Based on observation, interview and record review, it was determined that the facility failed to ensure a resident who was unable to carry out activities of daily living (ADL) received services to maintain good personal hygiene for 1 of 3 residents reviewed for ADL in a final sample of 37 residents (Resident Identifier #62). Findings include: Observation on 10/8/24 at 9:39 a.m. of Resident #62 revealed he/she was in their room dressed and sitting in a chair. Resident #62 had disheveled hair and long dark stubble on their face and chin. During an interview on 10/8/24 at 9:39 a.m. with Resident #62, the resident asked Can you help me shave and shower? Observation on 10/9/24 at 11:00 a.m. of Resident #62 revealed there was long, dark stubble on their face and chin. This was again observed on 10/10/24 at 9:25 a.m. Review on 10/10/24 of Resident #62's Quarterly Minimum Data Set revealed under Section GG - Functional Abilities and Goals, the resident had been coded as Dependent for showers/bathing and for personal hygiene (which included shaving). Review on 10/10/24 of Resident #62's care plan, initiated on 7/30/21 with a target date of 10/9/24, revealed that the resident had an activities of daily living self care deficit related to dementia. Further review revealed under Interventions that the resident needed 1 staff to assist for bathing and personal hygiene tasks. Review on 10/10/24 of Resident #62's weekly bath in the electronic record, which was where the nurses's aides document care that was received, revealed that Resident #62 was scheduled for a weekly bath on Fridays on the 7-3 shift. Further review for the months of September 2024 revealed on 9/6/24, 9/20/24 and 9/27/24, not applicable was coded and on 9/13/24 there was no entry that a shower had been given. Interview on 10/10/24 at 10:56 a.m. with Staff L (Licensed Practical Nurse), who was Resident #62's nurse, revealed that they were not sure when Resident #62 had last had a shower or shaved. Interview on 10/10/24 at approximately 11:30 a.m. with Staff R (Licensed Nursing Assistant (LNA)) and Staff S (LNA), who routinely work with Resident #62, revealed that neither had provided a shower or a shave to Resident #62 in the past 7 days. Interview on 10/10/24 at 11:23 a.m. with Staff AA (Assistant Director of Nursing) confirmed that showers for Resident #62 had not been documented in September 2024. Staff AA revealed that shaving should be done per resident preferences and with routine daily care. Review on 10/10/24 of the facility's policy Activities of Daily Living, revised 2/2023, revealed: . Care and services will be provided for the following activities of daily living; 1. Bathing . grooming . 3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good . grooming, and personal . hygiene .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 100's Medication Room Observation on [DATE] at approximately 8:30 a.m. of the medication refrigerator revealed influenza vaccine (1 box of prefilled syringes) and of Tuberculin Protein Derivitative (1 vial). Further observation revealed open/in use Tuberculin Purified Protein Derivative with two hand written dates [DATE] and [DATE]. Interview on [DATE] at approximately 8:30 a.m. Staff A (Licensed Practical Nurse) confirmed the above findings and he/she was not sure when the vaccine had been opened or when it expired. Review on [DATE] of manufacturer instructions for 'Aplisol' Tuberculin Purified Protein Derivative revealed: .Storage .Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. Based on observation, interview, and record review, it was determined that the facility failed to label and date opened multi-dose medications on 1 of 6 medications carts observed and 1 of 5 medication rooms observed. Findings include: 5 East Medication Cart Observation on [DATE] at approximately 8:14 a.m. of the 5 East Medication Cart with Staff F (Licensed Practical Nurse) revealed one opened Lispro Insulin Quik Pen with no name, open date or expiration date. Interview on [DATE] at approximately 8:14 a.m. with Staff F confirmed the above findings. Review on [DATE] of policy titled, Insulin Pen, date reviewed 2/2024, revealed: .2. Insulin pens must be clearly labeled with the resident name, type of insulin, amount to be given, frequency, and expiration date. 3. If the label is missing, the pen will not be used .

Based on observation, interview and record review, it was determined that the facility failed to provide dental services and assist the resident with making dental appointments when referred to an oral surgeon for 1 of 1 residents reviewed for dental services in a final sample of 37 residents (Resident Identifier #88). Findings include: Interview on 10/8/24 at 1:19 p.m. with Resident #88 revealed that their teeth were all broken. Resident #88 stated that they had been asking to see a dentist, but was told by the facility that they can't get him/her in to see a dentist. Observation on 10/8/24 at 1:19 p.m. of Resident #88's teeth revealed nearly all were broken and black. Review on 10/10/24 of Resident #88's care plan, initiated on 5/26/23 with a target date of 11/17/24, revealed that the resident had dental health problems with multiple decaying teeth and roots. Interventions included to coordinate arrangements for dental care and transportation as needed. Review on 10/10/24 of Resident #88's Dental Visit notes revealed the following; On 4/26/21, patient states all teeth are broken and wants all to be pulled and dentures made. Will be referred to oral surgeon for evaluation for extractions; On 10/5/21, patient report tooth #9 and #11 painful. Referred to outside oral surgeon; On 9/2/22, patient report tooth #12 and #26 bother when eating. Referred to oral surgeon; On 10/4/22, Staff X (Unit Manager) was informed that patient need extraction of tooth #12 and #26 and referred to oral surgeon. and On 5/8/23, patient with generalized breakdown of teeth, multiple decay, multiple roots. recommend dental treatment every 6 months. There were no additional dental visits noted for Resident #88. Review on 10/10/24 of Resident #88's outside provider dental visit revealed a treatment plan was made on 11/5/21 for removal of teeth and upper/lower dentures fabrication. There was no follow-up to this visit noted in the medical record. Interview on 10/10/24 at 10:13 a.m. with Staff X confirmed the above findings. Interview on 10/10/24 at 10:44 a.m. with Staff K (Medical Records) confirmed that there were no additional dental visits for Resident #88. Review on 10/10/24 of the facility's policy titled Dental Services revised 2/2023, revealed: .It is the policy of this facility to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care . 1. The dental needs of each resident are identified through the physical assessment and MDS [Minimum Data Set] assessment process, and are addressed in each resident's plan of care. a. Oral/dental status shall be documented according to assessment findings. b. Oral care . shall be provided with identified needs and as specified in the plan of care . c. Referral to . dental providers shall be made as appropriate . 4. The facility will, if necessary or requested, assist the resident with making dental appointments and arranging transportation to and from the dental services location . 8. For residents or resident representative who do not which to be referred for dental services: a. The physician shall be notified . c. The resident's plan of care will be revised to reflect preferences. 9. All actions and information regarding dental services, including any delays related to obtaining dental services, will be documented in the resident's medical record.

Resident #49 Interview on 10/9/24 at 8:11 a.m. with Resident #49 revealed Resident #49 had been served beef every time it was on the menu, but he/she had an allergy to beef listed on their meal ticket. Review on 10/9/24 of Resident #49's meal ticket confirmed beef was listed as an allergy. Review of the facility policy revised 9/2024 and titled, Food Preparation Guideline, revealed, .Resident preferences and allergies shall be obtained during the resident assessment process and added to the resident's dietary tray card. Staff shall accommodate resident allergies, intolerances, and preferences, providing appropriate alternatives when needed . Based on observation, interview, and record review, it was determined that the facility failed to follow menu preferences, allergies, and intolerances for 2 of 8 residents reviewed for meal/food concerns in a final sample of 37 residents (Resident Identifiers are #4 and #49). Findings include: Resident #4 Interview on 10/8/24 at approximately 8:15 a.m. with Resident #4 revealed they frequently received meal trays with items they have allergies to, such as chocolate and tomatoes. Resident #4 stated that they get sick to their stomach if they eat chocolate or tomatoes. Observation on 10/10/24 at approximately 11:45 a.m. of Resident #4's lunch tray revealed vanilla cake with chocolate frosting. Review of their meal ticket revealed an allergy to chocolate and tomatoes. Review on 10/10/24 of Resident #4's record revealed an allergy to chocolate and tomatoes. Interview on 10/10/24 at approximately 11:55 a.m. with Staff X (Unit Manager) stated Resident #4 had an allergy to chocolate and tomatoes and confirmed Resident #4 had received vanilla cake with chocolate frosting for lunch.

Based on record review and interview, it was determined that the facility failed to provide pneumococcal immunization for 1 of 5 residents reviewed for pneumoccocal vaccination in a final sample of 37 residents (Resident Identifier #73). Findings include: Review on 10/9/24 of Resident #73 immunizations revealed: Pneumococcal - historical type unknown: Pneumoccocal given 3/1/2017. Review on 10/9/24 of Resident #73 medical record revealed a consent for pneumococcal vaccine signed by the resident on 4/5/23. Further review revealed the pneumoccocal vaccine was not given to Resident #73. Interview on 10/10/24 at approximately 11:45 p.m. with Staff M (Infection Preventionist) confirmed Resident #73 had not received the consented second pneumoccocal vaccine. Review on 10/10/24 of the facility policy titled Pneumococcal Vaccine (Series), revised 5/2023, revealed: .Policy Explanation and Compliance Guidelines: .6. The type of pneumococcal vaccine (PCV15, PCV20, or PPSV23) offered .in accordance with current CDC (Center for Disease Control and Prevention) guidelines and recommendations .TABLE 1. Pneumococcal vaccine schedules for adults 65 years or older .Vaccine received previously at any age .PCV13 only .Schedule option A .Administer a single dose of PCV20 after a year or more interval since the last PCV13 .No specified immunocompromising condition .Schedule option B .Administer a single dose of PPSV23 after a year or more interval since the last PCV13 .Specified immunocompromising condition .Schedule option B .Administer a single dose of PPSV23 after 8 weeks or more interval since the last PCV13 .

Observation on 10/9/24 at 8:11 a.m. of Unit 1 [NAME] side kitchenette revealed there was a half loaf of slightly hard bread that had a fresh by date of 9/21/24. Interview on 10/9/24 at 8:22 a.m. with Staff CC (Unit Manager) confirmed the above. Review on 10/10/24 of the facility's policy titled, Date Marking for Food Safety, dated 5/2022, revealed: .2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded . Unit 1 Kitchenette: Review on 10/8/24 of Unit 1's West kitchenette refrigerator logs revealed the following missing September temperatures: 9/18, 9/19, 9/21, 9/25, 9/26, 9/27, 9/28, and 9/29. Review on 10/8/24 of Unit 1's East kitchenette refrigerator logs revealed the following missing September temperatures: 9/18, 9/19, 9/21, 9/25, 9/26, 9/27, 9/28, and 9/29. Unit 2 Kitchenette: Review on 10/8/24 at approximately 9:45 a.m. of the Unit 2 Kitchenette refrigerator and freezer temperature logs revealed the following missing September temperatures: 9/18, 9/19, 9/21, 9/25, 9/26, 9/27, 9/28, 9/29.Unit 3 Kitchenette: Observation on 10/08/2024 of the Unit 3 Kitchenettete freezer revealed that there was a plate containing a sandwich, pasta salad, a leaf of lettuce and a slice of tomato. The plate was not dated or labeled with a resident's name. Interview on 10/08/24 at 8:15 a.m. with Staff V (Licensed Nursing Assistant) confirmed the above findings Review on 10/8/2024 of the September 2024 refrigerator temperature logs for Unit 3 Kitchenette revealed the following missing September temperatures: 9/18, 9/19, 9/21, 9/25, 9/26, 9/27, 9/28, 9/29. Interview on 10/08/24 at approximately 8:45 a.m. with Staff N (Unit Manager) confirmed the above findings. Based on observation, interview, and review, it was determined that the facility failed to ensure that dietary staff used facial hair restraints when cooking and serving food from the steam table for 1 of 1 kitchens observed for meal service, and failed to label and store food in accordance with professional standards for food safety to prevent foodborne illness for 1 of 1 kitchens and 5 of 7 kitchenettes observed. Findings include: Review on 10/10/24 of the U.S. Food and Drug Administration Food Code, dated 2017, retrieved from https://www.fda.gov/food/FDA-food-code/food-code-2017 revealed the following: .Annex 3, Public Health Reasons/Administrative Guidelines .Chapter 2 Management and Personnel .2-402 Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in (B) of this section, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens .Chapter 3 Food .3-305.11 Food Storage .Food shall be protected from contamination by storing the Food: .On-premises preparation .(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical . (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded .; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods .Products which are damaged, spoiled, or otherwise unfit for sale or use in a food establishment may become mistaken for safe and wholesome products and/or cause contamination of other foods . (5) Certain foodborne pathogens that are anaerobes or facultative anaerobes are able to multiply under either aerobic or anaerobic conditions. Therefore special controls are necessary to control their growth. Refrigerated storage temperatures of 5°C (41°F) may be adequate to prevent growth and/or toxin production of some pathogenic microorganisms . Beard Restraints: Observation on 10/8/24 between 8:05 a.m. to 8:25 a.m. of Staff H (Cook) in the kitchen revealed that Staff H was preparing and cooking for lunch. Staff H had a beard that was over an inch long that was not covered with a beard restraint. Interview on 10/8/24 at 8:25 a.m. with Staff H revealed that he/she never wore a covering over his/her beard. Interview on 10/8/24 at 8:45 a.m. with Staff E (Director of Culinary) confirmed the above findings. Observation on 10/9/24 between 11:15 a.m. and 11:25 a.m. of Staff I (Dietary Aide) in the kitchen revealed that Staff I was preparing soup and salad for lunch to be served to the residents in the dining room. Staff I had a beard that was over an inch long that was not covered with a beard restraint. Observation on 10/9/24 at 11:27 a.m. of Staff H in the kitchen revealed that Staff H was cutting quiche that was to be served to the residents for lunch. Staff H had a beard that was over an inch long that was not covered with a beard restraint. Interview on 10/8/24 at 11:28 a.m. with Staff E confirmed the above findings that staff with beards who were cooking and serving in the kitchen should always be wearing beard restraints. Review on 10/10/24 of the facility's policy titled, Food Safety Requirements, last revised 2/2023, revealed: .1b. Storage of food in a manner that helps prevent deterioration or contamination of the food, including from growth of microorganisms .7d. Dietary staff must wear hair restraints (e.g. hairnet, and/or beard restraints) to prevent hair from contacting food . Main Kitchen: Observation on 10/8/24 at 8:20 a.m. of the dairy refrigerator revealed the following: 1 container of mayonnaise with a manufacturer's use by date of 7/22/24; 1 clear plastic container of pasta salad with no prepared date or use by date; 1 clear plastic container of sliced tomatoes with no prepared date or use by date; 1 open package of shredded cheddar cheese with no prepared date or use by date; 1 clear plastic container of cooked meat with a preparation date of 9/14/24. Observation on 10/8/24 at 8:25 a.m. of the dessert refrigerator revealed the following: 1 paper plate with 2 slices of pizza covered by saran wrap with no prepared or use by date; 1 metal container of salad exposed to the air with no prepared date or use by date; 1 open package of sliced cheese with no open or use by date; 15 slices of cheese, not wrapped, open to the air with dried edges sitting on the shelf of the refrigerator; 1 metal container of unknown liquid with a prepared date or use by date; 1 clear package of whipped cream topping with no manufacturer's, open, or use by date. Interview on 10/8/24 at 9:00 a.m. with Staff E confirmed the above findings.Unit 5 Kitchenette: Review on 10/8/2024 of September 2024 refrigerator temperature logs for Unit 5 Kitchenette revealed the following missing September temperatures: 9/18, 9/19, 9/21, 9/25, 9/26, 9/27, 9/28, 9/29.

Based on observation, record review, and interview, it was determined that the facility failed to follow established infection control guidelines for facility water management that had the potential to effect the facility census of 220 residents who resided at the facility. Findings include: Observation on 10/8/24 at approximately 8:30 a.m. of Unit 4 revealed the unit was not in use. Review on 10/9/24 of the facility's Legionella Surveillance with a revised date of 6/2023, revealed .5. Primary prevention strategies: .d. Temperature controls: . ii. Hot water shall be stored above 140 degrees Fahrenheit . Review on 10/9/24 of the facility's undated Water Management Plan Overview for: Premier Rehab and Healthcare revealed on page 12 .Control Measures: Hot Water Systems .Water Heater Control Measure: Check flow and return temperatures at hot water heater .Frequency: Monthly .Monitoring: Supply Temperature should be checked at the outlet of the Hot Water Heater and should not be lower than 140 degrees [Fahrenheit] . Further review revealed on page 21 .Risk factors: Little used Outlets Control Measures: .flush program .frequency: Twice weekly where users are at high risk . Interview on 10/10/24 at approximately 10:00 a.m. with Staff J (Maintenance and Environmental Services Director) confirmed that Unit 4 had been closed a long time. Interview further revealed that he/she had been performing random flushes of Unit 4 and had no documentation of flushes or monitoring of temperature for the water heater.

Based on observation, interview, and record review, it was determined that the facility failed to provide services or assist a resident in making appointments to maintain good foot health for 1 of 3 residents reviewed for foot care (Resident Identifier #5). Findings include: Interview on 7/26/24 at approximately 12:30 p.m. with Resident #5 revealed they had been requesting to see a podiatrist for overgrown toenails. Review on 7/26/24 of Resident #5's medical record revealed a podiatry visit note dated 9/14/23 that stated .Routine podiatry care is medically necessary due to patient's atherosclerosis of the extremities and DM II [Diabetes Mellitus Type 2] due to the associated increased risk of bone infection, and digital or limb loss . Further review of Resident #5's medical record revealed no other podiatry visit notes. Review on 7/26/24 of Resident #5's Dialysis Communication Book revealed an entry dated 7/3/24 from the Dialysis Center to the Facility that stated .Please make sure [name omitted] has [pronoun omitted] toenails trimmed ASAP [as soon as possible], they are too long and could cut [pronoun omitted] toes . Observation on 7/26/24 at approximately 1:55 p.m. of Resident #5's toes on the left foot with Staff A (Unit Manager) revealed all 5 toenails to be grown out past the end of the toes and the 4th toe nail was noted to be curled under the toe. (Right foot not observed) Interview on 7/26/24 at approximately 2:00 p.m. with Staff B (Director of Nursing) confirmed the above findings. Staff B stated that Resident #5 had been seen by the podiatrist but was at Dialysis when the podiatrist was at the facility. Review on 7/26/24 of the facility policy titled, Podiatry Services revised on 2/2023, revealed: .To ensure residents receive proper treatment and care within professional standards of practice and state scope of practice, as applicable, to maintain mobility and good foot health .Residents requiring foot care who have complicating disease process will be referred to qualified professionals such as a Podiatrist, Doctor of Medicine, and/or Doctor of Osteopathy .The social worker or designee will assist residents in making appointments to obtain needed services .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to document a complete discharge summary for 1 out of 3 residents reviewed for closed records (Resident Identifier is #236). Findings include: Review on 10/6/23 of Resident #236's medical record revealed that Resident #236 was admitted to the facility on [DATE] from the hospital. Review on 10/6/23 at 9:39 a.m. of Resident #236's social service note dated 7/13/23 revealed Emotional support extended to [name omitted] this am [morning] related to pain, discomfort and desire to return home. [Name omitted] was discharged at the end of June with good progress in therapy, when [pronoun omitted] returned to ortho [orthopaedics] for follow up the screws had loosened per [name omitted], [name omitted] had to have them corrected. [Name omitted] is in significant pain. Emotional support and encouragement extended. This writer reached out to APRN [Advanced Practice Registered Nurse] to follow up to extend support and assist with the discharge home services. Review on 10/6/23 at 11:42 a.m. Resident #236's social service note dated 7/13/23 revealed [Name omitted] is discharging home today, self directed. [Name omitted] would like to return home. APRN will order [name of services omitted] to follow post discharge. [Name omitted] does not feel that [pronoun omitted] needs functional support (with last stay that was the focus, [pronoun omitted] is focusing on pain that [pronoun omitted] is experiencing. [Name omitted] wishes to be home with [pronoun omitted] spouse. Review on 10/6/23 of Resident #236 medical record did not reveal a documented final summary that contained a summation of Resident 236's medical status at the time of their 7/13/23 discharge, a reconciliation of Resident #236's pre-discharge and post-discharge medications, nor an order for post-discharge services. Interview on 10/6/23 at 2:00 p.m. with Staff T (Assistant Director of Nursing) confirmed that there was no discharge summary completed by the nurse or provider. Review on 10/6/23 of the facility's policy, Transfer and Discharge (including AMA [Against Medical Advice]), revised 2/2023, revealed .Policy Explanation and Compliance Guidelines: .14. Anticipated Transfer or Discharges - resident initiated. a. Obtain physicians' orders for transfer or discharge and instructions or precautions for on care . b. A member of the interdisciplinary team completes relevant sections of the Discharge Summary. The nurse caring for the resident at the time of discharge is responsible for ensuring the Discharge Summary is complete .iii. Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to follow their policy for labeling and dating resident food items brought in by visitors for 3 of 5 kitchenettes observed. Findings include: Review on 10/2/23 at approximately 6:50 p.m. of Unit 5 kitchenette revealed the following: 1 bottle of French's Yellow mustard in the refrigerator with an expiration date of 2/2023 1 bottle of Gatorlyte in the refrigerator with no resident name or date present 1 pint of [NAME]-Dazs chocolate chocolate chip ice cream in the freezer with no resident name or date present 1 pint of Ben and Jerry's ice cream in the freezer with no resident name or date present 1 open box of Life Cereal in the cabinet with no resident name or open date present Interview on 10/2/23 with Staff U (Director of Food Services) confirmed the above findings. Observation on 10/2/23 at approximately 7:00 p.m. of Unit 6 kitchenette revealed 2 Stouffers frozen meals (1 beef stroganoff and 1 classic meatloaf) in the freezer with no resident name(s) and with expiration dates of 9/2023. Interview on 10/2/23 with Staff U confirmed the above findings. Review on 10/2/23 at approximately 7:20 p.m. of Unit 1 kitchenette revealed the following: 1 bottle of seltzer water with no resident name or date present 1 bottle of Simple Orange orange juice with no resident name or date present 1 frozen Chef [NAME] Lemon Caper Chicken meal with no resident name or date present Interview on 10/2/23 with Staff U (Director of Food Services) confirmed the above findings. Review on 10/4/23 of a document titled 'Food from Home revealed: .must be stored in an airtight, disposable container and labeled with the resident's name, name of the item, and date .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined that the facility failed to include a data collection tool that tracked residents when admitted to the facility while COVID-19 positive for 1 of 1 resident reviewed for transmission-based precautions (Resident Identifier is #396). Findings include: Observation on 10/2/23 at 6:00 p.m. of the facility's COVID-19 Notification and Daily Update dated 10/2/23 and posted in the main lobby revealed that there were no active COVID-19 cases in the facility (both resident and staff). Interview on 10/2/23 at approximately 7:00 p.m. with Staff R (Licensed Practical Nurse) revealed that Resident #396 was admitted to the facility COVID-19 positive and was currently on transmission-based precautions. Observation on 10/4/23 at 8:46 a.m. of Resident #396's room revealed signage on the door for droplet transmission-based precautions. Review on 10/6/23 of Resident #396's Discharge Summary dated 9/29/23 revealed that Resident #396 tested positive for COVID-19 on 9/25/23. Review on 10/6/23 of Resident #396's admission Record revealed that Resident #396 was admitted to the facility on [DATE]. Review on 10/6/23 of the facility's COVID-19 resident line list revealed that Resident #396 name was not included on the list for having COVID-19. Interview on 10/6/23 at 1:00 p.m. with Staff S (Infection Preventionist) confirmed the above. Staff S revealed that he/she does not track residents who are admitted with COVID-19 and only tracked those who tested positive after admission.

Based on interview and record review it was determined that the facility failed to provide documentation of pneumococcal vaccination for 1 out of 5 residents reviewed for pneumococcal immunizations (Resident Identifier is #143). Findings Include: Review on 10/6/23 of Resident #143's Immunization Tab in the electronic record revealed under pneumococcal was coded Resident Refused. Review on 10/6/23 of Resident #143's Immunization Consent form dated 10/20/22 revealed under pneumococcal vaccination was checked I have already received pneumococcal vaccination . with no date of when. Review on 10/6/23 of Resident #143 medical record revealed no follow-up to what type of pneumococcal vaccination had been administered prior to admission or if Resident #143 needed a follow-up vaccination. Interview on 10/6/23 at 9:52 a.m. with Staff V (Licensed Practical Nurse) confirmed the above findings. Review on 10/6/23 of the facility's policy titled Pneumococcal Vaccine (Series) revised 2/2023 revealed: . 1. Each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information shall be documented, including efforts to determine date of immunization or type of vaccine received .7. A pneumococcal vaccination is recommended for all adults 65 years and older and based on the following recommendations . b. For adults 65 years or older who have only received a PPSV23: Give 1 dose of PCV (pneumococcal conjugate vaccine)15 or PCV20 .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to implement policies and procedures regarding offering and educating residents and staff the COVID-19 vaccination series for 2 of 5 residents reviewed for COVID-19 immunizations and 1 of 1 staff reviewed for COVID-19 immunizations (Resident Identifiers are #143 and #208. Staff identifier is Staff AA). Findings include: Resident #143 Review on 10/6/23 of Resident #143's COVID-19 immunization tab in the electronic record revealed that Resident #143 last COVID-19 vaccination was 4/20/22. Review on 10/6/23 of Resident #143's medical record revealed that Resident #143 admitted to the facility on [DATE]. Further review revealed that there was no documentation that a COVID-19 booster shot had been offered. Interview on 10/6/23 at approximately 11:15 a.m. with Staff S (Infection Preventionist) confirmed the above findings. Staff S stated that he/she did not follow up on Resident #143. Resident #208 Review on 10/6/23 of Resident #208's COVID-19 immunization tab in the electronic record revealed that Resident #208's COVID-19 vaccinations were on 5/3/21 and 6/2/21. Review on 10/6/23 of Resident #208's COVID-19 Vaccine Consent and Education form revealed the following: - On 6/17/23 Yes I accept the vaccine was signed 6/17/23 and a note was written had boosters - On 8/14/23 Yes I accept the vaccine was signed 8/14/23 - No additional documentation was noted on these forms to clarify vaccination timeframes or when had received booster shots Review on 10/6/23 of Resident #208's medical record revealed that Resident #208 admitted to the facility on [DATE], discharged to the hospital on 8/6/23 and returned to the facility on 8/14/23. Further review of the medical record revealed no documentation that a COVID-19 booster had been offered and/or if Resident #208 was not medically eligible to receive a booster. Interview on 10/6/23 at approximately 11:15 a.m. with Staff S confirmed the above findings for Resident #208. Staff S stated that he/she did not follow up on Resident #143's and Resident #208's eligibility for COVID-19 boosters. Interview on 10/6/23 with Staff T (Assistant Director of Nurses) revealed that the facility had COVID-19 vaccines boosters available in August 2023. Staff AA (Licensed Nursing Assistant) Review on 10/6/23 of Staff AA's COVID-19 Vaccine Screening Forms revealed the following: - On 2/10/23 a first dose of vaccine was administered. The form indicated that this was the first dose of Pfizer COVID-19 vaccine that Staff AA had ever received. - On 3/10/23 Staff AA received the second dose of the Pfizer COVID-19 vaccine. Under Education Provided check yes or no was not completed. Interview on 10/6/23 at 10:26 a.m. with Staff AA revealed that he/she thought they may have been offered a COVID-19 booster a year ago, but was not sure. Interview on 10/6/23 at 10:32 a.m. with Staff S confirmed that the above COVID-19 vaccination information was all the facility had for Staff AA. Interview on 10/6/23 at 11:13 a.m. with Staff S revealed that the facility only tracks staff who received the COVID-19 vaccination and that they do not get declinations, document if offered to staff and declined, and/or that education was provided. Review on 10/6/23 of the facility's policy titled COVID-19 Vaccination revised 9/29/22 revealed, .Policy: It is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications from COVID-19 . by education and offering our residents and staff the COVID-19 vaccination . 6. For people who are not moderately or severely immunocompromised, see Table 1 for specific primary and booster dosing and timing intervals based on manufacture and age group . 9. People who are or who become moderately or severely immunocompromised should follow the COVID-19 vaccination schedule according to their age and immune status at the time of eligibility for doses . 24. All staff are required to receive the COVID-19 vaccination series (one-dose or two-dose) as per CMS (Centers for Medicare and Medicaid Services) or be up to date with recommended doses (CDC guidance) unless exempted for religious or medical reasons . 25. The resident's medical record will include documentation of the following: a. Education to the resident or resident representative regarding the risks, benefits, and potential side effects of the COVID-19 vaccine; b. Each dose of the vaccine administered to the resident, or: c. If the resident did not receive the COVID-19 vaccine due to medical contraindication or refusal . Table 1: COVID-19 vaccination schedule for people who are NOT moderately or severely immunocompromised . 18 years or older . Number of bivalent booster doses . 1 . Table 2: COVID-19 vaccination schedule for people who are moderately or severely immunocompromised . 18 years and older . Number of bivalent booster dose . 1 .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, it was determined that the facility failed to ensure that physician's orders were followed for 4 residents in a final sample size of 41 residents and 1 out of 28 medication administrations observed. (Resident Identifiers are #3, #64, #83, #158, and #163) Findings include: Standards: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #163 Review on 10/3/23 of Resident #163's September 2023 and October 2023 Medication Administration Records (MAR) revealed the following physician's order: Hydralazine HCL [Hydrochloric Acid] Tablet 25 mg [milligrams] Give 1 tablet by mouth four times a day for Hypertension, call MD [physician] with SBP [Systolic Blood Pressure] greater than 150, start date 9/22/23. Further review of the MAR revealed that Hydralazine HCL was administered when Resident #163's SBP was greater than 150 on the following dates and times: September 2023 8:00 a.m.: 9/23 SBP 172, 9/24 SBP 170, 9/26 SBP 158, 9/27 SBP 180, 9/28 SBP 176, 9/29 SBP 172 4:00 p.m.: 9/25 SBP 151, 9/27 SBP 158, 9/30 SBP 173 October 2023 8:00 a.m.: 10/1 SBP 155, 10/3 SBP 177 4:00 p.m.: 10/1 SBP 176, 10/3 SBP 152 Review on 10/3/23 of Resident #163's medical record revealed no evidence that the physician was notified of the above SBP's above 150. Interview on 10/5/23 at approximately 8:30 a.m. with Staff I (Unit Manager) confirmed the above findings. Staff I stated that the physician should have been notified on the above mentioned dates of when Resident #163's SBP was greater than 150. Resident #64 Review on 10/5/23 of Resident #64's current physician's orders revealed an order for 1800 ml [milliliter] Fluid Restriction every shift: 7-3 [7:00 a.m. to 3:00 p.m. shift] mls: 480 mls (Breakfast tray 240 mls, Lunch tray 240 mls), 3-11 [3:00 p.m. to 11:00 p.m. shift] mls: 480 mls (Dinner tray 240 mls), and 11-7 [11:00 p.m. to 7:00 a.m. shift] mls: 120 mls. All shifts enter cc's (cubic centimeters) consumed and 11-7 calculates the total, Start Date 5/22/23. Further record review revealed no documentation of Resident #64's fluid intake. Interview on 10/5/23 with Staff J (Director of Nursing) confirmed the above findings for Resident #64. Resident #3 Review on 10/4/23 of Resident #3's September and October 2023 MARs revealed the following physician's order: Metoprolol Succinate ER [Extended Release] Tablet 24 hour 100 mg [milligrams], Give 1 tablet by mouth one time a day for HTN [hypertension] hold for SBP less than 100, HR [heart rate] less than 50, Start Date 5/4/23. Further review of Resident #3's medical record revealed that there were no documented SBPs or HRs prior to administering the medication. Interview on 10/5/23 at approximately 8:30 a.m. with Staff J confirmed the above findings for Resident #3 Resident #83 Review on 10/4/23 of Resident #83's September and October 2023 MARs revealed the following physician's order: BP [Blood Pressure] daily in the AM [morning] one time a day for low BP monitor, Start Date 1/24/23. Further review of Resident #83's medical record revealed that there were no documented BPs in the morning as ordered by the physician. Interview on 10/5/23 at approximately 8:30 a.m. with Staff J confirmed the above findings for Resident #83. Resident #158 Observation on 10/4/23 at approximately 7:35 a.m. of medication administration with Staff H (Licensed Practical Nurse) revealed that Staff H was going to administer a Calcium 600 mg Vitamin D 400 Units tablet to Resident #158. Review on 10/4/23 at approximately 7:35 a.m. of Resident #158's October 2023 MAR revealed a physician's order to administer Calcium Vitamin D Tablet 600-200 mg/unit 1 tablet by mouth two times a day for bone health with a start date of 12/21/22. Interview on 10/4/23 at approximately 7:35 a.m. with Staff H confirmed the above findings for Resident #158.

Resident #128 Interview on 10/4/23 at 3:00 p.m. with Resident #128's family member revealed that their main concern was staff shortage. Family member stated that last month Resident #128 called [pronoun omitted] to come to the facility. When [pronoun omitted] arrived, Resident #128 was in a soiled brief. Resident #128 told the family member that he/she was waiting all morning to be changed. Resident #128's family member went to find help. Resident #128's family member was told there was only 1 aid on shift. Resident #128's family member had to change Resident #128's soiled brief. Based on interview and record review, it was determined that the facility failed to provide sufficient staff to meet the residents' needs for a census of 238 residents (Resident Identifiers are # 115, #128, #186, and #187). Findings include: Review on 10/6/23 of the facility assessment reviewed by the Quality Assessment and Assurance (QAA) Committee on 7/20/23 and 8/17/23 revealed the following staffing levels for direct care staff: 7 a.m. -3 p.m. shift (Day Shift) Units 1, 2, 5, and 6 - 2 Nurse (Registered Nurse (RN) or Licensed Practical Nurse (LPN)) and 5 Licenced Nursing Assistants (LNAs). Unit 3 - 3 Nurse and 5 LNAs. 3 p.m. -11 p.m. shift (Evening Shift) - Units 1, 2, 5, and 6 - 2 Nurse and 4 LNAs. Unit 3 - 3 Nurse and 4 LNAs. 11 p.m. -7 a.m. shift (Night Shift)- Units 1, 2, 5, and 6, 2 Nurse and 2 LNAs. Unit 3 - 3 Nurse and 3 LNAs. Interview with Staff F (Administrator) confirmed the above staffing levels. Review of Daily Staffing Sheets for the month of September 2023 revealed the following: September 4, 2023 Unit 6 - Day Shift - 3.0 LNAs and 1.0 Nurse - Census 46 Unit 2 - Night Shift - 1.0 LNAs - Census 47 September 5, 2023 Unit 1 - Day Shift - 3.0 LNAs - Census of 48 Unit 6 - Day Shift - 3.0 LNAs - Census of 48 September 7, 2023 Unit 2 - Evening Shift - 3.0 LNAs - Census 48 Unit 6 - Evening Shift - 3.0 LNAs - Census 47 September 9, 2023 Unit 2 - Day Shift - 3.0 LNAs - Census 48 Unit 3 - Day Shift - 3.0 LNAs - Census 46 Unit 5 - Day Shift - 3.0 LNAs - Census 48 Unit 5 - Evening Shift - 3.0 LNAs. Unit 6 - Day Shift - 3.0 LNAs and 1.0 Nurse - Census 46 Unit 6 - Evening Shift - 3.0 LNAs September 10, 2023 Unit 1 - Day Shift - 3.0 LNAs - Census 48 Unit 2 - Day Shift - 3.0 LNAs - Census 46 Unit 3 - Day Shift - 3.0 LNAs - Census 45 Unit 5 - Day Shift - 3.0 LNAs - Census 48 Unit 6 - Day Shift - 3.0 LNAs and 1.0 Nurse - Census 46 September 11, 2023 Unit 2 - Day Shift - 3.0 LNAs - Census 46 Unit 5 - Day Shift - 3.0 LNAs - Census 48 Unit 6 - Evening Shift - 2.5 LNAs - Census 46 September 12, 2023 Unit 2 - Day Shift - 3.0 LNAs - Census 46 Unit 5 - Day Shift - 3.0 LNAs - Census 46 Unit 6 - Day Shift - 1.0 Nurse - Census 48 September 13, 2023 Unit 5 - Day Shift - 3.0 LNAs - Census 49 Unit 6 - Day Shift - 1.0 Nurse - Census 48 September 14, 2023 Unit 3 - Day Shift - 2.9 LNAs - Census 45 Unit 5 - Day Shift - 3.0 LNAs - Census 49 Unit 6 - Day Shift - 1.0 Nurse - Census 48 September 16, 2023 Unit 2 - Day Shift - 3.0 LNAs - Census 47 Unit 5 - Day Shift - 3.0 LNAs - Census 49 Unit 6 - Day Shift - 1.0 Nurse - Census 47 September 17, 2023 Unit 1 - Day Shift - 3.0 LNAs - Census 48 Unit 2 - Day Shift - 3.0 LNAs - Census 47 Unit 5 - Day Shift - 3.0 LNAs - Census 49 Unit 6 - Day Shift - 3.0 LNAs - Census 47 September 18 2023 Unit 2 - Day Shift - 3.0 LNAs - Census 46 Unit 5 - Day Shift - 3.0 LNAs - Census 50 Unit 6 - Day Shift - 3.0 LNAs - Census 46 September 20, 2023 Unit 6 - Evening Shift - 3.0 LNAs - Census 48 September 23, 2023 Unit 3 - Day Shift - 2.9 LNAs - Census 41 September 24, 2023 Unit 3 - Day Shift - 3.0 LNAs - Census 42 Unit 6 - Day Shift - 3.0 LNAs - Census 49 September 30, 2023 Unit 3 - Day Shift - 3.0 LNAs - Census 45 Unit 5 - Day Shift - 2.9 LNAs - Census 47 Unit 6 - Day Shift - 3.0 LNAs - Census 49 October 1, 2023 Unit 2 - Day Shift -3.0 LNAs - Census 45 Unit 5 - Day Shift - 2.9 LNAs - Census 48 Interview with Staff P (Unit Manager) on 10/06/23 at 8:51 a.m. revealed that the unit has had two callouts today. He/She had to work as a medication nurse for the first part of the shift and there are only 3 LNAs working the 7 a.m. - 3 p.m. shift today. The current census is 48 on the unit. Interview with Staff F on 10/6/23 at 10:09 a.m. confirmed that the Daily Staffing Sheets were correct and included all staff call-outs.Observation on 10/2/23 at approximately 6:00 p.m. revealed a strong odor of urine on the nursing units. Interview on 10/3/23 at approximately 8:45 a.m. with Resident #115 revealed that he/she had concerns with staffing at the facility. Sometimes I have to wait for a half hour for my call light to be answered and then another hour or so for them to find someone help me. Interview on 10/3/23 at approximately 9:00 a.m. with Resident #187 revealed that receiving help from staff can be anywhere from 30 minutes to 2 hours. It is horrible, I wet myself sometimes and will be in pain for that long because there is no one to answer my call bell. Interview on 10/3/23 at approximately 10:00 a.m. with Resident #186 revealed, Over this past weekend there were a bunch of no shows which meant we waited for anything we needed. All of these people (staff members) are not on the floor helping out, this is only because you are here. Interview on 10/6/23 at approximately 9:15 a.m. with Staff L (Anonymous) and Staff M (Anonymous) revealed, Staffing is horrible and the residents suffer from it. At times we have worked with only 2 LNAs on the floor for like 50 people. Weekends are horrible too, we have to do bare minimum care to just get to everyone, the residents are not receiving the care they need.

Based on observation, interview, review of manufacturer's instructions, and review of the facility's policy and procedure it was determined that the facility failed to label opened multi-dose medications and biologicals, failed to ensure that medications were secured, and failed to ensure that expired medications were removed from supply and not given on 5 of 6 medications carts reviewed and in 1 of 3 medication rooms observed (Resident identifiers are #130, #140, #174, #234, #89, #146, and #20). Findings include: Building 2 East Side Medication Cart Observation on 10/2/23 at approximately 6:10 p.m. of the Building 2 East Side Medication Cart revealed an opened Ozempic Pen with no resident name and no date of opening. Interview on 10/2/23 at approximately 6:10 p.m. with Staff A (Licensed Practical Nurse (LPN)) confirmed the above finding. Review on 10/4/23 of the manufacturer's instructions for Ozempic, dated 2023 revealed: .Store your pen in use for 56 days at room temperature .The Ozempic pen you are using should be disposed of (thrown away) after 56 days, even if it still has Ozempic in it . Building 3E Middle Medication Cart Observation on 10/2/23 at approximately 6:15 p.m. of the Building 3E Middle Medication Cart revealed Resident #130's opened Lispro vial labeled with an expiration date of 9/19/23. Interview on 10/2/23 at approximately 6:15 p.m. with Staff B (LPN) confirmed the above finding on Building 3E Middle Medication Cart. Review on 10/4/23 of the manufacturer's instructions for Lispro insulin revealed that after vials have been opened to throw away all opened vials after 28 days of use, even if there is insulin left in the vial. Building 5-2 Medication Cart Observation on 10/2/23 at approximately 7:10 p.m. of the Building 5-2 Medication Cart revealed: Resident #140's Lispro insulin pen with an expiration date of 9/30/23 Resident #174's Novolin insulin vial opened and no open date An Ozempic Pen with no resident name and no date of opening 4 packets of Veltassa medication (potassium removing agent) Interview on 10/2/3 at approximately 6:15 p.m. with Staff C (Registered Nurse (RN)) confirmed the above findings on Building 5-2 Medication Cart. Review on 10/4/23 of the Novolin manufacturer's instruction revealed that you can carry the vial with you and keep it at room temperature for up to 4 weeks. Review on 10/4/23 of the manufacturer's instructions for Veltassa, dated March 2023 revealed: .Veltassa should be stored in the refrigerator .If stored at room temperature .must be used within 3 months of being taken out of the refrigerator. Unit 2 Medication Cart Observation on 10/2/23 at approximately 7:10 p.m. of the Unit 2 Medication Cart revealed: Resident #234's Glargine insulin opened and no open date Resident #89's Lispro insulin pen labeled with an expiration date of 9/26/23. Interview on 10/2/23 at approximately 7:20 p.m. with Staff E (LPN) confirmed the above findings on Unit 2 Medication Cart. Staff E also confirmed that Resident #89 received 4 units from the expired Lispro insulin pen prior to dinner on 10/2/23. Review on 10/4/23 of the manufacturer's instructions for Lantus [Glargine] pen, undated revealed: .After 28 days, throw your opened Lantus pen away-even if it still has insulin in it. Unit 2 Medication Room Observation on 10/2/23 at approximately 7:20 p.m. of the Unit 2 Medication Room revealed: Aplisol Solution labeled with an opening date of 8/26/23 Interview on 10/2/23 at approximately 7:20 p.m. with Staff A confirmed the above finding on Unit 2 Medication Room. Review on 10/4/23 of the Aplisol manufacturer's instruction revealed that vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. Building 1-1 Medication Cart Observation on 10/2/23 at approximately 7:25 p.m. of the Building 1-1 Medication Cart revealed: Resident #146's Lantus insulin pen labeled with an opening date of 9/4/23 Interview on 10/2/23 at approximately 7:25 p.m. with Staff D (LPN) confirmed the above finding on Building 1-1 Medication Cart. Resident #20 Observation on 10/4/23 at approximately 7:40 a.m. of Resident #20 revealed that he/she was lying in bed with a box of Salonpas medicated patches. Interview on 10/4/23 at approximately 7:40 a.m. with Staff H (LPN) revealed that Resident #20 does not have a physician's order for the Salonpas and that the patches should be locked in a medication cart or medication room. Review on 10/5/23 of the facility policy titled, Medication Storage, Revision Date 2/23 revealed: .All drugs and biologicals will be stored in locked compartments (i.e., medication cart, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. .6. Refrigerated Products: a. All medications requiring refrigeration are stored in refrigerators located in the pharmacy and at each med room .

Based on observation and interview it was determined that the facility failed to provide meals served at an appetizing temperature for 22 residents in a final survey sample of 41 (Resident Identifiers are #3, #21, #41, #46, #56, #63, #82, #86, #107, #114, #118, #125, #136, #138, #181, #186, #204, #221, #224, #231, #387, #397). Findings include: Review on 10/4/23 of the Food and Drug Administration (FDA) food code 2022, January 18, 2023 version revealed: .(D) TIME/TEMPERATURE CONTROLS FOR SAFETY FOOD that is cooked to a temperature . and received hot shall be at a temperature of 57 degrees [°] C [Celsius] (135 degrees F [Fahrenheit]) or above. Review on 10/4/23 of the facility's meal time schedule revealed that Unit 2 dining room lunch service time was scheduled for 12:50 p.m. Observation on 10/4/23 between 11:00 a.m. to 1:20 p.m. in the kitchen with Staff U (Director of Food Services) revealed the following: -during line service the plates and pellets were cold to touch. -meal line service completed and test tray was placed on Unit 2 dining room cart at 1:20 p.m. Interview on 10/4/23 at approximately 1:20 p.m. with Staff U confirmed the above findings. Observation on 10/4/23 at approximately 1:25 p.m. at Unit 2 dining room revealed that the test tray was removed from cart to be served. Further observation revealed that the food temperatures on the tray was checked by Staff U and showed the following temperature: Meatballs 127 (°) Fahrenheit (F), which was below 135 degrees F. Interview on 10/4/23 at approximately 1:25 p.m. with Staff U confirmed the above findings. Resident #136 Interview on 10/3/23 at 8:47 a.m. with Resident #136 revealed that the food is not hot when he/she gets served meals. Resident #136 stated that it has been going on for months. Resident #41 Interview on 10/3/23 at 10:00 a.m. with Resident #41 revealed that the food is always cold regardless of what he/she orders. Resident #41 stated that it has been going on for months. Resident #63 Interview on 10/3/23 at 10:05 a.m. with Resident #63 revealed that the food is not hot when he/she gets served meals. Review on 10/3/23 of Resident Council Meeting minutes dated 7/18/23 and 8/16/23 revealed that some residents feel food is cold at times. Interview on 10/3/23 at 2:00 p.m. with Resident Council revealed that the food is cold when delivered at mealtime. 7 out of 11 residents (Resident Identifiers are #3, #46, #56, #114, #118, #204, and #221) who attended Resident Council were in agreement that the food is cold when delivered at meal time. Resident #107 Interview on 10/3/23 at approximately 8:00 a.m. with Resident #107 revealed that meals are always cold. Resident #86 Interview on 10/3/23 at approximately 8:15 a.m. with Resident #86 revealed, My meals are almost always cold, they are never even warm. Resident #181 Interview on 10/3/23 at approximately 8:30 a.m. with Resident #181 revealed that meals are always cold. Resident #82 Interview on 10/3/23 at approximately 8:45 a.m. with Resident #82 revealed that meals are always cold and they have complained to staff several times. Resident #186 Interview on 10/3/23 at approximately 9:35 a.m. with Resident #186 revealed that his/her meals are always cold, The food comes here cold and they expect us to just eat it. Resident #56 Interview on 10/3/23 at approximately 9:45 a.m. with Resident #56 revealed What good is having a food committee, when either the concerns aren't addressed or the meetings keep getting delayed? The food is cold and you never get what you ordered. Resident #138 Interview on 10/3/23 at approximately 10:00 a.m. with Resident #138 revealed No one listens to concerns with food, I have even had hair in my food on several occasions. Interview on 10/3/23 at approximately 11:00 a.m. with Staff I (Unit Manager) revealed that he/she was aware of the food complaints and that they had been going on for a while. Interview on 10/5/23 at approximately 8:00 a.m. with Staff O (Dietitian) revealed that he/she has been aware of the food concerns from residents for a while now.Resident #387 Interview on 10/3/23 at 9:11 a.m. with Resident #387 revealed that the food and coffee is served cold. Resident #231 Interview on 10/3/23 at 11:32 a.m. with Resident #231 revealed that the food is always served cold. Resident #125 Interview on 10/3/23 at 12:20 p.m. with Resident #125 revealed that the food and coffee is always served cold. Resident #397 Interview on 10/3/23 at 12:24 p.m. with Resident #397 revealed that the food is served cold. Resident #224 Interview on 10/3/23 at 1:30 p.m. with Resident #224 revealed the food and coffee are served cold. Resident #21 Interview on 10/3/23 at 2:21 p.m. with Resident #21 revealed the food is always served cold.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Building 2 (200 Unit) Resident #48 Interview on 10/3/23 at 8:30 a.m. with Resident #48 revealed that Resident #48 never receives what he/she orders for breakfast. Resident #48 states that he/she was to get oatmeal this morning. Observation on 10/3/23 at 8:31 a.m. of Resident #48's breakfast tray revealed that there was no oatmeal served. Review of Resident #48's breakfast meal tickets for 10/3/23 revealed .Standing orders: .1/2 cup Oatmeal (Tu, Th, Sa, Su) . Resident #136 Interview on 10/3/23 at 8:47 a.m. with Resident #136 revealed that the menu provided by the facility for meals is not always followed. Resident #136 stated that when he/she orders an alternate meal he/she does not always get what he/she orders. Resident #41 Interview on 10/3/23 at 10:00 a.m. with Resident #41 revealed that Resident #41 does not always receive what he/she chooses for the meal. Resident #41 stated that he/she never received creamer for [pronoun omitted] coffee and this morning [pronoun omitted] received a hardboiled egg and fresh oranges for breakfast. Resident #41 stated that he/she dislikes eggs and any kind of fruit. Review of Resident #41's lunch meal ticket for 10/3/23 revealed .Standing orders: .8 fl oz coffee (creamer X2 sweet n low X4) .1 serv peanut butter & crackers . Dislikes: eggs . canned fruit and fresh fruit . Observation on 10/3/23 at 1:15 p.m. of Resident #41's lunch tray revealed no creamer or peanut butter and crackers. Interview on 10/6/23 at 10:40 a.m. with Staff Q (Licensed Nursing Assistant (LNA)) revealed that residents will receive the wrong food items and when a resident receives the wrong item, staff have to go down to the kitchen to get a resident something else because there is no phone in the kitchen. Staff Q stated that residents receiving the wrong food happens all the time. Resident #27 Interview on 10/3/23 at 9:30 a.m. with Resident #27 revealed that Resident #27 is on a special diet. Resident #27 stated that [pronoun omitted] often receives food that is dry and vegetables that are undercooked. [Pronoun omitted] has a hard time swallowing and dry food can make [pronoun omitted] cough. Resident #27 states that he/she has complained to staff multiple times. Observation on 10/3/23 at 9:30 a.m. of Resident #27's breakfast meal tray revealed a hardboiled egg, what appeared to be cornbread, and fresh orange slices. Review on 10/4/23 of Resident #27's medical record revealed that Resident #27 was admitted to the facility on [DATE] with a diagnosis of dysphagia. Review on 10/4/23 of Resident #27's Minimum Data Set (MDS) with an assessment reference date of 7/19/23 revealed Resident #27 had a Basic Interview for Mental Status (BIMS) score of 15 out of 15. Review on 10/5/23 of Resident #27's diet order dated 1/4/23 revealed that Resident #27 was on a regular, mechanical soft, nectar thick consistency, and extra moisteners diet. Review on 10/5/23 of Resident #27's meal ticket revealed .Diet Order: Mechanical Soft .Notes: No toasted breads, no oranges .Alerts: .Extra gravy, extra moisteners .Dislikes: Fruit (oranges), raw fruits & vegetables (only send canned fruit) . Interview on 10/6/23 at 11:00 a.m. with Staff O revealed that Resident #27 was on a mechanical soft diet and should be getting extra gravy and extra moisteners. Staff O stated that Resident #27 should not have received fresh oranges if Resident #27 dislikes oranges and should not receive raw fruit or raw vegetables. Review on 10/5/23 of a facility Grievance/Complaint form dated 7/6/23 revealed that .Resident #27 has been getting cold uncooked vegetables . Resident #210 Interview on 10/3/23 at 11:25 a.m. with Resident #210's family member revealed that Resident #210 was on a mechanical soft diet. Resident #210 was to receive meats that were moist and soft to chew. Resident #210 often receives meats that were dry. Resident 210's family member states that he/she tasted the pork once and the meat was crunchy. Review on 10/6/23 of Resident #210's medical record revealed that Resident #210 was admitted to the facility on [DATE] with a diagnosis of dysphagia following a cerebral infarction. Review on 10/6/23 of Resident #210's diet order dated 4/5/23 revealed that Resident #210 was on a regular, mechanical soft, thin liquids consistency, and extra moisteners (sauces, gravies, butter) diet. Review on 10/6/23 of Resident #210's meal ticket revealed .Diet Order: Mechanical Soft .Notes: Extra moisteners (sauces, gravies, butter) . Interview on 10/6/23 at 11:05 a.m. with Staff O confirmed the above findings. Review on 10/6/23 of the facility's policy titled, Menus and Adequate Nutrition, Revised 5/2023, revealed: .Policy Explanation and Compliance Guidelines: . 3. Menus will be followed as posted . 5. Menus shall reflect input from residents and resident groups. a. Resident preferences, including likes and dislikes will be documented in the resident's chart and shall be reviewed when planning menus. i. Alternates shall be immediately available if the primary menu or selections for a particular meal are not to a resident's liking . b. The resident council will be included periodically in menu planning, and efforts will be made to accommodate requests . 9. Resident preferences and allergies shall be obtained during the resident assessment process . Review on 10/6/23 of the facility's policy titled, Food Preparation Guidelines, Revised 2/2023, revealed: .Policy Explanation and Compliance Guidelines: . 4. Food shall be provided in form (i.e. regular, curt, chopped, ground, pureed) that meets each resident's individual needs in accordance with his or her assessment and care plan . 5. Staff shall accommodate resident allergies, intolerances, and preferences . Review on 10/6/23 of the facility's procedure titled Tray Line Procedure revealed: .7. Tray passed to the end of line to Checker to check for accuracy of tray, correct items. meal choice, and texture . Review on 10/6/23 of the facilities policy titled Therapeutic Diet Orders revised 4/23/23 revealed, .Policy: The facility provides all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences . 5. Dietary and nursing staff are responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed . Building 5 (500 Unit) Resident #107 Interview on 10/3/23 at approximately 8:00 a.m. with Resident #107 revealed that a lot of times he/she does not get what he/she has chosen for meals. Resident #86 Interview on 10/3/23 at approximately 8:15 a.m. with Resident #86 revealed, The food I get on my tray is never what I have ordered, and no one brings me what I actually ordered. Resident #181 Interview on 10/3/23 at approximately 8:30 a.m. with Resident #181 revealed that he/she does not get what he/she orders on the menu. Resident #83 Interview on 10/3/23 at approximately 8:40 a.m. with Resident #83 revealed that he/she does not get what he/she orders from the menu, Sometimes you get food that is not even on the menu at all. Resident #82 Interview on 10/3/23 at approximately 8:45 a.m. with Resident #82 revealed that there was no coffee available at the facility for days and no drinks were on the trays when they were delivered to him/her. Resident #186 Interview on 10/3/23 at approximately 9:35 a.m. with Resident #186 revealed that he/she recently signed a food petition that was going around the facility. No one ever gets what they ordered here, I get food all the time that I am not supposed to get. Resident #56 Interview on 10/3/23 at approximately 9:45 a.m. with Resident #56 revealed, What good is having a food committee, when either the concerns aren't addressed or the meetings keep getting delayed? The food is cold and you never get what you ordered. Resident #138 Interview on 10/3/23 at approximately 10:00 a.m. with Resident #138 revealed, No one listens to concerns with food, I have even had hair in my food on several occasions. Interview on 10/3/23 at approximately 11:00 a.m. with Staff I (Unit Manager) revealed that he/she was aware of the food complaints, Just yesterday the kitchen didn't have sausages, so they just sent fish (which was not an option on the menu) without any explanation to anyone. Staff I stated that this has been an ongoing issue. Resident #53 Interview and observation on 10/3/23 at approximately 11:45 a.m. with Resident #53 revealed that he/she has not been getting what he/she orders, I complain about it all the time and nothing changes, this has been going on for months. I get beef all the time and it clearly states allergy on my ticket. Look at my breakfast tray this is all I got for today. Observation of Resident #53's (Tuesday) breakfast tray revealed 1 dry bagel. Review on 10/3/23 of Resident #53's meal ticket revealed the following: 1 each bagel (peanut butter) (Tuesdays) 3/4 cup of cheerios (Tuesdays) 1 each fresh fruit 1/2 cup scrambled egg (Tuesdays) Review on 10/3/23 of Resident #53's medical record revealed the following Evaluation Summary, Dietary, dated 8/31/23: .Noted allergy to beef - kitchen aware . Resident with multiple complaints about the meals and dietary services, ongoing interaction to try to improve . Interview on 10/5/23 at approximately 8:00 a.m. with Staff O revealed that he/she has been aware of the food concerns from residents for a while now.Based on observation, interview, and record review, it was determined that the facility failed to follow menu preferences, allergies, and intolerances for 5 residents (Resident identifiers are #27, #56, #79, #138, and #210) of 19 residents reviewed for meal/food concerns (Resident Identifiers are #21, #41, #48, #53, #82, #83, #86, #107, #125, #136, #181, #186, #231, #397). Findings include: Building 3 (300 Unit) Resident #79 Review on 10/3/23 of Resident #79's lunch meal ticket revealed that Resident #79 was to have extra gravy and an egg salad sandwich along with his/her meal. Observation on 10/3/23 at 11:39 a.m. of Resident #79 eating his/her lunch revealed a plate of spaghetti with red ground meat sauce on it. Not all of the spaghetti has sauce on it. There was no egg salad sandwich on his/her tray. Interview on 10/3/23 at 11:39 a.m. with Resident #79 revealed that he/she had recently had 6 teeth removed and needed the extra gravy on foods to make it easier to chew and confirmed he/she did not get an egg salad sandwich nor the extra gravy on meal trays. Resident #79 also stated that he/she had requested creamer for coffee, but was told there wasn't any. Resident stated that there was not enough gravy/sauce on his spaghetti and that it was dry. Interview on 10/3/23 at 11:50 a.m. with Staff N (Licensed Practical Nurse (LPN)) confirmed the above. Staff N stated Resident #79 had not been getting sandwiches for the past few weeks. Staff N stated there was no coffee creamer available. Interview on 10/5/23 with Staff O (Dietitian) confirmed that Resident #79 should have received extra gravy/sauce on his/her spaghetti and an egg salad sandwich. Staff O revealed that the kitchen should have followed the meal ticket and that the nursing staff should have verified the meal ticket. Review on 10/5/23 of Resident #79's care plan revealed that Resident #79 was at risk for nutritional decline/malnutrition and that likes and dislikes were to be honored by staff. Review on 10/5/23 of Resident #79's Nutritional Note dated 9/29/23 revealed that Resident #79 was status post multiple tooth extractions, had pain and discomfort with chewing and had requested softer food and ground up meat with extra gravy. Resident #231 Interview on 10/3/23 at 11:32 a.m. with Resident #231 revealed he/she does not get what they requested for meals and has no choices for breakfast. Resident #125 Interview on 10/3/23 at 12:20 p.m. with Resident #125 revealed he/she gets no choices for breakfast. Resident #397 Interview on 10/3/23 at 12:24 p.m. with Resident #397 revealed he/she does not get requested coffee and tea and has to ask for it. Resident #21 Interview on 10/3/23 at 2:21 p.m. with Resident #21 revealed he/she did not get what he/she requested for meals, including chicken which he/she does not like.

Based on interview and record review, it was determined that the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the State Survey Agency for one of one resident reviewed for medication error and falls with a major injury out of a final sample of 39 residents. (Resident identifier is #146.) Findings include: Interview on 10/26/22 at approximately 9:30 a.m. with Resident #146 revealed that they had a fall that resulted in rib fractures at the facility. Review on 10/26/22 at approximately 9:55 a.m. of Resident #146's medical record revealed a hospital note dated 10/1/22 that stated .the patient was accidentally given 2 mg [milligrams] of Ativan [antianxiety] at 4:00 this morning instead of [pronoun omitted] scheduled oxycodone .got up to go eat breakfast and was apparently a little dizzy and fell forward .Final diagnosis .multiple rib fractures involving four or more ribs-Left side . Interview on 10/27/22 at approximately 11:45 a.m. with Staff A (Registered Nurse) revealed that on 9/30/22 at approximately 7:00 a.m., during shift count, they noticed that Resident #146 had been given the wrong medication. Staff A stated that this was reported to the unit manager, the provider, and the Resident. Staff A stated that once the medication error was discovered the two nurses went to assess Resident #146 with no abnormal findings. At approximately 8:00 a.m. Staff A stated they heard a thud and found Resident #146 had fallen and the Nurse Practitioner was notified. Review on 10/27/22 at approximately 12:15 p.m. of Resident #146's October 2022 physicians orders revealed no order for Ativan in place. Interview on 10/27/22 at approximately 1:30 p.m. with Staff C (Regional) confirmed that neither the medication error nor the fall had been reported to the State Survey Agency. Review on 10/28/22 of the facility policy titled Abuse, Neglect, and Exploitation, revised on 9/1/22, revealed .1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or b. Not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury .

Based on interview and record review, it was determined that the facility failed to ensure that all alleged violations of abuse, neglect, exploitation or mistreatment were thoroughly investigation for 1 of 2 residents reviewed for falls out of a final sample of 39 residents. (Resident identifier is #146.) Findings include: Interview on 10/26/22 at approximately 9:30 a.m. with Resident #146 revealed that they had a fall that resulted in rib fractures at the facility. Review on 10/26/22 at approximately 9:55 a.m. of Resident #146's medical record revealed a hospital note dated 10/1/22 that stated .the patient was accidentally given 2 mg [milligrams] of Ativan [antianxiety] at 4:00 this morning instead of [pronoun omitted] scheduled oxycodone .got up to go eat breakfast and was apparently a little dizzy and fell forward .Final diagnosis .multiple rib fractures involving four or more ribs-Left side . Interview on 10/27/22 at approximately 11:45 a.m. with Staff A (Registered Nurse) revealed that on 9/30/22 at approximately 7:00 a.m., during shift count, they noticed that Resident #146 had been given the wrong medication. Staff A stated that Resident #146 had received Ativan (Antianxiety) instead of the scheduled Oxycodone. At approximately 8:00 a.m. Staff A stated they heard a thud and found Resident #146 had fallen and the Nurse Practitioner was notified. Review on 10/27/22 at approximately 12:15 p.m. of Resident #146's October 2022 physician's orders revealed no order for Ativan in place. Review on 10/27/22 at approximately 12:30 p.m. of Resident #146's falls investigation for all occurring on 9/30/22 revealed no indication that Ativan had been given prior to the fall. Further review of Resident #146's falls investigation revealed the root cause was determined to be related to non-compliance. Interview on 10/27/22 at approximately 1:30 p.m. with Staff D (Director of Nursing) confirmed that the falls investigation did not include Ativan as a medication Resident #146 had taken prior to the fall occurring.

Observation on 10/25/22 at 10:34 a.m. of Resident's #31 room revealed Triamcinolone Acetone Cream USP0.1% and Nystatin Topical Powder USP 100,000 units per gram. Interview on 10/25/22 at 10:34 a.m. with Resident #31 revealed that the medications were there and that he/she doesn't know why the medications were there and he/she doesn't self-administer them. Interview on 10/25/22 at 10:45 a.m. with Staff F, (Unit Manager) confirmed that the Resident's #31 medications were on the bed side table. Staff F stated that those medications should not have been left at the bedside. Review on 10/26/22 of the Medication Administration Record (MAR) revealed a physician order for Triamcinolone Acetonide Cream 0.1%. Apply affected area topically as needed for itch twice per day. Start Date 8/1/22. Medication was administered 8/2/22-10/26/22. Further review on 10/26/22 of Resident's #31 Medication Administration Record (MAR ) revealed a physician order for Nystatin Powder 100,000 Unit/Gran (gm). Apply to under both breasts, groin area, and buttock topically every day shift for rash. Start date 8/15/22. Medication was administered 10/1/22-10/26/22. Interview on 10/27/22 at 11:26 a.m. with Staff F confirmed that Resident #31's medications should not have been left in the resident's room. Further review on 10/27/22 of the facility's policy Medication Storage revised 5/31/22 revealed .All drugs and biologicals will be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls . Based on observation and interview, it was determined that the facility failed to ensure that medications were stored, labeled, and disposed of in accordance to acceptable professional standards or manufacturer's instructions for 1 out of 6 medication carts observed for medication storage and 1 resident out of a final sample of 39 residents. (Resident identifiers are #20, #31, #210, #177) Findings include: Observation on 10/25/22 at 08:35 a.m of the medication cart middle cart 3rd floor with Staff G (Registered Nurse) revealed an insulin pen (Insulin Aspart Flex pen 100 units per milliliter (ml)) for resident #20 with an expiration date written on the bottle of 10/09/22 and Resident #177's bottles of eye medications Dorzolamide HCL 2 percent (%) drops (for glaucoma) and Latanoprost Solution eye drops 0.005% (for glaucoma) with no open date and no expiration dates on the bottles. Observation also revealed an open bottle of Latanoprost Solution 0.005% eye drops for Resident #210 without an open date or expiration date. Interview on 10/25/22 at 8:45 a.m. with staff G confirmed the above expiration dates, Staff G also confirmed that he/she had used the insulin pen during that morning medication pass for Resident #20. Interview on 10/25/22 with Staff H (Licensed Practical Nurse Charge) revealed that the eye medications for Resident #177 and #210 should have been labeled with an open date, an opened expiration date, and that the insulin pen should have been discarded. Review on 10/27/22 of the Pfizer manufacturer's package insert for Latanoprost ophthalmic Solution 0.0005% revised August 2011 revealed .How Supplied: Once a bottle is opened for use, it may be stored at room temperature up to 25 degrees celsius for up to 6 weeks. Review on 10/27/22 of the manufacturer's Novo Nordisk Inc. Revised December 2012, instructions for use of the Novolog FlexPen How should I store Novolog FlexPen? .The Novolog FlexPen you are using should be thrown away after 28 days, even if it still has insulin left in it.