Resident #97 Review of the facility's policy and procedure dated 05/08/2018, and titled Incident and Accident read in part . Policy: Accidents are to be reported, investigated and followed up in a timely manner. Procedure: 1. Reporting of Incidents and Accidents: a. Any employee who witnesses or becomes aware of an incident or accident must report it to the designated departmental supervisor. 3. Medical attention (nurse) a. Assess all incident and accident victims. b. Notify Physician c. Notify family/ responsible party 4. Investigative Action: a. The nurse conducts an immediate investigation of any Incident and Accident. The nurse collects pertinent data and completes an incident entry form (including taking vital signs). 5. Incident and Accident Report: a. Complete an incident and accident report on any incidents or accidents, regardless of how minor the incident or accident may be. c. Documentation in the nurse's note must clearly define the incident and record the resident's vital signs. 6. Instructions for responding nurse: a. Incident or accident without head injury i. Notify family/ responsible party and physician, then document in the electronic medical record (EMR) ii. Complete incident and or accident report. iii. Document incident or accident follow-up notes in the electronic medical record (EMR) including vital signs for 72 hours. Equipment: 1. Incident and Accident Report 2. Vital Signs if applicable 3. Resident Chart 4. Electronic medical record (EMR) Review of Resident #97's clinical record revealed an admit date of 09/01/2023, with diagnoses which included other lack of coordination; hereditary and idiopathic neuropathy; muscle weakness, repeated falls, spondylolisthesis, vitamin D deficiency; osteomyelitis and other muscle spasms. Review of Resident #97's Quarterly MDS with an ARD/ Target date of 07/16/2024, revealed a BIMS score of 15; Cognitively intact. Resident #97 uses a wheelchair and requires substantial/maximal assistance with wheeling 150 feet, and wheeling 50 feet with two turns. Resident #97 requires partial/moderate assistance with chair/bed to chair transfers and changing from a sitting to standing position. Review of Resident #97's Care Plan revealed in part The resident is at risk for falls r/t Fall Hx, COPD, SOB, Anemia, Depression, Neuropathy, OA, and Psychotropic drug use. Interventions included: Place me on the fall program as appropriate; monitor for changes in my condition that may warrant increased supervision/ Assist and Notify MD and remind me to ask for assist with all ambulation. The resident requires staff assistance with ADL's related to Anemia, COPD, Depression, Neuropathy and OA. Interventions included: I require assistance with ambulation. I use a wheelchair for mobility and assist me with locomotion. Interview with Resident #97 on 09/16/2024 at 09:50 a.m., revealed that Resident #97 had a fall on Saturday, 09/14/2024 at the front of the facility. Resident #97 stated that she was outside visiting with her son. Resident #97 stated that her son left and she was sitting outside when her phone fell and as she attempted to reach down and pick it up, she slid out of the wheelchair onto her left shoulder. Resident #97 stated that she was outside on the ground for about 5 minutes when a visitor saw her on the ground and alerted staff. Resident #97 stated that about 5 nurses came outside to help her. The nurses checked her out and she had no injuries and was not in any pain. She was wheeled back into the facility. Resident #97 stated that she joked with staff that she would never reach for her phone again. Review of Resident #97's clinical record revealed no documentation of a fall on Saturday 09/14/2024; no Physician notification and no responsible party notification. Requested Incident report of resident's fall on Saturday, 09/14/2024 from S1Administrator. Interview with S2 DON on 09/17/2024 at 12:14 p.m. revealed that she was unaware that Resident #97 had a fall. She started the procedure to open an investigation. S2 contacted S8 LPN who was on duty Saturday via phone for more information concerning Resident #97's fall. Interview with S2 DON and S5 Regional QI Nurse on 09/18/2024 at 11:21 a.m. revealed that the physician and responsible party were not notified of Resident #97's fall and confirmed they should have. S2 DON stated that she was made aware of fall when it was brought to her attention by S1 Administrator after request for Incident report from this surveyor. Based on interview and record review, the facility failed to ensure services were provided to residents according to accepted standards of clinical practice for 2 (Resident #97 and Resident #102) out of a total sample of 30 residents. The facility failed to notify the physician when: 1. Resident #102 had blood glucose levels greater than 451 mg/dL as ordered. 2. Resident #97 had an unwitnessed fall. Findings: Review of a facility policy titled Change in Condition Policy and Procedure dated 08/27/2018 revealed in part . Procedure: 2. The licensed nurse will assess the resident and note any signs and symptoms, including physical and mental changes in condition. Assessment may include but is not limited to: physical assessment findings, vital signs, blood glucose, oxygen saturation, etc. The licensed nurse will document assessment findings in the electronic medical record. 3. The resident's primary physician or designated alternate will be contacted promptly of a significant change in the resident's status. a. If unable to contact primary physician or designated alternate, the medical director is to be contacted. b. Document notification and any instructions/orders received in the electronic medical record and on the physician order as appropriate. Resident #102 Review of Resident #102's clinical record revealed an admission date of 04/23/2024 with diagnoses that included: Type 2 Diabetes Mellitus with Hyperglycemia; Hemiplegia And Hemiparesis following Cerebral Infarction Affecting Right Dominant; Unspecified Glaucoma; Apraxia following Cerebral Infarction; Aphasia following Cerebral Infarction; Dysarthria following Cerebral Infarction; and Hypertensive Heart And Chronic Kidney Disease with Heart Failure. Review of Resident #102's Quarterly MDS with an ARD of 06/29/2024 a BIMS score of 9, indicating moderate cognitive impairment. Resident #97's MDS revealed she required moderate assistance with eating and received seven days of insulin injections. Review of Resident #102's Care Plan with a Target Date of 10/16/2024 revealed in part .I have a diagnosis of Diabetes. Interventions: Administer my diet as ordered. Monitor my nutritional intake. Obtain my finger stick blood sugars as ordered. Administer my oral hypoglycemic agents as ordered. Observe me for signs of hypo/hyperglycemia. Monitor my blood sugar as ordered. Administer my insulin as ordered. Assess my response to the insulin changes and report to MD. Review of Resident #102's 08/2024 Medication Administration Record revealed in part . Order: Admelog Injection Solution. Inject as per sliding scale: if 60 - 200 = 0 units; 201 - 300 = 4 units; 301 - 400 = 8 units; 401 - 450 = 15 units; 451 - 999 = 20 units; 451-500 or above notify MD. Blood Glucose Levels: 08/01/2024 11:00 a.m. - 491 mg/dL 08/02/2024 11:00 a.m. - 492 mg/dL 08/02/2024 4:00 p.m. - 515 mg/dL 08/03/2024 11:00 a.m. - 471 mg/dL 08/04/2024 11:00 a.m. - 518 mg/dL 08/05/2024 11:00 a.m. - 543 mg/dL 08/06/2024 11:00 a.m. - 526 mg/dL 08/07/2024 11:00 a.m. - 490 mg/dL 08/07/2024 4:00 p.m. - 520 mg/dL 08/09/2024 4:00 p.m. - 503 mg/dL Review of Resident #102's 09/2024 Medication Administration Record revealed in part . Order: Admelog Injection Solution. Inject as per sliding scale: if 60 - 200 = 0 units; 201 - 300 = 6 units; 301 - 400 = 8 units; 401 - 450 = 15 units; 451 - 999 = 20 units; 451-500 or above notify MD. Blood Glucose Levels: 09/03/2024 11:00 a.m. - 464 mg/dL 09/04/2024 11:00 a.m. - 460 mg/dL 09/05/2024 11:00 a.m. - 467 mg/dL 09/05/2024 4:00 p.m. - 466 mg/dL 09/08/2024 11:00 a.m. - 466 mg/dL 09/09/2024 4:00 p.m. - 454 mg/dL 09/11/2024 11:00 a.m. - 455 mg/dL 09/11/2024 8:00 p.m. - 464 mg/dL 09/16/2024 11:00 a.m. - 456 mg/dL Review of Resident #102's Nursing Progress Notes from 08/01/2024 through 09/17/2024 revealed on the dates listed above there were no progress notes for notification of Resident #102's MD when her blood glucose levels were greater than 451 mg/dL. Interview on 09/18/2024 at 10:27 a.m. with S2 DON confirmed on the above listed dates when Resident #102's blood glucose levels were above 451 mg/dL the nurses did not document Resident #102's MD was notified, but they should have. S2 DON reported the nurses should have made a progress note in Resident #102's clinical record that the MD was notified.

FACILITY Based on observation and interview, the facility failed to ensure menus were followed in order to meet the nutritional needs of residents who required a puree diet. The facility failed to follow the recipe in regard to ingredients and portion size to ensure the nutritional adequacy of the meal for all 9 residents who received a puree diet. Findings: Review of the facility's policy titled: Preparation and Service of Pureed Diets read in part .Procedure 5: Follow recipes provided .Procedure: 6.A food thickener may be added to pureed foods to thicken the food to its desired consistency. In an interview during the initial kitchen tour at 8:43 a.m. on 09/16/2024, S3 Dietary Manager stated the facility had 9 residents being served a puree diet. In an observation on 09/16/2024 at 9:13 a.m., S4 Dietary [NAME] prepared puree pot roast and placed ½ of a roast in the blender with 6 pieces of bread, and approximately 1/2 pan of water in the blender to puree the roast. In an observation at 9:20 a.m., S4 Dietary [NAME] added 3 small cartons of whole milk to the 40 yam patties she placed in puree mixer and turned on the blender. At 9:30 a.m., S4 Dietary [NAME] put some cabbage in the blender. This surveyor asked how much cabbage she put in and she said, I just scooped some up. S4 Dietary [NAME] stated she used some of the juice the cabbage cooked in and then put some water in a pan and added it to the blender with the cabbage. During these observations, S4 Dietary [NAME] never measured the water before adding it to the pan and later the blender. Review of the recipe for puree pot roast revealed it required the use of water and food thickener bulk and did not require the use of bread. Review of the recipe for puree cabbage revealed it required the use of food thickener bulk and did not require the use of water. In an interview on 09/16/2024 at 4:10 p.m., S3 Dietary Manager confirmed S4 Dietary [NAME] did not follow the puree recipes, did not measure portion sizes according to puree recipe, and did not use food thickener bulk for recipes and should have.

Based on observation, record review, and interview the facility failed to maintain an effective infection prevention and control program and ensure staff practices were consistent with current infection control principles and practices to prevent possible cross contamination for 1 (#109) of 30 sampled residents. The facility failed to implement appropriate infection control precautions for Resident #109. Findings: Review of the facility's policy and procedure dated 04/01/2024, and titled Enhanced Barrier Precautions read in part . Policy: To follow CMS guidelines related to Enhanced Barrier Precautions, Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. Procedure: 1. EBP are indicated for residents with any of the following: b. Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO. i. Wounds generally include chronic wounds, not short-lasting wounds such as skin breaks or skin tears covered with an adhesive bandage (e.g., Band-Aid) or similar dressing. 1. Examples of chronic wounds include, but are not limited to, pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. ii. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. 2. EBP should be used for any resident who meets the above criteria, wherever they reside in the facility (resident room not in common area such as hallway, dining, or activity rooms). a. Outside the resident's room, EBP should be followed when performing transfers or assisting during bathing in a shared/ common shower room and when working with residents in the therapy gym. 4. For residents for whom EBP are indicated, EBP is employed when performing the following high contact resident care activities: a. Dressing b. Bathing/Showering c. Transferring d. Providing Hygiene e. Changing Linens f. Changing briefs or assisting with toileting g. Device care or use (central line, urinary catheter, feeding tube, tracheostomy) h. Chronic Wound Care: any skin opening requiring a dressing. 5. PPE is to be applied prior to performing the high-contact resident activity according to below and before moving on to another resident: a. Perform hand hygiene b. Put on a gown and gloves c. After resident care, throw away gown and gloves in trash receptacle d. Perform hand hygiene Equipment: 1. EBP sign 2. Gloves and gown 3. Hand Sanitizer Review of Resident #109's clinical record revealed an admit date of 06/05/2024, with diagnoses which included encounter for other orthopedic aftercare; other acute osteomyelitis, right ankle and foot; aftercare following joint replacement surgery; local infection of the skin and subcutaneous tissue; and other fracture of right lower leg, subsequent encounter for closed fracture with routine healing. Review of Resident #109's Significant Change MDS with an ARD date of 08/09/2024, revealed a BIMS score of 15, which indicated the resident was cognitively intact. Resident #109 required supervision or touching assist with personal hygiene, upper body dressing; oral hygiene; and eating. Resident was Dependent for toileting. Resident required partial or moderate assistance for showering/ bathing; lower body dressing and putting on and taking off footwear. Resident had a surgical wound. Review of Resident #109's Care Plan revealed in part The resident has a leg infection (07/02/2024). Interventions included: Administer my medication as prescribed by my physician; monitor me for signs and symptoms of my infection getting worse and provide me treatment as ordered by my physician. The resident has a surgical site to right lateral malleolus (06/27/2024). Interventions included: I need wound care as ordered by my physician; monitor for changes in my skin status that may indicate worsening of my wound and notify the physician and turn and reposition me as appropriate. Review of Resident #109's Wound Assessment report dated 08/04/2024 revealed the resident had a non-pressure wound-surgical incision to right lower leg. Review of Resident #109's physician's orders dated 09/18/2024 at 8:20 a.m. revealed no order for Enhanced Barrier Precautions. Review of Resident #109's Care Plan dated 08/03/2024 revealed no care plan for Enhanced Barrier Precautions. Observation of Resident #109 on 09/16/2024 at 9:30 a.m. revealed Resident #109 sitting in wheelchair. PICC line noted to right arm, dressing clean, dry and intact, dated 09/12/2024 and wound vac on and connected to right ankle hanging on back of wheelchair. No Enhanced Barrier Precaution signage noted on door or near room. Observation of Resident #109 on 09/17/2024 at 9:06 a.m. revealed Resident #109 sitting up in bed. PICC line noted to right upper arm, dressing clean, dry and intact, dated 9/16/2024. Wound Vac on and connected to right ankle. No Enhanced Barrier precautions posted on room door, in room or near room. Observation of Resident #109 on 09/17/2024 at 1:42 p.m. revealed Resident #109 in bed. PICC line noted to right arm and wound vac on floor next to bed, on and connected to ankle. No Enhanced Barrier Precautions on door, in room or outside room door noted. Interview with S7 CNA on 09/17/2024 at 2:24 p.m. revealed she was aware of residents that are on Enhanced Barrier Precautions by orange sign on the resident's door. Observation and interview with Resident #109 on 09/18/2024 at 8:50 a.m. revealed Resident #109 lying in bed. PICC line observed to right arm, dressing clean dry and intact and wound vac sitting on floor, on and connected to right ankle. Resident #109 stated CNA's have not been wearing gowns when transferring resident to and from wheelchair or when performing toileting hygiene. Resident #109 stated tubing was disconnected by CNAs from wound vac during transfers. Enhanced Barrier Precaution sign now on resident's door. Interview with S6 LPN on 09/18/2024 at 9:04 a.m. revealed that she placed the sign on the Resident #109's door at some point on Tuesday, 09/17/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to maintain dignity for 1 (Resident #19) of 36 sampled residents by failing to ensure she was free of facial hair. Findings: Review of Resident #19's medical records revealed she was admitted to the facility on [DATE] with diagnoses which included: Hyperlipidemia, Unspecified Mood disorder, Athsclerotic Heart Disease, Type 2 Diabetes Mellitus, Essential Hypertension, Unspecified Dementia, Alzheimer's disease and Anxiety Disorder. Review of Resident #19's Quarterly MDS with an ARD of 05/19/2023 revealed a BIMS score of 14 (indicating intact cognition). Resident #19 required physical assistance with 1-person physical assist for bed mobility, personal hygiene, bathing and toilet use. An interview and Observation on 08/21/2023 at 10:52 a.m. revealed Resident #19 sitting in dining room waiting for lunch with long facial hair on her chin and lip. Interview with Resident #19 revealed that she would like for her face to be shaved. An Observation and interview on 08/22/2023 at 11:21 a.m. with Resident #19 revealed her sitting in her wheelchair in the dining room with long facial hair on her chin and lip. Resident #19 revealed staff had not come to shave her and stated if I can find a razor I'll do it myself. An Interview with S4 LPN confirmed the long facial hair on Resident #19's chin and lip and that Resident #19 would like for it to be removed and it had not been done.

Based on observation, interview and record review the Facility failed to promote and facilitate residents' self- determination through support of the residents' choice about aspects of his or her life in the facility that were significant to the resident for 1 (Resident #47) of 31 sampled Residents. The facility failed to provide a diet according to Resident #47''s food preferences. Findings: Review of Resident #47's medical record revealed an admit date of 11/04/2020 with diagnoses which included: Morbid Obesity, Functional Dyspepsia, Peripheral Vascular Disease, Atherosclerosis of Native Coronary Arteries and Bilateral Amputee. Review of a Quarterly MDS assessment with an ARD of 07/25/2023 revealed Resident #47 had a BIMS score of 15 indicating intact cognition. Review of August 2023 Physician orders revealed Resident #47 was on a regular no added salt, no red meats and no fried foods diet. Review of Resident #47's dietary card revealed a regular no added salt diet with dislikes of: cream corn, pork roast, mashed potatoes, pork ham, pork chop, pulled pork, cheese, scallop potatoes and smothered potatoes. Interview on 08/21/2023 at 9:39 a.m. with Resident #47 revealed he received foods he did not like or want on his tray at meal times. Resident #47 stated he had talked to the dietary staff several times about receiving foods he did not like on his tray, and it had not helped. Observation and interview on 08/21/2023 at 11:25 a.m. of Resident #47's lunch tray revealed he had mashed potatoes on his tray. Resident #47's dietary card revealed mashed potatoes was listed under dislikes for the resident. Resident #47 confirmed he did not like or want the mashed potatoes on his tray and he had informed dietary of this several times. Interview on 08/22/2023 at 11:18 a.m. with Resident #47 stated he recently received a pork chop on his tray and ate some of it because he thought it was turkey. Resident #47 stated he disliked pork because it made him feel dizzy. Interview on 08/24/2023 at 8:55 a.m. with Resident #47 revealed approximately 2 weeks ago he went to the kitchen to speak with S3 Dietary Manager regarding his food preferences and S3 Dietary Manger informed Resident #47 she was dumping trays and did not have time to talk to him. Interview on 08/24/2023 at 9:00 a.m. with S3 Dietary Manager stated Resident #47 did not like pork and should not get it on his tray. S3 Dietary Manager confirmed Resident #47 had gotten a barbecued pork chop on Sunday and he shouldn't have. S3 Dietary Manager confirmed Resident #47 should not have gotten mashed potatoes on his tray on 08/21/2023. S3 Dietary Manager confirmed Resident #47 came to speak with her approximately 2 weeks ago about his diet and she informed him she was busy dumping trays and didn't have time to talk to him.

Based on observation and interview the facility failed to maintain a clean, comfortable and homelike environment, by failing to ensure the bathroom wall and door in Room A were in good repair. Findings: Observation on 08/21/2023 at 12:38 p.m. of the resident bathroom in Room A revealed several small holes in the wall near the commode with 2 exposed screws underneath the grab bar. Observation of the inside of the bathroom door revealed the door appeared shredded across the middle. Observation on 08/24/2023 at 10:30 a.m. of the resident bathroom in Room A revealed several small holes in the wall near the commode with 2 exposed screws underneath the grab bar. The inside of the bathroom door appeared shredded across the middle of the door. Observation of Room A bathroom on 08/24/2023 accompanied by S2 DON revealed the above concerns remained present. Interview at the time of observation confirmed the door was peeling and damaged across the middle and lower corners. Two exposed screws were present below the wall grab bar and several small holes were present in the wall beside the commode. S2 DON stated staff were responsible for reporting areas in need of repair. S2 DON stated Room A's bathroom conditions should have been reported and repaired and had not been.

Based on interview and record review, the facility failed to ensure a resident was free from misappropriation of property for 1 (Resident #81) of 1 resident sampled for misappropriation, in a total sample of 36 residents. The facility failed to prevent misappropriation of Resident #81's funds by S10 CNA. Findings: Review of the facility abuse policy revealed in part . Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. No one shall abuse a resident. This policy applies to facility staff, other residents, family members or resident representatives, and anyone else present in our facility. 7. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the residents consent. Review of Resident #81's clinical record revealed an admit date of 08/01/2022 with diagnoses that included Syringomyelia, Syringobulbia, Paraplegia, Neuromuscular Dysfunction of Bladder, and Pressure Ulcer of Left Buttock. Review of Resident #81's Quarterly MDS with ARD of 06/20/2023 revealed Resident #81 had a BIMS score of 15, indicating no cognitive impairment. Interview on 08/21/2023 at 10:18 a.m. with Resident #81 revealed a couple weeks ago Resident #81 had offered money to help S10 CNA out after S10 CNA told him she had fallen on hard times. Resident #81 stated S10 CNA declined to borrow the money. Resident #81 stated sometime after 2:00 p.m. he decided to check his account balance. Resident #81 stated after checking the last 4 withdrawals he noticed the last withdrawal was for $200.00 and had been transferred to a PayPal account. Resident #81 stated he reported the $200.00 transaction as fraud at that time and froze his card. Resident #8 stated a police report had been filed, and his son was notified. Interview on 08/23/2023 at 12:07 p.m. with S5 SSD revealed on 08/01/2023 Resident #81 called the nurses station to have the SSD go down to his room because his bank card was missing. S5 SSD stated she went to Resident #81's room, asked where the card was last seen, and searched Resident #81's room. S5 SSD stated Resident #81 told her I think that CNA (S10 CNA) took it, because she's the only one that's been in here, and because of the comment she made. S5 SSD stated she then went to S2 DON and S1 Administrator and reported the missing card. S5 SSD stated the police came to the facility and interviewed Resident #81. Interview on 08/23/2023 at 12:13 p.m. with S2 DON revealed on the evening of 08/01/2023, S5 SSD notified her that Resident #81's debit card was missing. S2 DON stated she interviewed Resident #81, and Resident #81 stated he had offered S10 CNA a loan because her ID and debit card were missing from her wallet. S2 DON stated she called S10 CNA and asked her about interactions between herself and Resident #81. S2 DON stated S10 CNA told her Resident #81 had offered to loan her money but she turned him down. S2 DON stated S10 CNA denied taking Resident #81's debit card. S2 DON stated she informed S10 CNA she was being suspended until the facility's investigation was complete. Interview on 08/23/2023 at 12:23 p.m. with S1 Administrator revealed on 08/08/2023 he contacted Resident #81's bank and spoke to a Liaison. S1 Administrator stated at that time he was informed by the bank liaison that $200.00 had been transferred from Resident #81's account to a CashApp account owned by S10 CNA. S1 Administrator stated S10 CNA was then terminated.

Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards for 2 (Resident #46 and Resident #211) of 2 residents reviewed for respiratory care. The facility failed to: 1. Provide humidification in accordance to the resident person centered plan of care 2. Ensure respiratory equipment was properly stored Findings: Resident #46 Review of Resident #46's medical records revealed a diagnoses of Chronic Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, Heart Failure, and Anxiety Disorder. Review of Resident #46's care plan with a review date of 09/27/2023 revealed Resident# 46 required oxygen therapy due to Chronic Obstructive Pulmonary Disease with facility interventions to provide humidification to oxygen therapy. An interview on 08/21/2023 at 11:30 a.m. with Resident #46 revealed she requested the facility add humidification to her oxygen concentrator multiple times because her nose became dry and irritated with oxygen usage without humidification. Resident #46 stated someone notified her (unsure of who) that the reason the facility could not add humidification to her oxygen was because they were unable to obtain distilled water. Observation on 08/22/2023 at 9:11 a.m. revealed Resident #46's humidification bottle for her oxygen concentrator was empty and her oxygen tubing was not attached. Resident #46 stated her nose was very dry and swollen. Resident #46 stated she had ask for her oxygen to be humidified several times but no one had been able to help. An interview on 08/23/2023 at 10:25 a.m. with S4 LPN confirmed Resident #46 did not have humidification connected to her oxygen concentrator and confirmed that she was care planned for humidification and it should have been applied. Resident #211 Facility's Policy on Nebulizer Machine Cleaning read in part .Procedure: (2) Store tubing, mouthpiece, and mask in plastic bag when not in use. Review of Resident #211's medical record revealed a diagnoses of Chronic Pulmonary Edema and Pneumonia. Resident #211 received Ipratropium BR 0.02% solution and Levalbuterol 1.25 MG/3ML solution one vial per nebulizer every 6 hours (breathing treatment). Observation and interview on 08/21/2023 at 10:14 a.m. revealed a nebulizer mask lying on Resident #211's bedside table uncovered with a brown hard substance on it. Resident #211 stated she used the nebulizer every day. Observation on 08/22/2023 at 9:10 a.m. revealed a nebulizer mask lying on Resident #211's bedside table uncovered. Observation and interview on 08/22/2023 at 9:14 a.m. accompanied by S2 DON revealed Resident #211's nebulizer mask lying on her bedside table uncovered. S2 DON confirmed Resident #211's nebulizer mask should have been in a plastic bag and it was not.

Based on observation, interview, and record review the facility failed to meet the nutritional needs of residents in accordance with established national guidelines. The facility failed to follow the menu in regard to portion size to ensure nutritional adequacy of the meal for all 113 Residents who receive meals prepared by the facility kitchen. Findings: Review of the facility's policy titled: Standardized Recipes read in part . Standardized recipes are used in preparation of food for control of quality, quantity, and uniformity of product. 2. A standardized recipe includes the following information: Yield and portion size. Review of the facility's policy titled: Portion Control read in part . Menus shall reflect standardized portion sizes to ensure nutritional adequacy of the diets, control production, and enhance food cost control efforts. 1. The established portion sizes for specific menu items are listed on the posted menu modification. 3. Employees are expected to follow established portions size for all menu items unless otherwise altered for nutrition care purposes or resident request. Review of the facility's approved 2023 Spring/Summer Menus revealed the facility was on week 3, day 2. Lunch menu consisted of: BBQ Pork Chop- 4oz, Homemade Potato Salad- ½ cup, Southern Style [NAME] Beans (Substituted with Lima Beans)- ½ cup, French Bread- 1 each, Lemon Mousse-1 each, Beverage Choice and Water. Observation and interview on 08/21/2023 at 10:45 a.m. revealed the dietary workers in the kitchen began serving resident's lunch trays. S8 Dietary prepared a resident's lunch tray by placing a pork chop and a 4oz scoop of lima beans on the plate, she then passed the plate down the line to S9 Dietary who placed potato salad and a dessert on tray. Surveyor asked S3 Dietary Manager if the prepared tray was the complete serving size. S3 Dietary Manager confirmed the tray was completely prepared, and the worker was to place the tray on meal cart to be served to a Resident. Surveyor requested S3 Dietary Manager weigh the pork chop that was observed on the prepared tray. Observation and interview on 08/21/2023 at 10:48 a.m. revealed S3 Dietary Manager carried the pork chop to the kitchen's scale. S3 Dietary Manager weighed the pork chop, and the scale read 1.9 oz. S3 Dietary Manager confirmed the portion size served on this tray was not adequate to meet the minimum required portion size of 4 ounces, and the staff should have served 2 pork chops to meet the requirement. Telephone interview on 08/23/2023 at 2:25 p.m. with S7 Registered Dietician revealed she reviewed and signed off on all menus the facility utilized, which included portion sizes. S7 Registered Dietician stated S3 Dietary Manager informed her of the surveyor findings on 08/21/2023 and she had begun preparing an in-service to ensure proper serving sizes are served to residents. S7 Registered Dietician stated a typical daily requirement for protein would consist of; 1oz served for breakfast, 3 oz. served for lunch, and 2 oz. served for supper. S7 Registered Dietician stated the facility needed to update their menu's to reflect this. S7 Registered Dietician confirmed the 1.9 oz. of protein observed as prepared for a Resident on 08/21/2023 was insufficient and the weight needed to be closer to 3oz to meet requirement.

Based on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This deficient practice had the potential to affect the 113 residents that received meals prepared by the kitchen. Findings: Review of the facility's policy titled: Cleaning and Sanitizing Equipment read in part . All equipment is kept clean and food contact surfaces are cleaned and sanitized. Observation of the facility's kitchen on 08/21/2023 at 8:25 a.m. accompanied by S3 Dietary Manager revealed: The kitchen's microwave was unsanitary with dried food splattered on the top and bottom. The dry food storage area contained 1 carton of thickened cranberry juice that had an expiration date of 07/28/2023 on the shelf for use. Interview with S3 Dietary Manager on 08/21/2023 at 8:35 a.m. confirmed the above findings. S3 Dietary Manager stated the microwave needed to be cleaned, and the shelf should not contain any expired items.

Based on record review and interview, the facility failed to transmit a MDS (Minimum Data Set) Assessment within 14 days of completion for 4 (Resident #4, Resident #15, Resident #63, and Resident #70 ) of 4 sampled residents with MDS record over 120 days old. Findings: Review of the facility MDS transmission reports for Resident #4, Resident #15, Resident #63, and Resident #70 revealed the MDS Assessments with ARD of 07/18/2023 for all the above residents had not been transmitted until 08/17/2023. Interview on 08/23/2023 at 11:10 a.m. with S11 LPN/MDS Team Leader and S12 LPN/MDS Coordinator confirmed the above findings. S11 LPN/MDS Team Leader and S12 LPN/MDS Coordinator denied any technological issues that may have hindered transmission of the noted assessments. S11 LPN/MDS Team Leader revealed assessments should have been transmitted within 14 days of completion and had not been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #3 Review of Resident #3's clinical record revealed an admit date [DATE] with diagnoses which included: Generalized Osteoarthritis, Chronic Kidney disease, Heart Failure, Anxiety Disorder, Unspecified Dementia, Diabetes Mellitus, and Essential Hypertension. Review of Resident #3's MDS with an ARD of 03/12/2023 revealed a BIMS score of 15 (indicating cognitively intact). Resident #3's MDS revealed he required extensive assistance with 1-person physical assist with bed mobility, transfers, toilet use, dressing, personal hygiene and bathing. An interview on 4/03/2023 at 2:45 p.m. with Resident #3 revealed that he had been missing two blankets for a few months. Resident #3 stated that he had notified different staff members about the missing blankets but the facility had failed to find them or replace the missing items. Review of Resident Council Meeting minutes dated 02/06/2023 read in part: Resident #3 stated he had a few blankets missing. Review of Resident Council Meeting minutes dated 03/06/2023 read in part: Resident #3 stated he is still missing a few blankets. An interview on 04/03/2023 at 4:00 p.m. with S1 Administrator revealed that a grievance for Resident #3's missing blankets had not been initiated because he was unaware that the items were missing. S1 Administrator revealed that he is given the resident council minutes monthly and had received the minutes for February and March. S1 Administrator confirmed that a grievance for Resident #3's missing items was not initiated in a timely manner and it should have been. Based on interviews and record review the Facility failed to ensure their grievance policy and procedure was followed for 2 Residents (Resident #1 and Resident #3) out of 5 sampled Residents (Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5) by failing to ensure prompt resolution of an allegation of missing property for Resident #1 and by failing to initiate a grievance for Resident #3. Findings: Resident #1 Review of the Facility's Grievance Policy and Procedure revealed in part . Policy: The Resident has the right to and the facility must make prompt efforts to resolve grievances. The facility grievance official/compliance liaison is the Administrator. Procedure: Follow-up/Resolution: The grievance official/compliance liaison or designee will follow-up with the complainant with a resolution within 5 business days of the date that the grievance was filed. NOTE: Depending on the nature of the grievance, establishing a resolution may take longer than 5 business days. In such cases: A. The grievance official/compliance liaison or designee shall update the complainant on the status of the investigation. Documentation: Document grievances made by a Resident, Resident family member, a visitor, volunteer, individual employee on the official Grievance form. Review of Resident #1's clinical record revealed an admit date of 10/29/2021 with diagnoses which included: Alzheimer's Disease, Dysphagia, Other Cerebral Infarction, Urinary Tract Infection and Pain, Unspecified. Review of Resident #1's SM5 MDS with an ARD of 02/16/2023 revealed Resident #1 had a BIMS score of 5 (indicating severe cognitive impairment). Resident #1's MDS revealed he required extensive assistance with 2 person physical assist with bed mobility, transfers and toilet use; extensive assistance of 1 person with dressing, personal hygiene and bathing and limited assistance of 1 person with eating. Review of the Facility's grievance log revealed Resident #1's responsible party filed a grievance on 03/09/2023 revealed in part . Resident #1 (son) reported his dad is missing 2 sweat suits. Telephone interview on 04/03/2023 at 10:23 with Resident #1's responsible party revealed Resident #1 had 2 sweat suits missing. Responsible party stated Resident #1 had been moved from one room to another room and during transport Resident #1's sweat suits came up missing. Responsible party revealed he and his brother washed Resident #1's clothes at home. Telephone interview on 04/03/2023 at 10:36 a.m. with second contact (Resident #1's son) revealed Resident #1 has had missing clothes in the past and that is the reason the family is washing his clothes now. Resident #1's son stated his dad changed rooms and his clothes came up missing when he moved. Resident #1's son revealed he reported the missing items to social services and to the laundry supervisor. Resident #1's son revealed the facility told him last week (the day of his care plan meeting dated 03/29/2023) they would reimburse him for the sweat suits after he provided the facility with a receipt. Resident #1's son stated the facility had not updated him on the grievance until 03/29/2023. Interview on 04/03/2023 at 11:50 a.m. with S1 Administrator revealed he was the grievance official. S1 Administrator stated he was aware of the grievance filed on 03/09/2023 in reference to 2 missing sweat suits for Resident #1. S1 Administrator stated Resident #1 had different family members washing his clothes and the facility was unable to verify if the 2 missing sweat suits were missing at the facility. S1 Administrator stated it was decided on 03/29/2023 during Resident #1's care plan meeting that the facility would reimburse Resident #1's son for the 2 missing sweat suits. S1 Administrator confirmed the grievance filed on 03/09/2023 with a resolution date on 03/29/2023. S1 Administrator confirmed this was not a prompt investigation and resolution to the allegation of missing property and he should have updated the complainant after 5 days of no resolution to the grievance.

Based on observation, interview and record review the Facility failed to meet the nutritional needs of Residents in accordance with established national guidelines. The Facility failed to follow the menu in regard to portion size to ensure nutritional adequacy of the meal for all 105 Residents who receive meals prepared by the Facility kitchen. Findings: Review of the facilities approved menu revealed the facility is on cycle day 16. Lunch menu included: fried chicken -4oz, au gratin potato- ½ cup, veggie blend -½ cup, dinner roll -1 each, frosted cupcake-1 each, beverage choice. An observation and interview on 04/03/2023 at 10:50 a.m. revealed Resident #4's lunch tray being served. Resident #4 opened the tray and revealed a piece of fried chicken thigh, pasta salad, slice of wheat bread, carton of milk and a chocolate cupcake. At the time of observation Resident #4 stated the serving size of the chicken appeared small and requested it to be measured. An observation and interview on 04/03/2023 at 11:05 a.m. revealed S1Administrator carrying Resident #4's tray back into the kitchen and stated the chicken ordered from Sysco is premeasured and that 1 piece of chicken is given to each resident. An observation on 04/03/2023 at 11:11 am with S3 Dietary Manager revealed that all chicken was not measured prior to being cooked and the piece of chicken served to Resident #4 weighed 2.5oz. S3 Dietary Manager confirmed that the portion size given to Resident #4 is not adequate to the minimum required portion of 4oz.

Based on observation, interview and record review, the Facility failed to ensure that Residents meals were distributed in a timely manner. This deficient practice had the potential to effect all Residents that are served meals in the dining room. Findings: A review of the Facility's Frequency of Meal policy read in part . 1. Meal service times for the Residents are as follows: a. Breakfast 7:15 a.m. b. Lunch 11:30 a.m. c. Dinner 5:15 p.m. An Interview on 04/03/2023 at 7:38 a.m. with Resident #3 revealed he was sitting in dining room awaiting breakfast. Resident #3 stated that he typically eats most meals in the dining room and at times has to wait for long periods of time to receive meals. Resident #3 stated that breakfast is typically the meal that he has to wait for longer times and that he often gets hungry while waiting. Staff interview on 04/03/2023 at 07:13 a.m. with S4 Dietary Staff revealed that breakfast meal trays are to begin being plated at 6:45 a.m. but were not because the eggs were not taken out of the freezer to defrost the night before. A breakfast observation in the dining room on 04/03/2023 revealed the first breakfast tray was served at 8:02 a.m. Interview on 4/03/2023 at 4:00 p.m. with S3 Dietary Manager confirmed that breakfast should have been served by the dietary staff in the dining room by 7:15 a.m. and was not served until 8:02 a.m.

Based on observation and interview, the facility failed to ensure garbage was disposed of properly. The total facility census was 105 residents. Findings: Observation on 08/07/2022 at 09:15 a.m. upon exiting the facility's kitchen accompanied by S6 Dietary [NAME] revealed three tied white trash bags, one tied black trash bag, an opened fast food bag labeled with contents scattered and multiple cigarettes butts scattered on the ground. Observation on 08/07/2022 at 09:15 a.m. of the facility's trash receptacles accompanied by S6 Dietary [NAME] revealed two large dumpsters partially enclosed in a wooden fenced in area. The lid to both dumpsters were open. There were multiple used dirty gloves and debris on the ground surrounded around both dumpsters. Interview with S6 Dietary [NAME] at the time of the observation confirmed the dumpster lids were open with dirty gloves and debris on the ground surrounding the dumpsters. S6 Dietary [NAME] further confirmed there were several tied trash bags, an opened fast food bag with contents scattered and multiple cigarette butts scattered on the ground. S6 Dietary [NAME] further confirmed the tied trash bags should have been placed in the dumpsters with the lids closed and was not done. Interview on 08/07/22 at 09:30 a.m. with S5 DM confirmed both of the dumpster lids were open and should have been closed. S5 DM further confirmed the trash bags should have been placed in the dumpsters with the lids closed but had not been done. Observation on 08/08/22 at 8:13 a.m. of the facility's trash receptacles accompanied by S5 DM revealed the lids to both dumpsters remained open with a trash bag overflowing off of the side of the dumpster closest to the kitchen door. Interview with S5 DM at the time of the observation confirmed that both of the dumpsters remained open and the dumpster closest to the kitchen was overflowing with a trash bag and should not have been. Interview on 08/10/2022 at 12:30 p.m. with S1 ADM revealed he had the lids to the dumpsters replaced yesterday due to them being damaged. He further revealed he was aware the lids to the dumpsters had been open and should not have been. Review of the facility's Waste Disposal policy revised 10/2018 in part revealed: Garbage containers are to be removed from the food preparation area before garbage containers are overfilled and are cleaned inside and outside daily. Outside storage areas are to be located away from the food production and storage areas, kept covered at all times, located on a nonabsorbent surface and kept clean of garbage and debris.