Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who during the overnight shift on 10/04/24 into 10/05/24 was found sitting on the floor by Nurse #1 and CNA #1 after an unwitnessed fall, the Facility failed to ensure nursing reported the incident to the Physician, his/her Health Care Agent, Administrative staff and to the oncoming shift Nurse (Nurse #2) as required, and per Facility policy. Findings include: Review of the Facility's policy, titled Notification of Changes, dated 03/04/24, indicated the purpose of this Policy is to ensure the Facility promptly informs the resident's Physician; notifies, consistent with his or her authority, the resident's Representative when there is a change requiring notification. The Policy indicated circumstances requiring notification include accidents with potential to require Physician interventions. The Policy indicated additional considerations included that for competent individuals, the Facility must still contact the resident's Physician and notify resident's Representative. Review of the Facility's policy, titled Fall Prevention Program, dated 03/04/24, indicated when any resident experiences a fall, the Facility will notify residents Physician and Family. Review of Facility's policy, titled Incidents and Accidents, dated 03/04/2024, indicated staff to alert Risk Management and/or Administration of occurrences that could result in claims or further reporting requirements. The Policy indicated staff will notify the Supervisor or other Designee of the incident/accident. The Policy indicated the Nurse will contact the resident's Physician and Family to inform them of the incident/accident. Resident #1 was admitted to the Facility in September 2024, diagnoses included congestive heart failure, atrial fibrillation, hypertension, shortness of breath, and muscle weakness. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 10/15/24, indicated that on 10/05/24, Resident #1's daughters were visiting Resident #1, he/she complained of back pain, told them he/she had fallen overnight, and the family requested Resident #1 be transferred to the hospital. The Report further indicated that Resident #1's fall was unwitnessed, Nursing assessment at the time of the fall did not reveal any acute injury, that Resident #1 had been toileted, place back into bed and had not complained of pain until later in the morning. The Report indicated Resident #1 was transferred to the hospital (during the day shift on 10/05/24), was diagnosed with edema and fracture of S3-S4 (break in the sacrum) and T11 (on of the 12 vertebrae of the thoracic spine). Review of Resident #1's Medical Record indicated his/her Family was involved in his/her care. Resident #1 was his/her own person, that his/her Health Care Agent contact information and Family member contact information were clearly indicated in his/her record. Review of Resident #1's Medical Record indicated that for overnight shift (10/04/24 into 10/05/24), there was no Nurse Progress Note, no Incident Report and no documentation to support Resident #1's Health Care Agent, Physician, Director of Nurses (DON) or the oncoming day shift Nurse were notified of Resident #1's fall/incident. During a telephone interview on 11/12/24 at 2:32 P.M., (which included a review of her Written Witness Statement, dated 10/09/24), Nurse #1 said on 10/05/24, somewhere around 2:00 A.M. she heard a sound, like a walker falling on the floor, that she went into Resident #1's room, and found him/her sitting on his/her buttocks on the floor. Nurse #1 said Resident #1 was able to move his/her legs, arms and denied having any pain or hitting, his/her head. Nurse #1 said she was satisfied with her assessment and waited to perform vital signs once Resident #1 was in bed since he/she had to go to the bathroom. Nurse #1 said she and CNA #1 helped Resident #1 ambulate to the bathroom with his/her walker, but upon return from the bathroom they transferred Resident #1 via wheelchair since Resident #1 said he/she was tired. Nurse #1 said she did not report Resident #1's fall to the Physician, the DON or to Resident #1's Health Care Agent. Nurse #1 said she was aware of the Facility's Policy related to Fall Prevention Program, Incidents and Accidents and Documentation, which included reporting any incidents and accidents. Nurse #1 said on 10/09/24 she wrote and provided the Facility with a written statement, in which she documented Resident #1's fall. Nurse #1 said looking back she should of followed the Facility's Policy and reported Resident #1's fall to the Physician, to the oncoming shift Nurse, the DON, his/her Health Care Agent and documented the incident for Resident #1's safety and for other staff to be able to identify any changes that may occur with him/her. Review of Resident #1's Hospital Magnetic Resonance Imaging (MRI) Report, dated 10/06/24, indicated that Resident #1 had a fall, pain, and a Thoracic spine/Lumbar MRI was completed. The Report indicated Resident #1 had a T11 vertebral body acute fracture/edema (bottom part of the thoracic spine) and a fracture of his/her S3 and S4 fracture (a break in the sacrum, a triangular bone at the base of the spine, between the hips). During an interview on 11/05/24 at 2:39 A.M. the Director of Nurses (DON) said she was not informed of Resident #1's fall by the Nurse (identified as Nurse #1) that worked the overnight shift on 10/04/24 into 10/05/24. The DON said she and Nurse #2 assessed Resident #1 on 10/05/24, after Resident #1's family members notified them that Resident #1 had a fall on the overnight shift and wanted him/her to be transferred to the hospital immediately. The DON said she went to assess Resident #1, who reported that he/she had fallen sometime during the overnight shift, that he/she fell landing on his/her buttocks, staff picked him/her up off the floor, placed him/her in a wheelchair, toileted him/her and then placed him/her back into bed. The DON said she could not find any documentation in Resident #1's Medical Record regarding his/her fall on 10/05/24, including any assessments or an Incident Report. The DON said it was her expectation that Nurse #1 should have assessed Resident #1 for injury, initiated obtaining neurological signs (fall was unwitnessed), and completed pain and skin assessments. The DON said Nurse #1 should have also notified the Physician, facility administrative staff, documented the incident in a progress note, completed an Incident Report, notified the oncoming shift nursing staff, and obtained staff members written statements, but she had not. The DON said she began an investigation on 10/05/24 after being informed of Resident #1's fall. The DON said she had Nurse #1 complete all the Resident #1's fall documentation as a late entry, but that Nurse #1 did not do so until several days after the Resident #1's fall since Nurse #1 was not returning her phone calls or texts. The DON said Nurse #1 told her she did not report Resident #1's fall on 10/05/24, because she had forgotten to report and document the incident.

Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who during the overnight shift (on 10/04/24 into 10/05/24) was found sitting on the floor by Nurse #1 and Certified Nurse Aide (CNA) #1 after an unwitnessed fall, the Facility failed to ensure he/she was provided with nursing care and treatment that met professional standards of quality care, when although Nurse #1 said she assessed Resident #1 prior to moving him/her off the floor, there was no documentation to support she adequately assessed Resident #1 after his/her fall for potential injury. The following day shift (7:00 A.M. to 3:00 P.M.) Resident #1 verbalized complaints of pain, reported he/she had fallen during the previous overnight shift, and was transferred to the Hospital Emergency Department (ED) for evaluation. Resident #1 was diagnosed with a T11 vertebral body acute fracture/edema (bottom part of the thoracic spine) and fractures of S3 and S4 fracture (a break in the sacrum, a triangular bone at the base of the spine, between the hips). Findings include: Standard Reference: Standard of Practice Reference: Pursuant to Massachusetts General Law (M.G.L), chapter 112, individuals are given the designation of registered nurse and practical nurse which includes the responsibility to provide nursing care. Pursuant to the Code of Massachusetts Regulation (CMR) 244, Rules and Regulations 3.02 and 3.04 define the responsibilities and functions of a registered nurse and practical nurse respectively. The regulations stipulate that both the registered nurse and practical nurse bear full responsibility for systematically assessing health status and recording the related health data. They also stipulate that both the registered and practical nurse incorporated into the plan of care and implement prescribed medical regimens. The rules and regulations 9.03 defined standards of Conduct for Nurses where it is stipulated that a nurse licensed by the Board shall engage in the practice of nursing in accordance with accepted standards of practice. Review of the Facility Policy titled, Fall Prevention Program, dated 03/04/24, indicated when any resident experiences a fall the Facility will: -Assess the resident. -Complete a post-fall assessment. -Complete an incident report. -Notify Physician and family. -Review the Resident's care plan and update as indicated. -Document all assessments and actions. -Obtain witness statements in the case of injury. Review of the Facility Policy titled, Accidents and Incidents, dated 03/04/24, indicated for Facility Staff to utilize Point Click Care (PCC) risk management to report and investigate any accidents or incidents that occur on Facility property involving a Resident. The Policy indicated staff to initiate the following: -Falls require an incident/accident report. -The Supervisor or other designee will be notified of the incident/accident. -The Nurse will contact the resident's practitioner to inform them of the incident/accident, report any injuries or other findings, and obtain orders, if indicated, which may include transportation to the hospital dependent upon the nature of the injury. -In the event of an unwitnessed fall, the nurse will initiate neurological checks as per protocol, document on the neurological flow sheet and abnormal findings will be reported to the Practitioner. -The resident's Family or Representative will be notified of the incident/accident and any orders obtained or if the resident is to be transported to the hospital. -Documentation should include the date, time, nature of the incident, location, initial findings, immediate interventions, notifications, and orders obtained or follow-up interventions. Resident #1 was admitted to the Facility in September 2024, diagnoses included congestive heart failure, atrial fibrillation, hypertension, shortness of breath, and muscle weakness. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated 10/15/24, indicated that on 10/05/24, Resident #1's daughters were visiting Resident #1, he/she complained of back pain, told them he/she had fallen overnight, and the family requested Resident #1 to be transferred to the hospital. The Report indicated Resident #1's fall was unwitnessed, and nursing assessment at the time of the fall did not reveal any acute injury. The Report indicated Resident #1 had been toileted, placed back into bed and had not complained of pain until later in the morning. The Report indicated Resident #1 was transferred to the Hospital Emergency Department where he/she was diagnosed with edema and fractures of S3-S4 and T11. During a telephone interview on 11/12/24 at 3:54 P.M., (which included a review of her Written Witness Statement, undated), CNA #1 said on 10/05/24, somewhere around 2:00 A.M. (exact time unknown) she heard a bang, went into Resident #1's room, and found him/her sitting on his/her buttocks on the floor. CNA #1 said Resident #1's walker was tipped over on the floor next to him/her and that Resident #1 said he/she was going to the bathroom. CNA #1 said Resident #1 said he/she was alright, so she and Nurse #1 assisted (lifted) Resident #1 up off the floor, assisted him/her to the bathroom, toileted him/her and then transferred Resident #1 back into bed. CNA #1 said prior to them moving Resident #1 off the floor she did not see Nurse #1 perform an assessment on Resident #1, other than hearing Nurse #1 ask Resident #1 if he/she was in pain. During a telephone interview on 11/12/24 at 2:32 P.M., (which included a review of her Written Witness Statement, dated 10/09/24), Nurse #1 said on 10/05/24, somewhere around 2:00 A.M. (exact time unknown) she heard a sound, like a walker falling on the floor, went into Resident #1's room, and found him/her sitting on his/her buttocks on the floor. Nurse #1 said Resident #1 was able to move his/her legs, arms, denied hitting his/her head and did not report having pain. Nurse #1 said she was satisfied with her initial assessment and waited to perform vital signs once Resident #1 was in bed, since Resident #1 said he/she had to go to the bathroom. Nurse #1 said she and CNA #1 helped Resident #1 ambulate to the bathroom with his/her walker but upon return from the bathroom they transferred Resident #1 via wheelchair since Resident #1 said he/she was tired. Nurse #1 said she did not document or complete any documentation related to Resident #1 fall and did not report Resident #1's fall on 10/05/24 to the next shift staff because Resident #1 said he/she was alright. Nurse #1 said she did not initiate neurological checks after Resident #1's unwitnessed fall since Resident #1 said he/she did not hit his/her head. However, although Nurse #1 said she assessed Resident #1 immediately after the fall, and that she had decided to wait and obtain a set of vitals after she and CNA #1 assisted Resident #1 back to bed, there was no documentation in Resident #1's medical record to support Nurse #1 had completed any type of assessment or that she had obtained Resident #1's vital signs on 10/05/24, after his/her unwitnessed fall. Nurse #1 said she was aware of the Facility's Policy related to Fall Prevention Program, Incidents/Accidents, Procedures, and what was required of nursing if a resident had an unwitnessed fall. Nurse #1 said on 10/09/24, (five days after the incident) she provided a written statement to the Facility and that was also when she documented Resident #1's unwitnessed fall in his/her medical record. During an interview on 11/05/24 at 4:02 P.M., (which included a review of her Written Witness Statement, dated 10/05/24), Nurse #2 said on 10/05/24 she worked the 7:00 A.M. to 3:00 P.M. shift and when she came on duty, she received change of shift report from Nurse #1 who had worked the overnight shift (from 10/04/24 into 10/05/24). Nurse #2 said during the change of shift report, Nurse #1 told her that Resident #1 had chronic pain, was on scheduled pain medications and had a wound that was not new to his/her coccyx area. Nurse #2 said Nurse #1 did not say anything in report to her about Resident #1 falling during the overnight shift. Nurse #2 said, on 10/05/24, she administered Resident #1's medications later in the morning (exact time unknown) which included scheduled pain medications, and shortly after that CNA #2 reported to her that Resident #1 said he/she was in pain due to a fall. Nurse #2 said since she had just administered pain medication to Resident #1, and she had not been informed of a fall in the change of shift report, she thought Resident #1 might have been talking about a fall he/she may have previously had at home. Nurse #2 said she was at the nursing station with the Director of Nursing (DON) when CNA #2 came to the desk a second time, reported that Resident #1 said he/she was still in pain and that Resident #1 had also said he/she had fallen during the previous overnight shift. Nurse #2 said shortly after she spoke with CNA #2, Resident #1's Family members came to the nursing station and questioned them saying he/she had a fall last night and you are not going to send him/her out to the hospital and that the family members continued to repeat that statement. Nurse #2 said she and the DON immediately went to assess Resident #1. Nurse #2 said upon entering Resident #1's room, Resident #1 was grimacing, as if he/she was in pain. Nurse #2 said Resident #1 was sent to the hospital via Emergency Medical Services (911). Review of Resident #1's Hospital Magnetic Resonance Imaging (MRI) Report, dated 10/06/24, indicated that Resident #1 had a fall, was in pain, and a Thoracic spine/Lumbar MRI was completed. The Report indicated Resident #1 had a T11 vertebral body acute fracture/edema (bottom part of the thoracic spine) and a fracture of his/her S3 and S4 fracture (a break in the sacrum, a triangular bone at the base of the spine, between the hips). During an interview on 11/05/24 at 2:39 P.M. the Director of Nurses (DON) said she was not informed of Resident #1's fall during the overnight shift (10/04/24 into 10/05/24) by Nurse #1. The DON said she assessed Resident #1 after Resident #1's family members notified them that Resident #1 told them he/she had a fall on the overnight shift and that they wanted him/her to be transferred to the hospital immediately. The DON said when she went to assess Resident #1, he/she said she/he had fallen sometime on the overnight shift, landed on his/her buttocks, and that staff had picked him/her up off the floor, placed him/her in the wheelchair, toileted him/her and then put him/her back into bed. The DON said she could not find any documentation in Resident #1's Medical Record regarding his/her unwitnessed fall on 10/05/24, including any type of nursing assessments or incident report. The DON said it was her expectation that Nurse #1 would have assessed Resident #1 for any potential injury, initiated obtaining neurological signs (since his/her fall was unwitnessed), completed pain and skin assessments, and notified the Physician and herself, The DON said Nurse #1 should have documented the fall in a Progress Note, and notified the oncoming shift nurse of the fall, but she had not. The DON said it was several days after the Resident #1's fall before she was able to speak to Nurse #1 regarding Resident #1's fall and determine what happened that night. The DON said Nurse #1 did not follow Facility's Procedures and Policy's.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and policy review, the facility failed to ensure residents were treated with dignity for one Resident (#28) out of a total sample of 17 residents. Specifically, for Resident #28, the facility failed to provide assistance with removal of unwanted chin hair. Findings include: Review of the facility policy titled Promoting/Maintaining Resident Dignity, dated 3/4/24, indicated that it is the practice of this facility to protect resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment that maintains or enhances resident's quality of life by recognizing each resident's individuality. Further review of the policy indicated that residents are to be groomed and dressed according to resident preference. Resident #28 was admitted to the facility in March 2021 with diagnoses including heart disease, kidney disease and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #28 scored an 11 out of 15 on the Brief Interview for Mental Status exam indicating moderately impaired cognition. Further review of the MDS indicated that the section indicating how Resident #28 completes personal hygiene is blank. Review of the facility document titled MDS [NAME] Report indicated that Resident #28 is totally dependent for personal hygiene. Review of Resident #28's current Activity of Daily Living (ADL) care plan, indicated for his/her personal hygiene: the Resident is an extensive assist to totally dependent of 1 staff with personal hygiene and oral care. Further review of the care plan failed to indicate Resident #28 refuses care. Review of the progress notes dated August 2024 and September 2024 failed to indicate Resident #28 refuses care. On 9/10/24 at 7:50 A.M. and 12:30 P.M., the surveyor observed Resident #28 with chin hair approximately 1 inch long. On 9/11/24 at 7:48 A.M., the surveyor observed Resident #28 with chin hair approximately 1 inch long. On 9/12/24 at 8:30 A.M., the surveyor observed Resident #28 with chin hair approximately 1 inch long. During an interview on 9/10/24 at 7:50 A.M. Resident #28 said he/she doesn't like the chin hair and wants it removed. During an interview on 9/12/24 at 8:34 A.M., Certified Nurse Aide (CNA) #3 said that it is the CNAs that are responsible for removing chin hair. CNA #3 said she didn't have time to remove Resident #28's chin hair yesterday.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) Resident #22 was admitted to the facility in January 2024 with diagnoses including combined systolic and diastolic heart failure, pleural effusion, atrial fibrillation, and pulmonary hypertension. Review of the Minimum Data Set (MDS) assessment, dated 4/9/24, indicated that Resident #22 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of Resident #22's nursing note, dated 4/12/24 indicated: - Note Text: Ok to transfer to hospital for evaluation - fall this morning 6am in own bedroom. Review of Resident #22's nursing note, dated 4/12/24 indicated: - Note Text: This nurse received report from hospital that resident would be admitted for hypokalemia, and congestive heart failure. On 9/10/24 and 9/11/24 the surveyor reviewed the electronic health record and the paper medical record. The surveyor was unable to locate documentation to support the facility staff notified the ombudsman of Resident #22's transfer. The surveyor requested the documents from the Regional Nurse on 9/11/24 at 11:30 A.M. During an interview on 9/12/24 at 12:01 P.M., the Regional Nurse said she was unable to find documentation to support the ombudsman was notified of Resident #22's transfer. Based on record review and interviews, the facility failed to provide a notice of transfer and failed to send a copy of the notice to the Ombudsman for one Resident (#30) and the facility failed to send a copy of the transfer notice to the Ombudsman for one Resident (#22) out of a total sample of 17 residents who were transferred to the hospital. Findings include: A review of the facility policy titled 'Transfer and Discharge (including AMA)', revised in March 2024, indicated the following: - Transfer and discharge include movement of a resident outside of the certified facility whether that bed is in the same physical place or not. 12. Emergency Transfers/Discharges initiated by the facility for medical reasons to an acute care setting such as a hospital, for the immediate safety and welfare of a resident. (g) Provide a notice of transfer to the resident and representative as indicated. (h) The Social Services Director, or designee, will provide copies of notices for emergency transfers to the Ombudsman. 1.) Resident #30 was admitted to the facility in July 2024 with diagnoses including dementia. A review of the most recent Minimum Data Set (MDS) dated [DATE], did not indicate a Brief Interview for Mental Status Score. A review of the cognition care plan, revised on 7/29/24, indicated that Resident #30 had impaired cognition due to developmental delays and traumatic brain injury. A review of Resident #30's nurse progress notes, dated 8/19/24 and 8/21/24, respectively indicated the following: - Resident was sent out to hospital this evening at 6pm due to critically low H&H (hematocrit and hemoglobin). Resident has been non-compliant with transfusion/lab draw on Friday 8/16. Resident informed 7-3 nurse that he/she was feeling terrible weak and wanted to be sent for a transfusion. NP (Nurse Practitioner) spoke with resident and confirmed he/she wanted to be sent out. Hospital was called and given report via 2nd floor nurse. Staff made aware, will follow up tomorrow with NP 8/20. [sic] - Pt (patient) came back from the hospital on a stretcher escorted by two EMT (emergency medical technician) personnel. He/she was sent out on the 19th for anemia related complications (H & H 6,1). [sic] A review of the facility census indicated that Resident #30 was at the hospital from [DATE] to 8/21/24. A review of Resident #30's medical record failed to indicate that a notice of transfer was issued to the Resident and a copy sent to the ombudsman. During an interview on 9/12/24 at 12:44 P.M., the Regional Nurse and the Director of Nurses (DON) #2 said Resident #30 was not issued a transfer notice prior to the hospital transfer on 8/19/24. They said transfer notices should be issued to residents or resident representatives prior to emergency transfers to the hospital. They both said a copy of the transfer notice should be sent to the ombudsman.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) Resident #22 was admitted to the facility in January 2024 with diagnoses including combined systolic and diastolic heart failure, pleural effusion, atrial fibrillation, and pulmonary hypertension. Review of the Minimum Data Set (MDS) assessment, dated 4/9/24, indicated that Resident #22 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of Resident #22's nursing note, dated 4/12/24 indicated: Note Text: Ok to transfer to hospital for evaluation - fall this morning 6am in own bedroom. Review of Resident #22's nursing note, dated 4/12/24 indicated: Note Text: This nurse received report from hospital that resident would be admitted for hypokalemia, and congestive heart failure. On 9/10/24 and 9/11/24 the surveyor reviewed the electronic health record and the paper medical record. The surveyor was unable to locate documentation to support Resident #22 was provided the bed hold policy. The surveyor requested the documents from the Regional Nurse on 9/11/24 at 11:30 A.M. During an interview on 9/12/24 at 12:01 P.M., the Regional Nurse said she was unable to find documentation to support Resident #22 was provided the bed hold policy. Based on record review and interview, the facility failed to provide a bed hold policy for two Residents (#30 and #22) out of a sample of 17 residents. Specifically, the facility failed to provide a facility bed hold policies to the Residents or Resident Representatives before Resident #30 and Resident #22 were transferred to the hospital. Findings include: A review of the facility policy titled 'Transfer and Discharge (including AMA)', revised in March 2024, indicated the following: - Transfer and discharge include movement of a resident outside of the certified facility whether that bed is in the same physical place or not. 12. Emergency Transfers/Discharges initiated by the facility for medical reasons to an acute care setting such as a hospital, for the immediate safety and welfare of a resident. (g) Provide the facility's bed hold policy to the resident and representative as indicated. 1.) Resident #30 was admitted to the facility in July 2024 with diagnoses including dementia. A review of the most recent Minimum Data Set (MDS) dated [DATE] did not indicate a Brief Interview for Mental Status Score. A review of the cognition care plan, revised on 7/29/24, indicated Resident #30 had impaired cognition due to developmental delays and traumatic brain injury. A review Resident #30's nurse progress notes, dated 8/19/24 and 8/21/24, respectively indicated the following: - Resident was sent out to the hospital this evening at 6pm due to critically low H&H (hematocrit and hemoglobin). Resident has been non-compliant with transfusion/ lab draw on Friday 8/16. Resident informed 7-3 nurse that he/she was feeling terrible weak and wanted to be sent for a transfusion. NP (Nurse Practitioner) spoke with resident and confirmed he/she wanted to be sent out. Hospital was called and given report via 2nd floor nurse. Staff made aware, will follow up tomorrow with NP 8/20. [sic] - Pt (patient) came back from the hospital on a stretcher escorted by two EMT (emergency medical technician) personnel. He/she was sent out on the 19th for anemia related complications (H & H 6,1). [sic] A review of the facility census indicated that Resident #30 was at the hospital from [DATE] to 8/21/24. A review of Resident #30's medical record failed to indicate that a bed hold policy was issued to the Resident or the Resident representative. During an interview on 9/12/24 at 12:44 P.M., the Regional Nurse and the Director of Nurses (DON) #2 said Resident #30 was not issued a facility policy for bed hold prior to the hospital transfer on 8/19/24. They said bed hold policies should be issued to Residents or Resident Representatives prior to emergency transfers to the hospital.

Based on record review and interviews, the facility failed to ensure that its staff completed a Preadmission Screening and Resident Review (PASRR - a federal and state required process that is used to identify evidence of serious mental illness (SMI) and/or intellectual or developmental disabilities in all individuals seeking admission to a nursing facility), in a timely manner after the expected length of stay exceeded 30 days for one Resident (#14) with SMI, out of 17 sampled residents. Findings include: Review of the facility policy titled Resident Assessment - Coordination with PASARR [sic] Program, dated 3/4/24, indicated: 9. If a resident who was not screened due to an exception and the resident remains in the facility longer than 30 days: e. The facility must screen the individual using the State's Level I screening process to the appropriate state-designated authority for Level II PASARR [sic] evaluation and determination. Resident #14 was admitted to the facility in August 2024 with diagnoses including bipolar disorder and depression. Review of the PASRR Level I Screening, dated 8/2/24, indicated the Resident had a positive SMI screen, but a Level II PASRR Evaluation (used to confirm if the individual has SMI and, if so, whether the individual requires a nursing facility level of care and specialized services) was not indicated at that time due to Exempted Hospital Discharge (maximum 30 calendar days). Further review indicated if the nursing facility determined that the Resident's stay would exceed the 30 day exemption period, the nursing facility must complete Section G on the form and submit Level I Screening to the Department of Mental Health (DMH) no later than the 25th calendar day from admission. Review of the clinical record on 9/11/24, which was 40 days after Resident #14's admission, did not indicate another PASRR Level I was ever completed once the nursing facility determined the Resident would exceed the 30 day exemption period. During a telephone interview on 9/11/24 at 12:01 P.M., the Admissions Liaison said she was responsible for PASRR Level I's only upon admission. The Admissions Liaison said she looked in the PASRR portal and there were no additional PASRRs completed for Resident #14 since 8/2/24, but there should have been another submitted before the 25th calendar day from admission since Resident #14 exceeded the 30 day exemption. The Admissions Liaison said she was not aware of who was responsible because she works remotely but knew the previous person responsible had resigned. During an interview on 9/12/24 at 10:55 A.M., the Social Worker said she was a consultant that came in once a week to help. The Social Worker said nobody had been completing PASRRs in the facility after admission because there is nobody in the facility who has access to the PASSR portal. The Social Worker said she told the Administrator multiple times, but they never got her access. During an interview on 9/12/24 at 1:05 P.M., The Administrator said he was unaware the PASRRs were not being completed but should be.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and interview, the facility failed to ensure staff developed and implemented a baseline care plan within 48 hours of the resident's admission, which included the instructions needed to provide effective and person-centered care to the resident which meet professional standards of quality care for three Residents (#25, #47 and #49), in a total sample of 17 residents. Specifically, the facility failed to ensure: 1. For Resident #25, a baseline care plan was developed for the Resident's dialysis treatment. 2. For Resident #47, a baseline care plan was developed. 3. For Resident #49, a baseline care plan was developed. Findings include: Review of the facility policy titled Comprehensive Care Plans dated 3/4/24, failed to indicate that a baseline care plan would be developed to ensure the minimum healthcare information necessary to properly care for each resident upon their admission, which would address resident-specific health and safety concerns to prevent decline or injury, and would identify needs for supervision and assistance with Activities of Daily Living. 1.) Resident #25 was admitted to the facility in August 2024 with diagnoses including end stage kidney disease, pneumonia and fracture. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #25 scored an 11 out of 15 on the Brief Interview for Mental Status exam indicating moderately impaired cognition. Further review indicated Resident #25 required moderate assistance for most activities of daily living. Review of the doctor's orders dated August 2024 and September 2024 failed to indicate a doctor's order for hemodialysis. Review of the medical record failed to indicate that a baseline care plan was developed within the required 48 hours of admission, including the development of a dialysis care plan. During an interview on 9/10/24, at 12:45 P.M., Nurse #4 said that there should have been a care plan created on admission that includes how to care for the Resident including the days, times and place the Resident is scheduled to go to dialysis. During an interview on 9/10/24 at 1:45 P.M., Nurse #6 said that Resident # 25 has a Central Venous Catheter (CVC) for dialysis access. Nurse #6 said that she would expect that there would be a doctor's order to monitor the CVC site for infection and drainage and that a baseline care plan would have been developed to include those interventions. 2.) Resident #47 was admitted to the facility in August 2024 with diagnoses including post-traumatic stress disorder (PTSD), hemiplegia and diabetes. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #47 scored a 15 out of 15 on the Brief Interview for Mental Status exam indicating intact cognition. Further review of the MDS indicated Resident #47 required assistance with most activities of daily living. Review of the medical record failed to indicate that a baseline care plan was developed within the required 48 hours of admission. During an interview on 9/10/24 at 4:38 P.M., Director of Nursing #1 said that he was unable to locate a baseline care plan. 3.) Resident #49 was admitted to the facility in August 2024 with diagnoses including hip fracture and malnutrition. Review of the medical record failed to indicate a baseline care plan was created within 48 hours of admission. During an interview on 9/10/24 at 12:33 P.M., Nurse #5 said that she could not locate a baseline care plan in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team for two Residents (#14 and #47) out of a total sample of 17 residents. Specifically: 1.) For Resident #14, the facility failed to update the comprehensive care plan to indicate a new change in advanced directives from full code to do not resuscitate (DNR) and failed to ensure the entire comprehensive care plan was reviewed and revised by an interdisciplinary team following the completion of a comprehensive assessment. 2.) For Resident #47, the facility failed ensure the entire comprehensive care plan was reviewed and revised by an interdisciplinary team following the completion of a comprehensive assessment. Findings include: Review of the facility policy titled Comprehensive Care Plans, dated 3/4/24, indicated: - The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS (Minimum Data Set). Review of the facility policy titled Residents' Rights Regarding Treatment and Advanced Directives, dated 3/4/24, indicated: - Decisions regarding advanced directives and treatment will be periodically reviewed as part of the comprehensive care planning process. 1.) Resident #14 was admitted to the facility in August 2024 with diagnoses including adult failure to thrive and malnutrition. Review of Resident #14's most recent Minimum Data Set (MDS) assessment, dated 8/6/24, indicated the assessment was completed on 8/14/24. Review of Resident #14's advanced directives care plan, dated as last revised 8/13/24, indicated the target date for goal review was overdue. The care plan further indicated: - No MOLST. - Resident #14 has not made any advance directives: Assume full code. - Discuss/Confirm Advance Directives and/or Living will decisions on admission, at least quarterly and PRN (as needed) with change in prognosis. Review of Resident #14's physician's order, dated 8/16/24, indicated: - Resident is a DNR/DNI (do not intubate). During an interview on 9/11/24 at 11:43 A.M., Nurse #5 said the nurses on the floor were responsible for updating all care plans since the MDS nurse and social worker had resigned. Nurse #5 said it was difficult to keep up with care plan updates because they didn't have enough time with staffing levels in the facility. Nurse #5 said Resident #14 advanced directives specified he/she was a full code on admission but the Resident opted to change his/her code status to DNR on 8/16/24. Nurse #5 said Resident #14's care plan should have been updated to reflect his/her current wishes for DNR on 8/16/24, but it was not done. During an interview on 9/12/24 at 10:08 A.M., Director of Nursing (DON) #1 said Resident #14's advanced directives care plan should have been updated immediately when his/her code status changed to DNR. During an interview on 9/12/24 at 1:10 P.M., the Social Worker said she was a consultant that came in once a week to help the facility. The Social Worker said she was not involved in the care plan process and was not aware of who was. The Social Worker said she did not hold any care plan meetings in over a month. During an interview on 9/12/24 at 1:14 P.M., Director of Nursing (DON) #2 and the Regional Nurse said the Social Worker and the MDS Nurse should have been responsible for care plan meeting coordination. DON #2 and the Regional Nurse said the comprehensive care plan should be reviewed and revised during a care plan meeting within seven days after the completion date of every comprehensive or quarterly MDS. They said since Resident #14's comprehensive MDS was completed on 8/14/24, there should have been a care plan meeting to review and revise the care plan to reflect their current status by 8/21/24. They said that the Resident #14's care plan relating to advanced directives should have been revised immediately, but also reviewed during the care plan meeting that should have been held by 8/21/24. DON#2 and the Regional Nurse said if a care plan meeting was held to review and revise the care plan it would be in the binder titled Care Plan Sign In but they would not be surprised if it was missed because they did not have an MDS Nurse at the time and the consultant Social Worker was only in once a week. Review of binder titled Care Plan Sign In failed to indicate a care plan meeting invitation was sent or a care plan meeting was held for Resident #14 on or after 8/14/24. Review of Resident #14's care plan indicates that no revisions were made after 8/13/24. Further review of the care plan indicated the care plan review was overdue and should have been completed by 8/21/24. 2.) Resident #47 was admitted to the facility in August 2024 with diagnoses including post-traumatic stress disorder (PTSD), hemiplegia and diabetes. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #47 scored a 15 out of 15 on the Brief Interview for Mental Status exam indicating intact cognition. Further review indicated Resident #47 required assistance with most activities of daily living. Further review indicated the MDS assessment was completed on 8/14/24. Review of Resident #47's active plan of care dated as last revised 8/6/24, indicated the target date for all goal reviews were overdue. The care plan was scheduled to be reviewed 7 days after the completion of the MDS and was not. The care plan further indicated: a. 12 separate problem focus's related to high-risk medication use indicated the following: Secondary to DX (diagnosis)/indication for use of (choose etiologies and identify DX, symptoms for use of each high-risk med (medication). Further review of the 12 separate problem focus's failed to indicate that the name of the medication, the diagnoses associated with the medication, or the symptoms for use, had been filled in. b. all 12 of the goals for the corresponding problem focuses listed above, were the same and did not include any specific goals related to any specific medications. Further review indicated that all 12 goals for each problem focus were overdue. During an interview on 9/10/24 at 4:38 P.M., Director of Nursing (DON) #1 said that he was unable to locate any specific/complete psychotropic medication use care plans. During an interview on 9/12/24 at 8:50 A.M., DON #1 said that the care plan should include the specific psychotropic medications used with their corresponding potential side effects, and resident specific interventions. The DON said that the care plan had not been reviewed/revised timely as all the goals indicated the care plan was overdue for review.

Based on record review and interviews, the facility failed to provide services that met professional standards of quality for one Resident (#19) out of a sample of 17 Residents. Specifically, for Resident #19 the facility failed the ensure nursing implemented an air mattress setting according to the physician's order. Findings include: Resident #19 was admitted to the facility in November 2020 with diagnoses including dementia, dysphagia, and osteoarthritis. Review of the facility policy titled, Use of Support Surfaces, dated as 3/4/24, indicated that support surfaces will be used in accordance with evidence-based practice for residents with or at risk for pressure injuries. 5. Except for the facility's standard mattresses and wheelchair cushions, support surfaces will be utilized in accordance with physician orders. 6. Support surfaces will be utilized in accordance with manufacturer recommendations (including considerations for contraindications) 7. For powered devices, or those requiring air, the licensed nurse will check each shift and as needed for proper functioning and/or inflation. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/30/24, indicated that Resident #19 had a severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 2 out of 15. On 9/10/24 at 7:32 A.M., 9/10/24 at 8:10 A.M., 9/10/24 at 2:34 P.M., 9/10/24 at 4:43 P.M., 9/11/24 at 6:58 A.M., 9/11/24 at 8:32 A.M., and on 9/12/24 at 2:05 P.M., the surveyor observed Resident #19 in his/her bed with the air mattress set to 150. Review of Resident #19's physician's order, dated 5/1/24, indicated: - Low air loss mattress at a setting of 140, three times a day for monitoring; comfort measures. Review of Resident #19's physician's order, dated 7/2/24, indicated: - Low air loss mattress at a setting of 130, check every shift to maintain setting at 130, three times a day for monitoring/prevention. Review of Resident #19's plan of care related to skin breakdown, dated as revised 8/23/24, indicated: - I have a pressure relieving air mattress on my bed and a cushion on my wheelchair, 5/9/24. Review of the air mattress settings indicated the following settings, 100, 150, 200, 250, and 325. Further review of the air mattress there was no ability for nursing to set the air mattress to 130 or 140. During an interview on 9/12/24 at 9:36 A.M., Certified Nurse Assistant (CNA) #4 said CNA's do not adjust air mattress settings. During an interview on 9/12/24 at 11:00 A.M., Nurse #2 said she should verify the physician's order and set the air mattress to the physician's order. During an interview on 9/12/24 at 12:02 P.M., the Regional Nurse said nursing should implement the physician's order for air mattress settings and should set air mattress settings according to the manufacture's guidelines.

Based on observation, record review, and interview, for one Resident (#34) out of a total sample of 17 residents, the facility failed provide services and treatment for a resident who was assessed to have a reduction in range of motion of his/her left hand. Findings include: Review of the facility policy titled, Brace and Splint Program, dated as revised January 2020, indicated the facility will ensure that any resident with a limited range of motion receives treatment and services to increase range of motion and prevent further decrease in range of motion. The facility will ensure that the resident reaches and maintains his or her highest level of range of motion and to prevent avoidable decline of range of motion. - If a resident enters the facility with a brace or splint, or if there is evidence of a decrease in range of motion and/or contractures are evident a physician's order will be obtained for a therapy evaluation. - If it is determined that a brace or splint is appropriate/needed a physician's order will be obtained and will define the following information: a. Where the splint/brace is to be worn b. When the splint/brace is to be worn c. Why the splint/brace is to be worn d. Who will apply the splint/brace (nursing or therapy) -A care plan will be developed that has measurable objectives and interventions that include the following: a. A scheduled program of applying and removing the appliance that includes: scheduled hours to be worn and when skin will be inspected for signs and symptoms of pressure areas, irritation rashes etc. and will be reported to charge nurse and attending physician. b. Communicate individualized interventions to the direct care providers. Provide specific directions and training as needed (e.g., correct splint application, range of motion techniques, skin integrity). Update Care Plan and Resident Care Guide as needed. - The splint/brace application and removal will be documented in the clinical record as will the skin inspection after removal. - Any issues with the splint/brace will be communicated to the physician (e.g. skin issues, discomfort etc.) and follow up therapy evaluation ordered as needed. - Goals and interventions will be modified as needed and communicated to the direct care providers. Resident #34 was admitted to the facility in May 2024 with diagnoses including dysphagia and hemiplegia and hemiparesis following a cerebral infarction. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/15/24, indicated that Resident #34 had a functional limitation in range of motion on one side in the upper extremity and one in the lower extremity. On 9/10/24 at 7:23 A.M., the surveyor observed a left-hand splint with a palm protector on Resident #34's nightstand. Resident #34 was unable to fully open his/her right hand. On 9/10/24 at 9:24 A.M., Resident #34 had just finished receiving care from two certified nurse assistants. Resident #34 was not wearing a left-hand splint with palm protector. On 9/10/24 at 12:15 P.M., 9/10/24 at 2:15 P.M., 9/10/24 at 4:45 P.M., 9/11/24 at 6:47 A.M., the surveyor observed Resident #34 without a left-hand splint and palm protector. On 9/11/24 at 7:59 A.M., the surveyor observed CNA #2 finish care for Resident #34. CNA #2 said that she was not aware that Resident #34 required a left-hand splint. CNA #2 said that Resident #34 has limited range of motion and pain in his/her left hand. Review of Resident #34's Occupation Therapy note, dated 8/27/24, indicated: Resident tolerates gentle stretches to left hand and wrist prior to application of a hand/wrist splint with palm protector. Nursing educated on schedule and left upper extremity (LUE) positioning. Pain = No pain present, per Resident verbal and nonverbal communication. Patient and Caregiver Training: LUE hand/wrist splint with palm protector application, wearing schedule and LUE positioning. Response to Session Interventions: complaint with skilled services Review of Resident #34's Occupational Therapy Discharge summary, dated as 8/27/24, indicated but was not limited to the following: Short term goal #5 met on 8/27/24: Patient will tolerate nursing application of left hand/wrist splint daily. Discharge level: Patient tolerates 8+ hours with application by nursing. Short term goal #6 met on 8/27/24: Patient will tolerate nursing application of left hand/wrist splint. Assessment and Summary of Skilled Services: Skilled interventions provided: Training with nursing for left hand/wrist splint with palm protector application, wearing schedule and repositioning. Discharge recommendations: left upper extremity hand/wrist splint with palm protector. Review of Resident #34's plan of care and active physician's orders on 9/11/24 failed to include any documentation to support a splint wearing schedule. During an interview on 9/11/24 at 10:12 A.M., Nurse #2 (who typically works the day and evening shift) said she was not aware that Resident #24 requires a left-hand splint. During an interview on 9/12/24 at 7:27 A.M., Nurse #3 (who typically works the evening and night shift) said that Resident #34 requires a splint. Nurse #3 said she thinks the splint is worn at night and would apply the splint based on the physician's orders. During an interview on 9/11/24 at 1:33 P.M., the Occupational Therapist said that she worked with Resident #34 for contracture management. The OT said when she finished with Resident #34 on 8/27/24 he/she was able to tolerate wearing a left-hand splint with palm guard for over 8 hours during the day shift. The OT said she completed training with nursing and nursing should have obtained and implemented physician's orders for the splint use but did not. During an interview on 9/12/24 at 11:52 A.M., the Regional Nurse said that nursing should have implemented a plan of care and splint wearing scheduled based on the OT's recommendations for the left upper extremity hand/wrist splint with palm protector.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure the size of an indwelling urinary catheter was documented in the physician's orders for one Resident #23 out of a sample of 17 Residents. Findings include: A review of the facility policy titled 'Catheter Care' with a revision date of 3/4/24 indicated the following: -It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care. Resident #23 was admitted to the facility in July 2024 with diagnoses including retention of urine. A 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. Further review of the MDS indicated Resident #23 had an indwelling catheter. On 9/10/24 at 9:24 A.M., and 9/11/24 at 9:09 A.M., Resident #24 was observed in bed with a Foley (urinary) catheter in place. A review of the Nurse's progress note dated 8/25/24 indicated the following: Complaints of penile/vaginal discomfort with urinary catheter. Light brown foul smelling penile discharge noted. This writer irrigated catheter with 60 ccs ns (normal saline) and cleaned surrounding areas well. Drained a total of 600 ml (milliliters) of clear, dark yellow urine throughout shift. Fluids encouraged. [sic] A review of Resident #23's September physician's orders indicated the following: - Foley Catheter care every shift three times a day. The physician's order failed to indicate the size of the Foley catheter and balloon. A review of the indwelling catheter care plan created on 8/6/24 failed to indicate the size of the Foley catheter and balloon. During an interview and observation on 9/11/24 at 9:29 A.M., Nurse #2 said she had no idea what Resident #23's catheter size was, she said it should be in the physician's order and care plan but wasn't. Nurse #2 said the size should be documented because the wrong catheter size could cause pain for the Resident. The surveyor and Nurse #2 observed the catheter size, 16 French (Fr) 10 Milliliters (ml). The Resident said this particular catheter size was comfortable. During an interview on 9/11/24 at 9:45 A.M., the Regional Nurse said Foley catheter sizes should be documented in the physician's orders.

Based on observation, record review and interview for one Resident (#19) of 17 sampled residents the facility failed to ensure acceptable parameters of nutritional status were maintained. Specifically, for Resident #19, a resident with weight loss, the facility failed consistently provide fortified foods and nutritional supplements. Findings include: Resident #19 was admitted to the facility in November 2020 with diagnoses including dementia, dysphagia, and osteoarthritis. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/30/24, indicated that Resident #19 had a severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 2 out of 15. This MDS indicated Resident #19 was dependent on staff for eating and had experienced weight loss of 5% or more in the last month or loss of 10% or more in last 6 months and received a mechanically altered diet. On 9/10/24 at 8:58 A.M., the surveyor observed Resident #19's breakfast tray which included the following: - Cream of wheat with cinnamon, regular apple juice, eggs, and pureed bread. Review of Resident #19's tray ticket on 9/10/24 at 8:58 A.M., indicated the following for breakfast: - 8 ounce chocolate shake - 6 ounce fortified juice - 6 ounce fortified milk - Super Cereal (fortified cereal with condensed milk, butter, and brown sugar) - Yogurt The staff member assisting Resident #19 with his/her meal said there was no chocolate shake, no fortified juice, no fortified milk, no super cereal, and no yogurt, on his/her tray. On 9/11/24 at 8:28 A.M., the surveyor observed Resident #19's breakfast tray which included the following: - Oatmeal, regular apple juice, eggs, and pureed bread. Review of Resident #19's tray ticket on 9/11/24 at 8:28 A.M., indicated the following for breakfast: - 8 ounce chocolate shake - 6 ounce fortified juice - 6 ounce fortified milk - Super Cereal - Yogurt The staff member assisting Resident #19 with his/her meal said there was no chocolate shake, no fortified juice, no fortified milk, no super cereal, and no yogurt, on his/her tray. Review of Resident #19's physician's order, dated 3/28/24, indicated: - fortified shakes on all meal trays, three times a day. Review of Resident #19's plan of care related to nutrition, dated as revised 5/9/24, indicated: - trialing high calorie smoothie, super mashed potato at lunch, 12/9/23. - Weigh as ordered and document findings, 5/9/24. Review of Resident #19's plan of care related to skin breakdown, dated as revised 8/23/24, indicated: - Give me any nutritional supplements I am ordered to help with my skin, 5/1/24. Review of Resident #19's weights in the electronic health record indicated the following: 4/4/24 142 pounds (lbs) 4/8/24 142 lbs 4/11/24 142 lbs 5/2/24 131.6 lbs 5/6/24 132 lbs 6/4/24 130 lbs 7/8/24 129 lbs 7/15/24 129 lbs 8/8/24 127 lbs 9/11/24 125 lbs Review of Resident #19's, Dietary/Nutrition Note, dated 7/11/24, indicated the following: He/she has had a 13-pound weight loss over past 3 months. He/she has been observed and reported poor oral intake he/she takes fortified nutrition shakes at all meals and boost between meals. Plan: - serve diet as ordered. - continue supplements between meals. Review of Resident #19's daily tray tickets indicated the following: Breakfast - 8 ounce chocolate shake - 6 ounce fortified juice - 6 ounce fortified milk - Super Cereal - Yogurt Lunch - 8 ounce chocolate shake - 6 ounce fortified juice Dinner - 8 ounce chocolate shake - 6 ounce fortified juice. During an interview on 9/12/24 at 9:38 A.M., Certified Nurse Assistant (CNA) #4 said that Resident #19 has a poor appetite, and he/she loves liquids. CNA #4 said the Resident #19 used to get a fortified shake on his/her meal trays, but CNA #4 has not seen a fortified shake in a few months. CNA #4 said fortified milk and juice has not been served in a while and they would have an F on the top of the drink. CNA #4 said that yogurt is rarely provided. During an interview on 9/12/24 10:59 A.M., Nurse #2 said that shakes between meals require a physician's order. Nurse #2 said the kitchen was sending shakes on Resident #19's tray, but the kitchen has not in a while. During an interview on 9/12/24 at 8:43 A.M., Dietary Staff #1 said on 9/10/24 and 9/11/24 she did not prepare any fortified milk or juices for resident meal trays, she did not prepare super cereal or super mashed potatoes. Dietary Staff #1 said there was no yogurt to serve residents. Dietary Staff #1 said that she was aware that Resident #19 required a fortified shake on his/her meal trays, and she did not make or provide the shake. During an interview on 9/12/24 at 8:45 A.M., the Food Service Director said that the Dietary Staff #1 should prepare and provide fortified foods from the kitchen. During an interview on 9/12/24 at 10:32 A.M., the Dietitian said that the kitchen should be providing fortified food and supplements on Resident #19's tray. The Dietitian said she was not aware that kitchen was not providing Resident #19's fortified shake on his/her meal tray but should have been. The Dietician reviewed her note from 7/11/24 and said she was not aware that Resident #19 did not have an order for shakes between meals, but she should have one. The Dietitian said these interventions are in place for weight loss and maintaining good nutritional status. During an interview on 9/12/24 at 12:08 P.M., the Regional Nurse said that the kitchen should provide fortified foods and supplements for Resident #19's weight loss.

Based on observation, record review, and interview the facility failed to adhere to professional standards for the administration of enteral feeding (nutrition taken through a tube directly to the stomach) for one Resident (#34) out of a total sample of 17 residents. Specifically, for Resident #34 the facility failed to administer enteral feedings in accordance to manufactures guidelines (product exceeded the expiration date). Findings include: Review of the facility policy titled, Care and Treatment of Feeding Tubes, dated as 3/4/24, indicated it is a policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. 9. Direction for staff regarding nutritional products and meeting the resident's nutritional needs will be provided: p. Ensuring that the selection and use of enteral nutrition is consistent with manufacturer's recommendations. r. Ensuring that the product has not exceeded the expiration date. Resident #34 was admitted to the facility in May 2024 with diagnoses including dysphagia and hemiplegia and hemiparesis following a cerebral infarction. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/15/24, indicated that Resident #34 had a tube feeding. On 9/10/24 at 7:47 A.M., the surveyor observed one bottle of Jevity 1.2 dated 9/6/24 at 9:00 P.M., in Resident #34's room. There were about 800 milliliters (mls) missing from the bottle. Review of the Jevity manufacture's guidelines, indicated the following: - Hang product up to 48 hours after initial connection when clean technique and only one new feeding set is used, Otherwise, hang no longer than 24 hours. Review of Resident #34's plan of care related to tube feeding, dated 8/23/24, indicated: - I am dependent with tube feeding and water flushes. See physician orders for current feeding orders. Review of Resident #34's physician's order, dated 7/25/24, indicated: - Jevity at bedtime for weight management and nutrition Jevity 1.2 cals at 55 ml starting at 9:00 P.M. ending at 1:00 A.M. (over 4 hours). (220 mls) Review of Resident #34's Dietary/Nutrition Note, dated 8/29/24, indicated: - plan going forward is to reduce tube feeding to 4 hours over night up at 9:00 P.M., down at 1:00 A.M. During an interview on 9/11/24 at 6:45 A.M., Nurse #1 said that she worked the overnight shift Monday 9/9/24 into Tuesday 9/10/24. She said she disconnected the tube feeding around 1:00 A.M. on 9/10/24, that was dated 9/6/24, Nurse #1 said she leaves the Jevity bottle up to use the next day since there is still feeding available to use. During an interview on 9/12/24 at 11:55 A.M., the Regional Nurse said nursing should change the bottle of Jevity daily and follow the manufactures' guidelines.

Based on observation, interview, and record review, the facility failed to provide the necessary respiratory care and services for two Residents (#2 and #22), out of a total sample of 17 residents. Specifically: 1.) For Resident #2, the facility failed to ensure a bilevel positive airway pressure (BiPAP) machine, which is a device which assists with breathing, was repaired after identifying it was unable to be utilized because it was broken. 2.) For Resident #22 the facility failed to ensure nursing consistently provided respiratory care in accordance with professional standards of practice. Findings include: 1.) Review of the facility policy titled Noninvasive Ventilation (CPAP), BiPAP, AVAPS, Trilogy TM), undated, indicated: - Replace equipment immediately when it is broken or malfunctions. Resident #2 was admitted to the facility in August 2017 with diagnoses including sleep apnea (a respiratory condition in which your breathing stops and restarts many times while you sleep) and asthma. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/30/24, indicated Resident #2 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS also indicated Resident #2 required non-invasive mechanical ventilator, which includes BiPAP. On 9/10/24 at 8:07 A.M., the surveyor observed Resident #2 being awoken from sleep by staff because his/her breakfast arrived. There was a BiPAP machine on a dresser across the room, not near Resident #2's bed. Resident #2 said he/she had not used the BiPAP in a few weeks because it was broken, but staff knew and had told him/her they called to get it fixed. Resident #2 said he/she sleeps better when using the BiPAP and said he/she had not been sleeping well without it. During a follow up interview on 9/11/24 at 7:29 A.M., Resident #2 said he/she had not been able to wear the BiPAP again last night and had not received an update on when it would be fixed by from staff. There was a BiPAP machine on a dresser across the room, not near Resident #2's bed. Review of Resident #2's active physician's order, initiated 9/16/21, indicated: - Bi-PAP settings 12 cm Exp, 18 cm Inspiratory @ (at) bedtime, every evening and night shift for Asthma, O2 (oxygen) Dep (dependency). Review of Resident #2's active plan of care related to asthma and sleep apnea, dated as reviewed 7/30/24, indicated: - BIPAP at night: see MD (physician) order. During an interview on 9/11/24 at 7:37 A.M., Nurse #7 said she noticed Resident #2's BiPAP was broken a few weeks ago and was unable to be used safely. Nurse #7 said she told the Director of Nursing (DON) #1 but was not sure if the call for repair had been made. Nurse #7 said the medical record should have reflected that the BiPAP was broken, unable to be used, and what the outcome or plan was. Review of Resident #2's medical record failed to indicate the BiPAP was broken, any repair had been requested or made, or that there were any changes in the plan of care regarding BiPAP use. During an interview on 9/12/24 at 12:31 P.M., Certified Nurse Aide (CNA) #3 said she cares for Resident #2 frequently on day shift and was not aware the BiPAP was broken but had not seen it in place in the morning during the last few weeks when she started her shift. During an interview on 9/11/24 at 9:05 A.M., the Director of Nursing (DON) #1 said he was told Resident #2's BiPAP was broken a few weeks ago, but never called for repair or ensured the plan of care was updated or changed when the Resident was unable to use the BiPAP. 2.) Review of the facility policy titled, Oxygen Administration, 3/4/24, indicated oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Resident #22 was admitted to the facility in January 2024 with diagnoses including combined systolic and diastolic heart failure, pleural effusion, atrial fibrillation, and pulmonary hypertension. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/2/24, indicated that Resident #22 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. On 9/10/24 at 7:34 A.M., 9/10/24 at 12:18 P.M., 9/10/24 at 2:20 P.M., 9/10/24 at 4:46 P.M., 9/11/24 at 9:50 A.M., the surveyor observed Resident #22 being administered oxygen at 2 liters per minute (LPM) via nasal cannula. Review of Resident #22's physician's order, dated 4/16/24, indicated: - Oxygen at 1 liter per minute (@ 1L/MIN) via nasal cannula to maintain oxygen (O2) saturations (sats) above 90%, every shift for CHF exacerbation, maintain O2 sats above 90%. Review of Resident #22's physician's order, dated 8/8/24, indicated: - Oxygen @ 2 L/min continuous at bedtime (QHS), at bedtime for Oxygen Therapy 2L QHS. Review of Resident #22's nursing notes dated 9/10/24 at 4:18 P.M., and 9/10/24 at 10:31 P.M., indicated Resident #22 received oxygen at 2 LPM. During an interview on 9/12/24 at 9:35 A.M., Certified Nurse Assistant (CNA) #4 said that Resident #22 requires oxygen administration. CNA #4 said she does not adjust oxygen settings and she is not aware of Resident #22 adjusting his/her own oxygen settings. During an interview on 9/12/24 at 11:05 A.M., Nurse #2 said that Resident #22 requires continuous oxygen at 2 LPM, and the flow rate is based on the physician's orders. Nurse #2 said that she is not aware of Resident #22 adjusting his/her own oxygen settings. During an interview on 9/12/24 at 11:59 A.M., the Regional Nurse said nursing should implement physician's orders for oxygen administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a plan of care was developed for Trauma-Informed Care for one Resident (#47), who was admitted to the facility with the diagnosis of Post-Traumatic Stress Disorder (PTSD), out of a total 17 sampled residents. Findings include: Review of the facility policy titled Trauma Informed Care dated 3/4/24, indicated that the facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event . Further review indicated that the facility will identify triggers which may re-traumatize residents with a history of trauma. Trigger specific interventions will identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident and will be added to the resident's care plan. Resident #47 was admitted to the facility in August 2024 with diagnoses including post-traumatic stress disorder (PTSD), hemiplegia, and diabetes. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #47 scored a 15 out of 15 on the Brief Interview for Mental Status exam indicating intact cognition. Further review of the MDS indicated Resident #47 required assistance with most activities of daily living. Review of the care plan dated 8/6/24, indicated an incomplete PTSD care plan, with a focus for alteration/risk for alteration in mood and/or behavioral status AEB (as evidenced by)/ Related to: Depression, history of suicidal ideation's, PTSD. Further review of the care plan failed to indicate what the potential Resident specific triggers were for PTSD and failed to indicate what interventions would mitigate or decrease the effect of the trigger for PTSD. During an interview on 9/12/24, at 8:50 A.M., Director of Nursing (DON) #1 said that Resident #47's PTSD care plan was not complete, and resident centered. The DON said that the PTSD care plan should include the triggers and the interventions required to help the Resident once a PTSD episode has been triggered. During an interview on 9/12/24 at 11:43 A.M., the MDS Nurse said that care plans are to be resident specific with resident specific interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to indicate the duration of a PRN (as needed) psychotropic medication for one Resident (#23) out of a sample of 17 residents. Specifically, the facility failed to indicate the duration of a PRN (as needed) antipsychotic medication. Findings include: A review of the facility policy titled 'Use of Psychotropic Medication', with a revision date of 3/4/24, indicated the following: - PRN orders for all psychotropic drugs shall be used only when the medications is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (i.e. 14 days). - 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 of the PRN order. Resident #23 was admitted to the facility in July 2024 with diagnoses including borderline personality disorder, suicidal ideations, major depression disorder and opioid abuse. A 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. A review of Resident #23's September 2024 physician's orders indicated the following: - Olanzapine oral tablet (an antipsychotic medication) 5 milligrams, give 1 tablet by mouth every 24 hours as needed for agitation. Start date 8/27/24. A review of the September Medication Administration Record (MAR) indicated the PRN Olanzapine was administered on 9/5/24. A review of the Behavioral health note, dated 9/4/24, indicated the following recommendation made by the Psychiatric Nurse Practitioner. - Recommend discontinuing PRN Zyprexa; antipsychotics can't be PRN unless scheduled. During a telephone interview on 9/16/24 at 1:07 P.M., the Psychiatric Nurse Practitioner said she made the recommendation for the PRN Zyprexa to be discontinued or scheduled if the Resident required the antipsychotic medication. She said after writing the recommendation, she emailed the Director of Nurses (DON) #1 after her visit on 9/4/24. She said she has a list of facility staff recipients' emails that get a copy of her progress notes after her visit, so she expects any recommendations she makes to be reviewed as soon as possible. During an interview on 9/12/24 at 9:32 A.M., DON #1 said psychiatric recommendations made by the Psychiatric Nurse Practitioner should be reviewed within 24 hours and if the physician is in agreement with the recommendations, they should be addressed within the same time period. DON #1 said PRN antipsychotics should have a stop date of 14 days, and if the PRN antipsychotic needs to be extended beyond the 14 days, there should be a rationale documented in the medical record by the physician.

Based on observation, interviews, and record review, the facility failed to ensure that the physician ordered therapeutic diet was followed for one Resident (#34), in a total sample of 17 residents. Findings include: Review of the facility policy titled, Therapeutic Diet Orders, dated 3/4/24, indicated the facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences. 1. Each resident's nutritional status is assessed by the interdisciplinary team in accordance with assessment policies. 2. Therapeutic diets, including mechanically altered diets where appropriate, will be based on the resident's individual needs as determined by the resident's assessment. Therapeutic diets may be considered in certain situations, such as, but not limited to: a. Inadequate nutrition b. Nutritional deficits c. Weight loss d. Medical conditions such as diabetes, renal disease, or heart disease e. Swallowing difficulty 3. Therapeutic diets are provided only when ordered by the attending physician or a registered or licensed dietitian who has been delegated to write diet orders, to the extent allowed by state law. Should the attending physician delegate the prescribing of therapeutic diets, he or she will supervise the dietitian and remain responsible for the resident's care. 4. The reason for a therapeutic diet is to be documented in the medical record and/or indicated on the resident's comprehensive plan of care. All diet orders are to be communicated to the dietary department in accordance with facility procedures. 5. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed. Resident #34 was admitted to the facility in May 2024 with diagnoses including dysphagia (difficulty swallowing) and hemiplegia and hemiparesis following a cerebral infarction. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/15/24, indicated that Resident #34 had a tube feeding (a tube that goes directly into the stomach through the abdomen to administer liquid food) and was on a mechanically altered diet. Review of Resident #34's plan of care related to alteration in nutrition, dated as revised 6/3/24, indicated: - Diet as ordered Review of Resident #34's physician's order, dated 7/16/24, indicated: - Diet Modification order: Speech Language Pathologist (SLP) to recommend upgrade to Dysphagia Advanced solids; cleared to have bread/dry items. Continue thin liquids. Review of Resident #34's physician's order, dated 7/25/24, indicated: - Regular diet, dysphagia advanced texture, Thin Liquids consistency, for diet upgrade Review of Resident #34's diet resident detail on 9/10/24 at 4:49 P.M., indicated the following texture as Mech Soft On 9/10/24 at 4:49 P.M., the surveyor observed Resident #34 eating his/her evening meal. The following was provided to Resident #34: - breaded fish, ground up - Coleslaw, whole - French fries, whole crinkle cut - pineapple tidbits, whole During an interview on 9/11/24 at 9:30 A.M. Dietary Staff #1 said that about 2 weeks ago the kitchen changed food vendors and the kitchen staff had not been provided breakdowns for meals for the therapeutic diets. Dietary Staff #1 said she just goes with what she thinks residents should get based off memory of the old therapeutic diets. During an interview on 9/11/24 at 9:36 A.M., the Food Service Director said she only has the menus, and she did not have therapeutic diet breakdowns. During an interview on 9/11/24 at 2:00 P.M. the Chief Nursing Officer (CNO) provided the surveyor with a therapeutic breakdown for the evening meal on 9/10/24. The CNO said dietary should follow the therapeutic diets as ordered by the physician. The menu breakdown indicated Resident #34 should have received the following for dinner on 9/10/24: - soft plain baked minced fish mixed with lemon sauce, not breaded ground fish. - carrots soft, minced, and drained, not coleslaw. - mashed potatoes, not French fries. - pureed fruit, not pineapple tidbits. During a follow up interview on 9/12/24 at 8:46 A.M., the Food Service Director said dietary staff should follow diet as ordered. During an interview on 9/12/24 at 11:57 A.M., the Regional Nurse said that the kitchen should follow therapeutic diets as ordered by the physician.

Based on observations, record review, and interviews, the facility failed to provide adaptive equipment for one Resident (#19) of 17 sampled residents. Specifically, the facility failed to ensure Resident #19 was consistently provided with a lip plate for use during his/her meals. Findings include: Review of the facility policy titled, Adaptive Feeding Equipment, dated 3/4/24, indicated that residents requiring assistance in feeding are potential candidates for a restorative dining program or adaptive utensil use, as determined by the occupational therapist. Any staff member may refer a resident for a program evaluation. 5. The dietary department should be notified of residents needing adaptive feeding equipment; the equipment is stored and maintained in the dietary department. Appropriate utensils should be placed on the resident's food tray, at each meal, and returned to the dietary department, on the food tray, for sanitization. Resident #19 was admitted to the facility in November 2020 with diagnoses including dementia, dysphagia, and osteoarthritis. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/30/24, indicated that Resident #19 had a severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 2 out of 15. This MDS indicated Resident #19 had experienced weight loss of 5% or more in the last month or loss of 10% or more in last 6 months and received a mechanically altered diet. On 9/10/24 at 8:35 A.M., and 9/11/24 at 8:32 A.M., the surveyor observed Resident #19 being served breakfast without a lip plate. Review of Resident #19's physician's order, dated 4/14/23, indicated: - Lip plate on all meal trays. During an interview on 9/12/24 at 9:37 A.M., Certified Nurse Assistant (CNA) #4 said that the kitchen supplies Resident #19 his/her lip plate. During an interview on 9/12/24 at 11:02 A.M., Nurse #2 said that Resident #19's lip plate is provided by the kitchen. During an interview on 9/12/24 at 8:41 A.M., the Food Service Director said the lip plate should be provided by the kitchen. During an interview on 9/12/24 at 12:03 P.M., the Regional Nurse said the kitchen should provide Resident #19's lip plate.

Based on observations and interviews, the facility failed to ensure residents on two of two units experienced a homelike dining experience. Findings include: Review of the facility policy titled, Promoting/Maintaining Resident Dignity During Mealtimes, dated 3/4/24, indicated that it is the practice of this facility to treat each resident with respect and dignity and care for each resident in a manner and in an environment that maintains or enhances his or her quality of life, recognizing each resident's individuality and protecting the rights of each resident. On 9/10/24 between 8:00 A.M., to 9:00 A.M., the surveyors observed Residents on the first floor and second floor being served hot coffee in Styrofoam cups, hot cereal was served in in Styrofoam bowls, and plastic cutlery was utilized for residents. On 9/10/24 at 12:17 P.M., the surveyor observed on the first floor 6 of 6 residents being served their lunch meals on trays in the main dining room and 5 of 6 residents being served their lunch meals on trays with plastic cups and plastic cutlery in the secondary dining area on the first floor. On 9/11/24 at 8:16 A.M., the surveyor observed on the first floor 3 of 8 residents being served their breakfast meal on trays in the dining room, 8 of 8 residents had items being served in Styrofoam bowls and Styrofoam cups. On 9/11/24 at 8:36 A.M., the surveyor observed on the second floor 7 of 7 residents being served their breakfast meal on trays in the dining room, and 7 of 7 residents had items served items in Styrofoam bowls and cups. During Resident Group meeting on 9/11/24 at 10:36 A.M., 1 of 4 residents said they think there are not enough staff to wash the plates, so the kitchen uses paper and Styrofoam products, 4 of 4 residents said they wished to be served their meals off the trays with actual dishes. During an interview on 9/12/24 at 9:39 A.M., Certified Nurse Assistant #4 said that residents complain about the food being served in Styrofoam. During an interview on 9/12/24 at 11:02 A.M., Nurse #2 said Styrofoam use on the trays is an ongoing issue because of staffing issues in the kitchen. During an interview on 9/12/24 at 8:47 A.M., the Food Service Director said that the kitchen should not be using paper and Styrofoam products during meal times. The Food Service Director said that residents should not be served their meals on trays in the dining rooms. During an interview on 9/12/24 at 12:09 P.M., Administrator #1 said that paper products and Styrofoam should not be used on resident trays. Administrator #1 said that staff should serve residents on the linens provided on tables and not on their trays during mealtime.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure staff developed and implemented a comprehensive person-centered care plan for four Residents (#4, #23, #25 and #47), out of a total sample of 17 residents. Specifically: 1.) For Resident #4, the facility failed to implement a fall care plan intervention to keep a urinal within reach and failed to develop a fall care plan intervention for fall mats. 2.) For Resident #23, the facility failed to develop personalized mood, behavior, and substance abuse care plans. 3.) For Resident #25, the facility failed to develop a comprehensive care plan for dialysis and antidepressant medication. 4.) For Resident #47, the facility failed to develop a comprehensive care plan for post-traumatic stress disorder (PTSD) and the use of psychotropic medication. Findings include: Review of the facility policy titled Comprehensive Care Plans, dated 3/4/24, indicated: - It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 1.) Review of the facility policy titled Fall Prevention Program, dated 3/4/24, indicated: 8. Each resident's risk factors and environmental hazards will be evaluated when developing the comprehensive care plan. a. Interventions will be monitored for effectiveness. b. The plan of care will be revised if needed. Resident #4 was admitted to the facility in December 2021 with diagnoses including vascular dementia and adult failure to thrive. Review of the most recent Minimum Data Set (MDS) assessment, dated 6/25/24, indicated Resident #4 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. This MDS also indicated Resident #4 had two falls since the previous MDS, dated [DATE]. On 9/10/24 at 8:18 A.M., the surveyor observed Resident #4 in bed with one fall mat under the bed, not fully in position. Only approximately one third of the fall mat was extended out from the left side of the Resident's bed. There was no urinal visible in his/her room. On 9/11/24 at 7:28 A.M., the surveyor observed Resident #4 in bed with one fall mat stored fully under his/her bed. No portion of the fall mat was extended to the area next to the Resident's bed. There was no urinal visible in his/her room. On 9/11/24 AT 8:20 A.M., the surveyor observed Resident #4 in bed eating breakfast. The fall mat had been moved and propped upright on the wall in the Resident's room. There was no urinal visible in his/her room. On 9/12/24 at 7:26 A.M., the surveyor observed Resident #4 in bed with one fall mat under the bed, not fully in position. Only approximately one third of the fall mat was extended out from the left side of the Resident's bed. There was no urinal visible in his/her room. During an interview on 9/12/24 at 7:29 A.M., Resident #4 said he/she used to have a urinal, but it's been gone for a long time. Resident said he/she would like to have the urinal again because then he/she wouldn't have to wait to go to the bathroom. Review of Resident #4's plan of care related to falls, revised 7/9/24, indicated: -Keep Urinal within reach. Review of Resident #4's plan of care related to falls, revised 7/9/24, failed to indicate use of fall mats. Review on Resident #4's physician's orders failed to indicate the use of fall mats. Review of Resident #4's medical record failed to indicate fall mats had been implemented or were in use. Further review of medical record failed to indicate any rationale for urinal not being within reach or any refusal of urinal. During an interview on 9/12/24 at 7:31 A.M., Certified Nurse Assistant (CNA) #3 said she cared for Resident #4 regularly on day shift. CNA #3 said Resident #4 had a history of falling out of bed. CNA #3 said Resident #4 should have two fall mats in place when in bed, not just one, but is not sure where the other one went. CNA #3 said a nurse a while back had told her in report that Resident #4 needed fall mats when in bed. CNA #3 said there is no urinal in the room. CNA #3 said this is because staff should never give Resident #4 a urinal because then he/she might use it. During an interview on 9/12/24 at 8:44 A.M., Nurse #5 said Resident #4 should have a fall mat on the left side of his/her bed whenever he/she is in bed. Nurse #5 said Resident #4 does not use a urinal. Nurse #5 said CNAs should be instructed on specific interventions necessary, such as fall mats and use of urinal, during shiftly report. Nurse #5 visualized Resident #4's care plan and said, based on the care plan, the Resident should have a urinal within reach to prevent falls. Nurse #5 said if this intervention was no effective or no longer necessary, the care plan should have been updated, but was not. Nurse #5 said there was not an intervention for fall mats, but there should have been one added because fall mats should not be used without either a physician's order or a care plan intervention. Nurse #5 said nurses are expected to check and update the care plan for interventions each shift, but it's not realistic because they don't have enough time with staffing levels in the facility. Nurse #5 said instead the nurses rely on shift report to communicate specific interventions, but that often doesn't happen either because of time constraints related to staffing levels. During an interview on 9/12/24 at 10:11 A.M., the Director of Nursing (DON) #1 said Resident #4's care plan should always be followed. DON #1 said fall mats should not have been used because they were determined to be a risk for Resident #4's roommate. DON #1 said the urinal should have been within Resident #4's reach because Resident #4's past falls were related to toileting needs. DON #1 said if interventions were not effective or no longer needed the care plan should have been updated but was not. DON #1 said Resident #4's care plan should always be followed but was not. 2.) Resident #23 was admitted to the facility in July 2024 with diagnoses including borderline personality disorder, suicidal ideations, major depression disorder and opioid abuse. A 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. A review of Resident #23's behavioral health medication management progress note dated 9/4/24 indicated the following: -Chief Complaint: follow up medication/mood management: Target Symptoms: Anxiety, Depression, Tearfulness, Suicidal and Homicidal ideation (history of present illness) HPI: Problem: Resident has a history of major depressive disorder, borderline personality d/o, suicidal ideation's, opioid abuse and autism is seen for a follow up visit. He/she is here s/p hospitalization for weakness and falls; did have a laminectomy 2 weeks prior to that. Troponin was elevated but stabilized then sent to rehab. He/she has chronic back and leg pain since 2012 when his/her SI thoughts started, previously admitted to psych for it and has hx ECT treatment as well. Since 2012, his/her SI thoughts have been gradually worsening. Recently he/she asked staff to give him/her more pills so he/she would overdose. Talked about a gun with staff another time. Sent to ER last visit for worsening depression and suicidal ideation, had plans to self-harm and also harm the doctor who he/she blames for not doing his/her surgery right. Said he/she would go to garden center, buy [NAME] glove seeds/digitalis, plans to grow them, then process/ferment them, then ingest. He/she additionally reported that he/she will be finding the license plate of the doctor who did his/her surgery and turn the Dr's car into a traveling bomb. [sic] -Substance Use / Addiction History: Opiates, Marijuana. -A review of Resident #23's progress note dated 9/4/24 indicated that a Certified Nurse's Assistant (CNA) reported the Resident was playing with his/her feces and had feces smeared on his/her hand and sheet. [sic] A review of Resident #23's care plan failed to indicate a history of homicidal ideation, opiate and marijuana abuse care plan with personalized interventions was developed. The care plan also failed to indicate the Resident's feces smearing behavior with personalized interventions. Further review of the mood care plan initiated on 8/6/24 indicated Resident #23 has a history of making suicidal statements, wanting to overdose on digitalis, but failed to indicate the Resident has a history of asking staff for more pills so he/she could overdose. During an interview on 9/12/24 at 9:21 A.M., the Social Worker said the Resident has a history of suicidal ideations, homicidal ideations, smearing feces, opioid abuse and marijuana abuse. The Social Worker there should be personalized care plans developed addressing Resident #23's mood and behavior.3.) Resident #25 was admitted to the facility in August 2024 with diagnoses including end stage kidney disease, pneumonia, and fracture. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #25 scored an 11 out of 15 on the Brief Interview for Mental Status exam indicating moderately impaired cognition. Further review indicated Resident #25 required moderate assistance for most activities of daily living. Review of the physician's orders dated August 2024 and September 2024 failed to indicate a physician's order for hemodialysis. Further review indicated an order for the antidepressants Mirtazapine 7.5 mg (milligrams) daily and Fluoxetine 60 mg daily. Review of the current care plan failed to indicate complete interventions for hemodialysis, including days, times and location of treatments. Further review failed to indicate how to care for the dialysis access site. Further review failed to indicate the use of antidepressant medications. During an interview on 9/10/24, at 12:45 P.M., Nurse#4 said that there should be a care plan that includes the days, times and place the Resident is scheduled to go to dialysis as well as how to care for the dialysis access site. During an interview on 9/10/24 at 1:45 P.M. Nurse #6 said that Resident # 25 has a Central Venous Catheter (CVC) for dialysis access, and she would expect that there would be a care plan to monitor the CVC site for infection and drainage. 4.) Resident #47 was admitted to the facility in August 2024 with diagnoses including post-traumatic stress disorder (PTSD), hemiplegia and diabetes. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #47 scored a 15 out of 15 on the Brief Interview for Mental Status exam indicating intact cognition. Further review indicated Resident #47 required assistance with most activities of daily living. Review of the physician's orders dated August 2024 and September 2024 indicated the following orders: 1. Zyprexa (an anti-psychotic) 5 mg (milligrams). 2. Trazodone (an anti-depressent) 50 mg. Review of the care plan dated 8/6/24, indicated a focus for alteration/risk for alteration in mood and/or behavioral status AEB (as evidenced by)/Related to: Depression, history of suicidal ideation's, PTSD. Further review failed to indicate a care plan for psychotropic medication use. During an interview on 9/10/24 at 4:38 P.M., Director of Nursing (DON) #1 said that he was unable to locate a psychotropic medication use care plan. During an interview on 9/12/24 at 8:50 A.M., DON #1 said that the care plan should include the specific psychotropic medications used with their corresponding potential side effects, and resident specific interventions. The DON then said that the care plan was not complete.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a plan of care for dialysis and failed to ensure staff implemented dialysis care and services consistent with professional standards of practice for one Resident (#25), out of 17 sampled residents. Specifically, the facility failed to provide ongoing communication between the nursing facility and dialysis facility. Findings include: Resident #25 was admitted to the facility in August 2024 with diagnoses including end stage kidney disease, pneumonia, and fracture. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #25 scored an 11 out of 15 on the Brief Interview for Mental Status exam indicating moderately impaired cognition. Further review indicated Resident #25 required moderate assistance for most activities of daily living. Review of the physician's orders dated September 2024 failed to indicate a physician's order for hemodialysis. Review of the dialysis communication book indicated 3 undated Dialysis Communication Forms (DCF). Further review indicated DCF's dated 8/15/24, 9/7/24 and 9/10/24 (only three dated communication forms out of a possible 12). On 9/10/24, at 12:44 P.M., Nurse #4 said that Resident #25 went out to dialysis at 10:00 A.M. The surveyor and Nurse #4 observed Resident #25's dialysis communication book at nurse's station with the DCF dated 9/10/24 still in the communication book. Nurse #4 then said that Resident #25 should have the book with him/her as that is how the facility and the dialysis center communicate needs, changes, and concerns. Nurse #4 then said that Resident #25 goes to dialysis 3 times a week. Nurse #4 said that there should be a communication form completed each time the Resident goes to dialysis. Nurse #4 said she was not aware of which type of dialysis access Resident #25 had. During an interview on 9/10/24 at 1:45 P.M., Nurse #6 said that Resident # 25 has a CVC (Central Venous Catheter) for dialysis access, and she would expect that there would be a physician's order to monitor the CVC site for infection and drainage.

Based on record review and interview, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility failed to meet the facility-determined minimum for certified nurse assistant (CNA) staff on the weekends. Findings Include: During the Resident Group interview on 9/10/24 at 1:00 P.M., the Resident Group expressed concern about certified nurse assistant (CNA) staffing. The Resident Group said they do not feel there is enough CNAs, and they often must wait too long for their call lights to be answered. On 9/11/24 at 1:50 P.M., the Chief Nursing Officer (CNO) said there was no facility assessment for the facility. The CNO gave the surveyor a list of current staffing needs for direct care staff. The CNO said this does not include any supervisors. The CNO said the following staffing was determined to be necessary based on the facility needs since at least April 1, 2024: *Nurses - 7-3: 2 - 3-11: 2 - 11-7: 2 *CNAs - 7-3: 5 - 3-11: 4.5 - 11-7: 2 During offsite preparation, the CASPER Payroll-Based Journal (PBJ) Staffing Data Report submitted by the facility for fiscal year (FY) Quarter 3, 2024 (April 1 - June 30) was reviewed. The facility's report triggered that the facility reported excessively low weekend staffing. Review of the weekend staff schedule, dated April 1, 2024 to June 30, 2024, indicated that the facility was staffed below their determined minimum necessary CNAs for 20 weekend shifts. On these days there were no additional nurses scheduled who could assist with CNA duties. The weekend staff schedules indicated the following staffing during this quarter: - Sunday April 7th, 2024: only 4 CNAs on 7-3, but should be 5. - Sunday April 7th, 2024: only 1 CNA on 11-7, but should be 2. - Saturday April 13th, 2024: only 4 CNAs on 7-3, but should be 5. - Sunday April 14th, 2024: only 3 CNAs on 7-3, but should be 5. - Saturday April 20th, 2024: only 2 CNAs on 7-3, but should be 5. - Saturday April 20th, 2024: only 4 CNAs on 3-11, but should be 4.5. - Sunday April 21st, 2024: only 2 CNAs on 3-11, but should be 4.5. - Sunday May 5th, 2024: only 3 CNAs on 3-11, but should be 4.5. - Saturday May 11th, 2024: only 4 CNAs on 7-3, but should be 5. - Sunday May 12, 2024: only 4 CNAs on 3-11, but should be 4.5. - Sunday May 19, 2024: only 4 CNAs on 3-11, but should be 4.5. - Saturday June 1, 2024: only 4 CNAs on 3-11, but should be 4.5. - Sunday June 2, 2024: only 4 CNAs on 7-3, but should be 5. - Sunday June 2, 2024: only 4 CNAs on 3-11, but should be 4.5. - Saturday June 8, 2024: only 4 CNAs on 3-11, but should be 4.5. - Sunday June 9, 2024: only 4 CNAs on 7-3, but should be 5. - Saturday June 15, 2024: only 4 CNAs on 7-3, but should be 5. - Sunday June 16, 2024: only 4 CNAs on 7-3, but should be 5. - Sunday June 16, 2024: only 4 CNAs on 3-11, but should be 4.5. - Sunday June 23, 2024: only 4 CNAs on 7-3, but should be 5. Further review of the weekend staff schedules, dated July 1, 2024 to September 1, 2024, continued to indicate the facility was staffed below their determined minimum necessary CNAs on 16 weekend shifts. On these days there were no additional nurses scheduled who could assist with CNA duties. The weekend staff schedules indicated the following staffing: - Saturday July 6, 2024: only 4 CNAs on 7-3, but should be 5. - Sunday July 7, 2024: only 3 CNAs on 7-3, but should be 5. - Sunday July 7, 2024: only 3 CNAs on 3-11, but should be 4.5 - Saturday July 13, 2024: only 4 CNAs on 7-3, but should be 5. - Sunday July 14, 2024: only 4 CNAs on 7-3, but should be 5. - Sunday July 14, 2024: only 3 CNAs on 3-11, but should be 4.5. - Sunday July 14, 2024: only 1 CNA on 11-7, but should be 2. - Sunday July 21, 2024: only 4 CNAs on 7-3, but should be 5. - Sunday July 21, 2024: only 4 CNAs on 3-11, but should be 4.5 - Saturday July 27, 2024: only 4 CNAs on 3-11, but should be 4.5 - Saturday August 10, 2024: only 4 CNAs on 7-3, but should be 5. - Saturday August 10, 2024: only 4 CNAs on 3-11, but should be 4.5. - Saturday August 10, 2024: only 1 CNA on 11-7, but should be 2. - Sunday August 11, 2024: only 3 CNAs on 7-3, but should be 5. - Saturday August 31, 2024: only 4 CNAs on 3-11, but should be 4.5 - Sunday September 1, 2024: only 4 CNAs on 3-11, but should be 4.5. During an interview on 9/12/24 at 1:32 P.M., CNA #5 said the CNAs do the best they can, but they often can't get to everything when they are short staffed. CNA #5 said the facility's CNA staffing was the worst during April 2024 to June 2024 on the weekends. CNA #5 said it has gotten better since the facility started with a new agency, but they still struggle at times. CNA #5 said even with fully staffed ratios it's hard to get everything needed done. During an interview on 9/12/24 at 1:36 P.M., CNA #6 said CNA staffing was really bad on weekends during April 2024 to June 2024, but it's getting better. CNA #6 said it was often because the CNAs from an agency they used to have would call out, but it's been getting better since they changed staffing agencies. During an interview on 9/12/25 at 8:39 A.M., Nurse #5 said there is often not enough CNAs scheduled to support the nurses across all shifts. Nurse #5 said it's been better since the facility changed staffing agencies, but the nurses still can't get all required duties completed because there aren't enough CNAs. Nurse #5 said its specifically hard to get their documentation, paperwork, and care plans updated, even when the suggested staffing ratios are met and that she had often expressed this to management. During an interview on 9/12/24 at 7:31 A.M., the scheduler said the staffing ratios the CNO gave the surveyor were accurate and had been the needed staffing ratios since at least April 2024. The scheduler said sometimes staff complains there isn't enough staff, and the facility will attempt to get more staff when the acuity is higher, but the ratios given were the minimum needed. The scheduler said she was aware that the facility triggered for low weekend staffing and it sounds accurate that during that time there were at least 20 weekend shifts without enough CNA staff working because they couldn't replace the call outs or just didn't have enough CNAs. During an interview on 9/12/24 at 10:01 A.M., the Director of Nursing (DON) #1 said he was aware the facility triggered for low weekend staffing during the quarter of April 1, 2024 to June 30, 2024. DON #1 said during that quarter there was insufficient staffing on the weekends, and they hired more staff and changed staffing agencies. DON #1 said even with those changes it's still difficult to staff CNAs at times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide Substance Abuse Services for one Resident (#47) out of a sample of 17 Residents, and additionally failed to provide Substance Abuse Services for 6 additional Residents identified by the Social Worker. Findings include: A review of the facility policy titled 'Safety for Residents with Substance Abuse Disorder' with a revision date of 3/4/24 indicated the following: -It is the policy of this facility to create an environment that is free of accident hazards as possible, for residents with a history of substance use disorder. -Substance use disorder is defined as recurrent use of alcohol and/or drugs that causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home. 7. The facility will make an effort to prevent substance use which may include providing substance use treatment services, such as behavioral health services, medication-assisted treatment (MAT), alcoholic/narcotics anonymous meetings, working with the resident and the family, if appropriate, to address goals related to their stay in the nursing home, and increased monitoring and supervision. Resident #47 was admitted to the facility in August 2024 with diagnoses including bipolar disorder, post traumatic stress disorder and borderline personality disorder. A review of the Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 15 out of a possible 15 indicating intact cognition. Review of the medical record indicated Resident #47's most recent behavioral medication management progress note. The progress note dated 8/14/24 indicated the Resident has a history of using substances such as heroin and alcohol. During an interview on 9/12/24 at 11:19 A.M., Resident #47 said he/she has a history of ingesting heroin and alcohol. He/she said he/she last ingested heroin and alcohol eight months ago. The Resident said he/she participated in Alcoholic Anonymous (AA)/ Narcotics Anonymous (NA) meetings in the community, so he/she wanted to continue those services while in the facility. The Resident said no one in the facility has offered AA/NA services until today. During an interview on 9/12/24 at 9:21 A.M., the Social Worker said the facility does not offer any AA/NA services for residents with a history of substance use. She provided the surveyor a list of six additional Residents in the facility with a history of alcohol, narcotics and marijuana use. The Social worker said none of these residents have been offered AA/NA services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and interview, the facility failed to ensure recommendations from the Monthly Medication Reviews (MMRs) conducted by the consultant pharmacist were addressed and acknowledged by the physician in a timely manner for two Residents (#33 and #47) out of a total sample of 17 residents. Findings Include: Review of the facility policy titled Documentation and Communication of Consultant Pharmacist Recommendations dated 10/1/19, indicated that comments and recommendations concerning medication therapy are communicated in a timely fashion. Further review indicated that in the event that a problem requiring the immediate attention of the prescriber, the responsible prescriber is contacted by the consultant pharmacist or the facility, and the prescriber response is documented on the consultant pharmacist review record or elsewhere is the medical record. 1.) Resident #33 was admitted to the facility in April 2023 with diagnoses including but not limited to dementia and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated that Resident #33 is severely cognitively impaired and is totally dependent for activities of daily living. Review of the Federal Drug Association (FDA) document Reference ID: 4029608, indicated that the initial Ativan dose for the elderly should not exceed 2 mg. Review of the doctor's order dated September 2024 indicated a new order for Ativan (an anti-anxiety, benzodiazepine medication) 5 mg. (milligrams) PRN (as needed) dated as initiated 7/26/24. Review of the MMR dated 8/18/24, indicated a request to the doctor for clarification of the Ativan dose. Review of the medical record failed to indicate the doctor was made aware of the MMR recommendation and failed to indicate a response to the MMR. 2.) Resident #47 was admitted to the facility in August 2024 with diagnoses including post-traumatic stress disorder (PTSD), hemiplegia and diabetes. Review of the Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #47 scored a 15 out of 15 on the Brief Interview for Mental Status exam indicating intact cognition. Further review indicated Resident #47 required assistance with most activities of daily living. Review of the doctor's orders dated August 2024 indicated an order for Zetia (a cholesterol lowering medication) 10 mg. Give 10 mg by mouth one time a day for Diabetes. Review of the MMR dated 8/18/24, indicated a request to the doctor for clarification of the of the diagnosis for the use of the medication Zetia. During an interview on 9/10/24 at 4:38 P.M., Director of Nursing #1 (DON) said that the pharmacist reviewed all residents on 8/18/24. DON #1 then said that he was unable to locate any of the MMR's from 8/18/24, or any of the responses by the physician.

Based on observation, policy review and interview, the facility failed to ensure nursing staff stored all drugs and biologicals in accordance with accepted professional standards of practice. Specifically, the facility failed to properly secure the medication room on two of two units. Findings include: Review of the facility policy titled Medication Storage, dated 3/4/24, indicated that all drugs and biological's will be stored in locked compartments (i.e. medication rooms). Further review of the policy indicated that only authorized personnel will have access to the keys to the locked compartments. On 9/10/24 at 8:33 A.M., the surveyor observed the medication room on the first floor open. The surveyor also observed that no staff were present within eyesight of the open medication room. On 9/11/24, at 7:51 A.M., the surveyor observed the medication room on the second floor open. The surveyor also observed that no staff were present within eyesight of the open medication room. During an interview on 9/11/24 at 8:11 A.M. Nurse #1 said she left the medication room open after she went in to get masks. Nurse #1 said that it was a mistake to leave the door unlocked and open. Nurse #1 said the medication door should never be left open.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure they provided laboratory services to meet the needs of its residents. Specifically, the facility failed to: 1.) Maintain a current Clinical Laboratory Improvement Amendment (CLIA) certificate appropriate for the level of testing performed within the facility, and 2.) For Resident #19 the facility failed to obtain an albumin level (a test that can help determine liver disease or kidney disease, or if the body is not absorbing enough protein). Findings include: 1.) On [DATE] at 8:30 A.M., during the entrance conference the surveyor requested the facility's CLIA certificate. Review of the facility policy titled, Laboratory Testing Waivers, dated [DATE], indicated the facility will ensure that laboratory services are provided to its residents in a manner that meets State and Federal regulations. 1. An application for a Clinical Laboratory Improvement Amendments (CLIA) will be made through the appropriate State agency for services that are categorized as waived under their requirements, i.e. bedside glucose testing 2. An agreement to provide laboratory services will be maintained with an off-site qualified laboratory to provide all other lab services. 3. The facility will assume responsibility to obtain services that meet professional standards and timeliness of the services. During an interview on [DATE] at 12:05 P.M., the Administrator #1 said that the facility did not have a current CLIA certificate but should. The Administrator #1 provided the surveyor with a CLIA certificate dated as expired [DATE] and the following document titled CLIA Laboratory User Fees dated [DATE], which indicated the payment was due by [DATE], for a CLIA renewal certificate period [DATE] to [DATE]. During an interview on [DATE] at 1:00 P.M. the Regional Nurse said there were 7 residents who required blood glucose monitoring. The Regional Nurse said the CLIA certificate should have been renewed but was not. 2.) Resident #19 was admitted to the facility in [DATE] with diagnoses including dementia, dysphagia, and osteoarthritis. Review of the facility policy titled, Laboratory Services and Reporting, dated [DATE], indicated the facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist in accordance with state law. 1. The facility must provide or obtain laboratory services to meet the needs of its residents. 2. The facility is responsible for the timeliness of the services. 6. All laboratory reports will be dated and contain the name and address of the testing laboratory and will be filed in the resident's clinical record. Review of Resident #19's physician's order, dated [DATE], indicated: - Check Albumin level next lab day [DATE]. On [DATE] at 12:30 P.M., the surveyor was unable to locate the results of the albumin level from [DATE] in the electronic health record or in the paper medical record. The surveyor requested the results from the facility. During an interview on [DATE] 10:01 A.M., Director of Nursing (DON) #1 said that Resident #19's albumin level was not obtained but should have been. During an interview on [DATE] at 12:04 P.M., the Regional Nurse said that they were unable to locate the results of the lab from [DATE]. The Regional Nurse said that nursing should have notified the laboratory service provider to perform the test but did not.

Based on observations, interviews and facility assessment review, the facility failed to have sufficient number of staff to effectively carry out the function of food and nutrition services. Findings include: A review of the Facility assessment dated /completed on 9/12/24 indicated the following: -Dietary-270 hours. On 9/10/24 at 7:08 A.M., the surveyor observed [NAME] #1 in the kitchen preparing breakfast for the residents. During an interview on 9/10/24 at 7:10 A.M., [NAME] #1 said there should be at least three staff in the kitchen on each shift, he said he is trying to get a Dietary staff to come in and work with him. [NAME] #1 said they have not had a Food Service Director for a while, he said one was hired but she is still in orientation. On 9/11/24 at 7:32 A.M., the surveyor observed Dietary staff #1 and Dietary staff #3 in the kitchen preparing breakfast. During an interview on 9/11/24 at 7:35 A.M., Dietary staff #1 said they never have enough staff in the kitchen. She said they should at least have three staff on each shift. On 9/11/24 at 11:25 A.M., the surveyor observed Dietary Staff #4 and [NAME] #2 in the kitchen preparing lunch. During interviews on 9/11/24 at 11:30 A.M., Dietary staff #4 and [NAME] #2 said they should have three staff working in the kitchen on each shift, but they never do. During a schedule review and interview on 9/12/24 at 1:20 P.M., the surveyor and Dietary staff #1 reviewed the 6:00 A.M.-2:00 P.M. August and September 2024 Dietary staff and [NAME] schedule. Dietary staff #1 said the following Dietary staff and Cooks worked on the following days: -8/18/24-Dietary staff #1 and [NAME] #1. -8/20/24-Dietary staff#1 and Dietary staff #6. -8/21/24-Dietary staff #1 and Dietary staff #6. -8/22/24-Dietary staff #1 and Dietary staff #6. -8/23/24-Cook #1 and Dietary staff #6. -8/24/24-Dietary staff #1 and #Cook #1. -8/25/24-Dietary staff #1 and #Cook #1. -8/27/24-Cook #1 and Dietary staff #6. -8/28/24-Dietary staff #1 and Dietary staff #6. -9/1/24-Dietary staff #1 and [NAME] #1. -9/3/24- [NAME] #2 and Dietary Staff #6. -9/7/24- [NAME] #1 and Dietary staff #6. -9/10/24-Cook #1 and Dietary staff #3. -9/11/24-Dietary staff #1 and Dietary staff #3. During the Resident Council meeting held on 9/11/24 at 10:36 A.M., one out of the thirteen residents who attended the Resident council meeting said the kitchen does not have enough staff to wash dishes, as a result the meals are served on styrofoam dishes. During an interview on 9/11/24 at 11:35 A.M., the Food Services Director said the kitchen should have a total of three staff, 2 Dietary staff and one [NAME] on each shift. During an interview on 9/12/24 at 12:53 P.M., the Regional Nurse and the Administrator said the kitchen should be staffed with three staff on each shift according to the facility assessment. During a telephone interview on 9/17/24 at 12:24 P.M., the Administrator said there should be two Dietary staff and one [NAME] during each shift in the kitchen. He said the Dietary staff can work as Dietary staff or Dishwasher, but the [NAME] should always remain a cook. He said the facility assessment hours are divided as follows, [NAME] hours-120 hours, Dietary staff hours-150 hours, a total of 270 hours, not including the Food Services Director's 40 hours.

2.) Resident #14 was admitted to the facility in August 2024 with diagnoses including adult failure to thrive and malnutrition. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/6/24, indicated Resident #14 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 14 out of 15. On 9/11/24 at 8:29 A.M., the surveyor observed Resident #14 sitting in front of his/her breakfast tray. Resident #14 said he/she was very upset because his/her tray is wrong. Resident #14 said his/her tray is always wrong and no matter how many times he/she tells staff, it never gets better. The menu slip on Resident #14's breakfast tray indicated it should contain oatmeal, 2 creamers, 2 coffees, and orange juice. The menu slip indicated Resident #14 disliked eggs. This breakfast tray contained scrambled eggs, one cup of coffee, one creamer. Resident #14 said he/she hates the eggs served at the facility and does not want them. The meal tray failed to have oatmeal, second creamer, the second cup of coffee, and orange juice on it. Resident #14 said every day he/she goes to remind staff about the oatmeal, two cups of coffee, and two creamers before the tray comes because it never comes. Resident #14 said it takes over an hour to get the oatmeal and coffee when he/she requests it. During a follow up interview on 9/11/24 at 11:28 A.M., Resident #14 said his/her food preferences are rarely honored. Resident #14 said that some of his/her preferences for breakfast, such as oatmeal and having two coffees, are listed on his/her meal slip because of multiple past complaints to staff. Resident #14 said staff never asks what he/she would like for a meal and is never offered an alternative. Resident #14 said he/she has not received what was indicated on the menu slip for any meals for over a week. Resident #14 said the oatmeal he/she was missing this morning took over an hour to come and it was cold, so he/she didn't eat it. Resident #14 said he/she is not eating enough because they send him/her things he/she doesn't like. Resident #14 said he/she wished the facility would allow him/her to be involved in his/her menu plan. On 9/12/24 at 8:36 A.M., the surveyor observed Resident #14 sitting in front of his/her breakfast tray. The menu slip on Resident #14's breakfast tray indicated it should contain 2 coffees and 2% milk. The breakfast tray contained one cup of coffee and fat-free milk. Resident #14 said his/her tray was incorrect because it was missing the second cup of coffee and had fat-free milk instead of skim milk. Resident #14 said he/she prefers to have two cups of coffee because one isn't enough, and it takes over an hour to get the second cup if he/she has to request it. On 9/12/24 at 12:18 P.M., the surveyor observed Resident #14 sitting in front of his/her lunch tray. The menu slip failed to indicate a selection for lunch meal. The lunch meal tray contained spaghetti with red sauce, spinach, garlic bread, and peaches. Resident #14 said he/she had told staff many times in the past that he/she didn't want spaghetti because it had no nutritional value. Resident #14 said he/she heard some other residents were being served ham and asked the surveyor to ask the staff to order him/her the ham because it's one of his/her favorites and needed more protein in his/her diet. Resident #14 said staff never asked what meal he/she would like, but wished they would have. During an interview on 9/11/24 at 12:08 P.M., Certified Nurse Assistant (CNA) #3 said menus are determined based on what the residents select with a staff member comes to complete menu selection with each resident. CNA #3 said each resident should receive what they order, but they often don't because the kitchen is missing a lot of items. During an interview on 9/11/24 at 12:35 P.M., The Activities Director said the kitchen had been responsible for completing the menu selection for the past two months, but she had not seen it being done in weeks. The Activities Director said she often hears that residents are upset because the receive incorrect or missing food or beverages. The Activities Director said sometimes staff must call multiple times and the food orders still doesn't come. During an interview on 9/12/24 at 8:42 A.M., Nurse #5 said the nurses are responsible for checking menu slips to ensure the correct items are on each resident's tray. Nurse #5 said if it doesn't match, they are supposed to call down to the kitchen. Nurse #5 said activities staff is responsible for meeting with each resident for menu selection, and that is how specific food preferences are communicated to the kitchen. Nurse #5 said resident meal preferences should be honored. During an interview on 9/12/24 at 9:05 A.M., the Food Service Director (FSD) and Dietary Staff #1 said activities is responsible for menu selection, but they don't have time so it's not being done. The FSD and Dietary Staff #1 said all items listed on the menu slips should be available except in rare cases. The FSD and Dietary Staff #1 said coffee, creamers, and oatmeal have been available and are not sure why they were not provided to the Resident. The FSD and Dietary Staff #1 said residents should not be served items listed on their ticket as dislikes such as eggs. The FSD and Dietary Staff #1 said food preferences need to be honored, and without the menu selection the kitchen isn't aware of what preferences residents have but should be. During an interview on 9/12/24 at 10:25 A.M., the Director of Nursing (DON) #1 said meal preferences should be honored and that meals served should match what is on the menu slip. DON #1 said each resident should have been involved in their menu selection for every meal. During an interview on 9/12/24 at 10:50 A.M., the Dietitian said she had noticed menu slips not matching what was served the residents. The Dietitian said residents should not be served items listed on their ticket as dislikes such as eggs. The Dietitian said meals served should match what is on the menu slip and meal preferences should be always honored to the best of the facilities ability, not just for medically necessary reasons. 3.) Resident #2 was admitted to the facility in August 2017 with diagnoses including sleep apnea (a respiratory condition in which your breathing stops and restarts many times while you sleep) and asthma. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/30/24, indicated Resident #2 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. On 9/11/24 at 8:23 A.M., the surveyor observed Resident #2 sitting on the side of his/her bed and said he/she had just finished eating breakfast. Resident #2 said he/she didn't get yogurt, banana, tea or diet ginger ale, but instead got a thickened yellow colored liquid that he/she did not want to drink. On 9/11/24 at 8:25 A.M., the surveyor observed Resident #2's breakfast tray in the hallway adjacent to his/her room with a menu slip on it indicating his/her name. The menu slip on Resident #2's breakfast tray indicated it should contain a yogurt, banana, tea and diet ginger ale. The tray did not show any packaging or evidence that those items were on the plate but did contain a full glass of a thickened yellow colored liquid. During a follow up interview on 9/11/24 at 11:21 A.M., Resident #2 said he/she has repeatedly asked to be served a banana every morning because he/she is worried about his/her potassium level but hasn't been served a banana in over a month even though it's on his/her slip. Resident #2 also said he/she has asked staff for yogurt repeatedly because he/she really likes it but hasn't been served yogurt for over a month. Resident #2 said his/her menu slip often does not match what he/she is served, and when he/she asks staff for it often doesn't come. Resident #2 said they always send the standard menu option. Resident #2 said the staff hasn't asked about menu selection for in at least 3 weeks but wishes that the facility would start doing it again because his/her meal preferences are not being honored. On 9/12/24 at 8:11 A.M., the surveyor observed Resident #2 sitting in front of his/her breakfast tray. The menu slip indicated Resident #14's tray should contain a banana. The meal tray failed to include a banana. Resident #2 said he/she really wanted the banana and nobody could give him/her a reason as to why he/she never gets a banana. On 9/12/24 at 12:25 P.M., the surveyor observed Resident #2 sitting in front of his/her lunch tray which did not contain a plate of food and only beverages. Resident #2 said he/she had to send the lunch meal back because it was ham, and he/she can't eat ham. Resident #2 showed the surveyor the menu slip on the tray he/she was served, which indicated dislikes ham. Resident #2 said he/she had not been asked which meal he/she would like for lunch, but would have selected the spaghetti, which was the alternative, and was waiting for it to arrive. During an interview on 9/11/24 at 12:08 P.M., Certified Nurse Assistant (CNA) #3 said menus are determined based on what the residents select with a staff member comes to complete menu selection with each resident. CNA #3 said each resident should receive what they order, but they often don't because the kitchen is missing a lot of items. During an interview on 9/11/24 at 12:35 P.M., The Activities Director said the kitchen had been responsible for completing the menu selection for the past two months, but she had not seen it being done in weeks. The Activities Director said she often hears that residents are upset because the receive incorrect or missing food or beverages. The Activities Director said sometimes staff must call multiple times and the food orders still doesn't come. The Activities Director said yogurt is available, but often not sent. The Activities Director said bananas have not been readily available and there have been numerous complaints about that. During an interview on 9/12/24 at 8:42 A.M., Nurse #5 said the nurses are responsible for checking menu slips to ensure the correct items are on each resident's tray. Nurse #5 said if it doesn't match, they are supposed to call down to the kitchen. Nurse #5 said activities staff is responsible for meeting with each resident for menu selection, and that is how specific food preferences are communicated to the kitchen. Nurse #5 said resident meal preferences should be honored. During an interview on 9/12/24 at 9:05 A.M., the Food Service Director (FSD) and Dietary Staff #1 said activities is responsible for menu selection, but they don't have time so it's not being done. The FSD and Dietary Staff #1 said all items listed on the menu slips should be available except in rare cases. The FSD and Dietary Staff #1 said bananas, yogurt, and diet ginger ale have been available and are not sure why they were not provided to the Resident. The FSD and Dietary Staff #1 said residents should not be served items listed on their ticket as dislikes such as ham. The FSD and Dietary Staff #1 said food preferences need to be honored, and without the menu selection the kitchen isn't aware of what preferences residents have but should be. During an interview on 9/12/24 at 10:25 A.M., the Director of Nursing (DON) #1 said meal preferences should be honored and that meals served should match what is on the menu slip. DON #1 said each resident should have been involved in their menu selection for every meal. During an interview on 9/12/24 at 10:50 A.M., the Dietitian said she had noticed menu slips not matching what was served the residents. The Dietitian said residents should not be served items listed on their ticket as dislikes such as ham. The Dietitian said meals served should match what is on the menu slip and meal preferences should be always honored to the best of the facilities ability, not just for medically necessary reasons. 4.) Resident #10 was admitted to the facility in December 2021 with diagnoses including a history of stroke and congestive heart failure. Review of the Minimum Data Set (MDS) assessment, dated 7/12/24, indicated Resident #10 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. On 9/11/24 at 7:43 A.M., the surveyor observed Resident #10 eating breakfast. Resident #10 said his/her tray is always wrong and his/her food preferences are not honored. The menu slip on Resident #10 breakfast tray indicated it should contain a banana, cheerios, and yogurt. The breakfast tray failed to have a banana, cheerios, or yogurt on it. On 9/12/24 at 8:25 A.M., the surveyor observed Resident #10 eating breakfast. The menu slip on Resident #10 breakfast tray indicated it should contain a banana and wheat toast. The breakfast tray failed to have a banana and wheat toast on it. During a follow up interview on 9/12/24 at 11:34 A.M., Resident #10 said every tray he/she had received in the past week has been either incorrect or missing an item. Resident #10 said he/she has not filled out a menu selection form for over a month, and even then, he/she did not get the correct items. Resident #10 said when he/she asks for yogurt and bananas he/she is told they are too expensive. On 9/12/24 at 12:19, the surveyor observed Resident #10 with a lunch tray in front of him/her. Resident #10 said he/she didn't have an option to choose what he/she would like for lunch and received spaghetti so he/she ate it, and it was okay, but wished he/she was able to choose what he/she would like to eat. During an interview on 9/11/24 at 12:08 P.M., Certified Nurse Assistant (CNA) #3 said menus are determined based on what the residents select with a staff member comes to complete menu selection with each resident. CNA #3 said each resident should receive what they order, but they often don't because the kitchen is missing a lot of items. During an interview on 9/11/24 at 12:35 P.M., the Activities Director said the kitchen had been responsible for completing the menu selection for the past two months, but she had not seen it being done in weeks. The Activities Director said she often hears that residents are upset because the receive incorrect or missing food or beverages. The Activities Director said sometimes staff must call multiple times and the food orders still doesn't come. The Activities Director said yogurt and cheerios are available, but often not sent. The Activities Director said bananas have not been readily available and there have been numerous complaints about that. During an interview on 9/12/24 at 8:42 A.M., Nurse #5 said the nurses are responsible for checking menu slips to ensure the correct items are on each resident's tray. Nurse #5 said if it doesn't match, they are supposed to call down to the kitchen. Nurse #5 said activities staff is responsible for meeting with each resident for menu selection, and that is how specific food preferences are communicated to the kitchen. Nurse #5 said resident meal preferences should be honored. During an interview on 9/12/24 at 9:05 A.M., the Food Service Director (FSD) and Dietary Staff #1 said activities is responsible for menu selection, but they don't have time so it's not being done. The FSD and Dietary Staff #1 says all items listed on the menu slips should be available except in rare cases. The FSD and Dietary Staff #1 said bananas, yogurt, and cheerios have been available and are not sure why they were not provided to the Resident. The FSD and Dietary Staff #1 said food preferences need to be honored, and without the menu selection the kitchen isn't aware of what preferences residents have but should be. During an interview on 9/12/24 at 10:25 A.M., the Director of Nursing (DON) #1 said meal preferences should be honored and that meals served should match what is on the menu slip. DON #1 said each resident should have been involved in their menu selection for every meal. During an interview on 9/12/24 at 10:50 A.M., the Dietitian said she had noticed menu slips not matching what was served the residents. The Dietitian said meals served should match what is on the menu slip and meal preferences should be always honored to the best of the facilities ability, not just for medically necessary reasons. Based on observations, staff interviews, and record review, the facility failed to ensure that staff accommodated food preferences for four Residents (#17, #14, #2, and #10), out of a total sample of 17 residents. Specifically, 1.) For Resident #17, the facility failed to honor the Resident's preferences and served the Resident foods that he/she disliked, including eggs. 2.) For Resident #14, the facility failed to honor the Resident's preferences and served the Resident foods that he/she disliked, including eggs. 3.) For Resident #2, the facility failed to honor the Resident's preferences and served the Resident foods that he/she disliked, including ham. 4.) For Resident #10, the facility failed to honor the Resident's preferences. Findings include: Review of the facility policy titled Menus and Adequate Nutrition, dated 3/4/24, indicated: - The purpose of this policy is to assure menus are developed and prepared to meet resident choices including their nutritional, religious, cultural, and ethnic needs, while using established guidelines. 4. Menus must reflect input from residents and resident groups: 1. Resident Preferences, including likes and dislikes will be documented in the resident's chart, and shall be reviewed when planning menus. Review of the facility policy titled Food Preference Record, dated January 2013, indicated: - Obtain the following information and record in the appropriate section on the form: allergies, beverage preferences at each meal, dislikes by food group. - Complete the Food Preference Record by interviewing a family member or responsible party if the resident is unable to be interviewed. - Transfer appropriate information to the computerized diet system in the kitchen. 1.) Resident #17 was admitted to the facility in November 2017 with diagnoses including dementia and dysphagia. Review of the most recent Minimum Data Set (MDS) assessment, dated 8/14/24, indicated that Resident #17 had a severe cognitive impairment, rarely/never understood. This MDS indicated Resident #17 required a mechanically altered diet and was dependent for eating. On 9/10/24 at 8:58 A.M., 9/11/24 at 8:28 A.M., and on 9/12/24 8:20 A.M., the surveyor observed nursing feeding Resident #17 eggs for breakfast. Review of Resident #17's on 9/10/24 at 8:58 A.M., 9/11/24 at 8:28 A.M., and on 9/12/24 8:20 A.M., diet slip indicated: - dislikes eggs. During an interview on 9/12/24 at 8:22 A.M., Nurse #2 was assisting Resident #17 with his/her breakfast. Nurse #2 was feeding Resident #17 scrambled eggs. Nurse #2 reviewed the diet slip and said that Resident #17 has a dislike listed as eggs. During an interview on 9/12/24 at 9:50 A.M., Certified Nurse Assistant #4 said she has been caring for Resident #17 for years and Resident #17 should not get eggs because he/she doesn't like them. During an interview on 9/12/24 at 8:42 A.M., the Food Service Director said the kitchen should honor Resident #17's food preferences. She said the diet aide calling out the food preferences during the food tray line should follow Resident preferences. During an interview on 9/12/24 at 12:15 P.M., the Clinical Nurse said nursing should review the diet slips for dislikes.

Based on observations, interviews, and review of the meal truck delivery schedule, the facility failed to offer a nourishing evening snack when there was greater than 14 hours between dinner and breakfast service. Findings include: Review of the facility policy titled, Frequency of Meals, dated 3/4/24, indicated the facility will ensure that each resident receives at least three meals daily without extensive time lapses. 1. The facility has scheduled three regular meal times, comparable to normal mealtimes in the community, per day and has scheduled three regular snack times. 3. There will be no more than 14 hours between an evening meal and breakfast the following day, unless a nourishing snack is served at bedtime; then, up to 16 hours may elapse between an evening meal and breakfast the following day if the resident council agrees to this meal time span. 5. Nutritious snacks and convenience foods (i.e., canned soups, peanut butter, crackers, cereal, and fruit) shall be available on the nursing units for those residents who request food outside scheduled meal and snack times. On 9/10/24 at 4:48 P.M., the surveyor observed the final food tray passed by facility staff from Cart #4 for the evening meal. Review of the Meal Truck Deliver Log, dated as current, indicated the following: -Dinner Start Time: 4:45 P.M., 2nd Floor Cart #1 at 4:55 P.M., 2nd Floor Cart #2 at 5:05 P.M., 1st Floor Cart #3 at 5:15 P.M., 1st Floor Cart #4 at 5:25 P.M., -Breakfast Start Time: 7:30 A.M., 2nd Floor Cart #1 at 7:40 A.M., 14 hours and 45 minutes between a substantial evening meal and breakfast the following day. 2nd Floor Cart #2 at 7:50 A.M., 14 hours and 45 minutes between a substantial evening meal and breakfast the following day. 1st Floor Cart #3 at 8:00 A.M., 14 hours and 45 minutes between a substantial evening meal and breakfast the following day. 1st Floor Cart #4 at 8:10 A.M., 14 hours and 45 minutes between a substantial evening meal and breakfast the following day. During a Resident Group Meeting for the 2nd Floor held on 9/10/24 at 12:58 P.M., 4 of 4 residents said they sometimes were provided with an evening snack when they asked for it. Residents said there are no sandwiches, or peanut butter. Residents said that there are less snack choices since the change of ownership. During a Resident Group Meeting for the 1st Floor held on 9/11/24 at 10:36 A.M., 4 of 4 residents said they sometimes were provided with an evening snack when they asked for it. Residents said there are no sandwiches, or peanut butter. Review of the Food Committee Notes, dated 8/21/24, indicated the following: - Snacks need more soft cookies choices. On 9/10/24 at 10:00 A.M., the surveyor observed in the 1st Floor snack kitchenette to have no soft cookies and no peanut butter. During an interview on 9/12/24 at 11:04 A.M., Nurse #2 (who works the day and evening shifts) said dinner is served on the first floor unit before 5:00 P.M., Nurse #2 said the residents often complain about the lack of snack choices. During an interview on 9/12/24 at 8:07 A.M., Nurse #3 (who typically works the evening and overnight shift) said snacks include, crackers, peanut butter, and supplement shakes. Nurse #3 said that the kitchenette is not always stocked. During an interview on 9/12/24 at 8:53 A.M., the Food Service Director said there needs to be no more than 14 hours between a sustainable evening meal and breakfast the following the day. The Food Service Director said that the evening meal on 9/11/24 started at 4:30 P.M., and she would need to adjust the times. During an interview on 9/12/24 at 10:35 A.M., the Dietician said that the kitchen should follow the tray line delivery times and there should be substantial evening snacks available for residents when there is greater than 14 hours between dinner and breakfast the following day. During an interview on 9/12/24 at 12:11 P.M., the Administrator said meals should be served after 5:00 P.M. and there should be a substantial evening snack available on the units.

Based on observations, interviews and policy review, the facility failed to store food in accordance with professional standards for food service safety. Specifically, the facility failed to label and date food in the refrigerator, store food in the freezer with dates opened and expiration dates and failed to store food directly off the floor. Findings include: A review of the facility policy titled 'Storage' effective November 2013 indicated the following: -Policy-To store food in a safe manner. -Dry Storage 4. Store products on shelves no less than six inches from the floor. -Refrigerator Storage 1. Store perishable foods in the refrigerator. 6. Label products with delivery date indicating month and year the product was received. 8. Label all leftovers with recipe name and date (month, day, and year) of storage. -Freezer Storage 5. Label products with delivery date indicating month and year the product was received. On 9/10/24 at 7:20 A.M., the surveyor observed the following in the refrigerator in the kitchen: -Five heads of lettuce wrapped in plastic placed directly on the refrigerator shelf, and on top of a food container with leftovers, not labeled or dated. -Tomatoes and cabbages placed in aluminum trays, not labeled, or dated. -An unidentified Styrofoam bowl covered with leftovers, not labeled or dated. -Left over Tuna in an aluminum bowl, covered in saran wrap, not labeled, or dated. -Sliced tomatoes in an aluminum bowl, covered in saran wrap, not labeled, or dated. -Left over doughnut placed in a plastic bag, not labeled, or dated. -A water jug with sliced yellow lemons, not labeled or dated. On 9/10/24 at 7:20 A.M., the surveyor observed the following in the dry food storage: -Four packs of ginger ale on the floor. -2 boxes of frozen bread on the floor. -1 box of dinner rolls on the floor. -1 box of canned potato sweet cuts on the floor. -1 box of canned halved apricot cuts on the floor. -6 large cans of black beans on the floor. -1 box of ground coffee on the floor. On 9/10/24 at 7:41 A.M., the surveyor observed the following in the freezer in the dry food storage room: -A bag of frozen French toast in an open bag, not labeled or dated. -A bag of frozen steak fries in an open bag, not labeled or dated. -A bag of frozen cookie dough, in an open bag, not labeled or dated. During an interview and observation on 9/11/24 at 8:00 A.M., Dietary staff #1 and the surveyor walked through the kitchen and the dry food storage room. Dietary staff #1 said that she had to throw out all the food and vegetables in the refrigerator that was not labeled and dated, she said all the leftovers in the refrigerator should be labeled and dated, all the vegetables should be placed in labeled and dated containers. Dietary staff #1 said the dry food storage room should not have any food on the floor, she said the cartons of food on the floor were deliveries that no one put away. Dietary staff #1 said the frozen food in the freezer should have labels and dates and the bags containing the food should not be left open. During an interview on 9/11/24 at 12:23 P.M., the Food Services Director said all left overs, vegetables and frozen food should be labeled and dated. She said the dry storage room should not have containers of food on the floor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2.) Resident #2 was admitted to the facility in August 2017 with diagnoses including sleep apnea (a respiratory condition in which your breathing stops and restarts many times while you sleep) and asthma. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/30/24, indicated Resident #2 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. This MDS also indicated Resident #2 required non-invasive mechanical ventilator, which includes BiPAP. On 9/10/24 at 8:07 A.M., the surveyor observed Resident #2 being awoken from sleep by staff because his/her breakfast arrived. There was a BiPAP machine on a dresser across the room, not near Resident #2's bed. Resident #2 said he/she had not used the BiPAP in a few weeks because it was broken, but nursing staff knew and had told him/her they called to get it fixed. Resident #2 said he/she sleeps better when using the BiPAP and said he/she had not been sleeping well without it. During a follow up interview on 9/11/24 at 7:29 A.M., Resident #2 said he/she had not been able to wear the BiPAP again last night and had not received an update on when it would be fixed by from staff. There was a BiPAP machine on a dresser across the room, not near Resident #2's bed. Review of Resident #2's active physician's order, initiated 9/16/21, indicated: - Bi-PAP settings 12 cm Exp, 18 cm Inspiratory @ (at) bedtime, every evening (3:00 P.M. to 11:00 P.M.) and night shift (11:00 P.M. to 7:00 A.M.) for Asthma, O2 (oxygen) Dep (dependency). Review of Resident #2's Treatment Administration Record (TAR), dated September 2024, indicated the physician's order for Bi-PAP settings 12 cm Exp, 18 cm Inspiratory @ bedtime, every evening and night shift for Asthma, O2 Dep was documented as implemented on the following shifts: - 9/1/24: evening shift. - 9/2/24: evening shift. - 9/3/24: evening shift and night shift. - 9/4/24: evening shift and night shift. - 9/5/24: evening shift. - 9/6/24: evening shift. - 9/7/24: evening shift and night shift. - 9/8/24: evening shift and night shift. - 9/9/24: evening shift. - 9/10/24: evening shift. During an interview on 9/11/24 at 7:37 A.M., Nurse #7 said she noticed Resident #2's BiPAP was broken a few weeks ago and was unable to be used safely. Nurse #7 said she told the Director of Nursing (DON) #1 but was not sure if the call for repair had been made. Nurse #7 said the medical record should have reflected that the BiPAP was broken, unable to be used, and what the outcome or plan was. Nurse #7 said she documented that the BiPAP as not implemented on 9/1/24, 9/2/24, 9/5/25, 9/6/24, 9/9/24, and 9/10/24 because it was broken on all these dates. Nurse #7 said the other evening and night shift nurses should not have documented it as implemented because it was broken and physically unable to be used. During an interview on 9/11/24 at 9:05 A.M., the Director of Nursing (DON) #1 said he was told Resident #2's BiPAP was broken a few weeks ago, but never called for repair or ensured the plan of care was updated or changed when the Resident was unable to use the BiPAP. DON #1 said since the BiPAP was broken and unable to be used, it should not have been documented as implemented.Based on record review and interview the facility failed to ensure they maintained complete and accurate medical records for four Residents (#22, #2, #28, and #23) out of a total sample of 17 residents. Specifically: 1.) For Resident #22, the facility failed to document weights in the Electronic Health Record (EHR). 2.) For Resident #2, the facility nurses documented a broken BiPAP was being used, when it was not. 3.) For Resident #28, the facility failed to document services provided each shift by the Certified Nurse Aide (CNA). 4.) For Resident #23, the facility failed to document weights in the medical record. Findings include: Review of the facility policy titled Documentation in Medical Record, undated, indicated: - Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. - Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. - Documentation shall be completed at the time of services, but no later than the shift in which the assessment, observation, or care service occurred. - False information shall not be documented. A review of the facility policy titled 'Weight Monitoring' with a revision date of 3/4/24 indicated the following: -A weight monitoring schedule will be developed upon admission for all residents. -Newly admitted residents-monitor weight weekly for 4 weeks. 1.) Resident #22 was admitted to the facility in January 2024 with diagnoses including combined systolic and diastolic heart failure, pleural effusion, atrial fibrillation, and pulmonary hypertension. Review of the most recent Minimum Data Set (MDS) assessment, dated 7/2/24, indicated that Resident #22 was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. Review of Resident #22's weights recorded in the Electronic Health Record (EHR) indicated the following: - 8/8/24 143.6 pounds. Review of Resident #22's physician's order, dated 9/3/24, indicated: - Record weights on Mondays, Wednesdays, and Fridays x (times) 2 weeks every day shift (7:00 A.M. to 3:00 P.M.) for monitoring for 2 weeks. Review of Resident #22's Medication Administration Record, dated September 2024, indicated nursing implemented the physician's orders on the following dates 9/4/24, 9/6/24, and 9/9/24. However, there was no documentation to support that nursing staff documented Resident #22's weight in the EHR. During an interview on 9/12/24 at 9:36 A.M., Certified Nurse Assistant (CNA) #4 said Resident #22 is weighed Monday, Wednesday and Friday. CNA #4 said she reports these weights to the nurse on duty. CNA #4 said that monthly weights are reported on the weight sheet and then given to the nurse, but weekly or daily weights are verbally provided to the nurse. During an interview on 9/12/24 at 11:05 A.M., Nurse #2 said Resident #22 has an order for weights on Monday Wednesday and Friday, she said CNA's will obtain the weights and the nurse will put the weight value in the weight tab in the EHR. Nurse #2 said there would be no paper documentation of weights. During an interview on 9/12/24 at 12:00 P.M., the Regional Nurse said that weights should be documented in the EHR under the weights tab. 4.) Resident #23 was admitted to the facility in July 2024 with diagnoses including type 2 diabetes mellitus. A 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. A review of Resident #23's census indicated he/she was out on a Medical Leave of Absence MLOA) on 8/2/24 - 8/3/24 and 8/7/24 -8/14/24. A review of Resident #23's initial weights physician's order dated 7/31/24 indicated the following: -Vital signs & Weights monthly, everyday shift every Tuesday for monitoring and prevention. A review of Resident #23's August Medication Administration Record (MAR) indicated the following: -Staff weighed the Resident on 8/20/24 and 8/27/24 (a week apart). Review of the medical record failed to indicate these weights were documented in the electronic medical record. -A review of Resident #23's physician's orders dated 8/16/24 indicated the following: -Obtain patient's weight weekly times 4 weeks in the morning every Monday for monitoring until 9/16/24. Further review of the MAR did not indicate any weights were done based on this physician's order. A review of Resident #23's August TAR (Treatment Administration Record) indicated the following: -Weigh weekly x4 weeks every day shift every Sunday for 4 weeks. Weight change of 3 lbs (pounds) or more, notify MD. [sic] Staff signed off that they weighed the Resident on 8/18/24 and signed off code 9 (see Nurse's notes) on 8/25/24. Further review of the electronic medical record failed to indicate the documented weight taken on 8/18/24, and no Nurse's progress note concerning weights in the medical record on 8/25/24. A review of Resident #23's weights indicated the following listed weights struck out in error: -8/29/24 195.0 lbs Standing -8/2/24 120.0 lbs Standing -8/1/24 195 lbs Standing -7/31/24 195 lbs Standing During an interview and record review on 9/12/24 at 10:23 A.M., the Dietician and the surveyor reviewed Resident #23's medical record together, she said she had no idea why all of the Resident's weights were struck out in error. The Dietician said if a weight is struck out in error, the Resident should be reweighed to get an accurate weight and the weight should be documented in the electronic medical record. She said Resident #23 has a history of refusing weights but there was no indication in the medical record that the Resident refused to be weighed. The Dietician said since there were no documented weights in the medical record, the Resident had not been weighed since admission. She said all newly admitted residents should be weighed weekly for four weeks and then a decision is made with the physician how often they need to be weighed after the four weeks. 3.) Resident #28 was admitted to the facility in March 2021 with diagnoses including heart disease, kidney disease and depression. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #28 scored an 11 out of 15 on the Brief Interview for Mental Status exam indicating moderately impaired cognition. During an interview on 9/12/24 at 8:30 A.M., Certified Nurse Aide (CNA) #3 said that the CNA's document the services they provide to each resident in the computer each shift. CNA #3 then said that the CNA documentation is located on the form titled Alpha Daily GG (CNA) - V2 and the top of the page indicates the date and shift being documented on. Review of the medical record indicated that for the month of August 2024 CNAs documented the services they provided to Resident #28 only 13 out of 93 shifts. During an interview on 9/12/24 at 8:49 A.M., Director of Nursing (DON) #1 said that it is the expectation that CNA's document the services they provide to each resident at the end of each shift. DON #1 then said that he was not able to locate a policy for CNA documentation. During an interview on 9/12/24 at 9:02 A.M., CNA #3 said that there is not enough time to complete all the tasks required of her because there are only two CNAs to care for 24 residents. CNA #3 then said that she has 12 residents to care for including getting them bathed, dressed, getting them up, assisting with two meals and toileting residents every two hours. CNA #3 said she also has three showers to give today. CNA #3 said there is just no time to document before the end of the shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to annually conduct, review, and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Findings include: Review of the facility policy titled, Facility Assessment, dated as 3/4/24, indicated this facility conducts and documents a facility-wide assessment to determine what resources are necessary to care for our residents competently during both day-to-day operations (including nights and weekends) and emergencies. The purpose of this policy is to establish responsibilities and procedures for the facility assessment process. 4. The Administrator is responsible for ensuring the completion of the facility assessment and maintaining all documents that pertain to the assessment. The Administrator serves as the leader of the facility assessment process, or may designate someone to lead the process. 10. The facility assessment will be reviewed and updated as necessary and at least annually, whenever there is, or the facility plans for, any change that would require a substantial modification to any part of the assessment. Additionally, the facility will consider specific staffing needs for each shift (e.g., day, evening, night, weekend shifts) and for each resident unit in the facility based on changes to resident population. Any changes to the assessment will be documented, along with a revision history. On 9/10/24 at 8:30 A.M., during the facility entrance conference the surveyor requested a copy of the facility assessment. On 9/11/24 at 9:00 A.M., the surveyor requested the facility assessment from Administrator #1. During an interview on 9/11/24 at 12:00 P.M., Administrator #1 said he was unable to locate the facility assessment. Administrator #1 provided the surveyor a copy of the facility assessment dated [DATE], and said he was unable to locate any other facility assessments. During an interview on 9/12/24 at 12:50 P.M., Administrator #2 said she was responsible to conduct the facility assessment review, but she did not. Administrator #2 said she was employed by the facility for about 10 weeks and that facility assessments are required annually. Administrator #2 said she did not have access to any previous facility assessments during her time as the Administrator. Administrator #2 said that the Director of Operations was aware she did not have any previous copies of facility assessments and that she was unable to complete the facility assessment. During an interview on 9/12/24 at 1:15 P.M., the Director of Operations said that Administrator #2 was supposed to complete the facility assessment update, but she did not. The Director of Operations said that facility assessments are required to be completed annually but one was not completed.

Based on records reviewed and interviews, for two of three sampled residents (Resident #1 and Resident #3), the Facility failed to ensure they maintained complete and accurate medical records, when documentation by nursing related to the conduction of weekly skin assessments was not consistently completed. Findings include: Review of the Facility Policy, titled Skin Assessment, dated 03/04/24, indicated a full body skin assessment would be conducted and documented by a licensed or registered nurse upon admission, readmission, daily for three days, and weekly thereafter. Review of the Facility Policy, titled Documentation in the Medical Record, dated 0/04/24, indicated licensed staff would document all assessments, observations, and services provided in the resident's medical record in accordance with state law and Facility policy. 1) Resident #1 was admitted to the Facility in April 2024, diagnoses included epilepsy and hypertension. Review of Resident #1's Skin Integrity Care Plan, dated 04/22/24, indicated he/she would have weekly skin checks conducted by nursing. Review of Resident #1's Medical Record indicated nursing conducted a weekly skin check on 05/27/24. Further review of Resident #1's Medical Record indicated there was no documentation to support that weekly skin checks, due 04/29/24, 05/06/24, 05/13/24, and 05/20/24 had been conducted by nursing, or any other weekly skin check after 05/27/24. 2) Resident #3 was admitted to the Facility in September 2021, diagnoses included nontraumatic subarachnoid hemorrhage, dysphagia and anxiety. Review of Resident #3's Treatment Administration Record (TAR) for August 2024 indicated he/she was scheduled to have weekly skin checks on 08/07/24, 08/14/24, 08/21/24, and 08/28/24. Further review of Resident #3's TAR indicated that all of these dates were checked off as having been conducted by nursing. However further review of Resident #3's Medical Record indicated that there were no Weekly Skin Assessment Forms completed for 08/14/24 and 08/21/24. During a telephone interview on 09/04/24 at 10:48 A.M., the Director of Nurses (DON) said weekly skin checks should be conducted every week by nursing and should be documented using the Weekly Skin Assessment Form in the electronic medical record, but were not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed, interviews and observations, the Facility failed to ensure the Dietary/Kitchen Department staff consistently prepared and followed the established, as posted, weekly menu for the resident meals. Findings include: Review of the Facility Policy, titled Menus and Adequate Nutrition, dated 03/04/24, indicated the Facility would assure menus were developed and prepared to meet resident choices including their nutritional needs, would be posted in areas accessible to residents one week in advance, and would be followed as posted. The Policy indicated that notification of any deviations from the posted menu would be made as soon as practicable, and substitutions would comprise of food with comparable nutritive value. Review of the Facility's Week 4 Menu, dated 09/03/24 indicated the planned breakfast meal was biscuits with gravy, oatmeal, hashbrowns, orange juice, milk, coffee or tea, and a choice of cold cereal. During a tour of the kitchen at on 09/03/24 at 07:10 A.M., which included an interview with [NAME] #1, the Surveyor observed the following: Cook #1 was observed plating breakfast which was two small biscuits, a small sausage patty, and cold cereal. Cook #1 said hashbrowns and gravy were not available. Review of the Facility's Week 4 Menu, dated 09/03/24 indicated the planned lunch meal was a tuna melt sandwich, buttered green beans, tater tots, deluxe fruit salad, coffee or tea, and the alternate entrée was honey Dijon chicken. During an observation of the kitchen on 09/03/24 at 12:11 P.M., [NAME] #1 was observed plating lunch which was a cold tuna sandwich, steamed mixed vegetables, tater tots, chocolate pudding, and the alternate meal was a grilled cheese sandwich. During an interview on 09/03/24 at 12:32 P.M., [NAME] #2 said she checked the kitchen and there were hashbrowns in stock for breakfast, and said sausage was not on the menu, and should not have been served. [NAME] #2 said there were missing ingredients which was why the lunch was a tuna sandwich instead of a tuna melt, said the menu was not followed as planned, but should have been. Cook #2 said they were having problems with [NAME] #1, and that she (Cook #1) often did not follow the planned meal menus which caused a [NAME] effect. [NAME] #2 said the following was an example; that last Friday (8/30/24) [NAME] #1 cooked the chicken that was needed for Monday (9/02/24) meal, so on Monday they made hamburgers instead of the planned chicken sandwiches. During an interview on 09/03/24 at 12:59 P.M., Resident #3 said they were often served random food that was not on the planned menu and said there was often no alternate meal to choose, only peanut butter and jelly sandwiches. During an interview on 09/03/24 at 04:35 P.M., the Administrator said meal menus should be followed as planned, but were not.

Based on records reviewed, interviews and observations, for one of two sampled resident care units (Unit 1), the Facility failed to ensure food and beverages provided to the residents were served at safe and appetizing temperatures, when food temperatures were not consistently measured and recorded, and the results of a test tray observation indicated that the food items were not served at appetizing temperatures and food items were not palatable. Findings include: Review of the Facility Policy, titled Maintaining a Sanitary Tray Line, dated 03/04/24, indicated hot foods would be maintained at or above 135 degrees Fahrenheit (F) and cold foods would be maintained at or below 41 degrees F, and staff would periodically monitor food temperatures throughout the meal service to ensure proper temperatures. Review of the Facility Policy, titled Food Safety Requirements, dated 03/04/24, indicated food and beverages would be distributed and served to residents in a manner to maintain food at proper temperature. Review of the Food Committee Notes, dated 08/21/24, with 11 residents in attendance, indicated residents complained about the quality of the food. During a telephone interview on 09/03/24 at 11:48 A.M., the Ombudsman said residents often complained about the temperature and quality of the food overall, served at the facility. Review of the Facility's Week 4 Menu indicated the planned breakfast meal for 09/03/24 was biscuit with gravy, oatmeal, hashbrowns, orange juice, milk, coffee or tea, and cold cereal of choice. During a tour of the kitchen on 09/03/24 at 07:10 A.M.,which included an interview with [NAME] #1, the Surveyor observed the following: - [NAME] #1 was plating breakfast which was two small biscuits, a small sausage patty, and cold cereal. - Breakfast was being plated onto paper plates. - [NAME] #1 said she was too busy which was why she was using paper plates. - [NAME] #1 said hashbrowns and gravy were not available, and there was not enough food prepared to set up a test tray. During an interview on 09/03/24 at 12:11 P.M., [NAME] #1 said she had not measured any food temperatures that day for breakfast or lunch because she was too busy. A Food Test Tray was conducted on 09/03/24 on the lunch time meal truck for Unit 1 by the surveyor and [NAME] #2, and results were based on the following standards: - acceptable standard temperature for hot foods was at or above 135 degrees F, - acceptable standard temperature for cold foods was at or below 41 degrees F. At 12:11 P.M., the lunch time truck for Unit 1 left the kitchen. At 12:15 P.M., Nursing staff began checking and distributing the residents' lunch trays. At 12:32 P.M., after the last resident meal tray was removed and served, the test tray was pulled from the cart by [NAME] #2. Test tray observations: The food temperatures were measured in the presence of the Surveyor by [NAME] #2, who also tasted the food items. Observations were as follows: -Cold tuna sandwich was 69.1 degrees F (28.1 degrees greater than the acceptable standard) and tasted bland. -There was very little filling in the sandwich, the filling was dry, and the bottom piece of bread was soggy from having been plated with steamed mixed vegetables. -Mixed vegetable were 106.9 degrees F (28.1 degrees less than the acceptable standard) they tasted bland, cold, and were mushy. -Tater Tots were 96.6 degrees F (38 degrees less than the acceptable standard) they tasted cold, salty, and raw. - [NAME] #2 also tasted the Tater Tots and said they were undercooked and cold. -Milk was 56.8 degrees F (15.8 degrees greater than the acceptable standard) and tasted warm. -There was no dessert on the test tray, and [NAME] #2 said the dessert served was pudding, but there was not enough prepared to put one on the test tray. During an interview on 09/03/24 at 12:32 P.M., [NAME] #2 said there was plenty of staff in the kitchen (one cook and 2 dietary aides) to prepare food for the residents. [NAME] #2 said food temperatures should be measured and recorded with every meal, and that temperatures should be maintained at acceptable ranges for hot and cold food. [NAME] #2 said the mixed vegetables should have been served in a separate bowl from the sandwiches to prevent the sandwiches from becoming soggy. Review of the Service Line Checklist Logs, dated 08/01/24 through 09/02/24 indicated: -08/02/24, no food temperatures were recorded for the breakfast or lunch meals. -08/06/24, no food temperatures were recorded for the lunch or dinner meals. -08/07/24, no food temperatures were recorded for the lunch alternate or dinner meals. -08/08/24, no food temperatures were recorded for the lunch or dinner meals. -08/09/24, no food temperatures were recorded for the dinner meal. -08/10/24, no food temperatures were recorded for the dinner meal. -08/11/24, no food temperatures were recorded for the breakfast or dinner meals. -08/12/24, no food temperatures were recorded for the dinner meal. -08/15/24, only the milk and coffee temperatures were recorded for the lunch meal. -08/16/24, no temperatures were recorded for the dinner meal. -08/17/24, no temperatures were recorded for the lunch or dinner meals. -08/18/24, no temperatures were recorded for the dinner meal. -08/26/24, no temperatures were recorded for the dinner meal. -08/28/24, no temperatures were recorded for the breakfast or lunch meals. -09/01/24, only the milk, coffee, and juice temperatures were recorded for the lunch meal, and only the main entrée temperature was recorded for the dinner meal. -09/02/24, no temperatures were recorded for the lunch or dinner meals. -09/03/24, no temperatures were recorded for the breakfast or lunch meals. -There was no documentation to indicate that food temperatures were measured or recorded for any meals on 08/03/24, 08/04/24, 08/05/24, 08/20/24, 08/21/24, 08/22/24, 08/23/24, 08/24/24, 08/25/24, 08/29/24, and 08/30/24. Cook #2 said all meal temperatures should be measured and documented, but were not. During a resident group interview on 09/03/24 at 12:59 P.M., Resident #3 said he/she had complained about the food to staff and said there had been discussions about the food with [NAME] #2 during monthly Food Committee Meetings. Resident #3 said breakfast that morning was atrocious, the biscuits were dry and hard, there was no gravy, and there was only one small slice of sausage. Resident #3 said he/she did not eat breakfast that morning and had only a few bites of lunch because he/she had lost his/her appetite. Resident #3 said there was not enough protein served in the meals, and said he/she gets his/her own snacks and protein drinks brought in from home. Non-Sampled Resident (NS-RT) #4 said the breakfast sausage that morning was sliced so thin you could see through it. NS-RT #4 said lunch that day was bad, there was only a tiny amount of filling in the sandwich, he/she could not tell if it was tuna or chicken salad, there was only a very thin slice of tomato on it and said the tater tots were cold and raw. Another resident said he/she often did not like the food but ate it anyway because there was no other choice. During an interview on 09/03/24 at 01:23 P.M., Nurse #2 said residents often complained about the food, and said that today's breakfast was terrible, that some residents said it was awful. Nurse #2 said she offered to make residents peanut butter and jelly sandwiches, but some residents did not eat. During an interview on 09/03/24 at 02:49 P.M., Nurse #3 said residents often complained that they do not like the food. Nurse #3 said sometimes for breakfast she has seen scrambled eggs and oatmeal served on the same plate, and said it was as though they were feeding a dog. During an interview on 09/03/24 at 04:35 P.M., the Administrator said the Facility had recently hired a Food Service Director (FSD), and that [NAME] #2 was filling in until the new FSD starts on 09/16/24. The Administrator said she had not approved the use of paper plates for breakfast. When the Surveyor reviewed the findings of the lunch time test tray with the Administrator, she agreed it sounded unappetizing. The Administrator said there were no other documented Food Committee Meeting Minutes besides the Minutes from 08/21/24 and said she had not reviewed them until the surveyor asked for them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who had an activated Health Care Proxy (HCP) and had been admitted on to Hospice Services, the Facility failed to ensure nursing notified his/her Health Care Agent(s) (HCA) and the Hospice Agency in a timely manner that he/she had died. On [DATE] Resident #1 died shortly after midnight, however the HCA(s) and Hospice Agency were not made aware until the following morning when, Resident #1's Family Member arrived to the Facility expecting to visit with him/her. Findings include: Review of the Facility's Policy titled, Notification of Changes, dated [DATE], indicated the Facility must inform the residents, consult with the resident's Physician and/or notify the Resident's Family Member or Legal Representative when there is a change requiring such notification. The Facility's Policy indicates a circumstance requiring notification would include a death of a resident. Resident #1 was admitted to the Facility in [DATE], diagnoses included lack of coordination, local infection of the skin and subcutaneous tissue, Respiratory Failure, Congestive Heart Failure, Atrial Fibrillation, Peripheral Vascular Disease, muscle weakness, Depression, Anxiety, and Chronic Venous Hypertension (high blood pressure in the veins) with Ulcer of the right lower extremity. Review of Resident #1's Physician Order's, dated [DATE], indicated Resident #1's HCP and had been activated. Review of Resident #1's Physician Order's, dated [DATE], indicated Resident #1 to be evaluated and admitted to Hospice Services. Review of Resident #1's Medical Record, dated [DATE], indicated the Hospice Agency evaluated Resident #1, the Physician was notified, and Hospice medications ordered by Resident #1's Physician. Review of Resident #1's RN/PA/NP Pronouncement of Death, dated [DATE], indicated Resident #1's time of death was 12:20 A.M. and the former Director of Nurses (DON), completed the RN Pronouncement. Review of Resident #1's Nursing Progress Note, dated [DATE] and written at 1:45 A.M., by the former DON, indicated the Next of Kin (NOK) and Hospice Services were notified. However, further review of Resident #1's medical record and based on staff interviews, Resident #1's HCA and/or Alternative HCA and the Hospice Agency, were not been informed until approximately 8 hours later. The Surveyor was unable to interview the former Director of Nurses as she did not respond to the Department of Public Health requests for an interview. During a telephone interview on [DATE] at 9:51 A.M., Nurse #1 said on [DATE], Resident #1 died after midnight, and that she did not call the Hospice Agency or Resident #1's HCA since she was unable to Pronounce Resident #1's death. Nurse #1 said she is a Licensed Practical Nurse (LPN) and it is not within her scope of practice to pronounce a death. Nurse #1 said the former DON, who is a Registered Nurse (RN) and could do a death pronouncement, was working in the Facility at the time of Resident #1's death, and that she had notified her immediately that Resident #1 had died. Nurse #1 said several hours later, the former DON had still not Pronounced Resident #1's death, so she waited to notify Resident #1's HCA and the Hospice Agency. Nurse #1 said on [DATE], approximately at 8:00 A.M., Resident #1's Family Member, who appeared to be distraught, approached her and said, I think Resident #1 is dead. Nurse #1 said she apologized to Resident #1's Family Member and shared that Resident #1 had passed away around 12:20 A.M. Nurse #1 said the Family Member asked why the Family was not notified and Nurse #1 said she explained to the Family Member she had been waiting for the former DON to complete an RN Pronouncement on Resident #1's death, before calling anyone. Nurse #1 said she was unable to locate Resident #1's Hospice Agency information in Resident #1's Medical Record, but said in hindsight, she could have called the Hospice Agency and the Hospice Nurse would have come to the facility and completed the RN Pronouncement for Resident #1's death. During a telephone interview on [DATE] at 12:44 P.M., the Hospice Nurse said on [DATE] at 3:00 P.M. she had conducted a Facility Visit with Resident #1 to assess his/her level of comfort. The Hospice Nurse said Resident #1 was actively dying during her visit. The Hospice Nurse said the Facility was aware of Resident #1's medical status. The Hospice Nurse said a verbal report was given to the nursing staff prior to her leaving the Facility and that nursing had been informed to call Hospice for any concerns pertaining Resident #1. The Hospice Nurse said on [DATE], at 10:44 A.M. she received a telephone call from the Agencies Hospice Triage staff stating Resident #1's Family Member had called to inform the Agency that Resident #1 had died in the middle of the night, that they had arrived at the Facility to find Resident #1 unresponsive and that the Nurse then told them that Resident #1 had died in the middle of the night. The Hospice Nurse said Facility Nursing had not informed the Agency on [DATE] that Resident #1 had died. During an interview on [DATE] at 4:45 P.M., the current Director of Nurses (DON) said that on [DATE] she was notified of concerns that there was a delay in providing Resident #1 with Hospice Services and that on [DATE] Resident #1's Family were not notified of Resident #1's death until several hours later. The current DON said it was her expectation when a Resident who is on Hospice has a change of condition, that Nursing notifies the Resident's Physician, the DON, the Resident's HCA and Hospice immediately after their death.

Based on records reviewed, interviews and observations for one of three sampled residents (Resident #1), the Facility failed to ensure they maintained Resident #1's dignity when he/she was observed with stains and what appeared to be dried food on the front of both of his/her sneakers. Findings Include: The Facility Policy titled Resident Rights, dated as revised 12/06/21, indicated a Facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The Policy indicated that the facility would make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity. Resident #1 was admitted to the Facility in March 2016, diagnoses included hemiplegia (partial paralysis on one side of the body) affecting the right non-dominant side, psychotic disorder with delusions, vascular dementia with behavioral disturbance, anxiety, depression, cerebral infarction (stroke, disrupted blood flow to the brain), dysphagia (difficulty swallowing), muscle weakness, and abnormality of gait and mobility. During a tour of the first floor Unit, on 03/26/24 at 8:10 A.M., the Surveyor observed Resident #1 seated in his/her wheelchair in his/her room. Resident #1 had on a pair of sneakers that were dirty, soiled with a dried red liquid and what appeared to be dried food particles on the front of both sneakers. On 03/26/24 at 9:35 A.M., the Surveyor observed Resident #1 seated in his/her wheelchair in the activity room, his/her sneakers had not been cleaned and were still in the same dirty condition that the Surveyor had observed earlier that morning. During an interview on 03/26/24 at 10:54 A.M., Family Member #1 said that Resident #1 was a messy eater and often times would spill food items that stained his/her clothing while eating and said nursing staff would leave him/her in stained clothing. During an interview on 03/26/24 at 12:58 P.M., Certified Nurse Aide (CNA) #3 said Resident #1 was on her assignment and said she had observed his/her sneakers with food on them. CNA #3 and said Resident #1's sneakers should have been scrubbed clean. During an interview on 03/26/25 at 3:55 P.M. and on 04/04/24 at 3:59 P.M., the Director of Nursing (DON) said (after seeing the pictures of Resident #1's soiled sneakers shown to her by the Surveyor) that nursing staff should not have put the sneakers on Resident #1 in that condition. The DON said her number one concern was that it (wearing soiled, dirty sneakers) was a resident dignity issue.

Based on records reviewed, interviews and observations, for one of three sampled residents (Resident #1), the Facility failed to ensure that staff provided a clean homelike environment when his/her wheelchair was observed to be dirty with dried food stuck to the seatbelt of Resident #1's wheelchair, with dried food also noted to be stuck to each side of his/her wheelchair. Findings Include: The Facility Policy titled Resident Rights, dated as revised 12/06/21, indicated a Facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The Policy indicated that each resident's rights included the resident has a right to a safe, clean, comfortable, and homelike environment. Resident #1 was admitted to the Facility in March 2016, diagnoses included hemiplegia (partial paralysis on one side of the body) affecting the right non-dominant side, psychotic disorder with delusions, vascular dementia with behavioral disturbance, anxiety, depression, cerebral infarction (stroke, disrupted blood flow to the brain), dysphagia (difficulty swallowing), muscle weakness, and abnormality of gait and mobility. During a tour of the first floor Unit, on 03/26/24 at 8:10 A.M., the Surveyor observed Resident #1 seated in his/her wheelchair in his/her room and observed his/her wheelchair to have multiple areas of what appeared to be dried food caked to the sides of the wheelchair and to his/her alarmed seat belt that was on the wheelchair. On 03/26/24 at 9:35 A.M., the Surveyor observed Resident #1 seated in his/her wheelchair in the activity room and his/her wheelchair was in the same condition as the Surveyor had observed earlier that morning. Review of the Housekeeping Wheelchair Washing Schedule indicated that Resident #1's wheelchair had not been washed since 02/14/24 (which had been approximately 6 weeks prior to the date of the survey). During an interview on 03/26/24 at 12:58 P.M., Certified Nurse Aide (CNA) #3 said Resident #1's wheelchair had been on a cleaning schedule and said it used to be cleaned weekly in the past but said she did not think it had been cleaned weekly since the former Administration had left. CNA #3 said Resident #1 was on her assignment and she had observed his/her wheelchair had food on it. CNA #3 said she was unable to use Resident #1's wheelchair tray for his/her breakfast because the tray was filthy. CNA #3 said Resident #1's wheelchair should have been scrubbed clean before using it. During an interview on 03/36/24 at 1:26 P.M., Nurse # 2 said some resident's wheelchairs were dirtier than others depending on how they feed themselves and said Resident #1's wheelchair was a mess. During an interview on 03/26/24 at 2:25 P.M., the Housekeeping Director said that wheelchairs were supposed to be washed at least once monthly and but also more often if needed. The Housekeeping Director said that Resident #1's wheelchair was supposed to be washed more often (than once monthly) because his/her wheelchair became dirty more often (however, according to the wheelchair washing schedule it had been almost six weeks since housekeeping had washed the wheelchair). The Surveyor showed the Housekeeping Director pictures she had taken of Resident #1's wheelchair. The Housekeeping Director said Resident #1's wheelchair appeared dirty and said his/her chair usually appeared that dirty when it needed to be washed and said his/her wheelchair should have been washed. The Housekeeping Director said that because he was filling in for another staff member, wheelchair cleaning had not been consistent for several weeks. During an interview on 03/26/25 at 3:55 P.M. and on 04/04/24 at 3:59 P.M., the Director of Nursing (DON) said(after seeing the pictures of the condition of Resident #1's wheelchair shown to her by the Surveyor), that Resident #1's wheelchair should have been cleaned right away when staff observed his/her wheelchair in the condition it had been in and said staff should not have put Resident #1 into the wheelchair.

Based on observations, records reviewed and interviews, the facility failed to ensure they stored and prepared food in accordance with professional standards for food service safety, when on 1/31/24, during a tour of the kitchen, the surveyor observed food items stored or placed in unsanitary conditions, expired food items, kitchen equipment used to prepare and/or store food items that were in need of cleaning, and a kitchen sink and dishwasher not functioning properly, all of which placed residents at risk for contracting food bourne illnesses. Findings include: Review of the Facility Policy Food: Preparation as revised 2/2023 indicated the following: - All foods are prepared in accordance with the Food and Drug Administration (FDA) Food Code. - All staff will practice proper handwashing techniques and glove use. - Dining Services Staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination. - The [NAME] thaws frozen items that requires defrosting prior to preparation using one of the following methods: - Thawing in the refrigerator, in a drip-proof container, and in manner that prevents cross-contamination; - Thawing the item in a microwave oven, then transferring immediately to conventional cooking equipment; - Completely submerging the item under cold water (at a temperature of 70 degrees Fahrenheit or below) that is running fast enough to agitate and float off loose ice particles; - Cooking directly from the frozen state, when directed; On 01/31/24 at 1:30 P.M., the Surveyor, accompanied by the Food Service Director (FSD) toured the facility's kitchen and observations were as follows: - Upon entrance to the kitchen four staff members were performing various food preparation and dishwashing activities, two of the four staff members were not wearing hairnets; - The paper towel dispenser (electric wall mounted unit) was not functioning at the kitchen staff hand washing station; - The front screen to the fan of the juice machine had dust caked on it; - The three compartment sink, the third sink was not functioning properly, and would not hold water; - The chemicals being used for the three compartment sink were stored on the floor with visible spillage from the container openings, had dripped down the sides of the container and onto the kitchen floor beside the sink; - Dust had collected and was adhered to the chemical containers and along a soiled water pipe beside the sink. - Two trays of chocolate chip cookies were observed cooling and uncovered on the bottom shelves of a food rack positioned beside the three compartment sink, where the chemical were stored; - Four packages of dinner rolls were in an uncovered container, and were being used and served to resident, but were undated and stale to the touch; - English muffins were also observed in the same uncovered container, were labeled 01/13/24 and were being served to residents; - One gallon of soy sauce, unlabeled without an open date, use by date or expiration date, was also being used for food preparation; - There was a half gallon container of red wine vinegar, 3/4 empty, with an expiration date of 2/2023; - The dishwasher was in use at the time of the tour and was leaking water onto the floor; - Rubber floor mats, mop heads and a utensil tray were stored under the dishwasher rack area, on top of the dishwasher piping; - The refrigerator had a cardboard box with chicken thawing, the chicken was not in a drip proof container and chicken juices had pooled under the cardboard box and onto the refrigerator floor; - A large cardboard container of raw eggs was stuck to the refrigerator floor; During an interview on 01/31/24 at 2:05 P.M., the Food Service Director (FSD) said the following: - the paper towel dispenser has been broken for quite some time; - the chocolate chip cookies should not have been cooling near a soiled area, - the bread items (rolls) should have had a use by date indicated and in place: - the soy sauce should have had a use by date indicated and visible; - that the red wine vinegar had expired; - that the thawing chicken should have been placed on a sheet pan to prevent juices from spilling, - the egg cartons should not have been stuck to the floor of the refrigerator; - that the issue of the leaking dishwasher would be reported to maintenance. The FSD said the safety and sanitation issues found in the kitchen related to food storage and preparation were unacceptable, and not per facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to review and revise the plan of care for one Residents (#20) out of a total of 29 sampled residents. Findings include: 1. Resident #20 was admitted to the facility in May 2020 with diagnoses including traumatic subarachnoid hemorrhage, cognitive communication deficit and dysphagia. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #20 is severely cognitively impaired and requires assistance with bathing, dressing and toileting. Review of Resident #20's nurse progress notes indicated the following: 7/26/23: Resident was found to be nibbling on an ice cream cup lid and earlier this week, doing the same with his/her paper napkin. Diet slip sent to the kitchen, NO PAPER PRODUCTS on meal trays. 8/5/23: Received in report that resident has been observed eating, chewing non-food items, paper items on tray, chewing his/her sheets. Review of Resident #20's care plans failed to indicate any care plan focus, interventions or methods or means for staff to monitor Resident #20's behavior of chewing non-food items was initiated. On 8/23/23 at 11:57 A.M., the surveyor observed Certified Nurses Aid (CNA) #4 serve Resident #20 his/her lunch meal. CNA #4 placed the tray in front of Resident #20, uncovered his/her plate and beverages and left the room. CNA #4 left a napkin, the meal ticket, and salt and pepper packets on the tray. (Resident #20's meal ticket failed to indicate no paper items on his/her tray as indicated in the 7/26/23 nursing note.) The surveyor also observed a large stack of napkins on the beside table and a yellow sticky note on the Resident #20's tray table. Resident #20 began to eat his/her meal with no staff in the room supervising to ensure he/she did not ingest any non-food items on the tray. During an interview on 8/23/23 at 11:59 A.M., Nurse #5 said that he had heard from other staff that Resident #20 had been chewing on paper products but he had not observed it. During an interview on 8/23/23 at 12:01 P.M., CNA #5 said that she is Resident #20's primary CNA and that Resident #20 eats things and cannot have paper items on his/her tray. The surveyor then informed CNA #5 of the surveyors observations and CNA #5 said she had to go and remove the items from Resident #20's tray.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews the facility failed to ensure professional standards of care were followed specifically related to physician's orders for two Resident's (#15 and #22) out of a total sample of 21 residents; Findings Include: 1. Resident admitted to the facility in February 2023 with diagnoses including diastolic congestive heart failure. Review of Resident #15's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident scored a 6 out of total 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The MDS further indicated the Resident requires total dependence of one-person physical assist for personal hygiene On 8/22/23 at 8:25 A.M., the surveyor observed Resident #15 sitting in his/her room. Resident #15 did not have tubi grips/ ted stocking on his/her legs. On 8/23/23 at 8:11 A.M., the surveyor observed Resident #15 sitting in his/her room. Resident #15 did not have tubi grips/ ted stockings on his/her legs. Review of current physician order indicated the following: Apply tubi-grips or teds (Stockings specially designed to help prevent blood clots and swelling in the legs) to bilateral lower extremities every AM prior to out of bed in the morning for edema. Review of the Treatment Administration Record (TAR) for August 2023 failed to indicate refusal of ted stockings. During an interview on 8/23/23 at 8:12 A.M., Certified Nursing Assistant (CNA) #3 said Resident #15 should have tubi grips or ted stockings on to his/her legs. She further said the night nurse is the one that puts them on. During an interview on 8/23/23 at 8:22 A.M., Nurse #2 said Resident #15 should have the tubi grips or ted stockings on to his/her bilateral lower extremities per the physician's orders. Nurse #2 further said nurses should not sign on the TAR that it was completed if not done. During an interview on 8/23/23 at 9:56 A.M., the Director of Nursing said it is the expectation that nurses follow the physician's orders and that night nurse should have put them on. 2. Resident #22 was admitted to the facility in October 2017 with diagnoses including Alzheimer's disease, dysphagia, and vitamin B 12 deficiency. Review of the most recent Minimum Data Set assessment dated [DATE], indicated Resident #22 was rarely understood and cognitive skills for decision making were severely impaired. The MDS further indicated Resident #22 was at risk for pressure ulcers. Review of Resident #22's medical record indicated the following: -Physician Order dated 2/22/23, to float heels every shift while in bed for redness. -Care Plan with revision date of 6/28/23 indicated Resident #22 was at risk for pressure ulcer development. On 8/22/23 at 9:02 A.M., 12:08 P.M. and 3:03 P.M., the surveyor observed Resident #22 lying in bed with his/her heels directly on the surface of the mattress. On 8/23/23 at 7:44 A.M., and 11:13 A.M., resident sitting up in bed with socks on but his/her heels were directly on the surface of the mattress. During an interview on 8/23/23 at 11:13 A.M., Nurse #5 said the expectation to follow physicians orders and he did not follow the order to float Resident #22's heels.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #15 was admitted to the facility in February 2023 with diagnoses including Dementia, and Alzheimer's. Review of Resident #15's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident scored a 6 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. The MDS further indicated the Resident requires total dependence of one person physical assist for personal hygiene. On 8/22/23 at 7:43 A.M., Resident #15 was observed sitting in his/her room, Resident #15 had long jagged fingernails. Resident #15 said no one here trims them. On 8/22/23 at 11:59 A.M., Resident #15 was observed sitting in his/her room having lunch. Resident #15 was washed and dressed for the day. Resident #15 had long jagged fingernails. On 8/23/23 at 8:12 A.M., Resident #15 was observed sitting in his/her room dressed for the day. Resident #15 had jagged fingernails. Review of Resident #15's care plan dated 11/13/2017 indicated: I have an ADL self-care performance deficit r/t (related to) Dementia, Fatigue, Impaired balance, decreased tolerance to activity, weakness. Intervention: I need extensive assist-dependent on 1 staff member for personal hygiene dependent on my level of fatigue and motivation. During an interview on 8/23/23 at 8:15 A.M., Certified Nursing Assistant (CNA) #3 said they offer nail trimming during resident's shower days and as needed. She further said Resident #15 does not refuse care. During an interview on 8/23/23 at 8:26 A.M., Nurse #2 said Resident #15 does not refuse care and if there was any refusal the CNAs would notify the nurse. During an interview on 8/23/23 at 9:57 A.M., the Director of Nursing said the expectation is that fingernails will be trimmed by the CNAs when they are long. Based on record reviews, observations and interviews the facility failed to ensure two Residents (#26 and #15) were provided required care out of a total sample of 29 residents. Specifically; 1. For Resident #26 the facility failed to provide with supervision with meals, and 2. For Resident #15 the facility failed to provide nail care to a dependent resident. Findings include: Review of the facility policy titled Activities of Daily Living, dated 12/22, indicated A 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. 1. Resident #26 was admitted to the facility in November 2017 with diagnoses including Alzheimer's disease, dysphagia, adult failure to thrive, and anorexia. Review of Resident #26's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she scored a 7 out of a possible score of 15 on the Brief Interview for Mental Status (BIMS). Further review of the MDS indicated Resident #26 required supervision for eating. On 8/22/23 from 8:06 A.M. to 8:12 A.M., the surveyor observed Resident #26 in bed with their breakfast tray set up in front of him/her. Resident #26 was observed to be reaching for his/her plate with his/her eyes closed. No staff were present in his/her room. On 8/22/23 from 11:58 A.M. to 12:03 P.M., the surveyor observed Resident #26 in bed with their lunch tray set up in front of him/her. Resident #26 was observed to be reaching for his/her plate with his/her eyes closed. No staff were present in his/her room. On 8/23/23 from 8:07 A.M. to 8:24 A.M., the surveyor observed Resident #26 in bed with their breakfast tray set up in front of him/her. Resident #26 was observed to be sleeping through the meal. No staff were present in his/her room. Review of Resident #26's physician orders, dated 5/3/23, indicated Full assist with all meals. Review of Resident #26's Activity of Daily Living (ADL), dated 5/19/2023, indicated EATING: I am supervised to eat. Sometimes I need assistance depending on how I am feeling. Review of Resident #26's Certified Nurse Aide (CNA) ADL Flow Sheet, dated August 2023, indicated CNAs were coding, Eating: Continual Supervision/Cueing 1:8 Ratio. During an interview on 8/23/23 at 8:25 A.M., CNA #1 and CNA #2 said that Resident #26 does need assistance to supervision with meals and said that staff should be in the room with him/her during meals. During an interview on 8/23/23 at 8:26 A.M., Nurse #2 said Resident #26 does need supervision with meals and said staff normally go in once they are done with tray pass.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide audiology services for one Resident (#2) out of a total sample of 29 residents. Findings include: Resident #2 was admitted to the facility in November 2020 with diagnoses including bell's palsy, bilateral hearing loss, cognitive communication deficit, and mild cognitive impairment. Review of the Minimum Data Set Assessment (MDS), dated [DATE], indicated the Resident scored 4 out of a possible 15 on the Brief Interview for Mental Status Exam (BIMS) indicating severe cognitive impairment. The MDS also indicated Resident #2 requires extensive assistance from staff for functional daily tasks. On 8/22/23 at 8:22 A.M., Resident #2 was observed sitting on the edge of his/her bed eating breakfast unassisted. Resident #2 did not respond to questions when asked and did not acknowledge the surveyor when knocking on the door. Review of Resident #2's medical record indicated an audiology referral on 1/10/23 due to recent fall and/or imbalance. Review of the audiology visit note dated 1/31/23 indicated the following recommendation: *Could not establish hearing loss in both ears. Wax is too deep for curette removal - both ears. Wax occluding canals and removal is needed. Recommendations include slow clear speech with visual cues. Wax needs removal in the left ear. Wax needs removal in the right ear. Re-evaluate patient after wax removal. Review of Resident #2's medical record indicated an audiology visit note dated 2/27/23 with the same recommendations from the audiology visit on 1/31/23: *Could not establish hearing loss in both ears. Wax is too deep for curette removal - both ears. Wax occluding canals and removal is needed. Recommendations include slow clear speech with visual cues. Wax needs removal in the left ear. Wax needs removal in the right ear. Re-evaluate patient after wax removal. During an interview on 8/22/23 at 1:36 A.M., Certified Nursing Assistant (CNA) #3 said he/she doesn't talk and just smiles because he/she can't hear you. CNA #3 said Resident #2 has never had hearing aids in his/her room. During an interview on 8/23/23 at 8:06A.M., the Director of Nursing (DON) said she schedules audiology appointments in a book for all residents. The DON said recommendations are to be followed up on and additional appointments to be made. The DON said Resident #2 should have been seen again after the audiology recommendations for assessment.

Based on observation, record review and interview the facility failed to ensure an air mattress was on the correct setting for one Resident (#45) who had actual skin breakdown out of a total sample of 29 Residents. Findings include: Resident #45 was admitted to the facility in January 2022 with diagnoses including, adult failure to thrive, Parkinson's disease, and hemiplegia of nondominant side. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/29/23, indicated a Brief Interview for Mental Status Score of 15 out of possible 15 indicating intact cognition. Further review of the MDS indicated Resident #45 has a stage 4 pressure ulcer which is full thickness tissue loss with exposed bone, tendon or muscle. On 8/22/23 at 9:04 A.M., Resident #45 was observed lying in bed with an air mattress set to a setting of 100 (lbs.) pounds. On 8/22/23 at 3:02 P.M., Resident #45 was observed lying in bed asleep with an air mattress set to a setting of 100 lbs. On 8/23/23 at 7:50 A.M., 10:50 A.M., and 11:29 A.M., Resident #45 was observed lying in bed with an air mattress set to a setting of 100 lbs. Review of Resident #45's physician orders indicated the following: - Order date 2/15/23 indicated air mattress check for proper function/setting every shift, setting at alternating pressure 150 lbs. Review of Resident #45's Care Plan indicated the following: - Skin at risk for pressure ulcer revision date 3/21/22 indicated Resident #45 has an air mattress on bed. Review of the Nurse Practitioner (NP) progress note dated 8/9/23 indicated the following: - Follow up for stage 4 coccyx wound which requires specialty air mattress and ongoing wound care. Recommendation to continue air mattress. During an interview on 8/23/23 at 11:31 A.M., Nurse #5 said the expectation is to follow physician orders and he was unsure why the air mattress was not set to 150 lbs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure nursing provided respiratory care consistent with professional standards of practice for two Residents (#1 and #13), out of a total sample of 29 residents. Specifically, the facility failed: 1. For Resident #1 to ensure nursing changed oxygen tubing as ordered; and 2. For Resident #13, to ensure nursing provided the correct concentration of Oxygen as ordered. Findings include: 1. Resident #1 was admitted to the facility in October 2019 with diagnoses including chronic diastolic heart failure, COVID-19, dysphagia and hypertension. Review of Resident #1's most recent Minimum Data Set (MDS), dated [DATE], indicated he/she was assessed by staff to have severe cognitive impairments. The MDS further indicated he/she was dependent on staff for activities of daily living. On 8/22/23 at 7:38 A.M., the surveyor observed Resident #1 in bed with oxygen on, the oxygen tubing was not dated. Resident #1 said that no one ever comes in to change their oxygen tubing. On 8/22/23 at 11:59 A.M., the surveyor observed Resident #1 in bed with oxygen on, the oxygen tubing was not dated. On 8/23/23 at 8:22 A.M., the surveyor observed Resident #1 in bed with oxygen on, the oxygen tubing was not dated. Review of Resident #1's physician orders, dated 8/4/23, indicated change and date oxygen tubing every night shift every Sat (Saturday). During an interview on 8/23/23 at 9:22 A.M., Nurse #3 said the expectation is that oxygen tubing is changed weekly as ordered and said the tubing should be dated. 2. Resident #13 was admitted to the facility in March 2021 with diagnoses including congestive heart failure, and respiratory failure with hypoxia. Review of Resident #13's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident scored 14 out of a possible 15, on the Brief Interview for Mental Status Exam (BIMS) indicating intact cognition. The MDS also indicated Resident #13 requires extensive assistance from staff for activities of daily living. On 8/22/23 at 8:15 A.M., 8/22/23 at 1:19 P.M., 8/23/23 at 7:25 A.M. and 8/23/23 at 11:42 A.M. Resident #13 was observed in bed with humidified oxygen on via nasal cannula. The oxygen flow rate was set at 3 Liters. Review of Resident #13's clinical record included a physicians order dated 11/18/22, indicating: Oxygen 0-2 liters/min via nasal cannula to maintain sat >90% every shift. Review of Resident #13's medical record failed to indicate any behavior notes or care plan interventions that Resident #13 changes the oxygen setting him/herself. During an interview on 8/23/23 at 11:55 A.M., Nurse #2 said orders for oxygen should be followed as ordered and changed appropriately. During an interview on 8/23/23 at 8:20 A.M., the Director of Nursing (DON) said oxygen orders need to be followed and residents on oxygen have parameters that nurses are expected to follow. The DON said the resident should not be receiving 3 liters/min of oxygen if the order parameter is 0-2 liters/min.

Based on observation and interview, the facility failed to follow proper sanitation and food handling practices during meal service to prevent the risk of foodborne illness. Findings include: During the lunch service line on 8/22/23 the surveyor made the following observations in the kitchen: *At 11:27 A.M., the cook was observed touching hamburger buns and sliced cheese directly with gloved hands. The cook was then observed touching utensils with the same hands. The cook was then observed touching his glasses repeatedly with gloved hands. The cook then proceeded to touch food directly with the same gloved hands without performing hand hygiene or changing gloves. *At 11:31 A.M., the cook left the serving line to get a bowl, he then proceeded to change his gloves without washing his hands. He was then observed touching his glasses with his gloved hands and then directly touching hamburger buns and sliced cheese repeatedly with the same gloved hands. *At 11:46 A.M., the cook grabbed a metal cart and then the meal delivery cart with his gloved hands. He then proceeded to change his gloves without performing hand hygiene. He then was observed directly touching hamburger buns with the same gloved hands. During an interview on 8/23/23 at 9:23 A.M., the morning cook said the expectation is to perform hand hygiene between changing gloves. He continued to say staff should not be touching their glasses with gloved hands and then touch food directly. He said he should have changed his gloves and performed hand hygiene after touching his glasses.

Based on observation, interview, and policy review, the facility failed to ensure open medications were dated as required on two out of four sampled medication carts. Findings include: Review of the facility policy titled, Medication Storage in the Facility, dated October 2019, indicated the following: -Beyond use dating, after initially entering or opening multi-dose containers is 30 days unless otherwise specified by the manufacturer. -No expired medication will be administered to a resident. -All expired medications will be removed from the active supply and destroyed in the facility regardless of the amount remaining. On 8/23/23, at 09:41 A.M., the surveyor observed the following in the second floor Unit medication cart: -One Fluticasone Propionate Nasal Spray 50 mcg (micrograms) dated as opened on 4/30/23. No expiration date indicated. Review of the manufacturer's instruction indicated it expires two months after opening. -One Albuterol inhaler 90 mcg dated as opened 1/20/23. No expiration date indicated. Review of the manufacturer's instruction indicated that the inhaler expires two months after opening. -Two boxes Carbamide Peroxide 6.5% Ear Drops open and undated. Unable to determine expiration date. On 8/23/23, at 10:13 A.M., the surveyor observed the following in the first floor Unit medication cart: -One bottle Sodium Bicarb 5 gr. (gram) dated as opened 9/1/21. No expiration date indicated. The manufacturer's expiration date on the bottle indicates medication expired in April 2023. -One box Banophen Allergy Capsules open and undated. Manufacturer's expiration date on the box indicated it expired in January 2023 -One bottle Fiber Therapy Psyllium Husk opened and undated. The manufacturer's expiration date on the box indicated it expired in July 2023. During an interview on 8/23/23, at 11:03 A.M., Nurse #3 said medications need to be dated when opened and expired medication should be discarded. During an interview on 8/23/23 at 12:53 P.M., the Director of Nursing (DON) said medications should be dated when opened and have an expiration date listed. The DON said all expired medications should be removed from the cart and not given to patients.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident #15 was admitted to the facility in February 2023 with diagnoses including chronic diastolic congestive heart failure. Review of Resident #15's most recent Minimum Data Set (MDS) dated [DATE] indicated the Resident scored a 6 out of total 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. On 8/22/23 at 8:25 A.M., 8/22/23 at 11:59 A.M., and 8/23/23 at 8:11 A.M., the surveyor observed Resident #15 without tubi grips/ted stockings, (stockings specially designed to help prevent blood clots and swelling in the legs). Review of current physician order indicated the following: Apply tubi-grips or teds to bilateral lower extremities every AM prior to out of bed in the morning for edema. Review of the August 2023 Treatment Administration Record (TAR) indicated the nurse marked the above order as completed on 8/22/23 and 8/23/23, contradicting the surveyors observations. During an interview on 8/23/23 at 8:22 A.M., Nurse #2 said Resident #15 should have the tubi grips or ted stockings on his/her bilateral lower extremities per the physician's orders. Nurse #2 said nurses should not sign on the TAR that it was completed if not done. Based on record reviews and interviews, the facility failed to maintain accurate medical records for four Residents (#22, #45, #13 and #15) out of a total sample of 29 residents. Findings include: 1. Resident #22 was admitted to the facility in October 2017 with diagnoses including Alzheimer's disease, dysphagia, and vitamin B12 deficiency. Review of the most recent Minimum Data Set assessment dated [DATE], indicated Resident #22 was rarely understood and cognitive skills for decision making were severely impaired. The MDS further indicated Resident #22 was at risk for pressure ulcers. On 8/22/23 at 9:02 A.M., 12:08 P.M. and 3:03 P.M., the surveyor observed Resident #22 lying in bed with heels directly on the surface of the mattress. On 8/23/23 at 7:44 A.M., and 11:13 A.M., resident sitting up in bed socks on and his/her heels directly on the surface of the mattress. Review of Resident #22's medical record indicated a physician's order dated 2/22/23, to float heels every shift while in bed for redness. Review of the Treatment Administration Record (TAR) for August 2023 indicated staff had completed the treatment of floating heels while in bed on 8/22/23 day, evening, and night shift and 8/23/23 day shift, contradicting the surveyors observations. During an interview on 8/23/23 at 11:13 A.M., Nurse #5 said the expectation for documentation is for it to be accurate and said he did not complete the treatment as documented. 2. Resident # 45 was admitted to the facility in January 2022 with diagnoses including, adult failure to thrive, Parkinson's disease, and hemiplegia of nondominant side. Review of the most recent Minimum Data Set (MDS) assessment, dated 5/29/23, indicated a Brief Interview for Mental Status Score of 15 out of possible 15 indicating intact cognition. On 8/22/23 at 9:04 A.M., Resident #45 was observed lying in bed with an air mattress set to a setting of 100 (lbs.) pounds. On 8/22/23 at 3:02 P.M., Resident #45 was observed lying in bed asleep with an air mattress set to a setting of 100 lbs. On 8/23/23 at 7:50 A.M., 10:50 A.M., and 11:29 A.M., Resident #45 was observed lying in bed with an air mattress set to a setting of 100 lbs. Review of Resident #45's medical record included a physician's order dated 2/15/23 indicating: air mattress check for proper function/setting every shift, setting at alternating pressure 150 lbs. Review of the Treatment Administration Record (TAR) for August 2023 indicated on 8/22/23 day, evening and night shift Air Mattress was checked for proper function and setting at 150 lbs. TAR also indicated on 8/23/23 the air mattress was checked during the day for correct settings, contradicting the surveyors observations. During interviews on 8/23/23 at 11:13 A.M. and 11:31 A.M., Nurse #5 said nursing documentation should be accurate. 3. Resident #13 was admitted to the facility in March 2021 with diagnoses including congestive heart failure, and respiratory failure with hypoxia. Review of Resident #13's most recent Minimum Data Set (MDS), dated [DATE], indicated the Resident scored 14 out of a possible 15, on the Brief Interview for Mental Status Exam(BIMS) indicating intact cognition. The MDS also indicated Resident #13 requires extensive assistance from staff for activities of daily living. On 8/22/23 at 8:15 A.M., 8/22/23 at 1:19 P.M., 8/23/23 at 7:25 A.M. and 8/23/23 at 11:42 A.M. Resident #13 was observed in bed with humidified oxygen on via nasal cannula. The oxygen flow rate was set at 3 Liters. Review of Resident #13's physician orders, dated 11/18/22, indicated: Oxygen 0-2 liters/min via nasal cannula to maintain sat >90% every shift. Review of the August 2023 Treatment Administration Record (TAR) indicated the nurse marked the above order as completed on 8/22/23 and 8/23/23, contradicting the surveyors observations. During an interview on 8/23/23 at 11:55 A.M., Nurse #2 said the Residents order for oxygen should have been followed and checked for correct settings. During an interview on 8/23/23 at 8:08 A.M., the Director of Nursing (DON) said oxygen orders need to be followed and nurses should not document incorrect settings.

Based on observation, record review and interview the facility failed to implement practices for the prevention of potential infection on 2 out of 2 resident units. Specifically, nursing staff failed to 1. perform adequate hand hygiene during a dressing change, 2. failed to perform hand hygiene and disinfect equipment used for multiple residents during the medication pass. Findings include: Review of the facility policy titled, Hand Hygiene effective date 3/8/20 included the following: -Alcohol based hand sanitizers are the most effective product for reducing the number of germs on the hands and is the preferred method of cleaning the hands in most clinical situations. Soap and water is appropriate for use whenever hands are visibly dirty, before eating and after using the restroom. Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, before touching patient or the patient environment. -Perform hand hygiene immediately after removing gloves. Use alcohol-based hand rub: -After touching a patient or the patients immediate environment -After contact with blood, body fluids or contaminated surfaces -Immediately after glove removal 1. On 8/23/23 at 10:45 A.M., the surveyor observed a dressing change on the second floor unit. Nurse #5 performed hand hygiene prior to donning gloves and setting up supplies. At 10:52 A.M., Nurse #5 closed the residents privacy curtain with gloved hands, doffed one glove and put on a new glove without performing hand hygiene. Nurse #5 removed the soiled dressing, doffed both gloves and donned clean gloves without performing hand hygiene. At 10:55 A.M. Nurse #5 cleansed the wound, doffed a pair of gloves, and failed to perform hand hygiene before donning a clean pair of gloves. Nurse #5 then dried the wound bed with gauze and doffed gloves and donned a clean pair without performing hand hygiene. At 10:56 A.M., Nurse #5 packed the residents wound, doffed the pair of gloves and donned a pair of clean gloves without performing hand hygiene. During an interview on 8/23/23 at 11:08 A.M., Nurse #5 said the expectation was to wash hands before and after glove use. 2. On 8/23/23 at 7:35 A.M., Nurse #2 was observed preparing medication for administration, Nurse #2 was observed using her bare finger to place the medication in the medication cup. During an interview on 8/23/23 at 8:20 A.M., Nurse #2 said should have not touched the medication with her bare hand. On 8/23/23 at 7:40 A.M., Nurse #2 was observed entering a resident's room to check his/her blood sugar. Nurse #2 was then observed wiping down the glucometer (machine used for checking blood sugar levels) with an alcohol wipe. (Alcohol is not an approved disinfectant for healthcare settings.) During an interview on 8/22/23 at 8:22 A.M., Nurse #2 said she uses alcohol wipes to disinfect the glucometer and did not know she was supposed to use any other wipe. On 8/23/23 at 8:14 A.M., Nurse #2 was observed donning Personal Protective Equipment (PPE), walking into a resident's room who is on contact precautions. Nurse #2 was observed checking the resident's blood pressure and oxygen saturation, with equipment removed from her pocket, located under her (PPE). Nurse #2 then used her gloved hand and placed the blood pressure cuff and pulse oximeter into her pocket. Nurse #2 then removed her PPE and exited the resident's room. Nurse #2 then removed the blood pressure cuff and pulse oximeter from her pocket with her bare hands and placed them on her med cart. Nurse #2 then used the same blood pressure cuff and pulse oximeter on a second resident without disinfecting the equipment. During an interview on 8/23/23 at 8:21 A.M., Nurse #2 said she should disinfect the blood pressure cuff and pulse oximeter between each resident use. On 8/23/23 at 9:44 A.M., Nurse #6 was observed checking a resident's blood pressure and pulse saturation and returned the blood pressure cuff and pulse oximeter to the nurse's station without disinfecting it. Nurse #6 was observed using the same equipment for another resident without disinfecting the equipment between the two patients. During an interview on 8/23/23 at 9:50 A.M., Nurse #6 said the facility no longer uses rolling vital sign machines and that she should have disinfected the equipment prior to using it on another resident. During an interview on 8/23/23 at 12:28 P.M., the Director of Nursing (DON) said nurses are to use disinfectant wipes with purple covers (sani-cloth) to disinfect shared medical equipment. The DON said alcohol wipes should not be used to disinfect shared medical equipment. The DON said nurses should not be placing equipment in pockets or touching contaminated equipment with their bare hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, the facility failed to ensure the building had a home-like environment. Examples included, gouged walls and floors, broken tile, cracked overhead light fixture and the use of a resident siting room for equipment storage. Findings include: During observations made throughout the days of 8/2/2022, 8/3/2022 and 8/4/2022, it was determined: First floor: * room [ROOM NUMBER]- ceiling above head of bed approximately 4 feet (ft) long cracked line. * room [ROOM NUMBER]- shared bathroom ceiling above toilet cracked bubbling plaster approximately 3 ft long and 3 inches wide. * room [ROOM NUMBER]- ceiling appears to have a water stain approximately 3 ft circle shape. * room [ROOM NUMBER]- scuffed paint near the entry to the door on the right wall approximately 1.5 ft by 0.5 ft. * room [ROOM NUMBER]- floor tile gouged, measuring approximately 5 ft long by one inch wide by 1/2 inch deep. * room [ROOM NUMBER]- scuffed paint above the baseboard heater approximately 5 ft long by 2 inches - scuffed paint behind door on left side of wall approximately 1 ft. long rectangular in shape. * Bathroom door in small sitting area/dayroom- paint chipped around the bottom outer edges approximately 2 ft. * Baseboard heater end cover missing on right side outside of room [ROOM NUMBER] in front of exit door. * Exit door next to first floor elevator- scuffed paint around bottom outer edges of the door approximately 2 ft long and left side of door frame approximately 3 ft long. Second floor: * room [ROOM NUMBER]- Ceiling light cover was cracked in 4 areas and held together with tape. * room [ROOM NUMBER]- Wall next to bed A was marked with screw or nail holes and had chipped paint; ceiling light cover was cracked and held together with tape. * room [ROOM NUMBER]- Wall next to bed A was gouged and had chipped paint; entry door frame paint was chipped and dirty; the sliding closet doors were off the track; bathroom wall tile was chipped and the towel bar was broken. * room [ROOM NUMBER]- Closet door finish peeled off in approximately 50 spots; walls have multiple chipped and gouged areas which are spackled and primed but not painted. * room [ROOM NUMBER]- Varnish on the two closet doors had peeled off. * Hallway outside room [ROOM NUMBER]- Ceiling light missing its cover and the fluorescent lights are exposed. * Sitting area next to room [ROOM NUMBER]- Area is cluttered with two mechanical lifts, a recliner chair, and a utility cart. * room [ROOM NUMBER]- Varnish on the closet doors had peeled. * room [ROOM NUMBER]- Varnish on the closet doors had peeled; wall light fixture at the head of bed B was missing a cover, exposing the fluorescent light bulbs. * room [ROOM NUMBER]- Walls are dirty and have chipped paint, holes in wall are filled in and primed but not painted.