**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of a social media post, staff and resident interviews, record review, and facility policy review, the facility failed to provide care for a resident in a manner that maintained the resident's dignity. A picture of Resident #1 was posted to the facility's social media account which portrayed the resident in an undignified manner for one (1) of four (4) residents sampled. Resident #1 Findings include: Record review of facility policy titled, Resident Rights dated 7/24/23, revealed, Employees shall treat all residents with kindness, respect, and dignity . 1. Federal and state aws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity . Record review of facility policy titled, Dignity dated 7/24/23, revealed, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem . Residents are treated with dignity and respect at all times. Observation and review of the social media page for the nursing facility with the date posted as 1/10/25, revealed Resident #1 sitting in her wheelchair holding a cup of ice cream. She was dressed in a blue, long-sleeved shirt and peach colored pants. The resident was wet between her mid thighs and on her right leg. The resident's lower abdominal and groin area appeared to be wet with clear fluid and the wetness extended to her knees and appeared dark in color. During an interview with the resident on 3/19/25 at 12:30 PM, Resident #1 stated she did not use the toilet often, had accidents, and wore briefs that were changed by the staff frequently. During an interview on 3/19/25 at 12:45 PM, the Administrator stated the Activity Director had taken the pictures during activities and other events and had posted these on the facility's social media page. She stated it was the facility's responsibility to ensure each resident's rights, including being treated with dignity and respect, were honored. During our interview, she reviewed the social media post dated 1/10/25 of Resident #1 and confirmed that the picture of Resident #1 was a resident rights concern and should have been monitored more closely prior to being posted. During the interview with the Administrator, the Director of Nursing (DON) came into the Administrator's office at 12:48 PM on 3/19/25 and confirmed that the picture on social media of the resident violated the resident's rights. She confirmed the facility failed to ensure that the rights of Resident #1 were not violated before the picture was posted to social media. Review of Resident #1's admission Record revealed the facility admitted Resident #1 on 3/24/23 with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD) and Alzheimer's Disease. Record review of Resident #1's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8 which indicated the resident had moderate cognitive impairment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and facility policy review, the facility failed to ensure accuracy of a code status based on the Power of Attorney for one (1) of 14 residents sampled. Resident #19 Findings include: Record review of facility policy titled, Advanced Directives reviewed 11/2022, revealed, Policy Statement: The resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy .If the Resident has an Advance Directive: 1. If the resident or the residents representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the residents medical record and are readily retrievable by any facility staff. 2. The director of nursing services (DON) or designee notifies the attending physician of advance directive (or changes in advance directives) so that appropriate orders can be documented in the residents medical record and plan of care . Record review of Resident #19's Durable Power of Attorney for Health Care signed and dated by the resident on [DATE], revealed, Special Instructions: Do not resuscitate after one (1) hour of trying. No life support machine(s) in any town city, or state. Record review of electronic physician's order dated [DATE], revealed an order for DNR (Do Not Resuscitate). Record review of Order Details dated 4/124 revealed a physician's telephone order for a DNR, which was signed by the physician. Record review of Code Status form for Resident #19 signed by a family member and not the Resident's Representative on admission [DATE], revealed Do Not Attempt Resuscitation (DNR). During an interview on [DATE] at 9:15 AM, the Administrator revealed the special instructions on Resident #19's Power of Attorney document for Do not resuscitate after one (1) hour of trying. No life support machine(s) in any town city, or state would indicate the Cardio-Pulmonary Resuscitation (CPR) should be initiated. She confirmed the physician's orders and code status form did not reflect the wishes conveyed in Resident #19's Durable Power of Attorney for Health Care document concerning his end-of-life care. She acknowledged this could lead to a resident not receiving the end-of-life care desired. She confirmed that record accuracy of end-of-life care was necessary to ensure the information concerning end of life care was reflective of the resident's wishes and the facility failed to accurately indicate Resident #19's choice for end-of-life care. Record review of Resident #19's admission Record, revealed the facility admitted the resident on [DATE]. Diagnoses included Dysphagia following cerebral infarction and Chronic kidney disease. Record review of Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE] revealed a Brief Interview for Mental Status (BIMS) of 12 which indicated the resident was moderately impaired cognitively.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, and facility policy review, the facility failed to provide a safe environment as evidenced by an overbed table with exposed jagged edges for one (1) of 44 resident's observed. Resident #37 Findings Included: Record review of the facility policy titled, Maintenance Service with revision date of December 2009, revealed, The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . On 08/21/24 at 9:10 AM, an observation and interview revealed Resident #37 lying in bed with her over bed table positioned beside her on the right side of the bed. The plastic protective border was missing from all four sides of the over bed table and there were rough, jagged areas exposed. Resident #37 revealed that the rough edges on her over bed table could scratch her and if she rubbed up against the edges, she stated, It might bruise me. Resident #37 also revealed that her skin was thin and would easily tear. On 08/21/24 at 2:00 PM, an interview with Director of Nursing (DON) confirmed that Resident #37's over bed table had rough outer edges exposed and that the protective border was missing from all four sides. She revealed that the rough edges on the over bed table could cause skin tears or bruising. She revealed that this should have already been noticed and replaced. Record review of Resident #37's admission Record revealed that she admitted on [DATE] and had diagnoses that included Unspecified Dementia, Anxiety, and Muscle Weakness. Record review of Resident #37's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 05/09/2024 under Section C revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated that she had moderate cognitive deficits.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and facility policy review, the facility failed to develop a person-centered care plan for residents with a diagnosis of Post-Traumatic Stress Disorder (PTSD) for two (2) of the 14 resident care plans reviewed. Resident #11 and Resident #37. Findings included: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered undated revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are: a. provided by qualified persons; b. culturally competent; and c. trauma-informed. Resident #11 Record review of Resident #11's care plans revealed the resident did not have a care plan regarding PTSD. During an interview on 8/20/24 at 1:16 PM, Resident #11 revealed she does have PTSD because she had a traumatic event happen to her as a child. An interview on 8/21/24 at 3:01 PM, Registered Nurse (RN)/ Minimum Data Set (MDS) Coordinator, confirmed Resident #11 does have a diagnosis of PTSD. However, she does not have a comprehensive care plan addressing this diagnosis. She revealed it was not developed because it was missed in error. She revealed that the care plan is developed so the staff knows how to care for each resident and Resident #11 should already have a care plan already in place for her PTSD. During an interview on 8/22/24 at 11:25 AM, the Director of Nurses (DON) confirmed Resident #11 has a diagnosis of PTSD. However, a trauma-informed care plan was not developed and was missed. She revealed it is very important that anyone with a PTSD diagnosis has a care plan addressing it. Record review of Resident #11's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus, Peripheral Vascular Disease, and a PTSD diagnosis which was added with an onset date of 10/27/2023. Record review of Resident #11's Minimum Data Set (MDS) with an Assessment Reference Date of 07/10/24, revealed in Section I that the resident had a diagnosis of PTSD and in Section C a Brief Interview Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact. Resident #37 Record review of Resident #37's Care Plans revealed there was not a care plan in place to address PTSD that included triggers or interventions. On 08/21/24 at 11:05 AM, an observation and interview with Resident #37 revealed she was sitting up in her wheelchair in her room. Resident #37 revealed that she had a three month old baby to die many years ago and also had an adult son who had passed away in his sleep about 20 years ago and this still bothered her. Resident #37 revealed that she often had nightmares, cried out in her sleep and had done this for a long time and didn't know what caused it. She also revealed that she worried about all of her kids and grandkids because she had lost her own children. On 08/21/24 at 3:05 PM, an interview with RN/MDS Coordinator confirmed the resident had a diagnosis of PTSD and did not have a comprehensive care plan addressing this diagnosis. She revealed that the care plan was developed so the staff knew how to take care of the individualized needs of the resident. The RN/MDS Coordinator confirmed that Resident #37's care plan for her PTSD had not been developed and that it should have been. On 08/22/24 at 11:45 AM, an interview with the DON revealed that the RN/MDS Coordinator was responsible for care planning the needs of each resident and that Resident #37's Trauma Informed Care Assessment should have been completed to help identify any possible triggers and these triggers should be included in her care plan. Record review of Resident #37's Psych Eval (Evaluation)dated June 20, 2024, revealed Recommendations: Add .Post traumatic stress disorder, chronic to diagnoses. Record review Resident #37's admission Record revealed that she was admitted on [DATE] with diagnoses that included Unspecified Dementia with other behavioral disturbance, Anxiety Disorder and Hallucinations. The diagnosis of Post-Traumatic Stress Disorder, Chronic was added on 06/24/24. Record review of Resident #37's MDS with ARD of 05/09/24 under Section C revealed a BIMS score of 10 which indicated that she had moderate cognitive deficits.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, record review, and facility policy review the facility failed to complete a Trauma Informed Care Assessment for a resident with Post Traumatic Stress Disorder (PTSD) diagnosis for one (1) of two (2) residents reviewed for PTSD. Resident #37. Findings Included: Record review of the undated facility policy titled Trauma Informed Care undated, revealed It is the policy of this facility to provide culturally competent, trauma-informed care to residents who are trauma survivors in accordance with professional standard of practice. On [DATE] at 11:05 AM, an observation and interview with Resident #37 revealed her sitting up in her wheelchair in her room. Resident #37 revealed that she had a three-month- old baby who died many years ago and also had an adult son who was found dead in his bed about 20 years ago and this caused her to worry a lot about her kids and grandkids. Resident #37 revealed that she often had nightmares and cried out in her sleep at night but didn't know what caused it. On [DATE] PM at 3:10 PM, an interview with Social Services revealed that she was responsible for completing the Trauma Informed Care Assessment on admission and any time there was a change in condition or a new diagnosis of PTSD. She revealed that she was not aware of Resident #37's PTSD diagnosis and confirmed that with this new diagnosis, she should have completed a Trauma Informed Care Assessment. Social Services revealed that they had a Care Plan Meeting with Resident #37 and her family and they reported that she yelled out at night during her sleep, that nothing seemed to trigger it, and that she had been doing it for a long time. She revealed that the family also denied any past traumatic events other than the death of two children that happened many years ago. Social Services revealed that Resident #37 was diagnosed with PTSD on [DATE] and it should have triggered them to do another Trauma Informed Care Assessment but they had missed it somehow. On [DATE] at 11:45 AM, an interview with Director of Nursing (DON) revealed that Resident #37 admitted to the facility on [DATE] for therapy services and was told by her family on [DATE] that she had to remain long-term in the facility and could not return to her home. The DON revealed that Resident #37 was upset and very tearful about having to stay long term. The DON revealed that they had not reported any other traumatic events in Resident #37's past other than her losing two of her children. The DON confirmed that they had discussed with the family about her crying out in her sleep and her family brushed it off and said that she cried out in her sleep all the time at home. She revealed that a psychiatric Nurse Practitioner evaluated Resident #37 and the new diagnosis of PTSD was added on [DATE]. The DON revealed that a Trauma Informed Care Assessment should have been completed with this new diagnosis and she didn't know why it wasn't done. Record review of Resident #37's Psych Eval (Evaluation)dated [DATE], revealed Recommendations: Add .Post traumatic stress disorder, chronic to diagnoses. Record review Resident #37's admission Record revealed an admission date of [DATE] with diagnoses that included Unspecified Dementia with other behavioral disturbance, Anxiety Disorder and Hallucinations. The diagnosis of Post-Traumatic Stress Disorder, Chronic was added on [DATE]. Record review of Resident #37's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of [DATE] under Section C revealed a Brief Interview for Mental Status (BIMS) Score of 10 which indicated that she had moderate cognitive deficits.

Based on observation, resident and staff interviews, and facility policy review the facility failed to ensure that a resident who was unclothed had privacy and was free from view to maintain personal privacy for one (1) of 47 residents reviewed during initial tour. Resident #38 Findings include: Record review of the undated facility policy entitled, Dignity and Respect, undated, revealed, Policy Statement It is the policy of this facility to treat each resident with respect and dignity .Procedure .3. Residents shall be examined and treated in a manner that maintains the privacy of their bodies. A closed door or drawn curtain shields the resident from passers-by . On 07/05/23 at 11:00 AM an observation was made of Resident #38 lying in bed with no shirt on and was covered with a blanket from his waist down. His door was not closed, and the resident was visible to anyone passing down the hallway. Resident #38 was lying in the first bed at the doorway just inside the room. On 07/05/23 at 12:00 PM, an observation was made of Resident #38 lying in bed with a brief on and with no top sheet or blanket covering him and he had no shirt or pants on. The door to the hallway was open and there was no curtain pulled to prevent exposure of resident from those ambulating in the hallway. Resident was lying flat in bed and was visible to those outside the room. On 07/05/23 at 2:00 PM, an observation of Resident #38 from the hallway, revealed the door to his room was open, and he was lying in bed with only a brief on and there was not a top sheet or blanket covering him. On 07/06/23 at 8:02 AM, an interview with Resident #38 revealed that he had trouble breathing and didn't like to wear shirts or pants. Resident stated, I don't want to put a shirt on. Resident revealed that he tried to keep the cover over him; but he sometimes got hot and felt like he was smothering and would kick the cover off. Resident #38 revealed that he would rather not be seen by other's when he was uncovered. Resident #38 stated, I don't want people to see my legs. On 07/06/23 at 9:20 AM, an interview with Director of Nursing (DON), revealed that Resident #38 constantly kicked his covers off, would not wear clothes, and the staff had to constantly watch him. She revealed that they had tried gowns, more comfortable shirts, and shorts; but he just took them off. She stated that the staff usually monitor him and when he was uncovered, they would go in and cover him back up. On 07/06/23 at 9:50 AM, an interview with DON, revealed that she agreed one hundred percent that the resident lying in bed uncovered with only a brief on was a personal privacy issue, especially because he didn't want anyone to see his legs. On 07/06/23 at 10:00 AM, an interview with the Administrator (ADM), revealed that she was made aware of the concern with Resident #38 today. The ADM confirmed that this resident lying in his bed unclothed and uncovered with the door to his room left open was a privacy issue. Record review of Resident's admission Record revealed an admission date of 06/02/23 with the following diagnoses to include Heart Failure, Chronic Obstructive Pulmonary Disease, Morbid Obesity, Restlessness and Agitation, and Weakness. Record review of Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 06/08/23, documented under Section C a Brief Interview for Mental Status (BIMS) Score of 08 which indicated that resident had moderate cognitive deficits.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and facility policy review the facility failed to implement a comprehensive care plan for a resident who required assistance with Activities Daily Living (ADL) nail care for one (1) of 12 residents sampled. Resident #40 Findings include: Record review of the facility's Using the Care Plan policy (undated) revealed It is the policy of this facility that the care plan be used in developing the resident's daily care routines .4. Daily care and documentation should be consistent with the resident's care plan. Record review of Resident #40's care plan revealed I have an ADL self-care performance deficit date initiated 09/09/2021 . Interventions/Tasks . Routine nail care weekly on Saturday, Bathing/Showering: Check nail length and trim and clean on bath day as necessary. Report any changes to the nurse . During an observation and interview on 07/05/23 at 3:15 PM, revealed Resident #40's fingernails on both hands was approximately one-half (1/2) inch long and jagged past the tip of the fingers, and had a brown substance underneath the nails. The resident revealed he wasn't sure when the last time they were cut, and he would like for them to be cut. The Director of Nurses (DON) reported during an observation and interview on 07/05/23 at 3:25 PM that according to Resident #40's physician orders the resident is supposed to get routine nail care weekly on Saturday. She revealed the residents are supposed to have their nails cleaned every day when they are bathed or cleaned up. She confirmed that Resident #40's nails were long and jagged and needed to be cleaned. She revealed with his nails long and dirty he could cut his skin and could also possibly spread infection. She stated I will make sure they get cleaned and cut right now. An interview on 07/06/23 at 2:40 PM, the DON confirmed Resident #40's ADL care plan was not being followed when she observed his long and dirty nails yesterday. An interview on 07/06/23 at 3:54 PM with the Minimum Data Set (MDS) Coordinator revealed she along with the interdisciplinary team is responsible for developing the residents' care plan. She revealed the care plan guides us on how to care for them and is individualized for each resident. A record review of Resident #40's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Depressive episodes, Chronic Respiratory failure, and Tachycardia. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/12/23 revealed Resident #40 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident is cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, record review, and facility policy review the facility failed to provide personal hygiene as evidenced by long, jagged fingernails with a brown substance underneath the nails for one (1) of 12 sampled residents. Resident #40 Findings include: Record review of the facility policy titled, Fingernails/Toenails, Care of with a revised date of February 2018, revealed, Purpose: The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections . An observation and interview on 07/05/23 at 3:15 PM, revealed Resident #40's fingernails on both hands were approximately one-half (1/2) inch long and jagged past the tip of the fingers and had a brown substance underneath the nails. The resident revealed he wasn't sure when the last time they were cut and he would like for them to be cut. An interview on 07/05/23 at 3:20 PM, Certified Nurse Aide (CNA) #1 revealed we are responsible for making sure the resident's nails are cleaned each time they are bathed but the nurses trim their nails on the weekends. She revealed she is assigned to Resident #40 but just came in to work and wasn't sure what was done today. An observation and interview on 07/05/23 at 03:25 PM, the Director of Nurses (DON) revealed according to Resident #40's physician orders the resident is supposed to get routine nail care weekly on Saturday. She revealed the residents are supposed to have their nails cleaned every day when they are bathed or cleaned up. She confirmed that Resident #40's nails were long and jagged and needed to be cleaned. She revealed with his nails long and dirty he could cut his skin and could also possibly spread infection. She stated I will make sure they get cleaned and cut right now. Record review of Resident #40's Order Summary report revealed an order dated 9/1/2021 for Routine nail care every Saturday . Record review of Resident #40's admission Record revealed the resident was admitted to the facility on [DATE] with diagnoses that included Depressive episodes, Chronic Respiratory failure, and Tachycardia. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of April 12, 2023, revealed Resident #40 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident is cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and facility policy review, the facility failed to ensure that an as-needed (prn) psychotropic drug was limited to 14 days for one (1) of four (4) residents reviewed for psychotropic medication use. Resident #10 Findings include: A review of the facility policy titled Antipsychotic Medication Use, dated 10/2022, revealed, The need to continue PRN orders for psychotropic mediations beyond 14 days requires that the practitioner document the rationale for the extended order. The duration of the PRN order will be indicated in the order. Record review of Resident #10's Order Summary Report revealed, Lorazepam Oral Concentrate 2mg/ml (milligram/milliliter) (Lorazepam) Give 0.5ml by mouth every 2 hours as needed for air hunger related to PERSONAL HISTORY OF MALIGNANT NEOPLASM OF BREAST Order start date 3/10/2023 and no end date. An interview on 07/06/23 at 9:15 AM with Registered Nurse (RN) #1 revealed when a resident is on a PRN (as needed) psychotropic medication we try to make sure they are reviewed and have a stop date and our hospice residents don't have stop dates on them because they are end of life. An interview on 07/06/23 at 9:20 AM, the Director of Nurses (DON) confirmed that Resident #10 did not have a stop date on her PRN Lorazepam and she should have. She revealed the resident is on hospice and we are still supposed to have a fourteen-day stop date. They can be re-evaluated by the physician with a continuation for the PRN medication but confirmed Resident #10 had not had a re-evaluation or a stop date on the medication. A phone interview on 07/06/23 at 9:50 AM, with the Pharmacy Consultant revealed all residents are supposed to have a stop date on PRN psychotropic medications. He revealed hospice is not an exception and he always makes sure to put that on his gradual dose reduction documentation to the physician. He revealed the resident just received the order in March and a gradual dose reduction had not been done yet and is scheduled for this month. An interview on 07/06/23 at 10:37 AM, the Infection Preventionist/Registered Nurse confirmed that Resident #10 has the liquid Lorazepam which was ordered when she went on hospice. She confirmed that it did not have a stop date and it should have one for fourteen days. Record review of Resident #10's admission Record revealed she was admitted to the facility on [DATE] with diagnoses that included Heart Failure, Alzheimer's disease, and Personal history of malignant neoplasm of breast. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/7/23 revealed a Brief Interview for Mental Status (BIMS) score of 05 indicating severe cognitive impairment.

Resident #25: An interview with Resident # 25 during initial tour on 7/5/23 at 10:30 AM, revealed the facility staff have to come into his room to get hot water for the other residents on this hall (C hall) and stated that his room had plenty of warm water. An observation during initial tour on 7/05/23 at 10:40 AM, of the bathroom water in Resident #25's bathroom revealed that the water was cold and had no warmth after running the faucet for 3-5 minutes. An interview on 7/05/23 at 11:02 AM, with Certified Nurse Aide (CNA) #2 revealed none of the water on C hall gets real warm. She stated a couple of the rooms get warmer water because they have individual hot water heaters going to those rooms. An interview with the Maintenance Director on 7/05/23 at 11:10 AM, revealed he had not been told anything about the water on C hall being cold. He revealed the warmness of the water temperature depended on how close the resident's room was to the water heater. The State Agent (SA) requested temperature check on the hot water in Resident #42's and Resident 18's bathrooms. The SA observed the temperature in Resident #42's bathroom to be 75 degrees Fahrenheit and in Resident #18's bathroom the water temperature was 80.2 degrees Fahrenheit. An interview with the Administrator (ADM) on 7/5/23 at 11:45 AM, revealed that she had not been told by any of the residents that the hot water was not working on C hall. She revealed that they have had issues in the past with the mixing valve on the hot water tank. Resident #18 An interview with Resident # 18 on 7/5/23 at 11:52 AM, revealed he has not had warm water in his bathroom since Christmas time. He stated he has told the maintenance man about the water in the past, but that particular maintenance man was no longer employed at the facility. Resident #18 stated, The pilot light has gone out several times and they have replaced the tank.He stated, I would like to have warm water to at least wash my face. He revealed he goes down the hall to get his shower and the water is always warm there. Resident #42 An interview with Resident # 42 on 7/5/23 at 12:01PM, revealed she has not had warm water in her bathroom for months. She stated, I like to wash my hair in the bathroom, and I would like warm water to do that. She revealed she has not had any issues with hot water in the shower room just in her bathroom in her room. An interview with the Maintenance Director on 7/05/23 at 12:35 PM, revealed when he started to work here 2 weeks ago the hot water was on his list of things to check. He stated that he had many other electrical issues on his list to fix first, as he felt that took top priority. He stated that he had not been doing any monitoring of the water in the facility to see if it was warm enough. An interview with the ADM on 7/05/23 at 1:00PM, revealed that the facility does not do any water temperature monitoring. An observation and interview with the ADM on 7/06/23 at 4:06 PM of the hot water Resident #18's bathroom confirmed the water was only tepid. She stated that they had replaced the water heater before and recently had issues with the pilot light going out. She stated, I'm not going to have the residents without hot water. Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/8/23 revealed in Section C a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident has moderate cognitive impairment. Record review of the MDS with an ARD of 5/10/23 revealed under section C a BIMS score of 15, which indicated Resident #25 is cognitively intact. Record review of the MDS with an ARD of 6/21/23 revealed under section C a BIMS score of 15, which indicated Resident #18 is cognitively intact. Record review of the MDS with an ARD of 05/12/23 revealed under section C a BIMS score of 15, which indicated Resident #42 is cognitively intact. Based on observations, staff and resident interviews and facility policy review the facility failed to provide furniture in the resident's room that was not broken and failed to provide warm water in resident's rooms for four (4) of 47 residents reviewed during initial tour. Resident #1 for furniture and Residents #18, Resident #25 and Resident #42 for water. Findings include: Record review of the facility policy titled, Resident Rights with a revision date of 11/28/16 revealed under section (i), Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment Also revealed under, (2) Housekeeping and maintenance services necessary to maintain sanitary, orderly, and comfortable interior; . (6) Comfortable and safe temperature levels Record review of the typed statement on facility letterhead July 6, 2023 and signed by the Administrator revealed the facility does not have a policy regarding replacing broken furniture. Record review of the policy titled, Weekly Water Temperature Checklist-Notes with no revision date revealed Resident room temperatures should be no less than 100 degrees and no more than 115 degrees. Resident #1 An observation and interview on 07/05/23 at 11:28 AM, revealed Resident #1 had a side table with a missing top drawer and a small chest of drawers with 3 out of six (6) that were missing handles and a bottom drawer that could not be opened all the way. Resident #1 revealed the missing top drawer had been that way since she moved in that room about 3 weeks prior and she just sits stuff around because she doesn't always have room with only two drawers in her nightstand. She stated the chest of drawers in the closet cannot be opened all the way because it sits in the corner and it hits the inside edge of the closet when you try to open the drawers. An observation on 7/5/23 at 4:30 PM, revealed the resident had personal belongings lying on the bed and on the overbed table. An interview and observation on 07/06/23 9:23 AM, with the Administrator confirmed that Resident #1's nightstand had a top drawer missing and needed to be replaced. She revealed that the bottom drawer of the chest of drawers in the resident's closet would not open all the way because it got stuck on the edge of the inside of the closet and needed to be moved so that all drawers could open. An interview on 7/6/23 at 3:00 PM, with the Director of Nurses (DON) revealed that when a resident is admitted or moved to another room, then the staff will review the room to make sure everything is in order and nothing needs to be replaced. She revealed that if the resident's nightstand had a missing drawer, then it should have been replaced.

Based on observation, staff interviews, and facility policy review, the facility failed to ensure items in the kitchen refrigerators, dry storage room and on metal shelves were dated, labeled and discarded by the expiration date for one (1) of two (2) kitchen tours. Findings include: Review of the facility policy titled, Food Storage dated August 18, 2011, revealed, It is the policy of this facility that food storage areas be maintained in a clean, safe, and sanitary manner . 8. All foods stored in refrigerators and freezers that have been opened, will be covered, and labeled with the date and name of food if appropriate, and will be discarded within the appropriate time frame. 9. All leftover foods are to be stored in covered containers, dated, & labeled .If not used by the (3rd) day, they are to be discarded .Cold leftovers not used by the third (3rd) day are to be discarded. An observation and interview on the initial tour of the kitchen on 07/05/23 at 10:05 AM, revealed: Refrigerator #1: A round plastic container with a date of 7/1/23 and no label. Dietary Worker #1 revealed these are great northern beans and they should have been thrown away. There was a round plastic container with a label of meatballs and a date of 6/30/23, a rectangular plastic container with no label or date. Dietary Worker #1 revealed its tuna fish, but I don't know when it was put in here nor how long it's been in here. There was a peeled onion wrapped in aluminum foil, with no date or label which was identified by Dietary Worker #1. Observed a pack of opened pack of celery with no date. Dietary Worker #1 revealed I'm not sure of the date, I'm going to throw this stuff out. She confirmed we are supposed to keep the refrigerators cleaned out and confirmed the food is supposed to have a label with the name of the food item on it and the date it is put in the refrigerator, and it is supposed to be thrown away within three (3) days. Refrigerator #2: Observed a container with a manufactured label of sour cream with an open date of 6/27/23. Dietary Worker #2 revealed this was supposed to be thrown away. A white round container with two labels on the top of the lid, one label with an opened date of 6/28/23 and another label with an opened date of 6/29/23 was observed. Dietary Worker #2 revealed, I think it was opened on 6/29/23 but I'm not sure because there's another label for 6/28/23. He identified the food as Pimento and Cheese and revealed regardless, it should have been thrown away. Dietary Worker #2 revealed I usually clean out the refrigerator every week but confirmed it had not been cleaned out. Supply Room: Observed three (3) bags of opened cereal in original bags. Dietary Worker #2 identified one package of [NAME] Krispies, one package of Corn Flakes, and the other package as Toasted Oats. Dietary Worker #2 confirmed these are supposed to be labeled and dated and in a plastic bag because they have been opened. He revealed I'm not sure who opened these and not sure how long they had been opened. He stated they could get stale. Metal Cart: Observed a three-tier metal cart with a large clear container with plastic bowls on the bottom shelf. Dietary Worker #2 identified the items in the bowls as cereal. A plastic lid was on each bowl which was too small for the bowl leaving the cereal exposed. Dietary Worker #2 revealed the Dietary Manager (DM) is supposed to be ordering the right size lids. She ordered these but they are too small. Dietary Worker #2 revealed he should have wrapped them with plastic wrap so they wouldn't be exposed. He confirmed there was no date or label on the lids and it should be and stated with the cereal not being properly covered it leaves the food exposed and something could get on the food. An interview on 07/06/23 at 8:45 AM, the DM revealed everyone is responsible for making sure the foods are labeled and dated. She revealed staff is being careless and not labeling, dating, and discarding out-of-date foods. She confirmed that foods that are not dated and discarded properly could possibly cause someone to get sick. The DM confirmed that the cups of cereal on the three-tier metal container should have been covered by plastic wrap being exposed like that could the food to become stale or allow something to get on the cereal. During an interview on 07/06/23 at 8:50 AM, the Registered Dietician confirmed the food items that were not dated, labeled, and exposed could cause cross-contamination and a possible food-borne illness.

Based on observation, resident and staff interview, facility policy and record review the facility failed to maintain a clean comfortable environment as evidenced by torn flooring in resident's bathroom, dirty wheelchair and damaged door and knob for three (3) of 43 residents reviewed. Resident's #4, #18 and #37. Findings include: Resident #4, Resident #18 and Resident #37 An observation and interview on 04/19/22 at 10:19 AM, of the linoleum rug on Resident #4, Resident #18's and Resident #37's shared bathroom floor, revealed a missing piece from the linoleum rug. There appeared to be a layer of brown substance that had collected at edge of the damaged area of the linoleum rug. Resident #18 revealed he had accidentally urinated on the floor a few times and had seen it go under the damaged area of the linoleum rug. The damaged area of the linoleum rug in the doorway of the bathroom, was in a horseshoe shape, and extended inside the bathroom over near the left side of the toilet. The damaged flooring appeared to be approximately seven (7) inches wide and approximately 11 inches long. The observation also revealed the base of the bathroom doorknob on the door to Resident #4's room was rusted, and an approximate one (1) one-half (½) inch in diameter area of the metal bathroom door surrounding the base of the bathroom doorknob was damaged by rust. Resident #18 revealed that the Maintenance Staff had been in the bathroom a few days ago and did not say anything about fixing the linoleum rug or the door and doorknob. Resident #37 revealed that he had reported the linoleum rug being torn to a Certified Nursing Assistant (CNA), but could not remember which CNA he told. An observation on 4/20/22 at 09:00 AM, of Resident #4's bathroom revealed that the base of the bathroom doorknob, that the area of the metal bathroom door surrounding the base of the bathroom doorknob, had not been repaired. An observation and interview on 4/21/22 at 09:30 AM, with the Maintenance Staff, revealed he was aware of the damaged flooring in Resident #4's, Resident #18's and Resident #37's shared bathroom. He was informed of the damaged flooring by the administrator one day last week and that an order had been placed for replacement supplies for the bathroom floor. The Maintenance Staff revealed that he had no other alternative for repair of the bathroom flooring. He also revealed he did not take the linoleum rug up off the bathroom floor because he did not know what other damage to the floor may have been under it. The Maintenance Staff confirmed the rust damage to the base of the doorknob and the rust damage to the area of the metal bathroom door surrounding the base of the doorknob for Resident #4. He revealed he had not observed the damage to Resident #4's metal bathroom door and doorknob, when he checked the damaged flooring the previous week. The Maintenance Staff confirmed Resident #4, Resident #18, and Resident #37 are not being allowed to live in a comfortable and clean, homelike environment, because the damaged doorknob and damaged metal bathroom door had not been repaired in their bathroom, and the possibility that the bathroom floor cannot be completely cleaned due to the damaged flooring. An observation and interview on 4/21/22 at 09:45 AM, with the Administrator, confirmed she was aware of the damaged flooring in Resident #4's, Resident #18's and Resident #37's bathroom. The Administrator revealed she had known about the damaged flooring for two (2) weeks, had informed the Maintenance Staff of the flooring damage, and an order had been made for the replacement bathroom flooring supplies. They were awaiting corporate approval. The Administrator also revealed she was not aware Resident #4 had rust damage to the base of the bathroom doorknob and the area of the metal bathroom door surrounding the base of the bathroom doorknob. The Administrator confirmed the damaged flooring could be a cause for the bathroom floor to not be cleaned adequately and can possibly cause germs and bacteria to grow in the flooring's damaged area. The Administrator confirmed Resident #4, Resident #18, and Resident #37 are not being allowed to live in a clean and homelike environment due to all of the damage not being repaired in their bathroom. An interview on 4/21/22 at 2:25 PM, with the Administrator, revealed she did not make the order for replacement supplies for the damaged bathroom flooring. Record review of the Maintenance Work Order Log did not reveal a work order for the damaged flooring in the bathroom for Resident #4, Resident #18 and Resident #37. Record review of the Maintenance Inspection Log did not reveal a section of the log for resident room inspections or resident bathroom inspections. Record review, of the most recent admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) date of 01/25/2022, for Resident #4, revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident #4 is cognitively intact. Record review of the Quarterly MDS with an ARD date of 02/16/2022, for Resident #18 revealed a BIMS score of 15, indicating Resident #18 is cognitively intact. Record review, of the Quarterly MDS, with an ARD date of 04/06/2022, for Resident #37, revealed a BIMS score of 13, indicating Resident #37 is cognitively intact. Resident #4 and Resident #18 Review of the facility policy titled, DISINFECTION OF DURABLE MEDICAL EQUIPMENT, with a procedure revision date of August 25, 2014, revealed, Purpose .Durable medical equipment (DME) shall be cleaned and disinfected routinely and following resident use. An observation and interview on 04/19/22 at 10:40 AM, with Resident #18 revealed his motorized wheelchair was not clean. The black/platform area, that was located behind and extended under the motorized wheelchair's seat, had an excessive amount of what appeared to look like dust, lint, and crumbs all over it. The black bars on each side of the seat were covered in a thick residue. The wide/single black foot petal had a collection of what appeared to look like lint, dust, and crumbs around the curved back area of it, behind Resident #18's feet. Resident #18 revealed he did want his wheelchair to be cleaned and had been told by a nurse that the CNAs were responsible to clean the wheelchairs weekly. The Resident revealed he could not remember which nurse told him about the wheelchair cleaning and did not remember the last time his wheelchair had been cleaned. An observation and interview on 04/19/22 at 11:04 AM, of Resident #4's manual wheelchair revealed a sticky brown residue on the bars, located on each side of the wheelchair's seat, and both manual wheelchair locks. Resident #4 revealed he could not recall the last time that staff had cleaned his wheelchair and he did want his wheelchair to be cleaned. Resident #4 stated he had been told before, by a nurse, that the wheelchairs are cleaned every week by the CNAs but could not remember which nurse told him about the wheelchair cleaning. An observation on 4/20/22 at 09:45 AM, of Resident #4's and Resident #18's wheelchair, revealed the chairs had not been cleaned. An observation and interview on 4/21/22 at 10:20 AM, with the Director of Nursing (DON), of Resident #18's electric wheelchair confirmed his wheelchair had what appeared to possibly be lint, dust, and crumbs covering the platform located behind and extended under the seat of the electric wheelchair and in the curved area of the foot petal. The DON confirmed the CNAs were scheduled to clean the residents' wheelchairs every Tuesday, that the unclean wheelchairs could possibly pose a risk of infection for Resident #4 and Resident #18. An interview on 4/21/22 at 10:30 AM, with the Administrator, revealed that all resident wheelchairs should be cleaned weekly by the CNAs, and Resident #4's manual wheelchair and Resident #18's electric wheelchair should have already been cleaned for the week. Record review of the CNA Daily Cleaning Checklist for your assigned residents, revealed, Tuesday .Wheelchairs, revised 7/22/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review and facility policy review the facility failed to submit a referral for a Preadmission Screening and Resident Review (PASARR) Level 2 for a resident admitted to the facility with a mental illness diagnosis for one (1) of two (2) residents reviewed. Resident #3 Findings include: Review of facility policy titled, PHYSICIAN CERTIFICATION FOR NURSING FACILITY AND MI/MR SCREENING, current revision date September 15, 2014, revealed, The admission Coordinator or designee will obtain a current Medicare certification, Pre-admission Evaluation .PAS (Pre-admission Screening) (MS)(Mississippi) and PASRR (Pre-admission Screening and Resident Review) if required on all Medicare Part A admissions. Record review of signed statement from the Administrator, undated, revealed, (Proper Name of Facility) follows Federal and State regulations regarding PASARR. An interview with the Administrator on 4/20/22 at 7:45 AM, revealed she was aware of some PASARRs that were not completed as required. She stated she is new in this position and the facility has had a large staff turnover and even though she was trying to update each one, she failed to submit this resident's referral for the Level 2. She stated it is her responsibility to ensure the PASARRs are submitted as required. An interview with the Administrator on 4/21/22 at 8:20 AM, revealed she contacted the referral agency to verify if a referral had been sent prior to her coming to the facility, and the referral agency stated they have not had a referral for this resident since 2015 and no Level 2 was done. The Administrator confirmed the resident was admitted to the facility on [DATE] with a diagnosis of Bipolar Disorder and a referral of the PASARR Level 2 was not submitted. The Administrator confirmed this should have been done to help ensure the safety for the residents and staff and to ensure proper placement of the resident. Record review of the Pre-admission Screening (PAS) Application for Long Term Care dated 6/8/2020, revealed the resident with an active medical condition of Bipolar Disorder. Part B - Level II Referral Criteria Person has a diagnosis of a major mental illness? This was answered No. Record review of The admission Record revealed that Resident #3 was admitted to the facility of 6/5/2020 with an admission diagnosis of Bipolar Disorder, current episode depressed, mild or moderate severity, unspecified. Record review of the Physician Orders for Resident #3 revealed an order dated 3/10/22 for Zoloft Tablet 25 milligrams (mg) one time a day related to Bipolar Disorder. Record review of Resident #3's Minimum Data Set (MDS) Section C - Cognitive with an Assessment Reference Date (ARD) of 4/13/22, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. Record review of MDS Section D - Mood, dated 4/13/22, revealed the resident with a symptom of feeling down, depressed, or hopeless for two (2) of six (6) days over the look back period of two weeks. This section revealed the resident had thoughts that you would be better off dead, or of hurting yourself in some way for 12-14 days of the two week look back period. Record review of MDS Section I - Active Diagnoses, dated 4/13/22, revealed the resident with a diagnoses of Bipolar Disorder and Depression. Record review of MDS Section N - Medications, dated 4/13/22, revealed for the seven (7) day look back period, the resident received an Antidepressant for seven (7) of the seven (7) days.

Based on observation, staff interview and facility policy review the facility failed to store medications in a locked medication cart for one (1) of two (2) medication carts. C Hall Findings include: Record review of the facility policy titled, Medications, Individual Medication Storage Cabinets, dated August 25, 2014 revealed, Purpose: Medication administration utilizing individual medication storage cabinets will meet the same criteria for timeliness, infection control, and medication safety as standard medication administration. Guidelines .2.The patient's individually packaged medications (blister packs) will be kept inside this container inside the storage cabinet . On 04/19/22 at 9:54 AM, the State Agency (SA) observed the medication cart parked against the wall on the C hall with three medication cards laying on top of the medication cart with visible pills observed in the medication cards bubble packs. The medication cards that were observed were for Resident#12. The medications included Baclofen, Carvedilol, Amlodipine. The SA surveyor stood in the hallway until the nurse exited Resident #12's room. An interview on 4/19/22 with Licensed Practical Nurse (LPN) #1 at 10:00 AM, confirmed that she had left medications unsecured on top of the medication cart and she stated, I thought they were empty. I had gotten those out to give to Resident#12. Those are his medicines and I left them out. It's my mistake. LPN #1 took the three medication cards and verified that they were not empty and that all three contained pills in the cards and placed them back into the locked medication drawer. An interview with the Director of Nursing (DON) on 04/21/22 at 1:55 PM, confirmed that all medications should be stored safely and in a locked medication cart and stated that the LPN had told her that she had left the medications on top of the medication cart unsecured.

Based on facility policy review, resident and staff interviews, and record review, the facility failed to provide activities on the weekends for four (4) of 16 residents reviewed. Resident #4, Resident #18, Resident #21, and Resident #37. Findings include: Record review of facility policy titled, Activities and Social Events, dated March 26, 2007, revealed, Policy Statement It is the policy of this facility that all residents have the right to choose the types of activities and social events in which they wish to participate Procedure . 6. Daily activities, including those on weekends and holidays, are provided, as well as scheduled religious and social activities . Resident #4 An interview on 4/19/22 at 11:45 AM, with Resident #4, revealed he wanted the facility to schedule more activities on the weekends. The Resident revealed there was nothing that he liked to do on the weekends. Record review of Resident #4's admission Record revealed an admission date of 1/18/22. Record review, of the most recent Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) date of 04/20/2022, that was in progress for Resident #4, revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating Resident #4 has moderately impaired cognition. Record review of the Section F revealed the question, F. how important is it to you to do your favorite activities, and revealed Resident #4's response of Very Important. Resident #18 On 4/19/22 at 11:33 AM, an interview with Resident #18, revealed there are not activities on the weekend and would like there to be something organized to do on the weekend. Resident #18 stated he had spoken to the Activities Coordinator and asked her to arrange weekend activities but have not seen any take place. Record review of Resident #18's admission Record revealed an admission date of 9/23/20. Record review of the most recent Quarterly MDS, with an ARD of 02/16/2022, for Resident #18 revealed a BIMS score of 15, indicating Resident #18 is cognitively intact. Resident #21 An interview on 04/19/22 at 10:45 AM, with Resident #21, who is also the Resident Council President, confirmed that there are limited activities on the weekend. Resident #21 revealed there were games left in cabinet drawers in the dining room for the residents to go get on their own. Resident #21 revealed she wanted more activities to take place on the weekends. Record review of Resident #21's admission Record revealed an admission date of 3/16/21. Record review of the most recent MDS, with an ARD of 02/23/2022, for Resident #21, revealed a BIMS score of 15, indicating Resident #21 is cognitively intact. Record review of the Section F, revealed the question, F. how important is it to you to do your favorite activities, and revealed Resident #21's response of, Very Important. Resident #37 An interview on 04/19/22 at 11:33 AM, with Resident #37, revealed he would like more activities to be scheduled for the weekends. Resident revealed there are games left in cabinet drawers, in the dining room for them to get on their own but wanted other entertainment on the weekend. Record review of Resident #37's admission Record revealed an admission date of 12/28/21. Record review of the most recent Quarterly MDS with an ARD of 04/06/2022, for Resident #37, revealed a BIMS score of 13, indicating Resident #37 is cognitively intact. An interview on 04/20/22 at 11:15 AM, with the Activities Coordinator, revealed that there were no scheduled activities for the residents on every weekend of the month, and that most of the weekend activity calendar entries were options for activities that the residents can seek out for themselves. She revealed she had two scheduled activities for the month on weekends, from January 2022 to March 2022, and that there were three (3) scheduled activities for the month on weekends for April 2022, but there were different types of games that were left in the cabinet drawers in the dining room for the residents to use on their own as entertainment. The Activities Coordinator revealed the residents would know the games were in the dining room cabinet drawers and were instructed they could go in the dining room themselves and could get the games at any time on the weekends. An interview on 04/20/22 at 11:30 AM, with the Administrator, revealed that daily activities are very important to the residents, that she knows that several of the residents look forward to participating in daily activities, and that daily activities should always be available, according to residents' individual preferences. An interview on 4/20/22 at 1140 AM, with the Director of Nursing (DON), revealed she was not aware that the residents did not have weekend activities, and did not schedule CNAs to assist with the weekend activities. The DON did confirm that the weekend CNAs should have been monitoring resident activities, should have ensured the residents were transported to and from the activities, if transport assistance was needed, and should have assisted in monitoring residents, during the activities, to ensure they were safe and assisted with any other needs. A telephone interview on 4/20/22 at 04:04 PM, with CNA #1 confirmed she was a weekend CNA, have seen some residents go into the dining room before and play the board games by themselves, but was not aware that activities took place for residents on the weekends. A telephone interview on 4/20/22 at 04:15 PM, with CNA #2, confirmed she was a weekend CNA and she revealed she rarely saw the residents in activities on the weekends. A telephone interview on 4/20/22 at 04:22 PM. with CNA #3, confirmed she was a weekend CNA and she revealed she had residents in weekend activities occasionally. CNA#3 revealed there were games in the drawers in the dining room, but the residents did not come to the dining room often to play games. A telephone interview on 4/20/22 at 04:29 PM, with CNA #4, revealed she was a weekend CNA and the residents do not normally have activities on the weekends. The CNA revealed she had seen some of the residents come to the dining room on their own to get the games out of the drawers to play. An interview on 4/21/22 11:30 AM, with the Ombudsman, revealed she was recently made aware of the residents not having scheduled activities on the weekends and that she had recently met with the Resident Council President regarding there being no weekend activities. Record review of the Activities Calendar for January 2022, February 2022, March 2022, and April 2022 revealed an entry, for an activity, for every Saturday and Sunday of each month. Record review revealed the entries consisted of a volunteer church group, that was scheduled for 2:00 PM, on January 8, 2022, on February 12, 2022, on March 12, 2022, and on April 9, 2022, and a church group, that was scheduled for 2:00 PM, on January 9, 2022, on February 13, 2022, on March 13, 2022, April 10, 2022, and there were weekend entries, for an individual piano volunteer, to come at 10:00 AM on April 3, 2022, on April 10, 2022, on April 17, 2022, and on April 24, 2022.

Based on resident and staff interviews, the facility failed to provide mail delivery on Saturday to residents, as voiced in Resident Council, for four (4) of 12 residents interviewed. Residents #4, #18, #21 and #37. This has the potential to affect 43 of 43 residents. Findings include: The Administrator provided a letter with documentation that revealed that the facility has no specific mail delivery policy. The Resident Council Meeting held on 04/19/22 at 02:56 PM, revealed the Resident Council Members had not been receiving mail on Saturdays. The Resident Council President, Resident #21, revealed the mail would be placed in the facility's post office box and would be picked up by a designated facility office staff member on Monday through Friday, and delivered to residents on those days only. Resident #21 revealed that there were no office staff members in the facility on the weekend to go to the post office to pick up their mail. Resident #21 noted she had no knowledge that mail could be delivered on Saturdays and always waited until Monday to receive any mail that may have been delivered to the post office box on Saturday. Resident #4, Resident #18, and Resident #37 confirmed they did not have knowledge of mail delivery being available on Saturdays and confirmed that they did not receive mail on Saturdays either. An interview on 4/19/22 at 3:45 PM, with the Administrator, revealed she was not sure if the local postal service delivered mail on Saturdays, but was aware that the residents were not getting mail delivery on Saturdays, and that there was no staff member assigned to pick up mail from the post office box on the weekends. An interview on 4/21/22 at 11:00 AM, with the Administrator, confirmed the mail was not picked up from the post office box, by a facility staff member, and delivered to the residents on Saturdays. The Administrator also revealed that there was an option available for the mail to be delivered to the facility on Saturdays through the local postal service which would have possibly ensured that the residents had the opportunity to receive mail on Saturdays. Record review of the most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/25/2022, for Resident #4, revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident #4 was cognitively intact. Record review of the most recent Quarterly MDS with an ARD of 01/16/2022, for Resident #18 revealed a BIMS score of 15, indicating Resident #18 is cognitively intact. Record review, of the most recent Annual MDS with an ARD date of 02/23/2022, for Resident #21, revealed a BIMS score of 15, indicating Resident #21 is cognitively intact. Record review, of the most recent Quarterly MDS with an ARD date of 04/06/2022, for Resident #37, revealed a BIMS score of 13, indicating Resident #37 is cognitively intact.

Based on observation, staff interviews and facility policy review the facility failed to ensure items in the kitchen refrigerator were dated and labeled and failed to discard food items by the expiration date for one (1) of three (3) dietary observations. Findings Include: Review of the facility policy titled, Food Storage revised April 2022, revealed Policy Statement: It is the policy of this facility that food storage areas be maintained in a clean, safe, and sanitary manner .8. All foods stored in refrigerators and freezers that have been opened will be covered and labeled with the date and name of food if appropriate and will be discarded within the appropriate time frame. 9. All leftover foods are to be stored in covered containers, dated, & labeled .If not used by the (3rd) day, they are to be discarded. Cold leftovers not used by the third (3rd) day are to be discarded. An observation on the initial tour of the kitchen on 4/19/22 at 7:55 AM, revealed in the refrigerator number one: Three peanut butter and jelly sandwiches laying on the top rack of the refrigerator. One was dated 4/8 and two were dated 4/9, a small bowl full of a brown substance, not labeled or dated, a 32 ounce container of supplement with an opened date of 4/6, a large gallon-sized bag of sliced cheddar cheese, not labeled or dated, a large gallon-sized bag of sliced white cheese, not labeled or dated, a large plastic container of red liquid substance dated 4/5/22. An observation revealed in kitchen refrigerator number two (#2) : A gallon size bag of five (5) croissants dated 3/29/22, a gallon size bag of leftover sausage and bacon that was not labeled or dated, a Styrofoam container of cooked scrambled eggs with a watery substance around the eggs that were not dated, one container of a red watery substance that was not labeled or dated and a Styrofoam container of three (3) cooked hamburger patties that were not dated or labeled. An interview on 4/19/22 at 8:00 AM, with Dietary Worker #1 revealed that she thinks the small bowl full of a brown substance was peanut butter and jelly. Dietary Worker #1 reported that the dietary staff was supposed to be throwing this stuff out every day. Dietary Worker #1 confirmed that they had not been cleaning out the refrigerators daily and that staff failed to date the leftover items that they had placed in the refrigerator. An observation and interview on 4/19/22 at 8:15 AM, of refrigerator #2 revealed Dietary worker #2 stated, What's all this stuff in here? He confirmed that the non-dated and unlabeled foods were not supposed to be in there and that they should have been dated and that all foods should be discarded after three days. An interview on 04/19/22 at 09:40 AM, with Dietary Worker #3 revealed she has been with the facility for about 2 months and is in training to be the Dietary Manager. Dietary Worker #3 confirmed the refrigerators should be checked daily, expired food should be thrown away and the dietary staff should be checking to see that they date the food items when they place them in the refrigerator. An interview with the Regional Dietary Manager (RDM) on 04/19/22 at 09:50 AM, revealed that she comes to the facility three days a week to work with the Dietary Manager in training. She confirmed that the food items should be dated before they place them in the refrigerator and that the items are to only be kept for 3 days and then discarded. The RDM confirmed that they have failed to keep the refrigerators cleaned out and the old food disposed of, but that they will make sure they are cleaned out right away.