**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff and family interviews the facility failed to implement an activity intervention on the comprehensive care plan for 1 of 22 residents (Resident #29). The findings included: Resident #29 was admitted into the facility on [DATE] with a diagnosis of dementia. A review of Resident #29's significant change Minimum Data Set assessment dated [DATE] revealed that she was severely cognitively impaired, had trouble falling or staying asleep, or sleeping too much for 12-14 days, trouble concentrating on things for 12-14 days, was sometimes understood and sometimes understood by others and had impaired vision. She had no behaviors and noted it was very important to have her family be part of the discussions regarding her care. A review of Resident #29's comprehensive care plan updated 12/19/24 revealed a problem of a need for daily stimulation by having her television and lights on daily in the morning. The goal and intervention to the problem included she would have her television and lights on by 10:00 AM each day. An interview was conducted with Resident #29's family member on 2/16/25 at 12:35 PM who indicated a concern of Resident #29 not receiving any type of mental, tactile, or visual stimulation that the family member was aware of. The family member stated they visited the resident at different times during the week and that when they visited they always had to turn on the television and open the window blinds. An observation of Resident #29's room on 2/16/25 at 12:30 PM noted the television and lights were not on, and the window blinds were closed. The resident was lying in bed with her eyes open. Observations of Resident #29's room on 2/17/25 at 11:00 AM and 1:00 PM noted the television and lights were not on, and the window blinds were closed. Resident #29 was lying in bed with her eyes open. An observation of Resident #29's room on 2/18/25 at 10:30 AM noted the blinds were open but the lights and television were not on. Resident #29 was lying in bed with her eyes open. An interview conducted on 2/18/25 at 10:25 AM with Nurse Assistant #1, who was working on Resident #29's hall, revealed that if a resident had a daily task that needed to be completed it was placed on the resident care card at the desk. Nurse Assistant #1 was not aware of any resident's care cards that had a notation of the lights or television turned on by a certain time. An interview conducted on 2/18/25 at 10:30 AM with Nurse Assistant #2, who was working on Resident #29's hall, indicated that any special tasks were on the resident care cards at the desk. She further indicated that she was not aware of any residents that had a certain time for the lights or television to be on. A review of Resident #29's care card did not reveal instructions for the lights and television to be on by 10:00 AM each day. An interview with the Activity Director on 2/18/25 at 12:38 PM revealed that she was not aware the care plan had the problem of the resident need for stimulation by having the lights and television on by 10:00 AM and stated she had not created that care plan, the former Social Service Worker had, and that the former Social Service Worker should have put that on Resident #29's care card so the nursing assistants were aware. She further stated that the activity department provided one-on-one visits to Resident #29 on Tuesdays and Thursdays. A telephone interview with the Administrator on 2/20/25 at 9:44 AM indicated that the Activity Director should have been aware of the care plan problem regarding the lights and television on by 10:00 AM and the information should have been placed on Resident #29's care card so that the nursing assistants were aware.

Based on observations and staff interviews, the facility failed to date opened food items and seal leftover frozen food stored in 1 of 1 reach-in freezer, 1 of 1 walk-in freezer, 1 of 1 dry goods storage area and failed to remove a bowl being used as a scoop observed nested in breadcrumbs in one of the dry ingredient storage bins in the kitchen. This practice had the potential to affect foods served to the residents. The findings included: On 02/16/25 at 11:28 A.M., an observation of the kitchen revealed the following: a. Reach-in freezer: - A plastic bag containing slider buns (this item had a label with 8/20/24 written in the shelf life spot on the label and 11/20/24 written in the use by spot on the label) - A zippered type of plastic storage bag containing pork loin with no date on it - A zippered type of plastic storage bag containing pulled chicken with no date on it b. Walk-in freezer: - A box of pre-cooked egg patties - the egg product was in the manufacturer's box and contained inside the box in a plastic bag; both the box and the plastic bag were left open to air and there was no date on it. c. Dry storage area: - An opened package of devil's food cake mix in a plastic package with no date on it. d. On 02/18/25 at 8:42 A.M., an observation of the kitchen revealed one of the white 3-bin dry ingredient storage bins contained a black bowl. The bowl had been left inside the bin and was observed in contact with the breadcrumbs being stored in the bin. The Dietary Manager, who was present during this observation, stated that she thought staff were using the bowl as a scoop and that it should not be stored inside the bin. An interview was conducted with the Dietary Manager (DM) on 02/18/25 at 11:28 A.M. The DM stated she thought staff were moving too fast as a possible reason why opened food items were not labeled or dated. When asked to explain what she meant, the DM gave an example of staff being busy on the line at mealtimes and had to run get an item for a resident and then forgot to go back after the busy period to properly label the food item that had been opened in a hurry. The DM stated it was her expectation that dietary staff seal opened food items appropriately and to label the items with the name of the item, the date it was opened and the expiration date of the item. An interview was conducted with the Administrator on 02/18/25 at 10:16 A.M. The Administrator stated it was her expectation that dietary and nursing staff label opened food items with the date opened and a use-by date. The Administrator also stated that if the opened food item cannot be packaged for storage appropriately, it should be discarded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident, family, staff, and Regional Ombudsman interviews the facility failed to assure a resident (Resident # 1) was treated respectfully during a meeting held with staff members to discuss her care and concerns. This was for one of one sampled resident who met with administrative staff during a formal meeting. The findings included: Resident # 1 was admitted to the facility on [DATE] for rehabilitation after being hospitalized for a respiratory illness. Resident # 1's admission Minimum Data set assessment, dated 1/16/23, coded Resident # 1 as cognitively intact. Resident # 1 was not coded as displaying any behaviors during the assessment period. Resident # 1's care plan, updated on 2/20/23, noted Resident # 1 suffered from chronic pain. The care plan also addressed that she also displayed manipulative behavior/ attention seeking behaviors. Although not all inclusive, some of the interventions to address behaviors on the care plan were as follows. Staff were directed to determine the reason for any behaviors, approach her in a calm manner, praise for desired behavior, and provide support as needed. Resident # 1 was interviewed on 2/25/23 at 9:40 AM and reported the following. She and two of her family members had a meeting within the past week with administrative staff members to discuss her care and concerns that she and her family had. One of the resident ' s main concerns, which was discussed, was pain management and getting her pain medication timely. The resident also reported that she had concerns that she heard staff talking about her from her room while they were in the hallway, and she did not appreciate that. Prior to the meeting, Nurse # 1 had informed Resident # 1 that upon her initial admission, Resident # 1 acted as if staff should drop everything and attend to her. According to Resident # 1, Nurse # 1 was a direct care nurse and had not been at the meeting. Resident # 1 did not recall anything specifically she had done to give staff this impression, and acknowledged that when she first came, she may not have remembered everything as clearly as she did currently. During the meeting with administrative staff, she stated she spoke up and apologized for anything she had done to upset facility staff. She told the administrative staff that she wanted everyone to get along. During the meeting she recalled the business office manager rolling her eyes during the meeting. She also recalled the social worker sat as if she had a chip on her shoulder and would not look at her. The resident stated it made her feel as if I was beneath them and a nobody to them. Resident # 1's family member was interviewed on 2/24/23 at 10:40 AM and reported the following. Resident #1, another family member, and she had met with several administrative staff members within the past week to discuss Resident # 1's care and concerns they had. The Regional Ombudsman was also present for the meeting. The family member reported the staff members looked down rather than at the resident and rolled their eyes during the meeting. The Regional Ombudsman was interviewed on 2/24/23 at 12:53 PM AM and reported the following. He had been in attendance during the meeting with Resident #1, two family members, and several administrative staff members within the past week. The administrative staff members who were present were the Rehabilitation Director, the Director of Nursing, the Social Worker, and the business officer manager. The Administrator was not physically present and had called in on the speaker phone. The Physician Assistant (PA) came for the first few minutes of the meeting and stepped out after discussing pain management. After the PA left, they further discussed concerns that the resident felt she had waited for care and pain medications, that the resident felt staff were talking about the resident in the hallway when she was not present, discharge planning, and the amount of assistance the resident needed to walk to the bathroom. The Regional Ombudsman corroborated that during the meeting he witnessed the social worker rolling her eyes as Resident # 1 was speaking. He also corroborated some of the administrative staff members would not look at the resident and looked down. The Regional Ombudsman reported Resident # 1 spoke up and said she was not asking for special treatment, but only to be treated the way they would treat their own family member. According to the Regional Ombudsman, none of the staff members spoke up when this was said by the resident. Following the meeting, the Regional Ombudsman stated he had spoken to the Administrator about how the staff had acted during the meeting. The Regional Ombudsman was interviewed again on 2/27/23 at 10:35 AM. The Regional Ombudsman reported the meeting with Resident # 1 and the family lasted approximately one hour and 15 minutes. They had also discussed what the social worker's role was during the meeting. He did see the social worker go up to the resident after the meeting had been concluded and as people were leaving. According to the Regional Ombudsman, as people were leaving the SW told Resident # 1 she cared. The Administrator was interviewed on 2/24/23 at 5:25 PM and again on 2/25/23 at 3:45 PM and reported the following. She had been out of town when the meeting was held. It would have been her preference to have been physically present during the meeting, but she had not wanted to delay the meeting for her return. This was because she wanted any concerns Resident # 1 and her family had to be resolved. Therefore, she had called in by speaker phone and she could not see how her staff were acting nor always hear every detail. Since the meeting, she had followed up with her staff who reported that after the meeting the social worker had tried to reinforce that they cared about Resident # 1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to refer a resident with a newly evident diagnosis of a serious mental illness for Preadmission Screening and Resident Review Level II for 1 of 1 resident reviewed for Preadmission Screening and Resident Review (Resident #72). Findings Included: Resident #72 was admitted to the facility on [DATE] with diagnoses which included, in part, unspecified dementia without behavioral disturbance. A record review of Resident #72's Significant Change Minimum Data Set (MDS), dated [DATE], indicated Resident #72 was not currently considered by the State Level II Preadmission Screening and Resident Review (PASRR) process to have a serious mental illness. Diagnoses on the MDS included non-Alzheimer's dementia and psychotic disorder. The MDS also indicated Resident #72 had received antipsychotic medication on a routine basis only. A review of Resident #72's medical doctor's progress notes revealed she was diagnosed with psychotic disorder with hallucinations due to known physiological condition on 04/28/22. In the Plan of Care in the progress note, the medical doctor (MD) indicated Resident #72 was to continue taking her antipsychotic medication daily. On 06/10/22, Resident #72's MD note specified, she has refused treatment and baseline has significant dementia with agitation .will also continue quetiapine (an antipsychotic medication) for psychosis and sertraline (an antidepressant medication) for depression and behaviors. During an interview with the Social Worker (SW) on 07/26/22 at 3:39 p.m., the SW stated she was the person responsible for referring residents with a newly evident diagnosis of a serious mental illness for a PASRR Level II screen. The SW explained she had been unaware Resident #72 had been diagnosed with psychotic disorder with hallucinations due to known physiological condition. The SW was unsure whether psychotic disorder had been erroneously checked on the MDS assessment or not. An interview was held with the MDS Coordinator on 07/26/22 at 4:22 p.m. The MDS Coordinator explained she had indicated Resident #72 had a psychotic disorder on the significant change MDS after reading the new diagnosis on the two MD notes, dated 04/28/22 and 06/10/22. A second interview was held with the SW on 07/27/11 at 11:11 a.m. The SW explained the process she followed for making a PASRR Level II screen on new residents and on established residents. For established residents, she stated she would run a report on all residents which included their diagnoses monthly and provided her most recent report dated 06/30/22. She further explained that residents on the report with newly evident mental illness diagnoses would be referred for a PASRR Level II screen. During the survey, the SW discovered Resident #72's new mental illness diagnosis had not been added to the resident's diagnoses listing in her electronic health record and the opportunity to refer for a PASRR Level II screen was missed. During an interview with the Administrator on 07/28/22 at 12:08 p.m., the Administrator stated after discussion with her interdisciplinary team (IDT), Resident #72 was not referred for a PASRR Level II screen because her newly evident mental illness diagnosis had not been added to the diagnoses listing in her medical record. The Administrator explained going forward, new processes were being put in place to ensure the MD and the IDT communicated new mental health diagnoses to ensure those residents who require a referral for a PASRR Level II screen would be referred.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and record reviews, the facility failed to provide a resident's tube feeding in accordance with the physician's order for 1 of 2 residents (Resident #55) reviewed for tube feeding. Findings included: Resident #55 was admitted to the facility on [DATE] with diagnoses that included stroke with difficulty swallowing and feeding tube placement. Review of physician's orders revealed an order dated 6/25/22 for standard tube feeding (TF) formula at 55 milliliters (ml) per hour through her feeding tube over 22 hours per day. A Care Plan dated 6/29/22 focused on tube feeding included a goal for Resident #55 to receive the appropriate number of calories from her tube feeding to maintain weight and hydration. Interventions included provide tube feeding as ordered and notify dietitian, doctor, and family of any weight changes. Resident #55's admission Minimum Data Set (MDS) dated [DATE] indicated a moderate cognitive impairment. She received greater than 51% of her calories and fluid from her TF. An observation was made on 7/25/22 at 12:45 PM of Resident #55 in bed with TF formula running at 60 ml per hour through her feeding tube. During an interview on 7/25/22 at 12:50 PM, Nurse #1 confirmed the TF was ordered for 55 ml per hour. She indicated that it was running at 60 ml per hour when she took over Resident #55's care from night shift and it had been changed by the night shift nurse. She revealed she had checked the TF that morning but was not aware it was not the correct rate. During an interview on 7/26/22 at 1:15 PM, the Director of Nursing (DON) indicated that the nurses should check the order when they start a new bottle of tube feeding formula. The nurses on each shift should confirm the TF was running as ordered. During an interview on 7/26/22 at 3:00 PM, the Administrator revealed TF should run as ordered by a physician. The nurse should have reviewed the order when she changed out the TF bottle.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, staff and physician interviews, the facility failed to obtain a physician order to administer oxygen for 1 of 1 resident (Resident #214) reviewed for respiratory care. The findings included: Resident #214 was admitted to the facility on [DATE]. His diagnoses included acute respiratory failure with hypoxia, acute and chronic respiratory failure with hypercapnia, congestive heart failure, and chronic obstructive pulmonary disease. The most recent comprehensive Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #214 was cognitively impaired and received oxygen therapy. Review of Resident #214's physician orders on 7/25/22 at 09:32 AM revealed no order for oxygen administration. During observation on 07/25/22 09:33 AM Resident #214 was observed with the oxygen nasal canula. Resident #214's oxygen regulator on the concentrator was set at 3 liters/minute when viewed horizontally at eye level. During observation on 07/26/22 09:16 AM Resident #214 was observed with the oxygen nasal canula. Resident #214's oxygen regulator on the concentrator was set at 3 liters/minute when viewed horizontally at eye level. During observation on 07/26/22 11:15 AM Resident #214 was observed with the oxygen nasal canula. Resident #214's oxygen regulator on the concentrator was set at 3 liters/minute when viewed horizontally at eye level. Resident #214's oxygen regulator was verified with Medication Aide #2 to be set at 3 liters/minute. During an interview on 07/26/22 at 11:15 AM with Medication Aide #2, she stated she thought Resident #214 was supposed to be on oxygen at 2 liters/minute via nasal cannula, but she could not locate the order. Medication Aide #2 stated the order would be documented under physician orders and in the Resident 214's medication administration record (MAR). During an interview on 07/26/22 at 11:22 AM with Nurse #2, she stated there was no order for Resident #214's oxygen administration under physician orders and medication administration records. Nurse #2 stated there should have been a physician order to administer the oxygen. An interview was conducted on 07/26/22 12:15 PM with the Director of Nursing (DON). She stated there should have been a physician order to administer oxygen to Resident #214. The DON further stated when the facility utilized standing orders, the standing order would be activated and documented under physician orders. During an interview on 07/26/22 at 12:32 PM with the facility Administrator, she stated she expected nursing staff to obtain a physician order to administer oxygen if there was need for oxygen administration. An interview was conducted on 07/27/22 08:38 AM with the facility Physician. He stated he could not recall if the facility had contacted him for an order to administer oxygen to Resident #214. He further stated if the facility had contacted him for an order, it would be documented under physician orders. The Physician stated he expected nursing staff to administer oxygen with an order and to contact him if there was need for oxygen administration or oxygen titration for any resident in the facility.