**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure staff treated residents in a dignified manner during the dining experience for one Resident (#24) out of a total sample of 22 Residents. Specifically, the facility failed to ensure that staff were not operating a cell phone while assisting Resident #24 with eating breakfast. Findings include: Review of the facility policy titled Quality of Life - Dignity, undated, indicated the following: - Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with dignity and respect at all times. Resident #24 was admitted to the facility in November 2024 with diagnoses including Parkinsonism, stage 4 pressure ulcer of sacral region, and unspecified protein calorie malnutrition. Review of Resident #24's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status score of 6 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated that the Resident is dependent on staff for all Activities of Daily Living including eating. During a telephone interview on 3/9/25 at approximately 3:30 P.M., the facility's Ombudsman reported to the surveyor that about two weeks prior, he observed a Certified Nursing Assistant (CNA) using her cell phone while feeding a resident and the resident was staring at the CNA with the food being untouched. On 5/13/25 during breakfast service at 8:44 A.M., the surveyor made the following observations: Resident #24 was observed to be assisted by a staff member while eating breakfast. Resident #24's bedroom door was slightly open, the surveyor observed a staff member sitting in a chair next to Resident #24 who was lying in his/her bed. The staff member was observed to be using both of her hands while texting on her cell phone over Resident #24's breakfast tray. At 8:47 A.M., the surveyor observed the staff member to continuing to text on her phone instead of feeding Resident #24. At 8:54 A.M., 10 minutes after the initial observation, the staff member was observed to continue texting on her phone instead of assisting Resident #24 with eating his/her breakfast. Review of the facility's Resident Council Minutes indicated the following: - February 27, 2025: Nursing - Being on phones has gotten better. - April 24, 2025: Staff using phones and headphones while working is an ongoing issue they (the residents) would like to see resolved, even though it has improved from the past. During an interview on 5/14/25 at 10:05 A.M., Unit Manager #1 said staff members should never be on their cell phones while assisting residents with feeding and every resident should have a dignified dining experience. During a follow up interview on 5/14/25 at 10:18 A.M., Unit Manager #1 said the staff member on her cell phone was Resident #24's hospice CNA (Certified Nurse Aide) from the outside hospice agency. Unit Manager #1 then said she would still expect the hospice CNA to follow the facility's policies and procedures and provide a dignified dining experience for Resident #24. During an interview on 5/14/25 at 10:22 A.M., the Director of Nursing (DON) said it was a hospice CNA who was texting while assisting Resident #24 with feeding. The DON said no staff member should be using their cell phone while assisting a Resident with feeding and Resident #24 should have a dignified dining experience.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents at risk for developing pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to prevent new ulcers from developing for two Resident (#24 and #53) out of a total of 22 Residents. Specifically, the facility failed to ensure the Resident's air mattress were set at the correct setting according to the physician's order. Findings include: Review of the facility policy titled Prevention of Pressure Injuries, dated and revised April 2020, indicated the following: - Support Surfaces and Pressure Redistribution: Select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice. Resident #24 was admitted to the facility in November 2024 with diagnoses including Parkinsonism, stage 4 pressure ulcer of sacral region, and unspecified protein calorie malnutrition. Review of Resident #24's most recent Minimum Data Set (MDS) assessment dated [DATE] indicated a Brief Interview for Mental Status score of 6 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated that the Resident has one stage 4 pressure ulcer and is at risk of developing pressure ulcers and is dependent on staff for all activities of daily living. The surveyor made the following observations: - On 5/13/25 at 9:40 A.M.,12:05 P.M. and 4:25 P.M., Resident #24 was lying on his/her bed. An air mattress was present and operating and was set to the first bar which indicated the softest setting. Next to the setting dial was a diagram indicating what each setting's corresponding weight setting should be. The setting at which Resident #24's air mattress pump was set to was for 50 pounds. - On 5/14/25 at 6:52 A.M., and 8:31 A.M., Resident #24 was sleeping in his/her bed. An air mattress was present and operating and was set to the first bar which indicated the softest setting. Next to the setting dial was a diagram indicating what each setting's corresponding weight setting should be. The setting at which Resident #24's air mattress pump was set to was for 50 pounds. Review of Resident #24's Physician's order dated 11/22/24 indicated the following: - Alternating pressure air mattress set to 150, check setting q (every) shift. Review of Resident #24's most recent weight dated 5/8/25 indicated that the Resident last weighed 91.5 lbs. (pounds). Review of Resident #24's skin integrity risk and sacral pressure ulcer care plan dated 11/21/24, indicated the following intervention: Air mattress as ordered. Review of Resident #24's Norton's Scale for Predicting Pressure Ulcers (an assessment that indicates the risk of developing pressure ulcers) dated 4/10/24 indicated that the Resident scored a 6 which indicates the Resident is at a high risk of developing pressure ulcers. During an interview on 5/14/25 at 8:55 A.M., Nurse #1 said air mattress settings are set to each resident's weight and by physician's order. During an interview on 5/14/25 at 10:05 A.M., Unit Manager #1 said air mattress settings are set by a resident's weight. Unit Manager #1 reviewed Resident #24's weight and the surveyor's photo of the air mattress pump and she said the settings are too low and they need to be adjusted. Unit Manager #1 said if the air mattress settings are too low it could affect Resident #24's skin and increase pressure ulcer risk. During an interview on 5/14/25 at 10:22 A.M., the Director of Nursing (DON) said air mattress settings should be set by a resident's weight and by the physician's order. The DON reviewed the surveyor's photo of Resident #24's air mattress settings, and she said it was set too low. 2.Resident #53 was admitted to the facility in March 2024 with diagnoses including adult failure to thrive. Review of Resident #53, the most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident scored a 2 out of a total possible 15 on the Brief Interview for Mental Status indicating he/she was severely cognitively impaired. The MDS further indicated the Resident was dependent for positioning and was at risk for developing pressure ulcers. On 5/13/25 at 8:07 A.M., the Surveyor observed Resident #53 lying in his/her bed. The air mattress was set at 380 lbs. (pounds). On 5/13/25 at 12:16 P.M., the Surveyor observed Resident #53 lying in his/her bed. The air mattress was set at 380 lbs. (pounds). On 5/13/25 at 4:28 P.M., the Surveyor observed Resident #53 lying in his/her bed. The air mattress was set at 380 lbs. (pounds). Staff entered the Resident's room and repositioned him/her. On 5/14/25 at 7:49 A.M., the surveyor and Nurse #1 observed the Resident lying in his/her bed the air mattress was set at 380 lbs. Nurse #1 said the air mattress should not be set that high as the Resident weighed less than 100 lbs. Review of the physician's order dated 8/26/24 indicated the following: -Air mattress with bolsters on bed set at 150 check setting every shift. Review of care plan Resident has potential for skin/tissue integrity risk related to decreased mobility, dated 4/3/25 indicated the following intervention: -Air mattress with bolsters on bed check each shift for proper inflation. During an interview on 5/14/25 at 7:49 A.M., Nurse #1 said she had not done her rounds yet to ensure air mattress was in the correct setting, she said nurses are responsible for ensuring correct setting every shift. During an interview on 5/14/25 at 8:35 A.M., Unit Manager #1 said air mattresses are set to resident's weights and that Resident #53's air mattress should be set to less than 100lbs and not 380 lbs. During an interview on 5/14/25 at 10:31 A.M., the Director of Nursing said physician orders should be followed for proper air mattress setting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to provide continued therapy services and recommended by the Occupational Therapist for one Resident #24 out of a total sample of 22 Residents. Specifically, the facility failed to ensure that Resident #24 continued to receive Occupational Therapy services as recommended for the use of a hand orthotic while under hospice services. Findings include: Review of the facility policy titled Scheduling Therapy Services, dated and revised July 2013, indicated the following: - Therapy services shall be scheduled in accordance with the resident's treatment plan. - The therapist shall interview the resident and consult with the attending physician as to the type of treatment to be administered. - Therapy is scheduled in coordination with nursing service and is documented in the resident's medical record. - Nursing service shall be responsible for preparing and escorting the resident to the therapy area unless such treatment is scheduled in the resident's room. Resident #24 was admitted to the facility in November 2024 with diagnoses including Parkinsonism, pressure ulcer of sacral region, stage 4 and unspecified protein calorie malnutrition. Review of Resident #24's most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated a Brief Interview for Mental Status score of 6 out of 15 indicating severe cognitive impairment. Further review of the MDS indicated that the Resident has upper extremity impairment on one side and is dependent on staff for all Activities of Daily Living. During an observation on 5/13/25 at 9:40 A.M., Resident #24 was lying in his/her bed, his/her left hand was clenched in a fist position. The surveyor asked and motioned if the Resident was able to open his/her left hand, the Resident attempted to but was unable to. The surveyor did not observe any handroll or splinting device in the Resident's room. During observations throughout the survey period from 5/13/25 through 5/14/25, the surveyor did not observe any hand splint device or any orthotics in use or in Resident #24's bedroom. Review of Resident #24's visits from the Nurse Practitioner (NP) indicated the following: - Dated 3/20/25: Left hand in fist while in resting position. Able to open with some stiffness noted. PLAN: spoke with DOR (Director of Rehab) regarding stiffness to left hand. Therapy to evaluate as member may benefit from handroll. - Dated 3/25/25: Left hand in fist with flexed wrist while in resting position. Able to open with some stiffness noted. Seen by OT (Occupational Therapist) with plans for splint. SW (social worker) met with HCP (health care proxy) earlier today, agreeable to hospice at home. Hospice referral placed while at SNF (senior nursing facility). - Dated 4/3/25: Left hand in fist with flexed wrist while in resting position. Able to open with some stiffness noted. Seen by OT with plans for splint. Review of Resident #24's Occupational Therapy Evaluation and Plan of Treatment dated 3/24/25 indicated the following: - Reason for Referral/Current Illness: Pt is a 79 y/o male/female who been a LTC (long term care) resident of this facility who was referred to OT services to assess L (left) hand for hand roll due to limited ROM (range of motion)/increased tightness in flexed position. - Assessment Summary: Pt noted to have pain with L wrist and hand movement. Pt would benefit from OT services to address deficits with limited L wrist and hand ROM and splinting for proper positioning of L UE (upper extremity). Review of Resident #24's Occupational Therapy Discharge summary dated [DATE] indicated the following: - Discharge Recommendations and Status: Pt seen for OT evaluation only due to pt transitioning to Hospice Care. Recommend splinting care under Hospice services. Review of Resident #24's physician's order dated 3/25/25 indicated the following: Hospice evaluation and admit if appropriate. Review of Resident #24's care plans failed to indicate a care plan for the use of Occupational Therapy or the use of any hand orthotic/device. During an interview on 5/14/25 at 8:03 A.M., Certified Nursing Assistant (CNA) #1 said Resident #24's hand has always been flexed in a fist position and she does not remember ever seeing a hand towel or splint in use. During an interview on 5/14/25 at 8:55 A.M., Nurse #1 said Resident #24 was admitted with his/her hand flexed and tightened. Nurse #1 said when therapy services make recommendations, they will tell nursing who will ensure an order gets implemented. During an interview on 5/14/25 at 9:27 A.M., the Director of Rehab (DOR) said residents are seen by therapy upon admission to the facility, quarterly and if nursing makes a request for the resident to be seen by therapy services. The DOR said if therapy recommendations are made, we would evaluate the resident, make a care plan and have a physician's order implemented for any recommendations made by therapy. The DOR then said Resident #24 was referred to OT by the Nurse Practitioner due to his/her left hand positioning. The DOR said after the NP made the recommendations for OT, Resident #24 was admitted to hospice services on 3/25/25 so the Resident did not see OT. The DOR reviewed the NP recommendation on 4/3/25, eight days after Resident #24 was admitted to hospice services, the DOR said she did not know the NP still planned for a hand splint. The DOR then reviewed the OT Discharge summary dated [DATE] and she was not aware that the OT recommended splinting care under hospice services. The DOR said the facility should have coordinated with hospice services to ensure that Resident #24 was being evaluated by OT to see if a splint would be recommended. During an interview on 5/14/25 at 10:22 A.M., the Director of Nursing (DON) said Therapy should have followed up with hospice services to see if therapy would be recommended and to see if a hand device would be appropriate for Resident #24. During a follow up interview on 5/14/25 at 10:58 A.M., the DOR said she spoke with hospice services, and they approved Resident #24 to be seen by OT. The DOR said she evaluated Resident #24 and she is trialing the use of a hand roll for Resident #24 now.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure practices to support nutritional needs for one Resident (#48), out of a total sample of 22 residents were implemented in accordance with professional standards of care. Specifically, Resident #48, who was assessed for nutritional risk, experienced a severe weight loss, which was not evaluated by the registered dietitian. Findings include: Review of the facility's policy titled, Weight Assessment and Intervention, revision date March 2022 indicated the following: Residents weights are monitored for undesirable and unintended weight loss or gain. Weight Assessment 1. Residents are weighed upon admission and at intervals established by the interdisciplinary team., 2. Weights are recorded in each unit's weight record or chart and in the individual's medical record. 3. Any wight change of 5% or more since the last weight assessment is retaken the next day for confirmation. a. if the weight is verified, nursing will immediately notify the dietician in writing. 4. Unless notified of significant weight change, the dietician will review the unit weight record monthly to follow individual weight trends over time. 5. The threshold for significant unplanned and undesired weight loss will be based on the following criteria (where percentage of body weight loss=(usual weight-actual weight)/(usual weight) x 100): a. 1 month-5% wight loss is significant; greater than 5% is severe. b. 3 months-7.5 % weight loss is significant; greater than 7.5 % is severe. c. 6 months-10% wight loss is significant; greater than 10 % is severe. Resident #48 was admitted to the facility in July 2024 and has diagnoses that include but are not limited to Parkinson's disease without dyskinesia, unspecified dementia, and depression. Review of the most recent comprehensive Minimum Data Set assessment dated [DATE], indicated Resident #48 scored an 8 out of 15 on the Brief Interview for Mental Status exam, indicating Resident #48 has moderately impaired cognition. Further, the MDS indicated Resident #48 requires supervision or touching assistance to eat, is 71 (5 foot nine inches) in height and weighs 130 pounds and is on a mechanically altered diet. On 5/13/25 at 7:44 A.M., and 8:31 A.M., Resident #48 was observed on his/her back in bed. Resident #48 did not respond to the surveyors greeting. Resident #48 was administered oxygen through a nasal cannula and looked to be frail and dependent. An open carton of Ensure (a dietary supplement) was on his/her bedside table. On 5/13/25 at 12:26 P.M., Resident #48 was sitting up in bed with a Certified Nursing Assistant (CNA) assisting him/her with eating his/her lunch. CNA # 3 said Resident #48 eats a little at a time and needs assistance. On 5/14/25 at 8:30 A.M., Resident #48 was observed sitting up in a wheelchair eating his/her breakfast. Resident #48 was feeding him/herself. His/her tray consisted of a pureed entree, whole milk, mighty shake (a dietary supplement), and hot cereal. The food was partially consumed by Resident #48. Review of Resident #48's care plan with the focus: Resident is at nutrition related risk d/t (due to) altered skin integrity and pmh (past medical history) including dementia, DVT (deep vein thrombosis) PNA (pneumonia) Parkinson's, TIA (transient ischemic attack), and depression. Date initiated 7/24/24 Goal: 1. Maintain a weight free from significant changes. 2. PO (by mouth) intake to meet daily nutrition and hydration needs. 3. Tolerates diet/textures a/o (as ordered), 4. Nutritional related labs wnl (within normal limits) and 5. Improved skin integrity, date initiated 7/24/2024 revision on 4/4/2025. Interventions included but not limited to Monitor/Record/report to MD (medical doctor) s/sx (signs /symptoms of malnutrition: Emaciation (cachexia) muscle wasting, significant weight loss: 3 lbs. (pounds) in 1 week, greater than 5% in 1 month, greater than 7.5% in 3 months, and greater than 10% in 6 months. RD (registered dietitian) to evaluate and make diet change recommendations PRN (as needed). Review of Resident #48's medical record indicated in part, the following on the weights and vitals summary. -10/4/2024 170.1 (sitting) -10/9/2024 167.6 (sitting -10/16/2024 165.6 (sitting) -10/24/2024 167.4 (sitting) -11/2/2024 167.4 (sitting -11/8/2024 168.6 (sitting) -11/13/2024 168 lbs. (sitting) -11/20/2024 166.8 lbs. (sitting) -12/4/2024 167.2 lbs. (sitting) -1/5/2025 166 lbs. (sitting) -1/23/2025 144 lbs. (sitting) a 13.25 % loss of total body weight since 1/5/25, 19 days, which meets the criteria of severe weight loss. -1/30/2025 140.8 lbs. (mechanical lift) -3/21/2025 130 lbs. (bed scale) -4/7/2025 131 lbs. (mechanical lift) -5/14/2025 132.1 lbs. (mechanical lift) Review of Resident 48's medical record did not indicate Resident #48 was in the hospital from 10/4//24 through 1/23/25 when Resident #48 sustained a severe weight loss. Review of Resident #48's active physician's orders indicated the following: Diet-order summary, -regular diet pureed texture. Thin liquids consistency, order date 1/22/2025 Dietary Supplements order summary -Ensure three times a day or nutritional equivalent order date 5/14/2025 -Mighty shake three times a day or nutritional equivalent order date 1/16/2025 -ProSource/liquid Protein (30 ml) two times per day, order date 5/142025. Review of active and discontinued dietary orders failed to indicate any new dietary orders were entered after the severe weight loss experienced by Resident #48 on 1/23/25 until 5/14/25. Review of Resident #48's medical record indicated the following: -A [NAME]-Nutrition Assessment Comprehensive with an effective date 7/24/2024 indicated a BMI (body mass index) of 20.9, most recent weight 149.9. oral supplement 237 ml Ensure TID (three times a day). -A [NAME]-Nutritional Assessment with an effective date 10/15/2024 with a most recent weight of 167.6 and BMI of 23.4. Oral supplement 237 ml Ensure TID (three times a day). -A [NAME]-Nutritional Assessment Comprehensive with an effective date 1/15/2025 with the most recent date weight of 166.0 and a BMI of 23.1, with Oral supplement to include: liquid protein and BID (twice a day) mighty shake TID (three times a day) Resident now receiving regular/pureed diet with thin liquids. Will cont. (continue) to monitor. Review of Resident #48's medical record failed to indicate a nutritional assessment was conducted when Resident #48's weight went from 166 pounds on 1/5/25 to 144 pounds on 1/23/25 a 13.25 % severe weight loss, occurring a week after the [NAME]-Nutritional Assessment Comprehensive dated 1/15/25. Review of the medical record indicated a progress note dated 1/16/25 and entered by the Registered Dietitian indicated: RT (resident) with poor intake and altered skin integrity. Diet orders remain appropriate with textures per the SLP (speech language pathologist) Rec [recommend] add 30 ml liquid protein BID (twice a day) and mighty shake TID (three times a day) to better meet nutrition needs. Will continue to monitor. Review of the medical record indicated a [NAME]-Nutrition Assessment Comprehensive dated 3/26/2025, 63 days since Resident #48 sustained a severe total weight loss of 13.25 % in one week and continued to have weight loss as indicated by the weight entered on 1/30/25 at 140.8 lbs. equaling a 15.18 % of total body weight. indicated the most recent weight of 130.0 lbs. and a BMI of 18.1. During an interview on 5/14/25 at 9:57 A.M., Unit Manager #1 said Resident #48 was monitored closely for weight loss. She said Resident #48 was at baseline and began to stop eating and drinking around January. Unit Manager #1 said Resident #48 was downgraded to puree diet texture change which he/she did not like and may have contributed to the weight loss. Unit Manager #1 said the Dietitian is involved in risk meetings where Residents are reviewed for weight loss. Unit Manager #1 said Resident #48 did have supplements ordered. Unit Manager #1 said the family was aware and a decision was made to put Resident #48 on hospice services. During an interview on 5/14/25 at 10:11 A.M., the Registered Dietitian (RD) said she is in the facility two times a week. The RD said on admission all residents are assessed, and a nutritional care plan is implemented as most residents are at some nutritional risk. The RD said residents are followed for the length of their stay. RD said she runs weight reports each week which tells her if there are any weight changes for residents including gains or losses. The RD said if there is a 3 lb. weight change a re-weigh is obtained to determine if it is significant or not and she will assess the resident to see if new interventions are required. The RD reviewed Resident #48's weights entered into the medical record. The RD said Resident #48 was on hospice. The RD said Resident #48 was followed in risk meetings. The RD said Resident #48 had desired weight gain after admission, and she assessed him/her in January before the significant weigh loss occurred. The RD reviewed the record and said she did not enter a note that she was aware of the significant/severe weight loss or that she re-evaluated Resident #48's nutritional status after the significant weight loss. The RD said she should have conducted an assessment or a thorough review of Resident #48's weight loss, even if he/she was signing on to hospice. During an interview on 5/14/25 at 12:47 P.M., the Director of Nursing (DON) said weights are entered in the electronic medical record and reviewed for gains or loss. The DON said Resident #48 was followed in risk meetings and the RD is present at the meetings. The DON said the RD drives the care plan for nutritional care planning and interventions and should have provided an assessment/evaluation after Resident #48 sustained a significant (severe) weight loss.

Based on observation and interview, the facility failed to ensure standards of practice to prevent the spread infection were implemented. Specifically, a Laboratory Technician providing laboratory services to residents, failed to adhere to infection control practices when she placed her bag, which she uses to store supplies and specimens and uses in other facilities, on top of a resident's bed. Findings include: During an observation on 5/13/25 at 11:36 A.M., a Laboratory Technician was observed in a resident room occupied by two residents. The room was marked by a sign at the door indicating enhanced barrier precautions. The Laboratory Technician's bag with her supplies was on top of the resident's bed and in contact with the linen. The lab technician did the blood draw to the resident in bed 2 and then moved to the bedside table of the resident in bed one to fill out a form and then removed her gloves and placed the specimen in a plastic bag and into the bag that was on the bed. During an interview on 5/13/25, when the Laboratory Technician exited the room, the Laboratory Technician said she goes to assisted living and nursing homes during the day to draw blood. The Laboratory Technician said she has been educated on infection control and uses PPE (personal protection equipment) as needed and always uses gloves. The Laboratory Technician said she put the bag on the resident's bed because it fell off the counter. The Laboratory Technician demonstrated that the bag had wheels used to push or pull the bag on the floor. During an interview on 5/14/25 at 8:39 A.M., Nurse #4 who was caring for the residents in the room, said the resident in bed 2 had laboratory services on 5/13/25. Nurse #4 said the Laboratory Technician should be following infection control guidance while performing services for the facility and said the bag should not be on a resident's bed. During an interview on 5/14/25 at 9:56 A.M., Unit Manager #1 said the Laboratory Technician should be following infection control practices when they are providing a service in the facility. During an interview on 5/14/25 at 7:52 A.M., the Infection Preventionist said she expects vendors, including laboratory technicians, to follow the facility's infection control practices, including standard precautions. The Infection Preventionist said the Laboratory Technician should not place an unclean bag that is in regular contact with the floor on top of a resident's bed or linen. The Infection Preventionist said this breach could potentially contaminate the bed and linen.

Based on observation and interview, the facility failed to provide a dignified dining experience for Residents on the Right Wing unit. Findings include: The surveyor made the following observations: - On 5/14/24 at 8:19 A.M., a Certified Nursing Assistant (CNA) was observed feeding a resident in bed while standing over him/her, not at eye level. - On 5/14/24 at 11:47 A.M., a resident was observed sitting at a table in the dining room with a second resident. The first resident received his/her tray at 12:08 P.M. and was being assisted by staff. At 12:08 P.M., the staff assisting the resident told the other resident Your food is in the next truck. The second resident received his/her meal at 12:42 P.M., 55 minutes after the first resident had begun eating. - On 5/15/24 at 8:13 A.M., a resident was observed sitting in a Broda chair at a dining room table with another resident who was being assisted with breakfast. At 8:17 A.M., a CNA was observed leaning on the initial resident's Broda chair talking to another CNA at a different table. At 8:27 A.M., a CNA sat down with the resident and assisted with feeding him/her, 14 minutes after the other resident at the table had begun eating. - On 5/15/24 from 8:19 A.M. to 8:27 A.M., a Certified Nursing Assistant was observed feeding a resident in bed while standing over him/her, not at eye level. During an interview on 5/16/24 at 8:30 A.M., the Nursing Supervisor said staff should be sitting at eye level when feeding residents and not standing over residents while they are assisting with feeding. The Nursing Supervisor continued to say when residents are sitting at a table together for meals they should be served at the same time. During an interview on 5/16/24 at 10:27 A.M., the Director of Nursing (DON) said staff should not be standing over residents while they are assisting them with feeding. The DON also said residents sitting at the same table during meals should be served at the same time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to protect one Resident (#54) from abuse out of a total of 22 sampled residents. Specifically, Occupational Therapist (OT) #1 yelled at Resident #54 in the presence of other residents and staff for not following his/her directions. Findings include: Review of the facility's Abuse Prohibition policy dated 2/20/23 indicated: *The facility prohibits the mistreatment, neglect and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends, etc. Each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. Residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers and staff of other agencies serving the resident. *Types of abuse: Verbal: oral, written or gestured language, that willfully includes disparaging and derogatory terms, to the resident/patient or their families, or within their hearing distance to describe resident/patient. Mental/Emotional Abuse: includes but is not limited to, humiliation, harassment and threats of punishment or deprivation. *Training: Staff will maintain a manner of courtesy and respect toward residents and their families. Staff will refrain from all actions that could be considered abuse, mistreatment and/or neglect. Any employee who as a Resident #54 was admitted to the facility in April 2024 with diagnoses including cerebral infarction (stroke), cognitive communication deficit and unspecified dementia. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #54 scored a 14 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS) indicating he/she is cognitively intact. On 5/14/24 at 12:05 P.M., the surveyors were at the nurses station, along with Nurse #1, the Wound Physician and Certified Nursing Assistant (CNA) #1 on the left side unit. The surveyors and facility staff observed Resident #54 being wheeled in his/her wheelchair by OT #1. OT #1 was loudly and sternly repeating to Resident #54, Pick up your feet! Pick up your feet! Resident #54 appeared unsure of these directions, stood up in the wheelchair and OT #1 abruptly, loudly and aggressively said What are you doing!? Where are you going!? Resident #54 then responded saying that he/she was picking up his/her feet and OT #1 yelled No! I told you to sit! and gestured to a nearby resident indicating she wanted Resident #54 to be seated next to him/her. The resident OT #1 was referring to was seated close by and attempted to intervene and speak and OT #1 said to him/her, you're not helping. Resident #54 then attempted to speak with OT #1 and he/she loudly and aggressively yelled Sit down! Resident #54 then turned slowly to sit down in the wheelchair with his/her shoulders slumped down and turned his/her head down. OT #1 then brought Resident #54's wheelchair and placed him/her next to the resident who attempted to intervene and said, There. Now you two can gripe together!, and walked into Resident #54's room to obtain his/her tray table. The surveyor approached Resident #54. Resident #54's face was drawn and sad. Resident #54 looked at the surveyor and said, She's so mean. She's just so mean. She's always yelling at me. At that time one surveyor left the area to alert the Director of Nursing and Administrator, and one surveyor remained and observed OT #1 bring Resident #54 his/her table. OT #1 then aggressively and repeatedly told Resident #54 I said pick up your feet, pick up your feet! At no time during the observation did staff intervene, remove OT #1 from the area or check on Resident #54 while he/she was being yelled at in the hallway. During an interview on 5/14/24 at 12:24 P.M., the DON said that OT #1 had been suspended from the building due to the interaction between her and Resident #54. During an interview on 5/14/24 at 1:00 P.M., Nurse #1 said that OT #1's behavior was inappropriate and she would not have wanted someone to speak to her in that way. During an interview on 5/14/24 at 12:38 P.M., Resident #54 said that he/she was upset during and after being yelled at by OT #1 in the hallway. Resident #54 said he/she was embarrassed. Resident #54 said that OT #1 is always like that. She's so mean. I just want to be treated like a person.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, policy review and interviews, the facility failed to ensure one Resident (#13) was free from restraints by locking the remote control for the bed, preventing the Resident to reposition him/herself in bed, out of a total sample of 22 residents. Findings include: Review of the facility policy titled, Physical Restraints, dated 1/1/17, indicated the following: -The facility recognizes each resident's right to be treated with respect and dignity including the right to be free from any physical restraint imposed for the purposes of discipline or convenience and not required to treat the resident's medical condition. -The policy includes an interdisciplinary process of assessment and reassessment in order to ensure that when a restraint is necessary to treat a resident's medical condition the least restrictive is utilized for the least amount of time to treat the resident's medical condition with the plan for continued assessment and reduction. -Components of constraint use: interdisciplinary assessment, MD order, consent, care planning, see period end. C.N.A. care card, reduction plan, reassessment. -Physical restraint is defined as any manual method, physical or mechanical device, equipment or material that meets the following criteria: restricts the patient's freedom of movement or normal access to his/her body. Resident #13 was admitted to the facility in December 2021 with diagnoses including dementia, diabetes, heart failure and pulmonary disease. Review of Resident #13's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15, which indicated the Resident had moderate cognitive impairment. The MDS also indicated the Resident is dependent on staff for all functional daily tasks. During an interview on 5/15/24 at 8:00 A.M., Resident #13 said he/she felt stuck in bed and that the staff had purposely broken his/her bed remote so that he/she could not change positions in bed. Resident #13 said he/she would like to be able to move his/her bed so his/her legs could be in different positions. Resident #13 was observed lying in bed with the foot of the bed flat and his/her bed remote was under the bed. The surveyor observed the bed remote and the buttons on the remote were lit up as locked so the foot of the bed and height of the bed could not be changed. Resident #13 said he/she never agreed to having the remote buttons locked. Review of Resident #13's medical record, including all care plans, failed to indicate a safety need for the bed remote to be locked or a restraint assessment. During an interview on 5/15/24 at 8:08 A.M., Certified Nursing Assistant (CNA) #2 said Resident #13 is a high fall risk and the facility intentionally locks the buttons on the Resident's bed remote so he/she can't move the bed. CNA #2 said the Resident used to raise the bed high and/or raise the foot of the bed high creating a fall risk so the facility started locking the bed remote to eliminate his/her ability to do so. During an interview on 5/15/24 at 8:16 A.M., the Nursing Supervisor said Resident #13 is cognitively intact and he/she is still capable of making his/her own decisions. The Nursing Supervisor said Resident #13 likes to play with his/her bed remote and at times put the bed in an unsafe position, which had caused the decision to lock his/her bed remote. The Nursing Supervisor said she could see how this could be a restraint due to the Resident not being able to change his/her position in bed. During an interview on 5/15/24 at 8:38 A.M., the Director of Nursing said a restraint assessment is completed whenever a device is in place that could limit a resident's movement. The DON said that if a resident is cognitively and physically able to use a bed remote, the remote should be within reach for a resident to use independently. The DON said she did not believe Resident #13's bed remote being locked was considered a restraint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure staff followed its abuse policies and procedures for one Resident (#54) out of a total of 22 sampled residents. Specifically, staff who were present when Occupational Therapist (OT) #1 yelled at Resident #54 did not intervene or remove OT #1 from the unit per policy. Findings include: Review of the facility's Abuse Prohibition policy dated 2/20/23 indicated: *The facility prohibits the mistreatment, neglect and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends, etc. Each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. Residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers and staff of other agencies serving the resident. *Types of abuse: Verbal: oral, written or gestured language, that willfully includes disparaging and derogatory terms, to the resident/patient or their families, or within their hearing distance to describe resident/patient. Mental/Emotional Abuse: includes but is not limited to, humiliation, harassment and threats of punishment or deprivation. *Identification: Instruct staff staff, resident/patient, family, visitor, etc to report immediately without fear of reprisal, any knowledge or suspicion of suspected abuse, neglect, mistreatment, and/or misappropriation of property. *Protection: Provide for the immediate safety of the resident/patient, upon identification of suspected abuse, neglect, mistreatment, and/or misappropriation of property; move resident/patient to another room or unit. provide 1:1 monitoring as appropriate. Immediate suspension of suspected employee pending outcome of the investigation. Resident #54 was admitted to the facility in April 2024 with diagnoses including cerebral infarction (stroke), cognitive communication deficit and unspecified dementia. Review of the Minimum Data Set Assessment (MDS) dated [DATE] indicated Resident #54 scored a 14 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS) indicating he/she is cognitively intact. On 5/14/24 at 12:05 P.M., the surveyors were at the nurses station, along with Nurse #1, the Wound Physician and Certified Nursing Assistant (CNA) #1 on the left side unit. The surveyors and facility staff observed Resident #54 being wheeled in his/her wheelchair by OT #1. OT #1 was loudly and sternly repeating to Resident #54, Pick up your feet! Pick up your feet! Resident #54 appeared unsure of these directions, stood up in the wheelchair and OT #1 abruptly, loudly and aggressively said What are you doing!? Where are you going!? Resident #54 then responded saying that he/she was picking up his/her feet and OT #1 yelled No! I told you to sit! and gestured to a nearby resident indicating she wanted Resident #54 to be seated next to him/her. The resident OT #1 was referring to was seated close by and attempted to intervene and speak and OT #1 said to him/her, you're not helping. Resident #54 then attempted to speak with OT #1 and he/she loudly and aggressively yelled Sit down! Resident #54 then turned slowly to sit down in the wheelchair with his/her shoulders slumped down and turned his/her head down. OT #1 then brought Resident #54's wheelchair and placed him/her next to the resident who attempted to intervene and said, There. Now you two can gripe together!, and walked into Resident #54's room to obtain his/her tray table. The surveyor approached Resident #54. Resident #54's face was drawn and sad. Resident #54 looked at the surveyor and said, She's so mean. She's just so mean. She's always yelling at me. At that time one surveyor left the area to alert the Director of Nursing and Administrator, and one surveyor remained and observed OT #1 bring Resident #54 his/her table. OT #1 then aggressively and repeatedly told Resident #54 pick up your feet, pick up your feet! and then left the area. At no time during the observation did staff intervene, remove OT #1 from the area or check on Resident #54 while he/she was being yelled at in the hallway. During an interview on 5/14/24 at 12:24 P.M., the DON said that OT #1 had been suspended from the building. During an interview on 5/14/24 at 12:38 P.M., Resident #54 said that he/she was upset during and after being yelled at by OT #1 in the hallway. Resident #54 said he/she was embarrassed. Resident #54 said that OT #1 is always like that. She's so mean. I just want to be treated like a person. During interviews on 5/14/24 at 1:00 P.M., and 5/15/24 at 8:08 A.M. Nurse #1 said that OT #1's behavior was inappropriate and she should have intervened and said something during the observation. Nurse #1 said she would not want someone to speak to her the way OT #1 spoke to Resident #54. During an interview on 5/15/24 at 8:47 A.M., CNA #1 confirmed she just started at the facility this week. CNA #1 said she thought Nurse #1 was going to say something and intervene during the incident. During an interview on 5/14/24 at 2:18 P.M., the Social Worker said that staff should have intervened while observing the interaction between OT #1 and Resident #54.

Based on record review and interview, the facility failed to report an allegation of neglect to the state agency as required for one Resident (#285) out of a total of 22 sampled residents. Findings include: Review of the facility's Abuse Prohibition policy, dated 2/20/23 indicated: The Administrator is responsible for ensuring that there has been notification [to] local law enforcement and the State Survey Agency within two hours of allegation after identification of alleged/suspected incident. All alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of an unknown source and misappropriation of resident property are reported immediately but not later than two hours after the allegation is made. Review of the grievance book included a grievance dated 6/13/23 which indicated that Resident #285's family member had found Resident #285 in his/her room not wearing oxygen (02). The grievance indicated that nurse staff then took Resident #285's 02 saturation level and he/she was at an Oxygen saturation of 81 percent. The family member documented on the grievance form this is neglect. Review of the facility's reporting history to the state agency failed to indicate the allegation of neglect was filed with he state agency regarding Resident #285's lack of needed oxygen. During an interview on 5/16/24 at 7:45 A.M., the Director of Nursing (DON) reviewed the grievance with the surveyor and said she recalled the incident. The DON said she wasn't sure if the incident was filed with the state agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.Resident #23 was admitted to the facility in 04/21 with diagnoses including cerebrovascular accident (CVA) or a brain attack, is an interruption in the flow of blood to cells in the brain, also known as a stroke with left hemiparesis, paralysis that affects only one side of your body and can result from a CVA. Review of the Minimum Data Set (MDS) dated [DATE] and Brief Interview for Mental Status (BIMS) assessment, indicated Resident #23 scored 6 out of a possible 15, indicating severe cognitive impairment. Further review indicated Resident #23 required moderate assist with eating. During an observation on 5/14/24 at 8:30 A.M., the surveyor observed resident sitting up in bed, being fed by a Certified Nursing Assistant (CNA). The meal was pureed with nectar thick liquids. The nectar thick liquid was being provided via a cup. During an observation on 5/14/24 at 12:42 P.M., the surveyor observed Resident #23 sitting up in bed eating with set up and supervision. The Resident was drinking thick liquids from a cup. During an observation on 5/15/24 at 1:27 P.M., the surveyor observed a CNA providing nectar thick milk to resident via a straw. Resident was observed coughing after drinking. During an observation on 5/16/24 at 8:42 A.M., CNA #2 was feeding resident breakfast. The CNA was alternating bites of puree food with sips of nectar milk from cup. Resident #23 had 2 episodes of coughing during the meal. Review of dietary communication sheet dated 2/12/24 indicated nectar thick liquids via spoon. Review of Resident #23's speech therapy (ST) discharge summary recommendation dated 9/8/23 indicated, to facilitate safety and efficiency, it is recommended that the patient use the following strategies during oral intake: - one bite at a time and swallow, small bites/sips, no straws, take a sip after every 2 bites -alteration of liquids/solids -lingual sweep, an oral motor exercise that involves moving the tongue between the cheek and teeth, and up and down, to clear the oral cavity with written and verbal cues and general swallow techniques/precautions Review of Resident #23's speech therapy discharge summary recommendation dated 4/19/24 indicated nectar thick liquids via spoon only. Review of the Fiberoptic Endoscopic Evaluation of Swallowing (FEES) test, a procedure that assesses how well someone swallows, results dated 8/17/23 indicated the following: -reflux finding score total score=9. The score is considered: higher than typical score; of concern for Laryngopharyngeal Reflux (LPR) or silent reflux which is when stomach contents reflux into the esophagus. Recommendation for feeding: upright during and after meal, elevate head of bed at non-feeding times, liquids by spoon only, assist with meals. Review of Resident #23's aspiration care plan indicated the following intervention: -No straws. Review of Resident #23's physician orders indicated the following: -pureed texture, nectar consistency, nectar thick liquids via spoon, add sauces and gravy to all puree meat. During an interview on 5/15/24 at 1:27 P.M., CNA #3 was asked if she knew of any dietary/feeding adaptations that are needed to ensure this Resident's safe swallowing. CNA #3 stated that Resident had pureed and thickened liquids. She stated that she learns what is required to provide care to a resident by asking other CNA's and nurses and by reviewing the care card (a form indicating the level of assistance required). CNA #3 confirmed Resident #23 was coughing during meal. During an interview on 5/16/24 at 8:42 A.M., CNA #2 said that Resident's precautions for eating include lip plate, built up utensils, puree and nectar thick liquid alternating with 2 bites of food. CNA #2 stated the dietician or nurse will communicate any changes in diets and that there is a communication at desk from SLP to sign off that received the education. During an interview on 5/15/24 at 1:36 P.M., Nurse #3 states resident's diet is puree, nectar thick and needs extra gravy/sauce if food is dry. Nurse #3 said she is not aware of any restrictions or needs. Nurse #3 said if a change is made to a resident's diet or specific recommendations are made by the speech therapist, a communication slip is brought to the unit and the nurse enters the order and updates CNA's and the care plan. During an interview on 5/15/24 at 1:47 P.M., the Nursing Supervisor states Resident #13's's diet needs are pureed texture, thickened liquids, lip plate, right sided angled and built-up utensils. The nursing Supervisor said Resident #13 can feed him/herself 50% of the time and the other 50% he/she needs to be fed. The nursing Supervisor said a communication slip is placed in the chart and a copy to kitchen for any diet change or adaptive equipment. Changes are put in care card binder for CNAs to learn of any changes. The Nursing Supervisor said all recommendations from the speech therapist should be followed. During an interview on 5/16/24 at 8:35 A.M., the Speech Therapist said when a recommendation is made, a diet communication form goes to the kitchen, it is signed by someone in kitchen, a photocopy is made to keep in the chart, and a second copy is kept for therapy. The Speech Therapist said when a resident is receiving speech therapy or is being discharged from SLP services, the staff is educated via an in-service sheet or verbally. The Speech Therapist said she would expect aspiration precautions to be followed because the risk of not being followed would be detrimental (aspiration). She said she would expect aspiration precautions to be always followed, as even one time not being followed has potential for aspiration. The Speech Therapist said Resident #23 had completed a FEES exam and in the past and the test showed resident was at significant risk for aspiration. The Speech Therapist said she discharged Resident #23 from services with recommendations for nectar liquids via spoon and part of education when discharged was that spoon was safest way to provide thickened liquids, always by spoon, never by straw as high risk for aspiration. The Speech Therapist has noticed inconsistency with staff following aspiration precautions in the 2 months since she has been at facility. During an interview on 5/16/24 at 10:31 A.M., the Director of Nursing (DON) said when a resident is discharged from speech therapy, the resident is followed at the weekly at-risk meeting and daily at morning meetings. The DON said the restorative aide checks diets ad does audits regularly. The DON said the risk for not following aspiration precautions is aspiration pneumonia and aspiration precautions should be always followed because even one time of not following the precautions can put resident at risk. w Based on record review, observations and interviews, the facility failed to ensure resident centered care plans were implemented for three Residents (#64, #182, #23) to ensure aspiration risk precautions were followed, out of a total sample of 22 residents. Findings include: Review of the facility policy titled Activities of Daily Living (ADLs), dated December 2022, indicated To provide support, assistance, and encouragement to remain as independent as possible with activities of daily living, including hygiene, mobility, elimination, dining, and communication; and that the care and services provided are person-centered, and honor and support each resident's preferences, choices, values, and beliefs. A resident who is unable to carry out activities of daily living will receive the services to maintain good nutrition, grooming, and personal and oral hygiene. 1. Resident #64 was admitted to the facility in June 2023 with diagnoses including dysphagia, type 2 diabetes, and chronic obstructive pulmonary disease (COPD). Review of Resident #64's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 4 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident has severe cognitive impairments. On 5/14/24 at 8:31 A.M., the surveyor observed Resident #64 in bed eating his/her breakfast, no staff were present in the room. On 5/14/24 from 11:53 A.M. to 12:01 P.M., the surveyor observed Resident #64 in the hallway eating his/her lunch tray. No staff were present supervising the Resident, staff were observed passing out other trays to other residents. The Residents' tray was noted to have ground meat and not pureed meat. On 5/15/24 at 8:11 A.M. to 8:20 A.M., the surveyor observed Resident #64 in the hallway eating his/her breakfast tray. No staff were present supervising the Resident, staff were observed passing out other trays to other residents. The Resident was observed to be using his/her hands trying to open his/her milk container and observed to cough and sneeze multiple times through out the meal. On 5/15/24 from 12:14 P.M. to 12:31 P.M., the surveyor observed Resident #64 in the hallway eating his/her lunch tray. No staff were present supervising the Resident, staff were observed passing out other trays to other residents. The Resident was observed to be coughing multiple times through out the meal. On 5/16/24 from 8:13 A.M. to 8:20 A.M., the surveyor observed Resident #64 in the hallway eating his/her breakfast tray. No staff were present supervising the Resident, staff were observed passing out other trays to other residents. On 5/16/24 at 12:26 P.M., the surveyor observed Resident #64 in the hallway eating his/her lunch tray. No staff were present supervising the Resident, staff were observed passing out other trays to other residents. Review of Resident #64's Speech Therapy Discharge summary, dated [DATE], indicated Supervision: How often does the patient require supervision/assistance at mealtime d/t swallow safety? 91-100% of the time. Review of Resident #64's physician order, dated 6/21/23, indicated CCD diet, Pureed texture, Nectar consistency. Review of Resident #64's activity of daily living care plan, dated 3/4/24, indicated EATING: Resident requires Physical Assist/dependent. Review of Resident #64's aspiration risk care plan, revised 3/4/24, indicated encourage to clear throat/cough after every 2-3 bites/sips. Review of Resident #64's active Certified Nurse Aide (CNA) Care Card, indicated the Resident is an aspiration risk and is a total dependent (fed) for eating. During an interview on 5/15/24 at 9:25 A.M., the Day Shift Nursing Supervisor said the CNA care cards are active and should be up to date so the CNA's can care for each resident appropriately. If there is a major change therapy or nursing update it immediately. The Nursing Supervisor said that the CNA's should be following what the care card says for each resident. During an interview on 5/15/24 at 12:15 P.M., the Director of Rehab said therapy keeps care cards up to date when major changes are made like a diet or transfer status. During an interview on 5/16/24 at 8:30 A.M., the Speech Therapist said supervision means someone being close by to remind Resident #64 of clearing his/her throat and to take sips of fluids. The Speech Therapist said the Resident has specific interventions and is an aspiration risk. The Speech Therapist reviewed the speech discharge summary for Resident #64 and said he/she should be closely supervised by staff. During an interview on 5/16/24 at 8:57 A.M., CNA #1 said that she follows each resident's care card and if a resident should be supervised [NAME] a staff member should be with that resident. During an interview on 5/16/24 at 9:13 A.M., the Director of Nurses (DON) said she expects that if a Residents plan of care says they should be supervised she expects staff to be in close proximity to the resident they are supervising so they can monitor for aspiration or assist the resident as needed. 2. Resident #182 was admitted to the facility in May 2024 with diagnoses that included pneumonia, type 2 diabetes, and end stage renal disease requiring dialysis. On 5/14/24 at 8:35 A.M., the surveyor observed Resident #182 in bed alone with his/her breakfast. No staff were present in the room. On 5/14/24 from 11:54 A.M. to 12:01 P.M., the surveyor observed Resident #182 in bed alone with his/her lunch. No staff were present in the room. On 5/16/24 from 8:36 A.M. to 8:40 A.M., the surveyor observed Resident #182 in bed alone with his/her breakfast. No staff were present in the room. On 5/16/24 at 12:27 P.M., the surveyor observed Resident #182 in bed alone with his/her lunch. No staff were present in the room. Review of Resident #182's physician order, dated 5/13/24, indicated the Resident needs to be out of bed and in a supervised area (for meals). Review of Resident #182's physician order, dated 5/14/24, indicated Renal diet, Regular texture, Nectar consistency. Review of Resident #182's active Certified Nurse Aide Care Care, indicated Diet: Regular, thin liquids. Review of Resident #182's nursing progress note, dated 5/14/24, indicated patient coughing with thin liquids, new order for nectar thick liquids, no straws and crush meds. Review of Resident #182's speech therapy evaluation and plan of treatment, dated 5/3/24, indicated Swallow Strategies: Upright with all PO (by mouth) and following 30 minutes, small bites and sips, supervision with meals. Review of Resident #182's speech therapy evaluation and plan of treatment, dated 5/14/24, indicated Patient and nsg (nursing) educated regarding recommendation for NTLs (nectar thick liquids), upright as tolerated with PO (by mouth), no straws. Education and training completed including but not limited to recommended diet change, supervision and positioning during meals and PO between meals. Review of Resident #182's nursing progress notes did not indicate that the resident refused staff to supervise him/her in his/her room. During an interview on 5/15/24 at 9:25 A.M., the Day Shift Nursing Supervisor said the CNA care cards are active and should be up to date so the CNA's can care for each resident appropriately. If there is a major change therapy or nursing update it immediately. The Nursing Supervisor said that the CNA's should be following what the care card says for each resident. During an interview on 5/16/24 at 8:43 A.M., the Speech Therapist said the Resident should be out of bed and closely supervised by a staff member. The Speech Therapist said the Resident is an aspiration risk and at risk for pneumonia. The Speech Therapist said Resident #182 does not refuse to be supervised. During an interview on 5/16/24 at 8:57 A.M., CNA #1 said that she follows each resident's care card and if a resident should be supervised then a staff member should be with that resident. During an interview on 5/16/24 at 9:13 A.M., the Director of Nurses (DON) said she expects that if a Residents plan of care says they should be supervised she expects staff to be in close proximity to the resident they are supervising so they can monitor for aspiration or assist the resident as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, policy review and interviews, the facility failed to provide showers for one Resident (#62) out of a total sample of 22 residents. Findings include: Review of the facility policy titled, Activities of Daily Living, dated 12/22/21, indicated the following: -the resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Resident #62 was admitted to the facility in January 2024 with diagnoses including heart failure. Review of Resident #62's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 9 out of a possible 15, which indicated Resident #62 had moderate cognitive impairment. The MDS also indicated Resident #63 required substantial assistance from staff for bathing tasks. During an interview on 5/14/24 at 7:44 A.M., Resident #62 said he/she had not received a shower in a long time and would like one. Resident #63 said he/she used to have regular shower but now just gets washed in bed. Review of Resident #63's decline in function care plan last revised, 4/18/24, indicated: -Assist with bathing, dressing tasks but encouraged to participate. The care plan failed to indicate Resident #63 refuses showers. Review of the Certified Nursing (CNA) documentation indicated Resident #63 was last provided with a shower on 4/5/24, 40 days ago. The documentation failed to indicate the Resident refused a shower. During an interview on 5/15/24 at 12:35 P.M., Nurse #3 said Resident #62 does not refuse activities of daily living care. During an interview on 5/15/24 at 12:38 P.M., CNA said all residents are scheduled to receive at least one shower a week. CNA #2 said she knows Resident #63 well and the Resident does not refuse care. CNA #2 said she does not know the last time the Resident received a shower. During an interview on 5/15/24 at 1:51 P.M., the Director of Nursing (DON) said all residents are scheduled to receive a shower at least once a week. The DON said the facility has been auditing the shower schedule because getting showers for people and determining from documentation when they last had a shower has been an issue at the facility. The DON reviewed the CNA documentation for Resident #62 with the surveyor and conformed the Resident's last shower was on 4/5/24.

Based on observation, record review and interview, the facility failed to provide vision services as requested for one Resident (#60) out of a total sample of 22 residents. Specifically, the facility failed to follow up with the Resident's and physician's request to schedule an appointment for glasses for Resident #60. Findings include: Review of the facility policy titled Vision and Hearing, dated and revised 12/21/21, indicated the following: - The facility will provide from an outside source ophthalmology and audiology services to meet the needs of the residents. - The facility will, if necessary or requested, assist the resident with: making appointments, arranging transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision of hearing assistive devices. - Assistive devices to maintain vision include, but are not limited to, glasses During an interview on 5/14/24 at 7:49 A.M., Resident #60 told the surveyor that he/she cannot see and he/she needs glasses. During an interview on 5/15/24 at 8:54 A.M., Resident #60 told the surveyor that he/she cannot see and it is hard to see. During an observation on 5/16/24 at 8:48 A.M., Resident #60 was speaking to another resident saying that he/she needs glasses and he/she was gesturing towards his/her eyes. Review of Resident #60's physician's order dated 6/5/23 indicated the following: - podiatry, audiology, dental, ophthalmology consults as needed. Review of Resident #60's comprehensive eye exam dated 1/8/24 indicated the following: - Plan: Monitor; order eyeglasses if pt. (patient) requests Review of Resident #60's physician's visit documentation dated 3/26/24 indicated the following: - The patient has also stated in the recent past that he/she would like to see an eye doctor. This has been related [sic] to the nursing staff. During an interview on 5/15/24 at 8:48 A.M., the Nursing Supervisor said if a resident requests to be seen by the eye doctor they will be put on the list to be seen. The Nursing Supervisor reviewed the upcoming schedule for the eye doctor and Resident #60 was not on the list to be seen. The Nursing Supervisor and the surveyor reviewed the previous eye doctor visit notes and physician's notes and she said that Resident #60 should have been seen or scheduled to be seen by the eye doctor. During an interview on 5/16/24 at 10:27 A.M., the Director of Nursing (DON) said Resident #60 should have been seen or scheduled to be seen by the eye doctor. The DON said that nursing staff was not notified by the doctor of Resident #60's request to be seen and it was missed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to ensure that a resident admitted with an indwelling catheter is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates continued catheter use is necessary for one Resident (#23) in a total sample of 22 residents. Findings include: Review of the facility policy which is according to the Resident Assessment Instrument (RAI), indicated the following: -Indwelling catheters should not be used unless there is valid medical justification. Assessment should include consideration of the risk and benefits of an indwelling catheter, the anticipated duration of use, and consideration of complications resulting from the use of an indwelling catheter. Complications can include an increased risk of urinary tract infection, blockage of the catheter with associated bypassing of urine, expulsion of the catheter, pain, discomfort, and bleeding. Resident # 23 was admitted to the facility in 04/18/2021 with diagnoses including left hemiparesis and readmitted after hospitalization in 01/26/2024 with diagnoses including acute kidney injury and urinary retention. Review of the Minimum Data Set (MDS) assessment dated [DATE] and Brief Interview for Mental Status (BIMS) indicated Resident #23 scored 6 out of a possible 15, indicating severe cognitive impairment. Further review indicated Resident #23 required an indwelling catheter. Review of the Physician's order dated 01/26/2024 indicated: Foley catheter #16 with 10 ml balloon due to urinary retention. Review of resident's care plan dated 01/31/2024 indicated: Has an Indwelling Foley Catheter for urinary retention. Review of the resident's medical history and diagnosis lists failed to indicate a diagnosis that indicates the continued need/use of a catheter. Review of Resident #23's record indicated that he/she was hospitalized from [DATE]-[DATE]. The hospital paperwork indicated the following: -the Resident had catheter inserted due to urinary retention. -the hospital recommended a voiding trial to possible remove the catheter. Further review of Resident #23's medical record failed to indicate a voiding trial was completed at the facility. During an interview on 05/16/2024 at 10:41 A.M., the Director of Nursing said the reason for having an indwelling foley catheter would be an approved diagnoses of neurogenic bladder or obstructive uropathy. The DON stated she was aware the Resident did not have a required diagnosis for the long-term use of a catheter. A resident that has an indwelling catheter without an approved diagnoses should have a voiding trial.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to address the nutritional status in a timely manner for one Resident (#19) out of a total sample of 22 residents. Specifically, the facility failed to address a significant weight loss in a timely manner for Resident #19. Findings include: Review of the facility policy titled Weight Monitoring, revised and dated 12/22/21, indicated the following: - Any weight change of 5% or more since the last weight assessment will be retaken within 24 hours for confirmation. If the weight is verified, nursing will notify the Dietitian, Physician and the resident/responsible party. - The Dietitian will review the weights monthly to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. The plan of care will be updated as needed. - The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a. 1 month - 5% weight loss is significant. b. 3 months - 7.5% weight loss is significant. c. 6 months - 10% weight loss is significant. Resident #19 was admitted to the facility in July 2022 with diagnoses including Parkinsonism, hyperlipidemia and anxiety disorder. Review of Resident #19 most recent Minimum Data Set Assessment (MDS) dated [DATE], indicated that the Resident had a Brief Interview for Mental Status score of 5 out of a possible 15 indicating severe cognitive impairment. Further review of the MDS indicated that the Resident requires assistance with activities of daily living. Review of Resident #19's weight log indicated the following: - 1/5/24: 125.7 lbs. (pounds) - 2/7/24: 116 lbs. - 2/8/24: 115.9 lbs. - 2/9/24: 115 lbs. - 2/16/24: 115.7 lbs. - 2/26/24: 113 lbs. - 3/8/24: 113 lbs. - 3/15/24: 114.8 lbs. - 3/20/24: 112.1 lbs. - 3/29/24: 115.6 lbs. - 4/5/24: 113.1 lbs. - 4/5/24: 113.1 lbs. - 5/3/24: 110 lbs. - 5/6/24: 112 lbs. From 1/5/24 to 2/7/24, Resident #19 had a significant weight loss of 7.72%. From 2/7/24 onwards, Resident #19's weight remained less than 116 lbs. Review of Resident #19's physician's order dated 1/25/24 indicated the following: - Record monthly weight every day shift starting on the 5th and ending on the 5th every month. Review of Resident #19's Nutrition risk care plan, dated and revised 4/10/24 indicated the following interventions: - Notify RD (Registered Dietitian), Physician and family of significant weight change. Review of Resident #19's comprehensive Nutrition assessment dated [DATE] indicated the following: - Nutrition Goal: Maintain weight - Additional comments: Resident #19 is flagging for 11.2% significant weight loss since 11/3/23 when he/she weighed 127.3 lbs. Rec (Recommend) adding 237 mL (milliliter) Ensure (a nutrition supplement) daily to better meet nutrition needs. Will continue to monitor. Care plan reviewed and updated. Review of Resident #19's physician's order dated 4/11/24 indicted the following: - Ensure supplement: one time a day Resident #19's documented significant weight loss was not addressed until the Nutrition Assessment on 4/10/24, over two months since the significant weight loss was documented. During an interview on 5/16/24 at 8:20 A.M., the Nursing Supervisor and the surveyor reviewed Resident #19's weights and she said the Resident has had some weight loss and has not gained any weight back. During an interview on 5/16/24 at 9:31 A.M., the Registered Dietitian (RD) said she started working in the facility in late March and works in the facility two days each week. The RD said the nursing aides take the residents' weights and once documented in the medical record she will review the weights for any significant weight changes. The RD said a significant weight loss is a loss of 5% in one month, 7.5% in 3 months and 10% in six months. The RD said if a significant weight loss is identified, a reweigh will occur to check accuracy, once confirmed, she will speak with the resident and interdisciplinary team and assess the resident. She would then recommend interventions for significant weight loss. The RD said she is continuing to catch up with all the residents' nutritional status as she just started the position. When asked about Resident #19's significant weight loss, she said he/she should have been assessed sooner than the 4/10/24 assessment so interventions could have been started sooner to combat the weight loss.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to provide respiratory care services in accordance with professional standards of practice one Resident (#8) out of a total sample of 22 residents. Specifically, the facility failed to follow Resident #8's physician's orders to implement the correct oxygen flow rate and ensure the external filter was clean. Findings include: Review of the facility policy titled Equipment Change/Disinfection, undated, indicated the following: - Oxygen Concentrators: Rinse and dry the external filter weekly and PRN (as needed) when visibly dusty. Resident #8 was admitted to the facility in March 2023 with diagnoses including chronic heart failure, type 2 diabetes mellitus and pneumonia. Review of Resident #8's most recent Minimum Data Set Assessment (MDS) dated [DATE], indicated that the Resident had a Brief Interview for Mental Status score of 13 out of a possible 15 indicating intact cognition. Further review of the MDS indicated that Resident #8 requires assistance with all activities of daily living and requires supplement oxygen. The surveyor made the following observations during survey: - On 5/14/24 at 8:03 A.M. and 12:41 P.M., Resident #8 was sleeping in bed receiving oxygen via nasal cannula at 1.5 Liters (L). The external filter on the back of the machine was covered in white dust. - On 5/15/24 at 7:04 A.M., Resident #8 was sleeping in bed receiving oxygen via nasal cannula at 1.5L. The external filter on the back of the machine was covered in white dust. - On 5/16/24 at 7:06 A.M., Resident #8 was sleeping in bed receiving oxygen via nasal cannula at 1.5L. The external filter on the back of the machine was covered in white dust. Review of Resident #8's physician's orders indicated the following: - Dated 4/12/24: Clean O2 (oxygen) concentrator filter and sponges every Tues and Fr 11-7 - Dated 4/30/24: O2 at 3L via N/C (nasal cannula to maintain sats (saturation) >90%. Review of Resident #8's care plan or pneumonia care dated 5/6/24 indicated the following intervention: - O2 as ordered. Review of Resident #8's care plan for bouts of shortness of breath dated 3/7/24 indicated the following intervention: - Resident can have O2 at 2L via n/c to maintain O2 sats >90% due to shortness of breath. Review of a nursing progress note dated 4/29/23 at 11:07 P.M., indicated the following: - O2 bump up to 3L. During an interview on 5/16/24 at 8:20 A.M., the Nursing Supervisor said when a resident is on oxygen, there are physician's orders stating the flow rate and for the external filter to be cleaned at least weekly. The Nursing Supervisor and the surveyor reviewed Resident #8's physician's orders and the Nursing Supervisor said his/her oxygen flow rate should be at 3 liters and the external filter should be changed on Tuesdays and Fridays. The Nursing Supervisor and the surveyor then observed Resident #8's oxygen concentrator, it was set to 1.5 L and the external filter was visibly covered in white dust. The Nursing Supervisor said the oxygen flow rate was incorrect and she corrected it, she then said the filter was very dirty and proceeded to clean it. The Nursing Supervisor said the night nursing staff should be cleaning the filter. During an interview on 5/16/24 at 10:27 A.M., the Director of Nursing said physician's orders should be followed for oxygen flow rate and for cleaning the external filter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #23 was admitted to the facility in 04/21 with diagnoses including cerebrovascular accident (CVA) or a brain attack, is an interruption in the flow of blood to cells in the brain, also known as a stroke with left hemiparesis, paralysis that affects only one side of your body and can result from a CVA. Review of the Minimum Data Set (MDS) dated [DATE] and Brief Interview for Mental Status (BIMS) assessment, indicated Resident #23 scored 6 out of a possible 15, indicating severe cognitive impairment. Further review indicated Resident #23 required moderate assist with eating. During an observation on 5/14/24 at 12:42 P.M. the surveyor observed Resident #23 sitting up in bed, being fed by a CNA. The Residents' tray was observed to have ground meat and not pureed meat. There was no gravy on the meat. Review of Resident #23's physician orders indicated the following order: - Pureed texture, nectar consistency, nectar thick liquids via spoon, add sauces and gravy to all puree meat, initiated on 2/12/24. The surveyors obtained a sample of the pureed lunch meat served that day. During an interview on 5/14/24 at 1:01 P.M., the Nursing Supervisor observed the pureed meat and said it looked like ground meat and that it was not moist enough to be pureed texture. The Nursing Supervisor said this has been an issue at times at the facility. During an interview at 5/14/24 at 1:21 P.M., the Speech Therapist observed the pureed meat and said it looked like it was ground consistency. The Speech Therapist said the meat would need to be smoother and have more moisture to be pureed. During an interview on 5/14/24 at 1:24 P.M., the Director of Nursing (DON) observed the pureed meat and said it looked like ground meat. The DON said the meat would need to be smoother and have more moisture to be pureed. Based on observations, interviews and record review, the facility failed to provide food in a form to meet the needs of three Resident (#64, #13, and #23) out of a sample of 22 residents. Specifically, for Residents #64 and #24, the facility to provide the correct diet texture during meals. For Resident #13, the facility failed to provide the correct diet during meals and failed to prevent the Resident from consuming food that was of a texture not ordered by the physician. Findings include: 1. Resident #64 was admitted to the facility in June 2023 with diagnoses including dysphagia, type 2 diabetes, and COPD chronic obstructive pulmonary disease. Review of Resident #64's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 4 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating the Resident has severe cognitive impairments. On 5/14/24 from 11:53 A.M. to 12:01 P.M., the surveyor observed Resident #64 in the hallway with his/her lunch tray. The Residents' tray was observed to have ground meat and not pureed meat. Review of Resident #64's physician order, dated 6/21/23, indicated Pureed texture, Nectar consistency. Review of Resident #64's aspiration risk care plan, revised 3/4/24, indicated encourage to clear throat/cough after every 2-3 bites/sips. The surveyors obtained a sample of the pureed lunch meat served that day. During an interview on 5/14/24 at 1:01 P.M., the Nursing Supervisor observed the pureed meat and said it looked like ground meat and that it was not moist enough to be pureed texture. The Nursing Supervisor said this has been an issue at times at the facility. During an interview at 5/14/24 at 1:21 P.M., the Speech Therapist observed the pureed meat and said it looked like it was ground consistency. The Speech Therapist said the meat would need to be smoother and have more moisture to be pureed. During an interview on 5/14/24 at 1:24 P.M., the Director of Nursing (DON) observed the pureed meat and said it looked like ground meat. The DON said the meat would need to be smoother and have more moisture to be pureed. 3. Resident #13 was admitted to the facility in December 2021 with diagnoses including dementia, diabetes, heart failure and pulmonary disease. Review of Resident #13's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 12 out of a possible 15, which indicated the Resident had moderate cognitive impairment. The MDS also indicated the Resident is dependent on staff for all functional daily tasks. Review of Resident #13's physician order initiated on 12/22/23 indicated the following: -NAS (no added salt) diet, pureed texture, thin liquids consistency. Review of Resident #13's nutritional care plan last revised 3/20/24, indicated the following: -Provide meals per physician diet orders. a.) On 5/14/23 at 12:40 P.M., Resident #13 was served lunch. The lunch tray was observed to have ground meat on the tray without any gravy on the meal. The surveyors obtained a sample of the pureed lunch meat served that day. During an interview on 5/14/24 at 1:01 P.M., the Nursing Supervisor observed the pureed meat and said it looked like ground meat and that it was not moist enough to be pureed texture. The Nursing Supervisor said this has been an issue at times at the facility. During an interview at 5/14/24 at 1:21 P.M., the Speech Therapist observed the pureed meat and said it looked like it was ground consistency. The Speech Therapist said the meat would need to be smoother and have more moisture to be pureed. During an interview on 5/14/24 at 1:24 P.M., the Director of Nursing (DON) observed the pureed meat and said it looked like ground meat. The DON said the meat would need to be smoother and have more moisture to be pureed. b.) Review of the facility policy titled, Family/Visitor Provided Food, dated 4/29/20, indicated the following: -Licensed nurse in charge, or nursing supervisor of the facility of the resident's unit will be notified by the visitor that they have brought their family member friend food or beverage. Nurse in charge or nursing supervisor will verify the resident's texture and restrictions. Throughout all days of survey, Resident #13 was observed lying in bed with several food items on his/her bedside table and in bags next to the bed that he/she could reach independently. The Resident was observed eating Oreo cookies, hard mints, and Cheez-it crackers. Review of Resident #13's medical record failed to indicate the Resident and/or his/her family was educated regarding the risks of eating foods not in pureed texture. During an interview on 5/15/24 at 8:16 A.M., the Nursing Supervisor said the Resident is prescribed a pureed food diet. The Nursing Supervisor said the Resident's family brings in food and that it does not meet the requirements of a pureed diet. The Nursing Supervisor said she is unaware if education had been provided to the Resident and/or his family regarding the risks of eating foods not in pureed texture. The Nursing Supervisor said a physician order also needs to be in place if a Resident chooses to consume food not in the texture ordered by the physician. During an interview on 5/15/24 at 8:38 A.M., the Director of Rehabilitation (DOR) said she was unaware Resident #13 had had food that is not allowed with his/her diet in his/her room. The DOR said the speech therapist would typically be told about that and would get involved to see if diet can be increased and if it is safe for the Resident to eat that texture of food. The DOR said Resident #13 had not had a speech therapy evaluation. During an interview on 5/15/24 at 8:58 A.M., the Director of Nursing said food in a resident's room should be in the texture of the physician order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately document one Resident's (#2) skin assessment out of a total sample of 22 residents. Findings include: Resident #2 was admitted to the facility in June 2021 with diagnoses including multiple sclerosis. Review of Resident #2's most recent Minimum Data Set (MDS) dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15, which indicated the Resident was cognitively intact. Review of the wound documentation dated 5/7/24 and 5/14/24 indicated Resident #2 had a stage 2 pressure wound to his/her right buttock, which first appeared on 5/5/24. Review of Resident #2's skin assessment dated [DATE] failed to indicate a right buttock pressure wound. During an interview on 5/16/24 at 8:41 A.M., Nurse #4 said all residents receive a skin assessment weekly and all skin issues are documented on those assessments regardless of the wound doctor documentation. During an interview on 5/16/24 at 8:51 A.M the Nursing Supervisor said skin assessments are completed weekly and should include any and all skin concerns. The Nursing Supervisor said if all skin issues are not documented on the assessment, the assessment would be inaccurate.

Based on observation, policy review, and interview, the facility failed to ensure treatment carts on two of two units were locked and secured while not in use. Findings include: Review of the facility policy titled, Storage of Medications, not dated, indicated the following: -Medications and biologicals are stored safely, securely, and properly. The medication supply is accessible only to licensed nursing staff is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. On 5/14/24 from 7:35 A.M. to 8:06 A.M., the surveyor observed the the Left Unit treatment cart unlocked and unsupervised in the hallway. On 5/15/24 at 7:52 A.M., the surveyor observed the the Left Unit treatment cart unlocked and unsupervised in the hallway. On 5/15/24 at 8:08 A.M., the surveyor observed the the Right Unit treatment cart unlocked and unsupervised in the hallway. During an interview on 5/16/24 at 9:11 A.M., Nurse #4 said the expectation is that the treatment carts are always locked unless a nurse is present at the cart. During an interview on 5/16/24 at 9:14 A.M., the Director of Nurses said she expects that treatment carts to be locked unless a nurse is present at the cart.

Based on observations, interviews, resident group meeting, and test tray results, the facility failed to ensure foods provided to residents were prepared by methods that conserve nutritional value, flavor, were palatable and at appetizing temperatures on 2 out of 2 units. Findings include: During the screening portion of the survey, numerous residents expressed concerns about poor food quality, palatability, and temperature. During the resident group meeting on 5/15/24 at 11:00 A.M., 8 out of 8 participating residents said that they did not like the food being served at the facility. Residents described the food as gross or disgusting. Review of the grievances book included two resident grievances regarding the quality of the food, food delivery and accurate meal orders. On 5/15/24 at 1:01 P.M., the left-wing unit food truck arrived. At 1:11 P.M., all resident trays were served, and the surveyors received test trays. The following results were recorded: 1a) -Pureed Chicken: 131 degrees Fahrenheit, no flavor, very bland. Warm to taste, not hot. - Pureed Vegetables: 132 degrees Fahrenheit, no flavor, very bland. Warm to taste, not hot. - Mashed potatoes: 136 degrees Fahrenheit, no flavor, very bland. Warm to taste, not hot. - Milk: 50 degrees Fahrenheit. Slightly warm, not cold to taste. - Coffee: 148 degrees Fahrenheit, no concerns. - Pureed fruit: 60 degrees Fahrenheit, cool, not cold to taste. 1b) - Macaroni and Cheese: 115 degrees Fahrenheit, cool to taste. No flavor, very bland and mushy. - Mixed vegetables: 114 degrees Fahrenheit. Cool to taste, mushy consistency, and no flavor. - Pineapple: 60 degrees Fahrenheit, had a canned, metallic taste. - Dinner Roll: 110 degrees Fahrenheit, no concerns. - Juice: 60 degrees Fahrenheit, slightly warm to taste. 1c) - Baked Chicken: 125 degrees Fahrenheit. Cool, not hot to taste. - Mashed Potatoes: 130 degrees Fahrenheit, warm, not hot to taste. No flavor, very bland. - Mixed Vegetables: 130 degrees Fahrenheit. Warm, not hot to taste. Mushy, no flavor. - Pineapple: 65 degrees Fahrenheit, slightly warm, not cold to taste. - Milk: 50 degrees Fahrenheit. Cool, not cold to taste. On 5/15/24 at 12:52 P.M., the left-wing unit food truck arrived. At 1:02 P.M., all resident trays were served, and the surveyor received a test tray. The following results were recorded: - Macaroni and Cheese: No flavor, very bland and mushy. During an interview on 5/16/24 at 8:09 A.M., the Activity Director said that residents report concerns about the food regularly during resident council meetings. During an interview on 5/16/23 at 8:30 A.M., the Nursing Supervisor said she has heard residents complaining about the poor quality and temperature of the food often. During an interview on 5/16/24 at 9:10 A.M., the Foodservice Director said she is aware that residents have been complaining about the food quality and temperature. During an interview on 5/16/24 at 10:27 A.M., the Director of Nursing (DON) said she knows the food is not good and they are trying to make it more palatable for the residents.

Based on observation and interview the facility failed to properly store food items and properly follow sanitation and food handling practices to prevent the risk of foodborne illness in accordance with professional standards for food service safety. Findings include: Review of the facility policy titled Food Receiving and Storage, undated, indicated the following: - Foods shall be received and stored in a manner that complies with safe food handling practices. - Food Services, or other designated staff, will maintain clean food storage areas at all times. - All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date) The surveyor made the following observations in the walk-in refrigerator during the initial walk-through of the kitchen on 5/14/24 at 7:10 A.M.: - A pan containing raw chicken was observed covered in plastic wrap with the date 5/7/24 written. The chicken was observed to be covered in slimy, pink juices. - A pan containing a cooked meat product covered with aluminum foil. There was no date or label identifying what the product was. - A sheet pan containing cooked bacon covered with plastic wrap with two dates written on it, 5/6/24 and 5/9/24. - A pan of pasta salad covered with plastic wrap with the date 5/6/24 written on it. - A box of raw mushrooms containing multiple mushrooms that were covered in brown, soft spots resembling decay. During the follow-up visit to the kitchen on 5/15/24 at 11:25 A.M., the surveyor observed the following on the tray line: - At 11:30 A.M., the diet aide left the tray line and was observed putting on new gloves without washing her hands before returning to the tray line. - At 11:34 A.M., a diet aide began preparing soup broth on a counter beside the tray line. She changed her gloves afterwards without washing her hands and returned to the tray line. - At 11:35 A.M., a diet aide entered the kitchen holding two drinking cups with bare hands. The diet aide was observed opening the ice machine and scooping ice directly into the cups while holding them with bare hands. Hand hygiene was not performed prior to this. - At 11:38 A.M., a diet aide was observed bringing over a food truck to the tray line. She then put on gloves without washing her hands. - From 11:25 A.M. through 11:40 A.M., the cook was observed grabbing dinner rolls directly with her gloved hands. The cook then asked a diet aide to bring her tongs. The aide grabbed the tongs by the part that touches the food with her bare hands and handed it to the cook. The cook then put the tongue in the pan containing the dinner rolls. During an interview on 5/16/24 at 9:10 A.M., the Foodservice Director (FSD) said staff should wash their hands before putting on gloves and staff should not be directly touching food with their hands, they should be using utensils. The FSD continued to say all food stored in the walk-in refrigerator should be labeled with an identifier and when it was put in the walk-in. The FSD said after three days of the written date the food needs to either be used or discarded. The FSD reviewed the surveyor's photos of the expired food and she said they should have been thrown away.

Based on resident group responses and interviews, the facility failed to provide a private space for residents of the facility to meet for resident group. Findings include: Resident group meeting was held on 3/23/23 at 11:00 A.M. During the meetings, 19 out of 19 participating residents said they meet for resident group meeting every month, however, feel the space in which they meet in is not private. The residents said that other staff are often walking through the space when they are meeting, kitchen staff are bringing food trucks through the space, and other residents are being taken out by staff to smoke and need to walk through the group meeting. Nineteen out of 19 residents also said they do not feel they can meet as a group without staff present. During an interview on 3/23/23 at 1:45 P.M., the Activity Director said she attends the resident group every month. She said the group is held in the only room available in the facility large enough to meet. The Activity Director said although the room does not have a closed door the meeting could be private if other staff did not enter the room during the group meeting. The Activity Director said she tries to stop people from walking through the room but the staff does not listen and agreed with the residents that the group meeting is not private.

Based on record review, policy review and interview, the facility failed to report an allegation of abuse in the required timeframe for 1 Resident (#59) out of a total of 30 residents. Findings include: Review of the facility policy titled, Abuse Prohibition, last revised 12/1/18, indicated the following: *Each resident has the right to be free from abuse, corporal punishment, and involuntary seclusion. Residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, volunteers, and staff of other agencies serving the resident, family members or legal guardians, friends or other individuals. *Allegations of abuse will be reported promptly and thoroughly investigated. *The administrator and director of nursing are responsible for investigation and reporting. *Notify the shift supervisor/charge nurse/manager immediately if person is suspected abuse, neglect, mistreatment or misappropriation of property occurs. *Report the incident immediately to the Director of Nursing, and Administrator the Administrator, Director of Nursing or designees will report to the corporate director of Clinical Manager. *Notify the local law enforcement and appropriate state agency immediately (within 2 hours). Resident #59 was admitted to the facility in September 2021 with diagnoses including muscle weakness, failure to thrive, anxiety and depression. Review of Resident #59's most recent Minimum Data Set (MDS) sated, 2/2/21, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 indicating he/she is cognitively intact. The MDS also indicated Resident #59 required extensive assistance from staff for bathing, grooming and toileting tasks. Review of a nursing note dated 2/2/23 indicated the Resident complained to the nurse that a Certified Nursing Assistant (CNA) walked into the Resident's room unannounced, took the Resident's blanket off without asking and spoke aggressively to him/her. Review of the incident report write-up dated 2/3/23 indicated the following: *Situation: during chart review it was documented that the resident reported this CNA was being verbally aggressive to (the Resident) and demanding that (the Resident) stand up and that the aid pulled the blanket off of (the Resident). Follow up to this allegation indicated potential verbal abuse. During an interview on 3/24/23 at 7:13 A.M., the Administrators said the expectation of the facility is for staff to call the administration immediately if there is a concern for abuse or an allegation of abuse made. The Administrator said if there is a concern for abuse, this allegation needs to be reported to the state agency within 2 hours. The Administrator said they discovered this allegation of abuse during a chart review and the nurse had never reported it to administration because the nurse made the determination that the Resident is racist and did not think it needed to be investigation. The Administrator said this was not the role of the nurse to determine if there was an abuse or not and said the facility did report this incident to the state agency but did not do it within the required 2-hour timeframe.

Based on interviews and record review, the facility failed to investigate an alleged incident for 1 Resident (#9) out of a sample of 30 Residents. Findings include: Review of the facility policy titled Abuse Prohibition last revised 12/1/18 indicated the following: *The facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends. *Allegations of abuse will be reported promptly and thoroughly investigated. *The shift supervisor is identified as responsible for immediate initiation of the reporting process. *The Administrator and Director of Nursing are responsible for the investigation and reporting. Resident #9 was admitted to the facility in July 2021 with diagnoses including depression. Review of the most recent Minimum Data Set (MDS) indicated a Brief Interview for Mental status (BIMS) score of 14 out of possible 15 indicating intact cognition. During a Resident group meeting held on 3/23/23 at 11:00 A.M., Resident #9 reported that staff do not take him/her to activities because he/she is too heavy. During an interview with the Certified Nursing Assistant (CNA #2) on 3/24/23 at 7:44 A.M., she said activities staff are the ones who have a hard time taking Resident #9 to activities, she/he makes sure Resident #9 is up and ready to go for his/her favorite activities on time. CNA #2 said other Residents have heard the activities staff make this statement in social activities I can't push him/her; she is too heavy. CNA #2 said the activities director is aware of them making this statement. During an interview with Resident #9 on 3/24/23 at 8:02 A.M., she/he said a few months ago, Resident #3 told him/her during a social activity in the dining room, she/he overheard two activity assistants saying that they do not want to push Resident #9 to activities because they might break their backs. Resident #9 told the surveyor these comments made him/her feel very embarrassed and ashamed about his/her weight, to a point where he/she did not want to leave his/her room to engage socially with other Residents in the facility. During an interview with Resident #3 on 3/24/23 at 8:04 A.M., she said a few months ago, she/he overheard two activities staff in the dining room say that Resident #9 is too heavy to push to activities. She/he told Resident #9 about it. During an interview with the Activities Director on 3/24/23 at 9:17 A.M., she said she was made aware of the above concern but did not tell the management team about it. The activities director said she verbally educated her staff, did not document the education, she said should have reported the concern to the unit manager, director of nurses and administrator. During an interview with the Unit Manager (UM#1) on 3/24/23 at 8:53 A.M., she told the surveyor she is just hearing about this concern, the facility staff are expected to report any incidents or concerns to her so she can initiate an investigation. During an interview with the Administrator on 3/24/23 at 10:10 A.M., she said she was surprised by this concern, she expects the staff in the facility to report any incidents to the unit manager who initiates an investigation, the administrator and director of nurses should also be notified of any incidents so they can work with the unit manager to complete the investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2). Review of facility policy titled 'Medication Orders', revised January 2018 indicated the following: Procedure: *E. 2 The following steps are initiated to complete documentation and receive the medications; c. Transcribe newly prescribed medications on the MAR (Medication Administration Record)or TAR (Treatment Administration Record)/electronic medical record. Resident #23 was admitted to the facility in February 2023 with diagnoses including cerebral palsy, anxiety disorder, depression. Review of Resident #23's Minimum Data Set (MDS), dated [DATE] indicated the Resident has a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 which indicates intact cognition. The MDS further indicated Resident #23 required limited assistance of one person for ambulation. Review of Resident #23's physician orders indicated the following medication should have been administered at 8:00 A.M. - Order date 2/19/23- Multivitamin one tablet once daily, one time a day for multivitamin. During an interview on 3/23/23 at 9:58 A.M., Nurse #1 reviewed the physician orders and acknowledged the multivitamin should have been administered, she further said there was an error of how the order had been transcribed which did not reflect in the medication administration record (MAR). During an interview on 3/24/23 at 7:40 A.M., the Director of Nursing said the nurses should double check the orders after transcribing. Based on record review and interviews, the facility failed to meet professional standards for 2 Residents (#14 and #23) by 1). checking the pacemaker for Resident #14 and 2). not following physician's order for Resident #23, out of a total of 30 sampled residents. Findings include: 1. Resident #14 was admitted to the facility in November 2019 with diagnoses including heart failure and presence of a cardiac pacemaker. Review of Resident #14's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident has a Brief Interview for Mental Status (BIMS) score of 6 out of a possible 15 which indicates he/she has severe cognitive impairment. The MDS also indicates Resident #14 requires extensive assistance from staff for functional tasks. Review of Resident #14's pacemaker care plan last revised 12/6/22 indicated the following intervention: *Arrange for pacemaker checks as needed. Review of Resident #14's physician orders and nursing notes failed to indicate pacemaker checks were regularly scheduled and completed. During an interview on 3/23/23 at 9:24 A.M., the Nursing Supervisor said pacemakers can be managed a couple of ways. She said if pacemakers are newer, the resident will go to a cardiology office to get checked. She said that most residents in the facility with pacemakers has had them for a while and will have a machine in their room and can do a pacemaker check over the phone. If done this, way, it is done every month and with a cardiology visit every 6 months. The Nursing Supervisor said Resident #14 had been receiving hospice services and came off hospice a few months ago. She said there has been no plan to check Resident #14's pacemaker since being discontinued from hospice services. Review of Resident #14's medical record indicated the Resident was discontinued from hospice services as of 6/6/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to provide assistance during mealtime for 2 Residents (#13 and #14) out of a total of 30 residents sampled. Findings include: Review of the facility policy titled, Activities of Daily Living, dated December 2022, indicated the following: *The facility will provide care and services for the following activities of daily living: Dining - eating, including meals and snacks. 1. Resident #13 was admitted to the facility in January 2023 with diagnoses including high blood pressure and spinal stenosis. Review of Resident #13's most recent Minimum Data Set, dated , 1/12/23, indicated the Resident has a Brief Interview for Mental Status score of 8 out of a possible 15 indicating he/she has moderate cognitive impairment. On 3/23/23 at 8:05 A.M., Resident #13 was observed lying in bed with his/her meal in front of him/her. From 8:05 A.M., to 9:00 A.M., the Resident attempted to feed him/herself. The Resident was able to drink his/her coffee but was unable to utilize utensils to eat solid foods. The Resident was observed picking up his/her yogurt container and bowl containing oatmeal and trying to drink from them to ingest the food. He/she was unsuccessful for the 55 minutes observed. On 3/24/23 at 8:23 A.M. Resident #13 was observed eating alone while lying in bed. There were no staff present to provide assistance or supervision if needed. Review of Resident #13's activity of daily living care plan, initiated 1/13/23, indicated the following intervention: *Eating: I (the Resident) require continual supervision/assist with eating tasks. Review of Resident #13's [NAME] (a form explaining the level of assist the resident requires) failed to indicate the level of assistance Resident #13 needs during mealtimes. During an interview on 3/23/23 at 10:31 A.M., Certified Nursing Assistant (CNA) #1 said Resident #13 often makes a mess of his/her meal and sometimes needs assistance while eating. 2. Resident #14 was admitted to the facility in November 2019 with diagnoses including heart failure and presence of a cardiac pacemaker. Review of Resident #14's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident has a Brief Interview for Mental Status (BIMS) score of 6 out of a possible 15 which indicates he/she has severe cognitive impairment. The MDS also indicated Resident #14 requires supervision for self-feeding tasks. On 3/22/23 at 8:39 A.M., Resident #14 was observed lying in bed eating breakfast. There was no staff in the room to provide supervision or assistance as needed. On 3/23/23 at 8:41 A.M., Resident #14 was observed lying in bed eating breakfast. There was no staff in the room to provide supervision or assistance as needed. Review of Resident #14's activity of daily living care plan, last revised 3/6/23, indicated the following intervention: *Eating: I (the Resident) require continual supervision/assist with eating tasks. Review of Resident #14's [NAME] (a form explaining the level of assist the resident requires) indicated Resident #14 requires continual supervision/assist with eating tasks. During an interview on 3/23/23 at 10:31 A.M., Certified Nursing Assistant (CNA) #1 said Resident #14 needs assistance with meals sometimes depending on his/her mood.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review and interview the facility failed to maintain a urinary catheter in a manner to reduce infection for 1 Resident (#225) out of a total 30 sampled residents. Findings include: Review of the facility policy titled 'Catheter Care' undated, indicated the following: Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Infection Control: *2. (b) Be sure the catheter tubing and drainage bag are kept off the floor. Resident #225 was admitted to the facility in March 2023, with diagnoses including, benign prostatic hyperplasia with lower urinary tract infection. Review of Resident #225's Minimum Data Set (MDS), dated [DATE], indicated the Resident has a Brief Interview of Mental Status (BIMS) score of 2 out of possible 15 indicating severe cognitive impairment. The MDS also indicates Resident #225 requires total dependence from staff for toileting. Section H of MDS indicates Resident has an indwelling urinary catheter. Review of physician's orders for Resident #225 indicated the following: - Foley catheter care every shift dated 3/3/23 Review of the medical record indicated the following: *A care plan with focus : Resident has an indwelling catheter due to retention from benign prostatic hyperplasia, failed voiding trials. Date initiated 3/14/23, with a goal: Resident will show no signs and symptoms of urinary infection and will remain fee from catheter- related trauma through next review. Interventions: position catheter bag and tubing below the level of the bladder, date revised 3/14/23. On 3/22/23 at 8:16 A.M., the surveyor observed Resident #225 in bed, with his/her urinary collection bag and tubing containing urine lying flat on the floor next to the bed. On 3/23/23 at 7:20 A.M., the surveyor observed Resident #225 in bed, with his/her urinary collection bag laying on the floor. During an interview on 3/23/23 at 2:17 P.M., the Infection Prevention Nurse said the urinary catheters should not be on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of facility policy titled 'Aerosolized Medication Administration', undated, indicated the following: Procedure: *10. The aerosol should be nebulized for approximately 10 minutes or until all of the medication is gone. Once the treatment is completed the nebulizer should be dismantled and rinsed under a stream of sterile water. The nebulizer should then be allowed to air dry on a paper towel. Once dry it can be reassembled and placed in a plastic storage bag. Resident #225 was admitted to the facility in March 2023, with diagnoses including, Chronic obstructive pulmonary disease (COPD). Review of Resident #225's Minimum Data Set (MDS), dated [DATE], indicated the Resident has a Brief Interview of Mental Status (BIMS) score of 2 out of possible 15 indicating severe cognitive impairment. The MDS also indicates Resident #225 requires total dependence from staff. Section I of MDS indicates Resident has an active diagnosis of COPD and asthma. Review of Resident #225 physician's order dated 3/6/23 included the following: Ipratropium- Albuterol solution 0.5-2.5 (3) mg/3 ml (milligram/milliliter) 1 vial inhale orally two times a day related to COPD. During an observation on 3/222/23 at 8:16 A.M., the surveyor observed Resident #225's nebulizer equipment laying on the nightstand, not bagged. During an observation on 3/22/23 at 11:10 A.M., the surveyor observed Resident #225's nebulizer equipment laying on the nightstand, not bagged. During an observation on 3/23/23 at 7:21 A.M., the surveyor observed Resident #225's nebulizer equipment laying on the nightstand, unbagged. During an interview on 3/23/23 at 2:20 P.M., the Infection Prevention Nurse said nebulizer mask and pipe should be cleaned and stored in the plastic bags after each use. Based on observation, policy review and interview the facility failed to 1) provide oxygen as ordered and store oxygen supplies in a manner that would reduce infection for 1 Residents (#14) and 2) failed to store nebulizer equipment in a manner that will reduce infection for 1 Resident (#225) out of a total 30 sampled residents. Findings include: 1. Review of the facility policy titled, Oxygen Administration Policy and Procedure, dated 12/6/22, indicated the following: *Oxygen is administered by licensed nurses with the physician's order in order to provide a resident with sufficient oxygen to their blood and tissues. Orders should specify the oxygen equipment and flow rate or concentration required as routine or PRN (as needed). Resident #14 was admitted to the facility in November 2019 with diagnoses including hemiplegia, dependence on supplemental O2 (oxygen), and heart failure. Review of Resident #14's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident has a Brief Interview for Mental Status (BIMS) score of 6 out of a possible 15 which indicates he/she has severe cognitive impairment. Section O of the MDS also indicates Resident #14 requires oxygen. On 3/22/23 at 8:24 A.M., Resident #14 was observed lying in bed. He/she was not wearing any oxygen and the oxygen tubing was placed on the floor, not in a bag. On 3/22/23 at 11:25 A.M., Resident #14 was observed lying in bed. He/she was not wearing any oxygen and the oxygen tubing was placed on the floor, not in a bag. On 3/23/23 at 6:51 A.M., Resident #14 was observed lying in bed. He/she was not wearing any oxygen and the oxygen tubing was placed on the floor, not in a bag. Review of Resident #14's physician orders indicated the following order: *Order O2 (oxygen) at 2 liters continuously via NC (nose cannula), written 10/4/21. Review of Resident #14's oxygen care plan, last revised 12/6/22, indicated the focus of care was oxygen therapy continuous at 2LPM (liters Per Minute) r/t (due to) heart disease with heart failure. During an interview on 3/23/23 at 8:48 A.M., Nurse #1 said oxygen tubing should be stored in a bag when not in use and should never be on the floor. Nurse #1 also said residents should be using oxygen as ordered by the physician. On 3/23/23 at 9:24 A.M., the Nursing Supervisor said oxygen tubing should be stored in a bag when not in use and should never be on the floor. The Nursing Supervisor also said residents should be using oxygen as ordered by the physician. She said Resident #14 may take the oxygen off him/herself but said he/she was not care planned for this behavior.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to implement a physician order for pain management for 1 Resident (#48) out of a total sample of 30 residents. Findings include: Review of the facility policy titled Pain Management and Management Program, dated 10/2021, indicated the following: - Purpose: to provide a consistent method for the assessment, observation, planning, development and evaluation of an effective pain management plan of care. - Pain is whatever the person experiencing it says it is, whenever he/she states it does exist. Resident #48 was admitted in 8/2016 with diagnoses including dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #48 scored a 10 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Review of the progress note, dated 11/15/22, indicated the following: - Resident complained of pain in his/her teeth and is not able to chew because of the pain. Resident said his/her dentist needs an ok from his/her doctor to get teeth removed. This write informed the NP (Nurse Practitioner). NP responded she already filed a paper to dentist. NP gave new order for oral gel TID (three times a day) before meals. order entered into electronic medical record. Review of the physician's orders and Medication Administration Record for November 2022 did not indicate that an order for oral gel was implemented. Review of the progress note, dated 11/18/22, indicated the following: - Resident complained of pain in his/her teeth and is not able to chew because of the pain. NP aware. New order to start Benzocaine 10% gel (a gel used to relieve oral pain) for 4 days and Amoxicillin (an antibiotic) 500 mg for 7 days . Review of the physician's orders indicated that the oral gel was implemented on 11/18/22, 3 days after the Resident initially notified nursing of pain. During an interview on 3/24/23 at approximately 10:00 A.M., the Administrator was made aware of the delay in medication implementation and acknowledged the delay.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure that an as needed (PRN) psychotropic medication did not exceed 14 days unless the prescriber documented the rationale and duration of use of the medication for one Resident (#46) out of a total sample of 30 residents. Findings include: Review of facility policy titled 'Use of Psychotropic Drugs', revised 12/6/21 indicated the following: Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition,as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Procedure/Guidelines *8. As needed (PRN) orders for psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (example 14 days). a. If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order. Resident #46 was admitted to the facility in February 2023 with diagnoses including anxiety disorder, schizoaffective disorder. Review of Resident #46's Minimum Data Set (MDS), dated [DATE], indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15 indicating moderately impaired cognition. The MDS further indicated the Resident did not have behaviors, hallucination or delusions. Review of Resident #46's physician order dated 3/9/23 indicated the following: * Lorazepam oral tablet 1 mg (Milligram). Give 1 mg by mouth every 8 hours as needed for anxiety. Further review of Resident #46's medical record failed to indicate a stop date for the prescribed PRN medication. During an interview on 3/23/23 at 12:32 P.M., Nurse # 2 said PRN psychotropic medications should have a 14 day stop date unless the physician indicates otherwise. During an interview on 3/24/23 at 7:45 A:M., the Director of Nursing said any as needed psychotropic should have a 14 day stop date unless indicated in the medical record by the physician for extended use.

Based on observation and menu review, the facility failed to follow the menu for a breakfast meal. Findings include: During resident group meeting on 3/23/23 at 11:00 A.M., 19 out of 19 participating residents said the food given at meals frequently does not match what is on the facility menu and it is very frustrating to them. Review of the menu for the date of 3/22/23, during the breakfast meal, indicated that residents should have received 2 pancakes with syrup and a 2 ounce piece of sausage. During an observation on 3/22/23 at 7:17 A.M., on the breakfast tray line, there were no 2 ounce pieces of sausage prepared.

Based on observation, interview, and test trays, the facility failed to maintain appropriate temperatures of the food to prevent foodborne illness. Findings include: During an observation, during the breakfast tray line service, on 3/22/23 at 7:17 A.M., the dietary staff was not putting any of the plated breakfasts on a plate warmer to prevent food from getting cold. During an interview on 3/22/23 at 7:28 A.M., the cook said that the plate warmer has been broken for a few days and that maintenance needed to fix it. During the resident group meeting on 3/23/23 at 11:00 A.M., 19 out of 19 participants said that the food is cold every day at every meal. During a test tray on 3/22/23 at 8:31 A.M., the following temperatures were taken: - Pancakes: 88 degrees Fahrenheit - Oatmeal: 93.7 degrees Fahrenheit - Coffee: 113.7 degrees Fahrenheit - Milk: 61 degrees Fahrenheit During a test tray on 3/23/23 at 12:12 P.M., the following temperatures were taken: - Milk: 46.5 degrees Fahrenheit

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #5 was admitted to the facility in November 2019 with diagnoses including Parkinson's Disease. Review of Resident #5's most recent Minimum Data Set, dated [DATE], indicated the Resident has a Brief Interview for Mental Status (BIMS) score of 8 out of a possible 15 indicating he/she has moderate cognitive impairment. During a lunch observation on 3/23/23 at 12:31 P.M., Resident #5 was observed eating his/her lunch in bed while lying at a 30-degree angle. The meal was stuffed cabbage and Resident #5 was observed attempting to eat an entire piece of cabbage that was uncut. The piece of cabbage was approximately 6 inches long and the Resident said he/she was having difficulty eating the meal. Review of Resident #5's physician orders indicate the Resident has an order for a regular diet with chopped meats texture as of 3/20/23. During an interview on 3/23/23 at 12:33 P.M., Nurse #1 said the staff should have cut the Resident's meal prior to his/her eating to ensure the correct diet was provided. During an interview on 3/23/23 at 12:46 P.M., the speech language pathologist said Resident #5 requires his/her food to be cut prior to eating. Based on observation, record review, and interview, the facility failed to provide the prescribed therapeutic diet for 2 Residents (#5 and #28), out of a total sample of 30 residents. Findings include: 1. Resident #28 was admitted in 04/2010 with diagnoses including dementia and dysphagia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #28 scored a 9 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. During an observation on 3/22/23 at 9:37 A.M., Resident #28 was laying in bed with his/her breakfast tray in front of him/her. Resident #28 had cheerios on his/her tray. Behind Resident #28's bed was a sign that stated Resident #28 should not have hard, crunchy items and is on a dysphagia diet. Review of Resident #28's diet order and speech therapy Discharge summary, dated [DATE], indicated that Resident #28 was on a dysphagia diet with thin liquids. During an interview on 3/23/23 at 12:07 P.M., the Speech Therapist said that Resident #28 should not be served cheerios and she has done education with the staff regarding the Resident's diet texture.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and tray ticket review, the facility failed to provide the dietary preferences for 1 Resident (#42) out of a total sample of 30 residents. Findings include: Resident #42 was admitted in 12/2022 with diagnoses including depression and type 2 diabetes. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #42 scored a 14 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of the MDS indicated that Resident #42 is independent with eating. During an observation on 3/22/23 at 8:45 A.M., Resident #42 was lying in bed with his/her breakfast untouched. Resident #42 said that he/she did not get what he/she ordered and was not going to eat breakfast. Review of the tray ticket for Resident #42 indicated that he/she was supposed to receive 1/2 cup of scrambled eggs and 1 slice of white toast. Resident #42's tray only contained 2 pancakes. During an interview on 3/22/23 at 8:50 A.M., Nurse #3 said that she checks the carts and did not notice that Resident #42 got the wrong items and that she would call and get the Resident another tray.

Based on observation, record review, and interview, the facility failed to 1. maintain kitchen sanitation practices and 2. failed to record and log temperatures of the food and dish machine. Findings include: Review of the facility policy titled Food Receiving and Storage, undated, indicated the following: - Food services, or other designated staff, will maintain clean food storage areas at all times. - Food in designated dry storage areas will be kept off the floor (at least 18 inches) and clear of sprinkler heads. - All foods stored in the refrigerator will or freezer will be covered, labeled and dated. 1. During the kitchen walk through on 3/22/23 at 7:17 A.M., the following was observed: - a box of juice was on the floor in the dry storage room - a container of fruit medley was not labeled or dated in the walk in refrigerator - a package of sliced ham was open and undated in the refrigerator - a container of vegetable soup was labeled 3/16/22 - a container of shredded cheese and sliced cheese was opened and unlabeled or dated. During an observation on 3/23/23 at 1:20 P.M., 3 staff members, who were not dietary staff, walked into the kitchen without hairnets. 2. During the tray line observation on 3/22/23 at 7:25 A.M., the cook recorded temperatures of the meal on a napkin. The cook said that he does not know where the temperature log book is kept and it has been missing. During an observation on 3/23/23 at 1:26 P.M., the dish machine log was not filled out with temperatures. The cook said that they have not been recording dish machine temperatures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. For Resident # 9, the facility failed to provide a dignified existence. Findings include: Review of the facility policy titled 'Dignity/Quality of Life' revised 12/6/21 indicated the following: *Residents shall always be treated with dignity and respect. *Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self esteem and self worth. Resident #9 was admitted to the facility in July 2021 with diagnoses including depression. Review of the most recent Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 14 out of a possible 15 indicating intact cognition. During a Resident group meeting held on 3/23/23 at 11:00 A.M., Resident #9 reported that staff do not take him/her to activities because he/she is too heavy. During an interview with the Certified Nursing Assistant (CNA #2) on 3/24/23 at 7:44 A.M., she said activities staff are the ones who have a hard time taking Resident #9 to activities, she/he makes sure Resident #9 is up and ready to go for his/her favorite activities on time. CNA #2 said other Residents have heard the activities staff make this statement in social activities I can't push him/her; he/she is too heavy. During an interview with Resident #9 on 3/24/23 at 8:02 A.M., she/he said a few months ago, Resident #3 told him/her during a social activity in the dining room, she/he overheard two activity assistants saying that they do not want to push Resident #9 to activities because they might break their backs. Resident #9 told the surveyor these comments made him/her feel very embarrassed and ashamed about his/her weight, to a point where he/she does not want to leave his/her room to engage socially with other Residents in the facility. During an interview with Resident #3 on 3/24/23 at 8:04 A.M., she said a few months ago, she/he overheard two activities staff in the dining room say that Resident #9 is too heavy to push to activities. She/he told Resident #9 about it. During an interview with the Activities Director on 3/24/23 at 9:17 A.M., she said she was made aware of the above concern, she verbally educated the activity assistants because she expects them to treat Residents with respect. During an interview with the Unit Manager (UM#1) on 3/24/23 at 8:53 A.M., she told the surveyor she is just hearing about this concern, the facility staff are expected to treat Residents in a respectful manner. During an interview with the Administrator on 3/24/23 at 10:10 A.M., she said she was surprised by this concern, she expects the staff in the facility to provide a respectful environment for the residents. 2. Resident #13 was admitted to the facility in January 2023 with diagnoses including high blood pressure and spinal stenosis. Review of Resident #13's most recent Minimum Data Set, dated , 1/12/23, indicated the Resident has a Brief Interview for Mental Status score of 8 out of a possible 15 indicating he/she has moderate cognitive impairment. On 3/22/23 at 8:40 A.M., Resident #13 was observed being fed by staff while lying in bed. The staff member was standing and not at eye level with the Resident. On 3/23/23 at 8:35 A.M., Resident #13 was observed being fed by staff while lying in bed. The staff member was standing and not at eye level with the Resident. During an interview on 3/23/23 at 2:01 P.M., the Administrator said she expects all staff to sit or be at eye level with the residents when they are assisting with meals. 3. Resident group meeting was held on 3/23/23 at 11:00 A.M. 19 out of 19 participating residents said they often worry if they will have clothes to wear due to the facilities lack of laundry services. The resident said there have been issues with laundry services for over a year and they have voiced their concerns repeatedly. Eight out of 19 residents said they have missing clothing that has not been returned to them and 1 resident said he/she often gets other resident's clothes and not his/her own. During initial rounds of the building, there was a significant amount of dirty linen bags gathered outside the building in trash bags waiting to be picked up by the laundry service. During an interview with Resident #9 on 3/22/23 at 9:12 A.M., she/he reported to not having enough linen and 'johnnies'(a collarless gown that ties in the back worn by patients) on most days because the dirty linen was not being picked up for cleaning on time. During an interview on 3/22/23 at 9:44 A.M., the Administrator said the facility has been having difficulty coordinating laundry services in this past week due to an issue with payment. The Administrator said the laundry has not been done in a week. Based on observation, record review, and interview, the facility failed to 1. provide a timely room transfer to 1 Resident (#49) and 2. provide a dignified dining experience for 1 Resident (#13), and 3. failed to provide linen services for the facility in order for residents personal clothing to be cleaned, and 4. provide a dignified existence for 1 Resident (#9) out of a total sample of 30 residents. Findings include: 1. Resident #49 was admitted in 09/2022 with diagnoses including dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #49 scored a 14 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. Review of the facility policy titled Room to Room Transfers, dated 03/2023, indicated the following: - Where feasible, the facility will make room transfers when requested by the a resident or their representative as it becomes necessary to meet the resident's medical and nursing care needs. - The facility reserves the right to make room to room transfers when necessary and as may be requested by the resident when feasible. Review of the progress note, dated 2/21/23, indicated the following: Resident accused his/her roommate of changing the channel on his/her TV. Roommate could be heard laughing at the patient then swearing at him/her. When this writer entered room this patient was standing up and very upset stating he/she wanted out of his/her room due to roommate . the patient did swear back at his/her roommate. Both redirected, no further fighting noted. During an interview on 3/23/23 at 8:49 A.M., the Social Worker said that she is the one that implements room changes. She said that she remembers the altercation, but thought it was resolved. She said that room changes are made if it is feasible and that the facility keeps some rooms open for Covid cases and that one section of the building is open for short term residents. During and interview on 3/23/23 at 9:07 A.M., Resident #49 said that his/her roommate would wake up at 5 in the morning and turn the TV on really loudly. Resident #49 said that it took over a month for the room change and it wasn't until he/she spoke up to nursing a second time stating how much longer do I have to deal with this. Resident #49's room was changed on 3/16/23, 3 weeks after the requested room change and roommate altercation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 3/22/23 at 8:30 A.M., the following were observed on the Right Wing unit: *Both entry doors to the unit had significant scuff marks. *In room [ROOM NUMBER], there were gouges in the wall with plaster exposed behind both beds. *In room [ROOM NUMBER], there was a piece of tile missing in the bathroom. The radiator in the bathroom had significant rust and both doors of the bathroom had significant scuff marks. *In room [ROOM NUMBER], two tiles at the end of the B bed were cracked and one tile was missing a piece. The walls were scuffed behind the A bed and there were two spots behind the B bed with paint missing. *In room [ROOM NUMBER], the privacy curtain was soiled with stains. *In room [ROOM NUMBER], the bathroom floor was missing piece of the tile, there were significant stains on wall next to sink, the radiator had significant rusting and there were 3 small holes next to toilet paper dispenser. There were scuff marks on wall next to A bed. *In room [ROOM NUMBER], there was a missing piece of baseboard between bathroom and closet wall. *In room [ROOM NUMBER], there were gouges in the wall with plaster exposed behind both beds. *In room [ROOM NUMBER], there were multiple scuff marks on wall next to A Bed. The wall behind the A bed was gouged with exposed plaster. There were scuff marks on the wall behind B bed. The privacy curtain between the two beds was soiled with stains. The radiator in the bathroom had significant rust stains and there was a broken floor tile by the sink. *The floor in the common area by the nursing station had multiple cracks and duct tape was being used to cover the cracks and hold the floor together. There were several areas on the floor where the laminate wood flooring was not flat and rising. During an interview on 3/24/23 at 8:39 A.M., the Maintenance Director said he completes rounds of the building daily and there are maintenance logs at the nursing stations as well as the front area that are checked throughout the day to see if there are any areas in the building that need attention from maintenance. The Maintenance Director said they complete high priority tasks first and then the smaller projects. The Maintenance Director said they wait until someone moves out of the room to fix room any environmental issues. The Maintenance Director said I'm going to say I was not aware of the rooms. the only thing i can recall is the floor. it has been like that as long as i have been here. I've had a safety meeting about the floor and they're working on quotes, but it is above and it's not safe. I believe they have gotten quotes for it. they came and looked at other things, but were talking about doing the floor at the same time. During an interview on 3/24/23 at 10:20 A.M., the Nursing Supervisor said the floor at the nursing station is very unsafe and does not look homelike with duct tape holding it together. The Nursing Supervisor said the current and previous Maintenance Directors have asked to fix the floor several times and nothing has happened.

Based on review of the grievance log, resident group response and interviews, the facility 1) failed to ensure residents of the facility were aware of the grievance process and had access to grievance forms and 2) resolved a grievance for 1 Resident (#15) out of a total sample of 30 residents. Findings include: 1. Resident group meeting was held on 3/23/23 at 11:00 A.M., 19 out of 19 participating residents said they were unaware of the process to file a grievance in the facility. None of the 19 residents were aware of the grievance process, where grievance forms are available, how to fill out a grievance form or who to give the form to. Nineteen of 19 participating residents said when they verbally tell staff of a grievance, they feel the facility does nothing to resolve it. The residents said they feel like they never get any feedback from the administrator or never feel like there is follow through. Nineteen out of 19 residents said they have been complaining of the same things (cold food, long call light wait times and staff members on their phone) for several months without a response from administration. On 3/23/23 at approximately 11:45 A.M., the surveyor attempted to find a grievance form on each unit. On both units, the forms were in an unlabeled area on the unit, in a binder covered by other materials. During an interview on 3/23/23 at 1:45 P.M., the Activity Director said she attends resident group every month. The Activity Director said all concerns from the group meeting are brought up at morning meeting and are also written down on grievance forms and puts them in the mailboxes of staff that would resolve them. The Activity Director says she never gets the forms back and the group concerns are not addressed. During an interview on 3/23/23 at 2:01 P.M., the Administrator said it is a team effort between staff to resolve facility grievances. The Administrator said the facility completed an in-service with staff to go over the grievance process but never completed an in-service for the residents. 2. Resident #15 was readmitted to the facility in July 2022 with diagnoses including dementia. Review of the grievance form, dated 5/28/22 indicated the following: *Resident states he/she is missing $150 from his/her lock drawer. Stated he/she has not been in the drawer for a month or so. States his/her brother gave him/her money for his/her birthday and Christmas. He/she typically keeps the key on the bedside table. *The part of the form titled Grievance/concern was empty, indicating the grievance had not been resolved During an interview on 3/23/23 at 2:01 P.M., the Administrator said this grievance happened before she was the administrator at the facility, but it looks like the grievance was never resolved.

Based on record review and interview, the facility failed to complete annual Certified Nurse Aide (CNA) performance reviews for 5 of 5 sampled CNAs. Findings include: During review of 5 CNA employee records, the Surveyor was unable to locate annual performance reviews for all 5 CNAs. During an interview on 3/24/23 at 10:13 A.M., the Corporate Human Resource Officer said the facility and corporate has fallen behind on training and performance reviews for staff. The Corporate Human Resource Officer said annual reviews for the 5 CNAs were not completed, as well as reviews for most if not all other staff members of the facility.

Based on observation, record review and interview, the facility failed to ensure that it was free of a medication error rate of 5 percent or greater. Two of four licensed nurses made errors during a medication administration on 2 out of 2 units. Three medication errors were observed out of 27 opportunities for error, resulting in a medication error rate of 11.11%. Findings include: Review of policy titled' Medication Administration-General Guidelines, undated indicated the following: Procedure: *4. Five rights-Right resident,right drug,right dose, right route and right time, are applied for each medication being administered. A triple check of these 5 rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication pt away. a. Check #1: select the medication-label, container and contents are checked for integrity, and compared against the medication administration record (MAR) by reviewing the 5 rights. b. Check #2 : Prepare the dose- the dose is removed from the container and verified against the label and the MAR by reviewing the 5 rights. c. Check #3: Complete the preparation of the of the dose and re-verify the label against the MAR by reviewing the 5 rights. During an observation of the medication pass on 3/23/23 at 7:43 A.M., Nurse #2 prepared and administered medications to Resident #1 including the following: -Calcium 600 mg (milligram) 1 tablet -Symbicort inhaler 160/4.5 mcg (micrograms) 2 puffs, Resident #1 rinsed and swallowed the water. Review of Resident #1's physician orders indicated the following. - An order dated 1/17/23- Calcium-Vitamin D oral tablet ( Calcium with vitamin D). Give one tablet by mouth one time a day for supplement. - An order dated 2/14/23- Symbicort inhalation Aerosol 160-4.5 mcg/ACT 2 puff inhale orally two times a day for shortness of breath. Rinse mouth and spit after each use. During an interview on 3/23/23 at 10:02 A.M., Nurse #2 acknowledged the calcium order did not specify the dosage and a clarification with the physician should have been done. Nurse #2 also acknowledged that she should have guided Resident #1 in rinsing and spitting out after using the inhaler. During observation of the medication pass 3/23/23 at 8:16 A.M., Nurse #1 prepared and administered medications to Resident #23 including the following. -Duloxetine DR (delayed release) 60 mg (milligrams) 1 capsule -Hydrochlorothiazide 12.5 mg 1 capsule -Clonezapam 1 mg 1 tablet -Tramadol 50 mg 1 tablet. Review of Resident #23's physician orders indicated the following medication should have been administered at 8:00 A.M.: - Order date 2/19/23- Multivitamin one tablet once daily, one time a day for multivitamin. During an interview on 3/23/23 at 9:58 A.M., Nurse #1 reviewed the physician orders and acknowledged the multivitamin should have been administered, she further said there was an error of how the order had been transcribed which did not reflect in the medication administration record (MAR). During an interview on 3/24/23 at 7:40 A.M., the Director of Nursing said the nurses should double check the orders and make sure they are using the 5 rights during medication administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #26 was admitted to the facility in November 2019 with diagnoses including hemiplegia and diabetes. Review of Resident #26's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident has a Brief Interview for Mental Status (BIMS) score of 10 out of a possible 15 which indicates he/she has moderate cognitive impairment. During an interview on 3/23/23 at 8:10 A.M., Resident #26 said he/she has been waiting for the dentist to come back and extract his/her teeth. Resident #26 said he/she would really like dentures and cannot get them until the dentist comes back. Review of Resident #26's physician orders indicated the following orders: *Dental consult, written 11/1/22. *Ophthalmic, Auditory, Dental & Podiatry Consults as needed, written 1/31/21. Review of a dental visit note dated 12/8/22, indicted the following: *Recommend extracting remaining teeth and recommend fabrication of complete set of dentures to improve chewing. Reviewed denture fabrication steps with patient. Discussed healing time prior to fabrication of dentures. Discussed with nurse. Action required by nursing home staff: Obtain Signature for Consent for Extractions Form. Recommend consult with MD/NP regarding holding Plavix prior to extraction appointment. Review of Resident #26's medical record failed to indicate a follow-up appointment had been scheduled for the Resident to have his/her teeth extracted. During an interview on 3/22/23 at 2:00 P.M., the Nursing Supervisor said the company that provides dental services upload their recommendations directly into the electronic medical records and she is responsible for looking through all recommendations and ensuring they are completed. The Nursing Supervisor said this recommendation for extraction was not completed and it is most likely because she was out on medical leave during this time and no one else probably checked to see if there were recommendations. 3. Resident #59 was admitted to the facility in September 2021 with diagnoses including muscle weakness, failure to thrive, anxiety and depression. Review of Resident #59's most recent Minimum Data Set (MDS) sated, 2/2/21, indicated the Resident had a Brief Interview for Mental Status (BIMS) score of 14/15 indicating he/she is cognitively intact. The MDS also indicated Resident #59, extensive assistance from staff for bathing, grooming and toileting tasks. During an interview on 3/23/23 at 8:11 A.M., Resident #59 said he/she has been waiting to see the dentist. The Resident said he/she has a tooth that moves in his/her mouth and would like it pulled out. Resident #59 said no one from the nursing staff has spoken to her about it. Review of Resident #59's physician orders indicated the following orders: *Dental consultation, written 9/10/21. *Podiatry, Audiology, Dental, Ophthalmology consults as needed, written 9/4/21. Review of a dental visit note, dated 12/8/22, indicated the following: dental note: *Dx: #19 hopeless periodontal condition. Recommend extraction of #19 to prevent possible choking/aspiration risk. Discussed with nursing supervisor. Patient has not had any extractions since last exam. Recommend extraction of tooth #19 (if approved). Please monitor lower left molar mobility. If concerned of aspiration or choking, please contact Dr. [NAME] immediately. Obtain Signature for Consent for Extractions Form Review of Resident #59's medical record failed to indicate a follow-up appointment had been scheduled for the Resident to have his/her teeth extracted. During an interview on 3/22/23 at 2:00 P.M., the Nursing Supervisor said the company that provides dental services upload their recommendations directly into the electronic medical records; she is responsible for looking through all recommendations and ensuring they are completed. The Nursing Supervisor said this recommendation for extraction was not completed and it is most likely because she was out on medical leave during this time and no one else probably checked to see if there were recommendations. Based on record review and interview, the facility failed to provide dental services to 3 Residents (#48, #26 and #59) out of a total sample of 30 residents. Findings include: Review of the facility policy titled Dental Services & Denture Services, dated 12/2022, indicated the following: -Purpose: to ensure that residents receive routine and emergent dental services to meet their individual needs. - Our facility has a contract with a dentist that comes to the facility and provides dental services on a routine basis. - Failure of a dentist to provide follow up services will result in the facility's right to use it's consultant dentist to provide the resident's dental needs. - Nursing services or designee is responsible for scheduling dental services as needed. 1. Resident #48 was admitted in 8/2016 with diagnoses including dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #48 scored a 10 out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Review of the dental consultation note, dated 5/2/22, indicated that Resident #48 had a partial denture that broke and it was recommended by the dentist to fabricate a partial upper denture. Review of the dental consultation note, dated 12/8/22, indicated that Resident #48 was requesting a flexible partial upper denture. Review of the clinical record does not indicate that Resident #48 was seen by a contract or outside service for a flexible upper denture. Review of the dental consultation note, dated 1/30/23, indicated that Resident #48 was requesting a flexible upper denture. A dental consult was ordered on 2/2/23. Review of the clinical record does not indicate that Resident #48 was seen by a contract or outside service for a flexible upper denture. During an interview on 3/22/23 at 1:59 P.M., the Nurse Supervisor said that she was not aware of the dental consult recommendation put in on 2/2/23.

The surveyor made the following observations on the Left Wing resident unit: On 3/23/23 at 7:19 A.M., Nurse #2 was observed at the nurses station with her mask below her nose and mouth. On 3/23/23 at 7:22 A.M., Nurse # 2 was observed entering resident room she lowered her mask below nose and mouth to speak to the surveyor. Nurse #2 was asked what the policy was for mask wearing, she said it should be worn properly covering nose and mouth at all times while in resident care area. On 3/23/23 at 12:22 P.M., Certified Nursing Assistant (CNA #3) was observed sitting next to a resident in the hallway who was having lunch with her mask below her nose and mouth. During an interview on 3/24/23 at 10:44 A.M., the Infection Preventionist said staff would be wearing masks when around residents. She said she reminds staff of this every day but it is still a work in progress Based on observations, record review and interviews, the facility failed to implement infection control practices by 1. failing to complete inspections for Legionella and other waterborne pathogens, 2. failing to store dirty linen appropriately for pick up and 3. failing to ensure staff wear PPE (personal protective equipment). Findings include: Review of the facility policy titled 'Water Management Plan' revised on 7/6/2018 indicated the following: *Control measures: eyewash station-to be activated weekly, Ice machine-biannual or according to manufacturer's instructions, water filter-according to manufacture's instructions, expansion tank-annually, water heater-monthly/annually, aerator/all faucets-quarterly or as necessary, back flow preventor-biannual, electronic and manual faucets-daily, showerhead,hose,sink-quarterly or as necessary, hot/cold water storage tank-annually, little used outlets-twice weekly. *Testing for legionella requires a skilled microbiological laboratory with experience and proper training for assessment and interpretation. 1. During a review of the Legionella water management program documentation on 3/23/23 at 9:19 A.M., the surveyor could not locate any evidence that any inspections were completed to help prevent and identify the growth of Legionella and other waterborne pathogens. During an interview with the Maintenance Director on 3/24/23 at 8:00 A.M., he said he had not done any inspections in the building to prevent or identify Legionella and other waterborne pathogens. He said he got a copy of the sheet he is supposed to document the inspections on yesterday, and he has no documentation. During an interview with the Administrator on 3/24/23 at 10:17 A.M., she said she expects the Maintenance Director to complete Legionella and other waterborne pathogens inspections and document the inspections as per the facility policy. 2. During observations made on 3/22/23 at 9:00 A.M., and 3/23/23 at 8:47 A.M., the surveyor observed several piles of dirty laundry outside of the facility, placed next to the trash cans. During an interview with Laundry Personnel #1 and #2 on 3/24/23 at 8:05 A.M., they told the surveyor the bagged laundry next to the trash cans were dirty linen waiting to be picked up for cleaning by the laundry truck. Laundry personnel #1 and #2 said they have not seen the laundry pick-up truck in a long time. They do not expect dirty laundry to be sitting outside next to the trash cans for days without being picked up for cleaning. During an interview with the Infection Control Nurse on 3/24/23 at 10:42 A.M., she said that storing dirty linen next to the trash can is unsanitary. She does not expect dirty laundry to be sitting out next to the trash can waiting to be picked up for days, she expects dirty laundry to be picked for cleaning up in a timely manner. 3. The surveyor made the following observations in the Activity Room: On 3/22/23 at 1:02 P.M., two activity staff members were observed eating lunch at the same table as 1 resident and while other residents were eating at another table. The staff were unable to wear masks while eating. On 3/23/23 at 12:54 P.M., two activity staff were observed eating lunch at a table with other residents who are were also eating. The staff were unable to wear masks while eating. On 3/23/23 at 2:48 P.M. an activity assistant had her mask on her chin. not covering her mouth or nose, eating ice cream with residents close by. During an interview on 3/24/23 at 10:44 A.M., the Infection Preventionist said staff would be wearing masks when around residents. She said she reminds staff of this every day but it is still a work in progress.

Based on record review and interview, the facility failed to ensure that 5 of 5 Certified Nursing Assistants reviewed received 12 hours of mandatory in-service training in a year. Review of 5 Certified Nursing Assistants (CNA) employee records indicated that 5 out of 5 did not complete the mandatory 12 hours of education required. During an interview on 3/24/23 at 10:13 A.M., the Corporate Human Resource Officer said the facility and corporate headquarters have fallen behind on training for staff. The Corporate Human Resource Officer said required in-service training for the 5 CNAs were not completed, as well as training for most if not all other CNAs in the facility.

Based on observation, review of the Quality Assurance Performance Improvement (QAPI) plan, and interview, the facility failed to ensure that the Quality Assurance Committee identified quality deficient areas and to develop and implement an appropriate corrective action plan, to ensure satisfactory outcomes from concerns brought forth from resident council meetings. Findings Include: Review of facility policy titled 'QAPI Plan' dated 2023 indicated the following: *Performance Improvement Projects The QAPI team at Belvidere Healthcare Center will review our sources of information to determine if gaps or patterns exist in our systems of care that could result in quality problems, or if there are opportunities to make improvements. During the group meeting on 3/23/23 at 11:00 A.M., 19 out of 19 participating residents said they had brought the following concerns to management and had not received resolutions or feedback. - On going issues with laundry not being done in a timely manner - Receiving cold food - Staff being on their own personal phones in resident care areas - Concerns with timely response to the call light. - Low staffing concerns affecting wait times on resident needs. During an interview on 3/24/23 at 11:17 A.M., the Administrator said she was not aware of these concerns and felt like the channel of system with resident council group was broken and it needs to be worked on. She further said the facility will do a better job in gathering information to ensure resident satisfaction is maintained.

Based on observation and interview, the facility failed to maintain functioning equipment in the kitchen. Findings include: During an observation, during the breakfast tray line service, on 3/22/23 at 7:17 A.M., the dietary staff was not putting any of the plated breakfasts on a plate warmer to prevent food from getting cold. During an interview on 3/22/23 at 7:28 A.M., the cook said that the plate warmer has been broken for a few days and that maintenance needed to fix it. The plate warmer was broken for the duration of the survey.