**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and policy review, the facility failed to prevent verbal abuse to Resident #1 for one (1) of three (3) residents reviewed for abuse/neglect. Findings Include: The facility policy titled Abuse, Neglect, and Exploitation dated approved 03/04/2025 read: Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Residents must not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals. Interview on 03/25/24 at 12:20 PM with the facility Administrator revealed that Hospital Dietary Employee #1 and Resident #1 had words in the dining area a few weeks ago when the resident had returned to the facility from being out on a pass. He stated the resident was requesting food in the dining room area of the facility when this incident occurred. The Administrator confirmed that on 03/08/24 when the verbal altercation between Dietary Employee #1 and Resident #1 occurred, Hospital Dietary Employee #1 was given a written warning at that time due to poor customer service. Record review of the Disciplinary Warning Notice #1, dated 3/8/24, issued to Dietary Employee #1 read: Date of Incident 3/8/24 Time of Incident 10:00 AM Shift AM Action Taken: Written Warning. Report of Incident: Dietary Manager and Administrator had a meeting with (Dietary Employee #1) to discuss her actions involving a resident. We discussed why they were wrong. How to not let it happen again. And the outcome if this type of behavior continues. The Disciplinary Warning Notice revealed Dietary Employee #1 received a verbal warning on 9/13/23. The document was signed by the (Dietary Manager) and dated 3/8/24. Record review of the Disciplinary Warning Notice #2 , dated 3/22/24, issued to (Dietary Employee #1) read: Date of Incident: 3/1/24-3/2/24 Time of Incident: Day Shift: AM Report of Incident: HIPPA violation 3 Day suspension and also admitted to telling Boyfriend about a resident. Will reassign HIPPA Inservice's when employee returns to work on Monday March 25th. Supervisor's recommendation to employee: 3-day suspension starting 3/22/24. Return to work on 3/25/24. Signed by the dietary manager and the employee on 3/22/24. Interview and observation on 03/25/24 at 12:45 PM with Resident #1 revealed he stated since he had been admitted to the facility, approximately four (4) weeks prior, that a female dietary worker had given him a hard time about his food choices and food requests. Resident #1 stated that almost daily he would go to the dietary department and either ask for more food or ask for something different to eat. When this dietary worker, Hospital Dietary Employee #1, was present, she would smart off at him or tell him that he should eat what was served. Resident #1 stated that he and Hospital Dietary Employee #1 would exchange words almost daily and that she would get loud with him arguing and fussing and he got loud back at her. Resident #1 stated that he went to the facility Administrator and the facility nurses and told them that he was getting into arguments with the dietary worker (Hospital Dietary Employee #1) about his food requests and that she was rude and verbally loud toward him. Resident #1 stated that the dietary worker would begin the arguments with him and that they both would cuss at each other. Resident #1 also stated that the administrator and the dietary worker had a meeting on 03/8/24 with him and Hospital Dietary Employee #1. During the meeting Hospital Dietary Employee #1 was told to give Resident #1 double portions at each meal to attempt to satisfy his hunger. Resident #1 stated that he thought the matter would be resolved after the dietary worker was told to give him double portions. Resident #1 stated that on 03/9/24, he signed himself out, as he always had, to go to the store across the street from the facility. While at the store, Resident #1 was approached by an unknown male and the male told him that he was the boyfriend of the dietary worker and that he would beat his ass in the ground if he ever talked to his girlfriend mean again. Resident #1 stated that the Hospital Dietary Employee #1 continued to work at the facility in the dietary department. Resident #1 stated that he had not seen her at the facility for a few days until the morning of 03/25/24 where she was working in the dietary department. Interview on 03/25/24 at 1:45 PM with the Assistant Director of Nursing (ADON) revealed that from her understanding, Certified Nursing Assistant (CNA) #1 was with Resident #1 when the verbal altercation between him and the dietary worker occurred. Interview on 03/25/24 at 2:00 PM with the CNA #1 revealed that she had been asked by Resident #1 for some more food and she had advised him to go to the dietary department and ask for whatever he wanted. He told CNA #1 that there was a female in the dietary department that gave him a hard time and talked badly to him when he asked for food. CNA #1 stated that she told Resident #1 that she would push him down to the dietary department in his wheelchair and that she would be with him, and she would do the talking and ask for whatever he wanted. CNA #1 stated that Resident #1 sat quietly in his wheelchair, and she asked the dietary worker #1 for the food for Resident #1. The dietary worker #1 loudly and offensively began talking about the resident as if he was not sitting there. The dietary worker stated that Resident #1 needed to eat the food that was sent to his room and stop coming down asking for food. The dietary worker stated that she was tired of Resident #1 asking for more food and that he didn't need to be in the nursing home. CNA #1 stated that the arguing and fussing between the female dietary worker and Resident #1 was bad and loud. CNA #1 stated that she reported the incident to the Director of Nursing (DON) and then later that afternoon the DON. CNA #1 failed to remove Resident #1 from the situation before the altercation escalated. Interview on 03/25/24 at 2:45 PM with the Administrator revealed that he had talked to CNA #1, but she had never told him or the DON the details or content of the argument between Resident #1 and Dietary Worker #1. The Administrator stated that he did not obtain any written statements from anyone and that he had not determined the incident to be verbal abuse, but that it was poor customer service. The Administrator did confirm Dietary Employee #1 had been suspended for 3 days for telling her boyfriend who the resident was and what he looked like that led to the resident being threatened while the resident was out on pass at a convenience store next door to the facility. The Administrator confirmed that Dietary Employee #1 returned to work on 3/25/24 after 3-day suspension. Interview on 03/25/24 at 4:30 PM with the Ombudsman revealed that she had gone to the facility on [DATE] for a regular visit with residents when Resident #1 had told her about the incident at the facility after he had been approached at the store across the street by the boyfriend of a facility dietary worker and that she was still working at the facility. The Ombudsman confirmed that when she was visiting the facility on 3/13/24 that the dietary worker was working at the facility and had not been suspended or terminated. Interview on 03/26/24 at 3:00 PM with the Director of Nurses (DON) revealed that she had talked to the CNA #1, and originally CNA #1 had not told her the full details of the incident between Resident #1 and the Dietary Worker #1. The DON stated that she talked to CNA #1 again today and that she gave the details more clearly of what had happened between Resident #1 and the Hospital Dietary Employee #1 on 03/08/24. The DON stated that when they interviewed the second dietary worker, she denied hearing the Hospital Dietary Employee #1 threaten Resident #1. The DON stated that she now understood that the facility is responsible for residents' safety when they are out alone on pass and that no employees, including hospital employees, should be allowed to talk to residents in a harsh manner. Record review of the face sheet for Resident #1 revealed that he had been admitted to the facility on [DATE] and revealed a Brief Interview of Mental Status (BIMS) score of 15 from the Minimum Data Set (MDS) dated [DATE] which documented that Resident #1 had no cognitive impairments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide dignity to residents as evidenced by leaving urinary catheter bags uncovered for two (2) of five (5) residents with a catheter. Resident #24 and Resident #89. Findings Include: Review of facility policy titled, Resident Rights, revealed, The resident has the right to a dignified existence .8. Privacy and confidentiality: The resident has a right to personal privacy . Review of a statement on facility letterhead dated 12/14/23 and signed by the Director of Nursing (DON) revealed, We do not currently have included in our policy that catheter bags have to be covered in dignity bag. Resident #24 An observation and interview on 12/12/23 at 12:01 PM, revealed Resident #24 sitting in her wheelchair. A urinary catheter bag with no privacy cover was observed hanging on the bottom of the back of the wheelchair. Observation and interview on 12/13/23 at 2:55 PM, observed Resident #24 lying in bed with the catheter bag placed in front of the privacy bag and not in the privacy covering. On 12/13/23 at 3:05 PM an observation and interview with the Director of Nursing (DON) confirmed the catheter bag is always to be in a privacy bag, if we are out of privacy bags, we use a pillowcase. She revealed this makes no sense for the catheter to be placed in front of the privacy bag instead of in it. Record review of the form LTC Physician Order Review/Renewal revealed Urinary Catheter Care with original order date of 08/28/23 ensure catheter bag is covered for dignity. Record review of Resident #24's LTC Physician Order Review/Renewal revealed she was admitted to the facility on [DATE] with diagnoses that included Bladder retention, Acquired hydronephrosis and Chronic renal failure. Record review of Resident #24's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 10/23/23, revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact. Resident #89 An observation on 12/12/23 at 10:45 AM, revealed Resident #89 lying in bed with a urinary catheter bag with no privacy covering hanging from the left side of the bottom of the bed visible from the hallway. Record review of the LTC Physician Order Review/Renewal physician orders physician order's dated 11/26/23 revealed, twice a day (BID), ensure catheter bag is covered for dignity. During an interview on 12/13/23 at 3:22 PM with the Director of Nursing (DON) confirmed that the urinary catheter bag is always to be covered in a privacy bag because that is a dignity and privacy issue for the resident. She revealed all nursing staff know that the catheter bags are supposed to be kept covered. She confirmed when the unit managers make their rounds, they are continually reminding the aides to make sure the bags are covered for privacy. Record review of Resident #89's LTC Physician Order Review/Renewal revealed she was admitted to the facility on [DATE] with diagnoses that included Indwelling Foley Catheter present and Congestive Heart failure. Record review of Resident #89's MDS with ARD of 10/3/23, revealed a BIMS score of 12 which indicates the resident had moderate cognitive impairment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, record review and facility policy review the facility failed to accommodate a resident's mobility needs for (2) two of (3) three sampled residents reviewed for mobility needs. (Resident #82, and #83) Findings include: Review of the facility policy titled, Use of Assistive Device, revealed Policy: The purpose of this policy is to provide a reliable process for the proper and consistent use of assistive devices for those residents requiring equipment to maintain or improve function and/or dignity. Policy Explanation and Compliance Guidelines: 1.) Assistive devices are tool, products, types of equipment, or technology that may help individuals perform tasks and activities . Resident #83 An interview on 12/12/23 at 10:30 AM, with Resident #83 revealed They took my side rails and now I don't have anything to hold on to when I get up. It's hard for me to hold on to my table and the arm of the bedside commode when I'm trying to transfer to the commode. She revealed she had complained about this and was told it was because of the State that the side rail was removed. She revealed I've even tried to hold on to the bedside table, but it moves around and isn't safe. An interview on 12/13/23 at 2:30 PM, Resident #83 revealed that maintenance came in one day and just removed them. She revealed Registered Nurse (RN) #4 came in and said that the State said it was a new rule and we had to take them off. She revealed I told her and anyone who would listen to me that I needed the bar to hold onto. She stated I used it to hold onto when I got up out of bed to use the bedside commode and to position myself in the bed. The resident revealed nobody came back in to see what I needed to help me with positioning since they took them away. An interview on 12/13/23 at 3:50 PM, with the Director of Nurses (DON) revealed Resident #83 was assessed for side rails on 6/28/23 but the side rail wasn't removed until 8/30/23. The DON confirmed that Resident #83 had been positioning herself using the rail and using it to get to her bedside commode but since she could get up on her own, we removed the side rails because that's what we thought we were supposed to do. She stated we didn't give the resident the option of signing a consent form to keep the side rails because she could get in and out of bed. The DON confirmed that according to the Bed Rail Use Assessment that was completed on 8/30/23, the resident had requested to keep her side rails and confirmed it was for mobility/transferring assistance. She confirmed that nothing was put in place for mobility or transferring assistance when the side rails were removed. An interview on 12/13/23 at 4:00 PM, with Licensed Practical Nurse (LPN) #1 confirmed that the resident had requested to keep the rails and that she was using them for mobility and transferring. Record review of Bed Rail Use Assessment Form with date of assessment 6/28/23 revealed, that the Resident #83 requested to keep rails for Mobility/transferring assistance. Under Benefit(s) to using the bed rails(s) Assists resident with turning side to side, provides resident with a feeling of comfort and security for fear of falling out of bed, and assists with balance while attempting to stand/standing was marked Yes. Record review of the Physician Order Review/Renewal revealed Resident #83 was admitted to the facility on [DATE] with diagnoses that included Risk for falls, Primary osteoarthritis of left knee, Osteoporosis, and Osteoarthritis. Record review of Resident #83's MDS with ARD of 10/19/23, revealed a BIMS score of 14 which indicates the resident is cognitively intact. Resident #82 An interview and observation on 12/12/23 at 11:10 AM, revealed the resident has a bariatric bed with no side rails. The resident stated, I used to have half rails on my bed, and I could use them to pull myself up and around in the bed, but the facility took my rails off of my bed and I want them back. The resident confirmed that the facility said they were taking all rails off the beds because they have to. The resident confirmed that she is mobile and active and liked having the rails to help turn herself and reposition while in the bed. An interview, on 12/15/23 at 8:00 AM, with the Director of Nursing (DON), regarding removal of the side rails for Resident #82, the DON stated, The resident has a bariatric bed and can move around. The DON confirmed that she was not aware the resident wanted her rails back or needed them back on. The DON confirmed that the facility was told by the Administrator to remove all the side rails from the beds. Record review of Bed Rail Use Assessment Form dated 07/06/2023 revealed that Resident # 82 benefits from the use of bed rails to assist resident with turning side to side and provides the resident with a feeling of comfort and security for fear of falling out of bed. The bed rail assessment also revealed that there was no potential risk of using the bed rails. A record review of the facility form LTC Physician Order Review/Renewal for Resident #82 revealed that she was admitted to the facility on [DATE] with a diagnoses including Depression, Endogenous obesity, Weakness, and Osteoporosis. Record review of the Minimal Data Set (MDS) with an Assessment Reference Date (ARD) of 11/10/2023 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident was cognitively intact.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, record review, and facility policy review, the facility failed to implement a care plan for a trapeze bar for (Resident #81), a side rail use care plan for (Resident #1), and a care plan for two handle adaptive cups for (Resident #41 and Resident #60) for four (4) of 29 resident care plans reviewed. Findings include: Review of the facility policy titled, Comprehensive Care Plans, revealed Policy: It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that identified in the resident's assessment . Resident #1 Review of the care plan titled, LTC (Long-Term Care) Falls IPOC (Individual Pan of Care), last updated 9/28/23, revealed Interventions: upper side rails ½ x (time) (2) two activated 9/28/23 . On 12/12/23 at 10:30 AM an observation revealed Resident #1 lying in bed with side rails up times four (4). A review of the care plans for Resident #1 with Registered Nurse (RN)/ Charge Nurse #2 on 12/13/23 at 2:35 PM, she revealed Resident #1 was to have the bilateral upper side rails up only and confirmed staff were not following his care plan. An interview with Certified Nurse Assistant (CNA) #3 on 12/13/23 at 2:55 PM, she revealed after review of Resident #1's [NAME] profile report, he should only have two side rails up on his bed. CNA #3 confirmed she did put all four side rails up because she felt that is what the sister would want to keep him safe. CNA # 3 confirmed she did not follow the plan of care for Resident #1. Review of the Profile History report for Resident #1 revealed, ADLS-upper side rails ½ x (2) two. An interview with the Director of Nursing (DON) on 12/13/23 at 3:00 PM, she confirmed staff were not following the care plan for Resident #1 regarding side rails and revealed the purpose of the care plan is to direct resident specific care and failing to follow the plan of care may result in the incorrect care of a resident. Record review of the LTC (Long-Term Care) Order Review /Renewal Form Resident #1 was admitted by the facility on 1/25/19 with diagnoses of Epilepsy and recurrent seizures, Cerebral palsy, and other abnormal involuntary movements. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 11/02/23, revealed that Resident #1 had a Brief Interview of Mental Status (BIMS) score of 5 which indicated that he was severely cognitively impaired. Resident #81 Review of the care plan titled, LTC ADL Rehab (Rehabilitation) IPOC, last updated 11/07/23, revealed Interventions: Trapeze bar to increase mobility in bed. A review of the Activities of Daily Living (ADL) care plan with Registered Nurse (RN)/Charge Nurse # 2 on 12/13/23 at 2:46 PM, she revealed Resident #81 had a Trapeze bar to increase mobility in bed added to his plan of care as starting 11/7/23 and confirmed there was not a trapeze bar on Resident #81's bed. An interview with the Director of Nursing on 12/13/23 at 3:40 PM, she confirmed staff were not following the care plan related to the trapeze bar for Resident #81. Review of the LTC (Long-Term Care) Order Review /Renewal Form Resident #81 was admitted by the facility on 5/28/20 with diagnoses of Hemiplegia of left nondominant side and Cerebrovascular accident. Record review of the MDS Section C with an ARD of 11/02/23, revealed that Resident # 81 had a BIMS score of 12 which indicated that he was moderately cognitively impaired. Resident #41 Record review of Resident #41's Nutritional Care Plan revealed, ADAP (adaptive) equip (equipment):2 handled cup . An observation of Resident # 41 during lunch meal on 12/12/23 at 11:57 AM revealed the resident being fed by staff. 8 ounces of iced tea and water provided in a clear plastic cup along with a bottled Ensure. Observation did not reveal a 2-handled cup for the lunch meal. Record review of Resident #41's Physician Order Review/Renewal revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Anxiety, Alzheimer's Disease, Cerebrovascular Disease, Major Depressive Disorder and Self-Care Deficit. Record review of the MDS with an ARD of 11/9/23 revealed under section C, a BIMS summary score of 3, indicating Resident #41 is severely cognitively impaired. Resident #60 Record review of Resident #60's Nutritional Care Plan revealed, Handled cup with lid per occupational therapy (OT) rec (recommendations) . An observation of Resident # 60 during a lunch meal on 12/12/23 at 11:52 AM, revealed the resident feeding herself ice cream. 8 ounces of iced tea and water provided in a clear plastic cup, along with a 12 ounce can of sprite and a bottled Ensure. Observation did not reveal a handled cup for the lunch meal. An interview with the Registered Dietician (RD) on 12/12/23 at 12:05 PM, confirmed that the handled cup for Resident #41 and #60 should have been sent out by the Dietary Department with the lunch meal. An interview with the Director of Nursing (DON) on 12/15/23 at 8:36 AM confirmed that the facility did not follow the care plan for Resident #41 and #60's 2-handled cup with meals. An interview with the MDS Nurse on 12/15/23 at 9:10 AM revealed the purpose of the care plan was to provide the staff with guidelines for resident care. She revealed that if it's on the care plan, it should be done. She confirmed that Resident #41 and Resident #60's care plan was not followed for the 2 handled cup with meals. Record review of Resident #60 LTC Physician Order Review/Renewal revealed the resident was admitted to the facility on [DATE] with diagnosis that included Dementia, Rheumatoid Arthrirtis and Pressure ulcer stage 1. Record review of the MDS with an ARD of 10/13/23 revealed a BIMS score of 07, indicating Resident #60 had severe cognitive impairment.

Based on staff interview, record review and facility policy review the facility failed to follow physician orders for a resident with side rails for one (1) of 27 sampled residents (Resident # 1). Findings include: A statement provided on facility letter head revealed, We do not currently have a policy on Following Physician Orders. Review of the Job Summary for Registered Nurses (RN) and Licensed Practical Nurse (LPN) provided by the Administrator in Training revealed, Duties and Responsibilities: Follows physician's orders in giving nursing care. An observation on 12/12/23 at 10:30 AM revealed Resident #1 lying in bed with side rails up times four (4). A review of the LTC (Long-Term Care) Order Review /Renewal Form revealed a physician's order for Resident #1 dated 9/28/23, upper side rails 1/2 x 2 (two) due to DX (diagnosis) of seizures and cerebral palsy with spastic involuntary movements. Review of the Bed Rail Use Assessment Form dated 9/8/23 and 12/5/23 for Resident #1 revealed, Recommended type: ½ length rail -left, right upper. A review of the physician's orders for Resident #1 with Registered Nurse (RN)/Charge Nurse #2 on 12/13/23 at 2:35 PM, she revealed Resident #1 was to have the bilateral upper side rails up only. An observation at the same time of Resident #1 with RN /Charge Nurse #2 she confirmed that Resident #1 had all 4 side rails up on his bed and stated he should not have all four rails up. She then revealed staff were not following the physicians order plan placed the resident at increased risk of injury with the use of the four rails. An interview with the Director of Nursing (DON) on 12/13/23 at 3:00 PM, she revealed Resident #1 should only have his top two side rails up and confirmed staff were not following the physician's orders placing the resident at increased risk for injury. Review of the LTC Order Review /Renewal Form Resident #1 was admitted by the facility on 1/25/19 with diagnoses of Epilepsy and recurrent seizures, Cerebral palsy, and other abnormal involuntary movements. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 11/02/23, revealed that Resident #1 had a Brief Interview for Mental Status (BIMS) score of 5 which indicated that he was severely cognitively impaired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview, record review and facility policy review the facility failed to accommodate a residents mobility needs for (1) one of (3) three sampled residents reviewed for mobility needs. Resident #81 Findings include: Review of the facility policy titled, Use of Assistive Device, revealed, Policy: The purpose of this policy is to provide a reliable process for the proper and consistent use of assistive devices for those residents requiring equipment to maintain or improve function and/or dignity . Policy Explanation and Compliance Guidelines: 1.) Assistive devices are tool, products, types of equipment, or technology that may help individuals perform tasks and activities . An interview with Resident #81 on 12/12/23 at 11:28 AM, he revealed the first part of November someone came and took his side rails off and stated he used the rails to help the staff with turning and positioning him and the staff said they can't use bed rails anymore. An observation at that same time revealed no side rails on Resident #81's bed. An interview with Resident #81 on 12/13/23 at 3:15 PM, revealed that a staff member he did not know came in earlier and asked about his trapeze bar for his bed and said she would make sure he got one put on the bed. Resident #81 then stated, I forgot the staff told me back in November when my side rails were taken off that they were going to put a trapeze bar on my bed and that was over a month ago. The resident confirmed he did tell staff he would try the trapeze bar to help with moving in bed. An interview with Registered Nurse/Charge Nurse (RN) #2 on 12/13/23 at 2:46 PM revealed Resident #81 should have a Trapeze bar to increase mobility in bed as of 11/7/23. An observation of Resident #81's bed RN/Charge Nurse #1 confirmed there was not a trapeze bar to the bed. An interview with the Maintenance Supervisor at 3:10 PM, he revealed had not received a requisition to apply a trapeze bar to Resident #81's bed. A record review of the requisitions submitted for November 2023 revealed no requisition for a trapeze bar. An interview with the Director of Nursing on 12/13/23 at 3:40 PM, she confirmed that Resident #81 should have had a trapeze bar applied to his bed on 11/7/23 when the side rails were removed to aide in his bed mobility and somehow it got missed and revealed a concern from not applying the trapeze bar is Resident #81 may have a decline in bed mobility status and would not be able to assist in his care. An interview with the Administrator on 12/14/23 at 9:20 AM, he revealed nursing staff was instructed to assess all residents using side rails to determine their needs. He confirmed Resident #81 should have had a trapeze bar placed on his bed to assist in his bed mobility and a physicians order should have been added for tracking instead of just adding the trapeze as an intervention. The Administrator confirmed the facility did not provide the equipment to accommodate the resident's bed mobility needs. An interview with RN #3 on 12/15/23 at 8:33 AM, she revealed she initiated the trapeze order for Resident # 81 because she thought the resident would benefit from the trapeze bar and confirmed she should have followed up to ensure the resident got the trapeze bar but did not. Review of the LTC (Long-Term Care) Order Review /Renewal Form revealed the resident was admitted to the facility on [DATE] with diagnoses of Hemiplegia of left nondominant side and Cerebrovascular accident. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 11/02/23, revealed that Resident # 81 had a Brief Interview of Mental Status (BIMS) score of 12 which indicated that he was moderately cognitively impaired.

Based on resident and staff interview, record review and facility policy review the facility failed to accommodate hydration needs for a resident when a water pitcher was not in accessible reach of the resident for (1) one of 109 residents with water pitchers. (Resident # 50) Findings include: Review of the facility policy titled, Hydration, revealed Policy: Water will be placed where it is easily accessible to the resident. During an observation down Hallway 1 on 12/12/23 at 10:25 AM, Resident #50 was overheard hollering out for help from his room. Upon entering the room Resident #50 was observed sitting in a reclining wheelchair. When asked if he needed help, the resident stated, I need some water. The water pitcher was located on a bedside table that was across the room from where the resident was sitting in his chair. The State Agency went directly to the nurse station and notified a staff member that Resident #50 requested a drink of water. She replied, We'll get him some. During the continued initial survey rounds on 12/12/23 at 10:45 AM, Resident #50 was heard from the hallway stating, I'm so thirsty so thirsty somebody please get me some water. Upon entrance to the room Resident #50 revealed again he could not reach his water pitcher and needed someone to get it for him because he is unable to get it. An observation revealed the water pitcher was sitting on the bedside table across the room from the resident. An observation and interview with Registered Nurse (RN) #3 on 12/12/23 at 10:48 AM, she confirmed Resident #50 was unable to reach his water pitcher and was unable to propel his wheelchair and get to the water pitcher. RN #3 also confirmed Resident #50 is capable of of drinking from the water pitcher independently and the water pitcher should have been placed in residents reach at all times and the revealed concerns from the resident not having his water in reach is that it placed the resident at risk for increased thirst and possibly dehydration. An interview with the Director of Nursing on 12/13/23 at 2:45 PM, she revealed Resident #50 should have had his water pitcher always placed in his reach. She confirmed by not having the water pitcher in reach staff were not meeting the residents needs and placed the resident at increased risk for dehydration. Review of the LTC (Long-Term Care) Order Review /Renewal Form Resident #87 was admitted by the facility on 11/07/19 with diagnoses of Self- Care deficit and at risk for deficient fluid volume. Record review of the Minimum Data Set (MDS) Section C with an Assessment Reference Date (ARD) of 11/08/23, revealed that Resident # 50 had a Brief Interview for Mental Status (BIMS) score of 11 which indicated that he was moderately cognitively impaired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy review the facility failed to provide a PEG (percutaneous endoscopic gastrostomy) tube feeding as ordered for one (1) of five (5) residents with PEG tubes observed during survey. Resident #54. Findings include: A review of the facility policy titled Standard Guidelines for Enteral Nutrition, revealed, .Provide the enteral feedings as ordered. An observation, on 12/13/23 at 7:30 AM of Resident #54's feeding pump at bedside, is observed as being turned off at that time. No feeding was infusing at the current time and the bag was empty. The feeding bag hanging had the date of 12/12/23 and 1700 written on it. An interview, on 12/13/23 at 7:35 AM with Licensed Practical Nurse (LPN) #1 confirmed that the bag hanging had 12/12/23 1700 written on it and that it is empty and that the pump is cut off. LPN #1 confirmed that the resident not having his feeding could cause him to be dehydrated or have weight loss. A record review of Resident #54's Physician Order revealed .Jevity 1.5 at 60ml(milliliters)/hour continuous via PEG. An interview, on 12/13/23 at 8:15 AM, with LPN #1 confirmed that she had just hung the Jevity 1.5 at 60cc/hour. LPN stated, There wasn't any feeding at the nurse's station, we had to get it from the kitchen, and they just brought it to the nursing station. LPN #1 stated, I called the night nurse, LPN #2 to see when the feeding ran out and she said it ran out at 6:00 AM on 12/13/23 and that she didn't have any more to put in the bag because the kitchen had not brought the feeding to the nurse's station. An interview, on 12/13/23 at 3:30 PM with the Administrator in Training (AIT), confirmed that Resident #54 should receive Jevity 1.5, 60cc/hour continuous. AIT stated They should have ordered the Jevity 1.5 from the kitchen on 12/12/23 so that they would not run out. AIT confirmed that the nurses also have a key to the kitchen so they could have gone and got it themselves from the kitchen. An interview on 12/14/23 at 3:15 PM with Registered Dietician (RD), regarding the weight loss for the resident and she stated that the resident had a 180-day weight loss of 15 percent. The RD stated that the weight loss occurred before the resident received his peg tube on 09/29/23 and the resident has not had any weight loss in the last month. An interview, on 12/14/23 at 6:00 PM with LPN #3 confirmed that she had placed 3 cans of Jevity 1.5 (711 milliliters) in his bag for his peg feeding at approximately 5:00 PM on 12/12/23 and that it should have lasted approximately 12 hours. An interview on 12/14/23 at 6:30 PM with LPN #2 confirmed that Resident #54's feeding pump ran out of feeding at approximately 6:00 AM on 12/13/23 and that the feeding that was ordered from the kitchen had not come to the nursing station to refill the bag. A review of the LTC (Long-Term Care) Order Review /Renewal form for Resident #54 revealed that he was admitted to the facility on [DATE] with diagnoses chronic obstructive pulmonary disease, constipation, and vascular dementia. Record review of the Minimal Data Set (MDS) with an Assessment Reference Date (ARD) of 10/26/23 revealed a Brief Interview for Mental Status (BIMS) score of 04 which indicated Resident #54 was severely cognitively impaired.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, record review and facility policy review, the facility failed to provide a resident with a handled cup for drinking during mealtime for two (2) of eight (8) residents observed with adaptive equipment for dining. Resident #41 and Resident #60 Findings Include: Record review of the facility policy titled Adaptive Eating Devices undated revealed, Policy: Adaptive eating equipment devices are available for those residents needing them . Adaptive devices in use are sanitized and provided for each meal. Adaptive devices are noted on each resident Tray Ticket and in the medical record . Resident #60 Record review of Resident #60's lunch meal ticket provided with the meal dated 12/12/23 revealed, Handled cup with lid. An observation of Resident # 60 during a lunch meal on 12/12/23 at 11:52 AM, revealed the resident feeding herself ice cream. 8 ounces of iced tea and water provided in a clear plastic cup, along with a 12 ounce can of sprite and a bottled Ensure. The observation did not reveal that the resident had a handled cup for the lunch meal. An interview on 12/12/23 at 11:53 AM, with Registered Nurse (RN) #5, confirmed that Resident # 60 did not have a handled cup with the lunch meal. She revealed that the Dietary Department was responsible for sending out the adaptive equipment with the meal tray. She revealed the purpose of the resident having a handled cup was to make it easier for the resident to hold the cup independently. Record review of the Occupational Therapy (OT) Evaluation and Plan of Care for Resident # 60 dated 9/28/23 revealed, Patient will safely utilize and 2- handled mug and standard straw with Set-up and occasional Verbal Cues in order to increase (I) independence with self feeding tasks. Record review of Resident #60's Physician Order Review/Renewal revealed, an order dated 8/18/23, .handled cup with lid per OT (Occupational Therapy) rec (recommendation) . Record review of Resident #60's Physician Order Review/Renewal revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Dementia, Rheumatoid Arthritis and Chronic Obstructive Pulmonary Disease. Record review of the MDS with an ARD of 10/13/23 revealed under section C, a BIMS summary score of 7, indicating Resident #60 is severely cognitively impaired. Resident #41 Record review of Resident #41's lunch meal ticket provided with the meal dated 12/12/23 revealed, 2-handled cup with lid . An observation of Resident # 41 during lunch meal on 12/12/23 at 11:57 AM revealed the resident being fed by staff. 8 ounces of iced tea and water provided in a clear plastic cup along with a bottled Ensure. The observation did not reveal that the resident had a 2-handled cup for the lunch meal. An interview with Certified Nurse Aide (CNA) #4 on 12/12/23 at 11:59 AM, confirmed that Resident # 41 did not get a 2-handled cup with the lunch meal. Record review of Resident #41's Physician Order Review revealed, an order dated 1/22/21, . ADAP (adaptive) equip (equipment); 2 handled cup with meals per resident request . Record review of Resident #41's Physician Order Review/Renewal revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Anxiety, Alzheimer's Disease, Cerebrovascular Disease, Major Depressive Disorder and Self-Care Deficit. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/9/23 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 3, indicating Resident #41 is severely cognitively impaired. An interview with the Registered Dietician (RD) on 12/12/23 at 12:05 PM, confirmed that the handled cup for Resident # 41 and Resident #60 should have been sent out by the Dietary Department with the lunch meal. She revealed if it's ordered on the meal ticket, the resident should have it during meals. She revealed that the Occupational Therapy (OT) Department recommends adaptive equipment for the residents to be able to feed themselves as much as possible. An interview with Dietary Department #3 on 12/14/23 at 9:05 AM, revealed the purpose of Resident #41 and Resident #60 having a handled cup was to allow the residents the ability to hold the cup and drink themselves. She revealed that the cups were ordered by the Occupational Therapist (OT) and should be sent with every meal. She confirmed that it was the Dietary Department's responsibility to provide the adaptive equipment as ordered. An interview with the Director of Nursing (DON) on 12/15/23 at 8:36 AM revealed the facility did not have any special monitoring to ensure the residents were getting adaptive equipment with meals. She revealed the Certified Nurse Aides (CNA's) were to look to see if it was provided with the meal and if not, will alert the kitchen that it was not provided.

Based on observations, resident and staff interviews, record review and facility policy review, the facility failed to address a grievance discussed in resident council for the use of bed rails for five (5) of 12 residents that attended resident council. Resident #15, Resident #27, Resident #37, Resident #61, and Resident #66. Findings Include: Record review of the facility policy titled Resident and Family Grievances undated revealed under, Policy Explanation and Compliance Guidelines: . 8. Grievances may be voiced in the following forums: . d. Verbal complaint during resident or family council meetings . An interview with the Resident Council President (Res #27) on 12/12/23 at 12:25 PM, revealed that the residents had discussed the facility's removal of the bed rails during a previous meeting. She revealed that most of the residents want them back so that it would make it easier for them to move from side to side and turn themselves in the bed. Record review of the Resident Council meeting minutes dated 11/01/23 revealed 12 residents discussed being upset about rails being taken off their beds and a desire to have them back. Record review of the 2023 Grievance Log revealed no grievances were documented related to bed rails. The Resident Council meeting was held on 12/13/23 at 3:00 PM with 12 active resident council members present. Residents #15, Resident #27, Resident #37, Resident #61 and Resident #66 revealed their biggest concern was the facility removed all the bed rails. Resident #66 revealed she relied on her bed rails for safety, turning over in bed and pulling herself up. She revealed that now she must lie one way once she's in the bed and was unable to turn over. She revealed she had to grab onto the mattress for repositioning in bed and the entire mattress moved, which she stated was unsafe. Resident #61 revealed he wanted his side rails for turning over in bed and to assist him with getting out of bed. Resident #15, Resident #27 and Resident #37 revealed they also depended on their side rails to turn over in bed and to stay pulled up in the bed. All residents agreed they had discussed the bed rail issue with multiple staff members during a previous resident council meeting. Resident # 37 revealed she was told by staff that they had to remove them by law because they could not have anything that confined them. Resident #100 that was in attendance revealed they were told it was a state guideline that the facility was unable to allow bed rails. The residents all voiced that the facility went throughout the entire building, removing all the bed rails except for a few and they wanted them back. An interview with Social Services (SS) #1 on 12/14/23 at 9:10 AM revealed she did not attend any recent resident council meetings and no concerns had been brought to her attention out of the meetings. She revealed the residents come to her with any problems and she will initiate a grievance report. She revealed the facility held meetings where they discussed the status of the grievances and how it was handled. She stated that Resident #27 had come to her after the bed rails were removed and requested an explanation. The resident revealed to her that she needed the bed rails to turn herself in bed and to assist with getting out of bed. SS #1 revealed that the nursing department explained to the resident why the bed rails had been removed, and the resident never returned to her to voice a complaint. She stated that a grievance had not been entered for any of the residents that voiced their concerns with the removal of the bed rails in the resident council meeting dated 11/01/23. She confirmed that issues or concerns discussed in resident council that had not been addressed and resolved should be considered an unresolved grievance. An interview with Activity Director #1 on 12/14/23 at 9:05 AM, revealed that she was aware of the residents' concerns regarding removal of bed rails. She confirmed that she was present in the meeting on 11/01/23 when the residents discussed that they needed the rails for getting up, pulling themselves up and rolling over in bed. She revealed that a list was made of the residents that requested to have their rails back, and it was given to the Director of Nursing (DON). She confirmed that the residents' voiced concerns should have been written up as a grievance and acted upon. An interview with the Administrator in Training (AIT) on 12/14/23 at 10:03 AM, confirmed that the residents' concerns related to the removal of bed rails discussed in a previous resident council meeting should have been written up as a grievance. She acknowledged that issues and concerns that are mentioned in resident council that have not been addressed by the facility should be considered an unresolved grievance. She revealed that the facility misinterpreted the information that was provided to the facility related to bed rail usage and removed the residents' bed rails thinking they were doing the right thing and now realize they were not. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/27/23 revealed under section C, a Brief Interview for Mental Status (BIMS) summary score of 13, which indicates that Resident #15 is cognitively intact. Record review of the MDS with an ARD of 11/15/23 revealed under section C, a BIMS summary score of 14, which indicates Resident #27 is cognitively intact. Record review of the MDS with an ARD of 11/28/23 revealed under section C, a BIMS summary score of 15, which indicates Resident #37 is cognitively intact. Record review of the MDS with an ARD of 9/26/23 revealed under section C, a BIMS summary score of 14, which indicates Resident #61 is cognitively intact. Record review of the MDS with an ARD of 10/09/23 revealed, under section C, a BIMS summary score of 15, which indicates Resident # 66 is cognitively intact. Record review of the MDS with an ARD of 12/12/23 revealed under section C, a BIMS summary score of 15, which indicates Resident #100 is cognitively intact.

Based on observation, staff interviews, and facility policy review, the facility failed to ensure food items in the kitchen refrigerators were dated and labeled and failed to ensure kitchen equipment was clean for two (2) of three (3) kitchen tours. Findings Include: Record review of the facility policy titled, Food Storage undated, revealed Food is stored, prepared and transported at appropriate temperatures and by methods designed to prevent contamination or cross contamination .13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 3 days or discarded. f .Meat, fish, and poultry should be stored on lower shelves . Record review of the facility policy titled, Ice undated, revealed, Ice will be produced and handled in a manner to keep it free from contamination .2. Ice machines will be maintained in a clean and sanitary condition to prevent ice contamination. Record review of the Weekly Cleaning Schedule, undated, revealed under Task to be completed, 3 compartment Refrigerator, 2 compartment Refrigerator. No Date/initials were recorded on the schedule. An observation and interview during the initial tour of the kitchen on 12/12/23 at 10:00 AM, with Dietary worker #1 revealed a 2-compartment refrigerator with two (2) opened, undated 5-pound (lb) containers with a manufacturing label of Tuna Salad. An undated 5 lb clear container with a manufacturer label of Chicken Salad. A 5 lb opened and undated clear container with a manufacturer label of Pimento cheese. A bag of rolls identified by Dietary Worker #1, that was unlabeled and undated. Dietary Worker #1 confirmed these food items are always supposed to be dated and labeled. She revealed foods out of date could make a resident sick. The inside of the refrigerator was noted with food substances on the bottom of the refrigerator. Dietary Worker #1 confirmed the inside of the refrigerator needed to be cleaned. She revealed no cleaning schedule is being used but revealed we need to use one to make sure things are getting done. An observation of the three (3) compartment refrigerator revealed a half tomato identified by Dietary Worker #1 wrapped in clear plastic wrap was unlabeled and undated. She revealed this needs to go into the trash. A large clear bag was identified by Dietary Worker #1 as cheddar cheese with no label or date. A brown shipping box with no label or date was observed sitting on the third shelf of the refrigerator, Dietary Worker #1 identified the food as a thawing turkey. She revealed this shouldn't be on this shelf but should be on the bottom shelf and should be labeled and dated. A rectangular metal pan unlabeled and undated, Dietary Worker #1 identified the food as chopped turkey. She confirmed this should be labeled and dated so we know how long it's been here. An observation of the bottom of the refrigerator was noted with dried and liquid substances throughout. The outside of the refrigerator was noted with dried substances and smudges. Dietary Worker #1 confirmed this refrigerator needs a good cleaning also. An observation inside the ice maker revealed the white plastic covering was noted with black and brown speckled substances. Dietary Worker #2 revealed maintenance is supposed to clean the inside of the ice makers. We wipe down the outside. She confirmed there was a black and brown substance inside of the icemaker and revealed that it shouldn't be there, and she wasn't sure when it was last cleaned. During an interview and observation on 12/13/23 at 9:50 AM, the Dietary Manager (DM) revealed I was out yesterday, but they told me of the stuff that was found. The DM revealed there is a cleaning schedule, but we don't use it. The staff know they are supposed to keep the equipment clean and the food items are always to be labeled and dated. During an observation of the ice maker, the DM confirmed there were black and brown specks of substance. He revealed I'm not sure when it was last cleaned but it needs to be cleaned. He revealed he is ultimately responsible for ensuring the kitchen equipment is kept clean and that includes the ice maker. He revealed maintenance is responsible for cleaning it monthly. During an interview and observation on 12/13/23 at 10:00 AM, the Maintenance Supervisor revealed it is the responsibility of the maintenance department to clean and sanitize the ice maker monthly. He confirmed that the ice maker had a lot of black substances inside and revealed it looked like mold. He confirmed it doesn't look like it has been cleaned in a while. During an interview and observation on 12/13/23 at 10:10 AM, Maintenance Worker #2 confirmed that we are responsible for cleaning the inside of the ice maker monthly. He confirmed that the ice maker doesn't look clean and that the black substance throughout the top looks like mildew. He confirmed, I guess I didn't clean it and it could potentially cause sickness to a patient. An interview and record review of the cleaning schedule on 12/14/23 at 11:00 AM, the DM confirmed all kitchen equipment is on the cleaning schedule form, but we haven't been using the form. He revealed it's the responsibility of all the dietary workers to clean the equipment but ultimately, it's my responsibility to make sure that everything is in place to ensure the tasks are completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident # 84 Record review of the Final Report Transfer Orders and Notification revealed Resident #84 was discharged to the hospital on [DATE]. Record review revealed there was no written notification of transfer/discharge sent to the resident or the resident representative for Resident # 84. Record review of the patient information sheet revealed Resident #84 was admitted to the facility on [DATE]. Resident # 78 Record review of the Electronic Medical Records (EMR) revealed that Resident #78 was admitted to the facility on [DATE]. Record review of the Final Report Transfer Orders and Notification revealed that Resident #78 was discharged to the hospital on [DATE]. Record review revealed that there was no written Transfer/Discharge notification sent to Resident # 78 or the resident representative. Resident #66 An interview on 08/22/22 at 08:08 PM, with Resident # 66 revealed she had been in the hospital not long ago and she thinks it was because she had pneumonia. An interview on 08/24/22 at 10:25 AM, with the DON revealed they were unaware of the regulation to send the resident representative a written notice of transfer/discharge and she confirmed that they have not been doing that. An interview on 08/24/22 at 1:34 PM, with Social Services # 1 confirmed she had not been sending a written notice of transfer/discharge to the responsible party. She revealed she was not aware that she needed to be sending them. She revealed she is not aware of a policy regarding this. An interview on 08/24/22 at 1:37 PM, with the DON confirmed the facility did not have a policy regarding sending a written notice to the resident representative or responsible party. On 08/25/22 at 12:15 PM, an interview with the Administrator confirmed the facility had not been sending written notice of transfer/discharge. He revealed he was confused and thought that the facilities bed-hold form covered the transfer/discharge notification. Record review of the patient information sheet revealed that Resident # 66 was admitted to the facility on [DATE] and discharged to the hospital on 7/4/2022 due to pneumonia. Record review revealed there was no written notice of transfer/discharge sent to Resident # 66's resident representative. Record review of Resident # 66's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/13/22 revealed a Brief Interview for Mental Status (BIMS) of 13, which indicated the resident is cognitively intact. Based on staff and resident interviews and record review the facility failed to provide the resident/resident representative with a written notice of transfer/discharge to the hospital for four (4) of (4) residents reviewed. Resident's #66, #67, #78 and #84. Findings Include Resident # 67 Record review of a typed statement on facility letterhead, signed by the Director of Nursing (DON) revealed, On August 24th, 2022, our Facility did not have a Written Transfer/discharge notice policy and/or form for resident being transferred/discharged from our facility. An interview with the Director of Nursing (DON) on 08/23/22 at 2:55 PM revealed Resident #67 was taken to the hospital on [DATE]. An interview with the DON on 8/24/22 at 10:25 AM, revealed the resident was transferred to the hospital. She confirmed the facility failed to provide a written notification of transfer to the resident's representative as required in the regulations. She revealed she was unaware of the requirement for a written notification of transfer. Record review of the Final Report Facility Transfer Orders and Notification dated 8/8/2022 by the Family Nurse Practitioner (FNP) revealed Resident #67 was transferred to the hospital. Record review revealed there was no written notice of transfer provided to the resident's representative. Record review of Resident #67's patient information sheet revealed the original admission date to the Skilled Care area of the facility was 07/08/22.

Based on interview and policy review, the facility failed to conduct an annual review of its Infection Prevention and Control Policies (IPCP). Four (4) of six (6) reviewed policies had not been reviewed and/or revised annually. Findings include: Review of the facility policy titled, Policy and Procedure Development and Maintenance, no date, stated the facility shall provide optimum quality patient care and services each department (clinical and nonclinical) shall develop, implement and maintain department specific policies and procedures that outline how the department assesses and meets the needs of the customer/patient population. Approval and Review Process are applied to policies in the policy manager to automatically prompt review by appropriate team members and disciplines depending on the content of the policy. The process is scheduled to promote regular review with most policies having a 12- or 24-month cycle between scheduled reviews. Review of the following policies and procedures titled, Immunization of Residents, Scabies, and Hand Hygiene had not been reviewed and/or revised for 2018. The policy and procedure titled, Immunization of Residents had last been reviewed and/or revised on 10/26/17, the policy and procedure for Scabies had last been reviewed and/or revised on 10/26/17, and the policy and procedure for Hand Hygiene had last been reviewed and/or revised on 10/27/17. Review of the policy and procedure titled, Transmission Based Precautions (Isolation) did not have a date on when the policy and procedure was last reviewed and/or revised. Interview with Infection Control Registered Nurse #1 on 5/9/19 at 1:27 PM, revealed she has been in her position as the Infection Control Nurse since April 2018. She stated she had not reviewed and/or revised any of the IPCP policies and procedures on a yearly basis. She stated she was unaware the IPCP policies and procedures needed to be reviewed yearly, rather had been instructed by the facility they had to be updated every two (2) years. Interview with the Director of Nurses on 5/9/19 at 1:47 PM, revealed she thought the policy and procedures for the IPCP needed to be reviewed and/or revised every two (2) years. Interview with the Administrator on 5/9/19 at 3:18 PM, revealed Infection Control Registered Nurse #1 should review the IPCP yearly and then forward on to the Administrative Team for final approval. He stated the clinical IPCP policies and procedures should be reviewed and/or revised yearly for any changes or updates.

Based on observation, interview and review of the facility policy on pest control, the facility failed to maintain an effective pest control program so that the kitchen was free of flies. This had the potential to increase the risk of illness for residents that received food from the facility kitchen. The facility's census was 159 and there were nine (9) residents documented with feeding tubes; this indicated 150 residents received food from the kitchen. Findings include: Review of the undated facility policy entitled, Pest Control, indicated, If pests are seen in the kitchen, the food service manager or appropriate staff shall be informed, describing where the pest was seen and when. Appropriate action will be taken to eliminate any reported pest situation in the department . If a pest situation is reported, the contractor comes in as soon as possible to spray at the appointed times. During observation on 5/9/19 at 9:00 AM, flies flew around the preparation area where lunch was being prepared. A fly landed on a ladle that hung with other food preparation equipment over the food preparation table. There were two (2) fly-catching devices in the kitchen. One (1) was on the wall near the restroom and the other near where the meat slicer sat on a preparation table. Neither fly-catching devices were plugged in. The AC cord for the one near the restroom hung down along the wall with its prongs near the electrical outlet. The AC cord for the fly-catching device near the meat slicer had its cord on the food preparation table with part of it running under the meat slicer. During an interview on 5/9/19 at 9:30 AM, [NAME] #1 said she had seen flies in the kitchen at other times. In an interview on 5/9/19 at 9:33 AM, [NAME] #2 said she had seen flies in the kitchen at other times. She said she did not know why the devices on the walls to catch flies were not plugged in. She said she had seen them plugged in before. In an interview on 5/9/19 at 12:30 PM, the Dietary Manager indicated the fly-catching devices should be plugged in. The one by the restroom may have been knocked out by a food cart passing by and the one by the meat slicer may have been unplugged when staff was working with the meat slicer earlier. In an interview on 5/9/19 at 12:30 PM, the Service Representative for pest control indicated that the fly-catching device had to be plugged in and lit 24 hours per day and seven (7) days per week (24/7) in order to be effective. He indicated they were unplugged every month when he came to service the kitchen. He would replace the glue boards in the fly traps each month. The blue lamps in the fly trap attracted the flies and they get stuck to the glue board. Review of the customer service reports showed the facility kitchen had been serviced for flies on 8/28/18, 10/16/18, 12/19/18, 1/16/19, 2/28/19, 3/20/19 and 4/17/19. However, the reports did not reflect the catching machines were not plugged in at the time of service. In an interview on 5/9/19 at 1:00 PM, the Administrator indicated the issue with the fly traps not being plugged in was going to be eliminated by perhaps hardwiring the devices.