**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff and resident interviews, the facility failed to assess the ability of a resident to self-administer medications and supplements for 1 of 1 resident with medication observed in the room (Resident #3). Findings included: Resident #3 was admitted to the facility 12/12/24 with diagnoses including hypertension (high blood pressure) and hypercholesterolemia (high cholesterol). Review of Resident #3's medical record revealed no documentation that Resident #3 was assessed for self-administration of medications or supplements. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 was cognitively intact. Review of Resident #3's physician orders revealed the following: CoQ10 (an antioxidant which protects cells from damage) 400 milligram (mg) daily ordered 12/20/24 Ezetimibe (a medication for high cholesterol) 10 mg once a day ordered 12/13/24 Fish Oil 1200 mg once a day ordered 12/20/24 Flax Seed Oil (a supplement that may decrease inflammation) 100 mg once a day ordered 12/20/24 Garlic Oil 1000 mg once a day ordered 12/20/24 Escitalopram (an antidepressant) 5 mg once a day ordered 12/13/24 Lisinopril 5 mg once a day hold for systolic blood pressure <120 ordered 12/17/24 Psyllium Husk (laxative) 2 capsules once a day ordered 12/20/24 Turmeric (a supplement that may decrease inflammation) 1000 mg once a day ordered 12/20/24 Zinc 30 mg once a day ordered 12/20/24 An observation of Resident #3's overbed table on 01/21/25 at 11:08 AM revealed a cup of medication with approximately nine pills sitting on the table. An interview with Resident #3 at the same date and time revealed she wasn't sure what most of the pills were, but she thought several of them were supplements. She stated she didn't want to take her medications when the nurse brought them to her the morning of 01/21/25 and asked the nurse to leave the medications on her table and she would take them later. Resident #3 stated nurses frequently left medications on her table at her request. An interview with Nurse #2 on 01/21/25 at 11:24 AM revealed when she brought Resident #3 her medications and supplements around 8:30 AM the morning of 01/21/25, Resident #3 did not want to take the medication because she hadn't eaten yet. She stated Resident #3 asked her to leave the medications on her overbed table and told her she would take them later. Nurse #2 stated she should have removed Resident #3's medication from the room instead of leaving it on the overbed table when Resident #3 informed her she did not want to take the medication. She confirmed the medications and supplements in the cup were CoQ 10, Escitalopram, Ezetimibe, Fish Oil, Garlic Oil, Turmeric, Zinc, and Lisinopril. Nurse #2 stated Resident #3's blood pressure was 130/77 the morning of 01/21/25. In an interview with the Director of Nursing (DON) on 01/24/25 at 12:24 PM she confirmed there were no residents with physician orders to self-administer oral medication or supplements. She explained if a resident wanted to self-administer medication, the physician was notified of the request, and she completed an assessment to see if the resident was safe to administer their medication. The DON stated if the resident was assessed as being safe to administer their medication, the interdisciplinary team was notified, and a physician order was obtained. She stated the medications were kept in the nightstand in a locked drawer. The DON stated unless a resident had an order to self-administer medications, the nurse should observe the resident taking medication or remove medication from the room and discard it. An interview with the Administrator on 01/24/25 at 1:01 PM revealed he expected nursing staff to follow facility policy for self-administration of medication or stay with the resident during medication administration.

Based on observations and staff interviews, the facility failed to remove food items past the date indicated for use in the walk-in refrigerator. This practice occurred in 1 of 1 walk-in refrigerator and had the potential to affect food served to residents. Findings included: An observation of the walk-in refrigerator on 01/21/25 at 9:22 AM with the Certified Dietary Manager (CDM) revealed the following: 1 a. A five pound container of sour cream dated 1/13 that had been opened and was available for use. During an interview on 01/21/25 at 9:22 AM the CDM revealed the date on the container was the date the sour cream was opened and she expected it to be discarded on 1/20/25, seven days after being in use. The CDM removed the container of sour cream from the walk-in refrigerator. c. Two containers of ham salad dated 1/20. During an interview on 01/21/25 at 9:22 AM the CDM revealed the date on the ham salad was the use by date and she expected both containers to have been discarded on 1/20/25. The CDM removed both containers of ham salad from the walk-in refrigerator. d. A half quart container of pinto beans dated 1/10 and 1/17. During an interview on 01/21/25 at 9:22 AM the CDM revealed the container of pinto beans was dated with both an open and used by date and she expected the beans to have been discarded on 1/17/25 according to the use by date. The CDM removed the container of pinto beans from the walk-in refrigerator. e. One large metal sheet pan of thawed raw chicken breast dated 1/20 stored on the bottom rack below other food items that were within the use by date and available for use. During an interview on 01/21/25 at 9:22 AM the CDM revealed the chicken was left over from 1/20/25 and should have been discarded on that day. The CDM further revealed it was the responsibility of the Kitchen Supervisor and dietary staff to check the dates on food items available for use and discard if out of date. During an interview on 01/22/25 at 4:38 PM the Kitchen Supervisor revealed he checked the walk-in refrigerator when he first arrived at work at approximately 6:45 AM and removed out of date food items. The Kitchen Supervisor revealed on 01/21/25 the food delivery truck had arrived, and he had not checked the walk-in refrigerator before the observation with the CDM and was why the out of date food items were not removed. During an interview on 01/24/25 at 1:02 PM the Administrator revealed if the use by date indicated a food item should be discarded those items should be removed and not stored in walk-in refrigerator and available for use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews, registered dietician (RD) and medical director interview, the facility failed to reweigh a resident to determine if a change in weight status was accurate and notify the RD of a significant weight loss for 1 of 1 resident reviewed for nutrition (Resident #15). The findings included: Resident #15 was admitted on [DATE] with diagnoses that included nutritional deficiency, dysphagia following a subarachnoid hemorrhage and dementia without behavioral disturbance. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #15 had severe cognitive impairment with no behaviors. She required supervision, cueing, and set up for meals. She had a mechanically altered diet, no swallowing or dental issues, was 5 foot 3 inches and weighed 100 pounds. In the past 6 months Resident #15 had no weight loss or it is unknown if weight loss occurred. An annual nutrition evaluation dated 3/5/22 revealed Resident #15 was on an easy to chew diet and was receiving supplements of Med Pass (nutritional supplement) 3 times a day mixed in juice. Resident #15 was to be offered snacks between meals. Physician orders for Resident #15 included: • Juice 4ounces (oz) with 2oz of Med Pass 3 times a day by mouth supplement with start date of 2/2/22 • Diet: Easy to chew consistency with start date of 5/1/20 • Weekly weights on Tuesdays due to low body weight with start date of 5/19/20 Resident #15's Care Plan updated on 5/20/22 revealed she was at risk for potential weight loss and other nutritional complications. The goals included the resident will consume at least 50% of meals and will remain free from significant weight loss greater than 7.5% in 3 months. The interventions included obtain and monitor weight as ordered, as needed, and follow up as indicated. Registered Dietician (RD) to evaluate and make recommendations as needed. The residents Care Plan did not address the actual weight loss. Resident #15's electronic medical record (EHR) revealed the following recorded weights: • 7/1/22 Resident #15 weight was recorded as 110.4 pounds (lbs) • 7/5/22 Resident #15 weight was recorded as 109.2 lbs • 7/12/22 Resident #15 weight was recorded as 109 lbs • 7/19/22 Resident #15 weight was recorded as 100.2 lbs • 7/26/22 Resident #15 weight was recorded as 100 lbs • 8/2/22 Resident #15 weight was recorded as 106.4 lbs. An interview was conducted on 8/4/22 at 8:56 AM with Nurse #1. Nurse #1 revealed she entered Resident #15's weight into the EHR on 7/19/22. She noticed the weight loss and reported it to the MDS Nurse. A nurse note dated 7/22/22 authored by the MDS Nurse revealed on 7/12/22 the resident weighed 109 lbs and on 7/19/22 she weighed 100.2 lbs. The note further revealed the weight could have been an error and weights would continue to be monitored. During an interview on 8/3/22 at 3:43 PM the MDS Nurse revealed she was aware of the changes in Resident #15's weight but was not concerned because she thought the weight was an error. She further revealed she did not request or obtain a reweigh for the resident. An observation on 8/2/22 at 8:25 AM revealed Resident #15 was in a small dining area eating breakfast. She had eggs, sausage, and biscuits and gravy. Resident #15 ate approximately 50% of her meal. During an observation on 8/3/22 at 8:18 AM Resident #15 was in a small dining area eating breakfast. Her sausage was cut into bite size pieces. She consumed approximately 50% of her meal. During an interview and observation with Nurse Aide #2 on 8/3/22 at 8:28 AM she revealed Resident #15 sometimes eats well and she sometimes doesn't. The resident doesn't request snacks between meals but if she wanted a snack, she would get her one from the nourishment room. An observation of Resident #15's tray with Nurse Aide #2 revealed Resident #15 ate 50% of her breakfast. A second interview was conducted with Nurse Aide #2 on 8/3/22 at 2:35 PM that revealed nurse aides were responsible for obtaining the resident's weights. The weight was then documented on a sheet called the vital sign report form. The form was given to the nurse to review and enter into the EHR. During an interview on 8/3/22 at 2:55 PM Nurse #1 revealed nurse aides obtained resident weights and reported them to the nurse on a vital sign sheet. Nurses were responsible for reviewing the weights and entering them into the medical record. She further stated that if she had a weight that was a large loss or gain she would reweigh the resident. If the weight was the same, she reported it. An on-site weight was obtained on 8/03/22 at 3:53 PM for Resident #15 by nursing staff. Resident #15 was observed being weighed on the sit-down scale by Nurse #1 and Nurse Aide #2. Resident #15 was placed in the sling of the mechanical lift and the sling was then attached to the lift. The scale was zeroed prior to weighing the resident. Resident #15 was lifted and placed on the seat of the sit scale via mechanical lift. Staff detached the sling from the mechanical lift, allowing the resident's weight to rest on the seat. The weight was obtained and equaled 100.2 lbs. An interview on 8/4/22 at 1:24 PM the Registered Dietician (RD) revealed she had not seen Resident #15 since 3/5/22 and was not aware of the recent weight loss. She further revealed if she were aware she would have added or increased her supplements to increase the resident's calorie and protein intake. The RD explained she was notified of weight loss through the nurses. The nurses would print out a list of weight losses for the week and put them in a box for her to retrieve. If the nurses had and urgent need, they could send her an email. If a resident was identified as at risk for weight loss, she saw them weekly. The RD stated the MDS Nurse was in communication with her and kept her up to date on the residents experiencing weight loss. The RD revealed she had only been working for the facility for a few months. She was part time and was only in the facility 2 days per week. She had not participated in any at risk meetings. An interview on 8/4/22 at 12:57 PM the Medical Director revealed that Resident #15's weight loss was unplanned but not unexpected because she has had ongoing issues with weight loss. The significant weight loss had no adverse outcome to Resident #15. On 8/3/22 at 4:54 PM an interview was conducted with the Director of Nursing. She revealed she reviewed resident weights weekly and was aware of the weight loss. She thought the weight was an error but could not be certain. She further revealed because the weight was thought to be inaccurate or an error, the resident should have been reweighed. If the reweight reflected a significant change, the dietician would have been involved and the MDS and care plans updated.

Based on observations and staff interviews, the facility failed to label and date food items in 1 of 1 walk-in cooler and 1of 1 walk-in freezer. This practice had the potential to affect the food served to residents. The findings included: An initial tour of the kitchen was made on 8/1/2022 at 11:13 AM with the Dietary Manager (DM). The following problems were observed in the walk-in cooler: • 1 opened and used pack of honey smoked turkey breast with no label and no date • ½ pack of opened and used corn beef with no label and no date • ½ container of opened and used thousand island dressing with no date • ¼ carton of opened and used milk with no date An observation of the walk-in freezer was made on 8/1/2022 at 11:18 AM with the DM. The observation revealed the following problems: • ¼ bag of opened and used carrots with no label and no date • ½ bag of opened and used corn with no label and no date • ½ bag of opened and used tater tots with no label and no date • ½ bag of opened and used waffle fries with no label and no date • ¼ bag of opened and used string beans with no label and date • ½ bag of opened and used breaded oysters with no label and no date • ¼ opened and used sugar free lemon meringue pie in covered dish with no label and no date A follow up tour of the kitchen was made on 8/2/2022 at 3:00 PM with the DM. The following problems were observed: • 1 scoop observed in the flour bin. The handle was observed to be resting in the flour • 1 scoop observed in the sugar bin. The handle was observed to be resting in the sugar An interview was completed with the DM on 8/2/2022 at 3:20 PM. She revealed the staff should label and date items in the refrigerator and freezer when they opened them. The DM stated unlabeled and undated items in the freezer were good for 7 days once opened. She revealed items unlabeled and undated in the cooler were good for 3 days once opened. The DM stated the cooler and freezer were last checked for labeling and dating on 7/29/2022 and on 8/1/2022 after the survey team entered the building. She explained the scoops should not have been left inside the flour or sugar bins and that it was not normal practice. She revealed the bins were last checked the morning of 8/2/2022. An interview was completed with the Administrator on 8/3/2022 at 11:19 AM. He revealed that opened items should have a date to be discarded and that he expected items to have a label and date. He continued to explain that scoops should not be left in bins. The scoops should be in a separate compartment.

Based on observations and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions previously put in place following the recertification survey of 8/04/22. This was for one deficiency cited during the 8/04/22 survey and subsequently recited on the 9/21/22 survey. The repeated deficiency was in the area of Food Safety Requirements. The facility's continued failure during two federal surveys shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross referenced to: F812- Based on observations and staff interviews, the facility failed to label, date and seal open food items stored for use in 1 of 1 walk-in freezer and 1 of 1 reach-in cooler. This practice had the potential to affect the food served to residents. On the recertification survey completed 08/04/22 the facility failed to label and date food items in 1 of 1 walk-in cooler and 1of 1 walk-in freezer. This practice had the potential to affect the food served to residents. An interview was conducted on 9/20/22 at 3:50pm with the Administrator who also headed the QAA committee. He stated dietary deficiencies were addressed by the Dietary Manager (DM) and based on reports from the weekly QAA meetings this was being completed. The DM oversaw the monitoring and brought findings to the QAA for discussion and revision. He revealed that items should be labeled & dated once opened.