**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 make prompt efforts to resolve grievances for missing personal belongings for 2 of 3 sampled residents (Residents #36 and #155). The findings include: Review of the medical record revealed Resident #36 was admitted to the facility on [DATE] with a diagnosis which included Multiple Sclerosis. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. During an interview on 6/13/2023 at 10:28 AM, Family Member #6 stated she had reported to Licensed Practical Nurse (LPN) #1 Resident #36 was missing an electric razor charging cord. During a telephone interview on 6/14/2023 at 10:29 AM, LPN #1 stated Family Member #6 had gone to Resident #36's previous room and could not find the cord to his electric razor. LPN #1 told Family Member #6 to call the Housekeeping department to see if they had retrieved the electric razor charging cord, and call the facility and report the item missing for reimbursement. LPN #1 confirmed she [LPN#1] did not tell the weekend supervisor. During an interview on 6/14/2023 at 10:52 AM, LPN #6, the 5th floor Unit Manager, stated the facility had not found the electric razor charging cord. LPN #6 confirmed she had not reported it to the Social Service Director (SSD) .Usually we contact the SSD for any missing item or the Concierge. During an interview on 6/14/2023 at 11:30 AM, the SSD stated, the first person who was informed of the missing item must fill out a grievance form. I have them in the office on the wall they [staff] have access to the logs on the weekends. During an interview on 6/14/2023 at 12:15 PM, the Administrator stated, there were grievance forms which all nurses had access to along with the front desk staff had keys to the SSD office to obtain more forms if needed. Review of the medical record revealed Resident #155 was admitted to the facility on [DATE] with a diagnosis which included Generalized Epilepsy. Review of the Quarterly MDS assessment dated [DATE] for Resident #155 revealed a BIMS score of 15 which indicated no cognitive impairment. During an interview on 6/13/2023 at 10:40 AM, Resident #155 stated, I have lost a very unusual watch it had a black face with gold numbers, a nice watch, hard to replace, I have had it for a long time. The nurses took it off to try and find a vein and after that it come up missing. [Named LPN #1] was the nurse that took it off, it was on 6/5/2023. I told the nurse it was missing. During an interview on 6/14/2023 at 10:55 AM, the SSD stated, I was not notified that [Named Resident #155] had lost his watch. During an interview on 6/15/2023 at 8:50 AM, Resident #155 stated, I still don't have my watch, someone probably took it. During an interview on 6/20/2023 at 8:50 AM, Resident #155 stated, I still haven't heard anything about my watch.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to provide a written bed-hold notice to the resident and the resident's representative at the time of hospitalization for 5 of 5 (Resident #91, Resident # 118, Resident #131, Resident #137, and Resident #224) sampled residents reviewed for hospitalization. Review of the facility policy titled, Bed-Holds and Returns, dated 5/18/2023 revealed, .Residents and /or representatives are informed [in writing] of the facility and state [if applicable] bed-hold policies .All residents/representative are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident's bed during periods of absence [hospitalization or therapeutic leave] . Review of the medical record revealed Resident #91 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Aftercare following joint replacement surgery, Type 2 Diabetes Mellitus with hypoglycemia, Epilepsy, and Cerebral Infarction. Resident #91 was transferred out of the facility on 5/30/2023. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] for Resident #91 revealed, a Brief Interview for Mental Status (BIMS) score of 00 which indicated the resident was not interviewable. Review of the Progress Notes for Resident #91 dated 5/30/2023 revealed, .This resident left facility via [by] 911 per NP [Nurse Practitioner] orders . No documentation was found regarding notice to the resident representative of the bed hold policy upon transfer to the hospital. Review of the medical record revealed Resident #118 was admitted on [DATE] and transferred on 4/22/2023. Resident #118 was readmitted on [DATE] with diagnoses which included Cerebral Infarction due to Embolism of Left Middle Cerebral Artery, Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side. No documentation was found in the medical record regarding notice to the resident representative of the bed hold policy. Review of the medical record revealed Resident #131 was admitted on [DATE] and transferred on 4/2/2023. Resident #131 was readmitted on [DATE] with diagnoses which included Chest Pain, Traumatic Subdural Hemorrhage with Loss of Consciousness of Unspecified Duration, and Chronic Obstructive Pulmonary Disease. No documentation was found in the medical record regarding notice to the resident/resident representative of the bed hold policy. Review of the medical record revealed Resident #137 was admitted to the facility on [DATE], transferred on 2/11/2023, and readmitted on [DATE] with diagnoses which included Thrombocytopenia, Human Immunodeficiency Virus Disease, Epilepsy, and Unspecified Fracture of Facial Bones. Review of the Significant Change MDS assessment dated [DATE] for Resident #137 revealed, a BIMS score of 2 which indicated severe cognitive impairment. Review of the progress notes for Resident #137 dated 2/11/2023 revealed, .at approximately 8:30 am pt [patient] was . sent out by EMS [Emergency Medical Services] to hospital . No documentation was found in the medical record regarding notice to the resident representative of the bed hold policy upon transfer to the hospital. Review of the medical record revealed Resident #224 was admitted on [DATE] and transferred on 3/27/2023 with diagnoses which included Unilateral Primary Osteoarthritis, Morbid Obesity, and Type 2 Diabetes Mellitus without complications. No documentation regarding notice to the resident/resident representative of the bed hold policy. During an interview on 6/21/2023 at 11:45 AM, the Administrator confirmed the residents (Residents #91, #118, #131, #137, and#224)and/or resident representatives were not notifed of the bed hold policy prior to transfer.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to follow the comprehensive care plan for 1 of 59 (Resident #92) sampled residents reviewed. The findings include: Review of the facility policy titled, Care Plans Comprehensive dated 5/18/2023, revealed, .developed and implemented for each resident .describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Review of the facility policy titled, Lifting Machine Using Mechanical dated 5/19/2023 revealed, .to establish the general principles of safe lifting using a mechanical lifting device .At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift . Review of the medical record revealed Resident #92 was admitted to the facility on [DATE] with diagnoses which included Metabolic Encephalopathy, Supraventricular Tachycardia, and Primary Generalized (Osteo) Arthritis. Review of the comprehensive care plan for Resident #92 dated 5/18/2021 and revised 12/28/2021, revealed, .requires assist with activities of daily living .Total Dependent x2 Staff (Mechanical Lift) for Transfers for Safety . During an observation and interview on 6/12/2023 at 3:24 PM, Certified Nursing Assistant (CNA) #9 was observed coming out of Resident #92's room with a mechanical lift. CNA #9 stated she had transferred Resident #92 using the mechanical lift without another CNA because she could not find anyone to help her with the transfer. CNA #9 confirmed staff was required to use two people for all mechanical lift transfers. During an interview on 6/12/2023 at 3:31 PM, Unit Manager #1 stated for resident safety, staff is required to use two person assist for all mechanical lift use. Unit Manager #1 reviewed Resident #92's [NAME] and confirmed she was care planned to use two person assist for mechanical lift.

**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 care plan conference meeting with the resident or resident's representative for 6 of 6 (Residents #30, #88, #91, #103, #137, #150) sampled residents reviewed. The findings include: Review of the undated facility policy titled Care Plans Comprehensive revealed, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented 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) assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission .Each resident's comprehensive person-centered care plan is consistant with the resident's rights to participate in the development and implementation of his or her plan of care . Review of the medical record revealed Resident #30 was admitted to the facility on [DATE] with diagnoses which included Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, Morbid Severe Obesity Due to Excess Calories, and Major Depressive Disorder, Recurrent Moderate. Review of the Quarterly MDS for Resident #30 dated 4/17/2023 revealed a Brief Interview of Mental Status (BIMS) score of 14 which indicated no cognitive impairment. Review of the Progress Notes for Resident #30 revealed care conferences were not done quarterly. The last completed care conference was on 2/24/2023. Review of the medical record revealed Resident #88 was admitted to the facility on [DATE] with diagnoses which included Acute and Chronic Respiratory Failure with Hypoxia, Anoxic Brain Damage, and Persistent Vegetative State. Review of the Annual MDS dated [DATE] revealed no BIMS score. Review of the Progress Notes revealed Resident #88's last care plan conference was conducted on 12/15/2022. Review of the medical record revealed Resident #91 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Aftercare following joint replacement surgery, Type 2 Diabetes Mellitus with hypoglycemia, Epilepsy, and Cerebral Infarction. Review of the Significant Change MDS assessment dated [DATE] for Resident #91 revealed, a BIMS score of 00 which indicated the resident was uninterviewable. Review of the Progress Notes for Resident #91 revealed no care conference with resident or resident's representative since 1/2/2023. Review of the medical record revealed Resident #103 was admitted to the facility on [DATE] with diagnoses which include Radiculopathy Lumbar Region, Unspecified Fracture of the Left Pubis Subsequent Encounter for Fracture with Routine Healing, Other Intervertebral Disc Degeneration Lumbar Region, and Intervertebral Disc Stenosis of Neural Canal of Lumbar Region. Review of the Quarterly MDS assessment dated [DATE] for Resident #103 revealed a BIMS score of 15 which indicated no cognitive impairment. During an interview on 6/13/2023 at 3:58 PM, Resident #103 stated, I don't know anything about anyone discussing directly with me about my care, this is the closest thing that I have had to talk about my care. Review of the medical record revealed Resident #137 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Thrombocytopenia, Human Immunodeficiency Virus Disease, Epilepsy, and Unspecified Fracture of Facial Bones. Review of the Significant Change MDS assessment dated [DATE] for Resident #137 revealed, a BIMS score of 2 which indicated severe cognitive impairment. Review of the Progress Notes for Resident #137 revealed no care conference with resident or resident's representative since 2/24/2023. Review of the medical record revealed Resident #150 was admitted to the facility on [DATE] with diagnoses which include Sepsis Unspecified Organism, Chronic Obstructive Pulmonary Disease Unspecified, Arthropathy Unspecified, and Type 2 Diabetes Mellitus Without Complications. Review of the Comprehensive MDS assessment dated [DATE] for Resident #150 revealed a BIMS score of 3 which indicated severe cognitive impairment. During a telephone interview on 6/13/2023 at 2:08 PM, Family Member #7 stated, [Named Resident #150] was having some skin problems to her bottom at one point but they haven't updated me about it. I am not sure about a care plan meeting. During an interview on 6/20/2023 at 3:00 PM, the Social Service Director (SSD) confirmed the care plan conference for the residents (Resident # 30, #88, #91, # 103, #137 and !150) had not been conducted. During an interview on 6/20/2023 at 3:30 PM, the MDS Coordinator confirmed the SSD sets up the care plan meetings and the meetings should be completed quarterly, after admission, and with a significant change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview, the facility failed to ensure 2 of 59 (Resident #11 and Resident #27) sampled residents received their showers/ baths as scheduled, and the facility failed to ensure 1 of 59 sampled residents (Resident #27) had clean and groomed fingernails. The findings include: Review of the policy titled, Bath, Shower/Tub dated 5/19/2023 revealed .The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin .Assist the resident into the bath chair, if applicable .Assist with dressing and grooming as needed .If resident refuses the shower/tub bath, the reason(s) why and the intervention taken .The signature and title of the person recording the date . Review of the policy titled, Activities of Daily Living (ADLs), Supporting dated 5/19/2023 revealed .Resident will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene .Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with .hygiene (bathing, dressing, grooming, and oral care) . Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses which include Type 2 Diabetes Mellitus with Diabetic Neuropathy Unspecified, Unspecified Severe Protein-Calorie Malnutrition, Hyperkalemia, and Dysphagia Oropharyngeal Phase. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] for Resident #11 revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Further review revealed Resident #11 required extensive assist with bed mobility, dressing, total assist with toileting, and extensive assist with bathing. Review of the current Comprehensive Care Plan for Resident #11 revealed, a focus for .resident requires assist with activities of daily living related to impaired balance, limited mobility, and Contracture of Right Foot .bathing .extensive assist x 1 staff . During an interview on 6/13/2023 at 10:23 AM, Resident #11 stated, I am not sure when I had a bath. I only get a bed bath, no showers. Review of Resident #11's task documentation for three showers per week scheduled on Tuesday, Thursday, and Saturday, night shift, revealed the following: No bath or shower documented for four days (3/6/2023-3/9/2023), for six days (3/19/2023-3/24/2023), for eleven days (3/27/2023-4/6/2023), for four days (4/8/2023-4/11/2023), for four days (4/19/2023-4/22/2023), for five days (4/24/2023-4/28/2023), for five days (5/2/2023-5/6/2023), for five days (5/22/2023-5/26/2023), and for six days (5/29/2023-6/3/2023). Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included Fracture of Tibia or Fibula following insertion of Orthopedic Implant, Joint Prosthesis, of Bone Plate, Left Leg, Local Infection of the Skin and Subcutaneous Tissue, Morbid Obesity, and Hypertension. Review of the Significant Change in Status MDS assessment dated [DATE] revealed Resident #27 had a BIMS score of 3 which indicated severe cognitive impairment. Further review revealed Resident #27 required total assist with bed mobility, total assist with dressing, total assistance with toileting, and extensive assistance with bathing. Review of the current Comprehensive Care Plan for Resident #27 revealed, a focus for .ADL [activities of daily living] Self Care Performance Deficit r/t [related to] Activity Intolerance, Impaired balance, Limited Mobility, Pain . Review of Resident #27's task documentation for three showers per week scheduled on Monday, Wednesday, Friday, Day shift, revealed the following: No bath or shower documented for six days (4/1/2023-4/6/2023), for three days (4/15/2023-4/17/2023), for five days (4/23/2023-4/27/2023), and three days (5/10/2023-5/12/2023). During an observation and interview in Resident #27's room on 6/12/2023 at 3:15 PM, Resident #27 was observed with dried brown debris under her fingernails on both hands. Resident #27 stated, I rarely have my nails cleaned. I don't like the way my nails look, they are dirty . During an observation and interview on 6/12/2023 at 3:20 PM in Resident #27's room, Licensed Practical Nurse (LPN) #11 stated nail care should be provided three times per week and as needed. LPN #11 confirmed Resident #27's fingernails were dirty. During an observation and interview on 6/12/2023 at 3:50 PM, the Director of Nursing confirmed Resident #27's fingernails were dirty and needed cleaning. During an interview on 6/21/2023 at 10:30 AM, Licensed Practical Nurse (LPN) #10 confirmed the task documentation was utilized by Certified Nursing Assistants when resident bathing was completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facilty failed to ensure proper treatment and assistive devices to maintain vision for 1 of 59 (Resident #155) residents reviewed for visual decline. The findings include: Review of the medical record revealed Resident #155 was admitted on [DATE] and re-admitted to the facility on [DATE] with diagnoses which included Generalized Epilepsy, Heart Failure, and Hypertension. Review of the Comprehensive Care Plan revealed Resident #155 had a focus for .resident has impaired visual function .arrange consultation with eye care practitioner as required . Review of the Nursing Progress Note dated 1/25/2022 revealed, .Resident informed nurse that he was concerned about his previous loss of vision to his right eye r/t [related to] a history of seizure activity. Resident expressed that he wanted to see a specialist for his eye. Signee informed resident that she would make NP [nurse practitioner] aware . Review of the Physician Progress Notes dated 8/3/2022 revealed .Reported poor right eye vision .We will request ophthalmology consult/referral . Continued review of the Physician Progress Notes dated 8/8/2022, revealed .decreased visual acuity noted on right eye .Placed consult order for Ophthalmology at [named hospital] . Review of the Order Summary Report for Resident #155 revealed an order dated 9/9/2022, .consult: may be seen and treated by an optometrist/ophthalmology, for poor blurry vision . During an interview on 6/13/2023 at 10:15 AM, Resident #155 was performing a word search puzzle. Resident #155 stated, The doctor said he was going to send me to the eye doctor but I haven't got to go. During an interview on 6/14/2023 at 5:35 PM, with the Social Service Director (SSD) and the Business Office Manager (BOM), the SSD stated, We did not know he was having eye issues . he could go out to have an eye exam . During an interview on 6/15/2023 at 8:50 AM, Resident #155 stated, I am going blind in my right eye. I was suppose to have cataract surgery in the eye . Since I had that seizure, my vision became worse. I I told them about it and they said they would check into it. I can't see out of it. I have to turn my head so I can look through my left eye.

**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 for 1 of 1 sampled residents (Resident #219) related to therapeutic diet. The findings include: Review of the medical record revealed Resident #219 was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease, Dysphagia, Unspecified Severe Protein-Calorie Malnutrition, and Hereditary Spastic Paraplegia. Review of the admission Minimum Data Set (MDS) dated [DATE], revealed coughing or choking during meals or when swallowing medications and complaints of difficulty or pain when swallowing. Review of the physician's orders dated 6/8/2023, revealed .Regular diet Mechanically Altered Ground texture, Nectar Thickened Liquids consistency . Observation on 6/20/2023 at 10:29 AM, revealed Resident #219 drinking a [named brand supplement drink] drink while watching television. During an observation and interview on 6/20/2023 at 10:35 AM in the door way of Resident #219's room, Resident #219 was observed drinking a (named brand supplement drink) drink while watching television. Licensed Practical Nurse (LPN) #8 stated, she gave the (named brand supplement drink) to Resident #219 because she thought it was considered a nectar thickened liquid. LPN #8 confirmed a resident could aspirate if given thin liquids instead of ordered nectar thickened liquids. During an interview on 6/20/2023 at 10:41 AM, LPN #6, acting 5th floor Unit Manager, confirmed the order for the (named brand supplement drink) was discontinued and thought (named brand supplement drink) was considered a thickened liquid. During an interview on 6/20/2023 at 10:54 AM, the Speech Therapist stated a bedside swallow study was completed on Resident #219 and upgraded his liquids to nectar thickened. When asked what the consistency of (named brand supplement drink) is, the Speech Therapist stated she didn't believe the drink was nectar thickened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review and medical record review, the facility failed to adequately monitor for side effects or behaviors for 1 of 6 sampled residents (Resident #27) reviewed for unnecessary medications. The findings include: Review of the facility policy titled, Psychotropic Medication Use, dated 3/8/2023 revealed, .Residents will not receive medications that are not clinically indicated to treat a specific condition .Drugs in the following categories are considered psychotropic medication and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications .Antidepressants . Review of the medical record revealed Resident #27 was admitted to the facility on [DATE], and readmission on [DATE] with diagnoses which included Fracture of Tibia or Fibula following insertion of Orthopedic Implant, Infection of the Skin and Subcutaneous Tissue, Morbid Obesity, and Hypertension. Review of the Significant Change in Status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of 3 which indicated severe cognitive impairment. Review of the current Comprehensive Care Plan for Resident #27 revealed, a focus for .uses antidepressant medication r/t [related to] depression, insomnia, anorexia .monitor/document/report to MD [medical director] .ongoing s/sx [signs/symptoms] of depression unaltered by antidepressant meds [medications] . Review of the Nurse Practitioner Notes dated 6/8/2023 revealed, .assessment and plan .poor intake .due to her recent loss of her spouse and possible depression, we will add Remeron [Antidepressant] . Review of Resident #27's Medication Administration Record (MAR) dated 6/2023 revealed daily administration of Remeron (Antidepressant) with no monitoring for side effects or behaviors. During an interview on 6/21/2023 at 2:00 PM, the Regional nurse reviewed Resident #27's 6/2023 MAR and was asked if she noted any monitoring for behaviors or side effects for the use of the Antidepressant. The Regional Nurse stated, If the resident has a diagnosis of Depression. Regional Nurse was asked if the resident should be monitored for adverse side effects? The Regional Nurse stated, .I don't know .

Based on facility policy review, observation, and interview, the facility dietary department failed to maintain and serve hot food at or greater than 135 degrees Fahrenheit (F) for 1 of 2 meal service observed. The findings include: Review of the undated facility policy titled, Food Production and Food Safety revealed .All hot food items must be cooked to appropriate internal temperatures, held, and served at a temperature of at least 135 F . During an observation on 6/12/2023 at 11:17 AM in the dietary department, the Certified Dietary Manager (CDM) was taking temperatures of the food on the steam table. During observation and interview on 6/12/2023 in the dietary department beginning at 11:40 AM through 11:42 AM, with the CDM present, the mid-day meal trayline service was in progress. Further observations of food temperatures revealed the chicken noodle soup was 130 degrees F, tomato soup was 129 degrees F, and the vegetable beef soup was 129 degrees F. Further observation revealed one tray cart had already been sent to the 500 hall. During an interview on 6/14/2023 at 9:52 AM, the CDM and Senior Food Service Director, confirmed the soups were not at the appropriate temperature on the steam table.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to accommodate dietary preferences for 5 of 5 (Resident #157, #170, #185, #186 and #194)sampled residents reviewed for dietary preferences. The findings include: Review of the facility policy titled, Resident Food Preferences, dated 5/18/2023, revealed, .determine current food preferences .If resident refuses or is unhappy with his or her diet, the staff will discuss a plan that the resident is satisfied with . Review of the facility's undated policy titled, Dining/Meal Service revealed, .A meal identification and food preferences card (meal ID (identification) card/ticket) will be used to properly identify each individual's needs, including food and beverage preferences .permanent meal ID card/ticket should include the name of the individual, diet order, beverage preferences, food dislikes and any other applicable diet information . Review of the medical record revealed Resident #157 was admitted to the facility on [DATE] with diagnoses which included Methicillin Resistant Staphylococcus Aureus (MRSA) Infection as the cause of diseases classified elsewhere, Human Immunodeficiency Virus (HIV) disease, and Tachycardia. Review of the Care Plan for Resident #157 dated 8/20/2021 revealed, .risk for weight loss/gain r/t (related to) .mouth pain . Interventions dated 12/9/2020 revealed, .Monitor weight, diet as ordered .encourage intake, food preferences . Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #157 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairment. During an interview on 6/12/2023 at 12:30 PM, Resident #157 stated, I have talked with [Certified Dietary Manager-CDM] multiple times about wanting ground up hamburger in my soup because it is easier to eat. [CDM] said they couldn't grind up the hamburger patty for me, staff would have to cut it up for me. I have to depend on someone else to come in and do it for me, why can't I just get it where I don't have to worry about it. I had my back teeth pulled but I manage with most of the food by chewing with my front teeth. The soup is hard to manage with my front teeth. I also talked to him about the wasted juice because they are constantly sending me apple and cranberry juice that I have told them I do not like. Review of the tray card dated 6/12/2023 revealed there were no dislikes or preferences specified for Resident #157. During an interview on 6/12/2023 at 4:30 PM Dietary Aide #1 stated, I check trays to make sure everything is right before they go on the cart. Allergies are listed on the tray ticket, food preferences are not on the ticket. If the ticket list grape juice and we run out of grape juice we put a substitute like cranberry juice on the tray. I would not know if the resident liked cranberry juice unless I looked at the computer. We do not look at the computer during tray line. The resident could get something they don't like as a substitute. During an interview on 6/12/2023 at 5:25 PM, the CDM reviewed the facility policy titled, Dining/Meal Service and Resident #157's tray ticket. The CDM confirmed the resident's dislikes were not printed on the tray ticket. The CDM stated, With the new system, the dislikes are not printed on the ticket. The system knows the resident's preferences and does not put foods and beverages the resident does not want on the ticket to be served. We [facility] just initiated the new system [computerized system to monitor resident diets including dietary preferences] about 2 months ago. The current policy does not reflect the new system printed tray cards. When asked if he had spoken to Resident #157 about his preference to have a beef patty ground and put into his soup, the CDM replied, I have spoke to [Resident #157 a few different times about the ground beef patty in his soup. I explained to him that we could not stop the tray line for 1 special request or we could not serve food in a timely manner. [Dietary] sends a beef patty up on his meal tray and staff cuts it up for [Resident #157] to put in his soup. [Resident #157] doesn't like it and wants to have the patty ground by the dietary department. We just cannot do that for every resident, it isn't feasible. During an interview on 6/15/2023 at 4:58 PM, the Registered Dietician (RD) stated she expected a resident's reasonable dietary preference to be honored by staff. The RD stated she did not feel that having a beef patty ground and put in vegetable soup was an unreasonable request. The RD stated the she works with the staff to interview residents about food preferences at least quarterly and updates the chart accordingly with any changes. Review of the medical record revealed Resident #186 was admitted to the facility on [DATE] with diagnoses which included Transient Cerebral Ischemic Attack, Unspecified Fall, and Essential Tremor. Review of the Annual MDS assessment dated [DATE] revealed Resident #186 had a BIMS score of 11, which indicated moderate cognitive impairment. During an interview on 6/13/2023 at 11:28 PM, Resident #186 stated, I have been asking dietary for a fruit plate for a really long time and they just do not send it to me. I have told [dietary] so many times I don't like eggs and oatmeal, but they keep on sending it to me. I also told [Unit Manager #1] and she said it would be taken care of right away. Review of the medical record revealed Resident #185 was admitted to the facility on [DATE] with diagnoses which included Left Bundle-Branch Block, Bradycardia, and Presence of Cardiac Pacemaker. Review of the Significant Change in Status MDS assessment dated [DATE] revealed Resident #185 had a BIMS score of 15, which indicated no cognitive impairment. During an interview on 6/13/2023 at 11:38 AM, Resident #185 stated, I have high blood pressure and they always send foods that contain a lot of salt. I have talked to the dietician [could not recall name, specified a female] and complained about the salty food and nothing has changed in my diet. Review of the medical record revealed Resident #170 was admitted to the facility on [DATE] with diagnoses which included Elevated [NAME] Blood Cell Count, Type 2 Diabetes Mellitus with Foot Ulcer, and Morbid (Severe) Obesity Due to Excess Calories. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #170 had a BIMS score of 15, which indicated no cognitive impairment. During an interview on 6/13/2023 at 11:40 AM, Resident #170 stated, I don't like onions, I still get food with onions present. Dietary has known about my dislike of onions for as long as I have been here. I have told several people including nurses, techs, and the Dietician. It just keeps happening, thankfully I usually have something to eat here in my room. Review of the medical record revealed Resident #194 was admitted to the facility on [DATE] with diagnoses which included Benign Paroxysmal Vertigo, Cerebral Infarction Due to Embolism of Left Cerebellar Artery, and Brain Stem Stroke Syndrome. Review of the Quarterly MDS assessment dated [DATE] revealed Resident #194 had a BIMS score of 15, which indicated no cognitive impairment. During an interview on 6/13/2023 at 11:55 AM, Resident #194 stated, I have filed a grievance because I got tired of telling dietary they were sending food on my tray that I specifically told them I didn't like to eat. I have repeatedly told dietary I don't want cream corn, green peas, and pudding, yet I continue to have them on my plate. I have had to buy my own condiments such as crackers, ketchup, and salt, because they never include them on my trays. I spoke with [CDM] after my grievance .but they continue to send the wrong food items occasionally and especially on the weekends. [CDM] told me they are implementing a new system and working out the process.

Based on facility policy review, observation, and interview, the dietary department failed to maintain and clean the range hoods during 1 of 3 observations. The findings include: Review of the undated facility's policy titled, Cleaning Instructions revealed .Stove hoods and filters will be cleaned according to a cleaning schedule, or at least monthly . During observation in the dietary department on 6/12/2023 10:31 AM, the range hood was covered with clear and shiny debris. During an interview on 6/12/2023 at 12:05 PM, the Certified Dietary Manager (CDM) confirmed the range hood was covered with clear and shiny debris. The CDM stated the hood was cleaned only twice a year. The last time it was clean was 2/9/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to respectfully address 1 resident (#212) out of 45 residents requiring feeding assistance, referred to as a feeder. The findings include: Facility policy review, Quality of Life-Dignity, dated 2001 and revised 2009, revealed .Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs . Medical record review revealed Resident #212 was admitted to the facility on [DATE] with diagnoses which included Quadriplegia, Muscle Weakness, Depression, and Pain. Medical record review of Resident #212's Quarterly Minimum Data Set (MDS) dated [DATE], the Significant Change MDS dated [DATE], and the Annual MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicated the resident was cognitively intact. Further record review of the MDS revealed the resident required extensive assistance for Activities of Daily Living (ADL's) including total dependence for eating. Medical record review of Resident #212's Care Plan (Nutrition) dated 3/26/19 revealed .Assist with meals as needed . Medical record review of Resident #212's Certified Nurse Technician (CNT) Notes dated 3/1/19-4/10/19 revealed .Eating: Total Dependence-full staff performance every time . Interview with Resident #212 on 4/8/19 at 9:30 AM in the room revealed resident has heard staff calling resident and other residents a feeder and has to wait to be fed last. Further interview revealed that multiple staff members have told her that the trays on the hall are passed first to residents who can feed themselves and then they bring the trays up for the feeders. Continued interview on 4/9/19 at 8:30 AM stated the resident has heard the CNT's talking in the hallway and in the resident's room referring to residents when trays are being passed as feeders. Examples given by resident were .who's got this feeder? .who's the next feeder? . Interview with CNT #1 on 4/10/19 at 4:30 PM in the 3rd floor hallway when asked how feeding assistance for residents was coordinated at mealtimes revealed .there are 9 feeders on the floor .they're (CNT's) assigned based on how long it takes the feeders to eat .usually the first cart is delivered to the floor for the self-feeders and then the 2nd cart has the feeders trays . Interview with Registered Nurse (RN) #1, identified as the facility Staff Educator in charge of training Paid Feeding Assistants and CNT's, on 4/10/19 at 4:35 PM in her office, confirmed .We (our facility) teach all staff to refer to residents as total assist or monitored assistance for feeding . Interview with the Administrator on 4/10/19 at 4:38 PM in the facility lobby confirmed residents requiring assistance for eating should be referred to as .total assistance for feeding or total assist diners. Interview with the Director of Nursing on 4/10/19 at 5:50 PM in the facility dining room confirmed .I expect all staff to refer to residents that require total assistance for feeding as total assist diners.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility investigation review, observation and interview, the facility failed to investigate an incident which involved a non-facility hypodermic syringe for 1 resident (#13) of 69 reviewed. The findings include: Review of the facility policy Accidents/Incidents Investigations dated 10/7/17 revealed .An investigation of the accident/incident will be made by the designated staff person . Medical record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses which included Hepatitis C (liver disease), Encephalopathy, Psychoactive Substance Abuse, and Generalized Anxiety Disorder. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated no cognitive impairment. Medical record review of the physician orders dated 2/16/19 revealed .Urine Drug Screen . Continued review revealed no orders for amphetamines. Medical record review of the Urine Drug Screen dated 2/16/19 revealed .Amphetamine Positive . Medical record review of the Physician Progress Note dated 2/27/19 revealed .Pt [patient] seen at administrator's request regarding recent + [positive] drug test for amphetamines after finding a syringe in pts bed. Pt continues to deny any drug use, but has a long history of drug dependence and addiction and agrees that [pt] needs drug rehabilitation and treatment for addiction . Review of the facility investigation revealed no investigation addressing the incident for Resident #13. Observation on 4/8/19 at 9:46 AM in Resident #13's room revealed the resident in bed eating breakfast and appeared very slow to respond and sluggish in movement. Interview with Resident #13 on 4/8/19 at 4:03 PM in Resident #13's room revealed .I just got Hepatitis C. I looked at it (syringe) and the nurse said I had it in my arm. I did not have any blood on me. I found the needle it was up under one of those boxes and I picked it up and looked at it. I never stuck that in my arm ever. It was up under the box and it looked like it was opened and not closed very well . Continued interview revealed .she [nurse] said what in the world are you doing, are you sticking that in your arm? I told her I was just looking at it and was going to give it back to her. I was cleaning in the box . Interview with the Administrator on 4/9/19 at 2:02 PM confirmed the hypodermic- needle did not belong to the facility. Continued interview revealed .It was not our needle. We did not leave it in there at all . Interview with Licensed Practical Nurse (LPN) #1 on 4/9/19 at 2:17 PM in the conference room revealed, LPN #1 was the weekend supervisor on the alleged date of the incident. Continued interview with LPN #1 when asked if a facility report was completed confirmed .I just wrote it on a piece of paper and placed it in a file. I did not feel it was appropriate to place it in the resident record . Interview with the Administrator 4/10/19 at 6:10 PM in her office confirmed, the hypodermic needle was found in Resident #13's room. Continued interview confirmed the facility failed to investigate an incident which involved a non facility hypodermic needle. Continued interview revealed .we need to make sure we are documenting everything we do .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility staffing schedules and interview, the facility failed to provide sufficient staffing to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident on 3/11/18 for 1 floor (5th) of 4 floors reviewed. Findings include: Record review of the facility staffing for 3/11/18 revealed 4 Certified Nurse Aides (CNAs) were scheduled for the 7:00 PM to 11:00 PM shift with 56 residents on the 5th floor. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #63 had a Brief Interview for Mental Status (BIMS) score of 15/15, (cognitively intact), and required total 1 person assistance for toileting. Interview with Resident #63 on 3/12/18 at 8:29 AM in the resident's room on the fifth floor revealed .they are not answering the call light .takes 40-45 minutes to answer and I can't hold it and wet myself . Medical record review of the Quarterly MDS dated [DATE] revealed Resident #54 had a BIMS score of 13/15, (cognitively intact), and required 2 person assistance for bed mobility and transfers. Interview with Resident #54 on 3/13/18 between 2:10 PM and 2:50 PM during the Resident Council interviews in the Cafe revealed .this pass weekend I had to wait to be put in bed .I usually go to bed between 8:00 PM - 9:00 PM but I had to wait and was put to bed between 10:00 PM - 11:00 PM . Medical record review revealed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Rheumatoid Arthritis, Spinal Stenosis, Contracture of unspecified Ankle and Hand, Major Depressive Disorder and Anxiety. Medical record review revealed Resident #5 had a BIMS score of 13 (cognitively intact). The resident needed extensive assist with 1 person for bed mobility, total dependent with 2 persons for transfer. Interview with Resident #5 on 3/12/18 at 2:48 PM in the resident's room revealed .last night I did not get to bed until 11:00 PM and was told by the tech (CNA) she had many other people that needed same care I did .I normally get to bed 9:00 PM-9:30 PM . Interview with CNA #3 on 3/14/18 at 6:00 PM on the 5th floor revealed they had 4 CNAs on each shift for the week-end. Further interview revealed if they are giving showers or taking care of other residents then the residents had to wait until they are finished to get care. Interview with CNA #2 on 3/14/18 at 5:45 PM on the 5th floor revealed she worked this past week-end and they had 4 CNAs on the floor for the 7:00 PM -11:00 PM shift. Further interview revealed on 3/11/18 on the 7:00 PM-11:00 PM shift Resident #5 had to wait 45 minutes to be put to bed because CNA #2 and another CNA were assisting 2 other residents at the time and couldn't put her to bed as she requested. Continued interview confirmed Resident #5 had to wait 45 minutes to be put to bed and the facility failed to provide adequate staffing to meet the needs of the resident.

Based on facility policy review, observation and interview, the facility failed to maintain a clean environment for 1 of 5 observed fans on the 5th floor. Findings include: Review of the facility policy Infection Control Standard Precautions effective date 11/1/07 revealed .Environmental Control .Ensure that environmental equipment and other frequently touched surfaces are appropriately cleaned . Observation on 3/12/18 at 3:12 PM in the room of Resident # 5 revealed a table top fan on the bed side table in operation and directed at the resident seated in power wheelchair. Further observation revealed the fan grate had a heavy accumulation of hanging debris. Interview with Assistant Director of Nursing #2 on 3/12/18 at 3:19 PM in Resident #5's room confirmed the fan was dirty and was directed toward the resident.