Based on observations, staff and resident interviews, and record review, the facility failed to provide one on one (1:1) activities for residents on isolation in the COVID-19 unit for one (1) of six (6) residents (Resident #32), with the potential to affect all residents on the unit. Findings Include: Review of the facility's policy, Activity Programs revised June 2018, revealed, Activity programs are designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. Policy Interpretation and Implementation .2. Activities offered are based on the comprehensive resident-centered assessment and the preferences of each resident. 3. The activities program is ongoing and includes .independent individual activities .12. Individualized and group activities are provided that .c. reflect the .personal preferences of the residents . During an observation and interview on 06/24/24 at 12:00 PM, Resident #32 was in her room on the COVID-19 unit. She stated she liked to watch television (TV) but enjoyed hunting or auto channels because it reminded her of her husband. She was unable to change the TV channel by herself. During an observation 6/25/24 at 13:25 PM, Resident #32 was in her room, but the TV program was not on a hunting or auto channel of her preference. She stated that since she had been in the unit, no one had asked her what she liked to do or had conducted any activities with her. During an interview on 06/26/24 at 9:00 AM, the Activities Director (AD) stated she had been in her position for a few months and had been assessing residents to determine their interests. Resident #32 had not been assessed yet to determine her interests and preferences. She explained Resident #32 had been receiving 1:1 activities and she had documented it on the participation record, however she was unable to produce a copy of the resident's participation record. On 6/27/24 at 10:00 AM, Certified Nurse Aide (CNA) #3 explained that she worked five (5) days a week, 12-hour days, Monday through Friday, on the COVID-19 unit. She was the only CNA that worked the unit on the day shift. She stated she had not observed any in-room activities for the residents on the unit and has not seen anyone from Activities on the unit. A record review of the Face Sheet revealed the facility admitted Resident #32 on 5/31/18 and she had current diagnoses of Type 2 Diabetes Mellitus. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/23/24 revealed Resident #32 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Review of Section F revealed it was very important for Resident #32 to do her favorite activities.

Based on observation, staff and resident interviews, record reviews and facility policy reviews, the facility failed to ensure that residents received food in a manner that was palatable and at a temperature that was satisfactory, for one (1) of 17 sampled residents. Resident #70 Findings include: A review of the facility policy titled, Meal Service, (undated), revealed, Policy . Food will be delivered promptly to ensure safe, palatable and high-quality food served at the appropriate temperature .Procedure: . 6. Food will be served at palatable temperatures as discerned by customary practices On 6/24/24 at 10:11 AM, during an interview with Resident #70, the resident stated everything is fine with the facility, except the food. The resident stated that he prefers to eat in his room, however, he complained that all of the meals that have been brought to his room have been cold. The resident added that he has been at the facility for three (3) weeks. During a Resident Council Meeting that was held on 6/25/24 at 1:00 PM, Resident #70 was in attendance. While the residents were discussing their complaints regarding the temperature of the meals served in their rooms, Resident #70 stated that the eggs and other food items brought to his room were cold. Other residents mentioned that there has been a persistent problem with cold meals. The residents in the Council meeting added that there has been no improvement in food temperatures noted, despite their complaints for several months about cold food. In an interview with the Administrator on 6/25/24 at 2:50 PM, she stated that CMS (Centers for Medicare and Medicaid Services) had not given the facility enough money to purchase insulated carts for food delivery to the hallways. On 6/26/24, during a follow-up interview with Resident #70, he complained that his food remains cold. The resident added that he is only able to consume around three-fourths (3/4) of his meals and he is only able to do that because he is hungry. He stated that is the food was hot, he would eat it all. A record review the Face Sheet, for Resident #70 reveals the facility admitted the resident on 5/10/2024. The resident's diagnoses included Essential (Primary) Hypertension and Hyperlipidemia. A record review of the Minimum Data Set (MDS), for Resident #70, with Assessment Reference Date (ARD) of 6/7/24, revealed a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, and resident council minutes review, the facility failed to resolve resident repeated concerns of cold food served to the residents rooms for three (3) of six (6) months reviewed. January 2024, April 2024, and May 2024. Findings Include: Observation and interview on 06/25/24 1:00 PM with the Resident Council revealed 12 residents attended the meeting. Residents were comfortable and multiple residents vocalized concerns with the temperature of food served in their rooms. Residents denied issues with food temperatures served in dining room. Resident #70 stated the food temperature of eggs and other food delivered to his room are cold. Resident #54 confirmed his food was cold as well. Other residents stated this is an ongoing issue with cold food. Resident #54 stated the council had complained to staff multiple times for several months about the food without improvement. Review of the monthly grievance log minutes revealed complaints related to the temperature of their food for the following months: [DATE] April 2024 May 2024 Review of January 2024 minutes revealed, Food that comes to rooms still seems to be inconsistent in temperature. Majority (residents) say it is cold. The May 7, 2024 minutes revealed residents suggested heated carts for food transport to rooms. There was no evidence of attempts by the facility to resolve the grievance. Observation and interview 06/25/24 2:10 PM of the kitchen revealed single runner stacked open metal carts with a clear plastic cover. The Dietary Manager (DM) confirmed these carts are used to deliver food to the halls. The DM said the trays are served according to hall, starting with 100, 200, 300, then 400 halls. The DM stated she was aware the facility residents have complained about food temperatures. She explained temperatures are checked on the food holding table in the kitchen prior to plating the food. Interview on 06/25/24 2:50 PM with the facility Administrator revealed the facility is monitoring and talking to residents and are aware of the cold food concerns. The Administrator stated she had talked to the DM about serving trays to 100 hall then 300 hall, then 200 and 400 shorter halls. The Administrator went on to say that CMS (Centers for Medicare and Medicaid Services) did not pay the facility enough to buy insulated or heated carts for delivery of food to the halls. She stated she would have to start back at square one to address the cold food complaints.

Based on staff interviews, record reviews, and facility policy review the facility failed to ensure residents were offered Influenza and Pneumonia vaccinations as evidenced by no documentation indicating vaccinations were either offered or administered to residents who were eligible for eight (8) of the 17 sampled residents. Residents #6, #12, #13, #29, #38, #39, #48 and #70 Findings include: Review of the facility's policy titled, Influenza Vaccine, revised 8/16, revealed, . residents admitted between October 1st and March 31st shall be offered the vaccine within five (5) working days of . the resident's admission to the facility . Review of the facility's policy titled, Pneumococcal Vaccine, revised 8/16, revealed, .Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series and when indicated, will be offered the vaccine series within thirty (30) days of admission to the facility unless medically contraindicated or the resident has already been vaccinated . A record review of the medical records for Residents #6, #12, #13, #29, #38, #39, and #48 revealed no documentation these residents received the Influenza Vaccine in 2023. There was no documentation the vaccine was offered and the residents declined. A record review of the medical records of Residents #38, #39, #48, and #70 revealed there was no documentation of the residents previously receiving the Pneumonia Vaccine or offered by the facility and declined. According to medical record reviews, Residents #6, #12, #13, #29, #38, #39, and #48 should have been offered the 2023 Influenza Vaccine and Residents #38, #39, #48, and #70 should have been offered the Pneumonia Vaccine. On 06/27/24 at 11:54 AM, in an interview with Registered Nurse (RN) #1/Infection Preventionist (IP), she stated when a resident is admitted to the facility, she checks their medical records for vaccine history. She stated if she cannot locate the information, she will ask the resident or family for information regarding recent immunization. If the resident has not had the recent Influenza Vaccine, or has not had the Pneumonia Vaccine, if it is appropriate for the resident to receive the vaccines, she is supposed to offer the vaccine(s) to the resident. However, she confirmed that she had not followed up and offered the vaccinations to many of the residents. The IP acknowledged that the vaccine should have been offered, as it decreases the residents' chance of getting the Flu and Pneumonia. Record review of the Face Sheets revealed admission dates for Resident #6 as 10/12/15, Resident #12 as 9/4/20, Resident #13 as 2/28/24, Resident #29 as 10/24/19, Resident #38 as 4/2/19, Resident #39 as 1/26/22, Resident #48 as 3/20/24, and Resident #70 as 5/10/24.

Based on staff interview, record review and facility policy review, the facility failed ensure that the Infection Preventionist was present in the QAPI (Quality Assurance and Performance Improvement) Committee for 12 of the 12 months of meetings reviewed. July 2023 through June 2024. This had the potential to affect the quality of healthcare for all residents residing in the facility. Findings include: A review of the facility's policy titled, Quality Assurance and Performance Improvement (QAPI) Program-Governance and Leadership, revised March 2020, revealed, .The Quality Assurance and Performance Improvement Program is overseen and implemented by the QAPI Committee .The following individuals serve on the committee: a. Administrator, or designee who is in a leadership role; b. Director of Nursing Services; c. Medical Director; d. Infection Preventionist .The committee meets at least quarterly (or more often as necessary) . Record review of the facility's QAPI Committee meeting sign in logs for the 12 meetings held from July 2023 through June 2024, documentation revealed the Infection Preventionist was not present for any of the 12 meetings. On 6/27/24 at 12:30 PM, during an interview with the Administrator, she acknowledged the facility's QAPI committee meets monthly, but did not have the Infection Preventionist present at all the meetings. The Administrator stated the importance of the IP being present is to improve the quality of healthcare for the residents. She stated that going forward, she will expect that the IP be present at the QAPI meetings.

Final version Based on observations, interviews, and record reviews the facility failed to revise the care plan when the desired outcome of a decrease in falls was not met for one (1) of eighteen residents, Resident #15. Findings include: Review of the facility's, Care Plans, Comprehensive Person -Centered policy , with a revision date of December 2016 revealed the Policy Statement 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. The policy further stated Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. The interdisciplinary team must review and update the care plan: .when the desired outcome is not met . Review of the Comprehensive care plan dated 07/21/21 revealed a problem of The resident has multiple falls and impaired cognition. which was implemented on 07/21/2022. The goal of the problem was to Have decreasing number of falls with a target date of 08/01/2022. The interventions included: Give verbal reminders not to ambulate or transfer without assistance. Ensure that resident wears properly - fitting non-skid soled shoes for ambulation. Assess resident's need for assistive /supportive device. Do not keep bedrails up unless necessary. Observe resident for adverse side effects toxicity of medications in current drug regimen. Maintain resident environment free of clutter and safety hazards. Place items frequently used by resident within easy reach to avoid resident reaching for items. Provide environment with adequate lighting free of glare and analyze previous falls by resident to determine weather pattern or trends can be addressed. Resident #15 During an interview on 05/16/22 at 12:25 PM with Resident # 15's sister, she stated the facility had not provided good supervision to prevent her brother from falling. The sister said Resident #15 had fallen several times in the courtyard because he went out there by himself during the day and at night without supervision. During an Observation 05/16/22 at 1:31 PM Resident #15 was observed walking out of the building to the courtyard and to the gazebo unsupervised, there were no staff present. The resident's gait was unsteady. The resident was outside for about 15 minutes. On 05/16/22 at 04:24 PM Resident #15 was observed walking outside of the side door of the facility to the gazebo. The resident's gait was unsteady and there were no staff present. During an interview on 05/18/22 at 03:46 PM with the interim Director of Nursing (DON)/Care Plan/Minimum Data Set (MDS) nurse, she confirmed the resident had fallen multiple times. The DON said the resident was impulsive and wandered all over the building. The DON confirmed the care plan was not revised with new interventions after interventions in place failed to prevent the resident from falling. The DON stated increasing monitoring of the resident had not been considered and stated the facility could not provide one-on-one supervision. The facility face sheet for Resident #15 revealed the facility admitted the resident on 7/06/21, with diagnoses including Major Depressive Disorder, Diabetes Mellitus and Hypothyroidism. Resident #15's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/12/22 revealed Resident#15 had a brief interview of Mental Status (BIMS) of 06 which indicated Resident #15 was cognitively impaired.

Based on staff interviews and record reviews, the facility failed to complete and submit quarterly Minimum Data Set (MDS) Assessments timely for seven (7) of 33 residents reviewed for MDS assessments. Resident #2, Resident #3, Resident #10, Resident #11, Resident #12, Resident #14, Resident #15 Findings include: A record review of the facility's policy MDS Completion and Submission Timeframes, with a revised date of July 2017, revealed a policy statement Our facility will conduct and submit resident assessments in accordance with the current federal and state submission timeframes. The policy had listed under policy interpretation and implementation the following: 1. The assessment coordinator or designee is responsible for ensuring that resident assessments are submitted . in accordance with current federal and state guidelines. 2. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument (RAI) manual . A record review of Centers for Medicare and Medicaid (CMS) RAI Version 3.0 Manual dated October 2019 revealed, The Quarterly assessment is an OBRA (Omnibus Budget Reconciliation Act) non- comprehensive assessment for a resident that must be completed at least every 92 days . Resident #2 A record review of the Face Sheet revealed the facility admitted Resident #2 on 01/14/2016. A record review of the most recent Minimum Data Set (MDS) assessment for Resident #2 revealed it was a quarterly review assessment with an Assessment Reference Date (ARD) of 01/04/2022. There were more than 92 days since the last assessment. Resident #3 A record review of the Face Sheet revealed the facility admitted Resident #3 on 08/31/2017. A record review of the most recent MDS assessment for Resident #3 revealed it was a quarterly review assessment with an ARD of 01/10/2022. There were more than 92 days since the last assessment. Resident #10 A record review of the Face Sheet revealed the facility admitted Resident #10 on 10/12/2015. A record review of the most recent MDS assessment for Resident #10 revealed it was a quarterly review assessment with an ARD of 01/11/2022. There were more than 92 days since the last assessment. Resident #11 A record review of the Face Sheet revealed the facility admitted Resident #11 on 08/28/2018. A record review of the most recent MDS assessment for Resident #11 revealed it was a quarterly review assessment with an ARD of 01/11/2022. There were more than 92 days since the last assessment. Resident #12 A record review of the Face Sheet revealed the facility admitted Resident #12 on 04/30/2013. A record review of the most recent MDS assessment for Resident #12 revealed it was a quarterly review assessment with an ARD of 01/11/2022. There were more than 92 days since the last assessment. Resident #14 A record review of the Face Sheet revealed the facility admitted Resident #14 on 03/11/2021. A record review of the most recent MDS assessment for Resident #14 revealed it was an annual assessment with an ARD of 01/11/22. There were more than 92 days since the last assessment. Resident #15 A record review of the Face Sheet revealed the facility admitted Resident #15 on 07/06/2021. A record review of the most recent MDS assessment for Resident #15 revealed a quarterly review assessment with an ARD of 01/12/2022. There were more than 92 days since the last assessment. On 05/18/22 at 10:23 AM, during an interview with the Director of Nursing (DON)/MDS nurse, she stated it was her responsibility to complete the MDS assessments. She stated she had been doing other duties in the facility related to her DON responsibilities and she had not been able to keep up with MDS Assessments. She stated she used the RAI manual for reference for completing MDS assessments. She confirmed the MDS Assessments on the residents were past due, and she was aware of the importance for MDS assessments to be completed in a timely manner. At 1:30 PM on 05/19/22, during an interview with the Administrator, she stated she was not aware the DON/MDS nurse was truly behind on MDS assessments. She expected the MDS nurse to be up to date with completing MDS assessments.

Based on observation, staff and family interview, record review, and facility policy review, the facility failed to provide adequate supervision to prevent falls for one (1) of four (4) residents investigated for falls resulting in six falls in the previous seven months for Resident #15. Findings Include: Review of the facility's, Fall-Clinical Protocol revised March 2018 revealed The staff and practitioner will review each resident's risk factors for falling and document in the medical record. The physician will identify medical conditions affecting fall risk. The staff will evaluate, and document falls that occur while the individual is in the facility; for example, when where they happen, any observations of the event etc. The falls should be identified as witnessed or unwitnessed events. Based on the preceding assessment, the staff, and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risk clinically significant consequences of falling. The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and document the individual's response to interventions intended to reduce falling or the consequences. If interventions have been successful in fall prevention, the staff will continue with current approaches and will discuss periodically with the physician whether these measures are still needed for example if the problem that required the intervention has resolved by addressing the underlining cause. If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and reconsider the current interventions. Review of the facility's, Safety and Supervision of Resident policy revised July 2017. Revealed our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accident are facility-wide priorities. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Review of Resident #15's facility incident reports for falls for the previous seven months revealed Resident #15 had experienced six (6) falls in that time period. The falls occurred on 10/27/21, 10/28/21, 11/12/21, 04/04/22, 04/18/22 and 05/8/22. All 6 falls were unwitnessed by staff. The resident was able to indicate he had fallen when found by staff. No significant injuries were sustained in any of the fall events. During an interview on 05/16/22 at 12:25 PM with Resident #15's sister, she stated she was concerned that the facility allowed her brother to fall several times. The resident's sister stated she thought the resident was falling a lot because of a lack of supervision in the facility. The sister said the resident's gait was unsteady and he seemed to fall a lot in the facility's courtyard. She stated she was notified of the resident's most recent fall that occurred on 05/08/2022 by Licensed Practical Nurse LPN #1 a day after he fell (on 05/09/2022). She stated later in the day on 05/09/2022 she received a call from the facility Social Worker who told her there had been an interdisciplinary team meeting to discuss Resident #15's behavior of wandering and it was determined the resident needed to be transferred to a facility with an Alzheimer's unit. Resident #15's sister state she asked the social worker why the facility could not just lock the door to the courtyard to prevent the resident from going out unattended. The social worker said the facility could not lock the courtyard door. The resident's sister stated she was told the facility could not monitor the resident one on one. She stated the Social Worker told her the interdisciplinary team felt the resident needed to be in a locked unit. A review of Resident #15's care plan revealed a problem with an onset of 07/21/2021 of Multiple falls related to impaired mobility and impaired cognition. There was a goal of Have decreasing number of falls with a target date of 08/01/2022. An observation on 05/16/22 at 1:31 PM revealed Resident #15 walking outside of the side door to the courtyard. The resident was going to the gazebo unsupervised; no staff was around. The resident's gait was unsteady. Resident #15 ambulated back inside the facility with no staff supervision. The resident was outside for about 15 minutes. An observation on 05/16/22 at 1:45 PM of the courtyard revealed the gazebo had a concrete floor. An observation on 05/16/22 at 04:24 PM of Resident #15 revealed he ambulated outside to the courtyard, then ambulated to the gazebo. The resident then turned around and came back into the facility without assistance. The resident's gate was unsteady. There were no staff observed to cue or assist the resident. During an interview on 05/17/22 at 03:34 PM with LPN #1, she confirmed Resident #15 had fallen several times. LPN #1 said the resident wandered the facility walking and propelling his wheelchair. LPN #1 stated Resident #15 was impulsive and hard to redirect. LPN#1 stated the resident goes in and out of the courtyard all day and during the afternoon without assistance. LPN #1 said she's the only nurse on that end of the building and cannot always keep an eye on him. LPN #1 stated on 04/18/22 at 5:00 PM she was notified by a Certified Nurse Assistant the resident on the ground at the gazebo. LPN #1 further stated the CNA was looking out the window and saw the resident on the ground. LPN #1 said no one knew how long the resident was out there on the ground. LPN #1 said on 05/8/22 the resident was again found on the ground in the courtyard under the gazebo. The resident's rolling walker was found in the grass across from the sidewalk. LPN #1 confirmed she didn't know how long the resident was there and because it was uncertain if the resident hit his head neurological checks were started immediately to assess the resident for any possible head injury. In an interview on 05/18/22 at 03:46 PM with the interim Director of Nursing (DON), she confirmed the resident had fallen multiple times. The DON said the resident was impulsive and wandered all over the building. The DON stated she didn't have enough staff to provide one on one supervision for Resident #15. During an interview on 05/19/22 at 1:00 PM with the Administrator, she acknowledged Resident #15 had multiple falls. The Administrator said the facility doesn't lock the door to the courtyard because the resident enjoys going outside. The Administrator stated staff are in the offices of the facility and there are windows all around the building. She stated staff could look out the window and see the courtyard. The Administrator confirmed the office staff is not there after 5:00 PM and on the weekends and stated she is unsure of how falls could be prevented. A review of the facility's face sheet for Resident #15 revealed the resident was admitted by the facility on 7/06/21, with diagnoses including Diabetes Mellitus and Hypothyroidism. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/12/22 revealed Resident#15 had a brief interview of Mental Status (BIMS) of 06 which indicated Resident #15 was cognitively impaired.

Based on interviews, record review, and facility policy review, the facility failed to implement monitoring of meal consumption amounts for residents with weight loss for two (2) of three (3) residents reviewed for nutrition. Resident #34 and Resident #52 Findings include: Record review of the facility's policy Food and Nutrition Services with a revision date of October 2017 revealed, .Policy Interpretation and Implementation . 8. Nursing personnel, with the assistance of the food and nutrition services staff, will evaluate (and document as indicated) food and fluid intake of residents with, or at risk for, significant nutritional problems . Resident #34 A record review of Resident #34's Face Sheet revealed the facility admitted him on 04/02/19 with diagnoses including Encounter for Surgical Aftercare for Surgery on the Teeth or Oral Cavity, Osteoarthritis, Chronic Obstructive Pulmonary Disease, and Congestive Heart Failure. A record review of Resident #34's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/23/22 revealed a Brief Interview for Mental Status (BIMS) score of 08, which indicated moderate cognitive impairment. The MDS also indicated Resident #34 had weight loss. On 05/16/22 at 11:59 AM, during an interview with Resident #34, he stated he believed he had lost weight because he had been sick, but now he is feeling better. A record review of Resident #34's Weight Change History revealed his weight was recorded on 11/06/2021 at 127.8 pounds (lbs.) and on 04/29/2022 at 122.8 lbs. He had a weight change of -3.91% (weight loss) from 11/06/2021 to 04/29/2022 (180 days). A record review of Meals/Snacks for Resident #34's meal consumption revealed on 05/01/2022 there was no documentation of percentage of meal consumption for the breakfast, lunch, or dinner meals. On 05/02/22 there was no documentation of percentage of meal consumption for the dinner meal. On 05/03/22 there was no documentation of percentage of meal consumption for the dinner meal. From 05/04/2022 through 05/06/2022, there was no documentation of percentage of meal consumption for the breakfast, lunch, or dinner meals. On 05/07/22 there was no documentation of percentage of meal consumption for the dinner meal. On 05/08/22, there was no documentation of percentage of meal consumption for the lunch or the dinner meals. From 05/09/2022 through 05/17/2022, there was no documentation of percentage of meal consumption for the breakfast, lunch, or dinner meals. Resident #52 A record review of Resident #52's Face Sheet revealed the facility initially admitted her on 03/09/18 and readmitted her on 02/14/22 with diagnoses including Pneumonia, Unspecified Atrial Fibrillation, Heart Failure, and Dysphagia. A record review of Resident #52's Significant Change MDS with an ARD of 03/26/2022 revealed a BIMS score 04, which indicated severe cognitive impairment. A Record review of Resident #52's Weight Change History revealed her weight was recorded on 11/02/2021 at 150.8 lbs; 04/29/2022 at 134.4 lbs. She had a weight change of -10.88% (weight loss) from 11/02/2021 to 04/29/2022 (180 days). A record review of Meals/Snacks for Resident #52's meal consumption revealed on 05/01/2022 there was no documentation of meal consumption for the breakfast, lunch, or dinner meals. On 05/02/22 there was no documentation of meal consumption for the dinner meal. On 05/03/22 there was no documentation of meal consumption for the dinner meal. From 05/04/2022 through 05/06/2022, there was no documentation of meal consumption for the breakfast, lunch, or dinner meals. On 05/07/22 there was no documentation of meal consumption for the dinner meal. On 05/08/22 there was no documentation for the lunch or dinner meals. On 05/09/2022 there was no documentation of the breakfast, lunch, or dinner meals. On 05/10/22 there was no documentation of meal consumption for the dinner meal. From 05/11/2022 through 05/17/2022, there was no documentation of meal consumption for the breakfast, lunch, or dinner meals. On 05/18/22 at 11:05 AM, during an interview with Certified Nursing Assistant (CNA) #4, she stated when residents eat meals in the dining room CNAs that are assigned to the dining room are responsible for inputting the meal consumption amount into the computer for those residents. On 05/18/22 at 11:25 AM, during an interview with Certified Nurse Aide (CNA) #1, she explained meal intakes are entered in the computer, but there were a lot of meal intakes in the red, which meant there were no meal consumption amounts documented for the days highlighted in red on the computer. On 05/18/22 at 2:10 PM, during an interview with the Director of Nursing (DON), she stated the documentation of meal intake amounts should be recorded on the MEALS/SNACKS record. She was unable to explain why there was missing documentation regarding meal intakes. She confirmed it was the CNAs responsibility to record the residents' meal consumption amount into the medical record and that currently there is no one who is checking behind the CNAs to ensure the documentation is completed. At 2:30 PM on 05/18/22, during an interview with CNA #1, she confirmed it is the CNA's responsibility to document and chart the resident's meal intakes. She stated the facility had a lot of agency CNAs and getting them to chart had been a problem. She reported the facility used to write all meal consumption on a meal log, but now they are recorded in the Kiosk. On 05/18/22 at 3:15 PM, during an interview with Licensed Practical Nurse (LPN) #3, she reported she does not review the CNA documentation regarding meal consumption for residents. At 4:20 PM on 05/18/22, during a phone interview with the Registered Dietician (RD), she stated she reviews the residents' meal consumption amounts during her assessments and could only review what was documented in the record. She confirmed she had not reported to anyone that there were residents at the facility whose meal consumption documentation was not completed.

Based on observation, record review, and review of the Quality of Life - Dignity policy, the facility failed to routinely ensure resident dignity for one (1) of 18 sampled residents, when the urinary catheter bag was uncovered/not in a privacy bag for Resident (R) #71. Findings include: Review of facility policy, Quality of Life - Dignity, revised August 2009, indicated: Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: Helping the resident to keep urinary catheter bags covered. Resident #71 was observed on 02/25/19 at 9:32 AM; he was resting in bed in his room. His urinary catheter drainage bag was hanging on the bedrail toward the hallway, uncovered, and visible to anyone in the hallway. Observation on 02/25/19 at 1:00 PM, showed Resident #71's urinary catheter drainage bag was hanging on the bedrail toward the hallway, uncovered, and visible to anyone in the hallway, including the resident's mother and sister, who were visiting. Observation on 02/26/19 at 9:40 AM, showed Resident #71 resting in bed in his room. His urinary catheter drainage bag was hanging on the bedrail toward the hallway, uncovered, and visible to anyone in the hallway. Observation on 02/26/19 at 10:55 AM, showed Resident #71 resting in bed in his room. His urinary catheter drainage bag was hanging on the bedrail toward the hallway, uncovered, and visible to anyone in the hallway. Review of the February 2019 Physician Orders, for Resident #71, revealed to check placement, patency, and drainage to Foley catheter every shift and as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the Repositioning policy, the facility failed to reasonably accommodate one (1) of one (1) resident, included in the sample, with specialized positioning dining support needs, to achieve more independent functioning, dignity, and well-being out of 18 sampled residents, Resident (R) #41. Findings include: Review of the facility policy on Repositioning, revised May 2013, under the section for Repositioning the Resident in Bed which documented the following instructions, Check the care plan . to determine resident's specific positioning needs. On 02/25/19 at 12:05 PM, an observation was conducted of Resident #41, being served lunch in her room. The surveyor was positioned in the hallway adjacent to her bedroom, with an unobstructed view of Resident #41 and her side of the room. Certified Nursing Assistant (CNA) #15 carried a food tray into the room and placed it on the surface of the rolling bed table positioned across Resident #41's bed. Resident #41 was sleeping in her bed. CNA #15 said R #41's name and roused her. CNA #15 raised the head of the bed, removed lids from the plated foods, and placed dining utensils on the right side of the tray. CNA #15 did not adjust the height of the bed and did not adjust the height of the rolling bed table. The surface of the bed table was at the same height as Resident #41's face. CNA #15 asked, You OK? Resident #41 nodded her head Yes. CNA #15 left the room, returned with Resident #41's roommates' food tray, and began assisted her with setting up her meal. CNA #15 then left the room and continued delivering food trays to other resident rooms. Resident #41 picked up her spoon and raised her right arm above the tray to scoop food from a bowl. As she did, her upper torso began slowly sliding to the right side of her bed. As she continued trying to scoop food from the containers on her tray, her upper torso continued to slide to the right until her face was resting on the bed mattress to the right of the pillows at the head of her bed. In this bent over position, Resident #41 continued attempting to dine, by reaching her left hand to the tray above her, and feeling the foods in the containers. Her hand and arm moved slowly and tremored. She gripped a small bowl that contained Tetrazzini and lowered it to the mattress near her face where she began finger feeding bits of the food into her mouth with her head still resting on the mattress. There was some spillage with food debris accumulating in Resident #41's bed near her face. As she could not see her plate with her head lower than the food tray, she used her left hand to feel around on her tray to try and acquire other food items. These attempts were not successful. During these observations no staff members checked on the progress of the meals underway in Resident #41's room. CNA #2, also delivering food trays to resident's rooms, looked at the surveyor standing in the hallway outside Resident #41's room. CNA #2 stopped delivering food trays, walked down the hall, and entered Resident #41's room. CNA #2 observed Resident #41's poor dining position, moved across the room to her, and said, Let's get you sitting up, so you can eat better. CNA #2 moved the rolling bed tray away from the bed, lifted Resident #41's torso into an upright position in the center of her mattress, and picked up food debris from the bed where Resident #41 had moved her bowl. CNA #2 reclined the head of the bed and assisted Resident #41 into a midline and upright orientation to her food. She placed a rolled-up towel along Resident #41's right side, lowered the bed, and positioned the tray near Resident #41's lap by lowering the rolling table surface. CNA #2 asked Resident #41, Is that better? and she stated said, Yes. On 02/25/19 at 12:30 PM, an interview was initiated with CNA #2. She reported Resident #41 tended to lean to the right in her bed, so during meals staff usually used a rolled-up towel on her right side to prevent her from sliding to the right. She said she learned about this intervention by talking to other staff. She said she did not believe this intervention was included in Resident #41's Care Plan. She said it was standard practice for CNAs to make sure table tray surfaces were at the optimal height as part of setting up meals for residents who dined in their rooms. On 02/25/19 at 12:42 PM, an interview was initiated with CNA #15. She confirmed delivering Resident #41's lunch tray and setting up her meal. She reported being aware that Resident #41 tended to lean to her right in bed but didn't observe her doing so when she served her meal tray. CNA #15 confirmed she did not make sure Resident #41's bed table was lowered to the appropriate height after placing the tray on her bed table surface. She confirmed she did not take any action to support Resident #41's position in her bed in preparation for the meal. She said she was rushing trying to get the lunch trays to residents. She said she did not recall any instructions about the use of positioning support for Resident #41 during meals. On 2/26/2019 at 10:15 AM, an interview was initiated with the Director of Nursing. He verified this incident of positioning for Resident #41, did not represent accepted practice at the facility and described actions underway to improve accommodations and supports for the residents of the facility. Review of the Resident #41's Minimum Data Set (MDS), dated [DATE], identified her relevant diagnoses as Chronic Obstructive Airway Disease, Heart Disease, Atrial Fibrillation, and Gastroesophageal Reflux Disease. Resident #41's Functional Status in Bed Mobility (how resident moves to and from lying position, turns side to side and positions body while in bed) as Total dependence - full staff performance . requiring one-person physical assist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility's policy, the facility failed to complete the discharge Minimum Data Set (MDS) for two (2) of three (3) residents' MDS's reviewed after discharge to the hospital, Resident #46 and Resident #64. Findings include: Review of the MDS 3.0 manual Obra Required MDS Assessments indicated, .Discharge Assessments .MDS no later than the discharge + 14 calendar days . Resident #46 Review of Resident #46's Hospital records revealed she was admitted to the hospital on [DATE], for Pneumonia; however, according to Section Z of Resident #46's discharge MDS, documented that the discharge MDS was not signed by the Registered Nurse (RN) as being completed until 3/8/19. Resident #64 Review of the facility's document titled, Detail Admission/Discharge Report, dated 11/15/18 through 5/15/19, indicated that Resident #64 was discharged from the facility to the hospital on 2/8/19, however, according to Section Z of Resident #64's discharge MDS, documented that the discharge MDS was not signed by the RN as being completed until 2/25/19. In an interview on 5/15/19 at 3:15 PM, the MDS consultant confirmed that Resident #46 and Resident #64's discharge MDS's were not completed timely as instructed in the MDS 3.0 manual. She indicated that the discharge MDS was to be completed by the 14th day after discharge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of the facility's policy, the facility failed to implement the therapy restorative nursing plan for two (2) residents, Resident #70 and Resident #39, of seven (7) residents reviewed for restorative nursing. Findings include: Review of the facility's policy titled, Restorative Nursing Services, revised July 2017, indicated, Residents will receive restorative nursing care as needed to help promote optimal safety and independence .2. Residents may be started on restorative nursing .when discharged from rehabilitative care. 3. Restorative goals and objectives are individualized and resident-centered, and are outlined in the resident's plan of care . During an interview on 5/15/19 at 3:38 PM, the Therapy Rehab Director (TRD) stated that Therapy has always screened each resident quarterly and more often if the resident experiences a fall or if nursing noticed a change in the resident. She stated that Therapy was conducting these screenings, which if the results of the screening indicated therapy, an evaluation and treatment program would be conducted. She stated that the therapy evaluation and treatment would include Physical, Occupational and Speech therapy. She stated since the survey on 2/28/19, Therapy has continued to conduct the therapy screening quarterly and more often if warranted and if the resident required therapy, the therapy department would keep that resident on their case load until the resident's goals are met. After the resident met their goals, Therapy would screen again quarterly and more often if necessary. If Therapy determined an evaluation is warranted, Therapy would add this resident to their case and and develop the therapy plan. She stated that Therapists has been providing the therapy for any resident warranted, until the resident meets their goals. Resident #70 Review of the medical record revealed Resident #70 was evaluated and admitted to physical therapy (PT) and occupational therapy (OT) on 8/20/18. On 10/18/18, Resident #70 met his therapy goals. Review of the PT/OT Discharge Summary dated 10/18/18, indicated, Discharge Disposition: skilled services no longer justified .Follow-up Care Recommended: Restorative treatment . Review of the Restorative Plans dated 10/17/18, documented that the therapist provided the restorative plan to Licensed Nurse (LN) #9 on 10/17/18. The document indicated signatures by both the therapist and LN #9. Review of the restorative documents indicated: 1. Restorative Plan-Active Range of Motion. Instructions: perform activity in : Sitting/Standing/Lying Down, Other sitting and standing special instructions: .kickouts (knee flexion and extension) side kickouts (hip abduction/adduction) heel raises (plantar/dorsal flexion) marching (hip flexion) ball squeeze, wheelchair pushups, bike x 10-15 minutes. Repetition: repeat all 20 times per set. Do three (3) session per day. 2. Restorative Plans-Gait. Instructions: Perform gait using: rolling walker/standard walker/wheelchair/cane. Special instructions: using gait belt GT, assist patient from therapy to his room. Patient requiring stand by assist. Distance to walk: 75-100 feet. Number of repetitions: 1-2. Do one (1) session per day. Review of Resident #70's care plan revealed that the Restorative Plan had not been included. Interview with the Rehab Director (RD) on 5/15/19 at 3:38 PM, revealed that once therapy educates nursing staff on the restorative plan, then therapy turns over the care of the resident to nursing. The Rehab Director stated that therapy creates the restorative plan, then nursing adds the restorative plan to the resident's care plan and implements the plan. During this interview, the RD stated that Resident #70 received therapy from 8/20/18 through 10/18/18, and was discharged to restorative nursing. She stated that on 11/19/18, the resident was admitted to the hospital, due to his respiratory condition, and returned from the hospital on [DATE]. She stated that Resident #70 was picked up by therapy until he was discharged from therapy on 1/28/19, due to his goals were met. The RD stated that Resident #70 was then screened quarterly, the last on 3/12/19, with the recommendation that a therapy evaluation and treatment was not needed. The RD stated that meant that Resident #70 had not declined from his functional status when he was discharged from therapy. She stated that therapy will continue to screen the resident quarterly, or more often, if nursing notices a change in the resident. Review of the Therapy Services Screening document dated 3/12/19, indicated: Patient observed and evaluation is not recommended. Resident #39 Review of the medical record revealed Resident #39 was evaluated and admitted to PT on 6/198/18. Resident #39 met her PT goals on 7/23/18. Review of the PT Discharge Summary, dated 7/23/18, indicated, Discharge Disposition: skilled services no longer justified . Follow-up Care Recommended: Restorative treatment . Review of the Restorative Plan dated 7/19/18, documented that the therapist provided the restorative plan to the previous Director of Nursing (DON) on 07/23/18. This document indicated signatures by both the therapist and the previous DON. Review of the Restorative Documents, revealed: 1. Restorative Plan-Active Range of Motion. Instructions: Perform activity in : Sitting/Standing/Lying Down .kickouts (knee flexion and extension)-side kickouts (hip abduction) heel raises (plantar flexion) bike times 10-15 minutes, Repetition: Repeat all 20 times per set. Do three (3) session per day. 2. Restorative Plans-Gait. Instructions: Perform gait using: rolling walker/standard walker/wheelchair/cane. Special Instruction: walk to dine with patient time (x) two (2). Distance to walk: 150 feet. Number of repetitions-three (3). 3. Repetition: Do 1-2 sessions per day. The DON was interviewed on 02/27/19 at 3:45 PM. He verified there had been no formal restorative nursing program in the building since the previous Restorative Nurse was separated from the facility in November 2018. He said when he was hired as the DON, he received a staffing schedule which included two (2) Restorative Nursing Assistants (RNAs), but neither of them ever reported to work. The DON said he never saw them and never met them. The facility terminated both RNAs for abandonment of job duties. He state that he had not yet reached the point where he could fill the vacancies in a formal restorative program. The DON explained, We are struggling to meet the basic clinical needs of the residents. In an interview with the DON on 5/16/19 at 3:00 PM, the DON confirmed that he had reviewed Resident #70 and Resident #39's clinical records and the documents in the medical record's room, that were loose in a box for various residents, and that he could not locate any documentation that the restorative plan was implemented by nursing for either resident. Also, during this interview the DON confirmed that neither resident's care plan addressed the restorative plan developed by therapy. The DON confirmed the restorative plans were not implemented, as recommended by therapy and should have been completed by staff during routine care. Review of therapy quarterly screenings for Resident #39, dated 8/24/18, 11/27/18, 12/11/18, and 2/29/19, indicated Patient observed and evaluation not recommended. In an interview on 5/15/19 at 3:38 PM, the Rehab Director stated that even though Resident #39 was referred to restorative nursing on 7/24/18, therapy continued to screen the resident at least quarterly and more often if nursing noticed any changes in the resident. The RD stated based on these screenings, Resident #39 did not decline from her functional status that was achieved on 7/23/18, when she was discharged from therapy. The RD stated nursing noticed Resident #39 was limping on 3/12/19, a screening was conducted, and an evaluation was recommended. The RD stated the resident was being seen by her physician for a problem with her toe nail, and requested to wait until the toe healed before further therapy evaluation and treatment.

Based on observation, record review, interviews and review of the Minimum Data Set (MDS) manual, the facility failed to ensure the accuracy of a comprehensive MDS assessment for three (3) of three (3) sampled residents. Resident #25, for accidents and pain; Resident #46 for diet, and Resident #22 for hearing, use of a hearing aid, and loose-fitting dentures. Findings include: Review of the MDS manual 3.0, indicates for Section Z0400, .the accompanying information accurately reflects resident assessment information for this resident and that I collected or coordinated collection of this information on the dates specified. To the best of my knowledge, this information was collected in accordance with applicable Medicare and Medicaid requirements . Resident #46 Review of Resident #46's quarterly MDS with an Assessment Reference Date (ARD) of 12/12/18, showed Resident #46 had diagnoses including Degeneration of Brain, Vascular Dementia and Chronic Obstructive Pulmonary Disease. Therapeutic diet was not marked on this MDS. Review of the Physician Orders showed active orders for Fortified foods to the lunch and dinner trays since 08/3/17, and a pureed diet with nectar thickened liquids since 10/28/17. This information was not included in the 12/12/18 MDS. During an interview with the MDS coordinator on 2/27/19 at 3:00 PM, she confirmed that there were accuracy problems with the MDS regarding the therapeutic diet and thickened liquids for Resident #46. Resident #25 Observation on 5/14/19 at 11:45 AM, revealed Resident #25 seated in the dining room in a regular chair with a small front-wheeled walker next to the resident. Observation of Resident #25's bedroom and bathroom on 5/14/19 at 11:50 AM, revealed non-skid strips on the floor of the resident's bedroom, and a silver grab bar located on the right side of the toilet in the bathroom. During a phone interview with Family Member #1, of Resident #25 on 5/14/19 at 4:30 PM, Family Member #1 stated, She [referring to Resident #25] really hasn't had any falls for quite some time. The one (1) fall in January, they [referring to staff] were with her in the bathroom and she leaned forward and fell. They put a grab rail in the bathroom next to the toilet and strips on the floor in her bedroom and I like that. She got a very slight hairline fracture of the wrist, and they splinted it. It has now been discontinued. Family Member #1 then stated, with her second fall in February, I really can't say it was even a fall or not. I think she was just coming out of the dining room and leaned over to the right side. She may or may not even had her walker as she forgets to use it at times, and with her dementia, that's to be expected. When Family Member #1 was asked about any concerns with Resident #25 regarding pain, Family Member #1 stated, No, she [referring to Resident #25] is doing quite well. She really doesn't have pain. They [referring to staff] haven't had to put her on anything new for pain. I think she gets something regularly for her arthritis that she has had for many years now Review of Resident #25's undated Face Sheet found in the electronic medical record (EMR), indicated the facility admitted Resident #25 with diagnoses that included, Dementia, Vitamin D Deficiency, Vascular Dementia, and Hyperlipidemia. Review of a Resident Incident Report dated 1/27/19, indicated, Resident was trying to sit on toilet and loss [sic] her balance. Resident fell on right side and landed on the floor. Certified Nursing Assistant (CNA) tried to catch her before she fell but couldn't. Review of a Resident Incident Report, dated 2/6/19, indicated, Resident was ambulating in hallway when she fell into the wall with the right side of her body. A loud bang was heard, and nurses could see the resident through the surveillance window leaning on the wall with her bottom on the floor .Resident could not give an accurate statement of how she fell. [NAME] was nearby. Review of the January 2019, February 2019, and March 2019, Medication Administration Record (MAR), indicated Resident #25 received Aspirin (a non-steroidal anti-inflammatory medication) 81 milligrams (mg) one (1) by mouth daily and Naproxen (a non-steroidal anti-inflammatory medication) 250 mg tablets daily. Review of Resident #25's quarterly MDS, with an ARD of 3/27/19, specified the resident had a BIMS score of 5 out of 15, which indicated Resident #25 had severe cognitive impairment. Further review of the MDS indicated the question, At any time in the last 5 days, has the resident: Received scheduled pain medication regimen? Was marked: No. Further review of the MDS indicated the question, Has the resident had any falls since admission/entry or reentry? Was marked: No. During an interview on 5/15/19 at 3:52 PM, the Director of Nursing (DON) stated, From looking at the MARs, she [referring to Resident #25] received the Naproxen and Aspirin. The DON then stated, the nurse who completed the 3/27/19, quarterly MDS Assessment should have indicated that on the MDS, that she was getting the Aspirin and Naproxen and the falls should have been noted too. During an interview on 5/15/19 at 3:54 PM, regarding the inaccurate coding on the quarterly MDS, the MDS Consultant stated, We should have had that coded correctly on the MDS [referring to the section regarding receiving scheduled pain medications and the two falls] and that was an error on her [referring to the previous nurse] part. I see on the MAR that she [referring to Resident #25] was getting the Naproxen regularly. She [referring to the previous nurse who completed the MDS] did not do a thorough review and it should have been coded correctly. Resident #22 Review of Resident #22's quarterly MDS, with an ARD date of 3/7/19, indicated for the category hearing Moderate difficulty . Hearing aid, yes and for the category loose fitting dentures was marked unchecked. Review of Resident #22's quarterly MDS with an ARD date of 12/7/18, indicated for the category hearing, moderate difficulty .Hearing aid, yes and for the category loose fitting dentures was documented unchecked. Review of Resident #22's annual MDS with an ARD date of 6/15/19, indicated for hearing, Adequate and for the use of a hearing aide, No. For the category loose fitting dentures the category was unchecked. Review of the document titled, Miracle Ear indicated Resident #22 was seen at the office on 2/27/19, and pt (patient) wanted aids that was purchased in 2008 repaired. Further, review of the document indicated that Resident #22 was see by Miracle Ear on 2/15/11, for the annual hearing test and the hearing aids were delivered 2/22/11. In an interview on 5/16/19 at 12:00 PM, Resident #22 indicated that she has worn a hearing aid for many years and that recently her hearing aid was broken and taped together with tape. Resident #22 stated that her daughter took her a few months ago to Miracle Ear so that she could get her hearing aid fixed. Observation of Resident #22 at this time, revealed a hearing aid in the right ear and no hearing aid in the left ear. Resident #22 stated that her son takes her to the dentist usually, but a while ago her daughter took her to the dentist to have her loose dentures relined. Whatever they did, it took them a long time to get the upper dentures to fit right. Resident #22 showed the surveyor that she could raise her lower dentures with her tongue. Resident #22 stated that she has to glue the dentures in every day, but she still can raise the lower dentures with her tongue. Observation of Resident #22 revealed that when she talked, her upper dentures did not appear to move, however, Resident #22's lower dentures were raised when resident used her tongue to lift the lower dentures. During an interview on 5/15/19 at 3:54 PM, regarding the inaccurate coding on Resident #22's quarterly MDS, the MDS Consultant confirmed, The MDS was coded incorrectly. The DON stated that he was aware that the son takes the resident to the dentist for her dentures and that the daughter took the resident to Miracle Ear in February to repair the hearing aid. The DON stated that the resident has additional hearing aids in her room in a box.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the facility's policy, and interviews, the facility failed to ensure interventions were documented as to specific dates when the interventions were being implemented on the care plan as well as the care plans including all of the residents' care needs for seven (7) of seven (7) sampled residents' care plans reviewed, Resident #81, Resident #71, Resident #25, Resident #39, Resident #22, Resident #70, and Resident #55. Findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person- Centered, revised December 2016, indicated, The comprehensive, person-centered care plan will: 8a. Include measurable objectives and timeframes; 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. Resident #81 Review of Resident #81's care plan, dated 1/15/19, revealed a sentinel problem of social isolation. However, nothing else was present in the care plan to address the plan for pain management, follow-up plans for B-cell lymphoma, and potential discharge. During an interview with Resident #81 on 2/25/19 at 10:57 AM, he complained of pain in his back. On 3/25/19 at approximately 11:00 AM, Licensed Nurse (LN) #5 stated Resident #81 had cancer and she would check on Resident #81's pain management plan; however, no documented evidence of a care plan addressing the pain was provided. Per interview with the facility's Unit Manager/Registered Nurse (RN) #1, Resident #81 had been refusing most treatments since his admission in January 2019; however, Resident #81 was receiving Aleve, as requested and needed. Review of Resident #81's Physician Orders revealed an order for Aleve 220 milligrams (mg) as needed since 3/4/19. According to the Face Sheet in the electronic medical record (EMR), Resident #81 was admitted to the facility on [DATE], with diagnoses B-Cell lymphoma, Pleural Effusion and Pneumonia due to community acquired MRSA (Methicillin-resistant Staphylococcus aureus), resolved at time of admission. According to the 1/17/19, Pain Evaluation: Resident #81 was not in pain at the time of evaluation, and was only considered at risk for pain. Prescription and over the counter medications for pain were listed as N/A (not applicable). Resident #71 Review of Resident #71's care plan did not include the use or care of an indwelling catheter; nor the use and care of the Continuous Positive Airway Pressure (C-pap) machine. According to the Face Sheet in the EMR, Resident #71 was admitted to the facility o 8/28/18, with current diagnoses including Diabetes Mellitus, Moderate Intellectual Disabilities, Bipolar Disorder, Obstructive Sleep Apnea, Neurogenic Bladder and Seizures. Review of the February 2019, Physician Orders, revealed orders for Foley catheter changes, as needed, starting on 8/30/18, and apply Continuous positive airway pressure (C-Pap) at bedtime, starting on 9/3/18. During an interview with the Minimum Data Set (MDS) Coordinator on 2/27/19 at 3:00 PM, she indicated there were problems with the care plans and confirmed the missing information for Residents # 81 and Resident #71's care plans. The Director of Nursing (DON) was interviewed on 2/27/19 at 8:00 AM, and confirmed the care plans did not reflect the residents' needs. Further, review on 5/15/19 at 2:45 PM, of Resident #81 and Resident #71's care plans, revealed that the missing information had been added to the care plans, however, there wasn't a date when the information had been added. Further interview on 5/15/19 at 2:45 PM, the DON confirmed that Resident #81 and Resident #71's care plans were revised when the facility was preparing their Plan of Correction (POC) after the completion of the survey February 25-28, 2019. Resident #25 Review of the fall care plan with a Problem Onset date of 03/06/14, indicated [name of Resident #25] is at risk for falls, related to decreased safety awareness from cognitive deficits related to Dementia. The care plan did indicate two (2) falls (fall on 1/27/19 and 2/6/19). Multiple interventions were identified, however no specific timeframes as to when the interventions were implemented were on the care plan. Observation on 5/14/19 at 11:45 AM, revealed Resident #25 sitting in the dining room in a regular chair watching television along with several other residents awaiting lunch to be served. At this time a small front-wheeled walker was observed next to the resident. The resident was well groomed and observed conversing and laughing with other residents. The resident made no attempts to rise from the regular chair she was seated in. Observation of Resident #25's bedroom and bathroom on 5/14/19 at 11:50 AM, revealed the bed was in the lowest position and wheels were locked. Observation also revealed non-skid strips on the floor of the resident's bedroom, and a silver grab bar located on the right side of the toilet in the bathroom. Review of a Resident Incident Report, dated 1/27/19, indicated, Resident was trying to sit on toilet and loss [sic] her balance. Resident fell on right side and landed on the floor. Certified Nursing Assistant (CNA) tried to catch her before she fell but couldn't. Review of a Resident Incident Report, dated 2/6/19, indicated, Resident was ambulating in hallway when she fell into the wall with the right side of her body. A loud bang was heard, and nurses could see the resident through the surveillance window leaning on the wall with her bottom on the floor .Resident could not give an accurate statement of how she fell. [NAME] was nearby. During a phone interview with Family Member #1, on 5/14/19 at 4:30 PM, Family Member #1 stated, The one (1) fall in January, they [referring to staff] were with her in the bathroom and she (Resident #25) leaned forward and fell. They put a grab rail in the bathroom next to the toilet and strips on the floor in her bedroom and I like that. Family Member #1 then stated, With her second fall in February, I really can't say it was even a fall or not. I think she was just coming out of the dining room and leaned over to the right side. She may or may not even had her walker as she forgets to use it at times, and with her dementia, that's to be expected. Observation on 5/15/19 at 8:40 AM, revealed Resident #25 seated in the dining room in a regular chair watching television and laughing and conversing with several other residents. At this time, a front-wheeled walker was observed next to the resident. The resident made no attempts to rise from the regular chair she was seated in. Observation on 5/16/19 at 9:10 AM, revealed Resident #25 in the activity room participating in the activity of ball toss. The resident was laughing and actively participating with the other residents. There were no attempts to rise from the regular chair she was seated in. Observation on 5/15/19 at 10:00 AM, revealed Resident #25 walked from the dining room to the nursing station with the front-wheeled walker. Staff was observed walking next to the resident. Observation on 5/15/19 at 11:32 AM, revealed Resident #25 walked from the dining room to the nursing station with the front-wheeled walker. Staff was observed walking next to the resident. Review of Resident #25's undated Face Sheet found in the EMR, indicated the facility admitted Resident #25 with diagnoses that included, Dementia and Vascular Dementia. Review of Resident #25's quarterly MDS with an Assessment Reference Date (ARD) of 3/27/19, specified the resident had a Brief Interview for Mental Status (BIMS) score of 05 out of 15, which indicated Resident #25 had severe cognitive impairment. Further review of the MDS indicated Resident #25 requires Supervision with one-person physical assistance for transfers, bed mobility, walking in room, and locomotion on the unit. The MDS further indicated no functional limitation in range of motion of the upper or lower extremities and uses a walker as a mobility device. The MDS indicated Resident #25 has had two (2) falls since admission/entry or reentry. During an interview on 5/14/19 at 3:20 PM, Registered Nurse (RN) #1 stated, We were having a lot of change over in staff towards the end of last year. Staff were coming and going, and I took over this role in January. She [referring to Resident #25] was one the first ones I looked at for care plans. I had to figure out my way, learn my role as a lot of people had quit. It was just a matter of sitting down and learning how to do this. I just had to sit down and play with the keys in the computer software to figure out on my own. RN #1 then stated, With regards to [name of Resident #25's] falls, I had gone into the electronic computer charting and did enter falls with the interventions, but I was finding for some reason, the dates entered for the interventions were not being saved. I did update the care plan back then, but the dates were not being saved. RN #1 then stated, During this time, we did have our morning clinical meeting reviews where we review all the 24-hour reports, Incident reports, nurses' notes. Therapy is involved in those meetings and we talk about what interventions to put into place. We have a computer in the room and are making updates and indicating what interventions right then. I know I was going through the electronic computer system and putting the dates of the falls, but I couldn't figure out how to get it to save the actual dates. An interview on 5/15/19 at 2:45 PM, the DON confirmed that the resident' care plan cited in the original survey February 25- 28, 2019, the information regarding their care was not added until after the survey and the facility was preparing their POC. Resident #39 Review of Resident #39's care plan revealed the restorative plan, provided by therapy for nursing to follow in order to provide restorative nursing care, was not addressed on the resident's care plan. Resident #39 was evaluated and admitted to Physical Therapy (PT) on 6/19/18. Resident #39 met her PT goals on 7/23/18. Review of the PT Discharge Summary dated 7/23/18, indicated, Discharge Disposition: skilled services no longer justified . Follow-up Care Recommended: Restorative treatment . Review of the document titled, Restorative Plan dated 7/19/18, documented that the therapist provided the restorative plan to the previous DON on 07/23/18. In an interview with the DON on 5/16/19 at 3:00 PM, the DON confirmed that he had reviewed Resident #39's care plan and that the restorative plan, provided by therapy for nursing to follow in order to provide restorative nursing care, was not addressed on the resident's care plan. Resident #70 Review of Resident #70's care plan revealed that a Restorative Plan had not been included. Resident #70 was evaluated and admitted to physical therapy (PT) and occupational therapy (OT) on 8/20/18. On 10/18/18, Resident #70 met his therapy goals. Review of the PT/OT Discharge Summary dated 10/18/18, indicated, Discharge Disposition: skilled services no longer justified .Follow-up Care Recommended: Restorative treatment . Review of the Restorative Plans dated 10/17/18, documented that the therapist provided the restorative plan to Licensed Nurse (LN) #9 on 10/17/18. Interview with the Rehab Director on 5/15/19 at 3:38 PM revealed that therapy creates the restorative plan then nursing adds the restorative plan to the resident's care plan. In an interview with the DON on 5/16/19 at 3:00 PM, the DON confirmed that he had reviewed Resident #70's care plan and that the restorative plan, provided by therapy for nursing to follow in order to provide restorative nursing care, was not addressed on the resident's care plan. Resident #22 Review of Resident #22's care plan on 5/15/19 at 2:45 PM, revealed that the resident's hearing difficulty and use of the hearing aid was addressed on the care plan. However, the DON was interviewed during the survey on February 25-28, 2019 on 2/27/19 at 8:00 AM, and confirmed the care plans did not reflect the resident's hearing difficulty and the use of the hearing aid. Further interview on 5/15/19 at 2:45 PM, revealed the DON confirmed that Resident #22's care plan did not initially identify the resident's hearing difficulty and/or the use of hearing aids and had been revised when the facility was preparing their POC, after the completion of the survey February 25-28, 2019. Resident #55 Review of Resident #55's care plan revealed that a fall on 5/7/19, with current interventions of a reacher, quarter side rails, and a low bed, were not included in the care plan. The care plan indicated that the last fall the resident had was dated 9/14. During the initial tour on 5/14/19 at 10:00 AM, Resident #55 was seated in a wheelchair and rolled down the hallway in front of the surveyor. Resident #55 stated that she fell over the weekend and that her side (pointing to her rib cage area) and her left knee was sore. Review of the admission MDS with an ARD date of 3/28/19, indicated that Resident #55 was cognitively intact. Review of the facility's document titled, Resident Incident Report dated 5/7/19, indicated that resident fell on 5/7/19 at 10:10 PM, while sitting on the bed she was trying to put on her slippers so that she could go to the bathroom and fell off the bed. Observation of Resident #55 in bed asleep on 5/15/19 at 2:15 PM, and 5/16/19 at 12:15 PM, revealed the bed was in a low position but not touching the floor, both upper quarter side rails were raised, the resident's slippers were next to the bed and the reacher device was on the bed side stand next to her bed. In an interview with the DON on 5/15/19 at 2:45 PM, the DON confirmed that Resident #55 was given the reacher device by therapy when Resident #55 was receiving therapy so that she could reach for items and not have to bend over. The DON confirmed after reviewing Resident #55's care plan, that the 5/7/19 fall, the use of the reacher device, the positioning of the bed, and the quarter upper side rails were not addressed on the care plan.

Based on observation, interview, record review, and review of the Refrigerators and Freezers policy, the facility failed to ensure the kitchen and dining services were sanitary for 86 out of 88 current residents and had: -cooking trays free from grease build-up; -cooking pans free from debris; -stove burner grates in good repair; and -expired milk had been discarded per facility policy. Findings include: The facility policy Refrigerators and Freezers from the Food and Nutrition Services Policy and Procedure Manual (Revised December 2014), revealed the following under Policy Interpretation and Implementation 8. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired or past perish dates. Supervisors should contact vendors or manufacturers when expiration dates are in question or to decipher codes .9. Supervisors will inspect refrigerators and freezers for gasket condition, fan condition, presence of rust, excess condensation and any other damage or maintenance needs. Necessary repairs will be initiated immediately. Maintenance schedules per manufacturer guidelines will be scheduled and followed. During the initial walkthrough of the kitchen on 02/25/19, commencing at 11:15 AM, a food storage cart was observed with two (2) trays caked with grease around the exterior lips of the pans. Per concurrent interview with the Dietary Manager (DM), the DM explained the trays were used exclusively for cooking but were still in need of cleaning. During a subsequent interview with the DM on 02/28/19 at 9:15 AM, he stated the trays could not be cleaned any further and had placed an order to replace 10 of them. Examination of the kitchen stove on 02/25/19 at approximately 11:15 AM, revealed two (2) grates were rusted with missing tips. The DM was present for the observation and stated he would contact maintenance for replacement. An observation of the refrigerated milk products on 02/25/19 at approximately 11:15 AM, revealed all the pint-sized cartons of chocolate milk and 2% milk revealed an expiration date of 02/22/19. The DM, who was present during the observation, pulled the entire crate from the refrigerator, examined a few of the milk container dates and stated it was the responsibility of the delivery company to ensure its products were pulled when the expiration date occurred. He also explained milk deliveries occurred twice a week on Tuesdays and Fridays. On 02/28/19, commencing at 9:15 AM, in a subsequent tour of the kitchen, observation revealed one (1) of three (3) facility's food preparation pans was noted to be pitted and coated with a film-like substance that could not be removed when the DM attempted to remove it with his finger. The DM stated in response to the observation he would also order new cooking pans.