**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, it was determined that the facility failed to provide restorative nursing services to increase or prevent a reduction in range of motion (ROM) for one of two sampled residents with limitations in ROM. (Resident 25) Findings include: Clinical record review revealed that Resident 25 had diagnoses that included left femur fracture, protein calorie malnutrition, muscle weakness, and dementia. Review of the Minimum Data Set assessment dated [DATE], revealed that Resident 25 had a limitation in range of motion to both sides of her lower extremities (hip, knee, ankle, foot). Record review of a physical therapy Discharge summary dated [DATE], revealed recommendations for a restorative nursing program (RNP) that included passive ROM and transfers to maintain current level of performance and prevent decline. There was no documented evidence that a RNP was implemented per the therapy discharge recommendations. In an interview on November 4, 2021, at 11:58 a.m., the Director of Nursing confirmed a RNP was not implemented for Resident 25 per the therapy discharge recommendations. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the dietary manual, clinical record review, observation, and staff interview, it was determined that the facility failed to provide food prepared in a form designed to meet individual needs for three of ten sampled residents who were on a mechanically altered diet. (Residents 5, 31, 60) Findings include: Review of the facility diet manual for modified menus, dated September 3, 2021, revealed that hot dogs should be in chopped form when served to residents ordered a mechanically altered diet that included chopped meats and that beef roast should be in chopped form when served to residents ordered a mechanically altered diet that included chopped meats. Clinical record review revealed that Resident 31 had diagnoses that included dysphagia (difficulty eating or swallowing). On June 1, 2020, the physician ordered for the resident to have a mechanically altered diet that included ground meats. The Minimum Data Set (MDS) assessment dated [DATE], indicated that the resident had some memory impairment, required supervision for eating, and that he received a mechanically altered diet. On November 2, 2021, during a lunch meal observation at 12:05 p.m., Resident 31 was sitting at a table in the dining room and he was observed being served and eating a hamburger. The hamburger was served as a patty, not chopped into small pieces or ground. In an interview on November 3, 2021, at 12:19 p.m., Dietary Aide 1 (DA 1) confirmed that Resident 31 was served a hamburger as a patty during the lunch meal on November 2, 2021. In a subsequent interview on November 4, 2021, at 9:39 a.m., the Director of Nursing (DON) confirmed that hamburger meat served to residents on a ground meat diet should be served in ground texture. Clinical record review revealed that Resident 60 had diagnoses that included hemiplegia, history of a stroke, slurred speech and aphasia (difficulty speaking). On August 6, 2020, a physician ordered for the resident to have a mechanically altered diet that included chopped meats. The MDS assessment dated [DATE], indicated that the resident had some memory impairment, required supervision for eating and that she received a mechanically altered diet. Review of a nutritional assessment dated [DATE], revealed that the resident chose to eat in her room and that she received a mechanically altered diet that included chopped meats. Observation on November 2, 2021, at 12:15 p.m., revealed that the resident was seated in her wheelchair in her room in front of her bedside table. Staff had served her lunch which included a whole hot dog on a bun. The hot dog was not chopped. The resident then ate the hot dog. In an interview on November 4, 2021, at 9:44 a.m., the DON stated that the resident was to receive chopped meats as ordered by the physician. Clinical record review revealed that Resident 5 had diagnoses that included dysphagia. On November 2, 2020, the physician ordered for the resident to have a mechanically altered diet that included chopped meats. The MDS assessment dated [DATE], indicated that the resident had some memory impairment, required supervision for eating, and that she received a mechanically altered diet. On November 3, 2021, during a lunch meal observation at 12:03 p.m., Resident 5 was observed sitting at a table in the dining room, she was observed being served and eating beef roast. The beef roast was not chopped. In an interview during this observation period, DA 1 confirmed Resident 5 should have received chopped beef roast, she was not served beef roast in the correct form.

Based on review of facility policy and observation, it was determined that the facility failed to store food under sanitary conditions on one of three nursing units. (Ivy Lane) Findings include: Review of the facility policy titled, Use and Storage of Resident Obtained Foods-HC, dated June 25, 2021, revealed that when a resident chose to consume food at the facility that was not obtained by the facility, safe and sanitary use, storage, and handling shall be maintained as follows: foods requiring refrigeration would be labeled with the residents name, dated, and placed in a designated refrigerator or freezer. Unconsumed foods would be disposed of as follows or upon evidence of spoilage: leftover food discarded after three days. Frozen items would be discarded after 30 days. The dietary department would monitor this. Observation of the nourishment refrigerator on the Ivy Lane nursing unit on November 4, 2021, at 9:58 a.m., revealed a container of lemon flavored yogurt product with a facility label that was dated September 12, 2021, and a manufacturer expiration date of October 5, 2021, a container of blueberry yogurt product with a manufacturer expiration date of September 22, 2021. There was a container of a food product with a date of October 28, 2021, a container of a food product that was dated October 24, 2021, a Whole Foods grocery store bag with a date of October 30, 2021, a bottle of a red Powerade drink that was not labeled with a resident name or dated. Observation of the freezer revealed a container of salted caramel lactaid ice cream product with a date of September 22, 2021, and a Rita's container of an orange frozen product that was not labeled or dated. CFR 483.60 Food Procurement Store/Prepare/Serve-Sanitary Previously cited 11/25/2020 28 Pa. Code 201.18(b)(3) Management.