**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to maintain or enhance resident's dignity and respect when 2 of 2 (Resident #5 and #48) sampled residents were not given showers on their assigned shower days per their preference. The findings include: 1. Review of the Resident Rights, dated 11/2018, revealed .The resident has a right to a dignified existence, self-determination .the resident's wishes and preferences must be considered .receive services in the facility with reasonable accommodation of resident needs and preferences . 2. Review of the medical record review revealed Resident #5 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Diabetes, Heart Disease, and Spondylosis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #5 was cognitively intact. Resident #5 needs moderate assistance with bathing/showers. During an interview on 4/07/2025 at 11:33 AM, Resident #5 stated, My shower days are on Tuesday, Thursdays and Saturdays. I haven't been getting them here lately, and I really like them better than baths. Review of the facility SHOWER ROOM LIST form updated 3/4/2025, revealed Resident #5 should receive his showers on Tuesdays, Thursdays, and Saturdays on day shift. Review of Resident #5's Hygiene Record . revealed Resident #5 did not receive showers on the days of 1/14/2025, 2/25/2025, 3/1/2025, 3/8/2025, 3/11/2025, 3/15/2025, 3/20/2025, 3/22/2025, and 3/29/2025. 3. Review of the medical record review revealed Resident #48 was admitted to the facility on [DATE], with diagnoses including Atherosclerosis, Heart Disease, Heart Failure, Atrial Fibrillation, and Diabetes. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, indicating Resident #48 was cognitively intact. Resident #48 was dependent on staff for bathing/showers. During an interview on 4/7/2025 at 3:41 PM, Resident #48 stated, I don't get enough showers, they don't offer me showers as much as they use to. Review of the facility SHOWER ROOM LIST form updated 3/4/2025, revealed Resident #48 should receive his showers on Monday, Wednesday, and Fridays on second shift. Review of Resident #48's Hygiene Record . revealed Resident #48 did not receive showers on the days of 1/1/2025, 1/8/2025, 1/10/2025, 1/13/2025, 1/20/2025, 1/22/2025, 1/24/2025, 1/29/2025, 1/31/2025, 2/3/2025, 2/5/2025, 2/12/2025, 2/14/2025, 2/17/2025, 2/19/2025, 2/21/2025, 2/24/2025, 2/26/2025, 3/3/2025, 3/10/2025, 3/12/2025, 3/17/2025, 3/21/2025, 3/24/2025, 3/26/2025, 3/28/2025, and 3/31/2025. During an interview on 4/9/2025 at 11:57 AM, the Director of Nursing (DON) confirmed residents should get their showers on their facility assigned days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to provide a communication process, including how the communication will be documented between the facility and the hospice provider to ensure resident needs are addressed and met for 1 of 1 (Resident #21) sampled residents. The findings include: 1. Review of the facility policy titled, Hospice Services Policy, revised 10/2021, revealed .A communication process, including how the communication will be documented between the facility and the hospice provider to ensure the needs of the Resident are addressed and met 24 hours per day . 2. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE], with diagnoses including Diabetes Mellitus, Cerebral Infarction, Chronic Obstructive Pulmonary Disease, and Hypertension. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated Resident #21 was moderately cognitively impaired. Further review revealed Resident #21 was assessed for hospice services. Review of Physician's orders dated 5/22/2024, revealed .Hospice Services provided . Review of the facility's hospice communication log revealed that no hospice visits were documented for November 2024, December 2024, January 2025, February 2025, and March 2025. During an interview on 4/8/2025 at 12:26 PM, Licensed Practical Nurse (LPN) D was asked where documentation of hospice visits were made. LPN D stated, .They should be signing the hospice book [communication log] when they come. During an interview on 4/8/2025 at 2:31 PM, the Director of Nursing (DON) was asked if the facility should maintain current up to date communication with hospice regarding hospice visits. The DON stated, Yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility policy review, medical record review, observations and interviews, the facility failed to ensure residents were free from accident hazards when staff failed to properly store and secure a portable oxygen cylinder for 1 of 1 (Resident #47) sampled resident. The findings included: 1. Review of the facility policy titled, Precautions-Oxygen Safety, dated 12/2013, revealed .One must remember that safety comes first. We expect these regulations to be followed as well as any others that may become necessary .Cylinders shall never be left free-standing . 2. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE], with diagnoses including Chronic Obstruction Pulmonary Disease (COPD), Chronic Respiratory Failure with Hypoxia, Anxiety Disorder, and Muscle Weakness. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #47 was cognitively intact. Review of the Physician's Orders dated 2/24/2025, revealed Oxygen @ [at] 2.5 LPM [liters per minute] by NC [nasal cannula] . to decrease the risk for Hypoxia R/T [related to] diagnoses for COPD and Chronic Respiratory Failure. Review of the Care Plan dated 4/1/2025, revealed .Respiratory or any distress and need oxygen for shortness of breath. Interventions .Staff to observe breath sounds as indicated, give oxygen per Medical Doctor [MD] orders, observe for shortness of breath (SOB) or any respiratory difficulty and report to the physician . Observation in Resident #47's room on 4/7/2025 at 9:27 AM, and 11:07 AM, revealed an unsecured portable oxygen cylinder that was free standing between dresser and chair. During an interview on 4/7/2025 at 11:09 AM, LPN D confirmed that the portable oxygen cylinder should not be free standing and should be secured in a roller, sling bag attached to back of wheelchair or secured in the oxygen storage room. During an interview on 4/8/2025 at 12:29 PM, the Director of Nursing (DON) confirmed that the portable oxygen cylinder should be secured in the oxygen storage room, in a roller or in a sling bag. Reviewed by [NAME] RN, PHNC1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure proper infection control practices were followed during medication administration when 1 of 3 nurses (Licensed Practical Nurse (LPN) A) completed a Percutaneous Gastrostomy, (Peg- peg tube a tube inserted into the stomach for nutrition and medications) medication administration and immediately gave eye drops to resident without changing gloves or perform hand hygiene. The findings include: 1. Review of the facility policy titled, .Hand Hygiene, dated 1/2025, revealed .This facility considers hand hygiene to be the single most important factor in the control of infection .Alcohol based hand sanitizer is the preferred method of hand hygiene .for the following situations .Before moving from a contaminated body site to a clean body site during resident care .after contact with blood or bodily fluids .Wash hands with soap and water .when hands are visibly soiled . 2. Review of the medical record review revealed Resident #33 was admitted to the facility on [DATE], with diagnoses including Cerebral Infarction with Dysphagia, Hemiplegia, and Hypertension. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #33 had a Brief Interview for Mental Status (BIMS) score of 14, indicting Resident #33 was cognitively intact. Further review revealed Resident #33's eating ability is not attempted due to medical condition and resident depends on staff for most activities of daily living. Review of the Physician Orders dated 5/29/2024, revealed .TUBE .Enteral Flush Orders .before and after medication administration . Review of the Physician Orders dated 10/22/2024, revealed .REFRESH OPTIVE ADVANCED .1 gtt. (drop) to both eyes . Observation during medication administration on 4/9/2025 at 7:36 AM, in Resident #33's room revealed LPN A completed administration of the Peg tube medications to Resident #33. LPN A then immediately administered eye drops to both eyes without changing gloves or doing hand hygiene. During an interview on 4/9/2025 at 10:01 AM, the Director of Nurses (DON) was asked should a nurse complete a peg tube administration and immediately move to administering eye drops without hand hygiene. The DON stated No . he should have removed his gloves and performed hand hygiene, then applied another pair of gloves.

Based on policy review, observation, and interview, the facility failed to ensure food was served under sanitary conditions when staff failed to properly label food items stored in the nourishment refrigerator and when 1 of 1 staff (Dietary [NAME] C) failed to perform hand hygiene when preparing meal trays. The facility had a census of 61 with 61 of those residents receiving a tray from the kitchen. The findings include: 1. Review of the facility policy titled, Handling, Serving, and Transporting Foods, dated 5/15/2020, revealed .Foods will be presented attractively, under sanitary conditions .Practice good personal hygiene . Review of the facility policy titled, Cleaning and Sanitation, dated 9/2/2020, revealed .Food service employees are educated on the use of Personal Protective Equipment (PPE), including aprons, gloves . Review of the facility policy titled, Hand Hygiene, dated 1/2025, revealed .Use an alcohol-based hand rub .or alternatively soap and water for the following .After contact with hair, uniform, or any object . 2. Observation in the Nourishment Room on 4/9/2025 at 11:30 AM, revealed an opened and undated container of vanilla ice cream in the nourishment freezer. Certified Nursing Assistant (CNA) B confirmed that she did not know which resident it belonged to. 3. Observation in the Kitchen on 4/9/2025 starting at 12:09 PM, revealed Dietary [NAME] C was on the serving line preparing meal trays. Dietary [NAME] C touched her neck, face/nose, and side of head multiple times with ungloved hand and continued to prepare meal trays. During an interview on 4/9/2025 at 1:00 PM, the Certified Dietary Manager (CDM) confirmed that all food items stored in the nourishment refrigerator should be labeled with resident's name and date. The CDM confirmed that staff should perform hand hygiene after touching face/body or contaminated items before returning to preparing or serving meal trays at the serving line.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to revise a care plan for 1 of 2 (Resident #10) residents reviewed for indwelling urinary catheters. Findings include: Review of the medical record revealed Resident #10 was admitted on [DATE], with diagnoses of Dementia, Hypertension, Depression, and a Pressure Ulcer of the Sacral Region. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #10 had a Brief Interview for Mental Status of 11, which indicated moderate cognitive impairment. Resident #10 was dependent for all Activities for Daily Living, always incontinent of bowel and bladder, and had a pressure ulcer on the sacrum. Review of the Physician Order dated 3/30/2024 revealed .16 Fr [French] 10cc [cubic centimeters] bulb for urinary retention .Foley [indwelling urinary catheter] Site Care Cleanse site with soap/water or peri [perineal] cleanser and dry area .May change foley catheter PRN [as needed] occlusion or leakage . Review of Resident #10's care plan revealed no documentation to address the resident's indwelling urinary catheter. During an interview on 4/18/2024 at 3:16 PM, the MDS Coordinator confirmed that the care plan should have been updated to address the indwelling urinary catheter when it was ordered by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to honor dietary preferences for 1 of 1 sampled resident (Resident #161) reviewed for food allergies. The findings include: Review of the facility's undated policy titled, Food Safety-Infection Control, revealed .Resident with food allergies or intolerance should receive a therapeutic diet that prevents the resident from exposure to any potential food allergens .To prevent the safety of our residents. To prevent allergic reactions, including anaphylaxis, severe swelling, throat swelling, edema, hives, rash, itchiness, stomach cramps, vomiting, diarrhea, etc . Review of the facility's undated policy titled, Tray Assembly, revealed .Residents trays will be assembled in accordance with the physician ordered diet, diet spreadsheet, and resident food preferences .To ensure each resident receives a meal that appeals to them and meets their nutritive and therapeutic needs .All food trays will be double-checked by staff member .to ensure accuracy . Review of the facility's undated policy titled, Resident Food Preferences, revealed .Participants will be able to identify resident food preferences on diet ticket and be aware of the importance of allowing residents to have food choices . Review of the medical record revealed Resident #161 was admitted to the facility on [DATE], with diagnoses of Heart Failure, Pain, Anxiety, Psychotic Disorder, Insomnia, and Allergies to Mandarin Oranges. Review of the Physician Orders sheets dated 4/11/204, revealed Resident #161 .Allergies .mandarin oranges . Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #161 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Review of Resident #161's meal ticket dated 4/17/2024, revealed .Allergies: Oranges . Observation on 4/15/2024 12:05 PM, revealed Certified Nurse Assistant (CNA #1) knocked on Resident #161's door and entered the resident's room with his meal tray. CNA #1 waked out of Resident #161's room holding a container of orange sherbet and stated, He (Resident #161) is allergic to orange .did it again. Observation in the resident's room on 4/17/2024 at 8:18 AM, revealed Resident #161's meal tray contained orange juice. Resident #161 stated, I cannot have that I am allergic to oranges . CNA #2 stated, Oh, I did not know that . During an interview on 4/18/2024 at 4:16 PM, the Dietary Manager confirmed kitchen staff should review the residents' meal ticket to ensure the residents are not getting anything that they are allergic to on their meal tray. During an interview on 4/18/2024 at 4:30 PM, CNA #3 confirmed when delivering residents' meal trays staff should review the resident's meal ticket to ensure nothing is on the meal tray that the resident is allergic to. During an interview on 4/18/2024 at 4:51 PM, the Director of Nursing (DON) confirmed the kitchen should not send out food items on the resident meal tray that the resident is allergic to. The DON confirmed she is aware Resident #116 received orange juice on his meal tray and Resident #161 is allergic to mandarin oranges. The facility failed to honor residents' dietary preferences related to food allergies.

Based on policy review, observation, and interview, the facility failed to ensure food was stored, under sanitary conditions as evidenced by a tomato in a box in the walk-in refridgerator that had black and white fur spots on the tomato with drainage from the tomato in the box, and flour, corn meal, brown sugar, frosted flakes and white sugar in undated bins in the dry storage area. The facility had a census of 66 with 65 of those residents receiving a meal tray from the kitchen. The findings included: Review of the facility's Food Storage, undated policy revealed .Food is stored and prepared in clean safe sanitary manner that will comply with state and federal guidelines .to minimize contamination and bacteria .Containers for bulk items (flour, sugar ect.) .Containers are to be label and dated with contents . Observation in the kitchen on 04/15/24 at 9:00 AM, and on 04/16/24 11:45 AM, revealed the following: A tomato in a box in the walk-in refridgerator that had black and white fur spots on the tomato with drainage from the tomato in the box. Flour, corn meal, brown sugar, frosted flakes and white sugar in undated clear bins in the dry storage area. During an observation and interview in the kitchen on 4/16/2024 at 11:45 AM, the Dietary Manager (DM) was asked about the decomposing tomato that was in the refridgerator. The DM confirmed that the tomato should have been thrown away. The DM was asked should the storage bins with the food inside have been dated. The DM stated, Yes .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview the facility failed to provide information regarding a resident's right to formulate an advance directive for 5 of 16 sampled residents (Resident #9, #19, #29, #34 and #36) reviewed for advance directives. The finding's include: 1. Review of the facility's policy titled, Resident's Rights, dated 11/28/2016 revealed, .non-compliance with the advance directives requirements and requests for information regarding returning to the community .Receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies .The facility must comply with the requirements specified in 42 CFR part 489, subpart 1 (Advance Directives) .These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive . Review of the facility's policy titled, Code / No Code, dated 1/2023 revealed, .Advance directive is written instruction that is recognized by State law which relates to providing care to incapacitated individuals. BE CERTAIN THAT DOCTOR'S ORDERS ARE IN COMPLIANCE WITH INDIVIDUAL RIGHTS AS DETERMINED BY STATE LAW . 2. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses of Encephalopathy, Alzheimer's Disease, Dementia, Dysphagia, and Diabetes Mellitus. Review of the annual MDS assessment dated [DATE] revealed Resident #19's BIMS was 00, which indicated severe cognitive impairment, was totally dependent on others for all ADLs and received a mechanically altered therapeutic diet. Review of Resident #19's medical record, revealed no Advance Directive was present, and there was no documentation the resident or the resident's legal representative were provided written information regarding her right to formulate an Advance Directive upon admission. 3. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses of Dementia, Hypertension, Peripheral Autonomic Neuropathy, Anxiety, Depression, Paranoid Schizophrenia, and Alzheimer's Disease. Review of the quarterly MDS dated [DATE] revealed Resident #34 had a BIMS of 4, which indicated severe cognitive impairment, and required staff supervision for most ADLs. Review of Resident #34's medical record revealed no Advance Directive was present, and there was no documentation the resident or the resident's legal representative were provided written information regarding her right to formulate an Advance Directive upon admission. 4. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses of Hypertension, Diabetes, Stroke, Hemiplegia or Hemiparesis, Anxiety, and Depression. Review of the quarterly MDS dated [DATE], revealed Resident #29 had intact cognition. Review of Resident #29's medical record revealed no Advance Directive was present, and there was no documentation the resident or the resident's legal representative were provided written information regarding her right to formulate an Advance Directive upon admission. 5. Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of Osteoarthritis of Knee, Peripheral Vascular Disease, Heart Failure, Chronic Obstructive Pulmonary Disease, Diabetes, and End Stage Renal Disease. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 6 which indicated severe cognitive impairment, and required staff assistance for all Activities of Daily Living (ADLs). Review of Resident #9's medical record revealed no Advance Directive was present, and there was no documentation the resident or the resident's legal representative were provided written information regarding his right to formulate an Advance Directive upon admission or informed of the right to develop one. 6. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Hemiplegia and Hemiparesis, Aphasia, Anxiety, and Gastrostomy. Review of the quarterly MDS dated [DATE] revealed Resident #36 had severe cognitive impairment and required staff assistance for ADLs. Review of Resident #36's medical record revealed no Advance Directive was present, and there was no documentation the resident or the resident's legal representative were provided written information regarding his right to formulate an Advance Directive upon admission. During an interview on 2/15/2023 at 6:16 PM, the Administrator was asked if the residents or their representative should be provided written information regarding their right to formulate an advance directive. The Administrator stated, Yes, everyone should have the opportunity to do an advanced directive on admission. We did implement the process, but we have 23 long term patients that we need to make sure we get them .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the Level 1 Pre-admission Screening and Resident Review (PASRR) form, medical record review, and interview, the facility failed to resubmit a PASRR after the resident had the addition of a new mental health diagnosis for 1 of 1 sampled resident (Resident #34) reviewed for PASRR. The findings include: Review of the .PASRR . form revised 9/20/2018 revealed, .This screening form applies to all persons being considered for admission to a Medicaid-Certified Nursing Facility (NF) .After admission, the NF must retain the Level I form as part of the resident record. In the event the resident experiences a significant change in condition .the NF must complete a new PASRR Level I .Significant change in physical or mental condition for PASRR purposes means a major decline or improvement in the resident's status that will not normally resolve itself without further intervention by staff or by implementing standard disease-related clinical interventions .Serious Mental Illness Indicators .Schizophrenic Disorders . Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses of Dementia, Hypertension, Anxiety Disorder, and Depression. Review of the medical record revealed a Level I PASRR was completed for Resident #34 on 1/19/2022. Review of the [Named] Mental Health and Wellness Psychiatric (Psych) Progress Note dated 5/02/2022 revealed, .Paranoid schizophrenia . Review of the medical record revealed the diagnosis of Paranoid Schizophrenia was added to Resident #34's medical record on 5/2/2022. A new Level I PASRR was not completed following the significant change of Resident #34's diagnosis. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #34 had a Schizophrenia diagnosis and received antipsychotic medications on 7 of the 7 days of the look back period. During an interview on 2/15/2023 at 1:37 PM, the Assistant Director of Nursing (ADON) confirmed a new PASRR should be completed upon a new Schizophrenia diagnosis. During an interview conducted on 2/15/2023 at 2:41 PM, the MDS Coordinator confirmed the diagnosis of Paranoid Schizophrenia was not documented in the chart until the Psychiatric Progress Note on 5/2/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure infection control practices for the use of an indwelling urinary catheter (a plastic tube inserted into the bladder used to drain urine into a plastic bag) and failed to obtain a physician's order for 2 of 2 sampled residents (Resident #36, #199) reviewed for the use of an indwelling urinary catheter. The findings include: 1. Review of the facility's policy titled, Catheter Care and Maintenance revised 1/23 revealed, .policy of this facility to provide catheter care to all residents that have an indwelling catheter in an effort to reduce bladder and kidney infections . 2. Review of the medical record revealed Resident #36 was admitted to the facility on [DATE] with diagnoses of Hemiplegia and Hemiparesis following unspecified Sequelae of Cerebral Infarction, Anxiety, Depression, and Atherosclerotic Heart Disease. Observation in the resident's room on 2/12/2023 at 10:55 AM, revealed Resident #36's indwelling urinary catheter was lying on the floor. Observation in the resident's room on 2/12/2023 at 4:44 PM and 2/15/2023 at 10:04 AM, revealed Resident #36's indwelling urinary catheter touched the floor. During an interview conducted on 2/15/2023 at 10:16 AM, the Director of Nursing (DON) was asked if the indwelling urinary catheter should be touching the floor. The DON stated, No, it should not. 3. Review of the medical record revealed Resident #199 was admitted to the facility on [DATE] with diagnoses of Gastrostomy, Depression, Diabetes Mellitus, and End Stage Renal Disease. Review of a Nursing Progress Note 2/9/2023 at 10:29 PM revealed, .admission .Resident admitted .from acute care hospital .patent foley catheter in place . Review of a Nursing Progress Note dated 2/10/2023 and 2/11/2023 revealed, .foley catheter in place, patent, and intact . Observation in the resident's room on 2/12/2023 at 10:30 AM revealed Resident #199 had an indwelling urinary catheter. During an interview on 2/12/23 at 11:45 AM, MDS Coordinator confirmed Resident #199 did not have a physician's order for an indwelling urinary catheter. During an interview on 2/15/2023 at 9:19 AM, the DON was asked when a new admission was admitted with an indwelling urinary catheter, should there be a physician's order for the catheter. The DON stated, Yes, Ma'am, they do need an order. The DON confirmed the admission nurse should have checked and added the order upon admission for Resident #199.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to provide a therapeutic diet and supplements as ordered for 2 of 2 sampled residents (Resident #10 and #19) reviewed for nutritional status. The findings include: 1. Review of the facility's undated policy titled, Tray Assembly revealed, .Resident trays will be assembled in accordance with the physician ordered diet .A tray ticket will be available during tray assembly for each resident, stating the physician order (including therapeutic restrictions and modified consistencies) .All food trays will be double checked by the staff member delivering the tray to ensure accuracy. Review of the facility's policy titled, Nutritional/Dietary Supplements dated 2/14/2020 revealed, .Nutritional/Dietary Supplements are provided to residents per physician's orders .To supplement a resident's nutritional needs .The Food Service Department will maintain a current list of residents and their physician ordered supplements(s) . Review of the facility's policy titled, Therapeutic and Modified Diets dated 8/24/2020 revealed, .To ensure residents receive foods with the appropriate textures and nutrients contents as prescribed by the physician .assure modified diets are being served appropriately . 2. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with Metabolic Encephalopathy, Gastrostomy Tube, Hypertension, Diabetes, Morbid Obesity, Cognitive Communication Deficit, Dysphagia, and Depression. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 00, which indicated severe cognitive impairment, required extensive to total staff assistance for most activities of daily living (ADLs), eating did not occur, and he had a Percutaneous Endoscopic Gastrostomy (PEG) tube for nutrition. Review of the Fiberoptic Endoscopic Evaluation of Swallowing dated 1/11/2023 revealed, .Initiate regular texture .with ground or chopped meat and thin liquids . Review of the Physician's Order dated 1/30/2023 revealed, .Diet - Regular Diet - Ground meats- thin liquids . Review of Resident #10's lunch Tray Ticket dated 2/12/2023 revealed, .GRND [ground] CHICKEN . Observation in the resident's room on 2/12/2023 at 11:12 AM, revealed Resident #10 lay in bed on his left side, his eyes were closed, the over bed table was next to his bed on the left side, and a closed box from a named restaurant was on his over bed table. Observation and interview in the resident's room on 2/12/2023 at 12:29 PM, revealed CNA #1 placed Resident #10's lunch tray on his over bed table and assisted Resident #10 to a sitting position. CNA #1 removed the lid that covered Resident #10's meal tray and revealed a divided plate with a baked chicken breast on the bone, ground chicken, mashed potatoes, glazed carrots, and a roll. The closed box from a named restaurant remained on Resident #10's over bed table. CNA #1 removed the baked chicken breast on the bone and laid it on the tray beside Resident #10's plate. CNA #1 was asked why Resident #10 had 2 different kinds of chicken. CNA #1 stated, They let him try that [pointed to the ground chicken] first to see how he does. CNA #1 lifted the lid of the closed box which contained 1 partially eaten chicken breast on the bone, 1 whole chicken breast on the bone, mashed potatoes and gravy, corn, macaroni and cheese, and a biscuit. CNA #1 closed the box and assisted Resident #10 with his lunch tray. CNA #1 returned the uneaten chicken breast on the bone which was delivered from the kitchen to his meal tray, left the box of restaurant chicken on his over bed table next to his bed, and left the room. Observation in the resident's room on 2/12/2023 at 4:44 PM, revealed Resident #10 was in bed and the the over bed table containing the box from a named restaurant was next to his bed on the left side. During an interview on 2/14/2023 at 5:19 PM, revealed the Director of Nursing (DON) confirmed that Resident #10 should not have had a whole chicken breast on his meal tray. The DON stated, .His family hasn't been bringing in any food because he was being fed by PEG .upgraded his diet on 1/30[2023], his wife was the one notified of the food change .she said it was his daughter [who brought the box of chicken and vegetables] and she would let her know . During an interview on 2/15/2023 at 9:01 AM, revealed the Speech Language Pathologist (SLP) confirmed a swallow study was performed on 1/11/2023, Resident #10's diet was upgraded to a regular diet with ground meats, and he required assistance with meals. The SLP was asked if Resident #10 should be served a chicken breast on the bone. The SLP stated, No, ma'am. The SLP was asked if the box of fried chicken should have been left on Resident #10's over bed table all day on 2/12/2023. The SLP stated, It should have been removed, because he is safest on ground meats according to my professional opinion . 3. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses of Encephalopathy, Alzheimer's Disease, Dementia, Dysphagia, and Diabetes Mellitus. Review of the annual MDS assessment dated [DATE] revealed a BIMS score of 00, which indicated severe cognitive impairment, required extensive staff assistance for eating, received a mechanically altered therapeutic diet, and was coded for weight loss. Review of the Physician's Telephone Order dated 12/29/2022 revealed, .Supplement .Nutrition Cup Supplement With Meals 08:00 [8:00 AM], 12:00 [12:00 PM], 17:00 [5:00 PM] for Malnutrition Risk Start date .12/29/22 .D/C [Discontinue] date 02/14/2023 09:09 [9:09 AM] . Review of the Care Plan revised on 1/5/2022 revealed, .I am at increased nutritional risk related to Medical Comorbidities .Staff should provide diet as ordered .frozen nutritional cup to all meals . Review of the Physician's Telephone Order dated 2/14/2023 revealed, .Ice Cream with all meals With Bkfst [Breakfast], Lun [Lunch], and Din [Dinner] .per RD [Registered Dietician's] recommendation Start date .02/14/23 09:11 [9:11 AM] . Review of a kitchen posting titled, SUPPLEMENTS dated 1/6/2023 revealed, .ICE CREAM ALL MEALS .[Named Resident #19] . Review of the [Named] SUPPLY CHAIN STATEMENT CONCERNING HEALTHCARE FROZEN TREATS dated 2/9/2023 revealed, .We are currently working to locate an alternative source .when an alternative supplier is available . Review of the Registered Dietician's (RD) Nutritional Note dated 2/14/2022, revealed, .CBW [Current Body Weight] 126 lbs .(healthy for age). Diet order is regular, pureed textures, thin liquids, SF [Sugar Free] house supplement .house shakes .ice cream with all meals with an HS [Hours of Sleep] snack. Res [Resident] is exceeding ENN [Estimated Nutritional Needs] with current intake and supplements. However, res continues gradual wt [weight] loss. Loss potentially from declining overall health/advancing dx [diagnosis] of Alzheimer's disease rather than inadequate intake. Res is not triggering for sig [significant] wt loss .Nutrition cup order was discontinued as facility is not able to acquire anymore [any more] at this time. Order was replaced with ice cream at all meals . Review of the weights documented from 11/15/2022 through 2/6/2023 revealed no significant weight loss for Resident #19. Observations in the resident's room on 2/12/2023 at 12:24 PM, and in the dining room on 2/14/2023 at 8:38 AM, revealed Resident #19's meal tray did not have a frozen nutritional treat or ice cream. During an interview conducted on 2/15/23 at 9:58 AM, the Dietary Manager stated, .The supply of supplements for the past 2 weeks on and off getting supplements .I received a notice of frozen treats that was not available .I let the Dietitian know about the frozen nutrition cups .The cook will check the tray card if I'm not here .they were supposed to be using ice cream .I have a list up on the wall, for them to refer to . The Dietary Manager was asked who is responsible to make sure the ice cream is on the tray. The Dietary Manager stated, The Dietary Aide. During a telephone interview conducted on 2/15/2023 at 10:40 AM, the RD confirmed all facilities are having problems getting supplements across the state, and Resident #19 should get ice cream. The RD confirmed he saw Resident #19 yesterday and did an order change from the nutritional frozen treat to ice cream.