**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable state laws for 1 of 5 CNAs (CNA A) reviewed for CNA certification. The facility failed to ensure CNA A's certification was current before allowing him to care for residents. CNA A worked in the facility providing resident care, on a full-time basis, with an expired certification during the period from [DATE] to [DATE]. This failure could place residents who received care from CNA A at a risk of decreased physical, mental, and psychosocial well-being.Findings included:Record review of CNA A's certification on [DATE] revealed the certification expired on [DATE]. In an interview with the DON at 12:16 PM on [DATE], the DON stated she was not aware CNA A's certification had expired. The DON stated each employee was responsible to ensure their license or certification was current. The DON stated HRC was responsible for reviewing the licenses and certifications of staff periodically and ensuring they were current. The DON stated an active certification showed the employee was capable and deemed fit to practice as a CNA. The DON stated a staff member without the proper certification or license may accidentally harm a resident. The DON stated CNA A was one of the best CNAs at the facility and he constantly got compliments from residents and their families. In an interview with the HRC at 12:30 PM on [DATE], the HRC stated she had been in her current role since [DATE]. The HRC stated it was her responsibility to track licensures and certifications of the staff. The HRC stated she ran audits of the employees periodically to ensure they were current. The HRC stated the last time she ran an audit was around [DATE]. The HRC stated she missed CNA A's certification had expired when she reviewed the audit. The HRC stated it was important to ensure all necessary staff were licensed or certified to keep the residents as safe as possible. In an interview with CNA A at 12:35 PM on [DATE], CNA A stated he had worked at the facility for approximately five years. CNA A stated he was not aware his certification had expired. CNA A stated when he first acquired his certification in 1988, the instructors told him as long he kept working then his certification would be automatically renewed. CNA A stated he thought the facility would maintain his certification. CNA A stated it was important for a CNA to be certified so they could provide the best possible care to a resident. Record review of page 26 of the Employee Handbook revealed the following paragraph: All professionally registered, licensed and certified staff is [sic] required to maintain current licensure, registration and/or certification. A copy of the current documentation must be submitted to your department head for inclusion in your personnel file. Failure to provide the documentation or failure to maintain status may result in suspension and/or termination. The cost for renewal is the responsibility of the employee. Record review of the signature page of the Employee Handbook revealed the form was signed and dated by CNA A on [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a residents medical, nursing, mental, and psychosocial needs, for 2 (Resident #5 and Resident #44) of 12 Residents reviewed for care plans in that: 1. The facility failed to implement a comprehensive person-centered care plan for Resident #5 to maintain the call light within reach of Resident #5. 2. The facility failed to ensure Resident #44's foley catheter ordered on 11/27/24 was care planned. This deficient practice could place residents at an increased risk of decline, and diminished quality of life. The findings included: 1. Record review of Resident #5's face sheet dated 02/03/25 revealed a [AGE] year-old male with an admission date of 01/20/20. Pertinent diagnoses included unspecified dementia, traumatic subdural hemorrhage (bleeding between the brain and the skull), and unspecified psychosis. Record review of Resident #5's comprehensive MDS dated [DATE] section C, cognitive function, stated Resident #5's BIMS score was 99, which indicated the resident was unable to complete the interview. Section GG, functional abilities, scored Resident #5 as a 1 (Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for eating, oral hygeine, toileting hygeine, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, and personal hygeine. Record review of Resident #5's care plan revealed the focus [Resident #5] has impaired communication due to impaired cognition and unclear speech initiated on 03/01/21 and revised on 05/12/21. One Intervention listed associated with the focus included: Ensure/provide a safe environment: Call light in reach, Adequate low glare light, Bed in lowest position and wheels locked, Avoid isolation initiated on 03/01/21. During an observation inside Resident #5's room and interview on 02/03/25 at 9:36 AM, Resident #5's call light was hung up on the wall, out of reach of Resident #5. Resident #5 was not interviewable. During an observation inside Resident #5's room on 02/03/25 at 1:20 PM, Resident #5's call light was hung up on the wall, in the same position it was in during the previous observation. In an interview with CNA A on 02/03/25 at 1:24 PM, CNA A stated a resident's call light should be within arms reach or clipped onto the bed. CNA A stated the staff went in Resident #5's room frequently. CNA A stated Resident #5 was not able to get up and walk around. CNA A stated Resident #5 can only move around in bed a little bit. This state surveyor and CNA A walked into Resident #5's room and CNA A stated Resident #5's call light was currently on the wall. CNA A stated Resident #5 will swing his call light around sometimes. CNA A stated they will sometimes put it out if reach for a few minutes and redirect him from swinging it around, before putting his call light back within reach. CNA A stated it was important for residents to be able to reach their call light in case they needed assistance going to the bathroom or if they needed anything. In an interview with LVN B on 02/03/25 at 1:31 PM, LVN B stated residents should have their call light within arm ' s reach. LVN B stated she was in Resident #5's room approximately 30 minutes ago and his call light was draped over the back of his bed at that time. LVN B stated Resident #5 had a family member with him in his room at that time. LVN B stated Resident #5's call light was within reach as well during her morning rounds around 6:30 AM. LVN B stated she had not seen Resident #5 swing his call light around before but had heard about it from other CNAs and nurses. This state surveyor and LVN B walked into Resident #5's room and LVN B stated Resident #5's call light was not currently within reach. LVN B stated it was important for residents to be able to reach their call lights in case they needed anything from staff. In an interview with the DON on 02/03/25 at 4:45 PM, the DON stated the call light should always be within reach of the resident unless otherwise stated. The DON stated she was not aware of any residents in the facility that should not have their call light within reach. The DON stated the only signaling system residents used in the facility were call lights. The DON stated she had never heard of Resident #5 swinging his call light around. The DON stated she had not heard of any issues with Resident #5 regarding his call light. The DON stated it was important for residents to have their call lights within reach so they could voice their needs if they had any. 2. Record review of Resident #44's face sheet date 2/4/25 reflected an [AGE] year-old-female with an original admission date of 8/22/24 and a re-admission date of 11/21/24. Diagnosis included chronic obstructions pulmonary disease (characterized by persistent respiratory symptoms like progressive cough and breathlessness) and type two diabetes (insufficient insulin production in the human body). Record review of Resident #44's orders dated 11/27/24 reflected: Urinary Foley Catheter 20F/10cc to gravity drainage every shift related to obstructive and reflux uropathy (blockage in your urinary tract). Record review of Resident #44's care plan initially dated 8/23/24 did not reflect foley care. Record review of Resident #44's Admission/Medicare MDS dated [DATE] reflected a BIMS of 14 (cognition intact) and indicated the resident had an indwelling catheter. In an interview on 02/04/25 at 02:47 PM LVN C stated she was unable to locate Resident #44's foley catheter care plan. LVN C stated Resident #44's foley catheter should have been care planned to ensure foley catheter care was being done and so direct care staff could monitor for infection. LVN C stated Resident #44's foley catheter instructions were on the medication administration record and treatment administration record. In an interview on 02/04/25 at 02:52 PM the MDS Coordinator stated Resident #44's foley care was not on the care plan. The MDS Coordinator stated it should have been care planned since it was part of Resident #44's plan of care. The MDS Coordinator stated she was not sure why foley care was not care planned. The MDS Coordinator stated it was a team effort to make sure the care plans are not overlooked and accurate. In an interview on 02/04/25 03:16 PM the DON stated Resident #44's foley should be care planned to ensure the proper plan of care was in place for Resident #44 and so staff were aware of the foley being in place. The DON stated it was a team effort to ensure the care plans are up to date and Resident #44's foley care plan was over looked. Record review of the facility's Comprehensive Care Planning policy not dated stated: The facility will develop and implement a comprehensive person-centered care plan for each resident consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The facility will establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to review and revise the care plans for 1 of 5 residents (Resident #232) whose care plans were reviewed, in that: The facility failed to ensure Resident #232's care plan was revised to accurately reflect current urinary or foley catheter status. These failures could place residents at risk of receiving inadequate individualized care and services. Findings included: Record review of Resident #232's face sheet revealed an [AGE] year-old male with an admission date of 1/13/25. Record review of Resident #232's Comprehensive MDS dated [DATE] revealed Resident #232 was unable to respond or answer questions, or rarely or never understood, so the brief interview for mental status was not performed. MDS also reflected Resident #232 was dependent with toileting hygiene, oral hygiene, showering/bathing and dressing. Record review of Resident #232's care plan revealed resident was care planned for an indwelling catheter on 1/14/25, and it was revised on 2/4/25 to still show indwelling catheter with 7 different interventions to meet urinary and catheter goals. Record review of Resident #232's physician orders revealed Foley catheter and Foley catheter care discontinued on 1/16/25. Record review of Resident #232's progress notes dated 1/13/25 revealed Resident was admitted from the hospital with the foley catheter. No other progress notes make a reference to having or removing a foley catheter. In an observation on 2/3/25 at 4:40 PM, Resident #232 was observed lying in bed with feeding tube attached and family at bedside. He would not wake to answer questions. No Foley catheter was observed. In an interview on 2/3/25 at 4:40 PM, Resident #232's daughter stated that her dad did have a foley catheter, but they removed it not long after he was admitted to the facility. In an interview on 2/4/25 at 12:12 PM with the Regional Nurse Consultant, she stated that care plans were updated typically by either the DON, ADON or MDS nurse. In an interview on 2/4/25 at 5:05 PM the DON stated that per the physician's orders, the foley catheter was discontinued on 1/16/25, and catheter and urinary status should have been removed from the care plan, especially since it was revised by someone today. In an interview on 2/5/25 at 9:29 AM with the Administrator, he stated that the DON normally initiates the care plans, then they were reviewed, revised, or updated by anyone on the Interdisciplinary Team. He stated that if care plans were not implemented or revised correctly, resident could end up getting improper care. Record Review of the Care Plan Policy, undated, revealed each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. The resident's care plan will be reviewed after each admission, quarterly, annual and/or significant change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safely for 1 of 1 kitchen reviewed for sanitation. The facility failed to properly label and date open, shelf stable food. The facility failed to dispose of expired shelf stable and refrigerated food. The facility failed to ensure items were stored properly in a refrigerator instead of on a pantry shelf. The facility failed to ensure the large containers of cooking oil were free from cracks or holes and not leaking on the floor. The facility failed to maintain and assure all chemicals in the kitchen area were labeled appropriately. These failures could place residents at risk of foodborne illnesses, as well as place residents and staff at risk for falls and injuries. Findings were: Observations and initial tour of the kitchen on 2/3/25 at 8:10 AM revealed a half-used jug of lemon juice labeled as refrigerate after opening was being kept on a pantry shelf; a large container of cooking oil on a bottom shelf in pantry that had leaked all over the floor and under shelving; an opened meat product, thawing in bloody water, past the hand written expiration date; three Ziploc bags of dry goods that were all past the hand written expiration date. Observation on 2/3/25 at 8:25 AM of the supply closet in the kitchen that houses the cleaners and chemicals revealed a large spray bottle with a light-yellow liquid or chemical inside it. Liquid or chemical had a very strong odor, and there was no label or writing on the bottle. In an interview on 2/3/25 at 8:25 AM with the Dietary Manager, he stated the unlabeled bottle had Clorox cleaner in it, and it should have been labeled or discarded. In an interview on 02/05/25 at 8:29 AM, housekeeping stated that labels should be put on the bottles by whoever pours the chemical into the bottle. She stated that it was not safe to have unlabeled chemicals sitting around because staff could use them without knowing what they were using, or a resident could get ahold of it and really hurt themselves if they drank it or got it on their skin. She also stated that it was not safe to leave spills, whether oil or something else, on the floor as someone could slip in it and hurt themselves. She stated it should be cleaned up as soon as the spill or mess was noticed. In an interview with the Dietary Manager on 02/05/25 at 08:55 AM, he stated serving expired food could cause residents to become ill, and If items were not being refrigerated like they should, this could also cause residents to become ill. He also stated that the oil had been leaking, and needed to be transferred to a different container and cleaned off the floor so an accident did not occur. He also stated that the person who transferred the chemical should have added the labels to the bottle, and if a chemical was not labeled appropriately, it could be hazardous if used for something else or if a resident got ahold of the chemical, it could cause harm to them. He stated that he was ultimately responsible for things being labeled or disposed of appropriately in the kitchen. In an interview with the Dietary Aide on 02/05/25 at 09:10 AM, she stated if food was used past the expiration date it could cause the residents to get sick. She also stated if things were not stored properly, they could go bad, and the residents could get sick from this as well. She also stated the person who opened and poured chemicals into a bottle was the person who would label the chemicals. She stated the staff or manager needed to dispose of the chemicals since there was no label or you could get it confused with other things. She also stated that a resident could have drunk the chemical or gotten it on their skin not knowing what it was, and it could have harmed them, and in regard to the oil all over the floor, whoever saw or noticed the oil spilled in the floor should have attended to it and cleaned it up, but that the Dietary Manager was ultimately responsible for everything in the kitchen. In an interview with the Administrator on 02/05/25 at 9:29 AM, he stated that the person who transferred the chemicals should have labeled it, but the Dietary Manager was ultimately responsible for everything in the kitchen, including labeling and discarding chemicals. He also stated that they do not have a policy regarding labeling chemicals or keeping chemicals labeled. He stated he was told that they teach and preach to label chemicals, but they do not have a specific policy for it. He also stated the Dietary Manager was ultimately responsible for getting rid of any expired food, and that serving expired food to the residents could cause them to become sick. He also stated that storing food improperly could cause it to go bad and could cause sickness as well if served; The Administrator also stated that the Dietary Manager was responsible for cleaning the oil off the kitchen floor, and if not cleaned up, someone could slip and fall. In an interview with the DON on 02/05/25 at 09:18 AM, she stated that serving expired food to the residents could cause them to get sick, and it was all kitchen staff's job to discard of expired food, but it was ultimately the Dietary Manager's responsibility to check to see if anything was expired. She also stated if food items or products were being stored improperly and served to the residents, this could also have caused them to get sick. The Dietary manager would be ultimately responsible for making sure if something was not labeled, it was discarded. The DON stated that the person who transferred the chemicals into the bottle should have labeled the bottle. If they did not label the bottle a resident could get injured or have poisoning if they had ingested the chemical. She stated the dietary manager was ultimately responsible for making sure something was labeled or was discarded, as well as should keep the oil contained, and the floor cleaned up because someone could slip and fall and become injured. Record review of the Food Storage and Supplies policy from the Dietary Services Policy and Procedure Manual 2012 revealed all facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas were clean and organized. If perishable food items were not stored at the proper temperature, spoilage bacteria could grow faster than anticipated and food becomes spoiled and should not be served. Record review of an email dated 2/5/25 at 10:38 AM from the Director of Environmental Services revealed they teach and preach to label chemicals, but there was no policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop and implement a comprehensive person centered care plan that included services to be furnished to attain or maintain the resident highest practicable well being for one resident (R#1) of 4 residents reviewed for skin care. A focus item of wound care treatment for Resident #1 was not listed on the care plan for over a month (from June to July). This failure could place Resident #1 at risk for lack of appropriate interventions and goals for the resident to meet their highest practicable level of care. This failure could lead to infection, progression of the growth, missing Dermatology and other specialty appointments and observations, and the excision of the growth. Findings were: Observation of Resident #1's wound care treatment with LVN #1 on 7/19/2024 at 1:46 p.m. This growth is softball sized with a rough textured surface. Wound care orders reviewed with LVN#1 and followed: clean area with wound cleanser and 4x4, pat dry, and cover with bordered gauze once daily. Aseptic technique was maintained during wound treatment. Record review of Resident #1's face sheet dated 7/22/24 indicated Resident #1 was [AGE] years old and admitted on [DATE] with diagnoses of Dementia (disorder that affects a person's ability to perform everyday activities), Hypertension (high blood pressure), Depression, Anxiety, and Cerebral Infarction (a pathologic process that results in an area of necrotic tissue in the brain). Record review of Resident #1's annual MDS assessment dated [DATE] and a quarterly MDS assessment dated [DATE] indicated Resident #1 has a BIMS of unable to complete. MDS indicated this resident is not coherent enough to complete this form. MDS does not indicate any skin issues currently. A record review of a Nursing Home visit by Resident #1's physician dated 6/7/2024 stated Large golf-ball sized left neck mass. Necrotic in appearance. Record review of Resident #1's care plan updated 7/19/2024 revealed this resident has a growth to the neck. The care plan does not indicate when this growth was first noted by a physician. The care plan indicated the resident is at risk for infection and complications due to the resident itching and scratching the site. A review of the Wound Care policy updated October 15, 2016, revealed Care planning in response to risk prediction must be completed. During an interview on 7/23/2024 at 9:35 a.m., LVN A verbalized Resident #1 could have been put on the Wound Care doctor's list for review. This is not an intervention listed in the care plan because the growth was not care planned until 7/19/2024. LVN A verbalized Resident #1 may have benefitted from being on the Wound Care doctor's list but is unsure how this would have benefitted the resident. During an interview on 7/23/2024 at 11:23 a.m., DON stated, Anything that has a doctor's order should be care planned. DON also stated there was no harm done or that could have been done to Resident #1t for lack of the growth being care planned because the wound care was being completed and the growth is scheduled to be removed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 5 of 24 residents (Resident #20, Resident #49, Resident #36, Resident #40 and Resident #58), reviewed for care plans. The facility failed to implement a comprehensive person-centered care plan for Resident #20 (R#20) in that: -Care plan did not address R#20's dominant left sided weakness. The facility failed to implement a comprehensive person-centered care plan for Resident #49 (R#49) in that: -Care Plan was not updated in regard to his diet. The facility failed to implement a comprehensive person-centered care plan for Resident #36 (R #36) in that: -Care plan did not include the resident's sleep/wake preferences. The facility failed to implement a comprehensive person-centered care plan for Resident #40 (R#40) in that: -Care plan did not state family occasionally brings R #40 outside food (R #40 was on pureed diet with nectar liquids). The facility failed to implement a comprehensive person-centered care plan for Resident #58 (R#58) in that: -The resident's diet changed from a regular diet to a g-tube/enteral feedings only. These deficient practices could place residents in the facility at risk of not being provided with the necessary care or services and implementing personalized plans developed to address their specific needs. Findings included: 1.) Record review of Resident # 20's face sheet documented a [AGE] year-old female with an original admission date of 04/26/21 and a re-entry date of 04/17/22. Diagnoses included a stroke with paralysis and weakness affecting the left non-dominant side, diabetes, depression, anxiety, high blood pressure, heart failure, reflux, and lung disease. Record review of R #20's MDS dated [DATE] revealed R #20 had a BIMS of 15 indicating cognitively intact, was left-handed, required 1 person assistance with ADL's, and was able to feed herself with adaptive equipment. Record review of R #20's comprehensive care plan dated 05/20/2021 documented R #20 had left sided hemiplegia (paralyzed) but did not address anything about R #20 having been left hand dominant, or resident centered focus, goals, and interventions for activities. Record review of R #20's [NAME] did not address anything about R #20 having been left hand dominant, resident centered focus, goals, or activities. Interview with the AD on 11/09/23 at 10:32 AM stated R #20 only liked to play bingo or [NAME]. The AD stated she encourages R #20 to do what she likes to do. The AD stated she tells her residents it's good exercise for their fingers. The AD did not know if anything was being done to address the resident's left dominant paralysis and was unaware R #20 was left-handed. Interview with the DOR on 11/09/23 at 10:38 AM stated R #20 was on Occupational Therapy (OT) services which she got every 3 months and had started OT on 10/29/23. Prior to that, she came off skilled services on 01/10/23. The DOR stated R #20 told her she wanted to start signing her name on Tuesday, 11/07/23, and that was the first time she had mentioned wanting to do something. The DOR stated R #20 had ROM in her left shoulder and much less in her left fingers. The DOR stated there had not been much progress because R #20 had come from another facility and there were a few years since her stroke and R #20 was not motivated to rehab. The DOR stated when they picked up R #20 here, she wanted to participate and get up out of bed. The DOR stated R #20 wanted to go home but family member said no-she needs too much care for them to handle. The DOR stated adaptive equipment should be care planned. The DOR did not know if the resident could hold or activate the call light with her left hand. The DOR stated she could not find anything about adaptive equipment in the orders or the care plan, as she scoured the electronic medical record. The DOR stated there should be something addressing R #20's left dominant paralysis, other than the hemiplegia and requiring assistance from staff. The DOR stated R #20 had a nosey cup and a plate guard. The DOR stated R #20 took her meals in her room because she spilled a lot. Interview with the MDS Coordinator on 11/09/23 at 01:07 PM stated the IDT (interdisciplinary team) care plan as needed and nurses communicate with administration when there were changes in resident care. Interview with the DON on 11/09/23 at 02:15 PM, stated care plans were done by the MDS Coordinator quarterly, for any acute changes, and any resident updates. The [NAME] stated staff utilized a 24-hour communication binder located at each nursing station that was utilized for resident changes and concerns. The DON stated when morning meetings were conducted with staff, resident changes were discussed with the MDS Coordinator present so any changes could be updated immediately. The DON stated possible negative outcomes for R #20 would be, direct care staff would not know to make sure the call light was properly positioned, or her food tray was set up properly. The DON stated she was responsible for making sure the MDS Coordinator was updating care plans by doing audits during care plan meetings but did not recall if she checked to see if R #20, #49, and #36's care plans were updated, and the care plan updates were just missed. The DON stated, moving forward, daily audits of care plans would be conducted, would make sure direct care staff would be using the 24-hour communication binder, and charge nurses would be updating direct care staff of any and all resident updates. Record review of R #49's face sheet documented a [AGE] year-old male with an original admission date of 04/02/20 and a re-entry date of 04/12/23. Diagnoses included a traumatic neck fracture and spinal cord injury with weakness affecting all limbs (quadriplegia), diabetes, low blood pressure, reflux, muscle spasms, depression, and neuromuscular dysfunction of the bladder requiring an indwelling catheter. Record review of R #49's MDS dated [DATE] revealed R #49 had a BIMS of 15 indicating he was cognitively intact. R #49 required assistance with ADLs, toileting, and mobility. Record review of R #49's comprehensive care plan dated 03/01/21 documented R #49 a potential risk for malnutrition date initiated 08/19/22 with an intervention including update food preferences as needed date initiated 08/19/22. Resident's diet order is mechanical ground meats, uses weighted utensils and plate guard with meals due to weakness and stiffness to his upper extremities. Date Initiated: 06/15/2021. Intervention included Determine food preferences and provide within dietary limitations. Date Initiated: 06/15/2021. There were no revision date(s) regarding R #49's food preferences. Record review of R #36's face sheet dated 06/16/23 documented a [AGE] year-old female with an initial admission of 06/16/23. Diagnoses included Lupus (when the immune system attacks its own tissues, causing inflammation, and can cause permanent tissue damage affecting the skin, joints, heart, lung, kidneys, blood cells, and the brain), reflux, arthritis, depression and anxiety, lung disease, insomnia, and chest pain. Record review of R #36's MDS dated [DATE] revealed R #36 had a BIMS of 15 indicating intact cognition. R #36 required minimal-1 person assistance/supervision in all areas. Record review of R #36's comprehensive care plan dated 06/19/23 did not document R #36's preferences for sleep/wake times. Interview with R #36 on 11/07/23 at 1:45 PM, revealed mornings were chaotic, and they want to wake me up at the crack of dawn! R #36 stated she had to tell staff repeatedly not to wake her up in the early mornings, and she preferred to wake up around 11:00 AM. Record review of R #36's comprehensive care plan dated 06/13/23 revealed preferences for sleeping until 11:00 AM were not Care planned. Interview with the ADON and the DON on 11/08/23 at 2:59 PM, both stated R #36's preferences should probably be care planned. Interview with the DON on 11/09/23 at 2:14 p.m. revealed care plans were reviewed quarterly and/or for any changes. The DON could not answer why revisions and changes were not made. The DON stated if something was not care planned, not everyone would know how to care for the residents. The DON stated the MDS was ultimately responsible for updating care plans. The DON stated she ensured the MDS made changes via a daily 24-hour report. The DON stated she did not recall Resident #49 coming up in the daily meetings. She stated there needed to be a daily review of care plans. Record review of R #49's face sheet documented a [AGE] year-old male with an original admission date of 04/02/20 and a re-entry date of 04/12/23. Diagnoses included a traumatic neck fracture and spinal cord injury with weakness affecting all limbs (quadriplegia), diabetes, low blood pressure, reflux, muscle spasms, depression, and neuromuscular dysfunction of the bladder requiring an indwelling catheter. Record review of R #49's MDS dated [DATE] revealed R #49 had a BIMS of 15 indicating he was cognitively intact. R #49 required assistance with ADLs, toileting, and mobility. Record review of R #49's comprehensive care plan dated 03/01/21 documented R #49 a potential risk for malnutrition date initiated 08/19/22 with an intervention including update food preferences as needed date initiated 08/19/22. Resident's diet order is mechanical ground meats, uses weighted utensils and plate guard with meals due to weakness and stiffness to his upper extremities. Date Initiated: 06/15/2021. Intervention included Determine food preferences and provide within dietary limitations. Date Initiated: 06/15/2021. There were no revision date(s) regarding R #49's food preferences. Record review of R #36's face sheet dated 06/16/23 documented a [AGE] year-old female with an initial admission of 06/16/23. Diagnoses included Lupus (when the immune system attacks its own tissues, causing inflammation, and can cause permanent tissue damage affecting the skin, joints, heart, lung, kidneys, blood cells, and the brain), reflux, arthritis, depression and anxiety, lung disease, insomnia, and chest pain. Record review of R #36's MDS dated [DATE] revealed R #36 had a BIMS of 15 indicating intact cognition. R #36 required minimal-1 person assistance/supervision in all areas. Record review of R #36's comprehensive care plan dated 06/19/23 did not document R #36's preferences for sleep/wake times. Interview with R #36 on 11/07/23 at 1:45 PM, revealed mornings were chaotic, and they want to wake me up at the crack of dawn! R #36 stated she had to tell staff repeatedly not to wake her up in the early mornings, and she preferred to wake up around 11:00 AM. Record review of R #36's comprehensive care plan dated 06/13/23 revealed preferences for sleeping until 11:00 AM were not Care planned. Interview with the ADON and the DON on 11/08/23 at 2:59 PM, both stated the resident's preferences should probably be care planned. Interview with the DON on 11/09/23 at 2:14 p.m. revealed care plans were reviewed quarterly and/or for any changes. The DON could not answer why revisions and changes were not made. The DON stated if something was not care planned, not everyone would know how to care for the residents. The DON stated the MDS was ultimately responsible for updating care plans. The DON stated she ensured the MDS made changes via a daily 24-hour report. The DON stated she did not recall Resident #49 coming up in the daily meetings. She stated there needed to be a daily review of care plans. 2.) Record review of Resident #40's face sheet dated 11/09/2023 documented an [AGE] year-old male with an initial admission date of 7/1/2022 and a readmission date of 7/3/2023. Diagnoses include Cerebral Infarction (type of stoke caused by impaired blood flow to the brain), Type 2 Diabetes (insufficient production of insulin in the body), Hypertension (high blood pressure), Stage 4 pressure ulcer (deep wound that exposes underlying muscle, tendon, cartilage or bone), right leg above knee amputation, Dysphasia (difficulty swallowing), Heart Failure, and Gastronomy (an opening in the stomach from the abdominal wall made surgically for the introduction of food). Record review of R #40's MDS dated [DATE] revealed R #40 had a BIMS of 3 (Severe Impairment), had a feeding tube, and required extensive assistance with bed mobility, transfer, dressing, personal hygiene, and toilet use. Record review of R #40's comprehensive care plan dated 7/5/2022 documented R #40 had pleasure feedings of purred with nectar liquids. Record review of R #40's physician orders dated 7/3/2023 documented R #40 had enteral feedings and pureed texture, nectar consistency diet. Record review of R #40's nursing documentation dated 10/12/2023 documented resident's (R #40) spouse was feeding resident a sandwich. educated her on his diet. notified RP. RP stated that they have been giving him tacos once in a while. Interview on 11/09/23 at 01:01 PM, the DON stated R #40's family had brought in regular food that contradicted with R # 40's MD dietary orders. The DON stated the MDS Coordinator did care plans for residents and should have been care planned and updated when the change had occurred. Interview on 11/09/23 at 01:05 PM, the ADON printed out R #40's care plan, dated 11/9/2023, that reflected, family occasionally brings outside food to resident (R #40). This surveyor informed ADON that previous care plan for R #40 was saved on 9/9/2023 at 9:24 AM. by this surveyor and did not reflect the changes on the care plan. The ADON stated that she was not sure what the previous care plan for R #40 documented since current care plan does reflect the change. Interview on 11/09/23 at 01:07 PM, the MDS Coordinator stated the IDT (interdisciplinary team) care plan as needed and nurses communicate with administration when there are changes in resident care. Interview on 11/09/23 at 02:15 PM, the DON stated care plans are done by the MDS Coordinator quarterly, for any acute changes, and any resident updates. The [NAME] stated staff utilized a 24-hour communication binder located at each nursing station that is utilized for resident changes and concerns. The DON stated when morning meetings are conducted with staff, resident changes are discussed with MDS Coordinator present so any changes could be updated immediately. The DON stated possible negative outcomes for R #40 would be, direct care staff would not know that family was bringing in outside food to R # 40 and staff would not know to monitor R #40's for any changed condition if outside food was eaten. The DON stated she is responsible for making sure the MDS Coordinator was updating care plans by doing audits during care plan meetings but did not recall if she checked to see if R #40's care plan was updated, and R #40's care plan update was just missed. The DON stated, moving forward, daily audits of care plans would be conducted, would make sure direct care staff would be using the 24-hour communication binder, and charge nurses would be updating direct care staff of any and all resident updates. 3.) Record review for R #58's admission record dated 11/7/23 revealed R #58 was admitted to the facility initially on 09/20/2023, was a [AGE] year-old male. R #58's diagnoses included unspecified protien-calorie malnutrition , Parkinson's (degenerative disorder of the central nervous system that mainly affects the motor system), Pneumonia due to inhalation of other solids and liquids, lack of coordination, and history of falls. Record review of R #58's care plan dated 10/05/23 indicated R #58 was changed to a NPO diet, NPO texture, NPO consistency however the care plan was not updated to implement that the resident could no longer receive food or fluids other than enteral feed. The care plan stated that R #58 could have a snack and it was encouraged to offer the resident drinks to maintain hydration. Observation on 11/7/2023 at 10:35 PM of R #58 in his room. R #58 was in his bed and had just finished physical therapy. R #58 noted with no drinks or food in sight. R #58 appeared calm, with pale skin. R #58 was nonverbal and could not express whether he was able to eat or drink anything or what was acceptable in his diet. This surveyor observed R #58 receiving an enteral feeding. Interview with CNA A and CNA B stated they were working the 500 hall on 11/8/23 at 2:08 PM. CNA A and CNA B stated they were not sure of the diet for R #58. This surveyor asked how do they know what R #58 can or cannot eat. CNA A and CNA B stated the charge nurse was the one that fed R #58 and they believed R #58 was fed only through R #58's g-tube but may be able to be pleasure fed. This surveyor asked CNA A and CNA B what could happen if they gave the R #58 food or drink because they were not sure of the R #58's diet. CNA A and CNA B stated R #58 could become very sick or even die if R #58 choked. Interview with the charge nurse for the assigned floor was on 11/8/23 at 2:32 PM, stated R #58's diet was an NPO diet and they had not changed it on R #58's care plan because R # 58's family member was not accepting of the diet change. This surveyor asked the LVN A where in the Care Plan can I find that R #58's family member had not been accepting of the diet and reason for not updating the plan? LVN A could not give this surveyor an answer. LVN A stated, I don't know. This surveyor asked if there was a reason why CNA A and CNA B did not know what the diet was for R #58. LVN A stated that CNA A and CNA B did not know R #58's diet and CNA A and CNA B could have simply gone to the [NAME] to verify, but CNA A and CNA B may have been nervous to answer or say they needed to check. Interview with the DON on 11/9/23 at 2:30 PM, revealed care plans began upon admission, quarterly, and updated as needed. The DON stated staff utilized a 24-hour communication binder located at each nursing station that was utilized for resident changes and concerns. The DON stated when morning meetings are conducted with staff, resident changes are discussed with the MDS Coordinator present so any changes could be updated immediately. The DON stated possible negative outcomes for R #58 would be that direct care staff could had given R #58 food or something to drink by accident because the care plan stated that it was encouraged. The DON stated she was responsible for making sure the MDS Coordinator was updating care plans by doing audits during care plan meetings but did not recall if R #58's care plan had been updated recently. The DON stated, moving forward, daily audits of care plans would be conducted. The DON stated she would make sure direct care staff would be utilizing the 24-hour communication binder, and charge nurses would be updating direct care staff of any and all resident updates. Review of Care Planning Policy not dated states: Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. 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. 8. The comprehensive, person-centered care plan will; a. Include measurable objectives and timeframe b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being. Record review of facility Comprehensive Care Planning Policy not dated stated; The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goal, and address the resident's medical, physical, mental, and psychosocial needs. The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented. Residents' preferences and goals may change throughout their stay, so facilities should have ongoing discussions with the resident and resident representatives, if applicable, so that changes can be reflected in the comprehensive care plan. A comprehensive care plan will be- Developed with 7 days after completion of the comprehensive assessment The resident's care plan will be reviewed after each Admission, Quarterly, Annually and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation in that: 1. The facility failed to label and date items in the nutrition rooms 2. The facility failed to maintain cleanliness of the ice machine in the nutrition room 3. The facility failed to dry storage items sealed 4. The facility failed to keep personal items out of the prep area These failures could place residents at risk of foodborne illnesses. Findings include: Initial tour of the kitchen on 11/07/23 beginning at 10:55 AM with the DS revealed a 16 oz. bag of potato chips in the dry storage area that was open to air. There was a 12 oz. bag of powdered gravy in the dry storage area that was open to air. Observation of the kitchen and interview with the DS on 11/08/23 at 11:25 AM, revealed a large personal container of a clear beverage on the prep table next to the stove, that belonged to one of the cooks. The DS told her there were no personal drinks allowed in the kitchen area due to the risk of cross contamination. Observation of the east wing nutrition room on 11/09/23 at 2:00 PM, revealed 4, 14 oz. containers of pudding expired 09/14/23, 1, 7.23 oz. bag of chocolate rice cakes expired 11/01/23, 1, 7.5 oz. bag of sugar free candies expired 05/01/23, 2, 7.5 oz. bag of sugar free candies expired 11/01/23, 1, 2 oz. opened, half empty and unlabeled bag of cheese flavored snacks. The ice machine had a thick, white cheesy substance on the ice chute. Interview with the cook on 11/08/23 at 11:25 AM, revealed having her cup in the prep area was not allowed and it just slipped her mind. The cook stated personal items were not allowed in the prep areas because cross-contamination could occur from touching the item, then touching something in the kitchen used to prepare food for the residents. It could make the resident sick. Interview with the DS on 11/09/23 at 2:10 PM, revealed floor staff were responsible for stocking, maintaining, and cleaning the nutrition rooms. Interview with the DON on 11/09/23 at 2:14 p.m., revealed floor staff were responsible for stocking, maintaining, and cleaning the nutrition rooms. A record review of in-services and training for the kitchen staff revealed 05/07/23 covered correct serving spoons, 05/12/23 tardiness, 06/03/23 handwashing, 07/26/23 dress code/jewelry, 08/26/23 harassment/cell phone use, 08/29/23 code of conduct, 09/22/23 professionalism/code of conduct, 10/01/23 handwashing, 10/15/23 legionella.