**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to revise a care plan to include fall interventions after 2 falls for 1 resident (Resident #40) of 4 care plans reviewed for falls. The findings include: Review of the facility policy titled, Comprehensive Care Plans, revised 2/9/2024, revealed .facility will develop and implement a person centered care plan for each resident, that includes measurable objectives and time frames to meet resident's medical, nursing, mental, and psychosocial needs .maintains a comprehensive care plan participate in the development of and reviewing and revising of the Comprehensive Care Plan . Review of the facility policy titled, Falls, revised 1/31/2025, revealed .A comprehensive Care Plan will be implemented based on the resident's risk for falls .interventions will be revised as applicable, with each new review . Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including Hypertension, Chronic Kidney Disease, Cerebral Infarction (stroke), Hemiplegia (total or partial paralysis of one side of the body), Difficulty Walking, and other abnormalities of gait and mobility. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident scored a 6 on the Brief Interview for Mental Status (BIMS) assessment which indicated severe cognitive impairment. Continued review revealed Resident #40 had impaired functional range of motion on one side of the upper and lower extremities. Resident #40 was dependent on staff for Activities of Daily Living (ADL) and for transfers. Resident #40 had a history of falls prior to admission. Review of a facility fall incident report for Resident #40 dated 8/25/2025, revealed .nurse was called to residents room per CNA [Certified Nursing Assistant] staff which reported Elder (Resident #40) was laying in the floor .observed him in the doorway of his room laying on his back feet facing the doorway, upper torso area resting in the leg rest of wheelchair. Elder stated he was trying to reach for something and was too far out .Elders seat cushion appeared to slide down with elder during the fall .New Interventions .remove cushion and move closer to nurses station . Review of a care plan for Resident #40 dated 8/25/2024, revealed no intervention to include remove cushion and move closer to nurses' station. Review of a facility fall incident report for Resident #40 dated 8/27/2025, revealed .Elder found by staff lying in the floor at foot of bed with head slightly under chair. Stated that he was trying to get to his dresser .nurse spoke with NP [Nurse Practitioner] r/t [related to] elder stating to social services that he stays dizzy a lot .New Intervention .medication review r/t elder stating to staff he is dizzy when he gets up . Review of a care plan for Resident #40 dated 8/28/2024, revealed .Encourage elder to be active with activities and out of room . There was no intervention to include medication review r/t elder stating to staff he was dizzy when he gets up or interventions related to the resident's complaints of dizziness. Continued review revealed the care plan was not revised to include the fall interventions from the 8/25/2025 fall of moving the resident closer to the nurses' station or to remove the cushion from wheelchair. During an interview on 4/3/2025, at 11:00 AM the Director of Nursing (DON) confirmed on 8/25/2024, the fall intervention for Resident #40 was to remove the cushion and to move the resident closer to the nurses' station and the interventions were not updated on the care plan. The DON further confirmed on 8/27/2024 the fall intervention related to the resident's dizziness and the medication review was not added to the care plan. The DON confirmed Resident #40's care plan was not updated on 8/25/2024 or 8/27/2024 to reflect the newly established fall interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observations, and interviews, the facility failed to timely implement interventions to reduce the risk of falls for 1 resident (Resident #43) of 4 residents reviewed for falls. The findings include: Review of the facility's policy titled, Falls, revised 1/31/2025, revealed .ensure the facility provides an environment that is as free from accident hazards, as possible over which the facility has control to prevent avoidable falls .based on the resident's risk for falls .interventions specific to each resident to attempt to reduce the risk . Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including Dementia, Altered Mental Status, Muscle Weakness, Abnormal Walking and Mobility, and Mood Disorder. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #43 scored a 3 on the Brief Interview for Mental Status (BIMS) assessment which indicated severe cognitive impairment and required maximum staff assistance for standing and transfers. Review of a Fall Event note dated 1/10/2025, revealed Resident #43 had a fall from the wheelchair in the hallway. Further review revealed Physical Therapy (PT) was to evaluate the resident's wheelchair as a new fall intervention. Review of a PT Evaluation and Plan of Treatment dated 1/14/2025, revealed Resident #43 was added to the PT case load (4 days after the fall). Continued review revealed Resident #43 received PT services for wheelchair propelling, upright posture while seated in the wheelchair, falls, and leg strength training for mobility. Review of a Fall Event note dated 2/16/2025, revealed Resident #43 had a fall from the wheelchair in the dining room. Further review of the Fall Event note revealed PT was to assess the resident for a different wheelchair as a new fall intervention. Review of a PT Discharge note dated 2/21/2025, revealed Resident #43 was discharged from therapy services (evaluation was 5 days after the fall). Further review revealed no new assessment, or evaluation was conducted for a different wheelchair as the intervention for the fall on 2/16/2025. Review of a Fall Event note dated 3/4/2025, revealed Resident #43 had a fall from the wheelchair. Further review revealed the fall intervention was for the resident's personal items to be moved closer to the resident for easier reach to prevent future falls. Review of a comprehensive care plan intervention for falls dated 1/29/2025, revealed .keep personal items within reach . and was not a new intervention after the fall on 3/4/2025. During an observation on 4/1/2025 at 6:00 PM, Resident #43 was observed in the resident's room seated in a tilted wheelchair which contained an anti-thrust cushion. During a medical record review and interview on 4/2/2025 at 10:00 AM, the Director of Rehabilitation (DOR) reviewed the medical record for Resident #43 and stated Resident #43 started physical therapy services on 1/14/2025 related to frequent falls from the wheelchair. The DOR also stated a specialty wheelchair was recommended during therapy services for Resident #43 after the falls in 2/2025 but the wheelchair had not yet arrived to the facility. During an observation on 4/2/2025 at 10:07 AM, Resident #43 was observed in the dining room seated in a tilted wheelchair which contained an anti-thrust cushion. During a medical record review and interview on 4/3/2025 at 5:30 PM, the DON reviewed the medical record with the surveyor for Resident #43 and revealed the following: On 1/10/2025, the resident fell from the wheelchair and the intervention was for PT to evaluate. Resident #43 was not admitted to therapy services until 1/14/2025 (4 days after the fall). On 2/16/2025, the resident had a fall from the wheelchair and the new intervention was for PT to evaluate for a different (specialty) wheelchair. PT did not evaluate for a specialty wheelchair until 2/21/2025 (5 days after the intervention). The DON also stated the specialty wheelchair had not been delivered to the facility, and no other interventions had been implemented after the 2/16/2025 fall. On 3/4/2025, the resident had a fall from the wheelchair, the interventions were to move personal items for easier reach and was noted as an intervention on the care plan on 1/29/2025 and was not a new fall intervention. During an interview on 4/3/2025 at 6:30 PM, the DON confirmed the facility failed to timely implement fall interventions after the falls on 1/10/2025, 2/16/2025, and on 3/4/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility documentation review, and interviews the facility failed to prevent loss or diversion of controlled medications (narcotics) for 1 resident (Resident #7) of 65 sampled residents reviewed for misappropriation of narcotics. The facility was cited as past non-compliance. Non-compliance began on [DATE] and ended on [DATE]. The facility is not required to submit a Plan of Correction for F-755. The findings include: Review of the facility's policy titled, Controlled Medications, dated [DATE], revealed .The facility will ensure Controlled Medications are handled, stored, disposed of, and recordkeeping is in place in accordance with federal, state, and other applicable laws and regulations .At each shift change or when keys are rendered, a physical inventory of all controlled medication is conducted by two staff members who are either licensed nurses, medication technicians, or appropriate staff per state regulations and is documented on the controlled medications accountability record .The licensed nurse .surrendering the keys along with the licensed nurse .assuming the keys will ensure the count of the remaining medication(s) match the medication accountability book. Both the licensed nurse .surrendering the keys along with the licensed nurse .assuming the keys will verify, together, the correct or incorrect accounting of medication(s). Any medication count discrepancies or medication card count discrepancies that can't be reconciled by the licensed nurse .need to be reported to the Director of Nursing (DON) immediately .Once the medication count is completed, both licensed nurses .will also count the number of individual narcotic control sheets, together and will sign the controlled medication accountability record .If a new medication is added or a medication is discontinued/removed, the controlled medication accountability record must reflect the above by completing the controlled medication accountability record by two licensed nurses . Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses including Heart Failure, Psychotic Disorder with Delusions, Vascular Dementia with Psychotic Disturbance, and Chronic Pain. The resident expired in the facility on [DATE]. Review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #7 scored 15 on the Brief Interview for Mental Status (BIMS) assessment, which indicated the resident was cognitively intact. The resident received opioids. Review of the physician's orders dated [DATE] for Resident #7 revealed .oxycodone-acetaminophen [opiod pain medicine] .10-325 mg [milligrams]; amt [amount] .10mg; oral [by mouth] Every 4 Hours - PRN [as needed] . Discontinued [DATE]. Review of a pharmacy shipping manifest (invoice) dated [DATE], revealed the facility received 90 oxycodone-acetaminophen10-325 tablets for Resident #7. Continued review revealed Licensed Practical Nurse (LPN) B received and signed for receipt of the medication on [DATE]. Review of pain assessments for Resident #7 revealed the resident's pain levels on a scale of 0-10 (0 being no pain and 10 being the worst possible pain) revealed: [DATE]: day shift-0 night shift-0 [DATE]: day shift-2 night shift-0 [DATE]: day shift-3 night shift-1 [DATE]: day shift-3 night shift-0 [DATE]: day shift-0 night shift-0 [DATE]: day shift-0 night shift-0 Review of the medication administration record for Resident #7 revealed the resident received Oxycodone-Acetaminophen 10-325 mg for pain as follows: [DATE] at 8:09 AM; 12:28 PM; 4:53 PM; and 10:11 PM [DATE] at 11:29 AM and 4:47 PM [DATE] at 7:50 AM and 12:00 PM [DATE] at 4:49 AM; 9:03 AM; 1:23 PM; and 8:31 PM Review of the facility's documentation dated [DATE], revealed the facility reported the following information to the state designated authority: .Allegation Type .Misappropriation of Resident Property .staff became aware of the incident XXX[DATE] [at] 1:00 PM .Alleged Victim .[Resident #7] .Alleged Perpetrator .unknown .On [DATE], a bubble pack card of 30 Oxycodone/Acet. [Acetaminophen] 10/325 .noted to be missing during a count of narcotics .Upon counting of narcotics, it was noted that [Resident #7] was missing one card [of 30 tablets] of his Oxycodone. He still had a remaining card of medications and had not missed any doses . Review of a police report dated [DATE], revealed .Crime Incidents Theft Of Property (theft From Building) .On [DATE], [named officer] dispatched to [facility] in regards to missing medication .[Facility Administrator] explained the situation that medication had been missing from the building .[facility] noticed the medication gone at 1:30 PM today. The medication was 10mg Oxycodone and a whole bubble pack was gone. A bubble pack contains 30 Oxycodone. She stated that she was in contact with the company that delivered them on [DATE]th to see if it was a miscount and would call back on [DATE]th if they were found or the company's count was incorrect. She stated that the charge nurses are the ones assigned to the medicine carts and are the only ones that have access to the medications . During an interview on [DATE] at 2:33 PM, the Director of Nursing (DON) stated she became aware 1 card (30 tablets) of Oxycodone10-325 mg for Resident #7 was missing when she pulled discontinued controlled medications from the medication cart on the 100 hall on [DATE]. The DON stated .I counted .I did not get the same number she [Registered Nurse-RN A] got .[RN C] counted the sheets [individual resident narcotic record] while I counted the cards [cards with medications/bubble packs]. The numbers were not adding up to what was in the book [controlled medication accountability record] .[RN A] pulled out [Resident #7's card of 60 [oxycodone] and said he's missing his card of 30 [oxycodone] . During a telephone interview on [DATE] at 5:50 PM, RN A stated she and LPN B counted the hall 1 medication cart narcotics the morning of [DATE]. RN A stated she counted the pills on the card and LPN B checked the individual resident's narcotic record/sheet to ensure the pill count was correct. RN A stated LPN B .was in a rush and had to get her kids to school . RN A stated she and LPN B did not count the medication cards and individual resident narcotic record/sheets together the morning of [DATE]. During a telephone interview on [DATE] at 7:46 PM, LPN B stated the process for counting narcotics included the oncoming and off going nurse counted the cards/bubble packs in the cart and the individual resident narcotic records to ensure the numbers were the same. The pills in each card/bubble pack were to be counted and compared with the individual resident narcotic record to ensure the number of pills was the same as recorded on the resident's narcotic record. LPN B stated .We [LPN B and RN A] counted pills and counted the cards .the papers [individual resident narcotic record] were not counted .We did not count the papers that morning [[DATE]] . During an interview on [DATE] at 11:53 AM, the DON stated she became aware of the missing medication .around 11:30 AM [[DATE]], when I went to collect controlleds [narcotics] for destruction . The DON stated she and RN A counted the individual resident narcotic sheets and cards. Each counted 68 individual narcotic sheets and 68 cards/bubble packs instead of 69 (number indicated on the narcotic inventory shift count sheet for the morning count on [DATE]). The DON stated RN C and the Regional Nurse also counted 68 cards and 68 individual resident narcotic sheets. Continued interview revealed RN A, went through the cards and remembered Resident #7 was supposed to have 2 cards of oxycodone 10-325, 1 with count of 60 pills and 1 with count of 30 pills. The card of 30 oxycodone 10-325 was not in the medication cart. The DON stated when medication cart keys exchanged hands, the expectation was 1 nurse counts the pills on the cards and the other nurse compares the pill count with the number documented on the individual resident narcotic sheet. The nurses verbalize the count to ensure the numbers match. At the end of the count, the nurses do a full count of cards and individual resident narcotic sheets .both numbers have to match . The DON stated both nurses were to sign the inventory shift count sheet to confirm the count was completed and was accurate. Staff were expected to notify clinical leadership if there was a discrepancy in the counts. The DON stated .one of the steps [card count and individual narcotic record sheet count] was not completed accurately . The DON confirmed RN A and LPN C did not verify the narcotic count was accurate and confirmed the facility's controlled medications policy was not followed. During a telephone interview on [DATE] at 10:50 AM, the pharmacy representative stated the pharmacy received a script for Resident #7 for Oxycodone 10-325 mg, 90 tablets on [DATE]. The pharmacy representative stated the Oxycodone was delivered to the facility, were checked in and signed for by facility staff on [DATE]. The pharmacy representative stated the facility notified the pharmacy the card of Oxycodone for Resident #7 was missing on [DATE]. Continued interview revealed the pharmacy performed a narcotic count which verified the pharmacy's narcotic count was correct and confirmed 90 tablets of Oxycodone for Resident #7 had been sent to the facility on [DATE]. During an interview on [DATE] at 11:53 AM, the Administrator and DON confirmed the facility had identified the misappropriation of property for Resident #7 and had taken actions to correct the non-compliance. A plan of correction was developed to address the deficient practice identified. The corrective actions were validated on-site by the surveyor on [DATE]-[DATE] through interviews and review of facility documents. The facility's Plan of Correction for Misappropriation of Property was presented to the survey team and documented the following corrective actions were implemented: On [DATE], Resident #7, who had a BIMS of 15 was interviewed and assessed for pain with no pain noted or reported. There were 60 Oxycodone/Acetaminophen 10-325 mg tablets were available for administration. Resident #7 missed no doses of the PRN Oxycodone/Acetaminophen. Pain assessments for uncontrolled pain were completed for all residents on Hall 1. Results concluded there were no residents with uncontrolled pain. Residents on Hall 1 with a BIMS equal to or greater than 8 were interviewed to determine if their pain was controlled and PRN medication had been administered when requested. All residents reported their pain was controlled and they had received their pain medication when requested. On [DATE], the pharmacy was informed of the missing medications for Resident #7. The pharmacy replaced the 30 tablets of Oxycodone/Acetaminophen 10-325 mg for Resident #7 at the cost of the facility. On [DATE] and [DATE], controlled medications were reconciled on every medication cart by the DON, Assistant DON (ADON) , or Wound Care Nurse with no findings of additional medication count discrepancies. On [DATE], urine drug screens were performed for RN A and LPN C with negative results. RN A and LPN C were suspended pending results of the investigation. Controlled medication records for all residents in the facility from [DATE]-[DATE] were audited from [DATE]-[DATE]. Results concluded there were no other residents with missing medications. All staff were interviewed on [DATE]-[DATE] to inquire if they had knowledge of controlled medication unaccounted for or if they had suspicion of anyone working while impaired. There were no findings from the interviews. On [DATE]-[DATE], all staff received education regarding the Abuse and Misappropriation policy. Any staff/agency staff who were not educated were to be educated prior to working their next shift. On [DATE]-[DATE], all licensed staff received education on the Controlled Medication Policy and process changes for counting/receiving/removing controlled medication. The process included: .The Director of Nursing will remove all controlled medications with a witness (empty and discontinued) from the medication cart, reconcile the Controlled Substance Count Sheets and compare the Controlled Substance Count Sheets to the Controlled Drug Records as they are removed from the cart to be secured for destruction. No one will remove controlled medication card/sheets without the Director of Nursing, Assistant Director of Nursing or wound nurse witnessing . Every nurse completed a competency on medication pass started on [DATE] and was completed on [DATE]. Any licensed staff, including agency nurses, who were not education were to be educated prior to working their next shift. Beginning [DATE], the DON or designee observed every nurse complete a narcotic count competency. On [DATE], the DON or designee began auditing licensed nurse's complete narcotic counts at shift change during varying shift 5 times/week for 2 weeks, the 3 times/week for 4 weeks, and then 2 times/week for weeks. On [DATE], the DON or designee began auditing pharmacy delivery reports to ensure the delivered controlled medications were accurately added to the medication carts and controlled substance count sheets: 5 deliveries/week times 2 weeks, then 3 deliveries/week times 4 weeks, then 2 deliveries/week for 4 weeks. Ad Hoc QAPI meetings were held on [DATE], [DATE], [DATE], and [DATE]. QAPI meetings were held weekly beginning [DATE] for 4 weeks, then 2 times/month for the next 30 days, then monthly or until the QAPI Committed determined substantial compliance had been achieved. Audit results revealed no further concerns of misappropriation of resident property. The facility continued to perform random monthly audits. 1. Surveyor interviewed the Administrator and DON on [DATE] at 11:53 AM, in the Administrator's office. Interview confirmed there had not been any further incidents involving loss or diversion of resident controlled medications. 2. Surveyor interviewed multiple licensed staff members (day shift and night shift) for knowledge of the in-services provided in the corrective action plan, and no knowledge deficits were identified. 3. Observations of several narcotic audits performed by licensed nursing staff revealed the staff followed proper procedure for reconciling controlled medications. The deficient practice was cited as past noncompliance for F-755 and the facility is not required to submit a plan of correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to revise the comprehensive care plan for 1 of 47 (Resident #22) sampled residents. The findings include: Review of the facility policy titled, Comprehensive Care Plans, dated 7/19/2018, revealed, .Care plans are ongoing and revised as information about the resident and the resident's condition change .The nurse/Interdisciplinary Team is responsible for the review and updating of care plans. The care plan should reflect the current status of the resident and be updated with changes on the residents' status . Review of the medical record revealed Resident #22 was admitted to the facility on [DATE] with diagnoses which included Unspecified Protein-Calorie Malnutrition, Unspecified Dementia, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, Muscle Weakness (generalized), and Gastro-Esophageal Reflux Disease without Esophagitis. Review of the Comprehensive Care Plan dated 4/26/2023 for Resident #22 revealed the care plan had not been updated to include the interventions for weight loss. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Mental Status of 8 which indicated moderately impaired cognition. Review of the Progress Note dated 5/5/2023 revealed, .Interdisciplinary Team (IDT) met and discussed weight loss. Weight order changed to weekly times 4 weeks. Diet modified to FFP [Fiber, Fat, Protein]. Elder was noted to have pour [sic] intake. Health shakes ordered TID [three times per day]. Will continue POC. [plan of care] . Review of the Progress Note dated 5/11/2023 revealed, .IDT met and discussed elders weight loss. New interventions in place . During an interview on 5/17/2023 at 10:32 AM, the Social Service Director (SSD) confirmed that weight loss interventions should be documented on the care plan and that Resident #22's weight loss interventions were not on the care plan. During an interview on 5/17/2023 at 2:20 PM, the Administrator confirmed care plans should be updated to reflect any new interventions or preventions for residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to assess and treat impaired skin integrity for 1 of 1 (Resident #4) sampled residents observed during the initial tour. The findings include: Review of the facility policy titled, Skin Integrity Policy reviewed by the facility 7/11/2022 revealed, .A resident with impaired skin integrity receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent avoidable skin integrity issues from developing .The licensed nurse shall initiate applicable Skin Integrity documentation if a new area of impairment is identified .In addition, to ongoing observations of skin integrity, nursing stakeholders shall observe the skin for areas of impairment with bathing, daily dressing, and peri care notify and notify the nurse if an area is identified . Review of the medical record revealed Resident #4 was readmitted to the facility on [DATE] with diagnoses which included Vascular Dementia and Type 2 Diabetes. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Review of the care plan intervention dated 3/7/2023, revealed, .Notify nurse immediately of any areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care . Observations in Resident #4's room on 5/15/2023 at 3:58 PM, revealed Resident #4 had raised red bumps and bumps with brown scabs in the center on the left upper arm. Observations and interview in Resident #4's room on 5/17/2023 at 3:12 PM, the Assistant Director of Nursing (ADON) observed and confirmed the raised bumps on Resident #4's left upper arm and in bilateral arm pits. During an interview on 5/17/2023 at 3:03 PM, the ADON stated the staff did not fill out skin observation forms after showers and baths. During an interview on 5/17/2023 at 3:19 PM, Certified Nurse Aide (CNA) #9 stated she had noticed the raised bumps and scabs on Resident #4's arm. CNA #9 stated, Those bumps and scabs had been on her arm for awhile. [Resident #4] picked at the bumps on her arm until they bleed. CNA #9 confirmed staff did not fill out observation sheets of the residents' skin after a shower or bath. CNA #9 confirmed she had not told the nurse of the bumps on Resident #4's arm. During an interview on 5/17/2023 at 3:31 PM, Licensed Practical Nurse (LPN) #2 stated, The nurses conducted weekly skin assessments and if someone identifies anything . LPN #2 stated Resident #4 had the bumps for a while, and they would not heal because she picked at them. LPN #2 confirmed Resident #4 was not receiving any medication for those areas. LPN #2 stated she gave Resident #4 some lotion last week for dry and itchy skin. LPN #2 stated she assessed the areas on Resident #4's left arm and saw the raised bumps. LPN #2 confirmed she did not document that she assessed the area or that she gave Resident #4 lotion. LPN #2 stated if there were new areas, she would have alerted the Director of Nursing (DON), Wound Care Nurse, and Physician. If the areas were old, she would have charted the findings and notified the ADON or DON. Continued interview revealed LPN #2 thought the Physician and Nurse Practitioner already knew of the areas on the left arm. During an interview on 5/17/2023 at 4:27 PM, the DON confirmed she expected the CNAs to notify the nurse of any skin impairments and the nurses to assess and document the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to supervise intrusive wandering for 1 of 6 (Resident #41) sampled residents and failed to provide supervision for transport of 1 of 1 (Resident #60) sampled residents. The findings include: Review of the medical record revealed Resident #41 was admitted on [DATE] with diagnoses which included Dementia with Behavioral Disturbances, Altered Mental Status, and Alzheimer's Disease. Review of the nursing progress notes dated 2/22/2023, revealed Resident #41 was found one evening lying in the floor of another resident's room, appearing to be asleep with her knees slightly bent without distress. Review of the nursing progress notes dated 2/25/2023, revealed Resident #41 was ambulating ad lib (without previous preparation) into another resident's room per normal, and was restless with anxiety and fidgeting. Review of the nursing progress notes dated 3/8/2023, revealed Resident #41 continued to have intrusive wandering with repetitive opening and closing of doors. Review of the nursing progress notes dated 4/14/2023, revealed Resident #41 continued to have intrusive wandering per normal behavior. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score was not obtained due to the resident being unable to complete the interview. Short- and long-term memory problems and severely impaired decision making skills were noted. Daily administered medications which included antipsychotic and antianxiety medication were noted. Observations in Resident #43's room on 5/15/2023 at 11:19 AM, revealed Resident #41 was in Resident #43's room on the right side of Resident #43's bed rummaging through items on the bedside table and touching the pillow. Resident #43 began to cry out. This surveyor called Certified Nurse Aide (CNA) #1 to the room at 11:21 AM for assistance. Observations in Resident #371's room on 5/15/2023 at 12:33 PM, revealed Resident #41 touched Resident #371's bed while the resident was in the bed and Resident #371 told Resident #41 it was not her room. Observations on the 500 hall on 5/15/2023 at 6:05 PM, revealed Resident #41 wandered into Resident #79's room. During an interview on 5/16/2023 at 11:11 AM, CNA #9 confirmed Resident #41 wandered into Resident #43's room on 5/15/2023 at 11:19 AM. CNA #9 also confirmed Resident #43 and Resident #90 would get upset when an intrusive wanderer entered their room. CNA #9 further stated Resident #41 had, at times, been verbally and physically combative with the staff when attempting to provide care. CNA #9 stated many times they staff would leave Resident #41 to calm down and then return and continue her care. During an interview on 5/16/2023 at 11:32 AM, CNA #8 stated the unit had many residents that wandered including Resident #41. CNA #8 confirmed some of the residents got upset because of the wanderers. During an interview on 5/17/2023 at 3:31 PM, Licensed Practical Nurse (LPN) #2 confirmed Resident #41 was difficult to redirect. LPN #2 stated Resident #79 did not like Resident #41 in Resident #79's room. Review of the medical record revealed Resident #60 was admitted to the facility on [DATE] with diagnoses which included Vascular Dementia with Mood Disturbances and Legal Blindness as defined in USA (United States of America). Review of the admission MDS assessment dated [DATE], revealed Resident #60 had a BIMS score of 8 which indicated moderate cognitive impairment. Review of the Transportation Request dated 3/10/2023, revealed, .Escort Needed . was not check marked by the nurse. The check mark indicated the need for an attendant to accompany a resident to an appointment. Review of a transportation document dated 3/10/2023, revealed, .Escort needed or riding with client . was marked .no . During a telephone interview on 5/16/2023 at 2:11 PM, Family Member #1 stated the [named transport company] lost Resident #60 because they dropped the resident off at the 2nd floor for a physician appointment instead of the 3rd floor. Family Member #1 stated Family Member #3 was supposed to meet Resident #60 on the 3rd floor and accompany Resident #60 to the eye appointment. Family Member #1 was told by Family Member #3 Resident #60 could not be found for an hour. During an interview on 5/17/2023 at 11:17 AM, Family Member #1 stated Resident #60 was not mobile, and she could not get around in the wheelchair unless someone pushed her. Family Member #1 stated the facility did not send anyone to accompany Resident #60 to the eye appointment. Family Member #3 called and informed Family Member #1 that Resident #60 had not arrived at the appointment. Family Member #1 called the facility, and the facility told her Resident #60 had already been picked up by [named transport service]. The facility called [named transport service] to see where Resident #60 was. Family Member #3 alerted the front desk clerk at the clinic on the 3rd floor, and the staff from the clinic helped find Resident #60. Family Member #1 stated, .I thought a staff member would accompany Resident #60 to the eye appointment .the family requested assistance with transportation from the facility . Family Member #1 and Family Member #3 had discussed with the facility before admittance about providing staff escorts to medical appointments for Resident #60. During an interview on 5/17/2023 at 12:14 PM, LPN #3 stated Family Member #3 had already scheduled the appointment but requested assistance with transportation. Whenever someone requested transportation, the nurses put the request on the calendar and filled out a transportation request sheet. Family Member #3 asked to meet Resident #60 at the doctor's office. LPN #3 confirmed staff did not accompany Resident #60 to her eye appointment. LPN #3 stated the Social Service Director (SSD) and DON decided if a resident required staff to accompany them to an appointment. A resident's BIMS score was reviewed and taken into consideration to make a decision. LPN #3 was not sure why a staff member did not accompany Resident #60 to the eye appointment. LPN #3 confirmed she did not mark on the transportation request form that Resident #60 would need accompaniment to the appointment because she was not told to do so. During an interview on 5/17/2023 at 12:23 PM, the ABOM stated once she got a request for transportation she contacted [named transport service] to set up the transportation. The nurses filled out the transport request and indicated whether the resident required an escort or not. The ABOM copied the request and sent it to the [named transport service]. Continued interview revealed the ABOM was asked to call [named transport service] to get with the driver to know where Resident #60 was dropped off. During an interview on 5/17/2023 at 12:45 PM, the Director Of Nursing (DON) stated the nurse working on a resident's medical appointment would fill out the transport sheet and indicate if an escort was needed. The nurses would then take the request to the ABOM. If a resident required an escort, it would be discussed at the morning meeting to determine which staff would accompany the resident. During an interview on 5/17/2023 at 1:01 PM, the Registered Nurse (RN) #1, also known as the Unit Manager, stated Family Member #1 called and said they could not find Resident #60. RN #1 called the eye clinic, and they said Resident #60 was not there. RN #1 called [named transport service], and they said they took her the appointment. The facility called back and informed RN #1 they had found Resident #60. During an interview on 5/17/2023 at 1:42 PM, the Administrator stated RN #1 informed her immediately that Resident #60 was missing, and the facility contacted [named transport service]. The ABOM communicated with the transport company, and RN #1 communicated with Family Member #3. Resident #60 was at a medical office building. The Administrator called and informed Family Member #3 that Resident #60 was at the the wrong office suite but had been located. The Administrator stated the charge nurse would decide if a resident needed staff accompaniment to an appointment because, They would know the patient best.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure safe handling, cleaning, and storage of breathing treatment and CPAP/BiPap (Continuous Positive Airway Pressure/Bilevel Positive Airway Pressure) equipment for 1 of 4 (Resident #44) sampled residents and failed to properly date and store oxygen equipment for 2 of 4 (Residents #66 and #77) sampled residents observed with oxygen therapy. The findings include: Review of the facility policy titled .Departmental (Respiratory Therapy) - Prevention of Infection Revised November 2011 .The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators among resident and staff .Infection Control Considerations Related to Oxygen Administration .Obtain equipment (i.e., oxygen tubing, reservoir, and distilled water)Change the oxygen cannulae and tubing every seven (7) days, or as needed .Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol .After completion of therapy .store the circuit in plastic bag, marked with date and resident's name between uses . Review of the medical record revealed Resident #44 was admitted to the facility on [DATE] with diagnoses which included Acute on Chronic (Diastolic), Congestive Heart Failure (CHF), Fibromyalgia, and Chronic Obstructive Pulmonary Disease (COPD). Review of the Discharge Minimum Data Set (MDS) dated [DATE] revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Review of the respiratory care plan dated 5/16/2023, revealed, .at risk for respiratory complications related to respiratory failure with hypoxia and hypercapnia, COPD, OSA [Obstructive Sleep Apnea], and CHF . Observations and interview in Resident #44's room on 5/17/2023 at 12:34 PM revealed Resident #44 had a CPAP/BiPAP mask and nebulizer (small machine that turns liquid medicine into a mist that can be easily inhaled) mask unbagged on the top of bedside table undated. Licensed Practical Nurse (LPN) #1 observed and confirmed the undated and unbagged masks. Review of the medical record revealed Resident #66 was admitted to the facility on [DATE] with diagnoses which included Acute Respiratory Failure with Hypoxia, Chronic Combined Systolic and Diastolic Congestive Heart Failure, and Morbid Severe Obesity due to Excess Calories. Review of the physician order dated 3/28/2023, revealed, .Oxygen Therapy: Oxygen via NC [Nasal Cannula] @ [at] 2 L [liters] per minute, Oxygen Therapy: Change tubing every week Once a Day on Wed [Wednesday]; Night . Review of the admission MDS assessment dated [DATE] revealed Resident #66 has a BIMS score of 15 which indicated no cognitive impairment. Continued review revealed Resident #66 had oxygen therapy. Review of respiratory care plan dated 4/27/2023, revealed, .at risk for respiratory complications due to dx [diagnosis] of respiratory failure with hypoxia and dx of CHF/SOB [Shortness of Breath] laying flat . Observations and interview in Resident #66's room on 5/15/2023 at 3:03 PM, revealed LPN #1 observed and confirmed there was no date present on the O2 tubing. Review of the medical record revealed Resident #77 was admitted to the facility on [DATE] with diagnoses which included Type II Diabetes Mellitus with Chronic Kidney Disease, Essential Hypertension and Systolic Congestive Heart Failure. Review of physician order dated 9/29/2021, revealed .Oxygen Therapy: Change tubing every week, and Oxygen Therapy: Oxygen via NC @ 2L per minute . Review of Annual MDS dated [DATE] revealed Resident #77 had a BIMS score of 6 which indicated a severe cognitive impairment. Review of the care plan dated 5/15/2023 revealed .oxygen therapy r/t [related to] my dx of CHF, SOB lying flat and with exertion . Observations and interview on 5/15/2023 at 2:59 PM and 3:03 PM, revealed Resident #77's O2 tubing was dated 4/19/2023. LPN #1 observed and confirmed the O2 tubing was dated 4/19/2023 (26 days old).

Based on facility policy review, observation, and interview, the facility failed to serve silverware for 1 of 2 carts on the 500 hall during a meal. The findings include: Review of the facility policy titled, Resident Rights reviewed 4/17/2023 revealed .When providing care and services, the stakeholders will respect the resident's individuality and value their input by providing them a dignified existence, through self-determination and communication with access to persons and services inside and outside the facility . Observations on the 500 hall on 5/15/2023 at 5:38 PM, revealed the first tray cart on the floor had 18 trays. Two of the trays on the cart had silverware, and the other 16 trays did not. Continued observation revealed Certified Nurse Aide (CNA) #9 had to go upstairs to the kitchen and retrieve silverware for the other trays on the cart. During an interview on 5/15/2023 at 6:34 PM, the Regional Food Service Manager (FSM) stated the staff had pulled the silverware off the trays because the cart was for residents eating in the dining room. The FSM thought the 500 hall dining room had silverware for the residents who ate in the dining room. The FSM confirmed all the trays on the tray carts were supposed to have silverware. During an interview on 5/16/2023 at 11:11 AM, CNA #9 confirmed the kitchen staff sent a tray cart without silverware for all of trays on the cart. CNA #9 stated the 500 hall dining room did not have silverware on hand to give to the residents when the cart arrived to the hall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview, the facility failed to provide a homelike environment for 2 of 5 (100 and 500) halls. The findings include: Review of the facility policy titled, Resident Rights reviewed by the facility on 4/17/2023 revealed .All residents will be treated in a manner and in an environment that promotes maintenance or enhancement of quality of life . Review of the undated facility policy titled, Housekeeping In-Service revealed .Spot clean walls: Vertical surface are not completely wiped down daily-but must be spot cleaned daily. Walls -especially by trash cans and light switches and door handles -will need special attention .Clean and sanitize sink and tub: The sink includes: the sink fixtures, pipes, under the sink, mirror and light above the mirror . Observations on the 500 halls on 5/15/2023 at 10:27 AM, revealed two vents located at the nurse's station and one vent located in front of the nutrition room were covered with black debris. Observations in room [ROOM NUMBER] on 5/15/2023 at 11:14 AM, revealed part of the wall in the corner was missing. Observations in room [ROOM NUMBER]'s bathroom on 5/15/2023 at 11:15 AM, revealed a ceiling tile was stained brown and sinking down. Observations on the 500 hall on 5/15/2023 at 11:56 AM, revealed Spa #1 had two vents which were covered with black debris. Observations in room [ROOM NUMBER] on 5/16/2023 at 10:20 AM, revealed various white spots of paint on the walls. Observations in room [ROOM NUMBER]'s bathroom on 5/16/2023 at 10:49 AM, revealed the left sink pipe and wall had brown and orange debris. Continued observation revealed white paint spots in the bathroom. Observations on the 500 hall on 5/18/2023 from 7:45 AM to 9:45 AM, revealed rooms 505, 507, 509, 511, 513, 515, 517, and 519 had scuffed closet doors. Rooms 501, 503, 505, 507, 509, 513, and 517 had chipped closet doors and frames. Continued observation revealed 500 hall had varnish scuffed off along the wooden hand rails. The 500 hall had scuffed and worn wooden hand rails toward the dining room. Observations on the 100 hall on 5/18/2023 from 9:49 AM to 10:19 AM, revealed rooms 102, 103, 108, and 115 had stained tubs. rooms [ROOM NUMBER] had scuffed doors and walls. Rooms 106, 107, 108, 109, 110, 111, 113, 114, 116, and 117 had scrapped walls and doors. rooms [ROOM NUMBERS] had chipped doors. room [ROOM NUMBER] had a missing towel bar. rooms [ROOM NUMBER] had dirty walls. room [ROOM NUMBER] had damaged ceiling walls and orange stained walls. room [ROOM NUMBER] had cracked walls. Observations in the Soiled Linen Room shared by 100/200 halls on 5/18/2023 at 4:45 PM, revealed the cabinet with a broken door handle on the upper right cabinet door and a broken handle on the drawer below the cabinet. During an interview on 5/15/2023 at 12:45 PM, the Director of Operations confirmed the black debris on the vents, and the vents were only replaced when the budget allowed. During an interview on 5/16/2023 at 9:55 AM, the Assistant Director of Operations confirmed the black debris was dust on the vents. During a telephone interview on 5/16/2023 at 2:45 PM, Family Member #2 stated room [ROOM NUMBER] could use a new paint job. During an interview on 5/18/2023 at 5:32 PM, the Director of Operations (DOO) observed all the above concerns and confirmed several rooms in the facility had issues which needed to be addressed. The DOO stated the facility only had two staff employees to address those issues at the facility. During an interview on 5/18/2023 at 5:45 PM, the Housekeeping Manager observed and confirmed the walls and tubs needed to be cleaned in the rooms listed above. The Housekeeping Manager stated each room should be deep cleaned (thorough scrubbing of all surfaces) once a week.

Based on facility documentation, observation, and interview, the facility failed to have sufficient staffing for 1 of 4 (500) halls. The findings include: Review of the undated facility documentation revealed the 500 hall had 11 assisted diners (residents who required assistance with meals). Review of the facility schedule dated 5/15/2023, revealed 2 Certified Nurse Aides (CNA) and 1 CNA scheduled from 12:00 PM to 6:00 PM. Observations on the 500 hall on 5/15/2023 at 12:08 PM, revealed the tray cart arrived to 500 hall. Observations at the 500 hall nurse's station on 5/15/2023 at 12:24 PM, revealed Resident #114 was seated in a wheel chair in front of the nurse's station. Observations in the 500 hall dining room on 5/15/2023 at 12:25 PM, revealed CNA #8 was assisting one resident with the lunch meal while another resident was seated in a wheelchair. Observations in the 500 hall dining room on 5/15/2023 at 12:51 PM, revealed Resident #114 was assisted with dining by a CNA. During an interview on 5/15/2023 at 12:37 PM, CNA #8 stated the 500 hall was her assigned hall. CNA #8 stated there were 3 CNAs staffed on the 500 hall regularly, but there were only 2 CNAs staff this week. CNA #8 confirmed the residents would have lunch in the dining room if there was enough staff. CNA #8 stated the residents rarely had meals in the dining room, and since the Coronavirus disease (COVID) pandemic, the residents had their meals in their rooms. CNA #8 confirmed Resident #114 had not eaten yet because she needed assistance. During an interview on 5/16/2023 at 11:11 AM, CNA #9 stated the 500 hall had 8 assisted diners and two residents that required prompts while dining. CNA #9 stated the facility had instructed the staff not pass trays to independent diners and then the assisted diners, but the trays had to be passed at the same time. CNA #9 stated,To get them out fast, it is not enough CNAs or help with just three people. Many of the assisted diners could not sit up in a wheel chair. That is one of the reasons we don't offer dining in the dining room. All of the independent diners won't sit and eat. They will be wandering the halls. When we have a wanderer we try to sit them in the chairs by the nurse's station. It is hard to do with two people [staff] and a nurse. During an interview on 5/17/2023 at 3:31 PM, Licensed Practical Nurse (LPN) #2 stated it would not have been so bad if the unit did not house so many assisted diners. LPN #2 stated she felt the administration was aware of the acuity (level of residents' needs and requirement for nursing care) of the unit. LPN #2 stated the facility typically had 3 CNAs on the day shift from Monday through Thursday, but this week there were only 2 CNAs because 1 CNA was on vacation. During an interview on 5/18/2023 at 3:32 PM, the Director of Nursing (DON) stated, They [facility] have had meals in the dining room. It is not a staffing thing. It is a matter of those that want to stay seated for dining. It is hard to tell day by day because they [staff] have the ones [residents] that are ambulatory that won't stay seated, and they have to attend to them also. The DON stated the 500 hall had the highest number of admissions and assisted diners, but the staffing had not increased.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility document review, observation, and interview, the facility failed to serve food in a timely manner to 9 of 123 (Resident #9, #14, #15, #16, #39, #92, and #113) residents who ate food prepared by the facility. The findings include: Review of the undated meal times sheet revealed the serving times for meals for the dining rooms and the halls revealed breakfast was served to the main dining room (DR) at 7:00 AM, 100 hall 1st meal tray cart at 7:15 AM, hall 300/400 at 7:30 AM, hall 200 meal tray cart at 7:45 AM, 500 hall DR and hall at 8:00 AM, hall 100 2nd meal tray cart at 8:15 AM, and hall 200 2nd meal tray cart at 8:30 AM. Lunch was scheduled for the main DR at 11:30 AM, hall 100 1st meal tray cart at 11:45 AM, hall 300/400 at 12:00 PM, hall 200 1st meal tray cart at 12:15 PM, 500 hall DR 12:30 PM, hall 100 2nd meal tray cart at 12:45 PM and hall 200 2nd meal tray cart at 1:00 PM. Dinner was scheduled for the main DR at 5:00 PM, hall 100 1st meal tray cart at 5:15 PM, hall 300/400 at 5:30 PM, hall 200 1st meal tray cart at 5:45 PM, 500 hall DR at 6:00 PM, hall 100 2nd meal tray cart at 6:15 PM, and hall 200 2nd meal tray cart at 6:30 PM. Observations on the 300/400 hall on 5/15/2023 at 12:56 PM, revealed the first lunch tray was delivered at 12:56 PM and the last tray was delivered at 1:16 PM. The stated delivery time to the 300/400 hall for lunch was 12:00 PM. Observations in the kitchen on 5/15/2023 at 4:45 PM, revealed the Regional Food Service Manager (FSM) for the contracted food service group, removed a pan of hamburger patties and tater tots from the convection oven, placed them on a stainless counter top, opposite the oven, and checked the food temps of both items. The FSM took the pans to the steam table and placed each food item in metal pans and covered the pans. Observations in the kitchen on 5/15/2023 at 4:55 PM, revealed the FSM was preparing the pureed bread for the steam table. Observations in the kitchen on 5/15/2023 at 5:10 PM, revealed the food for dinner was in place on the steam table. The food temps were checked by [NAME] #1, with the contracted food service group. The following food and temps were noted to be below regulation: mechanical ground beef 131 degrees Fahrenheit (F), pureed ground beef 128 degrees F, and regular mashed potatoes 131 degrees F. Continued observation at 5:15 PM revealed the FSM removed the mechanical ground beef, pureed ground beef, and regular mashed potatoes for reheating in the convection oven for 15 minutes. The food temps of the reheated food on the steam table revealed the mechanical ground beef was 170 degrees F, pureed ground beef was 171 degrees F, and the regular mashed mashed potatoes was 171 degrees F. Observations in the kitchen on 5/15/2023 revealed the following: At 5:30 PM food was delivered to the main DR to be served to the residents. The stated time for delivery to the main DR was 5:00 PM. At 5:40 PM a meal tray cart was delivered to the 500 hall. The stated time for delivery to the 500 hall was 6:00 PM. At 6:00 PM the 1st meal tray cart was delivered to 100 hall. The stated time for delivery to the 100 hall was 5:15 PM. At 6:13 PM a meal tray cart was delivered to the 300/400 hall. The stated time for delivery to the 300/400 hall was 5:30 PM. At 6:31 PM the 2nd meal tray cart was delivered to 100 hall. The stated time for delivery of the 2nd cart to the 100 hall was 6:15 PM. At 6:30 PM a meal tray cart was delivered to the 200 hall. The stated time for delivery to the 200 hall was 5:45 PM for the 1st cart delivery and 6:30 PM for the 2nd cart. Observations of the meal tray cart on 5/15/2023 at 6:30 PM, revealed the tray cart was delivered to the 200 hall and contained 21 meal trays. Delivery of 17 meal trays was started by 2 Certified Nurse Aides at 6:32 PM and completed at 6:50 PM. Four meal trays remained on the meal tray cart for the residents requiring assistance with meals. Observations in the kitchen with the Assistant Dietary Manager (ADM, contracted with the food service group), on 5/16/2023 at 6:50 AM, revealed breakfast food temps on the steam table that were below regulation were pre-cooked sausage patties at 124 degrees F, pureed eggs 114 degrees, and pre-cooked bacon slices 118 degrees F. The breakfast food temp that was above regulation was the milk carton 8 ounces (oz) 48 degrees F. Continued observation with the ADM and Director of Operations (DOO) for the contracted food service group at 6:55 AM, revealed the ADM reheated the sausage patties and bacon slices by pouring hot water on the meat. Further observation revealed the ADM placed metal pans containing the sausage and bacon in the convection oven along with the pureed eggs for reheating. Observations in the kitchen on 5/16/2023 at 7:10 AM, revealed the ADM checked the temps of the reheated food while the food was still in the convection oven. After the reheated foods were returned to the steam table at 7:15 AM, the reheated temps were pre-cooked sausage patties 168 degrees F, pre-cooked bacon slices 151 degrees F, and reheated pureed eggs 164 degrees F. Observations of the meal tray cart on 5/16/2023 revealed the following: At 7:25 AM breakfast was delivered to the main DR to be served to the residents. The stated time for the main DR was 7:00 AM. At 8:20 AM the meal tray cart was delivered to the 200 hall. The stated delivery time was 7:45 AM for the 1st cart and 8:30 AM for the 2nd cart; only 1 meal tray cart was delivered to the 200 hall. At 8:28 AM the meal tray cart was delivered to the 300/400 hall. The stated delivery time was 7:30 AM. At 8:40 AM the meal tray cart was delivered to the 100 hall. The stated delivery time was 7:15 AM for the 1st cart and 8:15 AM for the 2nd cart; only 1 meal tray care was delivered to the 100 hall. At 8:50 AM the meal tray cart was delivered to the 500 hall/downstairs DR. The stated delivery time was 8:00 AM. Observations on the 300/400 hall on 5/16/2023 at 8:55 AM revealed the first meal tray was delivered at 8:28 AM and the last tray at 8:45 AM. The stated delivery time for the 300/400 hall was 7:30 AM. Observations in room [ROOM NUMBER] (100 hall) on 5/16/2023 at 2:00 PM, revealed a resident was being assisted with a meal tray. The stated delivery time for lunch on the 100 hall was 11:45 AM for the 1st cart and 12:45 PM for the 2nd cart. During an interview on 5/15/2023 at 11:30 AM, Resident #15 (alert, oriented, and interviewable) stated the food was not delivered on time and was usually cold by the time it arrived. During an interview on 5/15/2023 at 11:45 AM, Resident #9, #16, #39, and #92 (alert, oriented, and interviewable) stated the meal trays were hardly ever delivered on time, and the food was usually cold. During an interview on 5/15/2023 at 12:30 PM, Resident #14 and #113 (alert, oriented, and interviewable) stated the meal trays seemed to usually be delivered late, and the food usually tasted cold. During an interview on 5/15/2023 at 4:45 PM (time given by the FSM to check dinner food temps), the FSM revealed some food was still being prepared for the steam table. The FSM stated the hamburger patties and tater tots were still in the convection oven, and the dinner food service was late due to inaccurate food temps. During an interview on 5/16/2023 at 7:15 AM, the ADM and DOO confirmed the food service was delayed due to the inappropriate steam table temps.

Based on facility policy review, observation, and interview, the facility failed to maintain appropriate temperatures (temps) for food served on a test tray dated 5/15/2023. The facility also failed to maintain appropriate temps for food on the steam table requiring re-heating and a delay in food service. The findings include: Review of the facility policy titled, Food: Preparation Policy 016, undated revealed .the Dining Service Director/Cook(s) will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to techniques which minimize the amount of time that food items are exposed to temperatures greater that 41 degrees Fahrenheit (F) and/or less than 135 degrees F or per state regulation .all foods will be held at appropriate temperatures greater that 135 degrees F .for hot holding and less that 41 degrees F for cold food holding .temperatures .for foods will be recorded at the time of service . Observations in the kitchen on 5/15/2023 at 4:45 PM, revealed the Regional Food Service Manager (FSM) for the contracted food service group, removed a pan of hamburger patties and tater tots from the convection oven, placed them on a stainless counter top, opposite the oven, and checked the food temps of both items. The FSM took the pans to the steam table, placed each food item in metal pans, and covered the pans. Observations in the kitchen on 5/15/2023 at 4:55 PM, revealed the FSM was preparing the pureed bread for the steam table. Observations in the kitchen on 5/15/2023 at 5:10 PM, revealed the food for dinner was placed on the steam table. [NAME] #1, with the contracted food service group, checked the food temps. The following food temps were below regulation: mechanical ground beef 131 degrees F, pureed ground beef 128 degrees F, and regular mashed potatoes 131 degrees F. Continued observation at 5:15 PM revealed the FSM removed the mechanical ground beef, pureed ground been, and regular mashed potatoes for reheating in the convection oven for 15 minutes. Food temps of the reheated food on the steam table revealed the mechanical group beef was 170 degrees F, pureed ground beef was 171 degrees, and the regular mashed mashed potatoes was 171 degrees F. Observations of the test tray on the 200 hall on 5/15/2023 at 6:43 PM, revealed the tray was being carried by the FSM. The test tray was placed on the tray cart for the 200 hall. Observations of the dinner test tray on the 200 hall on 5/15/2023 at 6:50 PM, revealed an appetizing appearing plate of a hamburger patty on a bun with a cheese slice, lettuce and tomato, french fries and cole slaw. The plate was in an insulated plate holder with an insulated lid. Observations of the dinner test tray food temps on the 200 hall on 5/15/2023 at 6:50 PM, revealed the hamburger patty was 115 degrees F, french fries were 126 degrees F, cole slaw was 48 degrees F, and carton of whole milk was 52 degrees F. Observations in the kitchen with the Assistant Dietary Manager (ADM, contracted with the food service group), on 5/16/2023 at 6:50 AM, revealed breakfast food temps on the steam table that were below regulation were pre-cooked sausage patties at 124 degrees F, pureed eggs 114 degrees, and pre-cooked bacon slices 118 degrees F. The breakfast food temp that was above regulation was the milk carton 8 ounces (oz) 48 degrees F. Continued observation with the ADM and Director of Operations (DOO) for the contracted food service group at 6:55 AM, revealed the ADM reheated the sausage patties and bacon slices by pouring hot water on the meat. Further observation revealed the ADM placed metal pans containing the sausage and bacon in the convection oven along with the pureed eggs for reheating. During an interview on 5/15/2023 at 4:45 PM (time given by the FSM to check dinner food temps), the FSM revealed some food was still being prepared for the steam table. Continued interview at 4:55 PM, the FSM stated she usually checked food temps as the food was removed from the oven and before placing the food on the steam table. The FSM stated she was unsure if the temps documented on the food temp form was from checking the foods from the oven or on the steam table. The FSM stated the hamburger patties and tater tots were still in the convection oven, and the dinner food service was late due to inaccurate food temps. During an interview on the 200 hall on 5/15/2023 at 6:50 PM, the FSM confirmed the food temps on the dinner test tray were not appropriate per regulations. During an interview with the ADM and DOO on 5/16/2023 at 7:10 AM, the ADM stated he reheated pre-cooked meat with hot water. The ADM stated he usually checked food temps straight from the oven instead of on the steam table. The ADM confirmed the food service was delayed due to the inappropriate steam table temps. The DOO stated he was unsure of the reheating procedure.

Based on facility policy review, facility maintenance documentation, observation, and interview, the facility failed to provide proper storage dating of foods. The facility also failed to provide proper sanitation of equipment after use and maintenance of equipment in the kitchen. The facility further failed to provide appropriately dated foods and sanitized equipment in 1 of 3 (500 hall) nutrition rooms. The findings include: Review of the facility policy titled, Food Storage: Cold Foods Policy 019 revealed .all time/temperature control for .foods, frozen and refrigerated will be appropriately stored .foods will be stored wrapped or in covered containers, labeled and dated and arranged in a manner to prevent cross contamination . Review of the facility policy titled, Ice policy 021, undated, revealed .the Dining Services Director will coordinate with the Maintenance Director to ensure that the ice machine will be disconnected, cleaned, and sanitized quarterly and as needed or according to manufacturer guidelines .the exterior of the ice machine will be cleaned weekly .ice bins will be cleaned monthly and as needed .ice scoops will be cleaned and stored in a separate container that limits exposure to dust and moisture retention . Review of the facility policy titled, Equipment Policy 027, undated, revealed .all foodservice equipment will be clean, sanitary, and in proper working order .equipment will routinely cleaned and maintained in accordance with manufacturer's directions .all food contact equipment will be cleaned and sanitized after every use .the Dining Services Director will submit requests for maintenance or repair to the Administrator and/or Maintenance Director as needed . Review of the facility policy titled, Food Storage and Retention Guide posted on the front of walk-in (W/I) cooler #3, undated, revealed .shredded cheese (mozzarella, cheddar, Parmesan) .1 month . Review of the facility maintenance documentation titled, Work History Report dated 3/31/2023, revealed the ice machine filters and coils were cleaned. The machine was de-limed as necessary. An invoice dated 5/1/2023 for a 3/8 inch mixing valve (valve used to adjust the temperature of water that comes out of the hot water heater before it reaches the faucet) for the handwashing sink revealed a shipping date of 5/1/2023. Observations during the initial kitchen tour with the Registered Dietitian (RD), contracted with the contract food service group, on 5/15/2023 at 10:30 AM, revealed the hot water pedal on the wash sink by kitchen office door and across from the hall door was inoperable and provided no hot water from the tap into the sink. Observations during the initial kitchen tour with the RD on 5/15/2023 at 10:30 AM, revealed W/I Cooler #1 in the right back corner of the back food storage room had water on the floor. Also observed was a white/light beige colored, dried appearing, crusty debris under the milk cartons containing 8 ounce (oz) milk cartons. The initial kitchen tour was joined by the Assistant Dietary Manager (ADM) with the contract food service group on 5/15/2023 at approximately 10:45 AM. Observations during the initial kitchen tour on 5/15/2023 at 10:45 AM, revealed W/I Cooler #2 along the back wall of the back food storage room contained uncovered food: apple crisp (as verbally named by the ADM) in 12 single serving sized bowls. W/I Cooler #2 also contained expired foods of 1 used pastry icing bag of a cream appearing colored substance (verbally labeled by the ADM as cake icing) dated 4/27 and Parmesan cheese in a gallon carton, approximately 1/2 full dated 3/27. Observations during the initial kitchen tour on 5/15/2023 at 10:50 AM, revealed W/I Cooler #3 located in the main kitchen on the back wall revealed no dates for 3 plastic 8 (oz) jars of beef base, 1 plastic 8 oz jar of chicken base, 1/2 of a tomato, 1 onion, 5 single-size bowls of applesauce (as verbally labeled by the ADM), 1-46 oz plastic jar of applesauce, and 1 gallon can of fruit cocktail-1/2 full (the can was covered with plastic wrap in the original can container), watermelon-cut-up in chunks, pureed bread (verbally labeled by the ADM) in a metal pan, sliced bologna (verbally labeled by the ADM) and grated cheddar cheese 1/2 package. Expired dates were noted on 20 hot dogs-5/11, 6 strips of pre-cooked bacon-5/11, gravy (verbally labeled by the ADM) in a metal pan-5/8, chicken patties (labeled by the ADM) in 2 metal pans-5/10, chicken gravy (verbally labeled by the ADM) in 1 metal pan-5/10, and baked beans (verbally labeled by the ADM) in 1 metal pan-5/10. A clear liquid substance was dripping from the interior top of W/I Cooler #3 onto plastic wrap covered metal pans of baked chicken legs and thighs, meat sauce (both verbally labeled by the ADM), and a pureed substance (unable to be labeled by the ADM). The clear liquid had gathered on the top of the plastic wrap causing the wrap to be unloosed from the sides of the metal pans and get onto the food. The chicken, meat sauce, and pureed substance were labeled with a red marker. The clear liquid had become red-pink tinted and caused the food it contacted to also be colored pink. Observations during the initial kitchen tour on 5/15/2023 at 10:55 AM, revealed Cooler #1 along the back wall of the kitchen contained 9 cartons of nectar thickening. On the bottom left of the cooler were 2-gallon pitchers both with a whisk inside each pitcher (verbally labeled by the ADM) as thickened tea and thickened milk. There were no dates or coverings on either pitcher. Observations during the initial kitchen tour on 5/15/2023 at 11:00 AM, revealed the milk cooler with a lift up lid, along the back wall of the kitchen had a soured milk odor with a black debris on the bottom of the cooler, both dried and moist appearing. Observations during the initial kitchen tour on 5/15/2023 at 11:05 AM, revealed the ice machine had smears on the stainless steel front. The front reservoir under the grill contained gray, moist appearing debris noted in the corners and edges of the tray. The grill contained crusty, scaly cream/beige colored debris at all joints. On the side of the ice machine were 6 horizontal openings running up the side approximately 10 inches to 12 inches in length. This area was covered with light gray dust, easily swiped or blown from the surface. Observations during the initial kitchen tour on 5/15/2023 at 11:10 AM, revealed the tea maker metal receptacle was empty under the filter basket with no plastic lid. The back of the tea maker had brown crusty, scaly, splattered appearing debris all over the back. Observations during the initial kitchen tour on 5/15/2023 at 11:15 AM, revealed the dish machine had scaled build-up appearing debris all along each cornered and linear crevice. The stainless area of the dish machine had a build-up of dark tan to light brown colored debris covering the surface and into the corners and crevices. The open air shelving on the wall of the dish room on the side the dish trays exit had dark red, brownish debris noted at each joint of the shelving. Observations during the initial kitchen tour on 5/15/2023 at 11:25 AM, revealed the 3-door freezer, located in the kitchen on the opposite wall from the dish room, had signs posted on the left and middle door which read the doors did not work due to broken hinges. The freezer contained 9 slices of French toast (verbally labeled by the ADM) in an opened, unsecured package and an undated package of 10 pancakes. Observations during the continued kitchen tour on 5/15/2023 at 2:15 PM, revealed the Regional Food Service Manager (FSM) for the contract food service group and the Corporate Clinical Document Reviewer/Certified Dietary Manager (CDM) for the facility were present. The convection oven exterior stainless doors had several smears. The interior doors on the glass windows contained a caramel, brownish coating with streaks that ran from the top of the glass to the bottom. The substance had a sticky feeling. The bottom of the oven was covered with a blacken, crusty substance. The stove hood had dark reddish/brown spots, approximately a dime-sized on the left front edge or lip of the outer hood over the steamer and at the top left of the hood over the steamer. The stove backsplash had blackened-brown coating/covering from the base to approximately 3 to 6 inches up from the base. The stove top had dried/cooked appearing debris with a crumb type substance. The stainless front of the stove had multiple smears and smudges on the oven doors. Observations in the nutrition room of the 500 hall on 5/15/2023 at 5:45 PM, revealed the ice machine had black debris on the top of the flap inside the machine. The refrigerator temp read 0 degrees F. Watermelon was in plastic cup without a resident name or date. Pudding was in a pudding container, covered and without a resident name or date. The ice scoop was located in the box of straws. The findings were observed and confirmed by Certified Nurse Assistant (CNA) #10 on 5/15/2023 at 5:49 PM. During an interview on 5/15/2023 at 10:30 AM, the RD confirmed .you're about to see some egregious behaviors . The RD confirmed the hot water was inoperable on the handwashing sink. The RD observed and confirmed the findings for W/I Cooler #1 listed above. The RD stated he was contracted with the contract food service group and was the interim RD until the regular RD returned from maternity leave. During an interview on 5/15/2023 at 10:40 AM, the ADM observed and confirmed the findings listed above in W/I Cooler #2, W/I Cooler #3, Cooler #1, the milk cooler, the ice machine, tea maker, dish machine, dish room, and 3-door freezer. The ADM confirmed the uncovered pitchers in the 2-door cooler were thickened tea and thickened milk, and the pitchers should be covered and without the whisk left in the pitchers. The ADM confirmed the odor emitting from the milk cooler when the lid was raised was the odor of soured milk. The ADM also confirmed the ice machine had not been cleaned since he had been hired approximately 2 1/2 months ago. The ADM confirmed he was unable to find the plastic lid for the tea container. The ADM confirmed the 3-door freezer had broken hinges on the left and middle doors and stated he was unsure how long the hinges had been broken or if the issue had been reported for repair. The ADM stated the maintenance company for the dish machine was here a couple of days ago, but he had received no paper work/invoices following the visit. During an interview on 5/15/2023 at 2:45 PM, the FSM and Corporate CDM observed and confirmed the observations made for the convection oven, stove hood, stove backsplash, stove top, and stove front. The FSM confirmed she was unaware if repair requests had been made for the hot water pedal on the handwashing sink or the hinges for the left and middle doors of the 3-door freezer. During an interview on 5/15/2023 at 3:00 PM, Dietary Aide #1 stated he had put in a maintenance order for the 3-door freezer broken hinges about 1 month and 1/2 ago. During an interview on 5/16/2023 at 10:30 AM, the Maintenance Director confirmed the mixing valve to fix the handwashing sink had not been received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to develop and implement a baseline care plan for the care and maintenance of a peripherally inserted central catheter (PICC) for 1 resident (Resident #250) of 1 residents reviewed for PICC lines of 30 residents reviewed. The findings included: Review of the facility policy Baseline Plan of Care, not dated, revealed .development and implementation of the Baseline plan of care will start at admission and within the first 48 hours .include the minimum healthcare information necessary to properly care for a resident including, but not limited to .goals based on admission orders .physician orders . Medical record review revealed Resident #250 was admitted to the facility on [DATE] with diagnoses of Osteomyelitis (bone infection) Requiring Antibiotic Intravenous (IV) Therapy. Medical record review of the Nursing admission assessment dated [DATE] revealed Resident #250 was admitted to the facility with a PICC line in the right upper extremity. Medical record review of the Baseline admission Care Plan dated 4/18/18 revealed no care plan for care and maintenance of the PICC line. Observation of Resident #250 on 04/23/18 at 2:43 PM, in the resident's room, revealed a PICC line in the resident's right upper arm. Interview with the Director of Nursing on 4/24/18 at 5:09 PM, in the conference room, confirmed the facility failed to develop a baseline care plan to address the care and maintenance for Resident #250's PICC line.