Based on observation, interview and record review, the facility failed to implement the comprehensive person-centered care plan for 1 (#83) of 4 (#17, #21, #76 and #83) sampled residents reviewed for care plans. The facility failed to monitor a medication that was self-administered by a resident. Findings: Review of the facility's policy titled, Medication - Self-Administration with no date, revealed the following, in part: .The nurse will check with the resident each day and document on the MAR if the medication was taken as reported by the resident . Review of Resident #83's medical record revealed an admit date of 09/02/2024 with diagnoses that included in part .Major Depressive Disorder, Hypertensive Heart Disease without Heart Failure, Obstructive and Reflux Uropathy, Shortness of Breath and Pain. Review of Resident #83's admission MDS with an ARD of 09/09/2024 revealed a BIMS summary score of 15, indicating Resident #83 was cognitively intact. Review of Resident #83's current care plan with a start date of 09/07/2024, revealed Resident #83 may keep Albuterol inhaler at bedside for self-use, and nursing staff was to assist with recording and monitor usage. Review of Resident #83's physician's orders dated 09/07/2024 revealed .may keep Albuterol inhaler at bedside, nursing staff to assist with reordering and monitor usage. Review of Resident #83's Medication Administration Record (MAR) from 09/07/2024 through 10/14/2024 revealed no documentation indicating that Resident #83 used his Albuterol inhaler. Observations on 10/15/2024 09:48 a.m. revealed an Albuterol inhaler on Resident #83's bedside table. An interview with Resident #83 at that time, revealed he self-administers his Albuterol inhaler 3 to 4 times a week at night. An interview on 10/15/2024 at 10:48 a.m. with S9 LPN, revealed he has been taking care of Resident #83 for approximately a month. S9 LPN indicated that he was not aware Resident #83 had an Albuterol inhaler at his bed side. An interview on 10/15/2024 at 10:50 a.m. with S2 DON, confirmed that Resident #83 was able to self-administer his Albuterol inhaler, and it was not being documented on the MAR. S2 DON indicated the nurses should have been asking Resident #83 if he self-administered his Albuterol inhaler and documenting his response on the MAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #47 Based on observation, record review and interview, the facility failed to ensure a resident received proper treatment and an assistive device to maintain and/or improve hearing for 1 (#47) resident reviewed for communication and sensory problems out of a total sample of 21 residents. Findings: Review of Resident #47's Medical Record revealed an admission date of 06/21/2023 with diagnoses that included in part . Benign Paroxysmal Vertigo, Unspecified Ear, Age-related Cataracts, Bilateral, Hypertensive Heart Disease with Heart Failure, Type 2 Diabetes Mellitus, Parkinson's disease and Speech and Language Deficits following unspecified Cerebrovascular Disease. Review of Resident #47's Quarterly MDS with an ARD of 07/25/2024 revealed a BIMS score of 15, indicative of intact cognition. Review of MDS revealed resident with moderate difficulty with ability to hear and speaker has to increase volume and speak distinctly. Resident did not use a hearing aid or other hearing appliance. Review of Resident #47's Care Plan with a Target date of 10/25/2024 revealed in part . Resident with difficulty hearing related to minimally Hard of Hearing, does not wear hearing aids and to refer to hearing center for hearing aid program. Review of Care Plan revealed an appointment on 02/26/2024 with hearing center today, cleaned ears bilaterally, noted significant hearing loss both ears, recommend trial with amplifier. Resident given (Louisiana Commission for the Deaf) LCD, meets criteria for hearing aid program. Contact hearing center to start process. Review of Resident #47's Progress notes per MD dated 02/26/2024 revealed: Clean ears bilaterally. Recommend trial with amplification. Patient given LCD/ referral. Review of email correspondence regarding Resident #47 dated 10/15/2024 at 3:25 p.m. titled, LCD Hearing Aid Program- Application Received revealed application received on 10/15/2024. Interview on 10/14/2024 at 10:18 a.m. with Resident #47 reported that she went to get tested back in February 2024 and never got a follow up appointment to get hearing aids and she needs them because she is hard of hearing. Interview with 10/15/2024 at 3:41 p.m. with S1 Administrator presented with receipt of application received by LCD Hearing Aid program dated 10/15/24 at 03:25 PM. S1 Administrator stated the program will contact us. Interview on 10/15/2024 at 3:45 p.m. with S11 SSD revealed that she had made a telephone call to a hearing aid program in Lake [NAME] after resident's appointment back in February for a hearing aid and not heard back from them and overlooked checking back with them. She stated she submitted an application for a hearing aid today with another program. S11 SSD confirmed that she did not follow up with the LCD Hearing Aid Program to assist Resident #47 in obtaining an assistive hearing device and should have.

FACILITY QAPI and QAA Based on interview and record review the facility failed to ensure the Quality Assessment and Assurance (QAA) committee meeting included the required 6 staff members for the facility's quarterly committee meetings. Findings: Review of the facility's 4th Quarterly Quality Assessment and Assurance (QAA) committee sign in sheet conducted on January, 06, 2024 revealed staff in attendance was the facility's Medical Director, Infection Preventionist, staff RN and a staff LPN. Interview on 10/16/2024 at 2:40 p.m. with S2 DON revealed that she was present as a staff RN at the time of the 4th Quarterly QAA meeting was held but the DON at that time was not present. During an joint interview on 10/16/2024 at 2:43 p.m., S1 Administrator and S2 DON indicated that the other members were not available at the time of the QAA meeting scheduled with the facility's Medical Director. S1 Administrator confirmed the required staff members were not in attendance for the Quarterly QAA meetings and should have been.

Based on record review, observation, and interview the facility failed to ensure that a resident maintained acceptable parameters of nutritional status for 1 (#11) of 2 (#11 and #23) residents reviewed for nutrition. The facility failed to provide ordered dietary supplements for a resident with significant weight loss. Findings: Resident #11 Review of the Resident #11's medical record revealed an admit date of 09/04/2021 with a reentry date of 03/18/2022. Diagnoses included .Parkinson's Disease, Mild Protein-Calorie Malnutrition, Dysphagia - Oropharyngeal Phase, and Muscle Wasting and Atrophy. Review of Resident #11's Quarterly MDS with an ARD of 08/14/2024 revealed a BIMS score of 13, which indicated the resident was cognitively intact. Resident #11 required extensive assistance by one person with eating. Review of Resident #11's medical record revealed the resident was care planned for a nutritional problem related to a diagnosis of Protein Calorie Malnutrition, no salt on tray, and mechanical soft diet. Interventions included in part: Monitor, record, and report to Medical Director as needed signs and symptoms of malnutrition .significant weight loss greater than 10% in 6 months . Registered Dietician to evaluate and make diet change recommendations as needed .provide and serve diet as ordered . monitor intake and record every meal. Review of Resident #11's progress notes revealed the following: 09/26/2024: Nutrition/Dietary Note by S13 RD: Resident weight changes -12.62% X 180 days . continues no salt on tray diet, mechanical soft texture with varied by mouth intake .on multiple supplements . mighty shake three times daily .will monitor weight changes, labs, and by mouth intake .recommend to continue the current plan of care .Registered Dietician to monitor. Review of Resident #11's current physician's orders revealed to give a mighty shake three times a day, with an order date of 08/28/2024. Review of Resident #11's weights revealed on 04/03/2024, Resident #11 weighted 136.1 lbs., and on 10/02/2024, Resident #11 weighted 119 lbs., which revealed a significant weight loss of 12.56% over the past six months. In an observation on 10/14/2024 at 12:30 p.m., Resident #11's lunch tray was noted with no mighty shake. In an interview on 10/15/2024 at 9:05 a.m., Resident #11 stated she has poor appetite. On 10/15/2024 at 11:57 a.m., Resident #11's lunch tray was observed and noted with no mighty shake. In an interview on 10/15/2024 at 11:57 a.m., Resident #11 stated she does not get any shakes or supplements. Observation on 10/15/2024 at 12:08 p.m., revealed Resident #11's lunch tray after lunch was observed after lunch was completed. Approximately 25% of meal was consumed. No mighty shake noted to her lunch tray. In an interview on 10/15/24 at 1:15 p.m., S9 LPN stated the nurses give the house supplements to the residents and the mighty shakes come from the kitchen. S9 LPN stated the kitchen sends the mighty shakes on the meal carts delivered to the resident rooms. S9 LPN confirmed physician orders that Resident #11 should receive a mighty shake three times a day. In an interview on 10/15/2024 at 1:20 p.m., S8 Dietary Manager stated that when the nurses receive an order for a mighty shake, they are to complete a diet slip and turn it in to the Dietary Manager. S8 Dietary Manager stated once the diet slip is received, the tray cards are updated in the record to reflect the new orders for supplements. S8 Dietary Manager stated that the process relies heavily on the nurses to communicate any updates regarding changes to supplements for weight loss. S8 Dietary Manager stated the dietary staff are aware to follow the tray cards and place any supplements on the meal carts as needed. Review of Resident #11's tray card on 10/15/2024 at 1:34 p.m. revealed no evidence of a mighty shake listed under the supplements category. In an interview on 10/15/2024 at 1:43 p.m., S8 Dietary Manager stated a mighty shake should be placed under the supplement category of the tray card. S8 Dietary Manager confirmed that Resident #11's tray card did not have a mighty shake noted to the supplement category. S8 Dietary Manager stated the dietary staff would not have placed a mighty shake on Resident #11's meal tray because it was not listed on her tray card. S8 Dietary Manager stated Resident #11's tray card had not been updated since September 2024; therefore, Resident #11 would not have gotten a mighty shake since September 2024.

Based on record review, observation, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary environment, to help prevent the development and transmission of infection for 3 (#26, #45, and #72) of 4 (#26, #45, #72, and #83) residents reviewed for infection control. The facility failed to: 1. Ensure staff wore proper PPE while providing wound care to Resident #26; 2. Ensure staff wore proper PPE while proving personal hygiene to Resident #45; and 3. Ensure staff performed proper hand hygiene and maintained a clean technique while performing wound care for Residents #26 and #72. Findings: Review of the facility's policy titled, Enhanced Barrier Precautions read in part . It is the policy of this facility to implement Enhanced Barrier Precautions (EBP) for the prevention of transmission of multidrug-resistant organisms (MDRO). 46. Enhanced Barrier Precautions - a. Nursing staff will place residents with any applicable conditions or devices on EBP. An order may be obtained. Applicable conditions and devices: i. Wounds and/or indwelling medical devices (e.g., central lines, hemodialysis catheters, urinary catheters, feeding tubes, tracheostomy/ ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO. Review of the facility's undated policy titled, Skin Program, Pressure Ulcers and Other Wounds revealed in part . 21. Clean technique, using a no touch method to avoid contaminating the wound is usually adequate for wound treatments. Clean technique and supplies will be used unless otherwise ordered . 48. High-contact resident care activities include: a. Dressing, b. Bathing, c. Transferring, d. Providing hygiene, e. Changing linens, f. Changing briefs or assisting with toileting, g. Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy tubes, h. Wound care: any skin opening requiring a dressing. Resident #45 Review of Resident #45's EHR revealed an admit date of 12/13/2023, with diagnoses that included: UTI and Neuromuscular Dysfunction of Bladder; Review of Resident #45's Quarterly MDS with an ARD of 08/21/2024, revealed a BIMS score of 8 (which indicated moderate cognitive impairment). Resident #45 had an indwelling Suprapubic catheter, and was always incontinent of bowel. The MDS revealed Resident #45 was at risk for pressure ulcers. Review of Resident #45's 10/2024 Physician's Orders revealed the following: 08/28/2024 - turn and reposition every 2 hours. 09/03/2024 - 22FR/10CC Suprapubic Catheter change every 3 weeks and prn leakage, occlusion, dislodgment. 09/03/2024 - Admit to hospice. 09/03/2024 - Enhanced barrier precautions related to catheter and wound. 10/07/2024 - PU Sacrum: Clean with wound cleaner, apply Mesalt and Honey to Slough, and cover with dry dressing daily. Review of Resident #45's Care Plan with target date of 11/21/2024, revealed the following in part . 1. Urinary Catheter - Indwelling: 22 FR/10CC Suprapubic Foley catheter. Dx - Neuromuscular Dysfunction of Bladder, and enhanced barrier precautions. Observation on 10/16/2024 at 11:30 a.m., revealed Resident #45's Hospice CNA was in the room, wearing scrubs, touching the resident and leaning over him while he was in the bed. The Hospice CNA was not wearing PPE equipment. Interview on 10/16/2024 at 11:31 a.m. with S12 MDS Nurse, confirmed there was someone in Resident #45's room dressed in scrubs, and leaning over the resident. S12 MDS Nurse revealed she did not know who the person was, but stated that she should be wearing a gown and gloves since Resident #45 was on enhanced barrier precautions. Interview on 10/16/2024 at 11:40 a.m. with Resident #45's Hospice CNA in Resident #45's room revealed she was Resident #45's Hospice CNA. She was observed carrying towels and washcloths, and stated she was preparing to give Resident #45 a bath. There was a basin at the resident's bedside with a used toothbrush noted in the basin. She was not wearing a gown and stated she was unaware that she should be wearing one. Resident #26 Review of Resident #26's Medical Record revealed an admit date of 12/10/2015, with diagnoses that included in part . Hypertensive Heart Disease with Heart Failure, History of Falling, Non-Pressure Chronic Ulcer of part of right lower leg with unspecified severity, Obesity due to excess calories and Unsteadiness on feet. Review of Resident #26's current Physician's Orders revealed the following orders in part . 10/16/2024: Enhanced Barrier Precautions (EBP) related to wound. 10/15/2024: Cleanse skin tear to RLE with wound cleanser, apply collagen and cover with dry dressing every day until resolved. 10/06/2024: Cleanse skin tear to RLE with wound cleanser, apply TAO and collagen and cover with dry dressing every 3 days until resolved. 09/24/2024: Right lower leg ulcer, cleanse with wound cleanser apply collagen and cover with dry dressing every day until healed. Review of Resident #26's Quarterly MDS with an ARD of 09/18/2024, revealed a BIMS score of 04, indicative of severe cognitive impairment. Review of the Skin Conditions section of the MDS, revealed Resident #26 had one venous/ arterial ulcer present, and received application of nonsurgical dressings and ointments/medications, other than to feet. Review of Resident #26's Care Plan with a Target date of 12/18/2024, revealed in part . 1. 03/04/2022 - Tissue integrity, impaired risk for fragile skin, history PU, history incontinent episodes, weakness, decreased mobility, cellulitis, candidiasis and abscess. 2. 10/07/2024 - Resident #26 with potential/actual impairment to skin integrity related to fragile skin, decreased mobility, and history of pressure ulcers, history of incontinent episodes, weakness, candidiasis and history of abscess. 10/06/2024: Clean skin tear to RLE with wound cleanser, apply TAO and collagen, and cover with dry dressing every 3 days until resolved. Interview on 10/15/2024 at 9:05 a.m. of S10 LPN, revealed the top wound was a skin tear that occurred over the past weekend. S10 LPN stated the wound to the right lower leg is an ulcer wound that she and the DON had assessed last week. Observation at that time revealed there was no EBP signage on Resident #26's door, and that S10 LPN entered without applying a gown. In an observation on 10/15/2024 at 9:05 a.m., S10 LPN performed wound care on Resident #26. S10 LPN set up the wound care supplies directly on the resident's over bed table, without a drape or clean field between the supplies and table. During wound care, S10 LPN removed the collagen from the RLE skin tear wound, then changed gloves without sanitizing hands after doffing the dirty gloves, and prior to donning new gloves. S10 LPN then cleaned the RLE wound with wound cleanser soaked gauze, and changed gloves again without sanitizing before donning new gloves. S10 LPN dried the wound with 4x4s, and changed gloves without sanitizing in between. S10 LPN then applied dry dressing to RLE wound, and began wound care to right lower leg ulcer wound after changing gloves and sanitizing. S10 LPN removed the old dressing from right lower leg ulcer wound, and changed gloves. S10 LPN removed the collagen and cleaned the wound with wound cleanser soaked 4x4s, and changed gloves without sanitizing her hands. S10 LPN dried the right lower leg ulcer wound with 4x4s, and changed gloves again without sanitizing hands. S10 LPN then applied dry dressing over the right lower leg ulcer wound. Interview on 10/15/2024 at 3:36 p.m. with S2 DON, confirmed Resident #26 was not on EBP for the venous ulcer wound to her right lower extremity, because the last treatment nurse had initiated the wound care order, but did not implement the order for EBP on resident's Physician's Orders for EBP, and should have. In an interview on 10/15/2024 at 3:50 p.m., S2 DON reported S10 LPN became the wound care nurse a couple of weeks ago, and was trained by the previous wound care nurse. S2 DON confirmed S10 LPN should have performed hand hygiene after doffing her gloves and setting up supplies on a clean field. S2 DON stated S10 LPN should not have touched the contaminated surfaces with her gloves while performing wound care. Resident #72 Review of Resident #72's medical record revealed an admit date of 11/01/2023, with diagnoses that included in part .Pressure Ulcer of right buttock, Pressure Ulcer of sacral region, and Chronic Pain Syndrome. Review of Resident #72's Quarterly MDS with an ARD of 09/20/2024, revealed a BIMS score of 15 (which indicated intact cognition). Review of the MDS revealed Resident #72 required supervision with eating, total dependence on two person physical assistance with toilet use, and extensive assistance by two persons with bed mobility. Review of Resident #72's current Physician's Orders revealed the following: 10/14/2024: Sacrum: Cleanse with normal saline, pat dry, apply Mesalt to wound bed, and cover with dry foam dressing daily every day shift. 10/14/2024: Right Gluteal fold: Cleanse with normal saline, pat dry, apply Mesalt to wound bed, and cover with dry foam dressing daily every day shift Review of Resident #72's care plan revealed a problem of: Risk for impaired skin integrity, with a review date of 10/17/2024. Interventions included in part .following the wound care orders, providing pressure reducing surfaces to bed and chair, and repositioning schedule. Observation of wound care for Resident #72, performed by S10 LPN, revealed the following: S10 LPN set up the wound care supplies directly on the resident's over bed table with no drape or clean field between the supplies and table. During wound care, S10 LPN removed the Mesalt from the right gluteal fold wound, then changed gloves without sanitizing hands after doffing the dirty gloves, and prior to donning new gloves. S10 LPN then cleaned the wound with normal saline soaked gauze, and changed gloves again without sanitizing hands and donning new gloves. S10 LPN dried the wound with 4x4s, and changed gloves without sanitizing in between. S10 LPN laid the new dressings in their package directly on the resident's bed sheet. S10 LPN changed gloves again without sanitizing, then picked up the scissors off the over bed table, (not on clean field) and opened and cut a piece of foam with the dirty scissors, and then covered the resident's gluteal wound with the foam and a dry dressing. S10 LPN began wound care to sacrum after changing gloves and sanitizing. S10 LPN removed the old dressing from sacrum and changed gloves. S10 LPN removed the Mesalt that was packed in the sacral wound, cleaned the wound with normal saline soaked 4x4s, and changed gloves without sanitizing her hands. S10 LPN dried the sacral wound with 4x4s, and changed gloves again without sanitizing hands. S10 LPN placed the dressings directly on the bed sheet in their packages. With the same gloves on that had touched the cart, dressings, and bed sheet, S10 LPN opened the Mesalt package, removed the Mesalt, and pushed the Mesalt into the sacral wound with her gloved fingers. S10 LPN then put the foam and dressing over the sacral wound. In an interview on 10/15/2024 at 3:50 p.m., S2 DON reported S10 LPN became the wound care nurse a couple of weeks ago, and was trained by the previous wound care nurse. S2 DON confirmed S10 LPN should have performed hand hygiene after doffing her gloves and setting up supplies on a clean field. S2 DON stated S10 LPN should not have touched the contaminated surfaces with her gloves while performing wound care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that each Resident was treated with respect and dignity and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #223) of 2 (Resident #12 and Resident #223) Residents sampled for dignity, by failing to ensure she was free of facial hair. Total sample size was 23. Findings: Review of Resident #223's medical record revealed she was admitted to the facility on [DATE] with diagnoses which included: Alzheimer's Disease, Depression Unspecified, Mild-Protein Calorie Malnutrition, Anemia, Age-Related Physical Debility and Unspecified Atrial Fibrillation. Review of Resident 223 #'s Annual MDS with an ARD of 09/26/2023 revealed she had a BIMS score of 3 (indicating severe cognitive impairment). The MDS revealed Resident #223 required two person physical assistance with bed mobility and transfers; total dependence with toilet use, bathing and personal hygiene and one person physical assistance with dressing. Resident #223 was coded as having no behaviors. Review of Resident #223's Care Plan with a review date of 12/06/2023 revealed she required assistance with all ADL's and interventions to assist Resident with ADL's as needed. Observation and interview on 10/30/2023 at 9:40 a.m. revealed Resident #223 in bed. Resident #223 noted have long facial hair approximately 1-inch long. Resident #223 stated she would like the facial hair to be removed. Observation on 10/30/2023 at 11:05 a.m. revealed Resident #223 sitting in a wheelchair in the front lobby. Resident #223 was noted to have long facial hair approximately 1-inch long. Observation and interview on 10/30/2023 at 11:17 a.m. with S2 DON in attendance revealed Resident #223 sitting in a wheelchair in the front lobby with long facial hair approximately 1-inch long. S2 DON confirmed Resident #223 had long facial hair and she should not. Interview on 11/30/2023 at 11:36 a.m. with S9 CNA revealed she had provided morning care for Resident #223 which included perineal care, lotion and clean clothes. S9 CNA stated she had not attempted to remove the facial hair from Resident #223 and she should have.

Based on interview and record review the facility failed to ensure a resident's right to be free from unsolicited sexual abuse (touching) for 1 (Resident #60) of 1 sampled residents. The facility failed to protect Resident #60 from sexual abuse by Resident #48 on 07/01/2023. Total sample size was 23. Findings: The review of the facility's policy titled Abuse Prevention and Investigation read in part . Sexual Abuse is non-consensual sexual contact of any type with a resident. Resident #60 Review of Resident #60's clinical record revealed an admit date of 03/31/2023 with diagnoses which included: Major Depressive Disorder, Unspecified Dementia, and Vascular Dementia. Review of Resident #60's Quarterly MDS with an ARD of 08/14/2023 revealed a BIMS score of 3 (indicating severe cognitive impairment). Review of Resident #60's Care Plan with a review date of 11/14/2023 revealed a problem of Altered Cognition related to diagnosis of Dementia, Depression and Suicidal Ideations with interventions that included: Ask simple questions with visual cues if possible and to assist with decision making as needed or enlist family to do so. Resident #48 Review of Resident #48's clinical record revealed an admit date of 05/06/2021 with diagnoses which included: Dementia Unspecified, Mild Cognitive Impairment of uncertain or unknown etiology, Cognitive Communication Deficit, and Mood Disorder due to known physiological condition unspecified. Review of Resident #48's Annual MDS with an ARD of 09/13/2023 revealed a BIMS score of 4 (indicating severe cognitive impairment). Review of Resident #48's Care Plan with a target date of 12/13/2023 revealed a problem of Disturbed thought process related to short-term memory/long-term memory deficits; impaired decision making skills secondary to diagnosis of Dementia, Cerebral Infarction, Depression, Anxiety, and Schizoaffective Disorder with interventions which included: Counseling as needed for noncompliance or inappropriate behavior; to redirect to not touch others, staff to do every 30 minute checks on Resident #48 (implemented after incident on 07/01/2023). Interview on 10/30/2023 at 2:48 p.m. with S1 ADM revealed on 07/01/2023 Resident #60's groin area was touched while in the front lobby of the facility by Resident #48. S1 ADM revealed this incident of Resident to Resident Sexual Abuse was witnessed by S10 CNA. S1 ADM confirmed Resident #60 was not cognitively intact to consent to being touched by Resident #48. Interview on 10/31/2023 at 10:05 a.m. with Resident #60 revealed no one at the facility had ever done anything inappropriate to him. Resident #60 stated no staff or Resident had ever made him feel uncomfortable or touched him anywhere he didn't want to be touched. Resident #60 stated he felt safe at the facility. Telephone interview on 10/31/2023 at 10:18 a.m. with S10 CNA revealed she was walking through the front lobby going to the dining room to get supper trays on 07/01/2023 when she witnessed Resident #48 touching Resident #60 in his groin area. S10 CNA stated she instructed Resident #48 to remove her hand from Resident #60's groin area and Resident #48 slid her hand to Resident #60's thigh area. S10 CNA stated she separated the two residents and notified S11 LPN of the incident. Interview on 10/31/2023 at 10:41 a.m. with S2 DON revealed she received a telephone call on 07/01/2023 around supper time from S11 LPN stating Resident #48 had touched Resident #60 in the groin area. S2 DON stated she instructed S11 LPN to separate Resident #48 and Resident #60; put Resident #48 on 1:1 supervision; and notify the doctor. S2 DON stated she then notified S1 ADM of Resident #48 touching Resident #60 in the groin area. Interview on 10/31/2023 at 10:51 a.m. with S9 CNA stated she was at the nurse's station the evening of 07/01/2023. S9 CNA stated Resident #48 and Resident #60 were both sitting on the couch, in the front lobby. S9 CNA stated S10 CNA came to the nurse's station and reported to S11 LPN she had witnessed Resident #48 touching Resident #60 in the groin area. S9 CNA stated she observed Resident #48's hand on Resident #60's thigh when S10 reported the incident to S11 LPN. Telephone interview on 10/31/2023 at 11:01 a.m. with S11 LPN stated she was the evening shift nurse for Resident #48 and Resident #60 on 07/01/2023. S11 LPN stated she was at the nurse's station when S10 CNA reported to her that Resident #48 had just touched Resident #60 in his groin area. S11 LPN stated Resident #48 and Resident #60 were both sitting on the couch, in the front lobby. S11 LPN stated she had been monitoring all residents in the front lobby. S11 LPN stated when the incident was reported to her Resident #48 and Resident #60 were separated and Resident #48 was put on every 30 minute checks. S11 LPN stated she called S2 DON and was instructed to separate Resident #48 and Resident #60; put Resident #48 on 1:1 supervision; and notify the doctor. S11 LPN stated she received orders to send Resident #48 to the behavioral hospital and Resident #48 left later that night. Interview on 11/01/2023 at 9:16 a.m. with Resident #48 revealed she had no recollection of the incident which occurred on 07/01/2023 involving Resident #60. Resident #48 stated she knew Resident #60, but did not know if he resided at the facility.

Based on interview and record review the facility failed to ensure an allegation of resident to resident sexual abuse was reported to the State Survey Agency immediately but not later than 2 hours after the resident to resident sexual abuse was discovered for 1 (#60) of 1 residents reviewed for abuse in a total of 23 sampled residents. Interview on 10/30/2023 at 2:48 p.m. with S1 ADM revealed on 07/01/2023 at 6:00 p.m. Resident #60's groin area was touched by Resident #48. S1 ADM revealed this incident of resident to resident non- consensual sexual contact was witnessed by S10 CNA. S1 ADM confirmed Resident #60 was not cognitively intact to consent to being touched by Resident #48. Review of the SIMS (Statewide Incident Management System) report dated 07/11/2023 revealed the allegation of sexual abuse for Resident #60 had been substantiated by the facility. Documentation on the SIMS report reflected the discovery date and time of sexual abuse for Resident #60 was on 07/01/2023 at 6:03 p.m. The SIMS entry time was noted as 07/02/2023 at 2:31 p.m. Interview on 10/31/2023 at 2:48 p.m. with S1 ADM confirmed the allegation of resident to resident sexual abuse was substantiated by the facility. S1 ADM confirmed a SIMS report was not entered immediately or within 2 hours after discovery of abuse because there was no serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that a resident's person-centered plan of care for use of a magnifying glass was followed for 1 (Resident #52) resident. Total sample size was 23. Findings: Review of Resident #52's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included: Legal Blindness Review of Resident #52's Annual MDS with an ARD of 07/26/2023 revealed resident had a BIMS score of 12 (which indicated moderately impaired cognition), and exhibited no behaviors or rejection of care. The MDS revealed Resident #52's vision was coded as being moderately impaired-limited vision, not able to see newspaper headlines but can identify objects. Review of Resident #52's Care Plan with a Review date of 01/11/2024 read in part .resident had impaired vision: Legally blind in right eye, left eye vision adequate, does not wear glasses with interventions that included provide large print materials and a magnifying reading glass to read smaller print. Observation and interview on 10/30/2023 at 10:29 a.m. of Resident #52 revealed she was unable to see out of her right eye but could see out of her left eye. Resident #52 revealed she could not see the clock on the wall which was positioned over her bathroom door approximately 12 feet from her bed. Resident #52's activity calendar was noted to be taped to the bathroom door and was in small print. When given the activity calendar Resident #52 was unable to read the small print. No magnifying glass noted in Resident #52's room at this time. Observation and interview on 10/31/2023 at 1:00 p.m. with S6 SSD revealed she was unsure if Resident #52 had a magnifying glass in her room. S6 SSD was unable to locate a magnifying glass in Resident #52's room. Resident #52 stated it had been a while since she had a magnifying glass but would have liked one, because she had a lot of books to read. S6 SSD confirmed Resident #52 did not have a magnifying glass in her room and she should have. S6 SSD confirmed Resident #52's activity calendar was not in large print and it should have been. Interview on 10/31/2023 at 1:15 p.m. with S7 Activity Director stated she was not aware that Resident #52 should have had a large printed activity calendar. S7 Activity Director stated she did not attend Care Plan meetings. Interview on 10/31/2023 at 1:20 p.m. with S8 RN MDS revealed she was unsure if Resident #52 had a magnifying glass. S8 RN MDS confirmed the Care Plan read to provide Resident #52 with a magnifying glass and large print materials.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out ADLs (Activities of Daily Living) received the necessary services to maintain good grooming and personal hygiene. The facility failed to provide nail care for 3 (Resident #2, Resident #18 and Resident #52) of 6 (Resident #2, Resident #11, Resident #18, Resident #26, Resident #35 and Resident #52) residents reviewed for ADL care. Findings: Review of the Facility's Nail Care read in part . Policy: The Purpose of this policy is to provide guidelines for the provision of care to a resident's nails for good grooming and health. 1. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 2. Routine nail care, to include trimming and filing, will be provided by nurse on a regular schedule per care plan unless contraindicated. Nail Care will be provided between scheduled occasions as the need arises. #2 Review of Resident #2's Care plan with a review date of 12/20/2023 revealed in part Self-care deficit related to generalized ? requires supervision and assistance with ADL's. Fingernails to be checked and cleaned daily. An observation and interview on 10/30/2023 at 10:16 a.m. revealed Resident #2 with long fingernails with a brown substance noted under fingernails. Resident #2 stated staff typically cut his nails but had not cut them lately. An interview on 10/30/2023 at 10:34 a.m. with S4 LPN confirmed Resident #2's nails are long with a brown substance noted under fingernails and should have been cleaned and cut but had not been. #18 Review of Resident #18's Care plan with a review dated of 11/9/2023 revealed in part . Resident requires assistance with ADL's. Assist with ADL's as needed. An observation on 10/30/2023 at 10:21 a.m. revealed Resident #18 nails were long and jagged. Resident # 18 stated she would like her nails clipped but was unsure who to ask. An interview on 10/30/2023 at 10:32 a.m. with S4 LPN confirmed Resident #18's finger nails were long and jagged needing to be cut and had not been. #52 Review of Resident #52's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included: Phantom Limb Syndrome with Pain, Other Reduced Mobility, Major Depressive Order, Legal Blindness and Acquired Absence of Left Leg below the Knee. Review of Resident #52's Yearly MDS with an ARD of 07/26/2023 revealed resident had a BIMS score of 12 (which indicated moderately impaired cognition), and exhibited no behaviors or rejection of care. The MDS revealed Resident #52 was coded as requiring extensive assistance with personal hygiene. Review of Resident #52's Care Plan with a Review date of 01/11/2024 revealed resident required extensive to total assistance with all ADL's with interventions that included to assist with ADL's as needed. Observation on 10/20/2023 at 10:05 a.m. revealed Resident #52 in bed. Resident noted to have long fingernails approximately 1-inch long with a black substance under them. Resident #52 stated the nurse was supposed to have trimmed her fingernails a couple of weeks ago, but didn't. Resident #52 stated she would have liked her nails trimmed. Observation and interview on 10/20/2023 at 11:20 a.m. revealed Resident #52 had been bathed, but her fingernails were still approximately 1-inch long with a black substance under them. Observation and interview on 10/30/2023 at 11:29 a.m. with S5 LPN confirmed Resident #52's fingernails were long with a black substance under them and it should not have been. S5 LPN stated the treatment nurse or hall nurse was responsible for trimming Resident #52's fingernails.

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 70 Residents who receive meals prepared by the Facility kitchen. Findings: Review of the facility's approved Menu Matrix revealed: Lunch: Fried Chicken 4oz. Instructions read in part Serve 4oz breaded portion=3oz meat 1 Breast or 1 Thigh + 1 Drumstick An observation on 10/30/2023 at 12:00 p.m. in the dining room during lunch revealed dietary staff preparing resident plates in the kitchen area. The meal included fried chicken. An observation of a resident plate revealed 1 drum stick as the only meat serving on the plate. The plate was covered and placed on the meal cart for facility residents dining in their room. An interview on 10/30/2023 at 12:05 p.m. with S3 Dietary Manager revealed there was no scale in the facility to weigh serving sizes and that staff usually just eye ball the food items that was being served to the residents. S3 Dietary Manager stated if staff do not feel like the meat serving size is big enough, dietary staff will serve 2 pieces of meat. S3 Dietary Manager confirmed there was not enough meat being served on the tray and 2 pieces of meat should have been given but it had not been. An interview on 10/30/2023 at 12:10 p.m. with S1 Administrator stated the piece of chicken served did not appear to be 4 ounces. S1 Administrator confirmed the correct serving size of 4 ounces of fried chicken was not served and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 (#1) of 5 (#1, #2, #3, #4, and #5) sampled residents. Findings: Review of the facility's Safe Resident Handling/Transfers policy revealed in part .The interdisciplinary team or designee will evaluate and assess each resident's individual mobility needs, taking into account other factors as well, such as weight and cognitive status. The resident's mobility needs will be addressed on admission and reviewed quarterly . Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included Dementia with Behavioral Disturbance, Parkinson's disease, Mild Cognitive Impairment and Difficulty in Walking. Review of Resident #1's Quarterly MDS with an ARD date of 02/27/2023 revealed a BIMS score of 13, indicating intact cognition. Resident #1 required extensive assistance with 2+ person physical assistance with bed mobility, transfers and toilet use. Review of Resident #1's Care Plan with a target date of 05/27/2023 revealed in part: At risk for falls with injury related to history of falls .2 person assist with transfers. Goal: Resident will remain safe in environment with least restrictive means. Interview on 05/09/2023 at 1:25 p.m. with S2 CNA revealed she transferred Resident #1 from the bed to the shower chair without assistance on 04/29/2023. S2 CNA stated she noticed a skin tear on Resident #1's leg immediately after the transfer. S2 CNA stated she was aware Resident #1 required two people for transfers. Interview on 05/09/2023 at 2:20 p.m. with S1 DON revealed Resident #1's MDS and care plan stated Resident #1 required two people for transfers. S1 DON confirmed S2 CNA transferred Resident #1 to the shower chair without assistance, but should not have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents were free of significant medication errors for 1 (#1) of 5 (#1, #2, #3, #4, and #5) sampled residents. Findings: Review of Resident #1's medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses that included Dementia with Behavioral Disturbance, Parkinson's disease, Mild Cognitive Impairment and Difficulty in Walking. Review of Resident #1's Quarterly MDS with an ARD date of 02/27/2023 revealed a BIMS score of 13, indicating intact cognition. Resident #1 required extensive assistance with 2+ person physical assistance with bed mobility, transfers and toilet use. Review of Resident #1's Physician orders dated 05/02/2023 revealed an order for Levaquin 750 mg IVPB q 24 hours x 7 days. Review of Resident #1's Nurses Notes and Medication Administration Record revealed the Levaquin was administered IVPB on 05/03/2023 at 10:20 a.m. by S1 DON. Interview on 05/09/2023 at 11:11 a.m. with S3 NP revealed Resident #1 was transferred to a local hospital on [DATE]. S3 NP stated Resident #1 had an increased temperature on arrival to the hospital and a chest X-ray revealed early infiltrates. S3 NP stated the hospital initiated IV antibiotics and it was decided that Resident #1 would return to the facility and continue the course of IV antibiotics. Interview on 05/09/2023 at 12:56 p.m. with S1 DON revealed Resident #1 returned to the facility in the evening on 05/01/2023 from the hospital after starting IV antibiotics and was to continue IV antibiotics at the facility. S1 DON stated the Levaquin ordered should have been administered at 9:00 p.m. on 05/02/2023 in order to continue the timed IV antibiotic therapy started in the hospital. S1 DON stated the evening nurse did not administer the Levaquin at 9:00 p.m. on 05/02/2023 and stated the reason was because she could not find an IV pole. Interview on 05/09/2023 at 12:58 p.m. with S1 DON confirmed the evening nurse did not administer the Levaquin at 9:00 p.m. on 05/02/2023, but should have. S1 DON stated that was a medication error.

Based on record review and interview the facility failed to complete a significant change MDS within 14 days after determining there was a significant change in 1 (#48) of 25 sampled resident's physical conditions after a fall with major injury Findings: Review of Resident #48's clinical record revealed an admit date of 06/02/2022 with diagnoses that included: Type II Diabetes Mellitus, History of falling, Osteoarthritis and Depression. Review of an MDS Assessment with an ARD of 08/22/2022 revealed Resident #48 required limited assistance for transfers, walking in room, hygiene and toileting. Further review revealed Resident #48 required supervision for locomotion on and off the unit, physical help in part of bathing activity and no upper or lower extremity functional limitations in ROM. Review of a Significant Change MDS Assessment with an ARD of date of 08/31/2022 revealed Resident #48 required extensive assistance for toileting, and hygiene. Further review revealed Resident #48 was total dependence for bathing and had lower extremity ROM impairment on one side. Continued review of the assessment revealed only sections C and D were complete. Interview on 09/20/2022 at 4:43 p.m. with S4 LPN/MDS Nurse revealed the resident's Significant Change MDS Assessment with ARD of 08/31/2022 had not been completed within 14 days of significant changes in resident's status and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to transmit a MDS (Minimum Data Set) Assessment within 14 days of completion for 1 (#2) of 1 sampled Resident with MDS record over 120 days old. Findings: Review of the clinical record for Resident #2 revealed the Resident was admitted to the facility on [DATE] with diagnoses that included Congestive Heart Failure, Depression, and Obesity. Review of Resident #2's Yearly MDS Assessment with ARD of 07/20/2022 revealed the assessment had been completed but not transmitted. Review of the facility's MDS transmission reports revealed Resident #2's Yearly Assessment with ARD of 07/20/2022 had been transmitted on 09/20/2022. Interview on 09/20/2022 at 2:15 p.m. with S4 LPN/MDS Nurse revealed she noticed the assessment had not been transmitted after this surveyor asked for transmission reports for the resident. She confirmed the Yearly MDS assessment had not been transmitted timely and should have been.

Based on observation, interview and record review the facility failed to ensure services were provided according to the resident's plan of care for 2 (#48 and #230) of 25 sampled residents. The facility failed to ensure a bed exit alarm was applied to Resident #48's bed and failed to ensure an air mattress was applied to Resident #230's bed. Findings: #48 Review of Resident #48's clinical record revealed an admit date of 06/02/2022 with diagnoses that included: Type II Diabetes Mellitus, History of falling, Osteoarthritis and Depression. Interview on 09/19/2022 at 11:44 a.m. with Resident #48 revealed she had fallen in her bathroom a few weeks ago and broke her leg. Observation at the time of interview revealed the resident seated in a wheelchair at her bedside with an immobilizer on her right leg. Further observation revealed no presence of fall mats or bed/chair alarms in use. Review of Resident #48's CPOC with target date of 11/06/2022 revealed in part Falls: At risk for falls, falls will not occur. 08/27/2022 Add pressure pad alarm to bed related to recent fall. Interview on 09/20/2022 at 10:53 a.m. with S3 LPN/admission Nurse revealed she was told by S2 DON to apply a bed exit alarm to the resident's bed earlier this morning. She confirmed resident #48 did not have a bed exit alarm in place prior to her applying the alarm and she should have. #230 Review of Resident #230's clinical record revealed an admit date of 08/30/2022 with diagnoses that included: Type II Diabetes Mellitus, Pain, and Pressure Ulcers. Observation on 09/19/2022 at 12:44 p.m. revealed Resident #230 in bed positioned on his back with his spouse seated at the bedside. A turn schedule was observed posted above the head of bed. No pressure relieving devices were observed in use. Interview with Resident #230's spouse at the time of observation revealed Resident #230 was supposed to have an air mattress to help his bed sores heal but he did not. Review of Resident #230's CPOC with target date of 11/30/2022 revealed in part . Pressure ulcer: Admit with unstageable (Slough and/or Eschar), Stage 2 Pressure Ulcer Left hip, Left heel blanchable redness, Right ankle blanchable redness, penile meatus erosion from foley catheter. Intervention: Provide pressure reducing Air Mattress to Bed. (start date 08/30/2022) Observation on 09/20/2022 at 11:15 a.m. of the resident's bed/mattress accompanied by S2 DON revealed the resident did not have an air mattress on his bed. S2 DON confirmed Resident #230 was care planned for and should have an air mattress on his bed and did not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure that a resident, who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 of 1 Residents reviewed for Activities of Daily Living (#7) in a total Stage 2 sample of 25. Findings: Review of Resident #7's medical record revealed he was admitted to the facility on [DATE]. Diagnoses included Hypertensive Heart Disease, Gastroparesis, Candidiasis, Hypomagnesium, Major Depression, Anorexia, Acute Cough, Type 2 Diabetes, Dysphagia, Cognitive Communication Deficit, Muscle wasting. Review of Resident #7's Quarterly MDS with an ARD of 06/08/2022 revealed a BIMS of 02 (indicating the resident was not cognitive). The MDS revealed Resident #7 exhibited he did not reject care during the assessment period. The MDS revealed Resident #7 required extensive assistance of 1 person for personal hygiene, and extensive assistance of 2 persons for bed mobility and extensive assistance 1 person for dressing. The MDS revealed Resident #7 had no ROM impairments for upper and lower extremities. Review of Hygiene Roster for 09/16/2022 revealed Resident received a complete bed bath. Further review of the Hygiene Roster revealed Resident #7 was not shaved. Review of Care Plan revealed Noncompliance r/t refusal to allow staff to assist with ADL's, use call light for transfers, refusal of meals, medications, refuses nail care at times, and refuses mask at times. Approaches revealed counseling as needed for noncompliance or inappropriate behavior. Further review revealed to notify MD/RP with any complications. Observation of resident #7 on 09/19/2022 at 11:39 a.m. revealed the resident was lying in the bed. The resident's face was not shaved with facial hair ¼ inch long. Interview on 09/19/2022 at 11:50 with wife revealed her husband needed to be shaved. She stated Resident #7 was not shaved on his bath day (09/16/2022). Interview on 09/20/2022 at 9:30 a.m. with S8 CNA revealed the facility used agency CNAs for the last month. S8 CNA revealed Resident #7's bath days were on Monday, Wednesday and Friday on the evening shift. S8 CNA revealed Resident #7 has never refused to be shaved; however, he would refuse to have a female CNA clean his private area. Interview on 09/20/2022 at 10:00 a.m. with Resident #7's wife revealed he has never refused to be shaved. She stated he enjoyed being shaved. Interview on 09/20/2022 at 10:30 a.m. with S9 LPN/MDS Nurse revealed Resident #7 was Care Plan for refusal of ADL Care; however, the refusal of ADL Care as related to peri-care by a female CNA. S9 LPN/MDS Nurse revealed Resident #7 was not identified as refusing to be shaved. Interview on 09/20/2022 at 11:39 a.m. with S10 Agency CNA revealed Resident #7 was bathe (bed bath) on Monday, Wednesday, and Friday. S10 Agency CNA stated that Resident #7 was to be shaved on his bath days. Interview on 09/20/2022 at 11:50 a.m. with S11 CNA revealed that she bathe Resident #7 on 09/16/2022 and he refused to be shaved. S11 CNA stated that she reported to S2 DON and S12 ADON that Resident #7 had refused to be shaved on 09/16/2022. Interview on 09/20/2022 at 11:58 a.m. with S2 DON revealed she was unable to recall if she had ever been informed by any Nurse/CNA of Resident #7 refusing to be shaved Interview on 09/20/2022 at 12:00 p.m. with S12 ADON revealed she was unable to recall if she had ever been informed by Nurse/CNA of Resident #7 refusing to be shaved. S12 ADON stated that whenever a resident refuses care, it's the Nurse's responsibility to document the refusal in the resident's medical record. S12 ADON confirmed that there was no documented evidence in Resident #7's medical record of the resident ever refusing to be shaved. S12 ADON further confirmed that Resident #7 should have been shaved during ADL care and wasn't.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure 1 (#230) of 1 sampled resident reviewed for pressure ulcers, received the treatments necessary to promote wound healing. Findings: Review of Resident #230's clinical record revealed an admit date of 08/30/2022 with diagnoses that included: Type II Diabetes Mellitus, Pain, and Pressure Ulcers. Observation on 09/19/22 at 12:44 p.m. revealed Resident #230 in bed positioned on his back with his spouse seated at the bedside. A turn schedule was observed posted above the head of bed. No pressure relieving devices were observed in use. Interview with the resident's spouse at the time of observation revealed Resident #230 was supposed to have an air mattress to help his bed sores heal but he did not. Review of Resident #230's CPOC with target date of 11/30/2022 revealed in part . Pressure ulcer: Admit with unstageable (Slough and/or Eschar), Stage 2 Pressure Ulcer Left hip, Left heel blanchable redness, Right ankle blanchable redness, penile meatus erosion from foley catheter. Intervention: Provide pressure reducing Air Mattress to Bed. (start date 08/30/2022) Review of Resident #230's Physician's Orders for September 2022 revealed in part : 08/30/2022 Pressure reducing air mattress to bed. Review of a Wound assessment dated [DATE] revealed Resident #230 had a Stage II pressure ulcer to the Left hip measuring 2.00 cm x 0.50 cm x 0.10 cm and an unstageable wound to his Sacrum measuring 5.50 cm x 3.00 cm x 0.20 cm that were present on admission. Observation on 09/20/2022 at 11:13 a.m. of Resident #230's room and bed accompanied by S6 LPN revealed the mattress on the resident's bed was not an air mattress. S6 LPN stated air mattresses' had pumps attached to them and Resident #230's mattress did not. Observation on 09/20/2022 at 11:15 a.m. of the Resident #230's bed/mattress accompanied by S2 DON revealed the resident did not have an air mattress on his bed. S2 DON confirmed Resident #230 should have an air mattress on his bed and did not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident received adequate supervision and assistive devices to prevent accidents for 1 (#48) of 1 sampled residents for incidents and accidents. The facility failed to ensure Resident #48 had a bed alarm applied to prevent falls after sustaining a fall with major injury. Findings: Review of Resident #48's clinical record revealed an admit date of 06/02/2022 with diagnoses that included: Type II Diabetes Mellitus, History of falling, Osteoarthritis and Depression. Interview on 09/19/2022 at 11:44 a.m. with Resident #48 revealed she had fallen in her bathroom a few weeks ago and broke her leg. Observation at the time of interview revealed the resident seated in a wheelchair at her bedside with an immobilizer on her right leg. Further observation revealed no presence of fall mats or bed/chair alarms in use. Review of the clinical record revealed Resident #48 was hospitalized from [DATE] through 08/27/2022 after falling in her bathroom and sustaining a right femur fracture that required an open reduction with internal fixation surgery. Review of Resident #48's CPOC with target date of 11/06/2022 revealed in part Falls: At risk for falls, falls will not occur. 08/27/2022 Add pressure pad alarm to bed related to recent fall. Observation on 09/20/2022 at 8:00 a.m. revealed Resident #48 asleep in bed. Resident #48's call light was within reach and no bed alarm devices observed in use. Observation on 09/20/2022 at 10:35 a.m. revealed Resident #48 asleep in bed. A bed exit alarm was observed in place on the resident's bed. Interview on 09/20/2022 at 10:40 a.m. with S7 CNA revealed he was assigned to Resident #48. He confirmed the resident did not have a bed alarm earlier this morning and he was unsure who had put the alarm on the resident's bed. Interview on 09/20/2022 at 10:42 a.m. with S6 LPN revealed she was the nurse assigned to Resident #48 and was not aware the resident had a bed alarm. She stated she had not applied a bed alarm to the resident's bed this morning and was not sure who had. Review of facility camera footage from the resident's hall accompanied by S1 Administrator revealed S3 LPN/admission Nurse entered Resident #48's room at 9:56 a.m. on 09/20/2022 with a bed exit alarm and then exited moments later without it. Interview on 09/20/2022 at 10:53 a.m. with S3 LPN/admission Nurse revealed she was told by the S2 DON to apply a bed exit alarm to Resident #48's bed earlier that morning. She confirmed Resident #48 did not have a bed exit alarm in place prior to her applying the alarm and she should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to: 1) store dishes and utensils under sanitary conditions and 2) ensure food stored was dated and expired food was disposed of. 3) preparation equipment was clean. This deficient practice had the potential to affect the 83 Residents that received meals prepared in the kitchen. Findings: Review of the Facility's Policy titled Cleaning Equipment/Wiping Clothes read in part: Policy: A detailed procedure for cleaning each piece of equipment should be maintained in the Dietary Department and reviewed periodically with the staff. 2. All parts should be cleaned and sanitized like kitchen utensils. 5. Allow to air dry. Review of the Facility's Policy titled Storage: Refrigerator read in part: 7. Keep refrigerated food wrapped or covered and in sanitary containers. Review of the Facility's Policy titled Storage: Freezer read in part: 3. Label and date all items. Review of the Facility's Policy titled Ice Pass, Water Pitchers, & Ice Machines read in part: 7. Scoop must be placed in clean plastic bag or clean holder when not in use. 9. Ice machines must be emptied and cleaned according to the manufacturer's instructions at least monthly. Observation of the kitchen on 09/19/2022 at 10:35 a.m. accompanied by S5 RN revealed the following: 1. Two 32 qt. clean pots on a storage cart were stacked on top of one another and were wet. 2. A storage cart with 20 clean steam line pans stacked inside one another on a storage cart with 11 of the pans noted to have dried food items and/or greasy film in the bottom and around the rim. 3. Ten 4.0 qt. food warmer pans, (2) 6.0 qt. food warmer pans, and (2) 9.3 qt. food warmer pans were stored on a 3 tier stationary cart stacked inside one another were noted to have been stored wet. 4. Bottles of imitation flavors were opened, undated, expired were stored on a shelf for use: (1) 10 oz. bottle of imitation rum flavor-expired on 09/06/2021. (1) 10 oz. bottle of almond flavor- expired on 01/23/2020. (1) 10 oz. bottle of banana flavor- expired on 03/30/2020. 5. The following food items were stored in refrigerator opened and undated: (1) gal. jar of Acteo Balsamico DI [NAME]. (1) qt. jar of gray master. (1) 10 oz. bottle maraschino cherries. (1) 9 qt. container of dill pickles. (1) gal. jar of soy sauce. (1) 5 lbs. plastic bucket of pimento cheese spread. (1) gal jar of honey mustard. 6. Deep fryer and stove were noted to have layers of thick brownish gel-like substance caked on the back panel and on the floor surrounding the areas of the legs of both. 7. Ice scoop was stored opened on top of the ice machine on a plastic serving tray. 8. Ice machine inner door panel, grooves and gasket with thick dark black substance. Interview on 09/19/2022 at the time of the observations accompanied by S5 RN, confirmed the above findings.