Based on observations, interviews and record review, the facility failed to ensure its staff provided appropriate treatment and services to maintain one Resident's (#25) comfort during dining, out of a total sample of 12 residents. Specifically, the facility failed to get Resident #25 out of bed for meals per preference, when the Resident required assistance from staff with transfers, and voiced concerns with choking and discomfort when eating while lying in bed. Finding include: Resident #25 was admitted to the facility in April 2022 with diagnoses including Fibromyalgia (chronic disorder characterized by widespread pain, fatigue, muscle stiffness and insomnia), Parkinsonism (brain condition that cause slowed movements, rigidity/stiffness and tremors), Traumatic Subdural Hemorrhage (condition where blood collects between the skull and the surface of the brain), Gastroesophageal Reflux Disease (GERD-chronic disease that occurs when stomach acid or bile flows into the food pipe and irritates the lining) and Irritable Bowel Syndrome (IBS-intestinal disorder causing pain in the belly, gas, diarrhea and constipation). Review of a Nurse's Note, dated 2/21/23, indicated Resident #25 called nursing staff into his/her room during breakfast stating that he/she choked on a prune pit and a Speech Language Pathologist (SLP) screen was submitted to evaluate his/her diet consistency for safety. Review of a Nurse's Note, dated 2/23/23, indicated that the SLP evaluated Resident #25 and made no diet texture/consistency changes. Review of the Minimum Data Set (MDS) Assessment, dated 3/13/23, indicated Resident #25 was cognitively intact as evidenced by a Brief Interview of Mental Status (BIMS) score of 14 out of 15, had no behaviors or refusals of care, required total assistance from staff with bed mobility and transfers and was independent with eating. On 4/12/23 at 9:20 A.M., the surveyor observed Resident #25 lying in bed. The head of the bed was elevated and an overbed table with a hot beverage mug was positioned in front of him/her. The Resident was wearing a hospital gown and crumbs were observed on the front of the Resident's chest. During an interview at this time, Resident #25 said that he/she had asked the facility staff to be out of bed and to be seated up in the wheelchair for breakfast because he/she was concerned about choking. The Resident said that he/she was unable to reposition/boost him/herself and relied on facility staff to assist with this. Resident #25 said that he/she had asked and that nothing had been done about his/her request. On 4/13/23 at 9:14 A.M., Resident #25 was observed lying in bed with the head of the bed elevated. An overbed table with a hot beverage mug was positioned in front of him/her. During an interview at this time, Resident #25 said that he/she didn't know why breakfast was so difficult and felt it was due to having to eat while lying in bed. He/she said it was difficult to drink liquids while lying in bed and would prefer to sit up in his/her wheelchair for better positioning during meals. On 4/14/23 at 8:22 A.M., the surveyor observed Resident #25 lying in bed, eating from a breakfast tray that was on an overbed table positioned in front of him/her. The head of the bed was elevated, and the Resident was eating cereal from a container on his/her lap. During an interview at this time, Resident #25 said that he/she had to eat while reclined in bed, and had told the facility staff that he/she preferred to be up in the wheelchair for breakfast. Resident #25 said that it had been months since he/she had made this request, that his/her family had also raised the concern that it was difficult to eat while reclined in bed and that he/she was fearful of choking. Resident #25 said that when his/her concern had been raised to facility staff, he/she was told that they don't have enough staff to get him/her up, and because he/she was not a choking risk and able to eat by him/herself, they didn't have to get him/her out of bed for breakfast. During an interview on 4/14/23 at 8:25 A.M., Certified Nurse Aide (CNA) #2 said Resident #25 gets up out of bed after breakfast and staff breaks. CNA #2 said Resident #25 was not a choking risk and was able to eat while in bed. CNA #2 further said that there were other residents who request to be up for breakfast, but the staff were unable to accommodate due to all of the residents who are required to be up out of bed due to their feeding/swallowing ability. CNA #2 said that once the meals arrive on the unit, they were unable to provide resident care while the meals were being served. During an interview on 4/14/23 at 8:38 A.M., Rehabilitation Staff #1 said that she had worked with Resident #25 numerous times. She further said that there were eight residents who needed to be out of bed for meals and supervised, and that she has heard Resident #25 request to be out of bed for breakfast but because the Resident was independent with eating, he/she was able to eat in his/her room. During an interview on 4/14/23 at 8:49 A.M., Nurse #2 said Resident #25 requests to be up out of bed in the morning prior to breakfast but other residents have priority due to their risk of aspiration (accidentally breathing food/fluids into the airway) and need for increased supervision with meals. Nurse #2 said Resident #25 was independent with meals therefore could eat in his/her room. Nurse #2 also said there was a list of residents that the 11:00 P.M. to 7:00 A.M. staff assist with getting out of bed in the morning prior to breakfast, but Resident #25 was not included on that list. During an interview on 4/14/23 at 10:52 A.M., the surveyor spoke with Resident #25's family member, who said that she was aware of the Resident's ongoing concern. She said Resident #25 got up early in the morning and liked to be out of bed for breakfast because he/she was not comfortable eating reclined in bed. Resident #25's family member said there was an incident recently where he/she was eating breakfast in bed and almost choked on a pitted prune but was able to catch it. The family member said that she thought this incident made Resident #25 more nervous and that eating while lying in bed really affected him/her. The family member said that Resident #25 would like to be seated in his/her wheelchair or in the dining room for breakfast and that the facility staff had explained that there was not enough people to help with this due to the number of residents that were required to be up and out of bed based on their level of assistance/supervision with meals or choking risk, and that these residents take priority. She further said that Resident #25 was very uncomfortable eating while lying in bed, that he/she never ate meals that way and wanted to be up in a wheelchair for breakfast. The family member said that this concern had been brought up for over six months and had been discussed in the last two care plan conferences, but nothing had been done. Review of the Care Plan Conference Reports dated 10/19/22, 1/4/23 and 3/29/23, indicated meetings with the Resident, family member and interdisciplinary team were held, that areas were discussed and that all who participated were in agreement with the plan of care. There was no documented evidence of the specific details of what was discussed during the care plan meeting nor any issues/concerns that were identified. During an interview on 4/14/23 at 11:42 A.M., Social Worker (SW) #1 said that she oversees the care plan meeting process. SW #1 said that Resident #25, his/her family member and the interdisciplinary team attended the meetings. She said at the most recent care plan meeting a grievance was discussed about the Resident's concern about not getting up out of bed for breakfast. SW #1 said that an explanation was given to the Resident and his/her family that those on altered diets needed to be up and out of bed for breakfast and that Resident #25 was independent with eating. During an interview on 4/14/23 at 12:08 P.M., the Director of Nurses (DON) said Resident #25 was offered to get out of bed on the 11:00 P.M. to 7:00 A.M. shift, that this would occur around 4:00 A.M., and the Resident declined. The DON did not think that there was documentation to indicate this. The DON said that there were approximately eight residents that were required to be up for breakfast for safety reasons and also 17 residents who needed to be up to attend morning services for religious purposes. During an interview on 4/14/23 at 12:10 P.M., the Regional Nurse said that at 7:00 A.M., the facility had two to three CNAs to provide care. She said that the religious residents needed to be washed and dressed and up as well as the other residents who require supervision/assistance prior to breakfast, and that the facility followed a Per Patient Day (PPD- hours of scheduled nursing staff divided by the total number of residents) for staffing on the unit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to accurately code a medication administered over the last 7 days on the Minimum Data Set (MDS) Assessment for one Resident (#231), out of a total sample of 12 residents. Findings include: Resident #231 was admitted to the facility in November 2021 with diagnoses including: -fracture of the left femur (the thigh bone of the upper leg) -surgical repair of the femur -history of stroke (poor blood flow to the brain) Review of the Physician's Orders, dated 11/12/21, indicated: Apixaban (A target specific oral anticoagulant medication used to treat and prevent blood clots and to prevent stroke) 2.5 milligrams (mg) give one tab (tablet) po (by mouth) 2 times a day. Review of the Medication Administration Record (MAR) for Resident #231, dated November 2021, indicated that from 11/12/21 through 11/18/21, Apixaban 2.5 mg was administered 11 times over 6 days. Review of the MDS assessment, dated 11/19/21, Section N titled Medications, indicated that no anticoagulant medication had been administered to the Resident beginning 11/12/21 through 11/18/21. During an interview on 12/1/21 at 10:39 A.M., the MDS nurse said that she had completed the MDS on 11/19/2021, and that she had not coded the Apixaban as an anticoagulant medication in Section N of the MDS assessment because she did not think it was an anticoagulant medication. During an interview on 12/1/21 at 12:38 P.M., the Staff Development/Infection Preventionist nurse said that she had never coded Apixaban as an anticoagulant, and it was her understanding that it was not required. Review of the MDS Resident Assessment Instrument (RAI) 3.0 Manual v1.17.1, October 2019, in reference to Section N0410-E: Medications Received, indicated but was not limited to: *N0410A-H: Code medications according to the pharmacological classification, not how they are being used. *N0410E, Anticoagulant (example: warfarin, heparin, or low- molecular weight heparin): Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). Do not code antiplatelet medications such as aspirin/extended release, dipyridamole, or clopidogrel here. *Anticoagulants such as Target Specific Oral Anticoagulants (TSOACs), which may or may not require laboratory monitoring, should be coded in N0410E, as an Anticoagulant. Review of the article titled Target-Specific Oral Anticoagulants published April 18, 2014 in the U.S. Pharmacist Journal, US Pharm. 2014;39(4):69-74, authors [NAME] and [NAME], included Apixaban as a target specific oral anticoagulant.

Based on observation, record review and interview, the facility failed to provide the necessary services to maintain grooming for one Resident (#14) in a total sample of 12 residents. Findings include: Resident #14 was admitted to the facility in April 2019. On 11/30/21 at 8:20 A.M., the surveyor observed Resident #14 sitting up in bed, eating breakfast, and he/she had noticeably long facial hair. Review of the Care Plan, updated 10/2021, indicated the Resident was dependent with grooming. Review of November 2021 Nursing Assistant Flow Sheets indicated the Resident required total dependent care for grooming tasks from the nursing assistants on the 7:00 A.M. to 3:00 P.M. and 3:00 P.M. to 11:00 P.M. shifts. On 12/1/21 at 8:16 A.M., the surveyor observed Resident #14 sitting up in bed eating breakfast, and he/she still had noticeably long facial hair. On 12/1/21 at 10:25 A.M., the surveyor observed the Resident sitting in his/her wheelchair beside the bed. Resident #14 was dressed, his/her hair was brushed, however his/her facial hair was still long and appeared unchanged since the initial observation on the morning of 11/30/21. During an interview on 12/1/21 at 10:30 A.M., Nurse #1 said that the Resident's morning care was completed. When asked about the Resident's facial hair, the nurse said the Resident should have been shaved. The nurse asked Resident #14 if he/she would like to have his/her facial hair shaved, and the Resident said yes. The Resident then told the nurse that the razor was in the top drawer.

Based on interview and Quality Assurance and Performance Improvement (QAPI) meeting sign-in sheets, the facility failed to ensure the required members were present for one out of four quarterly meetings. Findings include: Review of the last four quarters of QAPI meeting sign-in sheets indicated the Director of Nurses (DON) was not present for the most recent meeting held on October 26, 2021. During an interview on 12/1/21 at 2:18 P.M., the administrator reviewed the October 26, 2021 sign-in sheet and said the DON was not in attendance and should have been. He said the DON was supposed to attend every QAPI meeting.

Based on record review and interview the facility failed to use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week. Findings include: Review of the actual worked schedules from 11/6/21 through 11/30/21 indicated that on 11/6/21, 11/7/21, 11/20/21, 11/21/21, and 11/25/21 there were no RNs present at the facility in a 24 hour period. During an interview on 11/30/21 at 3:07 P.M., the Staff Development Coordinator/Infection Preventionist said that she did not believe there was an RN in the facility for 8 hours every day of the week. She said they only had licensed practical nurses (LPN) on the weekends, and sometimes they had an RN on one of the weekend days. During an interview on 11/30/21 at 4:07 P.M., the Director of Nurses said they had LPNs only, every other Saturday and Sunday, so one day per week there was no RN in the facility.