**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and document review, the facility failed to ensure an allegation of employee to resident abuse was immediately reported no later than two hours, to the State agency (SA) for 1 of 1 residents (R15) reviewed for abuse. Findings include: R15's quarterly Minimum Data Set (MDS) dated [DATE], identified R15 was cognitively intact and had diagnoses which included: dementia, anxiety and depression. Identified R15 was dependent on staff for transfers, dressing and personal hygiene. R15's Care Area Assessment (CAA) dated 10/25/24, identified R15 was cognitively intact and was able to follow a conversation and answer appropriately. Indicated R15 was at risk for falls and cognitive impairment due to diagnosis. R15's care plan dated 10/20/23, identified R15 had an activities of daily living (ADL) self-care performance deficit and limited physical mobility with interventions which included: assistance for bathing/showering, dressing, personal hygiene toilet use, and transfers with two staff and a sit to stand non-mechanical lift. Indicated R15 was a vulnerable resident related to nursing home placement, physical limitations and sensory impairments. R15 was to be safe and comfortable in R15's environment, free from abuse, neglect, exploitations, and maltreatment. During a telephone interview on 5/21/25 at 11:15 a.m.,complainant (C)-A indicated R15 made a complaint on 11/7/24, stating a nursing assistant (NA), unknown name, turned R15 in bed roughly on 11/5/24, and R15 received a bruise as a result. R15 asked C-A to speak with the administrator about the incident. C-A stated R15 was going to talk to the Care Transition Coordinator (CTC) about the incident. C-A further stated C-A spoke with the administrator on 11/26/24, and the administrator indicated she would follow-up on the information provided. C-A indicated C-A never heard back from the administrator. On 5/21/25 at 1:30 p.m., R15 declined an interview. During an interview on 5/21/25 at 2:27 p.m., CTC confirmed R15 had talked to the CTC about the incident that took place on 11/5/24. CTC did not remember the exact date and time R15 talked with the CTC. CTC stated R15 did not appear to have any bruising and a full investigation was completed. CTC further stated CTC did not feel it needed to be reported to the SA. During an interview on 5/21/25 at 2:34 p.m., administrator indicated if a resident had any abuse allegations the administrator would work with the director of nursing (DON) and social services to complete a through investigation. Administrator stated the staff member would be placed on a leave while the investigation was being completed. Administrator further stated she did not remember receiving a call from C-A and she would look for any information regarding this incident. Administrator indicated if abuse was suspected there should have been a report sent to the SA within two hours of the allegations being discovered. During an interview on 5/21/25 at 3:10 p.m., DON stated she was unaware R15 had any bruising and further stated if there was bruising it should have been investigated and reported. DON indicated she was going to look into R15's allegations and attempt to find documentation regarding the allegations. Requested a copy of the investigation report, however one was not provided. Review of facility policy titled Vulnerable Adult Abuse And Neglect Prevention revised 2/21/25, the plan, in accordance with Minnesota Statue, established the policies, procedures and responsibilities for protecting all adults who were dependent upon others for their care and for providing a safe environment for them to live in. The facility had an Abuse Prevention Committee, consisting of the Administrator, Director of Nursing, Director of Social Services, and the Inter-disciplinary Team. This committee would review all complaints/concerns/incidents involving any resident who was suspected of, has been abused or neglected, or had sustained a physical injury which was not reasonably explained. A resident incident report would be completed on all suspected incidents. The committee would complete a thorough investigation of the possible neglect or abuse cases taking appropriate action and providing protective and/or counseling services as needed. If the events did not result in serious bodily injury, the individual should report the suspicion immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to submit to the State Agency (SA) the results of the investigation within 5 working days for 1 of 1 residents (R15) reviewed for abuse, for 1 of 1 allegations of abuse reviewed. Findings include: R15's quarterly Minimum Data Set (MDS) dated [DATE], identified R15 was cognitively intact and had diagnoses which included: dementia, anxiety and depression. Identified R15 was dependent on staff for transfers, dressing and personal hygiene. R15's Care Area Assessment (CAA) dated 10/25/24, identified R15 was cognitively intact and was able to follow a conversation and answer appropriately. Indicated R15 was at risk for falls and cognitive impairment due to diagnosis. R15's care plan dated 10/20/23, identified R15 had an activities of daily living (ADL) self-care performance deficit and limited physical mobility with interventions which included: assistance for bathing/showering, dressing, personal hygiene toilet use, and transfers with two staff and a sit to stand non-mechanical lift. Indicated R15 was a vulnerable resident related to nursing home placement, physical limitations and sensory impairments. R15 was to be safe and comfortable in R15's environment, free from abuse, neglect, exploitations, and maltreatment. During a telephone interview on 5/21/25 at 11:15 a.m., complainant (C)-A indicated R15 made a complaint on 11/7/24, stating a nursing assistant (NA), unknown name, turned R15 in bed roughly on 11/5/24, and R15 received a bruise as a result. R15 asked C-A to speak with the administrator about the incident. C-A stated R15 was going to talk to the Care Transition Coordinator (CTC) about the incident. C-A further stated C-A spoke with the administrator on 11/26/24, and the administrator indicated she would follow-up on the information provided. C-A indicated C-A never heard back from the administrator. On 5/21/25 at 1:30 p.m., R15 declined an interview. During an interview on 5/21/25 at 2:27 p.m., CTC confirmed R15 had talked to the CTC about the incident that took place on 11/7/24. CTC did not remember the exact date and time R15 talked with the CTC. CTC stated R15 did not appear to have any bruising. During an interview on 5/21/25 at 2:34 p.m., administrator indicated if a resident had any abuse allegations the administrator would work with the director of nursing (DON) and social services to complete a through investigation. Administrator stated the staff member would be placed on a leave while the investigation was being completed. Administrator further stated she did not remember receiving a call from C-A and she would look for any information regarding this incident. During an interview on 5/21/25 at 3:10 p.m., DON stated she was unaware R15 had any bruising and further stated if there was bruising it should have been investigated and reported. DON indicated she was going to look into R15's allegations and attempt to find documentation regarding the allegation. Requested a copy of the investigation report, however one was not provided. Review of facility policy titled Vulnerable Adult Abuse And Neglect Prevention revised 2/21/25, The plan, in accordance with Minnesota Statue, established the policies, procedures and responsibilities for protecting all adults who were dependent upon others for their care and for providing a safe environment for them to live in. The facility had an Abuse Prevention Committee, consisting of the Administrator, Director of Nursing, Director of Social Services, and the Inter-disciplinary Team. This committee would review all complaints/concerns/incidents involving any resident who was suspected of, had been abused or neglected, or had sustained a physical injury which was not reasonably explained. A resident incident report would be completed on all suspected incidents. The committee would complete a thorough investigation of the possible neglect or abuse cases taking appropriate action and providing protective and/or counseling services as needed. The notice to the SA should include the occurrence of such incident, type of abuse that was committed, date/time the alleged incident occurred, name (s) of all persons involved in the alleged incident and what immediate action was taken by the facility. The administrator, or a designee, would provide the appropriate agencies or individuals listed above with a written report of the findings of the investigation within five working days of the occurrence of the incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure the resident or legal representatives had been provided a written notice of transfer for 2 of 2 residents (R22, R64), and failed to be informed of bed hold rights for 1 of 2 residents (R22) reviewed for discharges. In addition, the facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care (LTC) Ombudsman for 2 of 2 residents (R22, R64) reviewed for hospitalizations. Findings Include: R22 R22's quarterly Minimum Data Set (MDS) dated [DATE], identified R22 was cognitively intact and had diagnoses which included: arthritis, hemiplegia (partial or total paralysis on one side of the body)affecting left side, and peripheral vascular disease (disease of the circulatory system outside of the brain and heart). R22 required substantial/maximal assistance for dressing, shower/bathe self, and transfers and was dependent for personal hygiene. Review of R22's progress notes from 3/5/25 to 5/21/25, identified the following: -3/5/25 at 4:57 p.m., R22 admitted to hospital due to back pain associated with urinary tract infection (UTI). -3/6/25 at 7:44 a.m., writer spoke with daughter, who informed writer R22 was going to be in hospital a few days due to multiple infections. -3/9/25 at 9:40 a.m., hospital nurse stated R22 diagnosed with UTI, pyelonephritis (kidney infection), and refractory back pain (chronic pain that persists despite treatment), and will re-evaluate on Monday regarding discharge. -3/18/25 at 12:15 p.m., R22 was treated for pyelonephritis, acute back pain now improved. R22 will return today at 1:30 p.m. R22's medical record lacked documentation the notification of the emergency transfer was sent to the LTC ombudsman and lacked documentation that a transfer notification and bed hold was provided to the resident and/or resident's representative. During an interview on 5/21/25 at 8:18 a.m., social service designee (SSD)-A reviewed R22's medical record and confirmed it lacked documentation of a bed hold, written notice for transfer or notification of transfer to ombudsman. SSD-A indicated the facility expectation was the forms be completed when a resident was transferred. During an interview on 5/21/25 at 9:21 a.m., licensed practical nurse (LPN)-B indicated R22 was hospitalized for back pain and a UTI. LPN-B stated when a resident was transferred to the hospital, they printed a transfer/discharge record from the medical record and provided a verbal report to the hospital nurse. LPN-B stated they completed a bed hold and a written notice of transfer on the facility Transfer Discharge form and provide it to the resident or family and a copy is placed in their medical record. During a follow up interview on 5/21/25 at 9:42 a.m., SSD-A indicated R22 went independently to the walk in clinic on 3/5/25, and was then sent to the emergency room, where R22 was admitted and as a result, the bed hold was missed. SSD-A stated the facility expectation was to follow up and complete the bed hold. SSD-A indicated the facility did not complete written notice of reason for transfers, but after shown the facility Transfer Discharge form indicated often they were only notified verbally. SSD-A indicated the expectation was the Transfer Discharge forms were signed and sent to the ombudsman. During an interview on 5/21/25 at 12:13 p.m., director of nursing (DON) confirmed R22's medical record lacked a bed hold, written notification for transfer and ombudsman notification. DON stated the notifications were important for continuity of care and to update the correct people. R64 R64's admission MDS dated [DATE], identified R64 had moderate cognitive impairment and diagnoses which included: heart failure, diabetes mellitus and dementia. Indicated R64 required supervision/touching assistance with transferring, and partial assistance with lower body dressing, hygiene and to shower/bathe self. Review of R64's progress notes from 3/6/25 to 3/7/25, identified the following: -3/7/25 at 4:33 a.m., R64 transferred to hospital, for low blood sugar with seizure like activity. Bed hold verbal by daughter and daughter updated. R64's Bed Hold And Readmissions Policy dated 3/7/25, documented verbal from daughter on 3/7/25 at 4:15 a.m. R64's medical record lacked documentation the notification of the emergency transfer was sent to the LTC ombudsman and lacked documentation that a transfer notification was provided to the resident and/or resident's representative. During an interview on 5/21/25 at 8:18 a.m., social service designee (SSD)-A reviewed R22's medical record and confirmed it lacked documentation of a bed hold, written notice for transfer or notification of transfer to ombudsman. SSD-A indicated the facility expectation was the forms be completed when a resident was transferred. SSD-A stated R64 was discharged from the facility after he went to the hospital related to family dynamics. SSD-A stated the case manager completed all paper work for transfers and notified the ombudsman of transfers. SSD-A indicated the facility had not been notifying the ombudsman of transfers and discharges, and as a result, they put a new system in place beginning in April 2025. During a follow up interview on 5/21/25 at 9:42 a.m., SSD-A indicated R22 went independently to the walk in clinic on 3/5/25, and was then sent to the emergency room, where R22 was admitted and as a result, the bed hold was missed. SSD-A stated the facility expectation was to follow up and complete the bed hold in those situations. SSD-A indicated the facility did not complete written notice of reason for transfers, but after shown the facility Transfer Discharge form indicated often they were only notified verbally. SSD-A indicated the expectation was the Transfer Discharge forms were signed and sent to the ombudsman. At 9:49 a.m. SSD-A confirmed a written notice for transfer form had not been completed and the ombudsman had not been notified of R64's transfer. During an interview on 5/21/25 at 12:13 p.m., director of nursing (DON) confirmed R22's medical record lacked a bed hold, written notification for transfer and ombudsman notification. DON stated the notifications were important for continuity of care and to update the correct people. During a follow-up interview on 5/21/25 at 12:17 p.m., DON confirmed a written notice for transfer or ombudsman notification of transfer had not completed for R64's transfer as was the expectation. Review of facility policy titled Transfer/Discharge Policy revised 1/15/24, identified the resident and representative were notified in writing, which included: the specific reason for the transfer, effective date of the transfer, specific location and explanation of the resident rights, notice of facility bed-hold policies, and name and address and telephone number of the LTC Ombudsman. A copy of the notice was sent to the LTC Ombudsman at the same time the notice of transfer or discharge was provided to the resident and representative. When a resident was sent emergently to an acute care setting the notice would be provided as soon as was practicable. Bed-Hold policy would be provided to the resident and resident representative within 24 hours of emergency transfer. Documentation would include basis for transfer, that an appropriate notice was provided to the resident and/or legal representative, date and time of the transfer, new location of the resident, mode of transportation, summary of resident's condition and other as appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to follow the comprehensive care plan for 1 of 1 residents (R34) whose care plan was reviewed. Findings include: R34's quarterly Minimum Data Set (MDS) dated [DATE], indicated R34 was severely cognitively impaired and had diagnoses which included dementia and Parkinson's disease. Identified R34 required extensive assistance with transfers, toileting, bathing and personal hygiene. R34's care area assessment (CAA) dated 2/19/25, indicated R34 had an actual problem with Urinary Incontinence and Indwelling Catheter. R34 had an alteration of the urinary system related to a malignant neoplasm of the bladder (bladder cancer) and an AEB urostomy (a pouch on the outside of the bladder to catch and hold urine). R34 was to remain free from urostomy related trauma. Additionally, R34 triggered for physical restraints related to R34 utilizing a Velcro removable strap across R34's lap to remind R34 not to self-transfer. R34's care plan dated 4/8/24, indicated R34 required assistance with transfers and personal hygiene. R34 was at high risk for falls and R34 had a goal not to sustain serious injures. R34 had an intervention in place to use a front Velcro wheelchair seatbelt when in R34's wheelchair. Staff were to ensure the device was in placed every two hours or as needed (PRN). R34's had alterations of R34's urinary system with a goal R34 would remain free from urostomy related trauma. R34 would show no signs or symptoms of urinary tract infections (UTI). R34's intervention was to have R34's urostomy emptied every two hours. Review of R34's signed physicians orders dated 3/27/25, identified R34 was to have R34's urostomy emptied every two hours during the day. Orders further identified R34 would be monitored while in R34's wheelchair. Staff were to ensure R34's belt was loose around R34's waist every two hours. Review of [NAME] Village Care Center (GWVCC)-Alarm assessment dated [DATE], restraint use is only mandated if the resident is in imminent danger of injuring him/herself or others. Describe resident behavior prompting restraint use: -Unsteady Gait - Frequent falls - Sliding out of wheelchair/chair - Attempts to self-transfer - Other Interventions tried and failed. Describe events or failed interventions leading up to use of alarms. -Resident uses feet to propel wheelchair, and legs/ feet get caught up under wheelchair causing resident to fall forward out of wheelchair. Seatbelt will assist resident is staying seated in the event that resident falls out of wheelchair. What device is being used for the resident? - Resident is currently in a tilt and space wheelchair at its lowest position. along with the Velcro front wheelchair seatbelt Start Date of Alarm Use - 6/13/2024 Benefits of the resident using the alarm - Benefit is using Velcro front wheelchair seatbelt as resident is able to self-propel his wheelchair, without the danger of tripping/ catching his own feet and falling forward out of wheelchair. This includes independence to maneuver around facility. Resident is able to remove front Velcro seatbelt when desired. Education on identification of a medical symptom requiring the use of the device, the risks and/or benefits, the least restrictive interventions, and when/how long the device was going to be used for. - Resident received education on alarms - Resident Representee received education on alarms Who made the decision to implement the restraint? - Case Manager registered nurse (CMRN)/Case Manager licensed practical nurse (CMLPN) - Family Member/Guardian What family member/responsible party notified? - Family Member (FM)-D Date notification was given - 6/13/2024 Physicians order obtained with specific type of restraint, duration of application, reason for restraint and specify when it is to be used (i.e. seatbelt, while up in chair, for repeated attempts to rise unattended, release and ambulate for 10 minutes every two hours) - yes Ordering Physician R34's primary physician Review of Sunrise Cove/Golden Meadow resident report form undated, indicated staff were to monitor R34's urostomy every two hours. During a continuous observation on 5/21/25 at 7:10 a.m., to 9:46 a.m., R34 was in the hallway, dining room and personal room. R34's Velcro belt was not secured around R34's waist with one strap laying along side both R34's right and left outer legs. At 8:58 a.m., R34's FM-A returned R34 to R34's room, applied R34's jacket, turned R34's television on and sat next to R34 in personal room. During an interview on 5/21/25 at 9:38 a.m., trained medication aid (TMA) indicated R34 was to have R34's ostomy checked and changed whenever it comes bulging out. TMA identified all staff could check R34's ostomy and empty it when it was full. TMA stated nursing staff changed it a couple times a week. TMA identified R34 wore a seatbelt to remind him not to self-transfer. TMA indicated R34 could remove the belt and had several times before. TMA was unaware R34's ostomy was not checked, seatbelt was not fastened and no staff had checked either R34's ostomy or seatbelt. TMA confirmed both items were to be checked every couple of hours. Review of R34's belt, it remained unfastened and R34's ostomy needed to be emptied. TMA indicted TMA was going to finished passing morning medications and would get another staff person to check on R34's equipment. During an interview on 5/21/25 at 9:46 a.m., clinical manager (CM)-A confirmed R34's care plan and identified R34's urostomy and seatbelt were to be checked every two hours. CM-A stated R34 has taken the seatbelt off at times and staff were to place it back on him. Surveyor explained TMA had not checked on R34, CM-A called TMA and requested TMA to check on R34's ostomy and seatbelt at that time. TMA went into R34's room and checked ostomy and replaced seatbelt. Surveyor requested R34's restraint assessment, CM-A was going to locate it and provide it to surveyor. Follow-up interview on 5/21/25 at 12:23 p.m., CM-A identified R34's restraint assessment and stated it was called an alarm assessment that was created on 6/13/24. CM-A further stated the assessment included physician's orders and the seatbelt was to be reevaluated every two hours. During an interview on 5/21/25 at 3:18 p.m., director of nursing (DON) confirmed the above findings and indicated she was unaware R34's ostomy and seatbelt had not been checked for over two hours. DON stated her expectations were staff were to be following each residents care plan. Facility policy titled Comprehensive Care Plans revised 12/10/24, Each resident would have a person-centered comprehensive care plan developed and implemented to meet their other preferences and goals, and address the residents medical, physical, mental, and psychosocial needs. When developing the comprehensive care plan, facility staff must, at a minimum, use the Minimum Data Set (MDS) to assess the resident's clinical condition, cognitive and functional status, and use of services. Facility policy titled Restraints revised 7/1/24, It shall be the policy of the [NAME] Village Care Center that restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation , interview and document review, the facility failed to provide assistance with oral care for 1 of 7 residents (R34) and nail care for 1 of 7 residents (R40) reviewed for activities of daily living (ADL's). Findings include: R40 R40's annual Minimum Data Set (MDS) dated [DATE], identified R40 had moderate cognitive impairment and had diagnoses which included Alzheimer's, psychotic disorder, and hypertension (elevated blood pressure). Identified R40 required staff assistance with personal hygiene. R40's care plan dated 12/12/22, identified R40 had dementia and forgetfulness. Identified R40 required supervision and limited assistance with grooming. R40's annual comprehensive Care Area Assessment (CAA) dated 3/11/25, identified R40 required assistance with ADL's related to dementia and confusion. Identified R40 required partial to moderate assistance with hygiene. During an interview on 5/19/25, at 1:20 p.m., family member (FM)-A stated R40's fingernails were generally pretty long when he came to visit. FM-A stated R40 required staff assistance to cut his fingernails. During an observation, R40 was seated in a recliner in his room. R40's fingernails were approximately 3/4 inch long with a black substance noted underneath. During an observation on 5/20/25 at 8:29 a.m., R40 was seated in a recliner in his room. R40's fingernails continued to be approximately 3/4 inch long with a black substance noted underneath. During a joint interview on 5/20/25 at 8:37 a.m., nursing assistant (NA)-A and licensed practical nurse (LPN)-A verified R40's nails were long with a black substance present underneath. NA-A stated she had not offered to cut or clean R40's fingernails recently and was unsure of the last time R40's fingernails had been cut. LPN-A stated her expectation was that R40's fingernails were cleaned and cut weekly with his bath. R34's quarterly Minimum Data Set (MDS) dated [DATE], indicated R34 was severely cognitively impaired and had diagnoses which included dementia and Parkinson's disease. Identified R34 required extensive assistance with transfers, toileting, bathing and personal hygiene. R34's care area assessment (CAA) dated 2/19/25, indicated R34 was at risk for dental care and had problems with cavities. R34's care plan dated 4/8/24, indicated R34 required assistance with oral cares and personal hygiene. R34 required substantial assistance of one for orals cares and R34 had his own natural teeth. Staff were to report any changes in oral health to the nurse. Additionally, staff were to monitor and document R34's ability to perform ADLs. Any changes of improvement or decline were to be reported to the medical doctor (MD). During an observation on 5/21/25 at 7:19 a.m., R34 was in R34's wheelchair propelling self down the hallway towards the dining room. In R34's bathroom a pink basin was located in the wooden bathroom cabinet on the right side of the bathroom when entering the bathroom. The pink basin contained a tube of toothpaste and a small laminated tooth with a smiley face on it. Located below the tooth was written in black bold lettering If found please return to case manager. No toothbrush had been seen in pink basin or bathroom. During an observation on 5/21/25 at 8:58 a.m., remained the same as above. Review of R34's progress notes dated 2/20/25 through 5/19/25, lacked documentation R34 refused oral cares or any changes with R34's oral cares. Review of R34's electronic medical record treatment notes dated 3/1/25 to 5/21/25, lacked documentation of R34 receiving oral cares. Review of Sunrise Cove/Golden Meadow resident report form undated lacked documentation R34 was to have assistance with oral cares. During an interview on 5/19/25 at 1:37 p.m., family member (FM)-D stated staff did not assist R34 with oral cares and FM-D had expressed concerns with the nursing staff regarding R34's oral cares. FM-D indicated FM-D had checked R34's toothpaste tube daily and the same tube had remained in the bathroom without being used. FM-D indicated R34 used to brush R34's teeth daily and R34 would want to have R34's teeth brushed daily at the facility. FM-D stated FM-D wanted R34's teeth brushed daily. During an interview on 5/21/25 at 9:38 a.m., trained medication aid (TMA)-A expressed staff worked together to get residents up and dressed for the day including completing oral cares. TMA-A was not aware R34 did not have oral cares completed and R34 did not have a toothbrush in the bathroom. TMA-A stated TMA-A had not assisted with R34's cares that day. During an interview on 5/21/25 at 9:46 a.m., clinical manager (CM)-A confirmed the facility had been completing audits for oral cares and the laminated tooth should have been brought to CM-A when staff assisted R34 with oral cares. CM-A stated FM-D had spoken to CM-A about R34 not having oral cares completed and the audit tooth had been placed in the basin a few days ago, I think three days ago. CM-A stated if R34 refused, staff were expected to inform the nurse and it should have been documented in the progress notes. CM-A indicated additional training needed to be done because oral cares were obliviously not being done. During an interview on 5/21/25 at 9:27 a.m., director of nursing (DON) stated her expectation was that all residents nails would be cut and cleaned weekly with their bath. During a follow-up interview on 5/21/25 at 3:18 p.m., DON was not aware R34 did not have oral cares completed. DON stated oral care audits were being completed and CM-A should have removed the audit card within 12 hours of placing it to ensure R34 had oral cares completed that day. DON indicated oral cares should have been completed two times a day and staff should have returned the card to the CM. DON stated her expectations were residents received oral cares two times daily. Review of a facility policy titled Activities of Daily Living (ADLs), Supporting revised 3/20/25, identified residents would be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable. Identified, appropriate care and services would be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, shaving, grooming, and oral care).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to provide meaningful and engaging activities for 1 of 1 residents (R21) reviewed for activities. Findings include: R21's quarterly Minimum Data Set (MDS) dated [DATE], identified R21 had severe cognitive impairment and had diagnoses which included Alzheimer's disease and anxiety. Identified R21 required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers, and toileting. Identified watching the news was not important at all to R21. R21's care plan revised 3/22/25, indicated R21 was unable to carry out activities of past interest due to disease process. Indicated R21's personal interests included music (gospel),spiritual activity, animals, outdoors, looking through pictures, getting hair fixed, being with others, gardening, children. Identified resident spent ample time by TV day room. At most recent care conference, resident's family specified she had no past interest of watching the news or sports. Resident would benefit more from music or nature sounds. Further identified, set up music on R 21's CD player during afternoon rest time. During an observation on 5/20/25 at 11:00 a.m., R21 was sitting in her wheelchair in the day room and the television was on the news. During an observation on 5/20/25 at 12:35 p.m., nursing assistant (NA)-A wheeled R21 to her room and NA-A and NA-B assisted her to lie down in bed using the hoyer lift. R21's room was quiet no music was playing. During an observation on 5/20/25 at 1:25 p.m., R21 continued to lie in bed with no music playing in the room. During an observation on 5/20/25 at 3:35 p.m., NA-B and NA-C assisted R21 into her wheelchair using the hoyer lift. NA-B wheeled R21 to the day room where the TV was on the news R21 was the only one in the day room. During an observation on 5/20/25 at 4:07 p.m., R21 continued to be sitting in her wheelchair in the day room. The TV was on the news. Review of Resident Report Form undated, lacked R21's activity preferences. R21's care conference summary dated 3/22/25, stated activity interventions desired by family and to be included in R21's care plan at upcoming review date: transport to and from 2:00 Church on Sundays; set up Church live stream if no attendance at Church; turn on CD player in room during afternoon rest; continue assisting for visits w/spouse; adjust TV channel so Resident is not watching news/sports; engage in outdoor/garden activities (weather dependent). Review of the facility activities schedule for 2/19/25 through 2/21/25 , revealed the following: -Monday 2/19/25: 8:30 Daily Check- Ins 10:30 Spiritual Reading 11:00 Music Trivia 1:30 Chair Yoga 2:00 Golden Oldies 2:30 Coffee -Tuesday 2/20/25: 8:30 Daily Check -Ins 10:00 Men's Book club 10:30 Women's Book Club 1:30 Activity Planning Committee 2:00 Red Hat's Tea Party 3:00 Bingo -Wednesday 2/21/25 8:30 Daily Check In-s 9:30 Wednesday Wellness 10:30 Garden Club 10:30 Bingo 1:00 Resident and Food Council 2:30 Coffee And Social Time During an interview on 5/19/25 at 3:14 p.m., family member (FM)-B stated staff got R21 up early and she sat in the wheelchair most of the day. FM-A stated at the last care conference, R21's preference of not watching sports or news were discussed. FM-A indicated the family had requested for staff to lay R21 down in the afternoon and put music on for her in her room. During an interview on 5/20/25 at 4:33 p.m., NA-B stated she was not aware of R21's preference to listen to music in her room or to not watch the news while she was in the day room. NA-B indicated there was nothing on the Resident Report Form regarding R21's activity preferences. During an interview on 5/20/25 at 6:46 p.m., NA-C stated she was not aware of R21's preference to listen to music in her room or to not watch the news while she was in the day room. NA-B further indicated there was nothing on the Resident Report Form regarding R21's activity preferences. During an interview on 5/20/25 at 6:50 p.m., registered nurse (RN)-A verified R21 had been in the day room during his shift with the news playing and lying in her bed in her room without any music playing. RN-A stated he was not aware of R21's preference to listen to music in her room or to not watch the news while she is in the day room. RN-A stated he had not received any communication regarding R21's activity preferences. RN-A stated his expectation was that staff would have respected R21's activity wishes. During an interview on 5/21/25 at 7:25 a.m., FM-B stated her mom sat in the day room a lot and every time she visited the news was on. FM-B stated the family had talked to the facility about R21's preference of listening to music in her room and while in the day room R21 preferred to not listen to the news but she had not seen anything happen with their request for R21's activities. During an interview on 5/21/25 at 8:27 a.m., activity director (AD) stated she was aware of R21's activity preferences. AD stated she had discussed R21's activity preferences of listening to music in her room or in the day room and to not listen to news or sports in the day room at R21's last care conference with R21's family. AD stated she was unsure if R21's preferences were communicated to the staff working with R21 since the only form of communication was verbal. AD indicated R21 did not usually attend most group activities other than church so it was important for staff to look at R21's care plan to identify R21's activity preferences. During an interview on 5/21/25 at 8:49 a.m., clinical manager (CM)-A confirmed she had seen R21 in her room with no music playing and in the day room with the news on the TV. CM stated she was new to the facility and was not aware of R21's activity preferences. CM stated her expectation was that R21's activity preferences would have been followed. During an interview on 5/21/25 at 9:25 a.m., director of nursing (DON) confirmed the above findings. DON stated she was unsure why R21's activity preferences were not being followed. DON stated her expectation was that R21's activity preferences would have been followed. Review of a facility Policy titled Types of Activities revised 5/23, identified residents would be surveyed to determine their interest in the types of activities. Identified, individualized Care Plans would be developed with resident preferences, goals, and interventions, reviewed and updated with every MDS and PRN. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure timely assistance with repositioning occurred for 1 of 4 residents (R27) with a current pressure ulcer and for 2 of 4 residents (R21, R47) at risk for development of pressure ulcers. Further, the facility failed to ensure a pressure relieving device was implemented to prevent skin breakdown for 1 of 4 residents (R21) reviewed for pressure ulcers. Findings Include: R27 R27's quarterly Minimum Data Set (MDS) dated [DATE], identified R27 had mild cognitive impairment and had diagnoses which included: dementia, cancer, and chronic obstructive pulmonary disease. R27 was dependent on staff to turn left to right, transfer, dressing, and personal and hygiene. Indicated R27 was at risk for pressure ulcers and had no unhealed pressure ulcers. R27 had an air pressure mattress, and received applications of non surgical dressings and ointments to skin other than to feet. R27 was receiving hospice care with a prognosis of six months or less to live. R27's Pressure Ulcer Care Area Assessment (CAA) dated 12/10/24, identified R27 had potential impairment to skin integrity related to fragile skin, bowel and bladder incontinence, non-healing lesion to right lateral inferior mid-back classified as basal cell carcinoma and blood thinners. R27's care plan revised 4/17/25, identified R27 had an activities of daily living (ADL) self care deficit with interventions which included dependent on staff for personal hygiene, transfers, and extensive assistance with bed mobility. Indicated R27 had a sacral (base of spine) ulcer related to immobility. Interventions included to turn and reposition R27 at least every two hours, more often as needed or requested, bed as flat as possible to reduce shear, float heels when in bed, and air pressure mattress. R27 had terminal prognosis related to Alzheimer's. R27's Braden Scale For Predicting Pressure Ulcer Risk assessment dated [DATE], identified R27 scored 15, which identified R27 was at risk for pressure ulcers. During continuous observation on 5/20/25 at 10:25 a.m. to 12:52 p.m., identified the following: -10:25 a.m.-R27 lying in bed, in street clothes, covered with bedding, eyes closed, lying on back, door open. R27's bed unable to view from doorway, unless enter room. -10:29 a.m.- staff member walked by room, did not look into room. -10:46 a.m.- multiple staff members walked by R27's room, did not go into room. -11:01 a.m.-R27 remained in same position, eyes remain closed. Multiple staff members have walked by room, but did not enter. -11:13 a.m.-R27 remained in same position, eyes remain closed. -11:34 a.m. -R27 remained in same position, eyes remain closed, multiple staff members have walked by R27's room, but did not enter. -11:54 a.m. R27 remained in same position, staff assisting other residents in dining room. Nurse and other staff walked by R27's room, but did not enter. During an observation on 5/20/25 at 12:12 p.m., nursing assistant (NA)-F entered R27's room and asked R27 if she wanted to eat lunch and then asked if could try some V8 juice. NA-F applied gloves and asked R27 if she could apply lip balm, then applied lip balm to R27's lips. NA-F removed her gloves and left R27's room. At 12:16 p.m., NA-F entered R27's room and asked if R27 could try some V8 juice. NA-F applied gloves, sat in a chair next to R27, raised the head of bed up, asked R27 if wanted to try drinking the V8 juice, which R27 responded yeah. NA-F attempted to assist R27 to drink juice from straw. R27 did not suck on the straw. NA-F asked R27 again if wanted to drink the V8 juice and R27 responded, no, later. NA-F then lowered R27's bed, and stated she had taken care of R27 today. NA-F then left R27's room. NA-F did not offer to assist R27 to turn and reposition while NA-F was in the room. During an observation on 5/20/25, at 12:50 p.m., surveyor informed licensed practical nurse (LPN)-C that it had been over two hours since R27 had last been repositioned. At 12:51 p.m. LPN-C entered R27's room and applied a gown and gloves. LPN-C informed surveyor that NA-H would assist with repositioning R27. At 12:52 p.m., NA-H entered the room, asked R27 if they could reposition R27, and applied gown and gloves. LPN-C and NA-H assisted R27 by checking her brief, which was dry, and assisted R27 to turn and reposition onto her right side. LPN-C and NA-H placed a pillow under her left side after they boosted her up in bed, and applied a pillow under her lower legs to float her heels. NA-H informed surveyor she had not worked with R27 earlier that day. NA-H applied lip balm to R27's lips, lowered R27's bed and they left the room after removing their gown and gloves. R27's Weekly Wound Documentation assessment dated [DATE], identified R27 had signs and symptoms of a [NAME] Ulcer (skin wound that appears during final weeks of life) first identified on 4/17/25, on sacrum (base of spine) two centimeters (cm) length, two cm width, zero cm depth, not staged. R27's wound was identified as 100% eschar (hardened dry black or brown dead tissue covering a wound bed), with moderate brown drainage and odor present and edges frail and irregular. R27's family and physician were notified. R27's Weekly Wound Documentation assessment dated [DATE], identified Kennedy ulcer pending, on sacrum measuring three cm length, two cm width and zero cm depth, unstagable ulcer, with 50% slough (yellow, tan, or white dead tissue within a wound, covering a wound bed), 50% eschar, moderate amount brown drainage, odor present and wound had declined. R27 complained of pain with repositioning and during treatment, case manager working with hospice on pain management. R27's Weekly Wound Documentation assessment dated [DATE], identified R27's wound as a pressure ulcer stage three on sacrum measuring two cm length, 2.5 cm width and 2.5 cm depth 2.5 cm tunneling with 50% slough and moderate amount yellow drainage, odor present, no change. Area was debrided on 4/24/25 by wound care nurse. R27 had much discomfort at site during treatment, hospice notified. R27's Weekly Wound Documentation assessment dated [DATE], identified sacrum pressure wound stage three, two point five cm length, two cm width, two point five cm depth, tunnel two point five cm with moderate amount brown drainage, no odor, no change. Pain managed with topical and oral medication, minimal discomfort during treatment. R27's Weekly Wound Documentation assessment dated [DATE], identified sacrum pressure ulcer stage three, two cm length, two cm width, two cm depth, tunnel two cm. Moderate amount serosanguinous (thin watery fluid pink in color and normal discharge from wound) drainage, no change. R27 complained of discomfort during treatment. During an interview on 5/20/25 at 12:59 p.m., LPN-C reviewed her documentation on R27's electronic medical record and verified the last time they repositioned R27 was at 9:38 a.m. During an interview on 5/20/25, at 1:26 p.m., NA-F indicated had thought she offered R27 to reposition in bed when offered lunch, then stated was not able to reposition R27 at noon due to staff assisting other residents in dining room. NA-F stated the last time R27 had been repositioned was around 10:00 a.m. with LPN-C. NA-F stated R27 was to be repositioned every two hours because she had a sore on her bottom. During an interview on 5/20/25 at 4:52 p.m., NA-G stated R27 was on hospice, and was to be repositioned every two hours. NA-G stated she had never had problems repositioning R27 while in bed, and if was unable to reposition R27 timely, NA-G would do it as soon as possible. During a follow up interview on 5/20/25 at 5:17 p.m. LPN-C indicated R27 was to be repositioned every two hours and it was located in R27's medical record as a nursing assistant task. LPN-C stated the last time R27 had been repositioned was at 9:38 a.m. with NA-F. LPN-C indicated it was important to reposition R27 every two hours for R27's comfort and to prevent skin break down, and confirmed it had been at least three hours since R27 had last been repositioned prior to 12:50 p.m. R21 R21's quarterly MDS dated [DATE], identified R21 had severe cognitive impairment and diagnoses which included Alzheimer and asthma. Identified R21 required extensive assistance with activities of daily living (ADL's) which included bed mobility, transfers, and toileting. Identified R21 was at risk for pressure ulcers. R21's annual CAA dated 10/4/24, identified R21 required total assistance from staff with repositioning and was at risk for skin breakdown. Identified R21 was incontinent of bowel and bladder. R21's care plan dated 3/13/2020, identified R22 had self care deficits and a potential for an alteration in skin integrity related to Alzheimer's disease and dependence on staff for repositioning in bed and wheelchair. Identified R21 was to wear blue padded boots to bilateral lower legs/feet while in bed or up in chair. Care plan lacked direction of how often to reposition R21 in bed and in the chair. R21's Braden Scale for Predicting Pressure Ulcer Risk dated 3/19/25, identified R21 was at moderate risk of developing a pressure ulcer. During a continuous observation on 5/20/25 from 3:35 p.m. to 6:27 p.m., the following was revealed: -3:35 p.m., R21 was seated in her wheelchair in the dayroom. R21 had only socks on her feet and both heels were resting on the foot pedals. -4:07 p.m.,R21 remained seated in her wheelchair in the day room wearing only socks on her feet and both heels were resting on the foot pedals. -4:33 p.m., R21 remained seated in her wheelchair in the day room wearing only socks on her feet and both heels were resting on the foot pedals. -4:51 p.m., R21 was wheeled into the dining room by NA-B. R 21 continued to have only socks on her feet and both heels were resting on the foot pedals. -5:35 p.m., R21 remained seated in her wheelchair in the dining room and was being fed by NA-B. R 21 continued to have only socks on her feet and both heels were resting on the foot pedals. -6:07 p.m., R21 remained seated in her wheelchair in the dining room and was being fed by NA-B. R 21 continued to have only socks on her feet and both heels were resting on the foot pedals. -6:23 p.m., NA-B wheeled R21 to the day room and placed her in front of the TV. - 6:25 p.m., R21 had remained seated in her wheelchair in the day room. Surveyor requested NA-B to reposition R21 after R21 remained seated in her wheelchair without the blue boots on her feet and not repositioned for almost three hours. During an observation on 5/20/25 at 6:32 p.m., NA-B wheeled R21 to her room. NA-B, NA-C, and registered nurse (RN)-A sanitized hands, hooked R21 up to the mechanical lift and placed R21 onto the bed. R21's incontinent product was changed and R21 was repositioned. R21's medication administration record (MAR) dated 3/11/25, identified R21 was to have blue boots to both feet while in bed and in wheelchair. During an interview on 5/19/25 at 3:40 p.m., family member (FM)-A stated staff usually got R21 up early in the morning and put R21 to bed early in the evening FM-A indicated R21 sat in her wheelchair for most of the day. During an interview on 5/20/25 at 11:17 a.m., complainant (C)-A stated R21 sat in the chair most of the day and was not being repositioned. During an interview on 5/20/25 at 6:38 p.m., NA-B stated R21 required staff assistance to reposition and was to wear blue boots on her feet at all times. NA-B stated she was unsure of the last time R21 had been repositioned because when she arrived to work at 4:00 p.m., R21 had already been sitting in her wheelchair. NA-B stated staff had not documented the time that R21 had been repositioned and stated R21 should have been repositioned every two hours to prevent skin breakdown. During an interview on 5/20/25 at 6:46 p.m., NA-C stated R21 required staff assistance to reposition and was to wear blue boots on her feet at all times. NA-C stated she was unsure of the last time R21 had been repositioned. NA-C stated R21 should have been repositioned every 2 hours to prevent skin breakdown. During an interview on 5/20/25 at 6:48 p.m., RN-A stated R21 required staff assistance to reposition and was to wear blue boots on her feet at all times RN-A stated he was unsure of the last time R21 had been repositioned since staff do not document times. RN-A stated the normal process was to reposition all residents on the even hour. RN-A stated his expectation was the R21 was repositioned at least every two hrs and that she would have had her blue boots on both feet to prevent skin breakdown. During an interview on 5/21/25 at 8:49 a.m., clinical manager (CM )-A stated R21 required staff assistance to reposition. CM-A stated R21 was at risk for skin breakdown and her expectation was R21 would have been repositioned at least every two hours and would have had blue boots to both feet at all times. R47 R47's annual MDS dated [DATE], identified R47 had severe cognitive impairment and diagnosis which included Alzheimer's, depression and anxiety. Identified R47 required extensive assistance with ADL's which included bed mobility, transfers, and toileting. Identified R47 was at risk for pressure ulcers. R47's annual CAA dated 4/1/25, identified R47 required total assistance from staff with repositioning and was at risk for skin breakdown. Identified R47 was incontinent of bowel and bladder. R47's care plan dated 5/25/23, identified R47 had self care deficits and a potential for an alteration in skin integrity related to Alzheimer disease. Identified R47 had total dependence of one to two for positioning, checking and changing incontinent product at least every two hours. R47's Braden Scale for Predicting Pressure Ulcer Risk dated 3/19/25, identified R47 was at moderate risk of developing a pressure ulcer. During a continuous observation on 5/20/25 from 3:38 p.m. to 6:20 p.m., the following was revealed: - 3:38 p.m., R47 was up in R47's wheelchair and brought out to the day room. R47 was positioned facing out the window and staff covered R47 up with a red blanket. - 4:29 p.m., R47 remained in the same position. - 4:51 p.m., R47 into the dining room and placed R47 at the table to be fed supper. - 5:55 p.m., R47 was being fed by staff in the dining room. - 6:15 p.m., R47 nursing assistant (NA)-B pushed R47 out of the dining room and to the dayroom. During an observation on 5/20/25 at 6:20 p.m., NA-B wheeled R47 to her room. NA-B, NA-C, and registered nurse (RN)-A sanitized hands, and hooked R47 up to the mechanical lift, placed R47 onto the bed, changed R47's incontinent product and repositioned R47. During an interview on 5/20/25 at 6:38 p.m., NA-B stated R47 required staff assistance to reposition and change incontinent products. NA-B stated she was unsure of the last time R47 had been repositioned because when she arrived to work at 4:00 p.m., R47 had already been sitting in her wheelchair. NA-B stated staff had not documented the time that R47 had been repositioned but stated R47 should have been repositioned every two hours to prevent skin breakdown. During an interview on 5/20/25 at 5:57 p.m. director of nursing (DON) stated the usual facility procedure for pressure ulcer repositioning depended on a resident's Braden assessment, location of the resident's pressure ulcer, and repositioning could have been completed between one to three hours. DON stated if it was care planned for every two hours repositioning, it was expected to be done, unless the resident or family refused. DON stated repositioning was important to reduce risk for further skin breakdown. DON stated R27's pressure ulcer was first assessed as a Kennedy ulcer however, was then changed to a stage three pressure ulcer after the clinic wound nurse assessed it. During a follow-up interview on 5/20/25 at 7:02 p.m., DON confirmed the above findings and stated the clinical managers set up the turning and reposition programs. DON indicated the facility did complete tissue tolerance tests and each resident was monitored through the Braden scale. DON stated she was not aware R21 was not wearing her blue boots. DON said her expectations were for staff to follow the care plan for each resident and reposition them as indicated. Review of facility policy titled Preventing & Managing Pressure Ulcers And Wound revised 3/5/25, identified that a resident who was admitted to this facility without a pressure ulcer did not develop a pressure ulcer unless it was clinically unavoidable, and that a resident who had an ulcer received cares and services to promote healing and to prevent additional ulcers. The policy included instructions for a body audit to be completed with the first 24 hours of admission, a Braden scale be completed on admission then weekly times four, quarterly, and with any significant change and annually. The individualized resident care plan would indicate the frequency of repositioning and/or off loading, special cushions or devises to be used in the bed or chair, and special nourishments. With the guidance of the registered nurse, wound care nurse, or physician, staff would follow the treatment orders to care for the wound, and weekly wound documentation would be completed by a registered nurse. Review of a facility policy titled Repositioning Policy revised 3/24, identified a resident's repositioning schedule would be identified in the care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure staff were following fall risk interventions implemented for 1 of 1 (R15) residents identified at risk for falls. Findings include: R15's quarterly Minimum Data Set (MDS) dated [DATE], identified R15 was cognitively intact and had diagnoses which included diabetes mellitus, depression, and anxiety. Indicated R15 required extensive assistance from staff with toileting, transfers, and personal hygiene. R15's care area assessment (CAA) dated 10/25/24, triggered for a risk of falls due to use of anti-depression medications and a history of falls. Review of R15's care plan dated 10/20/23, lacked the immediate intervention implemented from fall on 5/6/25. Review of R15's progress notes dated 5/6/25, revealed R15 had a fall on 5/6/25, in R15's bathroom. R15 stated R15 was trying to get to her bathroom call light and the non mechanical standaid was in the way. R15 tried to turn around and got stuck and could not get R15's chair to move forward again and slipped out of the wheelchair. R15 stated R15 hit her head when she fell. Facility had an immediate intervention implemented to remove the non mechanical standaid out of R15's bathroom when R15 was not using the non mechanical standaid for R15. During an observation on 5/19/25 3:05 p.m., non mechanical standaid was present in R15's bathroom. R15 had a fall on 5/6/25, and the intervention was to remove the non mechanical standaid from R15's bathroom when not in use. During an observation on 5/19/25 at 5:26 p.m., non mechanical standaid was placed in R15's bathroom. During an observation on 5/20/25 at 10:37 a.m., non mechanical standaid was placed in R15's bathroom. During an observation on 5/20/25 at 12:31 p.m., non mechanical standaid remained in R15's bathroom. R15 left the dining room and was self propelling herself back to her room. During an observation on 5/20/25 at 12:47 p.m., R15 was in her room and nursing assistant (NA)-E assisted R15 to lay down in her bed. When NA-E was done assisting R15, NA-E pushed the non mechanical standaid into R15's bathroom and left R15's room. During an observation on 5/20/25 at 1:18 p.m., R15 was laying in her bed covered up with a blanket. The non mechanical standaid remained in R15's bathroom. During an observation on 5/21/25 at 7:16 a.m., R15 was in the dining room. The standaid remained in R15's room. During an interview on 5/20/25 at 4:30 p.m., NA-E confirmed NA-E assisted R15 to bed on 5/20/25, and placed the non mechanical standaid back in the bathroom. NA-E stated she was unaware the non mechanical lift was not supposed to be stored in R15's bathroom. During an interview on 5/21/25 at 9:41 a.m., trained medical aid (TMA)-A stated TMA-A was not aware the non mechanical lift was to be removed from R15's room after staff assisted R15. During an interview on 5/21/25 at 9:43 a.m., clinical manager (CM) indicated she was not aware of the new intervention for R15. CM stated that was implemented by another staff. CM confirmed it was not updated in R15's care plan. During a follow-up interview on 5/21/25 at 12:30 p.m., CM stated R15's care plan had been updated to reflect the fall intervention and the non mechanical lift had been moved out of R15's bathroom. During an interview on 5/21/25 at 3:10 p.m., director of nursing (DON) confirmed the above findings and stated it should have been added to R15's care plan. DON stated her expectations were if a new intervention was put in place that it was added to the care plan and staff were to follow it. Facility policy titled Fall Prevention and Management dated 12/10/24, the staff nurse will review the occurrence report and will: - Assess all factors contributing to the fall event such as environment, equipment, medication factors and which interventions were in place at the time of the fall using Fall follow up form as a guideline. - Recommend interventions and changes to plan of care to prevent repeat fall. - Communicate and document results. - The staff nurse will complete the follow up documentation in the medical record by the following schedule.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility's consultant pharmacist failed to identify and report irregularities related to prophylactic antibiotic use for 1 of 6 residents (R34) reviewed for unnecessary medications. Findings include: R34's quarterly Minimum Data Set (MDS) dated [DATE], indicated R34 was severely cognitively impaired and had diagnoses which included dementia and Parkinson's disease. Identified R34 required extensive assistance with transfers, toileting, bathing and personal hygiene. R34's care area assessment (CAA) dated 2/19/25, indicated R34 had an actual problem with urinary incontinence and indwelling catheter. R34 had an alteration of the urinary system related to a malignant neoplasm of the bladder (bladder cancer) and an AEB urostomy (a pouch on the outside of the bladder to catch and hold urine). R34 was to remain free from urostomy related trauma. R34's care plan dated 4/8/24, indicated R34 required assistance with transfers and personal hygiene. R34 had alterations of R34's urinary system with a goal R34 would remain free from urostomy related trauma. R34 would show no signs or symptoms of urinary tract infections (UTI). R34's intervention was to have R34's urostomy emptied every two hours. Review of R34's signed physicians orders dated 3/27/24, revealed the following orders for Cefuroxime Axetil Oral Tablet 500 milligrams (MG) (Cefuroxime Axetil). Give one tablet by mouth one time a day every Monday and Thursday for UTI prophylaxis starting 10/7/24. R34's physician orders lacked guidance to monitor for signs and symptoms related to UTIs or when to reevaluate prophylaxis antibiotic usage. Review of R34's electronic medication administration records (eMAR) from 3/1/25 through 5/21/25, revealed R34 received the above prophylaxis antibiotic every Monday and Thursday. Review of R34's Pharmacist Recommendations to Nursing from 4/29/24 through 2/18/25, revealed no recommendations to monitor for signs and symptoms of a UTI or to reevaluate the use of the prophylaxis antibiotic. During an interview on 5/21/25 at 12:23 p.m., case manager (CM)-A confirmed R34 had no documentation specifically related to R34's prophylaxis antibiotic usage. CM-A indicated R34's primary care provider was scheduled to complete rounds on 5/22/25, and the facility was going to ask R34's primary provider to add supporting documentation of the continued use. During a phone interview on 5/21/25 at 1:19 p.m., consultant pharmacist (CP) identified the facility had a couple different consultant pharmacists over the past six months. CP indicated R34 had a history of reoccurring sepsis with UTI's, urostomy, and a history of being treated for bladder cancer. CP stated notes were entered into the pharmacy's system however, not into the facility's system. CP stated it was important for the physician to have additional notes and justification to support the continued antibiotic usage. CP indicated the facility should have received a note to review this medication with the provider during last rounds. During a follow-up interview on 5/21/25 at 3:05 p.m., CM-B stated CM-B was not aware R34 was receiving the prophylaxis antibiotic. CM-B indicated R34 did have a lot of UTI's in the past and thought R34's primary provider ordered the medication due to another medication being stopped. CM-B was going to review R34's eMAR and would provide additional documentation if any was found. During an interview on 5/21/25 at 3:18 p.m., director of nursing (DON) confirmed the above findings and was unaware R34 was taking the antibiotic. DON stated her expectations were all medication had proper diagnosis and rationales with supporting documentation when receiving medications. During a follow-up phone interview on 5/22/25 at 10:46 a.m., medical director (MD) indicated he was not R34's primary provider and he was not aware R34 was receiving a prophylaxis antibiotic. MD stated he was aware R34 had experienced a lot of UTIs in the past and was probably on the medication due to R34's medical history. MD indicated he was going to talk to the provider and make sure that he updated a rationale on why the resident was taking the medication. Review of facility policy titled Antibiotic Stewardship Policy revised 2/21/25, it was the policy that [NAME] Village Care Center antibiotic stewardship program promoted the appropriate use of antibiotics and a system of monitoring to improve resident outcomes and the reduction of antibiotic resistance. Antibiotics would be prescribed for the correct indication, dose, and duration to appropriately treat the resident while attempting to reduce the development of antibiotic-resistant organisms or other adverse consequences or outcomes. The facility would monitor antibiotic use to identify appropriate use of antibiotics to improve resident outcomes and reduce antibiotic resistance. The facility would need to ensure that prescribing practitioners had documentation of periodic review of antibiotic use to monitor appropriate prescribing. In addition, the facility would be providing feedback to prescribing practitioners on antibiotic use, antibiotic resistance patterns and prescribing patterns as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure reevaluation for necessity and duration of ongoing antibiotic use for 1 of 1 residents (R34) reviewed for unnecessary medication use. Findings include: R34's quarterly Minimum Data Set (MDS) dated [DATE], indicated R34 was severely cognitively impaired and had diagnoses which included dementia and Parkinson's disease. Identified R34 required extensive assistance with transfers, toileting, bathing and personal hygiene. R34's care area assessment (CAA) dated 2/19/25, indicated R34 had an actual problem with urinary incontinence and had an indwelling catheter. R34 had an alteration of the urinary system related to a malignant neoplasm of the bladder (bladder cancer) and an AEB urostomy (a pouch on the outside of the bladder to catch and hold urine). R34 was to remain free from urostomy related trauma. R34's care plan dated 4/8/24, indicated R34 required assistance with transfers and personal hygiene. R34 had alterations of R34's urinary system with a goal to remain free from urostomy related trauma. R34 would show no signs or symptoms of urinary tract infections (UTI). R34's intervention was to monitor/record/report to primary provider for signs and symptoms of UTI: pain, burning, blood tinged urine,cloudiness, no output, deepening of urine color, increased pulse,increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, or a change in eating patterns. R34's care plan lacked a focus area for extended antibiotic use. Review of R34's signed physicians orders dated 3/27/24, revealed the following orders for Cefuroxime Axetil Oral Tablet 500 milligrams (MG) (Cefuroxime Axetil). Give one tablet by mouth one time a day every Monday and Thursday for UTI prophylaxis starting 10/7/24. R34's physician orders lacked guidance to monitor for signs and symptoms related to UTIs, when to reevaluate prophylaxis antibiotic usage, and duration. R34's provider visit notes dated 1/23/25, 3/27/25, and 5/1/25, lacked documentation for continued use rationale and duration of extended antibiotic use. Review of R34's electronic medication administration records (eMAR) from 3/1/25 through 5/21/25, revealed R34 received the above prophylaxis antibiotic every Monday and Thursday. Review of R34's electronic treatment administration records (eTAR) from 3/1/25 through 5/21/25, lacked documentation of monitoring R34 for signs and symptoms of a UTI or extended antibiotic use. During an interview on 5/21/25 at 12:23 p.m., case manager (CM)-A confirmed there was no documentation for reevaluation and duration of continued antibiotic use for R34. CM-A indicated R34's primary care provider was scheduled to complete rounds on 5/22/25, and the facility was going to has R34's primary provider to add supporting documentation of the continued use. During a phone interview on 5/21/25 at 1:19 p.m., consultant pharmacist (CP) identified the facility had a couple different consultant pharmacists over the past six months. CP indicated R34 had a history of reoccurring sepsis with UTI's, urostomy, and a history of being treated for bladder cancer. CP stated notes were placed into the pharmacy's system however, not into the facility's system. CP stated it was important for the physician to have additional notes and justification to support the continued antibiotic usage. CP indicated the facility should have received a note to review this medication with the provider during last rounds. On 5/21/25 at 1:36 p.m., a voicemail was left for the facility's medical director (MD). During a follow-up interview on 5/21/25 at 3:05 p.m., CM-B stated CM-B was not aware R34 was receiving the prophylaxis antibiotic. CM-B indicated R34 had a lot of UTI's in the past and thought R34's primary provider ordered the medication due to another medication being stopped. CM-B was going to review R34's eMAR and would provide additional documention if any was found. During an interview on 5/21/25 at 3:18 p.m., director of nursing (DON) confirmed the above findings and was unaware R34 was taking the antibiotic. DON stated her expectations were all medication had proper diagnosis, duration and rationales with supporting documentation when receiving medications. During a follow-up phone interview on 5/22/25 at 10:46 a.m., MD indicated he was not R34's primary provider and he was not aware R34 was receiving a prophylaxis antibiotic. MD stated he was aware R34 had a lot of UTIs in the past and was probably on the medication due to R34's medical history. MD indicated he was going to talk to the provider and make sure that he updated a rationale and duration for the medication use. Facility policy titled Antibiotic Stewardship Policy revised 2/21/25, It is the policy that [NAME] Village Care Center antibiotic stewardship program promoted the appropriate use of antibiotics and a system of monitoring to improve resident outcomes and the reduction of antibiotic resistance. Antibiotics would be prescribed for the correct indication, dose, and duration to appropriately treat the resident while attempting to reduce the development of antibiotic-resistant organisms or other adverse consequences or outcomes. The facility would monitor antibiotic use to identify appropriate use of antibiotics to improve resident outcomes and reduce antibiotic resistance. The facility would need to ensure that prescribing practitioners have documentation of periodic review of antibiotic use to monitor appropriate prescribing. In addition, the facility would be providing feedback to prescribing practitioners on antibiotic use, antibiotic resistance patterns and prescribing patterns as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure call lights were accessible for 1 of 2 residents (R23) reviewed for call light accessibility. Findings include: R23's quarterly Minimum Data Set (MDS) dated [DATE], identified moderate cognitive impairment and diagnoses which included hypertension (elevated blood pressure) and dementia. Identified R23 was dependent on staff for activities of daily living (ADLs) and mobility. R23's care plan dated 3/27/25, identified R23 was at risk for falls, with an intervention to ensure the call light was within reach and to encourage R23 to use the call light. During an observation on 5/19/25 at 11:26 a.m., R23 was seated in her reclining wheelchair in her room. Call light cord was attached to the wall and not within reach. During an observation on 5/19/25 at 3:09 p.m., R23 was lying in bed. Call light cord continued to be attached to the wall and was not within reach During an observation on 5/20/25 at 9:58 a.m., R23 was lying in bed. Call light cord was attached to the wall and not within reach. During a joint interview on 5/20/25 at 10:15 a.m., NA-A and LPN-A stated R23 was able to use the call light. NA-A verified call light cord was not within reach of R23 and removed the call light cord from the wall and placed the cord on the siderail next to R23. LPN-A stated R23 was able to use the call light and her expectation was that R23's call light would be placed within reach. During an interview on 5/21/25 at 9:25 a.m., director of nursing (DON) verified R23 was able to use the call light. DON stated her expectation was that R23's call light would have been within reach of R23 in her room. Review of a facility policy titled Call Light Policy revised 1/2024, identified, when the resident/patient was in bed or confined to a chair to be sure that the call light was within easy reach of the resident/patient, and that the resident/patient had a pendant on if they chose to do so.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure food was served at a palatable and appetizing temperature for 2 of 5 residents (R 22 and R62) who resided on the Blue Horizon and [NAME] Ridge units reviewed for food. This deficient practice had the potential to affect all 23 residents residing on these units. Findings include: R22's quarterly Minimum Data Set (MDS) dated [DATE], indicated R22 had intact cognition and was able to feed herself after staff set up her tray. R 62's admission MDS dated [DATE], indicated R62 had intact cognition and was independent with eating. During an interview on 5/19/25 at 1:35 p.m., R22 stated she usually ate her meals in the dining room and the hot food was usually lukewarm or cold. During an interview on 5/19/25 at 1:47 p.m., R62 stated the staff in the kitchen needed some training because the food was not very good. R62 indicated the hot food was not always hot and the cold food was not always cold. Review of resident council meeting minutes dated 1/15/25 and 2/19/25, identified residents had concerns with the food not being served hot. During an observation on 5/19/25 at 11:50 a.m., a tray was brought to the dining room which contained three metal containers which were placed in the steam table. The metal containers were placed a few inches above the hot water on the steam table. A container which contained potato salad was placed in a large plastic bin about two inches above the ice. .- at 12:46 p.m., as the last tray was being dished up a test tray was requested. The meal consisted of potato salad, mashed potatoes, au gratin potatoes. DA-A tested the food temperatures and the temps were as follows: -au gratin potatoes were 109 degrees Fahrenheit (F). -mashed potatoes were 110 106 degrees Fahrenheit (F). -Ribs were 95 degrees Fahrenheit (F). - potato salad was 51.9 106 degrees Fahrenheit (F). After temping the meal, the surveyor and dietary manager (DM) tasted the food from the test tray. The ribs were lukewarm, potatoes were cold and the potato salad was lukewarm. During a resident council meeting on 5/20/25 at 1:00 p.m., R22 stated she had brought up concerns about the food being cold at resident council meeting however, nothing had ever been done about it. During an interview on 5/19/25 at 1:05 p.m., DM stated the holding temperature for hot food should be at least 135 degrees Fahrenheit (F). and the temperature of cold food should be at 41 degrees Fahrenheit (F).or lower. DM stated her expectation was that all food would have been at the proper holding temperatures. During an interview on 5/19/25 at 1:39 p.m., R62 stated the meat and potatoes were cold and the potato salad was lukewarm. Review of a facility policy titled Food Service Policy revised 5/20/25 identified hot foods were to be served hot and cold food was served cold. Identified hot food must reach a holding temperature of 135 degrees Fahrenheit (F).and cold foods must be maintained at 41 degrees Fahrenheit (F).or below until served.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to disinfect a multi-use glucometer (a machine that is used for blood glucose monitoring) after use for 1 of 2 residents (R51) reviewed for blood glucose monitoring. This deficient practice had the ability to affect all 5 residents who required blood glucose monitoring. Findings include: The Centers for disease Control and Prevention (CDC) Infection Prevention for Blood Glucose Monitoring and Insulin Administration dated 2/6/2013, identified due to the risk of transmitting infectious diseases during assisted blood glucose (blood sugar) monitoring whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. R51's quarterly Minimum Data Set (MDS) dated [DATE] identified R51 had intact cognition and diagnoses which included asthma, heart failure and and diabetes mellitus (DM). R51's current physician orders signed 4/11/25, identified R51 required blood glucose monitoring checks two times weekly. During an observation on 5/20/25 at 8:45 a.m., licensed practical nurse (LPN)-B sanitized hands, applied gloves and removed a glucometer, strip and a lancet (small device with a needle used to get blood for blood glucose monitoring) from the top drawer of the medication cart. RN-A used the lancet to poke R11's finger and obtained a small drop of blood onto the glucometer strip. LPN-B removed gloves, sanitized hands and placed the glucometer in the top drawer of the medication cart. LPN-B did not sanitize the glucometer prior to placing it in the medication cart. During an interview on 5/20/25 at 9:00 a.m., LPN-B verified she had not disinfected the glucometer which was used for multiple residents prior to placing it in the medication cart. LPN-B stated she should have disinfected the glucometer per manufacturer's guidelines prior to placing it into the drawer of the medication cart to prevent the spread of blood-borne infections. During a joint interview on 5/21/25 at 9:19 a.m., infections preventionist (IP) and director of nursing (DON) verified the glucometer in the top drawer of the medication cart was used for multiple residents. IP and DON stated their expectation was that the glucometer would have been disinfected between residents using a Sani-wipe or per manufacturer's guidelines to prevent blood- borne infections. Review of Manufactures guidelines for Assure Prism multi Blood Glucose Monitoring System (BGMS) revised 9/24, identified disinfecting the glucometer was to be completed using a commercially available EPA-registered disinfectant detergent or germicide wipe, after every resident use. Identified ,what would happen when a blood glucose meter was not cleaned and disinfected after use. Per the CMS F-Tag 880 guideline, surveyors may issue a citation if they observed no cleaning and disinfecting of meters after a blood glucose test as they would not be in compliance with CMS F-Tag 880. Review of a facility policy titled Cleaning of Blood Glucose Meter revised 1/24, identified blood glucose monitors that are shared among residents must be cleaned and disinfected between each use per manufactures guidelines to prevent carry-over of blood and infectious agents.

Based on observation, interview and document review, the facility failed to ensure refrigerated food items were properly labeled, dated, and closed after the packaging was opened to prevent cross contamination which had the potential to affect all 63 residents currently residing in the facility. In addition, the facility failed to ensure refrigerated food items were disposed of after the expiration date. Findings include: During the initial tour of the main kitchen and kitchenettes on 5/19/25 at 11:22 a.m., with the dietary manager (DM)-A, the following areas of concern were identified and confirmed by DM-A: kitchen refrigerator: -Thirteen sandwiches were covered with plastic on a try, undated. -one bag cabbage wrapped, undated. Ruby Ridge kitchenette refrigerator: -tray with six small dishes of sherbet, uncovered and undated in freezer. -seven pasteurized eggs in bag undated. -cocktail sauce opened dated 1/31/25. -french dressing opened dated 4/3/25. -soy sauce opened, undated. -sweet and sour sauce, initialed, undated. -ranch dressing opened, undated. -barbeque sauce opened, undated. -ketchup opened, undated. -mustard opened, undated. Golden Meadow kitchenette refrigerator: -cocktail sauce opened dated 1/31/25. -ketchup opened, undated. Sunrise Cove kitchenette refrigerator: -cocktail sauce opened, dated 1/31/25. -french dressing opened, dated 1/13/25. -ranch dressing opened, dated 2/11/25. -soy sauce opened, undated. -ketchup opened, undated. Sunrise Cove resident refrigerator: -Chinese dish of food, not labeled, undated. -small cardboard container, initialed, undated. During an interview and initial tour on 5/19/25 from 11:22 a.m. to 11:55 a.m., DM-A confirmed the above findings and confirmed expectations of all foods to be covered, labeled and dated. DM-A stated the dietary aides were responsible for dating items and removing items out of date. DM-A indicated was unsure how long dressings and sauces should have been kept in the refrigerator once opened, and then disposed of dressings and sauces identified and listed above. Review of facility policy titled Food Storage, revised 5/20/25, identified purpose to store food in it's appropriate place and within it's appropriate expiration date to ensure foods were consumed by the safe used by date or discarded. Foods would be stored to prevent contamination and cross contamination. All food containers would be legible and accurately labeled. Review of facility policy titled Food Brought In By Family/Visitors Policy revised 2/18/24, identified food brought into the facility by visitors and family was permitted. The policy identified family was instructed that any food kept in facility coolers was to have resident name and date on the container. Any food not labeled or dated was to be discarded. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to conduct ongoing quality assessment (QA) and assurance activities, develop and implement appropriate plans of action to correct repeated quality deficiencies identified during the survey the facility was aware of or should have been aware of. This deficient practice had the potential to adversely affect all 63 residents which resided in the facility. Findings include: During an interview on 5/21/25 at 3:29 p.m., director of nursing (DON) indicated she was in charge of the facility's quality assurance and performance improvement (QAPI) program. DON stated the facility did not have any care related citations last year so the facility did not have any projects related to the standard survey completed in 2024. Reviewed 2024's standard survey with DON and discussed potential projects. DON stated yes we could use that the kitchen as a project. DON explained the facility had a huge turnover in the kitchen recently. DON indicated the facility only used citations from care areas as projects rather than any other citations. Review of CASPER Report 0003D Provider History Profile Report Selection Criteria dated 4/15/25, revealed the following repeat deficiencies: - residents provided assistance with activities of daily living. - nutritive value/appear, palatable/prefer temperature. - sanitary kitchen/dining services. Review of facility QAPI minutes dated 2/21/25 to 5/21/25, revealed the current QAPI projects included: hand hygiene, personal protective equipment (PPE), falls, and enhanced barrier precautions (EBP). QAPI plan minutes lacked documentation on activities of daily living (ADLs), concerns with the kitchen, and meal palatable/prefer temperature and other quality of life concerns. Review of the facility form titled, quality assurance/assessment an performance plan (QAPI) revised 10/21/2022 , revealed the QAPI Program was to utilize an on-going, data driven, pro-active approach to advance the quality of life and quality of care for all residents of [NAME] Village Care Center (GVCC) Quality Assurance and Performance Improvement principles would drive our decision making to promote excellence in all resident and staff related areas. All facility staff, families and residents would be encouraged to identify opportunities for improvement, partake in QAPI teams, imbed QAPI activities in all core processes and provide ongoing feedback. GVCC would review the designated sources of data; identify areas where gaps in performance may negatively affect resident or staff outcomes. Where opportunities for improvement were detected, the QAPI Committee, with input from the leadership team would prioritize focus areas for performance improvement project (PIP) development. In prioritizing activities, the team would consider: high-risk to residents and/or staff, high-volume or problem-prone areas, health outcomes, resident safety and resident autonomy. The team would be interdisciplinary with staff representing each job role affected by the project and may include resident and/or family representation when appropriate. A project lead would be selected and would be responsible for coordinating, organizing and directing the activities of that specific project PIP team. The PIP team would identify the information needed to evaluate the problem at hand, supplies required, staff participation, and any equipment needs. The project lead would communicate any identified resource needs to the QAPI Quality Manager. The team would utilize root cause analysis to identify the cause of the problem and any contributing factors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to help reduce unnecessary antibiotic use and reduce potential drug resistance for 1 of 1 residents (R34) reviewed for urinary tract infection (UTI) as part of their antibiotic stewardship program. Findings include: The Center's for Disease Control and Prevention (CDC)'s Core Elements Of Antibiotic Stewardship For Nursing Homes, dated 2015, included recommendations to identify clinical situations which may be driving inappropriate use of antibiotics such as UTI prophylaxis and implement specific interventions to improve use. Findings include: R34's quarterly Minimum Data Set (MDS) dated [DATE], indicated R34 was severely cognitively impaired and had diagnoses which included dementia and Parkinson's disease. Identified R34 required extensive assistance with transfers, toileting, bathing and personal hygiene. R34's care area assessment (CAA) dated 2/19/25, indicated R34 had an actual problem with urinary incontinence and had an indwelling catheter. R34 had an alteration of the urinary system related to a malignant neoplasm of the bladder (bladder cancer) and an AB urostomy (a pouch on the outside of the bladder to catch and hold urine). R34 was to remain free from urostomy related trauma. R34's care plan dated 4/8/24, indicated R34 required assistance with transfers and personal hygiene. R34 had alterations of R34's urinary system with a goal to remain free from urostomy related trauma. R34 would show no signs or symptoms of UTIs. R34's intervention was to monitor/record/report to primary provider for signs and symptoms of UTI: pain, burning, blood tinged urine,cloudiness, no output, deepening of urine color, increased pulse,increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, or a change in eating patterns. R34's care plan lacked a focus area for extended antibiotic use. Review of R34's signed physicians orders dated 3/27/24, revealed the following orders for Cefuroxine Laetrile Oral Tablet 500 milligrams (MG) (Cefuroxine Laetrile). Give one tablet by mouth one time a day every Monday and Thursday for UTI prophylaxis starting 10/7/24. R34's physician orders lacked guidance to monitor for signs and symptoms related to UTIs, when to reevaluate prophylaxis antibiotic usage, and duration. R34's provider visit notes dated 1/23/25, 3/27/25, and 5/1/25, lacked documentation for continued use rationale and duration of extended antibiotic use. Review of R34's electronic medication administration records (eMAR) from 3/1/25 through 5/21/25, revealed R34 received the above prophylaxis antibiotic every Monday and Thursday. Review of R34's electronic treatment administration records (ETAR) from 3/1/25 through 5/21/25, lacked documentation of monitoring R34 for signs and symptoms of a UTI or extended antibiotic use. During an interview on 5/21/25 at 12:23 p.m., case manager (CM)-A confirmed there had been no reevaluation of duration and continued antibiotic use for R34. CM-A indicated R34's primary care provider was scheduled to complete rounds on 5/22/25, and the facility was going to has R34's primary provider to add supporting documentation of the continued use. During a phone interview on 5/21/25 at 1:19 p.m., consultant pharmacist (CP) identified the facility had a couple different consultant pharmacists over the past six months. CP indicated R34 had a history of reoccurring sepsis with UTI's, urostomy, and a history of being treated for bladder cancer. CP stated notes were placed into the pharmacy's system however, not into the facility's system. CP stated it was important for the physician to have additional notes and justification to support the continued antibiotic usage. CP indicated the facility should have have reevaluated the use of this antibiotic. On 5/21/25 at 1:36 p.m., a voicemail was left for the facility's medical director (MD). During a follow-up interview on 5/21/25 at 3:05 p.m., CM-B stated CM-B was not aware R34 was receiving the prophylaxis antibiotic. CM-B indicated R34 had a lot of UTI's in the past and thought R34's primary provider ordered the medication due to another medication being stopped. CM-B was going to review R34's eMAR and would provide additional documention if any was found. During an interview on 5/21/25 at 3:18 p.m., director of nursing (DON) who was also known to be the infection preventionist of the facility, confirmed the above findings and stated she was unaware R34 was taking the antibiotic. DON stated her expectations were all medications had proper diagnosis, duration and rationales with supporting documentation when receiving antibiotics. DON stated antibiotic use would have been discussed at QAPI meetings. During a follow-up phone interview on 5/22/25 at 10:46 a.m., MD indicated he was not R34's primary provider and he was not aware R34 was receiving a prophylaxis antibiotic. MD stated he was aware R34 had a lot of UTIs in the past and was probably on the medication due to R34's medical history. MD indicated he was going to talk to the provider and make sure that he updated a rationale and duration for the medication use. Review of facility QAPI minutes dated 2/21/25 to 5/21/25 revealed the current QAPI projects included: hand hygiene, personal protective equipment (PPE), falls, and enhanced barrier precautions (EP). QAPI plan minutes lacked documentation of the antibiotic stewardship program. Facility policy titled Antibiotic Stewardship Policy revised 2/21/25, It is the policy that [NAME] Village Care Center antibiotic stewardship program promoted the appropriate use of antibiotics and a system of monitoring to improve resident outcomes and the reduction of antibiotic resistance. Antibiotics would be prescribed for the correct indication, dose, and duration to appropriately treat the resident while attempting to reduce the development of antibiotic-resistant organisms or other adverse consequences or outcomes. The facility would monitor antibiotic use to identify appropriate use of antibiotics to improve resident outcomes and reduce antibiotic resistance. The facility would need to ensure that prescribing practitioners have documentation of periodic review of antibiotic use to monitor appropriate prescribing. In addition, the facility would be providing feedback to prescribing practitioners on antibiotic use, antibiotic resistance patterns and prescribing patterns as necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to comprehensively assess and provide appropriate interventions to respect and promote resident rights and meet individual needs for 1 of 3 residents (R1) who had a Wander Guard placed on his wheelchair to restrict his access to the community despite his intact cognition, independent mobility with his electric wheelchair and the facility's failure to attempt least restrictive measures. Findings include: R1's Minimum Data Set, dated [DATE], identified intact cognition without behaviors. R1 felt little interest or pleasure in doing things and felt down, depressed, or hopeless 2 to 6 days out of 7 days and socially isolated himself. R1 felt it was very important to go outside to get fresh air when weather was good. R1 had functional limitation/impairment on both sides on upper and lower extremities. R1 used a electric motorized wheel chair for mobility. R1 required substantial/maximum assistance for toileting hygiene, shower/bathing, low body dressing, and application of footwear. R1 required supervision or touching assistance with sit to lying, lying to sitting, and partial/moderate assistance with sit to stand, chair/bed transfer, toilet transfers, and unable to ambulate. R1 was able to use motorized wheelchair independently once seated. R1 was occasionally incontinent of bowel and bladder. R1's diagnoses included stroke, aphasia (a brain disorder that affects speaking or understanding language), hemiplegia (one sided paralysis or weakness caused by brain or spinal cord problems), and seizure disorder/epilepsy, anxiety, and depression. No physical or electronic device (bed/chair alarms, wander guard, motion sensor) used to monitor and detect movement. R1's physician order dated 8/4/24, elopement-frequent checks (Note must be completed by a nurse). Follow paper form for frequent checks. Note on locations or attempts to leave facility every shift for one day. Order completed. R1's elopement risk assessment dated [DATE], BIMS score 0 and was identified as no wander risk. R1's elopement risk assessment dated [DATE], BIMS score 15 and was identified as no wander risk. Facility elopement investigation notes dated 8/4/24, identified R1 had never gone anywhere other than the sitting area at the front of the facility before. R1 was alert, orientated, and able to make his needs known but had a history of poor safety awareness AEB (as manifested by) call pendent not used to request assistance with transfers. Facility staff member identified over the past week she had seen R1 on the west side of the building on the sidewalk with no signs of attempting to leave the facility grounds. R1's sister had told facility he had again requested family purse possible admission to the local AL facility, frequently looked for a different room more suitable for himself at current facility he resided at. He had attempted on once occasion to leave facility through doors located by the chapel, redirected, and moved back into facility without question. R1 was transported to ER for evaluation, placed on frequent checks for 24 hours. Wander guard was placed on R1's motorized scooter as he was unable to walk or move independently in a manual wheelchair. R1's care area assessment (CAA) dated 6/12/24, identified recent change in mood; sad or anxious (e.g. crying, social withdrawal). R1's cognition was identified as having confusion, disorientation, and forgetfulness, and decreased ability to make self-understood or to understand others. R1 had a psychiatric or mood disorder and hearing or vision impairment that may have impacted his ability to process information (e.g. directions, reminders, and environmental cues). R1 had expressive communication (e.g. disruption in ability to speak, problems describing objects and events). R1 indicated he felt lonely and conditions identified that impede his ability to interact with others identified were: aphasia, depression, decline in functional abilities, and mood problems that impacted interpersonal relationships or that arises due to social isolation. R1's psychosocial change identified as recent move into a nursing home. R1 had little interest or pleasure in doing things and preferred group activities. Impairment on upper and lower extremity on one side. R1's care plan last updated on 8/5/24, identified communication problem and directed staff to use simple, brief and consistent words/cue and yes/no questions, and communication tools such as communication board/book, writing pad, gestures, signs, and pictures. R1's speech communication was limited to yes, no, bye, grunts in different tones that corresponded with his facial expressions to express his mood, and hand gestures. R1 was identified as an elopement risk on 8/5/24, as evidenced by (EVB) was not identified on care plan. Staff were directed to monitor location for at least 24 hours after elopement, wandering behaviors, and attempted diversion interventions in behavior log. Wander guard was located on back of R1's motorized scooter. R1 was allowed to sit in courtyard by himself with call light pendent and staff or family was required to be with resident if he wanted to sit outside the main entrance. R1 had limited physical mobility and identified with independent scooter use after transfer assistance into his chair. R1 had diagnosis of depression related to loss of independence from stroke that resulted in hemiplegia, loss of independence, separation from family, unable to communicate with others, not wanting to come out of his room and admitted to being lonely. Staff were directed to monitor/document/report signs/symptoms of depression, hopelessness, anxiety, sadness, insomnia, verbalizing negative statements, repetitive anxious or health-related complaints, and tearfulness. R1's goal was to discharge to assisted living. Staff were directed to assist resident with tours of facilities and coordinate community services, and information about alterative living arrangements to R1 and representative. R1's occupational therapy treatment note dated 7/12/24, identified R1 was classified as stable and uncomplicated decision making and deemed safe to operate power scooter. R1's progress noted from 8/4/24, through 8/5/24, identified: -8/4/24 at 10:24 a.m., Late entry: Received a call from community member lived at a local assisted living (AL) facility Estates at approximately 11:10 and reported to charge nurse believed one of our residents [R1] was outside of her place of residence and stuck in a ditch. When questioned how she knew it was [R1] she indicated she visited a family member at this facility and was familiar with him. She indicated had called the police department but was told they were unable to assist her. The charge nurse checked and confirmed [R1] was missing. Community member called again and stated the police department was at the scene. The police department called charge nurse requested the residents full name and date of birth (DOB). After confirmation [R1] returned to facility at 11:25 a.m. with emergency medical EMT's and police. He was then sent to evaluation to ER (emergency room) at 12:27 p.m. to ensure resident was safe after being out of the facility. POA (power of attorney) was notified by staff nurse and facility administrator notified at 11:48 am by charge nurse. [R1] returned from the ER with orders for antibiotics d/t (due to) urinalysis suggestive of a UTI (urinary tract infection). -8/4/24 at 3:47 p.m., Returned to facility via ambulance from hospital. -8/4/24 at 4:10 p.m., Change wander guard: please document initials, date, and serial number of new wander guard. Placed on back of electric scooter. Reason for placement explained to wife and [R1]. -8/5/24 at 2:59 p.m., Health Status Note: Elopement follow-up: Effective Date: 08/05/2024 14:59 Type: Health Status Note. Elopement Follow-up: Resident left building via motorized w/c (wheelchair) after breakfast. [R1] did not communicate to any staff he left facility. Destination was local assisted living facility to look inside facility at room availability. [R1's] wheelchair got stuck in a ditch on the way to the assisted living. Was assisted by local law enforcement and EMT and returned to facility. Was then taken to ER for evaluation. Diagnosed with UTI (urinary tract infection). Started on Cipro 250 mg (milligrams) BID (two times a day ) x (times) 3 days. Interventions: BIMS (brief interview for mental status) score was 15.0 (intact cognition). Wander guard- placed on motorized w/c. [R1] must have someone sit with him when wanting to sit outside at the main entrance. Must inform staff when leaving facility with any family member by himself after . Be sure resident has call pendant on self when going in the courtyard. Resident is aware of the plan and in agreement. During an observation on 8/15/24 at 10:20 a.m., R1's door was closed to his room. R1 laid across his bed with feet placed on electric wheelchair. R1 woke up after surveyor knocked at the door and entered. Wander guard was noted attached to the electric wheelchair on the back side located just below the head rest. During an observation on 8/15/24 at 11:11 a.m. staff nursing assistant (NA)-A stopped by R1's room and checked to see how he was doing. Additionally, at 11:12 a.m. female staff stopped by R1's room checked on him and left room. During an observation on 8/15/24 at 11:20 a.m., R1 came out of his room fully dressed in electric wheelchair, went down hallway and made a loop around the facility independently. Wander guard intact on back side of wheelchair located just below the head rest. During an observation on 8/15/24 at 4:00 p.m. R1 sat in his room alone in silence and looked out of window. Wander guard intact on back side of wheelchair located just below the head rest. During an observation on 8/16/24 at 9:25 a.m., R1's room door was open and he sat in motorized wheel chair alone at his desk and painted on a ceramic duck. Wander guard intact on back side of wheelchair located just below the head rest. During an observation on 8/16/24 at 2:30 p.m., and 4:00 p.m. R1 laid on top of his bed with door open to room, eyes closed in silence. Wander guard intact on back side of wheelchair located just below the head rest. During an interview on 8/15/24 at 10:20 a.m., R1 stated had left facility over one week ago in the electric wheelchair to cruise around the neighborhood and check on an AL facility. R1 stated he wanted to move so he would have more independence. R1 stated was aware of his surroundings and felt safe leaving the facility grounds in the electric wheelchair. R1 stated most of the time when he left the grounds in the past had a family member with him. R1 stated staff had informed him he was unable to leave the facility grounds independently. During a follow up interview/observation on 8/16/24 at 9:30 a.m., R1 sat in electric wheelchair with wander guard attached to the bar located on the backside below the head rest of the wheel chair. R1 was positioned at a table and pained a ceramic duck. R1 stated felt more restricted after the placement of the wander guard and isolated more in his room than before. R1 stated staff do not have the time to take him outside, they were so busy. R1 was aware he could go out into the courtyard but had been closed recently due to dug up ground. R1 stated hardly ever went out in the front of building anymore unless family visited. R1 stated he felt sad, isolated, and very much restricted. R1 stated felt his depression had gotten worse since staff placed the wander guard and restricted his independence going outside. R1 confirmed he had no thoughts of hurting himself and he talked to his sister, and she listened. During an interview on 8/15/24 at 2:25 p.m., nursing assistance (NA)-A stated R1 preferred to be independent, and cognition intact with no confusion or forgetfulness. NA-A stated R1 was independent with use of electric wheelchair allowed to go outside independently but due to recent elopement wander guard was applied to wheelchair and R1 was restricted as to where he could go. NA-A stated R1 was allowed to go out to the courtyard independently but area was closed off to residents, due to the ground being dug up and not safe to enter. NA-A verified R1 was allowed to sit out front of building but only if accompanied by a family member or staff. During a telephone interview on 8/16/24 at 8:11 a.m., R1's family member (FM) stated they knew R1 left the facility not to long ago to check out the AL next door. FM indicated R1 had told her he was the youngest resident in the facility and felt out of place. FM stated R1 had also told her he was not aware he had to sign out of the building prior to leaving and felt he told the truth. FM also stated there were times when she had taken R1 out of the facility, staff had her sign him out, but sometimes they would just say ok and not ask where they were going or when we would return. FM verified they had found R1 on the on the back side of the AL facility, that he wanted to move, and had gone there to check out the area. FM stated the facility had informed her prior to R1 leaving the facility he could go out and about and that would not be a problem. FM stated R1 had left the facility by himself for a stroll around that side of town by the facility about two months ago without any problems. FM indicated she had planned on finding R1 a cell phone to carry with him while outside in case he needed assistance. FM stated R1's cognition had improved in the past year 90%, was severely impaired and now his cognition was intact. FM stated R1 told her he felt totally isolated at this facility and she was afraid he would get more depressed. FM verified she had seen sadness in R1 the past few days, gave her the shrug of his shoulders and indicated he could just as well lay in bed, unable to go outside anymore unless someone had time. FM stated R1 loved the lake, sensory, and needed fresh air. FM stated, thank God he had his painting he can do in his room, that was most likely what was saving him from getting too down on things until he moved. During an interview on 8/16/24 at 9:53 a.m., licensed practical nurse (LPN)-B stated R1 valued his independence, drove his electric wheelchair well, and was important to offer R1 choices. LPN-B stated they had not completed an assessment for application of a wander guard since she started work at the facility (three months ago). LPN-B also stated R1 had no history of elopement, loved the outdoors, sat out in the front of building, and did not wander aimlessly without a purpose. LPN-B confirmed R1 was unable to leave facility without family or someone with him. During a telephone interview on 8/16/24 at 11:18 a.m., registered nurse (RN)-A stated a wander guard had been placed by another staff on R1's wheelchair and management team decided the following day (Monday) R1 would be allowed to go outside in the courtyard by himself unsupervised. The courtyard door (a contained area) would set off the wander guard, R1 was ok with that and happy to have the ability to go out there alone. RN-A verified no assessment for a wander guard was required and was a nursing judgement call. RN-A stated after R1's initial elopement risk assessment was completed upon admission; had been an ongoing thing an assessment was not required prior to the application of the wander guard. RN-A stated when a resident lacked safety awareness, it was a motherly instinct that indicated a safety issue. RN-A indicated staff completed 15-minute checks for 24 hours once R1 returned from ER but no other interventions were tried prior to the placement of the wander guard, adding she was not sure what else could have been done. During an interview on 8/16/24 at 11:54 a.m., LPN-A stated they worked the day R1 left the facility. LPN-A indicated R1 was alert and oriented that morning and no signs of confusion were noted. LPN-A stated R1 had told her upon his return that day he just wanted to check things out at the local AL facility. LPN-A stated it appeared to be an isolated incident. LPN-A stated R1's cognition was intact, was forgetful at times, and should have signed out when he left facility. During an interview on 8/16/24 at 12:45 p.m., social worker (SW) stated the facility courtyard was closed to residents and most likely will be for the next two weeks. SW stated R1 was independent in his electric wheelchair on and off the unit (to other units within the facility), not real clear in R1's care plan as to where he could go independently prior to the elopement. SW stated R1 had a wander guard applied to the backside of his wheelchair and unable leave the facility until next review date without staff or family. SW stated the courtyard had not been torn up yet so he was allowed to go out there independently so that he would not feel like he had a babysitter with him. SW stated R1 had intact cognition, speech therapy attempted a SLUMS (St. Louis University Mental Status) (screening tool designed to detect early signs of mild cognition impairment and dementia) however because he was non-verbal the test was unable to be completed. SW stated R1 had not left the facility prior to his elopement, two assessments were completed upon admission 6/17/24, and annual review on 7/11/24 and identified no risk for elopement. SW stated a wander guard was applied to R1's wheelchair and he was made aware of it and was ok with it. SW stated R1 and his family asked if wander guard was a permanent thing and were told we do not want to take away his freedom and planned on getting back to where he will not need it. SW stated the wander guard was placed for a testing period so that staff were made aware when he exited the building. SW verified no assessment was completed prior to the application of the wander guard on 8/4/24, once he returned from the emergency room visit (ER). SW stated an assessment should have been completed on R1's safety level outside beyond the building. SW stated the wander guard will lock the exit doors (included the courtyard door) when the resident was positioned five feet in front of it and would restrict R1 from going outside. SW stated R1 would be required wait until staff swiped badge to have allowed R1 out of building. SW stated the first 24 hours after the elopement supervision was increased but after the 24 hours no other interventions or non-restrictive options were tried prior to the application of the wander guard. SW indicated R1 had not tired to exit the building alone since the elopement and the use of the wander guard should have be reassessed and possibly removed. During an interview on 8/16/24 at 2:00 p.m., case manager RN-C stated R1's cognition was intact. RN-C stated unable to identify in R1's care plan if he had been assessed and/or if he was able to leave the facility grounds safely prior to the elopement. RN-C indicated a wander guard was placed on the back of R1's wheelchair on Sunday (day after elopement) and unsure if less restrictive options were attempted prior to that. RN-C stated the last elopement risk assessment completed was 6/11/24. RN-C stated the wander guard alerted staff R1 had entered the area by an exit door and required staff to swipe badge to open the door. RN-C stated the use of the wander guard on R1 restricted his movement outside the building. RN-C stated they had not discussed with R1 how he felt about the wander guard yet and hoped that someone explained it to him and what it was used for. RN-C stated after review of R1's medical record did not see any monitoring being completed for mood and hoped staff would have reported if there were any changes. RN-C stated R1's care plan was changed after the elopement and he was now required to have staff or family member outside the facility main entrance and courtyard independently. RN-C stated the court yard had been torn up and no residents were allowed to be in that area. During an interview on 8/16/24 at 2:36 p.m., director of nursing (DON) stated R1 had intact cognition was aware of what he was doing, and was able to communicate with people out in the community to yes and no questions. DON indicated R1 was not an elopement risk, had no previous elopement attempts, and could have left the building if he wanted to. DON verified an elopement risk assessment was not completed after the 8/4/24 elopement and should have been, it would have triggered R1 was an elopement risk. DON stated a wander guard was placed on R1's wheelchair to prevent another elopement. DON indicated the wander guard alert system was used to alert staff R1 tried to exit the building. DON stated if R1 really wanted to get out of the facility he would just wait a few seconds then hold door handle down, would open, and then exit the building. DON stated the wander guard was used to alert staff he was at the door. DON stated she would have expected staff to have attempted other interventions such as checked on R1 more frequently after the 24 hours were up before the application of the wander guard. DON the use of the R1's wander guard should have been reviewed weekly. During an interview on 8/16/24 at 3:13 p.m. floor manager RN-B stated R1's BIMS (brief interview for mental status) indicated cognition was intact. RN-B stated SLUMS or MoCA (Montreal Cognitive Assessment) (used to identify impairment of cognition) was not completed due to R1's deficits and inability to write and answer questions easily. RN-B stated assumed R1 was independent on and off the unit and independent outside prior to the elopement but hard to determine that after review of care plan. RN-B stated R1 had communication barriers, wanted out of this facility, felt like he did not fit in, no dementia, and younger than the residents that resided in the facility. RN-B stated R1 had made staff aware he wished to be moved to AL for more independence and family indicated he wanted to go over there to be re-evaluated. RN-B stated prior to elopement R1 had been outside with family, during activities, and had been safe without issues. RN-B stated she had applied a wander guard to R1's wheel chair after he returned from ER on [DATE]. RN-B stated no assessment was completed to the application of the wander guard and should have been. RN-B also stated every 15 minute checks were started and completed 24 hours later. RN-B indicated the wander guard would restrict R1's mobility for going outside and staff would have to open the door for him. RN-B stated anyone could open the door 15 seconds after the wander guard alarmed, door lock would have released, and R1 was not prompted for that. RN-B stated R1 used an electric wheelchair, moved rather fast, found the wander guard was the only option, unable to have someone at all the exit doors when staff assisted other residents. RN-B stated R1 and family asked how long would the wander guard be used and informed unsure of the plan. RN-C indicted R1 had not attempted to exit the facility building since the wander guard was applied and an assessment had not been completed to identify if it was still needed. Facility policy Elopement assessment dated [DATE], revealed a safe environment would be expected to be provided for each resident of the facility. Elopement would be defined as leaving the facility without following the facility's policies and procedures for leave of absence. A thorough elopement risk assessment would be completed during admission, annually, and with any significant change in condition to identify if a resident was at high risk for elopement. Residents identified as high risk for elopement would have preventive interventions initiated on the resident's care plan, direct care staff informed of resident's risk, and when actively exit seeking would have a wander guard placed to ensure residents' safety. Facility policy Wander Guard Blue Devices dated 4/27/22, revealed resident(s) identified to wear a wander guard: assessed to be a potential wanderer, assessed for safety risks and had be determined little or no regard for their own safety, and new admits whose behaviors suggested they maybe a wandering risk. Consider monitoring the new admits until actual risk can be determined.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure medications were administered safely for 2 of 2 residents (R13, R21) who had medications left at the bedside and had been assessed as not safe to self administer those medications. Findings include: R13 R13's quarterly Minimum Data Set (MDS) dated [DATE], identified R13 had moderate cognitive impairment and diagnoses which included Alzheimer's Disease, anxiety and depression. Indicated R13 required supervision or touching assistance for shower/bathing, upper body dressing and personal hygiene. R13's care plan revised 2/29/24, identified R13 had requested staff manage medications while in the facility. R13's care plan interventions included licensed staff and trained medication aide (TMA) would administer medications in a timely and safe manner. R13's Medication Review Report signed 1/25/24, included the following: -Nystatin External Powder 100000 UNIT/Gram (GM) Topical, Apply to Red area between breasts topically as needed for reddened area between breasts from moisture twice a day (BID) as needed (PRN). R13's Medication Review Report lacked orders for self administration of medications. Review of R13's March 2024 Medication Administration Record (MAR) identified Nystatin powder was last administered 3/1/24. R13's Self Medication Evaluation (SME) dated 9/26/23, identified R13 had not requested to self-administer medications. During an observation on 3/11/24 at 6:48 p.m., R13 was seated in a chair in her room. R13 had a bottle of Nystatin powder (medication to treat fungal infections of the skin) on a table next to her chair. R13 was unable to name the medication however indicated it was used under her breasts for sweating. During an observation on 3/12/24 at 8:28 a.m., R13 was in the dining room, R13's door was open and the Nystatin powder remained on the table next to R13's chair. During an observation on 3/12/24 at 4:49 p.m., R13 was seated in her chair in her room and the Nystatin powder remained on the table next to R13. R13's door was open. During an observation on 3/13/24 at 7:12 a.m., R13 was seated in her chair in her room reading a newspaper. The Nystatin powder remained on the table next to R13. R13's door was open. During an interview and observation on 3/13/24 at 11:29 a.m., clinical manager licensed practical nurse (LPN)-C entered R13's room, picked up R13's Nystatin powder and removed it from R13's room. LPN-C stated it absolutely was not to be left in R13's room. LPN-C indicated the medication should have been stored in the medication cart. LPN-C stated it was important to not leave medications in residents' room for safety reasons, since residents would potentially not know what it was, or other residents who were confused may enter the room and ingest it. LPN-C verified R13's SME dated 9/26/23, identified R13 had not requested to self administer medications and indicated R13 would not be appropriate to self administer medications. LPN-C reviewed R13's MAR and verified the last time Nystatin had been documented as administered was 3/1/24. R21 R21's significant change MDS dated [DATE], identified R21 was cognitively intact and had diagnoses which included: heart failure, anxiety and depression. Indicated R21 received antianxiety and antidepressant medications. R21's care plan revised 2/24/24, identified R21 had requested staff to manage medications. R21's care plan indicated R21 had a history of having medications in her room that were not from facility and R21 refused to provide to facility staff. R21's care plan identified R13's doctor of medicine (MD) would be updated when those situations occurred. During an observation on 3/11/24 at 7:03 p.m., R21 was seated in her chair in her room. A bedside table was in front of her with many items which included: a tube of benzodent (numbing medication), bottle of emetrol (nausea medication), earwax removal aide, allergy medication and various supplements. R21's Medication Review Report signed 2/15/24, included the following: -ok to self administer nitro (nitroglycerin) and keep in room. -nitroglycerin tablet sublingual 0.4 milligram (MG) give 1 tablet sublingually (applied under the tongue) as needed for chest pain/angina, may cause drop in blood pressure. R21's Medication Review Report lacked orders for self administration medications other than nitroglycerin. In addition, the report lacked orders for the benzodent, emetrol, earwax removal aide, allergy medications or supplements. R21's SME dated 10/12/23, identified R21 requested to self administer nebulizer treatment after set-up. R21's SME identified R21 could safely be left alone during administration of the nebulizer treatment. R21's SME lacked identification of R21 requesting to self administer any other medications. During an interview on 3/13/24 at 11:32 a.m., LPN-C stated R21 had multiple medications in her room, had made a list, and indicated R21's provider was aware. LPN stated R21 refused to allow staff to remove them. LPN-C stated R21's provider was aware and LPN-C and the provider had discussed it however the discussion had not been documented. LPN-C verified R21's last SME was completed on 10/12/23, and was for nebulizer treatment only. LPN-C indicated it was important to know what medications a resident had in their room due to possible drug to drug interactions and to ensure a resident had not been not taking something double of what receiving. LPN-C confirmed R21 did not have orders for the medications in her room or a current SME completed for self- administration of those medications. During a follow up interview on 3/13/24 at 11:48 a.m., LPN-C indicated it was important to complete a SME to verify the resident was cognitively intact, knew the potential side effects and how to take the medications properly. In addition,LPN-C stated the provider needed to be aware. LPN-C stated R21's medications should have been stored in the locked drawer, in case R21 was out of the room and another resident wandered into her room. At 4:52 p.m. LPN-C verified the list she had completed of R21's medications in her room one to two months ago. LPN-C indicated R21's physician had looked at the list, however the review had not been documented. The untitled, undated, hand written list of R21's medications in her room received from LPN-C contained thirty eight over the counter medications and supplements. Duringan interview on 3/13/24 at 3:34 p.m., director of nursing (DON) verified R13's SME dated 9/26/23, indicated R13 would not self administer medications and R13 did not have orders to self administer medications. DON stated the facility's usual practice was to complete a SME if a resident requested to elf-administer medications and was cognitively able to self administer medications. The facility would then contact the physician and obtain an order for self-administration of the medication. DON indicated it was important to lock up the medications and not leave out to assure residents who wandered or had a tendency to place items in their mouth would not ingest the medications. DON stated she was aware R21 had multiple medications in her room. DON stated R21 ordered medications on line. DON confirmed R21 did not have orders for the medications in her room. DON confirmed she had not discussed R21's medications in her room with R21's physician. During a telephone interview on 3/13/24 at 4:03 p.m., pharmacy consultant (PC)-A stated expectations were a self-administration assessment would be completed to ensure a resident was safe to self-administer medication and the assessment would be documented. PC-A indicated all medications in residents' rooms needed to be stored in a locked drawer or cupboard for safety of residents. In addition, PC-A stated she would expect all medications would have orders so medications could be monitored for potential interactions of medications. PC-A stated she would expect the resident's physician be notified of any medication a resident had in their room. PC-A stated she was unaware R21 had multiple medications in her room. During an interview on 3/13/24 at 5:24 p.m., R21 stated she had requested to self administer her heart medication, nitro, which the facility had allowed her to take herself. R21 indicated she had not requested to take her medications in her room however stated the facility was aware of the medications in her room. R21 stated she had not spoken to her physician about the medications in her room however felt he was aware as he could have seen them when he visited her. R21 indicated she was aware of how to take the medications which she took at times when needed. The facility policy titled Self-Administration Of Drugs revised 2/20/24, identified residents who desired to self administer medications were permitted to do so if the facility's interdisciplinary team had determined that the practice would be safe for the resident and other residents of the facility and there was a prescriber's order to self-administer. The policy identified a SME assessment would be completed by a licensed nurse to aid in determining a resident's ability to self administer medication. A physician's order would be obtained and recorded, which would include which specific medications may be kept at bedside and education provided to the resident. In addition, the policy identified the label would contain a notation that the medication may be self-administered. A nurse was expected to check with resident each shift for appropriate medication administration, monitor for side-effects, adverse events, and provide education. When the interdisciplinary team determined that bedside or in-room storage would be a safety risk to other residents, the medications of residents permitted to self-administer were stored in the central medication cart or medication room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to complete a discharge summary with recapitulation of stay, a final summary of the resident's status, or medication reconciliation for 1 of 1 residents (R57) who required home health services after discharge. Findings include: R57's admission Minimum Data Set (MDS) dated [DATE], identified R57 was cognitively intact and had diagnoses which included: fractures, hypertension and thyroid disease. Indicated an overall goal for discharge to the community and no referral was made to local contact agency, reason: referral not wanted. R57's care plan revised 12/27/23, identified R57's discharge goal was to discharge to own home. Review of R57's progress notes from 11/30/23 to 12/22/23, revealed: -11/30/23 at 3:30 p.m., R57 admitted from hospital. R57 fell at home and sustained fractures. Physical therapy (PT)/occupational therapy (OT) to evaluate and treat. R57 plans to return home. -12/21/23 at 3:23 p.m., R57 seen by physician and received orders to discharge home with home health-PT and home care. R57 may discharge with current medications and may discharge with narcotics. Call placed to home care with new orders. -12/22/23 at 1:34 p.m., R57 left facility at 1:15 p.m. with family to home. R57 discharged with medication Tramadol (narcotic pain medication) and remainder of medications sent back to pharmacy. Discharge paperwork given to R57 at time of discharge. Discharge orders included for home health/PT and home care. R57's medical record lacked documentation of a discharge summary, recapitulation of R57's stay, medication reconciliation of all pre/post discharge medications, and did not include a current summary of R57's health status and needs at the time of discharge to ensure continuity of care. During an interview on 3/13/24 at 3:21 p.m., director of nursing (DON) indicated she was not aware of the process the facility completed for resident discharges, as she was a new employee to the facility. DON stated it was important to complete a discharge summary to send to the next provider to ensure an accurate picture of why the resident was at the facility, is depicted so they could resume care. DON stated her expectation would be a discharge summary would have been completed for R57 with all the necessary information. DON confirmed a discharge summary had not been completed for R57. The facility policy titled Discharge Of A Resident dated 4/20/17, identified the case manager would begin the discharge record form and contact the interdisciplinary team to have each department complete their appropriate section. The policy indicated at the time of discharge, the case manager or the director of health care would complete a discharge summary that must be signed by the resident's physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure food was served at a palatable and appetizing temperature for 5 of 5 residents (R21, R27, R33, R42, R48,) reviewed for dining services. Findings include: R21's significant change Minimum Data Set (MDS) dated [DATE], indicated R21 was cognitively intact and was independent after setup with eating with supervision as needed. R27's admission MDS dated [DATE], indicated R27 was cognitively intact and was required setup assistance with eating. R33's quarterly MDS dated [DATE], indicated R33 was cognitively intact and was independent after setup with eating. R42's quarterly MDS dated [DATE], indicated R42 was cognitively intact and independent after setup with eating. R48's quarterly MDS dated [DATE], indicated R48 had severe cognitive impairment and required assist of one with eating. During an observation on 3/11/24 at 11:53 a.m., dietary aid (DA)-A placed food onto the steam table from kitchen and checked temperature of food with digital food probe. Temperatures were noted to be as follows: meatloaf 206 degrees Fahrenheit (F). chicken al a king 201 degrees (F). potatoes 156 degrees (F). peas 197 degrees (F). gravy 198 degrees (F). pureed peas 191 degrees (F). pureed chicken 184 degrees (F). DA-A placed the pureed food on the counter next to steam table as the steam table was observed to be full with other food items. DA-A left all food items uncovered. DA-A dished up food and delivered to residents seated in the dining area. At 12:19 p.m., DA-A went down the hall to ask residents what they wanted for lunch. The food remained uncovered on the steam table. DA-A went to R42's room and asked what they wanted for lunch, went to R27's room, knocked on R27's door, entered room and asked resident what they wanted for lunch. DA-A returned to the dining area, dished up food for R42 and placed on tray with cover. DA-A knocked on R42's door, placed food on bedside table, moved table to bedside while resident moved from recliner to sit on edge of bed and placed clothing protector on R42. At 12:27 p.m., DA-A was asked to temp the food. Temperatures were noted to be as follows: meatloaf 126.3 (F). potatoes 133.8. (F). DA-A stated she did not know what temperature food should be held at when asked and was not aware of what to do or where food temperature information was located at in the kitchen to refer to. DA-A then noted the food guide taped on cabinet above steam table and stated meatloaf should held at at 155 degrees (F). DA-A stated she would warm the food up and placed the plate in the microwave with a cover on and removed the plate after 20 seconds. DA-A checked the temperature of the food with a digital food thermometer. Temperature was noted to be as follows: meatloaf 140 degrees (F). DA-A placed plate with cover back into microwave and removed after 10 seconds. Temperature was noted to be as follows: meatloaf 151.7 (F) DA-A placed plate with cover back into microwave and removed after 20 seconds. Temperature was noted to be as follows: meatloaf 156.9 (F) DA-A stated she was not aware why foods needed to be held at a certain temperature when asked. DA-A placed the plate on tray and delivered tray to R33. DA-A did not re-temp potatoes or stir them. At 12:35 p.m., DA-A dished up potatoes and chicken onto a plate, left the plate sit on counter, returned to R27's room, knocked on door, entered R27's room and asked which vegetable he wanted. DA-A returned to the kitchen and dished up peas onto R27's plate. DA-A was asked to temp the food. Temperatures were noted to be as follows: chicken ala king 113 (F), moved probe to a different area of the chicken and temped at 125 (F), peas 123 (F). DA-A stated if she was unsure about food temperatures she would ask the dietary manager. DA-A confirmed she did not know what the chicken al a king would be classified as for food and did not know what temperature it should have been held at to be safe. DA-A placed the plate on the tray, covered the plate and delivered tray to R27's room. DA-A walked across hall, knocked on R21's door, entered R21's room, asked resident what she wanted for lunch and returned to the kitchen. DA-A placed mashed potatoes with chicken al a king on top with peas on the side on a plate, set plate on tray with cover, placed clothing protector on tray and delivered to R21. During an interview on 3/13/24 at 1:36 p.m., R42 stated the food was usually good however could be warm one night and the next night it was served cold. During an interview on 3/13/24 at 1:42 p.m., R27 stated the food was good however could be warmer when brought to his room. During an observation on 3/12/24 at 5:23 p.m., DA-B brought food from kitchen on cart and placed food onto steam table. Temperatures were noted to be as follows: chicken patty 205.5 (F). vegetables 162 (F). tator tots 158 (F). pureed chicken 180 (F). pureed vegetables 165 (F). DA-B applied gloves and delivered food to residents in the dining room. The food on the steam table remained uncovered during the entire meal time. At 5:44 p.m. DA-B was asked to temp the food. Temperatures were noted to be as follows: chicken patty 126.8 (F). vegetables 107.7 (F). tator tots 110.6 (F). pureed chicken 115.3 (F). pureed tator tots 117.6 (F). pureed vegetables 122.8 (F). DA-B stated there was usually a sheet at the kitchenette stating what temperatures food should be served at and she was unable to locate it. DA-B served the pureed food to R48. DA-B stated she did not know if the food she was serving was at the right temp. DA-B verified it was important for food to be held at the right temperature so food was served at a safe temperature to prevent food borne illness. During an observation on 3/13/24 at 7:29 a.m., DA-C brought the breakfast cart from the kitchen and placed food onto the steam table. Temperatures were noted to be as follows: oatmeal 202.5 (F). sausage links 178.4 (F). french toast 160 (F). scrambled eggs 162 (F). DA-C placed a cover completely on sausage and bacon container and partially on other food containers on steam table. DA-C served food to residents when they entered the dining room for breakfast. The sausage and bacon container remained covered except for when taking out meat for residents. The other foods were not completely covered at anytime throughout the meal time. At 9:28 a.m., DA-C was asked to dish a tray at the same time the last resident was served their tray. Temperatures were noted to be as follows: oatmeal 139.1 (F). french toast 103.7 (F). sausage 142 (F). scrambled eggs 113.8 (F). The breakfast food was tasted by surveyor; the oatmeal was luke warm, the french toast was cold and hard, the sausage was warm, the scrambled eggs were cold and hard. The food was not palatable. DA-C stated hot foods were supposed to be served above 135 degrees and food needed to be at certain temperatures to prevent food borne illnesses. During an interview on 3/13/24 at 11:48 a.m., the dietary manager (DM) confirmed temperatures on the steam table should have been kept at or above 135 degrees as that was the safe zone to prevent bacterial growth. DM stated the expectation was staff would know what temperatures food should be served at to be safe and enjoyable. The facility food service policy was requested however was not received.

Based on observation, interview and document review, the facility failed to serve food in a safe and sanitary manner to prevent the spread of cross contamination on 1 of 4 hallways reviewed for dining services. This deficient practice had the potential to affect all 15 residents who resided on the blue horizon unit of the facility. Findings include: During an observation on 3/11/24 at 11:49 a.m., cook-B removed food from the oven and placed on the food cart. Dietary aid (DA)-A covered the cart with a cloth and delivered cart to the blue horizon kitchen wing. DA-A removed the cloth covering cart and aluminum foil off food containers and placed food on the steam table. DA-A picked up a pen after checking temperature each time of food containers and wrote temperature down on paper. DA-A opened drawer in kitchen, retrieved spoons and utensils for serving food and placed in food containers. DA-A picked up adaptive plate with right hand, scooped food onto plate and delivered to resident. DA-A opened refrigerator, removed juice container, picked up drinking glass, poured juice into glass, placed container back into refrigerator, closed door of refrigerator with right hand and delivered juice to resident. DA-A placed plate on the counter, scooped food onto the plate and delivered to resident. DA-A picked up scoop from the top of the cooler in the kitchen. DA-A opened the cooler, scooped ice into a glass, closed cooler cover and placed scoop back on top of cooler. DA-A opened refrigerator door, retrieved chocolate milk, poured into glass and delivered both glasses to residents in dining room. DA-A opened the cupboard, took out new juice container for juice machine, removed plastic top on juice touching inner spout with fingers, opened juice machine front cover, removed empty juice container, placed new juice container in machine, closed front cover on machine and threw empty container into the garbage. DA-A placed a plate onto the counter, scooped food onto the plate, placed glove on right hand, used right hand to push meatloaf off spatula onto plate, dished up potatoes, removed glove, threw glove into garbage and delivered food to resident. DA-A removed scoop off cooler, lifted lid on cooler, placed ice into two glasses, filled glasses with water from refrigerator and delivered to resident in the dining room. DA-A placed plate onto counter, scooped food onto the plate and delivered to three different residents in the dining room. DA-A opened refrigerator, retrieved chocolate milk, poured into glass and delivered to resident. DA-A placed plate on counter, scooped food onto place and delivered to resident in the dining room. DA-A proceeded the down hall, knocked on R27's door which had a sign on the door stating enteric precautions-wash hands upon entering and leaving room. DA-A entered room, asked R27 lunch preferences and proceeded to kitchen to dish up food onto plate. DA-A opened refrigerator, poured chocolate milk into glass and placed food onto tray. DA-A knocked on R42's door, entered room and placed food tray on bedside table. DA-A held onto bedside table with her hands and moved the table over by R42's bed. DA-A placed clothing protector on R42 and connected the snaps on the back around R42's neck. DA-A did not complete hand hygiene at any time while serving food. During an interview on 3/13/24 at 11:48 a.m., dietary manager stated dietary staff had been trained annually on food safety, had a 90 day review on competencies upon hire that included hand washing. Dietary manager verified the expectation of staff would be to prepare and distribute food wearing gloves and washing hands to prevent cross contamination. Review of the facility policy titled, Hand Hygiene with a revised date of 8/21 stated staff were to sanitize hands before and after entering any isolation precaution settings. Anyone working with food needed to use hand washing techniques with soap and water. The facility food service policy was requested however was not received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to comprehensively assess incontinence and toileting needs to ensure appropriate bowel and bladder programs/interventions were in place for 2 of 2 residents (R2, R3) who were dependent upon staff for assistance with activities of daily living (ADLs). Findings include: R2's significant change Minimum Data Set (MDS) dated [DATE], identified R2 had severely impaired cognition with occasional wandering behaviors not directed at others. R2 required extensive assistance with bed mobility, dressing, locomotion, toilet use, personal hygiene, limited assistance with transfers, and supervision with eating. R2 was occasionally incontinent of urine and always continent of stool. The MDS identified R2 was not on a urinary or bowel toileting program. R2's diagnoses report dated 8/25/23, identified diagnoses Alzheimer's disease and dementia. R2's care plan dated 7/24/23, identified at risk for impaired urinary incontinence, had mixed incontinence, and directed staff to use bedpan for toileting needs, large tab brief, monitor for signs and symptoms of a urinary tract infection (UTI), and encourage adequate fluids. R2 was identified as continent of bowel. R2 was also at risk for impaired functional status and required total assistance of two staff to transfer with a full body lift and medium sling. R2's [NAME] dated 8/24/23, identified use bedpan for toileting needs. Bladder mixed incontinence and bowel continent. Transfers: total lift assist of two with EZ way full body lift and medium sling. R2's care plan and [NAME] did not indicate how often (frequency) she should have been toileted. R2's bladder assessment dated [DATE], identified impaired mobility, dependent transfer, and severe cognitive impairment. Current toileting program identified as per resident request. No changes in toileting program. Additional notes: R2 was incontinent during this look back, does communicate toileting needs, was dependent on staff for all toileting needs. Wears large briefs, staff manages. Decline in condition since last quarterly assessment. No new concerns or changes at this time. The assessment identified a decline in condition and did not identify whether a toileting plan or a check and change program would be implemented for R2. R2's bowel assessment dated [DATE], identified currently incontinent of bowel. Able to request bathroom and no change in toileting program. R2 had been incontinent of bowel, averaged every other day. Wears a large brief for incontinence and at risk for constipation related to narcotic use. No new orders or changes at this time. R2's toilet use documentation from 8/19/23, through 8/24/23, revealed: 8/19/23, at 10:57 a.m. and 9:17 a.m. total dependence for incontinent cares/incontinent 8/20/23, at 2:11 a.m., 11:02 a.m., and 9:37 p.m. total dependence for incontinent cares/incontinent 8/21/23, at 3:59 a.m., 9:30 a.m., and 10:29 a.m. total dependence for incontinent cares/incontinent 8/22/23, at 1:48 a.m., 10:28 a.m., 1:20 p.m., and 9:53 p.m. total dependence for incontinent cares/incontinent. 8/23/23, at 3:09 a.m., 2:29 p.m., and 11:14 p.m. extensive assistance/incontinent. 8/24/23, at 2:40 a.m., 10:40 a.m., 8:03 p.m., and 11:29 p.m. total dependence for incontinent cares/incontinent. During continuous observations on 8/23/23 from 10:00 a.m. to 12:15 p.m., and again from 12:35 p.m. to 4:20 p.m. R2 was observed seated in a Broda chair without being offered, or assisted, to reposition or toilet: -At 10:00 a.m. R2 sat in Broda chair in resident lounge area had compression stockings on both lower legs/feet without shoes, fully dressed and well groomed. R2 leaned forward and touched her foot while she talked to herself out loud. -At 10:39 a.m. and 10:50 a.m. R2 sat in Broda chair in resident lounge along with four other residents. Activities staff approached her and offered a hand massage. -At 11:00 a.m. R2 sat in Broda chair in resident lounge area and licensed practical nurse (LPN)-A removed R2 from lounge area, placed shoes on her feet and pushed her down the hallway to the dining room. -At 11:15 a.m. through 11:50 a.m. R2 sat in Broda chair in dining room. LPN-A stayed with R2. -At 12:00 p.m. R2 sat in Broda chair without shoes on in resident lounge area. -At 12:07 p.m. R2 talked out loud to herself, leaned forward in her Broda chair, and stated, I am going to go to the bathroom. -At 12:08 a.m. Activity aide approached R2 and informed her she would take her to dining room for lunch and pushed R2 in Broda chair down the hallway. At 12:09 p.m. dietary staff placed two plastic drinking glasses one with water and one with milk in front of R2 on the table. R2 reached up and accidentally knocked over the glass of water into her lap and onto the floor. R2 stated, can someone help me I am all wet. At 12:15 p.m. NA-A pushed R2 in Broda chair back into her room removed wet pants, urine soiled brief, and completed incontinence cares with NA-D's assistance. -At 12:35 p.m. NA-A pushed R2 in Broda chair back into the dining room. -At 1:00 p.m. NA-A pushed R2 in Broda chair down hallway and into the resident lounge. -At 1:35 p.m. R2 sat in Broda chair in resident lounge are. -At 2:00 p.m., 2:30 p.m., 3:00 p.m., 3:15 p.m., 3:30 p.m., 3:45 p.m., sat in Broda chair in same position. -At 4:00 p.m. a visitor approached R2 while she sat in Broda chair and stayed until 4:30 p.m. R3 quarterly MDS dated [DATE], identified severe impaired cognition and long and short-term memory, inattention/difficulty focusing, disorganized thinking, hallucinations (perceptual experiences in the absence of real external sensory stimuli), and delusions (a fixed false belief that conflicts with reality). R3 required extensive assistance with bed mobility, transfers, locomotion, dressing, toilet use, and personal hygiene. R3 used a walker and wheelchair for mobility. R3 was always incontinent of bowel and bladder. The MDS identified R3 was not on a urinary or bowel toileting program. R3's quarterly MDS dated [DATE], identified frequently incontinent of bladder and always incontinent bowel. R3's significant change MDS dated [DATE], identified frequently incontinent of bowel and bladder. R3's [NAME] dated 8/24/23, identified R3 was incontinent of bowel and bladder. Toilet use: upon waking, between meals, and at bedtime (HS) and as needed throughout the day as requested. Do not wake during night but assist if awake to use the bathroom. Toilet R3 after meals to promote continent bowel movements and 4:00 a.m. change brief if incontinent. R3's bladder assessment dated [DATE], identified incontinent of bladder, new onset, and precipitating event new benign prostatic hyperplasia (BPH) (enlarged prostate can cause blocking the flow of urine). R3 was most likely experiencing functional incontinence (a decreased awareness to find a toilet) and treatment program recommended was scheduled toileting /habit training. R3 was previously continent of bowel and bladder wearing only underwear at home. Scheduled toileting has not improved incontinence. Rarely voids when placed on the toilet. Goal must have continent voids during the day. Will continue with toileting schedule and encouragement to use the toilet to promote daytime continence and continent bowel movements. The assessment did not identify whether a toileting plan or a check and change program would be implemented for R3. R3's bowel assessment dated [DATE], identified R3 was incontinent of bowel and required extensive assistance to total dependence of two staff. R3's current toileting program upon walking, between meals, at bedtime (HS), and as needed (PRN) to reduce night bowel movements which lead to falls. R3 did not make his needs known. Goal to be continent of bowel movements during the waking hours has not been met since toileting initiated and will continue to encourage bowel movements during the day to prevent night ones. R3's toileting record indicated task was to toilet R2 upon waking, between meals, and at bedtime (HS) from 8/17/23, through 8/21/23, and 8/23/23, through 8/25/23: 8/17/23, at 12:39 a.m., continent of urine 8/17/23, at 12:43 p.m. 11:01 p.m. incontinent of urine 8/18/23, at 5:59 a.m., 2:18 p.m., 8:54 p.m. incontinent of urine 8/19/23, at 10:32 a.m., 9:14 p.m. incontinent of urine 8/20/23, at 2:09 a.m., 9:16 a.m., 9:21 p.m. incontinent of urine 8/21/23, at 5:43 a.m. did not void 8/21/23, at 9:27 a.m., 11:29 p.m. incontinent of urine 8/23/23, at 5:53 a.m., 5:54 a.m., 11:05 p.m. incontinent of urine 8/24/23, at 4:49 a.m. 10:25 a.m., 10:24 p.m., 11:26 p.m. incontinent of urine 8/25/23, at 11:12 a.m. and 10:29 p.m. incontinent of urine During continuous observations on 8/23/23 from 9:15 a.m. to 11:45 a.m., and again from 12:10 p.m. to 2:38 p.m. R2 was observed seated in a wheelchair without being offered, or assisted, to reposition or toilet: -At 9:15 a.m., 9:45 a.m., 10:10 a.m., 11:15 a.m. R3 sat in wheelchair eyes closed, fully dressed. R3's feet were placed on the floor and occasionally pushed himself backwards. R3's chair alarm was in a cloth bag hung over the right wheelchair push handle and activated. -At 11:45 a.m. LPN-A approached R3 and attempted to wake him up. R3 eyes remained closed. LPN-A asked R3 if he needed the bathroom, R3 did not respond. LPN-A stated unable to wake R3 up and walked away. -At 12:00 a.m. NA-C pushed R3 in wheelchair down the hallway to his room and NA-E followed. R3 appeared extremely tired, and NA-C attempted to wake him up. R3 opened eyes and agreed to go into the bathroom. NA-C placed gait belt around R3's waist and walker in front of him, together NA-C and NA-E assisted R3 to stand and set chair alarm off. R3 slowly walked with guidance from NA-C and NA-E then R3 leaned backwards, lost his balance, crossed feet to catch himself, and lowered onto the toilet by NA-C and NA-E. NA-C removed R3's incontinent brief solid with urine and R3 voided a large amount of urine into toilet. NA-C placed a clean brief on R3's upper legs, used gait belt and assisted to stand. NA-C completed peri care, pulled up brief and pants and together NA-C and NA-E assisted R3 back to wheelchair. NA-C sanitized hands and pushed R3 out of room and down to the dining room. -At 12:10 p.m., 12:40 p.m., R3 sat at dining room table with another resident, eyes closed, fluids and a small dish of pudding placed in front of him, and a cloth protector around his neck. -At 12:56 p.m. R3 sat at dining room table, eyes closed with plate of food, fluids, and small dish of pudding located in front of him. NA- attempted to wake R3 up and offered a drink of fluids, R3 refused. -At 1:02 p.m. dietary aide asked NA-F for assistance with meals. NA-F pulled up a chair next to R3, sat down and woke R3 up. NA-F offered fluids and food to R3, refused, closed eyes, and positioned unchanged. -At 1:08 p.m. NA-F stood up and informed NA-E could not wake R3 up, requested plate of food and fluids saved for later, and exited the dining room. R3 continued to sit in wheelchair with eyes closed, positioned unchanged. -At 1:20 p.m. R3 sat at dining room table, eyes closed, while another resident ate lunch. R3's right arm hung over the side edge of the wheelchair. Dietary passed by R3 glanced at him sleeping. -At 1:30 p.m. R3 sat at dining room table with eyes closed. Dietary removed R3's plate of food and dumped fluids down the sink. -At 1:45 p.m. R3 sat at dining room table position unchanged with eyes closed. -At 2:45 p.m. R2 sat in dining room, faced hallway, unattended with eyes closed, feet on the floor, right hand placed in lap and left hand located alongside his body. At 2:36 p.m. unidentified housekeeping staff requested NA-G remove R3 from dining room to sweep and wash floor. NA-G approached R3 and opened yes and stated hello. NA-G pushed R3 in wheelchair to resident lounge area, placed him in front of television, and walked away. -At 3:00 p.m., 3:15 p.m., 3:30 p.m., 3:40 p.m., and 4:00 p.m. R3 sat in wheelchair in lounge, eyes closed, and positioned unchanged. R3 was not approached by staff during this time. -At 4:00 p.m. NA-I pushed R3 in wheelchair into his room. R3 opened eyes, said hello and closed eyes. NA-I placed transfer belt around R3's waist and walker in front of him. NA-I and NA-H provided many cues and assisted R3 up to a standing position, walked to bathroom then leaned backwards. NA-I placed wheelchair behind R3 and sat down. R3 remained sleepy, NA-I offered drink of thicken water, R3 accepted. R3 was positioned in front of toilet when NA-H placed wheelchair closer to him, assisted R3 to pivot and sat back down in wheelchair. R3 was not toileted, NA-I stated too tired and allowed him some time and try again later. NA-A pushed R3 in wheelchair back out into the lounge area, eyes opened while R3 pushed himself backwards with feet on floor. During an interview on 8/23/23 at 3:16 p.m. NA-E stated all residents should have been checked and changed and/or toileted at least every two hours. NA-E indicated last time R3 was toileted was when surveyor watched on the day shift around 12:00 p.m., had not been toileted since then, and should have been. NA-E stated R3 was unable to make his needs known and should have been on a toileting program schedule, tired to get up by himself to go to the bathroom and was a high risk for falls. NA-E also stated R2 was fully dependent on staff and staff were expected to anticipate her needs, incontinent of bowel and bladder, and should have been toileted at least every two to three hours. NA-E indicated R2 was last checked and changed at around 12:00 p.m. today. During an interview on 8/23/23 at 5:30 p.m. NA-I stated R3 had not been toileted yet since the start of her shift at 2:00 p.m. NA-I attempted to toilet at 4:00 p.m. and unable, was too tired. NA-I stated planned to check on him again but have not had time. NA-I indicated R3 was incontinent frequently, voids a lot and should have been toileted every two hours. NA-I stated R3 was brought to the dining room for supper, would try again later this evening prior to bedtime. NA- stated R2 had not been toileted since before the shift started at 2:00 p.m., completed last on the day shift, and usually completed after supper. NA-I stated R2 was frequently extremely incontinent of urine and should have been checked and changed frequently. NA-I stated R2 did not use a bedpan. During an interview on 8/24/23 at 12:12 p.m. LPN stated R2 was not placed on a toileting program and probably should have been on 8/14/23, admission. LPN-A verified had just completed R2's bowel and bladder assessment on 8/18/23 and noted changes of increased incontinence of bowel and bladder. LPN-A stated staff were expected to anticipate R2's needs, R2's care plan needed to be updated and not sure if she could have used the bed pan, she had been so drowsy and hard to assess. LPN-2 stated she had not had time to get back to finish R2's toileting plan and would have included check and change in bed mostly at upon waking up, between meals, mid-afternoon, before bed, so that it would have been done 4 to 5 times a day is what would be expected. LPN-A stated R3 had mixed incontinence of bowel and bladder and went in the toilet when brought to the bathroom. LPN-A stated R3 should have been toileted in the morning when waking, before breakfast and lunch, mid-afternoon, before supper and then before bed, a total of at least six to eight times in a 24 hour period of time. LPN-A indicated toileting R3 more often would have possibly helped avoid falls for him. During an interview on 8/25/23 at 12:00 p.m. director of nursing (DON) stated we currently did not have a bowel and bladder program. DON stated lack of toileting could be a predisposing factor to falls that occurred at the facility. DON also stated there was a high rate of incontinent residents due to lack of a bowel and bladder program and scheduled toileting. DON indicated R3 frequently had gotten up at 4:00 a.m. and should have been offered the toilet. DON stated a three-day bowel and bladder assessment program should have been completed on him and all residents annually so they could have identified which ones needed to be on a toileting program. During a telephone interview on 8/29/23, at 3:00 p.m. MDS coordinator (MDSC) stated had not seen anything that would be a true toileting program at this facility since May 2023 when she had started to complete MDS's on the residents. MDSC also stated bowel and bladder information was collected on each resident from the progress notes documented in the medical record, toilet and bowel movement tasks, and bowel and bladder assessments. MDSC indicated she had completed the bowel and bladder MDS coding on approximately 80% of the residents at this facility and had not coded any of those residents as being placed on a toileting program. MDSC stated each resident should have been assessed upon admission and when changes were noted as to whether they should have been placed on a toileting program to have helped maintain their current bowel and bladder status along with measurable goals. MDSC verified R3 had a change in his bladder incontinence and had not been placed on a bowel and bladder program. MDSC stated she had seen many incontinent residents including those with dementia respond well to a toileting program especially during the day. MDSC also stated every three-hour toileting plan would not be appropriate for every resident, some need more often, and some do not and a resident placed on a random toileting plan would not be considered best practice. MDSC indicated it would have been expected that each facility had a toileting program to have helped assess the resident's urinary incontinence and allowed staff to provide more individualized interventions to enhance the resident's life and functional status. Facility policy titled Bladder and Bowel assessment dated [DATE], indicated a bowel and bladder assessment will be completed on all residents upon admission. If a change in continence status such as outcomes and/or goals and interventions of care plan are not effective or a decline of lack of improvement (if improvement was expected) in continence status another bowel and bladder assessment will be completed. This record will be part of the information gathered for bowel and bladder assessment form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review the facility failed to provide a dignified dining experience for 1 of 3 residents (R13) who received assistance with eating in the Golden Meadows dining room. Findings include: R13's quarterly Minimum Data Set (MDS) dated [DATE], identified R13 had severe cognitive impairment and diagnoses which included: Alzheimer's disease, muscle wasting, and dysphagia (swallowing disorder). R13's MDS identified R13 required total assistance with eating. R13's care plan revised 12/5/22, identified R13 had impaired cognitive function and was unable to verbalize any discomfort. R13's care plan identified R13 had self care deficit and required total dependence assist of one for eating. On 1/8/23, at 12:36 p.m. R13 was seated in her high back wheelchair in the dining room. Activity aide (AA)-A approached R13, positioned R13 to a bedside table and proceeded to set up her meal tray. At 12:40 p.m. AA-A sat in a chair next to R13, said oh, your chair is so high I will have to stand, stood up and began to feed R13 her meal while standing. AA-A did not attempt to adjust R13's wheelchair at any time so she could have been seated while feeding R13. From 12:40 p.m. to 1:40 p.m., AA-A continued to stand while feeding R13 her meal. Three other staff members were present in the dining room and did not re-direct or assist AA-A with adjusting R13's wheelchair. After R13 finished her meal, AA-A transported her via the wheelchair over to the sitting area next to the dining room. During an interview on 1/9/23, at 4:22 p.m. AA-A confirmed she had fed R13 while standing, and indicated she had attempted to sit, however felt R13's new wheelchair was to high. AA-A stated she was aware she should not feed residents while standing, however stated she had not been trained how to lower R13's wheelchair. During an interview on 1/9/23, at 4:48 p.m. clinical manager (CM)-A stated R13 required total assistance for all cares which included eating. CM-A indicated she would expect staff members to sit next to residents while assisting them with eating. CM-A confirmed staff standing next to a resident while feeding would not be a dignified dining experience. During an interview on 1/9/23, at 5:05 p.m. director of nursing (DON) indicated she would expect staff members to sit during the meal at one of the tables when assisting R13 to eat her meal and confirmed R13 was not fed in a dignified manner. The facility policy titled Dignity During Dining dated 3/23/17, identified the dining experience would enhance the resident's quality of life and recognized the resident's needs during dining to achieve and maintain the dignity and respect in full recognition of his or her individually. The policy procedure included to sit next to the residents while assisting them to eat, rather than standing over them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) level one assessment had been completed for 1 of 3 residents (R27) reviewed for PASRR. Findings include: R27's admission Minimum Data Set (MDS) dated [DATE], indicated R27 had moderate cognitive impairment and had diagnoses which included manic depression (bi-polar disease), peripheral vascular disease, hemiplegia or hemiparesis. The MDS identified R27 required one to two staff assistance with all activities of daily living (ADL's). R27's care plan revised on 1/2/23, indicated R27 was at risk for functional impairment related to mood disorder, bipolar disorder, manic depression, use of antidepressants, cognitive impairment and was dependent on staff for ADL's. Review of R27's medical record (MR) lacked a level one PASRR screening had been completed to consider a referral for further evaluation and determination of need for specialized services. During an interview on 1/9/23, at 3:22 p.m. medical records employee (MRE) confirmed R27's MR lacked a level one PASRR. MRE indicated it was the social workers responsibility to ensure the PASRR's were being completed as required. During an interview on 1/9/23, at 3:38 p.m. the social worker designee (SWD) indicated it was her responsibility to ensure the PASRR's were being completed on admission. The SWD confirmed R27's MR lacked a level one PASRR. During an interview on 1/9/23, at 3:41 p.m. the director of nursing (DON) confirmed the above findings. The DON indicated she would expect staff would ensure a level one PASRR to be completed prior to admission and to follow the facility policy. Review of the facility policy titled, Comprehensive Care Plans revised on 10/14/22, identified a PASRR for orientation, mood and behaviors would be completed for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to provide assistance with routine grooming which included facial hair removal and changing soiled clothing for 1 of 1 residents (R43) who was dependent upon staff for activities of daily living (ADLs). Findings include: R43's quarterly Minimum Data Set (MDS), dated [DATE], identified R43 had sever cognitive impairment and had diagnoses which included Alzheimer's disease, generalized muscle weakness and hypertension. The MDS indicated R43 required extensive assistance of staff for bed mobility, transfers, dressing, toileting, bathing and personal hygiene. R43's care plan revised on 1/6/23, indicated R43 had impaired functional status related to diagnosis of hypertension, Alzheimer's disease, dementia, muscle weakness and dependence in ADL's. The care plan indicated staff were to assist R43 with dressing and grooming. The care plan indicated staff were to shave R43's chin hairs daily and as needed. The care plan identified R43 would become agitated while shaving and staff would need to perform multiple sessions to complete a thorough shaving. During observations on 1/8/23, from 3:20 p.m. to 7:30 p.m., R43 was seated in his wheel chair propelling himself around the unit. R43 wore a black pair of pants which had several large soiled white spots/smudges on the upper thighs of his pants. R43 had several long white hairs approximately 1/4 inch long or longer under his nose area, on the sides of his mouth, on the lower side of his jaw bones and stubbles noted to be present all over the rest of his face. R43 continued to wear the same black pants and remained unshaven all evening until approximately 7:30 p.m. During observations on 1/9/23, from 9:14 a.m. to 6:03 p.m., R43 was seated in his wheel chair in the dining room area with other residents eating his breakfast independently. R43 continued to be wearing the same black pair of pants which had several large soiled white spots/smudges on the upper thighs of his pants. R43 continued to have several long white hairs approximately 1/4 inch long or longer under his nose area, on the sides of his mouth, on the lower side of his jaw bones and stubbles present all over the rest of his face. - at 12:06 p.m. R43 was seated in his wheel chair out in the dining room area with other residents eating his lunch independently and continued to wear the same soiled pair of black pants and remained unshaven. - at 12:37 p.m. R43 was seated in his wheel chair out in the dining room area with other residents and remained the same. - at 12:40 p.m. nursing assistant (NA)-B approached R43, asked if he would like more chocolate milk, R43 indicated he would and NA-B provided him with another glass of chocolate milk and exited the dining room area. - at 12:52 p.m. NA-C approached R43, asked him if he was done eating, assisted him in wiping his face and left the dining room area. - at 1:01 p.m. R43 began to propel his wheelchair with his feet independently down the hallway. R43 briefly stopped and visited with laundry staff that was delivering linen. - at 1:02 p.m. NA-D walked by R43 and said hi to him. - at 1:06 p.m. R43 was seated in his wheel chair up at the dining room table and his pants remained the same and he continued to be unshaven. - at 1:16 p.m. activity aid (AA)-A approached R43 and asked him what he ate for lunch. The AA-A proceeded to glove her hands, warmed up R43's food from lunch, sat down next to him and began feeding him bites of ham. - at 1:33 p.m. AA-A wheeled R43 down to the sitting area on the 200 wing and they began playing a balloon game on the TV with another resident. - at 2:15 p.m. R43 was propelling himself around the Blue Horizon unit in his wheel chair when clinical manager (CM)-C briefly stopped and went up to R43 and said I like your outfit and immediately walked away. R43's pants remained the same and he continued to be unshaven. - at 4:00 p.m. R43 was seated in his wheel chair out in the dining room area with other residents. R43 continued to wear the same black pair of pants although now he had several large soiled red and white spots/smudges on the upper thighs of his pants and several red smudges on the belly area of his black and white plaid shirt and he remained unshaven. - at 6:03 p.m. R43 remained the same. During an interview on 1/9/23, at 6:03 p.m. NA-A confirmed R43 required staff assistance with ADL's, shaving and dressing. NA-A verified R43's pants and shirt were visible soiled and indicated staff should have changed his clothing. NA-A indicated staff were suppose to shave R43 on a daily basis and indicated she had shaved R43 on Saturday morning, although he was being a little feisty. NA-A further indicated when R43 was being feisty staff are let him be and re-approach and try again later or try another staff member. NA-A indicated she had not offered to shave R43 again and this should have been done. During an interview on 1/9/23, at 6:05 p.m. licensed practical nurse (LPN)-A confirmed the above findings and indicated R43 required staff assistance with all of his ADL's. LPN-A indicated she would expect staff to change his clothes when they are visibly soiled and assist him with shaving. LPN-A indicated she would expect R43 to be neat and clean and well groomed. During interview on 1/10/23, at 11:13 a.m. the director of nursing (DON) confirmed the above findings and indicated R43 needed staff assistance with all of his ADL's. The DON indicated she expected staff to assist residents with shaving, grooming, personal hygiene and changing of their clothes when visibly soiled. The DON indicated R43 does refuse cares at times, although staff should re-approach or try different staff and she would expect staff to follow the the care plan. Review of facility policy titled, Shaving Residents dated 4/20/17, indicated men shall be shaved every day. Each resident shall provide their own electric razor. On 1/10/23, a policy regarding providing ADL's was requested and one was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to help reduce unnecessary antibiotic use and reduce potential drug resistance for 1 of 5 residents (R29) reviewed for unnecessary medication. Findings include: The Center's for Disease Control and Prevention (CDC)'s Core Elements Of Antibiotic Stewardship For Nursing Homes, dated 2015, included recommendations to identify clinical situations which may be driving inappropriate use of antibiotics and implement specific interventions to improve use, as well as pharmacists could provide assistance in ensuring antibiotics were ordered appropriately. R29's significant change Minimum Data Set (MDS) dated [DATE], identified R29 had moderate cognitive impairment with diagnoses which included: heart failure, chronic kidney disease and depression. Identified R29 had received antibiotics seven of the last seven days. Review of R29's Medication Review Report signed 12/22/22, identified R29's orders included: -clindamycin HCL (antibiotic) capsule 150 mg (milligrams), give 1 capsule orally (by mouth) two times a day for lifetime suppression, with start date of 11/17/21, and no end date. Review of R29's Pharmacist Recommendations To Providers dated 11/15/22, identified R29 continued clindamycin 150 mg two times a day for lifetime infection suppression with history of infected total knee arthroplasty (total knee replacement) (TKA). The form identified the recommendation to support continued use of long-term antibiotic use and to document a risk versus benefit statement in upcoming visit note for antibiotic stewardship purposes. Review of R29's physician visit and clinic notes dated 12/23/21, to 12/22/22, revealed the following: -12/23/21, lacked documentation regarding long term use of clindamycin. -1/26/22, lacked documentation regarding long term use of clindamycin. -2/10/22, lacked documentation regarding long term use of clindamycin. -3/2/22, lacked documentation regarding long term use of clindamycin. -3/8/22, lacked documentation regarding long term use of clindamycin. -4/27/22, included statement history of chronic antibiotic use and it is not clear to me why he is on lifetime clindamycin. I will have to review his past medical history and see if that should be continued. -6/22/22, lacked documentation regarding long term use of clindamycin. -8/25/22, lacked documentation regarding long term use of clindamycin. -10/13/22, lacked documentation regarding long term use of clindamycin. -12/22/22, lacked documentation regarding long term use of clindamycin and lacked risk versus benefit statement. During a telephone interview on 1/10/23, at 12:57 p.m. clinical pharmacist (CP)-A confirmed R29 received clindamycin on a long term basis. CP-A verified on 11/15/22, a pharmacy recommendation had been made to R29's primary care physician (PCP)-A to document risks versus benefits for continued use of the Clindamycin. CP-A indicated long term use of antibiotics was not recommended, however indicated typically the only time it was used was for orthopedic (branch of medicine for bones and muscle) reasons. CP-A stated the risks versus benefits for continued use should have been documented annually. During a telephone call on 1/10/23, at 1:11 p.m. a call was made to R29's previous PCP, who had originally ordered the antibiotic, and was informed by the clinic office nurse (CON)-A he had retired. CON-A stated R29 had last been seen by her orthopedic surgeon in April of 2021. At 1:15 p.m. the telephone call was transferred to PCP-A's nurse, and a voice message was left for a return call. No return call was received. During a joint interview on 1/10/23, at 11:47 a.m. director of nursing (DON) and clinical manager (CM)-B both confirmed R29 received clindamycin for prophylaxis and a risk versus benefit assessment for continued use had not been completed. DON confirmed prophylactic antibiotic use was not recommended as it could cause resistance to bacterial agents. During a follow up interview on 1/10/23, at 2:24 p.m. DON indicated she would expect the clinical manger to assure R29's pharmacy recommendation was addressed. The facility policy titled Antibiotic Stewardship reviewed 9/23/21, identified the facility antibiotic stewardship program promoted the appropriate use of antibiotics and a system of monitoring to improve resident outcomes and the reduction of antibiotic resistance. The policy procedures included if antibiotics were ordered, the practitioner would identify the diagnoses/indication, the right antibiotic, proper dose, duration and route. The policy identified if in the event the prescribing physician orders an antibiotic without identification of infection criteria, the physician would be requested to identify the rationale for ordered antibiotic and the medical director would be contacted for further direction. The policy further identified if a resident was admitted to the facility with an antibiotic ordered, the nurse would identify the indication for use, documentation for dose, route and duration (ensuring a stop date). The policy indicated the infection preventionist would track antibiotic use and monitor adherence to evidence-based criteria. The policy identified the facility would ensure that prescribing practitioners would document periodic review of antibiotic use to monitor appropriate prescribing.

Based on observation, interview, and document review, the facility failed to ensure food was served at a palatable and appetizing temperature for 2 of 2 residents (R 21 and R26) who resided on Blue Horizon unit and [NAME] Ridge unit reviewed for food. This had the potential to affect all 29 residents residing on these units. Findings include: R21's MDS indicated R21 had intact cognition and was able to feed herself after staff set up her tray. R26's MDS indicated R26 had intact cognition and was able to feed herself after staff set up her tray. During an interview on 1/8/23, at 1:30 p.m. R 21 stated the food did not taste very good and the vegetables were hard. During an interview on 1/8/23, at 3:23 p.m. R26 stated the food was often cold and tasted very bland. R26 indicated she had her family bring in food at times. On 1/9/23, at 11:42 food was brought to the steam table and meal service began on the unit. On 1/9/23, at 12:20 p.m. during the noon meal R26 stated her food was a little cold today and R21 stated the vegetables were hard. On 1/9/23, at 12:23 p.m. a test tray was requested from dietary assistant (DA)-A from the steam table. The meal consisted of ham and sweet potatoes. The ham was barely warm and had some flavor. The sweet potatoes were cold, hard, and lacked flavor. DA-A confirmed the ham was cold and the sweet potatoes were cold and hard. Another test tray was requested from the steam table and the temps were noted to be as follows: - ham was 123 degrees Fahrenheit (F). - sweet potatoes were 122 degrees F. During an interview on 1/9/23, at 12:27 p.m. DA stated she was not aware of the resident's concern of cold food. DA-A confirmed the above finding of improper temperature of food. DA-A indicated the steam table was plugged in and was working. During an interview on 1/9/23, at 1:15 p.m. dietary manager (DM) stated her expectation would have been all hot food should have been kept at least 135 degrees on the steam table. DM indicated if any food was not the correct temperature, staff were expected to reheat it to the appropriate temperature or obtain new food that was at the appropriate temperature. A facility policy titled Food Temperature dated 2010, indicated all hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees Fahrenheit. The policy identified temperatures should be taken periodically to ensure hot foods stayed above 135 degrees F.