**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews the facility failed to immediately inform the responsible party of tests results for 1 (#1) of 3 (#1, #2, and #3) residents reviewed for notification of change. The facility failed to ensure that resident #1's responsible party was notified of the resident's x-ray results, in a timely manner. Findings: Review of the medical record revealed resident #1 was re-admitted to the facility on [DATE] with diagnoses that included in part, Alzheimer's disease, psychotic disturbance, mood disturbance, anxiety and a personal history of other diseases of the musculoskeletal system and connective tissue. Review of the annual Minimum Data Set, dated [DATE] revealed resident #1 had a Brief Interview for Mental Status score of 11 which indicated the resident had moderate cognitive impairment with daily decision making skills. Further review revealed resident #1 required assistance with activities of daily living. On 03/31/2025 at 12:15 p.m., an observation revealed resident #1 lying in bed, resting with her right arm exposed. An observation of resident #1's right forearm revealed an area approximately the size the palm of the hand with a faint pinkish color to center of the area. Review of the nursing progress notes dated 03/07/2025 at 10:33 a.m. revealed resident #1 was seen per Nurse Practitioner (NP) with new orders for an x-ray of resident #1's right shoulder/arm. Review of patient report dated 03/07/2025 revealed resident #1 had an x-ray of the right shoulder with 2+ views. The report was electronically signed on 03/07/2025 at 1:23 p.m. by the interpreting physician. Further review revealed S3Licensed Practical Nurse (LPN) had signed and dated the report on 03/07/2025. Review of the medical record revealed there was no documented evidence of resident #1's responsible party being notified of the x-ray report results. On 04/02/2025 at 4:45 p.m., S2Director of Nursing (DON) confirmed resident #1's responsible party had not been notified of the x-ray results in a timely manner. On 04/02/2025 at 5:00 p.m., S1Administrator was notified of the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure each resident received services within a reasonable accommodations of their needs for 1 (#144) of 1 (#144) residents reviewed for accommodation of needs. The facility failed to ensure resident #144 was supplied with a call light that he could activate. Findings: Review of the medical record for resident #144 revealed he was admitted on [DATE] and had a diagnosis of wedge compression fracture of the T11-T12 vertebra. On 02/24/2025 at 12:50 p.m., interview with resident #144 revealed he was unable to activate his call light. Resident #144 demonstrated that he was unable to move his left arm and he was unable to move his right fingers to push the call light button. On 02/25/2025 at 12:45 p.m., S2Director of Nursing (DON) and the surveyor entered the room of resident #144. The resident demonstrated that he was unable to activate the call light due to physical disabilities. S2DON confirmed the resident was unable to activate the call light.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the provider failed to ensure an incident involving an elopement was reported to the State Survey Agency for 1 (#294) of 1 sampled resident reviewed for elopement. Findings: Review of the facility's policy and procedure for resident elopement (no date) revealed in part the following: Purpose: to ensure that all residents are afforded adequate supervision to provide the safest environment possible. Policy: all residents will be assessed for behaviors or conditions that put them at risk for elopement and all residents so identified will have these issues addressed in their individual care plans. Definition: For the purpose of this policy, missing resident shall be defined to mean a resident who has left the facility grounds without signing him/herself out of the facility. Further review of the policy for resident elopement revealed to call or fax a report within 24 hours of the incident and prepare a complete report at the completion of the incident. Contact all the people/agencies previously notified that resident has been found. Review of the record for resident #294 revealed an admission date of 11/07/2024 with the following diagnoses: unspecified dementia with other behavioral disturbance and wandering. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed resident #294 had a brief interview for mental status of 3 which indicated that resident #294 had severe cognitive impairment with daily decision making. The assessment also indicated the resident was independent with transfers and did not require mobility devices. Review of elopement risk assessment completed on 11/07/2024 revealed resident was assessed as high risk for elopement with a score of 13. Review of an incident report 11/08/2024 at 1:08 p.m. revealed the following: S7Licensed Practical Nurse (LPN) notified this nurse (S10LPN) that resident #294 was out of facility unattended. Resident #294 was observed walking up Hall A when a sitter leaving out of emergency exit door, let resident #294 out believing that she was a visitor. S7LPN went out of the facility to get resident #294 whom was walking up a side road next to building. S7LPN requested assistance from a neighbor. S7LPN and neighbor transferred resident #294 back to facility in personal vehicle. Resident #294 then assisted to her room. Vitals 138/70; pulse 78, respirations 20, temperature 98 and oxygen saturation was 97% room air and resident #294 denies pain. No skin issues noted. Resident #294 stated that she was headed to her mom's room. Physician aware, no new orders. Daughter notified. Immediate Action taken: resident #294 assisted back to facility; vitals, no skin issues, resident #294 not taken to hospital. No injuries observed at time of incident. Interview with S7LPN on 02/26/2025 at 9:15 a.m. revealed that on 11/08/2024 at approximately 1:00 p.m., S7LPN was working at her desk on Hall A when a sitter for another resident came to her door and stated she (sitter) let someone out of the building at the end of the hall while she was smoking. The sitter stated to S7LPN she thought she was a family member. S7LPN stated she immediately ran down to the door and saw resident #294 walking in the field off Hall A approximately 25 yards from the building. S7LPN stated she realized that she did not have her phone so she notified the sitter to go get staff. S7LPN then ran toward resident #294 and caught up with resident at the side road next to the facility. Further interview revealed that another staff member was driving up to the facility and saw S7LPN and resident #294. S7LPN and resident #294 got into her the car and returned to the front of the facility without incident. Resident #294 was pleasant, no agitation, but was confused. S7LPN stated she was able to return resident #294 into facility without incident. S7LPN stated resident #294 had a wander guard already on and the only way she got out was because the sitter opened the door for her when she (sitter) was smoking. S7LPN confirmed the facility's staff was not aware resident #294 exited the building until notified by sitter. S7LPN confirmed that she never lost visual sight of the resident. Further interview with S7LPN revealed the whole incident, including resident #294 being returned to her room, was less than 10 minutes. Observation at this time with S7LPN revealed the door at end of Hall A was locked. S7LPN opened the door and proceeded to demonstrate the incident. The place in which S7LPN first saw resident #294 was approximately 25 yards from Hall A's exit door. The side road (unpaved) was another 25 yards away and lead directly to the staff parking lot. This road was only for staff parking and there was no thru traffic. Further observation revealed there were no cars and the road was a single lane only leading into the parking lot. Interview with S1Administrator on 02/26/2025 at 10:15 a.m. confirmed that resident #294 was able to elope out of the facility without the staff aware of the incident until a sitter notified the nursing staff. Further interview with S1Administrator confirmed that he did not report resident #294's elopement in the Statewide Incident Management System (SIMS).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to ensure each resident received adequate supervision to prevent elopement for 1 (#294) of 1 sampled resident reviewed for elopement. Findings: Review of the facility's policy and procedure for resident elopement (no date) revealed in part the following: Purpose: to ensure that all residents are afforded adequate supervision to provide the safest environment possible. Policy: all residents will be assessed for behaviors or conditions that put them at risk for elopement and all residents so identified will have these issues addressed in their individual care plans. Definition: For the purpose of this policy, missing resident shall be defined to mean a resident who has left the facility grounds without signing him/herself out of the facility. Review of the record for resident #294 revealed an admission date of 11/07/2024 with the following diagnoses: unspecified dementia with other behavioral disturbance and wandering. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed resident #294 had a brief interview for mental status of 3 which indicated resident #294 had severe cognitive impairment with daily decision making. The assessment also indicated the resident was independent with transfers and did not require mobility devices. Review of elopement risk assessment completed on 11/07/2024 revealed resident was assessed as high risk for elopement with a score of 13. Review of the care plan revealed resident #294 was an elopement risk related to wandering with the following interventions: alert staff to my wandering behavior; if I wander away from unit, instruct staff to stay with me, converse and gently persuade me to walk back to designated area with them; monitor and document my behavior; notify my (medical doctor) MD and family if I attempt elopement; and place wander guard bracelet on me that sounds alarms when I leave building. Review of an incident report dated 11/08/2024 at 1:08 p.m. revealed the following: S7Licensed Practical Nurse (LPN) notified this nurse (S10LPN) that resident #294 was out of facility unattended. Resident #294 was observed walking up Hall A when a sitter leaving out of emergency exit door, let resident #294 out believing that she was a visitor. S7LPN went out of the facility to get resident #294 whom was walking up a side road next to building. S7LPN requested assistance from a neighbor. S7LPN and neighbor transferred resident #294 back to facility in personal vehicle. Resident #294 then assisted to her room. Vitals 138/70; pulse 78, respirations 20, temperature 98 and oxygen saturation was 97% room air and resident #294 denied pain. No skin issues noted. Resident #294 stated that she was headed to her mom's room. Physician aware, no new orders. Daughter notified. Immediate Action taken: resident #294 assisted back to facility; vitals, no skin issues, resident #294 not taken to hospital. No injuries observed at time of incident. Review of a statement from S7LPN dated 11/08/2024 revealed the following: I was sitting in my office on Hall A, when another resident's private sitter came to my door and stated, This lady just followed me outside the exit door on Hall A, and I don't know if she is a visitor or a patient. I immediately ran to the Hall A exit door and looked and saw it was a patient. I exited the door and started running toward the resident #294. My phone was on my desk, so I told the sitter to call the front desk and tell them I needed help. I kept my eyes on the patient the entire time. A neighbor assisted me in getting resident #294 back to the facility unharmed, without any injury or distress. Resident #294 was assisted inside stable condition. Interview with S7LPN on 02/26/2025 at 9:15 a.m. revealed that on 11/08/2024 at approximately 1:00 p.m., S7LPN was working at her desk on Hall A when a sitter for another resident came to her door and stated she (sitter) let someone out of the building at the end of the hall while she was smoking. The sitter stated to S7LPN she thought she was a family member. S7LPN stated she immediately ran down to the door and saw resident #294 walking in the field off Hall A approximately 25 yards from the building. S7LPN stated she realized that she did not have her phone so she notified the sitter to go get staff. S7LPN then ran toward resident #294 and caught up with resident at the side road next to the facility. Further interview revealed that another staff member was driving up to the facility and saw S7LPN and resident #294. S7LPN and resident #294 got into her the car and returned to the front of the facility without incident. Resident #294 was pleasant, no agitation, but was confused. S7LPN stated she was able to return resident #294 into facility without incident. S7LPN stated resident #294 had a wander guard already on and the only way she got out was because the sitter opened the door for her when she (sitter) was smoking. S7LPN confirmed the facility's staff was not aware resident #294 exited the building until notified by sitter. S7LPN confirmed that she never lost visual sight of the resident. Further interview with S7LPN revealed the whole incident, including resident #294 being returned to her room, was less than 10 minutes. Observation at this time with S7LPN revealed the door at end of Hall A was locked. S7LPN opened the door and proceeded to demonstrate the incident. The place in which S7LPN first saw resident #294 was approximately 25 yards from Hall A's exit door. The side road (unpaved) was another 25 yards away and lead directly to the staff parking lot. This road was only for staff parking and there was no thru traffic. Further observation revealed there were no cars and the road was a single lane only leading into the parking lot. Interview with S5LPN on 02/26/2025 at 9:30 a.m. revealed she did assessments and the care plan for resident #294. S5LPN confirmed resident #294 was admitted to the facility for high risk for wandering and a wander guard was placed on resident #294 on the date of admission, 11/07/2024. Interview with S2Director of Nursing (DON) on 02/26/2025 at 9:45 a.m. confirmed resident #294 was able to elope out of the facility via the Hall A exit door as result of another resident's sitter who was smoking outside the exit door and accidently let resident #294 exit the building. S2DON confirmed the nurse was immediately notified and resident #294 was quickly returned back to the facility. S2DON confirmed resident #294 was high risk for wandering and resident #294 was able to exit the facility without the staff being aware until reported by a sitter. Interview with S6Maintenace Supervisor on 02/26/2025 at 10:00 a.m. confirmed the exit door on Hall A does not have a code alert bracelet (wander guard) system to alert if a resident who was wearing a wander guard was in close proximity to the exit door. S6Maintenance Supervisor confirmed that resident #294 exited out of the facility and there was no alert due to the fact that there was no alert system on exit door of Hall A. Interview with S1Administrator on 02/26/2025 at 10:15 a.m. confirmed resident #294 was able to elope out of the facility without the staff aware of the incident until a sitter notified the nursing staff. Further interview with S1Administrator revealed that it was determined a sitter for another resident let resident #294 out of the facility by mistake as she thought resident #294 was a visitor. S1Administrator confirmed the Hall A exit door did not have a code alert bracelet system and as a result did not alert when resident #294 exited the facility through that door.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to accurately assess safety devices for effectiveness and elimination for 1 (#58) of 1 (#58) residents reviewed for restraints. Findings: Review of the facility's Safety and Supervision of Resident's policy and Procedure (undated) revealed the following, in part: 4. Implementing interventions to reduce accident risks and hazards shall include the following: e. Documenting interventions 5. Monitoring the effectiveness of interventions shall include the following: b. evaluating the effectiveness of interventions Review of medical records for resident # 58 revealed an admit date of 12/13/2021 with a diagnosis including muscle weakness (generalized), idiopathic orofacial dystonia, mood disorder due to known physiological condition, altered mental status, personal history of transient ischemic attack (TIA), and catatonic schizophrenia. Quarterly Minimal Data Set (MDS) assessment dated [DATE] revealed resident #58 had a Brief Interview for Mental Status (BIMS) score of 4 which indicates cognitive impairment for daily decision making and that the resident required two person assistance with transfers, toileting, and bed mobility. On 02/24/2025 at 08:40 a.m. resident #58 was observed lying in bed. Resident #58's mattress edges were observed to be raised approximately five inches on each side. On 02/25/2025 at 09:34 a.m. resident #58 was observed lying in bed on the mattress with raised edges. On 02/25/2025 at 03:40 p.m. interview with S2Director of Nursing (DON) and S5Licensed Practical Nurse (LPN) confirmed that the safety device assessment dated [DATE] did not include resident # 58's raised edge mattress.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure it provided an ongoing program to support the residents in their choice of activities for 1 (#26) of 1 (#26) residents reviewed for activities. The facility failed to provide adequate activities for resident #26 who had a diagnosis of blindness. Findings: On 02/24/2025 at 10:45a.m., interview with resident #26 revealed he was blind and didn't receive any activities. Review of the medical record of resident #26 revealed he had a diagnosis of blindness in the right eye category 3 and blindness in the left eye category 3 indicating a significant degree of vision loss in both eyes. Review of the quarterly activity assessment dated [DATE] revealed resident #26 was provided with the monthly activity calendar. He attended parties/socials and special events and he enjoyed 1:1 conversation while drinking coffee. On 02/25/2025 at 11:00a.m., interview with resident #26 revealed staff do not inform him of when activities are going to take place. On 02/25/2025 at 1:15p.m., interview with S3Activity Director revealed resident #26 was not individually told of upcoming activities. Resident #26 was then interviewed in the presence of S3Activity Director. Resident #26 was asked to rate, from 1 to 10, his satisfaction with the activities he was provided. He rated his satisfaction level as a 2.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to: 1) ensure residents had a physician's order for bed rails, 2) obtain informed consent from the resident or resident's representative for bed rail use, and 3) assess residents for the risk of entrapment from bed rails prior to the installation of bed rails for 4 (#23, #30, #34, and #60) of 4 (#23, #30, #34, and #60) residents reviewed for bed rails. Findings: Review of the facility's policy (undated), Restraint Devices - Physical Policy and Procedure revealed the following in part: Procedure: 1. Assess the resident's need for the safety device use. 2. Obtain informed consent for restraint device use. 3. Obtain physician's order for restraint device use. Resident #30 Review of the medical record revealed resident #30 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, hypertension, cerebrovascular disease, major depressive disorder, cerebral infarction, and osteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #30's Brief Interview for Mental Status (BIMS) score was 15 which indicated intact cognition for daily decision making. Resident #30 required extensive - total assistance with most activities of daily living. On 02/24/2025 at 8:52 a.m. and 02/25/2025 at 12:05 p.m., observations of resident #30 revealed she was in the bed with 1/2 bed rails raised on both sides of the bed and both bed rails were loose. On 02/25/2025 at 1:35 p.m., the surveyor and S6Maintenance Supervisor observed the resident's bilateral 1/2 bed rails, and both bed rails were loose. He confirmed the bed rails were loose and needed to be adjusted. Review of resident #30's record revealed no documented evidence of the following: a physician's order for bed rails, informed consent from the resident or resident's representative for bed rail use, and an assessment for the risk of entrapment prior to the installation of bed rails on resident #30's bed. On 02/26/2025 at 9:10 a.m., an interview with S2Director of Nursing (DON) confirmed they failed to obtain a physician's order for bilateral 1/2 bed rails, informed consent for bed rail use from the resident or resident's representative, and an assessment for the risk of entrapment before bed rails were installed on resident #30's bed. Resident #23 Review of the medical record revealed resident #23 was admitted to the facility on [DATE] with diagnoses including in part, bipolar disorder, Alzheimer's disease, unspecified dementia with agitation, anxiety disorder, insomnia, Spondylolisthesis, muscle weakness (generalized), and personal history of transient ischemic attack. Review of the annual MDS assessment dated [DATE] revealed resident #23's BIMS was documented as severely impaired. Resident #23 required total dependence with 2+ person's physical assist with bed mobility. On 02/25/2025 at 10:06 a.m. and 02/25/2025 at approximately 3:20 p.m., observations revealed resident #23 was lying in bed. Further observation revealed that resident #23's bilateral ½ bed rails were raised on both side of the bed. On 02/26/2025 at 9:30 a.m., an observation revealed resident #23 was lying in bed with ½ bed raised on the right side of the bed and the other ½ side lowered to the left side of the bed, however, the bed rail remained attached to the bed. Review of resident #23's record revealed no documented evidence of the following: a physician's order for bed rails, informed consent from the resident or resident's representative for bed rail use, and an assessment for the risk of entrapment prior to installation of bed rails on resident #23's bed. On 02/26/2025 at 2:35 p.m., S2Director of Nursing was notified of the above findings. She confirmed that after record reviews, resident #23's record revealed no documented evidence of the following: a physician's order for bilateral ½ bed rails, informed consent for bed rail use from the resident or representative's representative, and an assessment for the risk of entrapment prior to the installation of bed rails on the resident's bed. Resident #34 Review of the medical record revealed resident #34 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side, hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side, aphasia, cerebral palsy, lack of coordination, and difficulty in walking. Review of the quarterly MDS assessment dated [DATE] revealed resident #34's BIMS score was 04 which indicated the resident was severely impaired with his daily decision making skills. Resident #34 required total dependence with 2+ person's physical assist with bed mobility. On 02/25/2025 at 10:00 a.m., 02/25/2025 at 4:06 p.m., and 02/26/2025 at 9:04 a.m., resident #34 was observed lying in bed with ½ bed rails raised to both sides of the bed. Review of resident #34's record revealed no documented evidence of the following: a physician's order for bed rails, informed consent from the resident or resident's representative for bed rail use, and an assessment for the risk of entrapment prior to installation of bed rails on resident #34's bed. On 02/26/2025 at 2:35 p.m., S2Director of Nursing was notified of the above findings. She confirmed that after record reviews, resident #34's record revealed no documented evidence of the following: a physician's order for bilateral ½ bed rails, informed consent for bed rail use from the resident or representative's representative, and an assessment for the risk of entrapment prior to the installation of bed rails on the resident's bed. Resident #60 Review of the medical record revealed resident #60 was admitted to the facility on [DATE] with diagnoses including aphasia following cerebral infarction, hemiplegia, unspecified, affecting right dominant side. Review of the quarterly MDS assessment dated [DATE] revealed resident #60 had a BIMS score of 10 which indicated moderate cognitive impairment with daily decision making skills. On 02/25/2025 at 10:11 a.m., 02/25/2025 at 4:06 p.m., and 02/26/2025 at 3:35 p.m., observations revealed resident #60 was lying in his bed resting, in his room. Further observation revealed resident #60's 1/2 bed rails raised on both sides of the bed. Review of resident #60's record revealed no documented evidence of the following: a physician's order for bed rails, informed consent from the resident or resident's representative for bed rail use, and an assessment for the risk of entrapment prior to installation of bed rails on resident #60's bed. On 02/26/2025 at 2:35 p.m., S2Director of Nursing was notified of the above findings. She confirmed that after record reviews, resident #60's record revealed no documented evidence of the following: a physician's order for bilateral ½ bed rails, informed consent for bed rail use from the resident or representative's representative, and an assessment for the risk of entrapment prior to the installation of bed rails on the resident's bed.

Based on record reviews and interviews, the facility failed to ensure each resident's medication regimen was free from unnecessary medications by failing to monitor for bleeding for a resident who received anticoagulant medication for 1 (#15) of 1 (#15) residents reviewed for anticoagulants. Findings: Review of medical records for resident #15 revealed an admit date of 08/12/2024 with diagnosis including cerebral infarction, transient cerebral ischemic attack, atherosclerotic heart disease of native coronary artery without angina pectoris, old myocardial infarction, long term (current) use of anticoagulants, and chronic atrial fibrillation Review of the February 2025 physician orders revealed that resident #15 was ordered Eliquis (anticoagulant) 5 milligrams (mg) every 12 hours and Aspirin (anticoagulant) 81 mg daily. Review of the current care plan revealed resident #15 was at risk for bleeding due to anticoagulant therapy. Interventions included to watch orifices for signs and symptoms of bleeding and notifying the physician of any signs and symptoms of bleeding. Review of resident #15's medical record revealed no documented evidence of monitoring for bleeding. On 02/25/2025 at 1:00 p.m. interview with S2Director of Nursing (DON) confirmed that resident #15 received Eliquis and Aspirin and there was no documentation of monitoring for bleeding for resident #15. On 02/25/2025 02:25 p.m. an interview with S4Licensed Practical Nurse (LPN) confirmed that she does not document bleeding or bruising monitoring when she administers resident # 15's anticoagulants.

Based on observations and interviews, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety by, 1) storing clean pots on a shelf with old food particles, 2) having a buildup of an unknown black substance on the inside of the ice machine and a buildup of dust on the filters of the ice machine, 3) foods items being stored in the freezer that were open and exposed to air, and 4) storing flats of bottled water directly on the storage room floor. According to the Diet Type Report, there was a total of 84 residents who currently received a meal tray from the kitchen. Findings: On 02/24/2025 at 8:25 a.m., an observation of the food preparation table revealed pots and pans that had been turned upside down and stored on the bottom shelf. Further observation revealed there were old food particles scattered on the shelf and in direct contact with the pots and pans. An observation of the ice machine revealed that upon opening the top lid of the ice machine, there was a large amount of an unknown black colored substance that was scattered throughout the lid. Further observation revealed the unknown substance was also observed on an area that was located on the upper inside of the machine. S8Dietary Manager confirmed the ice machine needed to be cleaned. An observation of the outside of the ice machine revealed two large filters. Further observation revealed the filters had a buildup of dust on the slats. S8Dietary Manager confirmed the filters needed to be cleaned. An observation of the walk-in freezer revealed one large box of beef patties and one large box of Churro Bites. Further observation revealed that both boxes were open and the beef patties and Churro Bites were exposed to air. S8Dietary Manager confirmed the food items were not properly sealed. Further observation revealed a storage room that was located in the back of the kitchen. An observation of the storage room revealed two flats of bottled water that was sitting directly on the floor. S8Dietary Manager confirmed the flats should not have been stored on the floor. S8Dietary Manager presented the survey team with a Diet Type Report. Review of the report revealed there was a total of 84 residents who currently received a meal tray from the kitchen. On 02/26/2025 at 11:45 a.m., S1Administrator was notified of the above findings.

Based on observations and interviews, the facility failed to maintain a sanitary environment to help prevent the development and transmission of communicable diseases and infections by, failing to ensure employees did not store their personal belongings in the kitchen food preparation and storage room. According to the Diet Type Report, there was a total of 84 residents who currently received a meal tray from the kitchen. Findings: On 02/24/2025 at 8:25 a.m., an observation of the kitchen revealed one purse that was located on a top shelf next to a measuring cup and other food preparation items. There was a cart that had a large box of parchment paper stored on the bottom shelf. The end of the box was opened, the parchment paper was exposed and there was one large single sheet of the parchment paper lying on the outside of box. Further observation revealed a black colored jacket lying on top of and in direct contact with the exposed parchment paper. S9Dietary [NAME] was present in the kitchen during the observations. She revealed that she did not know who the jacket belonged to. S9Dietary [NAME] confirmed the purse belonged to herself. Further observation of the kitchen revealed a storage room that was located in the back of kitchen. An observation of the storage room revealed three jackets and one purse that were hanging on hooks. The jackets and purse was located next to a rolling cart that contained several cans of soups. S8Dietary Manager was present in the kitchen at the time of the observations. She confirmed that the kitchen staff were not supposed to have their personal belongings stored in the kitchen and storage room due to the possibility of cross contamination. S8Dietary Manager presented the survey team with a Diet Type Report. Review of the report revealed there was a total of 84 residents who currently received a meal tray from the kitchen. On 02/26/2025 at 11:45 a.m., S1Administrator was notified of the above findings.

Based on observations and interviews, the facility failed to maintain all mechanical equipment in safe operating condition by having a buildup of metal shavings on the can opener and a grease buildup inside of the deep fryer. According to the Diet Type Report, there were a total of 84 residents who currently received a meal tray from the kitchen. Findings: On 02/24/2025 at 8:35 a.m., an observation of the kitchen revealed the commercial can opener contained a large buildup of metal shavings underneath the blade. Further observation revealed the large gas fryer had a buildup of grease on the internal components. S8Dietary Manager was present during the observations and confirmed that the can opener and the gas fryer were not in safe operating condition. S8Dietary Manager presented the survey team with a Diet Type Report. Review of the report revealed there was a total of 84 residents who currently received a meal tray from the kitchen. On 02/26/2025 at 11:45 a.m., S1Administrator was notified of the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good personal hygiene for 1 (#1) of 5 (#1, #2, #3, #4, and #5) residents reviewed for activities of daily living by, failing to ensure resident #1's feet were kept cleaned and his face was groomed. Findings: Review of the medical record revealed resident #1 was readmitted to the facility on [DATE] with diagnoses that included in part, type 2 diabetes mellitus with diabetic retinopathy, hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, and dry eye syndrome of bilateral lacrimal glands and blindness of the right and left eye, category 3. Review of the quarterly minimum data set assessment dated [DATE] revealed resident #1 had a documented brief interview for mental status score of 15. A score of 13-15 indicated that resident was cognitively intact with daily decision making skills. Further review of the assessment revealed resident #1 required extensive assistance with one person physical assist with bed mobility, transfers, and personal hygiene. On 09/09/2024 at 10:53 a.m., an observation revealed resident #1 in his room and lying in bed. S4Certified Nursing Assistant (CNA) was present and preparing the resident for his morning bath. During the bath, a visual inspection of resident #1's skin was completed with S4CNA. During the inspection, resident #1 was observed to have a thick buildup of a black colored crust between the great toe and 2nd toe of both feet. There were areas of moisture with a thick, sticky white coating observed in between resident #1's 4th and 5th toe of the left foot and in between the 2nd - 5th toes of the right resident's right foot. Further observation revealed resident #1's left foot had a slight odor and resident #1 had long, untrimmed nasal hairs protruding from both nares. S4CNA confirmed that resident #1's toes needed to be cleaned and the nasal hairs needed to be trimmed. On 09/09/2024 at 11:45 a.m., S5Licensed Practical Nurse (LPN) was notified of the findings that were identified during the visual skin inspection. S5LPN inspected the resident's feet including the areas between the toes and confirmed the area needed further attention as she smelled the odor coming from resident #1's left foot. On 09/10/2024 at 9:05 a.m., S2Director of Nursing (DON) was notified of the findings regarding crusty buildup, moisture, and coating in between resident #1's toes. She was further notified of the resident having an odor to his left foot and long, untrimmed nasal hair. S2DON confirmed that resident #1's feet, including the areas in between his toes should be cleaned during his baths and his nasal hairs should have been trimmed. On 09/16/2024 at 6:15 p.m., S1Administrator was notified of the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to ensure that each resident's drug regimen was free from unnecessary drugs for 2 (#1, #5) of 5 (#1, #2, #3, #4, and #5) sampled residents reviewed for unnecessary medications. The facility failed to ensure the nurses' followed an insulin sliding scale as ordered (#1) and blood pressure parameters as ordered (#1, #5). Findings: Review of the facility's Medication Administration Policy and Procedure (no date noted) revealed in part, the facility shall provide medications as ordered by the physician. Resident #1: Review of the medical record revealed resident #1 was readmitted to the facility on [DATE] with diagnoses that included in part, type 2 diabetes mellitus with diabetic retinopathy, hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, dry eye syndrome of bilateral lacrimal glands and blindness of the right and left eye, and hypertension. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed resident #1 had a documented Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment and resident #1 required extensive assistance with most activities of daily living. Review of the medical record revealed resident #1 was care planned for having multiple medications. The documented approaches included to administer the resident's medications as ordered by the physician. Review of the August 2024 and September 2024 physician orders revealed resident #1 had an order for Lisinopril Oral Tablet 20 milligrams (mg); give 20 mg by mouth one time a day. Hold if Systolic Blood Pressure (SBP) is less than (<) 120 and /or Diastolic Blood Pressure (DBP) is <75. Review of resident #1's September 2024 Medication Administration Record (MAR) revealed documentation that the nurses failed to follow the above blood pressure parameters 5 times from 09/01/2024- 09/09/2024 when resident #1's dialystolic blood pressure was <75. Review of resident #1's August 2024 MAR revealed documentation that the nurses failed to follow the above blood pressure parameters 14 times from 08/01/2024 - 08/31/2024 when resident #1's diastyolic blood pressure was <75. On 09/10/2024 at 3:53 p.m., the surveyor reviewed resident #1's 08/2024 and 09/2024 MARS with S5Licensed Practical Nurse (LPN). She reported she was unable to view the parameters for the medication Lisinopril on the MARs. S5LPN confirmed that she did not know the hold the Lisinopril when resident #1 had a DBP result of <75 on dates of 08/07/2024, 08/09/2024, 08/12/2024, 08/16/2024, 08/17/2024, 08/18/2024, 08/22/2024, 08/26/2024, 09/01/2024, 09/04/2024, 09/05/2024, and 09/09/2024. On 09/16/2024 at 12:15 p.m., the surveyor reviewed resident #1's 08/2024 and 09/2024 MARS with S3LPN. S3LPN reported she thought she held resident #1's Lisinopril Oral Tablet 20 mg on the following dates: 08/01/2024, 08/04/2024, 08/05/2024, 08/15/2024, 08/28/2024, 08/31/2024, and 09/07/2024. S3LPN confirmed her documentation indicated that the Lisinopril was administered on the above dates. Review of the August 2024 physican's orders revealed resident #1 had an order for Novolog FlexPen subcutaneously Solution Pen-Injector 100 units/milliliter (Insulin Aspart); Inject 9 units subcutaneously with meals for diabetes mellitus, hold if Finger Stick Blood Sugar (FSBS) was <150. Review of resident #1's August 2024 MAR revealed documentation that the nurses failed to follow the insulin parameters 2 times from 08/04/2024 - 08/30/2024 when resident #1's FSBS was <150. On 09/10/2024 at 3:53 p.m., the surveyor reviewed resident #1's August 2024 MAR with S5LPN. S5LPN revealed that she was not aware that she was to hold the medication and confirmed that the Novolog Insulin was admistered on 08/30/2024. On 09/16/2024 at 12:15 p.m., the surveyor reviewed resident #1's August 2024 MAR with S3LPN. S3LPN revealed that she was not aware that she had administered Novolog insulin when resident #1's FSBS was 135 on 08/04/2024. She confirmed that she had not held resident #1 insulin as ordered. On 09/16/2024 at 2:00 p.m., an interview with S2Director of Nursing (DON) confirmed the nurses failed to follow resident # 1's blood pressure and insulin parameters as ordered for the above dates in 08/2024 and 09/2024. On 09/16/2024 at 6:15 p.m., S1Administrator was notified of the above findings. Resident #5: Review of the medical record for resident #5 revealed an admission date of 01/20/2024 with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, unspecified protein-calorie malnutrition, other seizures, and generalized muscle weakness. Review of resident #5's care plan dated 01/22/2024 revealed the resident's hypertension was identified with an intervention to administer the antihypertensive medication as ordered. Review of the Quarterly MDS assessment dated [DATE] revealed resident had a BIMS score of 15, which indicated no cognitive impairment and he required extensive assistance with most activities of daily living. Review of resident #5's Physician Orders revealed an order dated 01/20/2024 for Metoprolol Tartrate (blood pressure medication) 100mg every 12 hours, hold if pulse <60 or systolic blood pressure <110. Review of resident #5's September 2024 MAR revealed documentation that the nurses failed to follow the above blood pressure parameters 6 times from 09/01/2024 - 09/07/2024 when resident #5's pulse was <60 and/or his systolic blood pressure was <110. Review of resident #5's August 2024 MAR revealed documentation that the nurses failed to follow the above blood pressure parameters 10 times from 08/03/2024 - 08/30/2024 when resident #5's pulse was <60 and/or his systolic BP was <110. On 09/16/2024 at 12:00 p.m., the surveyor reviewed resident #5's 08/2024 and 09/2024 MARS with S3LPN. She reported she thought she held resident #5's Metoprolol Tartrate on the following dates: 08/15/2024, 08/23/2024, 09/02/2024, 09/06/2024, 09/07/2024, and 09/08/2024. However, she confirmed her documentation indicated that the Metoprolol Tartrate was administered on the above dates. On 09/16/2024 at 2:00 p.m., an interview with S2DON confirmed the nurses failed to follow resident # 5's blood pressure parameters as ordered for the above dates in 08/2024 and 09/2024.

Based on review of the QAA (Quality Assessment and Assurance) manual and interview, the facility failed to have documented evidence of having QAA meetings at least quarterly. Review of the Long-Term Care Facility Application for Medicare and Medicaid report revealed the facility had a census of 97. Findings: Review of the QAA (Quality Assessment and Assurance) manual revealed there was no documented evidence of a quarterly meeting being performed for the first quarter of 2023. On 03/13/2024 at 4:43 p.m., S1 Administrator confirmed that he did not have documented evidence of a quarterly QAA Committee meeting being held for the first quarter of the year 2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #345 Record review revealed resident #345 was admitted to the facility on [DATE] from a local hospital after being treated for novel coronavirus (COVID) and pneumonia. Resident #345 had recovered from COVID. Resident #345's diagnoses included the following: pneumonia, type 1 diabetes mellitus with unspecified complications, methicillin susceptible staphylococcus aureus infection as the cause of disease classified elsewhere, myelodysplastic syndrome unspecified, type 2 diabetes mellitus without complications, resistance to multiple antimicrobial drugs, and acquired absence of spleen. Review of resident #345's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental status (BIMS) score of 12 which represents moderate cognitive impairment. Review of resident #345's active March 2024 physician orders revealed an order dated 03/08/2024 with a start date of 03/09/2024 for Ceftriaxone Sodium 2 grams intravenously (IV), flush with 5 milliliters (ml) normal saline (NS) before and after every day until 03/13/2024. Review of resident #345's March 2024 electronic medication administration record (EMAR) revealed documentation on 03/09/2023 at 9:00 a.m. Ceftriaxone Sodium 2 grams intravenously was administered by S7Licensed Practical Nurse (LPN). Further review of the EMAR revealed documentation on 03/10/2023 Ceftriaxone Sodium 2 grams intravenously was not administered by S8 LPN. Further review of the EMAR revealed documentation on 03/11/2023 Ceftriaxone Sodium 2 grams intravenously was not administered by S4 LPN. On 03/11/2024 at 9:35 a.m., an interview with resident #345 revealed she was admitted to the facility on Friday (03/08/2024) from the hospital. The resident reported she was treated for COVID and pneumonia while in the hospital, and she had an intravenous catheter placed in her left hand on 03/03/2024 after being admitted to the facility. Resident #345 reported she is feeling better but still has an occasional cough. An observation of resident #345 revealed respirations were even and unlabored. On 03/12/2024 at 8:48 a.m., an observation of resident #345 revealed she was sitting in chair in room watching television. Interview with the resident reported she had not received any antibiotics yet. Resident #345 reported that she thinks they are waiting for the antibiotics to come in. On 03/12/2024 at 10:20 a.m., an interview with S4 LPN reported resident #345's antibiotic, Ceftriaxone Sodium 2 grams IV, just came in from the pharmacy this morning. S4 LPN revealed she had not administered resident #345 the Ceftriaxone Sodium 2 grams IV, but would be administering the first dose today when the resident returned from therapy. On 03/12/2024 at 3:35 p.m., an interview with S2 DON reported resident #345 was admitted to the facility on [DATE] and was ordered Ceftriaxone Sodium 2 grams IV every day to start on 03/09/2023 through 03/13/2024 related to pneumonia. S2 DON reported she ordered the antibiotic from the pharmacy on 03/08/2024. S2 DON revealed you have to have your physician order submitted to the pharmacy by 10:00 a.m. or you will not receive the medication that same day. S2 DON revealed the pharmacy reported resident #345's IV antibiotic would not be delivered to the facility until Monday (03/11/2023). S2 DON revealed they had the antibiotic in the emergency (ER) kit in the medication room and the nurses were to obtain the antibiotic from the ER kit until it arrived from the pharmacy. On 03/12/2024 at 2:40 p.m., an interview with S4 LPN revealed she administered resident #345's first dose of Ceftriaxone Sodium 2 grams IV today (03/12/2024) at 10:45 a.m. On 03/12/2024 at 3:30 p.m., an interview with S2 DON revealed resident #345 did not receive the Ceftriaxone Sodium 2 grams IV every day as ordered by the physician on 03/09/2024, 03/10/2024 or 03/11/2024. S2 DON confirmed S7 LPN did not administer Ceftriaxone Sodium 2 grams IV to resident #345 on 03/09/2024 that was ordered. S2 DON revealed resident #345's Ceftriaxone Sodium 2 grams IV was not delivered to the facility until this morning (03/12/2024). S2 DON confirmed S4 LPN administered resident #345's first dose of ceftriaxone sodium 2 grams IV on 03/12/2024 at 10:45 a.m. Based on observation, interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. The facility failed practice was evidenced by 1) not turning or repositioning dependent residents every 2 hours for 1 (#50) of 2 (#50, #28) residents investigated for position/mobility and 2) not administering medication as ordered by the physician for 1 (#345) of 2 (#345, #69) residents investigated for respiratory care. Findings: Resident #50 Record review revealed resident #50 was admitted to the facility on [DATE]. Resident #50 had active diagnoses that included Parkinson`s disease, dementia, neurogenic bladder, protein malnutrition, major depressive disorder, dysphagia, aphasia and anxiety. Review of the most recent minimum data set (MDS) dated [DATE] revealed resident #50 did not have a brief interview of mental status (BIMS) score because resident # 50 could rarely or never be understood to complete the assessment. Further review of MDS section G - activities of daily living (ADL) revealed resident #50 had total dependence on staff for bed mobility and required 2 person assistance. Review of the Certified Nursing Assistant (CNA) task history revealed that staff were to turn resident #50 every two hours while awake or in a chair. Further review revealed documentation by staff of resident #50 being turned every 2 hours from 02/29/2024 through 03/13/2024. On 03/13/2024 at 8:10 a.m., resident #50 observed lying in bed on her right side. On 3/13/2024 at 10:40 a.m., resident #50 was provided with wound care. After the procedure was finished, S3 Registered Nurse (RN) positioned resident #50 back on her right side. On 03/13/2024 at 2:10 p.m., an observation of resident #50 revealed she remained in the same position on her right side. Resident #50 appeared to be in the same position as she was at 10:55 a.m. when wound care was completed. On 03/13/2024 at 2:15 p.m., an interview with S5 CNA confirmed she was assigned to provide care for resident #50. S5 CNA confirmed that she had not turned or repositioned resident #50 since her shift began at 07:00 a.m. on 03/13/2024. On 03/13/2024 at 2:42 p.m., an interview with S2 Director of Nursing (DON) confirmed resident #50 should have been turned every 2 hours in accordance with the resident's plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to maintain acceptable parameters of nutritional status for 1 (#1) of 7 (#1, #11, #32, #33, #39, #72, #81) residents reviewed for nutritional intake. Findings: On 03/11/2024 review of the record for resident #1 revealed on 09/12/2023, Resident #1 weighed 109 pounds. On 03/11/2024, resident #1 weighed 97 pounds which was an 11.01 % weight loss. On 03/13/2024 at 9:42 a.m. review of the record for resident #1 revealed diagnoses in part of chronic congestive heart failure, mild protein calorie malnutrition, and anemia. Review of annual minimum data set (MDS) dated [DATE] revealed a brief interview of mental Status (BIMS) of 9 indicating the resident has moderate cognitive impairment. Review of the plan of care for Resident #1: High risk for actual continued weight loss, due to poor appetite and actual weight loss; Have dietician re-evaluate nutrition status as needed; Need current food likes and dislikes maintained by dietary; Meals served as ordered by physician; Remind or encourage to eat meals in dining room; Weigh as appropriate; Medications as ordered by physician. Review of the active physician orders revealed resident #1 was supposed to receive the house supplement four times a day (QID) at 9 a.m., 1 p.m., 5 p.m. and 9 p.m. Further review of the order dated 11/15/2023 for a magic cup with meals -three times a day (TID) and an order dated 10/25/2023 for mighty shakes with meals three times a day (TID). Further review of the current diet order revealed Resident #1 was to receive no added salt, mechanical soft chopped meats with gravy and regular fluid consistency. Review of the last dietary manager review note dated 12/18/2023 revealed resident #1 was on no added salt mechanical soft diet and there were no likes or dislikes listed in the note. Review of the most current registered dietician (RD) note dated 01/28/2024 by S10 RD revealed it was a referral for a weight change/ loss of 12.9 pounds in the past 6 months. Diet: Mechanical soft, no added salt (NAS) with staff assist and intake 75% recent meals. Current weight 98 pounds. Resident #1 underweight, 75 % of ideal body weight (IBW) and a body mass indicator (BMI) 15.8. A BMI of less than 18.5 indicates the resident is underweight. S10 RD recommended 120 cubic centimeters (cc) of house supplement between meals four times a day and continue magic cups and might shakes with meals. Monitor intake and weight. Review of the weight note dated 01/21/2024 by S2 director of nuirsing (DON) revealed resident #1 current weight was 98.5 pounds, appetite is 50-75%, remains on house supplements, might shakes and magic cup, will continue to monitor. Review of the weight note dated 02/06/2024 revealed a new order for 120 cc house supplement between meals QID and continue magic cups and mighty shakes with meals. On 03/13/2024 at 8:22 a.m. observation of resident #1 revealed she was up in wheelchair in her room and breakfast was just served and set up for resident. The breakfast consisted of grits, eggs, 1 sausage patty, juice and milk. There was no magic cup or might shake on the tray. On 03/13/2024 at 10:27 a.m., review of the dietary card revealed there were no likes or dislikes noted on the card. Further review of the dietary card revealed: NAS/mechanical soft diet Special notes: **Add Mighty shakes to all 3 meals** Hand cut meats Further review revealed the magic cup was not listed on the diet card as ordered. On 03/13/2024 at 11:51 a.m. observation of the lunch meal revealed resident #1 was served: mixed fruit, mixed vegetables, a slice of bread, meat over egg noodles, and iced tea. Resident #1 was not served the magic cup or mighty shake on the tray as ordered and resident #1 did not eat the meat on the tray. On 03/13/2024 at 12:10 p.m. review of the March 2024 medication administration record (MAR) revealed the magic cup with meals related to mild protein calorie malnutrition with a start date of 11/15/2023 revealed S7 licensed practical nurse (LPN) documented resident #1 received the magic cup for breakfast and lunch on 03/13/2024. Further review of the MAR revealed the mighty shake with meals related to mild protein calorie malnutrition with start date 10/15/2023 revealed S7 LPN documented resident #1 received the mighty shake for breakfast and lunch on 03/13/2023. On 03/13/2024 at 1:51 p.m., interview with S7 LPN confirmed she documented resident #1 had consumed both the mighty shake and the magic cup for breakfast and lunch. S7 LPN further said she assumed resident #1 received the might shake and magic cup on the tray but she said she did not actually look at the breakfast and lunch tray. On 03/13/2024 at 2:21 p.m. interview with S9 dietary manager (DM) revealed the supplements are supposed to come from the kitchen and should be on the diet card. S9 DM further revealed she received a text from the supplier regarding the mighty shakes and magic cups. Review of the text dated 02/26/2024 at 11:46 a.m. from the supplier revealed: the mighty shakes are not being produced by the manufacturer and don't know when they are going to be produced again. You need to contact the dietician to change the supplements. S9 DM said she told S10 RD about the issues with the mighty shakes and magic cups when S10 RD was in the facility on 03/05/2024. Review of the last documented registered dietician note for resident #1 was on 01/28/2024. On 03/13/2024 at 1:17 p.m., a phone interview was conducted with S10 RD and she revealed she was not aware the supplier did not have the mighty shakes or the magic cups but they have been trying to transition to house supplements and phasing out the mighty shakes and magic cups. S10 RD said she was not aware resident #1 had not been transitioned to the use of house supplements. On 03/13/2024 at 2:30 p.m., further interview with S9 DM revealed they did have some mighty shakes available. Observation of the refrigerator at that time with S9 DM revealed there were still 21 mighty shakes available for resident consumption but did not have any magic cups. On 03/13/24 at 4:05 p.m., interview with S2 DON revealed S9 DM did not specifically come to her and let her know of the issues with not being able to obtain mighty shakes and magic cups and was not aware resident #1 was not receiving them as ordered since the resident has had weight loss.

Resident #14 An observation of resident #14's meal tray on 03/11/2024 at 12:32 p.m., revealed the resident had not eaten the food items served to her. During an interview with resident, she reported that she had not eaten her lunch meal as it did not taste good. Resident #17 During an interview with resident #17 on 03/11/2024 p.m., the resident complained of the squash being cooked too done with no seasoning. Observation of the meal tray revealed a small bowl of squash. Further observation revealed the squash looked mushy and overcooked. Based on observation and interview the facility failed to serve food that was palatable to taste and attractive. Findings: On 03/11/2024 at 11:43 a.m., observation of the lunch meal revealed residents were served beef stew, a very small roll, squash and either cake or peaches. Observation of the squash revealed it was over cooked and mushy in texture. Interview with Resident #3 said the roll is too hard and small, he further said it ain't no good, the stew is not good, and Resident #3 only drank the punch and got up and walked out of the dining room. Observation of Resident #16 in dining room revealed he left the entire lunch tray un-touched. Observation and interview with Resident #46 revealed he said the meat in the stew was too tuff and he could not chew it and it did not taste good at all. Resident #46 only drank his drink and left the dining room. Observation of Resident #44 revealed he only ate the meat from the stew and the very small roll nothing else. Observation of Resident #85 revealed he was served a pureed tray. Resident #85 said it was no good. Observation of the tray revealed Resident #85 only consumed a few bites of the meal. Observation of Resident #82 lunch revealed she did not eat the meat out of the stew and said it was too tough. On 03/11/2024 at 2:17 p.m., Resident #54 said the food is terrible. The Worst. On 03/12/2024 at 11:15 a.m. observation of the main dining room revealed the lunch consisted of baked barbeque chicken, a baked potato, sour cream, cooked broccoli, a slice of bread and the alternate was chicken nuggets, mixed vegetables and rice. Observation of the cooked broccoli revealed it was over cooked and mushy in texture and the mixed vegetables were over cooked. Observation of Resident #16 lunch tray in the dining room revealed he had baked chicken, a baked potato with no butter available on the tray and broccoli. Resident #16 ate a few bites of the chicken and left the dining room. Observation of Resident #26 revealed he was sitting at a table with a CNA assisting him. Resident #26 asked for butter for his potato and was told they did not have any butter. He then said No butter that is sad. Review of the diet card revealed Resident #26 was on a regular diet. Further observation of the dining room revealed there was no butter on any of the trays served with baked potatoes. The residents had the option of only sour cream or nothing but a plain potato. On 03/12/24 at 2:15 p.m. interview with S9 DM (dietary manager) regarding no butter for baked potatoes revealed she replied they were waiting on the delivery truck and did not have any butter for the potatoes. On 03/12/2024 at 2:30 p.m., interview with Resident #29 regarding the food revealed there is a new DM but the food is still bad. They were getting browned hamburger meat with no seasoning and a side like mac and cheese and sometimes they would even put the meat on hotdog bun. The pizza they serve is terrible, the food has no seasoning and it looks bad and the vegetable are over cooked. On 03/11/2024 at 2:17 p.m,. interview with Resident #54 revealed she said the food is terrible, The Worst. On 03/12/204 at 2:38 p.m., interview with Resident #54 regarding the lunch meal today revealed she did not get butter on her tray but she keeps butter in her room. On 03/13/2024 at 2:39 p.m., interview with S9 DM revealed she must have forgotten to write down the in-service with the staff about the over cooked vegetables. S9 DM reported she just don't know what to do because the residents with little to no teeth are going to complain the vegetables are too hard and the others say they are over cooked. S9 DM further reported she will have to call someone about how to cook the vegetables without them getting over cooked and mushy. S9 DM further said if you cook the vegetables and then put them on the steam table they will continue to cook.

Based on observation and interview the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility failed to ensure 1) the prep table next to the fryer and the top of the fryer was clean and free from heavy grease build up; 2) the stove and small standup oven were free of spills and splatters, and 3) the flour scoop was stored properly and not in direct contact with the top of the flour bin; 4) the floor of the dry pantry was clean and dry by having a grease spill; 5) the inside of the ice machine contained black substance on the walls; 6) grease and carbon build up on muffin pans and cookie sheets; 7) food in the standup refrigerator was properly labeled and contained personal staff drink; 8) food in the walk in refrigerator was not stored properly by having bacon stored over raw cabbage; and by 9) having a sink drain next to the prep table that had been clogged allowing old food particles to drain onto the floor with wet blankets on the floor next to the drain. Findings: On 02/05/2024 at 8:40 a.m. observation of the kitchen environment revealed the prep table next to the fryer was covered with tin foil and the foil had grease build up noted. Observation of the top of the fryer revealed it was covered with tin foil; with grease saturating the tin foil. Observation of the stove revealed dark spills and splatters that were dried down the front of the stove. Interview with S3 Dietary Staff revealed the oven on the large stove does not work so they use the smaller stand up oven. Observation of the inside of the stand-up oven revealed large amount of grease and carbon build up. S3 Dietary Staff said they just wipe it down every day but don't scrub it. Observation of the ice machine revealed black substance on the walls inside the ice machine. Observation of the flour bin revealed the scoop used for the flour was sitting directly on top of the bin and not covered. Observation of the dry pantry revealed cooking oil was spilled on the floor and the floor was very slippery. Observation of the stand-up refrigerator revealed an open package of cream cheese with a date of 1/22, ½ tomato in plastic wrap with no date on it, a bowl of jello with no date on it and a 20 ounce bottle of personal coke for a staff member. Observation of the pots and pans revealed: carbon and grease build up to 3 muffin pans and 6 cookie sheets. Observation in the walk in refrigerator revealed an open box of bacon stored over a box of raw cabbage. Observation of the prep table revealed the drain from the sink on the prep table was stopped up. There was a toilet plunger sitting next to drain, old food particles on the floor around the drain and 2 wet blankets on the floor by the drain. On 02/05/2024 at 9:15 a.m., interview and observation of the kitchen area with S2 Dietary Manager confirmed the above observations. She said they have trouble with the plumbing and would get maintenance to unstop it. On 02/05/2024 at 3:00 p.m. interview with S1 Administrator agreed there are issues in the kitchen that need to be worked on.

Based on record reviews and interviews, the facility failed to inform each resident as soon as was possible of changes in Medicare covered services as evidenced by the provider's failure to send the Centers for Medicare and Medicaid Services (CMS) Form 10055 Skilled Nursing Facility (SNF) Advance Beneficiary Notice of Non-Coverage as required for 3 (#5, #68, #77) of 3 (#5, #68, #77) residents reviewed for Beneficiary Notification who required the notification. Findings: Review of the SNF Beneficiary Protection Notification Review form completed by the facility on 03/15/2023 revealed Resident #8 was discharged from Medicare Part A Services on 02/03/2023 with benefit days remaining because the resident had reached her maximum potential with therapy. Further review revealed the facility did not provide the CMS-10055 form to the resident or resident's representative. Review of the SNF Beneficiary Protection Notification Review form completed by the facility on 03/14/2023 revealed Resident #68 was discharged from Medicare Part A Services on 02/18/2023 with benefit days remaining because the resident had reached his maximum potential with therapy. Further review revealed the facility did not provide the CMS-10055 form to the resident or resident's representative. Review of the SNF Beneficiary Protection Notification Review form completed by the facility on 03/15/2023 revealed Resident #77 was discharged from Medicare Part A Services on 02/24/2023 with benefit days remaining. Further review revealed the facility did not provide the CMS-10055 form to the resident or resident's representative. An interview on 03/14/2023 at 2:30 p.m. with S8MDS (Minimum Data Set) Coordinator and S9MDS Coordinator revealed the corporate office in 2021 told them to stop completing the SNF Advance Beneficiary Notice of Non-Coverage CMS-10055 form. They revealed they didn't explain why the form was not required. An interview on 03/15/2023 at 9:30 a.m. with S8MDS (Minimum Data Set) Coordinator and S9MDS Coordinator confirmed she did not send the CMS-10055 forms to Resident #8, Resident #68, and Resident #77 or their representatives. Further interview revealed they misunderstood their corporate office and they confirmed that they should have been completing the form. During an interview on 03/15/2023 at 9:45 a.m., S1Administrator was notified of the above findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #13 Review of the Nail Care Policy and Procedure revealed the following: Procedure: 1. care of fingernails and toenails are part of the bath. Review of the medical record for resident #13 revealed the resident was admitted on [DATE] with diagnoses of end stage renal disease, chronic kidney disease, hemiplegia and hemiparesis following cerebrovascular disease, cerebral infarction, renal dialysis, left elbow bursitis, and osteoarthritis. Review of the Minimum Data Set, dated [DATE] revealed the resident had moderately impaired cognitive skills for daily decision making skills. The resident required one person assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident had range of motion impairment on one side of his upper and lower extremity. Review of the care plan revealed: the resident had an activities of daily living self care performance deficit. Further review of the interventions revealed to monitor and assist with bed mobility, transfers, eating, toileting, personal hygiene, dressing and mobility. Observation on 03/14/2023 at 9:30 a.m. revealed the resident was up in his wheelchair in his room. The resident had long dirty fingernails on his right hand. Observation on 03/14/2023 at 3:45 p.m. revealed the resident had long dirty fingernails on his right hand. Interview with the resident at this time revealed the resident reported that his son trimmed his left hand for him the other day. The resident reported that it had been awhile since the staff trimmed his nails. Observation on 03/15/2023 at 8:45 a.m. with S6LPN (Licensed Practical Nurse) revealed the resident's long dirty fingernails on his right hand. Interview with S6LPN at this time confirmed the resident had long dirty fingernails on his right hand. S6LPN reported that if the resident was not a diabetic then the CNAs (Certified Nursing Assistants) should trim their fingernails. Observation of the resident's fingernails on 03/15/2023 at 8:55 a.m. with S7CNA confirmed the resident had long dirty fingernails on his right hand. Interview at this time revealed the resident receives his bath on the night shift and if the resident is not a diabetic, the CNAs should trim the residents' nails during their bath. During an interview on 03/15/2023 at 1:10 p.m., S2Assistant Director of Nursing/Interim Director of Nursing, confirmed the resident should have recevied nail care during his bath. Based on observations, record reviews, and interviews, the facility failed to ensure residents who are unable to carry out activities of daily living receive the necessary services to maintain good grooming and personal hygiene for 2 (#2, #13) of 6 (#2, #13, #17, #35, #45, #62) residents reviewed for activities of daily living. The provider failed to: 1. Ensure resident's face was washed and cleaned (#2) and 2. ensure resident's fingernails were clean and trimmed (#13). Findings: Resident #2 On 03/13/2023 at 9:41 a.m. observation of Resident #2 revealed the upper lip had dried, cracking and flaking material. On 03/14/2023 at 8:45 a.m. observation of Resident #2 revealed she was lying in bed very restless and fidgety. Observation of the resident revealed there was a large piece of dry flaky matter adhered under the center of the nose, there was a large piece of dried matter in the resident's right nares, and there was dry crusty, flaky matter around the resident's mouth. Interview at that time with S3LPN (Licensed Practical Nurse) revealed Resident #2 will move and fidget until she wears herself out and sometimes she does that when she needs to be changed. On 03/14/2023 at 9:00 a.m. interview with S4CNA (Certified Nurses Assistant) revealed there were 2 CNAs assigned to the hall. She also confirmed that they try to bathe the residents that are mobile first thing in the morning and then the other residents get cleaned and bathed later. S4CNA confirmed Resident #2 had not been bathed or cleaned yet. S4CNA was instructed to get surveyor when resident #2 was bathed or cleaned up. On 3/14/2023 at 9:49 a.m. record review revealed diagnoses of paranoid schizophrenia, non-traumatic intracerebral hemorrhage in the brain stem, dementia with agitation, heart failure, syphilis, and general anxiety disorder. Review of the plan of care revealed in part: ADL (activity of daily living) care- totally dependent on staff for all ADLs. Has potential to be physically aggressive (grabbing during ADL care). Defined as aggressive towards another resident, staff, or visitor related to Alzheimer's disease. Provide physical and verbal support to alleviate anxiety. ADL self-care performance deficit requires extensive assist related to dementia, cerebrovascular accident and tremors with the following approaches: Ensure resident is cleaned and well-groomed, lotion to skin daily, totally dependent on 2 CNAs for repositioning and turning every 2 hours. Personal hygiene or oral care- totally dependent on 1 CNA for personal hygiene and oral care. The resident's needs will be met as evidenced by being clean, dry and odor free: and Provide oral care on routine basis. Review of annual MDS (Minimum Data Set) dated 12/13/2022 revealed: BIMS- (Brief Interview for Mental Status) - unable to assess BIMS. On 03/14/2023 at 11:36 a.m. observed Resident #2 in same condition as at 8:45 a.m. that morning with a large piece of dry flaky matter adhered under the center of the nose, a large piece of dried matter in the resident's right nares, and there was also dry crusty, flaky matter around the resident's mouth. Resident #2 had not been assisted with any ADL care. On 03/14/2023 at 1:00 p.m. observed S5CNA and S4CNA bathe resident. S5CNA said Resident #2 was a 2 person assist with all ADLs. The dried and crusty matter under resident's nose had to be soaked and wiped multiple times to be removed as well as the dried matter in the resident's right nares. The resident's face had to be wiped multiple times to remove the flaky matter from around the resident's mouth. S5CNA confirmed Resident #2's face had not been cleaned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interview, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 (#4) of 2 (#4 and #44) residents investigated for urinary catheter. The facility failed to ensure resident #4's Foley catheter urine collection bag was covered and the tubing was not in direct contact with the floor. Findings: Review of the Catheter indwelling, Insertion, and Removal Policy and Procedure revealed the following procedure as referenced: Insertion of Indwelling Catheter: #15. Secure urinary drainage bag below the level of the bladder and keep off the floor at all times. Coil extra tubing and secure. Review of the medical record revealed resident #4 was admitted to the facility on [DATE] with diagnoses including, in part, neuromuscular dysfunction of bladder, personal history of urinary (tract) infections, and cerebral palsy. On 03/13/2023 at 10:42 a.m., an observation revealed resident #4 sitting up in her wheelchair in the dining room area. Observation revealed resident 4's indwelling Foley catheter bag was uncovered with the urinary catheter bag and urine both exposed and visible to other residents and /or visitors. Further observation revealed the Foley catheter bag was secured on the bottom frame of the wheelchair with the tubing lying on and in direct contact with the floor. On 03/13/2023 at 12:15 p.m., an observation revealed resident #4 sitting up in her wheelchair in the dining room area. Observation revealed resident #4's indwelling Foley catheter bag was uncovered with the urinary catheter bag and urine both exposed and visible to other residents and /or visitors. Further observation revealed the Foley catheter bag was secured on the bottom frame of the wheelchair with the tubing lying on and in direct contact with the floor. On 03/14/2023 at 10:00 a.m., an observation revealed resident #4 sitting up in her wheelchair as S12Activities Director pushed the wheelchair throughout the hallway. Further observation revealed resident #4's Foley catheter tubing was positioned underneath the wheelchair and in direct contact with the floor. On 03/14/2023 at 11:40 a.m., an observation revealed resident #4 sitting up in her wheelchair, at the dining table. Further observation revealed the resident's Foley catheter tubing was positioned underneath the wheelchair and in direct contact with the floor. On 03/14/2023 at 11:45 a.m., an observation revealed resident #4's Foley catheter bag positioned on the bottom frame of the wheelchair with the catheter tubing underneath the wheelchair and in direct contact with the floor. S10LPN was notified of the findings. S10LPN confirmed resident #4's Foley catheter bag was not properly positioned on the wheelchair and the Foley catheter tubing was in direct contact with the floor. S10LPN reported that resident #4 had a personal history of urinary tract infections. On 03/15/2023 at 10:20 a.m., S11QA (Quality Assurance) and Staff Development Nurse was notified of the findings regarding resident #4's Foley catheter bag being uncovered and the Foley catheter tubing being in direct contact with the floor. S11QA (Quality Assurance) and Staff Development Nurse confirmed resident #4's Foley catheter bag should be covered and the catheter tubing not be in direct contact with the floor due to the possibility of cross contamination as resident #4 was a risk for urinary tract infections. On 03/15/2023 at 3:15 p.m., S1Administrator was notified of the findings regarding resident #4's Foley catheter bag being uncovered with the bag and urine being visible to other residents and /or visitors. He was further notified of the Foley catheter tubing in direct contact with the floor.