Based on medical record review, observations, staff interviews, and review of facility policy the facility failed to ensure a resident's bed was in the lowest position. This affected one resident (Resident #222) of two residents reviewed for accidents. The facility census was 73. Findings include: Review of medical record for Resident #222 revealed an admission date of 02/21/25. Diagnoses included acute and chronic respiratory failure with hypoxia, pneumonia, chronic obstructive pulmonary disease, asthma, and sleep apnea. The Multiple Data Set assessment was in progress and not available for review due to the admission date of 02/21/25. The admission assessment indicated Resident #222 was alert and oriented, able to communicate clearly, continent of bowel and bladder, had a history of falls, and had a moderate risk for skin breakdown based on Braden score of 17. Review of the care plan for Resident #222 revealed an intervention for the bed to be in the lowest position to reduce the risk of falls. Observation on 02/24/25 at 9:07 A.M. revealed Resident #222's bed was in the highest position. Observation on 02/25/25 at 6:50 A.M. revealed Resident #222's bed was in the highest position. Observation on 02/26/25 at 2:44 P.M. revealed Resident #222's bed was in the highest position. Observation on 02/27/25 at 11:45 A.M. revealed Resident #222's bed was not in the lowest position. Interview on 02/25/25 at 6:50 A.M. with Certified Nursing Assistant (CNA) #446 verified Resident #222's bed was in the highest position. Interview on 02/26/25 at 2:44 P.M. with Licensed Practical Nurse (LPN) #415 verified Resident #222's bed was in the highest position. Interview on 02/27/25 at 11:45 A.M. with LPN #441 verified Resident #222's bed was in the highest position. Review of the facility policy, titled Fall Reduction Policy, dated 04/29/16, indicated a fall risk assessment would be completed on admission. Further review indicated outcomes of the fall risk assessment would be incorporated into the resident's plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, resident interview, and review of facility policy the facility failed to ensure oxygen was administered as ordered. This affected one Resident (#222) of 19 Residents reviewed for the use of oxygen. The facility identified 19 resident on oxygen therapy (#7, #14, #16, #17, #18, #22, #23, #24 #30, #32, #37, #39, #43, #51, #55, #63, #176, #178, #222). The facility census was 73. Findings include: Review of medical record for Resident #222 revealed an admission date of 02/21/25. Diagnoses included acute and chronic respiratory failure with hypoxia, pneumonia, chronic obstructive pulmonary disease, asthma, and sleep apnea. The Multiple Data Set assessment was in progress and not available for review due to the admission date of 02/21/25. The admission assessment dated [DATE] indicated Resident #222 was alert and oriented, able to communicate clearly, and had an oxygen saturation of 91 percent (%) with oxygen being delivered via nasal cannula. Review of the physician orders for Resident #222 revealed an order dated 02/21/25 to administer oxygen at five liters per minute (L/m) via nasal cannula to maintain oxygen saturation greater than 90% and may titrate up to 10 L/m for mobility needs. Review of the care plan for Resident #222 revealed she is dependent on oxygen with interventions to give medications as ordered by the physician and to monitor for lethargy, confusion, and skin color. Observation on 02/24/25 at 9:07 A.M. revealed Resident #222 sitting in bed with eyes closed, pale coloring, and a nasal cannula resting on her chest. The nasal cannula was connected to the oxygen concentrator that was set to 8 L/m. Resident #222 was not responsive to voice. Interview on 02/24/25 at 9:13 A.M. revealed Certified Nurse Assistant (CNA) #451 knew Resident #222 was admitted recently but was not aware of the oxygen orders for this resident. Interview on 02/24/25 9:16 A.M. with Licensed Practical Nurse (LPN) #415 confirmed Resident #222's nasal cannula was on the her chest and her level of consciousness was decreased. Further interview revealed LPN #415 was unsure of the oxygen orders. Continued observation on 02/24/25 at 9:18 AM of LPN #415 providing care for Resident #222 revealed LPN #415 was attempting to arouse this resident with her voice but this resident would not fully awaken. LPN #415 placed the nasal cannula into Resident #222's nose. LPN #415 did not have a pulse oximeter with her and attempted to obtain one from the medication cart but none was available; she then left the floor to get a pulse oximeter. Continued observation on 02/24/25 at 9:20 A.M. revealed Resident #222's oxygen saturation was reading 82% via the pulse oximeter obtained by LPN #415. LPN #415 then went to get the respiratory therapist. Interview on 02/24/25 at 9:23 A.M. with LPN #415 confirmed Resident #222's oxygen saturation was 82% and it should be greater than 90%. Observation on 02/24/25 at 9:26 A.M. revealed Resident #222 was awake and interacting with staff. Her oxygen saturation was now 87%. Continued observation through 9:30 A.M. revealed Respiratory Therapist #419 arriving to Resident #222's room, adjusting the oxygen flow rate to 10 L/m, and obtaining an oxygen level of 90% via pulse oximeter. Resident #222 was conversing appropriately with Respiratory Therapist #419. Interview on 02/24/25 at 9:54 A.M. with Resident #222 revealed she did not remember taking off her nasal cannula and recalled it has fallen off in the past. Review of the facility policy titled Medication Administration - General Guidelines, dated 09/21/17 indicated medications were to be administered according to physician orders.

Based on observation, staff interview, review of the medical record, and review of the facility policy, the facility failed to ensure medication was stored appropriately. This affected one resident (#173) of the 16 residents (#6, #10, #12, #14, #19, #20, #21, #26, #36, #45, #173, #174, #176, #177, #178, and #179) who received medication from the E-Hall medication cart. The facility census was 73. Findings include: Review of the medical record for Resident #173 revealed an admission date of 02/21/25, with diagnoses that included, malignant neoplasm of pancreas, secondary malignant neoplasm of bone, malnutrition, chronic obstructive pulmonary disease (COPD), chronic obstructive pulmonary disease, asthma, lumbar radiculopathy, hypertension (HTN), depression, insomnia, gastro-esophageal reflux disease (GERD), hyperlipidemia, anemia, and neuropathy. Resident #173''s Minimum Data Set (MDS) assessment was in-process and not available due to an admission date of 02/21/25. Review of the current physician orders for Resident #173 revealed a physician order, dated 02/21/25, for Zenpep Oral Capsule Delayed Release Particles 40000-126000 unit, give two capsules by mouth with means related to malignant neoplasm of pancreas and give one capsule by mouth as needed for pancreatic cancer. Observation on 02/25/25 at 11:41 A.M. of the top drawer E-Hall medication cart revealed two capsules that were one-half orange and one-half white with 40 and Aptalis inscribed in black on each capsule. Interview on 02/25/25 at 11:42 A.M. with the Director of Nursing (DON) verified the medication was stored inappropriately in the top drawer of the medication cart for E-Hall. Further interview with the DON revealed these capsules were Resident #173's Zenpep Oral Capsule Delayed Release Particles 40000-126000 unit. Review of the facility policy titled, Medication Storage in the Facility, dated 02/11/21, revealed medications and biological's are stored safely , securely, and properly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review, the facility failed to ensure accurate and complete documentation in resident records. This directly affected one resident, #178, of 18 records reviewed for complete documentation. The facility census was 73. Findings include: Review of the medical record of Resident #178 revealed an admission date of 02/14/25. Diagnoses include infection and inflammatory reaction due to internal fixation device or other site, subluxation of left ankle, asthma, type II diabetes mellitus, systemic lupus erythematosus, protein-calorie malnutrition, palmar fascial fibromatosis, herpesviral infection, hepatitis A, chronic peripheral venous insufficiency, and vitamin D deficiency. Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #178 to be cognitively intact and to require partial to moderate assistance for toileting and lower body dressing. The assessment included surgical wounds but no moisture associated skin damage. Review of the progress note titled Clinical Admission, dated 02/14/25 at 5:13 P.M. revealed Resident #178 had the following wounds present upon admission: wound #1, on the intergluteal cleft identified as excoriation with no description and no measurements. Wound #2, on the genital identified as excoriation without description or size. Wound #3, identified on the left lateral ankle as a surgical wound with approximated edges, 14 sutures and measured 11.4 centimeters (cm) wide and 1.2 cm in length, no other description. Wound #4, identified on the left lateral shin as a surgical wound. The incision was approximated and dehiscence. Six sutures in place and measured one cm in length, 1.4 cm in depth, and 0.8 cm in depth. Wound #5, on left shin four areas of rod insertion sites, two on lateral and two medial, no other description noted. Review of a progress note dated 02/14/25 at 5:13 P.M., documented as a late entry on 02/26/25 at 10:28 A.M. by Registered Nurse (RN) #431, revealed the presence of wound #6. The wound was documented as a surgical wound to the left medial ankle. A wet to dry dressing was removed with scant drainage. The wound measured 2.4 cm in length, 3 cm in width and 0.8 cm in depth. The surrounding tissue had a small amount of redness around the wound with normal temperature. A negative pressure wound treatment was applied as ordered. Review of a wound doctor note dated 02/25/25 revealed a wound to the left medial ankle post-surgical wound. The wound measured two cm in length, 2.5 cm in width, and 0.8 cm in depth with moderate serous exudate, 40 percent granulation tissue and 60 percent (%) other viable tissue (tendon, fascia, muscle). A new treatment order to apply Vaseline gauze to the base of the wound to cover the tendon three times a week and then apply the negative pressure wound dressing therapy three times a week for 30 days at 125 millimeters of mercury continuous. Review of the progress note dated 02/26/25 at 11:18 A.M., documented by Registered Nurse (RN) #431, revealed wound #1 on middle intergluteal cleft excoriation, redness, measuring 0.8 cm in length, 0.3 cm in width with no depth. Wound #2 on the genital excoriation, redness, measuring 1.2 cm in length and 0.5 in width without depth. Wound #3 on the left lateral ankle was identified as a surgical wound measuring 11.3 cm in length, 1.2 cm in width with 14 sutures and approximated edges. Wound #4 on the lateral left shin as a surgical wound. The description had conflicting data. The wound measured one cm in length, 1.4 cm in width, and 0.8 cm in depth. RN #431 documented incision approximated and dehiscence. The incision had six sutures and no dressing was applied. Wound #5 on the left medial shin as a surgical wound with four rod insertion sites, two lateral ankle and two medial shin. This wound identified as painful with pain medications effective. A non-woven drain sponge was applied. Wound #6 identified on the left medial ankle as a surgical wound, not approximated. The wound was dressed with a negative pressure wound therapy. The length was two cm, width was 2.5 cm, and depth of 0.8 cm. The wound had 40 percent (%) granulation tissue with moderate serous (clear, watery fluid) exudate. Review of a progress note dated 02/27/25 at 11:36 A.M., documented by RN #431, revealed a clarification of wound #4. The entire wound measured one cm in length and 1.4 cm in width with a small area of dehiscence measuring 0.3 cm in length by 0.3 cm in width by 0.8 cm in depth at the medial end of the wound. The wound was without redness, drainage, or odor. Interview on 02/26/25 at 9:35 A.M. with Registered Nurse (RN) 431 and Clinical Support RN #439 revealed RN #431 admitted to having falsely documented a wound evaluation but not completing the evaluation. RN #431 stated the documentation was incomplete. Review of the policy titled Documentation Policy dated 03/17 revealed the facility will provide a complete and accurate account of the resident's signs and symptoms, as well as the progress of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, and staff interview the facility failed to ensure residents seated at the same table were served meals together. This directly affected four residents, #08, #20, #33, and #55, in the main dining room and one resident, #64, in the memory care dining room. The facility census was 73. Findings include: 1. Observation on 02/24/25 at 12:35 P.M. revealed two Residents, #33 and #49, seated at one table, three residents, #08, #37, and #58, seated at another, and three residents, #20, #52, and #55, seated at a third table. Meals were delivered on a cart from the adjacent kitchen and delivered to Residents #49, #37, #58, and #52, leaving at least one resident at the three tables without being served. The time lapse was no greater than 10 minutes. Interview at 12:40 P.M. with Certified Nursing Assistants #400 and #422 provided verification of residents #08, #20, #33 and #55 not being served. Additional interview with CNA #424 stated she had stacked the meal tickets together but was unsure as to why the meals were not served simultaneously. Review of the medical record of Resident #08 revealed an admission date of 06/11/18. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #08 was cognitively intact and required set-up assistance for eating. Interview on 02/24/25 at 12:45 P.M. with Resident #08 revealed she would prefer to be served at the same time as her tablemates. Review of the medical record of Resident #20 revealed an admission date of 03/23/15. Review of the quarterly MDS dated [DATE] revealed Resident #20 was cognitively intact and required only set-up assistance for eating. Interview on 02/24/25 at 12:40 P.M. with Resident #20 revealed she did not like to watch others eat while waiting for her food. Review of the medical record of Resident #33 revealed an admission date of 09/25/19. Review of the quarterly MDS dated [DATE] revealed Resident #33 was cognitively intact and required only supervision for eating. Interview on 02/24/25 at 12:40 P.M. with Resident #33 revealed he would rather eat at the same time as his tablemate. Review of the medical record of Resident #55 revealed an admission date of 08/28/23. Review of the quarterly 01/28/25 revealed Resident #55 was cognitively intact and was independent for eating. Interview on 02/24/25 at 12:40 P.M. revealed she feels as if all residents at the table should be served at the same time. 2. Observation of dining services in the memory care unit on 02/24/25 at 11:56 A.M. revealed meal trays arrived and were served to all residents except Resident #122. Resident #122 was sitting at a table with Resident #64 who was served her meal and eating. Observation on 02/24/25 at 12:04 P.M. revealed Resident #122 asked where her meal was and stated she was hungry. Observation on 02/24/25 at 12:18 P.M. revealed Resident #122's meal tray arrived after Certified Nursing Assistant (CNA) #479 went to the kitchen and retrieved an additional cart of meal trays. Interview with CNA #479 on 02/24/25 at 12:19 P.M. verified Resident #122 waited 22 minutes for her meal tray while her tablemate consumed her lunch.

Based on observation, staff interview, resident interview, review of the medical record, and review of facility policy, the facility failed to ensure staff used appropriate hand hygiene while distributing meal trays to residents. This affected seven residents (#1, #2, #4, #5, #17, #32 and #33) served meal trays on the C-Hall, with the potential to affect all 14 residents (#1, #2, #4, #5, #7, #11, #17, #22, #32, #33, #37, #52, #58, and #222) residing on C-Hall who receive meal trays. The facility also failed to ensure staff wore appropriate personal protective equipment (PPE) when entering a resident room who was in droplet precaution. This affected one resident (#2) of one resident reviewed for transmission-based precautions (TBP). Additionally, the facility failed to ensure resident's catheter collection bags were maintained off the floor and in a safe and sanitary manner. This affected one resident (#123) of one resident reviewed for indwelling catheters. The facility identified four residents (#12, #48, #123, and #177) with indwelling catheters. The facility census was 73. Findings include: 1. Observation on 02/24/25 at 12:55 P.M. of lunch tray distribution to the C-Hall revealed Certified Nursing Assistant (CNA) #479 delivered a lunch tray to Resident #32 without first performing hand hygiene. Concurrent observation by two Ohio Department of Health (ODH) Surveyors on 02/24/25 at 12:56 P.M. of lunch tray distribution to the C-Hall revealed Licensed Practical Nurse (LPN) #415 delivered a lunch tray to Resident #5 without performing hand hygiene before or after tray delivery. Concurrent observation by two Ohio Department of Health (ODH) Surveyors on 02/24/25 at 12:56 P.M. of lunch tray distribution to the C-Hall revealed Licensed Practical Nurse (LPN) #415 delivered a lunch tray to Resident #1 without performing hand hygiene before or after tray delivery. Observation on 02/24/25 at 12:57 P.M. of CNA #479 delivered a lunch tray to Resident #33 delivered a lunch tray to Resident #4 without performing hand hygiene before or after tray delivery. Concurrent observation by two Ohio Department of Health (ODH) Surveyors on 02/24/25 at 12:58 P.M. of lunch tray distribution to the C-Hall revealed LPN #415 bringing a tray out of Resident #2's room, stating Resident #2 stated she did not want to eat due to her nausea. LPN #415 offered Resident #2 alternate lunch options and Resident #2 declined. Further observation of this interaction revealed LPN #415 did not perform hand hygiene upon exiting Resident #2's room with the refused lunch tray. Concurrent observation by two Ohio Department of Health (ODH) Surveyors on 02/24/25 at 12:58 P.M. of lunch tray distribution to the C-Hall revealed LPN #415 delivered a lunch tray to Resident #17 without performing hand hygiene before or after tray delivery. In an interview on 02/24/25 at 1:02 P.M. with LPN #415, LPN #415 denied not performing hand hygiene, but it was observed by two ODH Surveyors that she did not perform hand hygiene in the above interactions. Interview on 02/24/25 at 1:05 P.M. with CNA #497 verified she did not perform hand hygiene when delivering lunch meal trays to Resident #4 and Resident #32. 2. Review of the medical record for Resident #2 revealed an admission date of 06/30/22, with diagnoses of dementia, chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, stage 3A chronic kidney disease (CKD3A), extended-spectrum beta-lactamase (ESBL) resistance, chronic migraine, bipolar disorder, cervicalgia, depression, chronic pain syndrome, atherosclerotic heart disease, carrier/suspected carrier of methicillin-resistant Staphylococcus aureus (MRSA), insomnia, hypertension (HTN), anxiety, osteoarthritis, acquired absence of left leg above the knee, gastro-esophageal reflux disease (GERD), hyperlipidemia, personality disorder, and fibromyalgia. Review of the most recent quarterly Minimum Data Set (MDS) assessment for Resident #2, dated 12/17/24, revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating Resident #2 was cognitively intact. Review of the current physician orders for Resident #2 revealed a physician order, dated 02/24/25 at 2:17 P.M., for droplet precautions. Observation on 02/26/25 at 9:00 A.M. of the signage by Resident #2's door revealed prior to entering the room, everyone must clean their hands, including before entering and when leaving the room and make sure their eyes, nose and mouth are covered before room entry. Observation on 02/26/25 at 9:03 A.M. revealed CNA #492 entering Resident #2's room without donning any personal protective equipment (PPE). Observation on 02/26/25 at 10:57 A.M. of CNA #479 revealed CNA #497 entering Resident #2's room without donning any PPE. Interview on 02/26/25 at 9:05 A.M. with CNA #492 verified she did not wear PPE when she entered Resident #2's room. Interview on 02/26/25 10:59 A.M. with CNA #497 verified she did not wear PPE when she entered Resident #2's room. Review of the facility policy titled, Transmission Based Precautions - Droplet, dated 08/22, revealed it is the intent of this facility to use droplet precautions in addition to standard precautions to decrease the risk of droplet transmission of infectious agents. A mask should be worn upon entry into the the resident's room. Gloves are indicated for all persons entering the room. 3. Review of Resident #123's medical record revealed an admission date of 02/21/25. Diagnoses included Alzheimer's, congestive heart failure, and urinary retention. Review of Resident #123's care plan revealed the resident suffered from bladder incontinence. Observation on 02/24/25 at 11:43 A.M. revealed Resident #123 was being transported from her room to the dining room in a wheelchair by Certified Nursing Assistant (CNA) #480. Further observation revealed the urinary catheter bag was covered in a pillow case and was tied to the bottom of the resident's wheelchair. The urinary catheter bag was dragging on the floor under the wheelchair. Interview with CNA #480 on 02/24/25 at 11:45 A.M. verified Resident #123's urinary catheter bag was dragging on the floor which was an infection control issue. Interview with the Administrator on 02/27/25 at 10:03 A.M. revealed the facility did not have a policy regarding catheter infection control.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, review of admission agreement, and facility policy the facility failed to honor a resident's choice to smoke. This affected one (Resident #27) of five residents reviewed for choices regarding smoking. The facility census was 70. Findings include: Medical record review of Resident #27 revealed the resident was admitted to the facility on [DATE] and discharged on 04/18/20. Per the record, the resident was re-admitted on [DATE]. Diagnoses included dysphagia, anxiety disorder, memory deficit and cerebrovascular disease. Review of Resident #27's comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had mildly impaired cognition and was not receiving supplemental oxygen. Review of Resident #27's care plan dated 11/18/22 revealed no focus for smoking cessation (quitting smoking) or safe smoking. Review of Resident #27's acknowledgement of documents and admission agreement, signed per the resident's Power of Attorney (POA), dated 11/18/22 revealed the POA and the resident were informed of the facility's smoking policy. Review of the facility admission agreement dated 05/2022 revealed under the section, 'Smoke-Free Environment,' stated the facility instructed all residents and visitors who smoked may do so under the following circumstances: under staff supervision or family/guardian supervision and only in designated areas. There was no mention of newly admitted residents being unable to smoke. Review of the facility policy titled, Smoking Policy, dated 10/2022 revealed for facilities who permit smoking, must provide a safe environment to those residents who wish to smoke. If the facility changes its policy to prohibit smoking, it should allow current residents who smoke to continue in designated areas. Further requests for an updated no smoking policy revealed the facility did not have a policy stating the facility was smoke-free. Interview on 06/11/23 at 10:02 A.M. with Resident #27 revealed the resident was alert and oriented and able to be interviewed. Resident #27 stated she had no concerns with her care except she was not allowed to smoke. Resident #27 stated she had seen other residents smoking outside but she was told the facility was a smoke-free facility. Resident #27 stated she knew she had not smoked for a long time but she still had the desire to go outside and smoke and was being told she was not allowed to by staff. Interview on 06/14/23 at 2:15 P.M. with the Administrator revealed during the COVID-19 pandemic, the facility decided to become a smoke-free facility. Per the Administrator all new admissions would no longer be allowed to smoke. The Administrator verified the admission document labeled 'Smoke-Free Environment' did not state the facility was a smoke-free facility nor did it say only previous admitted residents would be permitted to smoke. The Administrator verified Resident #27 did smoke prior to admission and was no longer allowed to smoke after her 2022 admission. Interview on 06/14/23 at 8:10 A.M. with Resident #27 stated chose to come to this facility because she was allowed to smoke in 2019 with her last admission. Resident #27 stated she had no idea she would be prevented from smoking when she was admitted to the facility. Resident #27 stated she knew the hazards of smoking but stated she still chose to smoke and felt she was being denied her choice. Interview on 06/14/23 at 8:15 A.M. with Licensed Practical Nurse (LPN) #400 revealed the staff was aware of Resident #27's desire to smoke. LPN #400 stated the facility was to be smoke-free and only certain residents were allowed to smoke.

Based on medical record review, observation, and staff interview, the facility failed to ensure residents nonverbal communication of hunger was responded to. This affected one (#53) of four residents observed on the secured unit who received meals in their rooms. The facility census was 65. Findings include: Review of Resident #53's medical record revealed an admission date of 12/18/19. Diagnoses included vascular dementia with behavioral disturbance, major depressive disorder, and anxiety disorder. Review of Resident #53's care plan, revised 03/30/21, revealed an intervention for a communication problem which included supports to anticipate and meet Resident #53's needs. An additional intervention was found for increased nutritional risk. Supports included saving Resident #53's meals for later consumption if Resident #53 did not eat. Observation on 04/13/21 at 12:25 P.M. found Resident #53 pacing in his room. Resident #53 was observed sitting on the bed, getting up and walking to the door, looking at the meal tray cart, going back in his room, sitting on the bed and positioning the gray side table in front of him. Resident #53 was observed repeating this process four times in three minutes. Observation on 04/13/21 at 12:28 P.M. of the meal trays on the hall cart found Resident #53's lunch tray was on the cart. The lunch tray was covered and appeared untouched. Interview on 04/13/21 at 12:29 P.M. with State Tested Nursing Assistant (STNA) #157 verified the untouched lunch tray on the meal cart was Resident #53's. STNA #157 reported Resident #53 placed the lunch tray in the hallway after it was initially delivered. STNA #157 verified she picked up the untouched tray and put it back on the cart. STNA #157 stated Resident #53 must have not wanted it. Coinciding observation of Resident #53 found him sitting on his bed with his side table in front of him, looking at the meal cart and his tray as it went by. STNA #157 did not stop and ask Resident #53 if he was hungry or if he wanted his meal. STNA #157 was observed pushing the meal cart down the hallway and adding other resident's used lunch trays to the cart to be taken back to the kitchen. Observation on 04/15/21 at 8:05 A.M. of Resident #53 found Resident #53 seated on his bed with his breakfast meal on the gray side table positioned in front of him. Resident #53 was observed eating and drinking independently. Interview on 04/15/21 at 8:07 A.M. with STNA #165 revealed Resident #53 was not able to verbally communicate if he was hungry. STNA #165 reported they knew he was hungry by his nonverbal communication. STNA #165 explained Resident #53 took his meals in his room and he would get fidgety when he was hungry. STNA #165 stated Resident #53 would pace and move his gray table around when he was hungry and wanted to eat. STNA #165 reported if Resident #53 refused his food they were to make additional attempts to offer his meal to him and/or offer an alternate.

Based on review of resident funds records, staff interview, and review of facility policy, the facility failed to return resident funds to the resident's responsible party within 30 days of the resident's death. This affected one resident (#165) of one resident reviewed for discharge funds. The facility census was 65. Findings include: Review of Resident #165's medical record revealed an admission date of 05/21/20 and a discharge date of 11/23/20. Diagnoses included osteoarthritis, emphysema, chronic kidney disease, and neoplasm of kidney Further review of medical record revealed the resident was private pay. Review of copy of check dated 02/04/21 addressed to the estate of Resident #165's revealed the amount of $1,417.48. Interview on 04/19/21 at 11:27 A.M. with Business Office Manager #177 verified Resident #165's funds were not returned within 30 days of the resident's death. Review of facility policy titled Resident Personal Funds dated November 2016, revealed within 30 days of a resident's death, the Manor will transfer funds in their personal account to their estate.