**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes or enhances his or her quality of life for 2 (#143, #14) of 2 residents. Findings: On 03/09/2025 at 1:06 p.m. observation of resident #143 revealed he was sitting in a high back wheelchair with a clean disposable brief behind his head cushioning his head and neck against the wheelchair headrest. On 03/11/2025 at 2:03 p.m., record review revealed diagnoses in part of Parkinson's disease, coronary artery disease, hypertension, dysphagia following cerebrovascular disease. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed resident #143 had a Brief Interview Mental Status (BIMS) of 11 indicating resident #143 had moderate cognitive impairment. Further review of the MDS revealed resident #143 was dependent on staff for activities of daily living. On 03/11/2025 at 3:29 p.m. S2Director of Nursing (DON) was notified of the disposable brief that was placed behind resident #143 head while in the high back wheelchair. Resident #14 Review of resident #14's medical record revealed that he was admitted to the facility on [DATE] with diagnoses including Parkinson's disease. Review of the Quarterly MDS assessment dated [DATE] revealed resident #14 had a brief interview for mental status score of 12, which indicated that she had moderate cognitive impairment with daily decision making skills. Further review of the MDS revealed that resident #14 had a self-care deficit and he needed set-up or clean up assistance with eating. Review of resident #14's record revealed he was care planned for having an activities of daily living self-care performance deficit related to the disease process Parkinson's and impaired balance. On 03/10/2025 at 8:05 a.m., an observation revealed resident #14 sitting in his wheelchair in the main dining room, eating his breakfast. Further observation revealed resident #14 was served a diet that consisted of in part, a patty sausage, scrambled eggs, and a biscuit. There were pieces of the patty sausage, scrambled eggs, and the biscuit observed lying on top of and in direct contact with the table top. Further observation revealed resident #14 picked up the food items directly from with his hand then in his mouth. S11Licensed Practical Nurse (LPN) was standing near to resident #14 at that time and observed resident #14 retrieving the pieces of the patty sausage, scramble eggs, and biscuit from the table top with his hand. S11LPN, S12Certified Nursing Assistant (CNA) and S13CNA was observed standing in the dining area, but did not address resident #14 eating his breakfast meal from the table top with his hand. On 03/10/2025 at 8:17 a.m., S8Assistant Director of Nursing was notified of the observation regarding resident #14 picking up his food from the table top and eating it with his hands without being offered assistance by staff during that time. S8ADON confirmed the staff should have offered to assist the resident with his meal. On 03/11/2025 at 3:45 p.m., S2Director of Nursing was notified of the observation regarding resident #14 eating his breakfast meal directly from the table top with his hands without assistance from the staff. On 03/11/2025 at 3:55 p.m., S1Administrator was notified of the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facity failed to document a discharge summary when a resident was discharged from the facility for 1 (#160) of 3 (#34, #160, and #213) sampled residents reviewed for discharge. Findings: Review of the closed record for resident #160 revealed an admission date of 12/04/2024 with diagnoses including cerebral infarction, acute and chronic respiratory failure with hypoxia, unspecified protein-calorie malnutrition, morbid obesity, epilepsy, and type 2 diabetes mellitus. Review of resident #160's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required partial to moderate assistance with activities of daily living. Review of the closed record revealed resident #160 was discharged home on [DATE]. Further review of the record revealed no documentation of a discharge summary was completed. An interview on 03/11/2025 at 2:06 p.m. with S2Director of Nursing (DON) confirmed that resident #160 was discharged from the facility on 12/30/2024, and the facility failed to document a discharge summary on discharge for this resident.

Based on observations and interviews, the facility failed to maintain a sanitary environment and to help prevent the development and transmission of communicable diseases and infections by, having employee's personal items lying on top of and in direct contact with tables that were designed for the folding of clean clothing and linen items. Findings: On 03/11/2025 at 3:09 p.m., an observation of the laundry department revealed S14Laundry Worker and S15Laundry Worker standing in the designated clean laundry room. S14Laundry Worker was holding a cell phone in her hand. Observation revealed S14Laundry Worker placing the cell phone on the top of and in direct contact with a table that contained clean clothing items and a bed pad. S14Laundry Worker confirmed the cell phone belonged to her (S14Laundry Worker). S14Laundry Worker further confirmed the table was designed for folding clean resident clothing and linen items. Observation of the clean laundry room further revealed a second table that had a cell phone lying on the table top of and in direct contact with the table top. S15Laundry Worker confirmed the table was also used for the folding of resident items such as clothing, linens, and bed pads. On 03/11/2025 at 3:15 p.m., S16Laundry Supervisor entered the clean laundry room and she was notified of the observations regarding the cell phones. S16Laundry Supervisor confirmed that the laundry worker's personal belongings should not have been placed on the top of and in direct contact with the two tables that were designated for the folding of the resident's clean clothing, linens, and bed pads due to potential cross contamination. On 03/11/2025 at 3:55 p.m., S1Administrator was notified of the findings regarding the laundry department.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure the resident's call light was within reach for 3 (#102, #141 #143) of 3 residents observed with call lights out of reach and were high risk for falls. Findings: Resident #102 On 03/10/2025 at 10:45 a.m., observation of resident #102's room revealed the call light was out of the resident's reach. Resident #102 was in a wheelchair and call light was out of reach on the bed. She agreed she would not be able to call for assistance if needed. Review of the medical record for resident #102 revealed diagnoses in part of cerebral infarction, psychotic disorders with delusions, chronic respiratory failure with hypercapnia, major depressive disorder with psychotic symptoms, vascular dementia with behavioral disturbances, neuropathy, convulsions, type 2 diabetes, and heart failure. Review of the Quarterly Minimum Data Set (MDS) assessment revealed resident #102 had a Brief Interview Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Further review of the MDS revealed resident #102 was always incontinent of bladder and bowel and was dependent on staff for all activities of daily living. Review of the current fall risk assessment revealed resident #102 was at high risk for falls. Resident 141 On 03/10/2025 at 10:50 a.m. observation of resident #141 revealed he was lying in bed and the call light was draped over the back of the recliner at the foot of the resident's bed out of the resident's reach. At that time the resident asked for a glass of water and he was unable to call for assistance. On 03/10/2025 at 11:05 a.m. observation again of resident #141's room revealed the call light remained out of reach of the resident and draped over the back of the recliner at the foot of the resident's bed out of the resident's reach. On 03/10/2025 at 2:10 p.m. observation again of resident #141's room revealed the call light remained draped over the back of the recliner out of the resident's reach. Review of the medical record for resident #141 revealed diagnoses in part of metabolic encephalopathy, unspecified protein calorie malnutrition, interstitial pulmonary disease with fibrosis, chronic atrial fibrillation, dysphagia following cerebrovascular disease, muscle wasting and atrophy lower leg and multiple sites, falls, seizures, anxiety, dementia mild with anxiety, and depression. Review of the significant change MDS assessment dated [DATE] revealed resident #141 had a BIMS score of 2 indicating significant cognitive impairment. Further review of the MDS revealed resident #141 was always incontinent of bladder and bowel and was dependent on staff for all activities of daily living. Further review of the medical record revealed resident #141 was at high risk for falls. Resident 143 On 03/10/2025 at 10:50 a.m. observation of resident #143's room revealed the resident was sitting up in a high back wheelchair. Further observation revealed the call light was lying on the bed out of the reach of the resident. Review of the medical record for resident #143 revealed diagnoses in part of Parkinson's disease, coronary artery disease, dysphagia following cerebrovascular disease. Review of the quarterly MDS assessment dated [DATE] revealed resident #143 had a BIMS score of 11 indicating moderate cognitive impairment. Further review of the MDS revealed resident #143 was always incontinent of bladder and bowel and required assistance from staff for all activities of daily living. Further review of the medical record revealed resident #143 was at high risk for falls. On 03/11/2025 at 3:27 p.m., S2Director of Nursing (DON) was notified of the call bells being out of reach of the residents #102, #141 and #143 who were all at high risk for falls and required assistance from staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure resident personal privacy was maintained during care for 1 (#102) of 1 residents observed exposed to the hallway during care. Findings: On 03/09/2025 at 1:45 p.m., observation from the hallway into resident #102's room revealed resident #102 was lying on the bed with no sheets covering her. Further observation revealed resident #102 was lying in the bed with her brief exposed to the hallway. On 03/09/2025 at 1:47 p.m., an interview with S6Certified Nurse Aide (CNA) and S7CNA revealed when S7CNA left out of the room the door must have swung back open when they went to get a gown for the resident. S6CNA and S7CNA agreed the door was open to the hallway and resident #102 was lying on the bed with no sheets covering her and her brief was exposed to the hallway, not maintaining the resident's privacy. Review of the record for resident #102 revealed diagnoses of cerebral infarction, psychotic disorders with delusions, chronic respiratory failure with hypercapnia, major depressive disorder with psychotic symptoms, and vascular dementia with behavioral disturbances. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #102 had a Brief Interview for Mental Status (BIMS) of 15 indicating the resident was cognitively intact. Further review of the MDS revealed resident #102 was always incontinent of bladder and bowel and was dependent on staff for all activities of daily living. On 03/11/25 at 1:45 p.m., an interview with resident #102 revealed she did not like when the staff came into her room to change her and left the door open, causing her to be exposed in her room with a brief on. On 03/11/2025 at 3:28 p.m. S2Director of Nursing (DON) was notified of the resident being left exposed during care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to provided a resident who is unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 2 (#14,#63) of 3 (#14,#25,#63) residents reviewed for ADL (Activities of Daily Living), by failing to ensure residents #14 and #63 received assistance with personal hygiene. Findings: Resident #14 Review of resident #14's medical record revealed that he was admitted to the facility on [DATE] with diagnoses including Parkinson's disease. Review of the quarterly minimum data set assessment dated [DATE] revealed resident #14 had a brief interview for mental status score of 12, which indicated that he had moderate cognitive impairment with daily decision making skills. Further review revealed resident #14 required partial to moderate assistance with personal hygiene that included shaving. Review of resident #14's record revealed he was care planned for having an activities of daily living self-care performance deficit related to the disease process Parkinson's and impaired balance. The documented approaches included that resident #14 required one staff assistance with personal hygiene. On 03/09/2025 at 8:17 a.m., an observation revealed resident #14 lying in bed resting. Further observation revealed the resident's eyebrows were long and untrimmed. Attempted an interview with resident #14, but he could not answer the questions appropriately. On 03/10/2025 at 8:03 a.m., S8ADON (Assistant Director of Nursing) was notified of the observation of resident #14 having long, untrimmed eyebrow hair to both eyebrows. On 03/10/2025 at 8:15 a.m., an observation of resident #14 and interview with S8ADON confirmed that resident #14's eyebrows needed to be trimmed. On 03/11/2025 at 3:45 p.m., S2Director of Nursing was notified of the observation of resident #14 having long and untrimmed eyebrows. On 03/11/2025 at 3:55 p.m., S1Administrator was notified of the above findings. Resident #63 Review of resident #63's medical record revealed she was admitted to the facility on [DATE] with diagnoses including, hemiplegia and hemiparesis following other cerebrovascular disease affecting right dominant side, weakness, and dementia. Review of the significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed resident #63 had a brief interview for mental status score of 03, which indicated that she had severe cognitive impairment with daily decision making skills. Further review of the MDS revealed that resident #63 had an impairment to one side of the upper extremity, she had a self-care deficit, and was dependent upon staff with personal hygiene that included shaving. Review of resident #63's medical record revealed the resident was care planned as she required staff assistance with activities of daily living care related to cardiovascular vascular accident with right sided hemiplegia and osteoarthritis. The documented approaches included in part, assist the resident with hygiene and grooming tasks. On 03/09/2025 at 8:02 a.m., an observation revealed resident #63 in bed, resting. Further observation revealed a large amount of long, untrimmed hair on resident #63's chin. On 03/10/2025 at 8:08 a.m., S8ADON was notified of the observation of resident #63 having long and untrimmed chin hair. On 03/10/2025 at 8:11 a.m., an observation of resident #63 and an interview with S8ADON confirmed that resident #63's chin hair needed to be trimmed. On 03/11/2025 at 10:41 a.m., S2Director of Nursing was notified of the observation of resident #63. On 03/11/2025 at 3:55 p.m., S1Administrator was notified of the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to provide necessary care and services for the provision of respiratory care in accordance with professional standards. The facility failed to ensure oxygen was administered as ordered by the physician for 2 (#48, #138) of 3 (#29, #48, #138) residents reviewed for oxygen therapy. Findings: Review of the Oxygen Administration Policy and Procedure revised 11/16/2024 revealed the following in part: Policy: Oxygen Administration will be performed as ordered by the physician. Procedure: 1. Check physician's order for liter flow and method of administration. 5. e. Set the flow meter to the rate ordered by the physician. 6. Nasal Cannula: connect tubing to humidifier outlet and adjust liter flow as ordered. Place prongs of cannula in the resident's nares. Addjust elastic loosely around head, above the ears. If cannula does not have elastic adjustment, lop the plastic around the ears and under the chin. Adjust the plastic slide to hold cannula in place. Resident #138 Review of the medical record revealed sample resident #138 was admitted to the facility on [DATE] with diagnosis that included subdural hemorrhage, insomnia, abnormal weight loss, depression, abnormalities of gait and mobility, muscle wasting, chronic atrial fibrillation, left artificial hip joint, hypertension, cardiomegaly, and altered mental status. Review of the quarterly Minimum Data Set assessment (MDS) dated [DATE] revealed the resident has a Brief Interview for Mental Status (BIMS) score of 12 which indicates the resident is cognitively aware and able to make daily decisions. Further review revealed the resident is dependent on staff with activities of daily living. Review of the health conditions revealed the resident has shortness of breath or trouble breathing with exertion and wears oxygen. Review of the March 2025 physician's orders revealed sample resident #138 has an order dated 07/12/2024 for continous oxygen at 3 liters per nasal cannula. Observation on 03/10/2025 at 9:20 a.m. and 03/11/2025 at 1:30 p.m. revealed sample resident #138 was sitting up in bed with oxygen per nasal cannula in place. Observation of the oxygen concentrator at both times revealed the oxygen set at 2 liters. Interview on 03/11/2025 at 2:00 p.m. with S9Licensed Practical Nurse (LPN), confirmed the resident's oxygen concentrator was set at 2 liters per nasal canula and the physician's order was to be at 3 liters per nasal canula. The nurse changed the oxygen concentrator to 3 liters per nasal canula at this time. Interview on 03/11/2025 at 4:00 p.m. with S2Director of Nurses (DON) confirmed resident #138's oxygen was ordered for 3 liters per nasal canula. Resident #48 Review of resident #48's record revealed an admission date of 04/11/2019 with diagnoses including other speech and language deficits following other cerebrovascular disease, personal history of pulmonary embolism, hemiplegia and hemiparesis following other cerebrovascular disease affecting left non dominant side, dyspnea, shortness of breath, and chronic obstructive pulmonary disease. Review of resident #48's March 2025 Physician's Orders revealed an order dated 07/01/2024 for oxygen at 2 liters per minute per nasal cannula continuous. Review of resident #48's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 indicating cognitvely intact. Further review revealed oxygen therapy marked on the MDS. Review of resident #48's current careplan revealed resident has oxygen therapy related to respiratory illness and intervention included oxygen via nasal prongs at 2 Liters continually humidified. Observations on 03/09/2025 at 10:30 a.m. and 03/11/2025 at 8:00 a.m. of resident #48 revealed resident's oxygen concentrator was set at 3.5 liters per minute. An interview on 03/11/2025 at 8:00 a.m. with resident #48 revealed she wears her oxygen all the time, and her oxygen should be set at 2 liters per minute. Resident #48 reported she does not adjust her oxygen settings. An interview on 03/11/2025 at 8:05 a.m. with S17LPN confirmed that resident #48 has an order for oxygen at 2 liters per minute per nasal cannula continuously. S17LPN confirmed during observation of resident #48 that her oxygen was set at 3.5 liters per minute, changed oxygen settings to 2 liters per minute. An interview on 03/11/2025 at 8:25 a.m. with S2DON confirmed that resident #48's oxygen should be set at 2 liters per minute per nasal cannula.

Based on record review, observation, and interview the facility failed to ensure the menus were followed for 7 of 7 (#5, #39, #63, #72,# 80,#104, and # 127) pureed diets by not serving pureed cornbread as per the menu. Findings: On 03/09/2025 review of the lunch menu for the pureed diets revealed they were supposed to receive a dinner roll but facility substituted cornbread on the menu. Further review of the menu for the pureed diets revealed they were supposed to be served pureed cornbread. On 03/09/2025 at 11:00 a.m., observation of the lunch meal revealed residents #5, #39, #63, #72, #80, #104, and #127 did not receive the pureed cornbread. On 03/10/2025 review of the lunch menu for the pureed diets revealed they were supposed to receive pureed cornbread with their meal. On 03/10/2025 at 11:00 a.m., observation again of the lunch meal revealed residents #5, #39, #63, #72, #80, #104, and #127 did not receive the pureed cornbread. On 03/10/2025 at 3:00 p.m., an interview with S3Dietary Manager agreed the pureed diets were not served cornbread.

Based on observation and interview the facility failed to store and distribute and serve food in accordance with professional standards for food service safety. There were 168 diets served from the kitchen. Findings: On 03/09/2025 at 8:06 a.m. observation of the reach in freezer revealed a personal drink was inside. Interview with S4Dietary confirmed the staff personal drink should not be in the refrigerator. At 8:10 a.m., observation of the walk in refrigerator revealed there was a pan of pureed rib meat that was not fully covered, and was not dated, there was also a pan of taco soup with a date of 02/27/2025 that should not have been available for resident consumption. At the time of the observation, S5Cook confirmed the items in the walk in refrigerator. At 8:20 a.m., observation of 2 large containers of powdered mashed potatoes revealed the scoop and handle were laying inside the powdered potatoes. Interview again with S5Cook confirmed the scoop and handles should not be stored inside the mashed potato bins. Further observation of the kitchen environment revealed the bowl, divided plates, regular plates, and insulated covers were stored facing in the upright position and not inverted. At that time S3Dietary Manager was notified of the dishes that were being stored in the upright position. At 11:00 a.m. observation of the lunch meat revealed S3Dietary Manager and S18Assistant Dietary Manager were picking up the cornbread with gloved hands after touching other items such as spoon handles, desserts, and drinks. Further observation revealed the residents who received the alternate meal choice of a chicken salad sandwich also received chips. Observation revealed when dietary staff handed S3Dietary Manager the bag of chip it fell on the floor. S3Dietary Manager picked up the bag of chips and handed it to S5Cook who then reached into the bag with the same hands that touched the outside of the bag that had fallen on the floor and got chips out of the bag. S5Cook continued to serve the lunch meal without changing her gloves. Further observation revealed S3Dietary Manager did not change her gloves after picking up the bag off the floor and continued to touch the bread to make chicken salad sandwiches and serve cornbread. On 03/10/2025 at 10:30 a.m., an interview with S5Cook while pureeing food revealed the menu for the lunch meal was beans, rice, spinach, ham, cornbread and dessert. S5Cook said she pureed the rice and beans together, pureed the ham with some broth and pureed the spinach with some broth. At 11:40 a.m. observation of the lunch meal revealed the cornbread again was served with gloved hands after touching other trays, plates, glasses and dessert bowls. Further observation revealed S19Dietary was observed using her gloved hand to take the dessert out of regular serving bowl and place into a styrofoam container for 2 isolation residents. S19Dietary was then noted to spill chocolate milk on the tray that contained pre-prepared milk, she then picked up a towel to wipe up the spill and then continued to serve the cornbread without changing her gloves and touching the cornbread with the same gloves she touched the towel with. At 12:30 p.m. observation of the food prep sink revealed there were three 10 pound tubes of hamburger meat thawing in standing water without out cold water running over the meat. On 03/10/2025 at 3:00 p.m. S3Dietary Manager was notified of the findings.

Based on observation and interview the facility failed to ensure mechanical equipment was in safe operating condition by having the manual can opener with metal shavings. There were 168 diets served from the kitchen. Findings: On 03/09/2025 at 8:00 a.m., an observation of the large mechanical can opener revealed there was a buildup of metal shavings. At that time an interview with S5Cook confirmed the metal shavings on the can opener.

Based on observation and interview, the facility failed to maintain an effective pest control program so that the facility is free of pests by having ants in the dry pantry area. This failed practice had the potential to affect the 168 residents receiving meals from the kitchen. Findings: On 03/09/2025 at 7:45 a.m., an observation of the dry food storage area of the kitchen revealed there were small black ants on the large containers of grits and sugar. At this time, S5Cook confirmed there were little black ants and they had been having issues with them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure all medical records regarding the resident's code status consistently reflected the resident's wishes for 1 (#77) of 38 residents reviewed in the initial pool screening for advanced directives. Findings: Review of the facility Advance Directive Policy and Procedure dated 04/10/2023 revealed in part: Identify, clarify, and periodically review the existing care instructions on whether the resident wishes to change or continue instructions. If changes are made to the existing advance directive, a copy of the updated advanced directive will be given to the director of nursing (DON) to ensure physician orders are carried out and the resident's medical record is updated accordingly. Review of resident #77's medical record revealed she was admitted to the facility on [DATE] with diagnoses of unspecified dementia, and cerebral infarction. Review of resident #77's Quarterly Minimum Data Set assessment dated [DATE] revealed she had a Brief Interview for Mental Status score of 3, which indicated she was severely cognitively impaired. Further review revealed she required supervision to moderate assistance for most activities of daily living. Review of resident #77's medical record (paper copy) revealed an Advance Directive Consent dated 06/01/2023 that revealed in part: Full Code was selected for her code status and the form was signed by resident #77's family member on 06/01/2023. Further review revealed a 10/11/2023 physician's order for Do Not Resuscitate (DNR). Also, resident #77's current care plan revealed on 07/17/2023 the resident's Advance Directive was a DNR. Review of resident #77's electronic medical record revealed a 10/11/2023 physician's order for Do Not Resuscitate (DNR). On 04/16/2024 at 4:29 p.m. an interview with S2Director of Nursing (DON) revealed she was not aware of the discrepancy in resident #77's code status when comparing resident #77 medical record (paper copy) to the electronic record. S2DON confirmed resident #77's Advance Directive Consent revealed she was a full code and her electronic medical record revealed her status was DNR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interviews, the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person centered care plan. The facility failed to address resident #69's positioning needs in a timely manner. Findings: Review of resident #69's medical record revealed she was admitted to the facility on [DATE] with diagnoses of Parkinson's disease, cerebrovascular disease, and unspecified dementia. Review of resident #69's Quarterly Minimum Data Set, dated [DATE] revealed she had a Brief Interview for Mental Status score of 99, which indicated the interview was not successful. Further review revealed she required moderate to maximal assistance for most activities of daily living (ADLs). Review of resident #69's current care plan revealed she required staff assistance for all ADLs. The care plan was revised on 03/08/2024 with an intervention to assist resident with repositioning while in her wheelchair with lap tray. On 04/16/2024 at 8:20 a.m. an observation revealed resident #69 was in her high back wheelchair with soft lap tray that was tilted to the right. Resident #69's feet were dangling and were not supported with the wheelchair footrest. On 04/16/2024 at 1:47 p.m. an observation revealed resident # 69 was in her high back wheelchair with soft lap tray that had a plastic overlay. There was an approximate 3 inch tear in the right corner of plastic overlay on the lap tray which caused a rough edge. Also, the lap tray was not level and was tilted to the right. Further observation revealed the footrest was folded up and the resident's heels were positioned on the top edge of the folded up footrest which was not properly supporting her feet. On 04/16/2024 at 4:41 p.m. an observation revealed resident # 69 was in the hall in her high back wheelchair with soft lap tray. She was leaning to the right with her arm dangling off the lap tray and her arm was positioned on top of the wheelchair wheel. On 04/17/2024 at 2:30 p.m., an interview with S9CNA, reported resident #69's wheelchair was not easy to work with and she had difficulty moving the footrest up. On 04/17/2024 at 2:42 p.m., an observation revealed resident # 69 was in her high back wheelchair with soft lap tray. She was leaning to the right with her arm dangling off the lap tray and her arm was positioned on top of the wheelchair wheel. On 04/17/2024 at 2:55 p.m., an interview with S8LPN revealed there has been an ongoing issue with resident 69's positioning in the high back wheelchair and the lap tray slanting down. She also confirmed that the height of the wheelchair footrest is not right and does not properly support her feet. On 04/17/2024 at 4:52 p.m., S2DON was informed of the positioning concerns with resident #69's high back wheelchair and that the soft lap tray was not level. She confirmed the facility failed to address resident #69's positioning concerns in a timely manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure pharmaceutical services was provided to meet the needs of each resident that were consistent with state and federal requirements and reflect current standards of practice by failing to ensure medications were not left at the bedside for 1 (#38) of 1 (#38) residents with medications observed at the bedside. Findings: On 04/17/2024 review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 had a Brief Interview Mental Status (BIMS) of 10 indicating moderate cognitive impairment. Further review of the record revealed Resident #38 had diagnoses in part of: cerebral infarct due to embolism of unspecified pre-cerebral artery, type 2 diabetes, hypertension, chronic atrial fibrillation, end stage renal disease requiring dialysis, systolic congestive heart failure, history of cardiac arrest, history of hypotension, chronic metabolic acidosis, and dysphagia. On 04/17/2024 at 7:25 a.m. observation of Resident #38 room revealed a cup of pills sitting on the bedside table. Further observation revealed Resident #38 was up in a wheelchair waiting on breakfast. On 04/17/2024 at 7:34 a.m. S6LPN confirmed there was a cup of pills left at the bedside. S6LPN said Resident #38 receives his medications at 6:00 a.m. prior to her arrival because he goes to dialysis and she does not give Resident #38 any medications until noon. S6LPN confirmed the medications should not have been left at the bedside. On 04/17/2024 at 10:31 a.m. interview with S2DON confirmed the medications were not supposed to be left at the bedside in Resident #38's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to ensure all patient care equipment was maintained in safe operating condition by failing to repair a wheelchair lap tray in a timely manner for 1(#69) resident reviewed for positioning. Findings: Review of resident #69's medical record revealed she was admitted to the facility on [DATE] with diagnoses of Parkinson's disease, cerebrovascular disease, and unspecified dementia. Review of resident #69's Quarterly Minimum Data Set, dated [DATE] revealed she had a Brief Interview for Mental Status score of 99, which indicated the interview was not successful. Further review revealed she required moderate to maximal assistance for most activities of daily living (ADLs). Review of resident #69's current care plan revealed she required staff assistance for all ADLs. The care plan was revised on 03/08/2024 with an intervention for a wheelchair with lap tray. On 04/16/2024 at 08:20 a.m. an observation revealed resident #69 was in her high back wheelchair with soft lap tray that was tilted to the right. On 04/16/2024 at 01:47 p.m. an observation revealed resident #69 was in her high back wheelchair with soft lap tray that had a plastic overlay. There was an approximate 3 inch tear in the right corner of plastic overlay which caused a rough edge. Also, the lap tray was not level and was tilted to the right. On 04/16/2024 at 04:41p.m. an observation revealed resident #69 was in the hall in her high back wheelchair with soft lap tray tilted to the right. On 04/17/2024 at 02:42 p.m., an observation revealed resident #69 was in her high back wheelchair with soft lap tray tilted to the right. Further observation of the tray revealed there was a blue substance under the torn right corner of the plastic overlay. Resident #69 was picking at this area with her right hand and she had a blue substance on her fingers. On 04/17/2024 at 02:55 p.m., an interview with S8LPN revealed there had been an ongoing issue with resident #69's lap tray slanting down to the right. She also revealed on 04/13/2024 she was made aware of the tear in the right corner of resident #69's lap tray and it was noted on the 04/13/2024 Nurses' Report Form. S8LPN was unsure if maintenance was aware that resident #69's lap tray needed to be repaired or changed out. On 04/17/2024 at 4:52 p.m., S2DON was informed of the following concerns with resident #69's soft lap tray: tear in the right corner of the soft lap tray, blue substance underneath the torn area, and the lap tray was not level, tilting to the right. S2DON confirmed the above areas should have been addressed and repaired.

Based on observation, interviews, and record reviews, the facility failed to provide services that met professional standards during medication administration for 1 (#90) of 2 (#46 and #90) sampled residents. The facility failed to follow policies and procedures to ensure safe medication administration practices. Findings: Review of the facility's Medication Administration Policy and Procedure dated 08/27/2018 revealed the following, in part: Procedure: 1. Medication Administration: Prior to administration, the Nursing staff member administering the medication shall ensure that the following steps are accomplished. a. verify the medication selected matches the order and label; b. verify the medication is being administered at the proper time, in the prescribed dose, and by the correct route; Resident #90: Review of the record for resident #90 revealed an admission date of 04/25/2022 with diagnoses including cerebral infarction, pressure ulcer of left hip, hemiplegia following cerebral infarction affecting left non-dominant side, type 2 diabetes mellitus, and hypertension. An observation on 04/16/2024 at 7:20 a.m. of resident #90's medication pass revealed S7Licensed Practical Nurse (LPN) administered a blood pressure medication, Nifedipine Extended Release (ER) 30 milligrams (mg) 1 tablet by mouth (po). Review of resident #90's April 2024 Physician's Orders revealed an order dated 02/04/2024 for Procardia XL 90 mg 1 tablet po daily (Nifedipine ER generic name for Procardia XL). On 04/16/2024 at 10:40 a.m., S7LPN and surveyor reviewed resident #90's current blister pack medication card label and found the following: Nifedipine ER 30 mg tablet, give 1 tablet po daily, and the date medication was filled 03/07/2024. S7LPN confirmed that resident #90's April 2024 Physician's orders revealed an order for Procardia XL 90 mg tablet po daily. S7LPN confirmed she did administer the wrong dosage of Nifedipine to resident #90 on 04/16/2024. S7LPN confirmed she did not check the medication card label against the Electronic- Medication Administration Record (e-MAR) before administration. An interview on 04/17/2024 at 12:20 p.m. with pharmacist (from pharmacy listed on medication label) revealed that Nifiedipine XR 30 mg was filled on 03/07/2024 for resident #90. An interview on 04/17/2024 at 12:40 p.m. with S2DON revealed that a nurse sent in a label from a previously discontinued dosage of Nifedipine for resident #90, therefore Nifedipine ER 30 mg was filled by pharmacy on 03/07/2024. S2DON confirmed that S7LPN did not follow policy and procedure for medication administration for resident #90 by failing to verify the medication selected matches the order and label, and verifying the medication being administered at the prescribed dose.

Based on observation, interviews, and record review, the facility failed to accurately obtain pharmaceutical services, including supplying routine medications with the appropriate strength as ordered by the physician for 1 (#90) of 2 (#46 and #90) residents observed during medication administration pass. Findings: Resident #90: Review of the record for resident #90 revealed an admission date of 04/25/2022 with diagnoses including cerebral infarction, dysphagia, pressure ulcer of left hip, hemiplegia following cerebral infarction affecting left non-dominant side, type 2 diabetes mellitus, and hypertension. Observation on 04/16/2024 at 7:20 a.m of resident #90's medication pass revealed S7Licensed Practical Nurse (LPN) administered a blood pressure medication, Nifedipine Extended Release (ER) 30 milligrams (mg) 1 tablet by mouth (po). Review of resident #90's April 2024 Physician's Orders revealed an order dated 02/04/2024 for Procardia XL 90 mg 1 tablet po daily (Nifedipine ER generic name for Procardia XL). An interview on 04/17/2024 at 12:20 p.m. with pharmacist (from pharmacy listed on medication label) revealed that Nifiedipine XR 30 mg 1 po daily was filled on 03/07/2024 for resident #90. An interview on 04/17/2024 at 12:40 p.m. with S2Director of Nursing (DON) revealed that a nurse sent in a label from a previously discontinued dosage of Nifedipine for resident #90, therefore Nifedipine ER 30 mg was filled by pharmacy on 03/07/2024. S2DON confirmed resident #90 should be receiving Nifedipine ER 90 mg tablet po daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident # 73 Record review revealed resident #73 was admitted to the facility on [DATE] with diagnoses that include atherosclerotic heart disease of native coronary artery with unstable angina pectoris, chronic obstructive pulmonary disease, chronic atrial fibrillation, type 2 diabetes mellitus with diabetic neuropathy, mild protein-calorie malnutrition, anemia, chronic pain, essential hypertension, dysphagia following unspecified cerebrovascular disease, hypothyroidism, and vascular dementia unspecified severity without behavioral disturbance. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 15 which indicated resident #73 was cognitively intact. Review of the active April 2024 physician orders revealed resident #73 was to receive a regular Low Concentrated Sugar (LCS), No Added Salt (NAS) diet. On 04/15/2024 at 09:52 a.m. an interview with resident #73 reported that she prefers wheat bread, but for the last couple months all they give her was white bread. On 04/15/2024 at 12:24 p.m. an observation of resident #73's lunch meal consisted of a chef salad, ranch dressing, turkey and Swiss cheese sandwich on white bread, vanilla pudding, ice water and ice tea. Review of resident #73's lunch meal slip revealed the following: regular, LCS, NAS diet. Dislikes: chili seasoning, toast, corndogs, fruit punch, gravy or BBQ sauce, white bread, [NAME]. Preferences: baked potato, broccoli, Brussel sprouts, cabbages, squash, chicken, cold sandwich on wheat, pasta sometimes, roast beef non gravy, thin liquids ice tea (1 cup). On 04/17/2024 at 08:20 a.m. an observation of resident #73's breakfast meal consisted of scrambled eggs, bacon, oat meal, white toast, jelly, salt/pepper, water and apple juice. Resident #73 reported that she already told them she does not like white bread and prefers wheat bread, but they keep giving her white bread. On 04/17/2024 at 08:35 a.m. an interview with S3Culinary Supervisor reveal they have wheat bread available. S3Culinary Supervisor was informed that resident #73 was served a turkey and Swiss cheese sandwich on white bread and chef salad for lunch on 04/15/2024. S3Culinary Supervisor was also informed resident #73 was served white bread toast with her breakfast meal today. S3Culinary Supervisor confirmed resident #73 should have been served wheat bread instead of white bread according to her preference. Based on observation, record review and interview the facility failed to ensure: 1) dietary orders were followed for 2 (#38, #62) of 2 (#38, #62) residents having orders for mighty shakes and 2) dietary preferences were followed for 1 (#73) of 1 (#73) resident reviewed for dining. Findings: Resident #38 On 04/16/2024 at 2:35 p.m. record review for Resident #38 revealed diagnoses in part of end stage renal disease, cerebral vascular accident due to embolism of pre-cerebral artery, type 2 diabetes, chronic atrial fibrillation, dysphagia, systolic congestive heart failure, and stage 3 pressure ulcer of the sacral region. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 10 indicating moderate cognitive impairment. Review of the current physician orders for April 2024 revealed an order for mighty shakes, three times a day (TID). Review of the dietary card revealed Resident #38 was receiving a regular, no added salt, low concentrated sweet diet. Further review of the dietary card under preferences for Resident #38 revealed for breakfast, lunch and supper Resident #38 was to receive mighty shakes. On 04/16/2024 at 4:59 p.m., observation of Resident #38 supper meal revealed Resident #38 did not receive the mighty shake. On 04/17/2024 at 7:30 a.m. observation of the breakfast meal revealed Resident #38 did not receive the mighty shake. On 04/17/2024 at 8:20 a.m. an interview with S4Culinary Supervisor Asst. revealed the dietary staff are supposed to put the mighty shakes in the tub on top of cart in ice with the other drinks. Observation at that time of the refrigerator revealed there was a full case of un-opened mighty shakes in the refrigerator available for the residents. S4 Culinary Supervisor Asst. confirmed the dietary department should have put the mighty shakes on the meal carts. On 04/17/2024 at 9:00 a.m., an interview with S5CNA (Certified Nursing Assistant) revealed they are supposed to read the diet cards and give the drinks from that to the residents with their meals. S5CNA confirmed there were no mighty shakes on the cart for the residents and then said, they don't drink them anyway. Resident #62 On 04/17/2024 review of the record for Resident #62 revealed diagnoses in part of bilateral above the knee amputation, abnormal weight loss, cerebral vascular disease, stage 3 pressure ulcer sacrum, type 2 diabetes, unspecified protein-calorie malnutrition, hypertension, vascular dementia, and atrial flutter. Review of the MDS assessment dated [DATE] revealed a BIMS of 8, indicating moderate cognitive impairment. Further review of the record revealed a current order for mighty shakes three times a day with meals. On 04/16/2024 at 8:22 a.m. observation of Resident #62's breakfast meal revealed there was no mighty shake on breakfast tray. On 04/16/2024 at 11:30 a.m. observation of Resident #62's lunch meal revealed there was no mighty shake served to Resident #62. On 04/16/24 at 4:22 p.m., review of the dietary card for Resident #62 revealed mighty shakes were listed to be served to Resident #62. On 04/16/24 at 5:00 p.m., observation of Resident #62 supper meal revealed there was no mighty shake served to Resident #62. On 04/17/2024 at 7:30 a.m., observation of Resident #62 breakfast tray revealed there was no mighty shake served to Resident #62. On 04/17/2024 at 8:20 a.m., an interview with S4 Culinary Supervisor Asst. revealed the dietary staff are supposed to put the mighty shakes in the tub on top of cart in ice with the other drinks. Observation at that time of the refrigerator revealed there was a full case of un-opened mighty shakes in the refrigerator available for the residents. S4 Culinary Supervisor Asst. confirmed the dietary department should have put the mighty shakes on the meal carts. On 04/17/2024 at 9:00 a.m., interview with S5CNA revealed they are supposed to read the diet cards and give the drinks from that to the residents with the meals. S5 CNA confirmed there were no mighty shakes on the cart for the residents and then said, they don't drink them anyway.

Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food under sanitary conditions. This had the potential to affect all residents who received meals from the kitchen. Findings: On 04/15/2024 at 08:20 a.m. during initial tour of the facility, an observation of the facility kitchen revealed the following: 1. Small and large deep fryers had a large build-up of grease and grime in the lower compartment underneath the fryers. 2. Large toaster had old food particles noted underneath the rack on the bottom surface of the toaster and there was a sticky build up on the front panel of the toaster and also around the control knobs. 3. Large covered bin on shelf in Dry Storage Area had 1 large opened spiral noodle bag with 1/2 of the spiral noodles noted in bag, 1 large opened macaroni with 1/4 of shells noted in bag, and 1 large opened small macaroni noodle bag with ½ of noodles noted in bag. There were no open dates on any of the pasta bags. On 04/17/2024 at 4:00 p.m., an observation revealed 2 of the small microwaves located on top of 2 of the covered dietary carts revealed there was old food particles noted on bottom, top, and sides of both microwaves. On 04/17/2024 at 4:00 p.m. an interview with S3CulinarySupervisor confirmed the above food items were not labeled with open dates and confirmed the above kitchen appliances were in need of cleaning.

Based on observations, record reviews, and interviews, the facility failed to protect the residents' right to be free from sexual abuse by other residents. The facility failed to ensure residents were free from sexual abuse for 1 (#1) of 3 (#1, #2, and #3) sampled residents. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be Past Noncompliance. Findings: Review of the facility's Abuse Prevention Policy revealed in part: this facility will not condone resident abuse by anyone including other . residents .sexual abuse is defined as, but limited to sexual assault. Review of the facility's Self-Reported Incident Report initiated on 08/27/2023 at 4:29 p.m. revealed an allegation of sexual abuse involving resident #1 (victim) and resident #2 (accused). Resident #2 was immediately relocated after the incident, and placed on 1:1 supervision pending the investigation. The following morning, resident #2 was admitted to a behavioral health unit. The facility's investigation was substantiated for the allegation of sexual abuse, and Resident #2 was discharged to a different facility after his stay at a behavioral unit. Review of Resident #1's clinical record revealed an admission date of 01/17/2023 with diagnoses including, but no limited to other speech/language deficits following other cerebrovascular disease, abnormalities of gait and mobility, other lack of coordination, age-related osteoporosis without pathological fracture, and dementia in other diseases classified elsewhere, unspecified severe, without behavioral, psychiatric, mood, and anxiety. Review of Resident #1's quarterly Minimum Data Set Assessment with a Reference Date of 07/05/2023 revealed resident #1 had a BIMS (Brief Interview for Mental Status) score of 10 indicating that resident #1 had moderate cognitive impairment with daily decision making. During an interview on 10/03/2023 at 9:41 a.m., S2Assistant Administrator reported that he had received a telephone call on 08/27/2023 from S3 DON (Director of Nursing) informing him of resident #1 reporting that resident #2 had come into her room and kissed her (Resident #1) on the lips as she was laying in her bed. S2 Assistant Administrator further reported that resident #2 was removed from the room, relocated to a different hall, and placed on 1:1 observation pending an investigation. Further interview revealed that resident #2 was transferred to a behavioral health unit the next morning and from there, he was discharged to a different long term care facility that would best meet his needs. S2 Assistant Administrator reported that after the incident occurred, resident #1 was assessed by nursing staff at the facility and then referred to a psychiatric nurse practitioner for further evaluation, counseling, and treatment as indicated. During an interview on 10/03/2023 at 10:21 a.m., resident #1's cognitive status revealed she was aware of the current date, month, and year. Observation revealed resident #1 was dressed appropriately and neatly groomed. Resident #1 revealed that she did recall the incident on 08/27/2023 regarding resident #2 kissing her on her lips. Resident #1 reported that she was in her bed, laying down when resident #2 came into her room, lifted her head up, and put his tongue into her mouth. Resident #1 further reported that resident #2 had said to her don't you want me? and resident #1 told him no I don't. She also stated that she pushed him away and used her call light to get the nurse. Further interview revealed that resident #1 was just trying to put it out of her mind. During the interview, resident #1 reported there had not been any other occurrences of that nature involving resident #2 or any staff prior to the date of 08/27/2023. Resident #1 reported that resident #2 had scared her, but she was ok now. During the interview, observations revealed resident #1 was calm, cooperative, and laughing some. Resident #1 was asked during the interview if she felt that she needed any type of counseling services. Resident #1 denied any feelings of being anxious or unsafe; she reported that she felt safe and was ok, and denied needing any type of counseling services at that time. During an interview on 10/03/2023 at 11:04 a.m., S4 LPN (Licensed Practical Nurse) reported that on 08/27/2023 after lunch, approximately 2:00 p.m. to 3:00 p.m., Resident #1 had told a CNA (Certified Nursing Assistant) that Resident #2 had raised her up, while in bed, and kissed her (Resident #1) on her lips. S4 LPN reported that Resident #1 was tearful and afraid of Resident #2 at that time. She further reported that Resident #2 was relocated to a different hall and placed on 1:1 observation. S4 LPN reported that she had checked on Resident #1 periodically throughout the day and had reassured her that Resident #2 was gone. She revealed there had not been any other incidents involving Resident #1 and Resident #2 prior to the incident on 08/27/2023. S4 LPN further reported there had not been any further incidents involving Resident #2 after his relocation to a different hall and the 1:1 observation was implemented. During an interview on 10/03/2023 at 12:20 p.m., S5 Restorative CNA revealed that she did recall an incident that occurred on the date of 08/27/2023 involving Resident #1 and Resident #2. She reported that she had not worked that day, but she had been called in to work the evening shift with Resident #2, as he had been relocated and was on 1:1 observation. S5 Restorative CNA reported that when she arrived at the facility, S3 DON had been providing 1:1 observation for Resident #2. Further interview revealed there had not been any other type of incidents involving Resident #2 after the 1:1 observation had been implemented. During a telephone interview on 10/03/2023 at approximately 1:30 p.m., S6 Nurse Practitioner reported that she had seen Resident #1 on 09/19/2023. S6 Nurse Practitioner reported she, herself, had assessed Resident #1 as the Geri-psychiatric nurse's schedule was full at that time and she was unable to see residents at the facility. Further interview revealed that during her assessment, Resident #1 was guarded, subdued, and not a good historian. S6 Nurse Practitioner reported that was not uncommon as Resident #1 did not know her. She further reported that there were no findings that indicated resident #1 wanted any counseling services at that time. Throughout the survey from 10/03/2023 and 10/04/2023, observations of Resident #1 revealed she was neatly dressed and groomed, she was calm, easy to talk with, very interactive during interviews and exhibited no signs of being frightened, withdrawn, and anxious. Resident #1 smiled a lot and looked to be very comfortable around staff. Further observations revealed residents interacting calmly with other residents and staff, and the staff were accommodating to the residents and in a respectful manner. Interviews with staff revealed they had received training on abuse and neglect, knowledgeable of the types of abuse, and were aware abuse should be reported to administration immediately. The facility has implemented the following actions to correct the deficient practice by 09/01/2023: 1. Corrective actions for Resident #1 regarding the incident with Resident #2 include: a. resident #2 was relocated to another room on another hall at the time of incident on 08/27/2023 and he was placed on 1:1 observation. b. Physician was notified of Resident #2's behavior and orders received to send him to inpatient psychiatric hospital for treatment on 08/28/2023. c. At the time of incident on 08/27/2023, the nurse notified family members of both Resident #2 and Resident #1 of the incident. d. Resident #2 was ultimately transferred to another facility upon his discharge from inpatient psychiatric facility. e. Resident #1 was assessed for injury at time of incident on 08/27/2023 with none noted. f. Resident #1 was referred to psychiatric consultation status post incident on 09/01/2023. 2. Corrective actions for all resident in facility include: a. staff was in-serviced on Abuse Policy and Procedure on 08/28/2023 and 08/29/2023. b. On 08/28/2023, residents on the hall where resident #1 resided were interviewed per DON to ascertain if they felt safe and did not have any issues. 3. Measures that will be put into place by facility to prevent recurrence: a. Staff was in-serviced on Abuse Policy and Procedure on 08/28/2023 and 08/29/2023. b. Administration staff to monitor on an ongoing basis for any incidents of abuse during routine QA rounds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences. The facility failed to administer pain medication as needed to 1 (#1) of 5 (#1, #2, #3, #4, #5) sampled residents reviewed for pain management. Findings: Record review revealed Resident 1 was admitted to the facility on [DATE] with diagnoses that included but not limited to the following: syncope and collapse, displaced artic head of left femur for closed fracture with routine healing (onset 05/03/2023), paroxysmal atrial fibrillation, cerebral ischemia, chronic kidney disease- stage 4, emphysema, muscle wasting and atrophy unspecified lower leg, abnormalities of gait and mobility, weakness, anemia, nausea, constipation, essential hypertension, arthritis, and hypothyroidism. Review care plans revealed Resident 1 had pain and hip fracture. Goal: I will be as comfortable as possible. Interventions include: Monitor pain level, administer pain medication as ordered, and report ineffectiveness to physician. Review of active June 2023 physician orders included but not limited to the following orders: Oxycodone-acetaminophen 7.5mg(milligrams)-300mg tablet give one tablet po(by mouth) every 4 hours prn (as needed) pain ordered on 06/23/2023. Acetaminophen 500 mg tablet give 2 tablets (1,000mg) po every 4 hours prn pain ordered on 06/23/2023. Review of June 2023 EMAR(electronic medication administration record) revealed documentation Resident 1 received a dose of oxycodone-acetaminophen 7.5mg-300 mg tablet on 06/23/2023 at 6:43PM for pain scale 5 on the evening shift. Further review of the EMAR revealed no documentation indicating Resident 1 received any PRN oxycodone-acetaminophen 7.5mg-300mg tablet or any PRN acetaminophen 500mg tablet give 2 tablets (1,000mg) during the night shift 06/23/2023. On 08/07/2023 at 02:21 p.m. a telephone interview with S4CNA (Certified Nursing Assistant) revealed she was assigned to provide care for Resident 1 on the night shift on 06/23/2023. S4CNA reported that Resident 1 complained of pain throughout the shift. S4CNA revealed she notified S3LPN (Licensed Practical Nurse) at least three different times during the night shift of Resident 1 complaining of pain and requesting pain medication. On 08/08/2023 at 08:17 a.m. a telephone interview with S5CNA revealed she worked the night shift on 06/23/2023. S5CNA reported that Resident 1 complained of pain throughout the shift. S5CNA revealed she notified S3LPN at least three different times during the night shift of Resident 1 complaining of pain and requesting pain medication. On 08/08/2023 at 10:56 a.m. a telephone interview with S3LPN revealed she worked the night shift (11 p.m. -7 a.m.) on 06/23/2023 and was assigned to provide care for Resident 1. S3LPN confirmed that she was informed by S4CNA and S5CNA of Resident 1 complaining of pain and requesting pain medication. S3LPN reported that she did not administer Resident 1 any pain medication during the entire night shift on 06/23/2023. On 08/09/2023 at 10:00 a.m. an interview with S2DON (Director of Nursing) confirmed S3LPN should have assessed Resident 1 for pain after being informed he was having pain. S2DON further confirmed S3LPN should have administered Resident 1 the pain medication as ordered.

Based on observations, record review and interviews, the facility failed to assure that menus are developed and prepared according to the resident's needs and preferences for 1 (458) of 1 residents (458) reviewed for food preferences. The facility failed to ensure they served resident 458 foods according to his likes and dislikes. Findings: Review of the medical record for resident 458 revealed diagnoses including morbid obesity, type 2 diabetes, unspecified protein-calorie malnutrition, and gastroesophageal reflux disease. Review of resident 458's 04/12/2023 Minimum Data Set revealed his BIMS (Brief Interview for Mental Status) was 15, which indicated he was cognitively intact. Further review revealed he required supervision and set up help for his meals. On 04/17/2023 at 1:40 p.m., resident 458 reported that he does not like pork, catfish, and seafood and he revealed he has still been receiving some of these food items for his meals. Resident 458 reported he got pork sausage with his tray this morning. He has told several workers (unsure of names) that he is still receiving food he does not like. Resident 458 revealed he has received pork, fish and gumbo since he reported his food dislikes to the workers. On 04/18/2023 at 8:15 a.m., an observation of resident 458's breakfast tray revealed the following: 2 biscuits, scrambled eggs, grits, pork sausage, whole milk, and orange juice. He reported he was not going to eat the pork sausage and that he would prefer turkey sausage or turkey bacon. Review of his dietary card at this time revealed he was on a Regular/No Added Salt Diet; however, there were no dislikes listed on the card. On 04/19/2023 at 8:50 a.m., resident 458 was eating breakfast in his room. An observation of his breakfast tray revealed there were 2 pork sausages left on his plate. Resident 458 reported that he received pork sausage again on his tray and he was not going to eat them. Review of his dietary card revealed there were no food dislikes listed. On 04/19/2023 at 10:40 a.m., an interview with S3Dietary Manager confirmed she was unaware of resident 458's food dislikes. S3Dietary Manager also confirmed she failed to ensure that resident 458's food dislikes were entered into the dietary system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #115 Record review revealed Resident # 115 was admitted [DATE] with diagnosis that included CVA (cerebrovascular accident), spinal stenosis, dementia, osteoarthritis, and dysphagia following CVA. Resident # 115 was a [AGE] year old male. Review of the most recent MDS (minimum data set) dated 04/07/2023 revealed in section GG - Functional Abilities and Goals, that Resident # 115 was dependent or at least needed assistance with all ADL (activities of daily living) care which included nail care. Review of active orders revealed an order dated 03/23/2023: assess/trim finger nails and toe nails monthly. Review of the ETAR (electronic treatment administration record) revealed the order to assess/trim finger nails and toe nails monthly was on the ETAR for March and April but no one had signed the ETAR to indicate the nails were assessed or trimmed as ordered since the order was written. On 04/17/23 at 09:42 a.m., observation revealed Resident # 115 had long and jagged fingernails that needed trimming. On 04/18/23 at 08:42 a.m., observation revealed Resident # 115 had long and jagged fingernails. On 04/18/23 at 03:21 p.m. an interview with S2 DON (Director of Nursing) confirmed resident #115`s fingernails should have been trimmed monthly as ordered. Based on observation, interview and record review the facility failed to provide assistance for residents who were unable to carry out activities of daily living and received the necessary services to maintain good grooming, and personal hygiene for 2 (#151,#115) of 2 (#151,#115) residents investigated for ADL (activities of daily living) care. Findings: Resident #151 On 04/17/2023 at 10:11 a.m. Resident #151 was observed in his room with long dirty fingernails to both hands. On 04/18/2023 at 1:51 p.m. an observation of Resident #151 in his room revealed long dirty fingernails to both hands that were in need of nail care. Record review revealed Resident #151 was a [AGE] year old male admitted to the facility on [DATE] with following diagnoses: cerebral infarction and dysphagia following cerebral infarction. Record review revealed a completed MDS (minimum data set) assessment was completed on 03/06/2023. Review of the MDS assessment revealed in section G - Functional Status revealed Resident #151 had total dependence on staff to maintain personal hygiene. Review of physician orders dated 03/05/2023 revealed an order to assess/trim finger nails and toe nails monthly. Review of care plan for resident #151 revealed he had deficits related to activities of daily living with an intervention in place that required nursing staff to assist with hygiene and grooming task. Interview on 04/19/2023 at 2:15 p.m. with S2 DON (Director of Nursing) confirmed resident #151`s fingernails should have been trimmed monthly as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure that a wound care assessment was completed for a resident when a new wound was identified for 1 (#1) of 3 (#'s 1, 2, 4) sampled residents reviewed for pressure ulcers. Findings: Review of the medical record for resident 1 revealed he was admitted to the facility on [DATE] with the following diagnoses in part: aftercare following joint replacement surgery, left knee; paroxysmal atrial fibrillation; Non-ST elevation myocardial infarction; chronic diastolic congestive heart failure, atherosclerotic heart disease of native coronary artery with unstable angina pectoris; unspecified protein-calorie malnutrition, and muscle wasting, and atrophy. Review of the 07/18/2022 Admit Minimum Data Set Assessment for resident 1 revealed he had a BIMS (Brief Interview for Mental Status) score of 12, which indicated he was moderately cognitively impaired. Further review revealed he required extensive, 1 person assistance for most activities of daily living. Resident 1 did not have any pressure ulcers upon admission to the facility. Review of resident 1's July 2022 Nurses' Notes revealed there was no documentation the resident had a pressure ulcer or any other skin condition during the time he resided at the facility from 07/08/2022 - 07/30/2022. Further review of resident 1's medical record revealed there was no documentation of any wound care assessments. Review of the 07/30/2022 at 10:00 a.m. Telephone Order for resident 1 revealed the following order: cleanse left buttock with wound cleanser, apply Zinc and cover with adhesive foam dressing every day and as needed. The order was signed by S2LPN (Licensed Practical Nurse)/Treatment Nurse. Review of resident 1's July 2022 TAR (Treatment Administration Record) revealed a treatment order dated 07/30/2022 to cleanse right buttock (location of wound differed from above order) with wound cleanser, pat dry, apply Zinc to area, and cover with adhesive foam dressing every day and as needed. Further review revealed documentation that S2LPN/Treatment Nurse provided the above wound care treatment on 07/30/2022 prior to resident 1's transfer to the emergency room on [DATE]. On 11/22/2022 at 2:20 p.m., an interview with S2LPN/Treatment Nurse revealed she provides wound care for the residents on the weekends. She confirmed she was working on 07/30/2022 when resident 1 was sent to the emergency room at 8:45 p.m. for chest pain S2LPN/Treatment Nurse reported that S3LPN informed her on 07/30/2022 about mid-morning that resident 1 had a small spot on his bottom. She revealed the area was red, looked like a blister had opened, there was no odor, and it did not look infected. S2LPN/Treatment nurse notified resident 1's physician and received an order for Zinc and a foam dressing. She reported she treated the area to his right buttock prior to him being transferred to the hospital on [DATE]. S2LPN/Treatment Nurse confirmed she failed to document an assessment of the area to resident 1's right buttock. On 11/28/2022 at 3:00 p.m., a phone interview was conducted with S4CNA (Certified Nursing Assistant). She confirmed she worked with resident 1 on 07/30/2022 and she noticed a small, little bitty area on his bottom. She stated she could not remember the exact location of the area and she reported this to S2LPN/Treatment Nurse. On 11/21/2022 at 4:00 p.m., during an interview with the S2DON (Director of Nursing), the surveyor informed her of the discrepancy in documentation regarding the location of the new found wound on resident 1's buttock. S2DON confirmed there was no documentation of an assessment on 07/30/2022 for the above area on resident 1's buttock.