**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure residents were comprehensively assessed for self-administration of medications for 1 of 1 resident (R35) reviewed for self-administration of medications. Findings include: R35's admission Minimum Data Set (MDS) assessment dated [DATE], identified R35 had intact cognition and required assistance with all activities of daily living (ADL)'s. R35's diagnoses included atrial fibrillation, heart failure, hypertension, renal failure, diabetes mellitus, thyroid disorder and arthritis. MDS indicated R35 required substantial/maximal assistance with personal hygiene. R3's physician orders included order for Ipratropium-Albuterol inhalation solution 0.5-2.5% (3) mg (milligram)/3 ml (milliliter) - inhale one vial orally three times a day related to respiratory syncytial virus as the cause of diseases classified elsewhere. During interview and observation on 3/24/25 at 1:56 p.m., R35 was sitting in a wheelchair in her room. Nebulizer mask and canister was laying on the over the bed table with solution remaining in the canister. R35 stated she completes the nebulizer herself after the nurse sets it up. During observation on 3/25/25 at 1:15 p.m., R35 was sitting in her wheelchair holding the nebulizer mask to her face. Nebulizer cup contained a clear solution and nebulizer machine was running with no staff present in room. R35's record identified neither a self-administration of medication assessment was completed or an order for self-administration. During interview on 3/27/25 at 8:42 a.m., trained medication aide (TMA)-A stated if a resident was able to self-administer medications, it would be displayed in the resident's electronic health record (EHR). TMA-A confirmed R35 did not have an order to self-administer medications which included nebulizer treatments. TMA-A stated she sets the nebulizer machine up placed the solution in the canister and will leave the room and come back in 10-15 minutes to ensure treatment is completed and shut the nebulizer machine off. During interview on 3/27/25 at 8:42 a.m., licensed practical nurse (LPN)-B stated the TMA's administers the nebulizer treatments. LPN-B stated if a resident was able to self-administer medications, it would be displayed in the resident's EHR. LPN-B confirmed R35 did not have a self-administration of medications order. During interview on 3/27/25 at 9:53 a.m., nursing assistant (NA)-A stated if we notice R35 does not have the nebulizer mask on, we go into her room and assist her with reapplying the mask. NA-A stated this morning, R35 had the mask on her face however, it was not correct and NA-A had to help R35 readjust the mask. During interview on 3/27/25 at 11:08 a.m., director of nursing (DON) stated she completes the self-administration of medications assessments. DON stated TMA's administer the nebulizer by placing the medication in the canister and places the mask on the resident's face and will go back later to ensure treatment is complete and shut off the machine. DON confirmed a self-administration of medications assessment was not completed and confirmed there was no order in place for R35 to self-administer her medications. DON stated it was important for the resident to be assessed for self-administration of medications as the medication would not be effective if R35 removed the mask. The facility Self-Administration of Medications policy, dated 2/24, identified residents have the right to self-administer medication if the interdisciplinary team (IDT) has determined that it is clinically appropriate and safe for the resident to do so. As part of the evaluation comprehensive assessment, the IDT assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide assistance with facial hair removal for 1 of 1 resident (R35) reviewed for activities of daily living (ADL')s . Findings include: R35's admission Minimum Data Set (MDS) assessment dated [DATE], identified R35 had intact cognition and required assistance with activities of daily living (ADL)'s. R35's diagnoses included diabetes mellitus, and arthritis. MDS indicated R35 required substantial/maximal assistance with personal hygiene. R35's care plan lacked evidence of resident's shaving preferences. During observation and interview on 3/24/25 at 1:46 p.m., R35 had white facial hair on chin approximately 1 inch long. R35 stated staff has assisted before and would like to be shaved. During observation on 3/25/25 at 10:47 a.m., R35 continued to have facial hair on chin. During observation on 3/26/25 at 7:12 a.m., R35 continued to have facial hair on chin. During observation on 3/27/25 at 9:22 a.m., R35 continued to have facial hair on chin. During interview on 3/27/25 at 9:53 a.m., nursing assistant (NA)-A stated if a resident had facial hair, she would ask the resident if they would like to be shaved. If resident stated they would like to be shaved, NA-A would go and find a shaver and assist resident with shaving. NA-A stated she has not asked or shaved R35. During interview on 3/27/25 at 10:36 a.m., NA-B stated they are supposed to shave residents if facial hair is noticed. NA-B stated she assisted R35 with morning cares and stated she noticed chin hairs but stated she did not shave R35. During interview on 3/27/25 at 10:39 a.m., licensed practical nurse (LPN)-B stated nursing assistants perform shaving when doing morning cares with residents, but it should be addressed on the resident's bath days. LPN-B stated R35's scheduled bath occurs Monday evenings. LPN-B confirmed R35 had facial hair and should have been shaved. During interview on 3/27/25 at 11:08 a.m., director of nursing (DON) indicated staff are to shave resident's facial hairs if seen, women especially. DON stated facility has razors to use if family members do not provide one. DON stated staff should have asked R35 if she would like to be shaved. DON stated it was important for the resident to be shaved for dignity of the resident. The facility Activities of Daily Living Policy, dated 3/31/23, indicated the facility is to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident; and that the care and services provided are person-centered, and honor and support each resident's preferences, choices, values and beliefs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to monitor orthostatic blood pressures for 3 of 3 residents (R7, R8, and R32) and failed to ensure residents were routinely assessed for side effects who received physician ordered antipsychotic medications for 1 of 5 residents (R8), reviewed for unnecessary medications. Findings include: R7's quarterly Minimum Data Set (MDS) assessment dated [DATE], identified R7 had intact cognition and required assistance with all activities of daily living (ADL)'s. R7's diagnoses included orthostatic hypotension, depression, bipolar disorder, secondary Parkinsonism, mild cognitive impairment of uncertain or unknown etiology, and insomnia. R7's physician orders included Aripiprazole (antipsychotic) 10 milligram (mg) by mouth in the morning for bipolar disorder and Olanzapine (antipsychotic) 5 mg by mouth at bedtime for bipolar disorder. R7's medical record lacked evidence orthostatic blood pressures had not been obtained three out of six months for R7 with use of an antipsychotic medication. R7's care plan indicated R7 had a potential for psychotropic drug adverse drug reactions related to daily use of psychotropic medication for diagnosis of bipolar disorder. Goal was for resident to not experience adverse drug reactions to current psychotropic drug medication regimen and have interventions of monthly orthostatic blood pressures. R8 R8's annual Minimum Data Set (MDS) assessment dated [DATE], identified R8 had intact cognition and required assistance with all activities of daily living (ADL)'s. R8's diagnoses included hypertension, anxiety disorder, depression, and schizophrenia. R8's physician orders included orders for Aripiprazole (antipsychotic) 10 milligram (mg) by mouth in the morning for bipolar disorder and Olanzapine (antipsychotic) 5 mg by mouth at bedtime for bipolar disorder. R8's medical record lacked any evidence orthostatic blood pressures had been obtained for R8 in the past six months. R8's had Abnormal Involuntary Movement Scale (AIMS) assessment (measures involuntary movements of tardive dyskinesia (TD)) completed on 8/1/24 . R8's care plan indicated R8 had a potential for psychotropic drug adverse drug reactions related to daily use of psychotropic medication for diagnosis of bipolar disorder. Goal was for resident to not experience and adverse drug reactions to current psychotropic drug medication regimen and have interventions of monthly orthostatic blood pressures and TD screening or AIMS per protocol. During interview on 3/26/25 at 10:22 p.m., consultant pharmacist (CP) stated any resident on an antipsychotic medication should have orthostatic blood pressures checked monthly and AIMS assessment should be initiated within 30 days of admission or upon start of an antipsychotic medication and be reassessed at least every six months. CP stated orthostatic blood pressures and AIMS assessment were important to monitor for side effects and for orthostatic blood pressures. During interview on 3/27/25 at 11:08 a.m., director of nursing (DON) stated monitoring for antipsychotic medications consisted of orthostatic blood pressures and a baseline AIMS assessment. DON stated orthostatic blood pressures should be obtained monthly and orthostatic blood pressures are important to see if the resident is displaying side effects of the antipsychotic medication and could increase risks for falls. DON confirmed the finding for R7 and R8 . DON stated AIMS assessments should be completed every six months and R8 should have had an AIMS assessment completed in February and confirmed last assessment was on 8/1/24. DON stated it was important to assess for TD to see if resident is having any symptoms of TD as the resident may need dosage of their antipsychotic medication changed. R 32 R32's Quarterly MDS dated [DATE], indicated cognitively intact with no behaviors. No limitations to upper and lower extremities, substantial assist for toileting and activities of daily living (ADL's) and was continent of bowels and occasionally incontinent of urine. R32's diagnoses list included psychotic disorder with delusions, mood disorder, anxiety disorder, and major depressive disorder. R32's provider orders included Aripiprazole (medication to treat psychiatric/mood disorders) 5 mg twice a day with a start date 9/3/2024, monitor orthostatic blood pressure while resident is receiving antipsychotic medications every day shift starting on the 7th of every month starting 10/7/24. R32's care plan included potential for psychotropic drug ADR's (adverse drug reactions) related to daily use of psychotropic medication. Interventions included monthly orthostasis blood pressure. A mobility care plan indicated R32 was an extensive assist of 1-2 with movement in bed and in/out of bed and extensive assist of 1-2 with transfers; use sit to stand lift [a machine used to assist residents to a standing position] when resident is tired. R32's medication administration indicated R32 received Aripiprazole October 2024- March 2025. Orthostatic blood pressure documentation was as follows: 10/7/24: Lying-118/66, Sitting-114/60, standing- NA 11/7/24: Lying-106/56, sitting-110/71, standing-143/67 12/7/24: lying-137/73, sitting-156/84, standing-indicated 9 1/7/25: Lying-108/50, Sitting- 117/51, standing- [left blank] 2/7/25: lying, sitting, and standing were left blank 3/7/25 lying, sitting, and standing were left blank. Progress notes dated 9/3/24-3/25/25 lacked documentation resident refused orthostatic blood pressures or orthostatic blood pressures were rescheduled. During interview on 3/26/25 at 9:58 a.m., nursing assistant (NA)-A stated R32 can stand and ambulate short distances with staff assistance. A sit to stand lift is used for transfers when R32 is feeling weak. During interview on 3/27/25 at 8:24 a.m., licensed practical nurse (LPN)-A stated residents on antipsychotic medications are monitored for side effects, orthostatic hypotension once a month, and extrapyramidal symptoms (uncontrolled muscle movements related to antipsychotic medication use). LPN-A stated R32 can stand and probably could stand long enough to get standing blood pressures because they walk [R32] During interview on 3/27/2025 at 9:59 a.m., the director of nursing (DON) stated orthostatic blood pressures are monitored monthly for residents who receive antipsychotic medications. If a resident is unable to stand safely, staff check a lying and sitting blood pressure only. The DON stated staff are expected to document a behavior note indicating a resident refused and attempt the blood pressures later. The DON stated orthostatic blood pressures are scheduled the entire day so staff can attempt on a different shift if there is a refusal. If a resident continues to refuse, the DON stated she would hope she is updated. The DON stated R32 does tire easily however, can stand and do a pivot transfer. The DON confirmed the MAR lacked documentation of orthostatic blood pressure or refusals for February and March 2025. The facility Psychotropic Medication use policy, dated 1/25, indicated with initiation of an antipsychotic medication, residents will have an orthostatic blood pressure performed on a monthly basis, unless otherwise indicated by provider. AIMS will be performed on residents receiving antipsychotic medications to screen for tardive dyskinesia at baseline, semi-annually, and after discontinuation every month x 3.

Based on observation, interview, and document review, the facility failed to ensure frozen food items were stored in a manner to reduce the risk of cross contamination and potential foodborne illness in 1 of 1 walk-in freezers, failed to ensure food stored in the refrigerators and dry storage were labeled, dated and discarded properly. This deficient practice had the potential to affect all 48 residents, staff and visitors who received food from facility kitchen. Findings include: Freezer During the initial kitchen tour on 3/24/25 at 12:50 p.m., a walk-in commercial freezer had a cooling fan mounted to the top of the unit which had visible ice built up on numerous places along the unit. The ceiling of freezer had ice built up, thick in some areas and in frozen droplet forms in other areas, that went from the back wall of the freezer towards the front of the freezer cover two-thirds of the ceiling on the left side. The back wall of the freezer had ice build-up with the thickest of the ice towards the bottom with a mound of ice on the floor. [NAME] substance, approximately 5-inch diameter, was melted into the mound of ice. The floor of the freezer and the metallic shelving used also had ice build-up present . Approximately, one-third of the floor was covered with thick ice build-up. The metallic shelving units were used to hold food and sat parallel with the walls of the freezer from the front wall to the back wall of the freezer. Immediately to the right of the cooling unit, there were several food items stored in boxes. Boxes were cardboard which were soft and somewhat mushy feeling to touch. Several boxes had visible ice buildup covering them. A gauge present measured the unit at -4 degrees Fahrenheit (F). During a subsequent visit to the kitchen on 3/27/25 at 10:15 a.m., ice continued to be present in the freezer. During interview on 3/27/25 at 10:23 a.m., culinary services director (CSD) confirmed ice buildup in the freezer's wall, ceiling, shelves and boxes. CSD stated the fan in the freezer was blocked and was not working. CSD stated maintenance looked at the fan yesterday and fixed it. CSD stated it has been an on-going process to get the ice out of the freezer since she started several months ago. CSD stated the ice buildup could be a concern as it could contaminate food, cause freezer burn on food or could cause food to rot from the mushy boxes that food is being store in. During interview on 3/27/25 at 12:30 p.m., administrator stated she was not aware of the ice buildup in the freezer. Administrator stated she would expect staff to notify her if there was ice buildup in the freezer. Administrator confirmed ice buildup was a concern on the last annual survey but to her knowledge it was addressed and taken care of. Administrator stated the ice buildup could impact food quality and overall functionality of the freezer. Label, cover and date of foods: During an observation and interview on 3/24/25 at 12:20 p.m., CSD confirmed the following food items were observed in the prep cooler in the kitchen that were not labeled or dated: -Jar of opened salsa that did not have an opened date on container. - Opened plastic storage bag with Hot dogs were dated 3/15/25. CSD stated they were expired. -Container of opened cottage cheese that did not have an opened date on container. - Container of opened egg salad that did not have an opened date on container and had an expiration date of 3/22/25. CSD stated it was expired. During observation and interview on 3/24/25 at 12:58 p.m., CSD confirmed the following food items were observed in the walk-in cooler were not labeled or dated: - Opened bag of lettuce had brown slime that did not have an opened date. - Opened plastic storage bag with sliced American cheese that had several slices that were dried out. Bag did not have an opened date. - Opened plastic storage bag with sliced white cheese that did not have an opened date. - Container of opened sour cream that did not have an opened date on container. During an interview on 3/24/25 at 1:12 p.m., CSD verified all items should be labeled, covered and dated as soon as food is removed from its original container. The CSD stated it was important to label and date food items to know when food items are fresh. During an interview on 3/27/25 at 10:15 a.m., cook stated when food is opened, they are to label and date before putting it away. [NAME] stated it was important to complete to know if a food was expired or should be thrown away. During an interview on 3/27/25 at 10:20 a.m., culinary aide (CA)-A stated when food is opened it needed to be labeled and dated so you know when it was opened or expired. The facilities Freezer policy, dated 9/12, indicated cleaning procedure of freezer which consisted of: 1. All items should be removed from freezer and transferred to another freezer. 2. Let all ice melt and unit warm up. 3. Wash out inside of freezer with warm soapy water. Rinse well. 4. Wipe out with weak solution of baking soda and water. Rinse well. 5. Dry inside with soft cloth. Let air dry. 6. Plug in unit and let freezer return to proper temperature. 7. Wash shelves with soapy water. Rinse, dry and replace in freezer. 8. Replace frozen food. 9. Clean per cleaning schedule of facility. The facility Food Storage policy, dated 9/12, indicated facility would maintain sanitary techniques in non-perishable food storage in order to protect the health of those dependent on the service. The remaining contents of opened food packages will be stored in plastic containers with tight-fitting lids or plastic zip lock bags. All containers will be properly labeled and dated as to contents.

MEAL DELAY: R29's admission Minimum Data Set (MDS) assessment, dated 4/8/2024 indicates R29 as cognitively intact with no behaviors, no functional limitations of range of motion (ROM), and is independent with eating. R29 has no chewing or swallowing disorder or dental concerns. R29's face sheet indicates diagnoses of major depressive disorder, anxiety disorder, and other endocrine, nutritional, and metabolic disease. During continuous observation on 5/28/24 beginning at 11:54 a.m., a dietary staff member was taking plates of food from the serving window and delivering to residents throughout the dining room. R29 was seated at table with 2 other residents. R29 had beverages in front of her however no plates of food. Her tablemate's had 50% of their food consumed. At 12:05 p.m., R29 continued to not have food. At 12:11 p.m., R29's table mates finished with their food. R29 still was not served. Residents who arrived to the dining room after R29 received their food. At 12:16 p.m., R29 still had not been served. Staff member present at neighboring table assisting residents with eating. No staff observed going from table to table to check on residents. At 12:20 p.m., the administrator walked through the dining room, smiled at the residents but did not stop to check on residents. R29 continued to not have food. Surveyor observed R12 shake her head at R29 and say that's not right. At 12:24 p.m., tablemate left the table and spoke to the dietary staff at the serving window. Dietary staff turned toward R29's direction and said, Oh my god and immediately turned to speak to someone in the kitchen. At 12:25 p.m., dietary staff arrived at table with grilled cheese sandwich, vegetable, and a serving of ice cream. Dietary staff apologized to R29 and informed her there was no dessert left but offered ice cream. During interview on 5/28/24 at 12:34 p.m., R29 stated her lunch was ok. When surveyor mentioned the wait, R29 stated she arrived in the dining room at 1130 a.m., and had waited an hour. During interview on 05/28/24 12:38 p.m., dietary aide (DA-A) stated breakfast is served first come first serve. They serve diabetic residents right away. Residents usually begin arriving for lunch at 11:00 a.m. after the morning activity. Lunch service begins at 11:30 a.m. DA-A stated the resident's meal tickets are laid out on the counter near the serving window. As she sees residents arrive, she takes their meal ticket and gathers beverages. She gives the meal ticket to the kitchen and delivers the resident's beverages at the table. DA-A stated she believes the cooks had an issue with the flattop not getting hot enough to cook R29's grilled cheese. She stated she did not realize R29 did not have her meal until R12 informed her. During interview on 5/28/2024 at 12:59 p.m., R29 stated every time she orders something other than the main entrée, she is served last. Today they had pork fritters, however resident ordered a grilled cheese sandwich. During interview on 05/29/24 09:49 a.m., R29 stated I feel like I don't matter when I don't get my food. If I change from what they are serving, I get served last. During interview on 05/29/24 1:00 p.m., DA-A stated food from the always available menu is made at the time of ordering and not at the end of meal service. During interview on 05/29/24 01:02 p.m., certified dietary manager (CDM) stated his staff tries serve residents first come first serve and by table. He stated food is served restaurant style and made to order as his staff gets the ticket. He prefers not to make too many food items, such as salads, ahead of time to maintain the integrity of the food. He stated he expects the dining room to be served within 30-40 minutes. Lunch service starts at 11:30 a.m. and should be done by 12:10 p.m. CDM stated he would not expect a resident to wait 1 hour for their meal. During a resident council meeting on 5/29/24 at 1:06 p.m., R12 stated the residents sometimes do a lot of waiting for meals and it is still an issue. R12 stated a resident (R29) came to the dining room a little late and sat there for 45 minutes to get food and did not get it until she (R12) went to the kitchen window and informed staff. R2 stated she is diabetic and often waits 45 minutes to get served food. R2 stated residents do not get served as the same time as tablemate's have to sit there while the rest of her table eats which really bothers her. R22 stated it has also happened to her and agrees she does not like it. During interview on 05/29/24 02:55 p.m., the CDM stated there wasn't a sense of urgency in his staff when became dietary manager. He stated he has educated his staff the importance of having a sense of urgency. He shortened the dining window to 1 hour and has been holding his staff accountable. He has not made any procedural changes. He has made observations at sister facilities and plans to meet with administration to brainstorm possibilities to improve mealtimes, including preparing more items ahead of time. During interview on 05/30/24 09:07 a.m., the administrator stated it is not the goal of the facility to have resident's wait for meals. She stated they have adjusted lunch service from 11 a.m. to 11:30 am however long wait times continue to be more prevalent than she would like. The administrator stated the facility plans to have items from the always available menu cooked and ready to go. She stated meals are served first come first serve by tables. She has spoken to resident council about mealtimes and most are fine with waiting because they don't want cold food. Her goal is for residents to wait no more than 15-20 minutes for their meal. The administrator stated items requested from the always available menu are prepared as request and not served at the end of the meal. She stated they implemented using an Ipad for ordering meals about 3 months ago so the cooks know ahead of time how many of the always available items to prepare. When asked what impact having to wait for meals would have on resident's, the administrator stated, some residents would be fine with it, some would have an emotional impact. Resident council minutes dated December 2023, indicate Residents brought up a concern regarding wait time for meals stating they felt the new way of ordering was not speeding up service. [CDM] will work with staff on these concerns during this month. The council concerns section on the last page of the minutes indicate, in part, taking longer with ordering with I-pad. Administrator and CDM were present. Resident council minutes dated January 2024 indicate there remain concerns about the length of time it takes to get meals, especially for lunch and supper. These issues are being addressed with staff. The old business as wait time for meals. Council concerns section is blank. CDM was present, administrator was absent. Resident council minutes dated February 2024 indicate, one resident said that mealtime wait continues and that if all residents are at the table, they should all be served at the same time. This has been addressed with Culinary over the weekend. The old concerns section indicate waiting for mealtimes remains a concern. The council concerns section is blank. Administrator was present, CDM was absent. Resident council minutes for March 2024 made no concerns brought up regarding mealtime. The last page indicates waiting for mealtimes remains a concern in old concerns. The council concerns section is blank. The next meet scheduled is March 13, 2024. Administrator and CDM present. Resident council minutes for April 2024 made no mention in specifically regarding meal wait times however the last page indicated menus and wait times under old business. Council concerns was blank. CDM and administrator were present. Resident council minutes May 2024 indicate [CDM] continues to address wait time for meals. The last page indicates wait times in dietary in old business section. Council concerns section is blank. The administrator and CDM were present at meeting. A facility policy titled Dining Room Audits revised October 2017 indicates Our facility audits the food and nutrition services department regularly to ensure that resident needs are met and that dining is a safe and pleasant experience for residents. Section 1 under Policy Interpretation and Implementation indicates dietary staff will make scheduled daily meal rounds to every dining room at all mealtimes to audit the dining room and the food service to the residents. Section 2.d. indicates The auditor will assess whether residents at each table are served together. Section 3 indicates results of the evaluation will be noted. Copies of the evaluation will be sent to department heads, as necessary, to notify of concerns. Evaluations will be kept on file and reviewed periodically for patterns of concern. Based on observation, interview and document review, the facility failed to ensure dignified, personal space was maintained for 1 of 1 resident (R8) who had staff enter their room without knocking or waiting for a response. In addition, the facility failed to ensure a dignified, homelike dining experience was provided for 1 of 1 resident (R29) observed to wait for an extended period of time for their meal despite tablemate's being served. Findings include: ROOM KNOCK: R8's annual Minimum Data Set (MDS) assessment, dated 2/29/24, identified R8 had moderate cognitive impairment and it was very important for her to be able to use the phone in private. On 5/28/24 at 11:01 a.m., R8 was seated in her personal room with the doorway closed to the unit' hallway. R8 was being interviewed by the surveyor when suddenly, without any audible knock or verbal warning, the doorway from the hallway opened and nursing assistant (NA)-A poked their head inside. NA-A turned and looked at the surveyor before turning back to R8 and voicing aloud, I'm just checking on you. NA-A then turned to the surveyor and expressed, Who are you? NA-A then closed the doorway. When interviewed immediately following, R8 stated staff sometimes knock but do, at times, just open the door without warning adding, I prefer that they knock. R8 stated she liked to keep her doorway closed and reiterated she wished they would knock before just entering the room adding, I don't like the fact that they don't [knock]. When interviewed on 5/28/24 at 11:06 a.m., NA-A was asked about not knocking on R8's doorway before opening it and NA-A responded abruptly, I did knock. NA-A stated they always knocked and tell them who I am and wait for a response before entering then adding, Some of them can't hear you [me]. NA-A stated they had heard a few residents, including R8, make comments about staff not always knocking before entering their rooms. NA-A stated R8 liked to keep her doorway closed and wanted staff to knock before entering her room adding, She [R8] doesn't like it [when they don't]. NA-A stated it was important to knock and wait for a response before entering as it was common sense and staff don't want to startle them [residents]. On 5/29/24 at 11:24 a.m., the director of nursing (DON) was interviewed. DON explained they had not noticed issues with staff not knocking or waiting for a response when entering resident' rooms and spaces, however, stated they expected staff to knock and wait a few seconds before entering resident' rooms. DON stated they teach the staff of the need to be respectful and to knock and ask permission to come in the door. DON stated this was important to do for resident' dignity and respect adding, We should all be aware of that and the privacy [of their space]. A provided Resident Rights Policy, dated 1/2024, identified the care center' practice was to uphold the rights of all residents. The policy outlined the care center would post and provide a copy of the resident' rights to them, however, lacked any information on what, if any, steps would be taken to promote resident' dignity or personal spaces. A facility' policy on dignity and resident spaces was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to comprehensive assess and, if needed, develop interventions to ensure an appropriate, proactive bowel management program was implemented to promote comfort for 1 of 1 resident (R31) reviewed who complained about constipation. Findings include: R31's admission Minimum Data Set (MDS), dated [DATE], identified R31 had intact cognition and was continent of bowel. Further, the MDS outlined a question labeled, H0600, which asked if constipation was present. This was responded, No. R31's Retiring MHM (Monarch Healthcare Management) Admission/Initial Data Collection - V5, dated 4/5/24, identified R31 admitted to the care center from home and was on hospice care. The evaluation outlined R31 had not evident memory problem along with a section labeled, Current Bowel and Bladder Function, which asked four questions about continence. This identified R31 was occasionally incontinent of bowel, however, lacked any further questions or evidence to demonstrate R31's bowels (i.e., patterns, preferences) had been evaluated. R31's most recent MHM Bowel Evaluation, dated 4/11/24, was labeled as, Admission, and identified R31 was continent of bowel. The evaluation contained other sections to outline medical conditions, medication use, and a physical inspection to demonstrate a comprehensive review of the bowel system, however, these sections were left mostly blank with just single dictation reading, peri rectal area intact per nurse assessment. Redness noted to buttocks on admission. The evaluation concluded with a section labeled, Individualized Treatment Plan, and spacing to record what, if any, interventions or plan would be in place. However, this was left blank and not completed. The completed evaluation lacked any comprehensive assessment of R31's bowel management including what, if any, input R31 had on her own bowel management issues or needs (i.e., wishes). The completed evaluation was signed by the director of nursing (DON). On 5/28/24 at 11:17 a.m., R31 was interviewed. R31 stated she was constipated and had trouble being regular here [at care center]. R31 explained she admitted to the care center not long prior, and used a routine at home to produce regular bowel movements which involved consuming prunes and graham crackers. R31 stated the staff had not talked with her, at least to her recall, about a proactive bowel management program (i.e., dietary options, medication options) but rather just had put me on a couple laxatives which I don't like. R31 stated she was typically getting prune juice with her breakfast but nobody had offered or helped her with graham crackers pointing to a box of them stored in her chair-side table. R31 added, I bought graham crackers myself but haven't eaten them. R31 reiterated she felt her bowels were not moving enough. R31's care plan, identified R31 was enrolled in hospice for heart failure and a lung mass. The care plan listed a problem statement which read, STRENGTH: Continent of bowel and bladder. Anticipating this to change as resident declines, along with multiple goals including, Resident will move bowels q3 [every three] days or greater. The care plan then listed a single intervention for this which read, Assist of 1 with toileting. The care plan lacked any other interventions for R31's bowel management. R31's progress notes, dated 4/8/24 to 5/10/24, were reviewed. On 4/8/24, a note was completed by hospice and identified R31 had a bowel movement two days prior adding, . generally moves bowels daily . not been getting prune juice in the AM . request made to dietary and will provide . reviewed hydromorphone [narcotic] effect on bowels . On 4/18/24, hospice visited and recorded an as-needed suppository was given on 4/16/24 with good results. On 4/25/24, hospice again visited and identified R31 may have potential constipation due to narcotic use adding, Need to increase Senna? Further, another note dated 5/10/24, identified hospice visited and recorded R31's bowels . remain sluggish, moving about every 3 days . does not want scheduled Senna increased at this time. However, the progress notes then lacked any further evaluation or documented follow-up on this potential issue by hospice or the care center after 5/10/24. R31's Follow Up Question Report, dated 5/15/24 to 5/28/24, identified R31's recorded bowel movements at the care center along with their characteristics (i.e., size, formed/loose). This identified the following: On 5/16/24, R31 had a large, formed bowel movement. On 5/21/24 (five days later), R31 had a large, formed bowel movement. On 5/24/24 (three days later), R31 had two bowel movements record. Both were a medium size, however, one was listed as being loose/diarrhea consistency. On 5/27/24 (three days later), R31 had a large, formed bowel movement. When interviewed on 5/29./24 at 9:27 a.m., nursing assistant (NA)-A verified they had worked with R31 on multiple occasions. NA-A explained R31 was on hospice care and needed stand-by assistance to use the bathroom mostly due to someone helping her with the oxygen tubing. NA-A stated R31 was mostly continent of bowel and bladder adding, She lets you know when she has to go. NA-A stated R31 had not expressed any concerns about her bowels or constipation, however, they had noticed R31 was sometimes a little loose adding this had last happened a couple days ago maybe. NA-A stated loose stools should be reported to the nurses and the staff will document resident' bowel movements in the POC charting. R31's medical record was reviewed and lacked evidence R31 had been comprehensively assessed including with R31's own preferences and input on what, if any, proactive or additional interventions were needed to promote a proactive bowel management program (i.e., additional dietary interventions, medication management). There was no evidence the facility had re-visited or evaluated R31's bowel management needs despite hospice recording potential constipation concerns (i.e., over three days between movements) and direct care staff seeing recent loose stools. When interviewed on 5/29/24 at 10:54 a.m., registered nurse (RN)-A explained the overnight nurse helps make a daily listing of which residents need a bowel intervention due to not having one (i.e., suppository), however, if there was an agency nurse working then sometimes there's lapses and the listing is not always done. RN-A verified they had worked with R31 and stated they had, at times, offered R31 some medication for her bowels but R31 would decline and want to wait and see what happens adding R31 was worried medications will work too well and then give her loose stools. RN-A stated R31 had not voiced any concerns with her bowel patterns or potential constipation to their recall but added hospice was aware of it and asked about it all the time to their knowledge. RN-A stated they had conversation with R31 shortly after she admitted about her bowels adding R31 seemed a little obsessed about it. RN-A stated they educated R31 about it adding R31 was told, I don't want you to go past three days. RN-A explained a comprehensive bowel evaluation would be hospice' responsibility since R31 was on their service adding, For her [R31], it would be hospice. RN-A stated they had not heard or been told about using graham crackers prior to the conversation with the surveyor. RN-A reviewed R31's medical record and acknowledged it lacked evidence hospice or the care center had re-evaluated R31 after 5/10/24 (hospice note) and stated comprehensive bowel management programs should be assessed and documented in the progress notes adding, We're not documenting maybe like we should. Further, RN-A stated they had not had any loose stools for R31 reported to them over the past week or so, and expressed it was important to ensure resident' bowel needs and, if needed, a management program was evaluated to reduce the risk of constipation and promote comfort adding, If they get constipated [there] could be all kinds of complications to that. On 5/29/24 at 2:46 p.m., the DON was interviewed and verified they had reviewed R31's medical record. DON explained resident' bowels are assessed on admission mostly using the NA charting and basing it off that. DON stated R31 wasn't using her as-needed narcotic upon admission but, if she had been, then it would have triggered more of an in-depth review for constipation. DON stated the hospice notes seemed to stop addressing R31's constipation and bowel patterns after the 5/10/24 note adding the subsequent notes were like they [hospice] were copying and pasting. DON stated they would speak to the hospice nurse about R31's bowel when they were next onsite. DON stated the floor staff do the data collection of a resident upon admission and then she herself (DON) does the bowel and bladder evaluations but those were more for incontinence and not for bowel management program evaluation. DON stated they had just visited with R31 about her bowel (after questioned by the surveyor prior) management and placed a note in the medical record adding R31 wanted to try using graham crackers like she had been prior to admission. DON stated hospice was involved in resident' care but evaluation and management of conditions was the facility' responsibility adding, Ultimately, she's living here so she's ours. Further, DON stated it was important to ensure bowel conditions, including the need for a proactive bowel management program, were assessed to promote resident' comfort adding constipation was not a good outcome. A facility' policy on bowel management programs was requested, however, none was received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure residents were assessed for appropriateness to be assisted by paid feeding assistants (PFA)'s at meals including residents with or without difficulty swallowing and/or with complicated feeding problems requiring a mechanically altered diet and/or special precautions for 6 of 6 residents (R4, R5, R6, R10, R16, and R30) reviewed. The facility also failed to ensure the PFA's were supervised at all times by a nurse while performing feeding assistance. Findings include: R4's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R4 had moderate cognitive impairment, was dependent on staff for Activities of Daily Living (ADL) and supervision or touching assistance for meals. R4's face sheet, printed 5/30/24, indicated R4 moved in on 1/12/10. Diagnoses included dementia with other behavioral disturbance, expressive language disorder, dsyarthria (speech disorder caused by weak muscles) following cerebral infarction (disruption of blood flow to the brain due to problems with the blood vessels that supply it), hemiplegia (paralysis of one side of the body) and hemiparesis (another term for hemiplegia) following cerebral infarction affecting right non-dominant side, ataxia (lack of voluntary coordination of muscle movements), and delusional disorder (mental health condition which a person can't tell what's real from what's imagined). On R4's therapy tab in the electronic medical record (EMR) indicated a diagnosis of dysphagia (difficulty swallowing). R4's orders, printed 5/30/24, indicated a regular diet, regular texture, regular consistency with a start date of 6/21/22. R4's care plan, printed 5/30/24, indicated R4 needed assist of 1 with eating with a start date of 10/5/22. R4 needs feeding assist; able to hold 'kennedy' cup and feed self finger foods. There was no mention of being able to be assisted by a PFA or mention of dysphagia diagnosis. R4's Clinical Nutrition Evaluation, dated 5/2/24, identified the following: under section f adaptive equipment: n/a (not applicable) and section f1 amount of feeding assistance required full assist. The assessment lacked identification of diagnosis of dysphagia or if R4 was able to be assisted by a PFA. R4's EMR lacked an assessment to identify if R4 would be appropriate to be assisted by a PFA. R5's quarterly MDS assessment dated [DATE], indicated R5 had moderate cognitive impairment, was dependent on staff for ADL's and supervision or touching assistance for meals. R5's diagnoses included osteoarthritis and osteoporosis. R5's orders, printed on 5/30/24, indicated a regular diet, pureed texture, regular consistency, small portions with a start date of 1/12/24. R5's care plan, printed 5/30/24, indicated R5 had potential for alteration in nutrition r/t [related to] need for mechanically altered diet secondary to hx [history] of chew/swallow difficult. R5's care plan lacked identification of assistance needed with eating, mention of being able to be assisted by a PFA. R5's Clinical Nutrition Evaluation, dated 3/6/24, identified R5 had a lost of 5% or more in the last month or loss of 10% or more in the last 6 month in her weights and a radio-button answered was marked yes, not on a prescribed weight-loss regimen. The assessment lacked identification if R5 was able to be assisted by a PFA. R5's progress note reviewed from 11/29/23 to 5/15/24 indicated the following: -4/14/24: resident had 1 episode of vomiting immediately upon leaving supper table. NAs reported resident ate a grilled cheese sandwich. Resident stated she felt fine after episode of emesis. -3/27/24: .1/12/24-diet downgraded to Pureed, may chop or mash foods. Initially trialed downgraded diet starting 12/31 d/t [due to] reports of prolonged chewing . -12/31/23: [R4] continues to have great difficulty eating-she chews for long periods of time before finally swallowing .we are going to try a pureed diet x 1 week . -12/29/23: .Per RN notes, [R4] has been pocketing foods and having some swallow difficulty .staff to continue to encourage adequate meal/supplement intakes, assist with intake PRN [as needed] . -12/26/23: [R4] was observed pocketing food at breakfast and lunch today. [R4] continued to keep putting food in her mouth without swallowing. When she drank it would run out of her mouth. CAN (certified nursing assistant) sat with R4, but she was unable to follow cues to swallow. -12/11/23: [R4] was having a difficult time swallowing and was coughing when she took a drink. R5's EMR lacked an assessment to identify if R5 would be appropriate to be assisted by a PFA. R6's quarterly MDS assessment dated [DATE], indicated R6 had moderate cognitive impairment, was dependent or maximal assistance of staff for ADL's in areas of toileting, dressing, showering, mobility, and transfers. R6's diagnoses included heart failure (heart not working properly), diabetes (disease that results in too much sugar in the blood), stroke (condition in which poor blood flow to the brain causes cell death), and unspecified toxic encephalopathy (a brain dysfunction caused by a toxin). R6's orders, printed on 5/30/24, indicated a regular diet, regular texture, regular consistency, and small portions with a start date of 6/17/22. R6's care plan, printed on 5/30/24, identified resident needs feeding assist; often refuses assist with a date initiated of 9/26/22. R6's care plan lacked identification of being assessed for appropriateness to be assisted by a PFA at meals. R6's Clinical Nutrition Evaluation, dated 3/12/24, identified R6 was independent regarding amount of feeding assistance required. R6's progress notes were reviewed from 12/4/23 to 5/15/24 indicated the following: -12/27/23: speech therapist came in at supper time. [R6] tolerated thin liquids, his egg sandwich, and his bowl of cereal with no difficulty. No coughing or choking noted. -12/27/24: [R4] tolerated mechanical pork with gravy and mashed potatoes. [R4] coughed on thin liquids but tolerated nectar thick liquids. R6's EMR lacked an assessment to identify if R6 would be appropriate to be assisted by a PFA. R10's quarterly MDS assessment dated [DATE], indicated R10 had intact cognition, was moderate to maximal assistance of staff for ADL's in areas of toileting, dressing, showering, mobility, and transfers. R10's diagnoses included dysphagia (difficulty swallowing), aphagia (inability or refusal to swallow), coronary artery disease (buildup of plaque in the coronary arteries), hypertension (high blood pressure), rheumatoid arthritis, gastro-esophageal reflux disease (disease in which stomach acid irritate the food pipe lining), and chronic obstructive pulmonary disease (progressive lung disease). R10's orders, printed 5/30/24, indicated a regular diet, regular texture, and regular consistency with a start date of 1/4/24. R10's care plan, printed 5/30/24, identified R4 has a history of mechanically altered diet due to dysphagia and aspiration. R4 refused altered textures despite repeated education on risks associated with non-compliance of recommendations. Provider liberalized diet on 1/4/24. R4's care plan lacked identification of need of assistance with eating, being assessed for appropriateness to be assisted by a PFA at meals. R10 was observed by speech therapy on 5/29/24. Initial assessment, dated 5/29/24, indicated R4's prior medical history was respiratory failure due to inhalation of food at a meal. Current recommendation was mechanical soft/chopped textures: chopped meat only. R10's progress notes were reviewed from 12/1/23 to 5/29/24 indicating the following: -5/27/24: R4 observed while eating supper meal in room to have choking episode while eating meat of beef commercial served. [R4] did not have dentures in while eating at time episode occurred. R4 was able to clear throat on own without nursing intervention -3/16/24: [R4] also reported during assessment she should not have eaten pork that was served for supper yesterday, as had a hard time swallowing it., Concern for possible aspiration pneumonia based on resident report -2/24/24: [R4] had a coughing episode during breakfast after medication was given. Episode lasted for approximately 10 minutes. -12/31/23: activities stated resident had a choking spell during the afternoon party when she was eating. R10's EMR lacked an assessment to identify if R10 would be appropriate to be assisted by a PFA. R16's quarterly MDS assessment dated [DATE], indicated R16 had intact cognition and independent with ADL's. R16's face sheet, printed 5/30/24, included diagnoses of dementia, fracture of left femur (broken bone in upper left leg), and heart failure. R16's orders, printed 5/30/24, indicated a regular diet, regular texture, and regular consistency with a start date of 9/27/23. R16's care plan, printed on 5/30/24, lacked evidence that R16 prefers to sit at the table with residents that need assistance with meals. It further lacked evidence that R4 was assessed to be appropriate to be assisted by a PFA at meals, if needed. R16's EMR lacked an assessment to identify if resident would be appropriate to be assisted by a PFA if needed. R30's admission MDS assessment dated [DATE], indicated severe cognitive impairment and was dependent or maximal assistance of staff for ADL's in areas of toileting, dressing, showering, mobility, and transfers. R30's diagnoses included, hypertension, diabetes, malnutrition, malaise (chronic tiredness). On R30's therapy tab in the electronic medical record (EMR) indicated a diagnosis of dysphagia (difficulty swallowing). R30's order, printed 5/30/24, indicated a consistent carbohydrate diet, mechanical soft texture, and regular consistency. R30's care plan, printed on 5/30/24, identified R4 has a history of chewing and swallowing difficulty. R30's care plan lacked identification of being assessed for appropriateness to be assisted by a PFA at meals. R30's progress notes were reviewed from 5/10/24 to 5/30/24 identifying the following: -5/28/24: staff report that he eats a lot at one time, which causes occasional emesis-last episode was 4+ days ago. -5/24/24: staff note that patient had 3 episodes of emesis on Wednesday and one earlier in the day today. Eating pattern, I minimal food intake for a day or two and then eat large amount of food .known sensitivity to dairy that does not deter intake . -5/10/24: resident on a CCHO [carbohydrate-controlled diet] diet with regular texture but expressed difficulty chewing/swallowing. Culinary Director spoke with administrator and [director of nursing] to help set up a speech eval . During observation on 5/28/24 at 12:00 p.m., activities director (AD)-A was observed sitting in the dining room with residents during lunch. AD-A was observed putting R4 peanut butter and jelly sandwich in her hand while prompting her to eat. AD-A was observed putting R4's cup in her hand and prompting her to take a drink. AD-A was observed feeding R4 her desert. AD-A was sitting next her while she ate and making conversation with her during the meal. R30's electronic medical record lacked an assessment to identify if resident would be appropriate to be assisted by a PFA if needed. On 5/28/24 at 12:19 p.m., AD-A was observed wiping R5 mouth as she had spilled pureed food on her chin. It was not observed how the food got on the R5's chin. During an interview on 5/29/24 at 3:38 p.m., AD-A stated that she can assist any resident that needs assistance with eating. AD-A stated that all the staff in the activity department, which includes herself and two activity aides, have taken the paid feeding assistant course. AD-A verified they are able to feed any resident. AD-A stated she took a course many years ago to assist residents with eating but took another course last year which was a lot more in depth. AD-A stated, we can assist anyone [in regards in to eating] no matter what the level of assistance is needed. AD-A verified she was assisting R4 yesterday at lunch and added, she usually needs more assistance than she did yesterday. AD-A stated that by having the training, it helps because if we do snacks or take residents out in the community, we are trained to assist with feeding them. AD-A verified the activities department are the only staff that are present on resident outings. During an interview on 5/30/24 at 8:39 a.m., activities aide (A)-A verified that she is familiar with the residents and worked at the facility for over 2 years. A-A verified that she has completed the paid feeding assistant training course. A-A stated that the activity department has been trained in assisting residents to eat and we are able to help anyone who needs helps eating. A-A verified that there is not a list of residents that they are able to assist, and they are able to assist any resident that needs assistance. A-A verified the activity department takes residents out to eat and may offer snacks during outings. A-A verified that a nurse is not present during these outings as when we go on resident outings, it is the three-activity staff that are present. A-A stated that if she were helping a resident eat on an outing without a nurse present and something happened, then she would notify her supervisor, the director of activities. A-A stated she doesn't typically get instructions from the nurses on residents and how they eat but she would ask if she had any questions. On 5/30/24 at 9:07 a.m., A-A was observed assisting R4 with breakfast by putting her cup to her mouth to take a drink. On 5/30/24 at 9:08 a.m., director of culinary services (CMD)-A stated there are 5-7 residents needing assistance with eating including some that sit at the table that is known to need assistance. CMD-A verified diets change frequently and at this time, they are serving 7 mechanical diets and 1 pureed diet which are some of the diets which are of residents that need assistance. CMD-A stated that residents are on modified diets as there is a choking risk and choking and aspiration are huge things. CMD-A stated don't want anyone to become injured by having the wrong diet. CMD-A stated, I believe everyone in the rec [recreation] department is trained .help residents who need assistance with eating. CMD-A is not sure if there is a list of residents the PFA's are able to assist. A document titled, Diet Type, was provided by the facility dated 5/30/24. The following information was included: -seven resident on a mechanical soft diet -one resident on a pureed diet On 5/30/24 at 9:16 a.m., director of nursing (DON) verified she oversees the paid feeding assistants. DON verified the facility has three paid feeding assistants (PFA) which are the staff in the activity department. DON stated they have no residents with feeding tubes or any complicated residents. DON verified they can assist any residents that need assistance. DON verified there is no formal assessment for residents to be appropriate to be fed by paid feeding assistance as we just know. DON stated that the director of activities is part of the interdisciplinary (IDT) team. DON stated that residents who need assistant sit at a specific table and sometimes we have a nurse in there [dining room] supervising. DON verified they do not have a list of residents that PFA's can or cannot assist. DON was unable to provide a list of residents who utilized assistance from the PFA's. DON stated if a resident uses a PFA, it should be on their care plan. On 5/30/24 at 9:46 a.m., administrator verified the facility utilizes PFA's. Administrator stated she believes the residents at the sitting at a specified table are the residents that are primarily assisted by the PFA's. Administrator verified that nursing assistants or nurses do not go on resident outings with residents. Administrator verified that resident outings may include meals and snacks and that some of those residents may needs assistance but cannot verify that without looking into it further. On 5/30/24 at 10:14 a.m., dietary aide (DA)-A indicated they are familiar with the residents. DA-A stated the following information regarding residents who sit at the table who need assistance: -R4: need to be fed, can eat things that are placed in her hands like a boiled egg or sandwich but needs assistance with silverware and drinks. -R5: eats pureed food because her dentures don't fit well, and was unsure if she has any swallowing issues adding, I don't think so, all we were told was it was related to her dentures. -R6: needs supervision and encouragement because he falls asleep. -R30: gets his food cut up into small pieces. -R10: needs supervision due to choking is what we were told. -R16: was grandfathered in as she was sitting at that table before they combined the residents who needed assistance. She likes the table, so they just keep her there. A facility policy, paid feeding assistant policy, undated was provided. The policy indicated resident selection of eligibility for feeding assistance will include an interdisciplinary team assessment of the resident's current condition, the latest comprehensive assessment, and plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to ensure recommended pneumococcal vaccinations, as outlined by the Centers for Disease Control (CDC), were offered and/or provided in a timely manner to reduce the risk of severe disease for 4 of 5 residents (R3, R2, R8, R24) reviewed for immunizations. Findings include: A CDC Pneumococcal Vaccine Timing for Adults feature, dated 3/2023, identified several tables with corresponding recommendations when to receive various versions (i.e., PPSV23, PCV13, PCV20) of the pneumococcal vaccine. The graph labeled, Adults [at or older than] [AGE] years old, outlined persons with a complete series of pneumococcal vaccination (i.e., PCV13 at any age, PPSV23 at or above [AGE] years old) should have shared clinical decision-making between the resident and healthcare provider to determine if PCV20 was appropriate. R3's quarterly Minimum Data Set (MDS), dated [DATE], identified R3 had moderate cognitive impairment, and several medical conditions including heart failure and diabetes mellitus. R3's Clinical - Immunizations listing, printed (from the electronic medical record (EMR) 5/30/24, identified R3 was [AGE] years old and had no known allergies. R3's immunizations, both prior to admission and since, were listed. This outlined R3 received the pneumococcal polysaccharide vaccine (PPSV23) in 1997; however, lacked evidence any other pneumococcal vaccinations, including the newer recommended pneumococcal conjugate (i.e., PCV15/20), had been offered or given. On 5/29/24 at 3:23 p.m., R3 was interviewed and stated they did not recall being offered or getting the subsequent pneumococcal vaccinations, either from the care center or their physician. R3 stated she was open to information on them. R3's medical record was reviewed and lacked evidence of shared clinical decision-making between the care center, physician and resident to determine what, if any, of the recommended pneumococcal vaccinations were needed or desired. R2's quarterly MDS, dated [DATE], identified R2 had intact cognition, and several medical conditions including diabetes mellitus and heart failure. R2's Clinical - Immunizations listing, printed 5/30/24, identified R2 was [AGE] years old and had no known allergies. R2's immunizations, both prior to admission and since, were listed. This outlined R2 received the PPSV23 in 2005; however, lacked evidence any other pneumococcal vaccinations, including the newer recommended pneumococcal conjugate (i.e., PCV15/20), had been offered or given. On 5/29/24 at 3:44 p.m., R2 was interviewed and stated they did not recall being offered or provided any subsequent pneumococcal vaccinations adding, I don't think so. R2's medical record was reviewed and lacked evidence of shared clinical decision-making between the care center, physician and resident to determine what, if any, of the recommended pneumococcal vaccinations were needed or desired. R8's significant change MDS, dated [DATE], identified R8 had moderate cognitive impairment, and several medical conditions including anemia and chronic kidney disease (CKD). R8's Clinical - Immunizations listing, printed 5/30/24, identified R8 was [AGE] years old along with her immunizations, both prior to admission and since, which were listed. The identified R2 received the PPSV23 in 2009 and pneumococcal conjugate (PCV13) in 2017; however, lacked evidence the newer recommended pneumococcal conjugate (i.e., PCV15/20) had been offered or given. On 5/29/24 at 3:33 p.m., R8 was interviewed and stated she didn't recall anyone ever offering or giving her the new vaccine. R8 stated she was open to listening to the information about it adding, I could stand the information. R8's medical record was reviewed and lacked evidence of shared clinical decision-making between the care center, physician and resident to determine if the newer recommended pneumococcal vaccination was needed or desired. R24's quarterly MDS, dated [DATE], identified R24 had intact cognition. R24's Clinical - Immunizations listing, printed 5/30/24, identified R24 was [AGE] years old along with her immunizations, both prior to admission and since, which were listed. This identified R24 received the PPSV23 in 2000 and the PCV13 in 2017; however, lacked evidence the newer recommended pneumococcal conjugate (i.e., PCV15/20) had been offered or given. On 5/29/24 at 3:29 p.m., R24 was interviewed and stated she didn't recall being asked or offered the newer, recommended vaccination. R24 stated she was open to getting though adding, I suppose. R24's medical record was reviewed and lacked evidence of shared clinical decision-making between the care center, physician and resident to determine if the newer recommended pneumococcal vaccination was needed or desired. On 5/30/24 at 9:30 a.m., the director of nursing (DON) and regional nurse consultant (RNC) were interviewed. DON verified they were in charge of the facility' vaccination efforts and they had reviewed the medical records of the involved residents (R3, R2, R8, R24). DON stated giving the newer pneumococcal vaccinations (i.e., PCV15/20) had been discussed and in the works but none of the identified residents had received them so far. DON provided each respective residents' consent form, which were all signed either 5/28/24 or 5/29/24, and verified they had not been offered or given the vaccinations prior. DON stated vaccinations were typically addressed right away on admission and verified the EMR immunization data (i.e., Clinical - Immunizations) contained all information on the residents the care center had including from the MIIC (Minnesota Immunization Information Connection). DON stated they believed, to their knowledge, the physicians were talking about the newer vaccines with residents and would provide documentation, if located. However, DON verified immunizations should be offered and given, if needed, adding it was important to do so reduce the risk of severe illness and make sure they're covered. Further, DON and RNC both verified they were aware of the CDC recommendations for shared clinical decision-making and use of the PCV15/20 series prior to survey. A facility' provided Pneumococcal Policy, dated 2/2024, identified the care center would offer vaccinations to all residents to aid in prevention of pneumonia infections adding a purpose of following recommendations of various healthcare entities including the CDC. A procedure was listed which included, Refer to the current CDC Recommended Adult Immunization Schedule to determine recommended vaccines .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure frozen food items were stored in a manner to reduce the risk of cross contamination and potential foodborne illness in 1 of 1 walk-in freezers using the main production kitchen. This had potential to affect all residents who could potentially consume the items. Findings include: On 5/28/24 at 9:57 a.m., an initial kitchen tour was completed. A single [NAME] walk-in commercial freezer was in use, opened and inspected. Inside, the unit had a cooling fan mounted to the top of the unit which had visible ice built up on numerous places along the unit. The ceiling of freezer had ice built up, thick in some areas and in frozen droplet forms in other areas, that went from the back wall of the freezer towards the front of the freezer cover two-thirds of the ceiling on the left side. The back wall of the freezer had ice build-up with the thickest of the ice towards the bottom. The floor of the freezer and the metallic shelving used also had ice build-up present on them. Approximately, one-third of the floor was covered with thick ice build-up. The metallic shelving units were used to hold food and sat parallel with the walls of the freezer from the front wall to the back wall of the freezer. Immediately to the right of the cooling unit, there were several food items stored including opened box of salmon and an unopened box of cod. Both boxes were cardboard which were soft and somewhat mushy feeling to touch. The salmon box had visible ice buildup covering the open box, the plastic bag that contained the salmon fillets was open and salmon fillets were partially out of the box. The salmon that could be seen was covered in ice in the box. The box of cod was sealed, appeared to have wet spots on the cardboard box but were dry to touch and pieces of the tape were starting to come unattached on the top. A gauge present measured the unit at -8 degrees Fahrenheit (F). When interviewed on 5/28/24 at 10:20 a.m., director of culinary services (CMD)-A verified that he is the director of culinary services and is responsible for overseeing the kitchen. CMD verified it has been an on-going process to get the ice out of the freezer. CMD stated that maintenance with chisel the ice out when it gets bad and it has been done approximately 4-5 times in the past 7 months. CMD stated that he notifies maintenance when it gets bad, and they assist with chiseling the ice out. CMD verified the ice buildup as listed above. CMD stated it is difficult to tell how thick it is but probably about 6 inches. CMD verified the salmon box was open, salmon fillets were exposed directly, and the box is covered in ice. CMD verified the box of cod was covered in ice and was unopened. CMD stated contamination would be of concern. CMD discarded the box of salmon. During a subsequent visit to the kitchen on 5/29/2024 at 2:45 p.m. it was observed the much of the ice had been removed from the freezer. It was observed the box of cod covered in ice continued to be present in the freezer. CDM verified that he chiseled the ice out of the freezer yesterday. During interview on 5/30/24 at 9:45 a.m., administrator stated she would refer to the director of culinary services for their expertise for concerns regarding ice buildup in the freezer in relation to food. A provided Refrigerators and Freezers Policy, dated 12/14, identified refrigerators and freezer will be kept clean, free of debris and mopped with sanitizing solution on a scheduled basis and more often as necessary. The policy outlined several steps to ensure refrigeration was maintained, however, lacked any guidance or direction on what, if any, steps were taken to ensure proper freezer storage given the repeated ice-build up from the dated equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to assess the resident and determine safety for self-administration of medications (SAM) for 1 of 1 resident (R14) who was observed to have medications at bedside. Findings include: R14's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated intact cognition, required one-person physical assist with bed mobility, transfers, dressing, toilet use, and personal hygiene, and indicated diagnoses including gastro-esophageal reflux disease (digestive disease), osteoarthritis, chronic kidney disease, coronary artery disease, heart failure, and hypertension (high blood pressure). R14's care plan dated [DATE], indicated risk for discomfort and interventions included: monitor for verbal and nonverbal indicators of discomfort, provide non medicinal forms of pain relief such as positioning, rest, massage, encourage resident to verbalize discomfort, document on pain, keep medical doctor informed. During an observation and interview on [DATE] at 1:45 p.m., R14 was seated in recliner and observed multiple containers of over-the-counter meds next to her recliner. On the bottom shelf of the bedside table was a bottle of Equate brand antacid (relieves indigestion and heartburn) tabs, bottle of MiraLAX (constipation medication) powder, Dulcolax (laxative) chewy bites; on the top of the bedside table were two tubes of Aspercreme (provides pain relief), one tube of Cortisone cream, and in the pocket of the recliner were two tubes of Aspercreme, one tube of Cortisone cream (for various skin conditions). R14 stated her family brought the medications and used the cortisone cream for itching, Aspercreme for knees and feet, MiraLAX and Dulcolax for help with constipation, and the antacid for sour stomach. On [DATE] at 7:00 p.m., licensed practice nurse (LPN)-A reviewed R14's record and stated R14 did not have a self-administration medication (SAM) assessment and confirmed since R14 did not have a completed SAM the medications should not have been left in R14's room because it was unknown if it was safe for R2 to self-administer. LPN-A further indicated R14's family was known to bring medications in the facility for R14. On [DATE] at 7:10 p.m., medications were still located in R14's room. LPN-A confirmed the medications located in R14's room were not administered or documented by facility staff. R14 stated the medications were used when she needed them for bowels and cream for her knees. LPN-A stated the medications were not expected in R14's room and removed the medications from the room. On [DATE] at 7:10 p.m., trained medication aide (TMA)-A stated she was aware of the creams in R14's room and notified a nurse about the medications. TMA-A stated she was not able to recall when or the name of the nurse notified. On [DATE] at 1:22 p.m., director of nursing (DON) stated R14 was not assessed for SAM and expectation was for medications not in R14's room. The DON stated the family was known to bring medications for R14 and place at the bedside. The DON stated family member-(FM)-A was educated today family was not to bring medications into R14's room. The DON stated staff were expected to removed medications from R14's room when observed. The facility policy and procedure titled Self administration of medications dated 12/16, indicated Policy: residents have their right to self-administer medications if the interdisciplinary team has determined clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation: 9. Staff shall identify and give to the charge nurse any medications found at the bedside that are not authorized for self-administration for return to the family are responsible party. 11. The nursing staff will routinely check self-administered medications and will remove expired, discontinued, or recalled medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to complete a level II preadmission screening and resident review (PASARR) for 2 of 2 residents (R3, R5), reviewed with new mental illness diagnoses. Findings include: R3's face sheet, printed on 6/6/23, indicated R3's original admission date was 5/10/19, diagnosis at time included anxiety disorder. Further review of the diagnosis listed on face sheet, indicated R3 was diagnosed with a mood disorder on 6/16/21 and psychosis (a mental disorder causing disconnection from reality), not due to a substance or known physiological condition, on 3/17/22. R3's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R3 had intact cognition and received antidepressant medication. R3's current physician orders, printed 6/6/23, included: monitoring for adverse side effects due to psychotropic medication use (medications altering mood/mental state), quetiapine fumarate (Seroquel, an antipsychotic (mood/mental state altering) medication); 125 mg twice daily related to psychosis not due to a substance or known physiological condition, and monitoring orthostatic blood pressures once monthly due to psychotropic medication use. R3's care plan, last reviewed on 6/1/23, included: R3 had behaviors related to (R/T) psychosis, mood disorder, and anxiety; may yell out for help, shout, scream, and swear at staff, hit, and attempt to bite staff. Interventions included social services to assist resident and family as needed (PRN). Furthermore, upon record review, R3 had not been evaluated for or had received mental health services with new mental illness diagnoses updated on 6/16/21 and 3/17/22. Record review of R3's PASARR screen, completed on 5/10/19, indicated negative level 1 screening, level 2 screening not needed at time. Record review indicated R3 had resided at facility since admission on [DATE], was sent to hospital for an acute medical condition and readmitted back to facility on 5/3/22, no PASARR screen completed prior to facility readmission. R5's face sheet, provided by via email to surveyor on 6/8/23, indicated R5's original admission date was 1/12/10, diagnosis at time included major depressive (mood altering) disorder. Further review of the diagnosis listed on face sheet, indicated R5 was diagnosed with delusional (false judgements/beliefs regarding reality) disorder on 5/5/16 and unspecified dementia (brain dysfunction) with behavioral disturbances on 10/1/22. R5's quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated R3 had moderately impaired cognition and received antipsychotic, antidepressant, and opioid medications. R5's current physician orders, provided via email to surveyor on 6/8/23, included: documentation of behaviors every shift to capture mood and behaviors for antipsychotic utilization, administer aripiprazole (antipsychotic) 4 mg daily in morning R/T delusional disorders, administer sertraline 200 mg daily in the morning R/T major depressive disorder, monitoring of orthostatic blood pressure once monthly while receiving psychotropic medications, and monitoring for adverse side effects due to psychotropic medication use. R5's care plan, last reviewed on 6/1/23, included: R5 had alteration in mood and behaviors, and potential for alteration in psychosocial well-being R/T dementia with behavioral disturbance, major depressive disorder, and delusional disorder. Interventions included monitoring and documentation of mood and behaviors occurred, social services to assist resident and family PRN, and monitoring mood state, refer PRN. Furthermore, upon record review, R5 had not been evaluated for or had received mental health services with new mental illness diagnoses updated on 5/5/16 and 10/1/22. Record review of R5's PASARR screen, completed on 5/4/16, indicated negative level 1 screening, level 2 screening not needed at time. Record review indicated R5 had resided at facility since admission on [DATE], was sent to hospital for an acute medical condition and readmitted back to facility on 8/27/18, no PASARR screen completed prior to facility readmission. During an interview, on 6/6/23 at 12:39 p.m., with registered nurse (RN)-A and director of nursing (DON), indicated PASARR screens were completed prior to facility admission, at time of a resident's significant change in status, or new mental health diagnosis was noted. RN-A stated all residents, when had a significant change in status or new diagnoses were reported, was discussed at interdisciplinary team (IDT) meetings once weekly. DON indicated social services (SS) present at weekly IDT meetings, SS manages PASARR screening evaluations and referrals for further follow-up. When interviewed, on 6/6/23 at 12:47 p.m., SS-A indicated she received resident PASARR level 1 screening evaluations prior to hospital discharge and facility admission, if resident needing PASARR 2 level screening prior to facility admission, hospital is responsible for referral of further follow-up for mental health service needs. SS-A stated if residents already admitted to facility had new mental health changes or new mental health diagnoses, SS-A was notified of these new changes at clinical meeting, held daily in the morning, with IDT. SS-A indicated new mental health changes or new mental health diagnoses were also discussed weekly with IDT at target behavior meetings, meetings held to discuss residents' psychotropic medications and behaviors. SS-A reviewed R3 and R5's most recent PASARR screens completed, SS-A indicated R3's most recent PASARR screen was completed 5/10/19, R3 had new diagnoses of mood disorder on 6/16/21 and psychosis, not due to a substance or known physiological condition, on 3/17/22 and R3 had not been referred for level II PASARR since diagnosed with new mental illness conditions. SS-A stated unawareness of R3's new mental health diagnosis and need for referral for mental health services, indicated awareness PASARR only needed to be completed prior to facility admission, SS-A confirmed she should have referred R3 to mental health services for further evaluation and follow-up of new mental illness diagnoses. SS-A indicated R5's most recent PASARR screen was completed 5/4/16, R5 had new diagnoses of delusional disorder identified on 5/5/16 and unspecified dementia with behavioral disturbances identified on 10/1/22; R5 had not been referred for level II PASARR since diagnosed with new mental illness conditions, SS-A confirmed R5 also should have been referred to mental health services for further evaluation and follow-up of new mental illness diagnoses. Facility policy titled Pre-admission Screening (PAS), revised date 4/23, indicated to ensure that residents admitted to the health care center meet specified criteria for appropriateness of placement. Procedure consisted of; Social Services will check for preadmission screening and OBRA Level II requirements, Pre-admission Screening assistance can be found at: Preadmission Screening/Minnesota Board on Aging (MBA) (mn.gov).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to mark/date opened containers of food stored in one kitchen refrigerators, a refrigerated sandwich prep table, and one freezer; and failed to ensure expired/damaged food were identified and removed. This had the potential to affect all 40 residents who were served food and beverages from the facility kitchen. Findings include: During interview and observation of kitchen on 6/6/23, at 11:50 a.m. with culinary director (CD)-D, observed food items in the refrigerated sandwich prep table, walk-in refrigerator, beverage service station refrigerator, and beverage service station freezer, that were not dated or marked and/or were expired/damaged. CD-D indicated all kitchen staff were responsible for checking food for opened dates and expiration dates, removing all expired/damaged foods when noted or per facility policy. CD-D indicated if any food or drink is not dated when opened, it should be removed immediately. CD-D indicated all left-over prepared food and beverages when dated/marked were good for 7 days from date opened per facility policy. The following items were observed during tour: Refrigerated sandwich prep table: 1. [NAME] 2% Low-fat cottage cheese- approximately½ full; not marked/dated when opened; expiration date 5/24/23. 2. Strawberry strudels enclosed in facility container- ½ full; not marked/dated when opened; use by date of 5/27/23 Walk-in refrigerator: 1.Premade scrambled eggs in sealed plastic bag- full; not marked/dated when opened; no expiration on bag 2.California Berry Farms fresh strawberries (2 small plastic cartridges)- approximately ½ full, unmarked/undated, no expiration date. Strawberries observed to have mold covering bottom half of strawberries, areas of strawberries appeared white with dark discoloration, had areas of fuzzy growth, foul odor present Beverage service station freezer: 1.One scoop plain white ice cream in facility Styrofoam cup (2)- uncovered, not marked/dated, no expiration/use by date. Ice cream slightly melted, refrozen During an interview on 6/6/23 at 1:03 p.m., CD-D indicated in discussion of unmarked/undated and expired/damaged food items; all staff were responsible to go through all refrigerators and freezers to check food items and remove all food items noted to be unmarked/undated and/or expired/damaged daily. CD-D stated having difficulty getting dietary staff to perform these routine food item checks when directed. CD-D indicated he has taken over performing routine food item checks, admitted was so busy with other dietary assignments, routine food item checks not completed daily as should have been. CD-D stated he had discussed concerns of dietary staff not performing dietary task assignments as directed to per CD-D's delegation with associate administrator (AA)-A, AA-A plans to further address with dietary staff. When interviewed on 6/7/23 at 11:40 a.m., AA-A indicated awareness of CD-D's concerns with dietary staff not performing dietary assignments, CD-D has had to perform most dietary task assignments by self. AA-A stated many staff are working through new adjustments of rules and expectations set per management team since new ownership of facility. AA-A stated this was a new concern was just recently brought to her attention per CD-D, management team currently working on plan for dietary job duties, including behavioral rules/expectations for culinary staff. Facility policy for food storage was requested on 6/6/23, received facility policy for food storage of non-perishable food items only. Facility policy titled Food Storage-Non-Perishable, revised date 9/12, consisted of; it is the policy of Monarch Healthcare Management to maintain sanitary techniques in non-perishable food storage in order to protect the health of those dependent on the service, the remaining contents of opened food packages will be stored in plastic containers with tight-fitting lids or plastic zip lock bags and all containers will be properly labeled and dated as to contents.