**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and resident and staff interviews, the facility failed to provide a safe transfer for 1 of 6 residents reviewed for accidents (Resident #51). The findings included: Resident #51 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease and type 2 diabetes. The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #51 was cognitively intact and dependent on staff for transfers. The care plan dated 12/02/24 revealed Resident #51 required 2-person assistance using the sit-to-stand lift for all transfers. An incident report dated 1/29/25 at 8:00 PM written by Nursing Supervisor #1 indicated Nurse Aide (NA) #3 was assisting Resident #51 to stand, pivot and transfer from the wheelchair to the bed and they both fell onto the bed. Resident #51 was assessed, and no injuries were noted. NA #3's written statement dated 1/29/25 indicated at approximately 8:00 PM she entered Resident #51's room to assist her into bed. Resident #51 stated she had been working with therapy, was feeling stronger and wanted to stand and pivot to transfer without using the sit-to-stand lift. NA #3 agreed to assist Resident # 51 with a stand and pivot transfer and positioned her close to the bed in the wheelchair. Resident #51 used the bedrail and pulled herself up to a standing position, but her legs were weak, and she started lowering down to the floor. NA #3 was able to pivot Resident #51 and they both landed in a seated position on the bed. An interview with NA #3 on 3/26/25 at 2:24 PM revealed she was Resident #51's assigned NA on 2nd shift (3pm-11pm) on 1/29/25. She stated Resident #51 required 2-person assistance with the sit-to-stand lift for all transfers. NA #3 indicated on 1/29/25 at approximately 8:00 PM Resident #51 was ready to lay down in bed. She revealed Resident #51 told her she was feeling stronger and instead of using the sit-to-stand lift she requested NA #3 assisted her to stand and pivot to the bed. NA #3 stated she wanted to honor Resident #51's choice, so she positioned her close to the bed Resident #51 used the bed rail to pull up into a standing position. She stated Resident #51 was able to pull up to a standing position, but her legs started shaking and she started lowering down to the floor. NA #3 indicated she pushed the wheelchair out of the way, put her arms around Resident #51, turned her around, and they both landed in a seated position on the bed. NA #3 revealed she then assisted Resident #51 to lay down and asked her if she was injured. She indicated Resident #51 stated she was not injured and that her legs must have been weak from sitting in the wheelchair too long. NA #3 stated she went out into the hall and notified a staff member that she needed the nurse. She revealed Nurse #4 responded to Resident #51's room, completed an assessment and no injuries were noted. NA #3 stated assisting Resident #51 to stand, pivot and transfer to the bed was not safe and she should have used the sit-to-stand lift. A phone interview with Nurse #4 on 3/27/25 at 1:41 PM revealed she was the 2nd shift nurse assigned to Resident #51 on 1/29/25. Nurse #4 stated she responded to Resident #51's room per NA #3's request and observed Resident #51 lying comfortably in bed. She stated NA #3 reported to her that Resident #51 requested to stand and pivot to transfer to the bed and did not want to use the sit-to-stand lift. Nurse #4 stated during the transfer Resident #51's legs became weak, and NA #3 had to put her arms around Resident #51 to turn her body and they both landed in a seated position on the bed. Nurse #4 revealed Resident #51 was not in any distress, her vital signs were stable, and no injuries were noted. An interview conducted with Resident #51 on 3/26/25 at 12:24 PM revealed staff used a mechanical lift to transfer her in and out of the bed. Resident #51 stated she was unsure if a NA had ever assisted her with a stand/pivot transfer and she did not recall the incident that occurred on 1/29/25. During an interview with the Director of Nursing (DON) on 3/27/25 at 12:13 PM she stated she was aware of the incident that occurred on 1/29/25. The DON indicated NA #3 assisting Resident #51 with a stand and pivot transfer was unsafe and she should have used the sit-to-stand lift. An interview conducted with the Administrator on 3/27/25 at 1:50 PM revealed Resident #51 required 2-person assistance and the sit-to-stand lift for all transfers. She indicated NA #3 wanted to honor Resident #51's request but should have used the sit-to-stand lift to ensure the transfer was safe.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, resident, staff, and Physician Assistant (PA) interviews, the facility failed to ensure oxygen was delivered at the prescribed rate (Resident #41 & Resident #101). These deficient practices occurred for 2 of 2 residents reviewed for respiratory care and services. The findings included: 1. Resident #41 was admitted to the facility on [DATE]. Resident #41 had diagnoses which included chronic respiratory failure with hypoxia. Review of the care plan dated 03/26/2024 and revised on 02/25/2025 revealed Resident #41 was at risk for respiratory complications secondary to chronic respiratory failure with hypoxia requiring supplemental oxygen. The interventions included administer oxygen as ordered and observed for signs and symptoms of respiratory complications. Review of Resident #41's electronic medical record (EMR) revealed a physician's orders dated 07/29/2024 for oxygen at 3 liters per minute (LPM) via nasal cannula continuous. Review of Resident #41's annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was cognitively intact. The MDS also indicated Resident #41 was receiving oxygen. Observations of Resident #41 were completed on 03/24/2025 at 2:16 PM, 03/25/2025 at 10:53 PM, 03/26/2025 at 8:53 AM, and 03/27/2025 at 8:24 AM. During each of the observations Resident #41 was observed in bed with her nasal cannula in her nostrils and the oxygen concentrator set at 4 liters per minute. An interview was completed on 03/27/2025 at 10:01 AM with Nursing Assistant (NA) #1 who was assigned to Resident #41. NA #1 stated she did not do anything with oxygen settings. NA #1 further stated she did make sure the nasal cannula was in place and applied correctly for residents receiving oxygen. An interview was conducted on 03/27/2025 at 10:06 AM with Nurse #2 who was assigned to Resident #41 on 03/27/2025 from 7:00 AM to 3:00 PM. Nurse #2 stated that all residents receiving oxygen should have a physician's order for oxygen which would include the flow rate. Nurse #2 also stated the flow rate should be set as ordered by the physician. Nurse #2 further stated she reviewed Resident #41's physician's orders and stated that Resident #41 should be on 3 liters per minute of continuous oxygen via nasal cannula. An interview was completed with Resident #41 on 03/27/2025 at 10:20 AM. Resident #41 stated that she used to be able to manage her oxygen, but her health had gotten so bad over the years that she could no longer do that. Resident #41 also stated that she did not touch her oxygen concentrator or adjust the flow rate. Resident #41 further explained that she did not know what her oxygen should have been set at. An interview was completed on 03/27/2025 at 10:39 AM with the Director of Nursing (DON). The DON stated Resident #41 did get up to the chair with assistance and Resident #41 could have changed the flow rate on the concentrator. The DON stated she expected the nursing staff to check the physician's order for the prescribed oxygen flow rate and check to make sure residents were receiving the correct oxygen flow rate. The DON further explained that three days of observations for an incorrect oxygen flow rate was not acceptable nursing practice. An interview was conducted on 03/27/2025 at 10:58 AM with the Administrator. The Administrator stated she expected all staff to follow the physician's order for oxygen settings. A telephone interview was conducted with the Physician Assistant (PA) on 03/27/2025 at 2:15 PM. The PA stated all residents receiving oxygen required an active physician's order for the prescribed liters per minute of oxygen they were to receive. The PA further stated nursing staff should follow the physician's orders for providing oxygen including the prescribed flow rate. 2. Resident #101 was admitted to the facility on [DATE]. Resident #101 had diagnoses which included congestive heart failure (CHF), respiratory failure with dependence on supplemental oxygen, and atrial fibrillation (AF). Review of the care plan dated 08/27/2024 and updated 02/05/2025 revealed Resident #101 was at risk for respiratory complications secondary to congestive heart failure and respiratory failure requiring supplementary oxygen. The interventions included to administer oxygen as ordered, encourage rest periods as appropriate, and observed for signs and symptoms of respiratory complications. Review of the electronic medical record (EMR) revealed a physician order for Resident #101 dated 08/28/2024 for oxygen at 3 liters per minute via nasal cannula (NC) continuous for shortness of breath related to CHF. A review of Resident #101's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #101 had severely impaired cognition. The MDS also indicated Resident #101 was receiving oxygen. Observations were completed of Resident #101 on 03/24/2025 at 3:16 PM, 03/25/2025 at 10:58 AM, 03/26/2025 at 8:58 AM, and 03/27/2025 at 8:28 AM. During each of the observations Resident #101 was observed resting in bed with her nasal cannula in her nostrils, the oxygen concentrator was set at 1.5 liters per minute, and Resident #101 was observed to not be in distress. An interview was completed on 03/27/2025 at 10:01 AM with NA #2 who was assigned to Resident #101. NA #2 stated she did not do anything with oxygen settings. NA #2 further stated she did make sure the nasal cannula was in place and applied correctly for residents receiving oxygen. NA #2 also stated she also checked to make sure the oxygen concentrator was plugged up correctly into the electrical outlet. An interview was conducted on 03/27/2025 at 10:27 with Nurse #3. Nurse #3 was assigned to Resident #101 from 7:00 AM to 3:00 PM on 03/24/2025, 03/25/2024, and 03/26/2025. Nurse #3 stated Resident #101 could not change her oxygen settings independently. Nurse #3 also stated she did not check Resident #101's oxygen flow rate on 03/24/2025, 03/25/2025, or on 03/26/2025. An interview was completed on 03/27/2025 at 10:39 AM with the Director of Nursing (DON). The DON stated Resident #101 could not change her oxygen setting independently. The DON stated she expected the nursing staff to check the physician's order for the prescribed oxygen flow rate and check to make sure residents were receiving the correct oxygen flow rate. The DON further explained she expected the nursing staff to provide oxygen at the prescribed flow rate. An interview was conducted on 03/27/2025 at 10:58 AM with the Administrator. The Administrator stated that she expected all staff to follow the physician's order for oxygen settings. A telephone interview was conducted with the Physician Assistant (PA) on 03/27/2025 at 2:15 PM. The PA stated all residents receiving oxygen required an active physician's order for the prescribed liters per minute of oxygen they were to receive. The PA further stated nursing staff should follow the physician's orders for providing oxygen to all residents including the prescribed flow rate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #126 was admitted to the facility on [DATE] with diagnoses including generalized weakness and diabetic neuropathy. The annual Minimum Data Set (MDS) dated [DATE] revealed Resident #126 cognitively intact requiring extensive assistant of one staff member for most activities of daily living (ADL). Resident #126 was assessed as having no skin conditions during the assessment period. On 03/24/25 at 12:25 PM Resident #126 was observed to have a lidded container of prescription topical medicated cream that treats fungal infections on his bedside table. Resident #126 stated, I put it on my legs and use it for itching. Resident #126 explained he had the cream prior to admission into the facility and had always applied it as he wanted. Resident #126 did not recall where the cream came from. He stated he left it sitting at his bedside and no staff member had ever said anything to him. During an observation of Resident #126's room on 03/25/25 at 2:26 PM the lidded container of prescription topical medicated cream that treats fungal infections remained on his bedside table. During an observation of Resident #126's room on 03/26/25 at 10:27 AM the lidded container of prescription topical medicated cream that treats fungal infections remained on his bedside table. An interview conducted on 03/26/25 at 10:35 AM with Unit Manager #1 revealed she was not aware of any medication on Resident #126's bedside table. She stated no residents in the facility were allowed to keep medications at the bedside. On 03/26/25 at 10:42 AM Unit Manager #1 was accompanied to Resident #126's room and observed the lidded container of prescription topical medicated cream that treats fungal infections located on Resident #126's bedside table. Resident #126 stated to Unit Manager #1, I put it on my groin. Unit Manager #1 removed the container of medicated cream from Resident #126's room. The container had an expiration date of January/2024. On 03/26/25 at 2:55 PM an interview was conducted with Nurse #1. During the interview she stated she was Resident #126's nurse during the 7:00 AM to 3:00 PM shift on 03/24/25, 03/25/25 and 03/26/25. She stated she had not noticed the container of medicated cream on the resident's bedside table. The interview revealed she felt the container was missed because the resident had a lot of items on his bedside table, and it was just missed. On 03/27/25 at 10:00 AM an interview was conducted with the Medical Director. During the interview she stated the medicated cream was appropriate but not for the resident to apply himself. The facility did not know Resident #126 had the container of medicated cream in his room. The Medical Director indicated Resident #126 was alert and oriented but had intermittent confusion and was not assessed to administer his own medications. She stated she had evaluated him on 03/26/25 and there was no harm caused by using the medicated cream. However, it was removed, and he received a new order for a cream to be administered by nursing staff. The Medical Director stated the label on the container indicated the medicated cream had been originally prescribed for application to the resident's groin. On 03/27/25 at 9:55 AM an interview was conducted with the Director of Nursing (DON). She stated a physician's order was required to have any medication at a resident's bedside. The DON stated the facility was unaware Resident #126 had the medicated cream at his bedside otherwise it would have been removed. The medicated cream was not prescribed in-house by the Medical Director. On 03/27/25 at 9:50 AM an interview was conducted with the Administrator. She stated the medicated cream was immediately removed from the resident's room when it was brought to Unit Manager #1's attention. Resident #126 kept it at his bedside without staff knowing. She stated she expected the nurses to be observant of medication at bedside. Based on record reviews, observations and staff interviews, the facility failed to discard expired medications in 1 of 2 medication rooms (South Hall Medication Room) and failed to store a lidded container of prescription topical medicated cream that treats fungal infections in a secure locked storage area for 1 of 1 resident observed with medicated cream at the bedside (Resident #126). The findings included: 1. An observation of the South Hall Medication Room was conducted on 03/25/2025 at 3:19 PM with the Director of Nursing (DON). The observation revealed an unopened bottle of Red [NAME] Oil (omega 3 vitamin) containing 60 soft gel tablets available for use. The expired bottle of Red [NAME] Oil was located in the top cabinet of the medication storage room. A review of the pharmacy label affixed to the bottle of Red [NAME] Oil indicated the expiration date was 07/16/2024. The printed manufacturer's expiration date was illegible. During the observation, an interview with the DON was conducted. The DON confirmed the expiration date and stated there should be no expired medications in the medication storage room or in the medication carts. She also stated the bottle of Red [NAME] Oil tablets should have been discarded. The DON further explained that all nursing staff were responsible for checking the medication rooms weekly for expired medications and the bottle of Red [NAME] Oil should have been discarded. An interview was conducted with the Administrator on 03/27/2025 at 8:23 AM. The Administrator stated that she expected all expired medications be discarded and not available for use.

Based on observations, record review, and staff interviews, the facility failed to follow their Hand Hygiene policy when the Treatment Nurse did not perform hand hygiene before each donning of clean gloves while providing wound care to Resident #63. This deficient practice occurred for 1 of 5 staff members observed for infection control practices (Treatment Nurse). The findings included: Review of the facility's policy and procedure entitled Hand Hygiene read in part: Hand hygiene continues to be the primary means of preventing the transmission of infection. The following is a list of some situations that require hand hygiene: - Upon and after coming in contact with a resident's intact skin, (e.g., when taking a pulse or blood pressure, and lifting a resident) - After contact with a resident's mucous membranes and body fluids or excretions; - After handling soiled or used linens, dressings, bedpans, catheters, and urinals; - After removing gloves or aprons; and - After completing duty. A wound observation was made on 03/25/25 at 2:13 PM on Resident #63 with the Treatment Nurse. The Treatment Nurse was observed cleaning the bedside table with disinfectant wipe and placed her wound supplies on wax paper on the table after it dried. The treatment nurse donned a clean gown and sanitized her hands and donned clean gloves and removed the old dressing from the resident's right lateral leg and measured the wound with a disposable paper measuring tape. The Treatment Nurse then doffed her gloves and without sanitizing her hands, donned a clean pair of gloves and proceeded to rub cream on the resident's right leg and foot. She then doffed her gloves and without sanitizing her hands, donned clean gloves and cleansed the wound with normal saline soaked gauze from the inside of the wound outward. The Treatment Nurse then doffed her gloves, sanitized her hands and donned clean gloves and patted the wound dry with gauze, doffed her gloves, sanitized her hands and donned clean gloves and applied silver alginate to the wound bed and covered it with bordered gauze and then covered the resident's leg with his sheet. She then proceeded to Resident #63's left leg posterior skin tear for treatment. The Treatment Nurse doffed her gloves, sanitized her hands and donned clean gloves and rubbed cream on the resident's left lower leg and foot. She doffed her gloves, sanitized her hands and donned clean gloves and removed the old dressing from the resident's left posterior lower leg skin tear. The Treatment Nurse doffed her gloves and without sanitizing her hands, donned clean gloves and cleansed the wound with normal saline soaked gauze from inside of the wound outward, doffed her gloves, and without sanitizing her hands, donned clean gloves and patted the wound dry with gauze. She doffed her gloves, sanitized her hands and donned clean gloves and applied xeroform to the wound bed and covered with a bordered gauze dressing. The Treatment Nurse doffed her gloves, sanitized her hands and donned clean gloves and cleaned her scissors she had used to cut the xeroform with soap and water and then placed them in her pants pocket. She then doffed her gown, washed her hands with soap and water, collected her supplies and trash and wiped down the table and left the resident's room. An interview on 03/25/25 at 2:47 PM with the Treatment Nurse revealed she was not aware that she had not sanitized her hands each time she had doffed her gloves. She stated she had to change gloves so much during the wound care that she must have forgotten to always sanitize her hands when she removed her gloves. The Treatment Nurse further stated she knew she was supposed to always sanitize her hands when she removed her gloves each time and before putting on clean gloves. An interview on 03/27/25 at 11:38 AM with the Infection Preventionist (IP) revealed he was aware of the errors made by the Treatment Nurse during wound care. He stated his expectation was that she would sanitize her hands every time that she removed her gloves and before putting on clean gloves during wound care. The IP further stated staff received education on infection control annually and multiple times during the year. An interview on 03/27/25 at 11:54 AM with the Director of Nursing (DON) revealed she was aware of the Treatment Nurse's errors during wound care and said she had been provided with additional education regarding doffing and donning and sanitizing in between glove changes. The DON stated it was her expectation that the Treatment Nurse follow infection control best practices to avoid introducing microorganisms into the wounds. She further stated there was a lot of donning and doffing and in the Treatment Nurse's mind she thought she had done the appropriate practice. An interview on 03/27/25 at 3:14 PM with the Administrator revealed she would expect the Treatment Nurse to follow the Hand Hygiene policy for wound care. The Administrator stated it was her understanding that the Treatment Nurse did do another dressing change in which she didn't make any errors in the procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to ensure dishware (divided plates and bowls) were clean for use for 1 of 1 meal service observation and failed to ensure the plate warmer was free of food debris. This practice had the potential to affect food served to residents. The findings included: On 03/26/25 at 11:30 AM observations of the lunch meal tray line revealed there were divided plates stacked on a cart to the side of the steam table in preparation for the lunch service. Seven of the divided plates were noted to have dried egg particles on the plates. There were also dried egg particles noted on the plate warmer that contained the regular plates for lunch meal service. In addition, there were plastic bowls stacked for meal service and two of the bowls were noted to have dried food particles inside the bowls and around the outside of the bowls. On 03/26/24 at 11:41 AM the food particles on the plate warmer, crumbs and dried egg particles on the divided plates and the food particles on and in the bowls were shown to the Registered Dietitian (RD) and the Regional Dietary Manager. The RD started examining the divided plates and confirmed most of the divided plates had crumbs or dried egg particles on them. An interview on 03/26/25 at 3:00 PM with the Dietary Manager and the Regional Dietary Manager revealed the procedure for assuring dishes were clean before using was a three-step process. The first check occurred when dishes were removed from the dishwasher, the second check occurred when the dishes were put on drying racks or in storage and then a third check when dishes were moved to the tray line for use. The Dietary Manager and [NAME] Dietary Manager stated the Dietary Aides had not paid close attention to the dishes prior to putting them on the tray line for meal service. An interview on 03/27/25 at 3:11 PM with the Administrator revealed she would have expected the dishes and the equipment to have been clean and free of debris and food particles prior to the meal service.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review interviews with the Hospital Case Manager, Veterans Affairs (VA) Case Manager and staff, the facility failed to allow a resident to return the facility after a facility-initiated transfer to the hospital for 1 of 1 (Resident #445) resident reviewed for readmission from the hospital. The findings included: Resident #445 was admitted to the facility on [DATE]. His diagnoses included epilepsy, acute respiratory failure with hypoxia, schizophrenia, delirium. The face sheet of Resident #445 stated that his discharge status was anticipated to return to the community from his short term stay at the facility. He had VA benefits that paid for the 32 day stay through the Corporate Nursing Home contract. A nurses note dated 6/20/23 at 10:56 PM read in part, Resident #445 was noted to be in bed with wet/clammy skin, drooling, and body jerking. Resident #445 was able to respond to name being called. Medical Doctor (MD) notified, and orders were to send Resident #445 to the hospital with a diagnosis of seizure activity. Resident #445 was transported to hospital. Resident #445 had a discharge Minimum data Set assessment dated [DATE] that was coded for discharge returned anticipated. A review of an email thread from the admission Director and VA case manager on 7/3/23 at 12:23 PM stated that the admission Director updated the VA case manager that Resident #445 was ready to discharge from the hospital to the facility on 7/5/23. The admission Director requested the VA case manager send a new authorization for respite stay at the facility due to the length of stay at the hospital. A review of hospital referral to the facility dated 7/3/23 revealed that Resident #445 was ready to return to the facility. The referral showed that the facility accepted Resident #445's referral for readmission on [DATE] at 3:08PM per admission Director. A review of Pre-admission Snapshot dated 7/11/23 at 12:34 PM stated that Resident #445 was not admitted because Resident #445 was not appropriate financially. The pre-admission snapshot was communicated from the hospital case manager and the admissions person at the facility. An interview with Resident #445's family member was conducted on 12/8/23 at 10:13 AM and revealed that Resident #445 did not return to the facility and was discharged home from the hospital with home health care. The family member further stated that Resident #445 had returned to the hospital two weeks later due to seizure activity and was readmitted to the hospital. Resident #445 was currently at another facility in a different town. The family member confirmed that the VA was paying for Resident #445's stay at the new facility. The family member stated that they wanted Resident #445 to return however they were upset about the back and forth with the hospital and the facility. An interview with the VA Case Manager on 12/8/23 at 1:48 PM revealed that the VA can authorize short term rehab care or respite stay at the facility. They further explained that the start date of benefits for the nursing facility stay for Resident #445 was 6/16/23 with an approved end date of benefits on 7/18/23. They stated that Resident #445 was discharged to the hospital on 6/20/23. If the VA veteran was out of the facility for more than 3 midnights, the VA would discharge them which meant that the authorization ends for the short-term rehab stay. The VA Case Manager stated that Resident #445 was expected to return to the facility after the hospital stay once medically stable. They stated that Resident #445 was re-evaluated on 7/7/23 and approved for a new authorization with a 32-day Corporate Nursing Home contract from the date that they would re-admit from the hospital. The VA Case Manager noted that Resident #445 was discharged from the hospital on 7/18/23 with home health care in place due to the facility's refusal to readmit. The VA Case Manager stated that all conversations were with the admission Director. The authorization form would have been sent to the facility on his re-admission date to the facility. A phone interview with the admission Director was conducted on 12/7/23 at 10:50 AM who stated that Resident #445 was eligible for short term stay benefits. The admission Director further stated if the resident had been accepted for readmission to the facility the VA authorization would have been approved. The interview further revealed if anyone had asked or contacted her, she would have informed them that the VA authorization was valid. A phone interview with the Hospital Case Manager was conducted on 12/7/23 at 10:45 AM and revealed that Resident #445 had been discharged home from the hospital with home health care on 7/18/23. The Hospital Case Manager stated that the family ended up taking the resident home due to the back and forth between the facility and hospital. They further stated that the facility declined to readmit Resident #445 back to the facility due to no financial source for Resident #445. The Hospital Case Manager stated that the authorization was approved and that the finances were covered for the facility stay after readmission from the hospital. The Hospital Case Manager stated that she spoke with the VA Case Manager around 7/5/23 and was informed of the approval for Resident #445's return to the facility. The Hospital Case Manager stated that she informed the admission Director of all of this in an email which included the pre-admission snap shot. She further stated that the authorization was approved on 7/7/23 and she informed the admission Director through the pre-admission snap shot information. An interview with the Director of Nursing (DON) was conducted on 12/6/23 at 11:18 AM and revealed that the DON did not recall any denials of readmission for residents from the hospital. The DON further stated that the admission Director followed up with the hospital around 7/7/23. The DON stated that the Business Office Manager would have verified that the VA authorization had been approved for readmission. The DON stated that the VA made the decision to deny Resident #445 to return to facility and was not made aware of any issues. The DON stated that Resident #445 did not come back and was not denied readmission. A phone interview with the Business Office Manager on 12/7/23 at 10:40 AM revealed that Resident #445 had short term VA benefits. The Business Office Manager did not recall any issues with the VA authorization and did not recall asking the VA for the authorization form for Resident #445. The Business Office Manager stated that the admission Director handled that. An interview with Corporate Business Office Consultant was conducted on 12/8/23 at 10:37 AM and revealed that the admission Director gave information to the business office regarding payor sources that would come from the hospital. The Corporate Business Office Consultant confirmed that they did have a contract with the VA. They stated that the VA authorization would be re-authorized for a 32-day Corporate Nursing Home contract with the current authorization on file for Resident #445. The Corporate Business Office Consultant stated that with the re-authorization for Resident #445 from the VA, they would have been able to re-admit from the hospital. An interview with the Administrator was conducted on 12/8/23 at 1:07 PM and revealed that they had been the administrator since 7/10/23 and was not the administrator at the time of Resident #445's re-admission discussion. The Administrator stated that the VA veteran would have been eligible for re-admission if the facility was able to care for them and if the restriction did not limit the number of admissions for VA veterans in the facility. The administrator further explained that the facility had a limitation on how many VA Veterans were able to be admitted to the facility with a cut off of 30 at a time. However, upon review of the census with the number of Veterans for this time frame, they would have been allowed to re-admit him if the limitation was in effect because they did not have 30 veterans in the facility during the proposed readmission time frame. The Administrator explained that the facility was limited to 30 residents with VA benefits. They further stated that the facility has around 28 to 30 residents that are veterans that used VA benefits monthly. During an interview with the VA Case Manager on 12/8/23 at 1:48 PM she stated that there was no cap for VA veterans' admission to facilities until October 2023 and would not have been in effect for Resident #445 during this specific time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2a. Resident # 52 was admitted to the facility on [DATE] with diagnoses inclusive of hypertension, malnutrition, and colitis. A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #52 was cognitively intact and required set up or cleanup with food. A review of Resident #52's lunch menu ticket dated 12/7/23 indicated no tomatoes as a preference. A review of a grievance report dated 4/3/23 indicated Resident #52 continued to receive tomatoes on her salad meal although she had an allergy to tomatoes and did not eat meat. Action taken included making dietary staff aware of Resident #52's allergy to tomatoes and that she did not eat meat. The grievance was investigated and signed by the Registered Dietician. An interview on 12/6/23 2:55 PM Resident #52 revealed she was served tomatoes on her lunch tray on 12/6/23 and tomatoes were listed on her meal ticket as dislikes. She further revealed tomatoes had been placed on her food tray in the past, despite being listed as dislikes on her meal ticket. She stated she submitted a grievance dated 4/3/23 related to receiving tomatoes on her salad and that she had an allergy to tomatoes. Resident #52 stated when she discovered the tomatoes on her salad on 12/6/23, she went to the kitchen and was given another salad without tomatoes. An interview on 12/6/23 at 3:37 PM the Dietary Director stated she and her dietary staff were very familiar with Resident #52's preferences. However, a new dietary aide, who was not familiar with the Resident's preferences, did not call out to the cook that the Resident should not receive tomatoes on her salad. The Dietary Director revealed she was aware Resident #52 received tomatoes on her salad on 12/6/23 although her meal ticket indicated no tomatoes. She stated it was the responsibility of the dietary aide to communicate resident preferences while building food trays. She further revealed she would have to re-train the dietary aides on communication with the cook. An interview on 12/7/23 at 6:35 PM the Administrator indicated she expected dietary staff to review and honor meal tray tickets before they leave the kitchen and for nurse aides to review the tray tickets upon delivery to residents. She further indicated, Resident #52's preferences should have been honored as indicated on her meal ticket. 2b. A review of Resident #52's breakfast and lunch menu tickets dated 12/7/23 indicated no options for plant-based meats and was not indicated as a preference. During an interview on 12/5/23 at 10:43 AM Resident #52 revealed she became a vegetarian in 2022 and during a recent Resident Council meeting, she requested alternative plant-based meat options. Resident #52 further revealed the Dietary Director attended that meeting and agreed to offer plant-based meat options as a menu item. The Resident received plant-based meat once or twice in October 2023 and had not been offered plant-based meat since then. The Resident also stated it was never added to the printed menu as a preference, although the Dietary Director was made aware of the Resident's preferences. During an interview on 12/6/23 at 3:37 PM the Dietary Director indicated the facility had been offering plant-based options to residents since August 2023 when residents requested the options during a Resident Council meeting. She further indicated plant-based options had not been added to the printed menu and would be written on the menus or discussed during the admission process. The Dietary Director stated although she was aware Resident #52 preferred plant-based options, she did not update Resident #52's preferences to include plant-based options because she assumed the Resident would write it on her menu when she wanted it. She stated there were only two vegetarians in the facility and did not think other residents were interested in plant-based options. During an interview on 12/6/23 at 2:34 PM the RD revealed she assessed residents at admission, significant weight loss, and at the request of residents and families. She further revealed she met with Resident #52 in September 2023 and plant-based options were never discussed. Further, she was not aware the Resident wanted plant-based options. During a follow-up interview on 12/7/23 at 1:39 PM Resident #52 indicated plant-based options were never placed on her preference list, although she recommended it during a Resident Council meeting during July or August 2023. She further indicated the Dietary Director told her it would be written on the menu ticket, but it was not written or offered since October 2023. Resident #52 stated if plant-based options were offered/ listed on the menu as promised, she would certainly choose those options, since she became vegan in 2022. During an interview on 12/7/23 at 1:53 PM Nurse Aide #1 (NA) revealed she never discussed plant-based options with Resident #52. She further revealed the Resident often complained about her food and periodically requested meat. During an interview on 12/7/23 at 11:56 AM Nurse #1 indicated Resident #52 said she was not getting plant- based options but Nurse #1 was unsure if the Resident was offered the plant-based options after she first received them in September or October 2023. During an interview on 12/7/23 at 6:25 PM the Administrator revealed the facility attempted to accommodate plant-based options requested by Resident #52 although it was not part of their menu. She further revealed she was aware the facility started ordering plant-based items in late summer 2023 but was not aware the plant-based items were not regularly offered to the Resident or any other resident via the menu. She expected the plant-based options to be added to Resident #52's menu and preferences honored. Based on observations, resident and staff interviews and record review, the facility failed to honor food preferences for 2 of 2 residents reviewed for food preferences (Resident #19 and #52). The findings included: 1. Resident #19 was admitted to the facility on [DATE]. Diagnoses included hypertension, gastroesophageal reflux disease, and renal insufficiency. Review of a Physician (MD) Orders diet list revealed a MD order dated 3/19/20 for a regular diet for Resident #19. An annual Minimum Data Set assessment dated [DATE] assessed Resident #19 with clear speech, adequate hearing, impaired vision without corrective lenses, understood, able to understand, moderately impaired cognition and fed herself after staff provided set up assistance. A care plan revised October 2023 recorded that Resident #19 was at risk for nutritional decline due to her diagnoses and a history of weight loss. Interventions included providing food preferences when possible. Resident #19 was observed in her room and interviewed on 12/04/23 at 1:54 PM. During the observation, Resident #19 fed herself her lunch meal which included chicken breast (white meat). The tray card on her lunch meal tray recorded Dislikes: Chicken [NAME] Meat. Resident #19 ate her remaining food but did not eat the chicken. Resident #19 stated I don't like white meat, they serve it to me all the time, I will ask for a peanut butter and jelly sandwich instead. Nurse #4 was interviewed on 12/07/23 at 2:54 PM. Nurse #4 stated that she was the 7 AM - 3 PM Nurse for Resident #19 and often observed her with breakfast and lunch meals. Nurse #4 stated that if Resident #19 received food she did not like, she went to the kitchen to get something else. Nurse #4 stated she observed Resident #19 receive white meat chicken before, but that she did not like white meat chicken and that she did not eat it. Nurse #4 stated that if a resident received food, they did not like the staff should offer the resident a substitute. An interview with the Dietary Manager (DM) on 12/06/23 at 5:01 PM revealed she was the DM for the past 4 months. The DM stated that meal preferences were obtained on admission, updated during care plan meetings, and the DM entered the preferences into the facility's tray card system. The DM stated that sometimes a resident received food that was listed on the tray card they disliked, but that the dietary aides were responsible to review the tray card and provide foods according to the resident's preferences. The DM stated that sometimes dietary staff did not always identify preferences correctly that were listed on the tray card and when that occurred the DM provided education. The DM stated that it was possible that the dietary aides did not know the difference between white/dark meat chicken and therefore did not tell the cook not to plate white meat chicken for Resident #19 during the meal tray line service. The DM stated that at times she checked meal trays for accuracy, her focus was to check for allergies and consistency, but during her checks, she did not lift the lid to look at the resident's plate. The Administrator stated in an interview on 12/08/23 at 1:06 PM that she was the Administrator in the facility since July 2023. The Administrator stated that she expected dietary staff to review tray cards when meals were plated and for nursing staff to review tray cards when they assisted a resident to set up their meal. The Administrator stated that resident meal preferences should be honored.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews and record review, the facility failed to provide Resident #95 a renal diet per physician order for 1 of 1 sampled resident reviewed for therapeutic diets. The findings included: Resident #95 was admitted to the facility on [DATE]. Diagnoses included hypertensive chronic kidney disease stage 5, end stage renal disease, and dependence on renal dialysis. Review of the medical record revealed a physician (MD) order dated 7/24/23 for a liberalized renal diet. An annual Minimum Data Set assessment dated [DATE] assessed Resident #95 with clear speech, adequate hearing/vision, understood, able to understand, intact cognition and fed herself after staff provided set up assistance. A care plan revised October 2023 recorded that Resident #95 was at risk for nutritional decline due to end stage renal disease, hemodialysis, and a therapeutic diet. Interventions included providing a diet as ordered. Resident #95 was observed in her room and interviewed on 12/04/23 at 12:54 PM. During the observation, Resident #95 fed herself lunch. She received a salad with diced tomatoes. A meal tray card on her lunch meal tray recorded Dislikes: tomatoes, potatoes. Resident #95 stated she received potatoes and tomatoes often, and stated, But I am not supposed to. Resident #95 explained potatoes and tomatoes were not foods she disliked, but foods she could not have on her renal diet. Review of the weekly menu therapeutic diet spreadsheet revealed a resident with a diet order for a renal diet should receive a salad without tomatoes and rice instead of potatoes. Nurse #4 was interviewed on 12/07/23 at 2:39 PM. Nurse #4 stated that she was the 7 AM - 3 PM Nurse for Resident #95. Nurse #4 stated she knew that residents with a diet order for a renal diet should not receive tomatoes or potatoes. Nurse #4 stated that she often saw Resident #95 receive meals that included tomatoes, tomato soup, and potatoes, but she did not report this to the dietary staff because she did not know if the diet rules were different in this facility. An interview with the Dietary Manager (DM) on 12/06/23 at 5:01 PM revealed she was the DM for the past 4 months. The DM stated that residents with a diet order for a renal diet should not receive foods high in phosphorus like tomatoes or foods high in potassium like tomatoes and potatoes. The DM stated the disliked section of the meal tray card included food preferences and foods not allowed on the therapeutic diet. The DM stated sometimes dietary staff did not always identify disliked foods correctly that were listed on the tray card and when that occurred the DM provided education. The DM stated that at times she checked meal trays for accuracy, her focus was to check for allergies and consistency, but during her checks, she did not lift the lid to look at the resident's plate. In an interview with the registered dietitian (RD) #1 on 12/06/23 at 5:10 PM she stated Resident #95 had a diet order for a liberalized renal diet which restricted foods high in potassium and phosphorus. A phone interview with RD #2 on 12/07/23 at 4:13 PM, revealed she was the RD at the dialysis facility where Resident #95 was a patient. She stated Resident #95 should receive a renal diet with foods low in potassium, low in phosphorus and low in sodium. RD #2 stated she would be more concerned about Resident #95 receiving foods high in potassium like potatoes and tomatoes because her potassium levels in October 2023 and November 2023 were on the upper limit. The Assistant Director of Nursing (ADON) stated in an interview on 12/06/23 at 1:44 PM that the dietary staff were responsible to send foods from the kitchen per the diet order and if something was missing or wrong, nursing staff should address it if they saw it. The Administrator stated in an interview on 12/08/23 at 1:06 PM that she was the Administrator in the facility since July 2023. The Administrator stated that she expected dietary staff to review tray cards when meals were plated and for nursing staff to review tray cards when they assisted a resident to set up their meal. The Administrator stated residents should receive food per diet order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident, family and staff interviews and record review, the facility failed to provide a dignified dining experience when Nurse Aide (NA) #4 fed Resident #10 while 5 residents who were seated at the same table did not have their lunch. This failure occurred for 5 of 5 residents sampled for dignity (Residents #8, #39, #119, #70 and #100). The reasonable person concept was applied as individuals have the expectation of dining in a dignified environment. The findings included: 1a. Resident #8 was re-admitted to the facility on [DATE]. A quarterly Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #8 with clear speech, adequate hearing/vision, no corrective lenses, or hearing aids, understood, able to understand, severely impaired cognition and fed herself after staff provided set up assistance. A care plan revised October 2023 recorded Resident #8 required assistance with setting up her meal tray, she fed herself and staff were to give her assistance to complete the task as needed. Resident #8 was observed on 12/4/23 at 12:45 PM seated in her wheelchair at a table in the 500/600 hall parlor with Residents #10, #39, #119, #70 and #100 while she waited for her lunch meal. During the observation, Resident #8, when asked how she was doing, replied to the surveyor, I'm hungry. NA #4 was observed on 12/4/23 to assist Resident #10 to eat from 1:13 PM until 1:25 PM, Resident #100 fed himself from 1:17 PM until 1:31 PM, and NA #4 fed Resident #39 at 1:32 PM while Resident #8 waited. Resident #8 received her lunch meal from NA #5 at 1:41 PM, twenty-eight minutes after NA #4 began assisting Resident #10. At the time of the observation, NA #5 stated Resident #8's meal tray was not on the meal delivery cart, so she went to the kitchen to get it. During an interview on 12/07/23 at 2:21 PM NA #4 stated she was a Restorative Aide and a NA who assisted residents with their meals. NA #4 stated Resident #8 ate her meals well, but that she was not that familiar with the Resident's care needs. NA #4 stated she sat down to feed Resident #10 lunch on Monday, 12/4/23, but once she noticed the other Residents who were seated at the same time did not have their lunch, she knew the meal trays were not delivered to the unit at the same time, so she went ahead and fed Resident #10 so that her meal would not get cold. NA #5 was interviewed on 12/06/23 at 12:06 PM. NA #5 stated she was the scheduler and a NA. She stated she was familiar with Resident #8 and described the Resident as able to make her needs known to staff. NA #5 stated she realized Resident #8 did not have a lunch meal when the last cart came on the unit around 1:20 PM, so she went to the kitchen to get her tray. NA #5 stated as it related to dignity she was trained that residents should not have to wait while others ate in front of them at the same table, but that was a frequent occurrence for residents who ate in the parlor on the 500/600 hall because their meal trays were delivered on different carts. NA #5 stated Residents who ate in the 500/600 hall parlor waited 15 minutes or so before the next cart was delivered, so residents without a meal tray sat and waited. A family interview occurred by phone for Resident #8 on 12/4/23 at 2:38 PM. When asked by the surveyor if Resident #8 would consider it undignified to wait at the dining table for her meal while other residents ate in front of her, the family member stated that he was not certain if Resident #8 would prefer to eat at the same time as her tablemates, but that he felt it was important for all residents seated at the same table to eat at the same time. 1b. Resident #39 was admitted to the facility on [DATE]. A quarterly MDS assessment dated [DATE] assessed Resident #39 with clear speech, adequate hearing, impaired vision, no corrective lenses, or hearing aids, understood, able to understand, severely impaired cognition and fed herself after staff provided set up assistance. A care plan revised September 2023 recorded Resident #39 required assistance with setting up her meal tray, she fed herself and staff were to give her assistance to complete the task as needed. Resident #39 was observed on 12/4/23 at 12:45 PM seated in her wheelchair at a table in the 500/600 hall parlor with Residents #10, #8, #119, #70 and #100 while she waited for her lunch meal. During the observation, Resident #39 asked Nurse #4 Where is my lunch? Nurse #4 replied, It's coming we are waiting on it now. Resident #10 was assisted with her lunch meal by NA #4 from 1:13 PM until 1:25 PM and Resident #100 fed himself from 1:17 PM until 1:31 PM while Resident #39 waited. Resident #39 received her lunch meal at 1:32 PM, nineteen minutes after NA #4 began assisting Resident #10. NA #4 set up her lunch meal and assisted Resident #39 with eating. During an interview on 12/07/23 at 2:24 PM NA #4 stated she was a Restorative Aide and a NA who assisted residents with their meals. NA #4 indicated over the last few months Resident #39 required more assistance with her meals. NA #4 stated she sat down to feed Resident #10 lunch on Monday, 12/4/23, but once she noticed the other Residents who were seated at the same time did not have their lunch, she knew the meal trays were not delivered to the unit at the same time, so she went ahead and fed Resident #10 so that her meal would not get cold. 1c. Resident #119 was re-admitted to the facility on [DATE]. A quarterly MDS assessment dated [DATE] assessed Resident #119 with clear speech, impaired hearing with the use of hearing aids, moderately impaired vision, no corrective lenses, sometimes understood, sometimes able to understand, memory problems with moderately impaired decision-making, and fed herself after staff provided set up assistance. A care plan revised November 2023 recorded Resident #119 required assistance with setting up her meal tray, she fed herself and staff were to give her assistance to complete the task as needed. Resident #119 was observed on 12/4/23 at 12:45 PM seated in a chair at a table in the 500/600 hall parlor with Residents #10, #8, #39, #70 and #100 while she waited for her lunch meal. During the observation, NA #4 was observed on 12/4/23 to assist Resident #10 with eating from 1:13 PM until 1:25 PM, Resident #100 fed himself from 1:17 PM until 1:31 PM and Resident #70 received her lunch at 1:19 PM and fed herself while Resident #119 waited. Resident #119 received her lunch meal from NA #6 at 1:24 PM, eleven minutes after NA #4 began assisting Resident #10. Resident #119 fed herself after her meal was set up. A family interview occurred by phone for Resident #119 on 12/4/23 at 3:45 PM. The family member stated that Resident #119 was very social and that she would prefer to eat together with her tablemates. 1d. Resident #70 was admitted to the facility 4/16/18. An annual MDS assessment dated [DATE] assessed Resident #70 with clear speech, adequate hearing, moderately impaired vision, no corrective lenses, understood, able to understand, severely impaired cognition, and required staff assistance with meal set up and feeding. A care plan revised September 2023 recorded Resident #70 required assistance with setting up her meal tray, she could feed herself at times, but required staff to give her assistance to complete the task as needed. Resident #70 was observed on 12/4/23 at 12:45 PM seated in her wheelchair at a table in the 500/600 hall parlor with Residents #10, #8, #119, #39 and #100 while she waited for her lunch meal. During the observation, NA #4 was observed on 12/4/23 to assist Resident #10 with eating from 1:13 PM until 1:25 PM while Resident #70 waited for her lunch meal. Resident #70 received her lunch meal from NA #6 at 1:19 PM, seven minutes after NA #4 began assisting Resident #10. Resident #70 fed herself after her meal was set up. Attempts to interview family for Resident #70 were unsuccessful. 1e. Resident #100 was admitted to the facility 3/7/22. A quarterly MDS assessment dated [DATE] assessed Resident #100 with clear speech, adequate hearing, moderately impaired vision, no corrective lenses, understood, able to understand, severely impaired cognition, and required staff assistance with meal set up and able to feed himself. A care plan revised September 2023 recorded Resident #100 required assistance with setting up his meal tray and was able feed himself. Resident #100 was observed on 12/4/23 at 12:45 PM seated in his wheelchair at a table in the 500/600 hall parlor with Residents #10, #8, #119, #70 and #39 while he waited for his lunch meal. During the observation, NA #4 was observed on 12/4/23 to assist Resident #10 with eating from 1:13 PM until 1:25 PM while Resident #100 waited for his lunch meal. Resident #100 received his lunch meal from NA #6 at 1:17 PM, four minutes after NA #4 began assisting Resident #10. Resident #100 fed himself after his meal was set up until 1:31 PM. A family interview occurred by phone for Resident #100 on 12/4/23 at 3:30 PM. When asked by the surveyor if Resident #100 would consider it undignified to wait at the dining table for his meal while other residents ate in front of him, the family member stated that he was not certain if Resident #100 would prefer to eat at the same time as his tablemates, but that he felt it was important for all residents seated at the same table to eat at the same time. NA #6 was interviewed on 12/07/23 at 1:32 PM. NA #6 stated that the meal trays for residents who ate in the 500/600 hall parlor were delivered at different times on different carts. NA #6 stated that sometimes the Residents in the parlor sat there and waited for their meal while other Residents ate because the meal trays were on different carts. NA #6 stated that meal trays were given to residents who fed themselves first, and those Residents who needed assistance received their meal tray last so that staff could assist them with their meal. During an interview on 12/07/23 at 2:39 PM, Nurse #4 stated she worked on the 7 AM - 3 PM shift since August 2023 and when asked by the surveyor about her training for dining she stated she was trained related to dignity not to feed a resident in front of residents who were not eating. Nurse #4 stated that since she had been a Nurse in the facility, the meal trays for residents who ate in the 500/600 hall parlor were delivered to the unit at different times which caused residents who ate in the parlor on that unit to wait for their meal tray while other residents ate. Nurse #4 stated that on 12/4/23, she recognized that Resident #10 received her lunch meal and was fed by NA #4 while Residents #8, #39, #70, #100 and #119 remained in the parlor but did not have their lunch tray. Nurse #4 stated she advised NA #4 that Residents were still waiting for their lunch tray while she fed Resident #10, but NA #4 stated that since she had already started feeding Resident #10, she did not want to take her tray away from her. Nurse #4 stated she did not think about asking NA #4 to ask Resident #10 if NA #4 could feed her in her room until the other Resident's trays came on the unit. Nurse #4 also stated staff did not want the meal trays to get cold, so staff served the meal as the trays came onto the unit. Nurse #4 stated Resident #8 was the last Resident to be fed because her meal tray was not delivered to the unit and staff had to go to the kitchen to get her tray. Nurse #4 stated Resident meal trays were delivered to the unit by room number and Residents who required assistance with meals ate in the parlor, but their trays were not delivered together. An interview with the Dietary Manager (DM) on 12/06/23 at 5:01 PM revealed she was the DM for the past 4 months. The DM stated residents were asked on admission where they preferred to eat their meals. She stated that the meal carts were delivered to the units and the meal trays were ordered by room number for residents who preferred to eat in their rooms. The DM stated the dietary staff were not aware of which residents ate meals in the parlors on the units, that was nursing staff's responsibility to distribute meal trays to residents who ate meals in their rooms or in the parlor on the unit. The DM stated that as it related to dignity, she was aware that residents who ate together at the same table should receive their meals at the same. The Assistant Director of Nursing (ADON) stated in an interview on 12/06/23 at 2:27 PM that it was brought to her attention when she and a surveyor observed Residents on the South unit that day (12/6/23) who ate in the parlor on that unit receive lunch meals at different times. The ADON stated staff were re-educated on 12/06/23 to provide a dignified dining experience by not giving a resident a meal tray if the rest of the trays were not available to provide to residents who ate together. The Administrator stated in an interview on 12/08/23 at 1:06 PM that she was the Administrator in the facility since July 2023. When asked by the surveyor her expectation for a dignified dining experience, the Administrator stated that she expected all residents eating in the same area or table would be served together and she was not aware this was an ongoing concern.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, resident and staff interviews, the facility failed to provide a written decision/resolution regarding a grievance related to missing bras belonging to Resident #52 and failed to submit a grievance per the facility's grievance policy for 3 of 3 residents (Resident #52's missing supply of salad dressing, Resident #446's missing property and Resident #141's concerns related to a disrespectful staff). Findings included: A review of the facility Grievances Policy dated 2/2018 revealed in part The facility recognizes two levels of communication: 1. Concern- A concern is defined as an oral communication that can be resolved immediately. 2. Grievance- A grievance is a written statement, which implies a breach of care or service. A follow-up telephone call or on-site conference shall be held within 5 working days from receipt of a grievance with a complainant outlining corrective action taken. A written decision regarding grievance issued to the resident and/or representative. A review of the facility's Lost or Missing Articles Grievance Policy (undated) revealed in part If the lost article is a piece of clothing, the Nurse or Social Service staff will notify the laundry department. If the article is a personal supply item or an article that would not be going to the laundry, the article may be considered misplaced, and the resident will be provided assistance in searching for the lost item/ article. All attempts will be made to locate the missing article. A Lost or Missing Articles Report will be completed and submitted to the Administration. The Administrator or his/ her designee will notify the Resident and/ or Family of the findings. 1 a. Resident # 52 was admitted to the facility on [DATE]. A quarterly Minimum Data Set assessment dated [DATE] indicated Resident #52 was cognitively intact. A review of the grievance log dated August 2023 revealed grievances for Resident #52, including a Lost/ Missing Articles Grievance dated 8/10/23. The grievance indicated Resident #52 had 3 bras missing (1 bra had been gone for 3 weeks and 2 bras had been missing for 3 months) and one bra was found. The findings section of the report indicated the article was not located. The report further indicated the facility was still looking for 2 more missing bras. The follow-up section of the report indicated the resident was notified on 8/17/23 that they were still looking for the other bras. The report was signed by the Social Worker and Administrator that the issue was resolved on 8/17/23 although 2 of the bras were still missing. During an interview on 12/5/23 at 10:43 AM Resident #52 revealed she was missing 5 (front snap) bras since July 2023. She stated she completed a grievance for 6 missing bras around that time and one bra was recovered from the laundry in August 2023. However, she was still missing 5 (front snap) bras that were labeled with her name. However, she continued to ask for the remaining missing bras and was told the facility was still looking for them. She last asked the Social Service Director (SSD) #1 about the remaining missing bras in November 2023. She further revealed she believed there was only one staff member working in the laundry room at that time. The resident explained that other than receiving the one found bra from in August, she had received no communication regarding the outcome of the grievance which was filed. During an interview on 12/6/23 at 5:34 PM, the Laundry Supervisor indicated the laundry department was short staffed until October 2023 and she was the only laundry staff person during the summer and fall months. She further indicated the laundry department labeled resident items with a quick press label device and if the label came off, the items may end up in lost/ found pile and held for 90 days before being donated or discarded. The Laundry Supervisor stated Resident #52 informed her about two weeks prior (mid- late November 2023) she was missing 3-4 bras. The Laundry Supervisor looked for the missing items, could not locate them, then told the SSD #1 that she would continue to look for them. The Laundry supervisor stated she had not filed a grievance regarding the missing bras because there was already a grievance in place from August regarding the missing bras. The Laundry supervisor further stated the resident continued to ask about the lost bras from August to November 2023. During an interview on 12/6/23 at 5:24 PM SSD #1 revealed she began working at the facility in July 2023 and Resident #52 reported she was missing 3 bras on 7/28/23 and one bra was found on 8/10/23. She further revealed she and the Laundry Supervisor looked for the bras and they were continuing to look for the bras. SSD #1 stated the laundry department had been short staffed until October 2023 and there was only one staff person working prior to being fully staffed. However, she had not followed up with a written resolution for the grievance regarding the outcome of the remaining missing bras. During a follow-up interview on 12/8/23 at 11:43 AM SSD #1 indicated she ordered 2 bras on 12/7/23 per Resident #52's selection. She further indicated there was no excuse why the grievance that was submitted in August 2023 was not resolved in a timely manner. She stated the facility should have come to a decision to reimburse or replace the bras long before 12/7/23 and she planned to reimplement the resident inventory log, which would include clothing. During an interview on 12/7/23 at 6:07 PM the Administrator revealed SSD #1 was the Grievance Official who wrote up the grievance, assigned it to the appropriate department supervisor for an investigation/ resolution, and provided the resident or family member with the resolution before the Administrator would sign off on it. The Administrator further revealed it was her understanding that her staff was still looking for Resident #52's bras. However, if items were misplaced or damaged by the facility, it would be replaced, or the resident would be reimbursed. She further stated SSD #1 had since ordered replacement bras for Resident #52 on 12/7/23 and the remaining missing bras from August 2023 should have been replaced long before 12/7/23. The Administrator clarified the follow-up to the resident was the facility staff continued to tell the resident they were still looking for the bras. b. During an interview on 12/6/23 at 2:55 PM Resident #52 revealed she ordered a box of salad dressing, and she discovered it was missing from her room when she was returned from recently being hospitalized in October 2023. She further revealed she reported it to the SSD #1 on multiple occasions and was told the salad dressing was locked in storage along with some of her other belongings that were packed up and stored while she was hospitalized . Resident #52 stated she asked the SSD #1 about the status of the salad dressing for over a month. She further stated that she was unaware if the SSD #1 completed a written grievance regarding Resident # 52's missing salad dressing. During an interview on 12/6/23 at 5:24 PM the SSD #1 indicated she was the Grievance Official and had mentioned on four occasions during morning meetings with clinical staff that Resident #52 made several requests for her salad dressing to be returned from the storage and the Administrator directed the Maintenance Director to obtain the salad dressing from the storage. SSD #1 further indicated Resident #52 continued to inquire about the return of her salad dressing long after the Maintenance Director was to retrieve it from the onsite storage. SSD #1 stated she was unaware why the salad dressing had not been returned to Resident #52 and she did not feel the need to submit a grievance on the Resident's behalf. During an interview on 12/7/23 at 12:40 PM the Maintenance Director revealed he placed 5-6 storage boxes of Resident #52's belongings in an onsite storage unit between the end of October and the beginning of November 2023. He further revealed he was asked during that time to retrieve the salad dressing from storage. After he searched Resident #52's belongings in the storage, he did not locate the salad dressing and did not follow-up with the Administrator, staff member or Resident #52 with the outcome of his search. During an interview on 12/7/23 at 12:22 PM the Assistant Director of Nursing (ADON) indicated she was made aware in morning meetings (which included the Maintenance Director) that Resident #52's salad dressing was supposed to be returned to her. During an interview on 12/7/23 at 6:00 PM the Administrator revealed it was her understanding Resident #52's salad dressing was in storage and upon her request, would receive a box at a time. She further revealed she had the Maintenance Director go to the storage and check Resident #52's storage boxes the same day as the interview (12/7/23) and no salad dressing was found. The Administrator stated a grievance was not completed and probably should have been. 2. Resident #446 was admitted to the facility on [DATE] and discharged on 10/9/23. A quarterly MDS assessment indicated Resident #446 had moderate cognitive impairment. During a phone interview on 12/5/23 at 8:50 AM Resident #446's family member revealed when they came back to the facility after the Resident was hospitalized in October 2023 and was not expected to return to the facility, they were unable to go to the Resident's room to collect his belongings. Instead, the family member waited in the front lobby while the SSD #1 packed Resident #446's belongings and brought them to her, in the lobby. The family member further stated the SSD #1 reassured her that the Resident's dentures and eyeglasses were in his packed belongings that consisted of two boxes and a duffle bag. The family member stated when they returned home and checked Resident #446's belongings, there were clothing items that did not belong to the Resident and the dentures, eyeglasses, and hall of fame certificate were missing. The family member stated they sent 2 emails to the Administrator and received a voice mail from the SSD#1 instead of the Administrator. The family member stated they did not have a good interaction with SSD #1 previously and preferred to speak to the Administrator, since she was in charge. However, the Administrator never replied to family member's emails. The family member further stated the facility lost Resident #446's wheelchair that was issued by the Veterans Administration and offered to replace the wheelchair with another wheelchair, but the family member refused it because it belonged to another resident. The family member preferred to have the personal wheelchair that was admitted with the Resident. The family member stated the Resident did have an appointment to get assessed for a new wheelchair from the Veterans Administration but was hospitalized the day before the appointment. Further, the family member was unaware if the facility initiated a grievance investigation regarding the missing items. During an interview on 12/8/23 at 11:24 AM the SSD #1 indicated the facility had not implemented inventory sheets for resident belongings until July 2023. She further indicated she and (former) SSD #2 packed Resident #446's belongings and she could only recall packing clothing items, eyeglasses, framed pictures, and items from the nightstand into 2 boxes and a duffle bag that was already packed with clothing items. She brought the belongings to Resident #446's family member who was in the lobby and the facility offered to replace the lost wheelchair with a high back wheelchair. However, the spouse refused it. The SSD #1 stated she assisted Resident #446's family member pack the Resident's belongings into the family member's vehicle. SSD #1 stated she called and left a voice mail message for the family member after the family member sent emails to the Administrator regarding the missing items. SSD #1 further stated she did not feel the need to complete a grievance or missing/ lost grievance because Resident #446 was not returning to the facility and the family had been restricted from visiting beyond the lobby and visitations needed to be scheduled due to the family member's conflict with facility staff. During an interview on 12/8/23 at 12:42 PM the Administrator revealed she received 2 emails from the family member of Resident #446, after the family member came to the facility to retrieve the Resident's belongings. The emails indicated requests to have missing and damaged items (dentures, eyeglasses, cell phone, clothing, damaged picture frames). She further stated she had the SSD #1 contact the family member after the first email was received. The Administrator stated SSD #1 left a voice mail message for Resident #446's family member and there was no further communication from the family member. The Administrator stated a grievance report was not submitted and it would have been a good idea to submit one due to the previous conflicts with the Resident's family member. 3. The facility Grievance Policy, reviewed 2018, recorded in part, Residents may express a grievance and may expect prompt efforts from the facility to resolve voiced concerns or grievances. Resident #141 was admitted to the facility on [DATE] from the hospital and discharged home on [DATE]. An admission nursing assessment dated [DATE] recorded Resident #141 was alert and oriented and required staff assistance with toileting. A social services admission progress note dated 10/10/23 written by Social Services Director #2 (SSD #2), recorded Resident #141 admitted to the facility for a short-term rehab stay with plans to return home. SSD #2 documented she introduced herself to Resident #141 in her room after the Resident had just returned from a therapy session. The SSD documented Resident #141 was very alert and oriented to surroundings and situations. A Minimum Data Set assessment, dated 10/20/23, assessed Resident #141 with intact cognition, required supervision of one staff with toileting, occasional bladder incontinence, independent with toilet transfers and active discharge plans for a return to the community. An interview with Nurse #2 occurred on 12/07/23 at 3:25 PM. Nurse #2 stated she was the assigned Nurse for Resident #141 on the 7AM - 3PM shift and she remembered Resident #141 stated to her that some of the nursing staff on the 11 PM - 7AM shift was disrespectful to her. Nurse #2 stated she did not recall if Resident #141 gave her the names of staff, but the Resident stated that she did not like the tone of some of the staff and it made her feel like she was being spoken to like a child. Nurse #2 stated she reported this to the Nurse Supervisor, SSD #2 and either the Director of Nursing (DON) or the Assistant Director of Nursing (ADON). Nurse #2 stated she did not record this in the Resident's medical record because she expected the SSD to write the concern as a grievance. Resident #141 was interviewed by phone on 12/08/23 at 11:02 AM. Resident #141 stated that the staff were disrespectful, she stated They didn't say ugly things but ignored me, the first night I was there I rang the bell, and they didn't come, I needed to get to bathroom, but it was locked, and somebody had to come unlock it. She stated that the Nurse Aide (NA) from that evening Came in after I peed on the floor, and talked loudly to me, I guess it was just the way she talked. Resident #141 stated she reported this to Nurse #2 and stated, It made me feel like what's coming up next, that was my first night there. Resident #141 stated no one came to talk to her about her concern after she expressed it to the Nurse, so she just learned to manage and care for herself. Review of the October 2023 grievances revealed there was no grievance documented regarding Resident #141. NA #3 was interviewed by phone on 12/07/23 at 6:09 PM. NA #3 stated she worked at the facility for the past three years on the 11 PM - 7AM shift during the week and the 7 AM to 3 PM shift on the weekends. NA #3 stated she did not recall being assigned to Resident #141, but when she met residents for the first time, she introduced herself, responded to the call bell, assisted the resident with anything they needed and if she was made aware that a resident felt disrespected, she would tell the Nurse. NA #3 stated if a resident said she was yelling, she would apologize and try to lower her voice. NA #3 stated she had not been advised that a resident felt like she talked to them like a child. An interview with Nurse #3 occurred on 12/07/23 at 6:02 PM. Nurse #3 stated she worked the 11 PM - 7 AM shift since May 2023. Nurse #3 stated she did not remember Resident #141, but if she were made aware of a resident grievance, she would talk to the resident to find out what happened, then talk to the Nurse Supervisor or the ADON. Nurse #3 stated she did not recall being informed of a resident expressing they were disrespected. The Nurse Supervisor was interviewed on 12/07/23 at 5:48 PM. She stated that she was the 3 PM - 11 PM shift supervisor, but that she did not recall Resident #141 or being told by Nurse #2 the Resident expressed that she was disrespected by staff. The Nurse Supervisor stated if the Nurse had notified her of this Resident's grievance, the Nurse Supervisor stated she would have talked to the Resident and staff, re-educated staff, left a note for the SSD to file a grievance, and removed the staff involved from the Resident's assignment. The ADON was interviewed on 12/07/23 at 4:59 PM. The ADON stated she did not remember Resident #141, but if a Resident filed a grievance with the Nurse, the ADON stated she expected the Nurse to notify the Nurse Supervisor, the Nurse Supervisor would notify the SSD, the SSD would follow the facility's grievance policy, record the concern as a grievance and notify either the ADON/DON. The ADON stated staff would follow the grievance policy. A phone interview with SSD #2 occurred on 12/07/23 at 4:44 PM. SSD #2 stated that she was the SSD in the facility from May 2023 to November 2023. SSD #2 stated she did not recall Resident #141 or being informed by Nurse #2 of a grievance. SSD #2 stated if she was notified, she would talk to the Resident, obtain a statement, write the concern as a grievance, and notify the Administrator. SSD #2 stated she would also check the nursing schedule to make sure the staff member involved was not assigned to care for the Resident again. SSD #2 stated after the grievance was documented, she would follow up with the Nurse and the Administrator or DON within the next 24 hours to see if the grievance was resolved. An interview with the DON occurred on 12/06/23 at 11:19 AM, the DON stated she did not recall Resident #141 or being advised that this Resident filed a grievance with a Nurse. The Administrator was interviewed on 12/08/23 at 1:06 PM. The Administrator stated she was the Administrator since July 2023. She stated if a resident expressed to the Nurse, they felt disrespected by staff, she would expect the Nurse who was informed to notify the Nursing Supervisor and the SSD so that the facility could implement the grievance policy. The Administrator stated she was not made aware of the concern voiced by Resident #141.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C. Resident #4 was admitted to the facility on [DATE] with diagnoses that includes dementia, cerebral vascular accident (CVA), diabetes mellites, and high blood pressure (HTN). Review of Resident #4's medical record revealed the last documented care plan meeting occurred on 11/30/2022. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had severe cognitive impairment. A phone interview was conducted with Resident #4's responsible party (RP) on 12/05/2023 at 9:01 AM. The RP revealed she had not been invited or attended a care plan meeting for Resident #4 in many months. She further stated she does not know the exact length of time since the last care plan meeting was held but it was quite a long time ago. The Social Service Director #1 (SSD) was interviewed on 12/6/2023 at 12:37 PM. The SSD confirmed Resident #4 had not had a care plan meeting since 11/30/2022. She stated she had only been in her position a few weeks and was working on a new process for care plan meetings. She further stated she expected care plan meetings to be scheduled quarterly with a phone call invite or an invitation letter mailed which would include the resident's RP. She also indicated she had been working on developing a care plan meeting calendar for all residents. She also stated it would be the SSD #1's responsibility to create and maintain the care plan meeting calendar, send out the care plan meeting invitations, and hold the care plan meeting. An interview was completed on 12/07/2023 at 10:06 AM with the Administrator. The Administrator stated that she realized the care plan meeting process was behind schedule and the SSD was currently working on a new process to ensure care plan meetings were being held. Based on record review, resident/ family and staff interviews, the facility failed to schedule, invite residents/representatives, and hold care plan meetings for 3 of 3 residents (#52, #28, #4) reviewed for care planning. Findings included: A. Resident # 52 was admitted to the facility on [DATE] with diagnoses inclusive of respiratory failure. A review of the medical record indicated the last care plan meeting for Resident #52 took place on 3/15/22. A quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #52 was cognitively intact. During an interview on 12/5/23 at 10:43 AM Resident #52 revealed she had not been invited to a care plan meeting since 2022. B. Resident #28 was admitted to the facility on [DATE] with diagnoses inclusive of anxiety and acid reflux. A review of the medical record indicated the last care plan meeting for Resident #28 took place on 7/19/22. A quarterly MDS assessment dated [DATE] indicated Resident #28 had moderate cognitive impairment. During an interview on 12/4/23 at 10:15 AM the family member of Resident #28 revealed the Resident had not been invited to a care plan meeting since July 2022. During an interview on 12/6/2023 at 5:08 PM the Social Service Director #1 (SSD) indicated Resident #52 had not had a care plan meeting since 3/15/22 and Resident #28 had not received a care plan meeting since 7/19/22. She stated she had only been in her position a few weeks and was working on a new process for care plan meetings. She further stated she expected care plan meetings to be scheduled quarterly with a phone call invite or an invitation letter mailed which would include the resident and/ or resident representative. She further indicated she had had only been in the SSD #1 position since July 2023 and was aware that care plan meetings were behind. She also stated it would be the SSD #1's responsibility to create and maintain the care plan meeting calendar, send out the care plan meeting invitations, and hold the care plan meeting. During a phone interview on 12/7/23 at 5:06 PM the (former) SSD #2 as of July 2023 revealed there were several barriers to completing the care plan meetings to include time constraints, training the current SSD #1 replacement, discharge planning and over all resident case load. She further indicated she was able to complete some care plans and some residents and families did complain about not having a care plan meeting. She also stated care plan meetings were to be scheduled one week after the MDS was completed. During an interview on 12/7/23 at 5:52 PM the Corporate Social Work Consultant indicated she was recently made aware that the facility was falling behind on care plan meetings. Her expectation was for care plan meetings to be scheduled within 1-1 and a half weeks after the MDS was completed. She further indicated prioritizing, increased census and staffing turnover contributed to missed care plan meetings. During an interview on 12/7/23 at 5:57 PM the Administrator revealed she started role at the facility in July 2023 and in September she was made aware that care plan meetings were not being conducted. She further revealed the SSD #1 had been working on creating a care plan meeting schedule. The Administrator's expectation was for care plan meetings to be scheduled, care plan invitations to be sent to residents/ representatives and care plan meetings to be conducted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, staff and resident interviews, the facility failed to maintain residents' wheelchair in good repair for 2 of 2 sampled residents reviewed for a safe, clean, comfortable, homelike environment (Residents #43 and Resident #94). The findings included: a. Resident #43 was admitted to the facility on [DATE]. Resident #43's quarterly Minimum Data Set (MDS) dated [DATE] indicated her cognition was moderately impaired. The MDS further specified Resident #43 was using wheelchair as the mobility device and was independent for locomotion on and off unit during the assessment. In an observation conducted on 04/25/22 at 1:25 PM, Resident #43 was seen sitting in her wheelchair with a frayed and torn right arm rest approximately 2 inches by 6 inches. The left arm rest was noted with 2 ripped lines approximately 1 inch and 3.5 inches in length respectively. An interview was conducted with Resident #43 during the observation. She could not recall how long the bilateral arm rests had been in disrepair. She denied she had notified any staff about the arm rests and stated it would be nice if the maintenance staff could fix it as it could cause skin irritation at times. The bilateral arm rests for Resident #43's wheelchair remained in disrepair during the following subsequent observations: 04/26/22 at 4:38 PM and 04/27/22 at 9:53 AM. b. Resident #94 was admitted to the facility on [DATE]. Resident #94's quarterly MDS dated [DATE] indicated her cognition was severely impaired. The MDS specified Resident #94 was using wheelchair as the mobility device and required extensive assistance for locomotion on and off unit during the assessment. In an observation conducted on 04/26/22 at 5:14 PM, Resident #94 was seen sitting in her wheelchair in the hallway with a peeled and torn right arm rest approximately 1.5 inches by 4 inches. The left arm rest was frayed and torn approximately 1 inch by 3 inches along with 1 ripped line approximately 3 inches in length. A subsequent observation conducted on 04/27/22 at 9:17 AM revealed Resident #94's wheelchair remained in disrepair. In an interview conducted on 04/27/22 at 9:23 AM, Resident #94 stated the damaged arm rests of her wheelchair just irritated her skin and it bothered her at times. During an interview conducted on 04/27/22 at 2:04 PM, Nurse #5 stated the arm rest for Resident #43 and Resident #94 needed to be replaced. She did not notice that the arm rest for both Residents' wheelchair were peeled, torn, ripped, and frayed when she was providing care. She stated if the repair needs were urgent or safety related, she would notify the Maintenance Manager (MM) immediately. Otherwise, she would submit a work order log in the nurse station. During a joint observation with the MM on 04/27/22 at 2:37 PM, he indicated the wheelchair for Resident #43 and Resident #94 were in disrepair. He stated he routinely checked the facility once every morning to identify repair needs. He had missed both wheelchairs during the walk through and admitted it was his oversight. He stated when the repair need was urgent or safety related, the staff would call or notify him in person immediately. All other less urgent repair needs would be submitted through the work order log located in each nurse station and he would check at least 5 to 6 times daily. He added he was unaware of these repair needs as he relied heavily on work orders filed by the staff. During an interview with the Director of Nursing on 04/27/22 at 2:51 PM, she stated the arm rest of the wheelchair for Resident #43 and Resident #94 needed to be fixed or replaced. She expected all the direct care staff to be more attentive to the condition of Resident's health equipment when providing care to ensure the MM was aware of repair needs in timely manner. Interview with the Administrator on 04/27/22 at 3:29 PM revealed it was her expectation for all the health equipment to be in good repair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for a restorative nursing program for 1 of 2 residents reviewed for restorative nursing splinting programs (Resident #86). Findings included: Resident #86 was admitted to the facility on [DATE] with diagnoses that included depression, vascular dementia, cerebrovascular disease, and hemiplegia. A physician order dated 02/25/21 was for restorative nursing to apply bilateral palm/carrot splints to Resident #86 6 days a week. Apply in the morning and remove at bedtime. Give gentle ROM prior to applying hand splints. Review of a quarterly MDS revealed Resident #86 had unclear speech, sometimes could understand, and was sometimes understood. Resident #86 had both short term and long-term memory deficits and required extensive assist of 1 staff member for bed mobility, transfers, eating, toileting, and hygiene. Resident #86 was non ambulatory and had impaired functional limitation in range of motion (ROM) to both (bilateral) upper and lower extremities. Resident #86 received restorative nursing program for splinting at least 15 minutes a day on 5 days of the review period. A review Resident #86's care plans most recently updated on included a need for contracture management and to maintain her range of motion (ROM) through the next review. Interventions included to have the restorative nursing splinting program to both palms 6 days a week; application of carrot splints every morning (AM) and removed at bedtime (PM) and receive gentle ROM to both palms before the carrot splints were applied. An interview with MDS Nurse #1 conducted on 04/28/22 at 1:53 PM revealed a review of the restorative nursing minutes recorded the hand splints applied to Resident #86 were less than 15 minutes a day on 02/01/22, 02/02/22, 02/04/22 and 02/07/22. The hand splints were not applied to Resident #86 on 02/05/22 or 02/06/22. The one day the restorative nursing assistant recorded the bilateral hand splints had been applied to Resident #86 as ordered for 15 minutes was on 02/03/22. MDS Nurse #1 explained the MDS assessment was coded with the incorrect number of days because Resident #86 received 15 minutes of Restorative Nursing hand splints only 1 day of the review or look back period. MDS nurse #1 revealed that it was important to code all areas of the MDS correctly.

Based on observations and staff interview the facility failed to remove expired milk from 1 of 2 refrigerator storage areas (walk in cooler), 42 potatoes and 4 green bell peppers with signs of spoilage from 1 of 2 refrigerator storage areas (walk in cooler) and salad mix with best by date of 04/8/22 with dark discolorations throughout the bag in 1 of 2 storage areas (walk in cooler). These practices had the potential to affect residents served this food. The findings included: 1. An observation of the walk-in cooler was made on 04/24/22 at 9:50 AM along with Dietary Manager. The observation revealed 16 cartons of light chocolate milk that expired on 04/20/22. The Dietary Manager instructed one of the dietary aides to discard the expired milk Dietary Manager was interviewed on 04/28/22 at 2:36 PM. Dietary Manager stated the staff were trained to discard anything that is out of date. He further stated the staff should have removed the milk and placed a sign do not use on it. He stated they can send it back to receive credit. 2. An observation of the walk-in cooler was made on 04/24/22 at 9:50 AM along with Dietary Manager. The observation revealed 42 potatoes in a box dated 03/21/22 mushy with dark areas, and creamy substance coming out. A continued observation revealed 4 green bell peppers that were mushy with some discoloration of orange and dark black areas. The Dietary Manager instructed one of the dietary aides to discard the potatoes and green peppers. Dietary Manager was interviewed on 04/28/22 at 2:36 PM . Dietary Manager stated the staff are trained to discard anything that is out of date. He further stated truck came in early today, and instead of the staff going through and checking and discarding expired food, they just placed the items from the truck in the cooler. 3. An observation of the walk-in cooler was made on 04/24/22 at 10:02 AM along with Dietary Manager. The observation revealed salad mix on the top shelf with best by date of 4/8/22 with dark discolorations throughout the bag. The Dietary Manager instructed one of the dietary aides to discard the salad mix. Dietary Manager was interviewed on 04/28/22 at 2:36 PM. Dietary Manager stated the staff are trained to discard anything that is out of date. He further stated truck came in early today, and instead of the staff going through and checking and discarding expired food, they just placed the items from the truck in the cooler. He stated that the salad mix should have been stored in the original box, and the staff just got in a hurry and placed it on the top shelf. The Corporate Dietician was interviewed on 04/28/22 at 2:36 PM . The Corporate Dietician states the Dietary Manager had only been there for a few weeks. And the truck came in super early. She further stated that the Dietary Manager had been doing a great job and this was just an oversight. The Administrator was interviewed on 04/28/22 at 4:10 PM. The Administrator stated that she expected all expired food products to be discarded. She further stated the Dietary Manager was new and had done a great job getting the kitchen in order.