Based on interview, the facility failed to inform residents and resident representatives in writing of a room change, including the reason for the change, when residents changed rooms due to a flooding event. for 8 (R #1-8) of 8 (R #1-8) residents that were moved. This deficient practice is likely to result in frustration and confusion for residents. The findings are: A. On 01/07/25 at 10:20 am during an interview with Nurse Manager (NM) #1, she stated the Managers were called into the facility because of the flooding on the 200 wing on 01/06/25. She stated the Managers were asked to assist in moving residents. She stated she assisted moving residents R #5 and R #3. She stated she did not call the residents' families or the resident representatives to inform them of the move or of the flooding issue. NM #1 states she was not aware if any staff called the families or resident representatives of R #1-8 to inform them of the move and flooding. B. Record Review of R #6's medical record revealed staff documented the following: - Dated 1/7/2025 at 11:15 am, due to water/ plumping issue, the resident was moved to another hall for safety. Staff notified the resident's POA/son on this date. No further questions or concerns at this time. - The record did not contain documentation that staff notified the POA in writing of the room change to include the reason for the change. C. On 01/07/25 at 11:57 am during an interview with R #6's family member, he stated the facility notified him about R #6's room change on 01/07/25 at 10:00 am. D. Record Review of R #3's medical record revealed the record did not contain documentation staff notified the resident or resident representative in writing regarding the room change to include the reason for the change. E. On 01/07/25 at 12:28 pm during a phone interview with R #3's Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, or medical care), she stated the facility did not notify her of R #3's room change, and she would have liked to know what was going on with R #3. F. Record Review of R #4's medical record revealed the record did not contain documentation staff notified the resident or resident representative in writing regarding the room change to include the reason for the change. G. On 01/07/25 at 12:45 pm during interview with R #4, she stated staff asked her to move rooms, but the did not tell her why she was moving. H. Record Review of R #1's medical record revealed the record did not contain documentation staff notified the resident or resident representative in writing regarding the room change to include the reason for the change. I. Record Review of R #2's medical record revealed staff documented the following: - Dated 1/7/2025 at 10:59 am, due to water/ plumping issue, staff attempted to move the resident to a room that did not have a water issue. The resident refused to move rooms. Staff re-attempted on this date, and the resident agreed to move. - The record did not contain documentation that staff notified the POA in writing of the room change to include the reason for the change. J. Record Review of R #5's medical record revealed staff documented the following: - Dated 1/7/2025 at 11:12 am, due to water/ plumping issue, the resident was moved to another hall for safety. Staff notified the resident's POA on this date, but she was not available at this time. Staff left a message for a call back. - The record did not contain documentation that staff notified the POA in writing of the room change to include the reason for the change. K. Record Review of R #7's medical record revealed the record did not contain documentation staff notified the resident or resident representative in writing regarding the room change to include the reason for the change. L. Record Review of R #8's medical record revealed the record did not contain documentation staff notified the resident or resident representative in writing regarding the room change to include the reason for the change. M. On 01/07/25 at 1:38 pm during an interview with the Director of Nursing (DON), she stated 18 residents resided on the 200 wing. She stated seven residents were able to ambulate on their own, and those were the residents that moved to other units of the facility.The DON stated staff notified the families of all the residents that were moved on 01/07/25 by 1:00 pm by phone, but staff did not provide documentation in writing. The DON stated the flooding issue started on 01/06/25, and residents were moved on 01/06/25. The DON stated the families for R #1-8 were not notified in writing at that time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain an environment in good condition when staff failed to repair a broken door knob for 1 (R # 52) of 4 (R #'s 10, 52, 100 and 168) reviewed for homelike environment. If the facility fails to maintain the building, then residents could feel uncomfortable in their environment. The findings are: A. On 06/27/24 at 12:51 PM during a random observation and interview with R #52, R #52's bathroom door did not have a doorknob and could not be opened. R #52 stated the doorknob was broken for several weeks, and he was not able to access his restroom. He stated he told the CNAs, and they were aware the doorknob was broken. B. Record review of R #52's Minimum Data Set, dated [DATE] revealed that R #52 was continent and was able to toilet himself. C. On 06/28/24 at 10:21 am, an observation of R #52's room revealed the bathroom door did not have a doorknob. D. Record review of facility work order request #2920, dated 06/17/24, revealed a work order was submitted for R #52's bathroom doorknob to be replaced. E. On 06/28/24 1:55 PM during an interview with the Administrator, he stated he was not sure if staff submitted a work order for R #52's bathroom doorknob to be repaired. He further stated he thought the doorknob was in need of repair for about two weeks. He stated all employees have access to the system they use to submit maintenance requests and that he expected employees to report issues. He further stated that the maintenance director had a medical emergency and was out of during the period of time that the work order had been submitted for the doorknob to be replaced/repaired.

Based on interview and record review, the facility failed to ensure the comprehensive care plan was accurate for 1 (R #37) of 1 (R #37) residents reviewed for care plan accuracy. This deficient practice could likely result in staff not understanding and implementing the most appropriate interventions and treatments for the resident. The findings are: A. Record review of R #37's care plan, dated 06/04/24, revealed the following focus areas: - R #37 may not smoke per smoking evaluation, initiated 02/26/23, - R #37 may smoke with supervision per smoking evaluation, initiated 05/05/23. B. On 06/28/24 at 11:03 am during an interview with the Director of Nursing (DON), she stated R #37 did not smoke nor did she have a history of smoking. She added the resident's care plan should not have either smoking statement listed.

Based on interview and record review, the facility failed to ensure the comprehensive care plan was accurately revised for 1 (R #37) of 1 (R #37) residents reviewed for care plans. This deficient practice could likely result in staff not understanding and implementing the most appropriate interventions and treatments for the resident. The findings are: A. Record review of R #37's care plan, dated 06/04/24, revealed R #37 had an active urinary tract infection (UTI; an infection in any part of the urinary system, which includes the kidneys, ureters, bladder, and urethra) and was at risk for sepsis, initiated 02/10/24. B. Record review of R #37's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 05/22/24, revealed the resident did not have a UTI in the past 30 days. C. On 06/28/24 at 11:03 am during an interview with the Director of Nursing (DON), she stated R #37 had a UTI in February 2024 and has not had once since. She added that the care plan should reflect that R #37 was at risk for developing UTIs, not that R #37 had an active UTI.

Based on record review, observation and interviews, the facility failed to ensure staff documented the medication refrigerator temperatures in the medication storage room. This deficient practice is likely to result in all residents living in the facility, as identified on the census list provided by the Executive Director (ED) on 06/24/24, receiving medication that has lost their potency or effectiveness due to not being stored at the proper temperature. The findings are: A. Record review of the medication storage room temperature log book for the medication #1 refrigerator, the medication #2 refrigerator, and the specimen refrigerator revealed staff did not document temperature recordings for the following dates: 1. 06/21/24 pm. 2. 06/22/24 am and pm. 3. 06/23/24 am and pm. B. On 06/24/24 at 10:28 am during observation of the medication storage room, the medication #1 refrigerator, the medication #2 refrigerator, and the specimen refrigerator contained insulin and other medications that required refrigeration. C. On 06/28/24 at 12:23 pm, during an interview with the Director of Nursing (DON), she stated staff must check all medication storage room's refrigerator and freezer temperatures twice a day (am and pm) and document the temperatures on the temperature log. She stated staff checked to make sure the refrigerators maintained a temperature range of 36 to 46 degrees Fahrenheit, which preserved temperature-controlled medications and specimens.

R #64 H. On 06/26/24 at 11:41 AM during an interview, R #64 stated the food from the facility rarely matched the menu, and she gets food from outside of the facility to ensure she had something she liked to eat R #30 E. On 06/28/24 at 12:16 pm, during an interview with R #30, she provided her meal tickets for May and June 2024 and hand wrote which items were missing on each meal ticket. R #30 stated she complained to the Dietary Manager several times about the issue. She stated staff still served her food that was not on the menu or her tray did not have the food her meal ticket said should be there. F. Record review of R #30's dietary meal tickets, the following was missing from her food tray when staff served them: 1. On 05/15/24, breakfast - staff did not deliver margarine or jelly with her food tray. 2. On 06/14/24, breakfast - staff did not deliver sugar, garnish, and eggs with her food tray. 3. On 06/14/24, lunch - staff did not deliver grilled onions on hamburger and red bliss potatoes with her food tray. 4. On 06/15/24, breakfast - staff did not deliver cinnamon roll with her food tray. 5. On 06/21/24 - staff did not deliver toast, just a slice of bread, and beverage with her food tray. 6. On 06/22/24, lunch - staff did not deliver pasta salad with her food tray. 7. On 06/22/24, dinner - staff did not deliver sour cream and flour tortilla with her food tray. 8. On 06/26/24, lunch - staff did not deliver ice cream and stewed tomatoes with her food tray. 9. On 06/28/24, breakfast - staff did not deliver toast and eggs with her food tray. 10. On 06/28/24, lunch - staff served the resident Mexican spiced chicken and mashed potatoes, but the lunch menu for today stated staff should have served cowboy casserole and rice pilaf. G. On 06/28/24 at 1:52 pm, during an interview with the Regional Dietary Manager (RDM), he acknowledged staff occasionally did not serve R #30 the food that was listed on her meal tickets. The RDM further stated staff should have served R #30 the Cowboy Casserole for lunch on 06/28/24, and he was not sure why staff served her Mexican spiced chicken instead. Based on record review, observation, and interview, the facility failed to ensure that residents received food according to their meal ticket for 3 (R #30, R #62, and R #64) of 4 (R #28, R #30, R #62, and R #64) residents reviewed for dietary services. This deficient practice could likely result in residents not receiving enough food or food that was expected according to the menu. the findings are: R #62: A. On 06/24/24 at 10:26 am, during an interview with R #62, he reported I don't get enough food. I am supposed to get double portions. B. Record review of R #62's dietary meal ticket (an individualized description from the kitchen of what staff should serve a resident), dated 06/28/24, revealed the following: - Regular/liberalized diet. - Double portions of all items. - King Ranch Chicken casserole - two squares, dinner roll - two each, margarine - two each, sliced peaches - 1 cup, vanilla ice cream- 1/2 cup, assorted beverage - 12 ounces, house supplement - two each. C. On 06/28/24 at 12:30 pm, during an observation of R #62's meal tray, the meal tray did not match R #62's meal ticket. He received one serving of the casserole, one dinner roll, one butter, one serving of peaches, and one house supplement. He did not receive ice cream. D. On 06/28/24 at 12:45 pm, during an interview with the Regional Dietary Manager, he confirmed R #62 should receive double portions of every item on the meal ticket.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to meet professional standards of quality by failing to obtain wound care orders for 1 (R #12) of 3 (R #12, 15, and 16) residents reviewed for pressure sores. If the facility does not get wound care orders, it could create confusion on what wound care should be provided, or the residents may not get wound care. The findings are: A. Record review of the admission history and physical (H and P) for R #12, completed on 12/14/23 indicated the following under skin: -Wound on L (left) heel and big toe of R (right) foot; -Stage 2 pressure wound (sore has broken through the top layer of the skin and part of the layer below wound is open and shallow and could have clear or yellow fluid) on sacrococcygeal (sacrum or tail bone). B. Record review of the face sheet for R #12 revealed the resident was admitted to the facility on [DATE] with a left heel wound and a wound on his right big toe. No documentation of a wound on his tail bone. C. Record review of the physician orders revealed wound care orders starting on 12/13/23 for the left heel and right big toe. D. Record review of the change in condition note for R #12 indicated the following: On 12/16/23 at 3:26 pm, Certified Nurse Assistants (CNA) reported redness and skin break down to the tail bone area, after resident had a shower, this nurse was able to take a swift (picture) on call provider notified, ordered facility skin breakdown protocol (standard orders that the facility would put into place) and for wound care nurse to evaluate on Monday. E. Record review of the wound assessment for R #12 dated 12/16/23 indicated the following for tail bone: Length was 4.25 centimeters (cm), and the width was 3.11 cm, and it was documented as a stage II. F. Record review of a wound care order dated 12/16/23 indicated the following: Wound care for pressure ulcer and facility protocol for skin care. Notify primary team on Monday please. G. Record review of the treatment administration record (TAR) for R #12 revealed the record did not contain any order and any treatment were on the TAR starting on 12/16/23 for the sacrum wound. H. Record review of a nursing progress note dated 12/17/23 indicated the following: wound care for skin breakdown. Resident (R #12) was found to have skin breakdown to bilateral buttocks . Cleaned and optifoam (a type of dressing) placed. I. Record review of the nursing progress notes dated 12/19/23 indicated the following: nurse went in to flush the Foley catheter (removes urine from the body), and the resident needed changing; the nurse helped and assisted CNA and the resident had a dressing on, and this nurse removed and noticed a few wounds to the sacrum. Resident appeared to be scratching at the area and noticed bowel movement (BM) was making resident's tail bone red and inflamed. This nurse cleaned the site and followed up with w/c (wound care). J. On 03/14/24 at 11:49 am, during an interview with wound care nurse, she stated that the first time she was involved with wound care for R #12 was likely on 12/16/23 when she saw the sacral (tail bone) wound and documented it. She stated that she was not clear on why there was no order for wound care on the TAR starting 12/16/23. K. On 03/14/24 at 12:47 pm, during an interview with the Director of Nursing (DON), stated that the wound nurse took a picture, measured and staged the sacrum wound (the use of a staging system to determine the severity of a pressure ulcer; and measuring the size of the wound assist in wound management) on 12/16/23. She stated that it was a stage II. An order was put it on 12/16/23 for wound care. She stated that she is not clear on why this order (noted in finding ) is not showing up on the treatment administration record (TAR). She said that it might have something to do with there not being a schedule for the wound care. She stated that she knew the wound care was being completed because she had conversations about it with the nursing staff. She said that the order was changed and on 12/22/23. She does see that one on the TAR with wound care being completed. L. On 03/14/24 at 2:29 pm, during an interview with the Unit Manager #1, she stated that orders need to be in place for treatment to occur. She stated that if a nurse sees a new dressing on a resident but does not see orders for that dressing or for wound care, the nurse needs to call and get an order for treatment. M. On 03/14/24 at 2:35 pm, during an interview with CNA #1, she stated that she remembers R #12 very well. She has worked with him since he was admitted . She remembers giving him a shower and changing him after he had a bowel movement (BM). She stated that he always had a dressing on sacrum and it appeared clean.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete a thorough investigation regarding an injury of unknown origin for 1 (R #6) of 3 (R#2, R #5, and R #6) residents viewed during a compliant investigation. If the facility is not going to conduct investigations, they may be unable to ensure that residents are free from neglect and could likely result in residents being at risk for further injury. The findings are: A. Record review of facility policy, Abuse Prohibition, revised 10/24/22, revealed, Injuries of unknown origin will be investigated to determine if abuse or neglect is suspected. The investigation will be thoroughly documented with in risk management portal. Ensure that documentation of witnessed interviews is included. B. Record review of the facility's nursing progress note, dated for 07/16/23, revealed the resident's family member reported something was different about the resident's nose. C. Record review of the risk management documentation, dated 07/16/23, for R #6, revealed the facility did not conduct an investigation of R #6's injury of unknown origin. D. Record review of the facility's five-day investigation report, showed the date of occurrence for R #6's injury of unknown origin was 07/16/23. The date of the initial state report was 07/18/23, with the five day summary dated 07/19/23. The facility's five-day investigation report revealed R #6 received hospice services, and the facility did not find a root cause (the process of discovering the cause of problems in order to identify appropriate solutions) for the discoloration of his nose. E. On 12/12/23 at 11:59 am, during an interview with R #6's family member, she stated came to the facility on [DATE], saw R #6's nose, and informed nursing staff R #6 had a bruise on his nose. The resident's family member stated she did not know what occurred, but R #6 had a bruise on the very tip of his nose. She said facility staff did not call her to follow-up; and when she called the facility, the Center Executive Director (CED) would not take her call or call her back. No one called her to follow up with her concerns. F. On 12/12/23 at 12:47 pm and 12/14/23 at 12:13 pm, during an interview, the CED stated he sent out a text message to the staff to ask if they knew what happened to R #6. He said none of the staff replied, and the initial risk management report was all the information they had to go on. The CED said he verbally asked the staff what might be going on, if they had seen anything, and all the staff said no. The CED said he did not have anything in writing. He said the facility reported in the initial state report all the information he received from the nurses. The CED said R #6 was on hospice and might be transitioning (dying), and that is why the resident's nose was discolored. The CED said he did not find a root cause for the injury. G. On 12/14/23 at 3:04pm, during an interview, Nurse Manager #1 stated when she conducted investigations, she would go down the hall the resident lived on, collect witness statements, and interview the staff to see if anything stood out to them. She said she wanted to know if they heard or saw anything, did they report it to the nurse, and did they follow up with the nurse. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R #6 F. Record review of R #6 face sheet revealed he was admitted into the facility on [DATE]. G. Record review of R #6 Change in Condition (CIC) revealed an irregularity in his nose (an injury of unknown origin). H. Record review of R #6's CIC follow-ups, dated 07/23 at 2:29 am and 07/18/23 12:40 am, revealed staff did not document they monitored the irregularity on the R #6's nose. I. On 12/14/23 at 3:04 pm, during an interview with Nurse Manager #1, she confirmed staff monitored R #6; however, nursing staff failed to mention R #6's nose in follow-up CIC documentation. She said staff completed the CIC form, because they were suppose to monitor the resident's nose. Based on record review and interview, the facility failed to document a resident assessment when they received a report of a health status irregularity and to document observations of an identified health status irregularity. These deficient practices was found to affect 2 (R #2 and R #6) of 5 (R #1, R #2, R #3, R #4, and R#6) residents reviewed for nursing assessments after a change in condition occurred. This deficient practice could likely result in: 1. Residents not being properly assessed and treated for new concerns and; 2. Staff not having information they need to provide, competent, comprehensive care, and services if vital information is missing from the assessments. The findings are R #2 A. Record review of a facility grievance, dated 07/18/23, R #2 stated, at approximately 1:00 am on 07/15/23, he started feeling numbness on his right side and told the nurse he wanted to go to the hospital. He stated the nurse told him that she needed to make a phone call. R #2 stated when the nurse hung up the phone, she told him that if he wanted to go to the hospital then he would have to go against medical advice (AMA). The resident said he went to the front office and called an ambulance. B. Record review of R #2's nursing notes, dated 07/15/23, revealed R #2 told the nurse that he felt like his leg could not carry him for the past couple of days, and he would like to be sent to the hospital to find out what is wrong with him. The nurse spoke with the doctor, and she said the resident should sign an AMA. The resident told the nurse, I can't sign any damn AMA, and he left the nurses desk yelling and kicking the wall. He was later led to the front office by the CNA (Certified Nurse Assistant). Further review of R #6's nursing notes revealed the CNA informed the nurse the ambulance was waiting to take the resident to the hospital, and they requested the resident's report. The nurse attempted to call the Unit Manager at 1:32 am and at 1:33 am for further directives, but there was no response. The ambulance left before the nurse went to the parking lot to give them the resident's face sheet and order summary. C. Record review of the assessment tab of R #2's Electronic Health Record revealed a nursing assessment for R #2's presentation of numbness on his right side was not on file. D. Record review of R #2's nursing notes revealed documentation related to an assessment of R #2's numbness on his right side was not on file. E. On 12/14/23 at 3:01 pm, during an interview with Nurse Manager #1, she confirmed the nurse did not document an assessment of the numbness on his right side. She also confirmed staff are expected to complete and document an assessment whenever a resident complained of health irregularities.

Based on interview and record review, the facility failed to ensure grievance (complaints over something believed to be wrong or unfair) documentation included a summary of the investigation and findings or conclusions regarding the resident's concerns, and no resolution that consisted of education for staff, for 2 (R #2 and R #5) of 3 (R #2, R #5, and R #6) residents reviewed for grievances. The deficient practice could likely result in residents feeling unimportant and/or unsatisfied with the results of the grievance process. The findings are: A. Record review of the facility's grievance book revealed: 1. A grievance filed by R #5, dated 07/11/23, revealed the record did not contain a summary of the investigation and findings results. The resolution was to consist of staff being educated on resident approach on 07/11/23. 2. A grievance filed by R #2, dated 08/02/23, revealed the record did not contain a summary of the investigation and the findings results. 3. A grievance filed by R #2, dated 08/23/23, revealed the record did not contain a summary of the investigation and the findings results. The resolution was to consist of staff being educated on resident approach on 08/23/23. B. Record review of the facility policy titled, Grievance/Concern, revised on 07/19/23, revealed the Department Manager would investigate the grievance and notify the person filing the grievance of resolution in a timely manner. C. On 12/14/23 at 12:13 pm, during an interview with the Center Executive Director (CED), he confirmed staff did not document a summary of the investigation or a resolution for the grievance R #2 or R #5. D. On 12/14/23 at 3:04 pm, during an interview with Nurse Manger #1, she confirmed the resolution for the grievance for R #2 or R #5 was not resolved. She said staff did not document a summary of the investigation for the grievance R #2 or R #5.

Based on observation and interview the facility failed to ensure sanitary conditions for 1 (R #36) of 1 (R #36) resident reviewed for physical environment by housekeeping not cleaning the residents floor properly leaving smeared juice and food on the floor. If the facility fails to maintain resident rooms in a homelike environment, then residents are likely to feel uncomfortable and could exacerbate (make worse) health issues. The findings are: A. On 03/06/23 at 2:48 pm, during an observation of R #36's room it was noted that R #36's floor was dirty with food and was sticky from spilled juice. B. On 03/06/23 at 2:49 pm, during an interview with R #36, stated, When housekeeping was finished mopping my floor this morning (03/06/23) they did not clean the floor properly. The floor was left sticky to walk on and food was still on the floor after being cleaned. C. On 03/06/23 at 2:54 pm, during an interview with Certified Nursing Assistant (CNA) #1 confirmed that the R #36's floor was dirty with food and sticky with juice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure that a safe, planned discharge occurred for 1 (R #95) of 3 (R #95, 96 and 201) residents reviewed for discharge. This deficient practice could likely cause the resident not to have their needs met outside of the facility and could decline and be re-hospitalized . The findings are: A. Record Review of a complaint report submitted to the (name of state agency) on 01/19/23 indicated the following: Report from Journal Entries on 01/20/23: Complainant, Acting Deputy State Ombudsman (ADSO) received text notification from Director of Nursing, (name of DON) and Administrator (name of ADM) that resident (R #95) would not be accepted back to facility after resident self initiated a 911 call for transport to hospital due to feeling anxious, experiencing mini seizures, and withdrawals from decreased/changed medications at facility upon admission. On January 19, 2023, (name of hospital) hospital attempted transfer back to the facility via stretcher transport. Upon arrival, the facility refused to accept the resident. The resident was then transported back to (name of hospital) where hospital advised she (R #95) would be sent to the (name of shelter) shelter. The Ombudsman program contacted (name of organization) for assistance in locating emergency temp housing. On 01/19/23 at 3:00 pm R #95 was transported to a motel. Resident (R #95) was given 1 portable bottle of oxygen, a non-charged electric wheelchair, and her personal belongings and left in the hotel room. Resident (R #95) uses 4 liters of oxygen and the portable bottle was running out quickly. Resident was not provided with her medications. ADSO (name of ADSO) ln conjunction with (name of community based agency) arranged for an oxygen condenser, adult briefs, clothing, and food for the evening. (name of agency) continues to work with the resident for in-home health, medications, 30 meals on wheels, and stable housing. B. Record review of the face sheet for R #95 indicated an admission date of 01/16/23 and was discharged on 01/18/23. C. Record review of the nursing progress notes dated 01/18/23 at 19:04 (7:04 pm), when this nurse came in on shift was yelling at nurses station stated staff is abusing her because the meds she is requesting has been d/c (discontinued) by doctor. This nurse after report did try to help resident with several options she continues to state my lawyer is [NAME] [sic] all this I continued to ask what can I do at this point she said I am dying I am withdrawing and need a hospital ASAP. This nurse called on call (name of provider) and the provider didn't give order for transfer she is very aware of resident. This nurse explained to her that at this point she has her choices. She continued to yell this nurse did inform DON during that time resident called 911 from her phone stated we are holding her at her will and she needs help because she is withdrawing. Resident (R #95) as soon as cop came in started yelling at him and now yelling at EMT (emergency medical treatment) because she is not staying and or leaving without her belongings. Waiting on outcome. D. Record review of the nursing progress notes dated 01/18/23 at 19:41 (7:41 pm) resident (R #95) did refuse to sign AMA (Against Medical Advice) stated she has every right to go to hospital and that she will make sure this place gets shut down and will not return here. E. On 03/08/23 at 10:46 am, during an interview with R #95, she stated that she was at the hospital for a long time and then she was admitted to (name of facility). She stated that everything was going ok and she was in activities when she felt like she was having a seizure and she felt like she was going through withdrawals from the Ativan (for anxiety) and Oxycodone (pain medication). She wanted to be sent to the hospital but they told her no and that she would have to call herself. So, she called the paramedics. She wanted to take all her stuff with her because she didn't trust to leave it there in the facility. When she got to the hospital, they told her you aren't going through withdrawals and they sent her back to the facility. She stated that the Administrator was waiting outside for the ambulance and he told her that she left AMA so they weren't taking her back. R #95 stated that she wanted to go back to the facility. She stated that no one told her that she was leaving AMA. She did not get any paperwork from the facility on discharge or medications or a wheelchair or anything. The hospital gave her a walker and the Ombudsman got her set up with (name of agency) and they helped with everything else. F. On 03/08/23 at 2:15 pm, during an interview with Social Services Director (SSD) stated, when R #95 came to the facility she was nervous and had some requests. She was upset about some of the medications, but it seemed like they got past that. R #95 was calmer for a little bit and started to engage in some activities. SSD stated that R #95 was particular about things but nothing they couldn't accommodate. She stated that when residents want to go out to the hospital they are allowed to call and go out if they feel like they want to do that. Going out AMA would not be discussed if a resident wants to go to the hospital. G. On 03/09/23 at 11:28 am, during an interview with the Center Executive Director (CED), he stated that no other facility would take her before they agreed to take her. He stated that they will take chances on people that other facilities deny. He stated that medically R #95 was not a problem. They could meet her needs, but she was rude, disrespectful and aggressive. He stated that everything was going fine and then she just became irate and wanted to leave the facility and go back to the hospital. R #95 called 911 and the ambulance came and picked her up, she left and didn't sign the paperwork and they discharged her from the system since she didn't want to come back. The CED stated that she left AMA and maybe they should have completed the AMA paperwork. He stated that then when the ambulance brought her back there was no paperwork from them and since she was discharged from their facility they didn't have any orders. He stated that they allow residents to go out to the hospital even if they know it's not medically necessary. He stated that best practice would be to put them on a bed hold if they have any days left and if they don't they have to discharge them. That doesn't mean they won't take them back. H. On 03/10/23 at 8:12 am, during an interview with (name of hospital) [NAME] President of Admissions indicated that the hospital finally got R #95 placed at a facility, after she had been at the hospital for more then 200 days; not because of medical need, because no facility would take her. They finally got her placed and she went to that facility on 01/16/23. Two days later (01/18/23) she wanted to be transferred back to the hospital and she was. When she arrived at the hospital there wasn't a medical reason for her to be at the hospital and the hospital wasn't going to admit her so the hospital sent her back. The facility refused to take her when she arrived back on 01/18/23. She stated that (name of) R #95 had agreed to go back to the facility. I. On 03/10/23 at 11:30 am, during an interview with the Center Nursing Executive (CNE), she stated that resident (R #95) wanted things her way and was bugged about the medications she had for pain being changed when she was admitted . The CNE said that R #95 would be fine and then the next minute she would be screaming about something. They knew when they admitted her she would be difficult, and they would check with her throughout the day. They thought that she was doing very well and then she decided to leave. She stated that she spoke to R #95 at the hospital and R #95 didn't know where she wanted to be. When the hospital sent her back to them they didn't send any paperwork and didn't inform them she was coming. She stated that R #95 was AMA at that point. The CNE stated that if R #95 wanted to come back they would have taken her back, but she didn't, so the facility sent her back to the hospital. J. On 03/13/23 at 3:00 pm during an interview with the Physician, she stated that the facility called her for an order to send R #95 out to the hospital, she stated that there was no medical reason to send her out, and she wasn't going to put an order in for that. She said that she (R #95) could go AMA if she wanted to go out to the hospital because there was no medical reason for it. The Physician stated that R #95 wanted more medications (pain killers) because since she admitted to this facility she had reduced the pain medications. She wasn't going through withdrawals. She stated that (name of facility) didn't want her back but she doesn't believe they refused to take her.

Based on observation, record review and interview, the facility failed to meet professional standards of quality for 1 (R #78) of 6 (R #9, R #12, R #30, R #51, R #69, and R #78) residents observed for medication administration. This deficient practice could likely lead to the resident having adverse (unwanted, harmful, or abnormal result) side effects. The findings are: A. On 03/07/23 at 09:29 AM, during an observation of medication pass for R #78, CMA (Certified Medication Aide) #2 administered Metoprolol Tartrate (medication used to treat high blood pressure) 25 mg (milligrams). CMA #2 documented R #78's blood pressure (force of blood on the walls of the blood vessels that carry oxygenated blood away from the heart to the tissues) as 116/66 and heart rate 64 (number indicating the times a heart beats per minute). B. Record review of R #78's orders revealed: Order date 04/04/22 Metoprolol Tartrate Tablet 25 MG. Give 25 mg by mouth one time a day for HTN (Abbreviation for hypertension/high blood pressure) Hold if HR (heart rate) < (less than) 65 bpm (beats per minute) AND/OR SBP (systolic blood pressure; top number of blood pressure reading) < 100 C. On 03/07/23 at 3:44 PM, during an interview, CMA #2 confirmed that she did give the medication to R #78 because she thought that both the blood pressure and the heart rate had to be lower than the numbers indicated on the physician's order. D. On 03/07/23 at 3:34 PM, during an interview, the DON (Director of Nursing) confirmed that the Metoprolol Tartrate should have been held (not given) per the physician's orders for R #78.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure resident safety for 1 (R #247) of 1 (R #247) resident reviewed for bed positioning. This deficient practice could likely result in the resident experiencing a fall and discomfort. The findings are: A. Record review of R #247's face sheet revealed that he was admitted to the facility on [DATE] with a pertinent diagnosis of: hemiplegia [paralysis on one side of the body] and hemiparesis [muscle weakness or partial paralysis on one side of the body] following cerebral infarction affecting left non-dominant side (paralysis on one side of the body as a result of a stroke), acquired absence (amputation) of right leg below knee, contracture in left knee (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints), muscle weakness, and lack of coordination. B. On 03/08/23 at 10:34 am, during an observation of R #247, it was observed that his bed was left in a high position. C. On 03/10/23 at 11:49 am, during an observation of R #247, it was observed that his bed was left in a high position. D. Record review of nursing notes, dated 01/01/23, revealed that R #247 experienced a fall. Further review of nursing notes, dated 01/02/23, revealed Resident complained to this nurse that he is having sharp pain in L [left] lower rib rated as 10/10 (pain scale 10 being the highest level of pain) and res [resident] states that it is due to recent fall last night and is aggravated by movement. E. On 03/13/23 at 1:49 pm, during an interview with Licensed Practical Nurse (LPN) #1, when asked to explain R #247's level of assistance, she explained He is a total assist. We have to do everything for him. Turn him, reposition him, to me, he is a total assist. When asked what position the bed should be in, she explained The bed should be in low position unless we are working with him. He tends to put it up, we have to remind him to put it down. We constantly have to remind him to put it down. He has fallen out of bed in the past so we have to keep reminding him. F. Record review of care plan date initiated 11/16/22, revealed [Name of R #247], is at risk for falls, Limited Mobility, left hemiparesis, hx [history] of CVA [cerebrovascular accident- Obstruction in blood flow to the brain], actual falls, [name of resident] attempts to transfer self without calling staff for assistance with call-light, potential to be lowered to floor [staff may need to catch and lower resident to floor] as staff notices patient trying to transfer self and nearly fall. Further review of the care plan revealed the intervention to be Bed in low position, date initiated: 01/03/23. G. On 03/14/23 at 4:05 pm, during an interview with the Director of Nursing (DON), when asked if it was ok for R #247's bed to be in a high position, she explained They should all be on the lowest position. She then explained that he is able to reposition his bed to his preferences and may be placing it in a high position himself. When asked, if his personal preferences go against recommendations of safety should be care planned, she confirmed yes. H. On 03/24/23 at 12:48 pm, during an interview with his family member #1, when asked how R #247 fell on [DATE], she explained They [facility nursing staff] told me that he rolled out of bed. There are no bed rails and he rolled out of bed and bruised his ribs.

Based on record review, observation, and interview, the facility failed to ensure that 1 (R #25) of 1 (R #25) resident reviewed for behavioral health concerns was receiving necessary behavioral health care to meet the resident's need. This deficient practice could likely cause the resident not to receive the mental health care and treatment that she may need to ensure her the highest practicable physical, mental, and psychosocial well-being. The findings are: Resident #25 A. On 03/08/23 at 1:44 pm during a random observation and attempted interview, R #25 appeared out of it, she was constantly confused and was unable to appropriately answer questions. R #25 was in and out of sleep during interview. B. Record review of Face Sheet dated 01/07/23 for R #25 revealed an initial admission date of 10/28/22 and included the following diagnoses: Depressive Episodes (a period of time, at least two weeks, when a person feels depressed or loses interest in things they generally enjoy), Dementia (a group of symptoms affecting memory, thinking and social abilities severely enough to interfere with you daily life), Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and Anxiety (the state of feeling nervous or worried that something bad is going to happen). C. Record review of Minimum Data Set (MDS - tool used to assess the health and needs of nursing home residents) dated 11/03/22 for R #25 revealed, Section D - Mood: Total Severity Score - 10 . (Scores are as follows, 5 = mild, 10 = moderate, 15 = moderately severe and 20 = severe depression) . Section I - Active Diagnoses - Psychiatric (relating to mental illness)/Mood Disorder: Depression . Section N - Medications - Medications Received: Antidepressant (medication used to treat depression) [past 4 days] . D. Record review of Physicians Orders for R #25 revealed the following: - Start date: 11/01/22 Cymbalta (prescription medication used to treat depression) Oral Capsule Delayed Release Particles 30 MG (milligrams - unit of measure) (Duloxetine HCl) (generic for Cymbalta) Give 3 capsule by mouth one time a day for depression aeb (as evidenced by) self isolation. - Start date: 01/07/23 Lorazepam (prescription medication used to treat anxiety) Oral Tablet 0.5 mg Give 1 tablet by mouth every 4 hours as needed for Anxiety and agitation. E. Record review of Electronic Medical Record for R #25 revealed no psychiatric assessments (an assessment based on present problems and symptoms of an individual's biological, mental, and social functioning) had been completed. F. Record review of Psychotropic Medication Administration Disclosure Form (consent form to receive specified anti-psychotic [drugs used to treat psychotic disorders - a group of serious illnesses that affect the mind], anti-anxiety [drug used to treat anxiety], anti-manic [drug used to treat bipolar disorders - serious mental illness characterized by extreme mood swings] and hypnotic [drugs used to treat insomnia - trouble sleeping] medications) for R #25 revealed that the form is not signed by either the physician or the resident/resident representative and there is no indication as to which specific medications are being identified on the form. G. Record review of Care Plan dated 11/03/22 for R #25 revealed the following: 11/03/22 - Focus: [Name of R #25] exhibits or is at risk of distressed/fluctuating mood symptoms related to: Sadness/depression caused by recent changes affecting relationships/personal loss/past traumas. Goal: [Name of R #25] will demonstrate improved mood state as evidenced by calmer appearance and happier demeanor by the next review. Interventions: 1) Refer to Mental Health Specialist as needed. 2) Observe for signs/symptoms of worsening sadness/depression/anxiety/fear/anger/agitation. 3) Facilitate [Name of R #25] contact with support system(s). H. On 03/16/23 at 5:48 pm during an interview, the Director of Nursing (DON) stated that R #25 was not seen by a psychiatrist (physician who specializes in the diagnosis, prevention, study, and treatment of mental disorders) and that it wasn't something that was needed on admission. DON stated that she will refer R #25 to their psychiatric provider and since she is now on hospice (supportive care for people in the final phase of a terminal illness and focuses on comfort and quality of life) they will check with hospice and see if they will pay for it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to keep residents free from unnecessary psychotropic medications (a medication that works by adjusting the number of major chemicals in the brain) for 1 (R #87) of 1 (R #87) resident sampled for unnecessary medications, when they: 1. Continued to administer Trazodone (used to treat depression, it is a type of medication called a serotonin modulator that works by increasing the amount of serotonin, a natural substance in the brain that helps maintain mental balance), a psychotropic medication to a resident with a documented refusal and declined consent to psychotropic medication treatment, and 2. Failed to monitor medication effectiveness by not notifying the physician of the resident's repeated refusals of psychotropic medication. These deficient practices could likely result in residents receiving unwanted psychotropic medications, residents being administered medications they do not need, residents experiencing potential adverse side effects, and feelings of frustration or not being valued when residents' wishes about their treatment are not honored by the facility. The findings are: A. Record review of R #87 medical record revealed the following: R #87 was admitted to the facility on [DATE] with the following diagnoses- cerebral infarction (when there is bleeding or blockage of a blood vessel in part of the brain called the cerebellum) due to unspecified occlusion (the blockage or closing of an opening, blood vessel, or hollow organ) or stenosis (when an artery inside the skull becomes blocked by plaque or disease) of unspecified cerebellar artery; occlusion and stenosis of unspecified vertebral artery; hemiplegia (the loss of strength or almost complete weakness in the half side of the body after a stroke) and hemiparesis (weakness on one side of the body) following cerebral infarction affecting left non-dominant side; other lack of coordination; difficulty in walking, not elsewhere classified; muscle wasting and atrophy, not elsewhere classified, unspecified site; muscle weakness (generalized); unsteadiness on feet; other reduced mobility; need for assistance with personal care; essential primary hypertension (high blood pressure); and other hyperlipidemia (an abnormally high concentration of fats or lipids in the blood). This diagnoses list is all-inclusive and contains all the medical diagnoses listed for R #87. No other medical diagnoses were identified. B. Record review of R #87's clinical physician orders revealed the following: an order for the psychotropic medication, Trazodone 50 mg (milligram) tablet, with directions to give one tablet at bedtime for aeb (as evidenced by) self-isolation, not wanting to participate. The start date was 01/20/23 and the order was active at the time of the review. A discontinued order for Trazodone 50 mg tablet showed a start date of 12/09/22 and discontinuation date of 01/20/23 with directions to give one tablet by mouth at bedtime for sleeplessness. The order was discontinued 01/20/23. C. On 03/16/23 at 5:10 pm, during an interview with the Director of Nursing (DON), she stated R #87 had orders for Trazodone when he was admitted to the facility. The order for Trazodone stated the medication was being used to treat depression. DON stated the order was rewritten on 01/20/23 because R #87 did not have a depression diagnosis. The original Trazodone order was discontinued and rewritten for clarity by the DON for off-label use (when a doctor prescribes a drug or medication for a different condition or at different dosage than the Federal Food and Drug Administration has approved for) for R #87's self-isolation. The clarified order was signed by the physician. When asked about the repeated refusals of medication, DON stated R #87 had a right to refuse the medication and signing the psychotropic consent form was to verify R #87 had received the information about the indications of psychotropic drug use. D. Record review of R #87 Medication Administration Record for 12/22 revealed Trazodone 50 mg was administered to R #87 on 12/09/22, 12/11/22, 12/21/22, 12/25/22, 12/26/23, 12/27/22. R #87 refused Trazodone on 12/10/23. R #87 refused Trazodone four nights in a row from 12/17/22-12/19/22, three nights in a row from 12/22/22-12/24/22. Trazodone was refused for 5 nights in a row from 12/28/22-01/01/23 by R #87. The Medication Administration Record for the months of 01/23, 02/23, and 03/01/23-03/15/23 revealed R #87 was administered Trazodone on 01/29/23. R #87 refused Trazodone 27 nights in a row from 01/02/23-01/28/23. He also refused Trazodone from 01/30/23-02/09/23 for a total of 11 nights in a row. Trazodone was refused for 6 nights in a row from 02/13/23-02/18/23. R #87 refused Trazodone for 4 nights in a row from 02/20/23-02/23/23. He refused Trazodone from 02/25/23-03/01/23. In the month of 02/23, R #87 received Trazodone a total of 4 times. Trazodone was administered to R #87 on 02/10/23, 02/12/23, 02/19/23, and 02/24/23. Trazodone was administered to R #87 two times from 03/01/23-03/15/23, on the dates of 03/05/23 and 03/08/23. E. Record review of R #87's progress notes revealed no documentation of notification to the physician of the repeated refusals of medication by the resident. F. On 03/16/23 at 5:18 pm during an interview, R #87 stated that he did not take the medication, Trazodone. He stated that he had refused to sign the consent, and that he refused to take the medication. R #87 stated that he did not want to take Trazodone, he did not like it and that it gave him nightmares. He stated the facility tried to give him the medication, but he said no. He remembered there were a few times when he had accidentally taken it but that had been a couple of weeks ago. G. Record review of R #87's medication orders revealed a pending, new order to discontinue the Trazodone was ordered on 03/16/23 at 5:23 pm. H. Record review of the R #87's Psychotropic Medication Administration Disclosure indicated information for Trazodone had been provided to R # 87. The document states The information above regarding the risks and benefits of psychotropic medication have been verbally explained to me and/or provided in writing. I understand that I have the right to refuse the administration of these medications and the right to withdraw consent of medication administration at any time by informing Center staff. The document is signed with the word Refused on the patient signature line with the additional information next to the line that states Pt refused to sign 12/8/22. I. Record review of policy titled Resident Medication Rights, provided by the facility, revealed: 4. Facility should notify the Physician/Prescriber of a resident's refusal of medications/treatment for periods greater than twenty-four (24) hours or per facility policy.

Findings for R #78 Q. Record review of Physicians Order dated 02/03/23 for R #78 reveled, Trazodone (antidepressant for treating major depressive disorders and anxiety) 50 mg. Give 1 tablet once a day for restlessness and anxiety and circadian rhythum disorder (problems that occur when your body's internal clock, which tells you when it's time to sleep or wake, is out of sync with your environment.) R. Record review of Physicians Order dated 12/08/22 for R #78 revealed, Clozapine (part of a group of drugs known as second-generation antipsychotics or atypical antipsychotics) 100 mg, give 1 tablet by mouth one time a day for treatment of Schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves). S. Record review of Physicians Order dated 02/03/23 for R #78 revealed Clonazepam (used to treat seizures, panic disorder, and anxiety) 0.25 mg, give 1 tablet by mouth twice daily for anxiety and restlessness. T. Record review of Psychotropic Medication Administration Disclosure from R #78 revealed no date on the from next to R # 78's signature, and there were two medications not listed as to what he would be receiving. U. On 03/07/23 at 3:45 pm during an interview, the DON was questioned about the process for how Psychotropic Medication Administration disclosure form should be completed? DON replied, They should be filling them out when they are admitted . We fill out the pieces of this (DON showed that staff are to fill out the date, the resident, and wait to fill out the medications in case they don't get any), then have the physician and resident or POA (legal authorization for a designated person to make decisions about another person's property, finances, or medical care) sign the form. DON then confirmed that R #78 did not consent for two or the three medication he was taking. R #78 did not give consent for Trazodone 50 mg 1 tablet once a day, or for Clozapine 100 mg 1 tablet once a day. DON took care of the consent as soon as it was handed to her, and shown what was not filled out 03/07/23. DON did this by having the resident and provider sign the form after an explanation was given to the resident. Based on record review and interview, the facility failed to ensure that residents were aware of and/or understood the risks and benefits of medication they were receiving for 3 (R's #25, 37 and 78) of 3 (R's #25, 37, and 78) residents by not informing residents of why a medication was being prescribed and administered and what diagnoses/condition it was treating. This deficient practice could likely result in residents feeling anxious and potentially receiving unnecessary treatment/medication. The findings are: Findings for R #25 A. Record review of Face Sheet dated 01/07/23 for R #25 revealed an initial admission date of 10/28/22 and included the following diagnoses: Depressive Episodes (a period of at least two weeks during which a person feels sadness or loss of interest), Dementia (group of symptoms affecting memory, thinking and social abilities severely enough to interfere with daily life) with Anxiety (feeling of uneasiness and worry), and Anxiety Disorder. B. Record review of Physicians Orders dated 10/31/22 for R #25 revealed, Cymbalta (medication used to treat depression and anxiety) Oral Capsule Delayed Release Particles 30 MG (milligrams - unit of measure). Give 3 capsules by mouth one time a day for depression aeb (as evidenced by) self isolation. C. Record review of Medication Administration Records (MAR) for R #25 for the months of March, February, January 2023, and December 2022 revealed the following: - Cymbalta Oral Capsule Delayed Release Particles 30 mg. Give 3 capsules by mouth one time a day for depression aeb self isolation was administered as ordered March 1 - 18, was held March 19-20. - Cymbalta . was administered as ordered February 1 - 22, was held on February 23, was administered as ordered February 24 - 28. - Cymbalta . was administered as ordered January 9- 31. Resident was out at the hospital January 1 - 7. - Cymbalta . was administered as ordered December 1 -14, was held December 15, was administered as ordered December 16 - 29. Resident was out at the hospital December 30 and 31. D. Record review of Psychotropic Medication Administration Disclosure Form (consent form to receive specified antipsychotic [drug used to treat psychotic disorders], anti-depressant [drug used treat depression and anxiety], anti-anxiety [drug used to treat anxiety], anti-manic [drug used to treat bipolar disorders] and hypnotic [drug used to treat insomnia] medications) for R #25 revealed no date on form and no resident or physician signature and there were no medications listed as to what was being administered. E. Record review of Electronic Medical Record (EMR) for R #25 revealed no evidence of psychiatric assessment [tool used to to help identify psychiatric and mental disorders to help get the best treatment for a specified condition]. F. On 03/09/23 at 2:20 pm during an interview, the Administrator (ADM) verified that there were no dates, resident or physician signatures, and no specified medications identified for R #25 on the Psychotropic Medication Administration Disclosure form. Findings for R #37 G. On 03/07/23 at 12:23 pm during an interview with R #37, R #37 stated that she was prescribed Seroquel (medication used to treat certain mental/mood conditions) and she doesn't know why. She stated that she thinks they are prescribing this to keep the residents quiet at night. She further stated that she was evaluated by a Psychiatrist (doctor who specializes in mental health) and the Psychiatrist discontinued the Seroquel. H. Record review of Face Sheet dated 02/18/23 for R #37 revealed this as an initial admission date and included the following diagnoses: Cellulitis and Abscess of Mouth, Encounter for Surgical Aftercare Following Surgery on the Skin and Subcutaneous Tissue (the deepest layer of skin), Deviation (change from the normal) in Opening and Closing of the Mandible (lower jaw), Morbid Obesity (being 100 or more pounds over your ideal body weight), Acute Respiratory Failure with Hypoxia (when the lungs cannot provide enough oxygen to the body), Type 2 Diabetes Mellitus (high blood sugar), Iron Deficiency Anemia (a condition in which blood lacks adequate healthy red blood cells), Dysphagia (difficulty swallowing) and Depression (mood disorder that causes a persistent feeling of sadness and loss of interest). I. Record review of Physicians Orders dated 02/18/23 for R #37 revealed, Quetiapine Fumurate (generic for Seroquel - medication used to treat certain mental/mood conditions) Oral Tablet 50 mg Give 1 tablet by mouth at bedtime for Depression. J. Record review of Physicians Orders dated 02/20/23 for R #37 revealed, Quetiapine Fumarate Oral Tablet 50 mg. Give 1 tablet by mouth at bedtime for aeb self isolation. K. Record review of Physicians Orders dated 03/02/23 for R #37 revealed, dc (discontinue) Seroquel. L. Record review of Medication Administration Record dated February 2023 for R #37 revealed, - Quetiapine Fumurate Oral Tablet 50 mg. Give 1 tablet by mouth at bedtime for Depression. Start Date: 02/18/23. Discontinue Date: 02/20/23. Administered as ordered on 02/19/23. - Quetiapine . Start Date: 02/20/23. Discontinue Date: 03/02/23. Administered as ordered on 02/20/23 - 02/25/23, resident refused on 02/26/23, was administered as ordered 02/27/23 - 02/28/23. M. Record review of Medication Administration Record dated March 2023 for R #37 revealed, - Quetiapine Fumurate Oral Tablet 50 mg. Give 1 tablet by mouth at bedtime for aeb self isolation. Start Date: 02/20/23. Discontinue Date: 03/02/23. Resident refused on 03/01/23. N. Record review of Psychotropic Medication Administration Disclosure form for R #37 revealed no date on form next to either the resident's signature or the physician's signature and there were no medications listed as to what was being administered. O. Record review of electronic medical record for R #37 revealed no evidence of psychiatric assessment. P. On 03/09/23 at 2:20 pm during an interview, the (ADM) verified that there was no date and no specific psychotropic medications identified for R #25 on the Psychotropic Medication Administration Disclosure form.

Based on record review and interview, the facility failed to ensure that staff maintain the right for residents to preserve personal items for 2 (R #53 and 247) of 2 (R#'s 53 and 247) residents reviewed for personal items. This deficient practice is likely to cause the resident to feel that their personal possessions are not treated with respect. The findings are: R #247 A. On 03/07/23 at 1:12 pm, during an interview with R #247, it was reported that he had verbally reported missing clothing items (unknown staff members). R #247 stated that magically the laundry will bring you clothes that you know are not yours. Its like its their attempt to replace your stolen items with other items. He stated that he is missing pant's. He said when they didn't replace them, laundry came with other pants and they didn't find my pants but laundry wanted me to have them so they gave them to me. They didn't fit. R #247 could not recall how long ago he reported the pants missing or who he had reported it to. R #53 B. On 03/08/23 at 10:38 am, during an interview with R #53, he reported missing clothing to the nursing staff (names unknown). He stated that he is missing a shirt and blue sweat pants and last month a pair of loafer shoes. He stated that he had not heard anything about the items. R #53 could not recall how long ago he reported his missing clothing or who he had reported to. C. On 03/13/23 at approximately 10:30 am, during an interview with the Laundry Manager, she stated that they have residents come into look for their missing clothing. She stated that they have had residents come up to them and tell them that someone else is wearing their clothes. So, when that happens they will wash them and give them back to the person that claimed them and write their name on them with a pen. She stated that this side of the clothing rack are clothing that has not been claimed for 3 months and is open to donating to other residents (observation made of a large hanging rack of missing clothes). This other side of the rack is clothing that is not marked and they (laundry staff) stated that they belong to a current resident. D. On 03/16/23 at 1:28 pm, during an interview with Certified Nursing Assistant (CNA) #3, she stated that she isn't really clear who is supposed to label the clothing. She stated that they (CNA staff) were told that it was their job. She stated that they don't really have time to label the clothing. She stated that laundry has the pens to label clothing and they are supposed to do it. She said that they are supposed to bring clothing down to the laundry to have them label them and if they don't get to it on their shift then they will pass it down to the next shift and so on and so on. E. On 03/16/23 at 2:32 pm, during an interview with with the Laundry Manger, she stated that the protocol for what is supposed to happen is this: if a resident comes in after hours the CNA's are responsible for the inventory sheet and marking the clothes with resident identifier. If a new resident or new clothing comes in during regular hours then the CNA is responsible for the inventory sheet and they will bring the inventory sheet down to laundry and bring all the residents clothing for laundry staff to label. The Laundry Manager confirmed that this wasn't really happening. F. Record review of the facility's policy titled Personal Property: Patient's, last revised 07/24/18, revealed 2. All possessions or clothing must be marked with patient's name upon admission. 2.1 The Center will provide a laundry marker to the patient and/or responsible party for this purpose. Further review revealed 6. The patient and/or resident representative will be notified of the loss or breakage of personal items, and advised if the loss or breakage will or will not be replaced or repaired at the Center's expense.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings for R #53: I. Record review of R #53's Electronic Health Record (EHR) revealed that R #53 was admitted to the facility on [DATE]. J. Record review of the Advanced Directives for R #53 revealed that the MOST form on file, in R #53's EHR was not R #53's. R #300's MOST form was scanned into R #53's EHR in place of R #53's. Findings for R #58: K. Record review of R #58's EHR revealed that R #58 was admitted to the facility on [DATE]. L. Record review of R #58's MOST form revealed that it was not signed by the facility's physician. Findings for R #247: M. Record review of R #247's EHR revealed that R #247 was re-admitted to the facility on [DATE]. N. Record review of R #247's MOST form revealed that it was signed by R #247 on 02/28/23 however; it was not signed by physician. O. Record review of a MOST form revealed MOST must be signed by an authorized healthcare provider and the patient/decision maker to be valid. P. On 03/09/23 at 2:13 pm, during an interview with the administrator, when asked if R #300's MOST form should be in R #53's EHR in place of his MOST form, he confirmed no and explained This is a PIP [Performance Improvement Plan] that I am working on now. There were a few (MOST forms) that were not in the correct chart. It is an ongoing issue to fix. When asked what is the expected time frame for the physician to sign the MOST forms, he explained We get them done within the week of admission for the physician to sign on Mondays. Findings for R #25 D. Record review of Advance Directive, NM MOST Form revealed no physicians signature, rather there was a written note on the signature line that read, verbal order [name of registered nurse] [name of hospice provider] for [name of physician]. Findings for R #57 E. Record review of Advance Directive NM MOST Form for R #57 revealed no physicians signature. Findings for R #62 F. Record review of Electronic Medical Record for R #62 revealed no evidence of Advance Directives such as NM MOST form being completed. Findings for R #63 G. Record review of Advance Directive NM MOST Form for R #63 revealed no signature from resident. There is a note on the form that reads, Presumed full code until legal guardian is established. - DON (Director of Nursing). H. On 03/09/23 at 2:20 pm during an interview, the Administrator (ADM) verified that there was no physician signature on NM MOST forms for R #25 and stated that they are no longer accepting [name of Hospice Provider] because they have issues with this provider in general. He verified that there was a note written on the form stating there was a verbal order from a registered nurse with the hospice provider for the physician and stated that there should not be a verbal order for a physicians signature, period. ADM verified that there was no physicians signature on the NM MOST form for R #57 and verified that there was a resident signature dated today, March 9, 2023 and that R #57's date of admission was 05/11/22 and stated, this must have been one of the ones who we could not find a MOST form for. ADM stated at this time R #63 does not have a guardian, Power of Attorney, or Healthcare Decision Maker. Based on record review and interview, the facility to ensure the MOST forms were complete for 8 (R #s 25, 53, 57, 58, 62, 63, 88, and 247) of 12 (R #s 25, 53, 57, 58, 62, 63, 69, 73, 79, 88, 197 and 247) resident's records reviewed for Advanced Directives (legal documents that allow you to spell out your decisions about end-of-life care ahead of time) the Medical Orders For Scope of Treatment (MOST) form were: 1. Signed by a physician for R #25, 57, 58, 88, and 247 2. Signed by a resident/Power of Attorney (POA) for R #63 3. Present in R #53 and 62 's records. This deficient practice is likely to affect resident's fulfillment of their end of life medical choices and could result in unnecessary suffering for the resident. The findings are: Findings for R #88 A. Record review of R #88's face sheet revealed admission date 08/10/22. B. Record review of R #88's the MOST form dated 12/19/22 revealed R #88 MOST Form was not signed by a physician as required. C. On 03/07/23 at 2:14 pm, during an interview with Administrator, confirmed that R #88's MOST form was not signed by a physician. Also stated, that MOST forms are usually signed by the physician on Mondays when she come to the facility.

Based on record review and interview, the facility failed to file a grievance for 2 residents (R #53 and #247) out of 2 (R #53 and #247) residents reviewed for personal property. This deficient practice could likely cause residents frustration at not getting their clothing back from the laundry or seeing other residents wear their clothing and that their grievance wasn't taken seriously. The findings are: R #247 A. On 03/07/23 at 1:12 pm, during an interview with R #247, it was reported that he had verbally reported missing clothing items (unknown staff members). R #247 stated that magically the laundry will bring you clothes that you know are not yours. Its like its their attempt to replace your stolen items with other items. He stated that he is missing pant's. He said when they didn't replace them, laundry came with other pants and they didn't find my pants but laundry wanted me to have them so they gave them to me. They didn't fit. R #247 could not recall how long ago he reported the pants missing or he had reported it to. R #53 B. On 03/08/23 at 10:38 am, during an interview with R #53, he reported missing clothing to the nursing staff (names unknown). He stated that he is missing a shirt and blue sweat pants and last month a pair of loafer shoes. He stated that he had not heard anything about the items. R #53 could not recall how long ago he reported his missing clothing or who he had reported to. C. Record review of the grievances revealed that no grievance was filed for R #247 or R #53's missing clothing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to create an accurate Baseline Care Plan within 48 hours of admission for 3 (R #s 25, 62, and 91) of 8 (R #'s 25, 37, 40, 57, 62, 63, 85, and 91) residents reviewed for Baseline Care Plans. This deficient practice could likely result in a decline in the residents condition due to staff not being aware of needed care and/or residents not being able to attain or maintain their highest practicable level of well-being. The finding are: Findings for Resident #25: A. Record review of Face Sheet dated 01/07/23 for R #25 revealed an initial admission date of 10/28/22 and included the following diagnoses: Encounter for Surgical Aftercare Following Surgery on the Digestive System, Squamous Cell Carcinoma of Skin (type of skin cancer), Type 2 Diabetes Mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel) with Diabetic Polyneuropathy (nerve damage caused by diabetes), Anal Fissure (a small tear in the lining of the anus that may cause pain and bleeding with bowel movements), Presence of Right Artificial Knee Joint, and Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). B. On 03/08/23 at 1:44 pm during a random observation and attempted interview, R #25 appeared out of it' as she was constantly confused as she was unable to appropriately answer questions. R #25 was in and out of sleep and unable to appropriately answer questions; she appeared uncomfortable, she was grimacing and moaning and kept repositioning herself on the bed. C. Record review of Care Plans dated 10/31/22 for R #25 revealed that the baseline care plan was not developed within 48 hours of admission for R #25 and the baseline care plan dated 10/31/22 did not address skin conditions [skin cancer] or pain management. D. On 03/16/23 at 5:45 pm during an interview, the Director of Nursing (DON) verified that the Baseline Care Plan for R #25 was developed on 10/31/22 (three days after admission) and did not include plans for skin conditions or pain management. Resident #62 E. On 03/08/23 at 12:46 pm during an interview, R #62 stated that she is here for mental health issues and that she does have Post Traumatic Stress Disorder (PTSD), (a mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations) really bad sometimes. F. Record review of Face Sheet dated 02/01/23 for R #62 revealed an initial admission date of 08/06/22 and included the following diagnoses: Depressive Episodes (a period of depression that persists for at least two weeks), Panic Disorder (when you have recurring and regular panic attacks, often for no apparent reason), Anxiety Disorder (disorders that cause persistent and excessive distress that affects daily life), Opioid Abuse (misuse of opioids [pain relieving drugs]), Alcohol Dependence (inability to stop drinking alcohol without experiencing withdrawal symptoms), and Depression (A mood disorder that causes a persistent feeling of sadness and loss of interest). G. Record review of Minimum Data Set, dated [DATE] for R #62 revealed, Section D - Mood . Feeling down, depressed, or hopeless occurred for several days .Section I - Active Diagnoses - Psychiatric/Mood Disorder (a disorder that can cause emotional and behavioral disturbances): Anxiety Disorder, Depression, Post Traumatic Stress Disorder (PTSD) . Additional Active Diagnoses: Opioid Abuse and Alcohol Abuse . Medications Received: Antipsychotic (medication used to treat psychotic disorders) [past 6 days], Antianxiety (medications used to treat or prevent anxiety) [past 6 days], Antidepressant [past 5 days], and Opioid (prescription drugs for pain relief) [past 6 days] . Antipsychotic Medication Review: Antipsychotics were received on a routine basis only . Nutritional Approaches: Therapeutic diet while a resident . H. Record review of Care Plans dated 08/07/22 for R #62 revealed that Baseline Care Plan for R #62 did not include care areas for Depression, Panic Disorder, Anxiety Disorder, Opioid Abuse and Alcohol Dependence, or Nutrition. I. On 03/16/23 at 5:48 pm during an interview, the DON verified that the Baseline Care Plan for R #62 dated 08/07/22 did not include care areas for Depression, Panic Disorder, Anxiety Disorder, Opioid Abuse, Alcohol Dependence or Nutrition. Findings for R #91 J. Record review of R #91's face sheet revealed R #91 was admitted into the facility on [DATE], diagnosis of: acute respiratory failure with hypoxia (disorders of the airways and the lungs that affect breathing with low oxygen in the blood), Encephalopathy (any disease of the brain that alters brain function or structure), pancytopenia (low amounts of blood cell platelets in the blood), myocardial infarction type 2 (result of an imbalance between oxygen supply and demand), open wound lower leg (injuries that involve a break in the skin), atherosclerosis of native arteries of extremities (hardening of the arteries) with gangrene left leg (death of tissue due to lack of blood flow), pressure ulcer stage 3 (skin sore with full thickness of skin loss involving damage that extends into fat tissue), nonrheumatic aortic valve stenosis (aortic valve in your heart becomes narrowed or blocked), chronic diastolic congestive heart failure (heart's main pumping chamber left ventricle becomes stiff and unable to fill properly), nicotine dependence (smoking cigarettes), hypothyroidism (underactive thyroid). K. Record review of facility's census list for residents use of Hoyer lift (an assertive device that allows patients to be transferred between a bed and a chair or other similar resting places, by the use of electrical or hydraulic power), provided by the Administrator on 03/14/23 revealed, staff uses a Hoyer lift with R #91 for transfers. L. Record review of R #91's care plan dated 02/23/23, revealed, Hoyer lift for transfers were not care planned. M. On 03/14/23 at 02:42 pm, during an interview with the DON, confirmed that staff uses a Hoyer lift for transfers with R #91 and that R #91's care plan does not have a Hoyer lift care planned for transfers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop and implement (put into place) a comprehensive person-centered care plan for 2 (R #s 20, and 40) of 7 (R #s 20, 25, 40, 57, 62, 63, and 247) residents reviewed for care plans. This deficient practice could likely result in staff's failure to understand and implement the needs and treatments of the residents. The findings are: Resident #40 A. Record review of Face Sheet dated 10/25/19 for R #40 revealed this as an initial admission date. B. Record review of Minimum Data Set (MDS) (MDS - tool used to assess the health and needs of nursing home residents) dated 11/01/19 for R #40 revealed, Section L - Oral/Dental Status: No natural teeth or tooth fragment(s) (edentulous - lacking teeth) . Section V- Care Area Assessment (CAA) Summary: Dental Care triggered for Care Plan . Location and Date of CAA Documentation: Care Plan in Place. [there is no care plan] C. Record review of Minimum Data Set, dated [DATE] for R #40 revealed, Section L - Oral/Dental Status: No natural teeth or tooth fragment(s) (edentulous) . Section V - Care Area Assessment (CAA) Summary: Dental Care triggered for Care Plan . Location and Date of CAA Documentation: CAA WS (Work Sheet) dated 11/7/2022. [there is no care plan] D. Record review of Care Plan dated 11/08/22 for R #40 revealed no Care Plan addressing Oral/Dental Care. E. On 03/06/23 at 9:43 am during a random observation of R #40 revealed that R #40 had only two visible teeth on her lower left side. F. On 03/16/23 at 5:48 pm during an interview, the Director of Nursing (DON) verified that per both the admission and annual MDS assessment there should be a care plan for Dental Care and verified that there is no Care Plan. Findings for R #20 G. Record review of R #20's face sheet revealed R #20 was admitted into the facility on [DATE], diagnosis: Alzheimer disease (brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), anxiety disorder (causes intense, excessive, and persistent worry and fear about everyday situations), schizophrenia (mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior), type 2 diabetes mellitus (high blood sugar), psychosis (conditions that affect the mind, where there has been some loss of contact with reality), dyskinesia (noncontrolled, involuntary muscle movement), insomnia (difficulty falling or staying asleep), hypertension (high blood pressure) cysts left upper eyelid (blockage of a gland in the eyelid), difficulty in walking (abnormal gait), muscle weakness (lack of strength in the muscles), major depressive disorder (disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life), psychotic disorder (mental disorders that cause abnormal thinking and perceptions). H. Record review of R #20's Minimum Data Set, dated [DATE] revealed, Transfer 3 - Extensive assistance- resident involved in activity, staff provide weight-bearing support. I. Record review of facility's census list for residents use of Hoyer lift (an assertive device that allows patients to be transferred between a bed and a chair or other similar resting places, by the use of electrical or hydraulic power), provided by the Administrator on 03/14/23 revealed, staff uses a Hoyer lift with R #20 for transfers. J. Record review of R #20's Care Plan dated 03/02/23 revealed, Hoyer lift (an assertive device that allows patients to be transferred between a bed and a chair or other similar resting places, by the use of electrical or hydraulic power) for transfers was not care planned. K. On 03/14/23 at 02:42 pm, during an interview with the DON, confirmed that staff uses a Hoyer lift for transfers with R #20 and that R #20's care plan does not have a Hoyer lift care planned for transfers

Findings for R #37 N. On 03/07/23 at 12:33 pm during an interview, R #37 stated, I have had to wait up to three hours for someone to answer my call light and change me after I had a bowel movement. I also waited one time from 5:00 pm until 4:00 am to be changed, I sat in a urine soaked depends for almost 12 hours. They are not cleaning me completely, I've had to call my husband to come and clean me down there because they don't clean me completely. I got a UTI (urinary tract infection - infection of any part of the urinary system) from waiting so long to be changed. O. Record review of Care Plan dated 03/01/23 for R #37 revealed, Focus: [name of R #37] is incontinent of urine with potential for improved control or management of urinary elimination. Goal: Resident will demonstrate improved urinary elimination control as evidenced by experiencing less than ___ episodes of urinary incontinence perday. Interventions: 1) Administer supplement as ordered. 2) Encourage resident to consume all fluids during meals. Offer/encourage fluids of choice. 3) Facilitate easy access to bathroom with assist as needed. 4) Monitor for signs and symptoms of infection and report to physician. P. Record review of Care Plan dated 03/11/23 for R #37 revealed, Focus . [name of R #37], has a UTI. Goal: Infection will be resolved within the review period . Q. Record review of Physicians Orders dated 02/25/23 for R #37 revealed, STAT (rush) CBC (Complete Blood Count - lab test used to detect a wide range of disorders including infections) Orders . one time only for burning pain upon urination for 1 (one) day. R. Record review of Physicians Orders dated 02/25/23 for R #37 revealed, Stat Urinalysis (lab test to check for infections in the urine) one time only for burning pain upon urination for 1 day. S. Record review of Physicians Orders dated 02/28/23 for R #37 revealed, Cranberry Oral Capsule. Give 425 mg (milligrams - unit of measure) by mouth two times a day for urinary pain and discomfort. T. Record review of Physicians Orders dated 03/02/23 for R #37 revealed, U/A (Urine Analysis) with C&S (culture and sensitivity - checks for type of bacteria and how to treat it) r/o (rule out) UTI (Urinary Tract Infection). Based on observation, interview, and record review, the facility failed to ensure that ADLs (activities of daily living) were maintained for 4 (R #'s 37, 88, 197, and 247) of 4 (R #'s 37, 88, 197 and 247) residents sampled for ADLs (Activities of Daily living) when staff failed to provide assistance with: 1. Bath/showers for R #197, 2. ADLs when needed for R #37, 88 and 247, This deficient practice could likely result in residents experiencing a decline in their ability to perform activities of daily living (ADLs). The findings are: Findings for R #197 A. Record review of #197's face sheet revealed, admission date 02/28/23. B. Record review of R #197's care plan dated 03/01/23 revealed, Focus: [name of resident] is at risk for decreased ability to perform ADLs bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting) related to: Limited mobility, impaired vision (loss of vision), hard of hearing, Goal: [name of resident] ADL care needs will be anticipated and met throughout the next review period. C. On 03/06/23 at 10:35 am, during an interview with R #197, R #197 stated , I have been in the facility for a week, and I give myself a sponge bath because I don't want to get my wound wet. My friend has been bringing in a wash cloth and towel for me to use. The staff have not asked me if I would like a shower/bath and have not provided me with any assistance or given me wash cloths or towels since I have been here. I don't even know about the routine for having baths or showers in this facility. D. Record review of facility's shower schedule revealed, R #197 shower days are on Mondays and Thursdays. E. Record review of facility's shower binder located at the nurses' station revealed no shower/bath sheet completed for R #197. F. On 03/15/23 at 02:38 pm, during an interview with Licence Practical Nurse (LPN) #1, confirmed no shower sheet for R #197 in the shower binder. G. On 03/14/23 at 3:01 pm, during an interview with Certified Nurse Assistant (CNA) #5, stated, On residents shower days for residents who like to shower themselves we take them to the shower room, get the shampoo, and body wash, standby while they wash themselves. Give the resident privacy as long as able to. Could not say why R #197 was not getting assistance with his shower. Findings for R #88 H. Record review of R #88's face sheet revealed, admission date 12/19/22. I. Record review of R #88's care plan dated 02/23/23, revealed, Focus: [name of resident]requires assistance/is dependent for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: limited mobility (any physical impairment that impacts a person's ability to move around freely, easily, and without pain). J. On 03/06/23 at 11:02 am, during an interview with R #88, stated, Yesterday (03/05/23) I had to wait an hour and a half for staff to answer the call light, I needed my brief changed. When a staff member came she brought me my lunch tray. I informed the CNA that I needed my brief changed. I don't want my rash to come back. The CNA informed me they are still passing out lunch trays. I ate my lunch in a dirty brief. I don't remember when they actually changed me (my brief) that day. The weekends are worse for staff responding timely to call lights. Findings for R #247 K. Record review of R #247's face sheet revealed admission date 02/27/23 L. Record review of R #247's care plan dated 03/15/23 revealed, Focus: [name of resident], is at risk for decreased ability to perform ADL(s) bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting), Goal: [name of resident] ADL care needs will be anticipated and met throughout the next review period. M. On 03/13/23 at 10:42 am, during an interview with R #247 stated, When I want to be changed it takes around 30 minutes for staff to respond. I had a bowl movement and waited over 30 minutes to be changed, not good.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Record review of R #55's medical face sheet revealed an original admission date to the facility of 05/10/21 and a diagnoses of Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movement, chiefly affecting middle-aged and elderly people), Mild Cognitive Impairment, and Generalized Anxiety Disorder (a condition of excessive worry about everyday issues and situations, lasting longer than 6 months, that may also include feelings of restlessness, fatigue, trouble concentrating, irritability, increased muscle tension, and trouble sleeping). These diagnoses are not all-inclusive and do not include all of R #55's medical diagnoses. J. On 03/08/23 at 10:36 am, during an observation and an interview, R # 55 was asked if he needed glasses and stated yes and that they were 200+(the magnification strength of the eyeglass readers). He stated the last conference plan that he had attended was six months ago. R #55 was in his room at the time of the interview and was observed not wearing any eyeglasses during the interview. No eyeglasses were observed to be present in his room. K. On 03/14/23 at 3:56 pm, during an interview with the DON, she stated that if a resident had no previous history of wearing glasses there would be no annual screening for vision for a resident. She would expect broken glasses or dentures to be evaluated if a resident had them. She stated R #55 has never requested non-prescriptive glasses and that he was very vocal about his needs. She stated if a resident needed glasses it maybe listed on the resident's Minimum Data Set (part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes that provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems). L. Record review of Minimum Data Sets for R #55 dated 05/17/21 and 08/17/21, under section B1200. Corrective Lenses identifies R #55 as using corrective lenses (contacts, glasses, or magnifying glass) when completing the assessment. M. On 03/15/23 at 3:35 pm, during an interview with SSA stated typically a resident will let us know (that they need glasses) during a care conference plan meeting. During that meeting, staff from nursing, dietary, activities and an insurance care coordinator will attend. They will discuss any recent falls, medication changes, answer resident questions, ask what activities the resident was participating in, and the resident's durable equipment needs (wheelchair, crutches, walker, etc.). SSA stated the staff are typically aware of a resident using hearing aids, dentures and eyeglasses based on if the resident already had those devices. The staff know of the resident's devices on their daily interactions with the residents. At the end of the meeting, residents are asked if they need anything. They do not specifically ask if the resident needs eyeglasses, hearing aids, or dentures. SSA was not aware of R #55 needing eyeglasses. His last care plan conference was 03/08/23. He was not asked if he needed eyeglasses during the meeting. R #55 is his own guardian. N. On 03/15/23 3:59 pm, during an interview with Registered Nurse MDS (RN MDS), she stated that R # 55 had been identified as needing corrective lenses Readers Only on the nursing admission of 05/10/21. Based on observation, interview, and record review, the facility failed to offer vision services for 3 (R #55, R #66, and R #299) of 4 (R#'s 55, 66, 298, and R #299) residents reviewed for vision needs. This deficient practice could likely result in an increased frustration and decreased enjoyment for the resident in daily life. The findings are: Findings for R #66: A. Record review of R #66's EHR (Electronic Health Record) revealed that R #66 was admitted on [DATE] with the following pertinent diagnosis: expressive language disorder (a lifelong condition that impacts the ability to use language to express your own ideas when speaking). B. On 03/08/23 at 10:49 am, during an observation, it was noted that R #66 was wearing his glasses on his face and the right temple of his frame was no longer attached to his glasses. C. On 03/08/23 at 10:49 am, during an interview with R #66, he confirmed that he would like new glasses. Findings for R #299: D. Record review of R #299's EHR revealed that R #299 was admitted on [DATE] with the following pertinent diagnosis: deaf non-speaking (inability to hear). E. On 03/08/23 at 11:39 am, during an interview, when asked if R #299 has any vision issues that have not been addressed, she explained I need an eye exam and new glasses. F. Record review of R #299's MDS [Minimum Data Set- an assessment that provides information related to a resident's functional abilities, goals, and limitations], dated 03/16/23, revealed that R #299's ability to hear is Highly impaired. Further review revealed that R #299 uses corrective lenses (eye glasses). G. On 03/13/23 at 11:16 am, during an interview with the Social Services Assistant (SSA), when asked if R #66 has had any recent care conferences, she confirmed yes and explained He didn't have a lot of complaints. We just had a meeting for him on 02/28/23. When asked if he attended, she confirmed no and explained that he declined his invitation to attend and does not have any family or representatives. When asked if he mentioned any needs when she invited him to attend, she confirmed no. When asked if she was aware of his broken glasses, she confirmed no. When asked if R #299 had any recent care plan meetings, she explained, She [R #299] was here before and then she left but returned. She admitted on the 3rd of this month and we did a post-admit conference meeting. When asked what is typically discussed during post-admit meetings, she explained For long-term care residents, our post-admit meetings are less detailed [compared to skilled residents]. We check in with the patient, ensure they will remain here for long-term care, and review their preferences. When asked to explain what was discussed during her post-admit meeting, she explained We have a template that we follow. She has a POA [Power of Attorney] who attended and was communicated with. We typically review the resident's prior level of function, current level of function , hospices needs and that's about it. When asked if R#66 and 299 had an eye appointment scheduled, she confirmed no. When asked how residents get an appointment scheduled, she explained Usually, they will just mention it, typically in their care conferences, or their family, or they just come up here and mention it. Typically, I think that they nurses will bring it to us. We rely on nursing to bring that to our attention. The patients also let us know. When asked if residents are asked specifically if they need any vision services during care plan meetings, she confirmed no but we just ask if they have any concerns. H. On 03/14/23 at 3:53 pm, during an interview with the DON (Director of Nursing), when asked what is the process for residents who have broken or old glasses to acquire replacements, she explained If we had a resident who had broken glasses or something it is my expectation for someone to notice and document it and say something to get new ones. Findings for R #55:

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings for R #61 J. Record review of R #61's face sheet revealed the following: a diagnosis of quadriplegia, C5-C7 incomplete (incomplete paralysis due to spinal cord lesion between fifth and seventh cervical vertebra {bones of the spine}); quadriplegia, C1-C4 incomplete (incomplete paralysis due to spinal cord lesion between first and fourth cervical vertebra {bones of the spine}); and schizophrenia (a mental health condition that interferes with a person's perception of reality), unspecified. This list does not include all of R #61's diagnoses. K. On 03/07/23 at 10:42 am, during an interview and observation, R #61 stated that he needed footcare. He needed help with cutting his toenails and stated he believed it would be better (for him) if his toenails were cut. His toenails on both feet were observed to be excessively thick, lumpy, and long in length in appearance. L. On 03/15/23 at 5:52 pm, during an interview, LPN #5 stated that she does not cut R #61's toenails. The toenails are usually only filed because they are too thick to cut. LPN stated she has only filed them twice. She reported that R #61 has a standing order to see a foot doctor (podiatrist) as needed for health and comfort. She was not aware if R #61 has been seen by a podiatrist. Based on observation, record review, and interview, the facility failed to arrange foot care services for 2 (R #3 and R #61) of 2 (R #3 and R #61) residents reviewed for toenail overgrowth. This deficient practice could likely result in residents feeling uncomfortable due to: 1. Appearance and/or feel of toenail overgrowth; and 2. Accidental scratching. Findings for R #3: A. Record review of #3's face sheet revealed that she was admitted to the facility on [DATE] with the pertinent diagnosis of type 2 diabetes mellitus without complications (a chronic disease that affects the way the body processes blood sugar). B. On 03/07/23 at 2:20 pm, during an observation of R #3, it was noted that her toenails had grown past her toes. C. Record review of physician orders, dated 02/08/21, revealed Podiatry, Dental and Ophthalmology Obtain as needed Consult and treatment for patient health and comfort. D. On 03/13/23 at 11:37 am, during an interview with the Social Services Assistant (SSA), she confirmed that R #3 had a podiatry consult on 01/03/23. E. On 03/13/23 at 12:30 pm, during an interview with transportation, when asked how outside appointments are obtained, he explained The doctor writes the order, they give them to me, I look at their insurance and I call the offices to schedule an appointment. When asked if R #3 has had any podiatry appointments, he explained I think the podiatrist said to call back and schedule one in a couple of months. The podiatrist did see her in January [2023] but the note doesn't have a future date, no follow-up. More than likely its PRN [as needed]. When asked how services would continue if it was PRN, he explained If it was PRN, I would wait for another order to come in. F. On 03/13/23 at 1:39 pm, during an interview with License Practical Nurse (LPN) #1, when asked if R #3 receives foot care, he explained She had her great toe nails extracted. So, now we are just doing skin prep on them just keeping them clean. Her little toe nails get trimmed by podiatry and if they [podiatry] don't we will do it. When asked how residents typically get their toenails trimmed, he explained If they request them, they can be trimmed, unless they are diabetic, then we refer them to podiatry. G. On 03/14/23 at 2:20 pm, during an observation of R #3, she was noted to be laying in bed and she had her left heel wrapped in gauze. H. On 03/14/23 at 2:20 pm, during an interview with R #3, when asked why her heel was wrapped in gauze, she explained that over the weekend, she was adjusting herself in bed and scratched her heel with her toenails. I. On 03/14/23 at 2:20 pm, during an interview with LPN #1, when asked why her left heel was wrapped in gauze, he explained She [R #3] mentioned that she scratched her heel with her right foot. When asked if she had toenails that needed care, he confirmed yes and explained Her toenails have grown out and she created some kind of friction and rubbed the skin off.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that 3 (R #'s 3, 6, and 66) out 4 (R #'s 3, 6, 53, and 66) residents were seen within 60 days. This deficient practice could likely result in residents not receiving the required medical assessment in a timely manner. The findings are: Findings for R #3: A. Record review of R #3's EHR (Electronic Health Record) revealed that R #3 was admitted to the facility on [DATE]. Further review revealed that the last time she was seen by a physician was 01/03/23. Findings for R #66: B. Record review of R #66's EHR revealed that R #66 was admitted to the facility on [DATE]. Further review revealed that the last time he was seen by a physician was 01/10/23. Findings for R #6: C. Record review of R #6's EHR revealed that R #6 was admitted to the facility on [DATE]. Further review revealed that the last time she was seen by a physician was 01/03/23. D. On 03/13/23 at 12:11 pm, during an interview with Medical records clerk, when asked if she has a role in monitoring physician visits to ensure they are seen within the expected time frame, she explained that the physician has her own schedule. E. On 03/13/23 at 12:26 pm, during an interview with the facility's administrator, when asked how physician visits are monitored, he explained The doctor's schedule is every 30 days. If there is any random occurrence, like if someone needs to be seen for a change in condition, we add them to her list of residents that are to be seen. We just hired a second doctor and he started last week. We are trying to get their schedules to where they are alternating. We are still trying to get a mid-level practitioner [physician assistants or nurse practitioners]. F. On 03/13/23 at 2:33 pm, during an interview with the facility's physician, when asked how often she sees each resident, she explained I see them every month, if not, they are definitely seen every 60 days. Right now I don't have a mid level practitioner on my team but I have another physician that helps out. Its been a challenge. February was a short month but I have the ability to search for residents, by facility, by last seen. That's how I search and filter. If I don't have a ton of new admits, then I can see residents by hall. I am not the one who comes up with my schedule it's usually my scribes. When asked when was her last visit for R #3, she confirmed that R #3 was seen on 01/03/23. She then explained She is due to be seen in March, I don't know how I missed her. I did the 200 hall in February. I will put her on the list for this week. When asked when was her last visit for R #66, she confirmed that R #66 was seen on 01/10/23. When asked when was her last visit for R #6, she confirmed that R #6 was seen on 01/03/23. She then explained that these residents are due to be seen in March.

Based on observation and interview the facility failed to properly store medications in the medication carts for all the residents on the 200-unit hallway (residents were identified by the Matrix provided by the administrator on 03/06/23) when they failed to store loose medications. This deficient practice could result in residents obtaining medications not prescribed for them and resulting in adverse (unwanted, harmful, or abnormal result) side effects. The findings are: A. On 03/07/23 at 2:24 PM, during an observation of the medication cart on 200 Hall, revealed 1 white medication tablet was on the bottom of the cart. B. On 03/07/23 at 2:28 PM, during an interview CMA (Certified Medication Aide) #1, confirmed the white medication tablet was loose on the bottom of the cart. CMA #1 stated they usually check the carts at the beginning of their shift. C. On 03/07/23 at 3:34 PM, during an interview, the DON (Director of Nursing) confirmed that any loose medications should be discarded, and that CMA's and nurses are supposed to check their carts at the beginning of each shift.

This is a repeat citation. Based on observation, record review, and interview, the facility failed to ensure the food was appealing and attractive for 5 (R #9, #19, #54, #70 and #94) of 5 (R #9, #19, #54, #70 and #94) residents sampled for food. This deficient practice could likely result in a decline in the psychosocial health (the health of someone's emotions, behaviors, and social abilities) of the residents due to developing feelings of frustration, anxiety (an excess feeling of fear, dread, and uneasiness), and disappointment and could likely result in resident weight loss, if resident refuses to eat what is served. The findings are: A. On 03/06/23 at 11:29 am, during a dining room observation, it was observed that the main entrée for the lunch meal was a burrito made with whole pinto beans with shredded cheese in a white flour tortilla which was folded over (single fold) in half, not rolled. There was a small side salad of diced tomatoes and chopped iceberg lettuce. The presentation was observed to be unappealing as there were no other items on the plate. The color of both the lettuce and tomatoes in the salad was observed to be very light (lacking in green or red color, nearly translucent) in appearance. No garnish was observed on the plate. Chocolate ice cream in an individually wrapped, plastic cup came on the tray. B. On 03/06/23 at 11:40 am, during an observation and interview, R #94 stood up from his lunch meal. He stated, Look at that! He had unfolded his tortilla to show the scoop of whole beans and cheese that were inside with some of the whole beans spilling out. He stated he could not eat that and that there was no meat. Only one bite had been taken from the folded burrito. C. On 03/06/23 at 11:45 am, during an observation, R #54 was observed having a conversation with the Dietary Manager. R #54 stated that he was unable to eat the burrito. He stated that when the menu says that the entree was to be a bean and cheese burrito, he was expecting the burrito to be folded in the traditional way with the tortilla being rolled. He stated that he was expecting the beans to also be mashed or refried and not whole beans in a folded tortilla. D. On 03/06/23 at 12:05 pm, during an observation and interview, R #19 stated that the Spanish rice was a little watery. The Spanish rice appeared soggy and that it had been overcooked, due to the over puffed appearance of the rice grains and water pooling around the rice on the plate. The rice was still formed in the shape of a large scooper on the plate. R #19 stated he had the rice today, and that he likes rice in general, but the rice doesn't taste good or look good. E. Record review of the facility's posted menu for week 1 revealed the Monday lunch meal was a bean and cheese burrito, shredded lettuce and diced tomatoes with vinaigrette, kale garnish, and seasonal mixed fruit. F. Record review of the facility's recipe titled Burrito, Bean and Cheese .Corporate Recipe - Number 25 Entree: Beef revealed the following: Under the ingredients, the recipe calls for refried beans. Under the heading Procedures, step 3 of the directions state To assemble .scoop beans in the middle of a tortilla, spread out to 1/4 inch from edge .Fold sides to center. Roll from bottom up. G. On 03/09/23 at 8:15 am, during an interview and observation, R #70 stated he could not eat the pancakes today and that they did not taste good. The pancake was observed to appear fried, due to the slick yellow appearance of the top of the pancake. H. Record review of the facility posted menu for 2 revealed the Monday lunch meal was Chicken Fillet on Roll, Confetti Coleslaw, Lettuce and Tomato, and Seasonal Fresh Fruit. I. On On 03/13/23 at 11:55 am, a lunch test tray was sampled for a resident, R #9, who was on a regular/liberalized-dysphagia advanced diet (non-restrictive)-dysphagia (difficulty with chewing or swallowing food or liquid) advanced diet (this diet level consists of food of nearly regular textures with the exception of very hard, sticky, or crunchy food). On the tray was a plate with two chicken fillet on roll sandwiches, a side of chopped iceberg lettuce and diced tomato, and a bowl of canned sliced peaches. The plate was a little messy in appearance due to the ground chicken filet. No other items were on the plate. The bread from the roll was a little difficult to chew due to it being chewy and the meat was slightly dry. No other items were on the sampled tray. The presentation was unappetizing due to the lack of color and messy appearance on the plate. J. On 03/14/23 at 11:35 am, during an interview with the Registered Dietician, stated the meal from finding I. needed a moistening agent such as gravy or sauces and should have had the coleslaw or the appropriate substitution for a dysphagia resident. K. Record review of the facility's Diet and Nutrition Care document titled Dysphagia Advanced (Level 3) or Mechanical (Dental) Soft Diet states Vegetables (include more dark green, leafy, red/orange vegetables: dry beans/peas/lentils as tolerated Cooked, tender, chopped, shredded. L. On 03/15/23 at 12:50 pm during an interview, [NAME] #1 stated she was unsure why the dysphagia meal for R #9 was missing the confetti coleslaw or substitution. She thinks that the side item was either green beans or mashed potatoes and gravy but she was unsure.

Based on observation, record review, and interview, the facility failed to accurately document resident information related to Activities of Daily Living (bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating) for 4 (R #'s 46, 53, 84, and 148) of 5 (R#'s 3, 46, 53, 84, and 148) residents reviewed for documentation. This deficient practice could likely result in residents not receiving showers as preferred and/or staff being unaware of resident needs due to a lack of documentation. The findings are: Findings for R #53: A. On 03/07/23 at 1:16 pm, during an interview with R #53, he explained that he has not had a shower in weeks. B. Record review of R #53's shower sheets located in the shower sheet binder revealed that the most recent shower sheet that was available was dated 12/28/22. He did not have any recent shower sheets in the binder. C. Record review of tasks located in R #53's EHR (Electronic Health Record) revealed that for the last 30 days, there was one entry relating to if he showered and what type of assistance was required. The entry was dated 03/01/23 and read refused. D. On 03/13/23 at 11:50 am, during an interview with Certified Nurse Assistant (CNA) #9 and CNA #1, when asked if R #53 has any shower preferences, she explained I believe he has COPD [Chronic obstructive pulmonary disease- a group of diseases that cause airflow blockage and breathing-related problems]and he needs you to give him a shower because he gets out of breath easily. He gets winded just by transferring. He usually stays in his room. His shower days are Wednesday and maybe Friday, I don't work Fridays so, I'm not sure. When asked if he refuses showers, she explained that he is inconsistent with agreeing to have a shower. When asked why he refuses, she explained that when she offers a shower and he refuses he will say 'Not right now. Not today. I don't want a shower today'. Or he will ask for a bed bath or he will ask for a basin to give himself a bird bath. When asked how showers should be documented, she explained We are supposed to document on both; the shower sheets and our tablets [the resident's EHR]. When asked what happens if a resident refuses, she explained We make multiple offers. If they refuse once, we tell the nurse, then we ask again, if he says he doesn't feel good, the bathroom is cold- then we tell the nurse, or if he is still just saying he doesn't want it then we say that he refused. Then, on the shower sheet, we document why he refused. When asked if documentation is consistent, CNA #1 explained Whenever we finish for the day, we make copies of the shower sheets and give it to the DON (Director of Nursing) and then put the original in the binder. You're supposed to have the nurse sign off on the shower sheet before we make copies, the nurse has to sign off and look them over. Usually, It doesn't happen like that. When asked why, she explained For example, if someone is running late or something. Also, we are supposed to document in the tablet. Not all of them [CNAs] do that. Sometimes we will look back for reference, we will look, and we won't find the shower sheet, or the papers are unorganized and we have to search for it. If we don't find anything, then we assume that they [residents] haven't showered because if its not documented then it never happened. When asked if the facility provided a training on how to document for showers, she explained There was not a meeting about how to do this. A lot of times, were not on the same page, for other things in general. The shower situation is a mess because its unorganized, people don't practice it, and you don't know what your supposed to do for them [residents] because the sheets are not there. When asked how this has effected other residents, she explained that [name of R #46] was not getting showered as scheduled and he now needs to be showered with a special soap because he was developing a rash. Findings for R #46 E. Record review of R #46's physician orders, dated 02/22/23, revealed Ketoconazole 2% shampoo [an azole antifungal that works by preventing the growth of fungus] apply to scalp/chest shampoo topically every day shift, every Monday [and] Thursday (bath days) for tinea versicolor [a common fungal infection of the skin] F. Record review of R #46's shower sheets revealed 3 shower sheets were located in the shower sheet binder, dated 03/01/23, 03/04/23 and 03/08/23. On 03/01/23, it was documented that he showered. On 03/04/23, it was documented that he showered. On 03/08/23, it was documented that he refused and moved his shower schedule to the day shift. G. On 03/13/23 at 1:20 pm, during an observation of R #46, it was noted that his general appearance was disheveled and his hair appeared oily. H. On 03/13/23 at 1:20 pm, during an interview with R #46, when asked if he has had any shower issues, he explained I have asked for a shower many times. They only shower you 2 days a week and if those are days that they are short handed then they don't give you a shower. If you don't ask for a shower, you surely wont get one. Most of the time you have to ask for it [shower]. I think staff should keep track better and tell you to shower. I think they need to keep track for me. I. On 03/14/23 at 3:50 pm, during an interview with the DON (Director of Nursing), when asked if the shower documentation meets expectation, she explained It is not up to par. I made a power point and print out for our new hires. We made it a part of QAPI [Quality Assurance and Performance Improvement] to identify staff members who did not document correctly in PCC [the EHR] or skin sheets. [Name of staff member] has been helping me. We go visualize to check the documentation, we redid the shower process and have someone to monitor that more closely. I have an algorithm to trouble shoot if the CNAs don't have access [to document in PCC]. Its been a problem for a while. R #84 J. Record review of the Activities of Daily Living (ADL)'s for R #84 indicated the following: For October 2022 for meals, out of 61 occasions for documentation 39 of those were blank. For November 2022 for meals, out of 90 occasions for documentation 58 of those were blank. For December 2022 for meals, out of 21 occasions for documentation 19 of those were blank. For October 2022 for snacks, out of 44 occasions for documentation 30 of those were blank. For November 2022 for snacks, out of 60 occasions for documentation 49 of those were blank. For December 2022 for snacks, out of 14 occasions for documentation 13 of those were blank. R #148 K. Record review of the Activities of Daily Living (ADL)'s for R #148 indicated the following: For January 2022 for meals, out of 84 occasions for documentation 37 of those were blank. For February 2022 for meals, out of 19 occasions for documentation 7 of those were blank. For January 2022 for snacks, out of 56 occasions for documentation 24 of those were blank. For February 2022 for snacks, out of 13 occasions for documentation 6 of those were blank. L. On 03/14/23 at 1:56 pm, CNA #4 she stated that they never have enough staff here. She doesn't know what the problem is. She stated that she works multiple halls not just this hall. She stated that the only thing that wouldn't get done would be their documentation. She stated that she has time to do her documentation today but that is really rare. She stated that she is a pretty fast worker so that helps but the residents are the priority. She doesn't know what she would do if she had a bunch of call lights going off all at once, everyone is busy so she wouldn't pull someone from another hall. M. On 03/16/23 at 7:45 pm, during an interview with the Center Nursing Executive (CNE) she stated that documentation is something they have really been working on with the staff especially CNA's. She stated that they will write them up for not documenting. She said that they know they have to do by the end of their shift and they may have to stay late, but it has to get done. She said some of them are great at it and others are not. She knows that the issue isn't resolved.

Based on observations, record review, and interviews, the facility failed to ensure staff followed proper infection control for Transmission-Based Precautions (TBP) of 2 (R #28 and R #84) of 2 (R #28 and R #84) residents reviewed for isolation precautions to prevent the spread of C. difficile infection (CDI- a germ that causes diarrhea and an inflammation of the colon) for all residents identified on the resident census list provided by the Center Executive Director on. This failure increased the risk of transmission of CDI to other residents, and staff by: 1. Staff failing to perform hand hygiene between each resident encounter. 2. Staff failing to ensure they were donning (putting on personal protective equipment {PPE}when entering the room, and doffing (took off PPE) when leaving the room. 3. Staff failing to correctly perform hand hygiene when exiting a room with contact precautions. These deficient practices are likely to result in the spread of infections and illnesses. The findings are: A. Record Review of facility policy titled 18.0 Contact precautions revision date 12/08/10, should have a STOP! please see the nurse before entering the resident's room. The sign further directed hand hygiene was to be performed before and after resident contact, contact with the equipment, and after removal of PPE (Personal Precaution Equipment, is equipment worn to minimize exposure to hazards that cause serious illness). Policy states Instruct staff, resident, and visitors regarding precautions and the use of personal protective equipments (PPE) that should be used prior to going in the residents room. Notification to the resident, family health care decision maker, physician, and all departments of the type of precautions that should be utilized. B. Record review of Procedure for Clostridioides Difficile Infection (CDI) revised 11/15/21, signage to be placed upon entering the resident's door to STOP, please see the nurse before entering the resident's room. Policy also stated that anyone going in the room must maintain stringent hand washing and explain precautions and proper hand washing to the resident and any visitors and staff. Do not use alcohol-based hand rub for hand hygiene. C. On 03/10/23 at 11:12 am, during an observation of R #28 of staff going in and out of the room, it was observed the standard precautions signage that was hung on her doorway entrance, was for standard precautions (personal protective equipment to carry out standard precautions includes gowns, masks, eye protection, face shield) use with droplet precautions (when a resident has an infection with germs that can be spread to others by speaking, sneezing, or coughing) on the signage. D. On 03/10/23 at 11:12 am, during an observation of Certified Nurse Assistant (CNA) #4 was Donning her PPE as she left the room. It was observed when CNA #4 left R #28's room that she failed to wash her hands with soap and water after coming out of an isolation room for CDI. E. On 03/13/23 at 12:40 pm, during an interviewed with IP (Infection Preventionist) when questioning her on what PPE should someone (staff) have on working with residents who are on CDI isolation, and how should they (staff) be cleaning their hands when done? IP replied before they (staff) come out of the room, they are supposed to DOFF (remove their gowns, gloves, dispose of this in the room in a container and wash their hands). Sanitation (conditions relating to public health, especially the provision of clean drinking water and adequate sewage disposal.) They (staff) are educated on this. Staff have been provided education for isolation precaution. The sign on the door should have read contact precautions (everyone coming into a resident's room is asked to wear a gown and gloves) and not standard precautions. F. On 03/13/23 at 12:48 pm, during an interview with Director of Nursing, (DON), when questioned on what expectations she has for her staff and isolations. DON claimed that staff would follow what is on the floor. DON was asked what type of precautions should be up for a CDI resident. DON confirmed that the isolation placed on the door should be contact precautions, and not standard. G. Record review of education from IP provided proof of education given to staff on Precaution's including contact, handwashing, and CDI transmission dated 01/2023 provided material was from the CDC (centers for disease control and prevention, no date given). Policy attached to training was named, IC203 Hand Hygiene revision date 11/15/22, IC301, Contact precautions revision date 10/24/22. Education of precautions shows they(staff) were educated, and knew what and how to take care of a resident on precautions. H. On 03/09/23 at 8:29 am, during a random observation of R #84 room, R #84 was observed resting in his bed. Posted outside the room was a red stop sign identifying that the room was a Standard plus Contact Precautions (the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where health care is delivered plus additional prevention and control interventions to prevent transmission of infectious agents which are spread by direct or indirect contact). The sign stated gloves should be worn when entering the room and taken off and thrown away prior to exiting the room. Additional information on the sign informed that gowns should be worn when entering the room and taken off prior to exiting the room. A station was set up outside the room, stocked with Personal Protective Equipment. Central Supply (CS) was observed to enter the room with briefs in her hand to restock the resident's room. She was wearing a pair of gloves when she entered the room. CS did not don (put on) a gown prior to entering the room. She did not doff (remove) the gloves she had been wearing when she entered the room. CS did not perform hand hygiene after exiting the room or before entering the next resident's room. I. On 03/09/23 at 8:39 am, during an interview, CS stated she was not aware R#84 had returned to the facility. She stated she should have removed her gloves prior to exiting the room and that she had not put on a gown prior to entering the room. She stated she should have put on a gown before going into the room. She stated while she was in R #84's room, she did not provide care to the resident or had any other close contact with the resident while she was in the room. She stated she had only been in the room long enough to restock the closet with briefs and had handed the remaining needed items (wipes) to the CNA.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to track and monitor the vaccination status for 3 (R#'s 25, 31, and 60) of 5 (R#'s 25, 31, 37, 60, and 298) residents reviewed for Pneumococcal (lung infections are caused by bacteria with illness range from mild to severe) and/or Influenza (infectious viral disease usually affecting the upper respiratory system, sinus, throat and large airways in lungs) vaccines. This deficient practice could likely result in increased Pneumococcal and Influenza related infections amongst residents. The findings are: A. Record review of the facility policy, titled IC 601 Pneumococcal Vaccination revised 11/15/22 revealed, in adherence with current recommendations of the Advisory Committee on Immunization practices (ACIP) as set forth by the Centers for Disease Control and Prevention (CDC) .Upon admission, obtain the pneumococcal vaccination history on all residents. Document the resident either received the pneumococcal vaccinations on the resident's MAR (Medication Administration Record) and in PCC (Point Click Care, the facility Electronic Health Record), did not receive the pneumococcal vaccination due to medical contraindications, refusal or already received in PCC. B. Record review of IC600 Influenza Program, revised 11/15/21 Influenza Immunization history will be obtained and documented upon admission for residents. If immunizations refused, document residents' refusal, or decision maker's refusal of immunization and education and counseling's given regarding the benefit of immunization in PointClickCare (PCC). It also states that consent, and declination should be done annually. Findings for R #25 C. Record review of R #25's face sheet revealed she was readmitted to the facility on [DATE] for surgical aftercare following surgery on the digestive (is a treatment for diseases of the parts of the body involved in digestion) system. D. Record review of R#25's Electronic Health Record (EHR) revealed no documentation for acceptance or declination of the influenza vaccination. Findings for R #60 E. Record review of R #60's face sheet revealed he was admitted on [DATE] for Chronic Respiratory Failure with Hypoxia (a state in which oxygen is not available in sufficient amounts at the tissue to maintain adequate homeostasis (A state of balance among all the body systems needed for the body to survive and function correctly). F. Record review of R #60's EHR revealed no influenza vaccine was administered for 2022-2023 and there was no declination consent form for 2022-2023. There was no up to date consents found in his record. Findings for R #31 G. Record review of R #31's EHR revealed no consent form on file for influenza or pneumoiccal. The last consent form influenza or pneumoiccal found in his EHR dated 11/3/19. H. On 03/13/23 at 12:30 pm, during an interview, the Infection Preventionist (IP) stated I do not know where they (staff) have put them (consent forms), when asked if the IP could provide all of the consent forms for influenza and pneumococcal vaccines for R #'s 25, 31, and 60.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** S. On 03/07/23 at 12:33 pm during an interview, R #37 stated, There is only one CNA on night shift, they are always short staffed. I have had to wait up to three hours for someone to answer my call light and change me after I had a bowel movement, and then they put me on oxygen because I was very upset and embarrassed and that caused my vitals to be off. I also waited one time from 5:00 pm until 4:00 am to be changed, I sat in a urine soaked depends for almost 12 hours and I think that is why I ended up with a UTI (Urinary Tract Infection - infection of any part of the urinary system). Based on observation, record review, and interviews the facility failed to maintain appropriate staffing levels to meet the needs of all 103 residents on the census list provided by the Administrator on 03/06/23 by: 1. Visitors waiting extensively (lengthily) long time outside the facility on the weekends to have access into the facility. 2. Not answering call lights in a timely manner. This deficient practice could likely affect direct patient care and limit the residents abilities to obtain optimal well-being while in the facility. The findings are: Findings related to visitors access into the facility: A. On 03/08/23 at 1:46 pm, during an interview with friend of R #197, stated, I had to wait over 30 minutes to be let into the facility yesterday (03/07/23). You ring the doorbell, and a staff member is supposed to let you in. There were other visitors waiting to enter the facility also. I called [name of resident] with my cell phone and told [name of resident] to tell a staff member to let me in I'm waiting along with other visitors. There is no receptionist on the weekends. Findings related to call lights. B. On 03/06/23 at 11:02 am, during an interview with R #88, she stated, I pressed the call light button to ask for a change of brief yesterday (03/05/23) and I waited over an hour for someone to answer the call light. When the Certified Nursing Assistant (CNA) came into my room, she brought me my lunch tray and I informed her that I needed a brief change. The CNA, I did not know her name said that she could not do it right now we are handing out lunch trays. I cannot remember when they actually changed me. I used to have a rash on my buttocks and I don't want it to come back. The weekends are the worst for CNA's not responding to call lights. C. On 03/07/23 01:16 pm, during an interview with R #53, stated, I can't really say when there is not enough staff but there are times when there is not enough staff and things go haywire when there's not enough staff to take care of us. Showers for example, some of us residents can't shower alone and we have to have CNAs come to help us. When there are not two CNAs on each hall, then we don't get showers. This has affected me. My shower days are officially Saturday and Wednesday. I haven't had a shower in 3 weeks it's not the CNAs fault but its the administrations fault cause if the CNAs don't show up, the administration doesn't get replacements. On Saturday, they only have one CNA. I'm not supposed to have to ask for a shower. They are supposed to come and ask me. D. On 03/13/23 at 10:42 am, during an interview with R #247 stated, Everything runs slow here. When I want to be changed it takes around 30 minutes for staff to respond. I had a bowl movement and waited over 30 minutes to be changed, not good. Happens all the time day and night shift are the same for responding to call lights. I also use the call light button for water as well. E. On 03/13/23 11:16 am, during an interview with R #85, stated, At night you have to wait a while for the staff to come. Evenings and nights, they are usually were the CNAs take so long could not say how long but the response time is poor. I call when I need to be changed or need ice water. Usually there is only one person working. I pressed the call light and they (CNA) said They will be back. They don't come back and then they forget about me. Then I press the call light again. F. On 03/13/23 02:06 pm, during an interview with CNA #4, stated, Yesterday (03/12/23) I work by myself, 400 hall the day shift hours 5:00 am to 5:00 pm. I took care of 32 people no help with the call lights I tried to keep up with the lights. We did have a floater (CNA that assist on facilities halls), but he was also covering 300 hall. When asked about answering the front door to visitors CNA #4 stated, for the weekend it is activities and the nurses at the station and sometimes the nurses ask us to open the front door. There is a buzzer sound for the front door that you can hear at the nurses station. G. On 03/14/23 at 10:59 am, during an interview with Staff Scheduler (SCH), stated, I scheduled 2 CNAs to each hall. I take into consideration residents that are a Hoyer lift for transfers and other needs. Staff that call in the schedule is rearranged and at least one CNA is schedule on the hall with the least number of residents. Right now, we are short on Sundays. I call CNAs to see if they could cover a shift when we need more staff. H. Record review of facility's staff schedule for 03/04/23 revealed, one CNA to work on 300 hall and 400 hall for day shift hours 5:00 am to 5:00 pm. One CNA scheduled to work on 300 hall for evening shift 5 pm to 5 am, and 1 CNA scheduled to work from 5:00 pm to 11:00 pm. I. Record review of facility's staff schedule for 03/05/23 revealed, one CNA scheduled to work on 200 hall from 5:00 am to 5:00 pm, and 1 CNA to work on 200 hall and 300 hall, and 1 staff member to work on 400 hall. J. Record review of facility's staff schedule for 03/12/23 revealed, one CNA to work on 100 hall, 200 hall, 300 hall, and 400 Hall. One CNA to work on 300 hall and 400. K. On 03/15/23 at 05:16 pm, during an interview with CNA #7, stated, Tonight I work from 5:00 am to 5:00 pm, and I will be floating between 200 hall and 300 hall. I worked on my own about 3 weeks ago. If I'm working on my own I don't do showers I don't have enough time. When my tasks are done the residents are in bed and its too late to give them showers. Also, when I'm working on my own I do the dining room when I get to work, then water and ice and put residents to bed. We have to do rounds every two hours during the night. On my days off they do call me to come in. L. On 03/15/23 at 05:20 pm, during an interview with License Practical Nurse (LPN) #2, stated that tonight (03/15/23) there is only 1 CNA working on Hall 200 and 300 hall, and 1 CNA floating between 200 hall and 300 Hall M. On 03/15/23 on 05:31 pm, during an interview with CNA #8, stated, The facility calls her most of the time to do extra shifts. They (facility) really need people/CNAs. [Name of scheduler] ask me every week to come in mainly on Saturday, Sunday, and Monday's. I can't get showers or tasks done if I am working on my own. Last time they asked me was this Sunday (03/12/23) and told me I would be working on my own. These halls are very hard to do. Tonight, I will be ok if the floater is able to help me. It gets overwhelming when you have to do hall on your own. Personally, I don't like working on my own because the residents don't get all the care they need. We change a lot of briefs during the night and that takes a long time. Rounds (going around to all residents being taking care of) are every 2-hours. When I'm a floater I only pick up the trays and help feed the residents, and help with rounds during the night. N. On 03/13/23 at 10:45 am, the following observations were made for the 100 hall: Observation made of 4 call lights on: room [ROOM NUMBER] for R #69 stated she had just turned her call light on. room [ROOM NUMBER] for R #59, she stated that her light had been on a long time. She stated that she needed to be changed. room [ROOM NUMBER] for R #28, her light was observed to be continuously on for 45 minutes. room [ROOM NUMBER] for R #46, his light was observed to be on for thirty minutes, when asked R #46 stated his light had been on longer than thrifty minutes and he needed his urinal dumped. O. On 03/14/23 at 12:05 pm, during an interview with Volunteer Ombudsman, he stated that he does hear complaints from the residents about call lights not being answered, but those complaints have gotten better. He stated that previously he had heard of residents waiting up to 45 minutes for a call light to be answered. He stated that they are staffed with more CNA's than he had seen so he knows they have been working on it. P. On 03/14/23 at 8:04 am, with Certified Nursing Assistant (CNA) #1, stated that she works this hall a lot. Stated that if the hall becomes to hectic she will ask a nurse for help. She said that as long as you have two CNA's on the hall you can get the work done. She stated that call ins can be a problem. Q. On 03/14/23 at 8:23 am, with CNA #5, she stated that this hall is busier than the other halls. She had been working on this hall a lot recently. She stated that you will be in a room helping one resident and come out of the room and there could be five call lights on. She stated that when that happens she will usually work her way down the hall answering call lights because you don't know which lights went on first. Sometimes she will see what they all need and then circle back around with whatever it was. R. On 03/14/23 at 1:56 pm, CNA #4 she stated that they never have enough staff here. She doesn't know what the problem is. She stated that she works multiple halls not just this hall. She stated that the only thing that wouldn't get done would be their documentation. She stated that she has time to do her documentation today but that is really rare. She stated that she is a pretty fast worker so that helps but the residents are the priority. She doesn't know what she would do if she had a bunch of call lights going off all at once, everyone is busy so she wouldn't pull someone from another hall.

This is a repeat citation. Based on record review, observation, and interview, the facility failed to maintain menu options by not following the menu and not placing all menu items on a resident's meal tray. This deficient practice has the potential to affect all 103 residents identified on the census list provided by the Administrator on 03/06/23 and could likely result in reduced food intake, weight loss, and a decline in a resident's psychosocial health (the health of someone's emotions, behaviors, and social abilities) due to developing feelings of frustration, anxiety (an excess feeling of fear, dread, and uneasiness), and disappointment. The findings are: A Record review of the lunch menu for 03/07/23 revealed the items to be served for lunch were a sloppy joe on roll, seasoned potatoes, mixed veggies, potato wedges, and pineapple crisp with whipped topping. B. On 03/07/23 at 11:27 am, during a observation of the lunch meals on the dining room tables, the pineapple crisp desserts were observed to be missing the whipped cream topping. C. On 03/09/23 at 10:13 am, during an interview with the Registered Dietician (RD), when asked about the missing whipped topping on the pineapple crisp dessert from 03/07/23, he stated there should not be deviation from the menu. D. On 03/15/23 at 1:16 pm, during an interview with Cook's Assistant #1, she stated she forgot to put the whipped topping on the desserts due to getting busy. E. Record review of the facility posted menu for week 2 revealed the Monday lunch meal was Chicken Fillet on Roll, Confetti Coleslaw, Lettuce and Tomato, and Seasonal Fresh Fruit. F. On 03/13/23 at 11:55 am, a random lunch test tray was sampled for a resident, R #9, who was on a regular/liberalized (non-restrictive)-dysphagia (difficulty with chewing or swallowing food or liquid) advanced diet (this diet level consists of food of nearly regular textures with the exception of very hard, sticky, or crunchy food). The tray was plated with two chicken fillet sandwiches on rolls, a side of chopped iceberg lettuce and diced tomato, and a bowl of canned sliced peaches. No other food items were observed on the tray. G. On 03/14/23 at 11:35 am, during an interview with the Registered Dietician, he stated the meal from finding F. needed a moistening agent such as gravy or sauces and should have had the coleslaw or the appropriate substitution for a dysphagia resident. H. Record review of the facility's Diet and Nutrition Care document titled Dysphagia Advanced (Level 3) or Mechanical (Dental) Soft Diet states Vegetables (include more dark green, leafy, red/orange vegetables: dry beans/peas/lentils as tolerated Cooked, tender, chopped, shredded. I. On 03/15/23 at 12:50 pm during an interview, [NAME] #1 stated she was unsure why the dysphagia meal for R #9 was missing the confetti coleslaw or substitution. She thinks that the side item was either green beans or mashed potatoes and gravy that day but she was unsure. J. Record review of the facility policy Healthcare Services Group Policy 004 titled Menus revealed: 6. Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal.

Based on record review, observation and interview, the facility failed to store and serve food under sanitary conditions by not: 1. Ensuring food items in the refrigerator/freezer and dry storage room were dated and labeled. 2. Ensuring that packages of dry food items were closed after opening. 3. Ensuring that dented cans were removed from the to use shelf. 4. Ensuring food in bulk, dry storage bins were dated and labeled. 6. Daily monitoring/logging of food temperatures at meal times. 7. Daily monitoring/logging of water temperature and chemical sanitizer strength on the three- compartment sink log. 8. Ensuring that the plastic display/housing of a digital thermometer does not touch the food item being measured. 9. Covering all food items on a resident's meal tray being transported through the facility for in-room dining. These deficient practices could lead to foodborne illnesses that could affect all 103 residents identified on the alphabetical census list, provided by the Administrator on 03/13/23, who eat food prepared in the kitchen. The findings are: A. On 03/06/23 at 9:13 am, during an initial brief tour of the kitchen, the temperature and sanitizing log for the three compartment sink was observed to be incomplete with missing temperatures and sanitizing strengths for the breakfast and lunch service on 03/03/23 and 03/04/23. B. On 03/06/23 at 9:16 am, during an initial brief tour of the kitchen, the following observations were made of the dry goods pantry: -A bulk-sized dented can of white hominy observed on the in-use shelf, -Several undated items, that included a 14.5 ounce can of diced red peppers, bag of regular 100% Arabica ground coffee, medium sized; and chocolate instant pudding package 24 ounces, -A bulk bin of a granulated white substance was observed to be undated and unlabeled, -A bulk bin of red potatoes was observed to be undated, -A bag of dried egg noodles was observed to be opened and undated, -A package of graham cracker crumbs was observed to be open and uncovered with a small, plastic cup sitting inside the graham cracker crumbs, -A box of cream of wheat cereal was open and unsealed. C. On 03/06/23 at 10:04 am, during an initial brief tour of the kitchen, the following observations were made of the refrigerator and the walk-in freezer: -A large block of undated, cream cheese that was unwrapped, and uncovered, -A large package of undated sliced turkey breast that was opened and unsealed, -An opened package of undated and unsealed shredded cabbage, -Tomatoes were observed to be in a bin that was undated. -2 unlabeled and undated pizzas in clear wrappers were observed in the freezer. D. On 03/06/23 at 9:45 am, during an interview with the Dietary Manager (DM), he stated that the white substance in the bulk bin was thickening powder and that it needed to be labeled and dated. He stated the package of cream of wheat should not be open and uncovered. It should have been placed into a plastic zippered food bag and sealed. He placed the opened box of cream of wheat in a zippered food bag and closed the seal. The DM confirmed that the graham cracker crumbs should not be opened and uncovered. He also stated there should not be a plastic cup sitting in the graham cracker crumbs. A food scooper should be used to get the crumbs out. Scoopers are kept outside the dry storage room to prevent staff from leaving them inside bulk food bins and packages of dried goods. The potatoes in the bin should be labeled with a date. The DM stated it looked like the label that was previously on the bin had fallen off. The DM stated the dented can of hominy should be removed from the stock and the undated can of diced red peppers along with the egg noodles should be dated. The DM explained that pudding and coffee packs were originally in dated bulk boxes but since these were the last individual packs and they were no longer in their original box, they needed dates. E. On 03/06/23 at 10:13 am, during an interview and observation, the DM observed the opened package of cream cheese, sliced turkey breast and shredded cabbage in the walk-in refrigerator. He stated that they had no label indicating when they had been opened and had to be thrown out. He stated the tomatoes did need to be a labeled with a date they were received. The DM observed the undated packages of pizza in the freezer and stated the packages needed a date. The pizzas had been received on the weekend. F. On 03/06/23 at 10:23 am, during an interview with the DM, when asked about the missing temperatures, sanitizing strengths and times on the three-compartment sink log, he stated that there should be no missing information-water temperatures and strengths of the sanitizer should be recorded for the required times (breakfast, lunch and dinner) each day. G. On 03/07/23 at 11:27 pm, during an observation and interview, Certified Nurse Assistant (CNA) #6 was observed to start to exit the facility dining room with a resident's meal tray. The pineapple crisp dessert was observed to be uncovered. At this time, CNA #6 stated that she was on her way to take the tray to a resident who would be eating the meal in the resident's room on the 300 unit. She then observed the pineapple crisp on the resident's tray that she was carrying and confirmed that the pineapple crisp needed to have a cover in order to transport it through the facility to the resident. She walked the tray back to the kitchen to get a cover for the dessert. H. On 03/09/23 at 11:12 am, during an observation and interview of [NAME] #1 taking the temperature of food items on the steam table for the facility's lunch meal, [NAME] #1 was observed to insert the display portion of a digital thermometer in addition to the thermometer's probe into the steam pan of rice on the steam table, while taking a reading. She was unable to obtain an accurate reading on the thermometer. The thermometer showed a reading that was low (96.6 degrees Fahrenheit). The Dietary Manager removed the thermometer from the rice, adjusted the thermometer's setting and re-inserted the probe portion only of the thermometer into the rice to obtain the correct temperature (190.6 degrees Fahrenheit). He stated the thermometer had been on a locked/hold setting and that was the reason the thermometer was not taking the temperature. I. Record review of the facility's service checklist logs for the steam table for dates 01/07/23-03/09/23 revealed the following: No documentation of temperature readings for breakfast and lunch meals for the dates of 01/08/23, 01/11/23, 01/15/23, 01/16/23, 01/22/23, 01/23/23, 01/25/23, 02/08/23, 02/09/23, 02/12/23, 02/13/23, 02/15/23, 02/16/23, 02/26/23, and 02/28/23. The dinner documentation for 01/20/23 had a temperature reading for milk only. The documentation for breakfast and lunch on 01/31/23 was partially filled in with temperatures only for milk and a hot beverage. No temperatures were documented for dinners on the dates of 01/09/29, 02/14/23, and 03/07/23. There were no service logs for the dates of 01/10/23, 01/18/23, 01/19/23, 01/27/23, 01/28/23, 01/29/23, 01/30/23, 02/02/23, 03/01/, 03/02/23, 03/03/23, 03/04/23, 03/05/23, 03/08/23, and 03/09/23. J. On 03/10/23 at 9:55 am, during an interview, the Dietary Manager confirmed the service checklist log was missing the temperature readings for the dates and times indicated in finding G. DM stated he was unsure why the log was missing those readings and that those readings should be filled in at each mealtime. When asked about the temperature readings taken during lunch on 03/09/23, he confirmed that the display portion of the digital thermometer should not touch the food when taking readings-only the metal probe of the thermometer should make contact with the food. K. On 03/15/23 at approximately 1:46 pm, during a random observation, an opened box of cream of wheat box cereal was observed in the dry goods room. It was not in a sealed bag and had a sheet of plastic wrap loosely covering the popped-up lid of the opened cardboard box. L. Record review of Healthcare Services Group Policy 018 titled Food Storage: Dry Goods 5. All packaged and canned food items will be kept clean, dry, and properly sealed. M. Record review of Healthcare Services Group Policy 019 titled Food Storage: Cold Foods 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. N. Record review of Healthcare Service Group Policy 017 titled Receiving 5. All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation. O. Record review of Healthcare Services Group Policy 023 titled Manual Warewashing 1. The Dining Service staff will be knowledgeable in proper technique including Wash temperature at no less than 110 degrees Fahrenheit .Chemical sanitizer testing and concentrations. 2. Appropriate test strips will be utilized to measure the concentrations of the sanitizer solution. Results will be recorded on the Three - Compartment Sink Log.

Based on observation and interview the facility failed to ensure residents were treated with respect and dignity for 2 (R #21 and #22) of 2 (R #21 and #22) resident's reviewed for dignity by not shaving the resident as frequently as R #21 would like and R #22 having torn ripped, ill fitting clothing. This deficient practice could likely result in the residents becoming depressed, anxious, feeling of hopelessness and lacking self-worth. The findings are: Findings for R #21 A. On 11/29/22 at 10:40 am, during an observation and interview with R #21, she asked if she could have her facial hair removed. She put her hand up to her chin and rubbed her chin. She was observed with stubble on her face. She said it's been two weeks since she was last shaved. She stated that she didn't like it. B. On 11/29/22 at 10:45 am, during an interview with Unit Manager #1, she stated that R #21 get's shaved every week. She will make sure that R #21 gets it done. C. On 11/29/22 at 2:25 pm, an observation was made of R #21, she still had her facial hair. D. On 11/30/22 at 12:05 pm, during an interview with Certified Nursing Assistant (CNA) #5, she stated that R #21 doesn't ever refuse showering and that she will ask her if she wants to be shaved and she will do it if she says yes. E. On 11/30/22 at 2:15 pm, during an interview with R #21, she stated that no one had asked her if she wanted a shower yesterday or today (this is when she would get shaved) and that she would get a razor herself if she knew how much they they cost. She stated that she would still need some help to shave. Findings for R #22 F. On 11/29/22 at 10:30 am, an observation was made of R #22, he was observed to have a ripped shirt. The arm was ripped, the back of the shirt was ripped almost all the way up the back. Part of the shirt was dangling off of him down by his legs. His undershirt was very dirty with dried food stains and appeared to not have been washed for a while. The undershirt didn't fit, his belly was hanging out. His flannel pants hanging down and his rear was partially exposed. G. On 11/29/22 at 10:30 am, during an interview with R #22, he stated that laundry shrunk all of his clothes and none of them fit anymore. He stated that the laundry also ripped his shirt and this is how it came back from the laundry. Observation was also made of large pile of clothing in a pile in his room which indicated that R #22 had other clothing to wear. H. On 11/30/22 at 12:08 pm, during an interview with CNA #5, she stated that R #22 can be difficult and refuses everything. Resident is independent with most Activities of Daily Living and dresses himself.

Based on record review and interview, the facility failed to create a comprehensive care plan for 1 (R #11) of 3 (R #11, R #12, and R #13) residents reviewed for person-centered care. Failure to develop a resident centered care plan is likely to result in staff's failure to understand and implement the needs and treatments for residents to achieve their highest level of well-being. The findings are: A. Record review of consumer complaint NM#61245 revealed that the complainant was concerned for the food intake and weight loss of R #11. B. Record review of section G of the annual Minimum Data Sets, dated 10/15/21, 01/15/22, 04/15/22, and 07/15/22 revealed that R #11's functional ability for eating required limited assistance, with 1 person assist. C. Record review of documented weights revealed that R #11 was weighed on the following dates with the following weights: 10/13/21- 220.1 11/01/21- 231.7 11/16/21- 227 12/14/21-225.1 01/04/22- 236.4 02/17/22- 212.1 03/09/22- refused 04/08/22- refused 07/30/22- 195.5 D. Record review of nursing notes, revealed that R #11 refused to eat on the following dates: 02/01/22, R #11 refused to eat the last 3 meals provided. Nursing notes also revealed that R #11 was on a BRAT diet (Banana, Rice, Applesauce, and Toast- a diet that is recommended for people who suffer diarrhea or the stomach flu) and had multiple snacks and drinks at bedside that he consumed. 02/15/22- R #11 refused to eat the last 3 meals provided. 05/10/22- R #11 refused to eat the last 3 meals provided. It also revealed that R #11 had multiple snacks and drinks at bedside that he consumed. 05/17/22- R #11 refused to eat the last 3 meals provided. It also revealed that R #11 had multiple snacks and drinks at bedside that he consumed. E. Record review of nursing notes revealed an irregular bowel movement consistency: 09/20/21- Resident has loose bowels daily, will adjust bowel regime. 01/11/22- Resident has had loose watery stools for 2 days. Unable to collect stool sample to test for C. Diff [Clostridioides difficile, a bacteria that causes diarrhea and inflammation of the colon]. 02/08/22- Resident again having loose stool x (times) 2 for day shift, he had been on a BRAT DIET for about 2 weeks, came off of it, calling family to bring him stuff to eat, which includes, not limited to chips, candy, soda. 02/22/22- Resident continues to have loose watery stools, unable to collect stool sample for C. Diff. 05/10/22- Patient only had watery stool in last 24 hours. Resident has history of loose stool, possibly due to the multiple snacks he eats through out the shift, instead of meals. 05/10/22- Resident has history of loose stool, possibly due to the multiple snacks he eats through out the shift, instead of meals. 05/17/22- Patient only had watery stool in last 24 hours. Loose stool is frequently resident's normal for 90% of the time. 05/30/22- Patient only had watery stool in last 24 hours. Resident has watery stool frequently, this seems to be his normal. 05/31/22- Patient only had watery stool in last 24 hours. This appears to be resident's normal bowel movement. No complaints of stomach pain, eats large amounts of junk food and soda, plus his meals. Bedbound. Does not drink water. This has been an on-going issue. F. Record review of the care plan, dated 07/19/22, for R #11 revealed that he did not have an entry related to his food preferences and how they may be affecting his health status. Further review of the care plan revealed that he did not have an entry related to the consistency of his bowel movements. G. On 11/30/22 at 1:07 pm, during an interview with Certified Nursing Assistant [CNA] #2, when asked if R #11 required help to eat, she explained He could feed himself. He would always ask for fried eggs. He liked Mountain Dew, candy, and pringles. When asked if he ate his meals provided by the facility, she explained It just depended on if he liked the food or not. I would see him eating chips or candy but not a whole meal. When asked if his bowel movements were normally considered a loose stool, she confirmed yes, that was his normal consistency. H. On 11/30/22 at 3:12 pm, during an interview with the Center Nursing Executive [CNE], when asked if the resident's baseline for eating preferences and bowel movements are out of the normal expectation, should they be care planned, she explained Yes and no . Best practice would be for us to list it as a potential.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that wound assessments with measurements were conducted as care planned and within professional standards of practice for 1 (R #11) of 3 (R #11, R #12, and R #13) residents reviewed for wound care. If the facility is not consistently monitoring for wound progress, then the resident is likely to have worsening wounds without appropriate intervention. The findings are: A. Record review of R #11's face sheet indicated that R #11 was admitted to the facility on [DATE] with the following pertinent diagnoses: artherosclerotic heart disease (the build up of fats and cholesterol on artery walls) of native coronary artery (arteries that supply blood to the heart) without angina pectoris (severe chest pain), other specified diabetes mellitus (when your pancreas doesn't produce enough insulin to control the amount of glucose in your body) without complications, and obesity (overweight). B. Record review of the nursing progress notes dated 07/11/21 indicated the following: Cardiovascular system reviewed. Right-lower extremity color is cyanotic/dusky (bluish skin color due to decreased amounts of oxygen). Left-lower extremity color is cyanotic/dusky Right pedal pulse (checking the pulse in the foot) is non-palpable (not detectable). Left pedal pulse is non-palpable. Lower extremity non-pitting edema (when excess fluid builds up in the body causing swelling that does not indent when pressure is applied) present. Description and location of non-pitting edema: Bi-lateral lower extremities. The following skin injury/wound(s) were previously identified and were evaluated as follows. C. Record review of the nursing progress notes for the following dates: 08/15/21 that the back of the left calf was found weeping (fluid leaking from the legs) that afternoon. 09/05/21 indicated a possible venous stasis ulcer (occur as a result of venous insufficiency in the lower limb. The insufficiency is due to deep vein thrombosis(a blood clot forms in one or more of the deep veins)) on the left calf. 09/26/21 a nursing progress note indicated that R #11 had a possible right upper calf venous/stasis ulcer. 11/07/21 a note from a skin check indicated that the left leg was macerated (skin that looks soggy, feels soft, or appears whiter than usual- often resulting from prolonged exposure to moisture), and the measurements were 8cm x 4cm, 5cm x 2cm. 01/27/22 Wound care done, revealed macerated wound 10 x 4 in size. 02/15/22 This RD (Registered Dietician) was asked to consult on (name of) venous stasis ulcer to LLE calf. Area is documented as venous stasis w/ worsened area where wound is resting. 03/01/22 Right leg has several unmeasurable areas of maceration of tissue that is oozing sero sanguineous (blood tinged) fluid and is bleeding when dressing removed . 05/20/22 Had wound care to lower extremities and heal wounds had copious (a lot) amounts of drainage and green drainage. Wounds cleansed open to air to dry and dressed and wrapped. 06/03/22 It was noted at time of dressing change that the date listed was 5/30 as the last day it was changed. There was a large amount of drainage noted on the dressing that had leaked onto the bed and a foul odor was emitting from the wound when the dressing was removed green sticky goo was present area cleaned and redressed excoriated skin was noted along the bottom of the left leg and c/o of increasing pain. 06/10/22 Wound care done to LLE. Resident medicated prior to treatment .surrounding skin macerated. Moderate purulent and bloody drainage. Foul odor noted. C/O pain to area. Pain relieved after treatment complete. Legs elevated, heels floated. 08/19/22 BLE legs weeping. D. Record review of R #11's care plan, created on 08/15/21. [Name of R #11] has Venous Stasis wounds [an open wound that that is caused by abnormal or damaged veins] to Bilateral lower extremities [both lower legs] . Review of the care plan revealed the goal to be Healing goal: [Name of R #11's] venous stasis wounds will heal as evidence by decrease in size, absence of erythema (skin redness) and drainage and/or presence of granulation [That part of the healing process in which lumpy, pink tissue containing new connective tissue and capillaries forms around the edges of a wound] Through next review Provide wound treatments as ordered, Weekly skin check by licensed nurse,weekly wound assessment to include measurements and description of wound status. E. Record review of weekly wound assessment documentation, the Skin Integrity Report which included measurements and observations of wound status, revealed that several weeks of documentation were missing. Skin Integrity Reports found on file include the following dates for the following wounds and their observations; Left calf: 1. 10/07/21- Left calf: appearance- epithelial 90% (the outermost layer of skin regenerating over a partial-thickness wound surface)/slough (cellular debris-protein, fiber strands, and dead skin cells) 10 %, measurement- 8 cm (centimeters) x (by) 7 cm x 0 cm (length x width x height), drainage- light serosanguineous (a thin and watery fluid that is pink in color due to the presence of small amounts of red blood cells), surrounding tissue- inflamed (red, swollen, or hot- often a sign of infection)/indurated (hardened skin), wound edges- macerated (skin that looks soggy, feels soft, or appears whiter than usual- often resulting from prolonged exposure to moisture), odor- no 2. 10/14/21- Left calf: appearance- epithelial 90%/Necrotic-eschar 10% (dead cells that are dry, thick, leathery tissue that is often tan, brown or black), measurement- 5 cm x 8 cm x 0.1 cm (length x width x height), drainage- light serosanguineous, surrounding tissue- deep purple/maroon, wound edges- macerated, odor- no 3. 10/21/21- Left calf: appearance- epithelial 90%/slough 10 %, measurement- 5 cm x 8 cm x 0.1 cm (length x width x height), drainage- light serosanguineous, surrounding tissue- inflamed/indurated, wound edges- macerated, odor- no 4. 10/28/21- Left calf: appearance- epithelial 90%/slough 10 %, measurement- 8 cm x 5 cm x 0.1 cm (length x width x height), drainage- light serosanguineous, surrounding tissue- macerated, wound edges- macerated, odor- no 5. 11/02/21- Left calf: appearance- epithelial 90%/slough 10 %, measurement- 8 cm x 7 cm x 0 cm (length x width x height), drainage- light serosanguineous, surrounding tissue- macerated, wound edges- macerated, odor- no 6. 03/10/22- Left calf: appearance- granulation 10% (the healing process in which lumpy, pink tissue containing new connective tissue and capillaries forms around the edges of a wound)/epithelial 50%/slough 40 %, measurement- 12 cm x 6 cm x 0 cm (length x width x height), drainage- moderate serosanguineous, surrounding tissue- inflamed/indurated, wound edges- macerated, odor- no 7. 04/05/22- Left calf: appearance- granulation 40%/epithelial 50%/slough 10 %, measurement- 12 cm x 5 cm x 0 cm (length x width x height), drainage- moderate serosanguineous, surrounding tissue- inflamed/indurated, wound edges- macerated, odor- no 8. 06/09/22- Left calf: appearance- not documented, measurement- 13 cm x 6 cm x 0 cm, drainage- purulent, surrounding tissue- macerated, wound edges- macerated, odor- yes 9. 06/29/22- Left calf: appearance- granulation 50%/epithelial 50%, measurement- 13 cm x 6 cm x 0 cm, drainage- purulent moderate, surrounding tissue- macerated, wound edges- macerated, odor- yes 10. 07/28/22- Left calf: appearance- granulation 50%/epithelial 50%, measurement- 13 cm x 6 cm x 0 cm, drainage- purulent, surrounding tissue- macerated, wound edges- macerated, odor- yes 11. 08/13/22- Left calf: appearance- granulation 60%/epithelial 40%, measurement- 14 cm x 8 cm x 0 cm, drainage- purulent moderate, surrounding tissue- macerated, wound edges- macerated, odor- yes Right shin: 1. 04/05/22- Right shin: appearance- intact 100%, measurement- 2 cm x 2 cm x 0 cm, drainage- light bloody, surrounding tissue- inflamed/indurated, wound edges- healthy, odor- no 2. 06/09/22- Right shin: appearance- epithelial 100%, measurement- 2 cm x 3.5 cm x 0 cm, drainage- purulent, surrounding tissue- macerated, wound edges- macerated, odor- yes 3. 06/29/22- Right shin: appearance- epithelial 100%, measurement- 2 cm x 5 cm x 0 cm, drainage- purulent moderate, surrounding tissue- macerated, wound edges- macerated, odor- yes 4. 07/28/22- Right shin: appearance- epithelial 100%, measurement- 2 cm x 4.5 cm x 0 cm, drainage- purulent, surrounding tissue- macerated, wound edges- macerated, odor- yes 5. 08/13/22- Right shin: appearance- epithelial 100%, measurement- 2.5 cm x 4 cm x 0 cm, drainage- serosanguineous moderate, surrounding tissue- macerated, wound edges- macerated, odor- yes F. Record review of physician's orders revealed the most recent wound care: 1. On 05/06/22, the physician ordered wound monitoring daily for status of surrounding tissue and wound pain. Monitor for status of dressing. G. On 11/30/22 at 2:01 pm, during an interview with Licensed Practical Nurse (LPN) #1 regarding R #11's wounds, she confirmed that she was responsible for R #11's wound care and evaluations and they were not being done on a weekly basis. She stated that taking measurements and doing wound care along with other nursing duties, she couldn't keep up with it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that residents received pneumoccal (pneumonia an infection in one or both lungs) vaccine after signing a consent that they wanted the vaccine, or the consent form was not fully completed for 3 (R #s 23, 24 and 25) of 3 (R #s 23, 24 and 25) residents reviewed for immunizations. If residents are not vaccinated as appropriate against pneumonia they have a higher likelihood of contracting that illness and spreading it to other residents and staff in the facility. The findings are: A. Record review of R #23 immunizations in the medical record revealed that R #23 had a pneumoccal vaccine pending (needed to be completed). B. Record review of the hard chart for R #23 indicated that on admission to the facility on [DATE] R #23 signed a consent form to receive the pneumoccal vaccine. C. Record review of R #24 immunizations in the medical record revealed that R #24 had a pneumoccal vaccine pending (needed to be completed). D. Record review of the hard chart for R #24 indicated that resident was admitted on [DATE] and was asked if she wanted the vaccine and R #24 signed the consent form to receive the pneumoccal vaccine. E. Record review of R #25 immunizations in the medical record revealed that R #25 did not have a pneumoccal vaccine listed in her record. F. Record review of the hard chart for R #25 indicated that on admission to the facility 07/22/22 the consent was signed but no information was filled in on whether or not R #25 wanted the pneumoccal vaccine. G. On 11/30/22 at 12:58 pm, during an interview with the Infection Preventionist (IP), she confirmed that R #23 had not received her pneumoccal vaccine yet. The IP stated that all residents are asked if they want pneumoccal when they come into the facility if they qualify for it. When asked who qualifies for it she stated that it is complicated. She agreed that not all of the information for the pneumoccal vaccines was being entered into the residents chart. H. On 11/30/22 at 1:30 pm, during an interview with Center Nursing Executive (CNE), she stated that it does appear that some of the residents aren't getting their pneumoccal vaccines. She stated that they don't really keep asking residents if they want the pneumoccal vaccine if they refused it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings for R #16 who does not have COVID- 19 is using a shared bathroom with R #17 who is infected with COVID-19. K. On 11/28/22 at 10:00 am, during an observation of R #5 and R #16's door to their room # 305, the door had a sign that stated, Precaution please see nurse before entering. L. On 11/28/22 at 10:05 am, during an interview with Certified Nursing Assistant (CNA) #1, she stated that R #5 and R #16 were exposed to COVID-19 because R #16 uses the same shared bathroom as R #17 who is positive (infected) with COVID-19. R #5 does not share the bathroom. M. Record review of facility's resident COVID-19 testing log for documenting test results for residents revealed, R #17 in room [ROOM NUMBER]B was tested on [DATE] and result was positive for COVID-19, and R #33 in room [ROOM NUMBER]A was tested on [DATE] and result was positive for COVID-19. N. On 11/28/22 at 10:12 am, during an interview with R #33, she stated that she does not use the bathroom, but her neighbor/roommate (R#17) does, she takes herself in her wheelchair. O. On 11/28/22 at 10:13 am, during an interview with R #17, she stated that she does use the (shared) bathroom. P. Record review of R #17's care plan revealed R #17 uses the bathroom for oral hygiene the care plan stated: [name of resident] exhibits or is at risk for oral health or dental care problems as evidence by anoxic brain damage. Interventions: assist and encourage brushing/cleaning of teeth 2 x (times) per day and as needed, date initiated 09/05/22. Q. Record review of R #17's nursing progress notes dated 10/18/22, revealed R 17 uses the bathroom progress notes stated, When moving on and off toilet patient is not steady, but able to stabilize with staff assistance. R. On 11/28/22 at 10:15 am, during an observation and interview with R #16, she stated that she uses the bathroom and observation of R #16's room the (shared) bathroom door was open. S. Record review of R #16's care plan revealed that R #16's uses the bathroom, care plan stated, ADLs (activities of daily living) for toileting, intervention: [name of resident] with supervision assist for toileting. T. On 11/29/22 at 10.54 am, during an interview with IP, stated that we don't expect residents to use the same bathroom (when residents have COVID-19) we hope they don't use it. They (R #16 and R #17) probably use the same bathroom to wash their hands. Based on observation, interview, and record review, the facility failed to provide proper infection control practices for all 103 residents identified on the resident census list provided by the Center Executive Director on 11/28/22 by: 1. Not having Personal Protective Equipment (PPE) bins placed outside of residents doors who were positive for COVID 19 (a contagious disease that can cause severe acute respiratory syndrome). 2. Not having used PPE disposal trashcans inside the COVID 19 positive resident rooms. 3. Allowing a resident from another hall to come and go on the Primarily COVID positive hall and not wearing a N95. 4. A staff member exiting a COVID 19 positive residents room in full PPE to get a chair. 5. Residents on the 100 hall who were COVID positive had the doors to their rooms open. 6. R #16 who does not have COVID-19 is using a shared bathroom with R #17 who is infected with COVID-19. These deficient practices could likely cause the spread of infections and illness to residents, staff and visitors within the facility. The findings are: Findings for PPE Bins A. On 11/28/22 at approximately 10:30 am, during observations of the facility, it was noted that the 100 hall was being primarily used for residents who were COVID 19 positive. There were bins full of clean PPE that were placed throughout the hall. Observation of the 200 hall revealed there were no bins with clean PPE in them placed on the hall, indicating that no one was positive on that hall. Observation of the 300 hall revealed three bins with clean PPE in them outside resident doors indicating some residents were COVID positive. Observation of the 400 hall revealed no bins with clean PPE in them for this hall, indicating that there was no COVID positive residents on that hall. B. On 11/29/22 at approximately 9:45 am, an observation was made of PPE bin on the 200 hall outside of one of the rooms. The 400 hall now had two bins with PPE in them outside resident rooms. C. Record review of the COVID testing sheets indicated that R #30 was found to be COVID 19 positive on 11/26/22 this resident resides on the 400 hall. R #7 and R #32 both tested positive on 11/22/22 and they reside on the 200 hall. Neither the room on the 200 hall or 400 hall on 11/28/22 had clean PPE bins for staff to put on before entering those rooms. D. On 11/29/22 at 3:30 pm during an interview with anonymous staff member it was confirmed that bins full of PPE are not always put out timely. It was confirmed that bins were not out on the 200 and 400 hall on Monday 11/28/22. Findings for other Infection Control Issues: E. On 11/28/22 at 1:20 pm, observations of the 100 hall revealed the following: 1. R #6 who resides on the 100 hall and an unidentified resident who was pushing R #6 in his wheelchair were coming through the 100 hall without masks on. The unidentified resident did not have a room on the 100 hall. 2. An unidentified staff member who was in a COVID 19 positive resident room and had full PPE on, opened the door of the residents room, looked around and ran down the hall, grabbed a chair, and took the chair into the residents room. 3. Residents who were COVID 19 positive on the 100 hall had their doors open. F. On 11/28/22 at 1:45 pm, during an interview with Unit Manager, she stated that they only have to wear goggles if they are working with the resident, like changing them. When asked about R #6 and the unidentified resident not wearing masks on the hall, she stated that they ask them but they always refuse. She stated that they can't force them to do it and she can't control it. G. On 11/29/22 at 11:03 am, during an interview with the Infection Preventionist (IP), she stated that she was recently positive and while she was out recovering no one else was officially in charge. She stated that it is everyone's responsibility to make sure that everything is being done and the PPE is being restocked and infection control practices are being done. The IP stated that when staff are doing direct patient care with a resident they need to wear gowns, gloves and goggles for COVID positive residents. She confirmed that staff should wear goggles and mask when on the 100 hall, and that no one should be taking their used PPE off in the hall. She stated that everyone knows what they are supposed to be doing and sometimes the staff become lax (lazy) about it. She confirmed that other residents who don't reside on the 100 hall should not be going down the 100 hall the staff should stop them. H. On 11/29/22 at 12:13 pm, an observation was made of the PPE bins that are used to discard PPE in were in the hallway for 100 hall and 400 hall and not inside the resident room. I. On 11/29/22 at 12:15 pm, during an interview with Certified Medication Assistant (CMA), she stated that that they have two residents positive down their hall (400 hall), one of them just tested positive. She stated that they PPE bins/trashcans should be inside the resident room and not outside in the hallway like they are now. J. On 11/30/22 at 9:36 am, during an interview with the Certified Executive Director (CED), he stated that it is everyone's responsibility to make sure that infection control practices are being done. He stated that he is sure that the bins for the PPE disposal were in place last week before Thanksgiving. He stated that he remembers staff getting the bins stocked up and placed next to the residents rooms. The CED stated that he wasn't sure what could have happened to the bins outside the resident rooms on 200 and 400 halls.

Based on observation and interview, the facility failed to promote care with dignity and respect for 1 (R #47) of 1 (R #47) resident reviewed during random observation. This deficient practice could likely result in a reduction of residents' quality of life, through feelings of humiliation and anxiety. The findings are: A. On 12/28/21 at 10:24 am, during an interview and observation with another resident who lives on the floor with R #47, Hospice Nurse (HN) #1, was overheard loudly talking, laughing, and joking with Certified Medication Aide (CMA) #1, about R #47's inability to remember names of staff members who worked with R #47. HN #1 stated that R #47 could not remember who HN #1 was and she had been working with R #47 for a long time so of course R #47 could not remember whether or not she had got her meds or not, or who gave the meds to R #47. This conversation was at the medication cart, which was located directly outside of R #47's door. Other residents of the floor were in the area and the conversation could be easily overheard by other residents who had their doors open on the floor and other staff who were walking by or working in the area. B. On 12/28/21 at 10:57 am, during an interview, CMA #1 stated that it was the Hospice Nurse for R #47, who had been talking and making jokes to him earlier. When asked if HN #1 typically makes jokes about residents, CMA #1 stated once in a while. C. On 01/18/22 at 3:41 pm, during a phone interview, HN #1 verified she is the Hospice Nurse for R #47. HN #1 stated that prior to her starting work with residents at the facility, the facility did not provide any orientation on expectations of dignity, or provide trainings on dignity, nor did the facility provide trainings of expectations of interactions of care for the residents of their facility. She follows her hospice company's expectations and training's of dignity and interactions with the patients/residents and providing care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that a Pre-admission Screening and Resident Review (PASRR) Level I screening (Identifies mental illness (MI) criteria, intellectual disability (IID) criteria or related condition (RC) criteria that affects intellectual or adaptive functioning) was completed and/or was accurate for 2 (R's #33 and 45) of 2 (R #'s 33 and 45) residents reviewed for PASRR. This deficient practice has the potential to result in: 1. Placement in a facility unable to meet their needs; 2. Residents not receiving appropriate services; The findings are: Findings for R #33: A. Record review of R #33's electronic medical record revealed there was no PASRR Level I in the chart. R #33 was admitted to the facility on [DATE]. B. Record review of R #33's paper medical record revealed there was no PASRR in the paper chart. C. On 01/05/22 at 10:45 am, during an interview, the Center Executive Director (CED), stated that PASRR screening is completed upon admission to the facility and there isn't just one staff that handles the admissions as they take an Interdisciplinary team (IDT) approach. He stated that different staff are looking at different things when someone is admitted to the facility. When a new resident is admitted from the hospital, the PASRR is routinely sent to the facility from the hospital prior to admitting the resident. If a new resident is admitted from home, the PASRR still needs to be filled out prior to admitting the resident to the facility. Staff from social services also review the PASRR for new admissions to make sure that they are getting completed and that nothing was missed. D. On 01/05/22 at 11:14 am, during an interview, the CED stated that R #33 does not have a PASRR Level I on file. Findings for R #45: E. Record review of R #45's paper medical record revealed the Level I PASRR on file in the paper chart, didn't indicate that R #45 had a qualifying mental illness. R #45 was admitted with a diagnosis of anxiety (intense, excessive and persistent worry and fear about everyday situations) and bi-polar disorder (causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). R #45 was admitted the the facility on 08/06/21. F. Record review of the Level I PASRR for R #45 also indicated that R #45 was going to be a short term stay (less then 30 days) at the facility, which would not require a Level II PASRR (level II is a comprehensive evaluation required as a result of a positive Level I Screening. A Level II is necessary to confirm the indicated diagnosis noted in the Level I Screening and to determine whether placement or continued stay in a Nursing Facility is appropriate) to be completed if R #45 had a qualifying condition. If R #45 stayed longer then the 30 days and became a long term care resident, the facility would be required to fill out another Level I PASRR form, which wasn't done. G. On 01/05/22 at 1:05 pm, during an interview, the CED agreed that the PASRR Level I form for R #45 was not accurate. He also agreed that a new PASRR Level I form should have been filled out for R #45 when she transitioned to long term care.

Based on interview, and record review, the facility failed to ensure that residents receive the necessary treatment and services to promote healing of pressure ulcers (skin damage which results from unrelieved pressure on the body) for 1 ( R #66) of 3 (R # 66, 147 and 298) residents reviewed, by not identifying and beginning treatment of pressure ulcers immediately, for a resident susceptible to pressure ulcers. This deficient practice likely resulted in the residents' pressure ulcers not healing and/or getting worse. The findings are: Findings for R #66: A. On 12/28/21 at 11:12 am, during a family interview, R #66's son who was at the bedside, stated that his mother has a sore [pressure ulcer] on her bottom, so we're monitoring the wound. B. Record review of the facility's Skin Integrity & Wound Management Book. revealed no wound care sheets for R #66. C. On 01/05/21 at 1:00 pm, during an interview, the Center Nurse Director stated that the facility's Skin Integrity & Wound Management Book, was designated by the nursing staff that if a resident was to have a pressure ulcer or injury in the facility, the documentation would be in that book. D. Record review of R #66's nursing notes dated 12/30/21 and 01/02/22, revealed the following: 1. On 12/30/21 at 4:30 pm, Nursing Documentation Note: General: Daily/Skilled Note, reason for skilled care/stay/documentation: Teaching and Training Therapy skilled care; Additional details about this note: Resident appears a/o (alert and oriented, meaning a description of one's level of awareness of reality at that moment). She is very soft spoken. She requires full assistance when feeding and doing ADLs (Activities of Daily Living), she is lethargic (sluggish, or lack of energy), and only responds when talked to. Resident has a wound to coccyx (tailbone) that requires daily nsg (nursing) assessment and dressings. Resident requires extensive assist with adl's and mobility .Note: A skin check was performed. The following skin injury/wound(s) were previously identified and were evaluated as follows: Pressure Area(s): Location(s): stage I (a sore that is not open, the skin may be painful, burning or itching, but there are no breaks or tears on the skin) resolving decubitus (bed sore) to coccyx. 2. On 01/02/22 at 5:47 pm, Nursing Documentation Note: General: Daily/Skilled Note, reason for skilled care/stay/documentation: Teaching and Training Therapy skilled care Additional details about this note: resident is AOx1 (alert and oriented to name only). She is very soft spoken. She requires full assistance when feeding and doing ADLs. Husband comes to see her everyday. She has a small pressure sore on her coccyx that has a daily dressing change and clean. Rehab services/ability reviewed. Skin Check completed: The following skin injury/wound(s) were previously identified and were evaluated as follows: Pressure(s):Description: coccyx . E. On 01/05/22 at 1:53 pm, during an interview, Registered Nurse (RN) #2 stated that the wound on R #66's coccyx was a stage 2 (when the sore digs deeper below the surface of the skin, the skin is broken, leaves an open wound; the area is swollen, warm and/or red, and is painful). RN #2 stated that she thought the wound was discovered on the night shift. When asked what the procedure was when a skin ulcer/injury was discovered what is the procedure. She stated, first a wound care skin sheet should be initiated and then obtain a physician order for wound treatments. RN #2 stated that she has known about the pressure injury for about a week and stated, this was the second time that I have dressed the wound. When asked how was she providing treatment to the wound, she stated, I cleanse the wound with wound cleanser, pat the wound dry, then apply a border dressing (a foam dressing covering the wound). When asked if the pressure injury has been measured? RN #2 stated, No, not that I am aware of. When asked if the pressure injury was in-house acquired [developed while in the facility]? RN #2 stated, Yes. F. On 01/05/22 at 2;00 pm, during an interview, RN #2 confirmed that there were no physician orders, for wound care treatment orders. G. Record review of R #66's Braden Scores (a tool used to determine if a resident is at risk for developing an acquired ulcer or injury - a score of 10 to 12 is at high risk; a score of 15 to 18 is at mild risk) indicated the following: 1. On 11/30/21 - 13.0; 2. On 12/07/21 - 13.0; and 3. On 12/14/21 - 17.0 H. Record review of the facility's policy and procedure titled Skin Integrity Management, last revised on 06/01/21, revealed the following: Purpose: To provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and promote healing of all wounds .Identify patient's skin integrity status and need for prevention intervention or treatment modalities through review of all appropriate assessment information .Perform wound observations and measurements and complete Skin Integrity Report upon initial identification of altered skin integrity, weekly, and with anticipated decline of wound .

Based on observation, interview, and record review, the facility failed to: 1) Ensure that medication/treatment carts were kept locked when not in use; and 2) Ensure that the vaccine medication refrigerator temperatures were monitored closely and daily. These deficient practices could likely result in all of the 89 identified on the alphabetical census list provided by the Center Executive Director (CED) on 12/27/21, having unauthorized staff access to unlocked medication/treatment carts and receiving vaccine medications that have lost their potency, effectiveness, and/or even becoming toxic due to improper refrigerated storage. The findings are: Findings related to the unlocked medication/treatment carts: A. On 01/05/22 at 12:35 pm, during an observation, noted the treatment cart on the 300 hall was unlocked. The top drawer was opened, and resident's insulin pens were noted. There was no one around the treatment cart at the time. B. On 01/05/22 at 12:40 pm, during an interview, Registered Nurse (RN) #2 was standing in front of the treatment cart. When RN #2 was questioned that the treatment cart was unlocked, she stated, I was in a resident's room. It's open now, because I'm in it. Findings related to the vaccine medication refrigerator temperature monitoring: C. Record review of the monthly Quality Consultant Pharmacist Summary from June - December 2021, under Drug Storage, Labeling, Security indicated, Please log temperatures daily; twice daily for fridge with vaccines. D. Record review of the Temperature Logs for Medication/Vaccine Refrigerators - Fahrenheit, for the months of June through September 2021, revealed the following: 1. June 2021, indicated no documented refrigerator temperatures for the following dates: 06/01/21, 06/07/21, 06/08/21, 06/09/21, 06/10/21, 06/15/21, 06/17/21, 06/22/21, 06/23/21, 06/24/21 and 06/29/21. For the month of June, there were 11 days out of 30 days when the vaccine refrigerator temperatures were not monitored. The remaining days of June had at least one time when the vaccine refrigerator temperatures were monitored. 2. July 2021, indicated no documented refrigerator temperatures for one day 07/06/21. The rest of the days, had at least one time when the vaccine refrigerator temperatures were monitored. 3. August 2021, indicated no documented refrigerator temperatures for one day 08/01/21. The rest of the days of the month had at least one time when the vaccine refrigerator temperatures were monitored. 4. September 2021, indicated no documented refrigerator temperatures for the following days: 09/01/21, 09/02/21, 09/03/21, 09/10/21, 09/12/21, 09/17/21, 09/18/21, 09/19/21, 09/20/21, 09/21/21, 09/22/21, 09/23/21, 09/27/21, 09/28/21 and 09/30/21. For the month of September, there were 15 days out of 30 days when the vaccine refrigerator temperatures were not monitored. The remaining 15 days had at least one time when the vaccine refrigerator temperatures were monitored. E. On 01/04/22 at 3:00 pm, during an interview, the Center Nurse Executive (CNE) confirmed that the vaccine refrigerator temperatures were not monitored according to their policy, which was twice a day. F. Record review of the facility's policy and procedure titled Storage and Expiration Dating of Medications, Biologicals (are made from a variety of natural sources -- humans, animals or microorganisms (a microscopic organism which can be bacteria or fungus). Biological's are used to treat, prevent, or diagnose diseases and medical conditions), Syringes and Needles, last revision date 10/31/16, revealed the following: .Facility should ensure that all medications and biological's, including treatment items are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors .Facility should ensure that medications and biological's are stored at their appropriate temperatures according to the United States Pharmacopeia guidelines for temperature ranges. Facility Staff should monitor the temperature of vaccines twice a day .

Based on interview, observation, and record review, the facility failed to provide enough kitchen staff for 7 (R #'s 14, 24, 33, 40, 45, 52 and 89) of 7 (R #'s 14, 24, 33, 40, 45, 52 and 89) residents reviewed for food temperature and palatability (pleasant to taste). This deficient practice could likely result in a decline in the use of dishware and inability to maintain palatable food temperatures. The findings are: Findings for R #89: A. On 12/29/21 at 12:08 pm, during an interview, R #89, when asked to explain her satisfaction with the food provided by the facility, R #89 explained that the facility does not serve food on regular plates that come with an insulated dome to cover the plate for temperature regulating purposes, they instead use Styrofoam plates with no cover. This then causes the food to arrive cold. Findings for R #24: B. On 01/03/22 at 11:24 am, during an interview, R #24, when asked to explain her lunch meal for that day R #24 stated, We get some toast but its not toasted or buttered, it's just a slice of bread. We have been receiving our food served on Styrofoam plates with plastic utensils. Yesterday for lunch, we received a tablespoon of veggies that were canned and overcooked. We received 'Chicken breast' smothered in some kind of beef or pork brown gravy. There was not a side. We have been receiving our meals on paper plates with no covers. C. On 01/03/22 at 11:24 am, during an observation, R #24 showed me her Styrofoam clamshell (a type of food container that has a hinge on one edge which allows it to open and close) with chicken nuggets and vegetables. Findings for R # 40: D. On 01/03/22 at 11:49 am, during an interview, R #40, when asked to explain his satisfaction with the food provided by the facility, R #40 stated, When we receive food on paper plates its cold. Findings for R #14: E. On 01/03/22 at 11:52 am, during an interview, R #14, when asked to explain her satisfaction with the food provided by the facility, R #14 stated, On the weekends or night time, they go right back to paper plates with cellophane wrapped on top. [When food is served on paper plates wrapped in cellophane] It's cold. They use tiny Dixie cups for fluids. F. On 01/04/22 at 11:05 am, observation during the resident council meeting, it was confirmed that resident council meets twice a month where concerns of food dissatisfaction were discussed during multiple meetings. G. On 01/04/22 at approximately 11:05 am, during an interview, the resident council president, when asked if the residents had other concerns, R #24 noted that the only issue was related to the food. H. On 01/04/22 at 3:07 pm, during an interview, the Dietary Manager, when asked to describe the use of disposable plates and eating utensils, he explained, At times we do use disposable ware because we had 3 call-ins [an occurrence in which an employee will unexpectedly call to report that they will not be available for work] and it was just a cook and I who were in the kitchen and we do use disposable ware during a COVID (a virus that is thought to spread mainly from person to person)outbreak [an occurrence where there are more than usual positive cases]. Only if we have positive residents, we use it [disposable ware]. When asked what type of disposable ware is used, he explained, We have the clam shell [a Styrofoam container that is made with a hinge on the top edge which allows the container to open and close]. We did have to use paper plates for a little while because the shells were out of stock. The last time we used clamshells was this past weekend. The last time we used the plates, has been a couple weeks. When asked if the disposables plates maintain the food's temperature, he explained that the kitchen staff cover it with another plate [to maintain heat] and then it disperses the meals. When asked to explain the number of staff working in the kitchen, he replied, Right now, I only have five employees. I ended up losing 4 employees and I hired new employees, but they don't last [remain employed]. I. On 01/05/22 at approximately 2:00 pm, during an observation, R #52 presented a Styrofoam plate that she received her dinner on during the previous night. The plate was melted and the melted area contained a 2 inch by 3 inch hole in the middle of the plate where her grilled cheese sandwich sat. J. On 01/05/22 at 3:18 pm, during an interview, Kitchen Staff #1, when asked how to prepare a grilled cheese sandwich, she replied, We prepare the sandwiches in advance and then when it is ordered, we put it on the pan on the stove. When asked if Styrofoam plates are used, she stated, Sometimes we use a Styrofoam plate if we don't have a dishwasher. We do not use it often but if we do, we cover with a plastic film. When asked if there was a dishwasher last night, she confirmed, No dishwasher last night. Last night we used the Styrofoam plates. We didn't have a staff member to wash the dishes. K. On 01/05/22 at 3:27 pm, during an interview, the Dietary Manager, when asked to explain the number of staff needed to work in the kitchen, he explained, We need 10 people. I currently have 4 or 5. I need a dishwasher, cook aids, and cooks. I need 4 dishwashers, 3 cook aids, and 3 cooks. Currently I have 3 cooks, 1 cook aid, 1 dishwasher who is out sick. Now, we do normal glassware for 2 meals per day. We serve one meal on Styrofoam. Tonight, someone picked up a shift. Three staff members will be here tonight. When asked to explain how cookware is washed, he explained Pots and pans are done by the cook aid, all the dishes on the trays are done by the dishwasher. Staff leave around 7:30-8:30 [pm], if there was a dishwasher, the latest would be 8:00 [pm]. If not, times vary. If we use regular plates with two employees, they would be here till 9:30 [pm]-10 [pm]. This is the reason to use the Styrofoam. When asked if the lack of staff allow him to meet contract requirements, he replied, no.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** X. On 12/29/21 at 11:08 am, during an observation, the lunch meal in the kitchen was observed on the preparation line in the steam pans. The posted lunch menu for the facility this day was Chicken Noodle Soup, Philly Cheese Steak Sandwich, Garlic Tator Tots, and Shortbread Cookies. The tator tots observed in the steam pan were not brown or were minimally brown in color. They were not crispy in appearance or texture. The Dietary Manager, DM tested the temperature of the tator tots (157.3° F), meat (165.5° F), and soup (160.3° F). As the tator tots were being stirred in the steam pan to test, the tator tots appeared somewhat mushy and would fall apart in the pan. Y. On 12/29/21 at 12:18 pm, a random sample tray for the lunch meal was pulled. The meal sampled was for R #17 who is on a regular/Liberalized diet (a regular diet that allows for resident choice is most often the preferred diet), regular texture. The Philly Cheese Steak sandwich consisted of meat, cheese and the roll. The cheese for the Philly Cheese Steak sandwich was observed to be a thick slice of yellow cheese on the bottom slice of the sandwich and was not fully melted. The sandwich did not have onions or green peppers on, or in, the meat. Garlic could not be detected by taste or smell on the Garlic Tator Tots. The tator tots outer texture was not crispy and overall, the tator tots were somewhat mushy in texture. The tempatrue of the chicken noodle soup was cool. The soup was served uncovered. The soup consisted of many noodles and very little broth giving the soup a gelatinous or stew-like consistency, texture, and appearance, due to the large quantity of white noodles sitting next to each other in the bowl. This made it difficult to detect any other vegetables in the soup broth. The bread in the sandwich, the tator tots on the plate, the large quantity of noodles in the soup and and the 2 chocolate chip cookies that accompanied the meal visually presents as a meal that contains a large amount of carbohydrates, due to the white coloration of the white bread roll in the main, the 2 sides and the dessert present on the tray, and the lack of diversity of colors associated with vegetables and fruit. Findings for R #299: Z. On 12/30/21 at 1:30 pm, during an interview, R #299 reported the food is often served at room temperature and comes on paper plates. The food is also uncovered 2 or 3 times a week. He reported being a cook previously for the military and stated he thinks that the practice of serving the food uncovered is unsanitary. He does not remember being served any fresh vegetables. R #299 stated the vegetables are so overcooked that all the nutrients are cooked out. Findings for R #40: AA. On 01/06/21 9:45 am, during an interview, R #40 stated a lot of times the food is served on a paper plate and the food is cold. He stated there are a lot of carbs {any of various neutral compounds of carbon, hydrogen, and oxygen (such as sugars, starches, and celluloses) most of which are formed by green plants and which constitute a major class of animal foods in the meals} in the meals and the vegetables are way overcooked. R #40 stated food is the only thing to look forward to since he can no longer leave the facility, so it is hard for the residents when the food is not right. He stated residents would be happier if the food served is better. BB. On 01/05/22 at 3:29 pm, during an interview, the DM reported the facility does have domes to cover the soup bowls, but they do not have enough to cover the all the bowls, so they are not being used. He also said the residents take the domes and keep them in their rooms, so the domes do not make it back to the kitchen. There are some on back order. He was asked about plastic, disposable lids for the bowls. The facility does not have any and he reported the cost would get expensive. Based on interview, observation, and record review, the facility failed to provide enough kitchen staff for 8 (R #'s 14, 24, 33, 40, 45, 52, 89 and 299) of 8 (R #'s 14, 24, 33, 40, 45, 52, 89 and 299) residents reviewed for food temperature and palatability. This deficient practice could likely result in a decline in the psychosocial health (the health of someone's emotions, behaviors, and social abilities) of the residents due to developing feelings of frustration, anxiety (an excess feeling of fear, dread, and uneasiness), and disappointment. The findings are: Findings for R #89: A. On 12/29/21 at 12:08 pm, during an interview, R #89, when asked to explain her satisfaction with the food provided by the facility, R #89 stated, Today's meal is not a 'Philly Cheese Steak'. The bread is a dinner roll. There's no onions or bell peppers. It has yellow cheese, which is no good. The tater tots are soggy. We don't get any breakfast meats. She then proceeded to explain that the facility does not serve food on regular plates that come with an insulated dome to cover the plate for temperature regulating purposes, they instead use Styrofoam plates with no cover. B. On 12/29/21 at 12:08 pm, during an observation, the lunch meal for R #89 was observed to be a meat sandwich served on a roll. It did not have bell peppers or onions. Findings for R #24 C. On 12/28/21 at 1:47 pm, during an interview, R #24, when asked to explain the satisfaction with the food provided by the facility, R #24 stated, We want some decent [better quality] food. Today was macaroni and cheese with tomatoes. It was supposed to be chicken tenders, but it's always the same chicken. They don't bake the apple crisps or peach cobbler. This is a picture of their version of peach cobbler . it's just peaches and flour. We can never get fresh fruit or vegetables. The Always Available Menu [food the facility always offers] has cottage cheese and fruit, but they never have the fruit. D. On 01/03/22 at 11:24 am, during an interview, R #24, when asked to explain her lunch meal for that day R #24 stated, We get some toast but its not toasted or buttered, it's just a slice of bread. We have been receiving our food served on Styrofoam plates with plastic utensils. Yesterday for lunch, we received a tablespoon of veggies that were canned and overcooked. We received 'Chicken breast' smothered in some kind of beef or pork brown gravy. There was not a side. We have been receiving our meals on paper plates with no covers. E. On 01/03/22 at 11:24 am, during an observation, R #24 showed me her Styrofoam clamshell (a type of food container that has a hinge on one edge which allows it to open and close) with chicken nuggets and vegetables. Findings for R #33: F. On 12/30/21 at 10:31 am, during an interview, R #33, when asked to explain her satisfaction with the food provided by the facility, R #33 stated, The food is beyond terrible. They are working on getting me a salad for lunch and dinner. He [the Dietary Manager] ordered romaine lettuce and he is going to see if he can get some avocados for me. I don't eat breakfast. If they don't have the salad, I eat top Ramen [pre-cooked dried noodles] or peanut butter. The last time I had a salad was yesterday but I didn't like it because it was iceburg lettuce, tomatoes, boiled egg and cheese. I like romaine lettuce. When asked how often to do you eat Ramen or peanut butter, she replied, Anytime they don't serve a salad or if my friend does not buy a pizza. The meals are not hot, not good, and not pleasant looking. They are not pleasant to taste. G. On 01/03/22 at 11:42 am, during an interview, R #33, when asked to explain her lunch meal for that day, R #33 stated, Look at this, I don't know what this is, tell me what this is. It looks like ground something. I can't make out what it is, it tastes bland. I'm eating the beans only. Today, the beans are cooked thoroughly, they aren't always. Yesterday, I ate the chicken, it was better, because it wasn't hard like a brick. I don't have a special diet. My food should not be ground. H. On 01/03/22 at 11:42 am, during an observation, R #33's plate contained pinto beans mixed with small pieces of shredded white meat. I. Record review of physician orders dated 01/15/20, revealed that R #33 was on a regular/Liberalized diet, regular texture. Findings for R # 40: J. On 01/03/22 at 11:49 am, during an interview, R #40, when asked to explain his satisfaction with the food provided by the facility, R #40 stated, When we receive food on paper plates its cold. Findings for R #14: K. On 01/03/22 at 11:52 am, during an interview, R #14, when asked to explain her satisfaction with the food provided by the facility, R #14 stated, On the weekends or night time, they go right back to paper plates with cellophane wrapped on top. [When food is served on paper plates wrapped in cellophane] It's cold. They use tiny Dixie cups for fluids. With my ileostomy [a surgical procedure at the small intestines where food is diverted out of the body and into a bag], I don't have a lot of area for the food to go to, it gets expelled into the bag. I explained this to the dietician. I told him the shells of the beans go straight through me and they make me very gassy. I can probably eat a few spoonfuls. They send me spicy foods, but I can't have that so end up with a grilled cheese sandwich or processed lunch meat, and the salads are just plain lettuce. I cannot eat corn, I tried to explain citrus; I can have mandarins & fresh fruit but they listed it as a dislike. They cook a meal for everybody but anyone who needs something special, they don't make something different- they don't add to it or take anything away. For the chef salad, its just plain lettuce with maybe a few tomatoes. There are no veggies and sometimes they might throw a little bit of cheese on top [of the salad]. Our Christmas dinner was horrible, a blob of something with carrots. Christmas eve was fish. New years was cold food on a paper plate. The veggies are over cooked. The beans are just ok. They send this kind of rice with everything, and it is usually dry. Today the rice has a little spice. They give us processed box [instant] mashed potatoes all the time. There are no nutrients because of how it has been processed. On Thanksgiving Day, they gave us a processed ham, tiny piece of turkey with no sides, no cranberry sauce, no yams, no dressing, no pumpkin pie. They water down the juices. It is not ok to receive this food for the price I pay to be here. They send out hot [NAME] but not enough for all the residents. They don't send out enough for everyone to receive. There have been days where I don't eat lunch or dinner and I'm hungry but I don't eat because they don't give snacks after snack time. L. Record review of physician orders, dated 06/29/21, revealed that R #14 was on a regular/Liberalized diet[relxed diet without restrictions], regular texture [no need to alter to meet any swallowing restrictions]. Findings for R #52: M. On 01/03/22 at 12:12 pm, during an interview, R #52, when asked to explain her satisfaction with the food provided by the facility, R #52 stated, I got rice, beans, & mashed potatoes today. I am a diabetic . these are 3 starches on my plate: potatoes, rice, and beans. The rice, to me has a lot of salt. I get too much processed meat. If I had a protein, it would probably be processed sliced meat, It's too much. I didn't get any drinks today just a paper cup of coffee. This is an odd combination [beans, rice and mashed potatoes]. N. On 01/03/22 at 12:12 pm, during an observation of the resident's meal, it was confirmed that she did not receive an additional drink aside from coffee. She did not receive meat on her lunch tray and her plate contained rice, beans, and mashed potatoes. O. Record review of physician orders for R #52, dated 11/23/21, revealed the following diet Gluten Free diet - Regular Texture. Findings for R #45 P. On 12/29/21 at 10:33 am, during an interview, R #45, when asked to explain her satisfaction with the food provided by the facility, R #45 stated, The last couple of weeks have been bad. For Thanksgiving and Christmas, we didn't get holiday food. We ate hamburgers on Christmas, I think [resident began to cry]. I am worried that I am not getting enough vitamins from my diet. I never know if I will get sugar with my coffee or condiments for my meal. I am served a hamburger without any lettuce, tomatoes, pickle, mustard, ketchup, or mayonnaise. I have to just eat a brick of meat with bread. Q. On 01/04/22 at 11:05 am, observation during the resident council meeting, it was confirmed that resident council meets twice a month where concerns of food dissatisfaction were discussed during multiple meetings. R. On 01/04/22 at approximately 11:05 am, during an interview, the resident council president, when asked if the residents had other concerns, R #24 noted that the only issue was related to the food. S. On 01/04/22 at 2:25 pm, during an interview, the Registered Dietician, when asked to describe what type of quality measures he participates in, he explained, I look at the meal and verify if it matches the menu that is posted for the day. If it meets the meal ticket [if what is printed on the ticket matches what is on the tray, e.g., to ensure a listed dislike is not served on the tray]. If there is room for improvement, I will let the Dietary Manager know. He also explained that as a dietician, he is able to see the meals at other centers since he practices at more than one [name of facility company] facility. He reported he has noticed that meals seem different in appearance in this facility. He then explained, Sometimes there are food complaints that I am not here to address since I am not here every day. I have had complaints about no breakfast meats and too many starches on a plate. Not every breakfast meal has a breakfast meat and it's not popular with patients. It's not always possible to get breakfast meats. The Dietary Manager has to have the budget to get meat and it has to be available from the supplier. When asked if the menu contains lunch or dinner meals without meats, he replied, There are no lunch or dinner meals that don't have meats except for about two. When asked if the lunch meal composed of mashed potatoes, beans and rice was an approved meal to not contain meat, he confirmed no and that R # 52 should not receive a plate with beans, rice, and mashed potatoes. When asked if macaroni and cheese with tomatoes was a meal that was approved to not contain meat, he explained that the cheese in the macaroni meets the protein requirements. When asked if a plate should have multiple food items that are considered starch, he replied, I have not had that complaint presented to me except for at resident council. T. On 01/04/22 at 3:07 pm, during an interview, the Dietary Manager, when asked to describe the use of disposable plates and eating utensils, he explained, At times we do use disposable ware because we had 3 call-ins When were the call ins? per the finding above it sounds like the food is like this all the time - he did not specify [an occurrence in which an employee will unexpectedly call to report that they will not be available for work] and it was just a cook and I who were in the kitchen and we do use disposable ware during a COVID (a virus that is thought to spread mainly from person to person)outbreak [an occurrence where there are more than usual positive cases]. Only if we have positive residents, we use it [disposable ware]. When asked what type of disposable ware is used, he explained, We have the clam shell [a Styrofoam container that is made with a hinge on the top edge which allows the container to open and close]. We did have to use paper plates for a little while because the shells were out of stock. The last time we used clamshells was this past weekend. The last time we used the plates, has been a couple weeks. When asked if the disposables plates maintain the food's temperature, he explained that the kitchen staff cover it with another plate [to maintain heat] and then it disperses the meals. When asked to explain the number of staff working in the kitchen Was this at observed of how many staff are working in the kitchen, the findings above are only the interviews and observation of the residents, is there anyother findings to support that there is not enough or insufficient staff? Is there a distrubtion of goods that is effectiting the issues? Is there more context to support the deficiency that the staff is effecting the issues? Please add in- See finding W , he replied, Right now, I only have five employees. I ended up losing 4 employees and I hired new employees, but they don't last [remain employed]. When asked how menus are made available for residents, he explained, It is posted in front of the dining area. I post them on the halls, outside of the double doors at each hall. Our admissions coordinator gives copies of the menu upon admission. When asked to explain if fruit from the Always Available Menu offers cottage cheese with fruit, he explained that cottage cheese with fruit is available; however, it depends what fruit is available for the day, whatever fruit can has been opened that day: sliced apples, peaches, pears, and pineapples. When asked if the Philly Cheese Steak sandwiches should be served with bell peppers and onions, he explained that they were out of stock and that we didn't receive them on the truck. When asked to describe the unsatisfaction of the texture of rice, he explained that the rice is parboiled [rice that is partially boiled while in the husk to simplify the cooking process and add nutrition] so it does not need to be cooked as long as regular rice. When asked to explain the dissatisfaction of over-cooked vegetables, he explained, We do the prepping, by the time you get to the bottom of the tray line, they become over cooked. When asked to describe how he prepares the tater tots, he explained, We're doing batch cooking instead of deep cooking. We're trying different things to get them better, however; the dome that they sit in softens them up. When asked to explain the ingredients of the salads, he explained that they contain iceberg lettuce, tomatoes, cucumbers, cheese and diced lunch meat. Some of them will come with boiled eggs. He then explained that Our distributor has a lot of items that are not often available. After submitting my order, within an hour or two, I receive an email about what is available or what will be substituted. I will then call [name of distributor] and go through their system to see what I can get or sometimes the truck will show up and the food will not be available or not on the truck. When asked to explain the availability of snacks, he explained, We have snacks that are sent out at 10 [am] and 2 [pm] for weight loss or special requests for a sandwich. They are for scheduled residents, someone who requires an intervention for weight loss. At 7 [pm] we send the scheduled snacks with extras. We will take the calculation of how many people are scheduled and depending on the purees, we will send about 6-10 purees for yogurts. We send out 6 half meat and cheese sandwiches, 6 half peanut butter and jelly, and the difference in census will be the snack cookies. We try to send at least 1 per resident in the building; however, we see that residents will go behind the nurse's station and stuff their pockets. U. On 01/05/22 at approximately 2:00 pm, during an observation, R #52 presented a Styrofoam plate that she received her dinner on during the previous night. The plate was melted and the melted area contained a 2 inch by 3 inch hole in the middle of the plate where her grilled cheese sandwich sat. V. On 01/05/22 at 3:18 pm, during an interview, Kitchen Staff #1, when asked how to prepare a grilled cheese sandwich, she replied, We prepare the sandwiches in advance and then when it is ordered, we put it on the pan on the stove. When asked if Styrofoam plates are used, she stated, Sometimes we use a Styrofoam plate if we don't have a dishwasher. We do not use it often but if we do, we cover with a plastic film. When asked if there was a dishwasher last night, she confirmed, No dishwasher last night. Last night we used the Styrofoam plates. We didn't have a staff member to wash the dishes. W. On 01/06/22 at 12:14 pm, during an interview with the Administrator, when asked to explain the food study that occurred in the facility, he explained The common denominator, for about a month straight, it seemed to taste good but the presentation was off. They [residents] were unwilling to try the food due to the presentation of the meal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings for R #95: D. Record review of the face sheet for R #95, revealed that the resident was admitted to the facility on [DATE] with hospice services. E. Record review of the electronic medical record for R #95 did not reveal ongoing communication between the hospice provider and the facility. F. On 01/05/22 at 1:06 pm, during an interview, LPN #1 when asked if there was a hospice book or any location where hospice services are communicated with the facility, he explained that a hospice book was not used as all communication occurs verbally. He stated, They [hospice staff] come in, but if there are any changes we will call the hospice [staff] or let them know verbally when they come in. G. On 01/05/22 at 2:03 pm, during an interview, the Director of Nursing, when asked if a written form of communication between the facility and hospice services was available, she stated no and confirmed that all communication between the facility and the hospice provider was done verbally. Based on record review and interviews, the facility failed to ensure there was relevant documentation in the resident's record indicating the delivery of hospice services for 2 (R #'s 31, and 95) of 8 (R #'s 7, 19, 31, 35, 38, 47, 95, and 152) residents reviewed that were receiving hospice services. This deficient practice of not ensuring that there was an appropriate collaboration between the facility and hospice services could result in the resident not receiving the services that they need. The findings are: A. Record review of the facility's policy titled Hospice, last revised on 03/01/18, revealed the following: .The hospice and Center must communicate, establish, and agree upon a coordinated plan of care which reflects the hospice philosophy, and is based on an assessment of the patient's needs. The plan of care must include: Directives for managing pain and other uncomfortable symptoms and be revised and updated as necessary to reflect the patient's current status; The most recent hospice plan of care; and the care and services that the Center will provide in order to be responsive to the unique needs of the patient and his/her expressed desire for hospice care. The Center and hospice are responsible for performing each of their respective functions that have been agreed upon and included in the plan of care . Findings for R #31: B. Record review of R #31's medical records, revealed that R #31's start of care date was 07/15/21, to receive hospice services. Further review revealed, there was no pertinent documentation from the hospice provider. C. On 01/05/22 at 3:00 pm, during an interview, Licensed Practical Nurse (LPN) #1 when asked where the hospice documentation would be located for R #31. He replied that if there was no documentation scanned in R #31's electronic record, there might be a notebook containing the documentation. LPN #1 confirmed there was no hospice notebook found for this resident. When asked if the hospice agency was leaving any written documentation at the facility, LPN #1 stated that he did not know. LPN #1 stated that the hospice staff communicate to the facility verbally regarding information about the resident.

Based on interview, the facility failed to ensure the completion of an annual nurse aide performance reviews for all the certified nurse aides (CNAs) employed by the facility and therefore was unable to utilize the annual performance reviews to determine the in-service education needed. This deficient practice could impact all 89 residents in the facility and could likely result in residents not receiving the appropriate care needed to meet their individual needs. The findings are: A. On 01/05/22 at 8:43 am, during an interview, the Center Nurse Executive (CNE) stated that she only had training on file (in a binder) for agency staff to make sure they are competent before working the floor and for the Certified Medications Assistants (CMA's) to make sure they are up-to-date with their annual licensing requirements for passing medications. CMA's are also CNA's and they would complete the same annual training as the CNA's. She did not have a binder of the annual training's for the CNA's and they are not in the CNA's personal files. She confirmed that they do have training's for the CNA's to take through Vital Learn (online training) on the computer and it offers training's such as safe handling for residents, giving bed baths, oral care and many more. B. On 01/05/22 at 8:45 am, during an interview, the Director of Human Resources (HR), stated that she only handles [coordinates and tracks] the Vital Learn (skills training completed online) training's when the staff get hired on. She doesn't handle any ongoing training's for any staff. C. On 01/05/22 at 11:11 am, during an interview, the Center Executive Director (CED), stated that they do have a system (Vital Learn) to do the training's for the CNA's, but at this time it doesn't look like it has been getting done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to communicate and maintain menu options by not following the menu, and not having the specified menu items on hand to meet this requirement. This deficient practice has the potential to affect all 89 residents identified on the census list provided by the Administrator on 12/28/21 and could likely result in reduced food intake, weight loss, and a decline in a resident's psychosocial health (the health of someone's emotions, behaviors, and social abilities) due to developing feelings of frustration, anxiety (an excess feeling of fear, dread, and uneasiness), and disappointment. The findings are: A. Record review of the facility Week 1 Menu revealed on Wednesday, 12/29/21, the posted lunch menu was Chicken Noodle Soup, Philly Cheese Steak Sandwich, Garlic Tator Tots, and Shortbread Cookies. B. On 12/29/21 at 11:08 am, during an observation, the lunch meal in the kitchen was observed on the preparation line in steam pans. The Dietary Manager, DM tested the temperature of the tator tots (157.3° F), meat (165.5° F), and soup (160.3° F). C. On 12/29/21 at 12:18 pm, a random lunch meal was pulled for sampling. The meal sampled was for R #17 who is on a regular/Liberalized diet (a regular that allows for resident choice is most often the preferred diet) regular texture. On the plate was a sandwich, tator tots, a bowl of soup and 2 cookies. The Philly Cheese Steak sandwich {a sandwich consisting of thinly sliced beef topped with melted cheese and condiments (such as fried onions or peppers)} consisted only of meat, cheese, and a roll. The cheese for the Philly Cheese Steak sandwich was observed to be a thick slice of yellow cheese on the bottom slice of the sandwich with the meat on top of the cheese. The cheese was only partially melted. There were no onions or green peppers present in the sandwich. Garlic could not be detected by taste or smell on the Garlic Tator Tots. No other seasonings were detected on the tator tots. Additional seasonings are indicated in the facility recipe for the Garlic Tator Tots listed below. The cookies were chocolate chip cookies and not shortbread cookies as posted and communicated on the lunch menu for 12/29/21. D. Record review of the facility menu recipes for lunch items for 12/29/21 revealed the following ingredients are indicated in the recipe for the Garlic Tater Tots: Potato, Tater Nugget, Frozen; Oil, Pan Coating/Food Release, Spray; Onions, Green, Fresh; Margarine. Solid; Spice, Garlic, granulated; Spice, Paprika; Spice, Pepper, Black, Ground; and Cheese, Parmesan, Grated. The recipe calls for preparing the tator tots by finely chopping the green onions, melting the margarine in a saucepan adding the onions, cheese, and remaining seasonings and coating the tater tots with the margarine blend. The tator tots are to be cooked in the oven at 400° F for 20-25 minutes prior to coating with the seasoned margarine blend. E. Record review of the facility menu recipes for lunch items for 12/29/21 revealed the following ingredients are indicated in the recipe for the Philly Cheese Steak Sandwich: Onions, Yellow, Fresh; Peppers, Green, Fresh; Garlic Cloves; Oil, Vegetable; Oil, Pan Coating/Food Release; Spray Beef, Steak, Minute, shaved; Pepper, Black, Ground; Cheese, American, Sliced, 160 Count; and .5 oz Bread, Roll, Steak, Soft, 6 inches. The onions and peppers are to be sliced and then cooked on the grill with the chopped garlic in oil on a grill. The recipe calls for the cheese to be grated and blended with the cooked steak meat and cooked at 325° F in the oven to a temperature of 165° F while setting on top of the bed of grilled onions and green peppers. F. On 01/05/22 at 12:56 pm, during an interview, Kitchen Staff #1 stated she follows the facility menu recipes. She stated she is the dinner [NAME] and sometimes ingredients are substituted, for example celery for onions, but that it does not happen very often. She does not know why the chocolate chip cookies were substituted for the shortbread cookies on 12/29/21, because she was on vacation the previous week. G. On 01/05/22 at 1:10 pm, during an interview, the Dietary Manager stated there are substitutions allowed for menu items, but outreach [email or call] should be made to the Dietician to obtain approval to make the substitutions. When asked if the Dietician approved the chocolate chip cookie substitution for the shortbread cookies for the lunch on 12/29/21, the Dietary Manager stated he was not aware of the substitution. He stated there are times when items are ordered from the food vendor, but the items that arrive on the truck do not match with what is ordered and/or the food items are mislabeled. There are times when items are out of stock, and do not arrive on the truck, such as the bell peppers and onions. The truck only comes once a week and if he wants to correct the order he has to drive himself to [NAME] to make the food item exchange. H. On 01/05/22 at 3:29 pm, during an interview, the Dietary Manager stated half of the items needed for the Christmas celebration meal were missing from the vendor's delivered order, so rather than serving the Christmas meal, the normal scheduled dinner meal of hamburgers was served. Findings for R #40: I. On 01/06/22 at 9:45 am, during an interview,when asked if he had any concerns about the food, R #40 stated sometimes the recipe isn't followed. Findings fro R #52: J. On 01/03/22 at 12:12 pm, during an interview, when asked to explain her satisfaction with the food provided by the facility, R #52 stated, I got rice, beans, & mashed potatoes today. I am a diabetic . these are 3 starches on my plate: potatoes, rice, and beans. The rice, to me has a lot of salt. I get too much processed meat. If I had a protein, it would probably be processed sliced meat, It's too much. I didn't get any drinks today just a paper cup of coffee. This is an odd combination [beans, rice and mashed potatoes]. K. On 01/03/22 at 12:12 pm, during an observation of the R #52's meal tray, it was confirmed that she did not receive an additional drink aside from coffee [e.g., juice, tea, or milk]. She did not receive meat on her lunch tray and her plate contained rice, beans, and mashed potatoes. L. Record review of physician orders for R #52, dated 11/23/21, revealed the following diet Gluten Free diet [a diet that excludes gluten, which is a mixture of proteins that occur naturally in wheat, rye, barley and crossbreeds of these grains] - Regular Texture. M. On 01/04/22 at 2:25 pm, during an interview, the Registered Dietician, when asked if the meal containing mashed potatoes, beans and rice, but no meat was considered an approved meal for R #52 and he confirmed no. N. On 01/06/22 at 1:31 pm, during an interview with the Registered Dietician, when asked to confirm if R #52 had any preferences that would prompt the kitchen staff to serve mashed potatoes, beans and rice, he confirmed no.