**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure timely notification of Resident #74's fall to the resident representative. This affected one resident (#74) of one resident reviewed for notification of change. The facility census was 82. Findings include: Review of the medical record for Resident #74 revealed an admission date of 09/13/24. Diagnoses included metabolic encephalopathy, cognitive communication deficit, and vascular dementia, moderate, with agitation. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #74 had severely impaired cognition. Review of the interdisciplinary team (IDT) progress note dated 01/22/25 at 3:45 P.M. revealed a fall on 01/13/25 was discussed. Resident #74 noted to be confused with agitation and was wandering into other residents' rooms. He was last seen sitting on his bed at 4:00 A.M. As an aide was answering another resident's call light, she heard a male voice coming from a resident room, and upon opening the door Resident #74 was laying on his right side behind the door. He was assisted up and placed in wheelchair and brought to the common area. The physician was notified regarding increased behaviors and medication adjustment made. Medication adjustment effective at this time. Review of the progress note dated 01/23/25 at 10:56 A.M. revealed a nurse attempted to contact emergency contact list on Resident #74's face sheet to inform Resident #74's resident representative of resident's fall on 01/13/25, but there was no answer, so a message was left to contact facility. Review of the progress note dated 01/23/25 at 11:11 A.M. revealed Resident #74's resident representative returned the call at 11:09 A.M., the fall was reviewed with her and advised of the medication adjustment made after the fall due to his wandering and agitation. She indicated that she was in contact with Resident #74's son who resided in another state and would update him as well. Review of the fall investigation dated 01/13/25 revealed the resident representative was notified on 01/23/25 at 11:09 A.M. noted under time of notification. Interview on 01/29/25 at 3:44 P.M. with Assistant Director of Nursing (ADON) #720 stated the internet was down on 01/13/25 so that was why the fall wasn't documented on that day. ADON #720 verified Resident #74's resident representative was notified on 01/23/25 and stated she was not sure why it took 10 days. ADON #74 stated the expectation for notifications were to be immediately if able. Reviewed policy Notification of Change, dated 07/2017 revealed the resident's physician and responsible party must be notified when an event involving the resident occurs or when the resident experiences a change in condition, potential discharge, room transfer, or death. Under notification, item number eight revealed the resident legal representative or interested family member is notified of a significant change in the resident condition unless the resident has specified otherwise. The legal representative or family member may indicate to the facility specific notification parameters. Should this occur, document and place behind the face sheet in the chart and care plan their preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of facility policy, the facility failed to ensure the interdisciplinary team was present as required when care plan conferences were conducted for Resident #24 and Resident #75. This affected two residents (Resident #24 and #75) of two residents reviewed for care planing. The facility census was 82. Findings include: 1. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including cellulitis of right lower limb, acute respiratory failure with hypoxia, sepsis, hypertensive chronic kidney disease, cognitive communication deficit, methicillin resistant staphylococcus aureus infection, type two diabetes mellitus with diabetic neuropathy, and hypertension. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he was cognitively intact. Review of the facility documents titled Care Conference, dated 10/30/24 and 01/13/25 revealed only Resident #24, Social Services (SS) #823, MDS Registered Nurse (RN) #811 and a therapist were present for the care conference on 10/30/24 and only Resident #24, SS #823 and MDS RN #811 were present for the care conference on 01/13/25 There was no additional information on the form to indicate any other members of the facility interdisciplinary care team took part in the care conferences. Interview with Resident #24 on 01/27/25 at 8:59 AM revealed he believed he had not had a care conference with members of the facility care team. Interview with SS #823 on 01/29/25 at 3:43 PM verified all members of the health care team at the facility do not attend care conferences for Resident #24 as required. SS #823 stated she sent a schedule out each Friday to the care team and before the scheduled care conferences to inform staff of the upcoming meetings the following week however not all required staff members attend. SS #823 stated her care conference with the residents last approximately 10 minutes and are very informal so the residents possibly misunderstand their care conferences as a general discussion. 2. Review of the medical record for Resident #75 revealed an admission date of 11/05/24 with diagnoses including acquired absence of right leg below knee, hereditary and idiopathic neuropathy, major depressive disorder and hypertension. Review of the MDS 3.0 assessment dated [DATE] revealed Resident #75 had intact cognition. Review of the facility documents titled Care Conference, dated 11/21/24 revealed only Resident #75, Social Services (SS) #823, MDS Registered Nurse (RN) #811, a therapist and another nurse were present for the care conference on 11/21/24. There was no additional information on the form to indicate any other members of the facility interdisciplinary care team took part in the care conferences. Interview with SS #823 on 01/29/25 at 3:43 PM verified all members of the health care team at the facility do not attend care conferences for Resident #75 as required. SS #823 stated she sent a schedule out each Friday to the care team and before the scheduled care conferences to inform staff of the upcoming meetings the following week however not all required staff members attend. SS #823 stated her care conference with the residents last approximately 10 minutes and are very informal so the residents possibly misunderstand their care conferences as a general discussion. Review of Resident Assessment Comprehensive Care Plans policy (updated 05/24/2022, reviewed 01/01/25) revealed, an interdisciplinary team, in conjunction with the resident, resident's family, surrogate, or representative, as appropriate, should develop quantifiable objectives for the highest level of functioning the resident may be expected to attain, based on the comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to give medications with an error rate of under five percent. This affected one resident (Resident #435) of two residents reviewed for medication administration. The total census was 82. Findings include: Record review of Resident #435 revealed he was admitted [DATE] and had diagnoses including chronic obstructive pulmonary disease (COPD), acute peptic ulcer with hemorrhage, and hypoxemia. He had active orders dated 01/17/25 for one pill of coenzyme Q10 30 milligrams (mg), one pill of vitamin E 268 mg, and one puff of Trelegy Ellipta (a combination inhalation medication for COPD) 200-62.5-25 micrograms. All of these medications were ordered to be given once daily between 7:00 A.M. and 11:00 A.M. Observation of medication administration for Resident #435 by Licensed Practical Nurse (LPN) #802 on 01/28/25 at 8:25 A.M. revealed she did not have the correct doses of coenzyme Q10 and vitamin E in the medication cart and held the medications. The Trelegy Ellipta container included specific instructions to swish and spit after administration. When the nurse administered the Trelegy Ellipta, she then exited the room without instructing the resident to swish and spit and the resident was not observed to do so before the nurse left the room. Interview with LPN #802 on 01/28/25 at 8:57 A.M. confirmed the above findings. Follow-up interview with LPN #802 on 01/28/25 at 11:18 A.M. revealed the coenzyme Q10 and correct vitamin E medications had to be ordered from pharmacy and were expected to arrive the next day, so she marked both medications as held due to not being available. The above findings identified three errors out of 28 observed opportunities for medication error, creating a total error rate of 10.7%.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, medical record review, and review of facility policy, the facility failed to ensure meal intakes were recorded for Residents #13, #18, #65, and #66, failed to ensure weights were obtained and recorded into the medical record for residents #13 and #41 and failed to ensure therapeutic diets were implemented as ordered for Residents #65 and #66 to allow for accurate nutritional assessment and monitoring of nutritional status. This affected five residents (#13, #18, #41, #65, and #66) out of five reviewed for nutrition. The facility census was 82. Findings include: 1. Review of Resident #66's medical record revealed an admission date of 11/01/24. Diagnoses included non-displaced fracture of greater trochanter of right femur, Alzheimer's disease, dementia, major depressive disorder, type two diabetes, and dysphagia. Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 01/15/25, revealed Resident #66 was severely impaired cognitively, dependent on staff for eating, had no significant weight loss over one and six months, and was on a therapeutic diet. Review of Resident #66's care plan, initiated on 01/15/24, revealed the resident was at risk for malnutrition. Interventions included assistance with meals as needed, diet per doctor's order, medication as ordered and monitor labs as needed. Review of Resident #66's labs revealed on 08/02/24 potassium (normal range 3.5 to 5.1 millimoles per liter) was low at 3.1 millimoles per liter (mmol/L), on 08/06/24 potassium level was low at 3.3 mmol/L, on 08/09/24 potassium level was low at 3.3 mmol/L, and on 9/03/24 potassium level was 3.7 mmol/L which was within the normal range but was at the lower end of the normal reference range which was 3.5 to 5.1 mmol/L. Review of physician orders for Resident #66 revealed an order dated 10/03/24 to push high potassium foods, regular diet with extra gravy on tray, sugar substitute, thin liquids with two glasses of punch/juice with meals. Review of the annual nutritional assessment dated [DATE] and authored by Registered Dietitian (RD) #826 revealed Resident #66 was on a regular diet, extra gravies, high potassium, sugar substitute diet and was consuming 75-100% of meals and ate in her room. Resident #66's weight had triggered a significant weight increase over three months, but weight had been fairly stable over the past month. Resident #66 had recently tested positive for Covid-19 on 01/06/25 and the dietitian indicated she would monitor intakes and make adjustments as needed. Review of meal intake records in Resident #66's medical record from 01/01/25 to 01/29/25 revealed there were no meal intakes recorded. Review of Resident #66's lunch meal tray ticket for 01/28/25 revealed Resident #66 was on a regular diet with sugar substitute. Listed under the section titled beverage/equipment on the tray ticket was two glasses of juice, ginger ale and juice water Observation on 01/28/25 at 12:57 P.M. revealed on Resident #66's lunch meal tray was ginger ale, iced tea, milk, sloppy joes, green beans, and rice crispy treat. At the time of observation, Certified Nursing Assistant (CNA) #513 confirmed there was no juice or juice water on the tray served to the resident. Observation on 01/28/25 at 5:40 P.M. of Resident #66's dinner tray revealed one can of ginger ale, one glass of water, one cup of coffee, one bowl of crushed pineapple, and one plate with chicken pot pie and broccoli. At the time of observation, CNA #616 confirmed what was on the meal tray. Interview on 01/29/25 at 10:01 A.M. with CNA #513 revealed meal intakes were supposed to be put into the resident's electronic medical record (EMR) but confirmed meal intakes hadn't been put into the EMR due to lack of time. She stated she had most of the intakes in her brain and would tell the nurse if a resident hadn't eaten a meal. Interview on 01/29/25 at 10:05 A.M. with CNA #511 confirmed meal intakes were not being documented into the EMR and the reason she hadn't documented meal intakes was she lost track of time. Interview on 01/29/25 at 2:31 P.M. with RD #826 revealed for residents on high potassium diet the facility would push high potassium foods by offering banana at breakfast and orange juice at all meals. RD #826 confirmed Resident #66 was to receive high potassium foods and beverages. After RD #826 reviewed Resident #66's meal tray ticket, she confirmed the meal tray ticket did not state to give orange juice at all meals. RD #826 also confirmed there were no meal intake records in the medical record for Resident #66 for the month of January 2025 so for purposes of nutritional assessments and monitoring of the therapeutic diet she would get her information from nursing on how much the resident was eating. RD #826 verified she was not aware Resident #66 was not getting orange juice at all meals. Review of facility policy Nutrition Assessment, revised August 2023, revealed nurse aides were to complete food intake and record daily. 2. Review of Resident #65's medical record revealed a readmission date of 12/31/24. Diagnoses included displaced interochanteric fracture of left femur, fracture of right forearm, essential hypertension, anxiety disorder, and localized edema. Review of the 01/06/25 admission MDS 3.0 assessment, dated 01/06/25, revealed Resident #65 was cognitively intact, required setup or clean up assistance for eating, had no significant weight changes and was on a therapeutic diet. Review of the care plan, initiated on 01/06/25, revealed Resident #65 was at nutritional/hydration risk. Interventions included 2000 cubic centimeter (cc) fluid restriction (1080 dietary/920 nursing), diet per doctor's orders, monitor for signs and symptoms of fluid imbalance, monitor labs as needed, and monitor meal intake/record. Further review of Resident #65's medical record revealed an admission nursing note dated 12/31/24 indicating the resident was to be on a 2,000 cc fluid restriction due to low sodium levels. Review of physician orders revealed an order dated 01/01/25 for a regular, thin liquids diet and an order dated 01/06/25 for 2000 cc/24 hr (hour) fluid restriction (1080 cc dietary and 920 cc nursing) Review of Resident #65's recorded meal intakes from 01/01/25 to 01/30/25 revealed there were no recorded meal intakes. Review of 01/06/24 initial nutritional assessment authored by RD #826 revealed Resident #65 was on a regular diet, and was consuming 75 to 100 percent of meals. The resident was receiving a 2000 cc fluid restriction due to low sodium levels. Review of labs in Resident #65's medical record revealed the last sodium lab level was drawn on 10/21/24 and it was 137 millimoles per liter (mmol/L), which was at the lower end of the normal reference range of 137 to 147 mmol/L. Observation on 01/27/25 at 12:46 P.M. revealed on Resident #65's lunch meal tray there was one full bowl of chicken noodle soup which consisted of broth, chicken, and noodles, one eight ounce (240cc) full glass of lemonade, one eight ounce (240 cc) carton of two percent milk and one eight ounce (240 cc) cup of hot chocolate. At the time of observation Certified Nursing Assistant (CNA) #620 confirmed the soup and beverages on the meal tray. Observation on 01/28/25 at 1:02 P.M. revealed on Resident #65's lunch tray was one eight ounce (240 cc) cup of hot chocolate, one full eight ounce (240 cc) glass of lemonade, and one eight ounce (240 cc) carton of two percent milk. Sitting on top of her overbed table was a full pitcher of water. At the time of observation, CNA # 511 confirmed the beverages on the meal tray and the full water pitcher. Observation on 01/28/25 at 5:44 P.M. revealed on Resident #65's dinner tray was one eight ounce cup (240 cc) of hot chocolate, and one full eight ounce (240 cc) cup of lemonade. There was a full water pitcher on the overbed table. At the time of observation CNA #620 confirmed the beverages on the meal tray and the water pitcher. Interview on 01/29/25 at 10:01 A.M. with CNA #513 revealed meal intakes were supposed to be put into the resident's electronic medical record (EMR) but confirmed meal intakes hadn't been put into the EMR due to lack of time. She stated she had most of the intakes in her brain and would tell the nurse if a resident hadn't eaten a meal. Interview on 01/29/25 at 10:05 A.M. with CNA #511 confirmed meal intakes were not being documented into the EMR and the reason she hadn't documented meal intakes was she lost track of time. CNA # 511 indicated she normally worked the unit where Resident #65 resided and was unaware of Resident #65 being on a fluid restriction and stated every resident had a water pitcher. Interview on 01/29/25 at 2:25 P.M. with RD # 826 confirmed Resident #65 was on a fluid restriction due to history of having low sodium lab levels. She stated Resident #65 was to receive one eight ounce (240cc) hot beverage and a half of an eight ounce (120cc) glass of juice for each meal for a total of 1080cc/day. She stated the aides should be reading the tray ticket and should be providing what is on the tray ticket. She also indicated that a resident on a fluid restriction was not supposed to have a water pitcher at bedside. She also stated if a resident received soup it would need to be strained. She went on to confirm there were no meal intakes recorded in the medical record for Resident #65 and stated she would get her information from nursing on how much the resident was eating for a meal. Review of facility policy Fluid Restrictions/Hydration, revised August 2023, revealed physician orders for fluid restrictions would be followed, and dietary and nursing would determine the amount of fluids to be given with meals and between meals. Review of facility policy Nutrition Assessment, revised August 2023, revealed nurse aides were to complete food intake and record daily. 3. Review of Resident #13's medical record revealed an admission date of 10/19/24. Diagnoses included fracture of right humerus, depression, anxiety, fracture of part of scapula, other fracture of second lumbar vertebra, essential hypertension, acute on chronic diastolic (congestive) heart failure, and hyperlipidemia. Review of Resident #13's quarterly MDS 3.0 assessment, dated 01/25/25, revealed the resident was cognitively intact, required partial/moderate assistance from staff for eating, had no significant weight changes, and received a therapeutic diet. Review of Resident #13's care plan, initiated on 10/25/24 revealed the resident was at nutritional risk related to being status post fracture of femoral head. Interventions included monitor meal intake and record, monitor tolerance of diet texture, make adjustments as needed, offer substitutes if consumes less than 50 percent of meals, and weight every month and or as needed and notify physician of significant change. Review of physician orders revealed an order dated 10/19/24 for weekly weights for four weeks following admission on ce a day on Monday, an order dated 12/09/24 for weekly weights for four weeks once a day on Monday, and an order dated 12/11/24 for Regular No Added Salt thin liquids diet. Review of the 10/25/24 initial assessment authored by RD #826 revealed at the time of the assessment the resident was on a regular diet, was eating her meals in her room, and was consuming 50 to 100 percent of meals with setup from staff. The facility diet was providing 2000 to 2200 calories, 85 to 100 grams protein, and greater than 1400 cubic centimeters of fluid (cc) a day, and Resident #13's estimated needs were 1301 to 1550 calories, 57 to 68 grams protein, and 1425 to 1710 cc fluid. Further review of Resident #13's medical record revealed a progress note dated 12/09/24 and authored by RD #826 indicatng the resident's monthly weight taken on 12/04/24 of 129.6 pounds had shown a significant weight loss for one month and the previous weight may have been in error with the resident reporting her usual weight was 125 pounds. In the progress note it was documented intakes had been good for Resident #13 with 50 to 100 percent of most meals being consumed; however, it was noted later in the progress note that therapy had reported resident was not eating much recently and the resident stated her appetite was fair. The dietitian was going to request a reweight and weekly weights for verification and stabilization to determine the need for further interventions and was going to try adding a mighty shake (nutritional supplement) to increase intakes and stabilize weights. Review of meal intakes for November 2024 revealed the only meal intake which was recorded was on 11/19/24 when Resident #13 consumed 51 to 75 percent of the dinner. In December 2024 the only meal intakes recorded was on 12/09/24 when Resident consumed 51 to 75 percent of breakfast and on 12/14/24 when Resident #13 consumed 76 to 100 percent of breakfast. In January 2025 there were no recorded meal intakes. Review of weights recorded in Resident #13's medical record revealed a weight of 137.8 pounds (lbs) on 11/14/24, a weight of 129.6 lbs on 12/04/24, a weight of 128.4 lbs on 12/31/24, and a weight of 128.6 lbs on 01/06/25 were the only weights recorded in the medical record. There were no weights recorded on 10/21/24, 10/28/24, 11/04/24, and 11/11/24 for the weekly weights for the order dated 10/19/24 for four weekly weights. Resident #13 had a 5.9 percent weight loss from 137.8 pounds on 11/14/24 to 129.6 pounds on 12/04/24. There were only two weekly weights on 12/16/24 and 12/23/24 out of four ordered for the order dated 12/09/24 for weekly weights for four weeks . Interview on 01/29/25 at 10:01 A.M. with CNA #513 revealed meal intakes were supposed to be put into the residents electronic medical record (EMR) but confirmed meal intakes hadn't been put into the EMR due to lack of time. She stated she had most of the intakes in her brain and would tell the nurse if a resident hadn't eaten a meal. Interview on 01/29/25 at 10:05 A.M. with CNA #511 confirmed meal intakes were not being documented into the EMR and the reason she hadn't documented meal intakes was she lost track of time. Interview on 01/29/25 at 2:51 P.M. with RD #826 revealed weekly weights were put into the medication administration record (MAR) and would auto populate so the nurses would know when a weight was needed. The nurses would then let the aides know who needed weighed and the nurses were to put the weight into the MAR. She confirmed there was no reweight obtained and the Resident #13 was missing weekly weights. Dietitian #826 went on to state no one told her she refused to be weighed. She confirmed the missing meal intakes and stated she got her information on how much a resident ate from nursing. 5. Review of the medical record review for Resident #41 revealed an admission date of 04/25/24. Diagnoses included acute respiratory failure with hypoxia, severe sepsis without septic shock, hypertension, solitary pulmonary nodule, cerebrovascular disease, type two diabetes mellitus without complications, hyperlipidemia, shortness of breath, constipation, obesity, and chronic atrial fibrillation. Review of the MDS 3.0 assessment, dated 12/12/24, revealed Resident #41 was cognitively impaired. Review of Resident #41's physician orders revealed an order dated 01/09/2025 for weekly weights once a day on Mondays to start on 01/13/25 for one month. Review of Resident #41's weights for January 2025 revealed no weekly weight was recorded for 01/13/25 and 01/27/25 per the physician order to be weighed weekly on Mondays. Observation on 01/29/25 at 11:05 A.M. with RD #826 revealed RD #826 presented a list of weekly weights for January 2025 for residents requiring weekly weights and Resident #41 was not on the weekly weight list. RD #826 stated the list was how the nursing staff identified which residents required weekly weights, in addition to the physician order. Interview on 01/29/25 at 11:05 A.M. with RD #826 verified Resident #41 had an order to be weighed weekly on Mondays to start on 01/13/25 and no weekly weights were obtained on 01/13/25 and 01/27/25. Review of the facility policy titled Weight and Height Records Policy, revised August 2023, revealed residents would have their weight obtained by certified and licensed staff at monthly intervals unless more frequent monitoring was needed as determined by resident weight record, medical condition, or clinical staff. Weight orders would be placed in the electronic medical record (EMR) if more frequent monitoring was needed than stated in facility policy. Weights would be recorded in EMR when obtained and residents have the right to decline weights and would document refusals of weights not obtained in the EMR as refused, combative, deferred due to condition, or unavailable. Review of facility policy Nutrition Assessment, revised August 2023, revealed nurse aides were to complete food intake and record daily. 4. Review of the medical record revealed Resident #18 was admitted on [DATE] with diagnoses including cognitive communication deficit, schizoaffective disorder, obsessive-compulsive disorder, generalized anxiety disorder, major depressive disorder, and constipation. Review of the MDS 3.0 assessment dated [DATE] revealed the resident was alert with minimal recall of current events, a weight of 177 pounds, no known swallowing disorder, and no known weight loss in the last month. Review of physician orders dated 12/11/24 revealed Resident #18 was ordered a regular diet with thin liquids, Prostat AWC (protein supplement) 30 cc twice a day, and a Mighty Shake (nutritional supplement) daily at lunch. Review of Resident #18's care plan initiated on 12/16/24 identified Resident #18 as a nutrition/hydration risk. Interventions included monitoring meals intake/records and weigh every month and as needed. Review of a dietary admission note dated 12/16/24 identified Resident #18 as at risk for malnutrition. Review of meal consumption records for December 2025 revealed Resident #18 was eating between 51 to 75 percent of her meals, however, the meal intakes were only recorded on eight of 20 meals reviewed. No meal consumption records were completed from 01/01/25 to 01/27/25. An interview on 01/27/25 at 1:10 P.M. with Resident #18's husband revealed Resident #18 required someone to feed her since she was unable to use regular cups or silverware, and she required special equipment if trying to eat by herself. The husband stated he visited her each day to assist her with eating. He stated he did not know if Resident #18 had lost weight. Observation of Resident #18 during the interview revealed she was alert with confusion and unable to answer simple or open-ended questions, so she was not a reliable source of information. An interview with Registered Dietician (RD) #826 on 01/28/25 at 11:08 A.M. revealed Resident #18 required adaptive equipment for eating that included built up silverware, scoop late and handled cup. RD #826 stated the resident was at risk of impaired nutritional status due to depression, weakness and constipation, and was consuming between 50 to 75 percent of her meals and supplements. An interview on 01/29/25 at 10:56 A.M. with Licensed Practical Nurse (LPN) #804 verified meal intake records for Resident #18 were partially documented during the month of December 2024 and not documented at all from 01/01/25 to 01/29/25. A follow up interview on 01/29/25 at 2:59 P.M. with RD #826 revealed there were meal intakes not being recorded for residents by nursing staff, so she got her information on how much a resident ate from nursing.

Based on observations, interviews, record reviews, and review of facility policy, the failed to ensure palatable meals were served to Resident #16, #17, #21, #24, #27, #31, #32, #56 and #73. This affected nine residents (#16, #17, #21, #24, #27, #31, #32, #56 and #73) of 21 residents reviewed for food. The facility census was 82. Findings include: 1.Review of facility menu Atrium Living Center Fall/Winter 2024/2025 Menus for week three dinner on 01/28/25 revealed chicken pot pie, buttered broccoli, pineapple cup, two percent milk and coffee/tea was to be served. Observation on 01/28/25 at 4:20 P.M. of Dietary [NAME] (DC) #700 taking the temperature of the tray line items using a facility thermometer revealed all items were at a safe temperature with the chicken pot pie at 206 degrees Fahrenheit (F), the broccoli at 179 degrees F, the pineapple at 42 degrees F and an eight-ounce carton of milk at 38.8 degrees F. Observations throughout the tray line process on 01/28/25 from 4:20 P.M. to 5:24 P.M. revealed the chicken pot pie for the regular diets had a very thin layer of biscuit on top and some servings of the pot pie for the regular diets had very little biscuit in the portion which was served to the residents. The facility utilized a heat retention system for the food which included a heating unit that heated both the plates and metal pellets. On the stainless steel table next to the range oven behind the steam table was a stack of metal pellets sitting at room temperature instead of being in the heating unit. When the tray line was three fourths of the way completed, Dietary Supervisor (DS) #702 was observed loading the metal pellets into the heating unit leaving a minimal amount of time for the metal pellets to heat up prior to being placed in the thermal plate base on the meal tray to keep the food hot. On 01/28/25 at 5:12 P.M. as the last cart for unit three was starting to be loaded a test tray was requested by the state surveyor. The test tray was plated at 5:24 P.M. and placed on the food cart. Also at 5:24 P.M. the state surveyor touched the metal pellets in the heating unit and the pellets were not warm to the touch. At 5:26 P.M. DS #702 wheeled the cart out of the kitchen and the cart arrived on unit three at 5:29 P.M. The first meal tray was passed at 5:30 P.M. and by 5:46 P.M. all the meal trays had been passed. The test tray was then taken off the meal cart at 5:46 P.M. by DS #702 and taken to an overbed table in the hallway. Using a facility thermometer DS #702 took temperatures of the food and beverage items. As DS #702 was taking the temperatures the state surveyor was tasting the items. The coffee was 166 degrees F and tasted warm. The milk was 37 degrees F and tasted cold and not spoiled. The pineapple was 52 degrees F but still tasted cold and was palatable. The chicken pot pie was 124 degrees F and tasted warm and bland. The broccoli was 113 degrees and didn't taste warm and tasted very bland. On 01/28/25 at 5:49 P.M. DS #702 tasted the chicken pot pie and broccoli and stated the pot pie tasted a little bland and the broccoli was not hot and had no flavor. DS #702 confirmed she had added the room temperature metal pellets part way through tray line to the heating unit since there was not enough room in the unit to house all the metal pellets for tray line. 2. Review of the medical record for Resident #32 revealed an admission dated of 06/22/19. Medical diagnoses included chronic pulmonary (lung) disease, major depression, chronic kidney disease and dysphagia. Review of Resident #32's physician orders revealed an order dated 01/21/25 for a regular diet with extra gravy on meats and thin liquids. Review of the Minimum Data Set (MDS) 3.0 annual assessment, dated 01/10/25, revealed Resident #32's cognition was intact. Interview on 01/28/25 at 5:52 P.M. with Resident #32 revealed she didn't think the chicken pot pie tasted good the last time it was served, and she didn't think it tasted good this time 3. Review of medical record for Resident #21 revealed an admission date of 01/15/14. Medical diagnoses included chronic pulmonary (lung) disease, hyperlipidemia, hypertension, and vascular dementia. Review of Resident #21's physician orders revealed an order dated 12/20/24 for a regular diet thin liquids. Review of the MDS 3.0 quarterly assessment, dated 01/28/25, revealed Resident #21's cognition was moderately impaired. Interview on 01/28/25 at 5:54 P.M. with Resident #21 revealed the chicken pot pie didn't taste like chicken pot pie, and she got very little biscuit with her serving of pot pie 4. Review of medical record for Resident #16 revealed an admission dated of 01/24/20. Medical diagnoses included cerebral infarction (stroke), anxiety disorder, major depression, and prediabetes. Review of Resident #16's physician order revealed an order dated 08/01/23 for a regular diet thin liquids. Review of the MDS 3.0 annual assessment, dated 01/01/25, revealed Resident #16 had mild cognitive impairment. Interview on 01/28/25 at 5:59 P.M. with Resident #16 revealed she got very little biscuit with her serving of chicken pot pie, and the pot pie had no flavor 5. Review of medical record for Resident #73 revealed an admission date of 09/06/24. Medical diagnoses included atherosclerosis, type two diabetes, hallucinations, and chronic kidney disease. Review of a physician order dated 10/01/24 revealed Resident #73 had an order for a regular diet with sugar substitute and thin liquids. Review of MDS 3.0 quarterly assessment, dated 12/13/24, revealed Resident #73's cognition was intact. Resident #73 needed supervision while eating and had a significant weight loss that was not physician prescribed. Interview on 01/28/25 at 6:01 P.M. with Resident #73 revealed if that was chicken pot pie, they left out the biscuit and Resident #73 stated the pot pie didn't have much flavor. 6. Review of medical record for Resident #27 revealed an admission date of 01/04/25. Medical diagnoses included pneumonia, congestive heart failure (CHF), cerebrovascular disease, and hypertension. Review of a physician order dated 01/05/25 revealed Resident #27 had an order for a regular diet with thin liquids. Review of the MDS 3.0 admission assessment, dated 01/10/25, revealed Resident #27's cognition was intact. Interview on 01/28/25 at 6:02 P.M. with Resident #27 revealed the chicken pot pie was bland. 7. Observation on 01/28/25 from 10:55 A.M. to 11:10 A.M. revealed DS #702 placed ten portions of green beans into a robo coupe (commercial food processor) to blend until a portion between pudding and mashed potatoes was achieved for a puree consistency. The final product, which was ready to be placed into a square serving pan for tray line for lunch on 01/28/25, had the appropriate puree consistency but was very salty when tasted. DS #702 at the time of observation tasted the final product and stated it was salty because they added salt. Registered Dietitian #826 who was also in the kitchen at the time of observation, also tasted the puree green beans and confirmed the pureed green beans were very salty. Review of the green beans pureed recipe, with a report date of 09/05/24, revealed the recipe called for green beans, margarine, and food thickener. The staff were to remove portions from the regular prepared vegetable (drain liquid), add drained vegetables with melted margarine to the food processor and process until smooth in texture; add a food thickener briefly until mixed while scraping sides of bowl; pour into the steamtable pan. There was nothing documented in the recipe indicating salt should have been added. 8. Interviews conducted with four residents (#17, #24, #31, and #56) during a resident council meeting held with the state surveyors on 01/29/25 at 11:05 A.M. revealed the residents voiced concerns about hot foods not being hot and describing the hot food as served cold and stated food was served bland and at times was too salty.

Based on observation, interview, record review and review of facility policy the facility did not ensure menu spreadsheets were followed to provide appropriate portion sizes to Resident #26, #40, #43, #55 and #57 who the facility identified as receiving pureed diets. In addition, the facility did not ensure all other residents receiving meals from the kitchen received appropriate portions sizes at meals excluding Resident #441 who received a full liquid diet and Resident #64 who the facility identified as receiving nothing by mouth (NPO). The facility census was 82. Findings include: 1. Review of the facility menu Atrium Living Center Fall/Winter 2024/2025 Menus for week three revealed for dinner on 01/28/25 chicken pot pie, buttered broccoli, pineapple cup, two percent milk and coffee/tea were to be served. Review of the facility week three dinner (01/28/25) spread sheet (expanded menu) revealed for the pureed chicken pot pie no specific scoop size listed, but one #16 (two ounce) scoop was to be used for the pureed broccoli. The spreadsheet did not indicate mashed potato was to be served for the puree diets at this meal. Review of Chicken Pot Pie Pureed recipe, with a report date of 09/05/24, revealed the chicken pot pie would be prepared as directed in the recipe. Remove portions required from the prepared recipe and add to food processor and process until fine in consistency. Gradually add hot broth while processing and scrape down sides of processor with a rubber spatula and process for 30 seconds. The serving size would be two number eight (four ounce) scoops. Review of the facility document titled Resident Listing Report, dated 01/27/24, revealed a list of of all residents in the facility and their diet order. Resident #26, #40, #43, #55 and #57 had diet orders including pureed texture. Observations during tray line on 01/28/25 from 4:20 P.M. to 5:24 P.M. revealed the puree entree/meat being served on the dinner tray line was pureed chicken and not chicken pot pie. The serving scoop sizes being provided on the pureed resident meals was one number six (5.3 ounces) scoop of puree chicken, one number eight scoop (four ounces) of mashed potatoes, and one number ten (3.2 ounces) scoop of puree broccoli. During the observation on 01/28/25 from 4:20 P.M. to 5:24 P.M. Dietary [NAME] (DC) #700 confirmed the puree meat was pureed chicken with gravy and not chicken pot pie, and the puree diets were receiving one number six scoop of puree chicken, one number eight scoop of mashed potatoes, and one number ten scoop of puree broccoli. An interview and record review of the week three dinner spread sheet (01/28/25) was conducted on 01/29/25 at 2:35 P.M. with Registered Dietitian (RD) #826 who verified the spread sheet for the dinner meal on 01/28/25 meal did not clearly specify what the serving size should have been for the pureed chicken pot pie, and she didn't know what the serving size should have been for the pureed chicken pot pie. She confirmed the puree diet should have received a pureed chicken pot pie and broccoli instead of puree chicken, mashed potatoes, and broccoli. 2. Review of the facility menu Atrium Living Center Fall/Winter 2024-2025 Menus for week three revealed for dinner on 01/28/25 chicken pot pie, buttered broccoli, pineapple cup, two percent milk and coffee/tea were to be served. Observations during tray line on 01/28/25 from 4:20 P.M. to 5:24 P.M. revealed residents on a regular diet were being served one number six scoop (5.3 ounces) of chicken pot pie and residents on a mechanical soft diet were being served one number six scoop (5.3 ounces) of chicken pot pie with ground meat. Interview on 01/28/25 at 4:49 P.M. with Dietary Supervisor #702 confirmed one number six scoop was being used for both the chicken pot pie and chicken pot pie with ground meat. Review of week three dinner (01/28/25) spread sheet (expanded menu) revealed the residents on a regular diet were to receive one eight-ounce ladle of chicken pot pie and residents on a mechanical soft diet were to receive one eight-ounce ladle of chicken pot pie with ground meat. An interview and record review of the week three dinner spread sheet (01/28/25) was conducted on 01/29/25 at 2:35 P.M. with RD #826 who verified one eight-ounce ladle was the serving for the chicken pot pie for regular diets and mechanical soft diets and the residents on those diets had received less than what would have been provided with the eight ounce ladle when facility used one number six (5.3 ounces) scoop. Review of facility policy Tray and Dining Room Meal Service, revised August 2023, revealed each employee should review the expanded menu at the beginning of their shift. The dietary manager or cook would go over the expanded menu with tray line personnel before starting to serve.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of facility policy, the facility failed to ensure food was stored, prepared and served under sanitary conditions. This had the potential to affect all residents receiving meals from the kitchen excluding Resident #64 who the facility identified as receiving nothing by mouth (NPO). The facility census was 82. Findings include: 1. Observation of the kitchen on 01/27/25 from 8:11 A.M. to 8:45 A.M. with Dietary Supervisor (DS) #702 revealed the following concerns: • The large industrial fan located in the corner of the kitchen revealed a build up of dust and debris on the blades and metal guard. • On the inside top of the microwave used for resident fooods was an accumulation of food particles and dried food splatters. • In the walk in cooler on the right hand side of the floor under the crates of milk was a moderate amount of a white dried substance resembling milk that had spilled onto the floor. There was one five pound container of cottage cheese which was unopened but had a best by date of 01/06/25. There was half of a factory bag of diced chicken on a shelf and it had been opened and resealed with no date. • The large industrial food mixer that was sitting on a two-tiered base had dried food splatters and visible build-up of dust and particles of debris on both tiers of the base. At the time of observation, DS #702 confirmed the areas of concern. Review of facility policy Dietary Sanitary Procedures for Infection Control, revised August 2023, revealed all equipment and counters would be sanitized per department guidelines and refrigerated items opened would be labeled with a use by date. 2. Observation of the unit refrigerators on 01/27/25 from 8:45 A.M. to 9:00 A.M. with Dietary Supervisor (DS) #702 revealed the following concerns: • In the refrigerator part of the refrigerator/freezer unit in the unit three nourishment room there was one carton of med pass supplement opened with no lid, one bacon and cheese sandwich wrapped in plastic with no name or date, one gallon pitcher of lemonade dated 01/18/25 with a throw out date of 01/24/25, one eight-ounce factory bag of shredded [NAME] jack cheese one fourth full with a best by date of 01/15/25, one small circular clear storage container with a lid with what looked like mayonnaise with no date or label, and one fast food restaurant bag with a breakfast sandwich with no name or date. • There was a buildup of debris on the inside top of the microwave sitting on the counter in the unit three nourishment room. • In the freezer part of the refrigerator/freezer unit in the unit one nourishment room there was one pint of Almost Heaven ice cream with no date or name and one pink colored fast-food drink with whip cream frozen solid with no name or date with a lid which had a circular opening in the lid leaving it open to air. • In the refrigerator part of the refrigerator/freezer unit in the unit one nourishment room there was one gallon pitcher half full of orange juice with a date of 01/18/25 and a throw out date of 01/24/25, one gallon pitcher full of cranberry juice with a date of 01/19/25 and a throw out date of 01/25/25 and one grocery plastic bag with a storage container with a piece of meat and sweet potatoes with no name or date. Interview with DS #702 at the time of observations confirmed areas of concern and stated dietary was responsible for cleaning, stocking, and ensuring nothing was outdated or unlabeled in the unit nourishment rooms. DS #702 confirmed these were storage areas for resident foods on the unit. Review of facility policy Foods Brought into Resident Education Material, revised August 2023, revealed food brought in must be stored in an airtight container; items would be labeled with the resident's name and date; and refrigerated cooked food items must be automatically disposed after three days. Review of facility policy Dry Goods Storage Guidelines, undated, revealed the storage length for refrigerated juice was five days, and storage length must be followed. Review of facility policy Dietary Sanitary Procedures for Infection Control, revised August 2023, revealed all equipment would be sanitized per department guidelines. 3. Observation on 01/27/25 at 12:29 P.M. revealed Certified Nursing Assistant (CNA) #607 took a meal tray, which had cake uncovered on the tray, out of the covered delivery cart and placed one eight ounce of glass of water uncovered on the tray and walked down the hallway on unit three to a common area to deliver Resident #4's meal tray. At the time of observation, CNA #607 confirmed the cake and beverage were uncovered, and she stated she complained about it all the time. Observation on 01/27/25 at 12:34 P.M. revealed CNA #620 took a meal tray, which had cake uncovered on the tray, out of the covered delivery cart and placed one cup of coffee uncovered on the meal tray and walked halfway down the hallway to Resident #22's room. At the time of observation, Resident #22 revealed she always received desserts and beverages in cups uncovered. At the time of observation, CNA #620 confirmed the cake and beverage were uncovered. Observation on 01/27/25 at 12:36 P.M. revealed CNA #620 took a meal tray, which had a piece of cake uncovered on the tray, out of the covered delivery cart and placed a cup of coffee and a glass of apple mango juice uncovered on the meal tray and walked halfway down the hallway to deliver the meal to Resident #8. At the time of observation, CNA #620 confirmed cake and beverages were uncovered. Observation on 01/27/25 at 12:40 P.M. revealed CNA #608 took a meal tray, which had a piece of cake uncovered, out of the covered delivery cart and placed one cup of coffee and a glass of grape juice uncovered onto the meal tray and walked the full hallway and into the unit three common area to deliver Resident #51's meal tray. At the time of observation, CNA #608 confirmed the cake and beverages were uncovered. Interview on 01/29/25 at 2:35 P.M. with Dietitian #826 revealed when delivering room trays, the aides were supposed to walk the meal delivery and beverage carts with them so they could stay close to the rooms, and when they delivered the meal trays, they were not supposed to walk extended distances with items uncovered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review the facility failed to ensure the physician and/or resident responsible party was notified of change in condition. This affected three residents (#15, #52, and #61) out of seven residents reviewed for change in condition. The facility census was 74. Findings include: 1. Review of the medical record for Resident #15 revealed an admission date of 05/05/20 with diagnoses including congestive heart failure, diabetes, dementia, altered mental status, and hypertension. Resident #15's medical record revealed she had a power of attorney (POA) for medical decisions. Review of the care plan dated 05/10/20 revealed Resident #15 was at nutritional risk due to congestive heart failure and confusion. The care plan revealed on 12/16/22 she triggered for weight loss of 7.8 percent in 30-days due to inadequate oral intake. Interventions included diet as ordered, monitor intake, weight every month, and notify physician of a significant change. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #15 had impaired cognition. She was independent with eating. Her weight was 154 pounds, and she had no weight loss. Review of the weight record revealed Resident #15 had a significant weight loss as on 11/04/22 her weight was 161.8 pounds and on 12/01/22 her weight was 149.2 pounds (7.8 percent weight loss). Review of the nursing notes dated 11/04/22 to 01/11/23 for Resident #15 revealed no documentation her physician and/ or her POA were notified of her significant weight loss. Review of the Nutrition Follow Up for Significant Weight Change assessment dated [DATE] and completed by Dietitian #415 revealed on 11/04/22 Resident #15's weight was 161.8 pounds and on 12/01/22 her weight was 149.2 pounds. The assessment revealed Resident #15 had a 7.8 percent weight loss in 30 days. The assessment revealed Dietitian #415 recommended Boost Breeze (supplement) every day at breakfast. The assessment revealed no documented evidence Resident #15's Primary Care Physician #900 and/ or Resident #15's POA were notified regarding her significant weight loss. Interview on 01/09/23 at 10:23 A.M. with Resident #15's POA revealed she did not feel the facility notified her regarding Resident #15's change in condition and/ or significant changes. Interview on 01/11/23 at 10:42 A.M. with Dietitian #415 verified Resident #15 had a significant weight loss of 7.8 pounds in 30 days on 12/01/22 and that she recommended a supplement to be provided at breakfast. She revealed she did not notify Primary Care Physician #900 and/ or Resident #15's POA regarding the significant weight loss. She revealed she was unsure of who notified the physician and/ or responsible party regarding significant weight loss. Interview on 01/11/23 at 11:33 A.M. with the Director of Nursing and Assistant Director of Nursing (ADON)/ Licensed Practical Nurse (LPN) #473 revealed the Former Dietitian #512 used to complete the notifications to the physician and/ or responsible party regarding significant weight loss and did not know the current Dietitian #415 was not doing the same. They verified there was no documented evidence Primary Care Physician #900 and/ or Resident #15's POA were notified regarding her significant weight loss on 12/01/22. 2. Review of the medical record for Resident #61 revealed an admission date of 06/28/22 with diagnoses including cerebral infarction, dementia, dysphasia, and diabetes. Resident #61 had a responsible party listed in her medical record. Review of the care plan dated 07/01/22 revealed Resident #61 was at nutritional risk due to difficulty swallowing and chewing due to recent stroke. Interventions included diet as ordered, monitor meal intake, and weight every month. Review of the weight record for Resident #61 revealed on 08/31/22 Resident #61's weight was 129 pounds and on 09/06/22 her weight was 121.2 pounds (5.9 percent weight loss). Review of the nursing notes dated 09/06/22 to 01/11/23 revealed there was no documented evidence Primary Care Physician #900 was notified regarding Dietitian #415's recommendation on 09/26/22 for a multivitamin with minerals and of her significant weight loss and on 12/14/22 again with the recommendation for a multivitamin with minerals. Review of the quarterly Dietary Review dated 09/26/22 and completed by Dietitian #415 revealed Resident #61 had a 30-day weight loss of 5.9 percent. The review revealed Dietitian #415 recommended to add a multivitamin with minerals. There was no documented evidence the physician and/ or responsible party were notified regarding her weight loss and recommendation. Review of the Nutritional assessment dated [DATE] and completed by Dietitian #415 revealed Resident #61 had a moderate decrease in food intake. The assessment revealed to have the physician consider multivitamin with minerals every day. There was no documented evidence the physician and/ or responsible party were notified regarding the recommendation. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #61 was cognitively impaired. She required extensive assist of one staff with eating. She had no weight loss. Interview on 01/11/23 at 10:42 A.M. with Dietitian #415's verified she recommended Resident #61 receive a multivitamin with minerals on 09/26/22 and on 12/14/22 per her assessments. She revealed she sends the Administrator and Director of Nursing her recommendations and that she thought nursing then notified the physician of her recommendations which would have included for Resident #61 to receive a multivitamin with mineral. She verified Resident #61 did not have an order for a multivitamin with minerals and was unsure if the physician was notified of her recommendations and/ or significant weight loss as she did not notify Primary Care Physician #900. Interview on 01/11/23 at 11:33 A.M. with the Director of Nursing and Assistant ADON/ LPN #473 revealed Former Dietitian #512 used to complete the notifications to the physician of any dietary recommendations and received the order from the physician. They verified there was no documented evidence the physician was notified regarding Resident #61's dietary recommendation on 09/26/22 and 12/14/22 for a multivitamin with minerals and/ or her significant weight loss. They revealed they were not aware Dietitian #415 was not contacting Primary Care Physician #900 regarding her recommendations and obtaining her own orders and/ or notifying the physician and/ or responsible party of significant weight loss. Review of the facility policy labeled Nutritional Plan for Weight Loss, dated January 2022, revealed the dietitian would be responsible for reviewing the weight variance report and making additional recommendations, documenting in the medical records, and discussing weight changes with the weight committee. The policy did not have any information regarding the notification to the physician and/ or responsible party of recommendations and/ or significant weight changes. 3. Review of the medical record for Resident #52 revealed the resident was admitted on [DATE] with diagnoses including cerebral infarction weakness, unspecified dementia, dysphasia, encephalopathy, and alcohol abuse. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #52 was moderately cognitively impaired and required extensive assist of two for activities of daily living (ADL). Review of the care plan dated 10/12/22 revealed care areas for impaired cognition and a risk of falls. Review of the face sheet revealed the resident's mother was listed as his POA and first emergency contact. Review of the 10/28/22 Event Report for Resident #52 revealed the resident had a fall at 10:20 P.M. during a transfer to bed when the resident became spastic. The fall resulted in a small red area under the resident's right shoulder. Review of the 10/28/22 progress note regarding the fall reported the Director of Nursing and physician were notified of the fall, and the resident's family would be notified in the morning. Interview on 01/12/23 at 12:20 P.M. with Resident #52's mother revealed she did not receive notification of the fall and was not aware the resident had fallen. She stated if her daughter, who was Emergency Contact #2, was contacted she would have told her of the fall. She reported communication was an ongoing problem with the facility. Interview on 01/12/23 at 11:58 A.M. with ADON /LPN #473 verified a resident's POA should be notified when a resident has a fall. The facility failed to provide documented evidence of notification of the Resident #52's family. Review of the January 2022 Notification of Change Policy revealed the resident's responsible party must be notified when an event involving the resident occurs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review the facility failed to ensure accurate and timely weights were obtained for Residents #52 and #171, who were both on feeding tubes. This affected two residents (#52 and #171) of three residents reviewed for weights. The facility census was 74. Findings include: 1. Review of the medical record revealed Resident #171 was admitted to the facility on [DATE] with diagnoses including diseases of intestine, atrial fibrillation, dysphasia, bacterial pneumonia, non-Hodgkin's lymphoma, iron deficiency anemia secondary to blood loss (chronic), and unspecified protein-calorie malnutrition. Review of the Medicare 5-Day Minimum Data Summary (MDS) 3.0 assessment of 12/28/22 revealed Resident #171 was cognitively intact, required extensive assist of two for most activities of daily living (ADL), was totally dependent for eating and received 51 percent (%) or more of his total calories through a feeding tube. Review of Resident #171's care plan of 12 23/22 identified a care area for treatment of a urinary tract infections and the need for ADL assistance. Review of the census revealed Resident #171 was discharged to the hospital on [DATE] and readmitted on [DATE]. The care plan was revised on 01/11/23 to include a care area for increased nutrient needs (related to weight loss in the last year and compared to hospital weight, a 6.6 % loss in nine days though unclear of weighing technique used during hospitalization with a history of brain cancer status post (s/p) chemotherapy, aspiration pneumonia, s/p nasogastric (NG) tube, underweight and triggering for malnutrition based on a mini nutritional assessment as evidenced by a body mass index (BMI) of 18.23. Review of the weights for Resident #171 revealed the only entries were on 01/06/23 with a weight of 152 pounds (lbs.) and a weight of 142 lbs. on 01/11/23. There were no weights recorded from 12/23/22 through 12/28/22 when the resident was at the facility. Interview on 01/12/23 at 11:20 A.M. with the Director of Nursing (DON) verified Resident #171 was not weighed after his admission on [DATE] and that residents were usually weighed within 24 hours of admission and monitored, usually with weekly weights upon admission for four weeks and monthly weights after that. Review of the April 2021 policy for Residents at Nutritional Risk revealed nutritionally at-risk residents included tube feed residents and those with below acceptable body weight range. Timely assessment and implementation of a plan, including monitoring, were essential for proper care of a resident at risk. 2. Review of the medical record revealed Resident #52 was admitted to the facility on [DATE] with diagnoses including cerebral infarction weakness, unspecified dementia, dysphasia, encephalopathy, and alcohol abuse. Diet orders included a mechanical soft diet with honey thick liquids, enteral nutrition via feeding tube three times a day, and supplemental Magic Cups twice a day. Review of the quarterly MDS 3.0 assessment of 10/03/22 revealed Resident #52 was moderately cognitively impaired, required total dependence of one for eating and received at least 51% of his nutrition from tube feeding. Review of Resident #52's care plan of 10/12/22 revealed care areas included risks of complications due to use of feeding tube, and nutrition/hydration risks. Review of the weights for Resident #52 revealed an invalid weight on 12/19/22 of 145.6 lbs., invalidated by the DON on 01/09/23 and a weight by Registered Dietitian/Licensed Dietitian (RDLD) #513 on 12/19/22 of 116 lbs. A second invalidated weight on 01/09/23 of 153.4 lbs. was reviewed with Assistant Director of Nursing (ADON) #473 on 01/09/23 and a reweigh on 01/09/23 indicated Resident #52 weighed 119 lbs. Interview on 01/11/23 at 10:41 A.M. with RDLD #513 revealed she reviewed all residents identified on the weight variance report as having a significant change. Sometimes she would request a reweigh if a weight seemed inaccurate. Accurate weights were important for those individuals at higher nutritional risk. She was reviewing Resident #52 monthly due to his low BMI/weight, refusal of eating, and tube feedings. Interview on 01/12/23 at 11:58 A. M with ADON #473 revealed the aides weighed the residents and the nurses entered them into the medical record. She verified inaccurate weights were entered for Resident #52 on 12/19/22 and 01/09/23 and the nurse should have questioned the accuracy in comparison with the other weights. She stated the weight on 01/09/23 of 153.4 lbs. included the weight of the resident's wheelchair. Review of the April 2021 policy for Residents at Nutritional Risk revealed nutritionally at-risk residents included tube feed residents and those with below acceptable body weight range. Timely assessment and implementation of a plan, including monitoring, were essential for proper care of a resident at risk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review the facility did not ensure pharmacy recommendations were addressed. This affected two residents (#11 and #61) out of six residents reviewed for unnecessary medications. The facility census was 74. Findings included: 1. Review of the medical record for Resident #11 revealed an admission date of 01/30/21 with diagnoses including dementia, psychotic disturbance, heart failure, hypertension, and acute kidney failure. Review of the pharmacy Consultation Report dated 04/07/22 revealed Pharmacist #901 recommended to consider changing the immediate release formulation of Metoprolol (medication to treat high blood pressure, chest pain, and heart failure) to the extended-release formulation. The pharmacy recommendation was not addressed. Review of the pharmacy Consultation Report dated 08/13/22 revealed Pharmacist #901 recommended discontinuing acetaminophen- hydrocodone (opioid pain medication) as she had not used the medication since 11/14/21. The pharmacy recommendation was not addressed. Review of the pharmacy Consultation Report dated 12/06/22 revealed Pharmacist #901 reviewed the medical record due to Resident #11 had a fall on 11/30/22 and identified medications that contributed to falls that included: Lorazepam (antianxiety), Remeron (antidepressant), Zoloft (antidepressant), tolterodine extended release (antispasmodic), metoprolol and acetaminophen-hydrocodone. Pharmacist #901 recommended the physician evaluate the medications as they possibly contributed to the fall and look at decreasing the lorazepam to 0.5 milligram (mg) in the morning and 1 mg at night. She also recommended to discontinue the acetaminophen-hydrocodone due to non-use. The pharmacy recommendation was not addressed. Review of the January 2022 physician orders for Resident #11 revealed she continued to have an order for acetaminophen-hydrocodone 5-325 mg given by mouth every six hours as needed for pain and lorazepam 1 mg twice a day. Review of the annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 had impaired cognition. Interview on 01/11/23 at 10:10 A.M. with the Director of Nursing revealed the Former Director of Nursing #511 had not followed up on the pharmacy recommendations as she verified the recommendations dated 04/07/22, 08/13/22, and 12/06/22 were not addressed for Resident #11. 2. Review of the medical record for Resident #61 revealed an admission date of 06/28/22 with diagnoses including cerebral infarction, dementia, dysphagia, and diabetes. Review of the care plan dated 07/13/22 revealed Resident #61 was at risk for complications related to diabetes. Interventions included administer medications as ordered, monitor blood glucose levels as ordered, and monitor for signs of hypoglycemia and hyperglycemia. Review of the pharmacy Consultation Report dated 11/04/22 revealed Pharmacist #901 recommended to discontinue Glimepiride (diabetic medication) 1 mg daily and after reevaluation of blood glucose levels initiate alternative therapy with glipizide (diabetic medication) as long- acting sulfonylureas are not recommended in older adults due to prolonged hypoglycemia. The pharmacy recommendation was not addressed. Review of the pharmacy Consultation Report dated 01/06/23 revealed Pharmacist #901 noted on the report Repeated Recommendation from 11/04/22 and to respond promptly to assure facility compliance with federal regulation as Resident #61 continued to receive Glimepiride 1 mg daily. The pharmacy recommendation was not addressed. Review of the Medication Administration Record (MAR) for January 2022 revealed Resident #61 continued to have an order for Glimepiride 1 mg once a day from 01/01/23 to 01/11/23. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #61 was cognitively impaired. Interview on 01/09/23 at 11:29 A.M. with Resident #61's responsible party revealed he was concerned that Resident #61 took too many medications that were not necessary and at times he felt Resident #61 appeared overmedicated. Interview on 01/11/23 at 10:10 A.M. with the Director of Nursing revealed the Former Director of Nursing #511 had not followed up on the pharmacy recommendations as she verified the recommendations dated 11/04/22 was not addressed for Resident #61 and that she continued to receive Glimepiride. Review of the facility policy labeled; Medication Regimen Review, dated 12/01/07, revealed the facility should ensure that the facility physicians/ prescribers were provided with copies of the medication regimen reviews. The policy revealed the facility should then encourage the physician receiving the medication regimen review to act upon the recommendations or reject with an explanation as to why the recommendation was rejected. The facility should maintain copies of medical regimen reviews.

Based on interview, observation, record review, and facility policy review the facility failed to ensure insulin was dated when opened. This affected two residents (#9 and #28) out of three residents observed during the medication storage review. This had the potential to affect eight residents (#6, #9, #10, #28, #38, #62, #174, and #219) that received insulin. The facility census was 74. Findings included: 1. Review of the medical record for Resident #28 revealed an admission date of 03/10/17 with diagnoses including diabetes with unspecified diabetic retinopathy without macular edema, and long-term insulin use. Review of the January 2023 Physician Orders revealed Resident #28 had an order for Novolin Regular U-100 solution (insulin) inject 10 units twice a day. Observation on 01/11/23 at 12:11 P.M. with Licensed Practical Nurse (LPN) #474 of 200-Back Hall medication cart revealed Resident #28's Novolin Regular U-100 insulin vial was opened and undated in the cart. Interview on 01/11/23 at 12:13 P.M. with LPN #474 verified Resident #28's insulin was not dated when it was opened. She revealed the insulin was dispensed from the pharmacy on 08/20/22 and she stated, I have no idea when it was opened. 2. Review of the medical record for Resident #9 revealed an admission dated of 11/14/19 with diagnoses including diabetes, dementia, and acute respiratory failure. Review of the January 2023 Physician Orders revealed Resident #9 had an order for Humalog U-100 insulin per sliding scale before meals and at bedtime. Observation on 01/11/23 at 12:18 P.M. with LPN #460 of the 300-Long Hall medication cart revealed Resident #9's insulin was opened and undated. Interview on 01/11/23 at 12:18 P.M. with LPN #460 verified Resident #9's insulin was opened and undated in the medication cart. Interview on 01/12/23 at 11:26 A.M. with the Director of Nursing verified all insulins were to be dated upon opening. Review of the facility policy labeled Maintenance of Medication Storage Areas, dated May 2019, revealed insulins, eye drops, saline solution multi-dose were to be dated when opened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were accurate related to medication usage and injections for Resident #2 and injections for Resident #29. This affected two residents (Resident #2 and #29) of 25 residents reviewed for MDS assessments. Findings include: 1. Review of Resident #2's medical record revealed an admission date of 05/28/19 with diagnoses including diabetes, tricuspid insufficiency (valve in the heart does not work properly), and endocarditis (infection in the heart). Review of the physician orders for Resident #2 revealed an order dated 05/18/19 for sulfamethoxalzole-trimethoprim (an antibiotic), 400/80 milligrams (mg), to be administered daily on Mondays, Wednesdays, and Fridays. Review of the quarterly MDS 3.0 assessment, dated 10/10/19, revealed Resident #2's was alert, oriented and had intact cognition. This assessment revealed Resident #2 received insulin injections daily during the seven days prior to the assessment reference date of 10/10/19 and had not received any antibiotics in the seven days prior to the assessment reference date of 10/10/19. Review of the October 2019 Medication Administration Record (MAR) for Resident #2 revealed he received sulfamethoxazole-trimethoprim on 10/04/19, 10/07/19 and 10/09/19. This MAR revealed no documentation of any insulin injections between 10/04/19 and 10/10/19. Interview on 01/30/20 at 2:24 P.M. with Registered Nurse (RN) #600 revealed the quarterly MDS dated [DATE] data was inaccurately coded in relation to the antibiotic and insulin. 2. Review of the medical record for Resident #29 revealed an admission date of 12/09/19 with diagnoses including atrial fibrillation, right leg fracture, and chronic lung disease. Review of the physician's orders for Resident #29 revealed an order dated 12/09/19 for Resident #29 to receive a Mantoux skin test (an injection under the skin to test for tuberculosis) upon admission. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #29's cognition was intact. This assessment revealed Resident #29 had been coded as not receiving any injections during the seven days prior to the assessment reference date of 12/12/19. Review of the December 2019 Medication Administration Record (MAR) for Resident #29 revealed she received a Mantoux injection to the right forearm on 12/09/19. Interview on 01/30/20 at 1:45 P.M. with RN #600 revealed the admission MDS dated [DATE] data was inaccurately coded and did not reflect the Mantoux injection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the care plan for Resident #2 was accurate and did failed to ensure a care plan was implemented for Resident #29 related to a a blood thinning medication. This affected two residents of 25 residents reviewed for care plans. Findings Include: 1. Review of Resident #2's medical record revealed an admission date of 05/28/19 with diagnoses including chronic lung disease, diabetes, tricuspid insufficiency (valve in the heart does not work properly), and endocarditis (infection in the heart). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/10/19 revealed Resident #2's cognition was intact. Review of the plan of care for Resident #2 revealed a care plan dated 06/10/19 stating Resident #2 required oxygen therapy for chronic lung disease. Review of the physician orders for Resident #2 revealed no order for oxygen therapy. Observation on 01/27/20 at 9:58 A.M. revealed no oxygen equipment in Resident #2's room. Interview with the Administrator on 01/30/20 at 3:17 P.M. revealed Resident #2 never received oxygen while a resident in the facility. Registered Nurse (RN) #600 was interviewed on 01/30/20 at 2:24 P.M. and verified the care plan was inaccurate. 2. Review of the medical record for Resident #29 revealed an admission date of 12/09/19 with diagnoses including atrial fibrillation, right leg fracture, and chronic lung disease. Review of the admission MDS 3.0 assessment dated [DATE] revealed Resident #29's cognition was intact. Review of the physician's orders for Resident #29 revealed an order dated 12/09/19 for Resident #29 to receive Warfarin (a blood thinning medication), 4 milligrams (mg) daily. Review of the Medication Administration Record for Resident #29 revealed she received Warfarin, 4 mg each evening. Review of the plan of care for Resident #29 revealed no care plan addressing the use of a blood thinning medication. Interview with RN #600 on 01/30/20 at 1:58 P.M. verified Resident #29 did not have a care plan in place for the blood thinning medication and one should have been implemented. Review of the policy, Resident Assessment Comprehensive Care Plans, updated 11/28/17, stated the comprehensive care plan must describe the resident's medical, nursing, physical, mental and psychosocial needs and preferences and how the facility will assist in meeting these needs and preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews the facility failed to collaboratively provide meaningful, individualized activities to meet the personal preferences of Resident #23. This affected one of 24 residents screened for activities. Findings included: Record review was conducted for Resident #23 who was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, chronic fatigue, [NAME]-[NAME] virus, rheumatoid arthritis, anxiety, hypothyroidism and anemia. The plan of care, initiated 09/21/18, revealed her preferences for everyday living activities included painting, sewing, drawing, caring for plants and gardening, reading books, newspapers and gardening magazines, going for walks for exercise, being around pets and watching documentaries and the cooking channel. There were no revisions made to Resident #23's preferences since the initial care plan date of 09/21/18. The annual, comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was alert, oriented and cognitively intact, exhibited no mood problems, no behaviors and no rejection of care. Resident #23 completed the preferences for activities section and indicated the activities very important or somewhat important to her were reading books, newspapers and magazines, listening to music and being around animals. She did not prefer group activities. Review of the Daily Participation Records for December 2019 and January 2020 revealed Resident #23 was provided one-to-one visits, did independent activities of choice and her mom and husband visited daily. There were no other activities listed as provided to Resident #23 and no record of the content of the one-to-one activities. Interview and observation was conducted on 01/28/20 from 9:57 A.M. to 10:10 A.M. with Resident #23 and her mom in the resident's room. Resident #23 was standing and verbally greeted the surveyor. She was very thin with a flat affect and was pacing during the interview and observation period. The room had an impersonal appearance with only a cell phone, television and electronic tablet, in addition to the standard room furniture. There were no pictures, decorations, books, magazines, newspapers, library materials, wall hangings, crafting materials, plants, therapeutic stuffed animals or any other sensory items for Resident #23, who primarily spent her time in her room. Resident #23 and her mom were asked if there were any concerns about the care and services at the facility. Resident #23's mom shared that her daughter was an anxious person who constantly stood or paced most of the day and said the facility was not thinking outside the box to find activities to engage her daughter's interests. When Resident #23 was asked if she thought she had enough activities, she quickly answered no and said she would like more things to do in her room. Her mother said someone from activities would come in now and then to invite Resident #23 to a group activity but when her daughter refused the group activity, the activity staff would just give up and not try anything else for the day. Her mom expressed concern for her daughter's mental health and felt adding some therapeutic activities would help her. On 01/29/20 at 1:01 P.M., Activity Director (AD) #602 was interviewed regarding her knowledge of Resident #23's involvement in activities. AD #602 said Resident #23 preferred to stand in her door way and people watch so AD #602 encouraged group activities, but also had her on the calendar for one-to-one staff visits. AD #602 said Resident #23's mother and husband visited her daily in her room. Interview was conducted on 01/29/20 at 2:30 P.M. with Resident #23 who was found standing in the doorway of her room. When asked if she went out side to take walks or garden with the staff she said no, but said she would like to do those activities. She said a lady brought in a dog once in a while but she did not get to spend time with the dog. She said her television only got three channels and she would like to watch the cooking channel, but it would not come in. She demonstrated by turning on the television and only three channels were available. The cooking channel was not available for her to watch. She said she would like to have her hair done but said it was not comfortable going to the salon in the facility. She said she did not want her nails painted and did not enjoy group activities. She said she enjoyed coloring, painting and looking at magazines. None of these items were available to her in her room. Interview was conducted on 01/29/20 at 3:13 P.M. with AD #602 who verified Resident #23's preferences for everyday living activities remained accurate as listed on the plan of care initiated 09/21/18 and she had been the person to collect that information from Resident #23. When asked about the content of the one-to-one visits for Resident #23, AD #602 shared she personally stopped by her room and talked to her, offered to comb her hair, do her nails, lotion to her hands and invite her to group activities or the beauty shop. AD #602 said they do have a dog coming to the facility visiting three weekends in a two month period when the owner (Activity Aide #900) comes in to do group activities with the residents. AD #602 said it was not a one-to-one activity and visiting with the dog was not offered to Resident #23. AD #602 verified Resident #23 did not get taken out for walks, did not do gardening or keep plants, did not receive regular pet visits, and had no preferred magazines, newspapers, crafts, library books, movies or art materials available in her room that she could work with if and when she preferred. AD #602 said Resident #23 did have cable television in her room consisting of 29 channels but said it may only get three channels if the resident did not use the remote correctly. Interview on 01/30/20 at 9:18 A.M. with Activity Aid #603 said one-to-one visits typically lasted 15 to 20 minutes and included an invitation to the group activity and discussion about daily events or interests. Activity Aid #603 verified Resident #23's preferred interests listed in the plan of care. Activity Aid #603 said Activity Aid #900 came to the facility today and took the dog specifically into visit Resident #23 and said she lit up and interacted very well with the dog. Interview was conducted on 01/30/20 at 11:34 A.M. with Social Service Director (SSD) #604 who revealed Resident #23 did see the facility psychologist for support but there had been no discussions between herself, the psychologist and the rest of the interdisciplinary team regarding ideas for or implementing therapeutic activities for Resident #23. She added Resident #23 would get severe anxiety over going out of the facility and preferred to stay in her room.

Based on observation, record review, and staff interview, the facility failed to ensure residents who smoked were free from accident hazards. This affected two (Resident #2 and Resident #14) of three residents reviewed for smoking. Findings include: 1. Review of Resident #2's medical record revealed an admission date of 05/28/19 with diagnoses including diabetes, tricuspid insufficiency (valve in the heart does not work properly), and endocarditis (infection in the heart). Review of the smoking care plan for Resident #2, dated 08/05/19, revealed he was at risk for injury related to smoking with interventions including for all lighters to be maintained at the nurse's station or other designated area. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/10/19, revealed Resident #2's cognition was intact. Review of the Safe Smoking Assessment for Resident #2 dated 12/17/19 revealed the resident was determined to be a safe smoker. Interview on 01/27/20 at 9:58 A.M. with Resident #2 revealed he smoked independently. He said he kept his cigarettes and lighter in his room. Resident #2 was observed on 01/29/20 at 9:06 A.M. smoking in the smoking room. No staff members were present during the observation. Resident #2 was observed independently returning to the 100 unit where he resided at 9:19 A.M. Resident #2 was asked to show his smoking paraphernalia at that time. Resident #2 removed a flip top carton of cigarettes from his sweatshirt pocket. The carton contained two cigarettes and a lighter. Licensed Practical Nurse (LPN) #601 verified the observation on 01/29/19 at 9:19 A.M. LPN #601 was interviewed immediately following the observation and stated Resident #2 kept his lighter and cigarettes in his room. The Director of Nursing (DON) was interviewed on 01/30/20 at 11:09 A.M. and stated she had only been with the facility for three months and was not yet familiar with the smoking policy. The DON reviewed the smoking policy at the time of the interview and stated residents were not to be in possession of smoking paraphernalia. On 01/30/20 at 1:43 P.M. the DON approached this surveyor and stated all lighters had been taken from residents who smoked independently. Review of the Smoking Policy, dated 03/2018, procedure #3, stated, Residents are not permitted to have lighters or other smoking paraphernalia on their person during non-smoking times. This includes both safe and unsafe smokers. 2. Review of Resident #14's medical record revealed an admission date of 12/04/10 with diagnoses that included diabetes, schizophrenia, and emphysema. Review of the smoking care plan for Resident #14, dated 10/22/13, revealed he was at risk for injury related to smoking with interventions including all lighters were to be maintained at the nurse's station or other designated area. Review of the Safe Smoking Assessment for Resident #14, dated 12/16/19, revealed the resident was determined to be a safe smoker. Review of the quarterly MDS 3.0 assessment, dated 01/04/20, revealed Resident #14's cognition was intact. Resident #14 was interviewed on 01/30/20 at 10:25 A.M. and stated he was an independent smoker and showed this surveyor the lighter he kept on his person. LPN #607 was interviewed on 01/30/20 at 10:25 A.M. and verified Resident #14 kept his lighter and cigarettes in his room. The DON was interviewed on 01/30/20 at 11:09 A.M. and stated she had only been with the facility for three months and was not yet familiar with the smoking policy. The DON reviewed the smoking policy at the time of the interview and stated residents were not to be in possession of smoking paraphernalia. On 01/30/20 at 1:43 P.M. the DON approached this surveyor and stated all lighters had been taken from residents who smoked independently. Review of the Smoking Policy, dated 03/2018, procedure #3, stated, Residents are not permitted to have lighters or other smoking paraphernalia on their person during non-smoking times. This includes both safe and unsafe smokers.

Based on observation, interview and record review the facility did not ensure insulin was dated when opened for Resident #226. This affected one resident (Resident #226) out of eleven residents (Residents #1, #16, #19, #21, #37, #45, #49, #54, #62, #73, and #226) on insulin. The facility census was 82. Findings included: Review of medical record for Resident #226 revealed an admission date of 01/09/20 and diagnoses including diabetes. Observation on 01/28/20 at 3:16 P.M. of medication cart on the 300-hall with Licensed Practical Nurse (LPN) #605 revealed Resident #226's Basaglar insulin, 100 units per milliliter Kwikpen (a disposable single patient pre-filled pen containing insulin), revealed the insulin had been opened, but was not dated with the open date. Interview on 01/28/20 at 3:18 P.M. with LPN #605 verified Resident #226's Basaglar insulin was not dated when the insulin was opened. She confirmed insulin was to be dated when opened. Interview on 01/28/20 at 4:29 P.M. with the Director of Nursing verified insulin was to be dated when opened. She revealed the facility followed the pharmacy insulin storage recommendations on how long different types of insulin were good for after they were opened. Review of facility pharmacy form labeled, Insulin Storage Recommendations, revealed a Basaglar insulin pen was only good for 28 days once opened. Review of facility policy labeled, Storage and Expiration Dating of Medications, Biologicals, Syringes, and Needles, dated 10/28/19, revealed once any medication or biological was opened the facility should follow manufacture guidelines and in respect to expirations dates for opened medications. The policy revealed facility staff should record the date opened on the primary container, vial, bottle or inhaler when the medication had a shortened expiration date once opened.

Based on interview, observation, and record review the facility did not ensure the glucometer meter (a medical device used to measure the concentration of glucose in the blood) was cleaned properly for infection control purposes after Resident #73's blood sugar was obtained. This affected one resident (Resident #7) out of two residents observed for glucometer checks. This had the potential to affect nine residents (Resident #1, #2, #21, #28, #37, #49, #54, #62, and #73) who had orders for blood sugar checks. Findings included: Observation on 01/28/20 at 3:48 P.M. of Licensed Practical Nurse (LPN) #606 for medication administration revealed she obtained Resident #73's blood sugar by piercing the right index finger and applying the blood sample to the test strip in the glucometer. LPN #606 set the glucometer on top of the medication cart after she obtained Resident #73's blood sugar and did not clean the glucometer. Observation on 01/28/20 at 3:58 P.M. revealed LPN #606 then took the same glucometer and obtained Resident #7's blood and applied it to the test strip in the glucometer. Interview on 01/28/20 at 4:00 P.M. with LPN #606 stated as she was walking out of Resident #7's room verified she had not cleaned the glucometer between use for Resident #73 and Resident #7. She said, Oh I forgot, darn it. She verified the glucometer was used for multiple residents and she should have used the bleach wipe to clean the glucometer between residents. She then cleansed the glucometer with a bleach wipe. No blood was observed directly on the glucometer between residents. Interview on 01/28/20 at 04:26 P.M. with the Administrator nurses were to clean the glucometer with the bleach wipe after obtaining a blood sugar for a resident. Review of facility policy labeled, Glucometer Cleaning, dated January 2017, revealed to prevent the transmission of infections the facility required disinfecting blood glucose meters between resident use. The staff, before and after using a blood glucose meter, were to disinfect the meter by cleaning the outside of the meter by using a commercially available Environmental Protection Agency (EPA) registered disinfectant detergent or germicidal wipe. Review of manufacturer guidelines titled, Cleaning and Disinfecting Your Assure Platinum Blood Glucose Meter, dated December 2014, revealed disinfection of the blood glucose meter can be accomplished with a EPA registered disinfectant detergent or germicide that was approved for healthcare settings or a solution of one to ten concentration of bleach. The guidelines revealed the blood glucose meter were at high risk of becoming contaminated with bloodborne pathogens due to contaminated blood. The guidelines revealed cleaning and disinfecting of meters between resident use can prevent the transmission of blood borne pathogens through indirect contact.