Based on medical record review, resident and staff interviews, and policy review, the facility failed to ensure a care plan reflected a resident's current status. This affected one (#61) of one reviewed for care plans. The facility census was 69. Findings include: Review of the medical record for Resident #61 revealed an admission date of 02/06/25. Diagnoses included myelofibrosis, muscle weakness, migraines, and infection of surgical site. The resident was cognitively intact. Review of Resident #61's care plan updated 02/28/25 revealed it did not include goals and interventions in place for Activities of Daily Living (ADLs). Interview with Resident #61 on 03/25/25 at 10:00 A.M. confirmed she uses a wheelchair and requires assistance from staff to complete ADLs. Interview on 03/25/25 at 1:35 P.M. with the Director of Nursing (DON) verified Resident #61's care plan did not address the resident's ADL needs. Review of the facility's policy titled, Resident Assessment Accuracy of Assessment, dated 11/28/27 revealed the facility must conduct initially and periodically a comprehensive and accurate assessment of each resident's functional capacity. The assessment must accurately reflect the residents' status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, the facility failed to ensure resident food preferences were honored. This affected one resident (#42) of one resident reviewed for food preferences. The census was 69. Findings include: Review of the medical record for Resident #42 revealed an admission date of 02/25/22 with diagnoses included but not limited to Alzheimer's disease, heart failure, and thyrotoxicosis. Review of the most recent completed Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #42 was severely cognitively impaired and was dependent for activities of daily living. Review of the care plan dated 03/03/22 revealed Resident #42 was at nutritional risk related to diagnoses. Interventions included but not limited to honoring preferences. Review of Resident #42's diet ticket revealed Resident #42 disliked chicken. Observation of lunch tray line on 03/26/25 at 12:10 P.M. revealed Resident # 42's tray was portioned up with pureed chicken alfredo and pureed broccoli. Resident #42's diet ticket stated Resident #42 disliked chicken. [NAME] #302 stated Resident #42 has gotten chicken already and eats it, so she did not need a substitute. Observation and interview on 03/26/25 at 12:40 P.M. revealed Resident #42's was served pureed chicken alfredo. An interview with daughter of Resident # 42 revealed her mother does not like chicken and would like a substitution. Regional Clinical Director #301 called the kitchen for an alternative. Interview on 03/26/25 at 5:18 P.M. with Registered Diet Technician #310 revealed she does a tray audit monthly but does not have access to the diet ticket system to audit the diet tickets and/or update preferences. Review of the facility policy dated 01/2025 titled, Resident Interviewing/Obtaining Nutritional History, revealed preferences will be obtained by the resident or resident representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, record review, and review of facility policy, the facility failed to ensure smoking materials were stored in a safe manner. This affected one (Resident #50) of one resident reviewed for storage of smoking materials. The facility census was 69. Findings include: Review of the medical record for Resident #50 revealed an admission date of 03/23/24. Diagnoses included hypokalemia, absence of right leg below knee, disorders of plasma-protein metabolism, Peripheral vascular disease, unspecified sequelae of cerebral infarction and depression. She required limited assistance with activities of daily living and she was cognitively intact. Review of Resident #50's smoking assessment dated [DATE] revealed she is to be supervised when smoking and all smoking materials are to be given to staff members to be kept in a locked location. Observation on 03/26/25 at 9:47 A.M. with Maintenance Man (MM) #473 revealed Resident #50 had four packs of cigarettes in the refrigerator in her room. Interview on 03/26/25 at 10:52 A.M. with Housekeeper Supervisor (HS) #472 revealed Resident #50 did not go out to smoke on 03/26/25 at 7:00 A.M. HS #472 confirmed she was not aware Resident #50 had cigarettes in her room but had a supply of cigarettes locked up behind the nurse's station. Interview on 03/26/25 at 11:00 A.M. with Medical Records Coordinator (MRC) #462 revealed Resident #50 went out to smoke on 03/26/25 at 10:00 A.M. She was given cigarettes to smoke that were kept behind the nurse's station locked up. She denied knowing Resident #50 had cigarettes in her room. Interview on 03/26/25 at 11:11 A.M. with Resident #50 revealed last night, she was short on cigarettes and a staff member in the afternoon shift was going to the store. Resident #50 gave the staff member money to buy her cigarettes. When she received her cigarettes, she put them in the refrigerator. She forgot they were in there until MM #473 and Surveyor found them in her refrigerator. Review of the facility's policy, Smoking Policy last updated 09/2022, revealed 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 .Residents will be given their cigarettes and E-cigarettes, upon arrival to designated smoking areas. All cigarettes that are unsmoked will be returned to facility staff for storage. Smoking material will be labeled and kept in a central location lock and key and available by staff members or family.

Based on observation, interview, and facility policy, the facility failed to ensure a clean and sanitary kitchen as well as hair restraints were worn by kitchen staff while in the kitchen. This had the potential to affect 69 residents out of 69 who received meals from the facility kitchen. The census was 69. Findings include: Observation on 03/25/25 at 10:27 A.M. revealed Interim Dietary Manager (IDM) #300 was not wearing a hair restraint. IDM #300 stated he did not know it was a regulation to wear a hair restraint in Ohio. Further observation of the kitchen revealed there was grease running down the front of the stove. IDM #300 verified the grease and stated that he would get it cleaned up. Observation on 03/26/25 at 11:45 A.M. [NAME] #302 was serving garlic bread with her gloved hand after touching other utensils and plates. She stated that she knew better and then got a pair of tongs. Observation on 03/26/25 at 11:58 A.M. revealed grease started to run down the front of the stove again. Looking at the stove, there was a grease tray that was overflowing, so when someone bumped the stove, it started to run down the front of the oven door. The shelf above the stove was greasy with dust on top of the grease. IDM #300 verified the grease and stated that he would get it cleaned up. Review of the facility policy from the diet manual dated 01/2025 titled, Sanitation Standards of Practice, revealed that it is policy to ensure food service areas are clean, sanitary and in compliance.

Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure the call light was positioned within reach of a resident. This affected one (#5) of six residents observed for call light placement. The facility census was 60. Findings include: Review of the medical record for Resident #5 revealed an admission date of 10/03/18. Diagnoses included type II diabetes mellitus, repeated falls, dysphasia, and aphasia. Review of the significant change Minimum Data Set (MDS) assessment, dated 03/23/22, revealed the resident was cognitively impaired. The resident was also totally dependent upon staff for all activities of daily living (ADLs). Review of Resident #5's plan of care, dated 04/24/22, revealed Resident #5 was at risk for falling due to a recent cerebrovascular accident (stroke). Interventions included monitoring the resident for attempts to get up unassisted, reminding the resident to call for help when needing assistance, and keeping call light in reach at all times. Observation on 06/13/22 at 9:20 A.M., revealed Resident #5 was in bed sleeping and the call light was unable to be seen within reach of the resident. Interview and observation on 06/13/22 at 9:21 A.M., with Non-Certified Nursing Assistant (NCNA) #538 verified Resident #5's call light was not in reach and was on the floor and wrapped around the foot of the bed. NCNA #538 had to move Resident #5's bed to untangle the call light and place it within reach of the resident. Observation on 06/14/22 at 9:53 A.M., revealed Resident #5 was sleeping in bed and her call light was on the floor near the foot of the bed. Observation and interview on 06/14/22 at 10:04 A.M., with Certified Nursing Assistant (CNA) #552 verified the call light was on the floor and not within reach of Resident #5. Observation on 06/27/22 at 9:36 A.M., revealed Resident #5 was sleeping in bed and her call light was unable to be seen. Observation and interview on 06/27/22 at 9:38 A.M., with Licensed Practical Nurse (LPN) #503 verified Resident #5's call light was not within reach and was on the floor and wrapped around the foot of the bed. LPN #503 untangled the call light cord and placed it within the resident's reach. Interview on 06/30/22 at 9:25 A.M., with the Director of Nursing (DON) verified Resident #5 was able to use her call light during the aforementioned times and it should have been within reach. Review of the policy titled Standards of Nursing Practices, revised May 2018, revealed staff would respond to resident requests for assistance by answering call lights within a reasonable amount of time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #7 revealed an admission date of 03/27/17. Diagnoses included Alzheimer's disease, dementia, type II diabetes mellitus, muscle weakness, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 had a weight of 204 pounds and required the extensive assistance of one staff member for bed mobility, transfers, dressing, toileting, and personal hygiene. Review of the quarterly MDS assessment dated [DATE] revealed Resident #7 had a weight of 158 pounds and was totally dependent on staff for bed mobility, transfers, dressing, toileting, and personal hygiene. Review of the quarterly MDS assessment dated [DATE] revealed Resident #7 had a weight loss of more than five percent in the last month or 10 percent in the last six months. Resident #7 was totally dependent on staff for bed mobility, transfers, dressing, toileting, and personal hygiene. Review of the MDS records for Resident #7 revealed no significant change assessment was completed related to Resident #7's weight loss or decline in activities of daily living (ADLs). Interview on 06/29/22 at 12:14 P.M., with MDS Coordinator #540 verified the lack of a significant change assessment. Review of the most recent version of the Resident Assessment Instrument (RAI) Manual revised October 2019 revealed a significant change in condition assessments are appropriate when a significant change in a resident's condition from their baseline has occurred as indicated by comparison of the resident's current status to the most recent comprehensive and quarterly assessments, or when there are two or more areas of decline. Review of the policy titled Resident Assessment Comprehensive Assessments Significant Change in Status, dated 11/28/17, revealed a significant change in status assessment must be completed within 14 days after a determination has been made that a significant change in the resident's status from baseline occurred. Based on record review, Resident Assessment Instrument (RAI) Manual review, policy review and staff interviews, the facility failed to complete a significant change in status assessment in the Minimum Data Assessment (MDS) when a resident displayed a significant change in health. This affected two (#61 and #7) of 25 residents reviewed. The facility census was 60. Findings include: 1. Record review for Resident #61 revealed an admission date of 05/01/21. Resident #61 was admitted to the hospital from the facility on 05/06/22 and returned to the facility on [DATE]. Diagnoses included encephalopathy, unspecified, acute kidney failure, hyperosmolality and hypernatremia, aphasia, dysphagia, oropharyngeal phase, altered mental status, and myocardial infarction. Record review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #61 was cognitively intact. Resident #61 required limited assistance for bed mobility, transfers, toilet use, personal hygiene, and dressing. Resident required supervision for ambulation. Resident ambulated with a walker. Resident was independent for eating and received a regular textured diet. Resident was always continent of bowel and bladder. Record review revealed an entry MDS was completed 05/11/22 to include identification information. Record review of the scheduled five day MDS assessment completed 05/15/22 revealed Resident #61 was severely cognitively impaired. Resident required extensive assistance of one for bed mobility, dressing, and personal hygiene. Resident #61 required extensive assistance of two for transfers and toilet use. Resident #61 had an indwelling catheter and was always incontinent of bowel. Resident required a wheelchair for locomotion with extensive assistance of one. Resident #61 required limited assistance of one for eating and received a mechanical altered diet. Review of the quarterly MDS dated [DATE] revealed additionally to the MDS dated [DATE], Resident #61 required extensive assist of one with eating. Interview on 06/29/22 at 2:43 P.M., with the Director of Nursing (DON) revealed prior to Resident #61 going to the hospital on [DATE], Resident #61 was alert and oriented. Resident #61 was able to transfer herself, ambulate without assistance, dress and groom herself, feed herself, and was continent of bowel and bladder. Upon return from the hospital on [DATE], Resident #61 was severely cognitively impaired, and required assistance with all activities of daily living including eating. Resident #61 returned with an indwelling catheter and was incontinent of bowel. DON confirmed Resident #61 had a significant change in condition. Interview on 06/30/22 at 10:41 A.M., with MDS Nurse #540 confirmed a significant change in status should have been completed for Resident #61 after returning from the hospital with a significant change in condition but was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, staff interview and policy review, the facility failed in involve a resident and/or a resident representative in the care planning process. This affected one (#13) of 23 residents care plans reviewed. The facility census was 60. Findings include: Record review for Resident #13 revealed an admission date of 05/16/22. Resident transferred to the hospital on [DATE] and returned 05/27/22. Diagnoses included unspecified fracture of shaft of the left tibia, hyperglycemia, unspecified injury of the right foot, acute kidney failure, history of falling, cellulitis of unspecified part of the limb, type two diabetes mellitus, and obstructive sleep apnea. Record review of the five-day Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #13 was cognitively intact. Resident required total dependence for bed mobility, and transfers, required extensive assistance for dressing. Resident was independent for eating. Resident was occasionally incontinent of urine and always continent of bowel. Resident was at risk for falls and had repairs of fractures. Interview on 06/13/22 at 8:44 A.M., with Resident #13 revealed he had not had any care plan meeting or discussion about a care plan meeting on admission or after. Resident#13 revealed he would like to have a care plan meeting because he had questions regarding his care and discharge plans. Interview on 06/27/22 at 2:06 P.M., with Social Service Designee (SSD) #553 revealed the DON completed the initial care plan meeting, to be completed within 48 hours of admission, and SSD #553, completed the remaining care plan meetings. SSD #553 revealed Resident #13 had a care plan meeting scheduled for 05/27/22. Resident #13 went to the hospital on [DATE] and returned 05/27/22. SSD #553 revealed she canceled the care plan meeting on 05/27/22 and rescheduled the meeting for 06/08/22. SSD #553 revealed she then realized she was on vacation the week of 06/08/22 and again rescheduled the care plan meeting for the next week (unable to recall the date), the next week all residents were evacuated to a sister facility on Tuesday, 06/14/22 and returned Friday, 06/17/22. SSD #553 revealed she then rescheduled the care plan meeting for 06/29/22. SSD #553 confirmed Resident #13 was admitted on [DATE] and did not have an initial care plan meeting to be completed within the first 48 hours of admission, or a comprehensive care plan meeting to be completed in the 14 days after admission. Interview on 06/27/22 at 3:58 P.M., with the DON confirmed she was to complete all residents initial care plan meetings within 48 hours of admission. DON confirmed Resident #13 did not have an initial care plan meeting completed. DON revealed he must have got missed. Review of the policy titled Resident Assessment comprehensive Care Plan updated 11/28/17, revealed the facility must develop an implement a comprehensive person centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3) that includes measurable objectives and timeframe's to meet a resident's medical nursing and mental and psychosocial needs that are identified in the comprehensive assessment. Each resident will have a person -centered comprehensive care plan developed and implemented to meet his other preferences and goals and address the resident's medical, physical, mental and psychosocial needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident interview, staff interview, review of shower sheets, and review of facility policy, the facility failed to ensure residents received assistance with showers and/or shaving as required. The facility failed to apply foot pedals to a wheel chair of a dependent resident. This affected two (#37 and #43) of three residents reviewed for Activities of Daily Living (ADLs). The facility census was 60. Findings include: 1. Review of Resident #37's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included type II diabetes mellitus, chronic obstructive pulmonary disease, weakness, and hypertension. Review of Resident #37's admission Minimum Data Set (MDS) assessment, dated 05/11/22, revealed the resident had a moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of nine. The assessment revealed the resident required extensive assistance of two staff for bed mobility, transfers, and toileting, and required physical help from two staff members for bathing. The resident was not noted to refuse or resist care. Review of Resident #37's plan of care, dated 05/13/22, revealed the resident was at risk for self care deficit and needed assistance with ADLs. Goals included the resident would be well groomed, proper hygiene would be maintained, and the resident would bathe twice per week. Review of the shower schedule revealed Resident #37 was to receive assistance bathing on Tuesdays and Fridays on first shift. Review of facility bathing records for 05/11/22 through 06/17/22 revealed no evidence Resident #37 received assistance bathing between 05/24/22 through 06/01/22 or between 06/0822 through 06/17/22. The resident was noted to have received bed baths on five occasions with two shower refusals and no there was no indication the resident was offered or received assistance shaving. Two additional shower sheets were not indicative of whether the resident received a shower or bed bath. Observation on 06/13/22 at 8:47 A.M., revealed Resident #37's facial hair was grown out and unshaven. Interview on 06/13/22 at 8:47 A.M., Resident #37 stated he had only received assistance bathing twice since he had been there, that he had never been offered a shower or assistance shaving, and that staff automatically gave him bed baths which were not thorough. Observations on 06/14/22 at 9:51 A.M., on 06/27/22 at 9:42 A.M., on 06/28/22 at 11:55 A.M., and on 06/29/22 at 8:23 A.M. revealed Resident #37's facial hair remained unshaven. Interview on 06/29/22 at 2:15 P.M., with Licensed Practical Nurse (LPN) #566 revealed residents normally had a bathing preference sheet although Resident #37 did not have one. LPN #566 was unaware of Resident #37's shower and/or shaving preferences. LPN #566 stated State Tested Nurse Aides (STNAs) offered showers to all residents and were required to inform the nurse on duty if a resident refused. LPN #566 reported the nurse would then attempt to encourage the resident to shower and if the resident refused they would then receive a bed bath. LPN #566 verified all shower refusals and assistance shaving was documented on resident shower sheets. Review of the policy titled Activities of Daily Living (ADLs)/Maintain Abilities, dated November 2021, revealed a resident who was unable to carry out ADLs would receive the necessary services to maintain good grooming and personal hygiene. 2. Record review for Resident #43 revealed an admission date of 12/09/21. Diagnoses included unstable burst fracture of fourth lumbar vertebra, subsequent encounter for fracture with routine healing, spinal stenosis, lumbar region with neurogenic claudication, delirium due to known physiological condition, muscle weakness, lack of coordination, and fusion of the spine, lumbar region. Review of the quarterly MDS assessment dated [DATE] revealed Resident #43 had moderately impaired cognition. Resident #43 was totally dependant for transfers, locomotion, dressing, personal hygiene, and bathing. Resident #43 used a wheel chair for locomotion. Observation on 06/13/22 at 11:25 A.M., revealed Resident #43 was sitting in the activity room, in a tilt and space chair, slightly declined with no foot pedals. Resident #43's feet were dangling in the air while sitting declined in the chair. Record review of the care plan for Resident #43 revealed there was no care plan developed for the use of the tilt and space chair. Observation on 06/14/22 at 10:06 A.M., revealed Resident #43 was sitting in the activity room, in a tilt and space chair, slightly declined with no foot pedals. Resident #43's feet were dangling in the air while sitting declined in the chair. Interview on 06/14/22 at 10:11 A.M. with Activities Coordinator #558 confirmed Resident #43 was sitting in the activity room, in a tilt and space chair, slightly declined with no foot pedals. Resident #43's feet were dangling in the air while sitting declined in the chair. Activities Coordinator #558 revealed Resident #43 normally does not wear foot pedals. Interview on 06/14/22 at 10:12 A.M., with Certified Nursing Assistant (CNA) #539 revealed Resident #43 refused her foot pedals foot pedals. Interview on 06/14/22 at 10:15 A.M., with Licensed Practical Nurse (LPN) #566 revealed she did not know where Resident #43's foot pedals were. Observation with LPN #566 revealed Resident #43 had one foot pedal for her chair in her closet in her room. LPN #533 revealed someone must have took the other pedal and put it somewhere else. Observation on 06/27/22 at 10:52 A.M., revealed Resident #43 was sitting up in her chair in the activity room. Resident #43 was sitting in the tilt and space chair sitting straight up. Interview on 06/27/22 at 11:01 A.M., with LPN #503 verified Resident #43 was sitting in a tilt and space chair. LPN #503 revealed she was not sure how long Resident #43 has been in the chair. Interview on 06/27/22 at 2:39 P.M., with Rehab Director #590 revealed Resident #43 was receiving therapy in January 2022 Resident #43 was discharged from therapy in January 2022 and at that time Resident #43 was in a standard wheel chair. Rehab Director #590 revealed Resident #43 was picked back up in April 2022 for therapy and at that time she was in the tilt and space chair. Interview on 06/27/22 at 2:12 P.M., with LPN #503 revealed the staff normally tilt the chair back for Resident #43 when she was not eating. LPN #503 revealed she was not sure how far the chair should be tilted back. Interview on 06/27/22 at 2:30 P.M., with CNA #513 revealed she always tilted Resident #43's chair so she didn't slide. CNA #513 revealed one of the other CNA's told her Resident #43 was supposed to be tilted in the chair. CNA #513 confirmed she was not sure how far back she was to be tilted in the chair. Interview on 06/27/22 at 2:33 P.M., with CNA #518 revealed she adjusted Resident #43's tilt and space chair according to the care plan. CNA #518 verified Resident #43 had no care plan for the tilt and space chair. CNA #518 then stated, Oh well, I just know when, I do it every two hours. Interview on 06/27/22 at 4:00 P.M., with DON confirmed Resident #43 had no physician orders or any information regarding the tilt and space chair or when or who placed Resident #43 in the chair. DON confirmed Resident #43 should have had physician orders, a care plan and a restraint assessment completed for Resident #43 and use of the specialized chair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview, and review of facility policy, the facility failed to ensure Resident #7 received audiology services in a timely manner. This affected one (#7) of one resident reviewed for hearing. The facility census was 60. Findings include: Review of the medical record for Resident #7 revealed an admission date of 03/27/17. Diagnoses included Alzheimer's disease, dementia, type II diabetes mellitus, muscle weakness, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively impaired and was totally dependent on staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The resident had moderate difficulty with hearing and was noted to have hearing aid(s). Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had minimal difficulty with hearing and was noted to have hearing aid(s). Review of the plan of care for Resident #7, dated 04/14/22, revealed the resident had hearing loss. Interventions included hearing aid as ordered, removing hearing aid at night and keeping in medication cart, and referral to audiology as needed. Review of the provider documentation dated 04/25/22 revealed Resident #7 had bilateral hearing loss and her hearing aids had been lost. The note stated the certificate of medical necessity (CMN) for hearing aids was left at the facility and needed to be signed by the resident's Primary Care Physician (PCP) prior to the hearing aids being ordered. Review of the CMN form for hearing aids, dated 04/25/22, revealed the form had not been signed or returned. Review of the missing item report dated 06/01/22 revealed Resident #7's hearing aids had been missing since before COVID. Interview on 06/13/22 at 11:36 A.M., with Resident #7 revealed the resident's hearing aids were lost at the facility and this was not being addressed. Interview on 06/30/22 at 11:18 A.M., with Social Services Director #553 revealed the CMN for hearing aids had been accidentally scanned in with other provider documents from the audiology visit on 04/25/22 and was not signed or returned until the need was identified during the survey on 06/30/22. Review of the policy titled Physician Services Ancillary, not dated, revealed arrangement of services from ancillary providers including audiologists would be arranged based on resident needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to obtain physician orders for the care and treatment of an indwelling urinary catheter. This affected one (#61) of three residents reviewed for catheter care. The facility census was 60. Findings include: Record review for Resident #61 revealed an admission date of 05/01/21. Resident #61 had a hospital stay from 05/06/22 through 05/11/22. Diagnoses included acute kidney failure and altered mental status. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 was always continent of bowel and bladder. Record review of the Critical admission assessment dated [DATE] completed by Licensed Practical Nurse (LPN) #503 revealed Resident#61 had returned from a hospital stay. Resident #61 had a Foley (indwelling) catheter draining yellow urine. Review of the scheduled five-day MDS assessment completed 05/15/22 revealed Resident #61 had an indwelling catheter. Record review of the care plan for Resident #61 revealed there was no care plan for an indwelling catheter. Record review of the physician orders for May 2022 and June 2022 for Resident #61 revealed there was no physician order for Resident #61 to have an indwelling catheter or for the care and treatment of an indwelling catheter for Resident #61. Record review of the nursing progress notes from 05/11/22 through 06/02/22 for Resident #61 revealed there was no nursing progress note documented regarding the use or care and treatment of the indwelling catheter for Resident #61. Review of the physician orders dated 06/03/22 for Resident #61 revealed an order to remove the Foley (indwelling) catheter and monitor for retention. Interview on 06/29/22 at 2:43 P.M., with the Director of Nursing (DON) confirmed Resident #61 returned from the hospital on [DATE] with an indwelling catheter. The indwelling catheter was removed on 06/03/22. DON confirmed Resident #61 had no order for the indwelling catheter or the care and treatment of the indwelling catheter, no diagnosis for the indwelling catheter, no care plan for the indwelling catheter, and no documentation of care or treatment provided for the indwelling catheter. DON confirmed the facility was responsible to obtain orders for the indwelling catheter and care and treatment of the indwelling catheter for Resident #61 on 05/11/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #7 revealed an admission date of 03/27/17. Diagnoses included Alzheimer's disease, dementia, type II diabetes mellitus, muscle weakness, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively impaired, had a weight of 204 pounds, and required the extensive assistance of one staff member for bed mobility, transfers, dressing, toileting, and personal hygiene. Review of the quarterly MDS assessment dated [DATE] revealed Resident #7 had a weight of 158 pounds and was totally dependent on staff for bed mobility, transfers, dressing, toileting, and personal hygiene. Weight loss of more than 5 percent in the last month or loss of 10% or more in last 6 months was marked No or unknown. Review of the quarterly MDS assessment dated [DATE] revealed Resident #7 was cognitively impaired and was totally dependent on staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The assessment indicated Resident #7 had a weight loss of more than five percent in the last month or 10 percent in the last six months. Review of the dietary note dated 03/23/22 and timed 12:15 P.M., revealed Resident #7 had sustained significant weight loss and was to be monitored per weekly weights for four weeks. Review of the plan of care dated 04/14/22 revealed Resident #7 had a risk for nutrition and hydration. Interventions included encouraging fluids at bedside and with activities, providing greater than 1,800 cubic centimeters (cc) of fluids per day, and weighing every month and/or as needed and notifying the physician of any significant changes. Review of the electronic weight record for Resident #7 revealed on 12/23/21 the resident weighed 193.6 pounds; on 01/01/22, the resident weighted 158 pounds; on 01/19/22 the resident weighed 155.4 pounds; on 02/02/22 the resident weighed 170 pounds; on 03/16/22 the resident weighed 147.8 pounds; on 03/30/22 the resident weighed 148.2 pounds; on 04/02/22 the resident weighed 145 pounds; and on 04/19/22 the resident weighed 142.6 pounds. Interview on 06/28/22 at 3:07 P.M., with Dietitian #587 verified Resident #7 sustained significant weight loss between 12/23/21 and 01/01/22, had continually fluctuating weights, and there was no evidence of an assessment being completed or interventions being implemented prior to 03/23/22. Dietitian #587 reported weekly weights were supposed to be monitored on a weekly basis for changes. Observation and interview on 06/28/22 at 8:36 A.M., revealed Resident #7 was eating breakfast in her room and had no beverages/fluids to drink with the breakfast meal. Resident #7 stated she hadn't received anything to drink with breakfast and would be happy with anything. Observation and interview on 06/28/22 at 8:39 A.M., with Certified Nursing Assistant (CNA) #573 verified Resident #7 did not receive anything to drink with breakfast. CNA #573 stated Resident #7 was likely in therapy so staff could not ask what she wanted to drink when they brought in her breakfast. Observation on 06/29/22 from 8:39 A.M. through 9:03 A.M., revealed Resident #7 was eating breakfast and did not have anything to drink with the breakfast meal. Interview on 06/29/22 at 9:03 A.M., with Resident #7 revealed Resident #7 was finished with breakfast and had not received anything to drink with her meal. Observation and interview on 06/29/22 at 9:04 A.M., with CNA #527 verified Resident #7 did not receive anything to drink with the breakfast meal. CNA #527 asked Resident #7 if she would still like something to drink and Resident #7 requested coffee and milk. Review of the policy titled Monthly and Weekly Weights, dated January 2019, revealed weekly weights would be conducted on residents that have experienced a significant weight loss or weight gain, and all significant weight losses and weight gains would be addressed as they appeared. Review of the policy titled Dehydration/Fluid Maintenance, dated January 2008, revealed the goal of the policy was to prevent dehydration and provide residents with sufficient fluid intake to maintain proper hydration and health. The policy stated once risk factors were identified a plan of care would be initiated to provide sufficient fluid, and plan for the amount of fluid provided at each meal, snack, and additional fluids provided. Based on observation, staff interview, record review, and policy review, the facility failed to obtain weights and address significant weight loss in a timely manner for two (#61 and #7) residents. The facility failed to consistently provide fluids with meals for one (#7) resident. This affected two (#61 and #7) of two residents reviewed for nutrition and hydration. The facility census was 60. Findings include: Record review for Resident #61 revealed an admission date of 05/01/21. Resident #61 had a hospital admission of 05/06/22 and returned on 05/11/22. Diagnoses included encephalopathy, acute kidney failure, lack of coordination, altered mental status, muscle weakness, cognitive communication deficit, and myocardial infarction. Record review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #61 was severely cognitively impaired. Resident #61 required extensive assistance with activities of daily living including eating. Resident #61 had no weight loss or gain. Resident received a mechanical altered diet. Review of the care plan dated 06/23/22 revealed resident was at nutritional /hydration risk. Interventions included to monitor meal intake. Record review of the weight history for Resident #61 revealed on 01/01/22, Resident #61 weighed 158.6 pounds. On 04/07/22, Resident #61 weighed 159.4 pounds. On 05/13/22, (first weight obtained upon return from the hospital on [DATE]) Resident #61 weighed 159.4 pounds. The next documented weight for Resident #61 was on 06/16/22 Resident #61 weighed 140.2 pounds, (loss of 19.2 pounds, 12.05% body weight in 34 days). Record review of the physician order dated 05/12/22 for Resident #61 revealed a diet order for pureed diet, thin liquids, and feeding assistance. Review of the medical records revealed no documentation was completed for Resident #61's meal intakes. Review of the progress note dated 06/23/22 at 11:42 A.M., completed by Dietitian #586, revealed the resident's current weight was 140.2 pounds, down 12% in the last 30 days. Recommend increasing med pass to three times a day. Interview on 06/28/22 at 4:08 P.M., with Dietitian #587 revealed Resident #61 should have had weekly weights obtained and monitored for interventions starting 05/11/22, when Resident #61 returned from the hospital. Dietitian #587 confirmed Resident #61 had a significant change in condition and a weight loss of 12% in 34 days. Dietitian #587 confirmed weekly weights were not monitored for weight loss during the 34 days, Resident #61 lost 12% of her body weight. Dietitian #587 confirmed weekly weights should have been completed for four weeks after readmission from the hospital. Interview on 06/29/22 at 9:56 A.M., with DON revealed all residents who are newly admitted or transferred and return from the hospital are required to have weekly weights completed every week for the first four weeks. DON also revealed resident meal intakes were to be monitored daily for each meal to determine consumption and notification to the physician of poor intake and weight loss of greater than three pounds in a week. DON confirmed Resident #61 meal intakes were not documented and weekly weights were not obtained for Resident #61 after returning from the hospital on [DATE]. DON confirmed Resident #61 had a loss of 19.2 pounds, 12.05% body weight in the 34 days when her weights were not obtained and her meal intake was not monitored. Review of the policy titled, Monthly and Weekly Weights dated January 2022, revealed weekly weights are conducted on residents that are newly admitted to the facility or are readmitted to the facility. Weekly weights are monitored for 30 days or more.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for Resident #7 revealed an admission date of [DATE]. Diagnoses included Alzheimer's disease, dementia, type II diabetes mellitus, muscle weakness, and hypertension. Review of the quarterly MDS assessment dated [DATE] revealed Resident #7 had a weight of 204 pounds. Review of the quarterly MDS assessment dated [DATE] revealed Resident #7 had a weight of 158 pounds. Weight loss of more than 5 percent in the last month or loss of 10% or more in last 6 months was marked No or unknown. Interview on [DATE] at 12:14 P.M., with MDS Nurse #540 verified Resident #7's weight loss of 22.5% was not accurately reflected on the MDS Assessment. Review of the policy titled Automated Data Processing Requirement, dated [DATE], revealed encoded MDS data accurately reflects the resident's status. Based on record review, staff interview, and policy review, the facility failed to accurately code the minimum data set (MDS) assessments to reflect the status of the resident. This affected three (#63, #55, and #7) of 28 residents records reviewed. for assessments. The total facility census was 60. Findings include: 1. Review of Resident #63's medical record revealed the resident was admitted to the facility on [DATE], with diagnoses including: metabolic encephalopathy, heart failure, anxiety, kidney failure, anemia, retention of urine, atrial fibrillation, hypomagnesemia, thrombocytopenia, tachypnea, obesity, pulmonary hypertension, hirsutism, and depression. Review of progress note dated [DATE] at 9:37 A.M., revealed the resident had an acute respiratory change and the facility called the physician and obtained orders to send the resident to the emergency room (ER). The staff called 911 and provided the resident an aerosol medication nebulizer treatment while waiting for the squad to arrive. Review of progress note dated [DATE] at 9:45 A.M., revealed the the squad arrived at 9:45 A.M. and the staff was still providing the resident the medication nebulizer treatment. The note documented the squad left the facility with the resident to the ER. Review of the progress note dated [DATE] at 12:42 P.M., revealed the ER called at 12:42 P.M. to say the resident had expired. Review of the MDS assessment dated [DATE], revealed the type of MDS was coded as death in the facility. Interview on [DATE] at 4:14 P.M., with the Director of Nursing (DON), confirmed the resident did not expire at the facility but was taken via squad alive to the emergency room and expired at the hospital. The DON verified the MDS was coded inaccurately as the resident did not expire in the facility but at the hospital. 2. Review of Resident #55's medical record revealed the resident was admitted to the facility on [DATE], with diagnoses including necrotizing fascitis, non pressure chronic ulcer of the buttock, sepsis, type two diabetes, cellulitis of buttock, acute embolism of lower extremity, anxiety and depression. Review of the [DATE] admission MDS and [DATE] 5-day assessment MDS revealed the resident is cognitively impaired, requires extensive assist for bed mobility transfers, dressing, toileting, hygiene and is independent in eating. The resident was coded for receiving seven days of insulin, injections, antipsychotic, antibiotic, and anti coagulant medications. Review of Resident #55's medication orders revealed the resident received the following medications daily, insulin (antidiabetic), Seroquel (antipsychotic), Xarelto (anticoagulant) and Paxil (antidepressant) in her care at the facility. Review of medical record revealed the resident had Paxil (anti depressant) 37.5 milligram extended release every 24 hours used in her care at the facility with an order date of [DATE]. Interview on [DATE] at 11:40 A.M., with the MDS Nurse #540, verified the Paxil was not coded on the MDS as being used when the resident in fact had received the medication on during the look back period.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review for Resident #19 revealed an admission date of 04/08/22. Diagnosis included retention of urine. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #19 had an indwelling catheter and was always incontinent of bowel. Record review of the Critical admission assessment dated [DATE] at 1:32 A.M., completed by Registered Nurse (RN) #529, revealed the resident was admitted with a 16 french indwelling catheter. Record review revealed Resident #19 had no care plan for the indwelling catheter. Observation on 06/13/22 at 10:16 A.M., of Resident #19 revealed Resident #19 had an indwelling urinary catheter. Interview on 06/27/22 at 5:00 P.M. , with MDS Nurse #540 confirmed she was responsible to complete residents comprehensive care plans. MDS Nurse #540 verified Resident #19 had no care plan for the indwelling catheter. 5. Record review for Resident #43 revealed an admission date of 12/09/21. Diagnosis included unstable burst fracture of fourth lumbar vertebra, subsequent encounter for fracture with routine healing, spinal stenosis, delirium due to known physiological condition, and muscle weakness, Review of the quarterly MDS assessment dated [DATE] revealed Resident #43 had moderately impaired cognition. Resident #43 was totally dependant for transfers, locomotion, dressing, personal hygiene, and bathing. Resident #43 used a wheel chair for locomotion. Observation on 06/13/22 at 11:25 A.M., revealed Resident #43 was sitting in the activity room, in a tilt and space chair, slightly declined with no foot pedals. Resident #43's feet were dangling in the air while sitting declined in the chair. Resident #43's scalp, forehead and bridge of her nose was covered with dry, flaking skin. The bridge of her nose was also red. Record review of the care plan for Resident #43 revealed there was no care plan developed for the use of the tilt and space chair nor was there a care plan for the care and treatment of Resident #43's dry flaking skin. Record review of the physician orders for June 2022 revealed Resident #43 did not have an order for the tilt and space chair and did not have an order for treatment to the dry flaking skin on Resident #43's scalp, forehead or bridge of her nose. Observation on 06/14/22 at 10:06 A.M., revealed Resident #43 was sitting in the activity room, in a tilt and space chair, slightly declined with no foot pedals. Resident #43's feet were dangling in the air while sitting declined in the chair. Resident #43's scalp, forehead and bridge of her nose was covered with dry, flaking skin. The bridge of her nose was also red. Interview on 06/14/22 at 10:11 A.M., with Activities Coordinator #558 confirmed Resident #43 was sitting in the activity room, in a tilt and space chair, slightly declined with no foot pedals. Resident #43's feet were dangling in the air while sitting declined in the chair. Resident #43's scalp, forehead and bridge of her nose was covered with dry, flaking skin. The bridge of her nose was also red. Activities Coordinator #558 revealed Resident #43 normally does not wear foot pedals. Interview on 06/14/22 at 10:12 A.M., with Certified Nursing Assistant (CNA) #539 revealed she washed Resident #43's face three to four times a day and puts a baby lotion or bath and body lotion on her face. Interview on 06/14/22 at 10:15 A.M., with Licensed Practical Nurse (LPN) #566 revealed the girls use over the counter lotions when they notice her skin dry and flaky. LPN #566 revealed she was not sure how long Resident #43 used the tilt and space chair for or how long she had dry flake skin for. Interview on 06/27/22 at 5:00 P.M., MDS Nurse #540 verified Resident #43 had no care plan for the tilt and space chair or treatment for the dry flaking skin. MDS Nurse #540 confirmed the care plans should have been completed for Resident #43. Interview on 06/27/22 at 11:01 A.M., with LPN #503 she was not sure how long Resident #43 has been in the chair or had dry flake skin to her face/forehead and scalp, but its been as long as she can remember. Interview on 06/27/22 at 11:13 A.M., with CNA #539 revealed she washed Resident #43's face and scalp with soap and water and put bath and body works lotion on her face and scalp. CNA #539 revealed a small bottle of bath and body coconut body lotion. CNA #539 confirmed this is what she used when caring for Resident #43, on her face and scalp for her dry fakery skin. CNA #539 revealed she was not sure how long Resident #43 had dry flake skin on her scalp, forehead and nose and revealed it was as long as she knew Resident #43. Interview on 06/27/22 at 2:39 P.M., with Rehab Director #590 revealed Resident #43 was receiving therapy in January 2022 Resident #43 was discharged from therapy in January 2022 and at that time Resident #43 was in a standard wheel chair. Rehab Director #590 revealed Resident #43 was picked back up in April 2022 for therapy and at that time she was in the tilt and space chair. Interview on 06/27/22 at 2:12 P.M., with LPN #503 revealed the staff normally tilt the chair back for Resident #43 when she was not eating. LPN #503 revealed she was not sure how far the chair should be tilted back. Interview on 06/27/22 at 2:30 P.M., with CNA #513 revealed she always tilted Resident #43's chair so she didn't slide. CNA #513 revealed one of the other CNA's told her Resident #43 was supposed to be tilted in the chair. CNA #513 confirmed she was not sure how far back she was to be tilted in the chair. Interview on 06/27/22 at 2:33 P.M., with CNA #518 stated she adjusted Resident #43's tilt and space chair according to the care plan. CNA #518 verified Resident #43 had no care plan for the tilt and space chair. CNA #518 then stated, Oh well, I just know when, I do it every two hours. Interview on 06/27/22 at 4:00 P.M., with the DON, confirmed Resident #43 did not have a care plan for the tilt and space chair or treatment to Resident #43 dry flaking skin. DON confirmed the care plans should have been completed for Resident #43. 6. Record review for Resident #61 revealed an admission date of 05/01/21. Resident #61 was admitted to the hospital on [DATE] and returned 05/11/22. Diagnoses included acute kidney failure, and altered mental status, unspecified. Record review of the scheduled five day MDS assessment completed 05/15/22 revealed Resident #61 had an indwelling catheter and was always incontinent of bowel. Record review of the Critical admission assessment dated [DATE] completed by LPN #503 revealed Resident #61 had a indwelling catheter draining yellow urine. Record review of the care plans for Resident #61 revealed Resident #61 did not have a care plan for an indwelling catheter. Review of the physician orders for Resident #61 revealed an order dated 06/03/22 to remove Resident #61's indwelling catheter and monitor for urine retention. Interview on 06/29/22 at 2:43 P.M., with DON confirmed resident had the indwelling catheter since she returned from the hospital on [DATE]. DON confirmed the catheter was discontinued 06/03/22. DON confirmed there was no physician order or care plan for the catheter. 7. Record review for Resident #2 revealed an admission date of 03/10/22. Diagnoses included blindness in one eye, low vision in the other. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #2 had severe cognitive impairment. Resident #2 have severely impaired vision. Resident was totally dependent for bed mobility, transfers, and toileting. Resident required limited assistance with meals. Record review of the care plan revealed Resident #2 had no care plan for assistance required for activities of daily living and no care plan for blindness in one eye and low vision in the other. Interview on 06/27/22 at 5:00 P.M., with MDS Nurse #540 confirmed Resident #2 had no care plan for activities of daily living or blindness in one eye and low vision in the other. Review of the policy titled Resident Assessment comprehensive Care Plan updated 11/28/17, revealed the facility must develop an implement a comprehensive person centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3) that includes measurable objectives and timeframe's to meet a resident's medical nursing and mental and psychosocial needs that are identified in the comprehensive assessment. Each resident will have a person -centered comprehensive care plan developed and implemented to meet his other preferences and goals and address the resident's medical, physical, mental and psychosocial needs. Based on observations, record reviews, resident interviews, staff interviews and policy review, the facility failed to develop comprehensive plan of care to meet the needs of the resident. This affected seven (#3 #24, #27, #2, #43, #61 and #19) of 28 resident records reviewed for care plans. The total facility census was 60. Findings include: 1. Review of of Resident #3's medical record revealed the resident was admitted to the facility on [DATE], with diagnosis of end stage renal disease. Review of 03/26/22, quarterly Minimum Data Set (MDS) assessment revealed the resident is cognitively intact. The resident is coded as receiving dialysis services. Review of Resident #3's care plans revealed there was no care plan in place for to address her dialysis treatment, use of central catheter for dialysis, or what the staff should monitor the resident for relating to her dialysis treatments. The care plans did include plans to address her skin ulcers, pain management, and nutrition and hydration needs. Interview on 06/28/22 at 11:03 A.M., with Resident #3, confirmed she has had dialysis treatment three times weekly since prior to her admission to the facility. Resident #3 stated she has a dialysis catheter for her treatment and her veins were not large enough for a arteriovenous shunt and she would need to have a cow artery transplant to have a shunt in her arm. Resident #3 stated she did not want a cow part in her body and had decided to have her treatment through the central dialysis catheter. Interview on 06/28/22 at 4:40 P.M., with the Director of Nursing, confirmed the resident has had dialysis services during her entire stay at the facility and there was no dialysis care plan present for the resident to reflect the resident goals and interventions related to her dialysis services. 2. Review of Resident #24's closed medical record revealed the resident was admitted to the facility on [DATE], with diagnosis of end stage renal disease. Review of the critical admission assessment dated [DATE] revealed the resident had a hemodialysis port in place at the time of admission. Review of the resident's assessments revealed there was a dialysis communication forms completed and part of the medical record starting on 01/11/22 and continuing until discharge. Review of the 06/14/22, return no anticipated MDS assessment revealed the resident was cognitively intact. The resident was coded as having dialysis services. Review of Resident #24's care plan revealed there was no care plan in place for to address her dialysis treatment, use of central catheter for dialysis, or what the staff should monitor the resident for relating to her dialysis treatments. Interview on 06/30/22 at 8:30 A.M., with Licensed Practical Nurse (LPN) #561 it was confirmed the resident had a dialysis catheter used for her dialysis treatment. Interview on 06/30/22 at 1:35 P.M., with the DON verified the resident care plan was not reflective of the resident as it did not have a dialysis care plan in place. 3. Review of Resident #27's medical record revealed the resident was admitted to the facility on [DATE], with diagnosis of schizophyta disorder. Review of the quarterly MDS assessment dated [DATE], revealed the resident has mild cognitive impairment, and no behaviors. The MDS coded the resident as receiving seven days of antipsychotic and antidepressant medications. Review of the resident Medication Administration Record (MAR) revealed the resident had orders for Ability (antipsychotic) 15 milligram (mg) daily by mouth, ordered on 01/14/22; Remeron (antidepressant) 30 mg daily at bedtime by mouth, ordered on 01/14/22; and Venlafaxine (antidepressant) extended release 24 hours ,150 mg daily ordered on 01/14/22. Review of resident care plans revealed there was no care plan in place related to the use of the psychotropic medications used in the care of the resident. Interview on 06/28/22 at 4:30 P.M., with the DON confirmed the resident care plans did not include a care plan for the use of psychotropic medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, staff interview, and policy review the facility failed to revise comprehensive care plans according to resident needs. This affected five (#3, #4, #7, #15, and #27) of 23 residents reviewed for comprehensive care plans. The facility census was 60. Findings include: 1. Review of the medical record for Resident #7 revealed an admission date of 03/27/17. Diagnoses included Alzheimer's disease, dementia, type II diabetes mellitus, muscle weakness, and hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 was cognitively impaired and was totally dependent on staff for bed mobility, transfers, dressing, toileting, and personal hygiene. The resident had minimal difficulty with hearing and was noted to have hearing aid(s). Review of the plan of care for Resident #7, dated 04/14/22, revealed the resident had hearing loss. Interventions included hearing aid as ordered, removing hearing aid at night and keeping in medication cart, and referral to audiology as needed. Review of the provider documentation dated 04/25/22 revealed Resident #7's hearing aids had been lost and the resident would begin trying new hearing aids once receiving necessary paperwork from the facility. Review of the missing item report dated 06/01/22 revealed Resident #7's hearing aids had been missing since before COVID. Review of Resident #7's comprehensive care plan revealed the plan was not updated to include addressing the resident's hearing loss while she was without hearing aids. Interview on 06/13/22 at 11:36 A.M., with Resident #7 revealed the resident's hearing aids were lost at the facility. Interview on 06/30/22 at 12:03 P.M., with the Assistant Director of Nursing (ADON) #504 verified Resident #7's care plan had not been revised to include alternative hearing needs once the resident's hearing aids were lost. 2. Review of of Resident #3 medical record revealed the resident was admitted to the facility on [DATE], with diagnoses including osteomyelitis, non pressure chronic ulcer of left heel and mid foot with fat layer exposed, obesity, bacterial infections of unspecified site, diabetes, cellulitis, end stage renal disease, edema, anxiety, depression, hyperlipidemia, peripheral vascular disease, osteoarthritis, obesity hypertension, post procedural anemia, and gout. Review of 03/26/22 quarterly Minimum data set revealed the resident is cognitively intact, had no behaviors, requires extensive assist with toileting, transfers, dressing, hygiene, bed mobility and is independent with eating. The resident is coded as receiving dialysis services. Review of the resident Medication and Treatment Administration Records revealed the resident had Doxycline Hyclate 100 milligrams (mg) twice daily for left foot wound dated 06/18/22 and Vancomycin 125 mg four times daily for clostridium difficle dated 06/07/22. Resident #3's current treatment to left foot wound of cleanse with normal saline pat dry apply prismal pad with 4x4 gauze and wrap with Kerlix and cover with stockinet dated 06/27/22. Interview on 06/28/22 at 8:20 A.M., with Resident #3 confirmed she admitted to the facility with her wounds. The resident stated at one time she had a wound vac in place to her left foot wound to assist with wound healing and stated the wound vac dressing was changed at the wound doctors office. The resident could not remember when the wound vac was discontinued but she stated the facility changes her dressings regularly and she has no complaints at the facility. Observation of a conversation between Resident #3 and the Wound Physician #1 on 06/28/22 at 11:04 A.M., revealed Wound Physician #1 stated to Resident #3 I know you like to lay on you back, and that in the past you have refused an air mattress, Resident #3 interrupted the physician and stated yes I am non compliant. Resident #3 continued to state I do not lay on my side and I do not want an air mattress. The physician asked if she would consider using pillows to assist in relieving pressure off her bottom to assist in healing the wound on her bottom and the resident stated she could try it. Observation of Registered Nurse #504 performing wound care on 06/28/22 in the afternoon revealed the dressing change was performed per standard and per the order. The wound was cleansed with normal saline, patted dry, prisma was applied covered with 4x4 and wrapped with a Kerlix. The resident tolerated the procedure with no complaints of pain or discomfort. Review of resident care plan revealed there was a care plan in place for wound vac to left foot. The care plan was additionally silent to the resident being non compliant with interventions related to skin care including trial of air mattress, and refusals of turning side to side, and the current antibiotics used in her care to treat acute illness related to her left foot wound and clostridium difficile. Review of medical record revealed the wound vac treatment for the resident left foot wound was discontinued on 04/12/22. Interview on 06/28/22 at 4:40 P.M., with the Director of Nursing confirmed the care plan was not updated to reflect the current treatment used for the resident's wound care to her left foot and still reflected the use of a wound vac that was discontinued on 04/12/22. The DON also confirmed the resident was not compliant with the use of an air mattress and with off loading by turning and the care plan did not reflect her non compliance with cares. Lastly the DON confirmed the care plan did not reflect the antibiotic treatment and acute conditions the resident was being treated for including Vancomycin for clostridium difficle which was initiated on 06/07/22 and continues to date, and the wound clinic initiating the use of antibiotics to treat the resident foot wound which was initiated on 06/18/22-06/28/22. 3. Review of Resident #4 medical record revealed the resident was admitted to the facility on [DATE], with diagnoses including: neuralgia, pneumonia, constipation, weakness, edema, anemia, heart failure, bipolar disorder, history of venous thrombosis, urine retention, neuralgia, and neuritis. Review of the most recent quarterly MDS dated [DATE] revealed the resident has mild cognitive impairment, has no behaviors, is always incontinent of bowel and bladder, requires extensive assist from staff for bed mobility, transfers, dressing, toileting, personal hygiene but is independent with eating. The resident is coded as receiving seven days of antibiotics during the look back period. Review of Resident #4 medication administration record revealed the resident had order for Macrodantin (Antibacterial) 50 mg daily by mouth for prophylaxis for urinary tract infection (UTI) ordered on 06/08/22. Review of resident progress notes revealed the progress note from 06/08/22 at 8:47 A.M., stated the physician gave orders for Macrodantin 50 mg daily at bedtime. Review of the care plan revealed the care plan was silent to the use of Macrodantin as prophylaxis for UTI. Interview on 06/28/22 at 8:34 A.M., with Resident #4, confirmed she had a history of frequent urinary tract infections. The resident verified she does not know when she must urinate and verified the staff cleanse her up using soap and water or cleansing wipes. The resident stated with her short-term memory loss she cannot tell exactly how long it takes the staff to provide care for her. Interview on 06/28/22 at 4:40 P.M., with the DON confirmed the resident care plan was not updated to reflect the antibacterial medication use to prevent UTI's for this resident. 4. Review Resident #15's medical record revealed the resident was admitted to the facility on [DATE] with diagnosis that include but are not limited to heart failure, dementia, hyponatremia and thyroid disorder. Review of the quarterly MDS dated [DATE] revealed the resident is cognitively impaired had no behaviors, is dependent on staff for transfers, requires extensive assist for bed mobility, dressing, toileting and personal hygiene and limited assistance for eating. The resident is coded as having a mechanically altered therapeutic diet an unstageable pressure ulcer with pressure relieving device to bed and chair. Review of resident medical record revealed the resident had orders for antibiotic Cephalexin 500 mg twice a day on 06/14/22-06/28/22 with indication of use UTI. Review of care plans revealed the care plan was silent for the resident receiving treatment for UTI with antibiotic. During an interview with the DON on 06/28/22 at 4:30 P.M. it was verified the resident's care plan was not up to date reflecting the antibiotic use the resident had for a UTI. 5. Review of Resident #24 medical record revealed the resident was admitted to the facility on [DATE], with diagnoses including cerebral infarction, end stage renal disease (ESRD), anemia, type two diabetes mellitus (DM), chronic kidney disease (CKD), chronic peptic ulcer, gastrointestinal hemorrhage, dysphagia, nausea, hypovolemia, gastroparesis, hyperkalemia, congestive heart failure (CHF) stenosis of vascular prosthetic device, paroxysmal atrial fibrillation, atrial ventricular block, left bundle branch block, vesicointestinal fistula, heart failure, encephalopathy, and bacteremia. Review of the discharge return not anticipated MDS dated [DATE] revealed the resident was cognitively intact, had no behaviors, was supervision for bed mobility, extensive assist with transfers, dressing, eating, toileting and personal hygiene. The resident is coded as always incontinent of bowel and bladder. Review of resident care plan revealed there was a care plan in place indicating resident is at nutritional hydration risk due to receives 100% of nutrition and hydration via tube due to nothing per oral (mouth) status cerebral infarct, ESRD, DM, CKD, peptic ulcer, electrolyte fluid imbalance hyperkalemia, CHF, ecoli bacteremia hypovolemia, necrotic third toe and right arm altered labs triggers for malnutrition, dated 01/25/22 initiated. The care plan was updated 02/22/22 to record changing to nocturnal tube feed Nepro at 55 milliliters/ hour (ml/hr) 6:00 P.M.-4:00 A.M., recommend discontinuing evening water flush continue day time water flush at 350 ml per percutaneous endoscopic gastrostomy (PEG) tube. Review of progress note dated 05/04/22 revealed new order to discontinue nocturnal tube feed, discontinue 350 ml flush, oral Nepro twice daily, 60 ml flush per peg to transition out of tube feed and into per oral (by mouth) diet exclusively. The resident and family are aware. Interview on 06/30/22 at 8:30 A.M., with Licensed Practical Nurse #561, confirmed the resident was not using the feeding tube for nutrition or medication, but had transitioned to taking medication by mouth and was eating a regular diet. Interview on 06/30/22 at 11:35 A.M., with the DON, verified the resident care plan was not updated when the resident transitioned from tube feeding to oral feeding on 05/04/22. Review of the policy titled Resident Assessment comprehensive Care Plan updated 11/28/17 revealed the facility must develop an implement a comprehensive person centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3) that includes measurable objectives and timeframe's to meet a resident's medical nursing and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must: Include areas assessed that indicate the resident is at risk, their strengths, or identify weakness per the MDS or the CAA's. Identify the care or services being declined, the risk the declination poses to the resident,and efforts by the interdisciplinary team to educate the resident and the representative as appropriate. Reflect changes in the residents preferences and goals as they change throughout their stay. The comprehensive care plan will be initially developed in Matrix, printed and kept either in the Resident's chart or a are Plan notebook at the nurse's station available to all staff, care givers, residents, resident representatives, physicians and physicians extenders as well as surveyors. Updates will be made to this printed comprehensive care plan as needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of hospital records, resident interview, staff interview, observation, and review of facility policy, the facility failed to assess Resident #62 for a change in condition. The facility also failed to assess and obtain physician orders for dry skin condition for Resident #43. This affected two (#62, and #43) of 23 residents reviewed for quality of care. The facility census was 60. Findings include: 1. Review of Resident #62's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included congestive heart failure, acute kidney failure, hypocalcemia, weakness, chronic kidney disease, sepsis, type II diabetes mellitus, hyperkalemia, and hyperlipidemia. Resident #62 was admitted to the hospital on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/23/22, revealed the resident had impaired cognition. The resident required the extensive assistance of one staff member for bed mobility, dressing, transfers, and personal hygiene. Review of the nursing notes dated 05/06/22 and timed 5:17 A.M., revealed a State Tested Nurse Aide (STNA) alerted Licensed Practical Nurse (LPN) #531 to Resident #62's room. The resident was noted to be a bit grey in color and had emesis of slight dark color and mucous consistency. The physician was notified. Review of the nursing notes dated 05/06/22 and timed 6:37 A.M., revealed the physician ordered stat labs and to start hypodermoclysis (fluids) of 0.45 sodium chloride running at 60 milliliters (ml). The Assistant Director of Nursing (ADON) started the fluids, family was updated, and the laboratory was contacted for stat labs. Review of the nursing notes dated 05/06/22 and timed 9:33 A.M., revealed the physician received and read the labs and advised to send Resident #62 to the emergency room. Review of the nursing notes dated 05/06/22 and timed 11:00 A.M., revealed emergency medical services (EMS) were contacted and transporting Resident #62 to the local emergency room. Review of the nursing notes dated 05/06/22 and timed 11:58 P.M., revealed Resident #62 was admitted to the intensive care unit (ICU) due to sepsis, urinary tract infection (UTI), hydronephrosis, and pneumonia. Review of the hospital documentation dated 05/06/22 and timed 11:35 A.M., revealed Resident #62's blood pressure was 85/62. Review of the hospital documentation dated 05/06/22 and timed 1:31 P.M., revealed Resident #62 was brought to the emergency room due to worsening confusion and low blood pressure. The resident was nonverbal and hypotensive. Review of Resident #62's medical record revealed the resident's vital signs including blood pressure were taken by a nurse in the facility on 05/02/22 at 9:07 A.M. There were no further blood pressures documented and there were no vital signs or assessments documented on 05/06/22. Interview on 06/27/22 at 3:45 P.M., with LPN #531 verified there were no vital signs or an assessment documented for Resident #62 on 05/06/22. LPN #531 reported she worked the night of 05/05/22 to 05/06/22 and the Assistant Director of Nursing (ADON) took over caring for Resident #62 on 05/06/22 at approximately 6:30 A.M. Interview on 06/27/22 at 3:48 P.M., with the Assistant Director of Nursing (ADON) revealed upon arrival to Resident #62's room on the morning of 05/06/22, Resident #62 looked like he didn't feel good and was pale pink in color. The ADON verified there was no assessment completed or any vital signs documented for Resident #62 on 05/06/22. Review of the policy titled Standards of Nursing Practices, revised May 2018, revealed residents having any change in condition would have a complete nursing assessment performed and documented which may include but is not limited to vital signs, bowel sounds, lung sounds, pulse ox, skin appearance, and mental status. 2. Record review for Resident #43 revealed an admission date of 12/09/21. Diagnoses included unstable burst fracture of fourth lumbar vertebra, subsequent encounter for fracture with routine healing, spinal stenosis, lumbar region with neurogenic claudication, delirium due to known physiological condition, muscle weakness, lack of coordination, and fusion of the spine, lumbar region. Review of the quarterly MDS dated [DATE] revealed Resident #43 had moderately impaired cognition. Resident #43 was totally dependant for transfers, locomotion, dressing, personal hygiene, and bathing. Observation on 06/13/22 at 11:25 A.M., revealed Resident #43 was sitting in the activity room, in a tilt and space chair. Resident #43's scalp, forehead and bridge of her nose was covered with dry, flaking skin. The bridge of her nose was also red. Record review of the care plan for Resident #43 revealed there was no care plan developed for dry flaking skin. Record review of the physician orders for June 2022 revealed Resident #43 did not have an order for treatment to the dry flaking skin on Resident #43's scalp, forehead or bridge of her nose. Observation on 06/14/22 at 10:06 A.M., revealed Resident #43 was sitting in the activity room, in a tilt and space chair. Resident #43's scalp, forehead and bridge of her nose was covered with dry, flaking skin. The bridge of her nose was also red. Interview on 06/14/22 at 10:12 A.M., with Certified Nursing Assistant (CNA) #539 revealed she washed Resident #43's face three to four times a day and put baby lotion or bath and body lotion on her face. Interview on 06/14/22 at 10:15 A.M., with Licensed Practical Nurse (LPN) #566 confirmed there were no physician orders to treat and care for Resident #43's dry flaking skin to her scalp, forehead and bridge of her nose. LPN #566 revealed the girls use over the counter lotions when they notice her skin dry and flaky. LPN #566 revealed she was not sure how long Resident #43 had dry flake skin for. Interview on 06/27/22 at 5:00 P.M., MDS Nurse #540 verified Resident #43 had no care plan for the treatment for the dry flaking skin. Observation on 06/27/22 at 10:52 A.M., revealed Resident #43 was sitting up in her chair in the activity room. Resident #43's scalp, forehead and bridge of her nose was covered with dry, flaking skin. The bridge of her nose was also red. Resident #43 did not answer when asked if her skin on her face or head was uncomfortable. Interview on 06/27/22 at 11:01 A.M., with LPN #503 verified Resident #43 had dry flake skin to face/forehead and scalp. LPN #503 verified there were no orders for the treatment to the dry skin on the scalp, forehead or nose. LPN #503 revealed she would let someone know. LPN #503 revealed she was not sure how long Resident #43 had dry flake skin to her face/forehead and scalp, but its been as long as she can remember. Interview on 06/27/22 at 11:13 A.M., with CNA #539 revealed she washed Resident #43's face and scalp with soap and water and put bath and body works lotion on her face and scalp. CNA #539 revealed a small bottle of bath and body coconut body lotion. CNA #539 confirmed this is what she used when caring for Resident #43, on her face and scalp for her dry fakery skin. CNA #539 revealed she was not sure how long Resident #43 had dry flake skin on her scalp, forehead and nose and revealed it was as long as she knew Resident #43. Interview on 06/27/22 at 4:00 P.M., with DON confirmed there was no documentation or assessments regarding the dry flaking skin on Resident #43's scalp, forehead or nose. DON confirmed the physician should have been notified of the skin condition and treatments implemented with a plan of care. Review of the facility policy titled Standards of Nursing Practices, revised May 2018, revealed residents having any change in condition would have a complete nursing assessment performed and documented which may include but is not limited to vital signs, bowel sounds, lung sounds, pulse ox, skin appearance, and mental status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, record review and review of the policy, the facility failed to safely store four (#66, #39, #47, and #32) residents medications. this had the potential to affect eight (#51, #23, #10, #45, #40, #31, #34, and #12) residents identified by the facility as being independently mobile and cognitively impairment. The facility census was 60 Findings include: 1. Observation on 06/13/22 at 8:45 A.M., revealed Resident #66 had two medication cups with medications inside and a cup full of water sitting on her bedside stand. Regional Registered Nurse #588 confirmed there were two medication cups of unidentified medications sitting on Resident #66's bedside stand and no nurse was in the area. Record review for Resident #66 revealed an admission date of 06/07/22. Diagnosis included unspecified fracture of the shaft of the left tibia subsequent encounter of closed fracture and post polio syndrome. Record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 was cognitively intact. Resident required extensive assistance with bed mobility and transfers. Record review of the Medication Administration Record (MAR) for Resident #66 revealed on 06/13/22 morning, medications administered to Resident #66, by Licensed Practical Nurse (LPN) #531, included: metoprolol 50 milligrams (mg) one tablet, ovuvite adult 50 plus 250-5-1 one capsule, pentoxifylline 400 mg one tab, polysaccharide iron complex 150 mg one tab, potassium chloride 20 milliequivalent (meq) one tablet, and vancomycin 125 mg one tablet. Interview on 06/13/22 at 8:56 A.M., with LPN #531 confirmed she left Resident #66's morning medications at her bedside. 2. Observation on 06/13/22 at 8:48 A.M., revealed Resident #39 had an unidentified pill sitting on her bedside stand. Resident #39 stated it was a water pill and that she had taken all the other medications. The Administrator observed and confirmed the medication was left on Resident #39's bedside stand at this time. Record review for Resident #39 revealed an admission date of 04/22/22. Diagnoses included lymphedema, open wound to the left lower leg, and cognitive communication deficit. Record review of the MDS assessment dated [DATE] revealed Resident #39 was cognitively intact. Resident #39 required extensive assistance with bed mobility and transfers. Record review of the MAR for Resident #39 revealed on 06/13/22 morning medications administered to Resident #39 by LPN #531 included medication lasix 40 mg one tablet. Interview on 06/13/22 at 8:56 A.M., with LPN #531 confirmed she left Resident #39's morning medications at her bedside. 3. Observation on 06/13/22 at 8:51 A.M., revealed the Administrator removed nasal spray and an inhaler from Resident #47's room. Administrator confirmed she was removing the nasal spray and inhaler from Resident #47's room due to the medications were unsecured. Record review revealed Resident #47 had an admission date of 12/22/20. Diagnoses included acute respiratory disease, lack of coordination, asthma, arthritis, dysphagia and weakness. Record review of the MDS assessment dated [DATE] revealed Resident #47 was cognitively intact. Resident #47 required assistance with activities of daily living. Record review of the MAR for Resident #47 revealed on 06/13/22 morning medications administered to Resident #47 by LPN #531 included breo ellipta 100-25 mcg one inhalation and fluticasone spray 50 mcg one spray in each nostril. Interview on 06/13/22 at 8:56 A.M., with LPN #531 confirmed she left Resident #47's morning medications at her bedside. 4. Observation on 06/13/22 at 9:09 A.M., revealed Resident #32 had a medication cup with unidentified medications inside sitting on her bedside table. Resident #32 stated, They do this every day, I'll take them later. Record review of the medical record for Resident #32 revealed an admission date of 04/18/22. Diagnosis included encounter of orthopedic aftercare following surgical amputation, acute osteomyelitis, weakness and lack of coordination. Record review of the MDS assessment dated [DATE] revealed Resident #32 was cognitively intact. Resident required extensive assistance for bed mobility. Record review of the MAR for Resident #32 revealed on 06/13/22 morning medications administered to Resident #32 by LPN #503, included: amiodarone 100 mg one tab, amlodapine five mg one tab, aspirin 81 mg one tab, cyanocobalamin 2,500 micrograms (mcg) one tab, eliquis five mg one tab, ferrous sulfate 325 mg one tab, ocuvite adult 50 plus 250-5-1 one capsule, potassium chloride 20 meq one tab, and vitamin D-3 50 mcg one tab. Interview on 06/13/22 at 9:34 A.M., with LPN #503 confirmed she left Resident #32'S medications at her bedside. Interview on 06/30/22 at 8:04 A.M., with Director of Nursing (DON) confirmed there were no residents residing in the facility that were to self administer their own medications and medications were to be kept secure until the nurse administered the medications to the residents. DON confirmed medications were never to be left unsecured with any resident. DON confirmed Resident #51, #23, #10, #45, #40, #31, #34, and #12 was identified as independently mobile and cognitively impairment. Review of the policy titled,General Dose Preparation and Medication Administration dated 12/01/07 revealed facility staff should not leave medications unattended. The facility was to identify the resident and observe the residents consumption of the medications.

Based on observation, record review, resident interview, staff interview, and policy review, the facility failed to ensure the menu was followed and proper portion sizes were served to residents. This had the potential to affect 60 of 60 residents residing in the facility. The facility census was 60. Findings include: Observation of tray line on 06/13/22 at 12:00 P.M., revealed Dietary [NAME] #558 served chili mac with one number (#) 8 scoop instead of one #5 scoop, served pureed green beans with one #12 scoop instead of one #16 scoop, and served pureed cornbread with one #20 scoop instead of one #10 scoop. Review of the lunch meal spreadsheet for 06/13/22 revealed that chili mac should be served using one #5 scoop, pureed green beans should be served using one #16 scoop, and pureed cornbread should be served using one #10 scoop. Interview on 06/13/22 at 12:30 P.M., with Dietary Cook, #558 verified at the time of observation that incorrect portion sizes were served to residents. Dietary [NAME] #558 verified she did not check the spreadsheet to see what scoop sizes were necessary. Interview on 06/13/22 at 12:39 P.M., with Dietary Manager #532 stated staff should know to empty out a little or use a scoop and a half to ensure proper portion sizes. Dietary Manager #532 reported the facility did not have all the scoop sizes available. Observation on 06/14/22 at 8:46 A.M., of the breakfast meal revealed residents received French toast sticks, cold cereal, and a banana for breakfast. Review of the menu for 06/14/22 revealed residents should have also received turkey links. Interview on 06/14/22 at 9:01 A.M. with Dietary [NAME] #536 verified residents did not receive turkey links and no substitute was made. Interview on 06/14/22 at 9:04 A.M., with Dietary Manager #532 revealed the facility had been having difficulty getting turkey links and the turkey links should have been replaced with regular sausage links which the facility had in stock. Observation of tray line on 06/27/22 at 12:18 P.M., revealed mashed potatoes were served with one #12 scoop instead of one #8 scoop, shredded pork was served with one #12 scoop instead of one #8 scoop, vegetables were served using one #8 scoop instead of one four-ounce spoodle, pureed pork was served using one #12 scoop instead of one #8 scoop, and residents did not receive a choice of roll as indicated on the menu. Review of the lunch meal spreadsheet for 06/27/22 revealed that mashed potatoes should be served using one #8 scoop, shredded pork should be served using one #8 scoop, vegetables should be served using one four-ounce spoodle, pureed pork should be served using one #8 scoop, residents should receive one choice of roll, and residents receiving pureed diets should receive two-thirds slice pureed bread. Interview on 06/27/22 at 12:34 P.M., with Dietary Manager #532 verified improper serving sizes as indicated in the aforementioned findings were used for the lunch meal. Dietary Manager #532 also verified there was no replacement made for the rolls or the pureed bread. Dietary Manager #532 reported the facility had difficulty getting rolls in and stated the dietary cook normally made replacements and must not have seen the roll on the menu to replace it. When asked if substitutions had to be preapproved, Dietary Manager #532 then stated she was actually the one who made replacements and that the dietary cook was supposed to give all residents a slice of bread in place of the roll. Dietary Manager #532 then furnished documentation which showed biscuits were ordered to replace the rolls. Observation on 06/27/22 at 1:08 P.M., of Dietary Manager #532 and Dietitian #587 revealed the staff members were seen quickly exiting a resident's room while laughing and carrying a container of what appeared to be rolls. During the resident council portion of the annual survey conducted on 06/27/22 at 1:44 P.M., with Resident #9, #15, #17, #26, #27, #28, #34, #40, and #47, revealed one resident reported receiving half of a hotdog bun as a snack prior to the resident council meeting. Numerous other residents reported they did not receive half of a hotdog bun or any other type of bread or snack. Review of the policy titled Portion Control, revised April 2021, revealed portion control would be achieved through adherence to the therapeutic menus and standardized recipes, and use of standardized serving utensils. The policy stated portions would be served according to the serving sizes listed on the therapeutic menus and portion control equipment would be used to assure appropriate portions.

Based on observation, resident interviews, and staff interviews, the facility failed to serve attractive foods at appropriate temperatures. This affected nine (Resident #9, #15, #17, #26, #27, #28, #34, #40, and #47) residents and had the potential to affect all 60 residents residing in the facility. The facility census was 60. Findings include: Interview on 06/07/22 at 1:44 P.M., during the resident meeting portion of the annual survey, with Residents #9, #15, #17, #26, #27, #28, #34, #40, and #47, revealed several concerns being mentioned regarding the lack of flavor and temperature of food and beverages served to residents. Observation on 06/13/22 at 12:40 P.M., of the lunch meal revealed residents were served a chili mac that appeared mushy and watery, and noodles were broken down into small pieces. Interview on 06/13/22 at 12:45 P.M., with Dietary [NAME] #569 revealed the staff member used egg noodles because there was no elbow macaroni available as indicated by the recipe. Observation and interview on 06/13/22 at 12:46 P.M., with Dietary Manager #532 verified the chili mac looked mushy and did not look appetizing. Dietary Manager #532 reported she always ordered enough supplies for the following week's menu but that dietary cooks went off the grid and changed the menu so the elbow macaroni was likely used for something else. Observation on 06/27/22 at 12:32 P.M., of a facility test tray, with Dietary Manager #532 revealed the milk being served to residents was 51 degrees Fahrenheit, and nectar-thick milk being served to residents was 59.7 degrees. Dietary Manager #532 verified the milk was way too warm.

Based on observation, staff interview and policy review, the facility failed to ensure food items were stored properly with a labeled and dated to prevent food borne illness. This had the potential to affect 60 of 60 residents residing in the facility. The facility census was 60. Findings include: Observation on 06/13/22 at 7:58 A.M., during an initial kitchen tour revealed the freezer contained one bag of undated and unlabeled breadsticks, one clear plastic package of undated and unlabeled egg patties, one clear plastic bag of undated and unlabeled cookie dough, and one clear plastic package of undated and unlabeled chicken breasts. Interview on 06/13/22 at 8:12 A.M., with Dietary [NAME] #569 verified the undated and unlabeled items found during the tour. Review of the facility policy titled Storage Procedures, revised April 2021, revealed food items in the freezer were to be labeled and dated.

Based on observation and staff interview, the facility failed to ensure medical records were available to nursing staff to administer medications and treatments to residents residing in the facility. This affected all 60 residents. The facility census was 60. Findings include: Observation on 06/14/22 at 7:06 A.M., revealed the facility's electric power failed. The facility's generator was functioning. Observation on 06/14/22 at 7:40 A.M., with Registered Nurse (RN) #530 revealed the facility used an Electronical Medication Administration Record (EMAR) to verify and prepare residents medications for administration. RN #530 was unable to log into the EMAR system. Interview on 06/14/22 between 7:41 A.M. and 8:05 A.M., with RN #530, Licensed Practical Nurse (LPN) #531 and #566, verified they were unable to administer medications for their residents due to the internet was down related to the power failure. RN #530, LPN #531 and #566 verified they had no paper MAR's, Treatment Administration Record (TAR) or physician monthly order reconciliation records in residents files to verify residents orders to administer medications or treatments to the residents. Interview on 06/14/22 at 8:10 A.M., with the Director of Nursing (DON) verified there were no resident records available for any residents in the facility for nurses to use for residents medication or treatment administration. DON revealed the facility had an emergency back up system for residents medication and treatment administration records, that would be used in case of a power outage. DON revealed the emergency back up system would allow the facility to print residents medication and treatment administration records in case of a power outage to allow nurses to administer the medications and treatments for residents using paper medication and treatment administration records. DON revealed the emergency back up system was not functioning. DON confirmed she never reviewed or ran the emergency back up system before and confirmed she did not know how to use it. DON revealed the monthly physician orders or residents face sheets were not kept in residents hard charts, they were all kept electronically. DON confirmed if a resident had a medical emergency and needed sent to the hospital, the facility would have no medical records, including diagnosis, medications, and treatments to send with the resident. DON confirmed residents were unable to receive any medications or treatments. Observation on 06/14/22 at 8:20 A.M., revealed Regional Nurse #589 was attempting to receive instructions on the phone to run the emergency back up system for the EMARS and ETARS. Regional Nurse #589 revealed the back up system was not connected to a red outlet which was ran by the generator. Interview on 06/14/22 between 9:56 A.M. and 10:00 A.M., with RN #530, LPN #531 and #566 verified they continued to be unable to pass medications or administer treatments to residents due to power failure. Interview on 06/14/22 at 11:15 A.M., with DON confirmed the facility continued to have an electrical failure, the generator was no longer working and residents would be evacuated to sister facilities from the facility. DON confirmed the emergency back up system did not work and the facility had not been able to administer medications or complete treatments for residents. DON confirmed this affected all residents residing at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical record, staff interview, and review of facility policy, the facility failed to to provide a transfer/discharge letter with appeal rights when residents were transferred/discharged from the facility. This affected one residents (#44) of three residents who were transferred/discharged from the facility. The facility also failed to notify the Ombudsman of a transfer/discharge from the facility. This affected one resident (#44) of three residents who were transferred/discharged from the facility. The facility census was 65. Findings include Review of Resident #44's medical record revealed the resident was initially admitted to the facility on [DATE], discharged with return anticipated on 03/25/19, readmitted on [DATE], discharged with return anticipated on 05/10/19 and readmitted on [DATE]. Diagnoses included acquired absence of left hip joint, right above the knee amputation, peripheral vascular disease, embolism and thrombosis of iliac artery, and type one diabetes. Review of comprehensive assessment dated [DATE] revealed the resident was cognitively intact. Resident #44 was independent to requiring limited assistance for activities of daily living. Review of Progress Notes on 03/24/19 revealed Resident #44 the resident was transferred to the hospital on [DATE] and returned on 04/06/19. Upon transfer/discharge from the facility the resident was only provided a bed hold notice. The facility did not provide a transfer/discharge letter with appeal rights to Resident #44 nor notify the Ombudsman of the transfer/discharge from the facility. Review of Progress Notes revealed Resident #44 was sent out to the hospital on [DATE] and was readmitted to the facility on [DATE]. The facility provided a bed hold notice and notified the Ombudsman of the resident's transfer/discharge from the facility. The facility did not provide a transfer/discharge letter with appeal rights to Resident #44. Interview on 06/18/19 at 05:34 P.M. with the Director of Nursing (DON) and Social Service Director (SSD) #72 verified the facility did not provide a transfer/discharge notice with appeal rights to the resident and/or representative when the resident was transferred to the hospital on [DATE] and 05/10/19. The DON and SSD also verified the Ombudsman was not notified when Resident #44 was transferred/discharged from the facility on 03/10/19. Review of facility policy titled Resident Transfers and Discharge Notification date 04/2018 revealed for a facility initiated transfer or discharge the facility must notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice of transfer or discharge to the representative of the Office of the State Long-Term Care Ombudsman.