Based on record review and staff interview, it has been determined that the facility failed to ensure that each resident receives necessary respiratory care and services in accordance with professional standards of practice relative to a continuous positive airway pressure device (CPAP-a type of ventilator that assists with breathing and provides continuous positive airway pressure) for 1 of 1 resident reviewed for respiratory care, Resident ID #23. Findings are as follows: According to Mosby's 4th Edition, Fundamentals of Nursing, page 314 states in part, .The physician is responsible for directing medical treatment. Nurses are obligated to follow physician's orders unless they believe the orders are in error or would harm the clients . Record review revealed Resident ID #23 was admitted to the facility in August of 2023 with diagnoses including, but not limited to, Chronic Obstructive Pulmonary Disease (COPD- a lung disease that restricts your breathing), acute bronchitis (inflammation of the airways leading to your lungs that causes coughing and mucus), and interstitial pulmonary disease (a lung condition that causes scarring of the lung.) Review of a care plan dated 5/16/2024, revealed that the resident requires supplemental oxygen related to his/her diagnoses of COPD, with an intervention including, but not limited to, CPAP at night with home settings. Record review revealed the following physician's orders with a start date of 10/21/2024: -CPAP attached to continual oxygen at bedtime -Clean CPAP machine and tubing daily Record review of the April of 2025 Medication Administration Record (MAR) revealed the following CPAP documentation: -4/27/2025- administered -4/28/2025- not administered broken Record review revealed a progress note dated 4/27/2025 which states in part, Cpap not working .Resident will use oxygen only tonight . Further record review failed to reveal evidence that the provider was notified that the CPAP machine was not working and was unable to be provided to the resident as ordered, although it was signed off as completed on the MAR for 4/27/2025. During a surveyor interview on 5/1/2025 at 11:57 AM with the Director of Nursing Services, she was unable to provide evidence that the CPAP was administered as ordered on 4/27/2025 and 4/28/2025. Additionally, she was unable to provide evidence that the physician was notified.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to prepare food and drink in a form designed to meet individual needs for 1 of 1 resident observed that had a physician's order for a ground diet, Resident ID #263. Findings are as follows: Record review revealed the resident was admitted to the facility in April of 2025 with diagnoses including, but not limited to, dysphagia (difficulty swallowing), and anxiety disorder. Record review of a physician order for April 2025 revealed a diet order for a ground diet. Record review of the facility's diet manual, states in part: .Ground consistency to safely provide adequate nutrition and to facilitate eating for individuals with impaired swallowing or chewing .Menu guidelines to include, but are not limited to, fruits and vegetables that are easy to chew i.e. [example] fork mashable .Food groups of vegetables listed vegetables that are to be soft, cooked-fork mashable and or finely ground raw vegetables or vegetables salads . Record review of the facility menu for 4/30/2025 revealed, residents that are on ground diets were to receive a ground turkey and cheddar sandwich with roasted zucchini. During a surveyor observation on 4/30/2025 at 12:31 PM, the resident was served ground chicken salad with shredded lettuce and two slices of fresh tomato. During a surveyor interview with the resident immediately following the above observation, s/he revealed s/he was unable to swallow the lettuce and tomato. During a surveyor interview on 4/30/2025 at 3:15 PM, with the Assistant Director of Food Service, he acknowledged the resident was not served the menu as written for a ground diet.

Based on record review and staff interview, it has been determined that the facility failed to ensure that hospice services meet professional standards and principles that apply to individuals providing services in the facility for 1 of 4 residents reviewed who is receiving hospice care, Resident ID #23. Findings are as follows: Record review revealed that the resident was admitted to the facility in August of 2023 with diagnoses including, but not limited to, Chronic Obstructive Pulmonary Disease (lung disease that restricts your breathing), interstitial pulmonary disease (scarring to the lung which makes it difficult to get oxygen), and pneumonia. Record review revealed a physician's order dated 4/19/2025 to admit to Hospice. Record review of a form titled, Hospice Care and Treatment Recommendations for Facility dated 4/28/2025, revealed a recommendation to start Atropine 1% drops (a medication prescribed to decrease saliva production), 2 drops every 2 hours as needed for increased secretions. This recommendation was noted by Registered Nurse, Staff D. Record review failed to reveal evidence that the hospice recommendation was communicated to the resident's physician to obtain an order. During a surveyor interview on 5/1/2025 at 11:26 AM with Registered Nurse, Staff E, the surveyor brought to her attention that the Atropine drops were recommended for Resident ID #23 on 4/28/2025 by hospice, but the surveyor was unable to find a physician's order. Staff E was unable to provide evidence that the hospice recommendation was communicated to the resident's physician to obtain an order. During a surveyor interview on 5/1/2025 at 11:57 AM with Registered Nurse, Staff D, he revealed that the resident was having increased secretions, so he had requested the Atropine. He further acknowledged that although he did note the Hospice recommendation, he did not recall communicating with the Physician or Nurse Practitioner to obtain an order. During a surveyor interview on 5/1/2025 at 11:57 AM with the Director of Nursing Services, she was unable to provide evidence that the physician was made aware of the recommendation made by Hospice for the Atropine drops. Record review revealed an order dated 5/1/2025 for Atropine 1% drops, 2 drops every 2 hours as needed for increased secretions, after it was brought to the facility's attention by the surveyor.

Based on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored, served, and distributed, in accordance with professional standards for food service safety, relative to the main kitchen. Findings are as follows: 1. The 2022 Food and Drug Administration (FDA) Food Code 2-402.11 states in part, .food employees shall wear hair restraints, beard restraints that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, linens . Surveyor observations of the dietary staff in the main kitchen and main dining room revealed the following: - 4/28/2025 at approximately 9:10 AM, Dietary Staff, Staff A, was observed wearing a hair net with her bangs fully exposed while working in the main kitchen. - 4/29/2025 at 9:41 AM, Staff A, was observed wearing a hairnet with her bangs fully exposed while working in the main kitchen. - 4/29/2025 at 3:00 PM, Dietary Staff, Staff B, was observed wearing a baseball cap with hair strands not in the cap while setting the dining room tables with silverware and glassware. - 4/30/2025 at 2:30 PM, Staff B, was observed wearing a baseball cap with hair strands not in the cap while setting the dining room tables with glassware and silverware. - 4/30/2025 at 3:15 PM, Dietary Staff, Staff C, was observed not wearing a beard restraint while working in the main kitchen. 2. The FDA Food Code 2022 4-101.11 states in part, .multi-use food contact surfaces shall be finished to have a smooth, easily cleanable surface and resistant to scoring . During a surveyor observation on 4/29/2025 at 3:00 PM of the main kitchen, ten red lip plates were observed with deep scorings on the surface. 3. The FDA Food Code 2022 4-201.11 states in part, .equipment and utensils shall be durable to retain their characteristic qualities . During a surveyor observation on 4/29/2025 at 11:41 AM, twelve burgundy colored beverage cups were observed with tan stains on the cavity of the interior. During a surveyor observation of the main kitchen on 5/1/2025 at 10:24 AM, eight white beverage cups were observed with brown stains on the cavity of the interior. 4. The FDA Food Code 2022 6-305.11 states in part, .lockers or other suitable facilities shall be provided for the storage of employees possessions . During a surveyor observation on 4/28/2025 at 9:15 AM, a cell phone was lying on a worktable in the main kitchen. During an additional surveyor observation of the main kitchen on 5/1/2025 at 12:17 PM, a cell phone was on top of a shelf above the serving line. 5. The FDA Food Code 2022 6-501.11 states in part, .physical facilities shall be cleaned as often as necessary to keep clean . A surveyor observation of the main kitchen on 4/28/2025 at 9:15 AM, revealed the areas behind the steam table and worktables there was dried black matter along the floor and baseboard. Further observation revealed brown spills on the yellow tiles behind the steam table and worktables. During a surveyor observation on 4/28/2025 at 9:30 AM of the dish room, revealed black dried matter behind the dish machine. During a surveyor interview on 5/1/2025 at 11:00 AM, with the Assistant Food Service Director, he acknowledged that hair restraints were not properly worn and that a beard restraint was not worn. Additionally, he acknowledged the scoring of the lip plates, the stained cups, and the black matter and brown spills on the floors and walls behind the worktables, and that the dish machine and steam table needed cleaning. He further acknowledged that the staff's personal possessions should not be stored on surfaces in the main kitchen.

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