Based on record review, staff, and Resident Representative (RR) interviews and facility policy review, the facility failed to notify the resident's RR of change a in the resident's condition for one (1) of four (4) sampled residents. (Resident #1) Findings include: Review of the facility's policy titled, Notification of Significant Changes, dated 10/17/14, revealed, POLICY: The facility shall immediately inform the resident, consult with the resident's physician, and if known, notify the resident's legal representative or an appropriate family member of the following: .Significant change in resident's physical, mental or psychosocial status . On 5/30/24 at 12:20 PM, during a telephone interview with the RR for Resident #1, he reported that he had not been notified that Resident #1 had a change of condition on 12/03/23. He stated that he was not notified until the resident experienced another change of condition on 12/06/23. Record review of the Progress Notes, for Resident #1 revealed that on 12/03/23 at 2:40 AM, the resident had an elevated temperature and productive cough and tested positive for COVID-19. There was no documentation of notification of the resident's RR. Record review of Progress Notes, for Resident #1 revealed that on 12/06/23 at 1:54 PM, there was a change noted in the resident's condition. The nurse noted a finger stick blood sugar revealed a reading as High. The Nurse Practitioner was notified, and new orders received regarding the resident's insulin orders. There was documentation, at that time, that there was an unsuccessful attempt to notify the RR. At 3:24 PM, the resident was unresponsive to verbal or tactile stimulation and the resident was transferred to a local acute care facility. Once again, there was an unsuccessful attempt to notify the RR. The RR returned the call at 4:05 PM and was notified of the resident's change of condition and transfer. On 5/30/24 at 2:25 PM, an interview with the Director of Nurses (DON) revealed that nurses were supposed to notify residents' RR of a change of condition, which would include a positive COVID-19 test. She stated that nurses were also supposed to document in Nurses Progress Notes that the RR was notified along with the time, date, and RR's response. She stated that if the nurse were unable to reach the RR by telephone, the attempt should be documented and passed along with instructions for the on-coming nurse to notify the RR. The DON stated she had not notified the RR of the change of condition for Resident #1 on 12/03/23, and was not able to find any documentation that an attempt was made. On 5/30/24 at 2:35 PM, during an interview with Charge Nurse #1, she revealed she had not notified the RR for Resident #1 of the resident's change of condition on 12/03/23, or at any time prior to 12/6/23. On 5/30/24 at 3:00 PM, an interview with Licensed Practical Nurse (LPN) #2, revealed she was not on duty on 12/03/23, but was assigned to the care of Resident #1 on 12/04/23 and 12/05/23. She stated the resident was on infection control precautions for COVID-19, but was alert and oriented with a cough. She stated that she had not notified Resident #1's RR of the change of condition. Record review of the admission Record for Resident #1, revealed the facility admitted the resident on 12/1/22 and discharged the resident on 12/9/23. The resident had diagnoses that included Unspecified Dementia with Anxiety, Type 2 Diabetes. There was a diagnosis of COVID-19 with an onset date of 12/3/23.

Based on observations and staff interviews the facility failed to ensure tiles in the resident shower area were free from black grime and broken tiles were repaired and floors in three (3) common areas were free from cracked tiles and gaps in the floor for one (1) of four (4) days of survey. Findings include: During an observation and interview on 4/24/24 at 9:06 AM, of the resident shower, the floor was noted to have buckling floor tile near the entrance of the shower. Inside the shower, dark black grime was noted in the corners. An interview with Certified Nursing Aide (CNA) #1 revealed she was the shower aide. She explained that the floor tile has been buckling for a while and the tile near the toilet has been broken for a long time. She stated she had made previous maintenance staff aware of the tile, but it had not been repaired yet. She confirmed the black grime in the corners of the resident shower. During an observation on 4/24/24 at 9:51 AM, of the resident shower and facility hallways with the Maintenance Director, he revealed that he was aware of the numerous cracked tiles and gaps in the floor throughout the facility in high traffic areas. He explained that he had been patching, as best he could. He revealed every time he replaced some of the tiles, more tiles became cracked and at this point, it's a no-win situation. The Maintenance Director stated he was not aware that the shower room had tile coming up and buckling. He confirmed that some of the cracks in the tile could be considered trip hazards and could cause injury to residents and employees, as they were large enough to cause an uneven surface. On 4/24/24 at 10:51 AM, during an observation and interview with the Administrator revealed that he was aware of the numerous cracked tiles and gaps in the floor throughout the facility. He explained that the maintenance staff have been patching the broken tile as best they could, however the facility was old and needed updating throughout. The Administrator revealed he was not aware that the shower room had tile coming up and buckling throughout and confirmed that this could be a hazard that could cause injury to residents and staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review and facility policy review the facility failed to ensure a resident was free from a physical restraint offer as evidenced by failure to identify a seatbelt as a restraint for one (1) of 15 sampled residents. Resident #1 Findings include: Record review of facility's policy titled, Restraints, revised 11/28/17, revealed, Policy: . The use of restraint shall be based on comprehensive resident assessment that includes the physical assessment to identify medical conditions that may be causing behavior changes in resident. The assessment will also be performed to determine the safety and protective needs of the resident prior to the application of restraint . Documentation: Documentation in the medical record should include: Restraint order, including the rationale for the restraint, the type of restraint . the duration (timeframe) for the restraint application .Alternatives or less restrictive interventions attempted .The resident's medical conditions or symptoms that warranted the use of restraint, The resident's response to the restraint, including the rational for continued use of the intervention, Assessment and reassessments of the resident, Revision to the treatment plan, Unanticipated changes in residence condition, Condition/behavior required of the resident for release of restraints, The discussion with resident family regarding need for restraints . During an interview on 04/21/24 at 12:53 PM, with Licensed Practical Nurse (LPN) #6, she revealed Resident #1 has always worn the seatbelt. LPN #6 confirmed there was not an order in place for the seatbelt. LPN #6 also revealed that there was no restraint flow sheet in place. In an observation on 04/21/24 at 1:43 PM, Resident #1 was sitting in her wheelchair with a seatbelt intact and no one in the room with her. The resident was unable to demonstrate the ability to open the seatbelt on her own. During an interview on 04/22/24 at 12:53 PM, the Director of Nursing (DON) stated the seat belt on the wheelchair met the definition of a restraint, as defined by facility policy. The DON revealed the facility had recently conducted an audit of restraints and had somehow missed the seatbelt used by Resident #1. The DON stated the facility's interdisciplinary team is responsible for collaborating with other facility staff regarding this issue and a physician's order, consent with reassessment and monitoring tools should be in place for all restraints. During an interview with the Administrator on 04/24/24 at 1:07 PM, confirmed a physician's order, consent with reassessment, as well as a monitoring tool should be in place for all restraints. Record review of the Order Summary Report, with active orders as of 4/23/24, revealed there was no physician order for the use of a seat belt as a restraint. Further review of the medical record revealed there was no documentation of an assessment regarding the use of a seat belt or the use of any type of least restrictive device, nor was there a restraint flowsheet in place for use. Record review of the admission Record revealed Resident #1 readmitted on [DATE] with diagnoses that included Intracranial Injury with Loss of consciousness, status unknown and Other developmental disorders of speech and language. Record review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 2/16/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 02, which indicated the resident had severe cognitive impairment. Further review of the MDS revealed the resident was dependent on staff for assistance with all her activities of daily living.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and facility policy review, the facility failed to develop and implement a comprehensive person-centered care plan to reflect the use of restraints for one (1) of 15 sampled residents. Resident #1 Findings include: Record review of facility policy titled, Comprehensive Plan of Care, revised 10/10/22, revealed, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . In an observation on 04/21/24 at 1:43 PM, Resident #1 was sitting in her wheelchair with a seatbelt intact. The resident was sitting alone in her room. The resident was unable to demonstrate the ability to open the seatbelt on her own. Record review of the care plan revealed Focus: Safety: Resident may have lap belt positioner . Goal . Resident will remain safe .Interventions .Monitor q (every) 2 (hours) while out of bed for proper application and correct if necessary. Perform safety risk evaluation .as needed . Further review of the care plan revealed there was not a restraint re-assessment since admission in February 2015 nor a physician's order for the use of a restraint or monitoring of the seatbelt restraint. During an interview on 4/22/24 at 12:53 PM, with the Director of Nursing (DON), she confirmed upon review of the care plan for Resident #1, there was a need for goals and interventions related to the use of a seat belt. The DON revealed the resident was a longtime resident, and this was somehow missing. The DON stated the facility interdisciplinary team is responsible for collaborating with other facility staff regarding this issue and a physician's order, consent with reassessment and monitoring tools that should be in place for all residents who use restraints. An interview was conducted with the Administrator on 4/24/24 at 1:07 PM, at which time the Administrator confirmed the care plans for Resident #1 did not reflect that the facility interdisciplinary team collaborated with other facility staff regarding the appropriateness of the use of a seatbelt for Resident #1, with a physician's order, consent with reassessment, along with a monitoring in place for the use of the restraint. Record review of the admission Record revealed Resident #1 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included Intracranial Injury with Loss of Consciousness, status unknown and Other developmental disorders of speech and language.

Based on interview, record review, and facility policy review, the facility failed to ensure physician orders were implemented and followed as ordered for one (1) of 15 sampled residents. Resident #11 Findings include: Record review of facility's policy titled, Standard of Care, revised 9/15/22, revealed, POLICY: It is the policy of this facility to provide a standard of treatment and care most beneficial to residents and to offer the highest quality services in a caring atmosphere Regardless .all residents shall have access to the following: .Care that is timely. Care that meets their needs . On 4/21/24 at 1:08 PM, in an interview with Resident # 11, he revealed he had been hospitalized because of low potassium. Record review of the Progress Notes dated 10/14/23 revealed the resident was transferred to a local acute care hospital related to critical labs received related to the resident's potassium levels. Record review of a Consultation Report dated 1/3/24 revealed . Renal U/S-(ultrasound) CKD 4 (chronic kidney disease) . Record review of Progress Note dated 1/5/24 revealed related to Situation: Elevated BUN (Blood Urea Nitrogen)and creat (creatinine) remains after fluids . Record review of a Consultation Report dated 2/12/24, from the office of the Nephrologist revealed . Order outpatient renal ultrasound . Record review of the medical records for Resident #11 revealed there was no documentation that a renal ultrasound had been ordered by the facility on 1/3/24 or 2/12/24 for Resident #11 as recommended by the nephrologist. Further review indicated no results for a renal ultrasound were in the medical record. On 4/23/24 at 1:37 PM, in an interview with the Director of Nursing (DON), she stated the Charge Nurse is responsible for taking off physician orders and following up with orders. She stated when the Charge Nurse is not here, the cart nurse is responsible for taking orders off. The DON revealed she was not aware the renal ultrasound had not been done, until it was brought to her attention. She stated it was just missed. She stated the resident sees a Nephrologist in a nearby town, as Resident #11 is in Renal Failure. The DON revealed renal ultrasounds are ordered to check the function of a resident's kidneys. On 4/23/24 at 3:08 PM, in an interview with Licensed Practical Nurse (LPN)#1/Charge Nurse, she revealed she was not aware Resident #11 had an ordered renal ultrasound that was not done. She stated she is responsible for taking orders off and putting them on the calendar. LPN #1 revealed that she is the one that took the order off, but she must have not followed it through to make sure that it was done. On 4/24/24 at 11:20 AM, in an interview with the Nephrology Medical Assistant stated all test results are reviewed at the time they are received. She revealed Resident #11 was seen by the Nephrologist on 1/3/24 and 2/12/24, and both times, a renal ultrasound was ordered, but had not been done. She stated it's important that all orders are followed in a timely manner, so that the physician can review the results of the test and make medication changes, as needed. On 4/24/24 at 12:34 PM, in an interview with DON, she stated the renal ultrasound from the 1/3/24 Nephrologist visit was scheduled, however, the resident got sick was hospitalized for an extended period of time and the renal ultrasound was not rescheduled when resident returned to facility. On 04/24/24 at 12:56 PM, in an interview with the Administrator, he stated he expects the Charge Nurse to have a system in place to monitor and review orders to make sure they are followed. Record review of the admission Record revealed the facility originally admitted Resident #11 on 5/23/13 with current diagnoses that included Type 2 Diabetes Mellitus and Chronic Kidney Disease, Stage 4 (SEVERE). Record review of the Minimum Data Set (MDS) for Resident #11, with an Assessment Reference Date (ARD) of 11/5/24, revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact.

Based on observation, interviews, record reviews, and facility policy review, the facility failed to ensure that a resident's CPAP (Continuous positive airway pressure) mask was properly stored, when not in use, for one (1) of (1) residents reviewed that required respiratory care. Resident #11. Findings include: Review of facility's policy titled, Oxygen, Nebulizer, CPAP/BIPAP (Bilevel positive airway pressure), with a revision date of 6/14/23, revealed, It is the policy of this facility to clean, disinfect, label and store supplies, nebulizer supplies, CPAP and BIPAP supplies appropriately . 3.vi. While not in use, store oxygen tubing, mask/cannula, nebulizer mask and tubing, and CPAP/BIPAP mask and tubing in a labeled (date) storage bag . On 04/21/24 at 1:08 PM, during an interview and observation with Resident #11, a CPAP mask was lying on table by the resident's bed. It was not in a labeled storage bag. Resident #11 stated it is never put in a bag. On 04/21/24 at 1:30 PM, in an interview with Licensed Practical Nurse (LPN) #1/Charge Nurse confirmed Resident #11's CPAP mask should be in a bag to keep it clean, as the bag will prevent germs from getting in it. On 04/24/24 10:26 AM, in an interview with LPN #3/IP (Infection Preventionist) stated when not in use, Resident #11's CPAP mask should be in a bag to prevent bacteria from getting on the mask and causing infection. She IP confirmed the staff should make sure this is done. On 4/24/24 at 12:56 PM, in an interview the Administrator stated he certainly expected staff to have knowledge of CPAP care and staff to monitor usage and follow protocol for safe storage when not in use. Record review of the Order Summary Report, with active orders as of 4/24/24 revealed an order dated 3/7/24 Wear CPAP @ (at) night . related to Sleep Apnea, Unspecified. Record review of the admission Record for Resident #11 revealed the facility admitted the resident on 5/23/13 .Current diagnoses included sleep apnea. Review of the Minimum Data Set (MDS), for Resident #11, with an Assessment Reference Date (ARD) of 4/4/24, revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident is cognitively intact.

Based on record review, interviews and facility policy review, the facility failed to ensure Advance Directives were completed according to the resident preference for two (2) of (2) residents reviewed for Advance Directives. This deficient practice had the potential to affect all residents who do not have an Advance Directive. Resident #7 and Resident #41. Findings Include: Review of the facility's policy titled, Residents' Rights Regarding Treatment and Advance Directives Policy, revised 8/23/22, revealed, Policy: It is the policy of this facility to support and facilitate a resident's right .to formulate an advance directive. Policy Explanation and Compliance Guidelines: 1. On admission, the facility will determine if the resident has executed an advance directive and, if not, determine whether the resident would like to formulate an advance directive. 2. The facility will provide the resident or resident representative information, in a manner that is easy to understand, about . an advance directive. 3. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to the staff . Resident # 7 Record review of the Code Status form dated 7/17/23 revealed CODE CLASSIFICATION .CODE A- All resident are considered Code A unless otherwise specified and will receive .FULL RESUSCITATION . Further record review revealed there was no documentation in the medical record that Resident #7 had an advance directive or had received information on formulating an advance directive. Record review of the admission Record revealed Resident #7 was admitted by the facility on 7/17/23. The resident's diagnosis included Unspecified Cord Compression, Muscle Weakness, Lack of Coordination and Osteoarthritis. Record review of the Minimum Date Set (MDS) with Assessment Reference Date (ARD) of 1/9/24 revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact Resident #41 Record review of the Code Status for dated 6/26/23 revealed CODE CLASSIFICATION .CODE A- All resident are considered Code A unless otherwise specified and will receive .FULL RESUSCITATION . Record review of the admission Record revealed the facility admitted Resident #41 on 6/28/23 with diagnoses including Major Depressive Disorder. A review of the MDS for Resident #41, with an ARD of 4/7/24, revealed a BIMS score of 13, which indicated the resident was cognitively intact. Further record review revealed there was no documentation in the medical record that Resident #41 had an advance directive or had received information on formulating an advance directive. On 4/22/24 at 11:22 AM, in an interview with the Social Service Director, she confirmed the current Code Status form on all resident files cannot be considered an Advance Directive. She revealed that when starting in the position two weeks ago, it came to her attention that there were no advance directives in the residents' charts or electronic records. She pointed out that since that time she has obtained the correct forms and is in the process of getting the correct forms signed and uploaded to the residents' charts. On 4/23/24 at 8:48 AM, in an interview with the Administrator, he revealed he was made aware yesterday the current form being used, as an advance directive, was not correct. He confirmed that none of the residents in the facility have an Advance Directive in their chart. However, the correct form is currently being uploaded into every resident's chart. He pointed out that by not offering residents an Advance Directive, it could cause nursing staff to elect a treatment during an emergency that the resident may not prefer or desire.

Based on observation, interviews, record review, and facility policy review, the facility failed to monitor and record freezer and refrigerator temperatures daily and discard expired foods for one (1) of four (4) kitchen observations. This has the potential to affect 48 of the 52 residents that reside in the facility. Findings include: Review of facility's policy titled, Food Safety Requirements, dated 10/12/22, revealed Policy: .Food will also be stored, prepared, disturbed, and served in accordance with professional standards for food service safety . Policy Explanation and Compliance Guidelines: 1. Food safety practices shall be followed throughout the facility's entire food handling process . Elements of the process include the following: b. Storage of food in a manner that helps prevent deterioration or contamination of the food including from growth of microorganisms . 3 . c. Refrigerated storage . c . Practices to maintain safe refrigerated storage include: i. Monitoring food temperatures and functioning of the refrigeration equipment daily and at routine intervals during all hours of operation . iv. Labeling, dating, and monitoring refrigerated food, including but not limited to leftovers, so it is used by its use-by-date or frozen (where applicable) discarded; and v. Keeping foods covered or in tight containers . On 04/21/24 at 11:35 AM, the initial tour of the kitchen with the Dietary [NAME] (DC), revealed seven (7) 32-ounce bottles of a browning and seasoning sauce, with an expiration date of 4/1/22. One of these bottles was opened and in the kitchen area. The was also a 32-ounce carton of opened liquid eggs, without a legible opened date. On 04/21/24 at 11:47 AM, while continuing the kitchen tour with the Dietary Manager (DM), review of the refrigerator/freezer/temperature logs, revealed the logs were pre-filled with temperatures for the entire month of April 2024 for three (3) of the six (6) units that required temperature checks. The logs for the additional three (3) units revealed no record of daily temperature checks. Review of the March 2024 refrigerator/freezer temperature logs revealed only five (5) of the six (6) units were monitored. On 04/21/24 at 11:58 AM, in an interview the DM, she stated staff know better. She confirmed all expired items are to be pulled on their expiration date. She stated Dietary Aid (DA) #1 is responsible for removing expired items from the storage. She stated staff should check the temperature on all units daily and record, as that lets staff know that the units are functioning properly. On 04/21/24 at 12:15 PM, in an interview with DA #1, stated she is responsible for checking all the freezer and refrigerator temperature logs. She admitted she pre-filled the refrigerator/freezer temperature logs due to trying to catch up on the logs, because there are times when she does not check them. On 04/22/24 at 10:50 AM, in an interview with the DM, stated all the unit's refrigerator/freezer temperature logs should be checked daily and revealed that it is her responsibility to check the logs. She confirmed that they did not have documentation of all the units being checked daily. On 04/24/24 1:00 PM in an interview with Administrator stated he expects DM and staff to know and understand the regulations and requirements and follow them.

Based on staff interview, record review, and facility policy review, the facility failed to accurately submit direct care staffing information based on payroll data to the Centers for Medicare and Medicaid (CMS) as required for the first quarter of Fiscal Year (FY) 2024 (October - December 2023) for one (1) of four (4) quarters reviewed. Finding include: Record review of facility's policy titled, Nursing Services and Sufficient Staff, revised 10/12/22, revealed, Policy: It is the policy of this facility to provide sufficient staff .The facility's census, acuity, and diagnoses of the resident population will be considered based on the facility assessment. Policy Explanation and Compliance Guidelines . 7. The facility is responsible for submitting timely and accurate staffing data through the CMS Payroll-Based Journal (PBJ) system. Record review of the Payroll Based Journal (PBJ) Staffing Data report from the Certification and Survey Provider Enhanced Reports (CASPER) database revealed the facility failed to have Licensed Nursing Coverage 24 Hours/Day. The dates were identified as 10/29 Sunday (SU), 10/31 Tuesday (TU), 11/26 SU, 11/27 Monday (MO), 11/28 TU and 11/29 Wednesday (WE). The Administrator stated in an interview on 4/21/24 at 12:16 PM, that he was aware that the facility failed to electronically submit PBJ staffing data to CMS accurately. He revealed that the inaccurate submission was related to a glitch in the software that was being utilized by the corporation. The Administrator stated that the Human Resources Coordinator (HRC) was responsible for submitting the PBJ staffing data for the facilities. He stated that he thought the glitch had been corrected but failed to follow up. The Director of Nursing (DON) revealed in an interview on 4/22/24 at 9:15 AM, that she was not aware of the PBJ staffing error that had been submitted to CMS. The DON deferred to the HRC as to why this error occurred. The Licensed Practical Nurse (LPN) #5/Educator revealed in an interview on 4/22/24 2:48 PM, that she was not aware that the facility failed to electronically submit PBJ staffing data to CMS accurately in the first quarter of FY 2024. Upon review of the staffing grids, LPN #5 revealed there was documentation that 10/29 (SU); 10/31 (TU); 11/26 (SU); 11/27 (MO); 11/28 (TU); 11/29 (WE) were appropriately staffed. The Human Resource Coordinator (HRC) revealed in an interview on 4/22/24 at 2:55 PM, that she was not aware that the facility failed to electronically submit PBJ staffing data to CMS accurately in the first quarter of FY 2024, but was aware that there had been an error in last quarter of 2023. The HRC stated that she was responsible for submitting the PBJ staffing data for the facility. She stated that the facility utilized a payroll software that at times did not accurately pull numbers. Upon review of the submitted data, it was noted that the reported information was not accurate, as it failed to account for salaried personnel that had worked, thus creating a shortage. The HRC confirmed that she had not been rechecking numbers, as she thought glitch had been corrected.

Based on observation, staff interviews, and facility policy review, the facility failed to store food in accordance with professional standards for food service safety related to food items not dated with a use-by date, and food items not discarded after the expiration date, for one (1) of three (3) kitchen observations. Findings Include: A review of the facility's Food Service Operational Standards for Purchasing, Receiving, Cooking and Storage of Food policy with a revised date of 10/17 revealed, The facility receives, stores, prepares, distributes and serves food under sanitary conditions to prevent the spread of food borne illness and to reduce those practices that result in food contamination and compromised food safety Follow First In First Out .foods should be labeled before being stored in the refrigerator or freezer .The date mark indicates the date of preparation or the discard date .Commercially processed foods will have a use by date. This use by date should be followed . On 8/28/22 at 11:35 AM, the State Agency (SA) conducted an initial tour of the kitchen with the [NAME] and observed the following: 1. In the Dry Storage room, there was an opened (6) pound (lb.) bag of Brownie Mix, a six (6) lb. bag of Blueberry Muffin Mix, a five (5) lb. bag of Basic American Foods Mashed Potatoes, a 16-ounce (oz) container of Imitations Bacon Bits, a five (5) lb. bag of Originals Villa Frizzoni Noodles, and a five (5) lb. container of Peanut Kid: Creamy Peanut Butter with no opened or use by dates. 2. In the freezer, there was an open ten (10) lb. bag of Tater Tots, a ten (10) lb. bag of French Fries, and a 2 lb. bag of shredded lettuce with no opened or use by dates. 3. In the Dry Storage room, there were two (2) five (5) oz. cans of Salsa De Arah Gelatizados with the expiration date of 8/17/22 and a 70 oz. container of Tostitos Salsa with the expiration date of 5/14/21. On 6/27/22 at 11:52 AM, during an interview with the Dietary Manager (DM), she stated that she and the Assistant DM are responsible for discarding expired foods. On 6/28/22 at 10:00 AM, during an interview with the DM, she stated that expired food items could cause harm to the residents. She confirmed that food items should be checked daily for expired items and labeling. On 6/30/22 at 02:18 PM, during an interview, the Administrator stated that the residents are at risk for a possible illness if they consume expired food products. He stated that it is very important to check the dates on food and that he does not expect to find expired items in the kitchen. Record review of an Associate In-Service Record, dated 12/14/21, revealed Points Covered/Overview .receiving and storage of food . revealed dietary staff received training on storage of food items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) for one (1) of 16 MDS assessments reviewed for accuracy. Resident #28 Findings Include: A record review of the facility's Comprehensive Assessment and Re-Assessment policy with revision date 11/28/2017 revealed, . The facility shall comply with Resident Assessment Instrument (R.A.I.) guidelines for comprehensive assessments and re-assessments .The sources of information for the M.D.S. include: Review of the resident's record . Review of Resident #28's Face Sheet revealed the resident was admitted to the facility on [DATE], with diagnoses that include Altered Mental Status, Pain, Edema, and Depression. A record review of Resident #28's Quarterly MDS with an Assessment Reference Date (ARD) of 07/14/2022 revealed, . Section C- Cognitive Patterns C0500 revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Section N-Medications N0410E: Medication received: Days: anticoagulant was listed as seven (7). A record review of Resident #28's Physician's Telephone Orders dated 6/7/2022 at 2:50 PM, revealed Discontinue (D/C) Eliquis per (Proper Name . A record review of Resident #28's Physician Orders for the month of July 2022, revealed there were no new orders for anticoagulant therapy. A record review of Resident #28's Medication Administration Record for the month of July 2022, revealed there were no anticoagulants administered. On 08/30/2022 at 2:20 PM, an interview with Licensed Practical Nurse (LPN) #2/MDS nurse, confirmed Resident #28's Quarterly MDS revealed the resident had received 7 doses of anticoagulant medication during the look-back period. The MDS nurse stated the resident's MDS had been coded in error, as the Eliquis had been discontinued on 6/7/2022. On 08/31/22 at 11:40 AM, during an interview with the Director of Nursing (DON), she explained she expects the MDS nurse to review medical records and accurately code the MDS. The DON stated prior to transmission of the MDS, Registered Nurse (RN) #1 reviews and signs the MDS assessments and meets with herself and the MDS nurse to review the MDS for accuracy prior to transmission. The DON confirmed the inaccurate anticoagulant coding was overlooked. On 08/31/22 at 11:52 AM, during an interview with RN #1, she explained she reviews and signs all MDS assessments prior to transmission. The nurse stated she meets with the DON and MDS nurse for a final review of the MDS prior to the transmission, but confirmed that Resident #28's last Quarterly MDS was transmitted with the incorrect coding for anticoagulants.

Resident #25 Review of Resident #25's Quarterly MDS assessment, with an ARD of 10/15/19, revealed the resident received an Anti-coagulant medication for four (4) days. Review of physician orders, dated 12/14/16, revealed Resident #25 had an for Plavix 75 milligrams (mg), by mouth for circulation. There was no order for an anti-coagulant medication for Resident #25. During an interview, on 12/05/19 at 12:42 PM, LPN #1/Care Plan Nurse, and the Director of Nursing (DON), stated Resident #25's MDS assessment was marked to indicate the resident was taking an anticoagulant, but the MDS assessment was incorrectly marked, because Plavix is an anti-platelet, not an anti-coagulant. Based on staff interview, record review, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) assessment, related to hospice for Resident #50, anti-coagulant medications for Resident #25, and oxygen therapy for Resident #30; for three (3) of 20 residents MDS assessments reviewed. Findings include: Review of the Long-Term Care Facility Resident Assessment Instrument (RAI) Version 3.0 Manual, revised October 2019, revealed the RAI process is the basis for the accurate assessment of each resident. Resident #50 Review of Resident #50's Significant Change Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 11/15/19, revealed, Special Treatments and Programs, documented, none of the above, and Hospice was left blank. Review of Resident #50's physician's orders, dated 11/4/19, revealed an order to admit to hospice, related to Liver Cancer. During an interview, on 12/05/19 at 12:55 PM, Registered Nurse (RN) #1/MDS Coordinator, confirmed Resident #50's MDS, with an ARD of 11/15/19, was not accurately coded for hospice, and it would affect the Care Area Assessments (CAAs), which trigger care plans. RN #1 stated the Resident Assessment Instrument (RAI) manual is followed to complete the MDS correctly. Resident #30 Review of Resident #30's most recent Quarterly MDS assessment, with an ARD of 10/21/19, revealed the assessment did not document oxygen therapy. Observations of Resident #30 on 12/03/19 at 10:13 AM, 11:55 AM, 2:50 PM, and 3:39 PM; and on 12/04/19 at 8:51 AM, revealed Resident #30 was lying in bed with oxygen via nasal cannula (NC). A review of Resident # 30's December 2019 physician's orders, dated 2/15/19, revealed an order for oxygen at two (2) liters per nasal cannula, as needed for shortness of breath. An interview, on 12/05/19 at 9:40 AM, with the MDS/Care Plan Nurse/Licensed Practical Nurse (LPN) #1, confirmed Resident #30 had been on oxygen at the time of the most recent quarterly MDS assessment, dated 10/21/19. LPN #1 confirmed Resident #30's assessment was not marked to indicate the resident received oxygen, while a resident of the facility. LPN #1 stated it was overlooked when the assessment was completed.

Based on staff interview, record review, and facility policy review, the facility failed to refer a resident for a Level II screening, when she was identified with a newly evident serious mental disorder, for one (1) of five (5) resident Pre-admission Screening and Resident Review (PASARR)s reviewed, Resident #31. Findings include: Review of the facility's admission to Facility + admission Checklist, revised 11/28/17, revealed a Pre-admission Screening (PAS) must be completed prior to admission. The policy did not address if a resident was later assessed or identified with newly evident or possible serious mental diagnosis, or a related condition, to refer the resident for a Level II screening. Review of Resident #31's Pre-admission Screening, dated 08/21/18, documented the resident had no major mental illness, but was taking psychotropic medications. Review of a letter from the state-designated screening authority, dated 08/27/18, indicated Resident #31 had a Negative Level I screening, and was appropriate for nursing home placement. No Level ll screening was required at the time of admission to the facility. A review of Resident # 31's History and Physical, dated 08/21/19, from admission for a Geri-psyche stay, revealed the resident was involved in disagreements with other residents and made threatening remarks. A review of Physician's Orders for, Resident # 31, revealed an order, dated 08/28/19, of return to the facility from a hospital stay with a change in medications including addition of Risperdone 1 milligram (mg), three (3) tablets at hour of sleep (HS), for Bipolar Disorder. There was no indication in the medical record that the resident had been referred for a level ll screening, with this new diagnosis and medication prescribed. An interview on 12/04/19 at 11:35 PM, with Licensed Practical Nurse (LPN) #2, revealed Resident #31 was hospitalized at a Geri-psyche unit a few months ago, because she became threatening to staff and others. An interview on 12/04/19 at 11:50 AM, with the Director of Nursing (DON), revealed she did not think Resident #31 had been referred for a level ll screening, after being diagnosed with Bipolar Disorder, and being prescribed Risperdone. The DON confirmed the resident went out for a Geri-psyche hospitalization, related to her becoming threatening to staff and other residents. An interview on 12/05/19 at 8:50 AM, with LPN #3, revealed she completed the PAS form when residents were admitted . LPN #3 confirmed Resident # 31 had a negative level l screening, so the resident did not get referred for a level ll screening on admission. LPN #3 stated she was unaware she should refer a resident for a level II PASARR evaluation, if a resident was identified with a newly evident or possible serious mental diagnosis. LPN #3 confirmed Resident #31 was threatening staff and other residents and was admitted to Geri-psyche. LPN #3 confirmed Resident #31 returned with a diagnosis of Bipolar Disorder, and had orders for Risperdone, an anti-psychotic medication.

Based on observation, staff interview, record review, and facility policy review, the facility failed to develop a comprehensive care plan, related to hospice for Resident #50, and failed to develop a care plan, related to oxygen usage, for Resident #30; for two (2) of 20 comprehensive care plans reviewed. Findings include: Review of the facility's Comprehensive Plan of Care, policy, with a revised date of 11/28/17, revealed the facility would develop a comprehensive plan of care for each resident, which would include the services to be furnished, to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Resident #50 Review of Resident #50's comprehensive care plan, with target dates of 12/15/19, revealed he did not have a care plan related to hospice services. Review of Resident #50's physician's orders, dated 11/4/19, revealed an order to admit the resident to Hospice services, related to a diagnosis of Liver Cancer. An interview, on 12/04/19 at 12:07 PM, with Registered Nurse (RN) #1/MDS Coordinator, confirmed Resident # 50's did not have a comprehensive care plan, related to Hospice services. She stated the care plan should have been developed, so the staff would be aware of the change in status. An interview, on 12/05/19 at 12:19 PM, with the Director of Nursing (DON), revealed the expectation was to develop a comprehensive care plan, after a comprehensive assessment; and Resident #50's care plan should have included the Hospice admission. Resident #30 Review of Resident #30's current comprehensive care plan, with target dates of 1/25/20, revealed no care plan related to shortness of breath or oxygen use. Observations on 12/03/19 at 10:13 AM, 11:55 AM, 2:50 PM, and 3:39 PM; and on 12/04/19 at 8:51 AM, revealed Resident #30 was lying in bed with oxygen (O2) usage from an oxygen concentrator. Review of Resident #30's December 2019 physician's orders, revealed an order, dated 2/15/19, for oxygen 2 liters per minute via nasal cannula as needed, related to shortness of breath. An interview, on 12/05/19 at 9:40 AM, with the Care Plan Nurse/Licensed Practical Nurse (LPN) #1, confirmed Resident #30 did not have a care plan developed for oxygen use. LPN #1 stated there should be a care plan to address the resident's shortness of breath and the use of oxygen. LPN #1 stated the resident had been using oxygen for several months.

Based on observation, staff interview, record review, and facility policy review, the facility failed to revise the care plan, related to the use of oxygen, for one (1) of three (3) care plans reviewed for oxygen, Resident #31. Findings Include: Review of the facility's Comprehensive Assessment and Re-Assessment, policy, revised 11/28/17, revealed any change in a resident's condition would require an immediate re-assessment, with changes in the plan of care, reflecting the change in condition. Review of Resident #31's Comprehensive Care Plan, initiated 08/27/19, revealed the resident at risk for pneumonia, related to a history of pneumonia, a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), and Asthma. There was also a care plan for smoking, which included the resident could go out to smoke with family and friends, but it did not address oxygen use. There was an intervention to administer medications as ordered, but not specific to include the use of oxygen. An observation on 12/03/19 at 10:32 AM, revealed Resident #31 in the hallway, at the door of her room, with oxygen (O2) administered via nasal cannula at 2 liters (L) per minute, with a portable O2 tank attached to the back of her wheelchair. Review of the December 2019 physician's orders, dated 10/29/18, for Resident #31, revealed orders for O2 saturation (sat) levels every (Q) shift; if below 90 percent (%), place O2 at 2L per minute, via nasal cannula. Observations on 12/03/19 at 11:12 AM, and 2:46 PM, revealed Resident #31 in the dining room, with O2 at 3L per minute, administered from a portable O2 tank. An observation and interview, in Resident #31's room, on 12/04/19 at 8:39 AM, revealed the oxygen concentrator was set on 2L per minute and the resident received the oxygen via bilateral nasal cannula. Resident #31 stated she had always been on 2L of oxygen. The resident stated the nurses check her Oxygen level two (2) or three (3) times a day. An interview on 12/04/19 at 11:45 AM, with the DON, confirmed she would expect the nurses to check O2 administration for residents, to make sure it is being administered at the correct rate. The DON stated the care plan should be revised to include Oxygen use, specific to Resident #31. An interview, on 12/05/19 at 8:35 AM, with the Care Plan Nurse/LPN #1, confirmed Resident #31 was care planned for COPD, Asthma, and history of Pneumonia, with an intervention to administer medications as ordered. LPN #1 stated she believed the care plan covered oxygen, as it is a medication, but it would be better to revise the care plan, to specifically address the use of oxygen for the resident, to make the care plan more person-centered. LPN #1 confirmed Resident #31 had been using oxygen for several months.

Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure residents were administered oxygen therapy, per physician's order, for two (2) of three (3) residents reviewed for respiratory care, Resident #30 and Resident #31. Findings Include: Review of the facility's Oxygen Policy, dated 06/23/17, revealed oxygen would be used with specific physician's orders and should never be above three (3) liters (L), without special physician's orders. The Medication Administration Record (MAR) is used to document continuous oxygen usage. The Oxygen Flow Sheet is used for PRN (as needed) oxygen usage. Resident #30 A review of Resident #30's December 2019 physician's orders, revealed an order dated 02/15/19, for Oxygen (O2) at two (2) Liters (L) via nasal cannula (NC) as needed (PRN), related to shortness of breath (SOB). Observations of Resident #30, on 12/03/19 at 10:13 AM, 11:55 AM, 2:50 PM, and 3:39 PM; and on 12/04/19 at 8:51 AM, revealed Resident #30 was lying in bed with oxygen being administered via nasal cannula to both nostrils at 3.5 liters (L) per minute from an oxygen concentrator. There was no Oxygen in Use sign (no smoking) on the door or posted in the room. In an interview, on 12/03/19 at 11:55 AM, Resident #30's daughter stated the resident had been on O2 for some time and she was unsure what the setting was supposed to be on. The resident's daughter stated she never adjusted the oxygen concentrator; only nurses do. During an interview, on 12/04/19 at 11:45 AM, the DON revealed she expected nurses to monitor oxygen periodically throughout the day, to ensure it was being administered at the correct rate. The DON stated she would expect the nurses to observe and document every shift, the O2 saturation level for the resident, and the rate of administration, accurately on the Medication Administration Record (MAR) or the oxygen flow chart. The DON stated there should have been an Oxygen in Use sign on the resident's door. In an interview, on 12/04/19 at 4:01 PM, LPN #4 stated she completed Resident #30's MAR for O2 use. LPN #4 stated she marks the MAR after checking O2 saturation levels for each resident. LPN #4 stated she did not check to see that the O2 was set at 2L per minute, for Resident #30, but she should have. Resident #31 Review of the physician's orders, dated 10/29/18, revealed Resident #31 had an order for O2 sats every (Q) shift, and if below 90 percent (%), place O2 at 2L via NC. An observation, on 12/03/19 at 10:32 AM, revealed Resident #31 in hallway, at the door to her room, with O2 being administered via nasal cannulas at 2L per minute, with a portable oxygen tank attached to the back of her wheelchair. At 10:34 AM, on 12/3/19, Resident # 31 was observed to go outside on the back patio area with visitors to smoke; she had no oxygen being administered. An observation on 12/03/19 at 11:12 AM, of Resident #31 in the dining room, revealed O2 being administered via bilateral NC at 3L per minute from a portable O2 tank. An observation on 12/03/19 at 2:46 PM, revealed Resident #31 in the dining room, during an activity, with O2 being administered via bilateral NC at 3L per minute from a portable O2 tank. An observation on 12/03/19 at 3:36 PM, revealed O2 being administered to Resident #31 at 2L per minute, via bilateral NC, from a portable tank on her wheelchair. An observation and interview, in Resident #31's room, on 12/04/19 at 8:39 AM, revealed the resident was being administered O2 at 2L per minute, via bilateral NC, from an oxygen concentrator. The resident stated she has been on oxygen continuously for several months and had been on 2L of oxygen since she had been using it. The resident stated her daughter turned off her oxygen, prior to her smoking yesterday, and back on after she finished, once she was inside. The resident stated her daughter was an Emergency Medical Technician (EMT) and had training on the use of oxygen. The resident stated she was unaware her O2 was being administered at 3L per minute for a period of time yesterday, but it should have been 2L. The resident stated the nurses check her oxygen level two (2) or three (3) times a day. The resident suggested a Certified Nursing Assistant (CNA) may have put her oxygen level on 3L, after she smoked yesterday, she was unsure, because they sometimes turn the oxygen on/off before and after smoke breaks. During an observation of Resident #31, and interview with LPN #2, on 12/04/19 at 11:30 AM, revealed Resident #31 lying in bed with O2 being administered via NC at 3.5 L per minute, via the oxygen concentrator. LPN #2 stated the O2 should be at 2L and adjusted to the rate to 2L. LPN #2 stated she had not checked the resident's oxygen, prior to this observation; she didn't normally work this hall. During an interview on, 12/04/19 at 11:35 PM, RN #1 revealed Resident #31 and all residents were monitored by staff when smoking, however, Resident #31's daughter did come and take her out to smoke on occasion. RN #1 stated sometimes staff were not aware when the resident's daughter visited, but she was an EMT and knew how to turn off oxygen. RN #1 stated staff should check periodically, to make sure the O2 level was correct, and it was possible the resident's daughter turned the O2 on and put it at 3L per minute. An interview on 12/04/19 at 11:45 AM, with the DON, confirmed Resident #31's daughter (an EMT) visits and takes the resident out to smoke. She indicated the daughter might manipulate the oxygen administration. The DON stated she would expect the nurses to check O2 administration for residents, to make sure it is being administered at the correct rate.