**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide trauma informed care for one sampled resident (Resident #37) with a diagnosis of Post-Traumatic Stress Disorder (PTSD, a mental health condition that is triggered by a terrifying event). This affected one of 15 sampled residents. The facility census was 58. Review of the facility policy, Trauma Informed Care, dated 09/06/24 showed: -Based on the comprehensive assessment of a resident, this facility must ensure that residents who are diagnosed with a mental disorder or who have a history of trauma/or PTSD, receive appropriate treatment and services to attain the highest practicable mental and psychosocial wellbeing; -Trauma informed care is an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma; -A trauma informed approach to care recognizes the widespread impact and signs and symptoms of trauma in residents and incorporates knowledge about trauma into care plans, and practices to avoid re-traumatization; -The facility should collaborate with the resident's family, friends and any other health care professionals to develop and implement and individualized plan of care with interventions; -In situations where a trauma survivor is reluctant to share his/her history, the facility should still attempt to identify triggers which may re-traumatize the resident and develop interventions which minimize or eliminate the effect of the trigger on the resident. 1. Review Resident #37's Quarterly Minimum Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 01/14/25, showed: -No cognitive impairment; -Independent for Activities of Daily Living (ADLs); -Takes antipsychotic, (a class of psychiatric drugs prescribed to treat mental health conditions), medication on a routine basis; -Diagnoses included, PTSD, schizophrenia, depression and anxiety. Review of the resident's care plan dated 02/13/25, showed: -Physically aggressive toward staff; -Refuses to take all medications; -At risk of change in mood or behavior. -There was no care plan regarding PTSD or staff interventions. Review of the resident's medical record showed: -Resident admitted on [DATE] with a history of adult physical abuse confirmed during a subsequent encounter; -Behavior note dated 11/11/2024, at 12:36 A.M., the resident yelled out most of the night. Resident observed yelling at the T.V. Staff attempted to talk to the resident. The resident asked staff to leave the room and not return. The staff left the room and the resident could still be heard yelling through the night; -Behavior note dated 4/24/2025 at 03:35 P.M., the resident refused to take medication this morning and refused to eat lunch. Staff went into resident's room to check on him/her. The resident wouldn't talk to the staff; -Event note dated 11/01/2025 at 03:18 P.M., the resident is hollering out. The staff went into the resident's room and the resident was setting on the floor; -Physician's Order Sheet (POS) dated April 2025, showed a diagnosis of PTSD. Observation and interview on 04/23/25 at 08:43 A.M., showed: -The resident's door was closed; -Upon entering the room the resident lay in bed in with his/her eyes open; -The resident said he/she is not from this town and then spoke unintelligible words at a fast rate of speed. Observation and interview on 04/24/25 at 11:18 A.M., showed: -The resident's door was closed; -Upon entering the room the resident lay in bed in with his/her eyes open; -The resident would not speak; -The resident looked at the ceiling and then said leave and shut the door. During an interview on 04/24/25 at 02:28 P.M., Certified Nurse's Aide (CNA) A said: -He/She did not know the resident had a diagnosis of PTSD; -The resident yells out at times and spends a lot of time in his/her room; -The resident can be heard yelling in his/her room and when the staff check on him/her the resident tells them to leave; -Sometimes the resident will refuse lunch; -The resident has attempted to hit another resident before; -The resident's care plan should include a diagnosis of PTSD and what upsets them; -Staff should know what triggers or upsets the resident; -The staff should know how to de-escalate the resident. During an interview on 04/24/25 at 02:42 P.M., CNA B said: -There are no longer any residents at the facility with a diagnosis of PTSD; -He/She was not aware the resident had a diagnosis of PTSD; -The resident's care plan should have the trauma history and what the resident's triggers are; -He/She did not know what the resident's triggers were or how to mitigate them. During an interview on 04/25/25, at 08:56 A.M., LPN A said: -The resident stays in his/ her room most of the time; -The resident has behaviors at times; -He/She was not aware the resident had a diagnosis of PTSD; -He/She did not know what the resident's triggers were; -The resident's diagnosis of PTSD should be care planned; -The resident's triggers and any interventions should be care planned; -The care plan determines how to care for the resident; -Staff could unintentionally trigger the resident if they do not know what his/her triggers are. During an interview on 04/25/25 at 09:23 A.M., the Resident's Guardian said: -The resident had a psychiatric stay on 09/13/23 and his/her assessment identified a history of PTSD; -He/She was notified by the facility on March 2024, that the resident hit another resident; -The facility said the resident was triggered by another resident and that is why he/she lashed out; -He/She expects the resident's diagnosis of PTSD to be on the resident's care plan; -He/She expects the staff to be able to identify the resident's specific triggers; -He/She expects the staff to know what specific interventions are required to mitigate triggers for the resident and de-escalate the resident. During an interview on 04/25/25 at 1:16 P.M. the Director of Nursing (DON) said: -She was not aware of Resident #37's PTSD diagnosis; -She expects the staff to look at the resident's care plan and know what triggers Resident #37; -PTSD should be included in Resident #37's care plan along with specify interventions; -The MDS Coordinator is responsible for updating the care plans; -The nurses add parts to the care plan if needed; -At the end of the day the MDS coordinator is responsible for adding PTSD to the care plan. During an interview on 04/25/25, at 1:20 P.M., the Administrator concurred with the DON.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide acceptable a sink accommodation for one resident (Resident #14) to the hot water at his/her sink and failed to provide transfer assistance for one resident so they could eat (Resident #156). This affected two of 15 sampled residents. The facility census was 58. Review of facility policy Activities of Daily Living (ADLs), revised 2/12/24, showed: - The resident will receive assistance as needed to complete ADLs. - Any change in the ability to perform ADLs will be reported to the nurse; - Assist residents with bed repositioning as necessary to promote good body alignment; Review of facility policy Resident Rights, revised 9/10/24, showed: - The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services; - The resident has the right to reside and receive services in the facility with reasonable accommodation of resident and preferences; - The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely; 1. Review of Resident #14's Quarterly minimum data set (MDS), a federally mandated assessment tool completed by facility staff, dated 2/18/25, showed: - Resident is cognitively intact; - Resident is dependent on a wheelchair for mobility; - Resident has limited range of motion on both sides of body for the lower and upper extremities; - Resident requires set up assistance for eating and oral hygiene; - Resident is dependent for toileting, showering and dressing; - Resident requires substantial assistance by staff for personal hygiene; -Diagnoses: Cerebral Palsy. Review of Care Plan, revised 1/9/25, showed: - Resident requires up to total assist with ADLs due to Cerebral Palsy; - Resident has his/her own teeth. Place toothpaste on his/her toothbrush and provide basin. Resident is able to brush own teeth; - Staff should encourage resident to perform tasks that he/she is able to do, such as washing own face; - Resident uses an electric wheel chair for mobility and is able to propel self; - Resident is encouraged to make his/her room as home-like as possible; - Resident has Cerebral Palsy and has multiple contractures (rigidity of joints and shortening of tendons leading to deformity);His/her room has been adapted in some way to help resident remain as independent as possible. Staff should encourage resident to engage in activities that will help improve coordination and encourage resident to do as much for self as possible. Observation on 4/22/25 at 2:58 P.M. showed the resident's sink had an accommodation device attached to the cold-water facet of the reisdent's sink so that the resident could turn on the cold water independently. The hot water facet had no accommodation device attached that would allow the reisdent to turn on the hot water independently. During an interview on 4/25/25 at 10:13 A.M., the Resident said he/she would like to be able to use the hot water and have the choice between cold and hot like other residents. He/she is able to independently turn on the cold water because of the assistive device. He/she is unable to turn on the hot water because their is no assistance device. During an interview on 4/25/25 at 10:24 A.M., the Maintenance Supervisor said he was not aware that the resident could not utilize the hot water. Normally physical therapy will notify him if any adjustments or accommodations that need to be made for residents. He was sure he could install a device like the one installed on the cold water facet, that would allow the resident to be able to use the hot water. During an interview on 4/25/25 at 11:48 A.M., COTA (Certified Occupational Therapy Assistant) A said occupational therapy had done an assessment on the resident's room a few years ago and set them up with the accommodation to operate their cold water so the resident could brush own teeth. They never set the resident up with hot water because all they needed was cold water for teeth brushing. It would not be hard to put in another device on the sink so the resident could operate his/her hot water. Currently therapy provides care to help the resident with their arms which have restricted mobility. No assessment had been done to see if the resident can reach farther into the sink, other than to use own toothbrush. During an interview on 4/25/25 at 1:30 P.M., the Administrator and DON said: - Unless there's a safety issue involved all residents should have access to hot and cold water in their room; - Reasonable accommodations should be made so residents can operate the fixtures, drawers, and cabinets in their rooms; - Room assessments for accommodations are done by nursing staff and the therapy department; - There are no safety issues with Resident #14 that would prevent them from having hot water access in their room; 2. Review of Resident #156's Entry MDS, dated [DATE], showed: - No cognitive status assessment completed; - No functional abilities assessment completed; Review of resident admission record, dated 4/24/25, showed a diagnosis of Dementia and osteoarthritis (arthritis causing loss of mobility and stiffness). Review of the resident's Care Plan, dated 4/14/25, showed: - Resident chooses to eat meals in his/her room and eats independently. Staff should offer assistance when serving meal tray; - Resident will remain independent with transfers through next review date; - Resident has moderate cognitive impairment; - Staff should allow adequate time for resident to respond to questions. Do not rush and ask yes/no questions with simple, brief, consistent words; - Observe for physical/non-verbal indicators of discomfort or distress and follow up as needed; - Anticipate and meet resident's needs, assist with ADLs as needed; - Resident has an alteration in musculoskeletal status due to diagnoses of osteoarthritis. Observe and report complications related to arthritis such as stiffness which is usually worse on wakening, decline in mobility, or decline in self-care ability; Observation on 4/23/25 at 8:30 A.M., showed: - Resident lying on his/her back struggling to raise to a sitting position with a grimace of facial pain; - A bedside table with their breakfast tray sitting on it and out of reach for the resident; - Resident's call light is out of reach, underneath the resident's blanket which is turned down; During an interview on 4/23/25 at 8:32 A.M., the resident said: - Breakfast was delivered to his/her room about 15 minutes ago; - He/she was not provided any help getting out of bed and was very stiff and in pain; - The staff member who originally delivered his/her food came into room to check on his/her progress and said they would get help to get the resident out of bed; - The staff member did not push the call light to alert the nursing staff and exited the room; - The resident asked the surveyor for help to get out of bed; During an interview on 4/23/25 at 8:42 A.M., CMT B said he/she would notify the nursing staff to help the resident since he/she was currently engaged in passing medications to residents in the hall. Observation on 4/23/23 at 9:02 A.M., showed CNA F entering resident's room and helping him/her out of bed. During an interview on 4/23/25 at 10:57 A.M, CMT B said within 10 minutes of being notified that the resident needed help he/she told two CNAs and the charge nurse at the nurse's station about the resident's request for help. During an interview on 4/24/25 at 8:34 A.M., the resident said he/she again struggled to get out of bed this morning but he/she was able to do it after a while. Yesterday's breakfast was completely cold by the time they got to it and no one offered to replace his/her breakfast tray or to warm it up. During an interview on 4/25/25 at 1:30 P.M., the Administrator and DON said depending on other tasks and work assignments it normally should not take more than 15 minutes for staff to help transfer a resident from their bed so they can eat breakfast in their room. MO251239

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide personal funds and a final accounting within thirty days upon discharge for two residents (Resident #157, Resident #53). The facility census was 58. Review of the facility policy, Resident Trust Policy and Procedures, dated [DATE], showed: - Conveyance of Funds after Death of Resident: After fulfilling any other authorized payments, the facility shall provide any remaining resident funds and a final statement of the resident's fund activity to the individual or probate jurisdiction administering the resident's estate. These will be provided within thirty days of the resident's death. 1. Review of the facility's interim aging report, dated [DATE], showed the following residents had money in the facility's operating account: -Resident #157 discharged on [DATE], with a balance of $803.00. -Resident #53 discharged on [DATE], with a balance of $5,618.32. Review of Request for Resident Refund invoices showed: -On [DATE], Business Office Manager (BOM) submitted invoice #2096-1 to corporate office to refund $803.00. -On [DATE], BOM submitted invoice #2890-1 to corporate office to refund $5,618.32. During an interview on [DATE] at 9:30 A.M., the BOM said: - Resident #157's refund has been processed in the system but the check had not been released by corporate and that will occur at the end of the month; - Resident #53's overage was due to family paying rent one month ahead of time and there was a balance at the time of discharge. Corporate should have the check issued by end of month; - She said that refunds should be processed and sent to discharged residents or family members upon resident death within 30 days of discharge; - She has been in contact with the corporate office to get these refunds processed. During an interview on [DATE] at 1:30 P.M., the Administrator said refunds should be provided within 30 days for deceased and discharged residents when required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Do Not Resuscitate Order's (DNR, medical order that instructs the health care provider not to do resuscitative measures if a person's heart stops) for Resident #2 and Resident #24 were correct when the guardian's name was printed on the DNR instead of the name of the resident. This affected two of 15 sampled residents (Resident #2 and Resident #24). The facility census was 58. Review of the facility's policy titled, Advanced Directives and Advance Care Planning, dated, 09/26/24, showed: -Residents have the right to self-determination regarding their medical care; -This includes the right to direct his/her own medical treatment, including the right to execute or refuse to execute an advanced directive; -The MDS should reflect the appropriate advance directives; -This information is reviewed at least quarterly. 1. Review of the Resident #2's Quarterly Minimum Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 03/04/25, showed: -Moderate cognitive impairment; -Partial assist for Activities of Daily Living (ADLs); -Diagnoses included, dementia, anemia and high blood pressure. Review of care plan dated 01/09/25, showed: -ADL self care deficit related to dementia; -The resident had a DNR in place; -Code status will be reviewed every quarter Review of the resident's medical record showed: - On 1/26/24 a physician's order for Do Not Resuscitate; -DNR showed the name of the resident's guardian printed on the line reserved for the name of the resident; -The DNR form was signed by the resident's guardian on 11/11/22 and by the physician on 11/12/22. During an interview on 04/24/25 at 02:28 P.M., Certified Nurses Aide (CNA) A said: -The nurses or the Social Services Designee (SSD) take care of getting signatures for the DNR's; -The guardian signs the DNR if the resident is incapacitated; -The name of the resident should be printed on the line designated for the resident; -The guardian's name should not be printed on the line reserved for the resident. During an interview on 04/24/25, at 02:42 P.M., Licensed Practical Nurse (LPN) A said: -The resident does not make his/her own decisions; -The resident is a DNR code status; -The name of the resident should be printed on the line designated for the resident; -The guardian's name should not be printed on the line reserved for the resident. 2. Review of Resident #24's Annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Dependent for ADLs and transfers; -Diagnoses included dementia, anxiety and muscle weakness. Review of the resident's care plan dated 04/10/25, showed: -ADL self care deficit related to dementia; -The resident has a DNR; -Code status will be reviewed every quarter. Review of the resident's medical record showed: - On 05/20/20 a physician's order for Do Not Resuscitate; - DNR showed the name of the resident's guardian printed on the line reserved for the name of the resident; -The DNR form was signed by the resident's guardian and physician on 05/20/22. During an interview on 04/24/25 at 03:24 P.M., CNA B said: -The name of the resident should be printed on the line designated for the resident; -The guardian's name should not be printed on the line reserved for the resident; -SSD oversees the DNR forms. During an interview on 04/24/25, at 03:45 P.M., LPN B said: -The resident is a DNR code status; -The name of the resident should be printed on the line designated for the resident; -The guardian's name should not be printed on the line reserved for the resident; -SSD reviews the DNR forms. During an interview on 04/25/25 at 11:18 A.M., the SSD said: -She reviews the resident DNRs every quarter; -Resident #2 and Resident #24 are both DNR code status; -The DNR is not correct if the guardian's name is printed where the resident's name is indicated; -The responsible party signed the DNR's for Resident #2 and Resident #24 because both residents are incapacitated; -The name of the resident should not be printed on the line designated for the resident; -The DNR for Resident #2 and Resident #24 are not correct; -The DNRs for Resident #2 and Resident #24 should be correct. During an interview on 04/25/25 at 01:16 P.M. the Director of Nursing (DON) said: -The resident's name should be printed on their DNR not the name of the responsible party; -She expects the DNRs to be correct; -SSD in charge of making sure the DNRs are correct. During an interview o 04/25/25, at 01:20 P.M., the Administrator said: - She expects the name of the guardian should not be printed on the line designated for the resident; -The DNR for Resident #2 and Resident #24 are not correct; -She expects the DNRs for Resident #2 and Resident #24 should be correct.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain a clean and comfortable homelike environment. This had the potential to affect all residents. The facility census was 58. Review of the facility policy, Housekeeping Services, dated 06/04/24 showed: -The facility will provide a safe, clean and homelike environment; -The floors will be cleaned daily. Review of the facility policy, Home Like Environment, dated 06/12/24, showed: -The facility will provide a safe, clean and homelike environment; - It is the responsibility of all staff to create a homelike environment and promptly address any cleaning needs. 1. Observation on 4/23/25 at 9:34 A.M., showed: - Housekeeping completed their morning clean up of the dining room; - Handwashing station and near the standing flag in the dining room has large amounts of dirt and food debris on the floor; - Food debris and crumbs on the floor leading to the kitchen area from the dining room; - Food debris visible on the floor behind chairs lining the wall; During an interview on 4/23/25 at 9:40 A.M., Housekeeper A said: - He/she does the sweeping and moping of the dining room floor and they don't normally sweep in the corners daily, just the main part of the floor; - Monday's are deep cleaning days and that's when they work the sides of the room; 2. Review of Resident 8's admission MDS, dated [DATE], showed: - Resident is cognitively intact; - Diagnosis: Anemia, renal insufficiency (kidney impairment), diabetes, and schizophrenia; Observation on 4/24/25 at 12:45 P.M., Resident' room showed: - Loose dirt all along the closet and door entrance of resident's room; - Floor extremely worn with dented marks and embedded dirt spots throughout the room; During an interview on 4/24/25 at 12:50 P.M., the Resident said: - I would prefer my room was clean but housekeeping comes in and does the job as fast as they can so they can get the job done and get out without cleaning the floors properly. 3. Review of Resident #38's Quarterly MDS, dated [DATE], showed: - Resident has impaired cognition ; - Diagnosis: Coronary artery disease, anemia, diabetes, and depression; Observation of the Resident's room on 4/23/25 at 7:51 A.M., showed: - Multiple dead bugs on the floor along the baseboards in resident's room; - Bathroom floor had heavy dirt and trash debris; During an observation on 4/24/25 at 1:33 P.M., showed: - Heavy loose dirt and dust build on the floor alongside the walls of the resident's room; - Floors extremely worn with [NAME] marks and embedded dirt spots throughout the room; During an interview on 4/24/25 at 1:36 P.M., the resident said he/she would prefer that the room was clean and dust and dirt be removed on a daily basis due to his/her medical conditions. During an interview on 4/25/25 at 9:00 A.M., Housekeeping Supervisor said: - Housekeeping staff service resident rooms by removing the trash, wiping down all surfaces with disinfectant, spray down the windows, sweep the floors and mop the floors with a wet disposable mop head. They sweep the whole room including corners and bathrooms. Corners can be difficult due to the mop size. During an interview on 4/25/25 at 1:30 P.M., the Administrator said housekeeping staff should sweep along the baseboards and in the corners of the rooms and the facility every time they deep clean or if the area is dirty. MO#251239

Based on observation, interview, and record review, the facility failed to store, prepare and serve food in accordance with professional standards of food service safety when staff failed to date and label food items, failed to dispose of expired food items, and failed to perform temperature checks on food items after the cooking process was completed. This effected all the residents at the facility. The facility census was 58. Review of facility policy, Food Safety, revised 4/26/23, showed: - Danger Zone means temperatures above 41F and below 135F, that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness. Bacteria multiply rapidly in a moist environment in the danger zone. Rapid death of most bacteria occurs at 165F or above; - Food is stored a minimum of six inches off the floor; - When an item is transferred to a new container the container will be labeled with the name of the contents and date transferred. A Use by Date is noted on the label; - Food is labeled with the date received if not already indicated on the item; - Leftovers are dated properly and discarded after 72 hours unless otherwise indicated; - Frozen, raw meat that is placed in a cooler, is in a pan and labeled with pulled and use by dates; Dry Storage: - Opened packages of food are resealed tightly to prevent contamination of the food item and use by date will be used when applicable; - Food not safe for consumption or the safety of the food is in question will be removed from storage; Steam Tables: - Must be able to maintain hot foods at temperatures of 135F or above; - Must not be used for cooking or warming foods, only for keeping food hot; Review of facility policy, Food Temperature Control, revised 6/28/24, showed: - Food temperatures are checked at the completion of the cooking process and before being placed on the serving line; if issues are identified, they are corrected, or the food is discarded; - Hot foods are held at a minimum of 135F or per state requirements; - While foods are on the serving line, the foods will be maintained at a safe temperature; - The steam table is not used to prepare and/or reheat foods; 1. Observation of the kitchen on 4/22/25 at 8:30 A.M., showed: Freezer: - Package of frozen food opened 4/21/25 and resealed with no content label; - Package of frozen onion rings opened and resealed with no open or expiration date on package; Refrigerator: - Defrosting frozen chicken not labeled with a use by date; - Lettuce package opened 4/20, resealed with no expiration date; Dry Storeroom: - Raisin Bran resealed in plastic container with expiration date of 3/12/25 not discarded; - Fruit Loops resealed in plastic container with expiration date 4/18/25 not discarded; - Cheerios resealed in plastic container with expiration date 3/12/25 not discarded; - Left over gravy mix not sealed; Main Kitchen Area: - Tortilla chips with expiration date 4/21/25 not discarded; Small Refrigerator: - Bag of apples, unlabeled, unsealed, and no expiration date; - Chicken base opened and resealed, expiration date unreadable; 2. During a continuous observation of the kitchen on 4/23/25, showed: - 10:15 A.M. [NAME] beans placed on steam line without any temperature check taken; - 10:20 A.M. Gravy placed on steam line from microwave without any temperature check taken; - 10:40 A.M. All of the puree and mechanically prepared items completed and placed on the steam line without temperature checks taken; - 11:12 A.M. Temperature checks conducted on all items on the steam line. Gravy has a temperature of 108F which is below the safe holding temperature of 135F required. - 11:16 A.M. The gravy is transferred to the stove for reheating; - 11:24 A.M. The DM (dietary manager) takes a temperature check while the gravy is still on a lit burner. The gravy now temps at 155F; Observation of the kitchen refrigerator on 4/24/25 at 2:20 P.M., showed leftover cooked sausage patties dated 4/20/25 with expiration date 4/22/25 that had not been discarded. During an interview on 4/23/25 at 11:30 A.M., the DM said: - The gravy was cooked improperly and should have been prepared on the stove instead of heated up in the microwave by one of the dietary staff; - Temperature checks are normally done on the steam line before serving the meal and not on the stove for side dishes. Main course meals like today's chicken should have temperature checks done until they reach the required temperature for cooking; During an interview on 4/23/25 at 3:28 P.M., the DM and Dietician said: - The danger zone for food bacteria growth are temperatures below 135F, 145F for fish, 155F for ground beef, and 165F for chicken. - Both staff members agreed that taking the temperatures at the steam table prior to serving was sufficient to ensure the safety of the residents and had no issues with not taking temperatures after cooking is completed at the stove; - Food items that are opened should be resealed and dated, items that are expired should be thrown away on the date of expiration; During an interview on 4/25/25 at 1:30 P.M., the Administrator said: - She would expect food items that have been opened to be resealed, dated with the open date and the new expiration date if being stored for future use; - Items that have been resealed should be clearly labeled as to the contents; - She would expect food temperature checks to be done prior to placing items on the steam table, prior to serving and prior to being served on the hall for residents; - She would not expect expired items in the refrigerator or storeroom; - All containers should be sealed tight when being used for leftovers or future serving.

Based on observations, interviews and record review, the facility failed to ensure staff provided services that met professional standards of quality of care when staff failed to obtain an order to check blood sugars and failed to ensure medications for a new admission were obtained. This affected one of the five sampled residents, (Resident #3). The facility census was 62. Review of the facility's policy for blood glucose monitoring, reviewed 9/15/23 showed, in part: - Associates who obtain capillary blood glucose specimens will do so in accordance with their scope of practice and in accordance with all applicable local, state, and federal guidelines. Review of the facility's policy for administration of medications, reviewed 8/24/23 showed, in part: - The facility will ensure medications are administered safely and appropriately per physician order to address resident's diagnoses and signs and symptoms; - Medication administration is the responsibility of those individuals who through certification and licensure are authorized in their state to administer medications in a skilled nursing facility; - Staff who are responsible for medication administration will adhere to the ten rights of medication administration: right drug, right resident, right dose, right route, right time and frequency, right documentation, right assessment, right to refuse, right evaluation/response, right education and information. 1. Review of Resident #3's admission Minimum Data Set (MDS) a federally mandated assessment instrument completed by facility staff showed it had not been completed; - 8/30/24 - the resident was admitted ; - 9/1/24 at 1:45 P.M., the resident was discharged . Review of the resident's physician order sheet (POS), dated August 2024 showed: - Order date: 8/30/24 - Atorvastatin Calcium 80 milligrams (mg.) in the evening for hyperlipidemia (elevated levels of lipids and cholesterol); - Order date: 8/30/24: Lantus (long acting) insulin, inject 20 units at bedtime for diabetes mellitus; - Did not have a physician's order to obtain blood sugars. Review of the resident's medication administration record (MAR), dated August 2024 showed: - Atorvastatin Calcium 80 mg. in the evening for hyperlipidemia; - Lantus insulin, inject 20 units at bedtime for diabetes mellitus; - Staff did not document they administered the Atorvastatin on 8/30/24 or on 8/31/24; - Staff documented the resident refused the Lantus insulin on 8/30/24 and it was administered on 8/31/24; - Staff did not document any blood sugars. Review of the resident's baseline care plan, dated 8/30/24 showed it was not completed. Review of the resident's POS, dated September 2024 showed: - Order date: 8/30/24 - Atorvastatin Calcium 80 mg. in the evening for hyperlipidemia; - Order date: 8/30/24 - Lantus insulin, inject 20 units at bedtime for diabetes mellitus; - Did not have a physician's order to obtain blood sugars. Review of the resident's MAR, dated September 2024 showed: - Atorvastatin Calcium 80 mg. in the evening for hyperlipidemia; - Lantus insulin, inject 20 units at bedtime for diabetes mellitus; - Staff did not document any blood sugars on 9/1/24; - The resident was discharged to home on 9/1/24 at 1:45 P.M. During an interview on 9/24/24 at 3:09 P.M., the Infection Preventionist (IP) said: - There should not be a delay in getting the resident's medications if they were a new admit; - Should have a physician's order to obtain blood sugars. During an interview on 9/24/24 at 5:15 P.M., Licensed Practical Nurse (LPN) A said: - He/she admitted the resident to the facility on 8/30/24; - The family brought in some medications but he/she could not remember what they were; - The family brought in the resident's Novolog (fast acting) insulin and Lantus insulin; - He/she should have contacted the physician and obtained an order for blood sugars; - He/she could not remember if he/she ordered the Atorvastatin from the pharmacy. During an interview on 9/24/24 at 4:44 P.M., the Director of Nursing (DON) said: - There should have been an order for blood sugars to be obtained if the resident was taking insulin; - She was unsure why the resident did not get the Atorvastatin, but he/she should have. MO241451

Refer to Event ID 1PK412. This deficiency is uncorrected. For previous examples, please refer to Statement of Deficiencies dated 1/5/24. Based on observation, interview and record review, the facility failed to ensure facility staff provided three of 15 sampled residents (Resident #2, #43, and #46), that were unable to complete his/her own activities of daily living, the necessary care and services to maintain good personal hygiene, when staff failed to reposition or provide incontinent care within a timely manner. The facility census was 59.

Based on observation, interview and record review the facility failed to provide adequate supervision during the noon meal in the dining room of the facility's memory care unit and failed to monitor the safety and choking risks of one resident (Resident #40) out of the 15 sampled residents; when the resident was observed eating food items from other residents' plates that were not appropriate for his/her mechanically altered diet as prescribed. Additionally, the nursing staff failed to remove the improper food items from the resident's grasp. Facility census was 59. No facility policy was provided regarding resident safety at mealtime. Review of Mechanically Altered Diet policy dated 3/13/22, states in part: This diet consists of foods that are mechanically altered by blending, chopping, grinding or mashing so they are easy to chew and swallow. Foods are soft and moist and are easily formed into a bolus. Meats are served ground and moist. Foods in large chunks or foods too hard to be chewed thoroughly should be avoided. 1. Review of resident #40's quarterly Minimum Data Set (MDS), (A federally mandated assessment completed by facility staff), dated 10/19/23, showed: -Resident is dependent on staff for all activities of daily living -Resident does not have the ability to discuss needs or wants -Diagnosis included: Dysphagia (swallowing problems), unspecified dementia( a condition characterized by progressive or persistent loss of intellectual functioning especially with impairment of memory and abstract thinking), and cognitive communication deficit (difficulty with thinking and how someone uses language). Review of resident # 40's Physician Orders, dated 1/2/23, showed the following orders and additional diagnoses: -Puree texture diet, pudding/extreme consistency, with double portions; -Dysphagia, oral phase (problems with using the mouth, lips and tongue to control food or liquid); -Dysphagia, oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat); -Moderate intellectual disabilities (observable delays in the development of speech or motor skills, which may be accompanied by physical impairments); -Abnormal weight loss (losing more than 5% of your weight over 6 to 12 months). Review of resident # 40's Care Plan, last review., dated of 11/30/23 showed: -Resident requires total assistance with all ADL's (activities of daily living); -Resident requires a Hoyer lift for all transfers; -Resident requires supervision when eating, for choking risks. -He/She consumes a pureed diet and thickened liquids per the physician's orders; -Resident is at risk for weight fluctuation related to current health status and interventions include assistance with meals as needed. Observation on 01/02/24 at 12:17 P.M., showed: Resident # 40 sitting at a table in the dining room of the memory care unit with three other residents. When three of the residents were done eating, they left the dining room and resident #40 remained at the table. Staff were not present at this time in the dining room. All dirty dishes from the meal were on the table and resident #40 grabbed the dirty plate of the resident who was seated to his/her left and took a piece of meat approximately the size of a half dollar and placed the meat in his/her mouth and started chewing. It appeared the meat was swallowed. The resident then took a piece of meat approximately the size of a quarter from the dirty plate to his/her right and placed it on his/her own plate. CNA F entered the dining room at this time while resident # 40 was attempting to pick up the piece of meat from the plate that he/she had taken from another resident's plate and eat it. Resident # 40 was then told by CNA F to use his spoon to eat the meat. Observation on 01/04/24 at 8:00 A.M., showed Resident # 40 placed a condiment packet in his/her mouth and started to chew. Social Services Director turned to face the resident and was able to remove packet from resident's mouth. During an interview on 01/04/24 at 9:00 A.M. Certified Nursing Assistant (CNA) G said: - One resident on the unit requires feeding assistance. - At least two residents on the unit are a choke risk. -There are usually two staff in the dining room and staff should not leave the dining room while residents are eating. During an interview on 01/05/24 at 3:10 P.M., the Director of Nursing (DON) said: -There should always be at least one person in the dining room. -Staff should not be walking in and out. -I would expect the staff to stay in the dining room and not allow the resident to eat food from other plates and regular food if on a pureed diet.

Based on observation, interviews and record review the facility failed to assist one resident (Resident #9) to eat when he/she was assessed as having a significant weight loss of 16.6 pounds, 10.3% in four months. The facility census was 59. Review of the nutrition policy dated 8/24/23 showed: - Each resident receives a sufficient amount of food to maintain acceptable national status; - If a meal or particular food item is refused by the resident, the staff were supposed to offer a substitute; - The staff were supposed to provide assistance as needed to help the resident consume meals; - An ongoing assessment of the residents ability to feed self and weight loss was supposed to be completed by the facility staff. 1. Review of Resident #9's quarterly Minimum Data Set (MDS, a federally mandated assessment completed by the facility staff) dated 12/13/23 showed: - He/She had a brief interview for mental status (BIMS) score of 3, indicating severe cognitive impairment; - He/She was independent for eating; - He/She required substantial assistance form the staff to personal hygiene and showers; - Diagnoses included: Abnormal weight loss, feeding difficulties, diabetes type II (a condition in which the body does not process blood sugar properly). Review of the resident's activities of daily living (ADL) care plan dated 7/3/23 showed: - The staff were supposed to monitor the resident for any decline in his/her ability to perform ADL's and report to the charge nurse; - The resident was able to open packets and cut up large pieces of food. Review of the resident's weight fluctuation care plan date 6/20/2023 showed: - The staff were supposed to provide the resident with assistance with meals as needed; - The resident was at risk for malnutrition, report decreased appetite to the charge nurse. Review of the Physician's Order Sheet (POS) dated 1/24 showed: - 6/19/23 Regular diet with regular texture, fortified cereal; - 9/8/23 House shake supplement three times per day for weight loss. Review of the resident's weight record showed: - 7/20/23 weight of 170.4 pounds; - 11/3/23 weight of 153.8 pounds, decreased 16.6 pounds, 10.3% weight loss over four months; - The facility did not provide a weight for the month of December 2023. Review of the nurses notes showed the following: - The MDS coordinator documented on 9/8/2023 The resident refused meals for two days, he/she encouraged the staff to sit with the resident during meals to promote meal intake. The resident's weight was 155.7 pounds; - Registered Nurse (RN) A documented on 9/15/23 the resident had a regular diet with fortified cereal and potatoes. The resident refused meals for two days. The registered dietician (RD) recommended house supplemental shakes three times per day. He/She encouraged the staff to sit with the resident during his/her meal to cut up his/her food and to promote meal intake. Review of the RD note dated 9/8/2023 showed: - The residents weight was decreased from 169 pounds one month prior resulting in a 7.7% weight reduction on 30 days; - The resident ate approximately 39% of his/her meals; - Recommend the house supplement three times daily; During an observation on 1/2/24 at 11:57 A.M. showed: - The resident sitting at the lunch table looking at his/her food and then looked around the room; - He/She took two bites; - Staff walk by him/her, do not address the resident; - The staff do not offer to help the resident during the meal; - The resident left the dining room after consuming less than 5% of his/her meal. During an interview and observation on 1/3/24 at 8:45 A.M. Certified Nurse Aide (CNA) G said: - The resident was in his/her bed asleep; - CNA G said the resident did not get up for breakfast; - Sometimes the resident would sleep through meals and the staff just let him sleep when he/she did not want to get up. During an observation on 1/3/24 at 11:39 A.M. showed: - The resident was seated at the dining room table with his/her food in front of him/her; - The resident ate three bites by him/herself; - The resident looked around the dining room; - The staff did not talk to the resident and did not assist the resident during the meal; - The resident walked out of the dining room after consuming less than 5% of his/her meal. During an interview on 1/4/24 at 11:31 A.M. CNA G said if a resident was not feeding themselves, the staff were supposed to assist as needed. During an interview on 1/5/24 at 10:30 A.M. the RD said he/she would expect the staff to help resident #9 if the resident was not eating. He/She would expect the staff to report the resident not eating to the charge nurse. During an interview on 1/5/24 at 3:10 P.M. the Director of Nursing (DON) said: - She expected the staff to encourage residents to eat when they were not consuming their meals; - She expected staff to sit with residents who were not consuming their meals; MO228222

Based on observations, interviews, and record review, the facility failed to ensure staff provided a safe and effective medication administration system that was free of significant medication errors when staff failed to prime insulin pens prior to administering the insulin which affected one of 15 sampled residents, ( Resident #45). The facility census was 59. Review of the facility's policy for guidance for using insulin products, dated 2021, showed, in part: - To minimize air bubbles in pen-like devices prime the pen prior to each and every injection by pushing two units into the air until a drop of insulin is seen at the top of the needle. 1. Review of Resident #45's care plan, revised 4/6/22, showed: - The resident had diabetes mellitus; - Blood sugar check as ordered; - Medication as ordered. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/27/23, showed: - Cognitive skills intact; - Lower extremities impaired on both sides; - Had seven insulin injections in the last seven days; - Diagnosis included diabetes mellitus. Review of the resident's physician order sheet, (POS), dated January, 2024, showed: - Order date: 8/24/23 - Humalog (fast acting insulin), 45 units with meals for diabetes mellitus. Hold for blood sugar less than 120; - Order dated: 6/2/21 - Humalog insulin per sliding scale before meals and at bedtime related to diabetes mellitus. Blood sugar 111- 150 - give two units. Review of the resident's medication administration record (MAR), dated January 2024, showed: - Humalog insulin,45 units with meals for diabetes. Hold for blood sugar less than 120; - Humalog insulin per sliding scale before meals and at bedtime related to diabetes. Blood sugar 111- 150 - give two units. Observation on 1/4/24 at 7:03 A.M. showed: - Licensed Practical Nurse (LPN) A did not clean the port of the Humalog insulin pen and attached the needle, did not prime the insulin pen and dialed the pen to 47 units; - At 7:18 A.M., LPN A administered the Humalog insulin in the resident's right abdomen. During a telephone interview on 1/5/24 at 11:42 A.M., LPN A said: - He/she should have cleaned the port of the insulin pen with an alcohol wipe before attaching the needle and administering the insulin; - He /she should have primed the insulin pen with one or two units of insulin before administering it. During an interview on 1/524 at 2:56 P.M., the Director of Nursing (DON) said: - Staff should make sure they clean the port of the insulin pens and the port on the vials of insulin with an alcohol wipe; - She would expect staff to prime the insulin pen with one or two units of insulin, then dial it to the amount to be administered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to promote the residents right to make choices regarding foods served for Residents #10, #35, #53 and #58 out of 15 sampled residents. The facility census was 59. Review of the facility's Resident Rights policy, with a review date of 9/25/23, showed: -The resident has a right to a dignified existence and self-determination; -The resident has the right to make choices about aspects of his/her life in the facility that are significant to the resident; -The resident has a right to a safe, clean, comfortable and homelike environment including but hot limited to receiving treatment and supports for daily living. Review of the facility's Menus, Substitutions and Alternatives, revised 4/14/23 showed: -Residents with known dislikes of food and beverage items, are offered a substitute of similar nutritive value; -The facility menu has a planned alternate that is nutritionally equivalent; -Residents' preferences are followed to the extent possible; -The facility will provide as available, food that accommodates resident preferences; -The facility will provide alternates to residents who request a different meal choice; -The residents are informed of the alternates at each meal; 1. Review of Resident #10's quarterly Minimum Data Set (MDS) a federally mandated assessment completed by facility staff, dated 10/10/23 showed: -The resident has no cognitive impairment; -The resident is occasionally incontinent of bladder; -The resident has upper extremity impairment on both sides; -The resident is independent with Activities of Daily Living (ADLs); -The resident's daily preferences are very important to the resident; -Diagnoses included, high blood pressure, anxiety and Bipolar Disorder (a mental illness that causes unusual shifts in a person's mood or behavior). Review of the resident's care plan, dated 8/3/23, showed: -The resident has an ADL self-care deficit related to impaired balance; -The resident prefers to eat meals in his/her room; -The resident desires to participate in his/her care; -The staff offer substitutes for uneaten foods. Review of the daily breakfast menu dated, 1/4/24, showed: -Breakfast, juice of choice, cereal of choice, egg cheese bake, sliced bacon, toast beverage of choice and milk. Review of the resident's breakfast meal ticket, dated 1/4/24, showed: -Preferences: Cheerios, Raisin Bran, crispy bacon, fried eggs, and oatmeal; -Beverages: Coffee and water. Observation and interview on 1/4/24 at 9:02 A.M., showed: -The resident was setting in his/her room with a tray of food on the bedside table in front of him/her; -The resident's plate contained egg bake, toast, and no cereal; -A cup of coffee sat on the table; -The resident said he/she tells the staff if he/she is going to eat breakfast; -The resident said the staff do not ask him/her what he/she would like for breakfast; -The resident said he/she liked fried eggs but he/she gets scrambled or some other type of food; -The resident said he/she only likes fried eggs; -The resident said staff do not ask him/her what kind of cereal he/she wants for breakfast; -The resident said he/she expects the staff to ask her what his/her preference for breakfast is. 2. Review of Resident #35's admission MDS dated [DATE], showed: -The resident has no cognitive impairment; -The resident has a urinary catheter; -The resident is occasionally incontinent of bowel; -The resident requires partial assistance with transfers; -The resident is dependent on staff for toileting; -The resident requires substantial assistance with bathing; -The resident's daily preferences are very important; -Diagnoses included, heart failure, anemia (a condition that develops when the body produces a lower than normal amount of healthy red blood cells) and high blood pressure. Review of the resident's care plan dated, 11/3/23, showed: -The resident requires extensive assistance with ADLs due to weakness; -The resident requires set-up assistance with meals. Review of the daily lunch menu dated, 1/2/24, showed: -Tuna noodle casserole, Italian vegetables, garlic bread, banana pudding, beverage of choice; -Alternate lunch choices - Salisbury steak, rice pilaf and buttered spinach. Review of the resident's lunch meal ticket, dated 1/2/24, was blank. Observation and interview on 1/2/24 at 12:31 P.M., showed: -Certified Nurses Aid (CNA) C and CNA D passing trays to the resident's in the dining room; -CNA C and CNA D did not look at the meal tickets before they placed the food on the table in front of the resident's in the dining room; -The resident was setting in the dining room with a plate of food on the table in front of him/her; -The resident's plate contained Salisbury steak, rice pilaf and buttered spinach; -A glass of water sat on the table in front of the resident; -The resident told CNA C he/she does not like rice; -CNA C told the resident he/she did not have to eat the rice but did not offer an alternative food to the resident; -The resident again told CNA C he/she does not like rice; -The resident said he/she would like to have a choice in the food he/she eats; -The resident ate the Salisbury steak but did not eat the rice pilaf. Review of the daily breakfast menu dated, 1/4/24, showed: -Breakfast juice of choice, cereal of choice, egg cheese bake, sliced bacon, toast, beverage of choice and milk. Review of the resident's breakfast meal ticket, dated 1/4/24, was blank. Observation and interview on 1/4/24 at 9:06 A.M., showed: -The resident was setting in the dining room with a plate of food on the table in front of him/her; -The resident's plate contained egg bake, toast, bacon and cold cereal; -A glass of water and a glass of juice set on the table in front of the resident; -The resident did not eat the cold cereal; -The resident said the staff has never asked him/her what he/she wants for breakfast; -The staff do not ask him/her what kind of cereal he/she wants for breakfast; -The resident said he/she expects the staff to ask her what his/her preference is for breakfast. During an interview on 1/4/23 at 9:17 A.M.,CNA C said: -He/she should bring the resident something else to eat if they do not like what they are serving; -He/she was not aware the resident did not like rice. 3. Review of Resident #53's quarterly MDS dated [DATE], showed: -The resident has no cognitive impairment; -The resident is independent with ADLs -The resident requires partial assistance with bathing; -Daily preferences are very important to the resident; -Diagnoses included, diabetes mellitus (a metabolic disease, involving inappropriately elevated blood glucose levels), heart failure and high blood pressure. Review of the resident's care plan, dated 11/3/23, showed: -The resident requires minimal assistance with ADLs; -The resident requires et up assistance with showers. A review of the daily breakfast menu dated, 1/4/24, showed: -Breakfast juice of choice, cereal of choice, egg cheese bake, sliced bacon, toast, beverage of choice and milk. Review of the resident's breakfast meal ticket, dated 1/4/24, showed: -Preferences: Cheerios, Raisin Bran, crispy bacon, fried eggs, oatmeal; -Beverages: Coffee and water. Observation and interview on 1/4/24 at 9:46 A.M., showed: -The resident was setting in his/her room with a tray of food on the bedside table in front of him/her; -The resident's plate contained egg bake, toast, and bacon; -A cup of water set on the table next to the residents food; -The resident said staff do not ask him/her what he/she would like for breakfast; -The resident said he/she liked fried eggs he/she gets scrambled or some other type of food sometimes; -The resident said he/she preferred fried eggs; -The resident said he/she expects the staff to ask her what his/her preference for breakfast is. 4. Review of Resident #58's admission MDS dated [DATE], showed: -The resident has moderate cognitive impairment; -The resident is independent with ADLs -The resident requires partial assistance with bathing; -Daily preferences are very important to the resident; -Diagnoses included, Dementia, high blood pressure and Asthma. Review of the resident's care plan, dated 12/21/23, showed: -Independent with most ADLs; -Supervision with bathing; -The resident eats meals in the dining room. Review of the daily breakfast menu dated, 1/3/24, showed: -Juice of choice, cereal of choice, scrambled eggs, bacon, toast, beverage of choice and milk. Review of the resident's breakfast meal ticket, dated 1/3/24, was blank. Observation and interview on 1/3/24 at 9:02 A.M., showed: -CNA C and CNA D passing trays to the resident's in the dining room; -CNA C and CNA D did not look at the meal tickets before they placed the food on the table in front of the resident's in the dining room; -The resident was setting in the dining room with a plate of food on the table in front of him/her; -The resident's plate contained two fried eggs, toast and hot cereal; -A glass of water and a glass of juice set on the table in front of the resident; -The resident ate a piece of toast and did not eat the eggs; -The resident said he/she hates eggs and he/she gets them every morning; -The resident said that staff do not ask her what he/she would like for breakfast; -The resident said he/she expects the staff to ask her what his/her preference is for breakfast. Review of the daily breakfast menu dated, 1/4/24, showed: -Breakfast, juice of choice, cereal of choice, egg cheese bake, sliced bacon, toast beverage of choice and milk. Review of the resident's breakfast meal ticket, dated 1/4/24, was blank. Observation and interview on 1/4/24 at 9: 14 A.M., showed: -CNA C and CNA D passing trays to the resident's in the dining room; -The resident was setting in the dining room with a plate of food on the table in front of him/her; -The resident's plate contained egg bake, toast, bacon and cold cereal; -A cup of coffee and a glass of juice set on the table in front of the resident; -The resident ate a piece of toast and did not eat the egg bake; -The resident said the staff has never asked him/her what he/she wants for breakfast; -The staff do not ask him/her what he/she wants for breakfast; -The resident said he/she does not like eggs; -The resident said he/she expects the staff to ask her what his/her preference is for breakfast. During an interview on 1/4/24 at 10:18 A.M., CNA C said: -The meal tickets are for the kitchen to use identify what the resident wants to eat; -He/she does not look at the meal tickets; -The nursing staff ask each resident what choice they would like for lunch and supper but not for breakfast; -The residents should get to choose different options for breakfast. During an interview on 1/4/24 at 10:20 A.M., CNA D said: -He/she does not look at the meal tickets before the tray is given to the resident; -The CNA's ask the residents what they would like for lunch and supper; -He/she has never asked the residents what they want for breakfast; -He/she did not know how the kitchen knew what choice the residents wanted for breakfast; -The residents should get to choose different options for breakfast. During an interview on 1/4/24 at 10:20 A.M., Dietary Aide A said: -The kitchen uses the meal tickets to know what likes and dislikes the resident has; -He/she did not know why Resident #10's, #35's and #58's meal tickets were blank; -Resident #53 prefers fried eggs for breakfast and he/she did not know why he/she received the egg bake; -Resident's should have a choice of different options for breakfast; -Resident meal tickets should not be blank. During an interview on 1/4/24 at 10:41 A.M., The Dietary Manager said: -The kitchen uses the meal tickets to know what likes and dislikes the resident has; -He/she did not know why Resident #10's, #35's and #58's meal tickets were blank; -Resident #53 prefers fried eggs for breakfast and he/she did not know why he/she received the egg bake; -Resident's should have a choice of different options for breakfast; -Resident meal tickets should not be blank; -He/she is responsible for ensuring all meal tickets have the correct information; -He/she has not had time to update the all the meal tickets. During an interview on 1/5/24 at 10:05 A.M., The Registered Dietitian (RD) said: -He/she expects the residents to have an alternate choice at meals and expects the dietary staff to be responsible for this; -Resident meal tickets should be current and accurate and reflect their food preferences; -Staff that are delivering the food to the residents should have a way to confirm the correct diet, the correct consistency and any allergies before the food is served to the resident; -He/she expects the DM to be responsible for ensuring resident meal tickets are current, accurate and reflect the resident's food preferences. During an interview on 1/5/24 3:10 P.M., the administrator said: -He/she expects the residents to have a choice at all meals; -An alternative choice should be offered at all meal times; -He/expects the staff delivery the food to the residents to check the meal tickets to ensure they are getting the correct food to the correct resident; -The meal tickets should include the resident's name, the type of diet, consistency and any allergies; -The meal tickets should not be blank; -He/she expects the DM to be responsible for the meal tickets being completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and interview , the facility failed to keep the floors, doors and handrails in good repair. The facility census was 59. Review of the facility provided Daily Cleaning policy reviewed 7/19/23 showed: -The resident has the right to a safe, clean, comfortable, and homelike environment. -The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior. The facility did not provide a policy on maintenance of floors, handrails and doors. Observations beginning on 1/3/24 at 2:26 P.M. showed areas of missing floor tile strips in multiple hallways that caused rough surfaces with crusted red and black debris and uneven flooring. These areas included: -five foot (ft) by 1 inch (in) strip outside of room [ROOM NUMBER]; -five ft by 1 in strip outside room [ROOM NUMBER]; -four ft by 1 in strip outside room [ROOM NUMBER]; -five ft by 1 in strip outside room [ROOM NUMBER]; -five ft by 1 in strip outside the staff break room; -ten ft by 1 in strip outside the laundry room door; -four ft by 1 in strip outside the dining room entrance; Observations on 1/3/24 beginning at 2:26 P.M. and continued throughout the survey showed: -Wooden handrails in the 100, 200 and 400 hallways had multiple areas of chipped brown paint, exposing the woodgrain underneath, multiple scratches, exposing the woodgrain and multiple gouges into the wood causing rough, unsafe surfaces. -The wooden hallway handrail between rooms [ROOM NUMBERS] was not fastened securely to the wall. Observations on 1/4/23 at 2:42 P.M. showed: -room [ROOM NUMBER] had a large chipped area in the laminate covering, causing a rough, unsafe area. -room [ROOM NUMBER] kick guard (a laminate covering used to protect the lower half of the door from wheelchair scratches and damage) was lose on one side and protruding away from the door frame. -room [ROOM NUMBER] had multiple chips in the laminate of the room door and exposed the wood underneath . -Dining room fire doors had chipped laminate and exposed the wood underneath. -room [ROOM NUMBER] had multiple chips in the laminate and exposed the wood underneath. Observation on 1/4/24 10:30 A.M., showed the baseboard trim separated from the wall three inches next to the packaged terminal air conditioner (PTAC) unit in room [ROOM NUMBER]. During an interview on 01/05/24 at 2:56 P.M the Administrator said handrails were the Maintenance Director's responsibility. During an interview on 01/05/24 at 2:56 P.M the Regional Clinical Operations Director said there was a plan to do a remodel of the facility and repair of the concerned areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure staff provided a written notice of transfer or discharge to residents or their responsible parties and the reasons for the transfer in writing and in a language they understood. The notice should include the effective date of discharge or transfer; the location to which there resident is transferred or discharged ; a statement of the resident's appeal rights, including the name, address (mailing and electronic mail), telephone number of the entity which receives requests and information on how to obtain the appeal form and assistance in completing and submitting it; the name, address (mailing and electronic mail) and telephone number of the Office of the State Long-Term Care Ombudsman; and for residents with a mental disorder or related disabilities, the mailing, electronic mail (e-mail) address and telephone number of the agency for protection and advocacy for individuals with mental disorders established under the Protection and Advocacy for Mentally Ill Individuals Act. This affected three of 15 sampled residents, ( Resident #21, #29 and #34). The facility census was 59. Review of the facilities policy for transfers and discharges, reviewed 8/9/23, showed, in part: - The facility will follow the limited conditions under which Centers for Medicare and Medicaid Services (CMS) has outlined how the facility may initiate transfer or discharge of a residence, the documentation that must be included in the medical record, and who is responsible for making the documentation. Additionally, the facility will ensure the information that must be conveyed to the receiving provider for residents being transferred or discharged to another healthcare setting is provided in accordance with federal guidance; - When the facility transfers or discharges a resident under any of the circumstances, the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider; - Documentation in the resident's medical record must include: the basis for the transfer; - Information provided to the receiving provider must include a minimum of the following: contact information of the practitioner responsible for the care of the resident; resident representative information including contact information; advance directive information; all special instructions or precautions for ongoing care; comprehensive care plan goals and all other necessary information, including a copy of the resident's discharge summary and any other documentation to ensure a safe and effective transition of care; - Facility initiated transfers or discharges: in the following circumstances, facilities may initiate transfers or discharges: the discharge or transfer is necessary for the resident's welfare and the facility cannot meet the resident's needs; the resident's health has improved sufficiently so that the resident no longer needs the care and/or services of the facility; the resident's clinical or behavioral status (or condition) otherwise endangers the health of individuals in the facility; the resident has failed, after reasonable and appropriate notice to pay, or have paid under Medicare or Medicaid, for his/her stay at the facility; or the facility ceases to operate; - Emergency transfers to acute care: when residents are sent emergently to an acute care setting these scenarios are considered facility-initiated transfer, NOT discharges, because the resident's return is generally expected. Residents who are sent emergently to an acute care setting, such as a hospital, should be permitted to return to the facility. 1. Review of Resident #21's electronic medical record on 1/5/24 at 9:21 A.M., showed: - 12/7/23 at 6:29 P.M., Certified Nurse Aide (CNA) reported the resident was not acting right. Resident had left facial drooping and her face was twitching. Resident was not able to speak, she would move her lips and no sound would come out. Vital signs were blood pressure 110/54, respirations 18, pulse 78, oxygen saturation ( amount of oxygen in the blood) was 93% on room air, temperature 98.5. Primary care physician contacted and gave the order to send to the emergency room for evaluation and treatment. The resident was sent to the emergency room at 1:00 P.M. The hospital called and the resident was admitted to the hospital; - 12/8/23 at 2:56 P.M., The resident arrived back from the hospital at 10:15 A.M., this morning in a wheelchair with facility transport. Vital signs blood pressure 135/80, pulse 83, respirations 18, temperature 97.5 and oxygen saturation 98% on room air. The primary care physician and family were notified. - The medical record did not have a copy of any discharge letter that would have been issued to the resident. Review of the resident's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/11/24 showed: - Cognitive skills intact; - Upper and lower extremity impaired on both sides; - Dependent on the assistance of staff for eating, toileting, dressing, transfers and personal hygiene; - Had a catheter (sterile tube inserted into the bladder to drain urine); - Always incontinent of bowel; - Diagnoses included neurogenic bladder ( the name given to a number of urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve problem), stroke, quadriplegia (paralysis of all four limbs), obstructive uropathy, and Parkinson's disease ( a progressive, degenerative neurological condition that affects a person's control of their body movements), diabetes mellitus, congestive heart failure (CHF, accumulation of fluid in the lungs and other parts of the body), anemia (not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues) and depression. 2. Review of Resident #29's electronic medical record on 1/3/24 at 11:24 A.M., showed: - 6/15/23 at 1:50 P.M., at approximately 12:30 P.M., the Activity Director informed the nurse the resident reported he/she was having pain between his/her shoulder. At 12:35 P.M., the assessment showed the resident with inspiratory ( wheezing sound when you inhale) and expiratory wheezing ( wheezing sound when you exhale) throughout and expiratory rub (sound that results from the movement of inflamed and roughened pleural surfaces against one another during movement of the chest wall) throughout. Vital signs: blood pressure 128/61, temperature 97.9, pulse 106, respirations 22, oxygen saturation 89% with oxygen at 5 liters/ nasal cannula. Primary care physician texted above information and called back and gave order to send to the emergency room for evaluation and treatment. Resident informed of the order and he/she was getting ready to go. Facility van driver notified of need for transfer to the emergency room at approximately 1:05 P.M. The Director of Nursing (DON) notified of above. Van driver here at 1:20 P.M. Report called to the emergency room. Resident left facility at 1:35 P.M. Attempted to contact the durable power of attorney (DPOA) and message left related to above. Resident's sister called and will meet the resident at the emergency room. - 6/15/23 at 4:02 P.M., received a call from the hospital and the resident was admitted for exacerbation of chronic obstructive pulmonary disease (COPD, obstruction of air flow that interferes with normal breathing). - The medical record did not have a copy of any discharge letter that would have been issued to the resident. Review of the resident's quarterly MDS, dated [DATE], showed; - Cognitive skills intact; - Independent with eating, oral hygiene, toilet use, dressing, and transfers ; - Always continent of bowel and bladder; - Diagnoses included seizure disorder (a disorder in which nerve cell activity in the brain is disturbed), anxiety and depression. 3. Review of Resident #34's quarterly MDS, dated [DATE], showed: - Cognitive skills intact; - Independent with eating; - Dependent on staff for toilet use, dressing, and transfers; - Had a catheter; - Had an ostomy ( a surgery to create an opening from an area inside the body to the outside); - Diagnoses included anemia, neurogenic bladder, depression, multiple sclerosis ( a long-lasting (chronic) disease of the central nervous system). Review of Resident #29's electronic medical record on 1/5/24 at 10:33 A.M., showed: - 11/23/23 at 7:30 P.M., the nurse went to check on the resident at 6:45 P.M., resident noted to have rapid breathing. This nurse tried to awaken resident and the resident barely opened his/her eyes and started to talk but was not making sense. Assessed resident: temperature 105.0, blood pressure 238/107, pulse 126, respirations 22, oxygen saturation on room air 94%. Contacted the physician at 6:50 P.M., and ordered to send resident to the emergency room. This nurse called 911 at 6:55 P.M. Called report to the hospital at 7:00 P.M. and called the DPOA at 7: 17 P.M. Emergency Medical Services (EMS) said the resident was being life flighted to the hospital. - The medical record did not have a copy of any discharge letter that would have been issued to the resident. During an interview on 1/3/24 at 11:19 A.M., the infection preventionist (IP) said: - When a resident is transferred to the emergency room, they send a copy of the resident's face sheet, the medication administration record (MAR), a transfer sheet and a bed hold policy; - If the resident is their own person, they give a copy to the resident; - The transfer form is just the basic information, resident's name, vital signs, emergency contact, and advance directives; - The transfer form did not have all the information it should have on it. During an interview on 1/5/24 at 9:03 A.M., the Social Services Director (SSD) said: - He/she gave the resident or the responsible party a copy of the bed hold policy; - He/she sent a monthly report to the Ombudsman. During an interview on 1/5/24 at 4:44 P.M., the DON said: - She was not aware until today that all that information was supposed to be included on the transfer form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility did not provide a policy for use or care of the Arivo 2 Nasal High Flow system (a portable warmed and humidified high flow oxygen delivery system: used to deliver high levels of respiratory gases to a patient.) Review of the manufacturer, [NAME] and Paykel, use and care guide showed the Airvo is not a closed system. Follow infection control guidelines to prevent cross contamination. Daily care: run the drying mode and rinse the patient interface and water chamber. Review of the manufacturer guidelines showed: the cannula is to be changed weekly and all tubing and chamber kits are to be changed every 2 weeks. The filter is to be changed every 3 months, 1000 hours or if discolored. These are all recommendations for a single use patient machine. Review of Continuous Positive Airway Pressure (CPAP) talk national website shows that the water used in the Arivo 2 should be changed every day to prevent bacteria from collecting in stagnant water, and chambers should be cleaned weekly to prevent bacteria buildup. 3. Review of Resident #17 Annual MDS dated [DATE] showed: - No cognitive defecits; -Need for moderate assistance with personal hygiene; -Use of Oxygen (O2); -Diagnoses of heart failure (a condition in which the heart does not pump enough blood and cannot carry adequate oxygen to, or carry waste away from the body), Chronic Obstructive Pulmonary Disease (COPD: a group of diseases that cause airflow blockage and breathing-related problems) and respiratory failure (a serious condition that makes it difficult to breathe on your own). Review of the resident's POS for January 2024 showed: - Arivo 31 Liters high pressure humidified with 3 cm of peep (positive expiration and pressure) every night shift for acute respritory failure. Order date of 8/3/23. -Check Distilled water level every four hours for shortness of breath, or low O2 saturation. Review of the resident's Comprehensive Care Plan dated 12/14/23 showed: -The resident has COPD. He/She will display optimal breathing patterns daily. -Arivo at night. He/She had been refusing. Review of the resident's January 2024 Treatment Administration Record (TAR) showed the resident refused the Arivo on January 1, 2 and 3. Observation and interview on 1/2/24 at 3:25 P.M. showed the Arivo machine at the bedside, with a clear bag hanging from a medication administration pole, connected by tubing to the machine. The bag showed over 1000 milliliters (ml) of clear liquid and a date of 12/21/23. The clear chamber on the Arivo machine had a moderate amount of condensation in it. The resident said he/she did not get the Arivo applied, because staff do not know how to use it. Observation on 1/3/24 at 11:01 A.M. showed the Arivo clear bag had over 1000ml of fluid and was dated 12/21/23. The clear chamber on the Airvo machine had a moderate amount of condensation. During an interview on 1/5/23 at 11:43 A.M. LPN C said he/she assumed the company that brought the Arivo in did education on it. He/She did not know how to use the Arivo. He/She had not recieved education on the Arivo. During an interview on 1/5/23 at 11:46 A.M. LPN D said he/she did not know how to set up, use or clean the Arivo. He/She had not recieved education on the Airvo. During an interview on 1/5/24 at 11:50 A.M. the Physical Therapy Assistant/Therapy Program Director said he/she did not know if a Respiratory Therapist came to the facility. There was not a Respiratory Therapist in the Therapy Department. During an interview on 01/05/24 at 2:56 P.M. the DON said the Arivo, and CPAP machines were the nurses responsibility to apply. He/She was unfamiliar with the Arivo. He/She was unsure how often the Arivo would need to be cleaned or parts changed but would assume at least weekly . He/She had not recieved eduction on the use, cleaning or standards for the Arivo. Based on observations, interviews, and record review, the facility failed to ensure staff followed professional standards of practice when they did not clean the port of two insulin pens, which affected two of 15 sampled residents, (Resident #21, and #45 ), failed to clean the port on the vial of insulin for Resident #45, and failed to appropriately change a water humidification system for one resident (Resident #17) . The facility census was 59. Review of the facility's policy, for guidance for using insulin products, dated 2021, showed, in part: - Use an alcohol wipe to clean the top of the insulin vial. 1. Review of Resident #45's care plan, revised 4/6/22, showed: - The resident had diabetes mellitus; - Blood sugar check as ordered; - Medication as ordered. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/27/23, showed: - Cognitive skills intact; - Lower extremities impaired on both sides; - Had seven insulin injections in the last seven days; - Diagnosis included diabetes mellitus. Review of the resident's physician order sheet, (POS), dated January, 2024, showed: - Order date: 8/24/23 - Humalog (fast acting insulin), 45 units with meals for diabetes mellitus. Hold for blood sugar less than 120; - Order dated: 6/2/21 - Humalog insulin per sliding scale before meals and at bedtime related to diabetes mellitus. Blood sugar 111- 150 - give two units; - Order date: 5/30/23 - Lantus (long-acting) insulin, 50 units twice daily for diabetes mellitus. Review of the resident's medication administration record (MAR), dated January 2024, showed: - Humalog insulin, 45 units with meals for diabetes. Hold for blood sugar less than 120; - Humalog insulin per sliding scale before meals and at bedtime related to diabetes. Blood sugar 111- 150 - give two units; - Lantus insulin, 50 units twice daily for diabetes mellitus. Observation on 1/4/24 at 7:03 A.M. showed: - Licensed Practical Nurse (LPN) A did not clean the port of the Humalog insulin pen and attached the needle, did not prime the insulin pen and dialed the pen to 47 units; - LPN A did not clean the port on the vial of Lantus insulin and drew up 50 units; - At 7:18 A.M., LPN A administered the Humalog insulin in the resident's right abdomen; - At 7:18 A.M., LPN A administered the Lantus insulin in the resident's left abdomen. During a telephone interview on 1/5/24 at 11:42 A.M., LPN A said: - He/she should have cleaned the port of the insulin pen and the port on the vial of Lantus insulin with an alcohol wipe before administering the insulin. During an interview on 1/524 at 2:56 P.M., the Director of Nursing (DON) said: - Staff should make sure they clean the port of the insulin pens and the port on the vials of insulin with an alcohol wipe. 2. The facility did not provide a policy for nasal sprays. Review of the leaflet for Flonase nasal spray, revised March 2016, showed, in part: - Shake the bottle gently; - Blow your nose to clear the nostrils; - Close one side of the nostril. Tilt your head forward slightly and carefully insert the nasal applicator into the other nostril; - Start to breathe in through your nose, and while breathing in press firmly and quickly down one time on the applicator to release the spray; - Repeat in the other nostril; - Wipe the nasal applicator with a clean tissue and replace the cap. Review of Resident #21's significant change in status MDS, dated [DATE], showed: - Cognitive skills intact; - Upper and lower extremities impaired on both sides; - Diagnoses included stroke, respiratory failure ( serious condition that makes it difficult to breathe on your own), and quadriplegia (paralysis below the neck that affects all four limbs). Review of the resident's POS,dated January, 2024, showed: - Order date: 12/4/23 - Flonase allergy relief nasal suspension 50 micrograms (mcg.), one spray alternating nostrils daily for allergies. Review of the MAR, dated January, 2024, showed: - Flonase allergy relief nasal suspension 50 micrograms (mcg.), one spray alternating nostrils one time a day for allergies. Observation on 1/4/23 at 9:23 A.M., showed: - LPN B did not shake the Flonase bottle; - LPN B did not have the resident blow his/her nose beforehand; - LPN B administered one spray in each nostril and did not close either side of the nostril during administration. During an interview on 1/5/24 at 2:56 P.M., the DON said: - Staff should follow the manufacturer's guidelines for the administration of Flonase ( shake the bottle, have the resident blow their nose, close one side of the nostril when administering in the opposite nostril and repeat in other nostril.) During a telephone interview on 1/9/23 at 4:08 P.M., LPN B said: - He/she should have followed the manufacturer's guidelines for administering Flonase, shake the bottle, have the resident blow their nose, close one side of the nostril and administer in the opposite nostril and repeat in the other nostril.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure facility staff provided two of 15 sampled residents (Resident #2 and Resident #21), that was unable to complete his/her own activities of daily living, the necessary care and services to maintain good personal hygiene. The facility census was 59. Review of the facility provided policy Activities of Daily Living (ADL's) Reviewed 8/23/23 showed: -The resident will receive assistance as needed to complete ADL's; -A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene; -Assist residents with bed/wheelchair positioning as necessary to promote good body alignment and to prevent skin breakdown. 1. Review of the resident #2's Quarterly Minimum Data Set (MDS: a federally mandated assessment tool completed by facility staff) dated 11/6/23 showed: -Brief Interview of Mental Status (BIMS) of 99, indicated severe cognitive deficits; -Severely impaired decision making ability; -Long term and short term memory problems; -Dependency on staff for completion of ADLs'; -Always incontinent of bowel and bladder; -Diagnoses of Epilepsy (abnormal electrical brain activity, also known as a seizure,) Profound intellectual disabilities, legal blindness, psychosis (a collection of symptoms that affect the mind, where there has been some loss of contact with reality) and anxiety (a feeling of fear, dread and uneasiness). Review of the resident's Comprehensive Care Plan initiated 6/18/19, with no updates, showed: -The resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to immobility and physical limitations; -He/She has an ADL self-care performance deficit; - Right elbow splint to be applied 4-6 hours per day. Apply when getting resident up each morning; -The resident was totally dependent on two staff for repositioning and turning in bed; -The resident was totally dependent on 1 staff for personal hygiene and oral care. Continuous observation starting on 1/03/24 at 9:48 A.M. showed; -The resident was sitting in his/her wheelchair in his/her bedroom. - He/She had his/her feet curled up and crossed in the seat of the wheelchair. -At 11:34 A.M. Staff assisted the resident to the dining room via wheelchair. -At 11:56 A.M. He/She was sitting at the dining room table, feet crossed and under him/her. -At 12:12 P.M. his/her meal was delivered to the table. At 12:14 P.M. staff sat to assist the resident with his/her meal. Continuous observation starting on 1/04/24 at 5:01 A.M. showed; - The resident in bed, privacy curtain pulled, covers tucked snugly around him/her. - At 6:03 A.M. he/she remained in bed, no staff had entered his/her room. - At 6:37 A.M. Certified Nurse Aide (CNA) A and CNA D stood at the resident's room door. CNA A said the resident was fine, then CNA A and CNA D went to the next room. - At 7:30 A.M. CNA D entered the resident's room, pulled the resident's blankets back, left the resident uncovered, washed his/her hands then applied gloves. - CNA D removed the resident's saturated incontinent brief and provided incontinent care. CNA D applied a new incontinent brief, and dressed the resident in pajama pants and a sweatshirt. CNA D placed a mechanical lift sling under the resident. CNA E entered the room with a mechanical lift. The resident's roommate asked CNA D to put on the resident's wrist splint. -CNA D and CNA E used the mechanical lift to transfer the resident to his/her wheelchair. -CNA D and CNA E did not straighten the resident's legs and the resident was seated in the wheelchair with his/her legs bent at the knee, legs crossed underneath him/her and sitting on his/her feet. During an interview on 1/4/23 at 7:35 A.M. CNA D said; - He/she had worked for the facility more than four months. -Residents who are incontinent need to be checked, cleaned up, or repositioned at least every two hours. -He/She was not sure why it was longer than two hours to assist Resident #2. -He/She was not aware the resident had a splint to apply. -He/She did not know how to apply the brace. -He/She did not know if stretches or exercises were done when providing care for dependent residents. -The resident always sits on his/her legs. -He/She was not sure what would happen if staff attempted to place the resident in the chair not sitting on his/her feet. 2. Review of Resident #21's care plan, revised 12/13/21 showed: - The resident had an ADL self-care performance deficit related to limited mobility, generalized pain and stroke; - The resident was totally dependent on one staff for personal hygiene and oral care. He/She had a full set of dentures. Review of the resident's significant change in MDS, dated [DATE], showed: - Cognitive skills intact; - Upper and lower extremities impaired on both sides; - Dependent on the assistance of staff for toileting; - Dependent on staff for oral hygiene; - Had a Foley catheter (a tube inserted into the urethra); - Always incontinent of bowel; - Diagnoses included neurogenic bladder ( the name given to a number of urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve problem), stroke, quadriplegia (paralysis of all four limbs), obstructive uropathy, and Parkinson's disease ( a progressive, degenerative neurological condition that affects a person's control of their body movements). Observation on 1/4/24 at 7:21 A.M., showed: - CNA B and CNA C provided catheter (sterile tube inserted into the bladder to drain urine) care, dressed the resident for the day and used the mechanical lift and transferred the resident into his/her wheelchair; - CNA C wiped the resident's face with a wipe, applied deodorant, brushed the resident's hair and used body spray per the resident's request; - CNA B and CNA C did not offer or provide oral care. During an interview on 01/04/24 at 8:04 A.M. Licensed Practical Nurse (LPN) A said he/she is the charge nurse, passing medications and completing treatments for the 400 hall. He/she cannot get to everything. Residents should be checked and changed every two hours, but staff are not always able to get that done. During an interview on 1/9/24 at 4:14 P.M., CNA B said he/she should have offered or provided oral care to the resident. During an interview on 1/9/24 at 4:30 P.M., CNA C said he/she should have offered or provided oral care to the resident. During an interview on 1/05/24 at 2:56 P.M. the Director of Nursing (DON) said: -She expected residents to be cleaned, changed, dressed, offered to brush teeth/hair, and do anything we would do to get ourselves ready for the day. -She expected incontinent care to be done every 2 hours. -She would not expect a dependent resident to go longer than two hours for a check and change or repositioning. -She expected staff to apply splints as ordered and know how to apply the splint.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of resident # 40 Minimum Data Set (MDS), (A federally mandated assessment completed by facility staff), dated 10/19/23 showed: -Resident is dependent on staff for all activities of daily living; -Resident does not have the ability to discuss needs or wants; -Diagnosis included dysphagia (swallowing problems), unspecified dementia(a condition characterized by progressive or persistent loss of intellectual functioning especially with impairment of memory and abstract thinking), and cognitive communication deficit (difficulty with thinking and how someone uses language). Review of resident # 40 Care Plan revised 6/1/23, showed: -Resident is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t cognitive deficits and physical limitations. -Staff to invite resident to scheduled activities; -Resident appears to like music activities: -Resident has several stuffed animals he/she enjoys keeping with them; -Care plan did not indicate how frequent resident should be offered activities or how staff is to recognize/meet social needs of resident. 4.Review of resident # 44 quarterly Minimum Data Set (MDS) dated [DATE], showed: -Brief Interview of Mental (BIMS) score of 7 consistent with severe cognitive impairment; -Resident requires a Hoyer lift for all transfers; -Resident requires staff assistance with all Activities of Daily Living (ADL). Review of resident # 44 Care Plan, revised on 12/18/23, showed: -Activity director to provide 1:1 visits with the resident as needed; -Resident enjoys outdoor activities; -Resident enjoys painting; -Resident enjoys activities involving music; -Resident enjoys watching TV. Observation on 01/02/24 at 2:37 P.M., showed: -Activity schedule for the month of January posted on hallway bulletin board of memory unit. -Daily activities for memory unit residents at 10:00 A.M., 2:00 P.M. and 7:00 P.M -Activities include: -Sundays-10:00 A.M. hand massage, 2:00 P.M. reading aloud, 7:00 P.M. movie time -Mondays-10:00 A.M. ball games, 2:00 P.M. trivia, 7:00 P.M. movie time -Tuesdays-10:00 A.M. Yoga/exercise, 2:00 P.M. Bingo, 7:00 P.M. movie time -Wednesdays-10:00 A.M. puzzles, 2:00 P.M. craft, 7:00 P. M. movie time -Thursdays-10:00 A.M. bean bag toss, 2:00 P.M. card houses, 7:00 P.M. movie time -Fridays-10:00 A. M. music, 2:00 P.M. Bingo, 7:00 P.M. movie time -Saturdays-10:00 A.M. balloon battle, 2:00 P.M. audio books, 7:00 P.M. movie time Observation on 01/03/24 at 10:03 A.M. and 10:24 A.M., showed: -No activities noted on memory unit or in the rooms of residents. Observation on 01/04/23 at 10:00 A.M., showed: -No resident activities at this time in memory care unit (MCU). Observation on 1/5/23 at 10:10 A.M., showed: - Activity of music was scheduled at 10 A.M. five of the 15 residents on the unit were in the common area listening to music playing on the TV. Three of the five residents had their head down and eyes closed. Interview with the Activities director on 1/4/23 at 4:00 P.M. Activities director said: -He/She does not have enough help to make sure each resident has his/her activity requirement; -He/ She was depending on the nursing staff to help with activities on the MCU but recently discovered they did not have time to complete activities with the residents; -There was not always enough staff to get the resident to activities, especially on the MCU; -He/ She had not been working one on one with the residents on the MCU, but does offer puzzle pages for the residents to complete and hallway bowling; -The evening movie time was the residents watching television in the their rooms. -Activities are supposed to be documented on an individual activity log; -He/She did not have anything logged for resident's #25, #40 or #44 because he/she had not completed individual activities with those residents; - Resident #49 had said he/she would like to participate in more activities, but the staff do not get him/her to them. Interview with Director of Nursing (DON) on1/5/23 at 3:10 P.M., DON said: -She expected residents to recieve an activity opprtunity twice daily seven days per week; -He/She would also expect church services on Sunday; -He/She would expect individualized activities for persons that cannot verbalize and would expect staff to help residents to the activities and encourage residents to attend activities. Based on observations, record review and interviews, the facility staff failed to provide activities to four (Resident #49, #25, #40 and #44) out of 15 sampled residents. The facilty census was 59. Review of the activites policy dated 9/21/23 showed: - The activities will be directed by a qualified Activities Director (AD); - The AD develops, implements, and supervises the resident activities; - The faciliy should implement an ogoing resident-centered activity program that incorpaortes the resident's interests and prefernces; - The activity porgram should improve the resident's physical and psychosocial well being; - The acitivity program should create opprotunities for the residents to have a meaningful life. 1. Reveiw of Resident #49s quarterly Minimum Data Set, (MDS, a federally mandated assessmet completed by the facility staff), dated 10/3/23 showed: - The resident had a brief interview for mental status (BIMS) score of 15, indicating no cognitive impairment; - He/She required assistance of one staff to get dressed, take a shower and use the toilet; - Diagnoses included: Parkinson's Disease (a progressive disorder that affects the nervous system and can cause uncontrolled shaking and tremors), Dementia (a disease that affects the brain, causes confusion and can affect reasoning), and phsychotic disorder (a mental disorder that is charachterized by a disconnect from reality). Review of the resident's activity care plan dated 10/28/22 showed: - The staff were supposed to invite the resident to all facility activities; - The resident enjoyed doing crafts; - The resident enjoyed visiting with other residents and staff; - The resident will voice satisfaction with type and amount of activity involvement. During an interview on 1/2/24 at 11:27 A.M. the resident said: - He/SHe liked to participate in Bingo; - He/SHe would like to go to other activities but the staff do not ask him/her to go; - The staff do not help him/her to other activities. Observation on 1/3/24 at 10:00 A.M. showed: - A puzzle activity was on the calendar to be completed; - No activity was offered to the residents of the Memory Care Unit. During an interview on 1/3/24 at 10:12 A.M. the resident said: - He/SHe did not get to go to the movie night activity last night becuase no staff helped him/her to the activity; He/She really wanted to go to the movie. 2. Review of Resident #25's quarterly MDS dated [DATE] showed: -He/She had a BIMS score of 0, indicating severely impaired cognitive function; - He/SHe had no behaviors; - He/She was dependent on the staff for all cares; - He/she was non verabl and did not make his/her needs known; - Diagnoses included: Dementia and depression. Review of the resident's activity care plan dated 7/12/22 showed; - The resident would attend at least one activity per week; - The staff were supposed to invite the resident to all activities; - The staff were supposed to offer and assist the resident to activities. Review of the resident's activity assessment dated [DATE] showed: - The resident enjoyed things of the past and cooking; - The resident liked to watch television (TV). - There was no type of activity documented. Review of the Activity logs dated October, Noveber and Decemer 2023 showed: - The resident had participation of an activity six times in October; - Participation in an activity nine times in November; - Participation in an activity eight times in December. Observation's on 1/2/24 through 1/5/24 at 10:00 A.M. and 2:00 P.M. showed: - The resident did not participate in any scheduled activity; - The resident did not recieve any individual activities; - The staff did not offer to take the resident to an activity; - The staff did not offer an individual activity. Observation on 1/3/24 at 10:00 A.M. showed: - The staff laid the resident into bed; - The staff did not offer to provide an activity for the resident or take him/her to an activity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to assure staff provided catheter (a sterile tube inserted into the bladder to drain urine) care in a manner to prevent urinary tract infections (UTIs) or the possibility of a UTI when staff failed to clean the drainage spout appropriately and placed the graduate ( a clear plastic container with markings used to collect and measure fluids) directly on the floor which affected two of 15 sampled residents, ( Resident #21 and #39). The facility census was 59. Review of the facility's policy for indwelling urinary catheter (Foley) management, reviewed 8/24/23, showed, in part: - The facility will ensure that residents admitted with a urinary catheter, or determined to need a urinary catheter for a medical indication will have the following areas addressed: insertion , ongoing care and catheter removal protocols that adhere to to professional standards of practice and infection prevention and control procedures. 1. Review of Resident #39's care plan, revised 7/31/23 showed: - The resident had an activities of daily living (ADL) self-care performance deficit related to amputation of both legs, fatigue, impaired balance, and limited mobility; - The resident is incontinent of bowel and dependent upon staff to cleanse after bowel movement. Review of the resident's urinalysis (UA, a test to analyze urine contents) dated 10/21/23, showed the presence of bacteria indicative of a possible UTI. Review of the resident's urine culture and sensitivity (UA with C & S, identifies the amount and type of bacteria present and the medications appropriate to treat the infection), dated 10/21/23, showed the presence of organisms indicative of a possible UTI. Review of the physician's order, dated 10/23/23, showed: -Bactrim DS twice daily for five days for UTI. Review of the physician's order, dated 10/27/23, showed: - Change to Cipro 500 milligrams (mg.) twice daily for five days for UTI. Review of the resident's significant change in status Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/17/23, showed: - Cognitive skills moderately impaired; - Lower extremity impaired on one side; - Had a Foley catheter; - Always incontinent of bowel; - Diagnoses included obstructive uropathy ( a disorder of the urinary tract that occurs due to obstructed urinary flow), stroke, benign prostatic hyperplasia (BPH, age-associated prostate gland enlargement that can cause urination difficulty) and peripheral vascular disease (PVD, a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Review of the resident's care plan, revised 1/2/24, showed: - The resident had a Foley catheter related to scrotal edema and obstructive uropathy; - Catheter care every shift; - Position catheter bag and tubing below the level of the bladder; - Observe and document for pain/discomfort related to the catheter. Observation on 1/4/24 at 5:09 A.M., showed: - Certified Nurse Aide (CNA) A placed a paper towel on the floor and placed the graduate on it. He/she removed the spout from the sleeve, unclamped it and emptied 700 milliliters (ml.) of yellow urine from the drainage bag. He/she clamped the spout and placed it back in the sleeve and did not clean it. - CNA H did not separate and clean all the frontal skin folds and used the same area of the wipe to clean different areas of the skin; - CNA A and CNA H turned the resident on his/her side; - CNA H wiped the rectal area with fecal material on the wipe, used a new wipe and wiped the rectal area with a smear of fecal material then folded the wipe and dabbed at both sides of the buttocks with the same area of the wipe; - CNA A applied peri guard ( house barrier) to the buttocks; - CNA A and CNA H placed a clean incontinent brief on the resident. During a telephone interview on 1/9/24 at 6:20 P.M., CNA H said: - He/she should have separated and cleaned all areas of the skin where urine or feces had touched; - Should wipe front to back, not back in forth; - Should not use the same area of the wipe to clean different areas of the skin; - Should clean the spout of the drainage bag with an alcohol wipe. During a telephone interview on 1/9/24 at 6:36 P.M., CNA A said: - He/she did not need to clean the spout of the drainage bag; - Should wipe from front to back, not back and forth; - Should not use the same area of the wipe to clean different areas of the skin; - Should separate and clean all areas of the skin where urine or feces had touched. 2. Review of Resident #21's care plan, revised 3/18/22, showed: - The resident was at risk for UTIs due to indwelling Foley catheter; - Catheter care every shift and as needed; - Encourage adequate fluid intake; - Keep catheter below the level of the bladder; - Monitor for signs and symptoms of UTI and report to the primary care physician as needed; - Monitor urine output for color, clarity and amount. Report any changes to the primary care physician as needed. Review of the resident's significant change in MDS, dated [DATE], showed: - Cognitive skills intact; - Upper and lower extremities impaired on both sides; - Dependent on the assistance of staff for toileting; - Had a Foley catheter; - Always incontinent of bowel; - Diagnoses included neurogenic bladder ( the name given to a number of urinary conditions in people who lack bladder control due to a brain, spinal cord or nerve problem), stroke, quadriplegia (paralysis of all four limbs), obstructive uropathy, and Parkinson's disease ( a progressive, degenerative neurological condition that affects a person's control of their body movements). Observation on 1/4/24 at 7:21 A.M., showed: - At various times from 1/2/24 to current date, the drainage bag hung on the side of bed facing the door and did not have a dignity cover; - CNA C did not separate and clean all of the front perineal folds; - CNA C turned the resident on his/her side and and wiped the rectal with fecal material noted and used a different wipe for each swipe. CNA C did not clean all areas of the buttocks; - CNA B and CNA C place a clean incontinent brief on the resident; - CNA C did not have a clean barrier and placed the graduate directly on the floor, removed the spout from the sleeve, unclamped it, emptied 700 ml of yellow urine into the graduate, cleaned the spout with an alcohol wipe, clamped the tubing and replaced the spout in the sleeve. During a telephone interview on 1/9/24 at 4:14 P.M., CNA B said: - All the drainage bags should have a dignity cover; - Should place the graduate on a paper towel; - Should separate and clean all areas of the skin where urine or feces has touched. During a telephone interview on 1/9/24 at 4;20 P.M., CNA C said; - Drainage bags should have a dignity cover; - Should separate and clean all areas of the skin where urine or feces has touched; - Should have a clean barrier to place graduate on. During an interview on 1/5/24 at 2:56 P.M., the Director of Nursing (DON) said: - Staff should place a barrier on the floor before placing the graduate on it; - Staff should clean the drainage spout with an alcohol wipe; - Staff should not use the same area of the wipe to clean different areas of the skin; - Staff should separate and clean all areas of the skin where urine or feces had touched. - Drainage bags should have a dignity cover.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure staff administered medications with a less than five percent medication error rate (5%). Staff made seven errors out of 25 opportunities for error, which resulted in an error rate of 28%. This affected 2 out of 15 sampled residents, ( Resident #26 and #45). The facility census was 59. Review of the facility's policy for guidance for using insulin products, dated 2021, showed, in part: - Use an alcohol wipe to clean the top of the insulin vial; - Meal time administration - Humalog insulin may be given within 15 minutes before or immediately after a meal; - To minimize air bubbles in pen-like devices prime the pen prior to each and every injection by pushing two units into the air until a drop of insulin is seen at the top of the needle. 1. Review of Resident #45's care plan, revised 4/6/22, showed: - The resident had diabetes mellitus; - Blood sugar check as ordered; - Medication as ordered. Review of the resident's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/27/23, showed: - Cognitive skills intact; - Lower extremities impaired on both sides; - Had seven insulin injections in the last seven days; - Diagnosis included diabetes mellitus. Review of the resident's physician order sheet, (POS), dated January, 2024, showed: - Order date: 8/24/23 - Humalog (fast acting insulin), 45 units with meals for diabetes mellitus. Hold for blood sugar less than 120; - Order dated: 6/2/21 - Humalog insulin per sliding scale before meals and at bedtime related to diabetes mellitus. Blood sugar 111- 150 - give two units; - Order date: 5/30/23 - Lantus (long-acting) insulin, 50 units twice daily for diabetes mellitus. Review of the resident's medication administration record (MAR), dated January 2024, showed: - Humalog insulin,45 units with meals for diabetes. Hold for blood sugar less than 120; - Humalog insulin per sliding scale before meals and at bedtime related to diabetes. Blood sugar 111- 150 - give two units; - Lantus insulin, 50 units twice daily for diabetes mellitus. Observation on 1/4/24 at 7:03 A.M. showed: - Licensed Practical Nurse (LPN) A did not clean the port of the Humalog insulin pen and attached the needle, did not prime the insulin pen and dialed the pen to 47 units; - LPN A did not clean the port on the vial of Lantus insulin and drew up 50 units; - At 7:18 A.M., LPN A administered the Humalog insulin in the resident's right abdomen; - At 7:18 A.M., LPN A administered the Lantus insulin in the resident's left abdomen; - At 8:11 A.M., showed the resident was in his/her wheelchair in his/her room dozing off at intervals. No meal has been served; - At 8:15 A.M., the dietary staff propelled the resident to the dining room for breakfast; - At 8: 20 A.M., the staff placed the resident's breakfast tray in front of him/her; - At 8:22 A.M., the resident took the first bite of his/her breakfast. During a telephone interview on 1/5/24 at 11:42 A.M., LPN A said: - He/she should have cleaned the port of the insulin pen with an alcohol wipe before he/she attached the needle; - He/she should have cleaned the port on the vial of Lantus insulin with an alcohol wipe before drawing up the insulin; - He /she should have primed the insulin pen with one or two units of insulin before administering it; - The resident should have had a meal within 15 - 20 minutes of receiving the Humalog and Lantus insulin. 2. Review of the facility's policy for general dose preparation and medication administration, revised 1/1/22 showed, in part: - Facility should crush oral medications only in accordance with pharmacy guidelines. Review of the website, www. webmd.com for multivitamin with minerals showed: - Swallow the tablets whole. Do not crush or chew the tablets. Review of the website, www.drugs.com for ferrous sulfate tabs showed: - Swallow the iron tablets and capsules whole: do not crush, open or chew. 3. Review of Resident #26's care plan, revised 5/19/21 showed: - The resident has anemia (not having enough healthy red blood cells or hemoglobin to carry oxygen to the body's tissues): - Give medications as ordered. Review of the Resident's quarterly MDS, dated [DATE] showed: - Cognitive skills intact; - Diagnoses not addressed. Review of the resident's POS, dated January, 2024, showed: - Order date: 8/11/23 - Ferrous Sulfate oral tablet 325 milligram (mg.) one tablet by mouth one time a day every two days for iron deficiency anemia; - Order date 1/20/22 - Multivitamins-minerals tablet one tablet by mouth daily for supplement. Review of the resident's MAR, dated January, 2024, showed: - Ferrous Sulfate oral tablet 325 mg. one tablet by mouth one time a day every two days for iron deficiency anemia; - Multivitamins-minerals tablet one tablet by mouth daily for supplement. Observation on 1/4/24 at 8:55 A.M., showed LPN B: - Placed the Multivitamins with minerals tablet and the Ferrous Sulfate tablet in a plastic bag and crushed the medications, placed the crushed medication in a medication cup with applesauce and administered to the resident. During an interview on 1/5/24 at 11:42 A.M., LPN A said: - Multivitamins with minerals and Ferrous Sulfate should not be crushed. During an interview on 1/524 at 2:56 P.M., the Director of Nursing (DON) said: - Staff should make sure they clean the port of the insulin pens and the port on the vials of insulin with an alcohol wipe; - She would expect staff to prime the insulin pen with one or two units of insulin, then dial it to the amount to be administered; - The resident should have a meal within 30 minutes of receiving a fast acting insulin; - Should not crush a multivitamin with minerals and was not for sure about the ferrous sulfate. During an interview on 1/9/24 at 4:08 P.M., LPN B said: - He/she thought you could crush Multivitamins with minerals and could crush Ferrous Sulfate.

Based on observations, interviews, and record review, the facility failed to ensure staff discarded an a expired open bottle of Lorazepam for Resident #46, failed to discard an expired open vial of house stock Lorazaepam, and failed to discard two bottles of expired house stock Fish Oil. The staff also failed to date and put the resident's name on an insulin pen after opening and failed to keep the medication cart free of loose pills. Additionally the staff failed to ensure resident's with medications at bedside (Resident #58 and Resident #29) had a physician's order to keep the medications at the bedside. The facility census was 59. Review of the facility's Storage and Expiration Dating of Medications and Biologicals, revised 8/7/23, showed: -The facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts and refrigerators and freezers; -Once any medication or biological is opened the facility should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened; -If a multi dose vial of an injectable medication has been opened or accessed, the vial should be dated and discarded within 28 days; -The facility will not administer or provide bedside medications or biological's without a physician's order; -The facility should destroy or return all discontinued and expired medications or biologicals according to federal regulations. Review of the facility's Guidance for Using Insulin Products, dated 2021, showed: -Upon opening, all insulin vials and pens should be dated and stored away form heat and light. 1. Review of Resident #58's admission Minimum Data Set (MDS, a federally mandated assessment instrument completed by facility staff), dated 12/8/23, showed: -The resident has moderate cognitive impairment; -The resident is independent with Activies of Daily Living (ADLs); -The resident requires partial assistance with bathing; -Diagnoses included, Dementia, high blood pressure and Asthma. Review of the resident's care plan, dated 12/21/23, showed: -Independent with most ADLs; -Supervision with bathing; -The resident will be administered medications as prescribed by his/her physician. Observation on 1/3/24 at 11:26 A.M. showed: -The resident in his/her room setting in a recliner; -A bottle of Systane Eye drops (used to treat dry eye) with an expiration date of 2/3/22, setting on the sink in his/her room. Observation on 1/4/24 at 2:17 P.M. showed: -The resident in his/her room at the sink washing his/her hands; -A bottle of Systane Eye drops still setting on the sink in his/her room. Review of the resident's Physician's Order Sheet (POS) dated January 2024, showed: -No order for Systane Eye drops; -No order for medication to be kept in the resident's room. During an interview on 1/4/24 at 2:32 P.M., Licensed Practical Nurse (LPN) A said: -He/she did not know the resident had the Systane eye drops in his/her room; -The resident should have physician's order for any medications in the resident's room. Observation on 1/5/24 at 12:01 P.M., of the [NAME] Medication Nurse's Room showed: - Resident #46 had an opened bottle of Lorazepam (used to treat anxiety) oral intensol, 2 milligrams (mg.)/milliliters (ml.), opened 8/29/23. The label on the box said to discard open bottle after 90 days; - An opened vial of house stock Lorazepam injection, 2 mg./ml., no date on the vial when it was opened. Observation on 1/5/24 at 12:24 P.M., of the East Hall Medication Room showed: - An unopened bottle of house stock Fish Oil 500 mg., expired 10/23; - An opened bottle of house stock Fish Oil 500 mg,. opened 8/1/22, expired 10/23. Observation on 1/5/24 at 12:37 P.M., of the medication cart on the Memory Care Unit showed: - An insulin Aspart (Novolog, fast acting insulin) flexpen, did not have a date when it was opened and did not have a label to indicate which resident it belonged to; - Found two round white pills, one round pink pill, one gray round pill and one oblong pill loose in the drawer of the medication cart. 2. Review of Resident #29's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/23/23, showed: - Cognitive skills intact; - Diagnoses included seizure disorder, anxiety and depression. Observation and interview on 1/2/24 at 10:50 A.M., showed: - The resident had Flonase 50 mcg., Combivent Inhaler 20 mcg./100 mcg. per activation and Advair Diskus, 250 mcg/50 mcg. on his/her bedside table; - The resident said the staff always leave those medications in his/her room. Review of the resident's physician order sheet (POS), dated January, 2024, showed: - Order date: 8/16/23 - Advair Diskus Aerosol Powder Breath Activated 250/50 mcg./dose, one inhalation orally every 12 hours for shortness of breath; Rinse mouth after use, do not swallow; - Order date: 6/16/23 - Combivent Respimat Aerosol Solution 20-100 mcg., inhale two puffs orally four times a day for shortness of breath; - Order date: 6/16/23 - Flonase Allergy Relief Suspension 50 mcg. one spray in each nostril two times a day related to allergies. During a telephone interview on 1/5/24 at 11:42 A.M., Licensed Practical Nurse (LPN) A said: - Medications should not be left at the resident's bedside unless there was a physician's order for them to be left at bedside. During an interview on 1/5/24 at 12:37 P.M., the Director of Nursing (DON) said the nurses and herself check the medication rooms for expired medications. The staff should not use medications that are expired. The medications should be dated when opened. There should not be any loose pills in the medication carts. During an interview on 1/5/24 at 2:56 P.M., the DON said, medications cannot be left at bedside unless there's a physician's order.

Based on observation, interview, and record review, the facility failed to ensure the Dietary Manager (DM) had the appropriate competencies and skills sets to carry out the functions of the food and nutritional services. The facility census was 59. Review of the facility's Department Leadership Requirements Policy, revised 8/15/22 showed: -The food and nutrition services department operates under the direction of a qualified individual who has appropriate competence and skills necessary to oversee the functions of the food and nutrition services. If a full-time dietician is not employed, the executive director designates a qualified person to serve as full time Director of Food and Nutrition Services with frequently scheduled consultations from a qualified dietician or other clinically qualified nutrition professional. -If a qualified dietitian or clinically qualified nutrition professional is not employed full time, the facility must designate a person to serve as the director of food and nutrition services who is: o A certified dietary manager or a certified food service manager; o Has a similar national certification for food service management; o Has an associate's or higher degree in food service or restaurant management; o Two or more years of experience in the position of a director of food and nutrition services and have completed a course of study no later than October 1, 2023; o If the Director of Food and Nutrition Services is not a qualified dietitian, the consultant dietitian is responsible for completing observation rounds at the facility during the visit; o The Director of Food and Nutrition Services is responsible for training and supervision of department associates including orientation and ensuring competentcies are completed per facility guidelines. Review of the Dietary Manager's (DM) personnel file showed: -Hire date of 1/5/23; -No certification of documentation of completion of dietary manager training was found. During an interview on 01/4/24 at 1:36 P.M., the DM said: -He/she has been the DM for a year; -He/she consults electronically with the Registered Dietitian (RD); -It has been one year since the RD has been onsite at the facility; -He/she is responsible for ordering food on a budget, ensuring the kitchen was staffed to meet the needs of the residents and managing the day to day activities of the kitchen; - The facility had not provided him/her with any dietary management training; - The facility had not sent him/her to a Certified Dietary Manager's course; -He/she has not had experience in managing the kitchen, ordering food for the kitchen, and managing dietary staff until he/she took this position. During an interview on 01/05/24 at 10:05 AM ., the RD said: -He/she expects the DM to be capable of managing the date to day operations of the kitchen; -He/she expects the DM to have the education and certifications for the dietary manager position according to the policy and procedure fof the facility and federal regulations. During an interview on 1/5/24 at 3:10 P.M., the administrator said: -He/she expects the DM to have the skills to manage the kitchen; -He/she expects the DM to be certified with in one year.

Based on observation, interviews, and record review, the facility failed to ensure staff stored food in a sanitary manner and failed to maintain the kitchen in a sanitary manner. This had the potential to affect all residents residing in the facility. The facility census was 59. Review of the facility's Cleaning Schedule Policy, revised 12/17/21, showed: -The Director of Food and Nutrition Services develops a cleaning schedule with assistance from the Registered Dietitian to ensure the kitchen remains clean and sanitary at all times; -The cleaning schedule is posted in a location where it can be easily read; -The Director of Food and Nutrition Services monitors the cleaning schedule to ensure the tasks are completed timely and appropriately. Review of the facility's Food Safety Policy, revised 4/27/22, showed: -Food is stored and maintained in a clean, safe and sanitary manner to minimize contamination and bacterial growth; -Food is stored a minimum of six inches off the floor; -Pre-packaged food is placed in a leak proof, pest proof, sanitary container with a tight fitting lid; -The container is labeled with the name of the contents and due date, and use by date is noted on the label; -Left overs are dated properly and discarded after 72 hours. Review of the facility's Sanitization and Maintenance policy revised 4/26/23, showed: -Food and Nutrition Services staff are trained in the proper use, cleaning and sanitation of all equipment and utensils; -Dish Machine Operation: o The temperature and parts per million (PPM) of the sanitizer (50-100 ppm) will be recorded on the temperature log a minimum of three times per day; o The staff will be trained on how to operate the dish machine and how to rinse, wash, dry and store items appropriately. 1. Observation of the kitchen on 01/02/24, at 10:01 A.M., showed: -Two vents above the entrance to the kitchen above the food serving window covered with dirt and debris; -The wall behind the round sink in the dish room covered with a black spotty substance; -Baseboards along the floor under the round dishwashing sink are missing with black spotty substance on the wall; -Paint is peeling from the ceiling around the vent above the dish storage rack; -Three pitchers stored face up on the top storage rack below the peeling ceiling with no lids; -The paper towel dispenser by the hand washing sink in the dish room contained no paper towels; -The paper towel dispenser by the hand washing sink by the walk in freezer contained no paper towels; -The top of the toaster covered in food debris; -Three plastic containers of utensils setting under the prep table with no lids with debris in the bottom of the containers. Refrigerator: -Two undated, open cartons of liquid eggs; -A plastic container of salad dressing dated with an open date of 9/27/23. Freezer: -Icicles along the line from the hose to the freezer fan; -A card board box of angel food cakes setting on a cardboard box on the floor under the line with icicles covered with wet liquid; -An undated open bag of french fries; -An undated open bag of frozen mixed vegetables; -An undated open bag frozen green beans. 2. Observation of the kitchen on 01/04/24 at 05:20 A.M., showed: -Two vents above the entrance to the kitchen above the food serving window are still covered with dirt and debris; -Paint is still peeling from the ceiling around the vent above the dish storage rack; -Three pitchers are still stored face up on the top storage rack below the peeling ceiling with no lids; -The paper towel dispenser by the hand washing sink in the dish room still does not contain paper towels; -Dietary Aide B washed his/her hands and applied clean gloves; -Dietary Aide B took eight bowls from the clean dish rack and set them on a table; -One of the bowls fell on the floor and Dietary Aide B picked up the bowl that fell on the floor and put it back on the clean dish rack -then poured cereal in the remaking bowls and put plastic lids on the bowls; -She did not wash her hands or change gloves after picking up the bowl of the floor; -The three bowls of the cereal were served to Resident #33, #35 and #58. 3. Observation and interview of Dietary Aide A on 01/4/24 at 07:35 A.M., showed: - Dietary Aide A loaded a rack of plates, cups and glasses into the dishwasher; -He/she removed the dishes after the wash/rinse cycles were complete; -He/she placed another rack of cups, glasses and silverware into the dishwasher and removed the dishes after the wash/rinse cycle was complete; -He/she said he/she had not checked the sanitizer in the dishwasher today; -He/she removed a test strip from the canister of Hydrion Sanitizer testing strips; -The table on the test strips showed lot number 062421, with an expiration date of 7/21/23; He/she dripped a sanitizer testing strip in the dishwasher for 10 seconds; - The strip remained white; - He/she used another sanitizer testing strip to test the sanitizer in the dishwasher and strip did not change color. - He/she said thought the strip should change color if there was sanitizer chemical in the dishwasher; he/she would have to talk to the dietary manager; - Dietary Aide A said the dishwasher should have the proper amount sanitizer in it since that was how he/she sanitizes dishes; - He/she would find out how to check the sanitizer in the dishwasher; -He/she did not know that the test strips were expired; -He/she said expired test strips should not be used. During an interview on 1/4/24 1:20 P.M., the dishwasher service technician said; -The sanitizer in the dishwasher should be check before any dishes are ran through; -The sanitizer should be checked before every meal service; -The staff should know how to properly use the test trips to check the levels of sanitizer; -The test strips should not be expired. During an interview on 1/4/24 at 2:19 P.M., the DM said: - The chemical sanitizer in the dishwasher should be checked daily; - The sanitizing strip should change color to indicate the sanitizer level in the dishwasher; - If the strip remains white that means there is no measurable amount of sanitizer in the dishwater; - The level of the sanitizer should be 50 - 100 Parts Per Million (PPM); - The level of sanitizer should be recorded in the log at least daily; - Dietary Aide B has been trained to use the dishwasher; -The floors, walls and ceilings of kitchen should be clean and in good repair; -Opened food items should have the date it was opened; -Foods in the walk in freezer should be kept off the floor; -The paper towel dispensers at the hand washing sinks should contain paper towels; -Dishes should be stored in a manner that prevents contamination; -He/she expects kitchen staff to wash their hands and apply clean gloves after touching items that have fallen on the floor; -The kitchen staff is responsible for cleaning the kitchen; -The maintence department is in charge of clearing the vents in the kitchen; -He/she has told the maintence director about the vents; -He/she did not know the last time the vents were cleaned. During an interview on 01/05/24 at 10:44 A.M., the Maintence Director said: -He/she is responsible for the HVAC vents cleaning and maintenance in the the kitchen; -He/she said the vents are cleaned every three months; -He/she is responsible for maintaining the repair and cleaning of the ceiling in the kitchen; -He/she did not know the ceiling was peeling in the kitchen by vent in the dish area; -He/she is informed of repairs that need to be made by word of mouth or by notes left in the maintence clip board up front; -The staff use the clip board up front to write maintence requests and repairs on; -He/she said he/she checks the clip board daily; -He/she said the vents and ceiling in the kitchen should be clean and in good repair. During an interview on 1/5/24 at 10:05 A.M., The Registered Dietitian (RD) said: -He/she expects the kitchen to be clean and sanitary; -The kitchen staff should be responsible for doing this; -The vents in the kitchen should be free of dirt and debris; -The kitchen should have no falling tiles or paint peeling; - Dishes should be stored to prevent contamination; -The staff should store and date food per the facility policy and the food should be dated to ensure it is fresh; -Food should be stored in a sealed container; -The hand washing sinks should be clean and in good repair, with soap and paper towels available; -Kitchen staff should be familiar with operation of the dishwasher which includes the ability to check the sanitizer level in the dishwasher; -The DM should have the training and skill set to manage the kitchen; -The education and certification requirements for the DM should follow the facility policy and federal regulations; -He/she was not aware that the DM had not completed the education and certifications required for the position. During an interview on 1/5/24 3:10 P.M., the administrator said: -He/she expects the kitchen to be clean and good repair daily; -He/she expects kitchen staff to wash hands and apply clean gloves after touching something that has touched the floor or is dirty; -He/she expects the hand washing sinks to be clean with paper towels and soap available; -He/she expects staff operating the dishwasher to able to check the sanitizer levels; -The DM should be responsible for training staff on the operation of the dishwasher.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility staff failed to maintain an effective infection control program when staff did not wash or sanitize their hands when passing resident food trays, when assisting one resident to eat (Resident #25), when staff left and entered the dining room during the meal service and when no hand hygiene was completed when eye drops were administered to one resident (Resident #49). The facility census was 59. Review of the hand hygiene policy dated 6/13/23 showed: - AN alcohol- based hand rub is acceptable in most instances when the hand are not visibly soiled; - The staff should perform hand hygiene before and after contact with the residents; - The staff should perform hand hygiene before eating; - The staff should perform hand hygiene after contacts with objects in the residents environment. 1. Review of Resident #25's quarterly MDS dated [DATE] showed: -He/She had a BIMS score of 0, indicating severely impaired cognitive function; - He/She had no behaviors; - He/She was dependent on the staff for all cares; - He/she was non verbal and did not make his/her needs known; - Diagnoses included: Dementia and depression. Review of the resident's activity of daily living (ADL) care plan dated 7/12/22 showed: - The resident at times was able to feed him/herself a bite or two; - Staff were to help the resident with feeding as needed. Observation on 1/2/24 at 11: 29 A.M. showed: - Certified Nurse Aid (CNA) H entered the dining room; - CNA H did not perform hand hygiene when he/she entered the dining room; - He/She repositioned the resident who was in their geriatric chair; - CNA H sat next to resident and fed the resident two bites; - CNA H got up from the resident, passed another resident his/her food tray, did not perform hand hygiene before or after passing the food tray; - CNA H passed another resident his/her food tray and did not perform hand hygiene; - CNA H left the dining room to take another resident to his/her room; - CNA H returns to the dining room and did not perform hand hygiene; - CNA H sat next to Resident #25 and fed him/her another bite of food; - CNA H did not perform hand hygiene before giving the resident another bite. During an interview on 1/5/24 at 8:56 A.M. CNA H said: - He/She was trained to wash his/her hands before serving food trays to the residents; - He/She should have washed his/her hands when he/she fed Resident # 25. Observation on 1/3/24 at 11:39 A.M. showed: - CNA G entered the dining room, did not perform hand hygiene, served Resident #25 his/her tray; - CNA G continued to serve other residents their meal trays and did not perform hand hygiene; - CNA G assisted another resident in his/her wheel chair to move from one side of the dining room to the other; - CNA G continued to pass residents their food trays and did not perform hand hygiene. During an interview on 1/4/24 at 11:31 A.M. CNA G said: - He/She was supposed to wash or sanitize his/her hands when he/she entered into a residents room and when he/she left the room; - He/She was supposed to wash or sanitize his/her hands when he/she entered the dining room and between each resident tray that was passed. 2. Review of Resident #49's quarterly Minimum Data Set, (MDS, a federally mandated assessment completed by the facility staff), dated 10/3/23 showed: - The resident had a brief interview for mental status (BIMS) score of 15, indicating no cognitive impairment; - He/She required assistance of one staff to get dressed, take a shower and use the toilet; - Diagnoses included: Parkinson's Disease (a progressive disorder that affects the nervous system and can cause uncontrolled shaking and tremors), Dementia (a disease that affects the brain, causes confusion and can affect reasoning), and psychotic disorder (a mental disorder that is characterized by a disconnect from reality). Review of the resident's Physician Order Sheet (POS) dated January 2024 showed: - 3/22/23 Artificial tears (used to treat dry eyes) 1.4%, instill one drop in both eyes two times daily. Observation of Licensed Practical Nurse (LPN) E on 1/3/24 at 10:17 A.M. showed: - LPN E arrived the the resident's room to administer the resident's eye drops; - He/She did not perform hand hygiene when he/she entered the room; - He/She obtained a pair of gloves from the resident's bathroom and put them on his/her hands; - LPN E instructed the resident to lay his/her head back and open his/her eyes; - He/She scratched his/her forehead with his/her gloved hand using his/her pinky finger to scratch; - LPN E used the same gloved hand to hold the resident's eye lid open placing the pinky finger on the residents upper eye lid and thumb on the resident's lower eye lid; - LPN E administered the resident's eye drops as ordered and washed his/her hands after the procedure was completed. During an interview on 1/5/24 at 9:23 A.M. LPN E said: - He/She expected staff to wash their hands when they enter a residents room, when care were provided to the resident and when the staffs hands were visibly soiled; - The use of an alcohol- based hand rub was acceptable when the staffs hands were not visibly soiled; - He/She should have washed his/her hands before putting gloves on to administer Resident #49's eye drops; - He/She should have taken his/her contaminated gloves off, washed his/her hands and put clean gloves on when he/she touched his/her forehead and then administered the resident's eye drops. 3. During an interview on 1/5/24 at 10:46 A.M. the Infection Preventionist (IP) said: - She expected the staff to wash or sanitize their hands before providing cares to residents; - She expected staff to wash their hands when they enter the dining room for meal service, before and between passing resident meal trays and before assisting residents to eat; 4. During an interview on 1/5/23 at 3:10 P.M. the Director of Nursing (DON) said: - She expected staff to wash or sanitize their hands when entering and exiting resident rooms; - She expected staff to wash their hands when visibly soiled; - She expected staff to wash their hands after tree instances of using alcohol- based hand rub; - She expected staff to wash or sanitize their hands when entering the dining room for meal service, when passing trays, and when assisting residents during meals; - She expected staff to wash or sanitize their hands when entering a resident's room to administer eye drops; - She expected staff to change their gloves when they touched their face and then administered eye drops.

Based on observation, interview and record review, facility staff failed to maintain proper documentation and monitoring for the use of a physical restraint and to document assessments to assess the use of a seat belt and a hand mitt as a restraint device or an enable for one resident (Resident # 5). The facility census was 60. Review of facility policy Restraint and Position Change Alarm Use dated 6/22/21 showed in part: -A physician's order is required for the use of a specific type of restraint; should include the specific type of restraint, condition/symptom that warrants the use, where and how the restraint is to be applied, and the time and frequency the restraint should be released. -The care plan is revised as needed and must contain: -the specific type of restraint -the Resident's condition and medical symptoms that warrant the use. -the length of time the restraint is anticipated to be used - who may apply and release the restraint -the time and frequency the restraint should be released -the type of specific direct monitoring and supervision provided during the use of restraint -The need for the restraint is assessed quarterly and as indicated. -Documentation in the clinical notes may include, but not limited to: -type of restraint -date and time of use -reason for use -resident tolerance -the effectiveness of the restraint Review of Resident #5 Minimum Data Set (a federally mandated assessment tool) dated 12/2/21 showed: -Brief Interview of Mental Status (BIMS) score of 0. Indicates severe/no cognitive ability. -Total dependence for all Activities of Daily Living (ADLs: collectively describes the fundamental skills needed to care for oneself) -Diagnosis of: Seizure Disorder, Anxiety, Psychosis, Congenital deformity of the feet, legally blind, contractors of elbow and wrist. Review of Physician order sheets for December 2021 showed: - Order date of 9/18/2019 - Seatbelt to w/c due to seizure disorder. - Check and release every 2 hours. - Assess skin beneath seatbelt every 30 minutes. - No order noted for soft mitt to left hand. Review of Resident Care plan dated 12/2/21 showed: - I have a seat belt in place while in my w/c. The seatbelt helps me maintain an upright position. Sometimes I rock and wiggle in my w/c. The seat belt does not prevent access to my body as I do not try to access my body. -I will not have any complications r/t my seat belt use through next review. - Apply my seat belt while I am up in my w/c. -Check skin below seat belt during routine cares and report any abnormalities to my charge nurse. -Monitor for any changes in my behavior. -I will hit myself in the head with my left hand, I wear a soft mitt on my left hand to keep me safe during episodes of hitting myself. The hand mitt allows me to continue behavior without injuring myself and does not limit access to my body. -Will be free of complications related to hand mitt use through next review. -Apply soft mitt to left hand. -Change my mitt if it becomes soiled. -Check my skin under my hand mitt during routine cares and report any abnormalities to my charge nurse. Review of Treatment Administration Record for December showed: -Check seatbelt every shift. Assigned to days and nights. -Initials are noted on all days and nights for December. Review of medical record showed: -Consent for seat belt signed December 18, 2005. -No updated consent is noted. -Care Plan meeting notes do not indicate the seatbelt or mitten have been reviewed with guardian. Observations on 12/07/21 at 4:18 P.M. showed: - Resident #5 sitting up in wheelchair has seatbelt on around waist. -Resident does not respond to verbal commands. Observation on 12/09/21 at 9:36 A.M. showed: - He/she has on left hand mitten with buckle latched. seat belt in place. Resident doesn't respond to request to remove either. -He/she is sitting up in w/c with seat belt on and mitt in place to left hand. Observation on 12/09/21 at 10:15 A.M.showed Resident #5 was taken to activities for exercise and music. Observation on 12/09/21 at 10:21 A.M. showed staff entered room to assist resident to bed. Staff removed the residents seat belt and mitt. During an interview on 12/9/21 at 10:21 A.M. Certified Nurse Aide (CNA) B said: - The residents seat belt is used to prevent falls. - Resident #5 wiggles and moves around. - The residents mitt is so he/she does not scratch/dig or harm him/herself when he/she hits herself. During an interview on 12/09/21 at 11:19 A. A.M CNA C said: - Resident #5's seatbelt is removed every 2 hours and he/she checks to make sure it's not rubbing his/her abdomen. - Resident #5 she wears the mitt to prevent injury when he/she hits him/herself. - He/she hasn't seen Resident #5 strike him/herself. During an interview on 2/09/21 at 3:27 P.M. interview with Licensed Practical Nurse (LPN) B said: - The charge nurse monitors the seat belt every shift, once a shift. - The CNAs are to remove the residents seatbelt and mitt when resident goes to bed. - He/she has no idea when the doctor re-evaluates the use of restraint. During an interview on 12/09/21 at 3:43 P.M. MDS Coordinator said he/she was told by the Corporate Certified Reimbursement Specialist not to mark the seat belt or mitt as a restraint. During an interview on 12/09/21 at 3:45 P.M. the Director of Nursing (DON) said: - Nurses Medication Administration Record (MAR) should include instructions for staff to check every 2 hours - The MAR should include what time to release seatbelt and mitten. - He/she would expect the MAR to have the check and release times specified. - He/she expects residents with restraints to be assessed quarterly with the care plan, and documented in the care conference summary form. - He/she expects restraint consent forms to be completed annually or with a significant change in condition.

Based on observation, interview, and record review, facility staff failed to ensure a medication error rate of less than 5%. Out of 26 opportunities observed, 2 errors occurred, resulting in a 7.69% error rate, which affected 1 of 6 sampled residents (Resident #29) The facility census was 60. Review of facility policy Administration of Medication dated 7/14/21 showed in part: -All medication s are administered safely and appropriately per physician order to address resident's diagnosis and signs and symptoms. -Medication Error : preperation or administration of medications which is not in accordance with manufacturer's specifications Review of Mosby's 2021 Nursing Drug Reference book showed: -Brovana inhalation : use this product before other medications allow 5 minutes between each. -Albuterol metered dose inhaler: give inhalation at least 1 minute apart Review of Quarterly Minimum Data Set ( MDS a federally mandated assessment tool) dated 10/19/21 showed: - Brief Interview of Mental Status (BIMS) of 13. (indicates little to no cognitive imapairment) -Independent for Activities of Daily Living (ADLs: collectively describes the fundamental skills needed to care for oneself) -Diagnosis of Chronic Obstructive Pulmonary Disease (COPD: a condition involving constriction of the airways and difficulty or discomfort in breathing), Hypertension, Diabetes, Depression Review of Care Plan dated 10/19/21 showed: -no specific instructions on the use of Brovana or Albuterol inhaler. Review of Physician Order Sheets for December 2021 showed: -Brovana 1 inhalation twice a day for COPD. -Albuterol inhaler 2 puffs every 6 hours as needed for Shortness of breath. Observation on 12/8/21 at 8:55 A.M. showed: - Certified Medication Technician (CMT) C administered Brovana inalation solution via nebulizer machine (a small machine that turns liquid medication into a mist for inhalation). -At nebulizers completion CMT C removed the nebulizer mask and handed resident his/her Alubertrol hand held inhaler. -Resident #29 immediately inhaled 2 puffs of Albuterol Metered Dose Inhaler. During an interview on 12/08/21 at 1:36 P.M. Pharmacist A said: -Brovana must be given adequate time to work - There is a problem with administering the Albuterol immediately after the Brovan: the Brovana wouldn't have the time to reach it's full effectiveness. -He/she might not have needed the albuterol if the Brovana was used correctly. During an interview on 12/08/21 at 3:24 P.M . CMT C said: -When using the same inhaler wait time is 5 minutes between puffs. -For different medications wait time is 15 minutes. - Resident# 39 likes his puffs together. During an interview on 12/09/21 03:45 PM Director of Nursing (DON) said: -He/she would expect staff to wait 15 minutes between Brovana and other inhaled medications to allow Brovana time to work. - He/she would expect staff to wait 3-5 minutes between puffs of the same inhaler. puffs of same inhaler is 3-5 minutes expect them to wait that amount of time.

Based on observation, interview and record review, the facility failed to provide a diet that meets the resident's daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Staff failed to follow provided recipes when preparing pureed meals. The facility census was 60. The facility's Policy on Pureed Food, dated 10/29/21, showed: -The Pureed Diet is designed to minimize the amount of chewing required and to facilitate the ease of swallowing food. - It is indicated for residents who have a fractured or wired jaw and those who are missing teeth or dentures. - This diet is also for residents who have neurological disorders and/or a generalized weakness that affects chewing. - Effort is made to prepare the pureed food without the addition of a thickening agent, since the texture, taste, and nutritional content may be altered. - Some residents placed on a Pureed Diet may already be nutritionally compromised by the time the diet is implemented. Therefore, every effort should be made to ensure adequate calorie and protein intake. Observation of food preparation on 12/8/21 at 10:49 AM, showed: -Cook A prepared a pitcher of water at the sink and brought to the food prep counter. -Cook A put 8 scoops of cooked noodles into the food processor then poured in an undetermined amount of water from the pitcher, then processed the food. During an interview on 12/8/21 at 10:52 AM, [NAME] A said: -He/she does not follow a recipe -He/she determines the appropriate texture and consistency by eye-balling it until it looks right. During an interview on 12/8/21 at 10:55 AM, Dietary Manager said: -There are recipes for the pureed food preparation somewhere but is unsure where. During a phone interview on 12/9/21 at 3:07 PM, the Registered Dietician for the facility said: - There are recipes available at the facility for the dietary staff to use when preparing the pureed meals. - He/she expects that the dietary staff would use these recipes when preparing the pureed meals. - He/she said it was possible to alter the nutritional value of the meals if the provided recipes are not followed.

Based on record review and interview, the facility failed to ensure they utilized the correct SNFABN form, a form that provides information to residents/beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility, for five residents sampled for beneficiary notifications (Residents #55, #56, #52, #26, and #57). The facility census was 60. Review of the facility policy, Denial or End of Benefits, dated March 2021, showed: -Upon end of coverage under Medicare, the resident and family will receive a notice that specifically states the reason for non-coverage. -The policy did not address using the correct updated forms. Review of Resident #55's Beneficiary Notice CMS-10055 form showed his/her last covered day of Part A services was 10/7/21. The resident signed the form on 10/5/21. The facility did not use the most updated form from 2020. The facility issued the old form dated 2018. Review of Resident #56's Beneficiary Notice CMS-10055 form showed his/her last covered day of Part A services was 6/11/21. The residents' representative signed the form on 6/9/21. The facility did not use the most updated form from 2020. The facility issued the old form dated 2018. Review of Resident #52's Beneficiary Notice CMS-10055 form showed his/her last covered day of Part A services was 6/22/21. The resident signed the form on 6/17/21. The facility did not use the most updated form from 2020. The facility issued the old form dated 2018. Review of Resident #26's Beneficiary Notice CMS-10055 form showed his/her last covered day of Part A services was 9/10/21. The resident signed the form on 9/8/21. The facility did not use the most updated form from 2020. The facility issued the old form dated 2018. Review of Resident #57's Beneficiary Notice CMS-10055 form showed his/her last covered day of Part A services was 9/14/21. The resident signed the form on 9/10/21. The facility did not use the most updated form from 2020. The facility issued the old form dated 2018. During an interview on 12/9/21 at 10:20 A.M. the Business Office Manager said: -ABN forms are directed from the corporate office. -He/she currently uses the 2018 CMS 10055 form. -He/she was unaware a 2020 form was available. During an interview on 12/9/21 at 2:35 P.M. the Administrator said: -ABN forms and direction come from corporate office. -He/she expected the facility to use the most up to date form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of facility policy Restraint and Position Change Alarm Use dated 6/22/21 showed in part: -A physician's order is required for the use of a specific type of restraint; should inlcude the specific type of retraint, condition/sypmtom that warrants the use, where and how the restraint is to be applied, and the time and frequency the restraint should be released. -The care plan is revised as needed and must contain -the specific type of restraint -the Resident's condition and medical symptoms that warrant the use. -the length of time the restraint is anticipated to be used - who may apply and release the restrainth -the time and frequency the restraint should be released -the type of specific direct monitoring and supervision provided during the use of retraint Review of Resident #5 Minimum Data Set (a federally mandated assessment tool) dated 12/2/21 showed: -Brief Intrview of Mental Status (BIMS) score of 0. Indicates severe/no cognitive ability. -Total dependence for all Activities of Daily Living (ADLs: collectively describes the fundamental skills needed to care for oneself) -Diagnosis of: Seizure Disorder, Anxiety, Psychosis, Congenital deformity of the feet, legally blind, contractures of elbow and wrist. -No restraint use. Review of Resident Care plan dated 12/2/21 showed: - I have a seat belt in place while in my w/c. The seatbelt helps me maintain an upright position. Sometimes I rock and wiggle in my w/c. The seat belt does not prevent access to my body as I do not try to access my body. -I will not have any complications r/t my seat belt use through next review. - Apply my seat belt while I am up in my w/c. -Check skin below seat belt during routine cares and report any abnormalities to my charge nurse. -Monitor for any changes in my behavior. -I will hit myself in the head with my left hand, I wear a soft mitt on my left hand to keep me safe during episodes of hitting myself. The hand mitt allows me to continue behavior without injuring myself and does not limit access to my body. H -Will be free of complications related to hand mitt use through next review. H -Apply soft mitt to left hand. -Change my mitt if it becomes soiled. -Check my skin under my hand mitt during routine cares and report any abnormalities to my charge nurse. During an interview on 12/9/21 at 10:21 A.M. Certified Nurse Aide (CNA) B said: -He/she uses the Care plan to know how to provide care to residents. During an interview on 12/09/21 at 3:43 P.M. MDS Coordinator said: -He/she was told by the Corporate Certified Reimbursement Specialist not to mark the seat belt or mitt as a restraint. -Care plan is in place. -Wasn't aware of all the things that needed to be included in the care plan. Druing an interview on 12/09/21 at 3:45 P.M. Director of Nursing (DON) said: --He/she expects the seatbelt to be assessed quarterly with the care plan, and documented in the care conference summary form. -He/she expects the care plan to be updated quarterly, annually and as needed with significant changes. Based on observation, interviews, and record review, the facility failed to implement the comprehensive care plan for two out of fifteen sampled residents (Resident #25 and #41) when staff failed to document meal intakes as directed from the care plan. Staff also failed to care plan the use of a restraint for one resident (Resident #5) not follwoing the facility policy and procedure, and standards of practice. Facility census was 60. Review of facility policy, Nutritional Intake, dated December 2021, showed: -Purpose: to ensure documentation of nutritional consumption and to identify any residents at risk for compromised nutritional status. -Nursing staff is responsible for documentation of nutritional intake on each individual resident. -Food intake at each meal is recorded by percentages. -Nutritional intake documentation will be part of the individual resident's permanent medical record. -Notify the nurse if there are any concerns related to the resident's nutritional intake. Review of facility policy, Resident Assessment Instrument and Care Plan, dated May 2021, showed: -By observing and interviewing the patient, family, and staff from all disciplines are required to develop an individualized person-centered care plan that provides a path toward the resident achieving or maintaining their highest practicable level of well-being. -The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. 1. Review of Resident #25 annual minimum data set (MDS, a federally mandated assessment completed by facility staff), dated 10/7/21, showed: -Brief interview for mental status score 5. This indicates severe cognitive impairment. -Resident has no natural teeth. -Resident requires set up only assistance for eating. -Care Area Assessment: nutritional status triggered and care planned. -Diagnoses include: stroke, dementia, depression, and hemiplegia or hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles). Review of the residents' care plan, dated 10/27/21 showed: -Resident is at risk for weight fluctuation related to current health status. Document intake at each meal. Review of dietician progress note, dated 11/19/21 showed: -Significant weight loss (166-202) follows gain, back into previous weight range. Down 10.8 pounds in one month, 3.7 pounds in three months, to 179.2 pounds. -Diet order remains regular and documented meal intakes are consistently good. -Will only further monitor weight/intake on liberalized diet at this time. Review of meal intakes showed no documentation for the following: -12/9/21 one meal. -12/7/21 two meals. -12/6/21 two meals. -12/5/21 one meal. -12/4/21 -12/3/21 -12/2/21 two meals. -12/1/21 two meals. -11/30/21 two meals. -11/29/21 two meals. -11/28/21 one meal. -11/26/21 one meal. -11/25/21 one meal. -11/24/21 two meals. -11/22/21 one meal. -11/21/21 two meals. -11/20/21 two meals. -11/19/21 one meal. -11/18/21 two meals. -11/15/21 two meals. -11/14/21 one meal. -11/13/21 one meal. -11/12/21 two meals. -11/10/21 one meal. 2. Review of Resident #41's quarterly MDS, dated [DATE], showed: -No BIMS score. This indicates severe cognitive impairment. -Resident requires set up only assistance for eating. -Diagnoses include: non-traumatic brain dysfunction and dementia. Review of recent weights showed: -12/6/2021 154.6 pounds. -11/3/2021 169.0 pounds. -9/22/20/21 168.8 pounds. Review of residents' care plan dated 11/5/21 showed: -Resident is at risk for weight flunctuation related to current health status. Resident wishes to maintain current weight through next review. Document intake with each meal. Review of meal intakes showed no documentation for the following: -12/9/21 one meal -12/8/21 -12/7/21 one meal. -12/6/21 one meal. -12/5/21 one meal. -12/4/21 -12/3/21 -12/2/21 two meals. -12/1/21 two meals. -11/30/21 two meals. -11/29/21 two meals. -11/28/21 one meal -11/26/21 one meal. -11/25/21 one meal -11/24/21 two meals -11/22/21 one meal -11/21/21 two meals -11/20/21 two meals. -11/19/21 one meal. -11/18/21 two meals. -11/15/21 one meal. -11/14/21 one meal. -11/13/21 one meal. -11/12/21 two meals. -11/10/21 one meal. During an interview on 12/08/21 at 03:15 P.M. Certified Nurse Aide A said: -He/she was not aware meal intakes should be documented. During an interview on 12/08/21 at 03:15 P.M. Certified Medication Techinician B said: -Meals should be documented on the memory care unit in the computer under the certified nurse aide charting. During an interview on 12/09/21 at 02:46 P.M. the Director of Nursing said: -Meal intake should be documented if it is care planned to be documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of facility policy Administration of Medication dated 7/14/21 showed in part: -All medications are administered safely and appropriately per physician order to address resident's diagnosis and signs and symptoms. -Medication Error : preperation or administration of medications which is not in accordance with manufacturer's specifications Review of Mosby's 2021 Nursing Drug Reference book showed: -Brovana inhalation : use this product before other medications allow 5 minutes between each. -Albuterol metered dose inhaler: give inhalation at least 1 minute apart Review of Quarterly Minimum Data Set ( MDS a federally mandated assessment tool) dated 10/19/21 showed: - Brief Interview of Mental Status (BIMS) of 13. (indicates little to no cognitive imapairment) -Independent for Activities of Daily Living (ADLs: collectively describes the fundamental skills needed to care for oneself) -Diagnosis of Chronic Obstructive Pulmonary Disease (COPD: a condition involving constriction of the airways and difficulty or discomfort in breathing), Hypertension, Diabetes, Depression Review of Care Plan dated 10/19/21 showed n o specific instructions on the use of Brovana or Albuterol inhaler. Review of Physician Order Sheets for December 2021 showed: -Brovana 1 inhalation twice a day for COPD. -Albuterol inhaler 2 puffs every 6 hours as needed for Shortness of breath. Observation on 12/8/21 at 8:55 A.M. showed: - Certified Medication Technician (CMT) C administered Brovana inalation solution via nebulizer machine (a small machine that turns liquid medication into a mist for inhalation). - At nebulizers completion CMT C removed the nebulizer mask and handed resident his/her Alubertrol hand held inhaler. - Resident #29 immediately inhaled 2 puffs of Albuterol Metered Dose Inhaler. During an interview on 12/08/21 at 1:36 P.M. Pharmacist A said: - Brovana must be given adequate time to work - There is a problem with administering the Albuterol immediately after the Brovan: the Brovana wouldn't have the time to reach it's full effectiveness. - The resident might not have needed the albuterol if the Brovana was used correctly. During an interview on 12/08/21 at 3:24 P.M . CMT C said: -When using the same inhaler wait time is 5 minutes between puffs. -For different medications wait time is 15 minutes. -Resident# 39 likes his puffs together. During an interview on 12/09/21 at 3:45 PM the Director of Nursing (DON) said: -He/she would expect staff to wait 15 minutes between Brovana and other inhaled medications to allow Brovana time to work. - He/she would expect staff to wait 3-5 minutes between puffs of the same inhaler. puffs of same inhaler is 3-5 minutes expect them to wait that amount of time. Based on observations, interviews, and record review, the facility failed to ensure staff provided and documented catheter care completed as ordered by the physician for one of fifteen sampled residents (Resident #27) and failed to empty the catheter bag timely for one additionally sampled resident (Resident #18). The facility also failed to follow standards of practice by failing to wait at least 5 minutes before each inhaled medication for one Resident (Resident #29) Facility census was 60. Review of facility policy: -The facility is obligated to follow and carry out the orders of the prescriber in accordance with all applicable state and federal guidelines. Review of facility policy, Monitoring Intake and Output, dated July 2021, showed: -Output monitoring may be initiated in the following circumstances: a resident who has an indwelling urinary catheter. -Output data will be documented in the electronic health record. -Certified Nurse Aides (CNAs) will collect output data throughout each shift and report their totals to the nurse for each resident who is on output monitoring at the end of shift. -The nurse will evaluate the data for that shift and notify the physician if there is a concern with output. Review of facility policy, Indwelling urinary catheter care and management, dated November 2021, showed: -Monitor output as ordered. -Empty the drainage bad regularly when it becomes one-half to two-thirds full to prevent undue traction on the urethra (the tube that allows urine to pass out of the body) from the weight of urine in the bag. 1. Review of Resident #27's admission minimum data set (MDS, a federally mandated assessment completed by facility staff), dated 10/8/21, showed: -admitted on [DATE]. -Brief interview for mental status score of 5. This indicates severe cognitive impairment. -Resident has an indwelling catheter. -Diagnoses include: non-traumatic brain dysfunction, coronary artery disease (damage or disease in the heart's major blood vessels, usually caused by plaque, this causes coronary arteries to narrow, limiting blood flow to the heart), and Alzheimer's disease. Review of progress notes showed: -11/29/2021; Resident completed antibiotic therapy today. -11/23/2021; Resident has been started on antibiotic treatment for urinary tract infection (UTI). -11/22/2021; Cipro Tablet 500 milligrams (Ciprofloxacin HCl, antibiotic), give one tablet by mouth two times a day for UTI for seven days. -11/18/2021; Residents subrapubic (surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow) catheter was changed this shift related to monthly change with sterile technique. -11/9/21; Catheter bag was full at shift change in 7 A.M., emptied 2000 out and at end of shift change 6 P.M., there was 400 out. Review of current physician orders, dated December 2021 showed: -Order date 10/22/21: Cleanse suprapubic catheter site with normal saline (sterile water), apply drain sponge, secure with tape on all sides, every day shift -Order date 10/18/21: Monitor output every shift -Order date 10/14/21: Flush suprapubic catheter with 60 milliters (ml) normal saline every night (HS). -Order date 10/13/21: Suprapubic catheter change monthly on the 13th and as needed (PRN). Flush catheter with 60-120 ml sterile water with every change and PRN. -Order date 10/1/21: Catheter care with warm water and soap, every shift. -Order date 10/1/21: Keep catheter site clean and dry, every shift. -Order date 10/1/21: Change catheter bag monthly on the 1st. Keep bag below level of the bladder. Review of the residents' care plan, dated 10/22/21, showed: -Resident has a Suprapubic Catheter. - Resident will have no complications related to indwelling catheter use. - Catheter care every shift. - Intake and output as per facility policy. - Resident has orders to flush his catheter with 60mls normal saline every night shift. - Resident's catheter is due to be changed on the 1st of every month. Review of Residents' December Medication Administration Record/Treatment Administration Record (MAR/TAR) showed no documentation for: -On 12/1/21 cleanse suprapubic catheter site with NS, apply drain sponge, secure with tape every day shift. -On 12/1/21 day and night, for monitor output every shift. -On 12/5/21 night, for monitor output every shift. -On 12/7/21 day, for monitor output every shift. -On 12/8/21 day for monitor output every shift. Review of Residents' November MAR/TAR showed no documentation for: -On 11/18/21 day shift for catheter care with warm water and soap every shift. -On 11/18/21 night shift for keep cath site clean and dry every shift. -On 11/16/21 day shift for cleanse suprapubic catheter site with NS, apply drain sponge, secure with tape. -On 11/18/21 day shift for cleanse suprapubic catheter site with NS, apply drain sponge, secure with tape. -On 11/20/21 day shift for cleanse suprapubic catheter site with NS, apply drain sponge, secure with tape. -On 11/18/21 for flush suprapubic catheter with 60 mls normal saline every hs. -On 11/16/21 day shift for monitor output every shift. -On 11/22/21 day shift for monitor output every shift. -On 11/23/21 day shift for monitor output every shift. 2. Review of Resident #18's quarterly MDS, dated [DATE], showed: -BIMS score of 15. (This indicates no cognitive impairment.) -Diagnoses include: debility (physical weakness) cardiorespiratory conditions (refers to lung disease). During an interview on 12/9/21 at 3:15 P.M. the resident said: - He/she has to empty his/her own catheter bag every morning. - The catheter bag was really full this morning and he/she thought it was going to burst. During an interview on 12/09/21 at 11:02 A.M. Nurse Aide A said: -He/she sometimes empty catheter bags, usually night shift empties, but he/she empties during the day if needed. -Output should be documented if it is being measured. The nurses let them know who is being monitored. -He/she was unsure how many millileters a catheter bag holds without looking. -If catheter bags are not emptied and are full, urine can back into the bladder and rupture or cause UTIs. During an interview on 12/09/21 at 11:30 A.M. Certified Medication Technician A said: -Catheters are emptied once every shift, more if needed. -He/she was unsure if output is documented. -He/she empties catheter bags when reach 500 ml. Most bags will hold 1000ml. -If catheter bags are full and not emptied, this could cause bladder damage and infection. -He/she has seen catheter bags full but never backing into the tubing. During an interview on 12/09/21 at 12:02 P.M. Licensed Practical Nurse B said: -Catheter care is completed twice a day, every shift and more if needed. -Output is documented if physician ordered. -Catheter bags can hold 1,000 or 1,500 ml. -He/she has never let a catheter bag go over being full, has never seen any full and backing into the tubing. -Output totals are documented each shift. During an interview on 12/9/21 at 03:45 P.M. the Director of Nursing said: -He/she expected cleaning and monitoring output of a suprapubic catheter to be documented on the TAR. -If it is ordered daily, it should be documented daily. -If it is not documented, then it is not done. -The nurse is reponsible for catheter care as it is on the TAR.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview record review, the facility failed to ensure staff stored and prepared food in a safe and sanitary manner and disposed of food in a timely manner. The facility census was 60. A review of the facility's Policy on Food Safety, dated 11/28/17, showed: -Food is stored and maintained in a clean, safe, and sanitary manner following federal, state and local guidelines to minimize contamination and bacterial growth. -Pre-packaged food is placed in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight-fitting lid. The container is labeled with the name of the contents and date (when the item is transferred to the new container). Use by Date is noted on the label or product, when applicable. The use by date guide is easily accessible to all associates involved with resident food storage. -The First in First Out method is used in food storage or according to state regulation -Leftovers are dated properly and discarded after 72 hours unless otherwise noted. -Opened packages of food are resealed tightly to prevent contamination of the food item and use by date will be used when applicable. -Opened food items will be removed from the original packaging that it was delivered in before being placed in an ingredient bin or storage container. Observations of the kitchen on 12/6/21 at 3:34PM showed: -tile missing on floor in front of 3 bin sink, a 4 tile by 10 tile section -open jar of grape jelly on the food prep counter, undated -top of the inside of the microwave is dirty with food matter Dry Storage: -bin of cheese puffs stored on a shelf above the two bin sink is dated with the use by date of 11/7/21 -bin of potato chips stored on a shelf above the two bin sink is dated with the use by date of 11/7/21 -a sign posted in the dry storage room states Open chips, use by 1 week. Open cereal, use by 3 months. -A bin of Cheerios cereal labeled with the use by date of 11/21/21 -Large bin of beans, label worn off, unable to read -Large bin of sugar, label worn off, unable to read use by date -Opened bag of dehydrated mashed sweet potatoes, no label -Opened bag of Orzo pasta, no label -10 pound container of baking powder, open, dated 2/14/2019 -Open gallon container of soy sauce, no label/date Refrigerator: -[NAME]/pound cake, no label -bag of several heads of lettuce, wilted with no label -open 5 pound container of cottage cheese, no label Freezer: -open bag, not sealed, of French fries, no label -open bag, not sealed, of tater tots, no label -open bag, not sealed, of beef patties, no label During an interview on 12/6/21 at 3:57PM, the Dietary Manager said: -He/she is new and not completely sure of all regulations -Food should be sealed and labeled after opened, whether in the dry storage, refrigerator or freezer -Leftovers should be disposed of after 3 days