Based on observation and staff interview, the facility failed to label and date food items when opened to reduce the risk of contamination and food-borne illness. The facility reported a census of 44 residents. Findings include: On 6/30/24 at 10:39 AM during the initial tour of the facility kitchen with Staff A, Dietary Aide, revealed the following: a. Two large bowls of broccoli salad not labeled or dated b. Opened bag of shredded lettuce not dated when opened c. Two opened bags of spaghetti noodles not dated when opened d. Opened bag of penne pasta not dated when opened e. Opened bag of egg noodles not dated when opened f. Opened bag of pudding pie filling not dated when opened g. Opened bag of plain gelatin not dated when opened In an interview on 7/2/24 at 6:01 PM, the Dietary Supervisor stated they expected the staff to mark and date food items when opened. The facility reported they didn't have a policy for labeling and dating food, as they follow the most recent food code, rules, and regulations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, family interview, and review of facility policy, the facility failed to provide care for 1 of 14 residents reviewed in a manner to promote dignity and respect (Resident #21). The facility reported a census of 45 residents. Findings include: Review of Resident #21's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 10, indicating moderately impaired cognition. The MDS included diagnoses of Parkinson's, depression, and adjustment disorder with anxiety. During an interview on 5/18/23 at 9:08 a.m., Resident #21's daughter reported she witnessed Staff D, Registered Nurse (RN) during medication administration state to Resident #21 you need to stop acting like a bitch. On 5/18/23 at 10:31 a.m., the Administrator reported that she expected staff to interact with residents in a dignified manner and by using appropriate language. On 5/18/23 at 10:49 a.m., Staff D, RN reported she was sorry for her actions. Staff D, RN stated she was out of line. Staff D, RN stated she had tried to give Resident #21 her pills and she clamped her mouth shut. Staff D, RN stated she asked Resident #21 twice to open her mouth and take her pills. Staff D, RN stated Resident #21 told her to stop being a bitch. Staff D, RN stated she was taken back by it and without thinking, she stated you are the one being a bitch. Staff D, RN stated she should not have said it, it was unprofessional, and she was so sorry. An undated facility policy titled Enhancing and Maintaining Quality of Life documented the facility will care for its resident in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life. The policy directed staff to treat each resident with dignity and respect in full recognition of his or her individuality as they carry out activities that assist the resident to maintain or enhance his/her self-esteem and self-worth.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #2's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS identified Resident #2 was independent with bed mobility, walking, and transfers using a walker . The MDS included diagnoses of congestive heart failure, atrial fibrillation and coronary artery disease. The MDS identified Resident #2 received diuretic medications for 7 days during the MDS 7 day look back period. A hospital Discharge summary dated [DATE] revealed Resident #2 was hospitalized from [DATE] to 4/5/23 for acute on chronic combined systolic and diastolic heart failure (heart can not pump or fill adequately). A Physician order dated 4/5/2023 directed staff to administer Torsemide (diuretic) 20 mg (milligrams) two tablets by mouth twice a day for acute on chronic combined systolic and diastolic heart failure. A Physician order dated 4/5/23 directed staff to administer Spironolactone (diuretic) 25 mg one tablet by mouth one time a day for acute on chronic combined systolic and diastolic heart failure. A Physician order dated 4/5/23 directed staff to obtain a daily weight and update the Physician if weight gain of 2-3 pounds overnight or 4-5 pounds in 5 days. The current Care Plan with a target date of 7/13/2023 lacked documentation of the use of diuretic medications, potential side effects and what to monitor for while taking the medications. The care plan did not address obtaining a daily weight and when to report to the Physician. The care plan did not address Resident #2's risk for congestive heart failure and signs and symptoms to monitor for. On 5/17/23 at 9:07 a.m. the Administrator reported the facility does not have a care plan policy. The Administrator reported the facility references the RAI (Resident Assessment Instrument) Manual regarding care plan revisions. On 5/17/23 at 8:05 a.m., Staff C, Licensed Practical Nurse (LPN)/MDS Coordinator acknowledged and verified diuretic medications were not addressed on the care plan. On 5/17/23 at 12:45 p.m., Staff C, LPN/MDS Coordinator reported she would expect diuretic medications and weight monitoring to be addressed in the nutrition care plan. Staff C, LPN/MDS Coordinator stated she had not addressed the risk for fluid imbalances on a care plan before. Staff C, LPN/MDS Coordinator stated weight parameters and reporting are addressed through the physician orders and she does not address the parameters on the care plan as they can fluctuate. Based on clinical record review, staff interview, and policy review, the facility failed to develop care plans related to diuretic medication and possible adverse effects for 2 out of 14 residents reviewed for comprehensive care plans (Resident #2 and #16). The facility reported a census of 45 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] showed Resident #16 received diuretic medication the last 7 out of 7 days. The Physician's Order dated 3/22/23 showed Resident #16 was ordered to receive diuretic medication, Lasix 40 Milligram (MG) daily, for heart failure. The Medication Administration for March 2023 showed Resident #16 received Lasix 40 mg daily for heart failure. The Care Plan dated 4/20/22 for Resident #16 lacked documentation pertaining to the usage of a diuretic medication and failed to inform the staff of the possible adverse effects the diuretic could cause. The Care Plan also failed to address the heart failure diagnosis related to the Lasix order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review, and facility policy review, the facility failed to provide an appropriate clinical rationale for declining a gradual dose reduction (GDR) for 1 out of 5 residents reviewed for unnecessary medications (Resident #29). The facility reported a census of 45. Findings include: Resident #29's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 07, indicating moderately impaired cognition. The MDS identified Resident #2 was independent with bed mobility, walking, transfers and toilet use. The MDS included diagnoses of dementia, anxiety, depression, and mild intellectual disabilities. The MDS identified Resident #2 received antipsychotic medication, antianxiety medication, and antidepressant medication for 7 of 7 days during the MDS look back period. A Physician order dated 12/13/2021 directed staff to administer Abilify (antipsychotic) 10 mg (milligrams) one tablet by mouth once a day for major depressive disorder. A Physician order dated 1/26/2022 directed staff to administer Buspirone HCL (antianxiety) 15 mg one tablet by mouth two times a day for anxiety disorder. A Physician order dated 9/12/2022 directed staff to administer Fluoxetine HCL (antidepressant) 10 mg two capsules by mouth once a day for major depressive disorder and anxiety disorder. A facility form titled Pharmacy Review-GDR Request Psychotropic Medications dated 11/30/22 documented the Psychiatrist response for a GDR request for Resident #29's Abilify medication was contraindicated due to a diagnosis of paranoid schizophrenia. The facility GDR form lacked a clinical rationale. A facility form titled Pharmacy Review-GDR Request Psychotropic Medications dated 11/30/22 documented the Psychiatrist response for a GDR request for Resident #29's Buspirone medication was contraindicated due to a diagnosis of paranoid schizophrenia. The facility GDR form lacked a clinical rationale. A facility form titled Pharmacy Review-GDR Request Psychotropic Medications dated 11/30/22 documented the Psychiatrist response for a GDR request for Resident #29's Fluoxetine medication was contraindicated due to a diagnosis of paranoid schizophrenia. The facility GDR form lacked a clinical rationale. Review of Resident #29's clinical record lacked supporting documentation for the diagnosis of paranoid schizophrenia that was listed on the facility GDR forms dated 11/30/22. On 5/16/23 at 10:00 a.m. the Director of Nursing (DON) reported she could not locate supporting documentation in Resident #29 's medical records for the paranoid schizophrenia diagnosis. The DON reported the facility had reached out to the Psychiatrist for further information. The DON stated the paranoid schizophrenia diagnosis was added to Resident 29's medical record. On 5/16/23 at 4:00 p.m. the DON reported the Psychiatrist reviewed his progress notes before and after the GDR request on 11/30/22 and believed the diagnosis of paranoid schizophrenia was an error. Review of a Psychiatry letter dated 5/16/23 clarified Resident #29 does not have a diagnosis of paranoid schizophrenia. A facility policy titled Antipsychotic Drug Use revised 7/07 documented residents who use antipsychotic drugs will receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these medications. The policy documented if a request for a reduction is denied, the physician must provide a risk benefit analysis, which should include a clinical rationale for why any reduction would be likely to impair the resident's function or increase distressed behavior.

Based on observation, staff interview, and facility policy review, the facility failed to ensure staff used proper food handling procedures to prevent possible contamination of food. The facility reported a census of 45 residents. Findings include: On 5/16/23 at 11:25 AM, Staff A, cook, was observed to be wearing food service gloves to serve the lunch meal, touching plates, ladle/tong handles, and paper menus filled out by residents. One of the residents required meat to be pulled off of the chicken leg and cut up. Staff A, while wearing the gloves she had been serving with, used the tongs to place two chicken legs on a plate, hold them with her left hand and pull meat off the bone with a fork, using her right hand. Staff A then threw the bones in the garbage, came back to the steam table, placed her left hand on the chicken pieces to hold them in place while she used a knife to cut the meat into smaller pieces. She then removed the gloves, threw them in the garbage, washed her hands and returned to serving. Review of document titled General Food Preparation and Handling, dated 9/1/09 revealed that food would be prepared and served with clean utensils or other suitable implements so as to avoid manual contact of prepared or ready to eat foods. In an interview on 5/17/22 at 10:00 AM with Staff B, Dietary Manager, it was revealed that her expectation is that staff wear food service gloves only when actually handling food, and not when serving with ladles and tongs due to this reason.