The facility had a census of 57 residents. Based on observation, interview, and record review the facility failed to store food in a safe, sanitary manner to prevent contamination or spoilage in the main food preparation kitchen and the storage building with the walk-in refrigeration units. This placed the 57 residents of the facility at risk for food-borne illness. Findings included: - On 12/16/24 at 08:52 AM, observation of the facility's walk-in refrigerator revealed a crate of grapes on the floor and the walk-in freezer had an opened box with two pies, two boxes of chicken breasts, and a large flat box of strawberries, all on the floor. On 12/16/24 (Monday) at 9:02 AM, Dietary Staff (DS) CC verified the boxes of food delivered by Sysco on the previous Friday were still stored on the floor of the walk-in refrigerator and freezer. On 12/16/24 at 09:10 AM, observation revealed the freezer in the kitchen, labeled for healthcare use, contained the following opened, undated foods: Two bags of frozen peach slices One bag of mango cubes One bag of French fries One bag of frozen potato slices One bag of ham cubes Four buckets of ice cream On 12/16/24 at 09:15 AM, DS DD verified the undated bags of food in the kitchen refrigerator. On 12/17/24 at 11:30 AM, DS EE verified boxes of food should not be on the bare floor. He stated staff tried to put away the deliveries after meals or whenever they could. On 12/17/24 at 01:00 PM, DS FF verified the delivery people sometimes left boxes of food on the floor and staff would put the items in the appropriate place after the meal was served. On 12/17/24 at 16:40 PM, Consultant GG verified staff were not to store boxes of food items on the floor and were to date food packages when opened. She verified Sysco delivered food on Tuesdays and Fridays. The facility's Food Storage policy, dated 04/23/24, stated sufficient storage facilities would be provided to keep foods safe. Food would be stored in an area that was clean, dry, and free from contaminants. Food would be stored at appropriate temperatures and by methods to prevent contamination. Dry storage rooms must be well-ventilated and illuminated with adequate temperature and humidity controls to prevent condensation of moisture and the growth of mold. Food items would be stored on shelves. Food should be stored a minimum of six inches above the floor and 18 inches from the ceiling. All foods should be covered, labeled, and dated routinely to assure that foods would be consumed by their use dates, frozen, or discarded. Frozen foods should be covered, labeled, and dated. The facility failed to store food in a safe, sanitary manner to prevent contamination or spoilage. This placed the 57 residents of the facility at risk for food-borne illness.

The facility identified a census of 57 residents. The sample included 15 residents. Based on interviews and record reviews, the facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during both day-to-day operations and non-routine situations that impact staffing and resident care. This failure placed all 57 residents residing in the facility at risk for impaired care. Findings Included: - An inspection of the Facility Assessment 2024 dated July 2024 provided by the facility on 12/16/24 revealed the following: The assessment identified the faciliy had 65 dually certified beds, with an average census of 57. The assessment included a staff compentnenceis tab which listed the skill sets for all depratments. The assessment had a personnel tab which stated staff assignment were based on the acuity og the neighborhoods and staffw ere assigned to specific neighborhoofd for icnreased continuity of care. A review of the entire Facility Assessment 2024 under all tabs revealed the assessment did not identify the specific staffing levels needed for each unit and identify the number of Registered Nurses (RN), Licensed Nurses (LPN/LVN), Certified Medication Aides (CMA), and Certified Nurse Aides (CNA) needed for each unit, on each shift including weekends. The assessment lacked an informed contingency plan for events that do not require activation of the facility's emergency plan but have the potential to impact staffing and resident care. The assessment lacked a plan to maximize recruitment and retention of direct care staff. The facility provided an additional document for review, the Bethel Health Care Facility Wide Resource Assessment dated July 2024. This document also lacked the above information (specific staffing level and staffing contingency plan for events that do not meet emergency criteria but still have the ability to impact staffing and resident care). On 12/17/24 at 03:45 PM Administrative Staff A stated the facility assessment was currently what they had gathered and implemented into utilizing the current facility assessment. The facility Facility Wide Resource Assessment(FWRA) policy dated 07/31/24 documented that the Bethel Health Care Center FWRA is required by the nursing home Requirements of Participation to identify and analyze Bethels Health Care Center's resident population and identify the personnel, physical plant, environmental and emergencies response resources needed to completely care for the residents during day-to-day operations and emergencies. The FWRA serves as a resource to support decision-making regarding the day-to-day operations and resources to support the operations. The FWRA collects information about the resident population to identify the number of residents; facility capacity; the care required; staff competencies; the ethnic, cultural, and religious aspects of the unique resident population; physical; and personnel resources needed; contractual agreements; health information technology resources; environment; equipment, supplies and other services utilized. Resources are identified and evaluated to ensure that care can be provided to meet resident's needs during day-to-day and emergency operations. The FWRA would be reviewed annually and updated as needed based on changes in the resident population, new types of care and services provided, or new technology, equipment, or other resources introduced. The facility failed to conduct a thorough, updated facility-wide assessment to determine what resources were necessary to care for residents competently during both day-to-day operations and events that had the potential to impact staffing and resident care. This failure placed all 57 residents residing in the facility at risk for impaired care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 58 residents. The sample included 16 residents with, one reviewed for dignity. Based on observation, record review, and interviews, the facility failed to promote care in a manner to maintain and enhance dignity and respect for one sampled resident, Resident (R) 38, who required assistance with meals. This placed the resident at risk for impaired dignity and decreased psychosocial well-being. Findings included: - The Electronic Medical Record (EMR) for R38 recorded diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (high blood pressure), and weakness (the state or condition of lacking strength). R38's Quarterly Minimum Data Set (MDS), dated [DATE], documented R38 had moderately impaired cognition and required extensive assistance of one staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The assessment further documented R38 required supervision with one staff for meals; she held food in her mouth/cheeks or had residual food in her mouth after meals, and received a mechanically altered diet. The Activities of Daily Living [ADL] Care Plan, dated, 01/17/23 documented R38 would benefit from assistance with ADL cares due to her anxiety, cognitive impairment, and weakness. The care plan directed staff to assist with ADL cares as she allowed, as R38 had become more accepting of assistance and offer, instead of asking, if she needed help. The care plan further documented R38's left arm was weak, and some things were difficult for her to do. The EMR documented R38 was placed into hospice care on 10/05/22. On 01/18/23 at 12:12 PM, observation revealed R38's meal tray was on a small black table that was positioned off to her right side. Further observation revealed a Styrofoam bowl of melted chocolate ice cream, in an empty fruit bowl, positioned on its side, and the ice cream had spilled over onto the food tray. R38 had a grilled cheese sandwich, untouched that was still partially in the aluminum foil it came in. Continued observation revealed R38 had chocolate running down her chin from her mouth and had a chunk of peaches on her face. R38 did not receive staff assistance per the observation. On 01/19/23 at 12:19 PM, R38 stated she required a lot of assistance and she would love it if staff would sit with her at meals to visit with her and to help her when she needed it. On 01/19/23 at 12:25 PM, Administrative Nurse E stated R38 had been declining and required assistance at meals, even if just sitting and visiting with R38. Administrative Nurse E further stated it was not dignified for R38 to have food running down her face and understood the need for staff to assist R38. On 01/23/23 at 10:40 AM, Administrative Nurse D stated anyone can get messy in a short period of time and that R38's abilities for self-care fluctuated. On 01/23/23 at 11:00 AM, Certified Nurse Aide (CNA) M stated R38 received hospice care and was totally dependent upon staff for all of her care. CNA M further stated R38 ate her meals in her room but had trouble staying awake during the meal. CNA M acknowledged R38's need for assistance with meals. The facility Dignity policy, undated, documented residents at the village would have certain rights and protections under Federal Law that would help and ensure they get care and services needed, the policy further documented, residents have the right to be treated with respect and dignity, and have the right to a safe, comfortable, and homelike environment that allowed residents to be as independent as possible. The facility failed to promote care for R38 in a manner to maintain and enhance dignity and respect. This placed the resident at risk for impaired dignity and decreased psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 58 residents. The sample included 16 residents, with five reviewed for activities of daily living (ADL). Based on observation, record review, and interview, the facility failed to provide one sampled resident, Resident (R) 38 with the necessary level of assistance for eating. This placed the resident at risk for weight loss. Findings included: - The Electronic Medical Record (EMR) for R38 recorded diagnoses of dementia without behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), hypertension (high blood pressure), and weakness (the state or condition of lacking strength). R38's Quarterly Minimum Data Set (MDS), dated [DATE], documented R38 had moderately impaired cognition and required extensive assistance of one staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The assessment further documented R38 required supervision with one staff for meals; she held food in her mouth/cheeks or had residual food in her mouth after meals, and received a mechanically altered diet. The ADL Care Plan, dated, 01/17/23 documented R38 would benefit from assistance with ADL cares due to her anxiety, cognitive impairment, and weakness. The care plan directed staff to assist with ADL cares as she allowed, as R38 had become more accepting of assistance and offer, instead of asking, if she needed help. The care plan further documented R38's left arm was weak, and some things were difficult for her to do. The EMR documented R38 was placed into hospice care on 10/05/22. On 01/18/23 at 12:12 PM, observation revealed R38's meal tray was on a small black table that was positioned off to her right side. Further observation revealed a Styrofoam bowl of melted chocolate ice cream, in an empty fruit bowl, positioned on its side, and the ice cream had spilled over onto the food tray. R38 had a grilled cheese sandwich, untouched that was still partially in the aluminum foil it came in. Continued observation revealed R38 had chocolate running down her chin from her mouth and had a chunk of peaches on her face. R38 did not receive staff assistance per the observation. On 01/19/23 at 12:19 PM, R38 stated she required a lot of assistance and she would love it if staff would sit with her at meals to visit with her and to help her when she needed it. On 01/19/23 at 12:25 PM, Administrative Nurse E stated R38 had been declining and required assistance at meals, even if just sitting and visiting with R38. Administrative Nurse E further stated it was not dignified for R38 to have food running down her face and understood the need for staff to assist R38. On 01/23/23 at 10:40AM, Administrative Staff A stated the care plan team would look at R38's care plan and would update it to reflect R38's need for assistance at meal times. On 01/23/23 at 11:00 AM, Certified Nurse Aide (CNA) M stated R38 received hospice care and was totally dependent upon staff for all of her care. CNA M further stated R38 ate her meals in her room but had trouble staying awake during the meal. CNA M acknowledged R38's need for assistance with meals. Upon request a policy for ADL assistance was not provided by the facility. The facility failed to provide an adequate level of meal assistance for cognitively impaired R38, placing the resident at risk for weight loss.

The facility had a census of 58 residents. The sample included 16 residents, with five reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure an appropriate indication for Resident (R) 47's antipsychotic (a medication used to treat any major mental disorder characterized by a gross impairment in reality testing) medication, Seroquel. This placed the resident at risk for adverse side effects related to antipsychotic use. Findings included: - The Electronic Medical Record (EMR) for R47 recorded diagnoses of dementia with behavioral disturbance (progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition). R47's 5 Day Medicare Minimum Data Set, dated 11/10/22, documented R47 had long and short term memory problems with moderately impaired decision making skills and required extensive assistance of one staff for bed mobility, transfers, dressing, toileting, and ambulation in the corridors. The MDS further documented R47 had disorganized thinking, verbal behaviors, rejection of care, wandering, had delusions (something that is believed to be true or real but that is actually false or unreal), and received an antipsychotic medication seven days during the lookback period. R47's Care Plan, dated 10/31/22, documented R47 had a history of aggressive behaviors, used antipsychotic medication for dementia with behaviors, and received psychiatric services. The care plan directed staff to administer medication as ordered by the physician, observe for and report any side effects, review the use of psychotropic medication use with the resident and/or family as needed. R47's Abnormal Involuntary Movement Scale (AIMS), (assessment for detection of involuntary movements related to use of antipsychotic medication) dated 11/09/22, recorded a score of 0 (a score of two or higher indicated the resident has involuntary movements). The Physician Orders, dated 04/20/22, directed staff to administer the resident Seroquel (antipsychotic), 25 milligrams (mg) by mouth in the morning for dementia without behavioral disturbance. The Physician Orders, dated 09/29/22, directed staff to administer the resident Seroquel, 75 mg twice a day for dementia with behavioral disturbance. The order further directed staff to administer 25 mg and 50 mg tablets to equal 75 mg. The Psychiatry Progress Note dated 11/30/22 documented R47 had diagnoses of dementia with behavioral disturbance, delusional disorder, insomnia (difficulty sleeping) and anxiety. The note, under the Symptom Description and Subjective Report recorded R47 was oriented to person but disoriented to place and time. R47 had exit seeking at times and was redirectable. Staff reported R47 had some falls, but no dizziness. R47 continued to have some wandering and exit-seeking at night time but was mostly redirectable. The section Response to Medication recorded only not specified. The note recorded R47 continued Seroquel 25 mg in the morning, 75 mg in the afternoon and 75 mg at bedtime in the Existing Prescribed Medication and Medication Moving Forward sections, though both sections were blank under the Symptoms Being Treated fields. On 01/17/23 at 02:31 PM, observation revealed R47 independently ambulated down the west hall without an assistive device. Further observation revealed R47 was turning right to go down a small hallway which led to another resident household. Administrative Nurse E saw the resident and went to assist him back to his room for toileting assistance. On 01/19/23 at 09:00 AM, Administrative Nurse E stated R47 had behaviors and at times required 1:1 assistance. On 01/23/23 at 10:40 AM, Administrative Nurse D stated staff spend a lot of time with R47 and he required Seroquel medication. Administrative Nurse D stated he would investigate the diagnosis and asked if he just needed to get the diagnosis changed. The facility Policy and Procedure Antipsychotic Medications policy, undated, documented the interdisciplinary team would ensure any resident who used antipsychotic drugs received gradual dose reduction and behavioral interventions unless clinically contraindicated in an effort to discontinue these drugs to ensure the resident did not receive unnecessary medications and the lowest possible dose was administered for the shortest amount of time. The policy further documented, residents who have not used antipsychotic drugs was not given the drug unless antipsychotic drug therapy was necessary to treat a specific condition as diagnosed and documented in the resident's clinical record. The facility failed to ensure an appropriate indication for the use of R47's Seroquel, placing the resident at risk for adverse side effects.