**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 provide a clean and homelike environment for 1 resident (Resident #41) of 94 residents reviewed for a homelike environment. The findings include: Review of the facility's policy titled, Cleaning Assignments, dated 4/2024, revealed .maintain a neat, clean .homelike environment . Medical record review revealed Resident #41 was admitted to the facility on [DATE] Diabetes Mellitus, Need for Assistance with Personal Care, and Muscle Weakness. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #41 was cognitively intact. During an observation in room [ROOM NUMBER] on 7/7/2024 at 11:50 AM, revealed the privacy curtain for Resident #41 had a large brown stain to the left bottom corner. During an interview on 7/7/2024 at 11:52 AM, Resident #41 stated the large brown stain to the bottom corner of the privacy curtain had been present awhile and was unsure of the substance. During an observation in room [ROOM NUMBER] on 7/8/2024 at 8:10 AM, revealed the privacy curtain for Resident #41 had a large brown stain to the left bottom corner. During an interview on 7/9/2024 at 7:31 AM, the Housekeeping Director (HD) stated privacy curtains located in the resident rooms are routinely cleaned at least quarterly and when visibly soiled. The HD confirmed the privacy curtain in room [ROOM NUMBER] should have been changed due to the presence of an unknown substance on the privacy curtain and did not reflect a clean, homelike environment for Resident #41.

**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 follow the policy for restraint usage for 1 resident (Resident #65) of 5 residents reviewed for restraints. The findings include: Review of the facility's policy titled, Restraints, dated 7/2023, revealed .It is the policy of this facility that restraints only be used for the safety and well-being of the Resident(s) .Before placing a Resident in a restraint, a pre-restraining assessment must be done to determine the need .a physician's order must be obtained indicating the specific reason, type, and medical reason for restraint . Medical record review revealed Resident #65 was admitted to the facility on [DATE] with diagnoses including Dementia, Hypertension, and Muscle Weakness. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #65 had severe cognitive impairment, required total to maximum staff assistance with bed mobility and transfers. Further review revealed restraints were not used. Review of the comprehensive care plan for Resident #65 dated 6/13/2024, revealed a restraint was not in use. Medical record review revealed Resident #65 had no order for a restraint, restraint consent, assessment, or ongoing re-assessment for restraint usage. During an observation on 7/7/2024 at 12:10 PM, revealed Resident #65 was asleep in the bed with the bilateral bed bolsters (a type of restraint) in place. During an observation on 7/8/2024 at 8:30 AM, revealed Resident #65 was asleep in the bed with the bilateral bed bolsters in place. During an observation and interview on 7/8/2024 at 2:06 PM, the Assistant Director of Nursing (ADON) stated he was not aware of Resident #65 having a restraint (bolsters)placed on the bed. During an interview on 7/8/2024 at 2:15 PM, the Director of Nursing (DON) stated when restraints are used it was her expectation an initial assessment, signed consent, and a physician's order was to be obtained. The DON confirmed Resident #65 did not have an order, signed consent, or an initial assessment prior to the use of a restraint.

**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 honor the right to self-determination related to resident choices for food preferences for 1 resident (Resident #25) of 12 residents reviewed for choices. The findings include: Review of the facility policy titled, Menu Substitutions and Alternatives, dated 2/14/2019, showed .Resident .who express a refusal of the food served are offered a substitute of similar nutritive value .Nursing Services offers the substitute in a timely manner when a resident refuses a menu item . Medical record review showed Resident #25 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Major Depressive Disorder, and Muscle Weakness. Review of Resident #25's comprehensive care plan dated 2/2/2021, showed the resident had a diagnosis of Diabetes and was not able to eat all of her meals. Further review showed .Staff to honor food and fluids preferences as able . Review of Resident # 25's physician's order dated 2/11/2021, showed .NSOT [no salt on tray] Diet- Regular Texture- Thin Liquids .add fortified foods with all meals (help meet est [estimated] needs) . Review of Resident #25's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. She required set up assist with meals, she had no weight loss, and received a therapeutic diet. Observation on 10/4/2021 at 12:42 PM, showed Resident #25's lunch tray was delivered by Certified Nursing Assistant (CNA) #1. CNA #1 entered the resident's room and set up the resident's lunch tray. Resident #25 stated to CNA #1 that she did not like anything on her lunch tray. CNA #1 stated, what about your orange cake and the resident stated to the CNA, it does not look good to me. The CNA stated what about your broccoli .I don't want it and the resident stated back to her I get broccoli every day. CNA #1 exited the room without offering the resident a substitute. During an interview on 10/4/2021 at 12:44 PM, Resident #25 stated she did not like the food on her tray. The resident stated she told CNA #1 she did not like the food and was not offered a substitute by the CNA. Resident #25 stated she would like to have a cold plate with cottage cheese. During an interview on 10/4/2021 at 12:47 PM, the Director of Nursing (DON) stated it was her expectation for residents to be offered a substitute if they do not like what was served on their tray.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview the facility failed to ensure Physician Orders for Scope of Treatment (POST) forms were completed for 1 resident (#47) of 16 sampled residents. The findings include: Review of the facility policy, Code/No Code, reviewed 1/2019 revealed .Complete a Physician Orders for Scope of Treatment .attending physician should review and a healthcare professional should initial POST . Review of the POST form, Directions for Health Care Professionals, revised June 25, 2015, revealed .POST must be signed by a physician . Medical record review revealed Resident #47 was admitted to the facility on [DATE] with diagnoses including Nontraumatic Intracerebral Hemorrhage, Hypertension, Hypothyroidism, and Altered Mental Status. Medical record review of the POST form with a Date Prepared date of 4/3/19 revealed Resident #47 had a Do Not Attempt Resuscitation status and Comfort Measures Only. Continued review revealed the Physician had not signed or dated the form for Resident #47. Interview with the Director of Nursing on 6/12/19 at 8:44 AM, in the conference room, confirmed the Physician failed to sign the POST form for Resident #47.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to develop a Comprehensive Care Plan to include predetermined resuscitation status for 1 resident (#47) of 16 sampled residents. The findings include: Medical record review revealed Resident #47 was admitted to the facility on [DATE] with diagnoses including Nontraumatic Intracerebral Hemorrhage, Hypertension, Hypothyroidism, and Altered Mental Status. Medical record review revealed no resuscitation status had been included in the Comprehensive Care Plan dated 4/12/19 for Resident #47. Interview with the Director of Nursing on 6/12/19 at 8:44 AM, in the conference room, revealed the facility failed to develop a Comprehensive Care Plan to include the resuscitation status for Resident #47.

**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 follow Physician's Orders for tube feeding for 1 resident (#19) of 5 residents reviewed for tube feeding of 16 sampled residents. The findings include: Review of the facility policy .Tube Feeding . revised date 1/2019, revealed .A resident who is fed by enteral means receives appropriate treatment and services . Medical record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including Dysphagia, Acute Respiratory Failure, Heart Failure, and Tracheostomy. Medical record review of a Dietitian Communication/Physician's Order dated 5/8/19 revealed .D/C [ discontinue] current tube feed order .new order glucerna [type of tube feeding] 1.5 at 75 ml [milliters] hour with 40 ml flush . Medical record review of a Dietitian Communication/Physician's Order dated 5/15/19 revealed .increase tube feed order to glucerna 1.5 at 80 ml hour with 40 ml flush . Observation of the resident on 6/10/19 at 10:15 AM, in the resident's room, revealed the resident's tube feeding was infusing at 75 ml per hour. Further observation of Resident #19 on 6/11/19 at 3:12 PM revealed the resident's tube feeding was infusing at 75 ml per hour. Interview and observation with Charge Nurse #1 on 6/11/19 at 3:15 PM, in the resident room, revealed the rate of the tube feeding was infusing at 75 ml with a 39 ml flush rate. Continued interview revealed the resident's tube feeding pump had been changed out (replaced) over the weekend and the rate should have been set at 80 ml per hour with a 40 ml flush as the order stated. Interview with Charge Nurse #2 on 6/12/19 at 8:28 AM, by phone, revealed the resident's tube feeding pump was changed out 6/8/19, and the Charge Nurse confirmed the tube feeding rate was incorrectly entered when the pump was changed out. Interview and medical record review with the Registered Dietician on 6/12/19 at 8:37 AM, in the Administrators office, revealed the resident's revealed the resident's incorrect rate of 75 ml per hour from 80 ml per hour from 6/8/19 to 6/12/19 would not be a substantial amount to influence the resident's overall weight. Interview with the Director of Nursing on 6/12/19 at 10:55 AM, in the conference room, confirmed the tube feeding rate was to be 80 ml hour, and the facility's policy for tube feeding had not been followed.