurse, acknowledged the MDS did not reflect the use of an anticoagulant even though it was actively prescribed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, family interviews, observation and record review, the facility failed to update individual Care Plans for 3 of 19 reviewed (Residents #20, #22, and #38). The facility failed to revise Care Plans for R#20 for Hospice services and failed to update R#22, R#28 for wanderguard (device to alert/inhibit elopements). The facility reported a census of 52 residents. Findings include: 1. The Signature Change Minimum Data Set (MDS) dated [DATE] documented Resident #20 diagnoses included cancer and malignant neoplasm of prostate, secondary malignant neoplasm of bone. The Brief Interview for Mental Status (BIMS) was scored 12 out of 15 which indicated moderate cognitive impairment. The Care Plan last reviewed/revised 01/22/25 documented resident diagnosis cancer with metastasis. The Care Plan did not document that Resident #20 received hospice services. During an interview on 1/21/25 at 3:30 PM Resident #20 reported to received hospice services which included nursing staff and massage therapist visits. During an Interview on 1/23/25 at 2:25 PM with MDS coordinator, Nurse Staff A, reported the Significant Change MDS was completed on 11/22/24 due to resident choice for hospice. Staff A relayed the Care Plan should have been updated to include hospice services. The facility policy titled, Resident Assessments, revised 3/2022 documented the resident assessments are used to develop, review and revise the residents comprehensive care plan. 2. The Quarterly MDS dated [DATE] documented Resident#22 with a BIMS score of 3 which indicted severe cognitive impairment. Diagnoses on the MDS included unspecified dementia. The MDS documented no wandering behaviors exhibited with no wander/elopement alarm in use. The Care Plan reviewed/revised on 1/7/25 included a problem statement indicating wandering behaviors with the placement of an elopement alarm. The Care Plan documented the wanderguard intervention start date as 10/29/24. During electronic record review, the Progress Note dated 11/28/24 documented Resident#22 exhibited active wandering behaviors with the placement of a wanderguard at this time. During an interview on 1/23/25 at 2:15 PM, Staff C, Unit Manager, explained Resident#22 had not shown exit-seeking behaviors prior to the incident on 11/28/24. Resident#22 had not worn a wanderguard alarm prior to the incident on 11/28/24. Staff C was not aware the Care Plan had the implementation date for the wanderguard as 10/29/24. During an interview on 1/23/25 at 2:25 PM, Staff A reported Care Plans updated as needed based on current information obtained during daily nurse meetings, such as placing or removing wanderguard alarms. Staff A reviewed Resident#22's Care Plan and acknowledged the wanderguard implementation date as 10/29/24. Staff A could not explain the discrepancy with the date on the Care Plan with the actual wanderguard placement date in November. The facility policy titled, Resident Assessments, revised 3/2022 documented resident assessments are used to develop, review, and revise resident comprehensive care plans. 3. The Quarterly MDS dated [DATE] documented Resident#38 with a BIMS score of 9, which indicated moderate cognitive impairment. The Care Plan reviewed/revised on 1/21/25 included a problem statement which indicated wandering behaviors with the placement of an elopement alarm. The Care Plan documented the wanderguard intervention start date as 10/10/24. During continuous observations from 1/22/25 thru 1/23/25, Resident#38 did not have wanderguard on her person. The whiteboard located on the third-floor nurses station listed out resident with active Wanderguards. Resident#38 was not on the list. The Progress Note dated 11/5/24 documented the wanderguard was initiated upon Resident#38's admission to the unit in October. Upon completion of the Elopement Evaluation, Resident#38 had shown no signs of elopement and the wanderguard was removed. The Progress Note dated 11/6/24 further documented the lack of elopement behaviors and removal of the wanderguard. During an interview on 1/23/25 at 2:25 PM, Staff A reported Care Plans updated as needed based on current information obtained during daily nurse meetings, such as placing or removing wanderguard alarms. Staff A acknowledged the presence of the wanderguard interventions on the current plan and noted that Resident#38 does not wear a wanderguard. Staff A relayed the Care Plan should have been updated in November when the wanderguard was removed. The facility policy titled, Resident Assessments, revised 3/2022 documented resident assessments are used to develop, review, and revise resident comprehensive care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and policy review the facility failed to refer one of one residents with a negative Level I result for the Pre-admission Screening and Resident Review (PASRR), who were later identified with newly evident or possible serious mental disorder or other related condition, to the appropriate state-designated authority for Level II PASRR evaluation and determination (Residents #17). The facility reported a census of 51 residents. Findings include: The annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #17 identified the resident not considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. The assessment documented the resident entered the facility on 2/8/22. The MDS documented diagnoses that included non-Alzheimer's dementia, anxiety disorder, depression, and bipolar disorder. The MDS indicated the resident took an antipsychotic, antidepressant, and hypnotic medications during the 7 day lookback period. The MDS documented the resident had disorganized thinking, inattention, and no other behaviors. The care plan revised 3/25/24 identified Resident #17 had diagnoses of bipolar disorder, mood disturbance, depression and generalized anxiety disorder. The care plan revealed the resident took antidepressant and antianxiety medications. The care plan directed staff to monitor the effectiveness of the medications and document target behaviors. Review of the clinical record revealed a Notice of Negative Level I Screen Outcome dated 2/28/22. The Level I screen documented Resident #17 had diagnoses of anxiety disorder and depression, but had no major mental illness such as bipolar disorder (manic depression). The PASRR required no further screening required unless the resident had a suspected major mental illness of intellectual or developmental disability or had a significant change in treatment needs. Review of the electronic health record diagnosis list revealed Bipolar disorder added on 9/19/22. The nurse practitioner progress note dated 9/26/23 revealed the resident had diagnoses of bipolar disorder. The clinical record lacked documentation the resident had been referred for a Level II evaluation and determination when he had a new/change in mental health diagnoses In an interview 3/27/24 at 11:30 AM, the Social Services (SS) Director reported she checked Resident #17's medical record documents and the Maximus website, and confirmed Resident #17 last had a PASRR completed 2/28/22. When she checked the resident's chart, she found he had a new medication added, so she resubmitted a request for a PASRR review to Maximus on 3/27/24 at 11:26 AM. The Social Services Director reported the nursing staff were supposed to let her know whenever a resident had a new medication or psychiatric diagnoses added so she could submit information for a PASRR review, if applicable. The SS Director reported the PASRR process being worked on by staff at the facility. In an email from the Administrator on 3/27/24 at 2:47 PM, the Administrator wrote the facility did not have a policy for PASRR but would work on it. The Administrator wrote nursing had been educated on the importance of informing the SS Director when there had been a significant change or medication change for a resident in order for SS to update the PASRR. The SS Director now attended the morning clinical meetings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, and staff interviews, the facility failed to update the Care Plan for one of three residents reviewed (Resident #15) following a change in condition. The facility reported a census of 52 residents. Findings included: Resident #15's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 00, indicating severely impaired cognition. The MDS included diagnoses of Alzheimer's disease and osteoporosis without a current pathological fracture. The MDS indicated that Resident #15 required total dependence on staff assistance for eating, dressing, toilet use and bathing. The MDS included additional information that Resident #15 required extensive staff assistance with positioning and transfers. The MDS listed that Resident #15 had an unhealed venous/arterial ulcer. The Care Plan with the goal target date of 11/30/22 identified the resident with the problem of being at stage 4 pressure ulcer to the left elbow. The Care Plan did not identify that Resident #15 had a pressure ulcer to her coccyx area. The Weekly Pressure Ulcer Record identified a date of onset as 11/30/22 of a pressure ulcer to Resident #15's coccyx. As of 1/3/23 Resident #15 continued to have a stage II (2) pressure ulcer to her coccyx that measured 1.3 cm (centimeters) long, 0.8 cm wide and 0.1 cm deep. On 1/13/23 the wound measured 0.9 cm long, 0.9 cm wide, and 0 cm deep. Resident #15's wound bed appeared pink and clear, with the surrounding skin mildly red. During an observation of care on 1/18/23 at 9:50 AM, Staff I, Certified Nurse Aide (CNA), and Staff J, CNA, used the correct technique to properly provide peri care and reposition the resident. During the observation, the surveyor witnessed two open areas, one on the coccyx and one on her right buttock, both appeared nearly healed without signs of infection. During an observation of wound care 1/19/23 at 9:04 AM, Staff K, Licensed Practical Nurse (LPN) and Staff A, CNA, provided the correct technique to cleanse the wound and treatment to Resident #15's left elbow. The site appeared nearly healed without signs of infection. A review of the radiology report dated 5/13/22 identified that Resident #15 had a non-displaced fracture of the distal ulna (bone that is part of the wrist). The Care Plan Problem with a start date of 8/31/22, and an end date of 11/30/22, indicated that Resident #15 had a fractured left wrist with appropriate interventions. The Care Plan lacked identification of the wrist fracture until 8/31/22. During an interview on 1/19/23 at 12:56 PM, Staff E, LPN, reported that Resident #15 had a fracture of her left wrist in May 2022 and the problem should have been identified on the Care Plan within a week after the fracture occurred. During an interview on 1/19/23 at 2:26 PM, Staff D, LPN, reported that Resident #15 had a fracture to her wrist in May 2022 and the MDS coordinator should have added the problem of the fracture to the Care Plan within a week after it occurred.

Based on observations, staff interviews, and facility policy review the facility failed to access temperatures of food before serving the meal to the residents to ensure hot food for 11 of 52 residents reviewed. The facility reported a census of 52. Findings: On 1/19/23 at 9:50 AM observed the preparation of pureed meal for five (5) residents on pureed diets by Staff H, Director of Food Services: a. 15 ounce (oz.) of ground seasoned meat added with five (5) buns and broth to the robo-coup mixed to pudding like consistency for five (5) residents, one (1) cup servings b. 28 steak fries, five (5) fries per serving (relayed by the dietary manager) was added to the vita-mixer and pureed to pudding consistency with milk for five (5) one (1) cup servings of potatoes c. Five (5) six-ounce servings of chicken noodle soup had been pureed for five (5) six-ounce servings of soup. Staff H moved the pureed food to the food warmer oven in aluminum containers. The oven indicated a temperature of 170 degrees . On 1/19/23 at 10:30 AM Staff H, reported a maid rite sandwich (seasoned ground beef), chicken noodle soup, fries, and apricots as the lunch menu. Staff H, relayed the kitchen prepared the meals for the health center and the Assisted Living facility. Staff H explained that the kitchen sent the health center their food to the second floor and third floor at around 11:45 AM. The health center served the meals to their residents from steam tables in the kitchenettes next to the second and third floor dining rooms. On 1/19/23 at 11:44 AM witnessed the food arrive at the second-floor kitchenette on a cart with food covered in aluminum containers. Staff G, Dietary AIde, moved the food from the cart in the aluminum containers to the steam table. The food included: a. Seasoned ground meat b. chicken noodle soup c. steak fries d. pureed meat with a bun (1 serving in a bowl, in an aluminum container) e. pureed potatoes (1 serving in a bowl, in an aluminum container) f. pureed soup (1 serving in a bowl, in an aluminum container) Staff G prepared the residents ' plates without assessing the meals temperature. On 1/19/23 at 11:50 PM, Staff F, Dietary Cook, acknowledged that the food should be tempted and left to retrieve a thermometer. Staff G present served and relayed that she had not been taught to temp the food prior to serving it. Staff G agreed to temp the food when a food thermometer retrieved by Staff F. On 1/19/23 at 11:54 AM observed Staff G check the food temperatures revealing the following: a. seasoned ground meat-------temperature 140 b. chicken noodle soup----------temperature 147 c. steak fries---------------------temperature 108 d. pureed meat with a bun ---- temperature 98 e. pureed potatoes --------------temperature 98 f. pureed soup ------------------temperature 98 On 1/19/23 at 11:56 with Staff F voiced the temperatures should be higher. On 1/19/23 at 12:02 PM Staff G relayed that she did not know the food should have its temperature checked before serving. Staff G explained that she did not receive any education on that process and has not checked the food ' s temperature before serving. Staff G served the food to second-floor residents. Staff G agreed to temp the food left at the end of serving. On 1/19/23 at 12:15 observed Staff G check the following food temperatures: a. seasoned ground meat-------temperature 140 b. chicken noodle soup----------temperature 130 c. steak fries------------------------temperature 100 pureed food was served, none left On 1/19/23 at 1:05 PM with Staff H acknowledged that the dietary staff lacked education. Staff H verified that the food temperatures should be checked before serving and if not high enough then the food could be reheated. Staff H acknowledged that the staff needed education. The undated facility provided policy titled Food Temp Procedure and Policy directed the following: a. food tempted and recorded prior to leaving the main kitchen b. food is tempted and recorded after arrival and placement into the steam table c. hot food must hold at 135 degrees or above d. If temp is unacceptable, instructions to call the Food Service Director or cook for instructions. The food would be replaced or corrected.