**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, medical record review, and interview the facility failed to determine and perform a significant change Minimum Data Set (MDS) assessment for 1 of 40 sampled residents (Resident #16) reviewed. The findings include: Review of the facility MDS/Care Plan Coordinator Job Description revealed, .MDS/Care Plan Coordinator is an experienced health care provider who ensures an accurate assessment and up-to-date care plan for all residents . Review of the Resident Assessment Instrument (RAI) Version 3.0 Manual revealed, .A significant change is a decline or improvement in a resident's status .will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions . Review of medical record revealed Resident #16 admitted to facility on 8/16/2020 with diagnoses which included Metabolic Encephalopathy, Hepatic Failure, and Alcoholic Cirrhosis of Liver. Review of Resident #16's Nursing Progress Notes revealed, .12/14/2022 resident noted with IV [intravenous] fluids for hydration .responsive sluggishly to name, unable to safely swallow hs [hour of sleep] meds at present d/t [due to] cognition, resident not following verbal commands effectively HOB [head of bed] elevated for aspiration precaution .12/16/2023 resident noted with IV fluids for hydration .12/30/2022 .resident AMS [altered mental status] .start Rocephin [antibiotic] for Covid PNA [pneumonia] .would need midline placed .1/4/2023 resident presents overall weak .1/30/2023 Right Heel Unstageable wound with 100 % Eschar . Review of the Quarterly MDS dated [DATE] revealed Resident #16 had a Brief Interview for Mental Status score of 11 which indicated moderately impaired cognition. Continued review of the MDS revealed Resident #16 experience no swallowing disorders and no unhealed pressure ulcers. Review of Resident #16's Nurse Practitioner Notes revealed, .1/06/2023 Covid f/u [follow up] .2/22/2023 Pt [patient] seen today for f/u per ST [Speech Therapy] .they think Pt's excess saliva and swallowing is due to esophagus issues .ST recommends PPI [proton pump inhibitors - medications that reduce the production of acid by the stomach] Omeprazole [PPI medication] ordered .3/14/2023 .IV fluids .ordered x 3 days .3/15/2023 CXR [chest xray] shows right basilar infiltrate . During an interview on 3/15/2023 at 11:26 AM, MDS coordinator confirmed a significant change MDS assessment would be completed if a new diagnoses, significant weight loss, or overall decline in a resident. The MDS coordinator confirmed the last MDS for Resident #16 was 12/26/2022 which was a Quarterly MDS assessment. During an interview on 3/16/2023 at 9:14 AM, Wound Care Nurse stated (Resident #16) had an overall decline that started in January. It started with Covid diagnose, her nutritional status decline, we had to assist her more with meals, and then the facility acquired unstageable pressure ulcer presented on 1/30/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interviews, the facility failed to create and provide a baseline care plan for 5 of 40 (Residents #59, #62, #100, #216, and #358) sampled residents reviewed for baseline care plans. The findings include: Review of the facility's policy titled, Care Plans Baseline, dated 11/30/2022, revealed, .A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission .A comprehensive care plan may be used in place of the baseline care plan providing the comprehensive care plan is developed within 48 hours of the resident's admission and meets the requirements of a comprehensive assessment .The resident and/or record . Review of the medical record revealed Resident #34 was readmitted on [DATE] with diagnoses which included Altered Mental Status, End Stage Renal Disease, and Cerebral Infarction. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #34's Brief Interview for Mental Status (BIMS) score of 8 indicated moderately impaired cognition. Review of the care plan history detail revealed the last review of the baseline care plan was completed on 1/21/2023. The baseline care plan was not reviewed after Resident #34's readmission. During an interview on 3/6/2023 at 9:25 AM, MDS Coordinator confirmed baseline care plans should be completed on admission by the admitting nurse. During an interview on 3/6/2023 at 9:35 AM, the Wound Care Nurse confirmed Resident #34's baseline care plan has not been reviewed since her readmission on [DATE]. During an interview on 3/6/2023 at 9:45 AM, Social Service Director (SSD) confirmed, I met with [Named Resident #34] on the day of admission within 24 hours. If a resident or family wanted a copy of the care plan, I think they would have to go through medical records to be able to obtain a copy. Review of the medical record revealed Resident #59 was admitted to the facility on [DATE] and readmitted to this facility on 2/10/2023 with diagnoses of Malignant Neoplasm of Prostate, Depression and Type 2 Diabetes Mellitus with Hyperglycemia. Review of the Quarterly MDS for Resident #59 dated 2/18/2023 revealed a BIMS score of 15 which indicated no cognitive impairment. Review of the baseline care plan for Resident #59 revealed the baseline care plan was not completed within 48 hours. Review of the medical record revealed Resident #62 was readmitted to the facility on [DATE] with diagnoses which included Type 2 Diabetes and Atrial Flutter. Review of the admission MDS assessment dated [DATE] revealed Resident #62 had a BIMS score of 15 indicating no cognitive impairment. During an interview on 3/13/2023 at 9:00 AM, Resident #62 confirmed the resident had not received a copy of the baseline care plan after admission to the facility. Review of the medical record revealed Resident #100 was admitted to this facility on 2/21/2023 with diagnoses of Infection and Inflammatory Reaction Due to Internal Left Hip Prosthesis, Subsequent Encounter. Review of the Comprehensive MDS for Resident #100 dated February 10, 2023 revealed a BIMS score of 15 which indicated no cognitive impairment. During an interview on 03/13/2023 at 11:15 AM, Resident #100 confirmed she had not received a copy of her baseline care plan. Review of the medical record revealed Resident #216 was admitted to the facility on [DATE] with diagnoses which included Abscess of Bursa Left Shoulder and Type 2 Diabetes Mellitus. During an interview on 3/13/2023 at 4:09 PM, Resident #216 confirmed he was not given a copy of his baseline care plan. Review of the medical records revealed Resident #358 was admitted to the facility on [DATE] with diagnoses which included Cellulitis of Left Lower Limb, Cellulitis of Right Lower Limb, Type 2 Diabetes Mellitus without Complications. Continued review confirmed a baseline care plan was not initiated for Resident #358.

**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 have quarterly care plan conference meetings with the resident or resident's representative for 11 out of 40 sampled residents (Residents #19, #30, #32, #49, #57, #60, #69, #76, #77, #81, and #82). The findings include: Review of the undated facility policy, Care Plans, Comprehensive Person-Centered, revealed, .The interdisciplinary team [IDT], in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident .The comprehensive, person-centered care plan is developed within seven [7] days of the completion of the required MDS [Minimum Data Set] [Admission, Annual or Significant Change in Status], and no more than 21 days after admission .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .The IDT team reviews and updates the care plan .when there has been a significant change in the resident's condition .when the desired outcome is not me .when the resident has been readmitted to the facility from a hospital stay .at least quarterly, in conjunction with the required quarterly MDS assessment . Review of the undated facility policy, Care Planning-Interdisciplinary Team, revealed, The interdisciplinary team is responsible for the development of resident care plans .The IDT includes but is not limited to .resident's attending physician .a registered nurse .nursing assistant .member of the food and nutrition services staff .Care plan meetings scheduled at the best time of the day for the resident and family .if it is determined that participation of the resident or representative is not practicable for development of the care plan, an explanation is documented in the medical record . Review of the medical records revealed Resident #19 was admitted to the facility on [DATE] with diagnoses which included Human Immunodeficiency Virus Disease, Unspecified Symptoms and Signs Involving Cognitive Functions following Cerebral Infarction, and Restless Leg Syndrome. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] for Resident #19 revealed a Brief Interview for Mental Status (BIMS) score of 11 which indicated moderately impaired cognition. Review of the medical records for Resident #19 revealed one Care Plan meeting on 3/24/2021 with family involvement. No further Care Plan meetings were noted. Review of the medical records revealed Resident #30 was admitted to the facility on [DATE]which included Alzheimer's Disease, Chronic Kidney Disease, and Unspecified Protein-Calorie Malnutrition. Review of the Significant change in status MDS dated [DATE] for Resident #30 revealed a BIMS score of 2 which indicated cognitive impairment. Review of the Care Plan for Resident #30 revealed one Care Plan meeting on 12/15/2021 with family involvement. No further Care Plan meetings were noted nor any family participation in the care planning process. Review of the medical records revealed Resident #32 was admitted to the facility on [DATE] with a readmission on [DATE] with diagnoses of altered mental status, vascular dementia without behavioral disturbance, mood disturbance and anxiety. Review of the Quarterly MDS dated [DATE] revealed a BIMS score of 5 which indicated a severe cognitive impairment. Review of medical records revealed MDSs for Resident #32 were updated on 7/8/2022, 7/14/2022, 7/21/2022, 9/14/2022, 9/16/2022, 9/21/2022, 12/18/2022, 12/19/2022, 1/28/2023. Review of medical records revealed care plans for Resident #32 were completed on 2/26/2022, 7/27/2022, 9/20/2022, 11/2/2022, and 3/7/2023. Review of the medical record revealed Resident #49 was admitted to the facility on [DATE] with diagnoses which included Dementia without Behavioral Disturbance, Chronic Kidney disease, and Cerebral Infarction. Review of the Significant change in status MDS dated [DATE] for Resident #49 revealed a staff assessment for mental status which revealed memory problems. Review of the medical record for Resident #49 revealed one Care Plan meeting on 8/25/2021 with family involvement. No further Care Plan meetings were noted nor any family participation in the care planning process. Review of the medical records revealed Resident # 57 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Acute Respiratory Failure with Hypoxia, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side and Metabolic Encephalopathy. Review of the Comprehensive MDS dated [DATE] revealed Resident #57 had no BIMS score present. MDS indicated BIMS should not be conducted and Resident #57 has short-term and long-term memory problems and was severely impaired. Review of the medical records revealed MDSs for Resident #57 were updated on 11/4/2021, 2/4/2022, significant change on 2/28/2022, 5/31/2022, 8/3/2022, 11/27/2022, 12/22/2022, and 2/16/2023. Review of the medical records revealed care plans for Resident #57 were completed on 4/17/2022, 8/3/2022, 9/20/2022 and 1/12/2023. Review of the medical records revealed Resident #60 was admitted to the facility on [DATE] with diagnoses which included Schizophrenia Unspecified, Chronic Obstructive Pulmonary Disease Unspecified, and Mild Intellectual Disabilities. Review of the Quarterly MDS dated [DATE] for Resident #60 revealed a BIMS score of 12 which indicated moderately impaired cognition. Review of the medical records for Resident #60 revealed one Care Plan meeting on 11/20/2020 with resident involvement. No further Care Plan meetings were noted nor any family participation in the care planning process. Review of the medical records revealed Resident #69 was admitted to this facility on 3/12/2021 with diagnoses of Atrial Fibrillation, Essential Hypertension and Major Depressive Disorder. Review of the Quarterly MDS dated [DATE] revealed Resident #69 had a BIMS score of 15 which indicated no cognitive impairment. Review of the medical records revealed MDSs were updated on 9/10/2021, 12/10/2021, 3/15/2022, 5/22/2022, 8/24/2022, 10/24/2022, 12/23/2022, 1/5/2023 and 3/16/2023. Review of the medical records revealed the care plans for Resident #69 were completed on 10/1/2021, 1/7/2022, 4/23/2022, 8/3/2022 and 10/11/2022. Review of the medical record revealed Resident #76 was admitted to the facility on [DATE] with diagnoses which included Myoclonus, End Stage Renal Disease, Dependence on Renal Dialysis, and Type 2 Diabetes Mellitus with Diabetic Neuropathy Unspecified. Review of the Quarterly MDS dated [DATE] for Resident #76 revealed a BIMS score of 10 which indicated moderately impaired cognition. Review of the medical records for Resident #76 revealed no Care Plan Conferences had been held. Review of the medical record revealed Resident #77 was admitted to the facility on [DATE] with diagnoses which included Acute Disseminated Encephalitis and Encephalomyelitis and Encephalopathy Unspecified. Review of the Comprehensive MDS dated [DATE] for Resident #77 revealed no BIMS score documented. Review of the medical records for Resident #77 revealed one Care Plan meeting on 4/13/2022 with resident and family involvement. No further Care Plan meetings were noted. Review of the medical record revealed Resident #81 was admitted to the facility on [DATE] with diagnoses which included Encounter for Other Orthopedic Aftercare, Pneumonia due to Coronavirus Disease 2019, and Displaced Intertrochanteric Fracture of the Left Femur Subsequent Encounter for Closed Fracture with Routine Healing. Review of the Comprehensive MDS dated [DATE] for Resident #81 revealed a BIMS score of 12. Review of the medical records for Resident #81 revealed one Care Plan meeting on 1/11/2022 with resident and family involvement. No further Care Plan meetings were noted. Review of the medical record for Resident #82 revealed he was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction, Chronic Obstructive Pulmonary Disease (COPD), Schizoaffective Disorder, and Anxiety Disorder. Review of the Quarterly MDS dated [DATE] for Resident #82 revealed a BIMS score of 3 which indicated cognitive impairment. Review of the medical record for Resident #82 revealed one Care Plan meeting on 5/19/2022 with family involvement. No past Care Plan meetings were noted nor any family participation in the care planning process. During an interview on 3/15/2023 at 9:37 AM, the Social Service Director confirmed that she only does care plan conferences for long term care residents at the resident's or the family's request. She also confirmed that she has not done care conferences with Residents #19, #30, #32, #49, #57, #60, #69, #76, #77, #81, and #82. During an interview on 3/15/2023 at 11:26 AM, the MDS Coordinator confirmed, The care plan should be reviewed and revised after each annual, Quarterly MDS assessment. Each department completes their part of the MDS, completes the CAAs (Care Area Assessments), and then the department would make the care plan decisions. Every department gets notified in Point Click Care (PPC-electronic computer system) that it is time to review and revise the care plan. If the care plan was reviewed or revised it would show under the care plan review of the PCC system.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to develop and implement an effective discharge planning process for 1 of 40 sampled residents (Resident #32) reviewed for potential discharge. The findings include: Review of the undated facility policy titled, Transfer or Discharge, Facility-Initiated, revealed, .A post-discharge plan is developed for each resident .This plan will be reviewed with the resident, and/or his or her family . Review of the medical record revealed Resident #32 admitted to facility on 9/21/2020 with diagnoses which included Atherosclerotic Heart Disease and Displaced Comminuted Fracture of Right Arm. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #32 had a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderately impaired cognition. Review of the care plan revealed Resident #32 had a focus of resident expects to return to his previous living arrangement out in the community with an intervention to make arrangements with required community resources to support independence post-discharge. During an interview on 3/13/2022 at 1:20 AM, Resident #32 stated, I would like to discuss my care. I came to the facility because I broke my arm, been here two years and I would like to go back home. During an interview on 3/15/2023 at 9:37 AM, Social Service Director confirmed no documentation related to his wish to discharge. During an interview on 3/15/2023 at 11:06 AM, the Discharge planner stated, Discharge planning starts upon admission.

**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 ensure 1 of 5 sampled residents (Resident #77's) enteral tube was labeled and dated. The findings include: Review of facility policy titled, Enteral Feedings-Safety dated 3/08/2023 revealed, .2. on the formula label document initial, date and time the formula was hung, and initial that the label was checked against the order . Review of the medical record revealed Resident #77 was admitted to the facility on [DATE] with diagnoses which included Acute Disseminated Encephalitis and Encephalomyelitis Unspecified, and Encephalopathy Unspecified. Review of the Comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #77 receives nutrition by enteral tube and no Brief Inteview for Mental Status (BIMS) score was documented. Review of the current Physician's Orders for Resident #77 revealed orders for the enteral tube. Observations in Resident #77's room on 3/14/2023 at 8:22 AM and 9:50 AM, revealed enteral tube was not labeled and dated. Observation and interview in Resident #77s room on 3/14/2023 at 9:53 AM, the Unit Manager confirmed that the enteral tube should be labeled and dated. During an interview on 3/14/2023 at 10:11 AM, the Director of Nursing (DON) confirmed Resident #77's enteral tube should be labeled and dated.

**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 apply hubs to the end of an IJ (Internal Jugular Vein) Catheter external limbs and failed to apply a hub on the end of an IV (Intravenous) tubing and date the tubing for 1 of 17 (Resident #216) residents. The findings include: Review of the undated facility's policy titled, Administration Set/Tubing Changes revealed .Label tubing with date, time and initials. If a facility requires, label may include the date and time that tubing was initated and when tubing should be discontinued or changed .Place a sterile end cap on the primary and/or secondary intermittent tubing when it is disconnected from the catheter . Review of the medical record revealed Resident #216 was admitted to the facility on [DATE] with diagnosis which included Abscess of Bursa Left shoulder. Review of the Physician orders dated 3/8/2023 revealed .Vancomycin HCl Intravenous Solution Reconstituted 750 mg (milligrams) intravenously every 12 hours for L [left shoulder] Osteomyelitis . Observation and interview on 3/13/2023 at 11:22 AM revealed Resident #216 had an IJ on the right torso with three external limbs. Continued observation revealed each limb did not have a hub on the end. To the right of Resident #216 was a IV pole with a IV bag of Vancomycin with the tubing undated and no hub on the end. Resident #216 stated he admitted to the facility without hubs on the IJ. Observation and interview in Resident #216's room on 3/13/2023 at 11:34 AM, the Licensed Practical Nurse (LPN) #4 confirmed the IJ did not have hubs on the ends of the external limbs and they were supposed to be capped. Continued interview revealed the IV tubing was supposed to be dated and the end of the tubing should be capped when not in use. During an interview on 3/14/2023 at 9:39 AM, the Unit Manager for 100 hall confirmed she was aware the IJ external limbs were not capped, and the IV bag of Vancomycin tubing was undated and not capped at the end. During and interview on 3/16/2023 at 2:25 PM, the Director of Nursing (DON) stated she expected the central lines to have a hub on the ends when not in use, and the iv tubing should be dated with a hub on the end when not in use.

Based on facility record review and interview the facility failed to obtain State approval to open a Long Term Care (LTC) Hemodialysis Unit. The findings include: Review of the facility policy titled, Long-Term Care Facility Renal Dialysis Coordination Agreement, dated 11/17/2020 revealed, .agreement where by the three [3] hours per treatment, and is administered up to five [5] treatments per week, pursuant to a physician's order .to residents of the LTC facility .on the premises of the LTC facility through the Dialysis Facility's home program, including the provision of training services in the delivery of Renal Dialysis to Residents . Review of the facility email from Tennessee Department of Health dated 6/6/2022 revealed, .[Named Facility] this office received your plan (s) for the above referenced project for review and approval. This [We Concur] letter and stamp will serve as full documentation for approval and installation of nine station dialysis den as reflected on revised the attached .sketch. This letter, however, does not relieve the owner, architects, sprinkler contractors or any other subcontractors from legal and/or regulatory responsibilities associated with the documents . Review of the (named dialysis in-house clinic's) time log dated 3/17/2023 revealed 10 residents scheduled to receive hemodialysis at the LTC facility. During an interview on 3/16/2023 at 3:38 PM the Administrator stated, Our first day the facility started in-house hemodialysis was 9/20/2021. I thought that our dialysis clinic was approved. We have 10 residents receiving in house dialysis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview the facility failed to have a declination form for Influenza and Pneumococcal Immunizations for 1 of 5 (Resident #8) sampled residents reviewed. The findings include: Review of the undated facility policy titled, Influenza Vaccine revealed .All residents and employees who have no medical contraindications to the vaccine will be offered the Influenza vaccine annually to encourage and promote the benefits associated with vaccinations aganist influenza .A resident's refusal of the vaccine shall be documented on the informed consent for Influenza vaccine and placed in the resident's medical record . Review of the undated facility policy titled, Pneumococcal Vaccine revealed .All residents are offered Pneumococcal vaccines to aid in preventing Pneumonia/Pneumococcal infections .Residents/representatives have the right to refuse vaccination. If, refused, appropriate information is documented in the resident's medical record indicating the date of the refusal of the Pneumococcal vaccination . Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses which included COVID-19, Acute Respiratory Failure with Hypoxia, and Type 2 Diabetes. Review of the Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed Resident #8 had a BIMS (Brief Interview for Mental Status) score of 7 indicating severe cognitve impairment. Review of the undated Influenza Immunization Informed Consent revealed the form was not signed for acceptance or decline of the immunization. Review of the undated Informed Consent for Pneumococcal Vaccine revealed the form was not signed for acceptance or decline of the immunization. During an interview on 3/15/2023 at 9:10 AM, Infection Preventionist confirmed the consent forms for Influenza and Pneumococcal are supposed to be filled out if refused.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to have a declination form for the COVID-19 vaccination for 1 of 5 (Resident #8) sampled residents reviewed. The findings include: Review of the medical record revealed Resident #8 was admitted to the facility on [DATE] with diagnoses which included COVID 19, Acute Respiratory Failure with Hypoxia, and Type 2 Diabetes. Review of the Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed Resident #8 had a BIMS (Brief Interview for Mental Status) score of 7 indicating severe cognitve impairment. Review of the undated COVID-19 Informed Consent Form revealed the form was not signed for acceptance or declination of the immunization. During an interview on 3/15/2023 at 9:10 AM, the Infection Preventionist confirmed the consent form for the COVID-19 vaccination was supposed to be filled out if they refuse.

Based on facility policy review, observation, and interview the facility failed to have 1 of 40 operable call lights. The findings include: Review of the undated facility policy titled, Answering the Call Light revealed .Be sure the call light is plugged in and functioning at all times . Observation and interview in Resident #62's room on 3/14/2023 at 9:22 AM, Resident #62 stated his call light was not working. Continued interview revealed I push the hell out of the button before it will come on. Observation and interview in Resident #62's room on 3/14/2023 at 9:35 AM, confirmed the Unit Manger pressed the call light and it was not working. The Unit Manager reset the call light button and the light lit up. Then she turned it off and pressed the button again and it did not work. During an interview on 3/14/2023 at 9:45 AM, the Director of Maintenance confirmed the call light cord was worn and had been dropped which caused it not to work.

Based on facility policy review, observation, and interview the facility failed to have adequate dining space for 3 of 3 rooms in the facility. The findings include: Review of the facility policy titled, TN COVID Communal Dining and Activity Programs, and Resident Outings revised 11/2022, revealed .Communal actvities and dining do not have to be paused during an outbreak, unless directed by the state or local health department . Observation in the 600 hall activties/dining room on 3/14/2023 at 7:55 AM revealed the door had a key pad which required a code before entering. There was a big TV (television) and various tables and chairs used for actvities. Contnued observation revealed games and activties stacked up aganist the wall on the shelves. Observation in the dining area for the 100, 200, 300, and 400 halls (Rehabilitation unit) on 3/15/2023 at 9:39 AM revealed one table with three chairs and two couches. Observation in the dining room on the 500 hall on 3/15/2023 at 9:55 AM revealed many items from different parts of the building stored in the room. The room had no space for communal dining. During an interview on 3/14/2023 at 8:48 AM, the Administrator stated the residents were having meals in their rooms at the time because of the construction which was currently happening at the facility. During an interview on 3/15/2023 at 9:42 AM, the Staffing Educator stated the Rehabilitation unit did not have communal dining area. During an interview on 3/15/2023 at 11:43 AM, the Activities Director confirmed the 600 hall dining room was a multipurpose room which held activities. The dining room held lunch club every day which was changed to movie time because many residents wanted to continue to watch TV or movies while eating. Continued interview revealed a dinner was held in the 600 hall dining room once a month. The residents who required assistance with their meals ate in their rooms. The Actvities Director stated it is not fine dining.

Based on facility policy review, observation, and interview, the facility failed to maintain clean and sanitary equipment for 1 of 3 ice machines and 2 of 2 stove drip pans. The facility also failed to properly store refrigerated foods in 1 of 2 walk-in coolers. The findings include: Review of the facility's policy titled, Sanitization, revealed, .The food service area is maintained in a clean and sanitary manner .Ice chests and coolers used to store and transport ice are cleaned regularly . Review of the facility's policy, Ice Machines and Ice Storage Chests, revealed, .Ice machines and ice storage/distribution containers will be used and maintained to assure a safe and sanitary supply of ice .Ice-making machines, ices storage chests/containers, and ice can all become contaminated by .unsanitary manipulation . Observation and interview in the kitchen on 3/13/2023 at 10:15 AM, revealed the small and large drip pans with large amounts of black, brown debris covering the width of pans. The Dietary Aide #2 confirmed the drip tray should be cleaned after every use. Observation and interview in the kitchen on 3/13/2023 at 10:20 AM, the Administrator confirmed the drip pans need to be cleaned immediately. Observation and interview of the walk-in cooler on 3/13/2023 at 10:30 AM, revealed sliced cheese wrapped in clear wrap with no label or date. The Dietary Aide #2 confirmed it should be labeled, dated, and the Dietary Aide #2 discarded the cheese. Observation and interview of the Kitchen ice machine on 3/13/2023 at 10:45 AM, revealed a carton (8 ounces) of liquid nutrition supplement was submerged down in the ice. The Dietary Aide #2 pulled the carton from the ice machine and stated, That should not be placed down in the ice chest.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interviews, the facility failed to report an allegation of abuse for 1 of 3 residents (Resident #1) reviewed. The findings include: Review of the facility's undated policy titled, Abuse Prevention Program, revealed, .Our residents have the right to be free from abuse, neglect, misappropriation or resident property, corporal punishment, and involuntary seclusion .Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Our abuse prevention program provides policies and procedures that govern, as a minimum: .d. The protection of residents during abuse investigations .f. Timely and thorough investigations of all reports and allegations of abuse .Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse . Review of the facility's undated policy titled, Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating, revealed, .All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported .If resident abuse, neglect .the suspicion must be reported immediately to the administrator and to other officials according to state law .The administrator .immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; The local/state ombudsman; The resident's representative; Adult Protective Services .Immediately is defined as: within two hours of an allegation involving abuse or result in serious bodily injury .All allegations are thoroughly investigated .Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete . Review of the facility's undated policy titled, Resident Rights, revealed, .Employees shall treat all residents with kindness, respect, and dignity .Residents are entitled to exercise their rights and privileges to the fullest extent possible . Review of Certified Nurse Assistant #1's employee file revealed date of hire as [DATE]. Continued review revealed an active CNA license #209088 with an expiration date of [DATE]. Continued review revealed he was educated on Resident Rights and the Abuse Policy on [DATE]. Continued review revealed a background check, including the Abuse Registry, was completed on [DATE]. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Malignant Neoplasm of Colon, Intra-abdominal and Pelvic Swelling, Mass and Lump, and Chronic Pain Syndrome. Review of the Significant Change in Status Minimum Data Set (MDS) assessment for Resident #1 dated [DATE], revealed a BIMS score of 11, which indicated moderate cognitive impairment. Continued review revealed she felt down, depressed, or hopeless nearly everyday during the assessment period. Review of the Care Plan for Resident #1 revealed she had problems/assessments for weight decline, the use of antidepressant medications, anemia, colostomy, requires assistance with activities of daily living (ADL)s, use of antipsychotics, and comfort measures only. Appropriate goals and interventions were in place. Review of the Progress Notes for Resident #1 revealed was seen by the Nurse Practitioner (NP) for an acute mental status change on [DATE]. She was also seen by the NP on [DATE] due to having 2 falls the day before. The note stated, . pt [patient] not oriented to place or time, but states she fell and hit back of neck/head area .Per nursing staff, pt is more confused than normal. Pt refuses to go to hospital . Continued review revealed she expired on [DATE] at 11:50 PM. During a phone interview on [DATE] at 9:30 AM, Lab Technician (Lab Tech) #1 stated she has only been to this facility once, and it was on the day she claimed she saw Resident #1 not being cared for. She stated when she entered the room, the resident had one leg off the bed and was yelling, Don't let me fall. She stated the bed covers were off the resident and she was exposed up to her chest area. She stated the resident told her she was afraid because the male CNA slaps her and pulls her blanket up over her head. She stated she went and asked the male CNA to help her pull her up in bed. She stated the male CNA, whom the resident had accused of slapping her, came in the room to help. She stated she went to a male Medication Technician (Med Tech) on the first floor and told him what she had witnessed and what the resident had told her about the CNA slapping her and pulling the blanket over her head. She stated he told her to go to the front lobby and tell the lady behind the desk. She stated she did go and tell (Named employee) what had happened. She stated this employee stopped her and took her to a conference room where the Assistant Director of Nursing (ADON) came in and she stated she told her everything she had witnessed and heard. She stated the ADON did not appear interested in what she was saying and told her the resident has cancer and it has moved to her brain. She stated the ADON told her the resident refused care that morning and that's why she looked like she did. During an interview on [DATE] at 10:00 AM, Med Tech #1 stated on [DATE] a Lab Tech came to him and said she had concerns about a resident in room [ROOM NUMBER]. He stated she was visibly upset and told him the resident was being abused by the CNA. He stated he stopped her and told her to go tell [Named Unit Manager.] During an interview on [DATE] at 10:33 AM, UM #1 stated on [DATE] the Lab Tech came to her and told her she saw something she didn't like. She stopped her there, and told her she would get the ADON, which she stated she did right away. She stated the ADON came and talked to her from there. During an interview on [DATE] at 10:45 AM, the ADON stated the Lab Tech had voiced concerns about Resident 1's care. She stated the Lab Tech told her the resident was uncovered, dirty and her mouth was dry. During a phone interview on [DATE] at 12:20 PM, CNA #1 stated he had taken care of Resident #1 several times. He stated she was always very pleasant and didn't ask for much. He stated she had never accused him of being mean to her. He stated last Monday ([DATE]) she had declined and was not as responsive as she usually was. He stated the Lab Tech asked him to help her get her straightened back up in the bed. He stated they straightened her out and repositioned the linens under her. He stated she was not incontinent. He stated he has never been accused of being abusive and has never been written up for anything. He stated he has never slapped her nor pulled her blanket over her face. During an interview on [DATE] at 3:34 PM, the Administrator stated the ADON told him a Lab Tech complained to her about a care issue with Resident #1. He stated he was told the resident was not appropriately being cared for. He stated he was not told the resident had accused a CNA of slapping her or pulling the covers over her head. He stated he should have been notified immediately of the allegation and was not. He confirmed the Med Tech should have reported the allegation immediately to either himself, or to his manager, and he did not. He confirmed he should have reported the accusation to the State Agency and an immediate investigation should have been started.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interviews, the facility failed to thoroughly investigate an allegation of abuse for 1 of 3 residents (Resident #1) reviewed. The findings include: Review of the facility's undated policy titled, Abuse Prevention Program, revealed, .Our residents have the right to be free from abuse, neglect, misappropriation or resident property, corporal punishment, and involuntary seclusion .Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Our abuse prevention program provides policies and procedures that govern, as a minimum: .d. The protection of residents during abuse investigations .f. Timely and thorough investigations of all reports and allegations of abuse .Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse . Review of the facility's undated policy titled, Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating, revealed, .All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported .If resident abuse, neglect .the suspicion must be reported immediately to the administrator and to other officials according to state law .The administrator .immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; The local/state ombudsman; The resident's representative; Adult Protective Services .Immediately is defined as: within two hours of an allegation involving abuse or result in serious bodily injury .All allegations are thoroughly investigated .Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete . Review of the facility's undated policy titled, Resident Rights, revealed, .Employees shall treat all residents with kindness, respect, and dignity .Residents are entitled to exercise their rights and privileges to the fullest extent possible . Review of Certified Nurse Assistant #1's employee file revealed date of hire as [DATE]. Continued review revealed an active CNA license #209088 with an expiration date of [DATE]. Continued review revealed he was educated on Resident Rights and the Abuse Policy on [DATE]. Continued review revealed a background check, including the Abuse Registry, was completed on [DATE]. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Malignant Neoplasm of Colon, Intra-abdominal and Pelvic Swelling, Mass and Lump, and Chronic Pain Syndrome. Review of the Significant Change in Status Minimum Data Set (MDS) assessment for Resident #1 dated [DATE], revealed a BIMS score of 11, which indicated moderate cognitive impairment. Continued review revealed she felt down, depressed, or hopeless nearly everyday during the assessment period. Review of the Care Plan for Resident #1 revealed she had problems/assessments for weight decline, the use of antidepressant medications, anemia, colostomy, requires assistance with activities of daily living (ADL)s, use of antipsychotics, and comfort measures only. Appropriate goals and interventions were in place. Review of the Progress Notes for Resident #1 revealed was seen by the Nurse Practitioner (NP) for an acute mental status change on [DATE]. She was also seen by the NP on [DATE] due to having 2 falls the day before. The note stated, . pt [patient] not oriented to place or time, but states she fell and hit back of neck/head area .Per nursing staff, pt is more confused than normal. Pt refuses to go to hospital . Continued review revealed she expired on [DATE] at 11:50 PM. During a phone interview on [DATE] at 9:30 AM, Lab Technician (Lab Tech) #1 stated she has only been to this facility once, and it was on the day she claimed she saw Resident #1 not being cared for. She stated when she entered the room, the resident had one leg off the bed and was yelling, Don't let me fall. She stated the bed covers were off the resident and she was exposed up to her chest area. She stated the resident told her she was afraid because the male CNA slaps her and pulls her blanket up over her head. She stated she went and asked the male CNA to help her pull her up in bed. She stated the male CNA, whom the resident had accused of slapping her, came in the room to help. She stated she went to a male Medication Technician (Med Tech) on the first floor and told him what she had witnessed and what the resident had told her about the CNA slapping her and pulling the blanket over her head. She stated he told her to go to the front lobby and tell the lady behind the desk. She stated she did go and tell (Named employee) what had happened. She stated this employee stopped her and took her to a conference room where the Assistant Director of Nursing (ADON) came in and she stated she told her everything she had witnessed and heard. She stated the ADON did not appear interested in what she was saying and told her the resident has cancer and it has moved to her brain. She stated the ADON told her the resident refused care that morning and that's why she looked like she did. During an interview on [DATE] at 10:00 AM, Med Tech #1 stated on [DATE] a Lab Tech came to him and said she had concerns about a resident in room [ROOM NUMBER]. He stated she was visibly upset and told him the resident was being abused by the CNA. He stated he stopped her and told her to go tell [Named Unit Manager.] During an interview on [DATE] at 10:33 AM, UM #1 stated on [DATE] the Lab Tech came to her and told her she saw something she didn't like. She stopped her there, and told her she would get the ADON, which she stated she did right away. She stated the ADON came and talked to her from there. During an interview on [DATE] at 10:45 AM, the ADON stated the Lab Tech had voiced concerns about Resident 1's care. She stated the Lab Tech told her the resident was uncovered, dirty and her mouth was dry. During a phone interview on [DATE] at 12:20 PM, CNA #1 stated he had taken care of Resident #1 several times. He stated she was always very pleasant and didn't ask for much. He stated she had never accused him of being mean to her. He stated last Monday ([DATE]) she had declined and was not as responsive as she usually was. He stated the Lab Tech asked him to help her get her straightened back up in the bed. He stated they straightened her out and repositioned the linens under her. He stated she was not incontinent. He stated he has never been accused of being abusive and has never been written up for anything. He stated he has never slapped her nor pulled her blanket over her face. During an interview on [DATE] at 3:34 PM, the Administrator stated the ADON told him a Lab Tech complained to her about a care issue with Resident #1. He stated he was told the resident was not appropriately being cared for. He stated he was not told the resident had accused a CNA of slapping her or pulling the covers over her head. He stated he should have been notified immediately of the allegation and was not. He confirmed the Med Tech should have reported the allegation immediately to either himself, or to his manager, and he did not. He confirmed he should have reported the accusation to the State Agency and an immediate investigation should have been started.

**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 and update a care plan for 1 resident (#46) of 52 residents reviewed. The findings include: Review of facility policy, Care Plans-Comprehensive revised September 2010 revealed .Assessments of residents are ongoing care plans are revised as information about the resident and the resident's condition change .The care planning/Interdisciplinary Team is responsible for the review and updating of care plans .When there has been a significant change in the resident's condition .When the desired outcome is not met .When the resident has been re-admitted to the facility from a hospital stay .At least quarterly . Medical record review revealed Resident #46 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Cognitive Communication Deficit and Dysphagia. Medical record review of Resident #46's Physician Order Summary Report dated 4/12/19 revealed .Consistent CHO [carbohydrate] diet mechanically altered ground texture, Nectar consistency .4/16/19 ST [Speech Therapy] downgrade patient to total feed for all meals to maximize PO [by mouth] intake and decrease weight loss . Medical record review of Resident #46's 5 day Minimum Data Set, dated [DATE] revealed the resident required extensive assistance with eating. Medical record review of Resident #46's Speech Therapy Encounter Note dated 4/16/19 revealed .Patient downgraded to total feed with staff educated on swallow strategies . Medical record review of Resident #46's [NAME] (aide care plan), undated, revealed .Eating: (0/1) Independent and Setup help needed . Medical record review of Resident #46's Daily Skilled Nursing Flowsheet dated 4/16/19 revealed .total assistance needed for eating and drinking . Observation on 4/23/19 at 8:15 AM and on 4/24/19 at 8:37 AM in Resident #46's room revealed the resident in bed with an untouched breakfast tray on the bedside table in front of the resident. Interview with Certified Nurse Aide (CNA) #1 on 4/24/19 at 8:55 AM in the family lounge revealed CNA #1 did not have residents which required assistance with meals. Continued interview revealed Resident #46 only needed cues during meals. Interview with Licensed Practical Nurse (LPN) #2 on 4/24/19 at 10:29 AM in the family lounge revealed, staff set up Resident #46's meal trays and the resident would feed himself. Continued interview revealed .it's more of an encouragement . than providing assistance. Interview with Registered Nurse #1 on 4/24/19 at 1:08 PM in her office confirmed Resident #46 required total assistance with all meals. Continued interview revealed .once we get the order we can update the [NAME] . Continued interview confirmed .theoretically the [NAME] needed to be updated as soon as the order comes through . Interview with the Director Of Nursing on 4/24/19 at 1:23 PM in her office when asked to review Resident #46's [NAME] she confirmed it wasn't updated to reflect total dependence with meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to follow physician orders to provide total assistance with meals for 1 resident (#46) of 52 residents reviewed. The findings include: Medical record review revealed Resident #46 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Cognitive Communication Deficit and Dysphagia. Medical record review of Resident #46's Physician Order Summary Report dated 4/12/19 revealed .Consistent CHO [carbohydrate] diet mechanically altered ground texture, Nectar consistency .4/16/19 ST [Speech Therapy] downgrade patient to total feed for all meals to maximize PO [by mouth] intake and decrease weight loss . Medical record review of Resident #46's 5 day Minimum Data Set, dated [DATE] revealed the resident required extensive assistance with eating. Medical record review of Resident #46's Speech Therapy Encounter Note dated 4/16/19 revealed .Patient downgraded to total feed with staff educated on swallow strategies . Medical record review of Resident #46's [NAME] (aide care plan), undated, revealed .Eating: (0/1) Independent and Setup help needed . Medical record review of Resident #46's Daily Skilled Nursing Flowsheet dated 4/16/19 revealed .total assistance needed for eating and drinking . Observation on 4/23/19 at 8:15 AM and on 4/24/19 at 8:37 AM in Resident #46's room revealed the resident in bed with an untouched breakfast tray on the bedside table in front of the resident. Interview with Certified Nurse Aide (CNA) #1 on 4/24/19 at 8:55 AM in the family lounge revealed CNA #1 did not have residents which required assistance with meals. Continued interview revealed Resident #46 only needed cues during meals. Interview with Licensed Practical Nurse (LPN) #2 on 4/24/19 at 10:29 AM in the family lounge revealed, staff set up Resident #46's meal trays and the resident would feed himself. Continued interview revealed .it's more of an encouragement . than providing assistance. Interview with Registered Nurse #1 on 4/24/19 at 1:08 PM in her office confirmed Resident #46 required total assistance with all meals. Interview with the Director Of Nursing on 4/24/19 at 1:23 PM in her office confirmed the physician's orders for Resident #46 were not followed related to meal assistance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review and interview, the facility failed to maintain an accurate and complete record for 1 resident (#18) of 52 residents reviewed related to the Physician Orders and Physician Orders For Life Sustaining Treatment/Physician Orders for Scope of Treatment (POLST/POST) form not matching. The findings include: Review of the facility policy, Advance Directives-MOLST (Medical Orders For Life Sustaining Treatment) / POLST (Physician Orders For Life Sustaining Treatment), undated, revealed .Residents of the facility will have their advance directives [including MOLST and POLST] honored .These will be reviewed upon admission and periodically throughout their stay .MOLST/POLST is a medical order form that tells others the resident's/patient's wishes regarding life-sustaining treatment .It is designed to communicate the individual's wishes about a range of life-sustaining and resuscitative measures .It is a portable, valid and immediately actionable medical order consistent with the individual's wishes and current medical condition, which will be honored across treatment settings .The MOLST/POLST form is legally sufficient and recognized as a medical order .The order will be added to the resident's admitting orders .If Do Not Resuscitate [DNR] is indicated on the MOLST/POLST, the facility will follow procedure for communication and documentation of the DNR . Medical record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses which included Chronic Obstructive Pulmonary Disease and Kidney Transplant Status. Medical record review of Resident #18's admission Minimum Data Set, dated [DATE] revealed the resident had a Brief Interview of Mental Status Score of 12 indicating the resident was moderately cognitively impaired. Further review revealed the resident makes self understood and understand others. Medical record review of Resident #18's POST/POLST form dated [DATE] revealed .the resident was to be resuscitated, meaning to perform Cardiopulmonary Resuscitation (CPR) if the resident had no pulse and was not breathing . Medical record review of Resident #18's Physician Order Summary dated [DATE] revealed .MOLST: Do Not Resuscitate (DNR) . Medical record review of Resident #18's comprehensive care plan dated [DATE] with revision on [DATE] revealed .Resident has advanced directive of DNR .Resident Advance Directives will be regarded and respected .Properly label medical records and follow Advance Directives . Interview with Licensed Practical Nurse #1 on [DATE] at 10:00 AM at the 600 Hall nurse station revealed when a resident codes (has no pulse and is not breathing) staff go to the chart and look at the POST form to determine whether the resident is full code (requiring CPR) or DNR. Continued interview revealed the resident's code status was also recorded on the resident's physician orders. Interview with the 600 Hall Unit Manager on [DATE] at 10:20 AM at the 600 Hall nurse station confirmed if a resident codes, staff were to look at the POST form in the resident's chart and verify it with the physician order. Continued interview when asked to review Resident #18's POLST/POST form and Physician Order Summary she stated these should match and they don't. Interview with the Director of Nursing on [DATE] at 10:23 AM in her office revealed the resident's POST form declares the resident resuscitation status. Continued interview revealed, once the declaration is confirmed the order is written and would match the POST form. Continued interview when asked to review Resident #18's POST form and Physician Order Summary confirmed the POST form and orders for Resident #18 did not match.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to report allegations of abuse within the 2-hour time frame as required to the State Agency for 2 residents of 7 sampled residents (Resident #82 and Resident #83) reviewed for abuse. Findings include: Review of facility policy Abuse Reporting revised 11/23/17 revealed, .All alleged suspected violations .are required to be promptly reported to appropriate state agencies .as required by law .The facility must report abuse .immediately but not later than 2 hours . Medical record review revealed Resident #82 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Altered Mental Status, Cognitive Communication Deficit, Diabetes Mellitus Type 2, Anemia, Chronic Kidney Disease Stage 3 and Metabolic Encephalopathy. Review of a facility investigation involving Resident #82 with an occurrence date of 2/8/18 at 5:40 PM revealed an allegation of abuse. Continued review revealed the facility reported the allegation of abuse on 2/9/18 at 3:23 PM (8 hours past 2-hour timeframe). Medical record review revealed Resident #83 was admitted to the facility on [DATE] with diagnosis including Alzheimer's Disease, Generalized Anxiety Disorder, Psychotic Disorder with Delusions, Major Depressive Disorder, Diabetes Mellitus Type 2 with Diabetic Polyneuropathy, Hypertension, and Status-post Myocardial Infarction. Review of a facility investigation involving Resident #83 with an occurrence date of 2/25/18 at 11:00 AM revealed an allegation of abuse. Continued review revealed the facility reported the allegation of abuse on 2/25/18 at 4:41 PM (14 hours and 41 minutes past 2-hour timeframe). Interview with the Administrator on 4/11/18 at 4:00 PM in the Administrator's office confirmed the facility failed to report the allegations of abuse for Resident #82 and Resident #83 to the State Agency within the 2-hour time frame.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to accurately assess the Minimum Data Set (MDS) for 1 of 44 sampled residents (Resident #60) reviewed for MDS accuracy. Findings include: Medical record review revealed Resident #60 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Hypertension and Malignant Neoplasm of the Bladder. Medical record review of the Physician's Order Summary dated 3/18/18, revealed an order for Humalog (insulin) inject as per sliding scale every 6 hours. Continued review revealed an order for Oxycodone (opioid pain medication) 15 mg (milligrams) every 6 hours as needed for pain. Medical record review of the Medication Administration Record (MAR) for 3/2/18 - 3/8/18 (7 day lookback period) revealed Resident #60 received insulin 2 of 7 days and an opioid 7 of 7 days of the lookback period. Medical record review of the 30 day MDS dated [DATE] revealed Resident #60 was assessed for receiving insulin 7 of 7 days and an opioid for 0 of 7 days in the lookback period. Interview with the MDS Coordinator on 4/11/18 at 12:53 PM in her office, after reviewing the MDS and the MAR, confirmed the facility failed to accurately assess the medication portion of the MDS for Resident #60.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and interview, the facility failed to provide wound care treatments as ordered for 1of 44 sampled residents (Resident #98) reviewed. Findings include: Medical record review revealed Resident #98 was admitted to the facility on [DATE] with diagnoses including Encounter for Surgical Aftercare following Surgery on the Genitourinary System, Infection Following a Procedure, Malignant Neoplasm of Vulva, Acute Kidney Failure, Cellulitis of Groin, Hypertension, Need for Assistance with Personal Care and Difficulty in Walking. Medical record review of a Brief Interview for Mental Status (BIMS) dated 4/9/18 revealed Resident #98 scored a 15 indicating she was cognitively intact. Observation and interview with Resident #98 on 4/9/18 at 11:57 AM in her room revealed the resident had a large dressing across her lower abdomen. Continued observation revealed the bottom of her gown was darker in color than the top of her gown and the resident reported it was wet. Interview with the resident revealed there were Physician's orders to change the dressing twice a day (once each shift) and as needed (PRN). Continued interview revealed the resident reported the surgical wound was draining so much the dressing became saturated and she could feel fluid running down her right groin area. This caused her gown and bed linens to become saturated. Further interview revealed Licensed Practical Nurse (LPN) #10 had changed the dressing at 7:00 AM and when she got up to use the bedside commode fluid was running down her legs and dripping onto the floor and the dressing was totally saturated again. Resident #98 stated she asked LPN #10 to change her dressing again but he told her that it could not be changed until the 2nd shift (night shift). Interview with Resident #98 on 4/10/18 at 9:00 AM in her room stated her dressing was not changed until 8:00 PM on 4/9/18 and she laid in a wet gown and bed linens until then. The resident stated her sheets and gown were soaked again this morning until 5:00 AM when the dressing was changed, and she was concerned about developing bed sores. Medical record review of Physician's Orders dated 4/5/18 for Resident #98 revealed .clean surgical site to groin with saline pack with wet to dry kerlex dressing to wound bed, cover with ABD [army battle dressing used for heavy drainage and large wounds] pad secure with tape or bordered gauze dressing twice daily and prn [as needed] . Medical record review of the Treatment Administration Record (TAR) dated 4/2018 for Resident #98 revealed omissions (no documentation) of dressing changes on 4/8/18 and 4/10/18 on night shift. Continued review revealed the dressing was changed 2 times PRN since admission [DATE]). Interview with LPN #5 (wound nurse) on 4/11/18 at 9:15 AM in the 400 hallway confirmed she changed Resident #98's dressing daily on day shift Monday-Friday and the nurses changed it when she was not there and on the weekends. Continued interview revealed the wound was open approximately 12 inches and draining large amounts of serosanguinous (blood and serum) fluid. Continued interview with LPN #5 stated she used 3-4 rolls of kerlix to pack the wound and stated, .It was changed at 5:00 AM this morning and we changed it at 9:00 AM and it was completely saturated . Interview with the Nurse Practitioner (NP) on 4/11/18 at 9:30 AM by the 300-400 hall nurse station confirmed the wound for Resident #98 was very slow to heal because of the location and stated, .It's draining copious [large] amounts of fluid . Continued interview revealed the wound would continue to drain due to the involvement of the lymphatic system and location of wound. The NP confirmed the wound measured 20 x 45 x 8.5 centimeters (cm) and had undermining (tunneling) at 3 o'clock of 6 cm and undermining at 6 o'clock of 8 cm. Medical record review of the TAR revealed LPN #5 performed dressing changes on 4/9/18, 4/10/18 and 4/11/18 on the day shift. Interview with Assistant Director of Nursing (ADON) on 4/11/18 at 6:05 PM in her office confirmed the facility failed to provide wound care as ordered on 4/8/18 and 4/10/18 night shift for Resident #98, and failed to provide more frequent dressing changes when requested by the resident and per physician order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Medical record review revealed Resident #36 was admitted to the facility on [DATE] on with diagnoses including Gastrostomy Status. Medical record review of a Dietary-Diet order dated 11/29/17 revealed .Jevity 1.5 via GT [gastrostomy tube] at 85 cc/hr [cubic centimeter] for 14 hours .(6p-8a) . Observation on 4/11/18 at 9:15 AM and at 9:40 AM revealed Resident #36 was receiving Jevity 1.5 tube feeding at 85 cc/hr. Interview with LPN #7 on 4/10/18 at 9:40 AM in Resident #36's room revealed the LPN was aware the residents tube feeding was to be administered from 6:00 PM - 8:00 AM. Further interview confirmed the feeding was to stop at 8:00 AM. LPN #7 had no explanation as to why the feeding was not stopped. The facility failed to follow the Physician's Order for the tube feeding administration of Resident #36. Based on review of the facility policy, medical record review, observation, and interview, the facility failed to administer the enteral feeding per the Physician's Order for 2 of 10 sampled residents (Resident #28, Resident #36) reviewed with enteral feedings. Findings include: Review of the Enteral Tube Feeding via Continuous Pump policy dated 3/2015, revealed .Preparation .Verify .there is a physician's order .Steps in the Procedure .Check the label on the enteral formula against the physician order .Initiate Feeding .On the formula label document initials, date and time the formula was hung/administered, and initial that the label was checked against the order . Medical record review revealed Resident #28 was originally admitted to the facility on [DATE] with diagnoses including Enteral Feeding. The resident was hospitalized from [DATE] to 3/19/18. The resident was readmitted to the facility on [DATE] with the Enteral Feeding. Medical record review of the Physician's Order dated 4/4/18 revealed the enteral feeding of .Jevity 1.5 .at 86 ml/hr. [milliliters per hour] x [for] 18 hrs/d [hours per day] . Observation on 4/9/18 at 11:15 AM of Resident #28's enteral (tube) feeding bottle label revealed the Jevity 1.5 was started at 8:30 AM at the rate of 70 ml/hr. Further observation revealed the tube feeding pump was set at 70 ml/hr. Observation on 4/9/18 at 4:40 PM revealed Resident #28 in his room in bed with the tube feeding being administered. Observation of the tube feeding bottle label revealed the rate was 70 ml/hr and the pump was set at 70 ml/hr which was not per Physician's Order. Medical record review of the April 2018 Medication Administration Record revealed the tube feeding had been administered at 70 ml/hr. on 4/7/18 through 4/9/18. Interview with Licensed Practical Nurse (LPN) #1 on 4/9/18 at 4:40 PM in Resident #28's room confirmed she was assigned to care for the resident. Further interview confirmed the LPN had hung the tube feeding bottle, completed the tube feeding bottle label information, and began the administration of the tube feeding on 4/9/18 at 8:30 AM. Further interview confirmed the tube feeding rate was set at 70 ml/hour which was not what was ordered by the Physician. Further interview revealed LPN #1 had administered the tube feeding at 70 cml/hr.for a couple of days now . Further interview, after reviewing the Physician's Order, confirmed the ordered rate for the tube feeding was 86 ml/hr. Further interview confirmed the facility failed to administer the tube feeding as ordered by the physician. Interview with the Director of Nursing (DON) on 4/10/18 at 8:30 AM at the 500 hall nursing station revealed the DON was .aware the nurse had administered the tube feeding at 70 ml/hr. the last 3 days . Further interview confirmed the facility failed to follow the Physician's Order to administer Resident #28's tube feeding at 86 ml/hr.

**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 administer pain medication in a timely manner as ordered for 3 of 44 sampled residents (Resident #90, Resident #342, and Resident #99) reviewed. Findings include: Review of facility policy Pain-Clinical Protocol revised March 2015 revealed .Strategies that may be employed when establishing the medication regimen include: Combining long-acting medications with PRNs[as needed] for breakthrough pain. Implementing the medication regimen as ordered, carefully documenting the results of the interventions. Administer pain medication as ordered. The staff will reassess the individual's pain and related consequences at regular intervals; at least each shift for acute pain or significant changes in levels of chronic pain at least weekly in stable chronic pain . Medical record review revealed Resident #342 was admitted to the facility on [DATE] with diagnoses including Fracture, Diabetes Mellitus, Heart Failure, and Depression. Medical record review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #342 had a Brief Interview of Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Medical record review of the Physician's Orders dated 3/28/18 revealed OxyContin (pain medication) Tablet ER (extended release) 12 hour give 10 milligrams (mg) by mouth two times every twelve hours. Roxicodone (pain medication) Tablet give 15 milligrams (mg) by mouth every four hours as needed. Medical record review of the 4/1/18 - 4/31/18 Medication Administration Record revealed the Oxycodone HCL ER 10 mg 1 tablet every 12 hours was to be administered at 9:00 AM and 9:00 PM. Medical record review of the Controlled Substances (to be completed when the medication was administered) dated 4/10/18 and 4/11/18 revealed Oxycodone HCL ER 10 mg 1 tablet by mouth every 12 hours was signed out at 1338 (1:38 PM), and 2100 (9:00 PM). Observation and interview with Resident #342 on 4/10/18 at 8:10 AM in the resident's room revealed the resident was rubbing her left leg. Interview revealed the resident had received PRN pain medication at 6:30 AM. Medical record review of the Progress Notes (automatically generated a time stamp of the medication administration) revealed Oxycodone HCL ER 10 mg 1 tablet by mouth every 12 hours was signed out electronically at 10:35 AM on 4/10/18, 1 hour and 30 minutes after the prescribed administration time. Further review revealed the Oxycodone was signed out electronically at 12:20 AM on 4/11/18, 3 hours and 20 minutes after the prescribed administration time. Interview with Resident #342 on 4/10/18 at 8:10 AM in her room revealed .My morning medications, I don't never get them until after breakfast. I have to wait a long time for my pain medication . Further interview revealed the resident asked the nurse why do I have to wait for pain medication? and the resident stated to the nurse you never gave me none in the first place. Why do I have to wait 2 more hours? Interview with Licensed Practical Nurse (LPN) #12 on 4/11/18 at 3:00 PM on the 200 hall confirmed she administered 9:00 AM dose of pain medication at 10:35 AM on 4/10/18. Interview with the Director of Nursing (DON) on 4/11/18 at 7:11 PM in her office confirmed the facility failed to administer the pain medication as ordered by the Physician to Resident #342. Review of facility policy Pain - Clinical Protocol revised 6/2013 revealed, .With input from the resident and/or advocate, the physician and staff will establish goals of pain treatment; for example, freedom from pain .Staff will assess pain using a consistent approach .appropriate to the resident's cognitive level .Acute pain should be assessed every 30-60 minutes after onset and reassessed as indicated after analgesic relief is obtained .Administer pain medications as ordered . Medical record review revealed Resident #90 was admitted to the facility on [DATE] with diagnoses of Non-displaced Fracture of Right Acetabulum, Fracture of Right Ischium, Muscle Weakness, Difficulty in Walking, Fracture of Shaft of Left Humerus, Fracture of Left Shoulder Girdle, Wedge Compression Fracture of T9-T10 Vertebra, Moderate Laceration of Left Kidney, Fracture of Lower End of Right Ulna, Fracture of Right Patella, Fracture of Right Radial Styloid Process, Moderate Laceration of Spleen, and Multiple Fractures of Ribs, Right Side. Medical record review of an admission MDS for Resident #90 dated 4/5/18 and 4/12/18 revealed no BIMS assessment was performed or documented. Medical record review of an electronic Admission/readmission Screen dated 4/5/18 revealed Resident #90 was alert to person, place, time and followed commands. Medical record review of a Pain assessment dated [DATE] revealed Resident #90 had pain almost constantly the last 5 days that made it hard to sleep and limited his day to day activities. The resident rated pain as severe and rated it an 8 on a 1-10 scale (1= no pain and 10=severe pain). The resident had received as needed (PRN) pain medication. Interview with Resident #90 on 4/10/18 at 10:01 AM in the resident's room reported he had 10 broken bones from a recent severe car accident. Continued interview revealed he received Oxycodone (narcotic pain medication) every 4 hours for pain and had not had any since 1:00 AM. When asked what his pain level was the resident stated It's a 10. Continued interview revealed the resident was told by a nurse they were out of his pain medicine and were waiting on it to be delivered by the pharmacy. Continued interview revealed the Doctor had rounded at 7:00 AM that morning and offered to prescribe something else for pain in the meantime. Further interview revealed the resident had not received any alternative pain medication. Medical record review of a Physician's Order for Resident #90 dated 4/6/18 revealed, Oxycodone HCl ER tablet 12 hour 10 milligrams (mg). Give 1 tablet by mouth every 8 hours. Continued review revealed an order dated 4/9/18 for Oxycodone HCl tablet 5 mg take 1 tablet by mouth every 4 hours for moderate pain as needed and 2 tablets by mouth for severe pain as needed. Medical record review of a Physician's Telephone Orders for Resident #90 dated 4/10/18 and untimed revealed, Tramadol [pain reliever] 50 mg 1-2 po [by mouth every] 8 hours PRN until Oxycodone available. Interview with Resident #90 on 4/10/18 at 11:05 AM in his room stated he was administered 2-5 mg Oxycodone tablets at approximately 10:30 AM and his pain level was now a 7. Continued interview revealed the resident was never offered Tramadol. Medical record review of Resident #90's Medication Administration Record (MAR) dated 4/1/18-4/30/18 revealed an omission of Oxycodone 10 mg on 4/9/18 at 6:00 AM. Continued review revealed the resident received a prn dose of Oxycodone at 2:00 AM on 4/10/18 and the next dose was administered at 10:32 AM on 4/10/18. Interview with the Assistant Director of Nursing (ADON) on 4/11/18 at 6:05 PM in her office confirmed the facility failed to manage the pain for Resident #90 by failing to administer Oxycodone 10 mg at 6:00 AM on 4/9/18 as ordered and failed to offer Tramadol as ordered until Oxycodone was delivered on 4/10/18. Medical record review revealed Resident #99 was admitted to the facility on [DATE] with diagnoses including Displaced Bi-malleolar Fracture of Right Lower Leg, Dislocation of Right Ankle Joint, Difficulty in Walking, Need for Assistance with Personal Care, Fibromyalgia, Pain in Left Ankle, Pain in Right Knee, Low Back Pain, Chronic Pain Syndrome, Hypertension, Major Depressive Disorder, and Diabetes Mellitus Type I2 with Polyneuropathy. Medical record review of an admission MDS dated [DATE] revealed Resident #99 had a BIMS of 15 and was cognitively intact. Medical record review of a Pain assessment dated [DATE] revealed Resident #99 had pain almost constantly over the last 5 days that made it hard for her to sleep and limited her day to day activities; she rated her pain as Severe and 7 on 1-10 pain scale. The resident received scheduled, PRN and non-medication interventions for pain. Interview and observation of Resident #99 on 4/9/18 at 4:59 PM in her room revealed she asked for PRN pain medicine between 3:30 PM - 4:00 PM and stated, Its 5:00 PM now and still no pain medicine. The resident reported a pain level of 10 and stated she received Morphine and Naprosyn scheduled and Percocet as needed. Observation revealed the resident was rocking back and forth on the side of the bed and rubbing her left knee and leg. Continued observation at 5:04 PM revealed Licensed Practical Nurse (LPN) #11 administered Lyrica and Naprosyn at 5:04 PM. The resident told the LPN her tech accidentally kicked her broken leg and it had been hurting for more than 30 minutes and requested her Percocet. LPN #11 stated, Let's wait and see how the other meds [medications] react first. LPN #11 never asked the resident what her pain level was and left the room. Medical record review of Physician's Order dated 4/2/18 revealed, Morphine Sulfate (narcotic pain medication) tablet 15 mg. Give 1 tablet by mouth two times a day for scheduled pain; Naproxen (non-steroidal anti-inflammatory pain medication) 250 mg by mouth two times a day for pain-take with meals; Percocet (narcotic pain medication) 10/325 mg (Oxycodone-Acetaminophen) Give 1 tablet by mouth every 4 hours as needed for pain rated 7-10; Orders dated 3/30/18 for Lyrica (Pregabalin) 150 mg by mouth three times a day for pain. Interview with Resident #99 on 4/10/18 at 9:07 AM in her room reported she waited until 6:00 PM and pushed her call light to ask for Percocet as her pain was still a 10. Certified Nurse Aide (CNA) #8 answered the call light and stated she would notify the nurse. The resident further stated she waited 30 minutes and pushed call light again and CNA #8 came and stated, She still hasn't got your medicine yet-let me go talk to this nurse. The resident waited another 15-20 minutes and pushed the call light again and the nurse popped her head in and the resident told the nurse she was still waiting on Percocet. Resident #99 reported the nurse stated, I didn't give you that already? The resident stated the nurse brought the Percocet at 7:30 PM (3 hours and 3 minutes after original request). Medical record review of Resident #99's MAR dated 4/1/18 - 4/30/18 revealed she received the PRN Percocet at 7:23 PM on 4/9/18 with a pain level of 9 and ineffective results. Further review revealed the resident received another Percocet at 2:00 AM on 4/10/18 for pain level of 8 with effective results after administration. Continued review revealed omission (no documentation) of Lyrica on 4/7/18 at 6:00 AM and omission of Morphine on 4/10/18 at 9:00 PM. Interview with the ADON on 4/11/18 at 6:05 PM in her office confirmed the facility failed to administer Lyrica on 4/7/18 and Morphine on 4/10/18 at 9:00 PM; failed to assess Resident #99's pain; and failed to administer PRN pain medication timely for a pain level of 10.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, document review and interview, the facility failed to conduct a drug regimen review for 1 of 8 sampled residents (Resident #60) reviewed. Findings include: Review of the facility policy Drug Regimen Review undated, revealed .The consultant pharmacist performs a comprehensive Drug Regimen Review (DRR) at least monthly on all residents of the facility . Medical record review revealed Resident #60 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Hypertension and Malignant Neoplasm of the Bladder. Review of the document Medication Regimen Review dated 3/14/18 revealed .The following residents' medication regimens were reviewed on the dates specified . The document did not include the name of Resident #60 indicating a drug regimen review was not performed for March 2018. Interview with the Director of Nursing on 4/11/18 at 2:29 PM in the conference room confirmed the facility failed to conduct a drug regimen review in March 2018 for Resident #60 as per facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview, the facility failed to properly store a medication in 1 of 3 medication rooms, failed to maintain current refrigeration temperature logs in 2 of 4 medication rooms, and failed to ensure 1 of 1 treatment cart and 1 of 7 medication carts were locked when not in use by staff. Findings include: Review of facility policy Storage of Medication, revised April 2007, revealed Compartments (including, but not limited to, drawers, cabinets, room, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others Medications must be stored separately from food and must be labeled accordingly . Review of facility policy Labeling of Medication Containers revised April 2007, revealed .Labels for each floor's stock medications shall include all necessary information . Observation on 4/9/18 at 10:15 AM of the 600 hall medication storage room revealed 1 opened and undated multi-dose vial of Tubersol (medication used to give a Tb skin test). The 600 hall refrigerator temperature log for April 2018 had omissions in documentation for 4/1/18, 4/2/18, 4/5/18, and 4/6/18. Observation on 4/9/18 at 10:35 AM of the medication room on the 100 hall, and of the medication room at 10:50 AM on the 200 hall revealed no temperature logs on the refrigerators for April 2018. Interview with Registered Nurse (RN) #2 on 04/9/18 at 10:50 AM in the 600 hall medication room confirmed the multi dose vial of Tubersol was undated and opened. Continued interview with RN #2 confirmed the refrigerator temperatures should be checked and documented daily by the nurses. Interview with the Director of Nursing (DON) on 4/9/18 at 11:15 AM in the conference room confirmed she expected the nurses to date all multi-dose vials when they are first opened. Further interview with the DON confirmed the refrigerator temperatures should be checked and logged daily. Observation of the treatment cart on 4/9/18 at 3:31 PM in the 600 hall dining area revealed the treatment cart was unlocked and unattended. Continued observation revealed Licensed Practical Nurse (LPN) #5 did not return to the cart until 3:45 PM. Interview with LPN #5 on 4/9/18 at 3:48 PM in the 600 hall dining room confirmed the treatment cart was left unlocked and unattended. LPN #5 stated, .I left the cart unlocked and just walked away for a few minutes . Interview with the DON on 4/9/18 at 3:53 PM on the 600 hall nurses station confirmed the treatment cart should be locked any time the cart was out of the nurse's direct sight. Observation on 4/11/18 at 6:09 PM on the 100 hall revealed the medication cart was unlocked and unattended. Interview with RN #3 on 4/11/18 at 6:10 PM at the 100 hall medication cart confirmed she left the medication cart unlocked and unattended. Interview with the DON on 4/11/18 at 6:13 PM on the 100 hall confirmed medication carts were to be locked when out of the nurse's direct sight. Review of the facility policy Storage of Medications revised April 2007 revealed .Drugs shall be stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications of several residents . Observation in Resident #590's room, room [ROOM NUMBER], on 4/11/18 at 5:51 PM revealed two tubes of topical ointment, Santyl (debridement) and Clotrimazole-Betamethasone (antifungal/steroid), lying on top of the wall divider in the Residents room. Both ointments were in their original packaging. Further observation revealed the Santyl ointment was labeled for Resident #63 from room [ROOM NUMBER] and the Clotrimazole-Betamethasone was labeled for Resident #590. Interview with the Director of Nursing on 4/11/18 at 6:00 PM in the conference room confirmed the facility failed to secure the medication in a locked cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Medical record review revealed Resident #36 was admitted to the facility on [DATE] with diagnosis including Gastrostomy Status. Medical Record review of Physician Order dated 11/29/17 revealed .Jevity [enteral/tube feeding] 1.5 via GT [gastrostomy tube] at 85 cc/hr for 14 hours . Medical Record review of a Physician's order dated 3/20/18 revealed .D/C [discontinue] current TF [tube feeding] orders Jevity 1.5 .give 6 cans @ [at] 85 ml per hour x 17 hours per day . Further review revealed the previous tube feeding order was not discontinued. Medical record review of the February - April 2018 MARs revealed no documentation of the tube feeding administration. Interview with Licensed Practical Nurse (LPN) #8 and LPN #9 on 4/10/18 at 8:20 AM at the 600 hall nurses station revealed they were unable to show where the tube feeding administration was documented. Interview with the DON on 4/11/18 at 7:55 PM in her office confirmed the facility failed to discontinue the tube feeding order dated 11/29/17 and failed to document the administration of the tube feeding for Resident #36. Based on medical record review and interview, the facility failed to maintain accurate and complete medical records for 2 of 44 sampled residents (Resident #28 and Resident #36) reviewed. Findings include: Medical record review revealed Resident #28 was originally admitted to the facility on [DATE] and was readmitted to the facility on [DATE] with diagnoses including Gastrostomy (Enteral/Tube Feeding). Medical record review of the Physician's Order dated 3/1/18 for enteral feeding of Jevity 1.5 at 70 cc/hour (cubic centimeter per hour) continuous for 22 hours. This order was discontinued on 4/4/18. Medical record review of the Physician's Order dated 4/4/18 revealed the enteral feeding of .Jevity 1.5 .at 86 ml/hr [milliliters per hour] x [for] 18 hrs/d [hours per day] . Review of the March 2018 through 4/4/18 Medication Administration Records (MAR) revealed no documentation of the tube feeding administration. Interview with the Director of Nursing (DON) on 4/12/18 at 9:29 AM in conference room confirmed the facility failed to document the tube feeding administration from 3/1/18 through 4/4/18. Further interview confirmed the DON expected nursing staff to document the administration of the tube feeding in the MAR. Further interview confirmed the facility failed to maintain a accurate medical record.

Based on observation and interview, the facility dietary department failed to maintain the slicer in a safe operating condition. Findings include: Observation on 4/10/18 at 10:25 AM in the dietary department with the Certified Dietary Manager (CDM) present revealed a plastic covered slicer. The cover was removed and the blade was not flush with the slicer table. Further observation revealed the thickness adjustment knob would not rotate to adjust the blade. Interview with the CDM on 4/10/18 at 10:25 AM in the dietary department confirmed the facility failed to maintain the slicer in a safe operating condition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Medical record review revealed Resident #86 was admitted to the facility on [DATE] with diagnoses including Psychotic Disorder, Malnutrition and Hypertension. Medical record review revealed the POST form was not completed to indicate the choice of cardiopulmonary resuscitation (CPR) and was not signed by Resident #86 or the resident's representative. Further review revealed the incomplete POST form was signed and dated [DATE] by the Physician. Interview with the DON on [DATE] at 5:16 PM in her office confirmed the advance directive was signed by the physician but not marked if the resident was a Do Not Resuscitate (DNR) or Full code. The DON confirmed the facility failed to obtain a completed advance directive for Resident #86. Medical record review revealed Resident #83 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Side, and Congestive Heart Failure. Medical record review of the electronic medical record and of the hard chart revealed no Advance Directive/POST (Physician Order for Scope of Treatment) form on the chart. Interview with the Director of Nursing (DON) on [DATE] at 5:17 PM in the hall near her office confirmed she had been unable to locate a POST form for Resident #83. The DON confirmed the facility failed to complete an advance directive for this resident. Based on facility policy review, medical record review and interview, the facility failed to obtain completed advanced directives for 8 of 31 sampled residents (Resident #90, Resident #91, Resident #98, Resident #99, Resident #590, Resident #28, Resident #83 and Resident #86) reviewed for advanced directives. Findings include: Review of the facility policy Advance Directive-MOLST (Medical Orders for Life Sustaining Treatment)/POLST (Physician Orders for Life Sustaining Treatment) undated revealed .Once the MOSLT/POLST form is completed, it must be signed by the resident or if the resident lacks capacity, the resident representatives AND the attending physician . Medical record review revealed Resident #90 was admitted to the facility on [DATE] with diagnoses of Nondisplaced Fracture of Right Acetabulum, Fracture of Right Ischium, Muscle Weakness, Difficulty in Walking, Fracture of Shaft of Left Humerus, Fracture of Left Shoulder Girdle, Wedge Compression Fracture of T9-T10 Vertebra, Moderate Laceration of Left Kidney, Fracture of Lower End of Right Ulna, Fracture of Right Patella, Fracture of Right Radial Styloid Process, Moderate Laceration of Spleen, and Multiple Fractures of Ribs, Right Side. Medical record review of an Advanced Directive dated [DATE] revealed Resident #90 had signed the form and requested full code status. Continued review revealed no physician signature was present. Medical record review revealed Resident #91 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus Type 2, Muscle Weakness, Rhabdomyolysis, Diabetic Foot Ulcer and Neuropathy, Cervical Disc Degeneration, End Stage Renal Dialysis and Sepsis. Medical record review of an Advanced Directive revealed Resident #91 had signed the form and requested full code status. Continued review revealed it was not dated and no physician signature was present. Medical record review revealed Resident #98 was admitted to the facility on [DATE] with diagnoses including Encounter for Surgical Aftercare following Surgery on the Genitourinary System, Infection Following a Procedure, Malignant Neoplasm of Vulva, Acute Kidney Failure, Cellulitis of Groin, Hypertension, Need for Assistance with Personal Care and Difficulty in Walking. Medical record review of an Advanced Directive revealed Resident #98 had signed the form and requested full code status. Continued review revealed it was not dated and no physician signature was present. Medical record review revealed Resident #99 was admitted to the facility on [DATE] with diagnoses including Displaced Bi-malleolar Fracture of Right Lower Leg, Dislocation of Right Ankle Joint, Difficulty in Walking, Need for Assistance with Personal Care, Fibromyalgia, Pain in Left Ankle, Pain in Right Knee, Low Back Pain, Chronic Pain Syndrome, Hypertension, Major Depressive Disorder, and Diabetes Mellitus Type II with Polyneuropathy. Medical record review of an Advanced Directive dated [DATE] revealed Resident #99 had signed the form and requested full code status. Continued review revealed no physician signature was present. Medical record review revealed Resident #590 was admitted to the facility on [DATE] with diagnoses including Congestive Heart Failure, Non-Rheumatic Tricuspid Valve Insufficiency, Muscle Weakness, Difficulty in Walking, Dyspnea, Plural Effusion and Hypertension. Medical record review of an Advanced Directive dated [DATE] revealed Resident #590 had signed the form and requested full code status. Continued review revealed no physician signature was present. Interview with the Director of Nursing (DON) on [DATE] at 11:20 AM in her office stated the facility treated all residents as a full code status until the physician rounded on Thursdays and signed the Advance Directives at that time. Continued interview revealed the DON stated, We identified a problem in January and began audits at that time but we're still working on a solution. Continued interview with the DON confirmed the facility failed to maintain completed Advanced Directives for Resident #90, #91, #98, #99 and #590. Medical record review revealed Resident #28 was originally admitted to the facility on [DATE] and was hospitalized from [DATE] to [DATE]. The resident was readmitted to the facility on [DATE] with diagnoses including Myocardial Infarction, Unstable Angina, Gastrostomy, Gastric Ulcer, and Major Depression. Medical record review revealed no Advanced Directive had been addressed. Interview with the DON on [DATE] at 8:30 AM at the 500 hall nursing station confirmed the medical record, paper and electronic, failed to include the Advanced Directive decision. Further interview confirmed the facility failed to obtain the Advanced Directive decision for Resident #28.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Medical record review revealed Resident #90 was admitted to the facility on [DATE] with diagnoses of Nondisplaced Fracture of Right Acetabulum, Fracture of Right Ischium, Muscle Weakness, Difficulty in Walking, Fracture of Shaft of Left Humerus, Fracture of Left Shoulder Girdle, Wedge Compression Fracture of T9-T10 Vertebra, Moderate Laceration of Left Kidney, Fracture of Lower End of Right Ulna, Fracture of Right Patella, Fracture of Right Radial Styloid Process, Moderate Laceration of Spleen, and Multiple Fractures of Ribs, Right Side. Medical record review of Resident #90's Order Summary Report dated 4/1/18-4/30/18 revealed wound care treatment orders to his left shoulder, right hip surgical site and right flank. Continued review revealed the resident received scheduled and PRN (as needed) pain medications. Medical record review of Resident #90's Baseline Care Plan Review dated 4/5/18 revealed it did not address the immediate care and services of the resident for wound treatments or pain management. Interview with the Assistant Director of Nursing (ADON) on 4/11/18 at 6:05 PM in her office confirmed the facility failed to address the immediate care and services required for Resident #90 including wound care treatments and pain management on the baseline care plan. Medical record review revealed Resident #98 was admitted to the facility on [DATE] with diagnoses including Encounter for Surgical Aftercare following Surgery on the Genitourinary System, Infection Following a Procedure, Malignant Neoplasm of Vulva, Acute Kidney Failure, Cellulitis of Groin, Hypertension, Need for Assistance with Personal Care and Difficulty in Walking. Medical record review of a TRANSFER FACILITY REPORT dated 4/4/18 for Resident #98 revealed Wound dressing change twice daily, pack loosely with 2 kerlix rolls and cover with ABD [army battle dressing used for heavy drainage and large wounds] & paper tape. Medical record review of Physician's Order dated 4/5/18 for Resident #98 revealed .clean surgical site to groin with saline pack with wet to dry kerlex dressing to wound bed, cover with ABD pad secure with tape or bordered gauze dressing twice daily and prn . Medical record review of Resident #98's baseline care plan dated 4/5/18 revealed it did not address the immediate care and service for the resident's wound treatments. Interview with the ADON on 4/11/18 at 6:05 PM in her office confirmed the facility failed to address the immediate care and services required for Resident #98 including wound care treatment on the baseline care plan. Medical record review revealed Resident #99 was admitted to the facility on [DATE] with Diagnoses including Displaced Bi-malleolar Fracture of Right Lower Leg, Dislocation of Right Ankle Joint, Difficulty in Walking, Need for Assistance with Personal Care, Fibromyalgia, Pain in Left Ankle, Pain in Right Knee, Low Back Pain, Chronic Pain Syndrome, Hypertension, Major Depressive Disorder, and Diabetes Mellitus Type 2 with Polyneuropathy. Medical record review of an Order Summary Report for Resident #99 dated 4/1/18 - 4/30/18 revealed orders for non-weight bearing to the right lower extremity along with scheduled and PRN pain medication. Medical record review of Resident #99's baseline care plan dated 3/29/18 revealed it did not address the immediate care and services including non-weight bearing to the right lower extremity and pain management. Interview with the ADON on 4/11/18 at 6:05 PM in her office confirmed the facility failed to address the immediate care and services required for Resident #99 including non-weight bearing status and pain management on the baseline care plan. Based on facility policy review, medical record review and interview, the facility failed to develop a baseline care plan addressing the immediate care needs for 5 of 44 sampled residents (Resident #28, Resident #89, Resident #90, Resident #98, Resident #99) reviewed for baseline care plans. Findings include: Review of facility policy Care Plans - Baseline revised 12/2016 revealed, .The baseline care plan will be used until the staff can conduct the comprehensive assessment .The resident .will be provided a summary of the baseline care plan that includes .any services and treatments to be administered by the facility and personnel acting on behalf of the facility . Medical record review revealed Resident #28 was originally admitted to the facility on [DATE] with diagnoses including Enteral Feeding. The resident was hospitalized from [DATE] to 3/19/18. The resident was readmitted to the facility on [DATE] with the Enteral Feeding. Medical record review revealed no baseline care plan for the 2/20/18 admission and for any revisions needed for the 3/19/18 readmission. Interview with the Director of Nursing (DON) on 4/11/18 at 3:00 PM in the conference room confirmed the facility failed to complete a baseline care plan for the 2/20/18 admission and any revision needed for the 3/19/18 readmission. Medical record review revealed Resident #89 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease, Dependent Renal Dialysis, and Left Above Knee Amputation. Medical record review revealed the care plan initiated on 3/31/18 failed to address the dialysis care along with the adjustment and care needs due to the amputation. Interview with the DON on 4/11/18 at 7:20 PM in her office confirmed the facility failed to develop a baseline care plan to address the immediate needs for Resident #89.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Medical record review revealed Resident #86 was admitted to the facility on [DATE] with diagnoses including Psychotic Disorder, Malnutrition and Hypertension. Medical record review of a Physician's Order dated 3/30/18 revealed an order for Clonazepam (antianxiety) 0.5 mg 1 tablet two times a day for anxiety and an order dated 4/6/18 for Risperdal (antipsychotic) 2 mg at bedtime for schizophrenia. Medical record review of the MAR dated 3/2018 and 4/2018 revealed the facility failed to monitor for side effects and behaviors of the Risperdal and Clonazepam. Interview with the DON on 4/11/18 at 6:02 PM in her office confirmed behavioral monitoring and monitoring of side effects was not included in any documentation for the psychotropic medications administered to Resident #86. Medical record review revealed Resident #21 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Parkinson Disease and Insomnia. Medical record review of a Physician's Order dated 2/19/18 revealed .Alprazolam [antianxiety medication] 0.5mg per tube @ [at] HS [hour of sleep] PRN insomnia . Physician's Order was only valid 2/19/18 - 3/5/18 according to 14-day rule. Medical record review of the February 2018 - April 2018 MAR revealed the resident was administered the alprazolam on the following dates: 2/27/18, 3/5-9/18, 3/11/18, 3/14/18, 3/17/18, 3/22-23/18, 3/31/18, 4/2-3/18 and 4/5/18. Medical record review revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including Hemiplegia and Hemiparesis following Nontraumatic Subarachnoid Hemorrhage Affecting Left Non-Dominant Side, Major Depressive Disorder, and Insomnia. Medical record review of a Physician's Order dated 3/7/18 revealed .trazadone (anti-depressant) 50mg @ HS PRN if first dose not effective . Physician's Order was only valid 3/7/18 - 3/21/18 according to 14-day rule. Medical record review of the MAR for March 2018 - April 2018 revealed Resident #35 received the trazodone on the following dates: 3/31/18 and 4/5/18 after 14-day stop date. Medical record review revealed Resident #36 was admitted to the facility on [DATE] with diagnoses including Chronic Respiratory Failure, Anxiety Disorder and Major Depressive Disorder. Medical record review of a Physician's Order dated 1/19/18 revealed .Clonazepam [antianxiety medication] 0.5mg PO [by mouth] BID [twice daily] PRN . Physician's Order was only valid 1/19/18 - 2/2/18 according to 14-day rule. Medical record review of the MAR for February 2018 - April 2018 revealed Resident #36 received the PRN Clonazepam on the following dates: 2/1/18, 2/3/18, 2/8/18, 2/11/18, 2/14/18, 3/6/18, 3/16/18, 3/20/18, 3/23/18, 3/28/18, 4/2/18 and 4/3/18. Medical Record review revealed Resident #82 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder, Psychotic Disorder with Delusions, Anxiety Disorder, and Alzheimer's Disease. Medical record review of a Physician's Order dated 1/31/18 revealed .Klonopin [antianxiety medication] 0.5mg PO @ HS PRN anxiety . Physician's Order was only valid 1/31/18 - 2/14/18 according to 14-day rule. Medical record review of the MAR for February 2018 - April 2018 revealed Resident #82 was administered the Klonopin on the following dates: 2/2/18, 2/9/18, 2/18/18, 2/19/18, 2/22/18, 3/5/18, 3/8-10/18, 3/13/18, 3/15/18, 3/18/18, 3/20/18, 3/27/18, 3/28/18, 3/31/18, 4/1-3/18, 4/5/18, 4/7/18 and 4/10/18. Continued review of the MARs revealed no behavior monitoring was documented. Interview with the DON on 4/11/18 at 2:40 PM in the conference room confirmed the facility failed to ensure PRN psychotropic medications had a 14-day limitation or prescriber documentation with medical rationale for continuation for Resident #21, Resident #35, Resident #36 and Resident #82. The DON also confirmed the facility failed to conduct behavior monitoring for Resident #82 receiving a psychotropic medication. Based on facility policy review, medical record review and interview, the facility failed to ensure as needed (PRN) psychotropic medications had a 14 day limitation or a prescriber documentation with medical rationale for continuation for 5 of 12 sampled residents (Resident #60, Resident #21, Resident #35, Resident #36, Resident #82) and failed to conduct behavior monitoring for 2 of 12residents (Resident #82, Resident #86) reviewed. Findings include: Review of the facility policy Behavioral Assessment, Intervention and Monitoring revised 3/2015 revealed .When medications are prescribed for behavioral symptoms, documentation will include: Monitoring for efficacy and adverse consequences. The nursing staff and the physician will monitor for side effects and complications related to psychoactive medications; for example, lethargy, abnormal involuntary movements, anorexia, or recurrent falling . Medical record review revealed Resident #60 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Hypertension and Malignant Neoplasm of the Bladder. Medical record review of a Physician's Order dated 2/9/18 revealed .Xanax [antianxiety medication] Tablet 0.5 MG [milligrams] - Give 1 tablet orally every 8 hours as needed for anxiety . Continued review revealed there was no stop date for the order. Medical record review of the March 2018 Medication Administration Record (MAR) revealed the resident was administered the medication on the following dates: 3/2/18, 3/4/18, 3/5/18, 3/7/18, 3/8/18, 3/10/18, 3/16/18, 3/19/18, 3/21/18 and 3/26/18. Interview with the Director of Nursing (DON) on 4/11/18 at 1:25 PM in her office, after reviewing the Physician's Orders and MAR for Resident #60, confirmed the facility failed to have a 14-day stop date for the PRN order for Xanax.

Based on observation and interview, the facility dietary department staff failed to ensure the resident meals were served per the menu, failed to obtain food preferences, and failed to honor resident food preferences for 6 of 86 residents receiving meals. Findings include: Observation on 4/9/18 at 12:20 PM of the dietary department resident mid-day meal tray line service revealed mashed potatoes were served to pureed diets. Further observation revealed no .mashed sweet potatoes . were available as the pureed diet indicated for residents disliking mashed (white) potatoes. Observation on 4/9/18 at 1:13 PM revealed Resident #73 with the lunch tray. Further observation of the tray card ticket revealed the diet was Pureed NAS (no added salt) and the food items included pureed ham, mashed sweet potatoes, pureed peas, pureed soup in a mug, and pureed fruit in a bowl. Observation of the food served revealed pureed ham, mashed (white) potatoes, pureed peas, and gelatin in a bowl. Further observation revealed no mashed sweet potatoes, soup in a mug or pureed fruit in a bowl had been provided. Interview with Resident #73 on 4/9/18 at 1:13 PM in her room revealed she could not eat mashed potatoes .just won't go down . Further interview revealed the resident had informed dietary staff of the dislike of mashed potatoes. Observation on 4/10/18 at 5:58 PM revealed Resident #73 in bed eating the evening meal. Observation of the tray card ticket revealed a Pureed NAS diet with the food items including mashed sweet potatoes. Observation of the food served revealed mashed (white) potatoes. Interview with Resident #73 on 4/10/18 at 5:58 PM revealed .see got it again . as she pointed to the mashed potatoes. Interview with the Certified Dietary Manger (CDM), Registered Dietitian, and Administrator on 4/11/18 beginning at 1:33 PM in the CDM's office confirmed Resident #73 .had multiple disliked items including mashed potatoes . Further interview revealed the CDM or her assistant would input the disliked food items in the computer tray card ticket system. Further interview revealed the tray card system process would automatically substitute the disliked food and the tray card ticket printed would only include the food to be served. Further interview revealed new staff was in training on the tray line and they were to check the tray card ticket to ensure the resident received the food on the tray card ticket. Further interview confirmed the facility failed to serve the food by the menu and by the resident's preference. Observation on 4/10/18 at 6:05 PM revealed Resident #91 received his supper tray. Further observation of the tray card ticket revealed a CCHO [Consistent Carbohydrate] NAS Large Portion diet and the foods included cod on a bun, pasta salad, zucchini, roll and frosted cake. Further observation revealed the resident failed to receive the pasta salad or the cake. Observation on 4/11/18 at 8:20 AM revealed Resident #91 eating from a tray. Further observation of the tray card ticket revealed a CCHO NAS Large Portion diet and the food included scrambled eggs-2 ounces (oz), crispy bacon-2 slices, toast-1 slice, and 1 carton 2% milk. Further observation revealed the resident received 2 oz scrambled eggs with cheese, 1 sausage patty, 1 slice of toast, 4 oz oats, and 1 carton 2% milk. Interview with Resident #91 on 4/11/18 at 8:20 AM in the resident's room revealed .I don't drink milk . Interview with the CDM, Registered Dietitian, and Administrator on 4/11/18 beginning at 1:33 PM in the CDM's office revealed there was no record of Resident #91's food dislikes. When asked regarding the large portion and the tray card ticket indicated a regular sized portion of 2 oz for the scrambled eggs, the CDM stated .should have been more . When asked why cheese would be added to the eggs and oatmeal be served if not on the tray card ticket the CDM stated .I don't know . Observation on 4/10/18 at 6:15 PM revealed Resident #98 in her room in bed and staff entered to deliver the resident her supper meal tray. Further observation of the tray card ticket revealed a Regular diet and the food items written onto the tray card ticket were hamburger with onion and cheese fries. Further observation of the meal served revealed a cheese burger on a bun with lettuce and tomato slice, plain steak fries, cake, and iced tea. Interview with Resident #98 on 4/10/18 at 6:15 PM in her room revealed she had contacted the dietary department because she did not want the menu items. Further interview revealed the resident had requested a hamburger patty with a slice of onion, and cheese on her french fries. Further interview revealed she did not want the bun, lettuce or tomato slice. Observation on 4/11/18 at 8:15 AM of Resident #98 in her room revealed the staff delivering the breakfast tray to the resident. Further observation revealed the resident lifted the plate cover and covered her nose with her hand. Further observation of the tray card ticket revealed a Regular diet and the food items included scrambled eggs-2 oz, 3 bacon-2 slices, [NAME] Krispies, toast, whole milk 2 oz, banana. Further observation revealed the food items served included 4 oz scrambled eggs, 6 slices bacon, [NAME] Krispies, biscuit, 8 oz whole milk, banana. Interview with Resident #98 on 4/11/18 at 8:15 AM in her room revealed .all I want is [NAME] Krispies, toast, enough milk for the cereal because I don't drink milk, bacon and a banana .I can't stand eggs much less the smell, I don't want the biscuit, but they send all this stuff anyway . Interview with the CDM, Registered Dietitian, and Administrator on 4/11/18 beginning at 1:33 PM in the CDM's office revealed Resident #98 contacted the dietary department for food requests. When asked regarding the resident not liking eggs the CDM stated .she never told me that . When asked why the requested items of a hamburger with a slice of onion and cheese fries had not been provided as requested the CDM stated .I don't know .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Medical record review revealed Resident #342 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Gastroesophageal Reflux Disease and Hyperlipidemia. Medical record review of the admission MDS dated [DATE] revealed Resident #342 had a BIMS score of 15 indicating the resident was cognitively intact. Interview with Resident #342 on 4/10/18 at 8:10 AM in her room revealed she disliked the food that was served at times and stated .The food is horrible . Interview with Resident #342 on 4/11/18 at 1:17 PM in her room revealed she was admitted to the facility two weeks ago and no one had obtained her food preferences. Interview with the Registered Dietician on 4/11/18 at 1:25 PM in Resident #342's room confirmed the dietary staff had not assessed the resident's food preferences. Medical record review revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction, Sepsis, Hemiplegia and Hemiparesis following Non-traumatic Subarachnoid Hemorrhage Affecting Left Non-Dominant Side, Aphasia, Dysphagia, Vascular Dementia and Acute Respiratory Failure. Medical record review of a 30 day Minimum Data Set (MDS) dated [DATE] revealed Resident #25 had a BIMS of 9 indicating he was moderately cognitively impaired. Continued review revealed the resident required limited assistance with eating from 1 person. Medical record review of a Nutrition Assessment for Resident #25 dated 2/28/18 revealed the resident was to have a regular mechanical soft diet with fortified foods. Medical record review of Physician's Orders for Resident #25 dated 3/26/18 revealed Regular diet Mechanically Altered Ground texture, Thin Liquids consistency, SNP [fortified foods] all meals related to Dysphagia Following Cerebral Infarction. Medical record review of the Care Plan for Resident #25 dated 3/4/18 revealed the resident was at risk for inadequate nutrition related to a mechanically altered diet with an intervention to provide and serve diet as ordered. Observation of meal tray ticket on 4/11/18 for lunch revealed a regular mechanical soft diet with .Chili & Beans 6 oz, Mechanical Soft SNP Mash Potatoes 4 oz, Tossed Salad 3/4 Cup, Banana Pudding 1/2 cup and crackers 1 pkg. [package] . Continued observation of the residents tray revealed mashed potatoes, banana pudding, tossed salad, roll and crackers. Interview with Certified Nurse Aide (CNA) #9 and Licensed Practical Nurse (LPN) #10 on 4/11/18 at 12:38 PM on the 400 hall confirmed there was no chili and beans on the tray. Interview with the Registered Dietician (RD) on 4/11/18 at 12:45 PM on the 400 Hall confirmed there was no protein item on Resident #25's tray, and tossed salad should not be included on a mechanical soft diet. Continued interview confirmed the tray ticket and the meal on the residents tray did not match. Medical record review revealed Resident #99 was admitted to the facility on [DATE] with diagnoses including Displaced Bi-malleolar Fracture of Right Lower Leg, Dislocation of Right Ankle Joint, Difficulty in Walking, Need for Assistance with Personal Care, Fibromyalgia, Pain in Left Ankle, Pain in Right Knee, Low Back Pain, Chronic Pain Syndrome, Hypertension, Major Depressive Disorder, and Diabetes Mellitus Type 2 with Polyneuropathy. Medical record review of an admission MDS dated [DATE] revealed Resident #99 had a BIMS of 15 and was cognitively intact. Interview with Resident #99 on 4/9/18 at 4:49 PM in her room stated she was Deathly allergic to tomatoes and suffers anaphylaxis (severe allergic reaction) if she eats anything with tomatoes. The resident further stated she carried an Epi (Adrenalin) pen to use if she was exposed to tomatoes unknowingly. Further interview revealed the resident reported she had been served tomatoes 3 days in a row with Spaghetti, Stew/soup and something else she couldn't remember. The resident reported she gave her preferences and told 2 different facility staff about her tomato allergy when she was admitted . Medical record review of Resident #99's demographic sheet revealed an allergy to tomatoes; Order Summary Report dated 4/10/18 revealed a tomato allergy ;Progress Notes for nurses revealed a tomato allergy; History and Physical from a hospital dated 4/10/18 revealed, .Allergies .TOMATO: facial swelling (Moderate to severe) . Medical record review of physician orders dated 3/29/18 revealed an order for EpiPen 2-Pak Solution Auto-Injector 0.3 MG/0.3 ML [milligrams per milliliters] (Epinephrine) Inject 0.3 mg intramuscularly every 12 hours as needed for allergies. Interview with the Assistant Dietary Manager on 4/10/18 at 12:06 PM in the conference room revealed she visited with Resident #99 on 3/29/18 after she was admitted . Further interview revealed the resident's daughter called the dietary department and told the Assistant Dietary Manager .some foods the resident can't have .didn't like .can't recall if I was told about the tomatoes or allergic to tomatoes .I check with the resident every 3 days when I do rounds . Interview with Resident #99 on 4/11/18 at 4:23 PM in her room revealed she was served chili with tomatoes today for lunch at 1:00 PM. Interview with the Assistant Director of Nursing (ADON) on 4/11/18 at 6:05 PM in her office confirmed the facility failed to prevent Resident #99 from receiving tomato products which cause a severe allergic reaction to the resident. Based on medical record review, observation, and interview, the facility failed to honor and/or obtain food preferences for 6 of 86 sampled residents (Resident #25, Resident #73, Resident #91, Resident #98, Resident #342) receiving a meal. Findings include: Medical record review revealed Resident #73 was admitted to the facility on [DATE] with diagnoses including Hospice, Congestive Heart Failure, Hypertension, Giant Cell Arthritis, Pain Thoracic Spine, Pain, Osteoporosis, Depression, and Anxiety. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #73 hearing and vision were adequate and she could make herself understood and understood others. Further review revealed the Brief Interview for Mental Status (BIMS) score was 15, indicating she was cognitively intact. Further review revealed the resident was independent with eating after set-up. Further review revealed the resident had no episodes of delirium, mood, psychosis or behaviors during the review period. Medical record review of the Physician Order dated 3/26/18 revealed Pureed consistency with No Added Salt (NAS) diet. Observation on 4/9/18 at 1:13 PM revealed Resident #73 in bed with the lunch tray on the over bed table. Further observation of the tray card ticket revealed the diet was Pureed NAS and the food items included pureed ham, mashed sweet potatoes, pureed peas, pureed soup in a mug, and pureed fruit in a bowl. Observation of the food served revealed pureed ham, mashed (white) potatoes, pureed peas, and gelatin in a bowl. Further observation revealed no mashed sweet potatoes, soup in a mug or pureed fruit in a bowl had been provided. Interview with Resident #73 on 4/9/18 at 1:13 PM in her room revealed she could not eat mashed potatoes .just won't go down . Further interview revealed the resident had informed dietary staff of the dislike of mashed potatoes. Observation on 4/10/18 at 5:58 PM revealed Resident #73 in bed eating the evening meal. Observation of the tray card ticket revealed a Pureed NAS diet with the food items including mashed sweet potatoes. Observation of the food served revealed mashed (white) potatoes. Interview with Resident #73 on 4/10/18 at 5:58 PM stated .see got it again as she pointed to the mashed potatoes. Interview with the Certified Dietary Manger (CDM), Registered Dietitian, and Administrator on 4/11/18 beginning at 1:33 PM in the CDM's office confirmed Resident #73 .had multiple disliked items including mashed potatoes . Further interview revealed the CDM or her assistant would input the disliked food in the computer tray card ticket system. Further interview revealed the tray card system process would automatically substitute the disliked food and the tray card ticket printed would only include the food to be served. Further interview revealed new staff was in training on the tray line and they were to check the tray card ticket to ensure the resident received the food on the tray card ticket. Further interview confirmed the facility failed to serve the food by the menu and by the resident's preference. Medical record review revealed Resident #91 was admitted to the facility on [DATE] with diagnoses including Sepsis, Diabetes Mellitus Type 2, Rhabdomyolysis, Cellulitis Lower Left Leg, Cervical Disc Degeneration, and Acute Kidney Failure. Medical record review revealed a Physician's Order dated 4/4/18 for a Regular textured Consistent Carbohydrate (CCHO) with No Added Salt (NAS) diet. Medical record review of the BIMS form dated 4/8/18 revealed a score 11, indicating moderate cognitive impairment. Observation on 4/10/18 at 6:05 PM revealed Resident #91 in his room seated in a wheel chair with an empty meal tray on the over bed table in front of him. Further observation revealed the supper trays were in the process of being delivered to residents and Resident #91 received his tray. Further observation of the tray card ticket revealed a CCHO NAS Large Portion diet and the foods included cod on a bun, pasta salad, zucchini, roll and frosted cake. Further observation revealed the resident failed to receive the pasta salad or the cake. Interview with Resident #91 and Certified Nurse Aide (CNA) #6 on 4/10/18 at 6:05 PM in the resident's room revealed the resident had returned from off-site dialysis treatment 30-45 minutes ago. Further interview revealed the meal consumed was the lunch meal the staff had saved for the resident while he was receiving dialysis treatment. Further interview revealed the resident routinely ate both the lunch and supper meal after he returned from dialysis. Observation on 4/11/18 at 8:20 AM revealed Resident #91 in his room seated in a wheel chair eating from a tray on the over bed table in front of him. Further observation of the tray card ticket revealed a CCHO NAS Large Portion diet and the food included scrambled eggs-2 ounces (oz), crispy bacon-2 slices, toast-1 slice, and 1 carton 2% milk. Further observation revealed the resident received 2 oz scrambled eggs with cheese, sausage patty-1, toast-1 slice, 4 oz oats, and 1 carton 2% milk. Interview with Resident #91 on 4/11/18 at 8:20 AM in the resident's room revealed .I don't drink milk . Interview with the CDM, Registered Dietitian, and Administrator on 4/11/18 beginning at 1:33 PM in the CDM's office revealed there was no record of Resident #91's food dislikes. When asked regarding the large portion and the tray card ticket indicated a regular sized portion of 2 oz for the scrambled eggs, the CDM stated .should have been more . When asked why cheese would be added to the eggs and oatmeal be served if not on the tray card ticket the CDM stated .I don't know . Medical record review revealed Resident #98 was admitted to the facility on [DATE] with diagnoses including Infection, Cellulitis Groin, Malignant Neoplasm, Morbid Obesity, and Chronic Obstructive Pulmonary Disease. Medical record review of the BIMS form dated 4/9/18 revealed a score of 15, indicating the resident was cognitively intact. Medical record review of the Physician's Order dated 4/4/18 revealed a Regular diet. Observation on 4/10/18 at 6:15 PM revealed Resident #98 in her room in bed and staff entered to deliver the resident her supper meal tray. Further observation of the tray card ticket revealed a Regular diet and the food items written onto the tray card ticket were hamburger with onion and cheese fries. Further observation of the meal served revealed a cheese burger on a bun with lettuce and tomato slice, plain steak fries, cake, and iced tea. Interview with Resident #98 on 4/10/18 at 6:15 PM in her room revealed she had contacted the dietary department because she did not want the menu items. Further interview revealed the resident had requested a hamburger patty with a slice of onion and cheese on her french fries. Further interview revealed she did not want the bun, lettuce or tomato slice. Observation on 4/11/18 at 8:15 AM of Resident #98 in her room revealed the staff delivering the breakfast tray to the resident. Further observation revealed the resident lifted the plate cover and covered her nose with her hand. Further observation of the tray card ticket revealed a Regular diet and the food items included scrambled eggs-2 oz, 3 bacon-2 slices, [NAME] Krispies, Toast, whole milk 2 oz, banana. Further observation revealed the food items served included scrambled eggs-4 oz, 6 slices bacon, [NAME] Krispies, biscuit, whole milk 8 oz, banana. Interview with Resident #98 on 4/11/18 at 8:15 AM in her room revealed .all I want is [NAME] Krispies, toast, enough milk for the cereal because I don't drink milk and a banana .I can't stand eggs much less the smell, I don't want the biscuit, but they send all this stuff anyway . Interview with the CDM, Registered Dietitian, and Administrator on 4/11/18 beginning at 1:33 PM in the CDM's office revealed Resident #98 contacted the dietary department for food requests. When asked regarding the resident not liking eggs the CDM stated .she never told me that . When asked why the requested items of a hamburger with a slice of onion and cheese fries had not been provided as requested the CDM stated .I don't know .

Based on review of the dish machine manufacturer's recommendation, review of the manual washing protocol, and interview, the facility dietary department failed to operate the dish machine per the manufacturer's recommended temperature range, failed to sanitize items appropriately in the 3 compartment sink, and failed to maintain dietary equipment in a sanitary manner in 1 of 6 observations in the dietary department. Findings include: Review of the posted dish machine manufacturer's recommendation revealed the minimum wash and final rinse temperature was 120 degrees Fahrenheit (F). Review of the manual washing protocol revealed the items in the sanitizer solution were to be in contact with the sanitizer solution for 30 seconds. Observation on 4/10/18 at 10:12 AM in the dietary department revealed the dish machine was in operation. Further observation revealed 2 racks of dirty dome lids were processed and the wash and rinse temperatures were 110 degrees F for both. The surveyor stated aloud to the 2 dietary employees and the Certified Dietary Manager (CDM) present the temperatures were 110 degrees. Further observation revealed the dome lids were stored on the drying rack. Further observation revealed 2 more racks with dirty dishes were processed in the machine and the wash and rinse temperatures were 118 degrees F each. The same 2 racks were processed again and the wash temperature was 118 degrees F and the rinse temperature was 120 degrees F. The dishes were removed from the dish machine and in process of being stored when the surveyor stopped the process. Observation of the 3 compartment sink revealed the sinks were in operation. Observation of the CDM revealed she placed a full size sheet pan in the sanitizer solution, waited approximately 15 seconds, turned the pan 180 degrees and splashed the sanitizer solution onto the pan. Further observation revealed the pan was placed in a rack to air dry. Interview with the CDM on 4/10/18 at 10:20 AM in the dietary department confirmed the water temperature of the dish machine was not 120 degrees for the wash and rinse per manufacturer's recommendation. Further interview confirmed the sheet pan was not in contact with the sanitizer solution for 30 seconds. Observation on 4/10/18 at 10:25 AM in the dietary department with the CDM present revealed a plastic covered slicer. The cover was removed and dried debris was present on the griper, slide arm, and base. Interview with the CDM on 4/10/18 at 10:25 AM in the dietary department revealed a plastic covered piece of equipment was considered clean. Further interview confirmed the dietary department failed to maintain the equipment in a sanitary manner.