**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the resident's current advance directive (a document which provides an individual's wishes for emergency and lifesaving care) was available in the resident's Electronic Health Record (EHR) and/or available in physical form for the facility staff for 1 (R #48) of 1 (R #48) resident reviewed for advance directives. This deficient practice is likely to cause confusion and delay potentially lifesaving procedures. The findings are: A. Record review of R #48's face sheet revealed R #48 was admitted into the facility on [DATE]. B. Record review of R #48's physician orders dated [DATE] revealed R #48 was a Do Not Resuscitate (DNR- a person has decided not to have cardiopulmonary resuscitation (CPR) attempted on them if their heart or breathing stops) for her advanced directive code status. C. Record review of R #48's care plan dated [DATE] revealed R #48 was a DNR for her advanced directive code status. D. Record review of R #48's EHR revealed the record did not contain an advanced directive form, the New Mexico Orders for Scope and Treatment (MOST). E. On [DATE] at 12:45 pm during an interview with the Director of Nursing (DON), she confirmed R #48's advanced directive code status, the New Mexico Orders for Scope and Treatment (MOST) was not uploaded into R #48's EHR nor was it available in physical form for nursing staff and should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to keep residents free from physical restraints for 1 (R #8) of 1 (R #8) resident observed during random observations. This deficient practice could likely result in physical restraints being used for discipline or staff convenience; unnecessarily preventing residents from freedom, movement, or activity. The findings are: A. Record review of R #8's face sheet revealed R #8 was admitted to the facility on [DATE] with the following diagnoses: 1. Alzheimer's (a progressive brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out even the simplest tasks), 2. Dementia (a general term for a decline in mental ability severe enough to interfere with daily life), 3. Depression (persistent feeling of sadness, loss of interest in activities, and changes in appetite, sleep, and energy levels), 4. Cognitive communication deficit (a communication problem stemming from impairments in thinking skills, rather than language or speech difficulties themselves), 5. Unsteadiness on feet, 6. Psychotic disorder with hallucinations (characterized by experiencing sensory perceptions that aren't real, such as hearing voices or seeing things that aren't present). B. Record review of R #8's care plan dated 03/01/23 revealed the following approaches for risk of elopement safety awareness: 1. Distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television and books. 2. Provide structured activities. 3. Educate the resident and family of the risks. 4. Engage resident in activities of choice. 5. Report to medical provider. 6. Supervise closely and make regular rounds when the resident is in her room. C. On 06/09/25 at 12:00 pm, during an observation of R #8, she was in the dining room, sitting in her wheelchair. R #8 made three attempts to wheel herself out of the dining room. D. On 06/09/25 at 12:15 pm, a follow up observation with R #8 revealed her sitting in a recliner with the foot part extended. R #8 was attempting to get out of the recliner. E. On 06/09/25 at 12:16 pm, during an interview with Certified Nursing Assistant (CNA) #3 she stated that R #8 was a wanderer so the recliner was used as a way to keep her safely in one place. CNA #3 confirmed that R #8 cannot get out of the recliner without assistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to complete and transmit (electronically sending encoded information) a Significant Change (major decline or improvement in the patient's health status) Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment within 14 days after the facility determined a significant change in the resident's physical or mental condition for 1 (R #23) of 1 (R #23) resident reviewed for MDS assessment timing. This deficient practice could likely result in the residents not receiving the appropriate care and services they need. The findings are: A. Record review of R #23's face sheet revealed she was admitted to the facility on [DATE] with the following diagnoses: 1. Chronic obstructive pulmonary disease (COPD; lung disease), 2. Major depressive disorder (depression; a mood disorder that causes a persistent feeling of sadness and loss of interest), 3. Cerebral aneurysm (a weak spot on an artery in the brain that fills with blood), 4. Chronic heart failure (an ongoing inability to pump enough blood through the body causing an insufficiency of oxygen). B. On 06/10/25 at 8:55 am, during an interview with R #23 she stated that she is on hospice (care and services for people nearing the end of life). C. Record review of R #23's MDS dated [DATE], revealed R #23 is not on hospice. D. Record review of R #23's electronic health record (EHR) revealed the following: 1. R #23's current clinical census showed Hospice Medicaid was started on 05/01/25. 2. An order dated 05/08/25 for hospice service to start effective 05/01/25. 3. A Significant Change MDS dated [DATE] revealed as In Progress indicated the assessment was started but not completed. E. On 06/13/25 at 12:30 pm, during an interview with the MDS Coordinator, she stated that she expects all Significant Change MDS assessments to be completed within 14 days and confirmed that R #23's was not.

Based on observation and interviews, the facility failed to maintain proper infection prevention practices for 3 (R #39, R #43, and R #76) of 4 (R #36, R #39, R #43, and R #76) residents. This deficient practice could likely result in the spread of infectious agents (viruses and bacteria) between the residents. The findings are: A. On 06/12/25 at 9:40 am, during an observation of Certified Medication Aide (CMA) #1 revealed the following: 1. CMA #1 did not clean the blood pressure cuff and vital sign equipment prior to taking vital signs for R #76. 2. CMA #1 then failed to sanitize her hands before beginning her medication pass for R #39. 3. CMA #1 then failed to put gloves on (don) gloves to open a capsule for R #43. B. On 06/12/25 at 10:15 am, during an interview with CMA#1, she confirmed she should have sanitized her hands before beginning the medication pass for R #39. She confirmed she should have sanitized all vital sign equipment before taking R #76's vitals and in between each resident afterwards. She confirmed she should have donned (put on gloves) her gloves before she opened the capsule to pour the medication in the medicine cup for R # 43. C. On 06/12/25 at 10:25 am, during an interview with the Director of Nursing (DON), she stated she would expect all nursing staff to perform hand hygiene before and after each medication pass for each resident. She confirmed she would expect all nursing staff to perform hand hygiene before and after each medication pass for each resident. She confirmed she would expect all nursing staff to sanitize the vital machines before and after use with each resident. She confirmed she would expect all nursing staff to don (put on gloves) gloves before touching any medication for any of the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure staff revised the care plan for 5 (R #2, R #23, R #54, R #56 and R #75) of 5 (R #2, R #23, R #54, R #56 and R #75) residents reviewed when staff failed to: 1. Update R #2's care plan to include the use of a trapeze bar (a short horizontal bar that is suspended from two ropes) for mobility. 2. Update R #23's and R #54's plan of care to include hospice (care and services for people nearing the end of life). 3. Update R #56's care plan to remove the use of a communication board (a tool used to help people with limited language skills or who are nonverbal to communicate) with word cards. 4. Update R #75's plan of care to include advanced directive. These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: R #2 A. On 06/10/25 at 1:46 pm, an observation of R #2's room revealed a trapeze bar at the head of R #2's bed. B. Record review of R #2's face sheet revealed he was originally admitted to the facility on [DATE] with the following diagnoses. 1. Unsteadiness on Feet, 2. Unspecified Lack Of Coordination, 3. Muscle Weakness, 4. Multiple Sclerosis (a chronic disease that affects the brain and spinal cord), 5. Myoneural Disorder (conditions affecting where nerves and muscles communicate). C. Record review of R #2's care plan dated 06/28/24 revealed no interventions for the use of a trapeze bar. D. On 06/10/25 at 1:48 pm during an interview with R #2, he stated he uses the bar to help with repositioning himself while in bed. E. On 06/12/25 at 12:32 pm during an interview with the Director of Nursing (DON), she confirmed R #2's care plan was not revised to include the use of a trapeze bar and should have been. R #23 F. Record review of R #23's face sheet revealed she was admitted to the facility on [DATE] with the following diagnoses: 1. Chronic obstructive pulmonary disease (COPD; lung disease), 2. Major depressive disorder (depression; a mood disorder that causes a persistent feeling of sadness and loss of interest), 3. Cerebral aneurysm (a weak spot on an artery in the brain that fills with blood), 4. Chronic heart failure (an ongoing inability to pump enough blood through the body causing an insufficiency of oxygen). G. Record review of R #23's care plan dated 05/01/25 revealed a focus area indicated R #23 has a terminal diagnosis of COPD and has the following interventions listed: 1. Adjust provision of ADLS (activities of daily living) to compensate for resident's changing abilities. Encourage participation to the extent the resident wishes to participate dated 02/28/24. 2. Assess resident coping strategies and respect resident wishes dated 02/28/24. 3. Consult with physician and Social Services to have hospice care for resident in the facility dated 02/28/24. 4. Encourage resident to express feelings, listen with non-judgmental acceptance, compassion dated 02/28/24. 5. Encourage support system of family and friends dated 02/28/24. 6. Keep the environment quiet and calm. Keep linens clean, dry and wrinkle free dated 02/28/24. 7. Keep lighting low and familiar objects near dated 02/28/24. 8. Observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain dated 02/28/24. 9. Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met dated 02/28/24. 10. Work with nursing staff to provide maximum comfort for the resident dated 02/28/24. H. On 06/13/25 at 12:53 pm, during an interview with the Assistant Director of Nursing (ADON) #2, she stated R #23 was previously on hospice and was taken off hospice in 2024. ADON #2 stated that all interventions listed in R #23's care plan for hospice are over one year old. ADON #2 confirmed there are no current interventions included in R #23's care plan for hospice. R #54 I. Record review of R #54's face sheet revealed she was admitted to the facility on [DATE] with the following diagnoses: 1. Chronic kidney disease (kidneys are damaged and gradually lose ability to filter blood effectively), 2. Unspecified heart failure (condition where the heart cannot pump enough blood to meet the body's needs), 3. Gastroesophageal reflux disease (GERD; A digestive disease in which stomach acid or bile irritates the food pipe lining), 4. Adult failure to thrive (a syndrome that describes a decline characterized by weight loss, decreased appetite, poor nutrition, inactivity and often accompanied by dehydration, depressive symptoms, and impaired immune function, among others). J. Record review of R #54's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 05/20/25, revealed R #54 is on hospice. K. Record review of R #54's comprehensive care plan last revised on 05/23/25, revealed no mention of hospice care. L. On 06/13/25 at 12:53 pm, during an interview with ADON #2, she confirmed that R #54 is on hospice and hospice is not included R #54's care plan. ADON #2 stated her expectation is for a resident's care plan to be revised to include hospice if or when it becomes relevant to the resident. R #56 M. Record review of R #56's face sheet revealed he was admitted to the facility on [DATE] with the following diagnoses: 1. Cognitive Communication Deficit (difficulties in communication arising from impairments in mental processes), 2. Dementia (a decline in mental ability severe enough to interfere with daily life). N. Record review of R #56's care plan dated 03/13/24 revealed a focus for cognitive communication deficit with the following approaches: 1. Ask simple questions that require short answers 2. Listen attentively and allow time to communicate 3. Use communication board with word cards 4. Speak slowing and clearly while facing resident 5. Use gestures an body movements. O. On 06/11/25 an observation of R #56 room revealed there was no communication board with word cards available for use. P. On 06/12/25 at 3:48 pm during an interview with Certified Nursing assistant (CNA) #3, she confirmed R #56 communicates by answering yes or no questions. She stated R #56 also uses nonverbal communication that require staff to pay attention to his body movements. CNA #3 confirmed R #56 does not have a communication board with word cards available. Q. On 06/13/25 at 12:32 pm during an interview with the Director of Nursing (DON), she stated R #56 does not have a communication board. The DON stated that the facility attempted to use a communication board and word cards with R #56, but it was ineffective. The DON could not remember the date of this trial. The DON confirmed the care plan should have been revised and was not. R #75 R. Record review of R #75's admission record revealed he was admitted to the facility on [DATE] with the following diagnoses: 1. Spinal Stenosis, cervical region (narrowing of one or more spaces within the spinal canal), 2. Type 2 diabetes mellitus with hyperglycemia (blood sugar levels rise significantly), 3. Depression, unspecified, 4. Chronic diastolic (congestive) heart failure. S. Record review of R #75's order dated 05/29/25, revealed an order for an advance directive of (do not resuscitate: DNR; lifesaving measures are not desired) code status in place. T. Record review of R #75's care plan dated 06/03/25 revealed R #75 was missing the advance directive for a DNR on his care plan. U. Record review of R #75's New Mexico Orders for Scope and Treatment (MOST) form dated 05/29/25 revealed R #75 has an advance directive of DNR code status in place. V. On 05/29/25 at 12:20 pm during an interview with the DON, she confirmed the facility failed to revise the care plan for R #75 after confirming his advance directive DNR code status.

Based on observation, record review and interview, the facility failed to ensure the medication error rate did not exceed 5 percent (%) when staff performed 3 medication errors out of 29 opportunities for 3 (R #39, R #43, R #76) of 4 (R #36, R #39, R #43, R #76) residents reviewed during medication administration. This resulted in a medication error rate of 10.34%. This deficient practice could likely result in the spread of infectious agents (viruses and bacteria) between the residents. The findings are: A. On 06/12/25 at 9:40 am, during an observation of Certified Medication Aide (CMA) #1 revealed the following: 1. CMA #1 did not clean the blood pressure cuff and vital sign equipment prior to taking vital signs for R #76. 2. CMA #1 then failed to sanitize her hands before beginning her medication pass for R #39. 3. CMA #1 then failed to put gloves on (don) gloves to open a capsule for R #43. B. On 06/12/25 at 10:15 am during an interview with CMA #1, she confirmed she should have sanitized her hands before beginning the medication pass for R #39. She confirmed she should have sanitized all vital sign equipment before taking R #76's vitals and in between each resident afterwards. She confirmed she should have donned (put on gloves) gloves before she opened the capsule to pour the medication in the medicine cup for R #43. C. On 06/12/25 at 10:25 am during an interview with the Director of Nursing (DON), she confirmed she would expect all nursing staff to perform hand hygiene before and after each medication pass for each resident. She confirmed she would expect all nursing staff to sanitize the vital machines before and after use with each resident. She confirmed she would expect all nursing staff to don (put on gloves) gloves before touching any medications for any of the residents. D. Record review of the Medication-Administration policy (not dated), provided by the Administrator (ADM) on 06/12/25, under the heading Procedure point number 2, wash hands before and after medication administration. E. Review of CDC guidelines Guideline for Disinfection and Sterilization in Healthcare Facilities, dated 2008, Section 4.c., stated staff should ensure that, at a minimum, noncritical patient-care devices are disinfected when visibly soiled and on a regular basis, such as after use on each patient or once daily or once weekly.

Based on observation and interview, the facility failed to ensure call lights in the residents' rooms were within reach of the residents while in the room for 2 (R #22 and R #56) of 4 (R #2, R #8, R #22, and R #56) residents reviewed for call lights. This deficient practice could likely result in residents being unable to notify staff when they are in need of assistance. The findings are: R #22 A. On 06/12/25 at 10:34 am during an observation of R #22's room revealed R #22 was asleep in her recliner. The call light laid on top of the bed where she could not reach it. B. On 06/12/25 at 10:36 am during an interview with Hospice Nurse (HN) #1, she confirmed the call light was not within R #22's reach and the call light should have been. R #56 C. On 06/11/25 at 8:58 am during an observation of R #56's room, revealed R #56 was asleep in his recliner. The call light laid on top of the bed where he could not reach it. D. On 06/11/25 at 9:05 am during an interview with Certified Nurse Assistant (CNA) #2, she confirmed the call light was not within R 56's reach and the call light should have been.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the hallway was accessible for residents. This deficient practice could likely result in residents living in an unsafe environment, could increase their risk for injuries, and decrease their quality of life. The findings are: A. On 06/09/25 at 8:10 am a random observation of the [NAME] Wing revealed the following: 1. A medication cart on the right side of the hallway near room [ROOM NUMBER]. 2. A shower chair on the left side of the hallway near room [ROOM NUMBER]. B. On 06/09/25 at 8:18 am during an interview with the Restorative Nursing Aide (RNA), she confirmed there were objects on both sides of the hallway blocking the residents' path. She stated that everything should be on one side of the hallway, so residents had a clear path. C. On 06/10/25 at 8:46 am a random observation of South Wing revealed the following: 1. A medication cart on the right side of the hallway near room [ROOM NUMBER]. 2. A medication cart on the left side of the hallway near room [ROOM NUMBER]. D. On 06/10/25 at 8:48 am during an interview with Certified Medication Aide (CMA) #1, she confirmed there were objects on both sides of the hallway blocking the residents' path. She stated that everything should be on one side of the hallway.

Based on observation, and interview, the facility failed to store and serve food under sanitary conditions by not ensuring food items stored in facility's freezer were labeled and dated. This deficient practice is likely to affect 76 residents listed on the resident census list provided by the Administrator on 06/09/25 and could likely lead to foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to. The findings are: A. On 06/09/25 at 11:03 am during observation of the facility's walk in freezer the following items were found open and undated: 1. Two bags of what appeared to be hash browns. 2. Two bags of what appeared to be French fries. B. On 06/09/25 at 11:05 am during an interview with the Dietary Manager (DM), he confirmed the items were not labeled and dated. DM stated that doesn't meet his expectations and everything in the fridge/freezer should be labeled and dated.

Based on record review and interview, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR; a screening to help ensure that individuals are not inappropriately placed in nursing homes for long term care) assessment was accurate for 1 (R #13) of 1 (R #13) residents reviewed for PASRR accuracy. This deficient practice is likely to result in the facility not providing the services needed by residents. The findings are: A. Record review of R #13's most recent PASRR, dated 12/27/21, revealed the following: - Individual information: Staff documented schizophrenia (a mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech, and behavior) as a pertinent diagnoses. - Identification of mental illness (MI) evaluation criteria: Staff documented No, the resident did not have a diagnosis or suspected mental illness in Section C1. The criteria listed schizophrenia as a MI, but staff did not enter the diagnosis of schizophrenia. B. Record review of R # 13's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 04/26/24, revealed R #13 had a diagnosis of schizophrenia. C. On 05/16/24 at 4:20 PM during interview with Admissions Coordinator (AC), she confirmed the PASRR for R # 13 was incorrect, because it did not acknowledge R #1's diagnosis of schizophrenia in Section C1. She stated the PASRR was completed by the discharging hospital, and facility staff should have reviewed it prior to admission. D. On 05/17/24 at 9:13 AM during interview with the Social Services Director, she stated the PASRR for R #13 was incorrect, because staff should have documented in Section C1 that the resident had a diagnosis of schizophrenia.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were invited to attend care plan meetings for 2 (R #23 and R #30) of 2 (R #23 and R #30) residents reviewed for participation in care planning. If residents are not able to participate in their care plan development, then residents could likely not get the care and treatment they want or need. The findings are: R #23 A. Record review of R #23's face sheet revealed R #23 was admitted into the facility on [DATE]. B. On 05/13/24 at 4:18 pm, during an interview with R #23, she stated she did not attend the last care plan meeting that was scheduled. R #23 stated it was important to her to attend her own meetings. She stated she previously talked with the Social Services Director (SSD) and explained to her that she wanted to be involved in her care and her meetings. C. Record review of R #23's Care Plan Conference (a document the facility uses to record details of a care plan meeting including attendees), dated 04/24/24, revealed R #23 did not attend her care plan meeting because she was napping and has not been sleeping well so nursing requested not to wake her. The meeting was held without the resident present. D. On 05/17/24 at 9:10 am, during an interview with the SSD she stated R #23 did not attend her care plan meeting. The SSD confirmed she knew it was important for R #23 to attend her meetings and stated this meeting should have been rescheduled until R #23 was able to attend. R #30 E. Record review of R #30's face sheet revealed R #30 was admitted into the facility on [DATE]. F. On 05/13/24 at 2:41 pm, during an interview with R #30 he said, I've never been invited to one of those [care plan meeting]. G. Record review of R #30's Electronic Health Record revealed the record did not contain documentation to show staff held a care plan meeting for the resident. H. On 05/17/24 at 9:10 am, during an interview with the SSD, she stated she could not produce a Care Plan Conference form to show a care plan meeting for R #30 occurred. The SSD stated Care Plan Conference forms should be kept in the resident's Electronic Health Record, but R #30's Electronic Health Record did not contain Care Plan Conference documentation. The SSD stated she was responsible to complete the Care Plan Conference forms for the residents' records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure a resident who was admitted with an indwelling Foley (name of device) catheter (a thin, sterile tube inserted into the bladder to drain urine) was assessed for the removal of the catheter for 1 (R #46) of 1 (R #46) sampled residents with an indwelling urinary catheter. This failed practice is likely to cause R #46 to not regain bladder control, to develop bladder incontinence, or to develop a bladder infection. The findings are: A. Record review of R #46's face sheet revealed the resident was admitted to the facility on [DATE] with a diagnosis of a pressure ulcer of the sacral region (the portion of the spine between the lower back and the tailbone), Stage 4 (a deep wound that may impact muscle, tendons, ligaments, and bone). B. Record review of R #46's wound reports, dated April and May 2024, revealed R #46's pressure injury was stable (had not changed since admission on [DATE].) C. Record review of R #46's physician orders revealed an order, dated 04/23/24, for a Foley catheter: Continue Foley catheter due to pressure wound of coccyx. D. Record review of R #46's progress notes, dated 05/01/24 and entered by the Nurse practitioner (NP), stated R #46 was alert, oriented, and able to follow commands. The note also stated R #46 did not have incontinence (loss of bladder control). E. On 05/14/24 at 10:50 am, R #46 lay in bed with a Foley catheter drainage bag (bag attached to end of tube inserted into the bladder that collects urine as it drains) attached to the bed frame. The catheter tubing and drainage bag contained light yellow, translucent urine with no foul odors. F. On 05/14/24 at 10:59 am during an interview, R #46 stated she did not want the Foley catheter in place, and she did not know why the facility staff did not removed it. R #46 also stated she utilized a bedside commode as needed. G. On 05/16/24 at 2:21 pm during an interview, LPN #1 stated R #46 came into the facility with the Foley catheter. LPN #1 stated she did not see a diagnosis in the resident's record that related to the Foley catheter use. She further stated she was not aware if staff attempted a trial to discontinue the resident's catheter (remove the catheter) since R #46 was admitted to the facility. H. On 05/16/24 at 6:17 pm during an interview with the Director of Nursing (DON), she stated the reason for R #46's Foley catheter was to promote wound healing. I. On 05/17/24 during an interview with the facility NP, she stated R #46's Foley catheter was left in place so the wound on her backside (a Stage 4 pressure injury) did not get infected or soiled. She further stated the catheter was to be left in place until the wound reached a healing stage. She stated typically staff attempted a trial void (the Foley catheter is removed and if the person is able to void within 8 hours of removal then the catheter is discontinued) with a resident as soon as possible. J. On 05/17/24 at 9:10 am during an interview with the Medical Director (MD), she stated if a resident was cognitively aware, could use their call light to call for assistance, and could use the bedside commode (such as R #46) then her expectation would be for staff to attempt to discontinue the catheter as soon as possible, especially if the resident stated she no longer wanted the catheter. She stated it was also her expectation that facility staff inform her of the resident's wish to discontinue the catheter, but staff did not make her aware of R #46's request to have the catheter removed. K. On 05/17/24 at 9:37 am during an interview with ADON/Wound Care Nurse, she stated R #46's wound remained the same, and R #46 did not express pain with dressing changes or when up to her chair or bedside commode, indicating R #46 was able to sustain transfers and bedside toileting without experiencing pain caused by the pressure injury.

Based on observation, record review, and interview, the facility failed to provide an adaptive eating device (a tool that helped a person with a disability do a certain task) for 1 (R #35) of 1 (R #35) residents reviewed during dining observation. If residents are not provided adaptive eating devices as needed, then residents might be unable to consume their meals and beverages and likely to have weight loss, malnutrition, and dehydration. The findings are: A. Record review of R #35's Physician's orders, dated 05/13/24, revealed the resident was to use a plate guard for meals as tolerated for improved self-feeding skills. B. Record review of R #35's meal ticket, dated 05/13/24, revealed it did not direct staff to provide adaptive feeding equipment for the resident. C. On 05/13/24 at 5:09 pm during a dining observation, R #35 ate her meal without an adaptive eating device. At 5:36 pm, Certified Nursing Assistant (CNA) #2 put a plate guard (a curved piece of material that fits around the rim of a plate to prevent food from falling off) on R #35's plate. D. On 05/13/24 at 5:40 pm, CNA #2 stated R #35 had an order for a plate guard, and she should have served the resident's meal with a plate guard on the plate.

Based on interview and observation, the facility failed to: 1. Ensure the facility had enough food to serve all residents the meal on the menu. 2. Ensure staff served residents a second portion of meal if requested. This deficient practice is likely to affect all residents who eat at the facility. If the facility fails to provide adequate food to meet the nutritional needs of the residents then residents are likely to lose weight and not get their nutritional needs met. The findings are: Ensure the facility had enough food to serve all residents the meal on the menu. A. Record review of Residents Council minutes, dated May 2024, revealed the residents discussed the Dietary Department ran out of food and coffee often. B. On 05/13/24 at 5:49 pm, during a dining observation, revealed staff served some of the residents meals without the vegetables. Further observation revealed the facility ran out of vegetables for the meal. C. On 05/13/24 at 5:50 during an interview, Certified Nurse Aide (CNA) #2 stated the facility ran out of vegetables for the dinner meal, so some residents did not receive vegetables on their plate. CNA #2 stated some of those residents wanted to receive vegetables with their meal. D. On 05/15/24 at 9:23 am, during an interview, R #25 stated the facility ran out of food often. R #25 could not say how often they ran out of food, but she stated it was at least twice a week or more. E. On 05/15/24 at 9:30 am, during an interview with R #54, she stated the facility ran out of coffee, and there were many meals the facility did not provide coffee. The resident stated this often occurred in the morning and the evening. R #54 stated the residents would like to get coffee with their meals when they requested it. R #54 further stated staff told her that they do not always make more then one pot of coffee so it did not get wasted. Ensure staff served residents a second portion of meal if requested. F. On 05/15/24 at 9:23 am, during an interview, R #25 stated residents seldom received a second serving when they requested it. R #25 further stated the staff would say the kitchen did not have enough for seconds. G. On 05/15/24 at 9:33 am, during an interview with R #57, she stated she asked for second portions, but staff tell the residents there was not any second portions available. She further stated the residents are often left hungry. H. On 05/15/24 at 9:35 am, during an interview with R# 58, she stated staff tell them to wait until they serve everyone before they can have seconds. R #58 stated the kitchen runs out of food, and the residents are not able to get a second portion. I. On 05/16/24 at 5:08 pm during a dining observation, staff served residents small portion of egg salad, and residents asked for a second helping. Staff told the residents there was not any second portions, because they ran out of the egg salad. J. On 05/16/24 at 5:10 pm during an interview and observation, the Dietary Aide (DA) stated they ran out of egg salad and were waiting for the kitchen to bring more. The DA left the dining room, and staff did not bring any more egg salad for the residents. K. On 05/16/24 at 5:39 pm during interview, R #37 stated she requested an extra serving of egg salad, and the DA told her there was not enough food for another serving.

Based on record review and interview, the facility failed to provide documentation confirming one Nurse Aide (NA), employed by the facility, had completed a Nurse Aide Training and Competency Evaluation Program (NATCEP) or a Competency Evaluation Program (CEP) within four months of being employed at the facility. This deficient practice is likely to affect all 68 residents residing in the facility. Residents are likely to experience substandard care because of the use of untrained or unqualified aides providing direct care to residents. The findings are: A. Record review of NA #1's personnel record revealed the following: - The NA's hire date was 12/01/23; - The record did not contain a Certified Nursing Assistant (CNA) License. - NA #1 was employed full time as of 05/17/24. - NA #1 completed the CNA training but did not complete the CNA state licensure exam. B. On 05/17/24, at 10:40 AM, during an interview with the Director of Nursing (DON), she stated NA #1 did not obtain her CNA license within four months of her hire date. The DON stated the NA completed the training but did not test in time DON further stated that NA #1 was working full time at the facility.

Based on observation and interview, the facility failed to ensure food was stored in accordance with professional standards of food service safety when staff failed to: 1. Ensure all food items in the dry storage area were stored properly. 2. Ensure all food items in the walk-in refrigerator were labeled and dated. 3. Ensure all food items in the freezer were sealed appropriately. This deficient practice is likely to affect all 75 residents identified on the resident census list provided by the Director of Nursing on 05/13/2024. These deficient practices are likely to expose residents to food borne illnesses. The findings are: Dry Storage Area: A. Observation on 05/13/2024 at 12:35 pm, during initial observation of the facility's food storage area, revealed one case of a 10 pound box of grape juice stored on the bare floor. B. On 05/13/24 at 12:51 pm during an interview with the Dietary Manager (DM), he confirmed the items were on the bare floor. The DM stated there should not be any boxes on the bare floor, and all items should be stored on the shelves. The DM further stated that all kitchen staff were responsible to make sure nothing was on the floors. Walk-In Refrigerator: C. On 05/13/24 at 12:35 pm, an initial observation of the facility's walk-in refrigerator revealed the following: 1. One small pan of orange fluff salad not labeled or dated. 2. One single tomato wrapped in saran wrap with no date. 3. One 2 quart plastic container of apple sauce not labeled or dated. 4. One case of 2 oz. sour cream packets no date. 5. One pack of flour tortillas open to air and not labeled and dated. 6. Two packs of corn tortillas not labeled or dated. 7. Two 2 quart pitchers of juice not labeled or dated. D. On 05/13/2024 at 12:51 pm during an interview with the DM, he confirmed the findings and stated all items should be labeled and dated. The DM stated all kitchen staff were responsible for labeling and dating all items. Facility Freezer: E. On 05/13/24 at 5:52 pm, observation of the facility freezer revealed the following: 1. One box of beef patties open to air and not sealed. 2. One box of cookie dough open to air and not sealed. 3. One box of Salisbury steak patties open to air and not sealed. F. On 05/13/24 at 12:51 pm during an interview with the DM, he confirmed the items should be sealed and not open to air to avoid freezer burn. He further stated the expectation was for staff to close the boxes after removing the food item.

Based on record review, observation, and interview, the facility failed to timely revise and update a care plan for 1 (R #49) of 2 (R #31 and R #49) residents reviewed for pain. This deficient practice could likely cause staff to be unaware of current resident needs and impair the safety of residents. The findings are: A. Record review of current facility face sheet dated 05/01/22 for R #49 revealed admitting diagnosis which included: Pain In Left Hand, Pain In Left Wrist, Mood [Affective] Disorder (mood swings), Anxiety Disorder (feeling of fear), Chronic Pain (constant pain), Hypertension (high blood pressure), Dorsalgia (back pain), Benign Prostatic Hyperplasia (difficulty urinating), Abdominal Pain, Weakness, Intracranial Injury With Loss Of Consciousness Of Unspecified Duration (brain injury), Personal History Of Covid-19 (viral lung infection), Dementia (memory loss), and Need For Assistance With Personal Care. B. Record review of pain care plan dated 04/14/23 for R #49 revealed an approach of: Encourage The Resident To: Call For Assistance When In Pain, Reposition Self, Ask for Medication, Verbalize How Much Pain Is Experienced, Verbalize What Increases Or Alleviates Pain. C. On 05/10/23 at 8:55 pm, during an observation of R #49, R #49 was observed in bed, appeared as though call light was out of reach and sitting on furniture next to bed. D. On 05/10/23 at 9:00 pm, during an interview with Infection Preventionist (IP), who also performs nursing duties on the floor, confirmed that the call light was not within reach of R #49. E. On 05/10/23 at 9:10 pm, during an interview with DON, she confirmed that the call light was not within reach of R #49 and would have to review his care plan to update it.

Based on record review, observation, and interview the facility failed to provide trauma informed care (care to help prevent furtherance of trauma and promote safety and well-being) to 1 (R #31) of 1 (R #31) resident diagnosed with a trauma incident. Failing to provide care and seek out knowledge of triggers is likely to cause the resident to become secluded (withdrawn), exhibit behaviors, or cause self harm. The findings are: A. Record review of current facility face sheet for R #31 revealed admitting diagnosis which included: Atherosclerotic Heart Disease Of Native Coronary Artery (hardening of the arteries), Muscle Weakness, Hypothyroidism (low hormone), Type 2 Diabetes Mellitus (high blood sugar), Hyperlipidemia (high cholesterol), Bipolar Disorder (mood swings), Major Depressive Disorder (feeling of sadness), Anxiety Disorder (feeling of fear), Post-Traumatic Stress Disorder (disorder caused by trauma), Mild Cognitive Impairment (memory loss), Polyneuropathy (nerve pain), Hypertension (High Blood Pressure), Heart Failure, Gastro-Esophageal Reflux Disease (acid reflux), Gastritis (intestinal swelling), Radiculopathy, Lumbosacral Region (pinched nerve in lower back), Urinary Incontinence, Hallucinations (seeing or hearing things not there), and Morbid Obesity Due To Excess Calories. B. On 05/09/23 at 10:26 am, during an observation R #31 appeared agitated (yelling out and over other residents) while at the resident council meeting. C. Record review of current care plan dated 07/04/22 revealed no care plan related to R #31's PTSD diagnosis. D. On 05/16/23 at 10:45, during an Interview with DON, she stated that R #31 did not have a current care plan to address PTSD diagnosis; and has not been to a behavioral health specialist since arrival to the facility (07/04/22) to see if she needed any help.

Based on observation and interview, the facility failed to ensure that pharmaceutical services for 1 (R #48) of 1 (R #48) resident reviewed for accurate dispensing and administration was correct. The pharmacy placed multiple orders for the medication on the same package creating confusion. This failure could cause a potential overdose of R # 48. The findings are: A. On 05/10/23 at 7:45 pm during an observation of R #48 during receipt of medication from License Practical Nurse (LPN) #2, two (2) blister packs (flat cardboard with medication attached with a plastic cover) for R #48 did not match the physician orders for May 1- May 31 on the MAR, (the label which directs the nurse what to give). On the blister packs, the following doses were listed: 1. Carbidopa/Levodopa (this medication is used to treat symptoms of Parkinson's disease such as shakiness, stiffness, difficulty moving) the tablets contain a combination of carbidopa 25 mg and levodopa 100 mg. The order on the blister pack stated, One (1) tablet every day at bedtime 2. Carbidopa/Levodopa 25/100 the order on the same blister pack stated, One and a half (1.5) tablets at bedtime. 3. Carbidopa/Levodopa 25/100 the pharmacy order in the computer states, 1 tablet three (3) times a day. 4. Quetipine (this medication is used to treat certain mental/mood conditions (such as schizophrenia and sudden episodes of mania or depression) the order on the blister pack stated, half (1/2) tablet twice daily. 5. Quetipine the order on the same blister pack stated, one (1) tablet twice daily, 6. Quetipine Physician Order on the May 2023 MAR was, two (2) tablets at bedtime. B. On 05/10/23 at 7:45 pm ,during comparison of orders LPN #2 stated, I will call the pharmacy and clarify the orders. C. On 05/10/23 at 7:48 pm during interview with [NAME] President of Clinical Operations (VPCO) regarding the conflict of these orders, VPCO stated she, would call the Director of Nursing, and the Pharmacy would be alerted right away. D. On 05/10/23 t 7:55 pm, during interview the VPCO said the phone calls to the DON and Pharmacy had been completed.

Based on observation and interview, the facility failed to maintain a safe and comfortable homelike environment in the dining area. This failure has the potential to affect the 54 residents that choose to eat in the main dining facility. The findings are: A. On 05/08/23 at 12:12 pm during lunch observation in the dining area the following was revealed: 1. The food arrived in the dining area 15 minutes later than the scheduled lunch start time of 12:00 pm. 2. The dining area was very crowded with residents, wheelchairs and walkers making moving around difficult to include entering the dining area, serving and assisting the residents with dining, and exiting the area after the meal was complete. 3. The overcrowding of the area caused high sound levels which made any conversation difficult as it was hard to hear another person. This also caused it to be difficult to get staff attention for assistance. 4. One of the two access doors was blocked by the serving carts and staff making any egress impossible. B. On 05/08/23 at 12:45 pm during an interview with the Corporate Dietary Director, he confirmed that the dining facility was crowded and loud. He went on to state that, they were working on a plan to correct that. C. On 05/09/23 at 10:00 am during the resident council meeting, resident council members brought up the following concerns : 1. The dining area is overcrowded and very loud during meals. 2. Some residents avoid eating meals in the dining area due to the overcrowding and noise levels. D. On 05/09/23 at 12:26 pm during lunch observation in the dining area the following was revealed: 1. The dining area was crowded with residents (54) causing high noise levels and making any conversation difficult. 2. One of two access doors was blocked by serving carts and staff. 3. Dining assistance staff having difficulty maneuvering around room and between residents to deliver meals. 4. One resident got impatient with the noise and yelled out quiet! to the other residents in order to get staff's attention. 5. Four (4) residents having difficulty leaving the area after their meal was complete due to the crowded conditions. Other residents had to move their wheelchairs, walkers and themselves in order for other residents to leave. E. On 05/10/23 at 8:10 am during an interview with the Administrator (ADM), she stated that the fire Marshall had put an occupancy on the room for 90 people, but understood that the area is crowded. She acknowledged that it would be difficult to maneuver through the area with a resident if they had an emergency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure adequate pain relief for 1 (R #41) of 1 (R #41) resident reviewed for pain. This failure could likely result in unrelieved pain and diminished quality of life for the resident. The findings are: A. On 05/09/23 at 12:45 pm while observing R #41 during a conversation with Licensed Practical Nurse (LPN) #1, as he was exiting the dining room, it was noted that R #41 stopped his motorized wheelchair, was bending forward, and grimacing between words while speaking to LPN #1. (Using a [NAME] faces pain scale allows medical personnel to visually assess pain with zero 0 being no pain, and ten 10 being the worst imaginable). R #41 appeared to be in discomfort, and had to stop and rest while talking. LPN #1 was asking R #41 if he needed anything at the moment. R # 41 was unable to speak more that a couple of words at a time. LPN #1 stated she, would meet him at his room and see what he could have. B. Record review of R #41's care plan dated 03/15/23 revealed R #41 had diagnoses which included cerebral infarction (stroke), COPD (chronic lung disease which causes shortness of breath), cognitive communication deficit (difficulty thinking and making self understood) depression (sadness or loss of interest), dysarthria (weakened speech muscles), and anxiety (a feeling of panic or doom, difficulty concentrating). 1. The Physician order dated 03/08/23 at 11:44 am reads, Acetaminophen Tablet 325 milligrams. Give 2 tablets by mouth every 4 hours as needed for general discomfort. 2. The MAR lists pain assessment as once a shift. C. Record review of R #41's care plan dated 03/15/23 revealed that R #41 had back pain. The desired outcome was documented as, R #41's pain will be relieved by rest, pain reliever and (name of R #41) will not have an interruption in normal activities due to pain. D. Record review of R #41's care plan revised on 05/09/23 revealed: 1. R #41 is at risk for pain from co-morbidities. (More than one health condition in a person at the same time.) a. administer pain medication as ordered. The order read, Acetaminophen tablet, 325 milligrams. Give two (2) tablets by mouth every four (4) hours as needed for general discomfort. b. evaluate characteristics and frequency/pattern of pain. The ordered frequency of pain assessment was once per shift. c. there is no order or documentation about the characteristics or pattern of pain on the MAR. d. monitor for potential nutritional problem r/t (related to) discomforts or pain. e. evaluate what makes R #41's pain worse. f. maintain adequate level of comfort as evidenced by no s/sx (signs or symptoms) of unrelieved pain or distress, or verbalizing satisfaction with level of comfort. h. The (MAR), for May 2023, indicated R #41 rated his pain as 8 on 05/02/23, 6on 05/08/23, 9 on 05/09/23, and 8 on 05/10/23 using the facility provided pain scale. i. The facility pain scale on the Medication Record for May 2023 lists the pain scale to be used, as, 0-No Pain, 1-4-Mild Pain, 5-7-Moderate Pain, 8-10-Severe Pain. R #41's May 2023, Medication Administration record (MAR) indicated R #41 rated his pain 5 days out of 10 days (May 1-10, 2023) as 6 or above. i. Review of R # 41's MAR showed Tylenol was given for pain on one shift for the month of May for a pain rating of 8 on 05/10/23 at 8:10 am. E. On 05/10/23 at 2:45 pm during an interview with R #41, he stated that, sometimes he had pain and, would like to try a different medicine if he could. F. On 05/10/23 at 3:30 pm during an interview with Licensed Practical Nurse (LPN) # 1, she stated, no, I don't think (R #41) has adequate pain control. G. Record review of the month of 05/23 MAR, it was indicated that during pain rating for R #41 complained of pain each day with five (5) of the ten (10) days being rated as, 6 or more. The MAR stated to do resident assessment for pain every day, but the physician order stated R #41 could have pain medication every 4 hours as needed.

Based on record review, observation, and interview, the facility failed to ensure that the mental health needs of 1 [R #31] of 1 [R #31] resident reviewed for mental health needs was assessed and care was offered/provided to ensure their highest practicable well being. This deficient practice is likely to negatively impact the health and well being of residents. The findings are: A. Record review of current facility face sheet for R #31 revealed admitting diagnosis which included: Atherosclerotic Heart Disease Of Native Coronary Artery (hardening of the arteries), Muscle Weakness, Hypothyroidism (low hormone), Type 2 Diabetes Mellitus (high blood sugar), Hyperlipidemia (high cholesterol), Bipolar Disorder (mood swings), Major Depressive Disorder (feeling of sadness), Anxiety Disorder (feeling of fear), Post-Traumatic Stress Disorder (disorder caused by trauma), Mild Cognitive Impairment (memory loss), Polyneuropathy (nerve pain), Hypertension (High Blood Pressure), Heart Failure, Gastro-Esophageal Reflux Disease (acid reflux), Gastritis (intestinal swelling), Radiculopathy, Lumbosacral Region (pinched nerve in lower back), Urinary Incontinence, Hallucinations (seeing or hearing things not there), and Morbid Obesity Due To Excess Calories. B. On 05/09/23 at 10:26 am, during an observation R #31 appeared agitated (yelling out and over other residents) while at the resident council meeting. C. Record review of current care plan revealed no care plan related to R #31's PTSD diagnosis. D. Record review of previous care plan dated 01/18/23 revealed a care plan which addressed PTSD diagnosis within the psychotropic drug use plan. (This plan was unavailable to other than one person currently working since the take over on 03/01/23). E. On 05/16/23 at 10:45, during an Interview with DON, she stated that R #31 did not have a current care plan to address PTSD diagnosis. The DON stated, after talking to the Social Services Director, that R #31 has not been to a behavioral health specialist since arrival to the facility (07/04/22) to see if she needed help.

Based on record review, observation, and interview the facility failed to provide meals that tasted good, and served at an appetizing temperature (at or above 135 degrees Fahrenheit) for 2 (R #38 and R #164) of 2 (R #38 and R #164) residents reviewed for food quality. This failed practice has the potential to affect all residents identified on the resident census list provided by the administrator on 05/12/23 that were able to eat meals from the kitchen. This deficient practice has the potential for residents to not want to eat meals, which could lead to significant weight loss and not meeting their highest level of well-being. The findings are: A. Record review of facility meal times revealed the following: 1. Breakfast - 7:00 am 2. Lunch - 12:00 pm 3. Supper - 5:00 pm B. On 05/08/23 at 2:32 pm, during an interview R #38 stated that the food had bad flavor and was tough, and that the facility was not posting a menu for them to see what was being served. C. On 05/08/23 at 3:11 pm during an interview with R #164, he stated that the meat (hamburger patty with mushroom sauce) tasted funny and he couldn't eat it. When asked if he asked for something else R #164 stated, I didn't want to make a fuss. R #164 stated that he often times eats in the room due to his condition (he gets dizzy when he gets up for too long) and his food is often cold. D. On 05/9/23 at 12:09 pm, the following was observed during the lunch meal: 1. The meal was just getting to dining area for placement on the steam table. 2. There were 54 residents in dining, those needing assistance did not have a beverage. 3. The staff were having difficulty with maneuvering around the room to deliver plates 4. At 12:35 pm, room trays were made in dining room with only dome cover for retention of heat. 5. At 12:47 pm, the room trays departed the dining room for delivery. 6. At 12:50 pm, the roomtrays were sitting on the cart in hallway waiting to be delivered. 7. At 12:51 pm, the trays were being delivered to rooms (24 minutes between being made and delivered) allowing for food temperatures to lose significant heat and be cold. E. On 05/10/23 at 7:45 am, The following was observed during the breakfast meal: 1. The room trays were being made, set on wire cart, and covered with dome (insulated cover). 2. At 7:54 am, trays leave dining room to be delivered to resident rooms (54 minutes past posted time), allowing for food temperatures to lose significant heat and be cold. F. On 05/10/23 at 8:10 am, during an interview the Director of Dining Services (DDS) stated that the meals are made in the kitchen then transported on open wire carts to the main dining room and placed on a steam table. The meals are then plated from the steam table and sent out to the residents. Room trays are made from the steam tables and the plate is then placed on the open wire cart and domed (insulated plate topper). He stated that several are made and then sent out to the residents rooms. He stated that the plates did not have a bottom insulated base to go along with the dome tops. When given the scenario of earlier observations of room trays being delivered and the times that the plates sat on the cart(s); he acknowledged that the plates could have lost significant heat and meals could have been served cold. G. Record review of facility Dining Services Standards policy dated 12/2020 revealed the following: Purpose: Residents are provided a positive meal experience. Policy: The facility staff will ensure the residents are provided with a positive meal experience. Procedure: 7. In-Room Service: General . b. Meal distribution: . v. Trays are passed by nursing or designated staff within 15 minutes after leaving the kitchen. vi. Food and beverage carts are moved down the hallway when distributing trays; uncovered trays are not carried down the hall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility had the responsibility to implement standard precautions (infection control practice to limit or eliminate the spread of infections). The facility failed to investigate, recognize, prevent, and maintain control of the spread of infection to (24 of 61) residents. Failure to adhere to an infection control program is likely to cause the spread of infections to and from residents within the facility. The findings are: A. On 05/08/23 at 11:15 am, during an observation of the [NAME] Hall shower area the following was revealed: 1. The [NAME] shower room contained a large spray bottle with a yellowish tan liquid hanging from the hand rail. 2. There was a jar of white, thick cream that had visible finger marks in it. 3. The hallway curtain, surrounding the outside of the shower door, revealed it had some brown smudges which looked like stool had dried on the shower curtain in several places. 4. There was a trash can full of soiled incontinent briefs stacked to the top of the trash bin which was not covered presenting an infection control issue. B. On 05/08/23 at 11:17 am, during an interview with CNA #6, she stated, the trashcan should not be so full. The yellowish liquid in a spray bottle hanging from the handrail in the shower is a cleaner that is sprayed on the shower chair to clean it between residents. C. On 05/08/23 at 11:26 am, during an interview with the DON, regarding the full, uncovered trash can, the personal items which could be used on other residents, as well as the shower curtain with stains, the DON stated she understands the infection control issue. D. On 05/09/23 at 2:20 pm, during an observation of the [NAME] shower room, it was observed to have items including a large spray bottle with a yellowish tan liquid with a [NAME] label Ph7Q hanging from the hand rail, a jar of white, thick cream marked with a [NAME] label moisture shield that has visible finger marks dug into it. E. On 05/10/23 at 09:30 am, during an interview CNA # 6 stated, no they (unmarked, open containers) should not be in here (the west shower), sometimes we get brain drain. She called CNA #7 and asked her to bag and remove the items, the razor was placed in the sharps container, and small bottles of shampoo and lotion that were not marked with a resident name per facility policy Personal Belongings to prevent use for other residents possibly spreading germs, were removed. F. On 05/10/23 at 11:20 am, during an observation of the [NAME] hall shower room contained a large green bar of soap, a razor, open bottles of soap, bottles of soap with scent, a large bottle of lotion, as well as large shampoo and conditioner pump bottles. G. On 05/10/23 at 11:45 am, during an interview with the Assistant Director of Nursing, she stated, these things definitely should not be in here. She called CNA # 6 over and asked her to call CNA # 7 over to observe the items. H. The policy provided by the facility dated 08/2020 Resident Rights-Personal Property stated, the resident's personal belongings will be inventoried and documented. Personal products prevents the spread of infection through using intimate personal products (creams, lotions, shaving creams, razors, and shampoos) only on and for the person it belongs to. I. On 05/09/23 at 2:36 pm, during an observation of R #164's room revealed a urinal on his over the bed tray (bedside table) along side of his meal that was not completed (25% eaten). J. On 05/09/23 at 3:15 pm, during an observation of R #164's room revealed a urinal was still sitting on his table and the meal had been removed from the table. K. On 05/09/23 at 4:30 pm, during an interview with DON and Administrator (ADM) they stated that the urinal for R #164 should not be on his bedside table where he eats, but placed somewhere away from that table, like the side of the bed or an area designated for it. L. Record review of the Infection Prevention and Control Program Policy dated 6/2020 on page 5 of 8 provided by the facility, it stated: II. A.The facility's infection control policies, and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.

Based on record review, observation, and interview, the facility failed to ensure that residents have the ability to directly contact caregivers from their rooms/toilet areas from a communication system for 5 (R #36, 41, 49, and 50, and 55) of 5 (R #36, 41, 49, and 50, and 55 ) residents reviewed for an equipped call light system. If the facility is not ensuring that residents have access to request assistance from their room or bathrooms, then residents may not get the care and services they need. The findings are: A. Record review of facility Communication - Call System policy dated 10/24/22 revealed the following: Purpose:To provide a mechanism for residents to promptly communicate with nursing staff. Policy I. The facility will provide a call system to enable residents to alert the nursing staff from their beds and toileting/bathing facilities. Procedure . II. Call cords will be placed within the resident's reach in the resident's room. VIII. An adaptive call bell (e.g. flat pad call cord, hand bell, etc.) will be provided to a resident per the resident's needs. R #36 A. On 05/09/23 at 3:30 pm, during an observation of R #36, R #36 was observed sitting in her recliner sleeping. The recliner was in front of the bedside table. Her call light was between the recliner and the bed, behind her on the bedside table. B. On 05/10/23 at 8:30 am, during an observation, R #36 was sitting on the side of the bed. The call light was wrapped around the top rail and had fallen between the recliner and bed. Resident asked that someone come assist her to reach her protein bar that had fallen behind the head of the bed. Certified Nursing Aide, (CNA) # 6 came into the room to ask resident if she would like a shower, bed bath or wait till later. CNA #6 was able to get the protein bar, threw it in the trash and went to get the resident another one. R #41 C. On 05/09/23 at 9:10 am, during an observation, R #41 was sitting in his wheelchair. His call light was observed on the opposite side of the bed from his wheelchair about 5 feet away from him. D. On 05/10/23 at 8:15 am, during an observation, R #41 was sleeping on his bed. The call light device was observed at the end of his bed outside the privacy curtain on the bedside table. This table was approximately 7 feet from the resident's arm reach ability. R #49 E. On 05/08/23 at 2:58 pm, during an observation of R #49 room, it was observed that his call light was out of R #49's reach on the floor about 4 feet from him. F. On 05/10/23 at 8:55 pm, during an observation of R #49, R #49 was observed in bed and it appeared as though his call light was out of his reach, sitting on a chest of drawers about 6 feet away from him. G. On 05/10/23 at 9:00 pm, during an interview with the Infection Preventionist/Licensed Practical Nurse (IP) it was confirmed that the call light was not within reach of R #49, sitting on a chest of drawers about 6 feet away from him. H. Record review of the Care Plan dated 04/14/23, revealed the resident having to call for assistance when in pain. R #50 I. On 05/08/23 at 2:44 pm, during an observation of R #50 room, it was observed R #50's call light was not within reach, sitting on a table approximately 4 feet away from the bed. R # 55 J. Record review of R #55's fall care plan dated 04/11/23, revealed that R #55 was to have his call light, reachable. K. Record review of R #55's fall care plan dated 05/04/23, CNA's are instructed to be sure call light is within reach and encourage (name of R #55) to use it for assistance. L. Record review of R #55's pain/ADL (activities of daily living) care plan dated 05/04/23, nurses are directed to, encourage resident to call for assistance for pain, repositioning and medication. M. On 05/09/23 at 3:15 pm, during observation of R #55, it was observed that R #55 was in bed, and appeared to be sleeping. His call light was not in reach, sitting under his bed approximately 4 feet from him. N. On 5/10/23 at 10:10 am, during an observation R #55, was observed in his wheelchair, hurrying to his restroom while calling out, hey, hey. The resident's call light was not within reach, sitting under his bed approximately 4 feet from him. O. 05/10/23 at 9:10 pm, during an interview with the DON, she confirmed that the call light was not within reach of R #49. She further stated she would have to review his care plan to update it and that the call lights for all the residents would need to be checked to ensure that they were within their reach.

Based on observation and interview, the facility failed to provide sufficient space for Dining. This failure has the potential to affect the all residents (as listed on the Resident Census provided by the Administrator on 05/08/23) living in the facility, and is likely to hinder safe movements, timely delivery of meals, and exceed acceptable noise levels while in the dining area. The findings are: A. On 05/08/23 at 12:12 pm, during the lunch dining the following observations were made: 1. The dining area was very crowded with residents wheelchairs and walkers, making moving around difficult to include entering the dining area, serving and assisting the residents with dining, and exiting the area after the meal was complete. 2. The overcrowding of the area caused high sound levels which made any conversation difficult as it was hard to hear another person. This caused it to be difficult to get staff attention for assistance. B. On 05/09/23 at 12:26 pm, during the lunch dining the following observations were made: 1. The dining area was crowded with residents. 2. Their talking caused high noise levels making conversation difficult. 3. A resident got so impatient with the noise he yelled out quiet! to the other residents in order to get staff's attention. 4. Four residents had difficulty leaving the area after their meal was complete due to the crowded conditions. Other residents had to move their wheelchairs, walkers and themselves in order for other residents to leave. C. On 05/09/23 at 10:00 am, during the resident council meeting/interview, members brought up the dining area is overcrowded and very loud during meals. D. On 05/08/23 at 12:45 pm, during an interview with the Corporate Dietary Director, he confirmed that the dining facility was crowded and loud. He went on to state that they were working on a plan to correct that.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to 1) Develop a comprehensive care plan and 2) Implement a comprehensive care plan for 4 (R #2, 30, 31 and 41) of 4 (R #2, 30, 31 and 41) reviewed for comprehensive care plans. This failure is likely to delay residents in developing plans of care that are effective for their optimal well-being. the findings are: Findings for R #2 A. Record review of facility face sheet for R #2 admitted on [DATE] revealed admission diagnoses which included: Heart Disease (conditions that affect the heart's function and blood flow), Kidney Failure (kidneys no longer function well on their own), Reflux (stomach acid repeatedly flows back into the tube connecting your mouth and stomach), Obesity (overweight), Hernia (organ or tissue bulges through a weak spot in the abdominal wall), Vitamin D Deficiency (low vitamin D levels), Fracture (bone break), Muscle Atrophy (loss or thinning of muscle), Dependence On Wheelchair, Hypothyroidism (low thyroid levels), Hyperlipidemia (high cholesterol), Dysphagia (trouble swallowing), Multiple Sclerosis (central nervous disease), Weakness, Need For Assistance With Personal Care, Pressure Ulcer ( injuries to skin and underlying tissue resulting from prolonged pressure on the skin), Fracture Of Right Tibia (broken leg bone), Fracture Of Right Fibula (broken leg bone), Cognitive Communication Deficit (trouble thinking and speaking). B. Record review of R #2's weights revealed on 12/02/2022, the resident weighed 242 lbs and on 05/04/2023, the resident weighed 204.6 pounds which is a -15.45 % weight loss.: C. Record review of R #2's Care Plan dated 04/21/23 revealed that it did not address weight loss. D. Record review of Progress notes for R #2 revealed the following: 04/27/2023 at 14:08 (2:08 pm) Nutrition Note Text: Name: (name of R #2) RD (Registered Dietician) following Rsd (resident) d/t (due to) wound and severe weight loss. Rsd is currently 201.5 lbs and within ideal range of 171-209 lbs and 99.8% of ideal weight, BMI (a measure of body fat: 24.5. Ht: 76 Severe weight loss of 69.8 lbs, 25.7% in 2 months. Diet order: Regular/Pureed; Supplements: Liquacel BID (2 times a day). Appetite: Poor/Fair, 25-50%; Nutrition Diagnosis: Inadequate oral intake related to increased nutrient needs as evidenced by wound and severe weight loss.; Recommendations: Ensure TID (3 times a day) d/t poor/fair appetite, recent severe weight loss and wounds.; RD following monthly/PRN. 05/4/2023 at 16:16 (4:16 pm) Nutrition Note Text: Name: (name of R #2) RD following Rsd d/t wound and severe weight loss. Rsd is currently 204.6 lbs and within ideal range of 171-209 lbs and 107.7% of ideal weight, BMI: 24.9. Ht: 76 . Severe weight loss of 67 lbs, 24.6% in 3 months. Diet order: Regular/Pureed Supplements: Liquacel BID/Ensure TID; Appetite: Poor/Fair, 25-50%; Nutrition Diagnosis: Inadequate oral intake related to increased nutrient needs as evidenced by wound and severe weight loss.; Recommendations: Ensure TID added 4/28(/23) for this wt loss, rsd with beneficial gain of 3.1 lbs, 1.5% in 1 mo., continue POC (Plan of Care) at this time. RD following monthly/PRN (as needed). E. On 05/11/23 at 5:47 pm, during an interview with the DON, she confirmed that a nutritional weight loss plan was not developed for R #2 after his significant weight loss. Findings for R #30 F On 05/08/23 during a record review of R #30's facility face sheet revealed admitting diagnoses for admission of 07/29/21 and included: Non-st elevation (nstemi) myocardial infarction (heart attack). Unspecified ectropion of left lower eyelid (watery eyes without proper drainage). Chronic pain (arthritis right knee). Other seasonal allergic rhinitis (allergies to environment). Mixed hyperlipidemia (fat in the blood). Major depressive disorder (sadness,or disinterest in things previously interested in). Anxiety (feeling of panic, doom, fast heart rate). Restless legs syndrome (inability to be still and rest, feeling like you must move your legs). Essential hypertension (high blood pressure not due to another condition). Atherosclerotic heart disease of native coronary artery without angina pectoris (hardening of the arteries, without pain). Old myocardial infarction (previous heart attacks). Chronic obstructive pulmonary disease (difficulty breathing) low back pain. Unsteadiness on feet(dizziness, lack of balance). Weakness (lack of strength or energy). Other malaise (feeling sick, lack of energy), other fatigue (tiredness, not improved with rest). Dependence on supplemental oxygen (requirement of more oxygen than room air for tissue health). Personal history of COVID-19. Dysphagia (difficulty swallowing for unknown reason). G. Record review of the facility provided smoker list (not dated) on 05/08/23 indicated R #30 was an independent smoker. H. Record review of R #30's initial care plan dated 05/08/23 identified the resident as a/an independent smoker. I. On 05/10/23 at 9:15 am, during an interview with R #30, she (R #30) stated she was/is a smoker. J. Record review of Minimum Data Set (MDS) for R #30 revealed the resident was not evaluated for smoking. K. Record review of smoker policy dated 12/2017, revealed: Nursing Policy and Procedure Subject Smoking. Policy: It is the policy of this home that :*All residents who smoke will be supervised. L. Record review of facility Smoking by Residents policy, dated 03/2022 revealed: Purpose . Policy . IV. Residents who want to smoke will be assessed for their ability to smoke safely prior to being allowed to smoke independently in these areas. V. Residents who are not able to smoke independently and safely will be accompanied by Facility Staff while smoking. Procedure I. Smokers shall be identified at the time of admission. A. Residents will be provided with a copy of this policy during admission process a. All smokers shall be assessed related to smoking safety at the time of admission and then at least quarterly as outlined by OBRA (Omnubus Budget Reconciliation Act of 1987) assessment time frames. b. If necessary, a referral to PT/OT (Physical Therapy/Occupational Therapy) to access for the necessary eye-hand coordination and cognitive skills for safe smoking may be required. II. The IDT (Interdisciplinary Team) shall create a Smoking Care Plan for the resident. X. All smoking sessions will be supervised by facility Staff members. M. On 05/10/23 at 9:30 am, during an interview with the Minimum Data Set (MDS) Coordinator/Care Plan Coordinator (CPC) about R #30's independent smoker status, she brought up the computer information and said, yes she is listed as an independent smoker and has a care plan for independent smoking, but she doesn't smoke. That is a mistake on the smoker list and care plan. R #30 is not a smoker, she (R 30) only went out to smoke once that I know of. When asked why she (R #30) was smoking, she (R #30) stated, I don't know, another resident gave me one and I smoked it. She is not a smoker. N. The MDS/CPC acknowledged the conflict of provided information documented for R #30, including R #30's interview, R #30 being on the smoker list, (undated), the care plan dated 05/08/2023), and the facility provided policy and procedure (dated 12/2017 and 03/2020) which stated, all smoking sessions will be supervised by facility Staff members. O. On 05/10/23 at 11:30 am during an interview the MDS/CPC she stated, I just spoke with the Director of Nursing about (name of R #30) and she (R #30) is not a smoker, she does not need a care plan for smoking, or to be on the smoker list. That will be corrected at our next IDT meeting. They happen in the morning and at night. That is when we update the resident information Findings R #31 P. Record review of current facility face sheet dated 07/04/22 for R #31 revealed admitting diagnoses which included: Atherosclerotic Heart Disease Of Native Coronary Artery (hardening of the arteries), Muscle Weakness, Hypothyroidism (low hormone), Type 2 Diabetes Mellitus (high blood sugar), Hyperlipidemia (high cholesterol), Bipolar Disorder (mood swings), Major Depressive Disorder (feeling of sadness), Anxiety Disorder (feeling of fear), Post-Traumatic Stress Disorder (disorder caused by trauma), Mild Cognitive Impairment (memory loss), Polyneuropathy (nerve pain), Hypertension (High Blood Pressure), Heart Failure, Gastro-Esophageal Reflux Disease (acid reflux), Gastritis (intestinal swelling), Radiculopathy, Lumbosacral Region (pinched nerve in lower back), Urinary Incontinence, Hallucinations (seeing or hearing things not there), and Morbid Obesity Due To Excess Calories. Q. On 05/09/23 at 10:26 am, during an observation R #31 appeared agitated (yelling out and talking over other residents) while at the resident council meeting. R. Record review of current care plan initiated on 03/01/23 revealed no care plan related to R #31's PTSD diagnosis. S. Record review of previous care plan dated 01/18/23 revealed a care plan which addressed PTSD diagnosis within the psychotropic drug use plan. T. On 05/16/23 at 10:45, during an Interview with DON, she stated that R #31 did not have a current care plan to address active PTSD diagnosis. Findings for R #41 U. Record review of facility face sheet for R #41 revealed admitting diagnoses which included: cerebral infarction (stroke) COPD (chronic lung disease which causes shortness of breath), cognitive communication deficit (difficulty thinking and making self understood) depression (sadness or loss of interest), dysarthria (weakened speech muscles), and anxiety (a feeling of panic or doom, difficulty concentrating). V. Record review of facility (undated) Smokers list provided by the facility revealed Smoking Hours for Supervised Smokers were as follows: 0800 (am), 1000 (am), 2 (pm) and 6 (pm) W. Record review of R # 41's care plan for nursing dated 03/15/23 indicated R #41, needs supervision while smoking. The care plan also indicated, Encourage resident to wear smoking apron while smoking to prevent injuries, and to smoke with supervision. X. Record review of R # 41's activity care plan dated 05/09/23 indicated that he is an independent smoker. Y. Record review of smoker policies provided by the facility dated 12/2017, and 03/2022 stated: 1. All residents will be supervised by staff during smoking. 2. Resident was observed smoking, outside facility set smoking hours. AA. On 05/10/23 at 9:45 am, during an observation of R #41 revealed he was out on the patio smoking. He was unaccompanied, and there were no staff members outside supervising smoking. BB. On 05/10/23 at 9:47 am, during an interview R #41 stated, I am an independent smoker and I don't want to wear an apron.

Based on observation, record review and interview, the facility failed to store food under sanitary conditions by not ensuring (1) Food items stored in facilities dry storage were labeled and dated, (2) Food items in the dry storage area were stored in the correct locations, and (3) expired foods were either used or discarded prior to expiration date. These deficient practices are likely to affect all 61 residents residing in the facility, and are likely lead to foodborne illnesses in residents if food is not being stored properly and safe food handling practices are not adhered to. The findings are: A. On 05/08/23 at 9:55 am during the initial tour of the facility kitchen the following was observed: 1. Two- 1.5 gallon Tupperware container of cereal was labeled use by 03/02/23 and was still on the shelf. 2. One- 1.5 gallon Tupperware container of cereal was labeled use by 05/02/23 and was still on the shelf. 3. One large metal mixing bowl with a powdery substance was wrapped in plastic wrap, unlabeled and stored on the shelf. 4. One undated package of gelatin was wrapped in plastic and stored on the shelf. 5. One undated box of brownie mix was stored on shelf. 6. Two undated bags of Frito were stored on the shelf. 7. Several boxes of food products were sitting on the bare floor. B. During observation of the lunch meal 05/08/23 at 12:12 pm the following was observed: 1. The food traveled the entire length of the facility from the kitchen to the dining area in an unheated wire cart. 2. There were not any posted menus in the dining area. C. During observation of the dining area at lunch on 05/09/23 at 12:26 pm the following was observed: 1. Food arriving to the dining area was over 15 minutes late. 2. Menus were not posted in the dining area. 3. A resident did not want the food on the menu and ordered an alternative. The alternative menu took 25 minutes to arrive for the resident's meal. D. On 05/10/23 at 8:10 am, during an interview the Director of Dietary Services (DDS) stated that the facility had ordered hot boxes (insulated food transport carts), however they had not come in yet, as well as the menu displays which had not been placed up for resident viewing. He acknowledged that the equipment used to serve meals impedes the entry and exit of the right side door use. E. On 05/10/23 at 8:30 am, during an interview the Director of Dietary Services (DDS) stated that menus had been made for both the south and main dining areas and sent out to the nurses stations, but could not say as to why they had not been displayed. DDS stated that the meals are made in the kitchen then transported on open wire carts to the main dining room and placed on a steam table. The meals are then plated from the steam table and sent out to the residents. Room trays are made from the steam tables and the plate is then placed on the open wire cart and domed (insulated plate topper). He stated that several are made and then sent out to the residents rooms. He stated that the plates did not have a bottom insulated base to go along with the dome tops. When given the scenario of the earlier observation and the times that the plates sat on the cart; he acknowledged that the plates could have lost significant heat. F. On 05/11/23 at 12:49 pm during a subsequent visit to the kitchen and interview with the dietary manager he confirmed the above findings and stated that, all food items should be labeled and dated and nothing should be set on the bare floor. G. Record review of the facility's Food Storage policy dated 12/2020 revealed: Purpose: To establish guidelines for storing, thawing, and preparing food. Policy: Food items will be stored, thawed, and prepared in accordance with good sanitary practice. XIII. Dry Storage Guidelines F. Foods should be stored off the floor. G. Any opened products should be placed in storage containers with tight fitting lids. H. Label and date storage products.