**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review the facility failed to ensure staff ensured a dignified dining experience for Resident #3 during lunch time dining. This affected one (Resident #3) of three (Resident's #2, #3, and #21) who required feeding assistance. The facility census was 30. Findings include: Review of the medical record revealed Resident #3 was admitted on [DATE] with diagnoses including Parkinson's disease, heart failure, dysphagia a swallowing disorder. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #3 had impaired cognition and required extensive assistance of one staff for eating. Review of Resident #3's care plan initiated on 05/17/22 for activities of daily living (ADL) revealed self-care performance deficit related to Parkinson's disease with an intervention including to provide one staff assistance for eating. Dining observation on 07/05/22 at 12:54 P.M. of the lunch meal revealed State Tested Nurse Aide (STNA) #100 was standing next to Resident #3 providing feeding assistance. Interview on 07/05/22 at 1:10 P.M. with STNA #100 confirmed she was standing while feeding Resident #3. STNA #100 stated she would normally sit while feeding a resident. Review of the facility policy titled Assistance with Meals, dated July 2017, revealed residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: Not standing over residents while assisting them with meals.

Based on observation and staff interview the facility failed to maintain its kitchen area in a manner to prevent food spoilage and prevent food borne illnesses. This had the potential to affect all 30 residents who received food from the facility kitchen. The facility census was 30. Findings include: During the initial kitchen tour conducted on 07/05/22 between 8:15 A.M. and 8:33 A.M. the following was observed and verified with [NAME] #997 at the time of the observation: • Three cabbage heads were observed to be significantly brown in color. • Two stalks of celery were noted to be extremely wilted and brown in color. • Significant ice buildup was noted on the facility freezer. • An unlabeled and undated bag of approximately 15 to 20 frozen omelets were noted in the freezer. • The outside rubber seal was noted to be dislodged from the refrigerator door, and the temperature of the refrigerator was noted to be 48 degrees Fahrenheit (F) which was reading outside normal on the refrigerator temperature gauge.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment was coded accurately. This affected two of 11 sampled residents (Residents #2 and #23). Findings include: 1. Record review revealed Resident #2 was admitted to the facility on [DATE] with diagnoses that included chronic atrial fibrillation, coronary heart disease, heart failure, pneumonia, and Alzheimer's disease. Review of Resident #2's MDS 3.0 assessment dated [DATE] indicated the resident exhibited severe cognitive impairment and received dialysis. Review of Resident #2's medical record, physician orders, medication administration records (MARS) and treatment administration records (TARS) for [DATE] revealed Resident #2 expired while on hospice in the facility. The discharged MDS was not completed for Resident #2. Interview on [DATE] at 11:06 A.M. with Director of Nursing confirmed Resident #2's discharged assessment dated [DATE] was not complete and the resident expired in the facility on hospice. 2. Record review revealed Resident #23 was readmitted to the facility on [DATE] with diagnoses that included end stage renal disease, anxiety disorder, bipolar disorder, and peripheral vascular angioplasty status. Review of Resident #23's MDS 3.0 assessment dated [DATE] indicated the resident exhibited intact cognitive impairment and received an anticoagulant. Review of Resident #23's medical record, physician orders, medication administration records (MARS) for [DATE] revealed Resident #23 received Plavix, an antiplatelet agent, and not an anticoagulant. Interview on [DATE] at 11:06 A.M. with Director of Nursing confirmed Resident #23's MDS 3.0 assessment dated [DATE] was inaccurate and the resident did not receive an anticoagulant.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure consistent use of adaptive equipment. This affected one resident (Resident #15) of three residents observed for adaptive equipment. The facility census was 30 residents. Findings include: Review of Resident #15's medical record revealed a readmission date of 08/23/18 and diagnoses including heart failure, major depressive disorder, and cerebrovascular disease. Review of the quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #15 was moderately impaired and had no diet restrictions. Review of Resident #15's meal ticket revealed that Resident #15's food should be cut up prior to serving, all beverages in a two handled cup with a lid and a divided dish for meals. Review of a nutritional care plan updated 07/09/19 revealed Resident #15 was to use sipper cup for fluids and a divided plate. Observation of the lunch meal on 07/08/19 at 12:53 P.M. revealed that Resident #15 was being assisted with eating with a glass of juice at her place setting instead of a sipper cup and entrée was not served on a divided plate. This was verified by Licensed Practical Nurse (LPN) #100 at the time of observation. Observation of the breakfast meal on 07/10/19 at 8:03 A.M. revealed that Resident #15 was feeding herself with a two handled cup with no lid and the entrée was not served on a divided plate. This was verified by State Tested Nursing Assistant #102 at the time of the observation. Review of policy entitled, North Park Retirement Community Policy and Procedure- Assistive Devices revealed that assistive devices shall be provided to residents who need them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and review of infection control policies and procedures, the facility failed to ensure proper placement of urine collection bag. This affected one resident (Resident #16) of one resident with a urine collection bag. Findings include: Record review revealed Resident #16 was readmitted to the facility on [DATE] with diagnoses including methicillin resistant staphylococcus aureus, atherosclerotic heart disease and chronic atrial fibrillation. Review of the quarterly minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #15 was cognitively intact and required extensive assistance with one person for most Activities of Daily Living. Review of physician orders revealed Resident #16 was ordered a catheter for urine output. Observation of Resident #16 on 07/08/19 at 11:09 A.M. revealed Resident #16's urine collection bag and tubing were on the floor. Interview with State Tested Nurse Aide (STNA) #103 on 07/08/19 at 11:09 A.M. verified the catheter bag and tubing were on the floor and stated that it should not have been on the floor and got a nurse to change it. Review of Catheter policy, not dated, revealed that catheter or tubing should not be left on the floor.