**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility document review, and staff interview the facility failed to send notice to the State Long Term Care Ombudsman for hospitalizations for 3 of 3 residents (Residents #2, #27 and #64) reviewed. The facility reported a census of 71 residents. Findings include: 1. Resident #2's Census List reviewed on 3/11/25 reflected she discharged to the hospital on [DATE] and returned to the facility on [DATE]. The General Nurses Note written on 12/24/24 at 3:15 PM identified an ambulance took Resident #2 to the hospital. The General Nurses Note written on 12/24/24 at 9:59 PM documented the hospital admitted Resident #2 to the hospital for outpatient observation. The N ADV Clinical admission Note completed on 12/26/24 at 1:30 PM reflected Resident #2 returned to the facility. The Notice of Transfer Form to Long Term Care Ombudsman for December 2024 lacked documentation of Resident #2's transfer to the hospital. 2. Resident #27's Census List reviewed 3/13/25 identified he transferred to the hospital on [DATE] and returned to the facility on [DATE]. The General Nurses Note written on 11/20/24 at 7:30 AM reflected Resident #27 transferred to the hospital by ambulance. The N ADV Clinical admission Note written on 11/22/24 at 2:16 PM identified Resident #27 returned from the hospital. The Notice of Transfer Form to the Long-Term Care Ombudsman report for November 2024 lacked documentation of Resident #27's transfer to the hospital. 3. Resident #64's Census List reviewed 3/13/25 indicated she transferred to the hospital on 1/19/25 and returned to the facility on 1/27/25. The General Nurses Note written on 1/19/25 at 2:15 PM reflected Resident #64 transferred to the hospital. The General Nurses Note written on 1/19/25 at 6:32 PM identified Resident #64 admitted to the hospital. The N ADV Clinical admission Note completed on 1/27/25 at 1:52 PM reflected Resident #64 returned to the facility. The Notice of Transfer Form to the Long-Term Care Ombudsman report for January 2025 lacked documentation of Resident #64's transfer to the hospital. In an interview on 3/12/25 at 2:50 PM Staff A, License Practical Nurse/ Admissions Coordinator, reported she added the residents to the Ombudsman's report each month who have discharged . She reported she didn't know that anything else needed to be on the report such as hospitalizations so she missed putting the residents on the list.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview the facility failed to complete a discharge Minimum Data Set (MDS) for 1 of 5 residents reviewed (Resident #2) for discharge. The facility reported a census of 71 residents. Findings include: Resident #2's Census List reviewed on 3/11/25 reflected she discharged to the hospital on [DATE] and returned to the facility on [DATE]. Resident #2's MDS log reviewed 3/11/25 reflected a quarterly MDS assessment on 10/11/24 with a Entry MDS assessment on 12/26/24. The list lacked an assessment completed for her discharge on [DATE]. The electronic health record listed the next tracking/discharge due as: Discharge - assessment reference date (ARD) 12/24/24, 63 days overdue. During an interview on 3/13/25 at 9:49 AM the MDS Coordinator reported she didn't know Resident #2 discharged to the hospital and if she could complete a late MDS. During an interview on 3/13/25 at 9:57 AM the Director of Nursing (DON) explained the MDS Coordinator would complete a late discharge MDS for Resident #2 that day to comply. She added she expected the MDS assessment get completed timely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interviews and policy review the facility failed to ensure 1 of 3 residents with a facility acquired pressure ulcer were provided with proper assessment and treatment to prevent pressure ulcers while living at the facility (Resident #66). The facility reported a census of 71 residents. The facility fixed the concern on 3/7/25, prior to the survey start through the following action plan: a. 2/27/25: The Director of Nursing (DON), or Assistant Director of Nursing (DON) if the DON is absent, would double check all new admission/readmission orders. b. 2/28/25: The facility checked all residents to ensure no other residents affected. c. 3/7/25: Anytime a resident has an order to wear any device fitted on a resident extremity (such as a brace), the standing order will be for the nurse to remove or loosen the device and check the skin twice a day. d. 3/7/25: Unit managers to check details of any new device/brace orders entered in the electronic health record (EHR) to ensure nurse will check the skin under the device twice a day. e. 3/7/25: Each nursing station will have skin monitoring forms for the Certified Nurse Aides (CNA). The facility conducted a meeting to remind staff of how to use the form. Findings include: Resident #66's Minimum Data Set (MDS) assessment dated [DATE] listed an admission date of 12/31/24. The MDS identified a Brief Interview of Mental Status (BIMS) score of 12, indicating mild cognitive impairment. Resident #66 required total assistance from staff for toileting, showering, bathing, and dressing. Resident #66 couldn't stand, transfer to the toilet or walk. The MDS included diagnoses of cancer, hypertension (high blood pressure), anemia (low blood iron levels), diabetes mellitus, bacteriuria (bacteria in the urine), and a left hip fracture. The MDS reflected Resident #66 had a risk for developing pressure ulcers/injuries. At the time of assessment Resident #66 didn't have one or more unhealed pressure ulcers/injuries. Resident #66 received an antihyperglycemic medication during the lookback period. The N ADV Clinical admission Note dated 12/31/24 at 1:45 PM indicated Resident #66 had a knee immobilizer on her upper leg and a bilateral Podus boots (specialized boots used to prevent pressure to the heels and hip rotation) to be worn at all times. The functional note listed Resident #66 as non-weight bearing (NWB) on the left lower extremity and used an immobilizer on her left leg. Resident #66's Hospital Clinical Summary dated 12/31/24 listed her transfer orders for restricted activities as toe-touch weight bearing to her left lower extremity with a knee immobilizer on at all time. Remove/loosen brace for twice daily skin checks. Resident #66's January 2025 Treatment Administration Record (TAR) lacked the restricted activities order for the toe-touch weight bearing, the knee immobilizer, and the removal of the brace twice daily for skin checks. The TAR did include an order dated 12/31/24 to apply Eucerin Advanced Repair cream to both of her legs every morning and night for dryness. The Doctor Visit Form dated 1/9/25 reflected the facility requested to get a second immobilizer due to Resident #66 complaining of extreme pain to her leg. The provider responded the fracture appeared stable, continue with care - NWB, toe-touch weight bearing for balance. No knee range of motion (ROM), may do quad sets with knee brace on. The Doctor Visit Form dated 1/20/25 listed the reason for visit as follow-up visit with orthopedics. The doctor's instructions directed NWB to left lower extremity, follow-up in 6 weeks, keep left knee immobilizer on at all times (may remove for hygiene, showers, and home physical therapy (PT) exercises. The additional comments included to avoid falls, ice, and elevation. The 2/6/24 Encounter Note completed by Staff F, Advanced Registered Nurse Practitioner (ARNP) documented Resident #66 used an immobilizer. The assessment of the skin reflected it as dry, with no unusual rashes, lesions, or excessive bruising. The note reflected the leg had normal color with the immobilizer intact to her left lower extremity. The Doctor Visit Form dated 2/24/25 listed the reason for visit as follow-up with orthopedics. The doctor's instruction section included to continue toe-touch weight bearing to her left lower extremity for 6 weeks, follow-up in 6 weeks, and additional PT orders. Resident #66's February 2025 TAR included the following orders: a. Eucerin Advanced Repair Cream dated 12/31/24 - apply to bilateral lower extremities every morning and bedtime for dryness. b. Hinge Brace on left knee at all times dated 2/25/25, discontinued 2/26/25. c. Per provider dictation on 2/24/25 Left leg hinged knee brace to be worn at all times dated 2/26/25: Can be removed for showers only. The Incident Report dated 2/25/25 at 1:45 PM identified Resident #66 had a skin issue that measured 8 centimeters (cm) by (x) 3 cm x 0.1 cm with a small amount of red drainage. The provider gave an order for cephalexin (antibiotic) 500 milligrams (mg) 4 times a day for 7 days for wound healing. The report listed the root cause as wearing left leg immobilizer at all times until 2/24/25. The untitled handwritten document dated 2/25/25 written by Staff C, Certified Nurse Aide (CNA), documented she did care on Resident #66 daily and she didn't see any open areas on her when Staff D, CNA, gave her a bath the week before. She added Resident #66 didn't have her brace on at the time and she didn't see any open areas. Staff C reported that day as the first time she ever saw an open area to her lower leg. The untitled handwritten document dated 2/26/25 by Staff B, Registered Nurse (RN), documented on 2/24/25 she removed Resident #66 boot and socks to lotion her lower extremities (legs). At that time, she saw her legs dry and scaly but she didn't notice any open wounds. The untitled handwritten document dated 2/26/25 by Staff D documented on 2/19/25 she gave Resident #66 a bath and removed her leg brace from her leg and applied lotion to them, she didn't see a sore. The 2/27/24 Encounter Note completed by Staff F, Advanced Registered Nurse Practitioner (ARNP) documented Resident #66 had a new skin concern the nursing staff found on 2/25/25. The note described the area as an unstable pressure ulcer on her left lower extremity caused by the bar of her knee immobilizer. The area measured 8 cm x 3 cm x 0.1 cm with cellulitis from the knee to the ankle. The wound had a small amount pink drainage. The wound had 70% slough (dead, non-viable tissue that forms on the surface of a wound), 25% eschar (dead tissue that appears dry, thick, and leathery, often appearing tan, brown, or black) and 5% granulation tissue (a type of new, temporary tissue that forms in response to an injury or wound). During an interview on 3/12/25 at 2:38 PM the Director of Nursing reported she didn't have documentation that the facility staff completed twice a day assessments for the removal of the immobilizer. A letter written by Staff F dated 3/13/25 reflected Resident #66 had an unstageable pressure ulcer to her left lateral lower extremity. The nursing staff noted the wound on 2/25/25. Staff F suspected the appearance and quick deterioration of the wound is secondary to the underlying comorbidities (multiple diagnoses), including type 2 diabetes and a history of chondrosarcoma s/p (has a history of chondrosarcoma, a rare type of tumor that usually begins in the bones, and went through a form of treatment, like surgery, radiation, or chemotherapy), and current immobility secondary to left femur fracture being conservatively managed and known poor nutritional intake. Resident #66 has thick scales of hyperkeratosis (a condition characterized by thickening of the outermost layer of skin (stratum corneum) due to an overproduction of keratin, often appearing as calluses, corns, or rough patches) on her left lower extremity that likely masked any developing concerns with tissue integrity. During an interview on 3/13/25 at 11:35 AM the Administrator explain he expected the staff to document on the TAR the completion of twice a day removal and skin assessment of Resident #66's immobilizer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Clinical record review for Resident #57 revealed a certification for hospice services beginning on 2/19/24. The MDS for Resident #57 was signed as complete on 3/13/24. This is outside the required 14-day time frame. During an interview on 3/20/24 at 1:40 PM the MDS Coordinator explained she thought she had 14 days after a significant change was identified to set an Assessment Reference Date. She further explained she thought she had an additional 14 days to complete the MDS assessment. She acknowledged the MDS for Resident #57 was outside the 14 days required time frame. She stated the facility did not have a policy for MDS completion, they follow the RAI Manual. Based on record review, staff interview, and Resident Assessment Instrument (RAI) Manual the facility failed to ensure 2 of 4 residents (Resident #37 and #57) Significant Change Minimum Data Set (MDS) assessments were completed within 14 days of identifying a significant change occurred. The facility reported a census of 63 residents. Findings include: 1. Record review of Resident #37's Hospice Certification and Plan of Care dated 2/27/2024 documented he went on Hospice services on 2/27/24. Record review of Resident #37 Progress Notes revealed on 2/27/24 a hospice nurse came to the facility and signed Resident #37 up for hospice services. Record review on 3/19/24 of Resident #37's Significant Change MDS dated [DATE] revealed the MDS was not completed. Record review of the current RAI Manual dated 10/2023 on page 2-25 instructed the following: A Significant Change MDS is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The Significant Change MDS date must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). A Significant Change MDS must be performed regardless of whether an assessment was recently conducted on the resident. This is to ensure a coordinated plan of care between the hospice and nursing home is in place. A Medicare-certified hospice must conduct an assessment at the initiation of its services. This is an appropriate time for the nursing home to evaluate the MDS information to determine if it reflects the current condition of the resident, since the nursing home remains responsible for providing necessary care and services to assist the resident in achieving their highest practicable well-being at whatever stage of the disease process the resident is experiencing.

Based on record review and staff interview the facility failed to ensure all diagnoses that were present on admission were on the Preadmission Screening and Resident Review (PASRR) upon admission to the facility for 1 of 1 residents (Resident #49). The facility reported a census of 63 residents. Findings include: Record review of Resident #49's PASRR dated 11/29/2023 documented resident had one (1) mental health diagnosis, major depressive disorder. Record review of Resident #49's current diagnosis upon admission to the facility on the, Transfer/Discharge Report dated 11/30/2023 included six (6) mental health diagnosis: pseudobulbar affect (episodes of sudden uncontrollable and inappropriate laughing or crying), delusional disorders, major depressive disorder, other symptoms and signs involving cognitive functions and awareness, adjustment disorder with mixed disturbance of emotions and conduct, and anxiety disorder due to known physiological condition. During an interview with the Social Worker on 3/20/2024 at 12:10 PM revealed Resident #49's PASRR did not include all of his current diagnosis and she just submitted a new PASRR to the local agency with all of his mental health diagnosis to review. During an interview with the Social Worker and admission Coordinator on 3/20/24 at 12:41 PM revealed they do not currently have a process in place to compare and review new resident admission diagnosis and what's on the PASRR to ensure they match, but they are going to start now.

Based on record review, staff interview, and policy review the facility failed to ensure 1 of 3 residents reviewed for catheters (Resident #37) Care Plan was updated to inform and instruct staff of the reason and how to care for his catheter. The facility reported a census of 63 residents. Findings include: Record review of Resident #37's Progress Notes on 2/28/24 revealed a new order for catheter. Record review of Resident #37's Telephone Order dated 2/28/24 revealed a new order for a catheter. Record review of Resident #37's current Care Plan on 3/19/24 did not include that he had a catheter. During an interview on 3/20/24 at 1:40 PM the MDS Coordinator revealed she would Care Plan if a resident would have a catheter placed while living at the facility, she stated she would put it on the Care Plan as soon as she found out about it. Review of an undated facility policy, Care Planning Comprehensive Care, lacked instruction on when to update Care Plans for changes in nursing care needs.

Based on observation, policy review, and staff interview the facility failed to maintain safe holding temperatures of 135 degrees Fahrenheit for hot foods and under 41 degrees Fahrenheit for cold foods to prevent foodborne illness. The facility reported a census of 63. Findings include: Premeal temperatures taken on 3/19/24 at 11:42 AM revealed the pureed vegetables and gravy were not heated to an internal temperature of 135 degrees Fahrenheit (°F) before being served to residents. The vegetables reached a temperature of 125.7° F and the gravy 134.7° F directly before being plated. Post meal temperatures taken at 12:32 PM revealed the following foods did not maintain the internal holding temperature of 135° F: a. Pureed vegetables (on unit): 125.1° F b. Ground Pork (on unit): 100.0° F c. Pork loin (on unit): 102.0° F d. Sweet potatoes (on unit): 128.0° F e. Gravy (on unit): 120.0° F An observation on 3/19/24 at 12:47 PM revealed the steam table was not plugged in on the back unit. The pork loin was placed on the counter, not on the steam table. An observation on 3/21/24 on the back unit from 7:48 AM to 8:26 AM revealed the milk set directly on the counter for the duration of the breakfast meal. The post meal temperature was 58.5° F. The undated facility policy titled Safe Food Preparation: Final Cooking Temperatures instructed staff to cook fresh, frozen, or canned fruits and vegetables to a hot holding temperature of 135° F to prevent the growth of pathogenic bacteria. It further delineated the use of a steam table to heat food as unacceptable. The undated facility policy titled Food Distribution: Tray line and Alternative Meal Preparation and Service Area instructed staff to avoid risks including holding foods in danger zone temperatures which are between 41° F and 141° F and using steam tables to heat food. It further instructed staff to reheat hot pureed, ground, or diced foods that have fallen below 141° F to reach 165° F for 15 seconds prior to serving. The undated facility policy titled Food Service and Distribution instructed staff to avoid food handling risks including food left on trays or countertops beyond safe time and/or temperature requirements. During an interview on 3/21/24 at 8:45 AM the Food Services Supervisor reported he expected foods to be cooked to the correct initial temperature indicated on the menu chart. Altered consistency foods must be brought back to temperature in the oven and then placed on the steam table. He expected anything not up to temperature upon cooking to go back into the oven before going on the steam table. He reported anything on the steam table needs to be 135° F or above for service. He explained milk must be on ice to keep below 41° F and cold items that can spoil must be kept under 41° F. He confirmed staff must follow the policies and have been trained on them.

Based on observation, policy review, and staff interview the facility failed to keep the kitchen area clean, use gloves appropriately for assembling and serving meals, keep hands off the drinking surfaces of glasses, keep bare hands off of foods, and keep serving utensils clean in order to serve meals under sanitary conditions. The facility reported a census of 63 residents. Findings include: During an observation of the kitchen on 3/18/24 at 11:10 AM, food particles were present on the floor throughout the kitchen and on the bottom shelf of the steam table where resident insulated lids were stored. Food particles continued to be present during an observation on 3/19/24 at 11:13 AM. An observation on 3/20/24 at 11:06 AM revealed food particles on the floor and steam table along with crumbs on the counter near the clean plates, bread crumbs coating the counter near the toaster, and paper and a cleaning cloth on the floor near the dish washing station. During an observation of the noon meal on 3/18/24 from 11:52 to 12:38, Staff A, Environmental Aide, Staff B, Certified Nursing Assistant (CNA), Staff C, Certified Medication Aide (CMA), and the Food Services Supervisor (FSS) served 12 glasses to 7 residents in the main dining area handling the cups with fingers on the drinking rim surface of the glasses. During a continuous observation of puree preparation on 3/19/24 from 11:01 AM to 11:40 AM, Staff D, Dietary Staff failed to measure out portion sizes prior to pureeing the pork, mixed vegetables, and sweet potatoes. He then failed to measure the volume of the pureed pork, mixed vegetables, sweet potatoes, and cake after altering consistency. He divided the food into containers for the front and back dining rooms without measuring for the requisite number of residents. During a continuous observation of the puree preparation on 3/20/24 from 11:02 AM to 11:39 AM Staff E, Dietary Staff failed to measure the volume of the ground beef, pureed steak, and pureed cake after altering consistency. She divided the food into containers for the front and back dining rooms without measuring for the requisite number of residents. An observation of the noon meal preparation on 3/19/24 revealed the following: A. At 12:07 PM The FSS failed to secure the scoop for the sweet potatoes. The handle he touched with his bare hands fell into the dish. The affected food was then served to residents and the scoop was not replaced. B. At 12:16 PM Staff D wore gloves and touched a butter knife to spread butter onto a sandwich. He then failed to change gloves and touched the bread, meat, and cheese and assembled the sandwich. C. At 12:16 PM Staff H, Dietary Staff wore gloves to assemble a sandwich. He failed to change gloves after he touched the spatula to flip the sandwich and then used his hands to assist in turning it. He failed to change gloves after closing the lid of the cheese container and then touched the sandwich to plate it. D. At 12:20 PM The FSS used tongs to remove the lid from a pan. He then used the tongs to take a burger patty out and then to place the lid back on. E. At 12:26 PM Staff H wore gloves and opened a chip bag. He failed to change gloves and then touched a hot dog and chips in the bag. F. At 12:38 PM Staff D wore gloves and untied and opened a bread bag. He failed to change his gloves and then touched bread. He failed to change his gloves after he opened the lid to the cheese container and then touched the cheese. An observation of the noon meal preparation on 3/20/24 revealed the following: A. At 11:58 AM Staff I, Dietary Staff wore gloves and took bread out of a bag. He then touched plates, the oven handle, and his glasses. He failed to change gloves and then retouched the bread. B. At 11:59 AM Desserts were transported uncovered to the back units. C. At 12:18 PM Staff G, Dietary Staff grabbed the food lid with her bare hand and placed it face down on the counter. She replaced the lid on the food with her bare hands and placed serving tongs on top of the food lid. She proceeded to serve 8 residents with the tongs. In an interview on 3/19/24 at 11:01 AM Staff D explained he eyeballs the number of slices and amounts of food to puree. He makes sure there is enough left for the residents on normal diets and goes from there. The undated facility policy titled Safe Food Preparation: Cross-Contamination instructed staff to clean and sanitize work surfaces and food-contact equipment between uses. The undated facility policy titled Food Distribution: Tray Line and Alternative Meal Preparation and Service Area instructed staff to avoid risks including handling food with bare hands or improperly handling equipment and utensils. The undated facility policy titled Food Distribution instructed staff to cover all foods transported through public corridors. The facility lacked a policy on handling of dishes, puree procedures, and use of gloves in food preparation. During an interview on 3/21/24 at 8:45 AM FSS indicated his expectation of the puree process was for staff to start with one more serving than needed, puree the food, divide it into the two serving tins for the front and back units, and use the indicated scoop size from the menu book to serve the food. He further acknowledged that he had not considered the reduction in volume. He voiced he was not aware of the pureed diet portion sizes chart. He reported he expected staff to clean as they go and clean the whole area after each shift. He confirmed staff must wear gloves when handling ready to eat foods or assembling a sandwich. They are not to touch multiple surfaces when wearing gloves. He expected staff to use tongs to get bread or chips out of bags. They are not to use the same tongs to get both items. Staff are not to touch any food bare handed. He explained they are to handle the bottom half of cups and not on the rim where residents put their mouths. He confirmed staff must follow the policies and have been trained on them. 2. During an observation on 3/18/24 at 12:26 PM Staff G removed the crust from a slice of garlic bread with her bare hands, without performing hand hygiene, and served it to Resident #45. During an observation on 3/18/24 at 12:32 PM Staff G removed the crust from a slice of garlic bread with her bare hands, without performing hand hygiene, and served it to Resident #13. During an observation on 3/18/24 at 12:33 PM Staff G removed the crust from a slice of garlic bread with her bare hands, without performing hand hygiene, and served it to Resident #66. During an observation on 3/18/24 at 12:39 PM Staff G removed the crust from a slice of garlic bread with her bare hands, without performing hand hygiene, and served it to Resident #2.

Based on facility record review and staff interviews, the facility failed to provide satisfactory evidence that they identified their own high risk, high volume, and problem-prone quality deficiencies, and made a good faith attempt to correct them. The facility reported a census of 63 residents. Findings include: Review of the facility records, revealed repeated deficient practices identified during the facility's previous survey completed on 12/15/22, during a complaint and facility reported incident survey completed on 8/11/23 and current survey investigations. During an interview on 3/21/24 at 10:28 AM, the DON reported QA meets monthly and go over each department's areas, audit and concerns. She reports prior deficiencies from previous surveys are talked discussed at the meeting. Each month will go over the concerns and the corrective actions in place. The QAPI Plan dated August 2023 directed the facility will examine and improve care or services in areas that are identified as needed attention. It directs the committee meets monthly to go over the plan, interventions and continue to monitor the effectiveness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, resident council minutes and facility policy review the facility failed to answer resident call lights within the allotted professional standards of 15 minutes, (Resident #4 and #5) The facility identified a census of 67 residents. Findings include: During an interview on 8/9/23 at 2:56 p.m. Resident #4 confirmed she timed her call light on for ½ hour to 45 minutes at times as she used her watch. The resident indicated that it really made her feel unimportant. The resident also stated recently she had been on the toilet for a lengthy period of time and it caused her legs to go to sleep and tingly. A Device Activity Report dated 8/9/23 at 3:39 p.m. identified the resident's call light on longer than 15 minutes as follows from 8/8/23 thru 8/9/23: a. 8/8./3 at 7:16 a.m. - 16 minutes and 11 seconds. b. 8/9/23 at 7:21 a.m. - 26 minutes and 31 seconds. During an interview on 8/9/23 at 3:36 p.m. Resident #5 stated she had not known what to think due to the fact when she put on her call light no one answered. The resident described staff as kind however they propelled her to her room and just left her. The resident indicated she timed her call light on for about 45 minutes around noon as she utilized her watch located on her left wrist which caused frustration and a feeling of having been upset. A Device Activity Report dated 8/9/23 at 3:39 p.m. identified the resident's call light on longer than 15 minutes as follows from 8/8/23 thru 8/9/23: a. 8/8/23 at 5:28 a.m. - 22 minutes and 48 seconds. b. 8/9/23 at 11:10 a.m. - 22 minutes and 37 seconds, at 6:48 p.m. - 16 minutes and 12 seconds. A Device Activity Report dated 8/9/23 at 3:39 p.m. identified the call light on from room [ROOM NUMBER] bed 2 as follows: a. 8/8/23 at 12:22 p.m. - 20 minutes and 30 seconds. b. 8/9/23 at 6:54 a.m. - 26 minutes and 31 seconds. During an interview on 8/10/23 at 11:18 a.m. Staff H, CNA confirmed staff as unable to answer resident call lights within 15 minutes because of staffing and when we are short. The staff member indicated there had not been enough walkie talkie's for all staff which is where the call system ran through and there had only been 1 computer screen on East side of the building and none on the West. During an interview on 8/10/23 at 11:32 a.m. Staff I, Certified Medication Aide (CMA) indicated she knew call lights had been identified through walkie talkies and a screen at the nurse's station however there had been times there were not enough walkies for everyone. Additionally, staff turned off their walkie's at times. According to the facilities Call Light System policy (not dated) the purpose identified the policy established guidelines for the operation and staff response to the call light system. The policy aimed to ensure prompt and effective communication between residents and staff to have met their needs and ensured their safety and well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, document review, and policy review, the facility failed to prevent two sexual abuse interactions on the secured dementia unit between 2 (Resident #17 and Resident #44) of 2 residents sampled for abuse. Findings included: The undated facility policy titled, Abuse Prevention, Identification, Investigation, and Reporting, revealed, A. 2. Resident must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The policy also indicated resident abuse was defined as D. Sexual abuse is non-consensual sexual contact of any type with a resident. A review of Resident #17's medical diagnoses sheet revealed a diagnosis of dementia with behavioral disturbance. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's cognitive skills for daily decision making were severely impaired according to the staff assessment for mental status. The MDS revealed the resident had continuous disorganized thinking and inattention and fluctuating levels of altered mental status. The resident had delusions and hallucinations. The resident had behaviors including verbal behavioral symptoms directed toward others for one to three days during the seven day look back period, rejecting care for four to six days during the seven day look back period, and daily wandering. A review of Resident #17's care plan, revised 11/18/2022, revealed the resident was at the facility for long term placement. One intervention included the resident's breast was touched by a peer and staff intervened and separated them on 11/02/2022. Another intervention included another resident was rubbing Resident #17's breasts over the resident's shirt. Resident #17 had both hands on Resident #44's hips. The residents were separated immediately and neither resident was agitated or hurt. A review of Resident #44's medical diagnoses sheet revealed diagnoses of dementia with behavioral disturbance and Alzheimer's disease. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 4, indicating severe cognitive impairment. The MDS revealed the resident had continuous disorganized thinking and inattention, hallucinations, and delusions. The resident had behaviors including daily rejection of care, daily wandering, and daily behaviors not directed toward others. A review of Resident #44's care plan, revised 11/22/2022, revealed the resident was at the facility for long term placement. One intervention included the resident touched Resident #17's breasts and staff separated them on 11/02/2022. Another intervention included the resident was rubbing Resident #17's breasts, and Resident #17 was holding Resident #44 by the hips and staff separated them on 11/17/2022 A review of the abuse investigation, dated 11/03/2022, revealed the file contained a state Self Report, and copies of three nursing notes dated 11/02/2022 which documented the physician being notified. No other portions of an investigation were available. A review of the Self Report form, dated 11/03/2022, revealed a certified nursing assistant (CNA) reported to the charge nurse that Resident #44 walked up to Resident #17 while Resident #17 was standing next to Resident #44's bed. Resident #44 then took both of their hands and touched both of Resident #17's breasts. The CNA reported to the charge nurse that Resident #17 was standing there with their eyes closed after Resident #44 touched Resident #17's breast. Resident #17 was fully clothed at that time. The Corrective Action Description on the Self Report form revealed staff were instructed to watch both residents closely to ensure that both residents did not engage in any further instances of this nature. A review of the abuse investigation, dated 11/18/2022, revealed the file contained a state Self Report, one progress note dated 11/17/2022 which described the incident, and a Risk Management note dated 11/17/2022 which listed who was notified. No other portions of an investigation were available. A review of the Self Report form, dated 11/18/2022, revealed facility staff saw that Resident #44 wandered into room [ROOM NUMBER] with Resident #17 and was rubbing Resident #17's breasts over their shirt as Resident #17 was holding Resident #44 by the waist. Resident #17 and Resident #44 were not upset at time of discovery. They were immediately separated by facility staff. Both residents were redirected very easily with no adverse behaviors. Both families were notified at time of incident. The Corrective Action Description on the Self Report form revealed staff were re-educated on the importance of ensuring future situations of this nature were prevented through situational awareness. A quick meeting was provided to staff to sign off on as well in regard to this incident and preventing any further occurrence. During an interview on 12/14/2022 at 2:33 PM, CNA #7 stated Resident #17 was somewhat restless and got up to walk often. CNA #7 stated the resident's family came in to visit the resident. The resident did not know them but appeared to trust them, and they walked in the hall together on the unit during visits. CNA #7 stated the resident spoke, but the words did not make sense, and staff had to anticipate the resident's needs. The CNA stated the resident rejected care at times. During an interview on 12/15/2022 at 1:55 PM, CNA #11 stated Resident #17 had behaviors of yelling, mainly when the resident needed to use the restroom. She stated the resident would raise their fist at times toward the staff and wandered the unit daily. She stated the resident did touch other residents' hands when they walked, and if it bothered them, staff would redirect the resident away from that resident. CNA #11 stated Resident #44's behaviors were toward staff; the resident asked the staff to lie in bed with them. CNA #11 stated she was educated on abuse last month, and sexual abuse education was part of that training. She stated if the residents wanted to touch on this unit, she thought it would be abuse because the residents could not consent to it. If she saw something she thought was abuse, she would separate the residents and report it to the nurse or to the Director of Nursing (DON). During an interview on 12/15/2022 at 2:07 PM, CNA #6 stated Resident #17 was not oriented to self, and during showers and toileting would swing at and hit the staff. She stated staff had identified the resident would become agitated when they needed to use the bathroom, and staff anticipated the resident's care. She stated staff walked down the hall with the resident and held their hand when the resident wanted to walk. CNA #6 stated Resident #44's behaviors included touching the staff or attempting to touch them in a sexual way and making sexual comments. She stated she was aware of the two incidents of sexual touching between Resident #17 and Resident #44 and had not received any additional education after those events, except staff was instructed to keep the residents apart and watch them. She stated that on this unit, the residents were Not with it enough to consent to sexual touch, and Resident #17 and Resident #44 could not consent. CNA #6 stated she completed abuse for dementia training, including sexual abuse. She stated if she saw something she thought was abuse, she would separate the residents and report it to the nurse. During an interview on 12/15/2022 at 2:23 PM, CNA #17 stated she was aware of the sexual interactions between Resident #17 and Resident #44. She stated she did not notice any behavior changes for either resident after the incidents. CNA #17 stated Resident #44 made sexual comments and attempted to touch staff when they provided care, but the resident had not acted inappropriately to any other residents. She stated if Resident #17 and Resident #44 sat by one another on the couch, staff moved one of the residents to another chair. CNA #17 stated she was trained on abuse, including sexual abuse, and thought both residents were not able to give consent to sexual touching, because they Were not in the right mind to give consent; they would not understand. CNA #17 stated she had not received any additional education after the touching incidents. She stated if she saw something she thought was abuse, she would separate the residents and report it to the nurse. During an interview on 12/15/2022 at 2:34 PM, CNA #18 stated she was educated on abuse, including sexual abuse, within the past three days. She stated sexual abuse included anything of a sexual nature which was unwanted or if the resident was not able to give consent to it. She stated if she saw something she thought was abuse, she would make sure the residents were safe and report it to a supervisor. During an interview on 12/15/2022 at 3:33 PM, the Unit Manager/QAPI Coordinator (UM/QC) stated she did not investigate abuse allegations. She stated her role during an abuse investigation was the DON or the Administrator would ask her if she identified a trend in that behavior, or if it happened to other residents. She stated that when there was a report of abuse, it was reported to a supervisor, then the information went to the DON or Administrator, and the UM/QC would be called to conduct a head-to-toe assessment on the residents involved. During a follow-up interview on 12/15/2022 at 7:12 PM, the UM/QC stated she was aware of the two incidents between Resident #17 and Resident #44, and no specific interventions were put in place after the first incident to prevent the second incident. She stated the Administrator educated that day on monitoring and activities to keep Resident #44 engaged, but the education was not done before 12/15/2022. She stated the staff and residents on the secured unit were monitored by the nurses doing rounds, assessments, and they evaluated the environment, checked on the residents, and asked the staff how things were going during the shift. The UM/QC stated her role after an incident was to ensure the charting was done and to conduct a head-to-toe assessment on the residents. She stated she was not called to conduct head-to-toe assessments on Resident #17 or Resident #44, and she thought the nurse at the time charted the assessment, but agreed it was not a head-to-toe assessment. During an interview on 12/15/2022 at 7:13 PM, the DON stated she thought the incidents between Resident #17 and Resident #44 would fall under the abuse category because both residents were demented. She stated it would have made sense to get written statements from staff and conduct more thorough investigations to clarify the situations. The DON stated she did not believe abuse could be prevented, because We cannot be one on one with every patient, but the intention was to deter abuse. She stated more interventions to prevent the abuse depended on the interventions and if the staff would comply with the interventions. The DON stated the UM/QC was the nurse who had oversight on the unit. She stated the immediate intervention was separating the residents but, We could have had something more aggressive in place to prevent another occurrence of abuse. During an interview on 12/15/2022 at 7:37 PM, the Administrator stated he reported to the state the incidents between the residents as potential sexual abuse because the residents could not consent to sexual touching. The Administrator stated, Of course abuse can be prevented; certain situations are harder than others. He stated interventions could be put in place to separate the residents. He stated the staff was trained on abuse and immediate reporting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, document review, and policy review, the facility failed to report sexual abuse to the state agency within two hours for 2 of 2 incidents of sexual abuse between Resident #17 and Resident #44. Findings included: The undated facility policy titled, Abuse Prevention, Identification, Investigation, and Reporting, revealed, F. Reporting: 1. All allegations of Resident abuse, neglect, exploitation, mistreatment, injuries of unknow origin and misappropriation should be reported immediately to the charge nurse. 2. The charge nurse is responsible for immediately reporting the allegations of abuse to the Administrator, or designated representative. 3. All allegations of Resident abuse shall be reported to the [State Agency] not late then two (2) hours after the allegations is made. A review of Resident #17's medical diagnoses sheet revealed a diagnosis of dementia with behavioral disturbance. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's cognitive skills for daily decision making were severely impaired according to the staff assessment for mental status. The MDS revealed the resident had continuous disorganized thinking and inattention and fluctuating levels of altered mental status. The resident had delusions and hallucinations. The resident had behaviors including verbal behavioral symptoms directed toward others for one to three days during the seven day look back period, rejecting care for four to six days during the seven day look back period, and daily wandering. A review of Resident #17's care plan, revised 11/18/2022, revealed the resident was at the facility for long term placement. One intervention included the resident's breast was touched by a peer and staff intervened and separated them on 11/02/2022. Another intervention included another resident was rubbing Resident #17's breasts over the resident's shirt. Resident #17 had both hands on Resident #44's hips. The residents were separated immediately and neither resident was agitated or hurt. A review of Resident #44's medical diagnoses sheet revealed diagnoses of dementia with behavioral disturbance and Alzheimer's disease. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 4, indicating severe cognitive impairment. The MDS revealed the resident had continuous disorganized thinking and inattention, hallucinations, and delusions. The resident had behaviors including daily rejection of care, daily wandering, and daily behaviors not directed toward others. A review of Resident #44's care plan, revised 11/22/2022, revealed the resident was at the facility for long term placement. One intervention included the resident touched Resident #17's breasts and staff separated them on 11/02/2022. Another intervention included the resident was rubbing Resident #17's breasts, and Resident #17 was holding Resident #44 by the hips and staff separated them on 11/17/2022 A review of the Self Report form, dated 11/03/2022, revealed a certified nursing assistant (CNA) reported to the charge nurse that Resident #44 walked up to Resident #17 while Resident #17 was standing next to Resident #44's bed. Resident #44 then took both of their hands and touched both of Resident #17's breasts. The CNA reported to the charge nurse that Resident #17 was standing there with their eyes closed after Resident #44 touched Resident #17's breast. Resident #17 was fully clothed at that time. The Self Report indicated the approximate date/time the incident occurred was 11/02/2022 at 3:00 PM. The report's submission date to the state agency was on 11/03/2022 at 1:03 PM. A review of the Self Report form, dated 11/18/2022, revealed facility staff saw that Resident #44 wandered into room [ROOM NUMBER] with Resident #17 and was rubbing Resident #17's breasts over their shirt as Resident #17 was holding Resident #44 by the waist. Resident #17 and Resident #44 were not upset at time of discovery. They were immediately separated by facility staff. Both residents were redirected very easily with no adverse behaviors. Both families were notified at time of incident. The Self Report indicated the approximate date/time the incident occurred was 11/17/2022 at 12:49 PM. The report's submission date was 11/18/2022 at 5:47 PM . During an interview on 12/15/2022 at 7:13 PM, the Director of Nursing (DON) stated she thought the incidents between Resident #17 and Resident #44 would fall under the abuse category because both residents were demented. The DON stated the Administrator was responsible for reporting to the state, and she thought it should be done within the appropriate time frame. During an interview on 12/15/2022 at 7:37 PM, the Administrator stated he reported to the state the incidents between Resident #17 and Resident #44 as potential sexual abuse because the residents could not consent to sexual touching. He stated he thought the period for reporting to the state was 24 hours, and he did report within the 24 hours, but now realized the federal regulations required a report within two hours, and the state regulations had the 24-hour period. He stated he would report sooner if the staff told him about the incidents sooner; they may wait until the next workday to report it to him. The Administrator stated, I understand the reporting was late.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, document review, and policy review, the facility failed to conduct a thorough investigation of two incidents of sexual abuse on the secured dementia unit for 2 (Resident #17 and Resident #44) of 2 residents sampled for abuse. Findings included: The undated facility policy titled, Abuse Prevention, Identification, Investigation, and Reporting, revealed, G. Investigation. 1. Should an incident or suspected incident of Resident abuse (as defined above) be reported or observed, the administrator or his/her designee will designate a member of management to investigate the alleged incident. 2. The administrator or designee will complete documentation of the allegation of Resident abuse and collect any supporting documents relative to the alleged incident: A. Review documentation in resident record (including review of assessment if resident injury). B. Assess the resident for injury if the allegation involves physical or sexual abuse; D. Attempt to obtain witness statements (oral and/or written) from all known witnesses. A review of Resident #17's medical diagnoses sheet revealed a diagnosis of dementia with behavioral disturbance. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's cognitive skills for daily decision making were severely impaired according to the staff assessment for mental status. The MDS revealed the resident had continuous disorganized thinking and inattention and fluctuating levels of altered mental status. The resident had delusions and hallucinations. The resident had behaviors including verbal behavioral symptoms directed toward others for one to three days during the seven day look back period, rejecting care for four to six days during the seven day look back period, and daily wandering. A review of Resident #17's care plan, revised 11/18/2022, revealed the resident was at the facility for long term placement. One intervention included the resident's breast was touched by a peer and staff intervened and separated them on 11/02/2022. Another intervention included another resident was rubbing Resident #17's breasts over the resident's shirt. Resident #17 had both hands on Resident #44's hips. The residents were separated immediately and neither resident was agitated or hurt. A review of Resident #44's medical diagnoses sheet revealed diagnoses of dementia with behavioral disturbance and Alzheimer's disease. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 4, indicating severe cognitive impairment. The MDS revealed the resident had continuous disorganized thinking and inattention, hallucinations, and delusions. The resident had behaviors including daily rejection of care, daily wandering, and daily behaviors not directed toward others. A review of Resident #44's care plan, revised 11/22/2022, revealed the resident was at the facility for long term placement. One intervention included the resident touched Resident #17's breasts and staff separated them on 11/02/2022. Another intervention included the resident was rubbing Resident #17's breasts, and Resident #17 was holding Resident #44 by the hips and staff separated them on 11/17/2022 A review of the abuse investigation, dated 11/03/2022, revealed the file contained a state Self Report, and copies of three nursing notes dated 11/02/2022 which documented the physician being notified. No other portions of an investigation were available, such as witness statements, observations of the residents before the incident, a root cause analysis, steps taken to protect the residents during the investigation, identification of any other victims, a five-day conclusion of the investigation, et cetera (etc). A review of the abuse investigation, dated 11/18/2022, revealed the file contained a state Self Report, one progress note dated 11/17/2022 which described the incident, and a Risk Management note dated 11/17/2022 which listed who was notified. No other portions of an investigation were available, such as witness statements, observations of the residents before the incident, a root cause analysis, steps taken to protect the residents during the investigation, identification of any other victims, a five-day conclusion of the investigation, etc. During an interview on 12/15/2022 at 2:07 PM, CNA #6 stated she was aware of the two incidents of sexual touching between Resident #17 and Resident #44 and had not receive any additional education after those events, except staff was instructed to keep the residents apart and watch them. During an interview on 12/15/2022 at 2:23 PM, CNA #17 stated she was aware of the sexual interactions between Resident #17 and Resident #44. She stated she did not notice any behavior changes for either resident after the incidents. CNA #17 stated Resident #44 made sexual comments and attempted to touch staff when they provided care, but the resident had not acted inappropriately to any other residents. She stated if Resident #17 and Resident #44 sat by one another on the couch, staff moved one of the residents to another chair. CNA #17 stated she was trained on abuse, including sexual abuse. CNA #17 stated she had not received any additional education after the touching incidents. During an interview on 12/15/2022 at 3:33 PM, the Unit Manager/QAPI Coordinator (UM/QC) stated she did not investigate abuse allegations. She stated her role during an abuse investigation was the DON or the Administrator would ask her if she identified a trend in that behavior, or if it happened to other residents. She stated that when there was a report of abuse, it was reported to a supervisor, then the information went to the DON or Administrator, and the UM/QC would be called to conduct a head-to-toe assessment on the residents involved. During a follow-up interview on 12/15/2022 at 7:12 PM, the UM/QC stated she was aware of the two incidents between Resident #17 and Resident #44, and no specific interventions were put in place after the first incident to prevent the second incident She stated she was not called to conduct head-to-toe assessments on Resident #17 or Resident #44, and she thought the nurse at the time charted the assessment, but agreed it was not a head-to-toe assessment. During an interview on 12/15/2022 at 7:13 PM, the Director of Nursing (DON) stated she thought the incidents between Resident #17 and Resident #44 would fall under the abuse category because both residents were demented. She stated it would have made sense to get written statements from staff and conduct more thorough investigations to clarify the situations. During an interview on 12/15/2022 at 7:37 PM, the Administrator stated he reported to the state the incidents between the residents as potential sexual abuse because the residents could not consent to sexual touching. The Administrator stated, I understand the reporting was late, and a thorough investigation should have been done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, it was determined that the facility failed to have consistent communication with the dialysis center for 1 (Resident #41) of 1 sampled resident reviewed for dialysis services. Findings included: A review of an admission Record revealed Resident #41 had diagnoses that included end stage renal disease and dependence on renal dialysis. Review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Review of a care plan, dated as initiated 05/11/2022, revealed Resident #41 required dialysis related to end stage renal disease and had a fistula (a surgically created connection between an artery and a vein to facilitate dialysis) in the left forearm. Interventions included to administer medications as ordered (initiated 05/11/2022); check for thrill (a rumbling sensation that should be present and can be felt over a dialysis fistula) to the dialysis site in the left arm every shift and notify the physician and dialysis center if not present (initiated 05/11/2022); encourage the resident to go to the scheduled dialysis appointments on Tuesdays, Thursdays, and Saturdays (initiated 05/11/2022); and monitor for any complications from dialysis such as hemorrhage, access site infections, or hypotension and notify the physician and dialysis center of any concerns (initiated 11/09/2022). Review of an Order Summary Report, which listed Resident #41's active orders as of 12/15/2022, revealed the resident had a physician's order dated 09/19/2022 for dialysis every Tuesday, Thursday, and Saturday. A review of Resident #41's medical record revealed, Doctor Visit Forms that were used for communication between the facility and the dialysis center. No communication forms were found in the resident's record for dialysis treatments on Thursday 11/17/2022, Tuesday 11/22/2022, Saturday 11/26/2022, Saturday 12/03/2022, Tuesday 12/06/2022, Thursday 12/08/2022, Saturday 12/10/2022 or Tuesday 12/13/2022. During an interview on 12/14/2022 at 4:15 PM, the Director of Nursing (DON) stated she realized the communication with the dialysis center was not consistent. She stated she expected communication to occur with the dialysis center every time the resident went to the center. The DON stated if the dialysis center did not send back the communication form, then the nurse should be contacting the center to have them send it over. She stated this was important for continuity of care. During an interview on 12/13/2022 at 12:35 PM, Licensed Practical Nurse (LPN) #12 stated a form was sent with the resident to the dialysis center, and sometimes the center would complete and send it back with the resident and other times they did not. LPN #12 stated when the form was returned, it would be placed in the file to be uploaded to the resident's record. She stated there was no certain person who was the liaison with the dialysis center. LPN #12 indicated if there were any changes with the resident, the dialysis center would call or the family would inform the facility. During an interview on 12/13/2022 at 12:40 PM, LPN #11 indicated the communication with the dialysis center was not consistent. During an interview on 12/15/2022 at 7:18 PM, the Administrator stated he expected communication with the dialysis center to improve. He stated communication with the dialysis center had been an ongoing issue. He stated the facility would send the communication form to the dialysis center but would not get it back. The Administrator stated he expected the staff to follow up with the dialysis center if the resident returned without the communication form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, document review, and facility policy review, the facility failed to provide a complete diet which lacked the appropriate nutritive value for 2 (Residents #29 and #54) of 3 residents who required pureed diets. This had the potential to affect 14 residents who received pureed or partially pureed diets. Findings included: A review of the facility policy, Therapeutic Diets, undated, revealed, 1. Therapeutic diets must be prescribed by the attending physician. 3. A current therapeutic diet manual shall be readily available to attending physicians, nurses, and dietetic service personnel. This manual shall be used a s a guide for writing menus for therapeutic diets. 4. A licensed dietitian shall be responsible for writing and approving the therapeutic menu and reviewing procedures for preparation and service of therapeutic menus. 5. Personnel responsible for planning, preparing, and serving therapeutic diets shall receive instructions on those diets. A review of Resident #29's medical diagnoses sheet revealed the resident had diagnoses which included dementia and dysphagia. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's cognitive skills for daily decision making were severely impaired according to the staff assessment for mental status. The MDS further revealed the resident was on a mechanically altered therapeutic diet and completed speech therapy on 08/04/2022. A review of Resident #29's nutrition care plan, revised 11/12/2022, revealed an intervention, dated 08/03/2022, for pureed foods. A review of the Order Recap Report revealed a physician's order, dated 12/02/2022, for a general diet, pureed texture. A review of Resident #54's medical diagnoses sheet revealed the resident had a diagnosis which included dementia. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's cognitive skills for daily decision making were severely impaired according to the staff assessment for mental status. The MDS further revealed the resident was on a mechanically altered diet and completed speech therapy on 08/23/2022. A review of Resident #54's nutrition care plan, revised 10/20/2022, revealed an intervention, dated 08/23/2022, for pureed foods. A review of the physician's orders, revised 10/11/2022, revealed a general diet, pureed texture. A review of the facility Diet Type Report, dated 12/12/2022, revealed Resident #29 and Resident #54 were listed for a pureed diet. A review of the Menu Planning Guide, updated August 2019, revealed, [Company name] base menus are designed to include foods in amounts that will meet or exceed the Dietary Reference Intakes (DRIs) for older adults. The following components are included daily: Protein: 5-6 oz [ounce] equivalents. A review of the facility's menu plan for 12/13/2022 revealed residents receiving a regular diet were to receive one cheese stick and residents receiving a pureed diet were to receive one serving of pureed cottage cheese (in place of the cheese stick) for the noon meal. A review of the label on the cheese sticks planned for the noon meal on 12/13/2022 revealed the cheese stick contained 6 grams (g) of protein. An observation of the kitchen serving line on 12/13/2022 at 11:49 AM revealed Dietary Staff (DS) #4 did not add a cheese stick to Resident #29's tray and did not add any alternate protein source to the pureed meal tray. An observation on 12/13/2022 at 12:24 PM revealed Resident #54 did not have pureed cottage cheese or any alternate protein on their tray. During an interview on 12/13/2022 at 12:24 PM, DS #3 stated he forgot to prepare the pureed cottage cheese, which was the pureed diet alternate for the cheese stick; therefore Resident #54 did not receive the cottage cheese. During an interview on 12/13/2022 at 12:39 PM, DS #4 stated the pureed diets should have had pureed cottage cheese according to the spreadsheet menu, but none was available. DS #4 verified none was given to Resident #29 and Resident #54 . During an interview on 12/13/2022 at 12:40 PM, the Dietary Manager stated the staff used the spreadsheet menu to identify the replacements for the pureed diet textures. She stated the cottage cheese should have been served for the pureed diets, and the residents who did not receive it were short of 6 g of protein. During an interview on 12/14/2022 at 11:26 AM, the Registered Dietician stated for the missing cottage cheese, those residents were short 6 g protein for that meal. During an interview on 12/15/2022 at 6:49 PM, the Director of Nursing stated dietary should follow what the assigned dietary menu said and if there was a substitute for something else on the menu, it should have been put in place. During an interview on 12/15/2022 at 7:36 PM, the Administrator stated his expectation was for the dietary staff to follow the menus and prepare all the foods.

Based on interviews and review of a facility document, the facility failed to ensure the Dietary Manager was a Certified Dietary Manager (CDM). This had the potential to affect all residents. Findings included: A review of a document provided by the facility Administrator of the State regulations for Dietary Managers, which went into effect 07/13/2016, revealed the facility should employ a qualified dietary supervisor who, (4) Has completed an ANFP [Association of Nutrition & Foodservice Professionals]-approved course curriculum necessary to take the certification examination required to become a certified dietary manager; (5) Has documented evidence of at least two years' satisfactory work experience in food service supervision and who is in an approved dietary manager association program and will successfully complete the program within 24 months of the date of enrollment. During an interview on 12/12/2022 at 8:55 AM, the Dietary Manager (DM) stated she did not complete the Certified Dietary Manager (CDM) course but was registered to take the course in January 2023. During an interview on 12/14/2022 at 11:26 AM, the Registered Dietician (RD) stated the DM started in March 2022, directed the kitchen, and trained the kitchen staff. The RD stated as the RD she was not the manager of the kitchen, did not train the staff, and was not an employee of the facility, but did identify training needs for the staff last week which fell through the cracks. She stated she was a consultant who worked 20 hours per week. The RD further stated she advised the DM to get her CDM, and that she had one year to complete the course. The RD stated she would find the State regulation for the one-year period for the DM to obtain her CDM certificate. During an interview on 12/15/2022 at 6:48 PM, the Director of Nursing (DON) stated she would find the regulation and then give the DM a timeline to complete it within the regulations. During an interview on 12/15/2022 at 7:29 PM, the Administrator stated his expectation was the DM completed the course as soon as possible. He stated the state regulations were the same as the federal regulations; there was nothing about a one-year period to complete the certification.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, document review, and facility policy review, the facility failed to provide food prepared in a manner to meet individual needs for 2 (Resident #52 and Resident #63) of 3 sampled residents reviewed for food consistency. Additionally, the facility failed to prepare pureed foods correctly to meet resident needs during 1 of 2 meal services observed. Findings included: A review of an undated facility policy titled, Therapeutic Diets, revealed, 3. A current therapeutic diet manual shall be readily available to attending physicians, nurses and dietetic service personnel. This manual shall be used as a guide for writing menus for therapeutic diets. 4. A licensed dietitian shall be responsible for writing and approving the therapeutic menu and reviewing procedures for preparation and service of therapeutic menus. 5. Personnel responsible for planning, preparing and serving therapeutic diets shall receive instructions on those diets. The policy also indicated, Mechanically altered diet is one in which the texture of a diet is altered. When the texture is modified, the type of texture modification must be specific and part of the physician's order. All diets will have a corresponding description in the Simplified Diet Manual. A review of the facility's Diet Type Report, dated 12/12/2022, revealed there were 14 residents who required either a pureed diet, a mechanical soft diet with pureed meats, or a mechanical soft diet with ground meats. 1. On 12/13/2022 at 1:42 PM, the Dietary Manager stated the Simplified Diet Manual was considered the facility's policy. Page 56 of the undated manual revealed the following for, Soft & [and] Bite-Sized (chopped texture): - Biting is not required for this level, but chewing is required. - 1. Provides foods that are soft, tender, and moist. - 3. Bite-sized pieces shall be no larger than 1.5 cm [centimeters] x [by] 1.5 cm for adults. - The size limit was determined to minimize choking risk. Page 57 of the manual revealed the following for a, Minced & Moist (ground texture): - Biting is not required but minimal chewing ability is required. - 1. Soft and moist. No thin liquid should separate. - 3. The texture includes smaller and cohesive pieces compared to [chopped] making it easier to manage in the mouth. 1. a) A review of Resident #52's Medical Diagnosis list revealed the resident had diagnoses including anemia, chronic kidney disease, and dementia. A review of Resident #52's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident was severely cognitively impaired. The MDS further revealed the resident received a mechanically altered diet and was receiving services from speech therapy (ST). A review of the Clinical Physician Orders revealed a diet order dated 08/24/2022 for Resident #52 to receive a regular texture diet, regular consistency, with chopped meats, and finger foods when able. A review of the nutritional care plan dated 09/07/2022 for Resident #52 revealed an ST alert dated 08/19/2022 that indicated the resident required chopped meats. A review of the facility's Diet Type Report dated 12/12/2022 revealed Resident #52's diet type was a regular diet with chopped meats and finger foods when able. A review of Resident #52's diet card, kept in the dining room of the resident's unit, revealed the resident was on a regular diet with chopped meat and finger foods when able. An observation of the meal service on 12/12/2022 at 12:23 PM on Resident #52's unit revealed Dietary Staff (DS) #1 served the resident a whole slice of meatloaf. An interview at that time with Certified Nursing Assistant (CNA) #5 revealed Resident #52 had been on a regular texture diet for a while now. CNA #5 stated she thought the Dietary Manager instructed staff that the resident had a diet change to regular texture, which would include a slice of meat. At 12:25 PM, CNA #5 reviewed the resident's diet card and stated Resident #52 should have received ground meat instead of a slice of meatloaf. During an interview on 12/12/2022 at 12:30 PM, DS #1 stated there was a book on her cart which contained copies of residents' diet cards. She stated she looked at the cards if the texture or diet had changed but did not look at the cards every day because the diets were the same every day. DS #1 stated if a resident's diet changed, the Dietary Manager (DM) would update the resident's diet card and pass along the information to the dietary staff. DS #1 stated she made a mistake serving Resident #52 a whole slice of meatloaf because the resident should have received ground meat. During an interview on 12/12/2022 at 12:27 PM, the Unit Manager / Quality Assurance Performance Improvement (QAPI) Coordinator acknowledged Resident #52 received the wrong texture of meat. During an interview on 12/13/2022 at 1:13 PM, the Dietary Manager (DM) stated Resident #52 required chopped meat and indicated DS #1 or the CNA should have cut the resident's meat before serving. 1. b) A review of Resident #63's Medical Diagnoses list revealed the resident had diagnoses including dementia and psychosis. A review of Resident #63's admission Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident was severely cognitively impaired. The MDS further revealed the resident did not have a swallowing disorder and was receiving services from speech therapy (ST). A review of a Therapy Alert dated 11/17/2022 revealed Resident #63 required a mechanical soft diet with ground meats and indicated all foods were required to be cut up for the resident prior to serving. A review of the Clinical Physician Orders revealed Resident #63's diet order dated 11/17/2022 was for a general diet with a mechanical soft texture, regular consistency ground meats, and food was required to be cut prior to serving. A review of Resident #63's nutritional care plan, dated 11/16/2022, revealed an ST alert for a mechanical soft diet with ground meats, thin liquids, and to cut all food prior to serving. A review of the Diet Type Report, dated 12/12/2022, revealed Resident #63's diet type was a mechanical soft diet with ground meats, and food cut up prior to serving; however, a review of Resident #63's diet card, kept on the dietary serving cart, revealed the resident was to receive chopped meats. An observation of the meal service on 12/12/2022 at 12:15 PM revealed Dietary Staff (DS) #1 served Resident #63 chopped meat instead of ground meat. During an interview on 12/12/2022 at 12:26 PM, Certified Nursing Assistant (CNA) #5 indicated Resident #63 received chopped meat, but after reviewing the resident's diet order, the CNA stated the diet should have been ground meat. She stated, It's all the same anyway, chopped and ground. She stated if there was a diet change, it was listed on the diet cards but stated it took the kitchen a while to update diet cards after a diet change. During an interview on 12/12/2022 at 12:27 PM, the Unit Manager / Quality Assurance Performance Improvement (QAPI) Coordinator stated Resident #63 should have been served ground meat, not chopped meat. During an interview on 12/12/2022 at 12:30 PM, Dietary Staff (DS) #1 stated during the noon meal service that there was a book on her cart that contained copies of the diet cards for the unit. She stated she looked at the cards if the resident's food texture or diet had changed but did not look at the cards every day because the diets were the same every day. DS #1 stated if a resident's diet changed, the Dietary Manager (DM) would update the diet card and pass the information to the dietary staff. She stated she cut the meat for Resident #63, and she thought it was correct. DS #1 stated the residents should get the correct food texture so they could swallow more easily and not choke. During an interview on 12/13/2022 at 1:13 PM, after reviewing the physician's order, the DM stated, Oh, they changed [Resident #63's] order! She stated the resident was to receive ground meat now and should have been served ground meat the previous day, not chopped meat. The DM stated chopped and ground meat were not the same. The DM stated the risk of receiving the wrong food texture was choking. An observation on 12/13/2022 at 12:57 PM revealed Resident #63 received pureed meat and pureed coleslaw at the noon meal. During an interview at this time, DS #3 stated he served the pureed foods because he thought it was what the resident's physician ordered. DS #3 acknowledged he did not refer to the book containing the diet cards when serving the meal. During an interview on 12/14/2202 at 1:45 PM, CNA #6 stated dietary staff did not check diet cards before they served the food to the residents, and CNAs had to tell them what the residents were supposed to receive. CNA #6 stated a resident could choke if they received the wrong diet texture. During an interview on 12/14/2022 at 1:53 PM, CNA #7 stated the dietary staff did not always check the diet cards before serving food to the residents, but the nursing staff did check the cards. She stated dietary should have a book to check what the resident's diet was. The risk was the residents might start choking if they could not swallow the food. During an interview on 12/14/2022 at 2:04 PM, CNA #8 stated dietary had a book with the residents' diet cards. She stated the dietary staff did not look at the cards and at times would question the CNAs about the residents' diets. CNA #8 stated the risk of receiving the wrong food texture was choking. During an interview on 12/14/2022 at 11:26 AM, the Registered Dietitian (RD) stated chopped and ground meat were not the same. She stated chopped meat had larger pieces than ground meat. She stated the residents should receive diet textures according to the physician's orders, and the DM should have placed current order information on the residents' diet cards. The RD also stated the staff serving should have referred to the diet cards to determine the appropriate diet to be served. The RD acknowledged Resident #52 received the incorrect diet texture and that Resident #63 received the incorrect diet texture twice during observations. She stated the risk of receiving the wrong diet texture might be difficulty swallowing the food. 2. A review of an undated facility manual titled Simplified Diet Manual revealed page 58 of the manual was about pureed foods and indicated Level 4 Pureed (PU4) is designed for individuals with difficulty biting, chewing and forming a bolus to swallow. Further review revealed pureed food must be provided as a smooth texture. Most foods will require blending and must not be sticky or contain lumps. The manual indicated, 3. Pureed foods should mostly maintain their shape when served. Thin liquids should not separate from PU4 foods. According to the manual To achieve the correct consistency, additional liquid or thickener may need to be added. Observation of food preparation on 12/13/2022 at 11:50 AM revealed Dietary Staff (DS) #4 stated they needed seven servings of pureed coleslaw for residents who received a pureed or ground meat diet. Further observation revealed DS #4 referred to the Pureed Coleslaw recipe, which did not have directions for seven servings. DS #4 and DS #2 worked together to add the ingredients for the pureed coleslaw. DS #4 used a #12 size scoop to add seven scoops of prepared coleslaw. DS #2 added 8 ounces (oz) of milk and approximately 2 and ½ tablespoons (T.) of thickener to the coleslaw. A review of the Pureed Coleslaw recipe revealed there was a recipe for six servings and nine servings of coleslaw and no recipe for seven servings. The recipe for six servings was to add 6 oz of milk and 2 T. thickener to six servings of prepared coleslaw (using a #8 size scoop). The recipe for nine servings was to add 9 oz of milk and three T. of thickener to nine servings of prepared coleslaw. According to the recipe, milk and thickener should be added to the coleslaw in a food processer and processed until there was a smooth pudding-like consistency. The recipe indicated not all of the liquid may be required. During an observation, and interview on 12/13/2022 at 11:57 AM, DS #2 completed pureeing the coleslaw mixture and stated the mixture contained too much liquid but proceeded to serve the coleslaw mixture to residents. During an interview on 12/13/2022 at 12:22 PM, DS #4 stated the recipe for pureed coleslaw had directions for six servings and that she just added a little more of the ingredients to make seven servings. During an interview on 12/14/2202 at 1:45 PM, Certified Nursing Assistant (CNA) #6 stated a resident could choke if they received the wrong diet texture. During an interview on 12/14/2022 at 1:53 PM, CNA #7 stated the risk of receiving an incorrect diet texture was the resident might start choking if they could not swallow the food. During an interview on 12/14/2022 at 2:04 PM, CNA #8 stated the risk of the incorrect diet texture was the residents might choke on the food. During an interview on 12/13/2022 at 12:40 PM, the Dietary Manager (DM) stated staff should have separated out some of the liquid from the coleslaw before pureeing it, so it was not runny. During an interview on 12/14/2022 at 11:26 AM, the Registered Dietician (RD) stated staff should have thickened the seven servings of pureed coleslaw. She stated there was a risk of aspiration by the resident if it was too thin. During an interview on 12/14/2022 at 1:32 PM, the Unit Manager/Quality Assurance/Performance Improvement (QAPI) Coordinator stated the risk of eating the wrong texture food could be choking or aspiration. During an interview on 12/15/2022 at 6:53 PM, the Director of Nursing (DON) stated the risk, if the resident could not swallow the food, was weight loss or choking. During an interview on 12/15/2022 at 7:35 PM, the Administrator stated he expected the staff to be trained on the various diet textures and therapeutic diets and pay attention to detail. The Administrator stated risk was the resident choking on the incorrect diet texture.

Based on observation, interview, and facility policy review, the facility failed to check the temperature of soup prior to serving the soup to residents to ensure it was served at the proper temperature for 4 of 4 bowls of soup served. Findings included: A review of the undated facility policy titled, Safe Food Preparation: Final Cooking Temperatures, revealed, 4. Foods should reach the following internal temperatures: A. Poultry and stuffed foods 165 degrees F [Fahrenheit]. An observation in the kitchen on 12/13/2022 at 12:09 PM revealed a resident ordered leftover chicken rice soup from the previous day. Dietary Staff (DS) #2 placed the container in the oven to heat. At 12:13 PM, DS #2 removed it from the oven and placed a bowl of the soup in the microwave and did not check the temperature after microwaving it and before serving the soup to the resident. At 12:15 PM, a resident ordered chicken noodle soup. DS #2 microwaved canned soup but did not check the temperature before serving the soup to the resident. At 12:18 PM, a resident ordered chicken noodle soup. DS #2 microwaved canned soup but did not check the temperature before serving the soup to the resident. At 12:20 PM, a resident ordered chicken noodle soup. DS #2 microwaved canned soup but did not check the temperature before serving the soup to the resident. During an interview on 12/13/2022 at 12:40 PM, the Dietary Manager (DM) stated the soups should have had temperatures taken and should have been above 165 degrees F before serving. During an interview on 12/14/2022 at 11:26 AM, the Registered Dietician stated the soup should have had temperatures taken for food safety and should have been at 165 degrees F or higher. During an interview on 12/15/2022 at 6:52 PM, the Director of Nursing stated all food should have temperatures taken to make sure it was the proper temperature to serve. During an interview on 12/15/2022 at 7:34 PM, the Administrator stated he expected dietary staff to take temperatures in order to properly reheat food. The risk of not taking the temperature might be foodborne pathogens.

Based on document review, interviews, and review of facility policies, the facility failed to consider and respond to grievances and recommendations from the Resident Council for 7 (June, July, August, September, October, November, and December 2022) of 7 months of council minutes reviewed. Specifically, the facility was unable to demonstrate that responses were provided to the council regarding their verbalized and documented concerns involving dietary, housekeeping/laundry, and nursing services. Findings included: A review of an undated facility policy titled, Resident Council revealed, 1. The Activity Department will organize a Resident Council. 2. The Resident Council will meet monthly. 3. All residents will be invited. The policy also indicated, 7. Minutes will be kept of all meetings. The policy did not address how any concerns or grievance from the council would be handled. Review of an undated facility policy titled, Grievance Procedure, revealed, Purpose: 1. To resolve residents and families concerns or grievances. 2. To ensure the highest quality of services is offered to the facilities residents and families. The policy also indicated the following: - Procedure: 1. The person the grievance is identified to will initiate the form. - 4. The Social Services/Administrator is responsible for resolving the grievance along with the appropriate Department Head. - 6. The Social Services/Administrator will follow-up with the resident/family as to resolution within 48-72 hours of receiving the grievance. - 7. The findings, resolution and resident/family response will be documented on the grievance form. Completed grievance forms will be kept in the Social Services and/or Administrator's office. A review of a Resident Council Meeting form dated 06/13/2022 revealed 20 residents attended the meeting and had concerns and requests that the dietary department have an alternate vegetarian menu and that the revolving trays on the tables in the main dining room be cleaned and stocked. The section at the end of the form titled, Team Leader Review and Initial was not initialed as reviewed by the dietary department. A review of a Resident Council Meeting form dated 07/18/2022 revealed 15 residents attended the meeting, during which a concern was recorded that the food needs to be a little hotter. The section titled Follow-up on issues/concerns was blank. The section titled, Team Leader Review and Initial was not initialed as reviewed by the dietary department. A review of a Resident Council Meeting form dated 08/15/2022 revealed 19 residents attended the meeting. Concerns for dietary included that it took too long to get food to the residents and that the residents would like for food to be served on alternating sides each week. Additionally, the residents felt housekeeping/laundry staff were not attentive to problems. A concern for the nursing department indicated the certified nurse aides (CNAs) were talking to each other too much, resulting in the residents being unable to tell them what they needed. The section titled Team Leader Review and Initial was not initialed as reviewed by the dietary or housekeeping/laundry departments. A review of a Resident Council Meeting form dated 09/12/2022 revealed 22 residents attended the meeting, and a concern was recorded under dietary that indicated the need to do better with special dietary considerations (examples included unable to eat bread, cheese, vegetarian). The section titled, Team Leader Review and Initial was initialed as reviewed by the dietary department. The section titled Follow-up on issues/concerns was blank. A review of a Resident Council Meeting form dated 10/03/2022 revealed 16 residents attended the meeting, and a concern was recorded under dietary that indicated foods like oatmeal were cold, even when served in the dining room. Additionally, the concern indicated, All food is cold! Seems that the current staff level makes it difficult to serve at the correct time. A concern for the nursing department indicated the CNAs were talking to each other when providing care and could not hear the residents. The section titled Follow-up on issues/concerns was blank. The form was initialed as reviewed by the dietary department and the Director of Nursing (DON). A review of a Resident Council Meeting form dated 11/14/2022 revealed 22 residents attended the meeting. A new form had been initiated. The section titled, Follow-up Concerns revealed, Still having issues with food being cold, and CNAs still talking among themselves when providing cares and ignoring resident. The section of the form titled, Dietary revealed the residents suggested that every other week, the side of the dining room where they start serving should change. Additionally, the form indicated one resident suggested serving the residents who required assistance last so that their food would still be hot when staff sat down to assist them. The section of the form titled, Nurses/CNAs/Medication Aids [sic] revealed a resident reported receiving wrong pills last night. The resident asked for a record of the medications and was told, I don't know. A review of Resident Council Meeting form dated 12/05/2022 revealed 21 residents attended the meeting. The section titled, Follow-up Concerns revealed one side of the dining room was still being served first and the residents who required assistance were being served first even though they have to eat last. The section titled, Dietary indicated the food served in the dining room is still cold, especially vegetables. Additionally, napkins, straws, pepper, and salt were consistently empty. The section for nursing indicated the CNAs were still talking while giving care. Additionally, the residents indicated staff would say just a second then not come back. On 12/13/2022 a meeting was held with four Resident Council members, including Resident #4, Resident #21, Resident #47, and Resident #59. The meeting minutes for the last six months were discussed, and the residents all stated they had not heard back or had any resolution for the following issues: - CNAs talking to each other during care and ignoring the resident. - Cold food: The residents indicated this was still frequently an issue and that most of the time, the vegetables were cold. - Order of meal service: The residents indicated residents who needed assistance with eating still received their meals first but ate last due to waiting for staff to finish passing meals and assist them. Additionally, there had been no follow-up on alternating which side of the dining room was served first. An interview was conducted on 12/13/2022 at 11:22 AM with the Director of Nursing (DON). She stated that when the Activity Director, who oversaw the Resident Council meeting each month, brought the meeting minutes to her, she made notes on the issues and tried to investigate them for resolution, education, or teaching. She indicated she would then attach that information to the minutes form. The DON acknowledged that she had not followed up/communicated with the Resident Council regarding any efforts to resolve the issues they had brought up at the meetings. The DON stated she saw there was a need to close the loop and follow up on the residents' concerns. An interview was conducted on 12/13/2022 at 2:51 PM with the Activity Director (AD). He stated that after he conducted a Resident Council meeting each month, he would give the meeting minutes with the issues and concerns to the DON at the morning meeting. He stated he believed that after he gave them to the DON, she would read them and investigate the issues that were mentioned by the residents. The AD stated that the following month, he would just repeat the process and follow the template on the Resident Council Meeting form. He indicated that in November 2022, a new form was initiated, and one of the first areas addressed on the form was Follow up on Concerns. He stated that when he read that section to the residents, he felt stressed because he saw that the same issues were still happening. He stated he was upset that there had not been any follow up with residents on their concerns. A follow-up interview was conducted on 12/15/2022 at 8:29 AM with the DON. She stated the concerns that were brought up in Resident Council were looked at and addressed on the Resident Council form but not transferred to a concern or grievance form. She stated she was aware that a system of addressing concerns from the Resident Council meeting had not been completed. The DON stated there should be follow-through and a report back to Resident Council members on resolution of their concerns. An interview was conducted on 12/15/2022 at 5:30 PM with the Administrator. He stated his expectation for the concerns brought forward at Resident Council meetings would be that the Activities Director would bring the meeting minutes to the morning meeting. From there, whichever department had a concern from the Resident Council meeting would be assigned to take care of it to investigate and fix the problem. The Administrator stated he would expect that an answer or resolution should be given back to the members of the Resident Council about their concerns.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, it was determined that the facility failed to ensure assessments were completed and documented and informed consents were obtained prior to utilizing side rails on residents' beds for 3 (Residents #28, #49, and #46) of 3 sampled residents reviewed for the use of side rails. Findings included: On 12/14/2022 at 10:02 AM, a copy of the facility's side rail policy was requested from the Director of Nursing (DON) and was not provided by the end of the survey. 1. A review of an admission Record revealed Resident #28 had diagnoses that included cerebral infarction (stroke) with left sided weakness, osteoarthritis, and rheumatoid arthritis. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact. The MDS indicated the resident required extensive assistance of two or more people with bed mobility and transfer. According to the MDS, the resident had functional limitation in range of motion to both upper extremities and had no restraints in use. Review of a care plan, dated as initiated 05/22/2020, revealed the resident required assistance with activities of daily living (ADLs). An intervention dated as revised 12/13/2022 indicated the resident required extensive assistance of two people for bed mobility and had quarter side rails at the head of the bed to assist the resident. The care plan indicated the side rails do not restrict or limit my ability to move about freely in the bed. An observation on 12/12/2022 at 2:06 PM revealed Resident #28 had quarter side rails raised on both sides of the head of the bed. A review of Resident #28's medical record revealed no assessment or consent for the use of side rails. A review of Resident #28's physician orders revealed no orders for the use of side rails. During an interview on 12/13/2022 at 4:16 PM, the Director of Nursing (DON) stated all beds in the facility had quarter side rails at the head of the bed. She stated the facility had not viewed the side rails as a restraint and had not obtained consents or done assessments for any of them. She stated she had been the DON for four months and, when asked for the assessments during the survey, she realized they had not been done. She stated she immediately implemented an action plan for this. She stated a nurse went to Resident #28's room and got a consent form signed by the resident for the side rails and completed an assessment. She stated the facility did not have a specific bedrail assessment that could be completed in the electronic record, so she implemented this. During an interview on 12/14/2022 at 10:02 AM, the DON stated she spoke with the maintenance director that morning and confirmed that all beds in the facility had side rails and no side rail assessments had been completed for any of the residents. The DON stated some of the residents had consents for the side rails but not all of them. She stated her plan was to go down the list of residents and assess each resident to determine if the side rails were needed or not. She stated if they were needed, the facility would get a consent signed and obtain a physician's order. The DON stated if the side rail was not needed, then maintenance was going to zip tie the rails down to the frame to prevent them from being raised. The DON stated she was not sure why the assessments had not been completed. The DON stated she checked the list of risk management (incident reports) for the last three months and there had been no adverse outcomes related to the use of side rails. During an interview on 12/14/2022 at 12:35 PM, Licensed Practical Nurse (LPN) #12 stated the facility did not consider the side rails to be restraints. They were used for mobility, so she thought they did not have to have an assessment. During an interview on 12/14/2022 at 12:40 PM, LPN #11 stated she had not done any side rail assessments. She stated the side rails were used for mobility and not considered a restraint, so she did not think an assessment was required. During an interview on 12/15/2022 at 2:16 PM, Certified Nursing Assistant (CNA) #13 stated the residents used the side rails to hold themselves over in bed while care was being provided. During an interview on 12/15/2022 at 7:18 PM, the Administrator stated if a resident requested or needed a side rail, then he expected an assessment to be completed to determine if the use of the side rail would be detrimental or beneficial to the resident. He stated if side rails were needed, a physician order should be obtained. He stated if the side rail was not going to be used, then it would be zip tied down. 2. A review of an admission Record revealed the facility admitted Resident #49 with diagnoses that included right-sided weakness and low back pain. Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated the resident was cognitively intact. The MDS indicated the resident was independent and required only set-up support for bed mobility and transfer. According to the MDS, the resident had functional limitation in range of motion to the upper and lower extremities on one side and had no restraints in use. Review of a care plan, dated as initiated 09/02/2022, revealed Resident #49 required some assistance with activities of daily living (ADLs) and had right-sided weakness due to a stroke. An intervention dated as revised 09/21/2022 indicated the resident had quarter side rails at the head of the bed to assist with bed mobility and repositioning. The care plan indicated the side rails do not limit or restrict my ability to move about freely in bed. An observation on 12/12/2022 at 12:17 PM revealed Resident #49 had quarter side rails raised on both sides of the head of their bed. A review of Resident #49's medical record revealed no assessment or consent for the use of side rails. A review of Resident #49's physician orders revealed no orders for the use of side rails. During an interview on 12/13/2022 at 4:16 PM, the Director of Nursing (DON) stated the facility had not viewed the side rails as restraints and had not obtained consents or done assessments for any of them. She stated she had been the DON for four months and when asked for the assessments during survey she realized that they had not been done. She stated she immediately implemented an action plan for this. During an interview on 12/14/2022 at 10:02 AM, the DON stated a side rail assessment was not even an option in the facility's electronic charting system until she implemented one the previous day. The DON stated some of the residents did have consents for the side rails but not all. During an interview on 12/15/2022 at 2:16 PM, Certified Nurse Aide (CNA) #13 stated some residents used the side rails to hold themselves over in bed while care was being provided. During an interview on 12/15/2022 at 7:18 PM, the Administrator stated if a resident requested or needed a side rail, then he expected an assessment to be completed to determine if the use of the side rail would be detrimental or beneficial to the resident. He stated if it was needed, then a physician order should be obtained. He stated if the side rail was not going to be used, then it would be zip tied down. 3. A review of an admission Record revealed Resident #46 had diagnoses that included fracture of the lumbar vertebra (a bone in the lower spine) with back pain and osteoporosis (a condition that weakens bone strength). The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #46 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required extensive assistance with bed mobility and transfer. Review of a care plan, dated as initiated 09/02/2022, revealed Resident #46 required assistance of one person for bed mobility and had quarter side rails at the head of the bed. The care plan indicated the side rails did not restrict or limit the resident's ability to move about freely in bed. An observation on 12/12/2022 at 11:27 AM revealed Resident #46 had quarter side rails raised on both sides of the head of their bed. A review of Resident #46's medical record revealed no assessment or consent for the use of side rails. A review of Resident #46's physician orders revealed no orders for the use of side rails. During an interview on 12/13/2022 at 4:16 PM, the Director of Nursing (DON) stated all beds in the facility had quarter side rails at the top of the bed. She stated the facility had not viewed the side rails as restraints and had not obtained consents or done assessments for any of them. During an interview on 12/15/2022 at 7:18 PM, the Administrator stated if a resident requested or needed a side rail, then he expected an assessment to be completed to determine if the use of the side rail would be detrimental or beneficial to the resident. He stated if it was needed, then a physician order should be obtained. He stated if the side rail was not going to be used, then it would be zip tied down.