**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and observation, the facility failed to ensure one Resident (#175) was able to dine in a dignified manner. Findings include: Review of the facility policy Dignity dated as revised February 2021, indicated, but was not limited to: - Provided with a dignified dining experience. Resident #175 was admitted to the facility in January 2025 and had active diagnoses which included chronic kidney disease, heart disease, muscle wasting and atrophy, difficulty walking, lack of coordination and dysphagia. As of the date of survey, a Minimum Data Set assessment had not yet been completed for Resident #175, including a Brief Interview for Mental Status exam. Resident #175's Activity of Daily Living care plan dated 1/17/25, indicated he/she required staff assistance with setup or clean-up assistance. Resident #175's admission Functional Abilities and Goals assessment dated [DATE], indicated he/she required setup or clean-up assistance with meals. On 1/21/25 at 8:00 A.M., the surveyor observed a staff person enter Resident #175's room and place his/her meal tray, which contained pancakes, juice and coffee, on the over bed table. The staff person offered to open the lids covering the food, and Resident #175 was agreeable. The staff person removed the lid from a juice cup, then left the bedroom. Resident #175 then picked up a creamer with his/her right hand and opened the lid with his/her teeth. Resident #175 then picked up a pancake with both hands, brought it to his/her mouth, and took bites from it. Resident #175 said she does not have the use of two of his/her fingers on the left hand and so was unable to open lids or cut up his/her food. Resident #175 said today was the first day since admission to the facility that a staff person was nice and offered to open the lids, and that no one has offered to cut up his/her food. Resident #175 said staff have until now just dropped the meal trays off on his/her table and left without offering any assistance. Resident #175 said she has not asked staff for help because he/she was unsure if this was a service provided. During an interview on 1/22/25 at 12:22 P.M., Unit Manager #2 said staff are supposed to offer to cut up Resident #175's meals. Unit Manager #2 said there is a new meal distribution system in place involving more staff but unfortunately some staff are still learning about individual resident's assistance needs. During an interview with Resident #175 on 1/22/25 at 12:24 P.M., he/she said a staff person cut up his/her lunch meal and that this was the first time this had happened since admission.

Based on record review, interview and observation, the facility failed to follow physician's orders for two Residents (#175 and #68) of 24 sampled residents. Specifically: 1. For Resident #175, the facility failed to change a soiled wound dressing for three days. 2. For Resident #68, the facility failed to change oxygen tubing for approximately three weeks because staff did not obtain a physician's treatment order for the procedure. Findings include: Review of the facility policy titled Dressing, Dry/Clean dated as revised September 2013, indicated, but was not limited to: - Review the physician's order. - Label tape or dressing with date, time and initials. - Document the wound appearance, including wound bed, edges, presence of drainage. - How the resident tolerated the wound change procedure. 1. Resident #175 was admitted to the facility in January 2025 and had active diagnoses which included chronic kidney disease, muscle wasting and atrophy, difficulty walking, and lack of coordination. As of the date of survey, a Minimum Data Set assessment had not yet been completed for Resident #175. Review of Resident #175's physician orders dated 1/19/25, indicated: - Ulcer in left great toe - wash with normal saline apply dry protective dressing daily, every day shift. Review of Resident #175's Treatment Administration Record (TAR) on 1/21/25 indicated staff changed the toe dressing on 1/19/25, 1/20/25 and 1/21/25. Review of Resident #175's care plan dated 1/20/25, indicated he/she had an ulcer on the left great toe and was at-risk for pain. The care plan did not reference dressing changes, or other interventions to address the wound. Review of Resident #175's nursing progress note dated 1/19/25, indicated: - No new changes noted to skin integrity. Resident has treatable wounds present. Dressing(s) changed as per treatment orders. No notable changes to wound(s) observed. Review of the Physician's progress note dated 1/20/25, indicated lesion of the left toe - dressing in place with mild serosanguinous drainage. Review of Resident #175's nursing progress notes dated 1/20/25 and 1/21/25, indicated there was no reference to the ulcer on the Resident's toe, an assessment of the wound, as required by facility policy. The notes did not indicate the Resident was offered or declined a dressing change on these days. On 1/21/25 at 8:50 A.M., the surveyor observed Resident #175's left great toe dressing. The dressing was dated 1/19/25. There was no staff initial on the dressing. The dressing had areas of black color from what appeared to be dirt. During an interview with Resident #175 on 1/21/25 at 8:50 A.M., he/she said he/she fell at home and injured his/her toe. The Resident said a nurse at the facility dressed the wound a few days ago, but staff seemed to have forgotten about the wound. On 1/22/25 at approximately 7:10 A.M., the surveyor observed Resident #175 lying in bed. The Resident had the same dressing covering the toe ulcer, dated 1/19/25. On 1/23/25 at approximately 9:25 A.M., the surveyor observed the Wound Physician had removed the toe dressing and was examining the wound. During an interview with Nurse #1 on 1/23/25 at 9:30 A.M., the surveyor informed her that the surveyor observed Resident #175's left great toe dressing on 1/21/25 and 1/22/25, dated 1/19/25. The surveyor said the physician's order required that it be changed daily but no dressing changes had occurred over the past three days. Nurse #1 said she thought the dressing was to be changed as needed. The surveyor told Nurse #1 that she and another nurse documented in the TAR they had changed the dressing on 1/20/25 and 1/21/25, but that this was not possible because the dressing was dated 1/19/25. Nurse #1 said she did not understand how this error occurred. During an interview with the Director of Nursing (DON) on 1/23/25 at approximately 10:00 A.M., the surveyor informed her of the observation of Resident #175's dressing on 1/21/25 and 1/22/25, yet the dressing was dated 1/19/25 and the TAR indicated dressing changes occurred on 1/20/25 and 1/21/25. The DON said it was nursing staff's responsibility to follow the physician's treatment orders, the facility's wound dressing policy and to document accurately in the clinical record. 2. For Resident #68, the facility failed to change oxygen tubing for approximately three weeks. Resident #68 was admitted to the facility in January 2025 and has active diagnoses which include chronic obstructive pulmonary disorder (COPD), emphysema and chronic respiratory failure with hypoxia. Review of Resident #68's Minimum Data Set assessment indicated he/she was cognitively intact and required the use of continuous oxygen to help with breathing. Review of Resident #68's physician order dated 1/4/25, indicated: - Oxygen 3 liters per minute via nasal cannula, continuous, every shift for COPD. The physician's orders did not include a schedule for changing the oxygen tubing. Review of Resident #68's Treatment Administration Record dated through 1/21/25 failed to indicate the Resident's oxygen tubing had been changed since his/her admission to the facility. Review of Resident #68's progress notes did not reference changing his/her oxygen tubing On 1/21/25 at 10:25 A.M., the surveyor observed Resident #68 lying in bed with a nasal cannula under his/her nose. The oxygen concentrator ran at 3 liters per minute. The surveyor observed the tubing was undated and disconnected from the concentrator. The surveyor left the room and informed Nurse #2 that the tubing was undated and disconnected from the concentrator, resulting in the Resident not receiving concentrated oxygen. Nurse #2 then replaced the tubing and attached it to the concentrator. During an interview with Nurse #2 on 1/21/25 at approximately 11:30 A.M., she said she thought oxygen tubing was changed as needed and not weekly. Nurse #2 said there was no recorded date of if, or when, the tubing was last changed. Following the surveyor's conversation with Nurse #2, a new physician's order was entered into Resident #68's clinical record, dated 1/21/25, at 4:45 P.M. (approximately three weeks after the start of oxygen use): - Oxygen Equipment Maintenance every night shift every Sunday, During an interview with the DON on 1/23/25 at 10:00 A.M., she said it was the standard of practice and facility policy to obtain a physician's order for weekly oxygen tubing changes and to document these changes on the TAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and observation, the facility failed to ensure it provided one Resident (#175) with the assistance required for meal setup. Findings include: Resident #175 was admitted to the facility in January 2025 and had active diagnoses which included chronic kidney disease, heart disease, muscle wasting and atrophy, difficulty walking, lack of coordination and dysphagia. As of the date of survey, a Minimum Data Set assessment had not yet been completed for Resident #175, including a Brief Interview for Mental Status exam. Resident #175's Activity of Daily Living care plan dated 1/17/25, indicated he/she required staff assistance with setup or clean-up assistance. Resident #175's admission Functional Abilities and Goals assessment dated [DATE], indicated he/she required setup or clean-up assistance with meals. Review of Resident #175's Activities of Daily Living care plan dated 1/21/25, indicated he/she has a self-care performance deficit related to activity Intolerance, deconditioning, disease process and spinal stenosis. Interventions included: Required setup and clean-up assistance. On 1/21/25 at 8:00 A.M., the surveyor observed a staff person enter Resident #175's room and place his/her meal tray, which contained pancakes, juice and coffee, on the over bed table. The staff person offered to open the lids covering the food, and Resident #175 was agreeable. The staff person removed the lid from a juice cup, then left the bedroom. Resident #175 then picked up a creamer with his/her right hand and opened the lid with his/her teeth. Resident #175 then picked up a pancake with both hands, brought it to his/her mouth, and took bites from it. Resident #175 said she does not have the use of two of his/her fingers on the left hand and so is unable to open lids or cut up his/her food. Resident #175 said today was the first day since admission to the facility that a staff person was nice and offered to open the lids, and that no one had offered to cut up his/her food. Resident #175 said staff have until now just dropped off the meal trays on his/her table and left without offering any assistance. Resident #175 said she had not asked staff for help because he/she was unsure if this was a service provided. During an interview with Unit Manager #2 on 1/22/25 at 12:22 P.M., she said staff are supposed to offer to cut up Resident #175's meals. Unit Manager #2 said there is a new meal distribution system in place involving more staff but that unfortunately some staff are still learning about individual resident's assistance needs. During an interview with Resident #175 on 1/22/25 at 12:24 P.M., he/she said a staff person cut up his/her lunch meal and that this was the first time this had happened since admission.

Based on record review and interview, the facility failed for one Resident (#175) to communicate with the Dialysis Center nurse regarding Resident #175's care, document his/her condition after dialysis treatment, and notify the practitioner of fistula bleeds out of a total sample of 24 residents. Findings include: Review of the facility's policy Hemodialysis Catheters - Access Care of dated as revised February 2023, indicated: - Mild bleeding from the site (post-dialysis) can be expected. Apply pressure to insertion site and contact dialysis center for instructions. - The nurse should document in the resident's medical record every shift as follows: 1. Location of the catheter. 2. Condition of the dressing (interventions if needed). 3. If dialysis was done during shift. 4. Any part of the report from dialysis nurse post-dialysis being given. 5. Observations post-dialysis. Resident #175 was admitted to the facility in January 2025 and had active diagnoses which included dependence on renal dialysis, arteriovenous fistula, chronic kidney disease, muscle wasting and atrophy, and lack of coordination. As of the date of survey, a Minimum Data Set assessment had not yet been completed for Resident #175. Review of Resident #175's physician orders, dated 1/20/25, indicated: - Resident to have dialysis on: Tuesday, Thursday, Saturday. - Right arm with hematoma bleeding - change daily and prn (as needed) until stop bleeding. - Monitor access site for bleeding, redness, tenderness and/or swelling every shift for monitoring. Notify Practitioner of abnormal findings as indicated. If bleeding noted, apply pressure and notify the Practitioner. Review of Resident #175's care plan dated 1/20/25, indicated he/she needs dialysis related to renal failure. Interventions included: - Monitor/document/report PRN for signs and symptoms of bleeding, hemorrhage, bacteremia, or septic shock. Review of Resident #175's nursing progress notes dated 1/19/25, 1/20/25 and 1/21/25 indicated there was no reference to the location of the catheter or condition of the dressing (interventions if needed), as required by facility policy. Review of Resident #175's Treatment Administration Record (TAR) dated 1/19/25, 1/20/25 and 1/21/25, indicated on these days the Resident's fistula site bled, and staff changed the dressing. Review of Resident #175's progress note dated 1/19/25 and 1/20/25 and 1/21/25, indicated there was no reference to staff informing the Practitioner that the Resident's fistula site was bleeding, as required by the order. Resident #175's nursing progress notes dated 1/21/25 indicated he/she went to the Dialysis Center for treatment. After returning to the facility, the nursing progress notes did not document (as required by facility policy): - Location of the catheter. - Condition of the dressing. - Any report from the dialysis nurse post-dialysis. - Observations post-dialysis. Review of Resident #175's Dialysis Center Communication Book on 1/23/25, indicated it consisted of blank communication forms. There was no reference to the Resident's visit to the Dialysis Center on 1/21/25. There was no report from the dialysis nurse post-dialysis, observations post-dialysis, the location of the catheter, or condition of the fistula dressing. On 1/21/25, 1/22/25 and 1/23/25, the surveyor observed Resident #175's covered fistula, located on the right arm. On each of these days, the fistula was covered with a 4 x 4 dry sterile dressing. The dressings were undated and not initialed by staff. During an interview with Resident #175 on 1/21/25 at 8:50 A.M., he/she said the fistula site often bleeds following dialysis. A 4 x 4 dry sterile dressing covered the fistula, and it was undated and not initialed by staff. On 1/22/25 and 1/23/25, during the morning, the surveyor observed a 4 x 4 dry sterile dressing covering Resident #175's fistula, and it was undated and not initialed by staff. During an interview with Nurse #1 on 1/23/25 at 9:30 A.M., she said she had changed Resident #175's fistula dressing on 1/21/25 because of bleeding after his/her return from the Dialysis Center on 1/21/25. Nurse #1 said she did not recall if she notified the Practitioner that the site had been bleeding or that she applied a dressing. Nurse #1 said she did not know if the Dialysis Center had communicated with the facility regarding the Resident's status post-dialysis visit on 1/21/25. During an interview with Unit Manager #2 on 1/23/25 at 9:32 A.M., she reviewed Resident #175's Dialysis Center Communication Book and determined the book did not contain any information about the Resident's visit to the Center on 1/21/25. Unit Manager #2 said that the book did not contain communication from the Center it was nursing staff's responsibility to call the Center to obtain the required information. During an interview with the Director of Nursing (DON) on 1/23/25 at approximately 10:00 A.M., she said it was nursing staff's responsibility to obtain the required information from the Dialysis Center, per facility policy, and follow the physician's treatment orders.

3. Resident #175 was admitted to the facility in January 2025 and had active diagnoses which included chronic kidney disease, muscle wasting and atrophy, difficulty walking, and lack of coordination. As of the date of survey, a Minimum Data Set assessment had not yet been completed for Resident #175, including a Brief Interview for Mental Status exam. Review of Resident #175's physician orders dated 1/19/25, indicated: - Ulcer in left great toe - wash with normal saline apply dry protective dressing daily, every day shift. Review of Resident #175's nursing progress note dated 1/19/25, indicated: - No new changes noted to skin integrity. Resident has treatable wounds present. Dressing(s) changed as per treatment orders. No notable changes to wound(s) observed. Review of Resident #175's care plan dated 1/20/25, indicated he/she had an ulcer on the left great toe and was at-risk for pain. The care plan did not reference dressing changes, or other interventions to address the wound. Review of the Physician's progress note dated 1/20/25, indicated lesion of the left toe - dressing in place with mild serosanguinous drainage. Review of Resident #175's nursing progress notes dated 1/20/25 and 1/21/25, indicated there was no reference to the ulcer on the Resident's toe. The notes did not indicate the Resident was offered a dressing change on these days. Review of Resident #175's Treatment Administration Record (TAR) on 1/21/25, indicated nursing changed the toe dressing on 1/19/25, 1/20/25 and 1/21/25. On 1/21/25 at 8:50 A.M., the surveyor observed Resident #175's left great toe dressing. The dressing was dated 1/19/25. There was no staff initial on the dressing. The dressing had areas of black color from what appeared to be dirt. During an interview with Resident #175 on 1/21/25 at 8:50 A.M., he/she said he/she fell at home and injured his/her toe. The Resident said a nurse at the facility dressed the wound a few days ago, but staff seemed to have forgotten about the wound. On 1/22/25 at approximately 7:10 A.M., the surveyor observed Resident #175 lying in bed. The Resident had the same dressing covering the toe ulcer, dated 1/19/25. On 1/23/25 at approximately 9:25 A.M., the surveyor observed the Wound Physician had removed the toe dressing and was examining the wound. During an interview with Nurse #1 on 1/23/25 at 9:30 A.M., the surveyor informed her that the surveyor observed Resident #175's left great toe dressing on 1/21/25 and 1/22/25 and it was dated 1/19/25. The surveyor said the physician's order required that it be changed daily but it appeared no dressing changes had occurred over the past three days. Nurse #1 said she thought the dressing was to be changed as needed. The surveyor told Nurse #1 that she and another nurse documented in the TAR they had changed the dressing on 1/20/25 and 1/21/25, but that this was not possible because the dressing was dated 1/19/25. Nurse #1 said she did not understand how this error occurred. During an interview with the Director of Nursing (DON) on 1/23/25 at approximately 10:00 A.M., the surveyor informed her of the observation of Resident #175's dressing on 1/21/25 and 1/22/25, yet the dressing was dated 1/19/25 and the TAR indicated dressing changes occurred on 1/20/25 and 1/21/25. The DON said it was nursing staff's responsibility to accurately document in the clinical record. Based on observation, record review, and interview, the facility failed to maintain an accurate medical record for three Residents (#91, #13 and #175), out of a total sample of 24 residents. Specifically: 1 For Resident #91, the nurses documented in the Treatment Administration Record (TAR) the Resident was wearing his/her right hand splint and arm wedge, when he/she was not; 2. For Resident #13, the nurses documented in the TAR the Resident was wearing his/her right hand roll, when he/she was not; 3. For Resident #175, nursing staff documented they changed a dressing when they did not. Findings Include: Review of the facility policy titled Charting and Documentation, dated July 2022, indicated the following: Policy Statement: - All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between interdisciplinary team regarding the resident's condition and the response to care. Policy Interpretation and Implementation: - Documentation in the medical record will be objective (not opinionated or speculative), complete and accurate. - Documentation of procedures and treatments will include care-specific details, including: a. the date and time the procedure/treatment was provided. e. whether the resident refused the procedure/treatment. 1. Resident #91 was admitted to the facility in August 2023 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, right wrist contracture, right hand contracture, right shoulder contracture, and right elbow contracture. Review of Resident #91's most recent Minimum Data Set (MDS) assessment, dated 11/21/24, indicated Resident #91 had a Brief Interview for Mental Status (BIMS) exam score of 8 out of a possible 15, indicating moderate cognitive impairment. The MDS further indicated Resident #91 substantial/maximal to dependent assistance with functional daily activities and upper extremity range of motion (ROM) impairment on one side. On 1/21/25 at 8:15 A.M., the surveyor observed Resident #91 laying in his/her bed. Resident #91 was not wearing his/her right-hand splint or right upper extremity wedge. On 1/21/25 at 12:33 P.M., the surveyor observed Resident #91 laying in his/her bed. Resident #91 was not wearing his/her right-hand splint or right upper extremity wedge. Resident #91's hand splint was observed resting on the nightstand and right arm wedge was not visible in the room. On 1/21/25 at 4:32 P.M., the surveyor observed Resident #91 laying in his/her bed. Resident #91 was not wearing his/her right-hand splint or right upper extremity wedge. Resident #91's hand splint was observed resting on the nightstand and right arm wedge was not visible in the room On 1/22/25 at 6:55 A.M., the surveyor observed Resident #91 laying in his/her bed. Resident #91 was not wearing his/her right-hand splint or right upper extremity wedge. Resident #91's hand splint was observed resting on the nightstand and right arm wedge was not visible in the room On 1/22/25 at 7:59 A.M., the surveyor observed Resident #91 laying in his/her bed. Resident #91 was not wearing his/her right-hand splint or right upper extremity wedge. Resident #91's hand splint was observed resting on the nightstand and right arm wedge was not visible in the room. On 1/22/25 at 10:16 A.M., the surveyor observed Resident #91 laying in his/her bed. Resident #91 was not wearing his/her right-hand splint or right upper extremity wedge. Resident #91's hand splint was observed resting on the nightstand and right arm wedge was not visible in the room. On 1/22/25 at 12:39 P.M., the surveyor observed Resident #91 laying in his/her bed. Resident #91 was not wearing his/her right-hand splint or right upper extremity wedge. Resident #91's hand splint was observed resting on the nightstand and right arm wedge was not visible in the room. On 1/23/25 at 6:47 A.M., the surveyor observed Resident #91 laying in his/her bed. Resident #91 was not wearing his/her right-hand splint or right upper extremity wedge. Resident #91's hand splint was observed resting on the nightstand and right arm wedge was not visible in the room. Review of Resident #91's physician order indicated the following order initiated on 11/26/24: - Right flex hand splint to be worn up to 4-6 hrs (hours), daily, as tolerated. Put on in morning, take off in evening. Regular skin checks for any redness, irritation, indication of pain., every day shift. - Right 90-degree elbow wedge cushion to be worn up to 4-6 hrs, nightly, as tolerated. Regular skin checks for any redness, irritation, indication of pain. every evening shift Review of Resident #91's Physical Mobility care plan interventions indicated the following: - Maintain usage of wrist/elbow braces to prevent contractures, date initiated, 11/25/2024. Review of the January 2025 TAR indicated that nursing documented on January 21st and January 22nd, 2025, that Resident #91 was wearing his/her right hand splint and arm wedge, contrary to direct observation that he/she was not. Review of Resident #91's medical record failed to indicate he/she refused to wear his/her right hand splint or arm wedge. During an interview on 1/23/25 at 8:54 A.M., Unit Manager #1 said the nurses should be following physician's orders and should not document in the TAR if a task has not been performed. During an interview on 1/23/25 at 9:07 A.M., the Director of Nursing said she expects the splint and wedge to be worn as ordered by the physician, accurately documented in the medical record, and indicate if the resident refuses. 4. Resident #13 was admitted to the facility in November 2022 with diagnoses including quadriplegia, C5-C7 central cord syndrome and right-hand contracture. Review of Resident #13's most recent Minimum Data Set (MDS) assessment, dated 1/9/25, indicated Resident #13 had a Brief Interview for Mental Status (BIMS) exam score of 9 out of a possible 15, indicating moderate cognitive impairment. The MDS further indicated Resident #13 is dependent with functional daily activities and upper extremity range of motion (ROM) impairments on both sides. On 1/21/25 at 7:50 A.M., the surveyor observed Resident #13 seated in his/her wheelchair. Resident #13 was not wearing his/her right-hand roll. On 1/22/25 at 8:00 A.M., the surveyor observed Resident #13 seated in his/her wheelchair. Resident #13 was not wearing his/her right-hand roll. On 1/2/25 at 10:16 A.M., the surveyor observed Resident #13 seated in his/her wheelchair. Resident #13 was not wearing his/her right-hand roll. On 1/22/25 at 12:14 P.M., the surveyor observed Resident #13 laying in his/her recliner chair. Resident #13 was not wearing his/her right-hand roll. On 1/23/25 at 8:31 A.M., the surveyor observed Resident #13 seated in his/her wheelchair. Resident #13 was not wearing his/her right-hand roll. Review of Resident #13's physician order indicated the following order initiated on 8/12/24: - Right hand roll to be worn up to 6-8 hrs (hours), daily, as tolerated. Put on in morning, take off in evening. Regular skin checks for any redness, irritation, indication of pain. Review of Resident #13's Skin Integrity care plan interventions indicated the following: - The resident needs assistance to apply hand roll, date initiated, 8/12/2024. Review of the January 2025 TAR indicated that nursing documented on January 21st and January 22nd, 2025, that Resident #13 was wearing his/her right hand roll, contrary to direct observation that he/she was not. Review of Resident #13's medical record failed to indicate he/she refused to wear his/her right hand roll. During an interview on 1/23/25 at 8:54 A.M., Unit Manager #1 said the nurses should be following physician's orders and should not document in the TAR if a task has not been performed. During an interview on 1/23/25 at 9:07 A.M., the Director of Nursing said she expects the hand roll to be worn as ordered by the physician, accurately documented in the medical record, and indicate if the resident refuses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to ensure a home-like environment on the A Unit. Findings include: On 1/21/25 at approximately 8:30 A.M., the surveyor observed a sample of bedrooms located on the A Unit. - room [ROOM NUMBER]: bed D, bed frame side rail has approximately 12 inches of chipped enamel. - room [ROOM NUMBER]: window shade is missing its draw chain, unable to raise or lower the blind. - room [ROOM NUMBER]: unpainted, unsanded plaster on bedroom wall next to bathroom measuring approximately 13 x 6. - room [ROOM NUMBER]: window shade is missing its draw chain, unable to raise or lower the blind. - room [ROOM NUMBER]: wired wall receptacle for television control is dangling from the wall, wires and wall cavity exposed. Review of the Maintenance Log on 1/23/25 indicated the above items in need of repair were not documented. During an interview with the Consulting Maintenance Director on 1/23/25 at 1:30 P.M., he said the blinds, unpainted wall plaster, chipped bed frame paint, and loose television control were not documented in the log book.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and interviews, the facility failed to ensure resident centered care plans were developed and/or implemented for three Residents (#12, #91 and #13) out of a total sample of 24 residents. Specifically, 1. For Resident #12, the facility failed to a. develop a comprehensive resident centered care plan for a pacemaker and b. failed to implement the Resident's fall intervention of non skid strips on the floor next to his/her bed. 2. For Resident #91, the facility failed to implement a right hand splint and arm wedge as per the plan of care. 3. For Resident #13, the facility failed to implement a right hand roll as per the plan of care. Findings include: Review of the facility policy titled Comprehensive Person-Centered Care Plans, dated March 2022, indicated The interdisciplinary team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Review of the facility policy titled Care of a Resident with Pacemaker, dated December 2015, indicated The purpose of this procedure is to provide information about and guidance for the care of a resident with a pacemaker. The pacemaker battery will be monitored remotely through the telephone or an internet connection. The resident's cardiologist will provide instructions on how and when to do this. For each resident with a pacemaker, document the following in the medical record: a. The name, address and telephone number of the cardiologist; g. paced rate. When the resident's pacemaker is monitored by the physician, document the date and results of the pacemaker surveillance, including: a. [NAME] the resident's pacemaker was monitored (phone, office, internet); b. Type of heart rhythm; c. Functioning of the leads; d. Frequency of utilization; and e. Battery life. 1a. Resident #12 was admitted to the facility in July 2023 with diagnoses that included dementia, presence of a cardiac pacemaker, adult failure to thrive, and cognitive communication deficit. Review of Resident #12's most recent Minimum Data Set (MDS) assessment, dated 12/5/24, indicated he/she scored a 6 out of a possible 15 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairments. Review of Resident #12's physician order, dated 9/18/23, indicated Pacemaker check as ordered. Review of Resident #12's pacemaker care plan dated 9/13/23, indicated Pacemaker checks as ordered. The resident's Pacemaker information: was left blank. During an interview on 1/22/25 12:22 P.M., Unit Manager #1 said there should be a comprehensive pacemaker care plan in place so the nurses know how to monitor the pacemaker. Unit Manager #1 said she is not sure how the Residents' pacemaker is being monitored because there is not a monitoring device in his/her room. The Unit Manager said the Resident has not been followed by cardiology. During an interview on 1/22/25 at 12:58 P.M., the Director of Nurses (DON) said she expect a Resident who has a pacemaker to have a complete and comprehensive care plan in place with the paced rate and how the pacemaker is to be monitored. 1b. On 1/21/25 at 12:33 P.M., the surveyor observed Resident #12 in bed, non skid strips were not in place on the floor next to bed. On 1/22/25 at 8:00 A.M. and 12:13 P.M., the surveyor observed Resident #12 in bed, non skid strips were not in place on the floor next to bed. Review of Resident #12's fall care plan, dated 9/30/24, indicated non skid strips to floor- Next to bed. Review of Resident #12's active Certified Nurse Aide (CNA) Kardex (from indicating the Resident needs to staff), dated 1/21/25, indicated non skid strips to floor- Next to bed. During an interview on 1/22/25 at 12:15 P.M., Certified Nurse Aide (CNA) #1 said she has taken care of the Resident multiple times and he/she is a fall risk. CNA #1 said the Resident does not have non skid strips on the floor next to the bed. During an interview on 1/22/25 12:22 P.M., Unit Manager #1 said the Resident is a fall risk and should have non skid strips on his/her floor next to bed if the care plan says they should be there. During an interview on 1/22/25 at 12:58 P.M., the Director of Nurses (DON) said if a resident is care planned to have non skid strips on the floor next to the bed then they should be in place. 2. Review of the facility policy titled Orthotics and Assistive Devices, dated February 2022, indicated the following: - An assistive device is any piece of equipment that assists a resident coping with the effects of his or her disability/limited range of motion due to medical condition. These devices are intended to assist residents maneuver or perform other daily functions of daily life or prevent further complications. - If resident refuses notify nurse/provider and update care plan. - The reason for the use of the joint stabilization device is documented in the medical record. Resident #91 was admitted to the facility in August 2023 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, right wrist contracture, right hand contracture, right shoulder contracture, and right elbow contracture. Review of Resident #91's most recent Minimum Data Set (MDS) assessment, dated 11/21/24, indicated Resident #91 had a Brief Interview for Mental Status (BIMS) exam score of 8 out of a possible 15, indicating moderate cognitive impairment. The MDS further indicated Resident #91 substantial/maximal to dependent assistance with functional daily activities and upper extremity range of motion (ROM) impairment on one side. On 1/21/25 at 8:15 A.M., the surveyor observed Resident #91 was observed laying in his/her bed. Resident #91 was not wearing his/her right-hand splint or right upper extremity wedge. On 1/21/25 at 12:33 P.M., the surveyor observed Resident #91 laying in his/her bed. Resident #91 was not wearing his/her right-hand splint or right upper extremity wedge. Resident #91's hand splint was observed resting on the nightstand and right arm wedge was not visible in the room. On 1/21/25 at 4:32 P.M., the surveyor observed Resident #91 laying in his/her bed. Resident #91 was not wearing his/her right-hand splint or right upper extremity wedge. Resident #91's hand splint was observed resting on the nightstand and right arm wedge was not visible in the room On 1/22/25 at 6:55 A.M., the surveyor observed Resident #91 laying in his/her bed. Resident #91 was not wearing his/her right-hand splint or right upper extremity wedge. Resident #91's hand splint was observed resting on the nightstand and right arm wedge was not visible in the room On 1/22/25 at 7:59 A.M., the surveyor observed Resident #91 laying in his/her bed. Resident #91 was not wearing his/her right-hand splint or right upper extremity wedge. Resident #91's hand splint was observed resting on the nightstand and right arm wedge was not visible in the room. On 1/22/25 at 10:16 A.M., the surveyor observed Resident #91 laying in his/her bed. Resident #91 was not wearing his/her right-hand splint or right upper extremity wedge. Resident #91's hand splint was observed resting on the nightstand and right arm wedge was not visible in the room. On 1/22/25 at 12:39 P.M., the surveyor observed Resident #91 laying in his/her bed. Resident #91 was not wearing his/her right-hand splint or right upper extremity wedge. Resident #91's hand splint was observed resting on the nightstand and right arm wedge was not visible in the room. On 1/23/25 at 6:47 A.M., the surveyor observed Resident #91 laying in his/her bed. Resident #91 was not wearing his/her right-hand splint or right upper extremity wedge. Resident #91's hand splint was observed resting on the nightstand and right arm wedge was not visible in the room. Review of Resident #91's physician order indicated the following order initiated on 11/26/24: - Right flex hand splint to be worn up to 4-6 hrs (hours), daily, as tolerated. Put on in morning, take off in evening. Regular skin checks for any redness, irritation, indication of pain., every day shift. - Right 90-degree elbow wedge cushion to be worn up to 4-6 hrs, nightly, as tolerated. Regular skin checks for any redness, irritation, indication of pain. every evening shift Review of Resident #91's physical mobility care plan interventions indicated the following: - Maintain usage of wrist/elbow braces to prevent contractures, date initiated, 11/25/2024. Review of Resident #91's medical record failed to indicate he/she refused to wear his/her right hand splint or arm wedge. During an interview on 1/23/25 at 8:54 A.M., Unit Manager #1 said Resident #91 has a hand splint and the splint schedule should be followed per the doctor's order and documented if the resident refuses. Unit Manager #1 was not aware that Resident #91 right hand splint and wedge were not on the past two days. During an interview on 1/23/25 9:07 A.M., The Director of Nursing said a splint schedule should be followed as ordered by the physician. The Director of Nursing said if a resident refuses to wear the splint it should be documented in the medical record. 3. Resident #13 was admitted to the facility in November 2022 with diagnoses including quadriplegia, C5-C7 central cord syndrome and right-hand contracture. Review of Resident #13's most recent Minimum Data Set (MDS) assessment, dated 1/9/25, indicated Resident #13 had a Brief Interview for Mental Status (BIMS) exam score of 9 out of a possible 15, indicating moderate cognitive impairment. The MDS further indicated Resident #13 is dependent with functional daily activities and upper extremity range of motion (ROM) impairments on both sides. On 1/21/25 at 7:50 A.M., the surveyor observed Resident #13 seated in his/her wheelchair. Resident #13 was not wearing his/her right-hand roll. On 1/22/25 at 8:00 A.M., the surveyor observed Resident #13 seated in his/her wheelchair. Resident #13 was not wearing his/her right-hand roll. On 1/2/25 at 10:16 A.M., the surveyor observed Resident #13 seated in his/her wheelchair. Resident #13 was not wearing his/her right-hand roll. On 1/22/25 at 12:14 P.M., the surveyor observed Resident #13 laying in his/her recliner chair. Resident #13 was not wearing his/her right-hand roll. On 1/23/25 at 8:31 A.M., the surveyor observed Resident #13 seated in his/her wheelchair. Resident #13 was not wearing his/her right-hand roll. Review of Resident #13's physician order indicated the following order initiated on 8/12/24: - Right hand roll to be worn up to 6-8 hrs (hours), daily, as tolerated. Put on in morning, take off in evening. Regular skin checks for any redness, irritation, indication of pain. Review of Resident #13's skin integrity care plan interventions indicated the following: - The resident needs assistance to apply hand roll, date initiated, 8/12/2024. Review of Resident #13's medical record failed to indicate he/she refused to wear his/her right hand roll. During an interview on 1/23/25 at 8:54 A.M., Unit Manager #1 said Resident #13 has a hand roll, but he/she does not like to wear it all the time. Unit Manager #1 said a hand roll order should be followed per the doctor's order and documented if the resident refuses. Unit Manager #1 was not aware that Resident #13 right hand roll was not on the past two days. During an interview on 1/23/25 9:07 A.M., The Director of Nursing said a hand roll order should be followed as ordered by the physician. The Director of Nursing said if a resident refuses to wear the hand roll it should be documented in the medical record.

Based on observation, record review and interview, the facility failed to regularly inspect bed frames and mattress spacing to identify areas of potential entrapment. Specifically, the facility failed to regularly inspect and document findings regarding the seven zones of bed entrapment of Residents' beds for potential areas of entrapment as evidenced by a bed bolster (an object used to fill gaps between the mattress and headboard/footboard of a bed) that did not fit properly. Findings include: According to The Guidance for Industry and FDA Staff Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment Document issued on March 10, 2006 by the U.S. Department of Health and Human Services Food and Drug Administration Center for Devices and Radiological Health, The HBSW (Hospital Bed Safety Workgroup) identified 7 potential entrapment zones for hospital beds. Review of the facility policy titled Bed Safety and Bed Rails, revised and dated August 2022, indicated the following: - Resident beds meet the safety specifications established by the Hospital Bed Safety Workgroup. - Bed frames, mattresses and bed rails are checked for compatibility and size prior to use. - Bed dimensions are appropriate for the resident's size. - Regardless of mattress type, width, length and/or depth, the bed frame, bed rail and mattress will leave no gap wide enough to entrap a resident's head or body. Any gaps in the bed system are within the safety dimensions established by the FDA. - Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks. The surveyor made the following observations on the same resident's bed: - On 1/21/25 at 9:17 A.M., on the B-unit, a resident was observed sleeping in his/her bed. There was a bolster on the foot of the bed between the mattress and the footboard. The bolster was less than half the length of the mattress and the gap between the space above the bolster to the footboard was about six inches. - On 1/22/25 at 10:25 A.M., on the B-unit, there was a bolster on the foot of the bed between the mattress and the footboard. The bolster was less than half the length of the mattress and the gap between the space above the bolster to the footboard was about six inches. The surveyor was able to put his entire arm between the mattress and the footboard. Review of the facility binder titled Bed Inspection indicated that the Maintenance Director completed Bed entrapment measurement tests on nine beds on the A Unit. Review of the nine checks indicated they were incomplete and did not have documentation on all of the entrapment zones. These checks were done on 7/24/24. The facility bed capacity is 126 beds. During an interview on 1/22/25 at 10:15 A.M., the Administrator told the surveyor that the previous Maintenance Director did not complete the yearly bed entrapment rounds. The Administrator continued to say he has a Maintenance Director from another facility completing them today. During an interview on 1/22/25 at 11:17 A.M., the visiting Maintenance Director from a sister facility said bed inspections for entrapment should be done yearly. He said this building's maintenance director never finished them so he was asked to do them. The visiting Maintenance Director said if there is a space between the headboard or footboard of the bed then a bolster that is the same thickness of the mattress should be used and the bolster should be level with the mattress so there are no gaps. The surveyor showed the visiting Maintenance Director photos of the current bolster being used and he said that is the wrong type of bolster being used and it needs to be thicker and higher up to properly fill the gap as a resident can get entrapped in the space. During an interview on 1/22/25 at 2:18 P.M., the Director of Nursing (DON) said bed safety checks for entrapment were not done. The DON said they had a previous Maintenance Director who quit and told the facility they were complete when they were not but she would expect them to still be complete. The surveyor showed the DON the photos of the bed bolster and she said it is the incorrect bolster and needs to be changed as the resident can be entrapped in the spacing with the current bolster.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, interview and observation, the facility failed to ensure it provided a means for residents to communicate to staff on the A Unit. Findings included: The Facility's policy titled Answering the Call Light dated as revised September 2022, indicated: - The purpose of this procedure (answering the call light) is to ensure timely responses to the resident's requests and needs. - Be sure the call bell is plugged in and functioning at all times. On 1/21/25 at approximately 8:30 A.M., the surveyor observed that the call bell system was broken on the A Unit. The surveyor sampled the call bell system from several bedrooms and noted that the call bell did not sound, either in the hallway of the nursing station, and the call bell board at the nursing station did not illuminate to identify which bedroom requested help. The surveyor observed that in some of the sampled bedrooms the call light button illuminated the light outside the bedroom doorway. The surveyor observed that the call lights in the hallway located on the left wing of the unit, and the end of the hallway of the right wing, were not visible from the nursing station. During the morning of 1/21/25 and the afternoon of 1/22/25, the surveyor observed: - room [ROOM NUMBER]W: No hand bell. The Resident was unaware the call light system was broken. - room [ROOM NUMBER]W: No hand bell. The Resident was unaware call light system was broken. - room [ROOM NUMBER]D and 7W: No hand bells in the bedroom. The Residents said they were unaware the call light system was broken. - room [ROOM NUMBER]D: No hand bell. The Resident was unaware the call light system was broken. - room [ROOM NUMBER]W: Resident lying in bed and a hand bell was located on windowsill, beyond his/her reach. The Resident was aware the call light system was broken. - room [ROOM NUMBER]W: Resident lying in bed and hand bell on windowsill, beyond his/her reach. The Resident was aware call light system was broken. - room [ROOM NUMBER]D: Resident lying in bed and hand bell was located on over bed table, within reach. Resident said light in the hallway outside the bedroom illuminates when the call bed cord button is pushed, but no alarm sounds or light illuminates at the nursing station. The Resident said sometimes staff respond to the hall light, other times he/she needs to call out for help. - room [ROOM NUMBER]D: No hand bell, and the call bell cord was on the floor, beyond the Resident's reach. The Resident was unaware the call light system was broken. - room [ROOM NUMBER]W: No hand bell, and the call bell cord was on the floor, beyond the Resident's reach. The Resident was aware call light system was broken. During an interview with Unit Manager #2 on 1/22/25 at 11:20 A.M., she said the call light system began to stop functioning in some of the residents' bedrooms in November 2024, and that by mid-December 2024 the system stopped functioning in all the bedrooms. Unit Manager #2 said none of the call bells sounded, but that some of the hallway call lights still activated, but not at the nursing station. Unit Manger #2 said she did not when the call system was to be repaired. Unit Manager #2 said she had instructed staff nurses to distribute hand bells to each of the residents and to place them within reach. The surveyor told Unit Manager #2 that many residents did not have handheld bells, and for those that did these were sometimes out of reach. The surveyor told Unit Manager #2 that many of the residents did not know the call light system was broken, yet were still using the call bell, and complained about the late response time. On 1/22/25 at 11:25 A.M., the surveyor was on the A Unit hallway and heard the Resident in room [ROOM NUMBER]D calling for help, from his/her bed. The surveyor entered the bedroom and observed that room [ROOM NUMBER]D still did not have a hand bell. During an interview with the Administrator on 1/23/25 at 9:36 A.M., he said he was aware the call light system was broken, and that staff should have given each resident a hand bell to ring for assistance. During an interview with the Consulting Maintenance Director on 1/23/25 at 1:30 P.M., he said the building has been without a Maintenance Director for approximately a week, and he was not familiar with required repairs in the building. The surveyor and Consulting Maintenance Director reviewed the Maintenance Log, and it indicated staff documented the A Unit call light system needed repairs in October and December 2024. The Log indicated the call light system had not been repaired.

2) For Resident #8 the facility failed to provide a dignified dining experience. Specifically, the facility failed to ensure that staff did not feed Resident #8 while standing over the Resident. Review of the facility policy titled Dignity, revised February 2021, indicated, but was not limited to, the following: -Each Resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. -Residents are treated with dignity and respect at all times. -When assisting with care, residents are supported in exercising their rights. For example, residents are provided with a dignified dining experience. Resident #8 was admitted to the facility in February 2011 with diagnoses including aphasia and dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/30/23, indicated that Resident #8 scored a 10 out of 15 on the Brief Interview for Mental Status examination, indicating moderate cognitive impairment. The MDS indicated Resident #8 required extensive one person physical assist with eating. Review of Resident #8's Activities of Daily Living (ADL) care plan indicated Resident #8 is independent to dependent with eating depending on level of fatigue. On 1/2/24 at 9:03 A.M., the surveyor observed Resident #8 in bed. A staff member standing beside the bed, looking down at Resident #8 while providing feeding assistance. On 1/2/24 at 1:16 P.M., the surveyor observed Resident #8 in bed. A staff member standing beside the bed, looking down at Resident #8 while providing feeding assistance. During an interview on 1/3/24 at 1:15 P.M., the Director of Nursing (DON) said staff should not be standing while feeding residents unless they are at eye level with the Resident. The DON said staff should either lower the bed enough so that the staff can remain seated while feeding the Resident, or raise the bed so that the staff and the Resident are at eye level. During an interview on 1/3/24 at 1:19 P.M., the maintenance director said Resident #8 has a newer, functioning, bed with a wide range of motion which staff could easily either lower or raise the bed so that staff would be at eye level with the Resident while providing feeding assistance. Based on observations, record review and interviews the facility failed to provide the right to a dignified existence for two Residents (#44 and #8) out of a total sample of 28 residents. Specifically, 1. For Resident #44, who is dependent on staff for personal hygiene and grooming, the facility failed to remove unwanted facial hair. 2. For Resident #8 the facility failed to provide a dignified dining experience. Findings include: 1. For Resident #44, who is dependent on staff for personal hygiene and grooming, the facility failed to remove unwanted facial hair. Review of the facility policy titled Activities of Daily Living (ADL's), Supporting, dated as revised March 2018, indicated that residents who are unable to carry out ADL's independently will receive the services necessary to maintain good grooming. Resident #44 was admitted to the facility in December 2023 with diagnoses including heart failure and generalized muscle weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/19/23, indicated that Resident #44 scored a 13 out of 15 on the Brief Interview for Mental Status exam, indicating intact cognition. The MDS further indicated that Resident #44 requires substantial assistance for ADL completion. Review of the current ADL care plan indicated that Resident #44 requires an assist of one staff member to complete personal hygiene tasks. Further review failed to indicate that Resident #44 refuses care. On 1/2/24 at 8:30 A.M., the surveyor observed Resident #44 with a significant amount of 1/2 inch long white hair on her/his chin. On 1/3/24 at 9:25 A.M. the surveyor observed Resident #44 with a significant amount of 1/2 inch long white hair on her/his chin. During an interview on 1/3/24 at 9:26 A.M., Resident #44 said that he/she certainly would like for someone to help him/her to remove the chin hair. Resident #44 said that none of the staff had offered to remove the chin hair and it is embarrassing. On 1/3/24 at 12:35 P.M., the surveyor observed Resident #44 with a significant amount of 1/2 inch long white hair on her/his chin. On 1/4/24, at 8:25 A.M., the surveyor observed Resident #44 with a significant amount of 1/2 inch long white hair on her/his chin. During an interview on 1/4/24, at 8:25 A.M., Resident #44's Certified Nursing Assistant (CNA) #1 said that it is the responsibility of the CNA's to shave the residents.

2) For Resident #11 the facility failed to ensure that the air mattress was set to the correct setting, as ordered by the Physician. Review of the facility policy, titled Support Surface Guidelines, dated as revised September 2013, indicated, but was not limited to, the following: -Redistributing support surfaces are to promote comfort for all bed or chairbound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction. -Support surfaces alone are not effective in preventing pressure ulcers, but studies indicate that the use of appropriate support surfaces with interventions such as turning, repositioning and moisture management can assist in reducing pressure ulcer development. -Support surfaces are modifiable. Individual residents' needs differ. Resident #11 was admitted to the facility in July 2023 with diagnoses including dementia. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/21/23, indicated that Resident #11 scored a 15 out of 15 on the Brief Interview for Mental Status examination, indicating intact cognition. The MDS further indicated Resident #11 was dependent on staff assistance for bed mobility and transferring out of bed. Review of Resident #11's current Physician orders indicated an order: -Air mattress to bed at all times. (weight Range Setting: 160 lbs.) Check setting and function every shift, start date 10/25/23. Review of Resident #11's current skin care plans indicated Resident #11 has potential for pressure ulcer development related to limited mobility, frail fragile skin, decreased activity. Interventions included: -Air mattress to bed; monitor setting and function as ordered. During an interview and observation on 1/2/24 at 8:25 A.M., the surveyor observed Resident #11 lying in bed. Resident #11 said his/her bed was uncomfortable because the mattress was too firm. The surveyor observed the air mattress control for the bed, the arrow was set just below 240 pounds. On 1/2/24 at 1:35 P.M., the surveyor observed Resident #11 lying in bed. The air mattress was set just below 240 pounds. On 1/3/24 at 8:37 A.M., the surveyor observed Resident #11 lying in bed. The air mattress was set just below 240 pounds. During an interview and observation on 1/3/24 at 10:12 A.M., Nurse (#4) said an air mattress should be set according to a resident's physician order, and that the function and setting of the air mattress should be checked every shift. Nurse #4 said that if the setting is not what is ordered it must be adjusted. Nurse #4 said Resident #11 utilized an air mattress for comfort as the Resident was on hospice services, but also because the Resident had a history of a pressure ulcer. Nurse #4 and the surveyor observed Resident #11's air mattress set just below 240 pounds. Nurse #4 said the setting was incorrect as the air mattress needed to be set to 160 pounds, and that this would need to be adjusted. Nurse #4 said that if an air mattress was too firm it may damage the Resident's skin. During an interview on 1/23/24 at 10:21 A.M., Nurse Unit Manager (#3) said nurses should check the setting and function of air mattresses every shift, and as part of this check nurses should adjust the setting if it is not set according to the Resident's physician order. During an interview on 1/3/24 at 10:37 A.M., the Director of Nursing said nurses should check the setting and function of air mattresses every shift, and as part of this check the nurses should adjust the setting if it is not set according to the Resident's physician order. Based on observation, record review and interview the facility failed to implement a plan of care for two Residents (#110 and #11) out of a total sample of 28 residents. Specifically: 1. For Resident #110 the facility failed to provide assistance with eating. 2. For Resident #11, the facility failed to ensure that the air mattress was set to the correct setting as ordered by the Physician. Findings include: Review of the facility policy titled Activities of Daily Living (ADLs) dated revised March 2018, indicated that residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition . 1. Resident #110 was admitted to the facility in November 2023 with diagnoses including dysphagia (difficulty chewing and swallowing) and stroke. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/4/23, indicated that Resident #110 scored a 3 out of 15 on the Brief Interview for Mental Status exam, indicating severely impaired cognition. The MDS further indicated that Resident #110 required substantial/maximal assistance-helper does more than half the effort for eating. Review of Resident #110's care plans, dated 12/8/23, indicated a problem for nutrition, written by the dietitian, with the following intervention: Monitor/document/report PRN (as needed) any s/sx (signs/symptoms) of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing . On 1/2/24 at 8:45 A.M., the surveyor observed Resident #110 sitting in a chair in his/her room with a breakfast tray on the over the bed table. Resident #110 was not eating and there were no staff in the room observing Resident #110 for signs of choking or for encouraging the Resident to eat. On 1/3/24 at 9:00 A.M., the surveyor observed Nurse #8 deliver Resident 110's food tray, place it on the over the bed table, open the containers and leave the room, leaving Resident #110 alone for the meal. On 1/4/24 at 8:46 A.M., the surveyor observed Resident #110 lying in bed with a breakfast tray on the over the bed table. Resident #110 was not eating and there were no staff in the room observing Resident #110 for signs of choking or for encouraging the Resident to eat. On 1/4/24 at 1:08 P.M., the surveyor observed Resident #110 sitting in a chair in his/her room with a lunch tray on the over the bed table in front of her/him. Resident #110 was not eating and there were no staff in the room observing Resident #110 for signs of choking or for encouraging the Resident to eat. During an interview on 1/3/24, at 1:39 P.M., the Dietitian said that it was the expectation that staff would supervise Resident #110 during meals in order to determine if she/he was exhibiting s/sx of dysphagia. During an interview on 1/4/24, at 1:11 P.M., Nurse Unit Manager (#1) said that she was not aware of the dietitian's recommended intervention to monitor/document/report PRN any s/sx (signs/symptoms) of dysphagia with meals. Nurse Unit Manager #1 said that in order to follow this intervention staff would have to be continually supervising the Resident with his/her meals.

2. Resident #83 was admitted to the facility in September 2021 and had diagnoses that include dysphagia (difficulty chewing and swallowing) following cerebral infarction (stroke) and Gastrostomy tube (feeding tube). Review of the most recent Minimum Data Set (MDS) assessment, dated 11/01/23, indicated that on the Brief Interview for Mental Status exam Resident #83 scored an 8 out of a possible 15, indicating moderately impaired cognition. The MDS further indicated Resident #83 had no behaviors and was dependent on staff for all aspects of Activities of Daily Living (ADLs). Review of the current Physician orders, with a start date of 12/19/23, was an order: Enteral Feed: Jevity 1.2/Fibersource HN 1.2 at 85 ml/hr. Up at 10p and down at 8a. Run time of 10hr., one time a day and remove per schedule. Review of the current care plan for Resident #83 indicated the following: -A G tube (Gastrostomy tube) care plan, dated as revised 11/6/23, with an intervention: Resident #83 is dependent with tube feedings and water flushes. See MD orders for current feeding orders. -A dehydration care plan, initiated 09/03/21 and revised on 2/7/21, indicated Resident #83 was at risk for dehydration due to diuretic use, Gtube feedings (sic). The one intervention on the care plan, dated as revised 2/15/23, indicated: monitor labs, water flushes, G tube feedings, monitor for loose stools. On 1/2/24 at 8:03 A.M., Resident #83 was observed asleep in bed. The tube feed was running. There was no date or time on the tube feed bag, or the hydration bed to indicate when the bags were hung. A syringe bag hung alongside the other two bags and was dated: 12/31/23 up at 10pm, down at 8am (sic). On 1/5/24 at 7:37 A.M., Resident #83 was observed asleep in bed. The tube feed was running. There was no date or time on the tube feed bag, or the hydration bed to indicate the date and time that the bags were hung. During an interview on 1/5/24 at 7:43 A.M., with the Nurse (#6) he said that it is the expectation that the nurse that hangs the tube feed bag and the hydration bag label and date both bags with the time that it goes up and the time that it should comes down. The surveyor and Nurse #6 observed Resident #83's bags together and he said that the nurse that hung the bags is training with him and that he will re-educate her. During an interview on 1/5/24 at 7:58 A.M., with the Nurse Unit Manager (#3) she said that it is the expectation that staff label and date the tube feed and hydration bag when they are hung. Nurse Unit Manager #3 is aware that this is not consistently being done. During an interview on 1/5/24 at 8:39 A.M., with the Director of Nursing she said that staff should always label and date the tube feed and hydration bag when they are hung. Based on observations, record review and interview, the facility failed to provide care in accordance with professional standards of practice for two Residents (#112 and #83) out of a total sample of 28 Residents. Specifically, 1) for Resident #112, the facility failed to follow the most current doctor's order for G-tube (gastric tube, a tube placed directly through the abdomen for the purpose of instilling nutrition) feeding and failed to label and date the tube feeding bottle and water flush bag with the date and time hung. 2) for Resident #83 the facility failed to label and date the tube feeding bottle and water flush bag with the date and time hung. Findings include: Review of the facility policy titled Enteral Feedings-Safety precautions, dated revised November 2018 indicated the following: Sterile formula in a closed system has a maximum hang time of 48 hours. Check the Enteral nutrition label against the order and the rate of administration, before administration. On the formula label document the initials, date and time the formula was hung and initial that the label was checked against the order. 1. Resident #112 was admitted to the facility in December 2023 with diagnoses including dysphagia (difficulty chewing and swallowing), cancer of the mouth and G-tube placement. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/8/23, indicated that Resident #112 requires assistance with all Activities of Daily Living (ADLs). The MDS further indicated that Resident #112 scored a 13 out of 15 on the Brief Interview for Mental Status exam, indicating Resident #112 is cognitively intact. On 1/2/24, at 8:15 A.M., and 11:22 A.M., the surveyor observed Jevity 1.5 cal (calorie) G-tube feeding running at 75 ml/Hr. (milliliters/hour)(not the current doctor's order) into the trash can. The surveyor observed that approximately 400 ml was left in the bottle. The surveyor then observed Resident #112 sitting in the hallway without the G-tube feeding connected. Review of the current Physician's orders, included the following active orders: -Dated 12/11/23, for Enteral Up/Down Schedule: Feed Up at 6 p.m. Down at 6 a.m. ; in the evening Jevity 1.5 75 ml/hr 150 ml flush every 4 hours AND in the morning for Jevity 1.5, 75 ml/hr -Dated 12/18/23, indicated an another active order for Enteral Feeding via G-tube Jevity 1.5. up at 3:00 P.M. down at 9:00 A.M. 50 ml/hr., in the afternoon for feeding up at 3 p.m., in the morning for feeding down at 9:00 A.M. or until full amount given. Review of the Medication Administration Records dated December 2023 and January 2024 indicated that Resident #112 received the following G-tube feeding: Enteral Up/Down Schedule: Feed Up at 6 p.m. Down at 6 a.m. ; in the evening Jevity 1.5 75 ml/Hr (not the current doctor's order since 12/18/23). On 1/3/24, at 7:23 A.M. the surveyor observed a bottle of Jevity 1.5 hanging without a date or time hung. The surveyor also observed that approximately 200 ml of Jevity was left in the bottle. The surveyor then observed Resident #112 sitting in the hallway without the tube feeding connected. During an interview on 1/3/24, at 9:04 A.M., Nurse Unit Manager #1 said that the tube feeding bottle and the water should both be labeled with the date and time hung. During an interview on 1/3/24, at 1:06 P.M., the Dietitian said that a person can not have more than one order for tube feeding and that she didn't know why Resident #112 had two different orders for tube feeding. The Dietitian then said that when a new order is written the old one should be discontinued. On 1/4/24, at 7:05 A.M., the surveyor observed Resident #112 sitting in the hallway without the tube feeding connected to the Resident. The surveyor also observed the tube feeding pump in the Resident's room running at 75 ml/Hr with 200 ml left in the bottle (not the current doctor's order). The surveyor also observed a water bag attached to the tube feeding pump without a label for the date and time it was hung. During an interview on 1/4/24, at 7:10 A.M., Nurse #9 said that she checks the tube feeding pump every 35 to 40 minutes during the night to make sure everything is infusing appropriately and said that the tube feeding pump is running at 75 ml/Hr as ordered. The surveyor and Nurse #9 reviewed the current Physician's orders which read for Enteral Feeding via G-tube .Jevity 1.5. up at 3:00 P.M. down at 9:00 A.M. 50 ml/hr in the afternoon for feeding up at 3 p.m., in the morning for feeding down at 9:00 A.M. or until full amount given. Nurse #9 then said that she wasn't sure what the tube feeding should be running at. Nurse #9 then said that the previous order should have been discontinued when the new order was taken.

Based on observations, interviews and record review, the facility failed to assist one Resident (#90) out of a sample of 28 residents to replace lost hearing aids. Specifically, the facility failed to assist the Resident in obtaining services to replace hearing devices lost at the facility. Findings include: A review of the facility policy titled Hearing Impaired Resident, Care of, dated as revised February 2018, indicated the following: -Staff will assist hearing impaired residents to maintain effective communication with clinicians, caregivers, other residents and visitors. -Staff will help residents who have lost or damaged hearing devices in obtaining services to replace the devices. Resident #90 was admitted to the facility in March 2023 with diagnoses including hearing loss. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/7/23, indicated Resident #90 had a Brief Interview for Mental Status examination score of 14 out of a possible 15, indicating intact cognition. The MDS indicated Resident #90 did not have a hearing aid. Review of the MDS assessments dated 3/28/23, 6/21/23 and 09/13/23 indicated Resident #90 had a hearing aid at the time of the assessments. During an interview and observation on 1/2/24 at 8:05 A.M., Resident #90 was observed to be very hard of hearing and needed the surveyor to speak very loudly directly into his/her ear. Resident #90 said that he/she lost his/her bilateral hearing aids about a year ago when they went down in his/her pants to the laundry and never returned. Resident #90 said the facility told his/her daughter hearing aid replacement was not covered by insurance and so they were never replaced. A review of the request for ancillary services consent form dated 3/22/23 indicated only podiatry services were requested, and that the facility had not requested audiology services. During an interview and observation on 1/5/24 at 8:35 A.M., Resident #90 again had a very hard time hearing the surveyor. Resident #90 said as soon as he/she realized the hearing aids were missing, he/she told the staff in the facility, as well as his/her daughter. Resident #90 said his/her daughter was working on replacing the hearing aids. During an interview on 1/5/24 at 8:31 A.M., the Certified Nurse's Assistants (CNA) #2 and #3 said they were not aware Resident #90 ever had hearing aids. During an interview on 1/5/24 at 9:16 A.M., Nurse Unit Manager (#3) said she was not aware Resident #90 had lost his/her hearing aids. Nurse Unit Manager #3 said staff are expected to initiate a grievance when a resident reports a missing item and that it is inappropriate for a staff member to tell the Resident that missing hearing aids would not be replaced because they were not covered by insurance. During an interview on 1/5/24 at 10:51 A.M., the Director of Nurses said Resident #90's missing hearing aids should have been replaced even if the Resident was not enrolled to receive audiology services through the facility.

Based on observation, interview and record review the facility failed to implement the plan of care for one Resident (#67) out of a total sample of 28 residents. Specifically, for Resident #67 who has a Stage 3 pressure ulcer on his/her foot, the facility failed to offload his/her feet as ordered by the Physician and Wound Physician. Findings include: The facility policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated as revised April 2018, indicated the following: -The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss and a history of pressure ulcer(s). -In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces; and e. All active diagnoses. -The Physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing, and debridement approaches (occlusives, absorptive, etc.), and application of topical agents. Resident #67 was admitted to the facility in June 2022 with the following diagnoses: dementia and pressure-induced deep tissue damage of the left heel. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/1/23, indicated that on the Brief Interview for Mental Status examination Resident #67 scored 6 out of a possible 15 points, indicating severely impaired cognition. The MDS further indicated Resident #67 had no behavior of rejecting care and required maximum assistance from staff for lower body care. Review of the facility Matrix report dated 1/02/24, indicated Resident #67 had a facility-acquired pressure ulcer. Review of the current Physician orders included: heels up cushion, every shift for offloading of bilateral heels, start date 9/6/22. Review of the January 2024 Treatment Administration Record indicated nursing had signed off that Resident #67's heels were up on a cushion three shifts a day, each day in January. Review of the current Skin care plan for Resident #67 indicated the following interventions: -Offload heels, dated as revised 2/15/23. -Offloading booties while in bed as Resident will allow/tolerate, dated as revised 2/15/23. Review of the current Activities of Daily Living care plan indicated Resident #67 requires staff assist for bed mobility and positioning. Review of the Wound Physician weekly visit notes indicated the following: -Resident was seen on 12/27/23 for wound care and treatment recommendations for a left heel pressure ulcer. The progress of the wound was noted as deteriorating and had changed from a Stage 2 to a Stage 3. The wound size was 1.5 x 2 x 0.5 [centimeter] with moderate serosanguinous exudate (drainage). The treatment plan indicated Resident #67's heel should be offloaded, per facility protocol. On 1/2/24 at 12:46 P.M., the surveyor observed Resident #67 in bed, asleep. Resident #67's heels lay flat on the mattress. There was no heels-up cushion or booties observed in the bed or vicinity. On 1/4/24 at 7:19 A.M., the surveyor observed Resident #67 in bed, asleep. Resident #67's heels lay flat on the mattress. There was no heels-up cushion or booties observed in the bed or vicinity. On 1/4/24 at 8:57 AM., the surveyor observed Resident #67 in bed, asleep. Resident #67's heels lay flat on the mattress. There was no heels-up cushion or booties observed in the bed or vicinity. During an interview on 1/05/24 at 10:19 A.M., with Resident #67's Certified Nursing Assistant (CNA) #3 she said Resident #67 did not refuse care and the amount of staff assistance needed varied depending on the day. CNA #3 said Resident #67 had very sensitive skin and he/she had no open areas. CNA #3 said she thinks the area Resident #67 had on his/her heel was healed. CNA #3 said she was not aware Resident #67 was supposed to have his/her heels offloaded in bed. During an interview on 1/5/24 at 10:23 A.M., with the Nurse Unit Manager (#3) she said Resident #3 had an area on his/her foot that is scabbed. Nurse Unit Manager #3 said Resident #67's feet should be offloaded when in bed, per the Physician's order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to address continued weight loss in a timely manner for one Resident (#110) out of a total sample of 28 residents. Findings include: Resident #110 was admitted to the facility in November 2023 with diagnoses including dysphagia (difficulty chewing and swallowing) and stroke. Review of the most recent Minimum Data Set (MDS) dated [DATE], indicated that Resident #110 scored a 3 out of 15 on the Brief Interview for Mental Status exam, indicating severely impaired cognition. The MDS further indicated that Resident #110 required substantial/maximal assistance-helper does more than half the effort for eating. Review of the current nutrition care plan, dated 12/8/23, written by the dietitian included the following intervention: Monitor/document/report PRN (as needed) any s/sx (signs/symptoms) of dysphagia: Pocketing, Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing. Review of the medical record indicated that Resident #110 had a significant weight loss of 7.26% in one month from 11/28/23 to 12/27/23 registering the following weights: -11/28/23: 124.4 pounds (lbs) -11/29/23: 123.2 lbs -12/5/23: 117.4 lbs -12/27/23: 115.0 lbs Review of the medical record indicated a Dietitian note, dated 12/6/23, that indicated the Dietitian recognized a significant weight loss and recommended a nutritional supplement and Speech Therapy (ST) and Occupational Therapy (OT) for feeding. Further review of the medical record failed to indicate any review by the Dietician when on 12/27/23, it was determined that Resident #110 continued to lose weight. Review of the ST and OT treatment notes failed to indicate that Resident #110's eating and swallowing abilities were evaluated and addressed. During an interview on 1/3/24, at 1:39 P.M., the Dietitian said that the dietician should continue to monitor a resident who had sustained a significant weight loss and put in further interventions if weight loss continued. The Dietitian said that she was not aware that Resident #110 had continued to lose weight. The Dietitian also said she could not locate in the medical record that any new interventions had been implemented to prevent further weight loss once the continued weight loss had been determined.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 1/4/24, at 1:34 P.M., the surveyor exited the elevator onto the [NAME] Unit and observed a medication cart unattended and unlocked. The surveyor was able to open and access the cart. A few moments later a Certified Nursing Assistant (CNA) exited a resident room and the surveyor asked her where the nurse was. The CNA said that she did not know. During an interview on 1/4/24, at 1:35 P.M., Nurse #4 came running from the other end of the hallway. Nurse #4 said that the medication cart was supposed to be locked when not attended but that she had left to assist a resident. Based on observations, policy review, and interview the facility failed to ensure two medication carts were locked when unattended. Findings include: Review of the facility policy titled Storage of Medications, dated revised November 2020, indicated that Compartments (including but not limited to . carts) containing drugs and biological's are locked when not in use. Unlocked medication carts are not left unattended. On 1/2/24, at 8:02 A.M., the surveyor observed a medication cart unlocked in the Unit A hallway. The surveyor observed a resident sitting next to the medication cart. The surveyor was able to access the medication cart, open all of the drawers, have full access to the medications in the cart for a period of 15 minutes. During an interview on 1/2/24, at 8:17 A.M. Nurse #1 was informed by the surveyor that the medication cart was not locked and the surveyor was able to access the medications for 15 minutes. Nurse #1 said that she was in a resident's room and forgot to lock the medication cart before leaving it. Nurse #1 said that the medication cart should be locked at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure grievances voiced in the monthly Resident Council meetings were adequately addressed or resolved. Findings include: The facility policy titled Nursing Home Resident Rights: Grievances, undated, indicated the following: -Grievance is meant to be broad and includes: concerns with respect to care and treatment (which has been provided or not provided), the behavior of staff and of other residents, and other concerns regarding their LTC (Long Term Care) facility stay. 1. The nursing home must create an environment whereby every resident feels safe to report a concern/file a grievance. 2. The facility must make prompt efforts to resolve grievances the resident may have and the resident has the right to receive the written result of the grievance. 3. The facility must make information on how to file a grievance of complaint available to the resident. 4. Standard Grievances must be resolved within 5-7 business days. During an initial tour of the [NAME] Unit, on 1/2/24, the surveyors met with residents, and they expressed the following concerns: -At 7:54 A.M. Resident #71 said the food is terrible and explained it was the taste, a lot of rice and mashed potatoes, and they were short staffed which resulted in food being delivered late. -At 8:02 A.M. Resident #34 said he/she dislikes the food served in the facility. -At 8:05 A.M., Resident #90 said the food looks like garbage and tastes like garbage. -At 8:10 A.M. Resident #8 said he/she dislikes the food served in the facility. -At 8:15 A.M., Resident #61 said the food does not taste good. -At 8:21 A.M. Resident #65 said he/she dislikes the food served in the facility. -At 8:24 A.M., Resident #12 told the surveyor that the only concern he/she had was the food is not good. Review of the 2023 Resident Council Minutes indicated in 2023, 11 of the 12 monthly meetings were held (there was no meeting documented in June 2023). During those meetings residents voiced concerns regarding cold food temperature for 7 of the 11 meetings and long call light wait times for 4 of the 11 meetings. -November 2023 action items included: *Food is cold when delivered to rooms late. Plan: we take temperature before with server and we do test tray on the unit to make sure the food is hot. -October 2023 actions items included: *Juice is frozen, food is cold, not getting what's on the menu. Plan: weekly test tray. *Call lights not answered timely all shifts all days. Plan: new unit manager will conduct an audit of call lights. -September 2023 action items included: *Breakfast sometimes cold. Plan: we take temperature of the food before going to the floor. *Lights are not being answered in a timely manner. Plan: need more info i.e. shifts, weekends or weekdays. Will address in next Resident Council meeting after interviewing residents. -August 2023 action items included: *Residents stated that the food is cold. Plan: will inform servers to fill the steamer with more hot water to solve the issue, also reminded the residents that we have a microwave and can heat up the meal if needed. -July 2023 action items included: *Food is cold. Requesting a meeting with Dietary Director (done 8/3/23). The Resident Council minutes did not indicate any further steps to resolve this grievance. -May 2023 action items included: *Food=cold. The Resident Council minutes did not indicate a plan or steps to resolve this grievance. -April 2023 action items included: -Food is too hard & cold. The Resident Council minutes did not indicate a plan or steps to resolve this grievance. -Documentation of old/unfinished business: call lights not being answered in a timely manner. The Resident Council minutes did not indicate a plan or steps to resolve this grievance. -March 2023 action items included: -Residents feel that we need more nurses and CNAs. They feel they wait too long for the buzzer to be answered, we need more help. The Resident Council minutes did not indicate a plan or steps to resolve this grievance. During the Resident Group meeting on 1/3/24 at 10:37 A.M., the surveyor met with 21 residents. The residents said the Activity Director arranges the monthly Resident Council meeting and takes the meeting minutes, including documenting their concerns. The following month she hands out the prior meeting summary, including the facility's responses to the grievances. The residents said, we do not get resolution and month after month the same concerns are voiced. During the Resident Group meeting residents further expressed the following: -A resident said part of the reason for the cold food was They forget to turn on the food plate warmer or they are not used consistently. The doors are left open (to the food truck while they pass the trays. -Another resident said, If people ask what I am eating, I can't tell. -15 of 21 residents said that even though they complain about food month after month, it does not improve. -17 of 21 residents said the food is consistently not hot; -17 of 21 residents said the taste of the food is poor and no seasoning or seasoning packets are provided. -20 of 21 residents said there are not enough staff to meet their needs. They said waiting an hour for their call bell to be answered is a regular occurrence. Review of the December 2023 Grievance Log Book included the following grievances: -12/28/23 Grievance: Son reported that his dad called him last night and reported waiting 1 hour for his call light to be answered. Resolution: Staff reminded that call lights need to be answered. Staff report that the light was answered timely. -12/27/23 Grievance: Reports long wait times anytime she rings the call light. Resolution: Staff to be educated on call light response time. -12/6/23 Grievance: Reports waiting over 30 minutes to get anyone to answer call light. Resolution: Staff to improve response time and educated on this importance. During an interview on 1/04/24 at 8:00 A.M., the Activity Director said: -She runs the monthly Resident Council meetings and food temperature complaints and concerns regarding the call bell wait times come up regularly at the meetings. She said residents complain the food is cold when delivered and call bell wait times, particularly in the evenings, are an issue of concern. -The Activity Director said that after the meeting she fills out a form identifying each issue of concern the residents raised and gives the form to the department with which the resident(s) have a concern. The Activity Director said her expectation is the department addresses and attempt to resolve the concern. -The Activity Director said that at the following month's Resident Council meeting she reviews the response to each concern and then new or repeated concerns are addressed. The Activity Director said, if it isn't fixed, we will address it again. During an interview on 1/4/24 at 12:30 P.M., the Social Services Director said it is her expectation that grievances be resolved within 72 hours, but ideally much sooner. The surveyor reviewed with the Social Services Director the food and call bell wait time grievances raised during the Resident Council meetings held in 2023. The Social Services Director said, I 100% agree that it's a problem, if it's coming up month after month. She added there are many grievances in the grievance logbook for this year regarding food and call bell wait times. During the Quality Assurance Performance Improvement meeting on 1/5/24 at 9:16 A.M., with the Nursing Home Administrator (NHA) and Director of Nursing (DON), the NHA said grievances should be resolved within three business days. The NHA and DON said they are aware of food temperature and quality concerns, and call bell wait times are concerns. The NHA and DON said they have been working to resolve the food concerns, by changing the truck delivery times, which they think helped. Ref F725

Based on observation, interview and record review, the facility failed to maintain a safe environment for two Residents (#18 and #21) out of a total sample of 28 residents. Specifically, 1. For Resident #18, the facility failed to ensure adequate supervision was provided, resulting in eight falls in 2023, including two that required emergency room evaluations. 2. For Resident #21, who has a diagnosis of epilepsy, the facility failed to ensure bilateral padded side rails were in place to prevent injury in the event of a seizure. Findings include: 1. For Resident #18, the facility failed to provide adequate supervision and implement effective interventions to prevent falls, resulting in eight falls in 2023, including two that required emergency room evaluations. The facility policy titled Falls-Clinical Protocol, dated as revised March 2018, indicated the following: 1. For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. 2. If the cause of a fall is unclear, or if a fall may have a significant medical cause such as a stroke or an aversive drug reaction (ADR), or if the individual continues to fall despite attempted interventions, a physician will review the situation and help further identify causes and contributing factors. a. After a fall, the physician should review the resident's gait, balance, and current medications that may be associated with dizziness or falling. b. Many categories of medications, and especially combinations of medications in several of those categories, increase the risk of falling. 3. The staff and physicians will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable. -If the individual continues to fall, the staff and physicians will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions. Resident #18 was admitted to the facility in April 2021 and had diagnoses that included Alzheimer's disease and a history of falling. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/21/23, indicated that on the Brief Interview for Mental Status exam Resident #18 scored a 10 out of a possible 15, indicating moderately impaired cognition. The MDS further indicated Resident #18 had no behaviors and transferred with supervision or touching assistance. During an initial tour of the C Unit on 1/2/24 at 7:49 A.M., the surveyor observed Resident #18 seated on the left side of his/her bed with an armchair blocking his/her ability to transfer. Resident #18 had a black eye and bruising on the forehead. Resident #18 said, I can't get up, it needs to be moved as he/she gestured to the chair. Resident #18 said the bruise was from a fall in his/her room but was unable to recall more details. Review of the Matrix report dated 1/2/24 indicated Resident #18 had fallen in the past 120 days. Review of the most recent Functional Abilities and Goals assessment, dated 12/21/23, indicated that for Mobility, Resident #18 required supervision or touching assistance. Review of the behavior tracking sheet for the past 14 days, 12/20/23 through 1/2/24, indicated Resident #18 had no behaviors. Review of the 3 most recent Fall Risk Assessments indicated the following scores (a score of 6 or more means the resident is at high risk for falls): -12/5/23, Resident #18 scored an 8; -10/7/23, Resident #18 scored an 6; -8/19/23, Resident #18 scored an 7; Review of the current care plans for Resident #18 indicated the following: 1. An Activities of Daily Living (ADL) care plan, last revised 4/11/23, indicated Resident #18 required assistance/dependent for ADL care in bathing, grooming, personal hygiene, dressing, bed mobility, transfer, locomotion, toileting related to weakness, chronic CHF [congestive heart failure], and anxiety. Interventions included: -Resident #18 is assisted by staff for bed mobility and positioning (last revised 6/2/21); -Resident #18 is assisted by staff for toileting and personal hygiene (last revised 6/2/21); -Resident #18 is supervised or assisted for all transfers and ambulation with a rolling walker (last revised 9/16/22). 2. A Falls care plan last revised 12/6/23, indicated Resident #18 is at risk for falls related to cognitive loss and history of falls, and decreased mobility. Interventions included: -Place call light within reach while in bed or close proximity to the bed (initiated 4/1/21); -Remind Resident #18 to use call light when attempting to ambulate or transfer (initiated 4/1/21); -Provide reminders to Resident #18 to reach back when attempting to sit in his/her chair to ensure he/she is close enough (revised 2/15/23); -Monitor for assist with toileting needs. Resident #18 will not always wait for staff assistance (revised 3/16/23). -Ensure that all of Resident #18's necessary items are within reach of him/her once he/she gets up in his/her chair (initiated 4/6/23); -Resident #18 will not always wait for staff assistance. Staff to assist Resident #18 with retrieving items from the closet as he/she will allow (initiated 6/12/23); -Encourage resident to remain in common areas when awake (initiated 10/7/23); -Remind Resident #18 during care to call for assist with any mobility including reaching (initiated 12/5/23); -Visual reminder to call for assist (initiated 12/6/23). 3. A Behavior care plan was in place; however, it failed to address behavior potentially contributing to repeated falls in his/her room. In addition, the care plan interventions to prevent falls did not address Resident #18's refusal to remain in common areas when awake (see 10/7/23 fall accident). Review of the clinical progress notes indicated Resident #18 sustained the following falls in 2023: a. On 12/29/23, Resident #18 sustained an unwitnessed fall in his/her room at 3:32 P.M. The note indicated Resident #18 fell in his/her room while walking toward the bureau to look for socks. According to the note, the new intervention put in place was to educate Resident #18 on call light use with return demonstration, despite this already being an intervention on the falls care plan since 4/1/21. b. On 12/5/23, Resident #18 had an unwitnessed fall in his/her room at 10:05 A.M. Staff responded to Resident #18's roommate yelling and found Resident #18 lying next to his/her recliner chair. The note indicated Resident #18 fell out of the chair when attempting to pick up Corn Flakes that dropped on the floor. Resident #18 had a large hematoma to the left side of the forehead and required transfer to a Hospital emergency room for evaluation. According to a follow-up note on 12/5/23 at 9:35 P.M., Resident #18 returned from the hospital and staff reminded him/her to use the call light for assistance, although this intervention had already been in place since 4/1/21. c. On 10/7/23, Resident #18 had an unwitnessed fall in his/her room at 9:45 A.M. Staff responded to Resident #18's roommate yelling and found Resident #18 on his/her back, lying on the floor, with his/her head resting on the metal foot brace of the bed. The nurse observed a scant amount of blood coming from the back right side of Resident #18's head and two large hematoma's beginning to form at the back of the head. Resident #18 was transferred to a hospital emergency room for evaluation. In the emergency room Resident #18 was treated for a .5 centimeter laceration to the back of the right side of the head. It was repaired with tissue adhesive and left open to air. d. On 8/19/23, Resident #18 had an unwitnessed fall in his/her room at 11:19 P.M. Staff heard a loud sound and someone calling out for help. Staff entered Resident #18's room and found him/her on the floor in front of the dresser. Resident #18 told the nurse that he/she was trying to get pajamas. Resident #18 was assessed to have no injury and according to the note instructed resident to call for help when he/she needs to get OOB (out of bed). e. On 6/12/23, Resident #18 had an unwitnessed fall in his/her room at 12:00 P.M., and sustained no injury. According to the report Resident #18 was trying to get clothes from the closet when he/she lost balance and fell. f. On 4/6/23, Resident #18 had an unwitnessed fall in his/her room at 9:25 A.M. Staff heard a loud noise from Resident #18's room and on entering the room, found Resident #18 on the floor. Resident #18 was half sitting and half laying down on his/her back, with a breakfast tray on the floor. Resident #18 said he/she was reaching to pick up the dietary form that was on the floor and fell. Resident #18 sustained no injury aside from complaining of bilateral knee pain. g. On 3/4/23, Resident #18 had an unwitnessed fall in his/her bathroom at 14:44 P.M. Staff entered the bathroom and found the Resident on the floor, complaining of knee pain. The Resident sustained a 1 inch bruise on the left knee and a 1-2 inch bruise on the back of the right knee. h. On 1/22/23 at 5:00 P.M., Resident #18 had an unwitnessed fall in his/her room. Staff found the Resident on the floor in front of his/her chair. No injuries were noted. Review of the Falls Incident Reports provided by the Director of Nursing (DON) indicated the following: 1. For the 12/29/23 fall, the DON provided an incident report, however the facility had not yet initiated an investigation, interviewed staff or collected statements to determine the root cause of the fall. 2. For the 12/5/23 fall, the facility's investigation consisted of three statements from staff. One of the statements indicated Resident #18's call light was right beside him/her when the fall occurred. The documented care plan intervention was to remind to use call light with a visual reminder. 3. For the 10/7/23 fall, (the Resident's 5th fall in his/her room in 2023) the facility did not collect statements from staff to investigate the root cause of the fall. The care plan was updated to encourage Resident #18 to be in the common area when awake. 4. For the 8/19/23 fall, the facility did not collect statements from staff to investigate the root cause of the fall. The care plan was not reviewed or updated. Resident #18 fell attempting to get his/her clothes, despite an intervention introduced from the previous fall on 6/12/23 for staff to assist Resident #18 with retrieving items from the closet. 5. For the 6/12/23 fall, the facility did not collect statements from staff to investigate the root cause of the fall. The care plan was updated for staff to assist Resident #18 getting items from the closet, as he/she will allow. 6. For the 4/6/23 fall, the facility obtained only one statement from staff, which indicated Resident #18 was found after a fall and assisted back to his/her chair. The incident report indicated Resident #18 was encouraged to ask for help. The care plan was updated to ensure necessary items are in place; however, the reason for the fall was overreaching to pick up a piece of paper that fell to the floor. 7. For the 3/4/23 fall, the facility did not collect statements from staff to investigate the root cause of the fall, nor was the care plan reviewed and updated. The fall occurred in the bathroom and at the time of the fall the ADL care plan indicated staff are to assist Resident #18 for toileting and personal hygiene. 8. For the 1/22/23 fall, the facility failed to provide an incident report or written statements, nor was the care plan reviewed or updated. During an interview on 1/5/24 at 11:31 A.M., with Resident #18's Certified Nursing Assistant (CNA) #4 she said she has only worked at the facility twice and that this day was the first day working with Resident #18. CNA #4 said that she was told nothing about Resident #18 having a history of falls, and that she thinks Resident #18 knows how to use the call bell if he/she needs anything, although Resident #18 had not yet used the call bell that day. CNA #4 said the only information she was given is that Resident #18 needs help to get ready in morning. During an interview on 1/5/24 at 11:36 A.M., with Resident #18's Nurse (#6) he said Resident #18 is generally very weak and needs supervision because he/she is unsteady on his/her feet. Nurse #6 said Resident #18 has been declining, needs reorientation due to memory loss and has a lot more confusion in the past couple months. Nurse #6 said he knew Resident #18 fell about two weeks ago but is not sure if he/she had any other falls in the past. Nurse #6 said the facility used to have 15 minute checks for high fall risk residents but doesn't think that they do anymore. For Resident #18, Nurse #6 said staff just try to poke in and keep an eye on him/her through the day and added I think we should encourage him/her to be out in the day room more. Nurse #6 was not aware there had been an intervention on the care plan since 10/7/23 to encourage Resident #18 to remain in common areas when awake. Nurse #6 said the Unit Manager and DON are supposed to investigate falls, including obtaining statements from staff, and updating the care plan. During an interview on 1/5/24 at 11:46 A.M., with the Nurse Unit Manager (#3) she said when a resident falls, and after they are assessed, it is the expectation a complete risk assessment be conducted. Nurse Unit Manager #3 said nursing staff are responsible for developing new interventions to prevent future fall(s) and include these in the updated care plan. Nurse Unit Manager #3 said staff working on the unit should be asked to write a statement about accidents such as when the Resident was last seen, last toileted, or any other contributing factors to the fall. Nurse Unit Manager #3 said she was concerned Resident #18 was on an antianxiety medication (Xanax) which she thinks may be contributing to the falls. Nurse Unit Manager #3 said she addressed this concern with the Physician, but she wasn't concerned. Nurse Unit Manager #3 said Resident #18 has declined a lot in the past few months and that she thinks Resident #18 would easily accept an invite to spend time in the common area when awake. During an interview on 1/5/24 at 12:00 P.M., the DON said that it was the responsibility of the nurse on the floor to manage the fall investigation. The DON said the nurse should be collecting statements from all the staff on the floor at the time of the fall. The DON said there should be a huddle on the unit following the fall to determine what happened and what interventions should be put in place to prevent another fall. The DON said this investigation process wasn't happening at this time at the facility. The DON said right now she is hoping to get statements from staff following a fall. The DON said she is aware the falls investigation and care planning update process needs to be addressed. The DON said nursing staff need to update the plan of care plan to initiate interventions that will prevent future falls. 2. For Resident #21, who has a diagnosis of epilepsy, the facility failed to ensure bilateral padded side rails were in place to prevent injury in the event of a seizure. Resident #21 was admitted to the facility in February 2022 and had diagnoses that included epilepsy and repeated falls. Review of the most recent Minimum Data Set (MDS) assessment, dated 10/18/23, indicated that on the Brief Interview for Mental Status examination Resident #21 scored an 11 out of a possible 15, indicating moderately impaired cognition. The MDS further indicated Resident #21 had no behaviors and required maximum assistance with upper and lower body care. Review of the current Physician orders indicated the following: -Monitor for s/s (signs and symptoms) of seizure activity every shift, start date 6/7/23. -Side rail padding, start date 9/8/23. Review of the current care plan for Resident #21 indicated the following: -A Seizure Disorder care plan due to epilepsy, with interventions that included protect from injury. -An Activities of Daily Living (ADL) care plan with an intervention side rail padding to upper side rails. -A Behavior care plan indicated Resident #21 refused care; however, the care plan failed to indicate any behavior of refusing siderail padding. On 1/2/24 at 8:17 A.M., the surveyor observed Resident #21 in bed, asleep. A seizure pad was affixed to the bed's right siderail, but the left bed siderail was not padded, exposing Resident #21 to the siderail should he/she have a seizure. On 1/2/24 at 9:14 A.M., the surveyor observed Resident #2 in bed, eating breakfast. A seizure pad was affixed to the bed's right siderail, but the bed's left siderail was not padded, exposing Resident #21 to the siderail should he/she have a seizure. On 1/3/24 at 9:14 A.M., the surveyor observed Resident #21 in bed, asleep. A seizure pad was affixed to the bed's right siderail, but the bed's left siderail was not padded, exposing Resident #21 to the siderail should he/she have a seizure. The left siderail seizure pad was hanging loose below the left siderail, near the floor. On 1/4/24 at 7:17 A.M., the surveyor observed Resident #21 in bed, asleep, and leaning to the left side of the bed. A seizure pad was affixed to the bed's right siderail, but the left siderail was not padded, exposing Resident #21 to the siderail should he/she have a seizure. The left seizure pad was hanging below the left siderail, near the floor. During an interview on 1/5/24 at 8:16 A.M., Nurse (#7) said Resident #21 was supposed to have padded siderails. Nurse #7 said the inside of the bed siderails should be covered with pads to protect Resident #21 should he/she have a seizure. The surveyor and Nurse #7 observed Resident #21 in bed and Nurse #7 said Oh no, that it is not on right at all and should cover the side rail to protect [the Resident]. Nurse #7 said The girls may not fix it properly when they are taking care of [the Resident], but as a nurse it is my job to make sure it is in place properly and to remind them. During an interview on 1/5/24 at 8:44 A.M., the DON said a pad should cover the entire inside of the rail when the Resident is in bed to protect him/her if he/she has a seizure.

Based on facility document review and interview, the facility failed to provide Certified Nursing Assistants (CNA) in-services, for at least 12 hours in a year, based on the outcome of performance reviews for 3 out of 3 CNA inservice records reviewed. Findings include: During review of 3 sampled CNA records, the Surveyor was unable to locate annual performance reviews for 1 of the 3. Further review failed to indicate that 3 out of 3 CNA's had been provided with at least 12 hours of training per year. During an interview on 1/4/24, the Administrator and the Director of Nursing said that all CNA's are required to complete at least 12 hours of inservices per year.

Based on observation and interviews, the facility failed to serve food that is palatable, and at a safe and appetizing temperature, on two out of three units: Findings include: During an initial tour of the C Unit on 1/2/24 the surveyors met with the residents and the following concerns were expressed: -At 7:54 A.M. Resident #71 said the food is terrible and explained it was the taste, a lot of rice and mashed potatoes and the unit was short-staffed, so food is always late. -At 8:02 A.M. Resident #34 said he/she dislikes the food served in the facility. -At 8:10 A.M. Resident #8 said he/she dislikes the food served in the facility. -At 8:15 A.M., Resident #61 said the food does not taste good. -At 8:05 A.M., Resident #90 said the food looks like garbage and tastes like garbage. -At 8:21 A.M. Resident #65 said he/she dislikes the food served in the facility. -At 8:24 A.M., Resident #12 said that the only concern he/she had was the food is not good. Review of the last three months of Resident Council Minutes indicated the following: -October 2023 actions items included juice is frozen, food is cold, not getting what's on the menu. Plan: weekly test trays. -November 2023 action items: food is cold delivered to rooms late. Plan: we take temperature before with server and we do test tray on the unit to make sure the food is hot. -December 2023 Residents state food is improved. [Staff member] explained the new order of carts to the units that will resolve the cold food tray delivery. Review of the Dietitian records binder failed to indicate weekly test trays, implemented in October 2023 as a response to Resident Council food complaints, were being conducted. A total of three test trays were conducted since October 2023. During an interview on 1/4/24 at 9:13 A.M., the Food Service Director (FSD) said the previous Dietitian would conduct test trays, but he did not conduct test trays weekly. The FSD said hot food should be served at 145 degrees Fahrenheit. During the Resident Group Meeting on 1/3/24 at 10:37 A.M., the surveyor met with 21 residents. The resident's said that the Activity Director arranges the monthly Resident Council meeting and takes the meeting minutes, including documenting their concerns. The following month she hands out the prior meeting summary, including what the response was to the complaints that they have made. The residents said we do not get resolution and month after month the same concerns are voiced. They indicated the following: -A resident stated, they forget to turn on the food plate warmer or they are not used consistently and the doors are left open (to the food truck) while they pass the trays. -Another resident added if people ask what I am eating I can't tell. -15 of 21 resident said that even though the food is an issue month after month, it still remains an issue of concern -17 of 21 residents said that the food is consistently not hot; -17 of 21 residents said that the taste of the food is poor and that no seasoning or seasoning packets are provided. On 1/3/24 at 8:33 A.M., the C Unit food truck arrived to the resident care unit. The surveyor observed the tray pass process and observed that one of the doors on the food truck remained open throughout the entire tray passing process. After all resident trays were served the surveyor received the test tray at 8:49 A.M., and the following was recorded and observed: -Scrambled eggs had a rubbery texture; the eggs had areas of brown coloration consistent with overcooking, and had no perceivable seasoning. The eggs were 88 degrees Fahrenheit and tasted room temperature, not hot; -Toast was 73.5 degrees Fahrenheit; -Hashbrown had an unpleasant texture, a combination of crunchy and difficult to chew which required a knife to cut a piece off. The hashbrown was 82 degrees Fahrenheit and tasted cool, not hot; -Oatmeal was 122 degrees Fahrenheit and tasted warm; -Milk was 44 degrees Fahrenheit and cool to the taste; -Juice was 36 degrees Fahrenheit but not fully defrosted, and the juice had large chunks of ice floating in it; -Coffee was 132 degrees Fahrenheit, was warm to taste, but tasted watery. On 1/3/24 at 8:39 A.M., the Transitional Care Unit food truck arrived to the resident care unit. After all resident trays were served the surveyor received the test tray at 8:43 A.M., and the following was recorded and observed: -The surveyor observed one staff member tell another staff member the smell of this truck makes me a nauseous; -Scrambled eggs were 120 degrees Fahrenheit and tasted lukewarm not hot; -The hashbrown was 99 degrees Fahrenheit but tasted cool, not hot. The hashbrown had a rubbery texture; -The toast was 50 degrees Fahrenheit and tasted cold; - The coffee was 162 degrees and was too hot to swallow; - The oatmeal was 158 degrees Fahrenheit and tasted bland; - The milk was 40 degrees Fahrenheit and tasted cool; - The juice was 42 degrees Fahrenheit and tasted cool.

Based on record review policy review, and interview the facility failed to ensure that at least 12 hours of in-service training was completed for three of three Certified Nurse Aides (CNAs). Findings include: Review of the Facility Assessment Tool, most recent revision dated 11/21/2023, indicated but was not limited to the following: Staff training/education and competencies Training for nurses' aides includes: -Required in-service training for nurses' aides, in-service and training must: -Be sufficient to ensure the continuing competence of nurses' aides and must be no less than 12 hours per year. -Include dementia management training and resident abuse prevention training. -Address areas of weakness as determined in nurses' aide performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff. For nurses' aides providing services to individuals with cognitive impairments, also addresses the care of cognitively impaired. -Identification of resident changes in condition including how to identify medical issues appropriately, how to determine if symptoms represent problems in need of intervention, how to identify when medical interventions are causing rather than helping relieve suffering or improve quality of life. Consider the following competencies: -Person centered care -Activities of daily living -Disaster planning procedures -Infection control, medication administration-measurements: blood pressure, orthostatic blood pressure, body temperature, urinary output including urinary drainage bags, height and weight, radial and apical pulse, respirations, recording intake and output, urine test for glucose/acetone. Review of the training records for three of three CNA records reviewed failed to indicate that the required yearly 12 hour training was completed. All three CNA training records failed to indicate that dementia training and abuse training had occurred. During an interview on 1/4/24, at 10:30 A.M., the Human Resource Director said that she was not able to locate any more training records other than what was given to the surveyor.

Based on observations, record review and interview, the facility failed to ensure that 1. Sufficient staffing levels were maintained to adequately meet residents' care needs. 2. For Resident #44, who is dependent on staff for personal hygiene and grooming, the facility failed to remove unwanted facial hair, which the staff attributed to being short staffed. Findings include: 1a.) Review of the facility assessment, dated as reviewed 11/21/23, indicated the following during a typical month: -An average daily resident census of 120 with a facility capacity for 126 residents. -The daily number of Certified Nurse's Aides (CNA) required to care for residents in the facility is 31 full time equivalents (FTE's); 1.00 hours per resident per shift on the 7 A.M.- 3 P.M. and 3 P.M.-11 P.M. shifts and .4 hours per resident per shift on the 11 P.M.-7 A.M. shift. -The Facility Assessment failed to indicate if staffing levels change based on the acuity level of the residents and failed to indicate what the current acuity level of the residents is. Review of the staffing schedules dated 12/1/23, through 12/31/23, indicated the facility failed to ensure staffing levels for CNA's were maintained at the level their facility assessment indicated was needed to safely and adequately meet each resident's personal care needs. Further review indicated the following: - On 7 A.M.-3 P.M. 30 out of the 31 shifts did not meet the required number of hours. - On 3 P.M.-11 P.M. 31 out of the 31 shifts did not meet the required number of hours. - On 11 P.M.-7 A.M. 13 out of the 31 shifts did not meet the required number of hours. 1b.) During the Resident Group meeting on 1/3/24 at 10:37 A.M., the surveyor met with 21 residents. Twenty of 21 residents said there are not enough staff to meet their needs. They said waiting an hour for their call bell to be answered is a regular occurrence. The residents said that they complain about this monthly at the facility's Resident Council meeting and added we do not get resolution. 1c.) Review of the December 2023 Grievance Log Book included the following grievances: -12/28/23 Grievance: Son reported that his dad called him last night and reported waiting 1 hour for his call light to be answered. Resolution: Staff reminded that call lights need to be answered. Staff report that the light was answered timely. -12/27/23 Grievance: Reports long wait times anytime she rings the call light. Resolution: Staff to be educated on call light response time. -12/6/23 Grievance: Reports waiting over 30 minutes to get anyone to answer call light. Resolution: Staff to improve response time and educated on this importance. 2. Review of the facility policy titled Activities of Daily Living (ADL's), Supporting, dated as revised March 2018, indicated that residents who are unable to carry out ADL's independently will receive the services necessary to maintain good grooming. Resident #44 was admitted to the facility in December 2023 with diagnoses including heart failure and generalized muscle weakness. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/19/23, indicated that Resident #44 scored a 13 out of 15 on the Brief Interview for Mental Status exam, indicating intact cognition. The MDS further indicated that Resident #44 requires substantial assistance for ADL completion. Review of the current ADL care plan indicated that Resident #44 requires an assist of one staff member to complete personal hygiene tasks. Further review failed to indicate that Resident #44 refuses care. On 1/2/24 at 8:30 A.M., the surveyor observed Resident #44 with a significant amount of 1/2 inch long white hair on her/his chin. On 1/3/24 at 9:25 A.M. the surveyor observed Resident #44 with a significant amount of 1/2 inch long white hair on her/his chin. During an interview on 1/3/24 at 9:26 A.M., Resident #44 said that he/she certainly would like for someone to help him/her to remove the chin hair. Resident #44 said that none of the staff had offered to remove the chin hair and it is embarrassing. Resident #44 then said that there doesn't seem to be enough staff and you have to wait a long time for them to help you. On 1/3/24 at 12:35 P.M., the surveyor observed Resident #44 with a significant amount of 1/2 inch long white hair on her/his chin. On 1/4/24, at 8:25 A.M., the surveyor observed Resident #44 with a significant amount of 1/2 inch long white hair on her/his chin. During an interview on 1/4/24, at 8:25 A.M., Resident #44's Certified Nursing Assistant (CNA) #1 said that it is the responsibility of the CNA's to shave the residents but sometimes there just isn't enough time. She then said that most of the time they are short staffed and it is difficult to complete everything that is expected. During an interview on 1/4/24, at 2:00 P.M., the director of Nursing and the Administrator said that they are aware that the facility is short CNA staff and that they are trying to hire more CNA staff.

Based on observation, policy review, and interview, the facility failed to store food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure staff did not store their drinks with resident food ingredients and that food was labeled and not kept beyond the use-by date in the main kitchen and the A unit Kitchenette. Findings include: Review of the undated facility's policy titled Preventing Foodborne Illness - Food Handling, revised July 2014, indicated, but is not limited to, the following: - Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. On 1/2/24 at 7:01 A.M., during the initial walkthrough of the main kitchen the surveyor made the following observations: - An energy drink was in the walk-in refrigerator, stored with resident food and ingredients. - Sliced cheddar cheese opened, unlabeled and undated, in the walk-in refrigerator. - A container labeled chicken with a use-by date of 12/31/23 in the walk-in refrigerator. - A container labeled egg salad with a use-by date of 12/29/23 in the walk-in refrigerator. - A container labeled pudin (sic.) with two dates, 12/30/23, and 12/1/24. - A container of hard boiled eggs labeled 12/19 During an interview on 1/2/24 at 7:10 A.M., the cook said the energy drink belonged to her. On 1/2/24 at 7:30 A.M., during the initial walkthrough of the A unit kitchenette the surveyor made the following observations: - A bottle of prune juice, opened and undated. - Two containers of take-out food undated and unlabeled Review of a sign posted on the refrigerator indicated the following: -Resident refrigerator only. -Please label any resident food items with: -Resident name; -Date item was brought in; -Date of expiration. -All unlabeled & undated items will be discarded. On 1/2/24 at 7:40 A.M., the surveyor made the following observations inside the unlocked A unit dining room refrigerator: -Tabouleh salad with a sell-by date of 11/25/23; -Cheese pizza in a pizza box, undated; -Two yogurts with best by dates of 09/24/23; -One yogurt with a best by date of 10/3/23; -One yogurt with a best by date of 11/20/23; -One yogurt with a best by date of 11/3/23. On 1/4/24 at 9:40 A.M., the surveyor observed that the A unit dining room refrigerator remained unlocked, and residents continued to have access to the refrigerator containing expired food. During an interview on 1/4/24 at 9:13 A.M., the Food Service Director (FSD) said all food must be labeled with a prepared or opened date, and a use by date. The FSD said that all opened or prepared foods must be discarded after three days and/or beyond the use by date. The FSD said the hard boiled eggs were labeled with the date they were received at the facility, and should have also been dated the day they were open. The FSD said that the labels are available on each unit kitchenette and that nursing is expected to label resident leftovers before storing in the kitchenette refrigerators. The FSD said staff drinks should not be stored with resident food even if the drink is unopened, the FSD said staff should store their drinks in the staff break room. The FSD said the dinning room refrigerator should either be cleaned out or locked so that expired and potentially hazardous food is not accessible to residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3) For Resident #76 the facility failed to accurately transcribe the physician order for an alternate wound dressing. Resident #76 was admitted to the facility in March 2023 with diagnoses including pressure ulcer of sacral region Stage 4, and moderate protein calorie malnutrition. Review of the most recent Minimum Data Set assessment, dated 12/7/23, indicated Resident #76 scored a 14 out of 15 on the Brief Interview for Mental Status examination, indicating intact cognition. Review of Resident #76's current physician orders indicated the following orders: -Wound Vac/NPWT (negative pressure wound therapy) dressing: to sacrum: Cleanse wound bed with Normal Saline, pat dry. Apply skin prep to periwound. Cut sponge to wound size and place in wound. Cover with Transparent Dressing. Attach NPWT at [125 mmHg] Continual. initiated 5/26/23; - If NPWT malfunctioning; apply H-Chlor 12 (Dakins Solution) moist gauze and cover with dry protective dressing until NPWT can be replaced or new treatment ordered. and notify NP MD. Initiated 12/20/23 Review of Resident #76's most recent wound clinic visit note, dated 12/20/23, indicated the following regarding his/her coccyx pressure ulcer: -They will replace the negative pressure wound therapy device in his/her skilled nursing facility, if the negative pressure wound therapy device can not be used please use the quarter strength Dakin's solution wet to dry. Review of Resident #76's nurse progress note, dated 12/20/23, indicated the following: - Resident #76 returned to unit from wound clinic before dinner. New order to use Dakins Solution Wet to Dry PRN [as needed] when wound vac is not placed secondary to loose stool incontinence. Resident #76 had loose stool large amount. New Wet to Dry dressing applied using Dakins Solution. Review of Resident #76's medical record indicated a nurse progress note, written by Nurse (#5) on 01/01/24 which indicated the following: -Wet to Dry Dakins solution Dressing applied secondary to stool incontinence Further review of the nurse progress notes indicated that the wound vac was not applied and the wet to dry alternative dressing was used on 01/01/24, 12/30/23, 12/29/23, 12/27/23, 12/22/23, and 12/21/23. During an interview on 1/4/24 at 12:18 P.M., Nurse #5 said Resident #76 frequently required the alternate dressing secondary to loose stools, and occasionally for refusal, per the wound clinic's recommendations. Nurse #5 said that the wound vac has never malfunctioned. During an interview on 1/4/24 at 11:15 A.M., Nurse Unit Manager (#3) said orders should be transcribed accurately and should be specific. Nurse Unit Manager #3 said the current order for the alternate dressing did not accurately reflect the wound clinic recommendation as it was written. Nurse Unit Manager #3 said the order has been utilized for loose stools primarily, and that the wound vac has never malfunctioned. Nurse Unit Manager #3 said the order should specify that the alternate dressing can be utilized for loose stools and not just for a malfunctioning wound vac as a nurse who is not familiar with Resident #76 may not know that the alternate dressing could be used outside of a malfunctioning wound vac. During an interview on 1/4/24 at 2:04 P.M., the Director of Nursing said physician orders should be transcribed accurately. 4) For Resident #11 the facility failed to accurately document in the Treatment Administration Record (TAR) regarding an air mattress setting. Review of the facility policy, titled Support Surface Guidelines, revised September 2013, indicated, but was not limited to, the following: -Redistributing support surfaces are to promote comfort for all bed - or chairbound residents, prevent skin breakdown, promote circulation and provide pressure relief or reduction. -Support surfaces alone are not effective in preventing pressure ulcers, but studies indicate that the use of appropriate support surfaces with interventions such as turning, repositioning and moisture management can assist in reducing pressure ulcer development. -Support surfaces are modifiable. Individual residents' needs differ. Resident #11 was admitted to the facility in July 2023 with diagnosis including dementia. Review of the Minimum Data Set (MDS), dated [DATE], indicated that Resident #11 scored a 15 out of 15 on the Brief Interview for Mental Status examination indicating the Resident is cognitively intact. Further review of the MDS indicated Resident #11 is dependent on staff assistance for bed mobility and transferring out of bed. Review of Resident #11's physician orders indicated the following order, initiated 10/25/23: -Air mattress to bed at all times (weight Range Setting: 160 lbs.). Check setting and function every shift. Review of Resident #11's Care plans indicated the following: -Resident #11 has potential for pressure ulcer development related to limited mobility, frail fragile skin, decreased activity -Air mattress to bed; monitor setting and function as ordered During an interview and observation on 1/2/24 at 8:25 A.M., the surveyor observed Resident #11 lying in bed, the Resident said his/her bed was uncomfortable as the mattress is too firm. The surveyor observed the air mattress control for the bed, the arrow was set between 160 and 240 pounds and was much closer to 240 pounds than it was to 160 pounds. On 1/2/24 at 1:35 P.M., the surveyor observed Resident #11 lying in bed, the air mattress control was set between 160 and 240 pounds and was much closer to 240 pounds than it was to 160 pounds. On 1/3/24 at 08:37 A.M., the surveyor observed Resident #11 lying in bed, the air mattress control was set between 160 and 240 pounds and was much closer to 240 pounds than it was to 160 pounds. Review of Resident #11's TAR indicated that a nurse had signed off that the air mattress setting was checked on the 1/2/24 day shift, evening shift, and night shift. During an interview and observation on 1/3/24 at 10:12 A.M., Nurse #4 said an air mattress should be set according to a resident's physician order, and that the function and setting of the air mattress should be checked every shift. Nurse #4 said that if the setting is not what is ordered it must be adjusted. Nurse #4 said Resident #11 utilized an air mattress for comfort as the Resident was on hospice services, but also because the Resident had a history of a pressure ulcer. Nurse #4 observed Resident #11's air mattress control which was set between 160 and 240 pounds and was much closer to 240 pounds than it was to 160 pounds. Nurse #4 said the setting was incorrect as the air mattress needed to be set to 160 pounds, and that this would need to be adjusted. Nurse #4 said that if an air mattress was too firm it may damage the Resident's skin. During an interview on 1/23/24 at 10:21 A.M., Unit Manager #3 said nurses should check setting and function of air mattresses every shift, and that as part of this check nurses should adjust the setting if it is not set according to the Resident's physician order. During an interview on 1/3/24 at 10:37 A.M., the Director of Nursing (DON) said nurses should check setting and function of air mattresses every shift, and as part of this check nurses should adjust the setting if it is not set according to the Resident's physician order. The DON also said that nurses should not sign off that an order for a mattress setting was completed when it was not. 2. For Resident #67, who has a stage III pressure ulcer on his/her foot, the facility documented that his/her heels were offloaded on a heels up cushion, as ordered by the physician when they were not. Resident #67 was admitted to the facility in June 2022 and had diagnoses that included dementia and pressure induced deep tissue damage of the left heel. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/1/23, indicated that on the Brief Interview for Mental Status exam Resident #67 scored an 6 out of a possible 15, indicating severely impaired cognition. The MDS further indicated Resident #67 had no behavior of rejecting care and required maximum assistance from staff for lower body care. Review of the current Physician orders included an order: heels up cushion, every shift for offloading of bilateral heels, start date of 9/6/22. Review of the January 2024 Treatment Administration Record (TAR) indicated that nursing had signed off all 3 shifts, each day in January, that the heels up cushion was in place. Review of the current skin care plan for Resident #67 indicated the following interventions: -Offload heels, dated as revised 2/15/23 -Offloading booties while in bed as resident will allow/tolerate, dated as revised 2/15/23. On 1/2/24 at 12:46 P.M., Resident #67 was observed in bed asleep, with his/her feet flat on the mattress. There was no heels up cushion or booties observed in the bed or vicinity, and Resident #67's heels were not offloaded. On 1/4/24 at 7:19 A.M., Resident #67 was observed in bed asleep, with his/her feet flat on the mattress. There was no heels up cushion or booties observed in the bed or vicinity, and Resident #67's heels were not offloaded. On 1/4/24 at 8:57 AM., Resident #67 was observed in bed asleep, with his/her feet flat on the mattress. There was no heels up cushion or booties observed in the bed or vicinity, and Resident #67's heels were not offloaded. During an interview on 1/5/24 at 10:19 A.M., with Resident #67's Certified Nursing Assistant (CNA) # 3 she said that she was not aware that Resident #67 was supposed to have his/her heels offloaded. During an interview on 1/5/24 at 10:23 A.M., with the Nurse Unit Manager (#3) she said that nurses should not be documenting in the TAR that a heels up cushion is in place, when it is not. Based on observation, record review and interview, the facility failed to maintain an accurate medical record for three Residents (#110, #67 and #76 ) out of a total sample of 28 residents. Specifically, 1. For Resident #110 the facility failed to ensure that Enteral feeding orders were not conflicting. 2. For Resident #67, who has a stage III pressure ulcer on his/her foot, the facility documented that his/her heels were offload, as ordered by the physician and wound physician, when they were not. 3. For Resident #76, the facility failed to accurately transcribe the physician order for an alternate wound dressing. Findings include: Review of the facility policy titled Enteral Feedings- Safety precautions, dated revised November 2018 indicated the following: Check the Enteral nutrition label against the order and the rate of administration, before administration. 1. Resident #110 was admitted to the facility in November 2023 with diagnoses including dysphagia (difficulty swallowing) and stroke. Review of the most recent Minimum Data Set (MDS) assessment, dated 12/4/23, indicated that Resident #110 scored a 3 out of 15 on the Brief Interview for Mental Status exam, indicating severely impaired cognition. The MDS further indicated that Resident #110 required substantial/maximal assistance-helper does more than half the effort for eating. On 1/2/24, at 8:15 A.M., and 11:22 A.M., the surveyor observed Jevity 1.5 cal (calorie) G-tube (gastric tube) feeding running at 75 ml/Hr. (milliliters/hour). into the trash can. The surveyor also observed that approximately 400 ml was left in the bottle. Review of the doctor's order indicated the following two conflicting active orders for Enteral feedings: A) dated 12/11/23, indicated an active order for Enteral Up/Down Schedule: Feed Up at PM Down at 6 am; in the evening Jevity 1.5 75 ml/hr 150 ml flush every 4 hours AND in the morning for Jevity 1.5 75 ml/hr B) dated 12/18/24, indicated an active order for Enteral Feeding via G-tube .Jevity 1.5. up at 3:00 P.M. down at 9:00 A.M. 50 ml/hr. in the afternoon for feeding up at 3 p.m. , in the morning for feeding down at 9:00 A.M. or until full amount given. Review of the Medication Administration Records dated December 2023 and January 2024 indicated that Resident #112 received the following G-tube feeding: Enteral Up/Down Schedule: Feed Up at PM Down at 6 am; in the evening Jevity 1.5 75 ml/Hr. On 1/3/24, at 7:23 A.M. the surveyor observed a bottle of Jevity 1.5 hanging with the feeding pump set at 75 ml/Hr. During an interview on 1/3/24, at 1:06 P.M., the Dietitian said that a person can not have more than one order for tube feeding and that she didn't know why Resident #112 had two different orders for tube feeding. The Dietitian then said that when a new order is written the old one should be discontinued. On 1/4/24, at 7:05 A.M., the surveyor observed the tube feeding pump in the Resident's room running at 75 ml/Hr with 200 ml left in the bottle. During an interview on 1/04/24, at 7:10 A.M., Nurse #9 said that the tube feeding pump is running at 75 ml/Hr as ordered. The surveyor and Nurse #9 then reviewed the current doctor's order which read for Enteral Feeding via G-tube .Jevity 1.5. up at 3:00 P.M. down at 9:00 A.M. 50 ml/hr. in the afternoon for feeding up at 3 p.m., in the morning for feeding down at 9:00 A.M. or until full amount given. Nurse #9 said that she had been documenting on the wrong order.

Based on observations, interviews and record review, the facility failed to 1. Perform hand hygiene before entering and exiting a room with isolation droplet/contact precautions, specifically, a room with a resident positive with COVID-19 (Coronavirus disease 2019) on the B unit. 2. Maintain monthly chlorine water testing and weekly water pressure testing as a measure to prevent the growth of Legionella and other waterborne pathogens and 3. Failed to disinfect blood pressure cuffs between residents. Findings include: Review of the facility policy titled Handwashing/Hand Hygiene, with a revision date of August 2019, indicated the following: -Use an alcohol-based hand rub containing at least 62%alcohol or alternatively soap and water for the following situations: (f) Before donning gloves (m)After removing gloves (n) Before and after entering isolation precaution settings Review of the facility policy tilted Legionella Water Management Program. with a revision date of July 2017, indicated the following: -Our facility is committed to the prevention, detection and control of water borne contaminants, including Legionella. -The water management program includes the identification of situations that can lead to Legionella growth such as water pressure changes, the presence of biofilm, scale or sediment and inadequate disinfection. Review of a list of all logs and inspections to be maintained by the facility indicated the following: -Chlorine testing monthly Review of the weekly water report form indicated the following needed to be completed: -Line and tank pressures 1. During an observation on 01/03/24 at 8:19 A.M., Certified Nurse's Assistant (CNA) #4 was observed entering a resident's room carrying a breakfast tray. A sign at the entryway to the room indicated that the resident in the room was on isolation droplet/contact precautions. The sign instructed staff to Clean hands when entering and exiting. CNA #4 did not perform hand hygiene prior to entry, carried the breakfast tray in and placed it on a table in the room. Then, without performing hand hygiene, CNA #4 exited the room, walked down the hall, and grabbed a tray table, that she pushed back to the room. Without performing hand hygiene, CNA #4 donned a pair of gloves, pushed the tray table into the room, cleaned the table with a wipe, then placed the breakfast tray on the tray table. CNA #4 doffed the gloves in the room, and without performing hand hygiene, exited the room. During an interview on 1/3/24 at 8:27 A.M., CNA #4 said she should have performed hand hygiene before entering and exiting a room with COVID-19 isolation precautions. As well, she said she should have performed hand hygiene before donning gloves and immediately after she doffed the gloves. During an interview on 1/5/24 at 10:06 A.M., with the Director of Nursing and the Infection Preventionist they said staff are expected to perform hand hygiene before entering and exiting a room with isolation precautions. As well, they said that staff are expected to perform hand hygiene before donning gloves and immediately after doffing gloves. 2. A record review of the Legionella water management program indicated the following: -Since the last survey on 11/10/22 to 12/31/23, there was no documented monthly chlorine testing and weekly water pressure testing. During an interview on 1/5/24 at 8:50 A.M., the Administrator and Maintenance Director said the facility water management program has not been up to par for a while. The Administrator said he has had difficulty keeping a Maintenance Director in the position and that he just hired the new Maintenance Director who started in November 2023. Both the Maintenance Director and the Administrator said they could not find any documentation indicating that the weekly water pressure and monthly chlorine testing was done from 11/10/22 to 12/31/23, and that it is the expectation that chlorine is tested monthly, and the water pressure is tested weekly. 3. Review of the facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment, dated as revised October 2018, indicated that durable medical equipment must be cleaned and disinfected before reuse by another resident. On 1/2/24, at 8:08 A.M., the surveyor observed Nurse #2 exit a resident's room on the A unit after taking a resident's vital signs and enter another resident's room and took vital signs without cleaning the blood pressure equipment. During medication pass on 1/3/24, at 8:55 A.M., on the C unit, the surveyor observed Nurse #3 obtain the blood pressure of a resident. The surveyor then observed Nurse #3 obtain the blood pressure of the resident's roommate without disinfecting the blood pressure cuff first. During an interview on 1/3/24, at 8:53 A.M. Nurse #3 said he didn't disinfect the blood pressure cuff between patients and should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop and implement a comprehensive care plan related to a pacemaker (an implanted device to help control heartbeat) for 1 Resident (#23) out of a total sample of 25 residents. Findings include: Review of the facility's policy titled, Care of a Resident with a Pacemaker, not dated, indicated: 1. For each resident with a pacemaker, document the following in the medical record and on a pacemaker identification card upon admission: a. The name, address and telephone number of cardiologist; b. Type of pacemaker; c. Type of leads; d. Manufacturer and model; e. Serial number; f. Date of implant; and g. Paced rate. 2. When the resident's pacemaker is monitored by the Physician, document the date and results of the pacemaker surveillance, including: a. How the resident's pacemaker was monitored (phone, office, internet); b. Type of heart rhythm; c. Functioning of the leads; d. Frequency of utilization; and e. Battery life. 3. Ensure the presence of a care plan related to the resident's Cardiovascular condition, the placement and ongoing care, support and monitoring thereof. Review of the American Heart Association guidelines for pacemaker monitoring titled Living with your pacemaker indicated: - After you have your pacemaker implanted, your doctor will go over detailed restrictions and precautions. Make sure that you and your caregiver fully understand these instructions. Don't be afraid to ask questions. - Before you leave the hospital, be sure to understand your pacemaker's programmed lower and upper heart rate. Review of the American Heart Association guidelines for pacemaker monitoring titled 'Checking in on your device' indicated the following: Modern pacemakers are built to last. Still, your pacemaker should be checked periodically to assess the battery and find out how the wires are working. Be sure to keep your pacemaker checkup appointments. At such appointments: - Your doctor will make sure your medications are working and that you ' re taking them properly. - You can ask questions and voice any concerns you may have about living with your pacemaker. Make sure you and your caregiver understand what your doctor says. It's a good idea to take notes. - Your doctor will use a special analyzer to reveal the battery's strength. This diagnostic tool can reveal a weak battery before you notice any changes. - Eventually, the battery may need to be replaced in a surgical procedure. This replacement procedure is less involved than the original surgery to implant the pacemaker. Your doctor can tell you about the procedure when the time comes. Resident #23 was admitted in August of 2021 with diagnoses that included presence of cardiac pacemaker, chronic diastolic (congestive) heart failure unspecified atrial fibrillation, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. On 11/8/22 at 8:38 A.M., this surveyor observed a Boston Scientific Latitude pacemaker monitoring system on night stand next to Resident #23's bed with a green light on. Review of Resident #23's clinical record failed to indicate a care plan or any physician's orders regarding the ongoing monitoring of his/her pacemaker. Review of Resident #23's nursing progress notes indicated a note written on 8/22/2021 at 4:31 P.M., which- Pacemaker site is covered with drsg. C/D/I. Education was provided to patient Material used: verbal Content taught: reporting any pain to chest or pacemaker site to nurse. Additional review of Resident #23's medical record indicated a Practitioner Note dated 2/3/2022 at 9:43 P.M., indicated the following- This is a [AGE] year-old who was initially admitted to [NAME] health on August 12, 2021 due to mental status change.Patient underwent submuscular dual-chamber permanent pacemaker placement TSH B12 and folate were all within normal limits, sodium level improved to 133 upon discharge he/she was transferred to [NAME] house for short-term rehab care. During an interview and review of Resident #23's medical record on 11/10/22 at 7:58 A.M., Unit Manager #1 acknowledged there was not a plan of care in place for Resident #23's pacemaker and said there has not been any communication from cardiology with the facility. Unit Manager #1 said the details of the pacemaker paced rate is unknown among other details. During an interview on 11/10/22 at 8:10 A.M., the Assistant Director of Nursing (ADON) said the expectation for Resident's with a pacemaker is to have a plan of care in place so nursing knows how to care for the resident appropriately. The ADON said she would also expect there to be communication between the facility and cardiology. During an interview on 11/10/22 8:54 A.M., Nurse Practitioner #1 said she would expect that nursing would develop a plan of care for the pacemaker and have communication with cardiology. During an interview on 11/10/22 9:00 A.M., Nurse #2 said she was not aware that Resident #23 had a pacemaker, this surveyor inquired about the Boston Scientific Latitude pacemaker monitoring system and Nurse #2 said I was wondering what that box was.

Based on observation, record review and interview, the facility failed to provide adequate supervision and implement and update a falls care plan resulting in falls for 1 Resident (#97) out of a total of 25 sampled residents. Findings include: Review of the facility's Fall Reduction policy, dated 1/10/17 indicated: *Universal Safety Standards must be implemented on admission for all residents as listed below: Orient resident to room. Personal belongings and assistive aids - purse, wallet, books, tissues, cane or walker within easy reach. Instruct resident to rise slowly from a supine position to avoid possible dizziness and loss of balance. Remind resident to move slowly an cautiously in his/her environment. Keep room free from clutter, clear path to bathroom. Provide adequate lighting. Instruct resident to ask for help. *In the event a resident falls the following measures will be instituted: Evaluate why the resident may have fallen. Implement interventions as appropriate to prevent recurrence. Resident #97 was admitted to the facility in April 2021 with diagnoses including Parkinson's disease. Review of his/her Minimum Data Set Assessment indicated he/she is moderately cognitively impaired and requires assistance with ambulation, dressing and toileting. Record review indicated a physician's order to activate Resident #97's Health Care Proxy on 9/15/21, indicating Resident #97 is not his/her own decision maker. On 11/8/22 at 8:09 A.M., the surveyor observed Resident #97 on his/her side on the floor of his/her room. Staff were present and responding to his/her fall. Review of Resident #97's care plans indicated: Resident #97 is at risk for decreased ability to perform Acitivies of Daily Living (ADL), 4/21/21 Goal: Resident ADL care needs will be anticipated and met throughout the next review period. Interventions: Resident is supervised to assist for bathing, grooming, dressing, bed mobility and positioning, toileting, 6/2/21. Resident #97 has impaired/decline in cognitive function or impaired thought process, 4/9/21: Goal: Resident's functional ability will be optimized through modifications and alterations within their environment. Interventions: Observe and evaluate types of changes in cognitive status, Administer pain medications as ordered and document the effectiveness, side effects break down tasks to support short-term memory decline and provide cueing/assistance as needed. , stress key words and present just one thought, question or command at a time. Resident #97 is at risk for falls, impaired mobility Parkinson's, frequent falls, 4/2/21 Goal: Resident should have no falls with injury X 90 days Interventions: Provide verbal cues for safety and sequencing as needed, provide verbal cues for proper pacing and energy conservation techniques, remind resident to use call light when attempting to ambulate or transfer, maintain a clutter free environment in the resident's room and consistent furniture, place call light within reach while in bed or close proximity to the bed 4/2/21; Provide with education for safe techniques when feeling dizzy while ambulating or transferring, 6/2/21, When resident is in bed, place all necessary personal items within reach, 9/15/21. Review of Resident #97's fall incident reports indicated he/she sustained 12 falls from June 2022 through November 2022. The incident reports indicated the following: On 6/25/22 at 9:50 A.M. Resident #97 was bringing food from his/her bed to the bedroom door to get heated, then stated he/she was falling asleep and knees got weak. Staff then rushed over and assisted Resident to the floor. There were no updates to his/her fall care plan. On 6/28/22 at 12:29 P.M. Resident #97 was found on floor of his/her room and said he/she was trying to clean out his/her trash can. Updates to Resident #97's fall care plan indicated: Staff to assist Resident with emptying of trash can. (An intervention already taking place by housekeeping staff.) Continue to provide resident education and reminders on utilizing assistive device when transferring. (An ineffective intervention as Resident #97's cognition would not allow him/her carry over to retain education or reminders) On 7/16/22 at 9:00 A.M., Resident #97 was observed by a Certified Nurses Aide (CNA) to be losing his/her balance and CNA was able to lower Resident to the floor. Updates to Resident #97's care plans included: Continue working with PT/OT services (An intervention which does not detail a method or means to prevent recurrence.) When Resident is in recliner, place all necessary personal items within reach. (A Universal Safety Standards as outlined in the facility's policy.) On 8/11/22 at 8:00 A.M., Resident #97 was found on floor of his/her room by the end of his bed and said he/she got dizzy and fell. Updates to Resident #97's care plan indicated: Encourage Resident to lay down and rest and take periods of rest when feeling dizzy. On 8/25/22 at 9:20 A.M. Resident #97 was witnessed losing his/her balance and falling backwards landing on buttocks in room. There were no updates to his/her fall care plan. On 9/9/22 at 9:00 A.M. Resident #97 was found on the floor of his/her bathroom on one knee and said he/she felt dizzy and fell. In bathroom on one knee. There were no updates to his/her fall care plan. On 9/16/22 at 10:45 A.M. Resident #97 was found on the floor of his/her room and said that he/she had felt dizzy and fell. Updates to Resident #97's fall care plan indicated a medication review. There was no follow up regarding the outcome of the medication review or if any medications were found to have contributed to his/her fall. On 9/24/22 at 1:50 A.M. A.M., Resident #7 was found on the floor of his/her room and said he/she was trying to go to the bathroom and did not have his/her walker with him/her. Resident said he/she was going to use the bathroom. Did not have walker. Updates to Resident #97's fall care plan indicated for staff to monitor for and assist with toileting as needed as resident will allow throughout shifts. (Resident #97's ADL care plans indicated he/she had required supervision to assistance with toileting since 2021.) On 9/28/22 9:45 A.M. Resident #97 was found on floor by the doorway to his/her room and sustained skin tears. Updates to Resident #97's fall care plan included to encourage to ask for assistance when trying to get up without a walker and when he/she is trying to dress himself/herself. (An ineffective intervention as Resident #97's cognition would not allow him/her carry over to retain education or reminders) On 10/4/22 at 9:50 A.M. Staff found Resident #97 laying in doorway of his/her room. Updates to his/her fall care plan included : Orthostatic blood pressures X 3 days. (There was no follow up documented about the outcome of the blood pressure monitoring and no ongoing interventions implemented regarding his/her falls.) On 10/24/22 11:15 A.M. Resident #97 was sitting on the floor at the foot of the bed. Resident #97 said he/she was attempting to walk to the hallways when he/she lost his/her balance and fell. A witness statement indicated staff had seen Resident #97 standing in front of his/her recliner 5 minutes prior to the fall, but failed to indicate that staff approached Resident #97 when they saw him/her standing as he/she requires supervision with ambulation. Updates to Resident #97's fall care plan indicated for family to alert nursing staff of outings prior to pick up to avoid increased anxiousness with resident. On 11/8/22 at 8:00 A.M., staff found resident laying by the radiator in his/her room and Resident stated he/she was walking lost his/her balance and his/her legs felt weak resulting in a fall. Resident was unable to say where or what he/she was attempting to go/do at the time of the fall. Updates to Resident #97's fall care plan indicated: Resident is encouraged to use walker/assistive device when ambulating/transferring as well as ask for assistance when feeling weak. (An ineffective intervention as Resident #97's cognition would not allow him/her carry over to retain education or reminders) During an interview with the Director of Nursing on 11/9/22 at approximately 12:45 P.M., she said that resident fall care plans should be updated with new interventions after a fall occurs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain accurate medical records for 2 Residents (#22 and #116) out of a total sample of 25 residents. Findings include: Review of facility policy titled 'NSG113 Nursing Documentation' revised 11/01/19 indicated that nursing documentation will follow the guidelines of good communication and be concise, clear, pertinent, and accurate. 1. For Resident #116 the facility failed to ensure a nurse's note was accurate. Resident #116 was admitted to the facility in October 2022 with diagnoses including urinary tract infection, acute kidney failure and Alzheimer's Disease. Review of Resident #116's Minimum Data Set assessment dated [DATE] indicated the Resident was severely cognitively impaired and scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS). The MDS further indicated the Resident had no hallucinations or delusions, had physical and verbal behavioral symptoms and rejected care 1 to 3 days out of the previous 7 days and required extensive assistance with a two person physical assist. Review of Resident #116's medical record on 11/08/22 at 11:38 A.M., indicated the following: -A clinical nurses note written by Nurse #5 on 10/22/22 at 8:50 P.M.: Pt was displaying signs of increased agitation/anxiety around 4 P.M. I bladder scanned pt with results showing 236 ml (milliliters). Pt was uncooperative with bladder scan. Pt returned to dining room for dinner. Pt was non-compliant with wheelchair. He/she continued getting out of wheelchair, walking around dining room/unit even after many attempts from staff to sit him/her back down. At this time, I was advised by the other nurse to straight cath (a soft, thin tube used to pass urine from the body intermittently) patient even though bladder scan only showed 237 ml but based on patient's behavior and pt not voiding all day and having adequate fluids throughout the day and his/her brief being dry it seemed like the best option for the moment. Pt was very uncooperative and combative with straight cath procedure. It took 3 staff members to hold him/her in order to straight cath pt. Straight catheterized of 775 ml dark amber colored urine with some cloudy colored drainage towards the end. After procedure pt went back into the dining room where he/she was still non compliant with wheelchair. On 11/8/22 at 2:00 P.M., the surveyor asked for any incidents or investigations for Resident #116. On 11/9/22 at 7:30 A.M., the surveyor asked for Resident's #116's progress notes for October and November to be printed out. Review of Resident #116's medical record on 11/9/22 at 1:00 P.M. indicated the above clinical nurse's note was struck out and a new late entry note written 11/9/22 at 8:02 A.M. effective for 10/22/22 at 8:50 P.M. indicated the same wording to the struck out note with the exception of the sentence: It took 3 staff members to hold him/her in order to straight cath pt. This sentence was replaced with: It took 3 staff members to assist in comforting pt. During an interview on 11/09/22 at 1:17 P.M., Nurse #5 said she was familiar with Resident #116. Nurse #5 said he/she could be combative, and would hit staff with his/her fist and kick. Nurse #5 said she was told by other staff that the Resident gets anxious when his/her bladder is full and based on the lack of urine from the Resident and his/her behavior on 10/22/22 she thought the Resident needed a straight cath. Nurse #5 said she brought another nurse and 2 aides in to assist with the Resident. Nurse #5 said the other staff held his/her hands while she performed the straight cath. Nurse #5 said she changed her original note this morning at the request of the Director of Nursing because it sounded bad. Nurse #5 said the initial note indicated that the Resident was held by 3 staff members in order to be straight cathed which could give an impression that the Resident was held down for the straight cath and that was inaccurate wording. During an interview on 11/09/22 at 1:35 P.M., the Administrator and Assistant Director of Nursing said nursing notes are reviewed the next day by either the unit manager or the management team during morning meeting. The Assistant Director of Nursing said if a note is checked off to be included as the 24 hour review, it should be reviewed. The Assistant Director of Nursing and Administrator acknowledged the note written by Nurse #5 on 10/22 and reviewed yesterday 11/8/22 was changed this morning 11/9/22. The Assistant Director of Nursing and Administrator said that review of the note in accordance with the usual practice of reviewing notes the next day was an oversight and this specific note was reviewed this morning with Nurse #5 and that the note sounded bad and that it sounded like the Resident was held down. The Administrator and Assistant Director of Nursing said they talked to Nurse #5 and she said the Resident's hands were being held and he/she was being comforted. The Administrator and Assistant Director of Nursing said that after speaking with Nurse #5 they felt that it was just the wording of the note that was inaccurate and there was not a concern for abuse. The Administrator and Assistant Director of Nursing acknowledged the note was inaccurate and had been available in the Resident's medical record. During a follow up interview on 11/09/22 at 2:04 P.M., the Assistant Director of Nursing said the facility reviewed the note after the surveyor had asked for any incidents for Resident #116 and then had asked for his/her progress notes, they reviewed the progress notes and saw the original note from 10/22/22. 2. For Resident #22 the facility failed to ensure an order for wound care was complete. Resident #22 was admitted to the facility in March 2017 with diagnoses including dementia and adult failure to thrive. Review of Resident #22's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident was severely cognitively impaired and scored a 3 out of 15 on the Brief Interview for Mental Status Exam (BIMS). The MDS further indicated the Resident was incontinent of bowel and bladder, required extensive assistance with care activities and was at risk for developing pressure ulcers/ injuries. On 11/08/22 at 8:41 A.M., Resident #22 was observed sleeping in bed on an air mattress set to 120. He/she appeared thin and frail. Review of Resident #22's medical record indicated the following: -A late entry nurse's note dated 11/3/22: Aide was performing AM care and reported an excoriation on resident's sacrum. Upon inspection, open area is approximately 1 x 1 centimeters (cm) with a red center. No odor, no drainage and surrounding skin is healthy. Left message for daughter, Nurse Practitioner (NP) and hospice nurse. -A phone order dated 11/3/22: Collagenase Powder (used to help wound healing)- apply to sacrum topically as needed for excoriation discontinue when resolved. -An order dated 11/4/22: Monitor dressing every shift. -November Treatment Administration Record (TAR) which indicated monitor dressing every shift was signed off on all shifts 11/4/22 evening shift through 11/9/22 day shift. Further review of Resident #22's medical record failed to indicate any additional orders or documentation indicating any information about what type of dressing was to be used, what type of cleansing agent should be used and where the dressing was located. During an interview on 11/10/22 at 8:06 A.M., Nurse #1 said she is familiar with Resident #22. She said the Resident has a small open area on his/her sacrum with a treatment. She said the treatment is collagenase powder and a dry dressing on top. During an interview on 11/10/22 at 9:00 A.M., Unit Manager #2 said she performed Resident #22's dressing change early this morning. Unit Manager #2 said the area is cleansed with soap and water, collagen powder is applied and a dry protective dressing is placed over the area. Unit Manager #2 said dressing orders should include what is being used to clean a wound and what the dressing is. Unit Manager #2 reviewed Resident #22's orders with the surveyor and acknowledged the order was incomplete and missing the cleanser and what type of dressing should be used and it should include that.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. For Resident #23, the facility failed to ensure staff were properly monitoring his/her pacemaker. Review of the facility's policy titled, Care of a Resident with a Pacemaker, not dated, Documentation 1. For each resident with a pacemaker, document the following in the medical record and on a pacemaker identification card upon admission: a. The name, address and telephone number of cardiologist; b. Type of pacemaker; c. Type of leads; d. Manufacturer and model; e. Serial number; f. Date of implant; and g. Paced rate. 2. When the resident's pacemaker is monitored by the Physician, document the date and results of the pacemaker surveillance, including: a. How the resident's pacemaker was monitored (phone, office, internet); b. Type of heart rhythm; c. Functioning of the leads; d. Frequency of utilization; and e. Battery life. 3. Ensure the presence of a care plan related to the resident's Cardiovascular condition, the placement and ongoing care, support and monitoring thereof. Review of the American Heart Association guidelines for pacemaker monitoring titled Living with your pacemaker indicated: - After you have your pacemaker implanted, your doctor will go over detailed restrictions and precautions. Make sure that you and your caregiver fully understand these instructions. Don't be afraid to ask questions. - Before you leave the hospital, be sure to understand your pacemaker's programmed lower and upper heart rate. Review of the American Heart Association guidelines for pacemaker monitoring titled 'Checking in on your device' indicated the following: Modern pacemakers are built to last. Still, your pacemaker should be checked periodically to assess the battery and find out how the wires are working. Be sure to keep your pacemaker checkup appointments. At such appointments: - Your doctor will make sure your medications are working and that you ' re taking them properly. - You can ask questions and voice any concerns you may have about living with your pacemaker. Make sure you and your caregiver understand what your doctor says. It's a good idea to take notes. - Your doctor will use a special analyzer to reveal the battery's strength. This diagnostic tool can reveal a weak battery before you notice any changes. - Eventually, the battery may need to be replaced in a surgical procedure. This replacement procedure is less involved than the original surgery to implant the pacemaker. Your doctor can tell you about the procedure when the time comes. Resident #23 was admitted in August of 2021 with diagnoses that included presence of cardiac pacemaker, chronic diastolic (congestive) heart failure unspecified atrial fibrillation, unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. On 11/08/22 at 8:38 A.M., the surveyor observed a Boston Scientific Latitude pacemaker monitoring system on night stand next to Resident #23's bed with a green light on. Review of Resident #23's clinical record failed to indicate a care plan or any physician's orders regarding the ongoing monitoring of his/her pacemaker. Review of Resident #23's nursing progress notes indicated a note written on 8/22/2021 at 4:31 P.M., which- Pacemaker site is covered with drsg. C/D/I. Education was provided to patient Material used: verbal Content taught: reporting any pain to chest or pacemaker site to nurse. Additional review of Resident #23's medical record indicated a Practitioner Note dated 2/3/2022 at 9:43 P.M., indicated the following- This is a [AGE] year-old who was initially admitted to [NAME] health on August 12, 2021 due to mental status change.Patient underwent submuscular dual-chamber permanent pacemaker placement TSH B12 and folate were all within normal limits her sodium level improved to 133 upon discharge he/she was transferred to [NAME] house for short-term rehab care. During an interview and review of Resident #23's medical record on 11/10/22 at 7:58 A.M., Unit Manager #1 acknowledged there was not a plan of care in place for Resident #23's pacemaker and said there has not been any communication from cardiology with the facility. Unit Manager #1 said the details of the pacemaker paced rate is unknown among other details. During an interview on 11/10/22 at 8:10 A.M., the Assistant Director of Nursing (ADON) said the expectation is to have a plan of care in place so nursing knows how to care for the resident appropriately. The ADON said she would also expect there to be communication between the facility and cardiology. During an interview on 11/10/22 8:54 A.M., Nurse Practitioner #1 said she would expect that nursing would know details of the pacemaker like the paced rate. I would expect the facility to have communication with cardiology. During an interview on 11/10/22 9:00 A.M., Nurse #2 said she was not aware that Resident #23 had a pacemaker, this surveyor inquired about the Boston Scientific Latitude pacemaker monitoring system and Nurse #2 I was wondering what that box was. Based on observation, record review and interview, the facility failed to 1.) properly assess 1 Resident (#18) for newly acquired skin tears, and 2.) failed to monitor pacemakers for 2 Residents (#61, #23) within accordance of professional standards out of a total of 25 sampled Residents. Findings include: 1. For Resident #18, the facility failed to properly assess his/her skin to identify newly acquired visible skin tears. American Nursing Associations Scope and Standards of Nursing Practice, 2010, pg 32,: Standard 1. Assessment: The Registered Nurse (RN) collects comprehensive data pertinent to the consumer's health and/or the situation. Competencies: Collects comprehensive data including but not limited to physical functional, psychosocial, cognitive and ongoing process while honoring the uniqueness of the person. Resident #18 was admitted to the facility in July 2022 with diagnoses including heart failure and adult failure to thrive. Review of his/her most recent Minimum Data Set assessment dated [DATE] indicated he/she is moderately cognitively impaired and requires assistance with bathing, dressing and toileting. On 11/8/22 at 8:47 A.M. the surveyor observed Resident #18 resting in bed. The surveyor observed 2 skin tears on his/her right arm. Review of Resident #18's progress note on 11/8/22 at 9:00 A.M., indicated the following: 11/7/22: Skin tear was noted by CNA (Certified Nurses Aide) on right outer forearm, 1X2, with small spot of unstageable scabbing. Cleaned and dressed with antibiotic ointment and dressing. Will pass on to next nurse. Review of Resident #18's clinical record at 11:00 A.M. on 11/8/22 revealed a progress note written by Unit Manager #1 on 11/8/22 at 10:12 A.M. : Upon follow up, resident noted to be without skin tear/skin breakdown. Scattered purpura present which is baseline for resident. On 11/8/22 at approximately 11:40 A.M. the surveyor observed Resident's #18 arm with the Director of Nursing. The DON observed and acknowledged Resident #18's skin tears. The DON said that she was not aware of his/her skin tears and she would follow up Unit Manager #1. During an interview with the DON on 11/9/22 at approximately 12:45 P.M., she said that Unit Manager #1 told her she did not see Resident #18's skin tears when she assessed Resident #18. 2. For Resident #61, the facility failed to ensure staff were able to properly monitor his/her pulse after the implantation of a new pacemaker. Review of the American Heart Association guidelines for pacemaker monitoring titled Living with your pacemaker indicated: After you have your pacemaker implanted, your doctor will go over detailed restrictions and precautions. Make sure that you and your caregiver fully understand these instructions. Don't be afraid to ask questions. Before you leave the hospital, be sure to understand your pacemaker's programmed lower and upper heart rate. Resident #61 was admitted to the facility in December 2019 with diagnoses including coronary artery disease. Review of his/her Minimum Data Set assessment dated [DATE] indicated he/she is cognitively intact and requires assistance with bathing and dressing. During an interview with Resident #61 on 11/10/22 at 10:26 A.M. he/she said that he/she got a pacemaker a few weeks ago. Review of Resident #61's physicians orders indicated: Pacemaker apical pulse check, check apical pulse for one minute daily. Pulse rate should be the same as pacemaker rate or faster. Notify physician if pulse is more than 5-10 beats lower than pacemaker setting, every day shift, initiated 10/26/22 Additional review of Resident #61's clinical record failed to indicate any information regarding Resident #61's pacemaker settings or what his/her pulse rate should be. During an interview with Nurse #5 on 11/10/22 10:48 A.M., she said she took Resident #61's pulse earlier this morning and it was 64. Nurse #5 was unable to say what Resident #61's pulse rate Resident #61's pacemaker was set at and when she re-read the order, she said that there were no parameters in the physicians orders and she would have to look in the record. During an interview with Unit Manager #1 on 11/10/22 at 11:16 A.M., she said that she was aware that Resident #61's pulse setting was missing from the order and she had looked in the record but could not find the setting in the paperwork.

Based on observation, interview and record review, the facility failed to ensure it was free of a medication error rate of 5% or greater. Two of 3 nurses on 2 of 3 units observed made 5 errors in 27 opportunities resulting in a medication error rate of 18.52%. This impacted 3 Residents (#33, #104 and #323) out of 6 residents observed. Findings include: During observation of the medication pass on 11/9/22 at 9:30 A.M., Nurse #6 prepared and administered medications including the following for Resident #33: -Acetaminophen (a pain reliever) 325 milligrams (mg) 2 tablets. Review of Resident #33's current physician orders indicated the following: -Tylenol tablet (Acetaminophen) 325 mg- give 650 mg by mouth three times a day for pain at 8:00 A.M., 2:00 P.M. and 8:00 P.M. This medication was administered 1 hour and 30 minutes after the time it was ordered. During observation of the medication pass on 11/9/22 at 9:34 A.M., Nurse #6 prepared and administered medications including the following for Resident #104: -Buspirone (a medication used to treat anxiety) 5 mg- 1 tablet -Acetaminophen 500 mg- 2 tablets Review of Resident #104's current physician orders indicated the following: -Buspirone 5 mg- give 1 tablet by mouth two times a day for anxiety at 8:00 A.M. and 8:00 P.M. This medication was administered one hour and 34 minutes after it was ordered. -Tylenol (Acetaminophen) Extra Strength Tablet 500 mg- give 2 tablets by mouth three times a day for pain at 8:00 A.M., 2:00 P.M. and 8:00 P.M. This medication was administered 1 hour and 34 minutes after it was ordered. During an interview on 11/09/22 at 11:43 A.M., Nurse #6 said there is a one hour window before and after a medication is ordered to administer. Nurse #6 acknowledged the medications were given late. During observation of the medication pass on 11/9/22 at 9:55 A.M., Nurse #1 prepared and administered medications including the following for Resident #323: -Furosemide (a diuretic) 40 mg- 1 tablet -Metoprolol Tartrate (a medication used to treat high blood pressure) 50 mg- 1 tablet Review of Resident #323's current physician orders indicated the following: -Furosemide 40 mg: give 1 tablet by mouth two times a day for at 8:00 A.M. and 12:00 P.M. This medication was administered 1 hour and 55 minutes after the time it was ordered for. -Metoprolol Tartrate Tablet 50 mg: give 1 tablet by mouth two times a day at 8:00 A.M. and 8:00 P.M. This medication was administered 1 hour and 55 minutes after the time it was ordered for. During an interview on 11/09/22 at 11:04 A.M., Nurse #1 aid there is a one hour window before and after an order to administer it. Nurse #1 said something like Furosemide should not be given too close to the second dose because it can potentially cause kidney issues. Nurse #1 acknowledged the medications were given late. During an interview on 11/09/22 at 12:50 P.M., the Assistant Director of Nursing said there is a one hour window before or after a medication is ordered to administer it and acknowledged the late medications. During an interview on 11/10/22 at 10:30 A.M., the Director of Nursing said that there is a one hour window before and after a medication is ordered to administer.

Based on observation and interview, the facility failed to ensure food items were discarded after their expiration dates or used by dates had passed in the main kitchen. Findings include: During the initial walk through of the kitchen on 7/8/22 at 7:19 A.M., the surveyor made the following observations: In the reach in refrigerator there was: *5 wrapped sandwiches labeled to be used by 11/6/22 *2 milks and 1 yogurt labeled to be used by 11/1/22 In the walk in refrigerator there were *2 plastic bins of 5 total hams labeled 11/7/22 *1 bin of 3 turkey breasts labeled 11/7/22 *1 metal bin covered in tinfoil marked pork for 11/4 During an interview with the Food Service Director on 11/10/22 at 9:37 A.M. she said that the food items should have been discarded on the dates they were labeled.