**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 5 residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1 was treated respectfully when CNA B spoke to Resident #1 in a loud manner and patted her hand on 04/14/2025. This failure could place residents at risk of embarrassment, feelings of worthlessness, decreased self-worth, loss of dignity, and a diminished quality of life. Findings included: 1. Record review of a face sheet dated 05/08/2025 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Parkinsonism (condition that impacts movement and causes muscle stiffness, slow movement, speech impairment, tremors, slowed reaction time, frequent falls), anxiety disorder (mental illness defined by feelings of uneasiness, worry and fear), and major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks). Record review of the Quarterly MDS assessment dated [DATE] indicated, Resident #1 was usually understood and usually understood others. The MDS assessment indicated Resident #1 had a BIMS score of 10, which indicated her cognition was intact. The MDS assessment indicated Resident #1 required substantial/maximal assistance with showering/bathing, toileting, and partial to moderate assistance with personal hygiene. Record review of Resident #1's care plan revised 04/15/2025 indicated, she screamed out at staff/other residents during anxious episodes and is at times hard to redirect or console related to anxiety. Resident #1's interventions indicated to maintain a calm environment and approach. Record review of the Provider Investigation Report with incident date 4/14/2025 at 2:25 PM, indicated Description of Allegation CNA B went and told the BOM Resident #1 was hitting her and cussing at her. CNA B stated she smacked Resident #1's hand like you would a toddler. The Provider Investigation Report indicated the conclusion of the investigation was that it was unfounded. CNA B had no intention to harm resident and was only attempting to distract resident from aggressive behavior. During an interview on 05/07/2025 at 11:08 AM, when Resident #1 was asked if staff had yelled at her, she said I am sure they have, but was unable to report who it was or when it happened. Resident #1 said she did not remember any staff hitting her or patting her hand. Resident #1 said she felt safe in the facility. During an interview on 05/07/2025 at 12:26 PM, LVN A said she was the nurse when the incident between Resident #1 and CNA B occurred. LVN A said Resident #1 was agitated when CNA B started her shift that day. LVN A said she was sitting at the nurse's station behind the desk and heard CNA B raise her voice at Resident #1, so she told her hey you need to stop doing that, and CNA B walked away. LVN A said she did not see CNA B hit Resident #1. LVN A said CNA B could get loud sometimes, and she had to tell her that was not how she needed to talk to the residents. LVN A said examples were CNA B would tell the residents you are my patient and you are not doing what I want you to do or ma'am we need to go in and get you cleaned up, we need to do it now, and if the they said no CNA B told them yes, we are we are going to go do it now. LVN A said she had to step in and tell CNA B if the resident was agitated, she was not going to be able to care for them. LVN A said CNA B speaking to the residents loudly and making such comments was disrespectful, and she was not treating the residents with dignity. LVN A said she had reported this to management when they asked her to write a witness statement for the incident between CNA B and Resident #1. During an interview on 05/07/2025 at 4:28 PM, CNA B said Resident #1 was in her room and she was trying to change her, and Resident #1 was hitting her and being physically and verbally abusive towards her, so she tapped her hand to try to calm her down, when she saw that she was not deescalating, she walked out of her room and went to get Resident #1's wheelchair. CNA B said she went back into Resident #1's room and got her in her chair and Resident #1 did it again and she said to her stop hitting. CNA B said after this, she went to the BOM and told her Resident #1 was hitting her and she tapped her hand because she was hitting. CNA B said she had not gotten loud with Resident #1, and she had removed herself from the situation. CNA B said when a resident was aggressive, she should stop providing care, and return later. CNA B said she had made comments to the residents such as they were her patients and they needed to do things now. CNA B said speaking to the residents this way could make them feel like poop and that their rights did not matter. CNA B said she had received training on how to handle residents with behaviors and how to speak to the residents when she first started, but she had not received any training since then. During an interview on 05/07/2025 at 5:34 PM, the BOM said CNA B went in her office and told her Resident #1 was pushing and hitting her. The BOM said she told CNA B Resident #1 could not swing that far so she needed to just back up. The BOM said CNA B told her she got Resident #1's hand and tapped it. The BOM said she told CNA B to hold on and got the DON to takeover. During an interview on 05/08/2025 at 3:54 PM, the DON said the BOM had gone to her and told her CNA B just told her she hit Resident #1 on the hand. The DON said she asked CNA B to explain what happened with Resident #1. CNA B said Resident #1 was hitting and flinging her arms and CNA B could not get Resident #1's attention so she grabbed Resident #1's hand and patted it to get her attention. The DON said she did not allow CNA B to return to provide care. The DON said she sent CNA B home. The DON said CNA B had no history of abuse. The DON said if the residents refused care they should not continue and get the social worker involved. The DON said she was not aware CNA B was loud with the residents, and LVN A had not reported the comments CNA B made to the residents to her. The DON said the residents should be treated respectfully, and CNA B speaking to them in such way could make them feel pressured into doing what she wanted them to, and it could be misconstrued by the residents as the staff being confrontational. During an interview on 05/08/2025 at 4:51 PM, the Administrator said she was not aware CNA B was loud with the residents or of her speaking to the residents disrespectfully. The Administrator said she expected for the staff to speak to the residents gently and encourage them to be assisted. The Administrator said if the resident was refusing, the staff should leave and return later. The Administrator said she expected for the staff to explain what they were doing to the residents, and not just tell them they were going to do something. The Administrator said if the residents were spoken to loudly and told what to do this could make them feel like they were pressured to do things right then and there and like they were on a time schedule. Record review of an Inservice Attendance Record dated 04/17/2025, indicated the subject was Abuse/Neglect-Dealing with resident behaviors, the instructors were the Administrator and the DON, and for the name of attendee it indicated, by phone with CNA B prior to returning----verbalizes understanding. Summary of Meeting indicated reviewed abuse/neglect policy discussed ways to deal with dementia and other resident behaviors such as distraction, activities, offering snacks or getting a different caregiver. Record review of the facility's policy titled, Resident Rights, revised February 2021, indicated, Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity .

Based on observation, interview, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 2 medication carts (South Hall Nurse Medication Cart) reviewed for drugs and biologicals. The facility failed to ensure LVN C secured the South Hall Nurse Medication Cart, when it was not in use on 05/07/2025. This failure could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion. Findings included: During an observation on 05/07/2025 starting at 1:22 PM, there was an unlocked medication cart next to the nurse's station. The housekeeper was cleaning and moved the unlocked medication cart to the opposite side of the hallway. The nurse was not observed near the medication cart or in the hallway. The housekeeper said she thought the nurse, LVN C, was at break. During an interview on 05/07/2025 at 1:27 PM, LVN C said she was on break, and the medication cart was hers. LVN C said she guessed she got distracted and did not realize she did not lock it. LVN C said the nurse should ensure the medication cart was locked when not in use. LVN C said it was important for the medication cart to be locked because they had dementia patients, and someone could go and inject themselves or someone could take stuff. LVN C said that is was super dangerous for the medication cart to be left unlocked. During an interview on 05/08/2025 at 3:54 PM, the DON said the medication cart needed to be locked at all times when not in use. The DON said she conducted rounds daily to check to ensure the medication carts were locked. The DON said the nurses were responsible for ensuring the medication carts were locked. The DON said if the medication cart was left unlocked somebody could access the medications or treatments in it. During an interview on 05/08/2025 at 5:12 PM, the Administrator said she expected for the medication carts to be locked anytime the nurses were not in front of them. The Administrator said if the medication cart was left unlocked a resident could get into the medication cart. Record review of the facility's policy, titled, Security of Medication Cart, revised April 2007, indicated, 4. Medication carts must be securely locked at all times when out of the nurse's view.

Based on interview and record review, the facility failed to provide sufficient number of nursing staff on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans and the facility assessment for 1 of 1 facility reviewed for care and services. The facility failed to provide sufficient CNAs according to the facility assessment on 02/01/2025, 02/04/2025, 02/05/2025, 02/06/2025, 02/07/2025, 02/08/2025, 03/01/2025, 03/07/2025, 03/10/2025, 03/12/2025, 03/25/2025, 03/29/2025, 04/01/2025. This failure placed residents at risk of inadequate supervision, an unsafe environment, falls, serious harm and injury, exacerbations of disease processes, abuse, and death. Findings included: During an interview Anonymous Staff Member #1 said they had been working short staffed for a while, but it was getting better. Anonymous Staff Member #1 said there were multiple nights where there was one CNA for the whole building. Anonymous Staff Member #1 said they worked as a team to care for the residents. Anonymous Staff Member #1 said they provided care to the residents as they could that it might not be as timely as the residents required but the care was provided. Anonymous Staff Member #1 said the residents had to wait until they could get to them. Anonymous Staff Member #1 said not having enough staff placed the residents at risk of not receiving the care they needed. Anonymous Staff Member #1 said management was aware that they were short, and it was difficult to provide timely care to the residents. During an interview Anonymous Staff Member #2 said the facility was short staffed, and some of the residents required the use of a mechanical lift. Anonymous Staff Member #2 said at times they had used a mechanical lift without the assistance of another staff member because the nurses were not helping. Anonymous Staff Member #2 said they had made management aware of the difficulty completing tasks due to the staffing shortage and was told they were trying to get more help. During an interview Anonymous Staff Member #3 said there had been nights when they were the only CNA for the entire building. Anonymous Staff Member #3 said they were not able to round on the residents every 2 hours. Anonymous Staff Member #3 said nobody could provide the care the residents needed on their own. Anonymous Staff Member #3 said management was aware they were unable to complete all the resident care as the only CNA for the building. Anonymous Staff Member #3 said this placed the residents at risk for being neglected. During an interview on 05/08/2025 at 3:54 PM, the DON said staffing had been better that they were having a lot of people all in. The DON said to cover the shifts she had worked the floor, her previous ADON had work, and they had CNAs stay over. The DON said their goal was to have 3 CNAs on the 6 AM-2 PM shift, 3 CNAs on the 2 PM-10 PM shift, and 2 CNAs on the 10 PM-6 AM shift. The DON said she thought the facility assessment said something different. The DON said they had worked with 2 CNAs on the 6 AM-2 PM shift, 2 CNAs on the 2 PM-10 PM shift, and 1 CNA on the 10 PM-6 AM shift. The DON said she believed the 10 PM-6 AM shift could be covered with 1 CNA. The DON said there were 2 nurses during that shift, and the nurses could help the CNAs. The DON said when they first started having 1 CNA on the night shift one of the CNAs had reported to her, she did not know how she was going to do it, and then she did not hear anymore complaints after that. The DON said typically their census was 44-45 residents. The DON said if they did not have enough nursing staff they would be slower getting to the residents' needs. During an interview on 05/08/25 at 4:51 PM, the Administrator said the staff had not made her aware they were having difficulties providing care with 1 CNA on the 10 PM-6 AM shift. The Administrator said they had 2 nurses on the night shift, and they had a lot of independent residents. The Administrator said they started hiring agency staff to fill in for the staffing shortage. The Administrator said according to their facility assessment they could have 1-2 CNAs on the night shift. The Administrator said where the facility assessment indicated direct staff ratio 1:30 it was referring to the number of CNAs required, so if their census was more than 30, they required 2 CNAs on the night shift. The Administrator said she thought they ultimately were providing the care the residents needed because the CNA had the support of the nurses. Record review of the Facility Assessment with date of assessment or update 01/31/2025 indicated, Direct care staff, Plan 1: 30 ratio Nights. This indicated 1 CNA was necessary per 30 residents for the night shift (10 PM-6 AM). Record review of the Daily Census Report indicated: 02/01/2025, the census was 47. 02/04/2025, the census was 48. 02/05/2025, the census was 48. 02/06/2025, the census was 49. 02/07/2025, the census was 49. 02/08/2025, the census was 48. 03/01/2025, the census was 45. 03/07/2025, the census was 47. 03/10/2025, the census was 48. 03/12/2025, the census was 47. 03/25/2025, the census was 47. 03/29/2025, the census was 49. 04/01/2025, the census was 49. Record review of the time sheets indicated only 1 CNA worked on the 10 PM-6 AM shift on the following dates: 02/01/2025 02/04/2025 02/05/2025 02/06/2025 02/07/2025 02/08/2025 03/01/2025 03/07/2025 03/10/2025 03/12/2025 03/25/2025 03/29/2025 04/01/2025. Record review of the facility's policy titled, Staffing, revised September 2023, indicated, Our center provides sufficient nursing staff with the appropriate skills and competencies necessary to provide care and related services to ensure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with resident care plans and the facility assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the right to formulate an advanced directive was provided for 2 of 19 residents (Residents #40 and #44) reviewed for advanced directives. 1. The facility did not ensure Resident #40's OOH-DNR included the physician signature and licensed number. 2. The facility did not ensure Resident #44's full code status was discontinued after Resident #44 signed a DNR. These failures could place residents at risk of not receiving care and services to meet their needs. Findings included: 1. Record review of Resident #40's face sheet, dated [DATE], indicated Resident #40 was a [AGE] year-old male, originally to the facility on [DATE] with diagnoses which included dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of Resident #40's physician order report, dated [DATE]-[DATE], indicated an active physician's order for code status: DNR with an order date [DATE]. Record review of Resident #40's quarterly MDS, dated [DATE], indicated Resident #40 made himself understood, usually understood others. Resident #40's BIMS score was 9, which indicated his cognition was moderately impaired. Record review of the comprehensive care plan, revised [DATE], indicated Resident #40 was a DNR. The care plan interventions included, CPR will not be initiated, and DNR status will be documented in Resident #40's chart. Record review of Resident #40'ss OOH-DNR form dated [DATE] reflected a missing physician signature and physician licensed number. 2. Record review of Resident #44's face sheet, dated [DATE], indicated Resident #44 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses which included liver cell carcinoma (liver cancer). Record review of Resident #44's general order, dated [DATE] indicated an active physician's order for code status: full code. Record review of Resident #44's quarterly MDS, dated [DATE], indicated Resident #44 made himself understood and understood others. Resident #44's BIMS score was 15, which indicated his cognition was intact. Record review of the comprehensive care plan, revised [DATE], indicated Resident #44 was a DNR. The care plan interventions included, will review on admission, quarterly and PRN. Record review of Resident #44's OOH-DNR form dated [DATE] reflected a completed DNR that was signed by all responsible parties. During an interview on [DATE] at 1:10 PM, Resident #44 stated he signed an OOH-DNR at the facility and that was his wishes. During an interview on [DATE] at 9:35 a.m., the Social Worker stated she was responsible for completing DNRs. The Social Worker stated she started working at the facility around [DATE]. After reviewing Resident #40's electronic medical record, stated Resident #40 OOH-DNR was missing a signature and date by the physician. After reviewing Resident #44's electronic medical records, the Social Worker stated once Resident #44 completed the DNR the full code should have been discontinued. The Social Worker stated the risk associated with not discontinuing the full code or ensuring DNRs were completed would means their wishes were not carried out. During an interview on [DATE] at 12:39 p.m., the Administrator stated he expected DNRs to be filled out completely, including signatures. The Administrator stated he expected Resident #44 order to match the documents that were in the charts as long the documents were accurate. The Administrator stated the previous social worker was responsible was for overseeing and monitoring the DNR. The Administrator stated it was important to ensure residents code status was up to date and DNRs completed to respect the resident preference. Record review of the facility's policy titled Advanced Directive revised 2.29.24 indicated . it is the policy of this facility to adhere to residents' rights to formulate advance directive. In accordance with these rights, the facility will implement procedures to communicate a resident's code status to those individuals who need to know this information .4. The nurse who notates the physician order is responsible for documenting the directive in all relevant sections of the medical record .9. The Social Services Director shall maintain a list of residents who had an advance directive on file . 14. A code status audit will be conducted by the DON or designee quarterly or as needed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 1 of 19 residents (Resident #42) reviewed for reasonable accommodation of needs. The facility did not ensure Resident #42 was able to easily use the door to her room. This failure could place residents at risk for unmet needs and decreased quality of life. The findings included: Record review of the face sheet, dated 11/07/24, reflected Resident #42 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of chronic pain, difficult in walking, muscle weakness, unsteadiness of feet, and lack of coordination. Record review of the quarterly MDS assessment, dated 10/16/24, reflected Resident #42 had clear speech and usually understood others. The MDS reflected Resident #42 was usually able to understand others. The MDS reflected Resident #42 had a BIMS score of 12, which indicated moderately impaired cognition. The MDS reflected Resident #12 was independent with bed mobility and transfers and used a walker. Record review of the comprehensive care plan, edited 08/26/24, reflected Resident #42 had impaired ADL function and was at risk for falls. The interventions did not address easy use of functional items. Record review of the work orders from 05/01/24 - 11/05/24, reflected no work orders had been put in the system for Resident #42's hard to open room door. During an observation and interview on 11/04/24 beginning at 11:28 AM, Resident #42's room door was hard to open upon entrance to her room. Surveyor had to put weight into the shoulder which was pressed against the door for it to open. Resident #42 stated her door to her room was extremely hard to get open. Resident #42 stated she had reported it to the facility staff several times. Resident #42 stated the Maintenance Supervisor had looked at it and said he would fix it but has not fixed it yet. Resident #42 said she had to shove, push, or use her butt to open the door. Surveyor had to push her body weight into her shoulder, which was pressed against the door in order to exit the room. During an interview on 11/06/24 beginning at 2:47 PM, the Maintenance Supervisor stated he was aware Resident #42's door was hard to open. The Maintenance Supervisor stated multiple rooms on the hall were hard to open because the whole building had shifted. The Maintenance Supervisor stated he had started making calls to have contractors come out to the facility to place bids on lifting the facility. The Maintenance Supervisor stated there were other things he could have tried to ensure the doors were easy to open but he had not had time. The Maintenance Supervisor stated it was important to ensure Resident #42 could get in and out of her room easily. During an interview on 11/07/24 beginning at 12:20 PM, the Administrator stated she expected Resident #42's door to have been fixed. The Administrator stated when the facility staff noticed or found out about an issue, it should have been placed into the system that generated a work order for the Maintenance Supervisor. The Administrator said the system used for work orders, alerted the team as a whole so it could have been followed up on. The Administrator stated the Maintenance Supervisor was responsible for monitoring to ensure environmental issues were addressed. The Administrator stated it was important to ensure the accommodations were made to promote an environment that was easily accessible to residents. Record review of the Accommodation of Needs policy, revised March 2021, reflected Our facility's environment and staff behaviors are directed toward assisting the resident in maintain and/or achieving safe independent functioning, dignity, and well-being .the resident's individual needs and preferences are accommodated to the extent possible .the resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment, are evaluated upon admission and reviewed on an ongoing basis .in order to accommodate individual needs and preferences, adaptation may be made to the physical environment, including the resident's bedroom and bathroom .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide appropriate treatment and service of care for 1 of 3 residents (Resident #30) reviewed for indwelling catheter. The facility failed to ensure Resident #30's indwelling catheter securement device was in place. The facility failed to ensure Resident #30's indwelling catheter drainage bag was kept from touching and resting on the floor. These failures could affect residents with an indwelling urinary catheter and place them at risk of at risk for urethral tears, discomfort, infection, and hospitalization. Findings included: Record review of a face sheet dated 11/07/24 indicated Resident #30 was a [AGE] year-old male, admitted on [DATE] and re-admitted on [DATE] with a diagnosis of Obstructive uropathy (a urinary tract disorder that occurs when urine flow is obstructed, either structurally or functionally),. Record review of a significant change in condition MDS dated [DATE] indicated Resident #30 rarely made himself understood and rarely understood others. Resident #30 had severely impaired cognitive skills. The MDS indicated Resident #30 required total dependence with transfers, dressing, toileting, bed mobility, personal hygiene, bathing, and eating. The MDS for Resident #30 indicated that he had an indwelling catheter. Record review of the care plan revised on 11/06/24 indicated Resident #30 required the need for an Indwelling catheter (16 french 10 cubic centimeters bulb) related to a diagnosis of Obstructive uropathy secondary to Prostate cancer. Interventions: Change the indwelling catheter and drainage bag as needed for indications of blockage, increased sediment, infection, and displacement. Record review of Resident #30's physician orders dated 03/24/24 indicated, that the Foley catheter was to be secured to the leg to promote comfort and minimize catheter tension/tissue trauma. Record review of Resident #30's MAR dated 11/01/24 through 11/07/24 revealed the staff signed indicating a Foley catheter strap was secured to his leg. During an observation on 11/04/24 at 11:50 a.m., Resident #30 was lying in his bed without an indwelling catheter securement device in place, and the indwelling catheter bag was on the floor. During an observation on 11/05/24 at 9:01 a.m., Resident #30 was lying in his bed without an indwelling catheter securement device in place, and the indwelling catheter bag was on the floor. During an interview on 11/05/24 at 1:47 p.m., CNA G verified by looking and said Resident #30 did not have a leg strap on and his indwelling catheter bag was on the floor. She said Resident #30 should have an indwelling catheter securement device on to keep it from pulling out. She said the indwelling catheter bag should not be on the floor because it was cross-contamination. During an interview on 11/05/24 at 1:54 p.m., LVN D said all residents with indwelling catheters should have a leg strap. She said a leg strap would be applied to prevent tension or someone pulling them out. She said indwelling catheter bags should not be on the floor for infection control reasons. During an interview on 11/07/24 at 10:37 a.m., the DON said nurses should ensure residents always had a leg strap on to prevent dislodgement. She said the indwelling catheter should not be on the floor for infection control issues. She said all staff should ensure the residents who had indwelling catheters had on a leg strap and the indwelling drainage bag was not on the floor. During an interview on 11/07/24 at 11:22 a.m., the Administrator said she expected for the residents to have on an indwelling catheter leg strap to prevent it from pulling out. Record Review of policy titled, Indwelling Catheter Use and Removal revised 2022 indicated Policy: It is the policy of this facility to ensure indwelling urinary catheters that were inserted or remain in place justified or removed according to regulations and current standards of practice. #7 Additional care practices included: D. Keeping the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodgement of the catheter; and E. Securement of the catheter to facilitate flow of urine, prevention of kinks in the tubing, and positioning below the level of the bladder. Record review of Lippincott procedures, Indwelling urinary catheter (Foley) care and management revised 11/27/22, Lippincott procedures - Indwelling urinary catheter (Foley) care and management (lww.com), quoted in part, Keep the drainage bag below the level of the patient's bladder to prevent backflow of urine into the bladder, which increases the risk of CAUTI (catheter associated urinary tract infection) . However, do not place the drainage bag on the floor to reduce the risk of contamination and subsequent CAUTI.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 5 residents (Resident's #15 and Resident #11) reviewed for respiratory care. 1. The facility failed to ensure Resident #11's oxygen was placed on 2 liters per nasal cannula as ordered by the physician. 2. The facility failed to change oxygen tubing weekly on Sunday nights for Resident #11 and Resident #15. These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care. Finding included: 1.Record review of Resident #11's face sheet, dated 11/06/24 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease also known as COPD, (a chronic inflammatory lung disease that causes obstructed airflow from the lungs),. Record review of Resident #11's quarterly MDS assessment, dated 09/20/24, indicated Resident #11 usually understood and sometimes understood others. The MDS assessment indicated she had a BIMS score of 12 indicating she was moderately cognitively impaired. Resident #11 required assistance with bathing, toileting, dressing, bed mobility, and set-up assistance with personal hygiene, and eating. The MDS indicated she required oxygen. Record review of Resident #11's physician's order dated 10/23/23 indicated Oxygen at 2 liters per nasal cannula every shift as needed for shortness of breath. Record review of Resident #11's comprehensive care plan, dated 10/09/24, indicates Resident #11 required oxygen therapy related to COPD. The intervention of the care plan was for staff to administer oxygen at 2 liter per nasal cannula. During an observation on 11/04/24 at 12:37 p.m., Resident #11 was lying in her bed with oxygen set at 5 liters per nasal cannula. The oxygen tubing was dated 10/28/24. During an observation on 11/05/24 at 9:04 a.m., Resident #11 was lying in her bed with oxygen set at 3 liters per nasal cannula. The oxygen tubing was dated 10/28/24. 2. Record review of Resident #15's face sheet, dated 11/06/24 indicated a [AGE] year-old female who was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (no airflow for breathing). Record review of Resident #15's quarterly MDS assessment, dated 09/10/24, indicated Resident #15 was usually understood and was usually understood by others. Resident #15's BIMS score was 10, which indicated she was moderately cognitively impaired. The MDS indicated Resident #15 required assistance with dressing, personal hygiene, toileting, bathing, bed mobility, transfers, and set-up for eating. The MDS during the 7-day look-back period indicated Resident #15 was receiving oxygen. Record review of Resident #15 physician orders dated 08/12/23 indicated, Nasal Cannula Continuous at 2-4 liters per minute for dyspnea or shortness of breath. Record review of Resident#15's care plan dated 08/26/24 indicated, Resident #15 had a diagnosis of COPD. The intervention was for staff to administer oxygen as ordered, monitor for signs or symptoms of respiratory infection, and report to the doctor. During an observation on 11/04/24 at 12:32 p.m., Resident # 15 was lying in her bed with her eyes closed. Her nasal cannula tubing was dated 10/25/24. During an interview on 11/05/24 at 1:54 p.m., LVN D looked at Resident #11's oxygen rate and said it was at 3 liters per nasal cannula. She said she thought she was supposed to run at 2-4 liters. She looked in the electronic medical records for Resident #11 and read her order for oxygen at 2 liters per nasal as needed for shortness of breath. She said she would fix her order. LVN D said the oxygen tubing should be changed on Sunday nights. She went to look and verified Resident #11 and Resident #15 oxygen tubing had not been changed since 10/25/24. She said she was not aware it had not been changed. She said she was also responsible for looking on Monday to ensure it had been changed and she did not. She said she would get them changed. During a telephone interview on 11/06/24 at 2:22 p.m., LVN K said he was the nurse on duty Sunday night (11/03/24). He said they did not have any nasal cannulas to change out Resident #11 and Resident #15 oxygen tubing. He said the weekend supervisor called the DON, but he said he was not sure of the whole conversation. He said he signed the medication administration record out of habit, but he did not change Resident #11 or Resident #15's nasal cannula because they did not have any in the facility. During an interview on 11/07/24 at 10:37 a.m., the DON said the charge nurses were responsible for following the physician's orders. She said not following the orders could cause respiratory issues. She said the charge nurses were responsible for ensuring the oxygen tubing was changed and dated weekly on Sunday night. She said she did receive a call from the weekend supervisor on Sunday (11/03/24). She said the weekend supervisor asked her where the nasal cannulas were located, and she told her in the blue bind; she said did not realize they were out until LVN D told her on Tuesday (11/05/24). She said she was the overseer for making rounds on Resident #15 and Resident #11. She said she did not make rounds on Monday (11/04/24) or Tuesday (11/05/24). The DON said oxygen tubing should be changed and dated for infection control. During an interview on 11/07/24 at 11:22 a.m., the Administrator said she was not clinical and did not know all the requirements for oxygen. The administrator said the DON was the overseer of orders and oxygen. Record review of facility policy titled, Oxygen revision date as of February 2010, indicated Purpose: The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation: 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 3 residents (Resident # 49) reviewed for trauma-informed care. The facility did not ensure Resident #49 had a trauma screening upon admission that identified possible triggers when Resident 49 had a history of trauma. This failure could put residents at an increased risk for severe psychological distress due to re-traumatization. Findings included: Record review of a face sheet dated 11/07/24 indicated Resident #30 was a [AGE] year-old male, admitted on [DATE] and re-admitted on [DATE] with diagnoses including stroke, Obstructive uropathy (a urinary tract disorder that occurs when urine flow is obstructed, by either structurally, or functionally), anxiety (a feeling of fear, dread, or uneasiness), depression (a mood disorder that causes a persistent feeling of sadness), and post-traumatic stress disorder also known as PTSD (is a mental health condition that can develop after a person experienced or witnessed a traumatic event). Record review of a significant change in condition MDS dated [DATE] indicated Resident #30 rarely made himself understood and rarely understood others. Resident #30 had severely impaired cognitive skills. The MDS indicated Resident #30 required total dependence on transfers, dressing, toileting, bed mobility, personal hygiene, bathing, and eating. The MDS for Resident #30 indicated he had PTSD. Record review of the care plan revised on 11/06/24 indicated Resident #30 was at risk for adverse consequences related to administering medication for the diagnosis of anxiety and post-traumatic stress disorder. The interventions were to give medication as ordered. The care plan did not indicate any triggers. Record review of Resident #30's trauma assessment was not located in his electronic medical records. During an attempted interview on 11/04/24 at 9:01 a.m., Resident #30 was lying in his bed. He did not respond when asked about his history of trauma. During an interview on 11/07/24 at 9:40 AM, the Social Worker said she was not sure of the process for trauma-informed care. The Social Worker said she was new to the facility and had only been employed for a few weeks. The Social Worker said she thought the trauma assessments should have been completed on admission and quarterly. The Social Worker said Resident 30's assessment should have been completed. The Social Worker said it was important to ensure trauma assessments were completed to ensure the residents' needs were met and they were safe and comfortable. During an interview on 11/07/24 at 10:25 a.m., the MDS nurse said the previous SW did the care plans on trauma. She said she was the overseer of care plans and should have ensured Resident #30 had his trauma or PTSD triggers on the care plan. She said having triggers on the care plan would alert staff of things not to do and how to help him through his triggers. During an interview on 11/07/24 at 10:37 a.m., the DON said the SW was responsible for the trauma-informed care assessment. She said the trauma assessment was done to see if a resident had any underlying trauma or behaviors. She said she was not sure if the MDS nurse or the SW put the PTSD/trauma care on the care plan. She said she was not aware Resident #30 did not have a trauma assessment done on admission as she was new to the facility. The DON said it was important for any triggers to be on the care plan so staff would know how to address them and provide the resident with the best care for their overall well-being. During an interview on 11/07/24 at 11:22 a.m., the Administrator said it was important for the trauma assessment to be completed and for staff to have access to that information so they could accurately meet the resident's needs. Record review of the facility's policy titled Trauma Informed Care last revised 12/2019, indicated, Policy: The facility ensures residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice. The care accounts for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident. Resident-Care Strategies: #1 As part of the comprehensive assessment, identify the history of trauma or interpersonal violence when possible. Identifying past trauma or adverse experiences may involve record review or the use of screening tools.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 24.24%, based on 8 errors out of 33 opportunities, which involved 2 of 6 residents (Resident #4 and Resident #25) reviewed for medication administration. The facility failed to ensure Resident #4 medications were administered during the scheduled time on 11/04/24. The facility failed to ensure LVN appropriately dosed Resident #25's MiraLAX on 11/05/24. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. Findings included: 1. Record review of Resident #4's face sheet dated 11/06/24, indicated a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had diagnoses which included dementia (memory loss), depression (persistent feeling of sadness and loss of interest), chronic pain, essential hypertension (high blood pressure), and congestive heart failure (an impairment in the heart's ability to fill with and pump blood). Record review of Resident #4's quarterly MDS assessment dated [DATE], indicated Resident #4 was able to make herself understood and understood others. The MDS assessment indicated Resident #4 had a BIMS score of 6, indicating her cognition was severely impaired. The MDS assessment indicated Resident #4 received scheduled pain medication and did not have pain within the last 5 days of the look back period. The MDS assessment indicated Resident #4 had received an anticoagulant and a diuretic within the last 7 days of the 7-day look back period. Record review of Resident #4's comprehensive care plan dated 10/04/24, indicated Resident #4 had polyosteoarthritis (arthritis that affects multiple joints simultaneously) and was at risk for increased discomfort. The comprehensive care plan also indicated Resident #4 had congestive heart failure and hypertension. The care plan interventions included to administer medications as prescribed. Record review of Resident #4's physician order report dated 10/06/24-11/06/24, indicated Resident #4 had the following orders: *Bumetanide 1mg give one tablet by mouth once a day with a start date of 05/26/23. *Vitamin D3 125mcg give one tablet once a day on Monday with a start date of 05/26/23 *Eliquis 2.5mg give one tablet twice a day with a start date of 05/26/23. *Isosorbide mononitrate 30mg give one tablet once a day with a start date of 05/25/23. *Tylenol 650mg give one tablet twice a day with a start date of 05/26/23. *Potassium chloride 20mEq give one tablet twice a day with a start date of 05/26/23. *Ranolazine 500mg give one tablet twice a day with a start date of 10/16/23. During an observation and interview on 11/04/24 at 12:36 PM, LVN A said the medications she was about to prepare for Resident #4 were late because she was the only person who gave medications in the entire building. LVN A prepared and administered Resident #4's medications: *Bumetanide 1mg one tablet *Vitamin D3 125mcg one tablet *Eliquis 2.5mg one tablet *Isosorbide mononitrate 30mg one tablet *Potassium chloride 20 mEq one tablet *Ranolazine 500mg one tablet LVN A failed to administered Tylenol 650mg tablet as ordered to Resident #4. Record review of Resident #4's medication administration record dated 11/01/24-11/06/24, indicated the following medications were scheduled to have been administered from 6:00 AM-10:00 AM on 11/04/24: *Bumetanide 1mg one tablet *Vitamin D3 125mcg one tablet *Eliquis 2.5mg one tablet *Isosorbide mononitrate 30mg one tablet *Potassium chloride 20 mEq one tablet *Ranolazine 500mg one tablet *Tylenol 650mg on tablet 2. Record review of Resident #25's face sheet dated 11/06/24, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included gastrointestinal hemorrhage (forms of bleeding in the gastrointestinal tract), constipation, atrial fibrillation (irregular heart rhythm), and congestive heart failure (impairment in the heart's ability to fill with and pump blood). Record review of Resident #25's admission MDS assessment dated [DATE], indicated Resident #25 was understood and understood others. The MDS assessment indicated Resident #25 had a BIMS score of 15, indicating her cognition was intact. The MDS assessment did not indicate Resident #25 had constipation. Record review of Resident #25's comprehensive care plan dated 11/01/24, did not address Resident #25's diagnosis of constipation. Record review of Resident #25's physician order report dated 10/06/24-11/06/24, indicated Resident #25 had an order for MiraLAX 17grams/dose give 17 grams by mouth once a day with a start date of 10/26/24. Record review of Resident #25's medication administration record dated 11/01/24-11/06/24 indicated Resident #25 had received MiraLAX 17gram by mouth daily. During an observation on 11/05/24 at 08:22 AM, LVN A opened the MiraLAX bottle and poured the MiraLAX in a medicine cup between the 15ml-20ml lines. LVN A failed to use the MiraLAX cap as instructed on the directions on label of the MiraLAX bottle to obtain the 17 grams as prescribed. During an interview on 11/06/24 at 1:27 PM, LVN A said she was responsible for administering the medications to the entire facility. LVN A said by administering medications late could cause the medications to be less effective. LVN A said if medications were ordered more than one time a day, it could cause medications to be administered to close to the second dose. LVN A said she was responsible for ensuring medications were administered as scheduled. LVN A said she should have administered Resident #4's Tylenol as ordered and failure to do so could have caused Resident #4 pain. LVN A said the medications rights were the right time, right dosage, right amount, right resident and right route. LVN A said no one trained her on the medication pass when she started in October of 2024. LVN A said had told the DON and the Administrator the medication load was too heavy for one person and medications were not being given on time. LVN A said they had the liberalized medication pass and the one-hour rule before and after still applied. LVN A said she should have used the cap on the MiraLAX bottle for the measurement of the MiraLAX for Resident #25. LVN A said failure to do so could have resulted in either under or over administration of the prescribed dosage. LVN A said she was responsible for ensuring the correct dosage was administered. During an interview on 11/07/24 at 09:30 AM, the DON said she had not received any reports that LVN A was having any issues. The DON said the pharmacy consultant had reported LVN A was doing great. The DON said she was unable to answer the risks of what could occur with medication being administered late. The DON said by Resident #4 not receiving the Tylenol as ordered she could potentially be in pain. The DON said she expected LVN A to have used the lid of the MiraLAX bottle to measure Resident #25's MiraLAX, as it was to have been used for the correct measurement. The DON said by not using the lid of the MiraLAX, Resident #4 could have received the incorrect amount and could have caused Resident #4 constipation. The DON said the medication aide, nurse, and herself were responsible for ensuring the medications were given on time and by physician orders. During an interview on 11/07/24 at 09:48 AM, the Administrator said she expected medications to be given correctly and in a timely manner. The Administrator said the DON and the clinical staff oversaw the medication pass. The Administrator said since the MiraLAX was not given as prescribed the resident could potentially be given the incorrect dosage. The Administrator said she was unable to answer the risks of what could happen for medications not being administered on time. The Administrator said the medication aide was responsible for ensuring medications were being administered as scheduled and per physician orders. Record review of the facility's policy Medication Administration- General Guidelines dated 06/01/22, indicated . Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so . 4. Five rights- right resident, right drug, right dose, and right time are applied for each medication being administered . 12) Medications are administered within [60 minutes] of scheduled time, except before, with, or after meal orders, which are administered [based on mealtimes]. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents were free of significant medication errors for 1 of 6 residents (Resident #4) reviewed for pharmacy services. The facility failed to ensure Resident #4 medications were administered during the scheduled time of 6:00 AM and 10:00 AM on 11/04/24 which resulted in medications being administered 1 hour and 36 minutes late after the 1-hour grace period. The facility failed to ensure Resident # 4's medications were administered during the scheduled time of 6:00 AM and 10:00 AM on 11/05/24 which resulted in medications being administered 4 hour and 55 minutes late after the 1-hour grace period. These failures could place residents at risk of medical complications and not receiving the therapeutic effects of their medications. Findings included: 1. Record review of Resident #4's face sheet dated 11/06/24, indicated a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. Resident #4 had diagnoses which included dementia (memory loss), depression (persistent feeling of sadness and loss of interest), chronic pain, essential hypertension (high blood pressure), and congestive heart failure (an impairment in the heart's ability to fill with and pump blood). Record review of Resident #4's quarterly MDS assessment dated [DATE], indicated Resident #4 was able to make herself understood and understood others. The MDS assessment indicated Resident #4 had a BIMS score of 6, indicating her cognition was severely impaired. The MDS assessment indicated Resident #4 received scheduled pain medication and did not have pain within the last 5 days of the look back period. The MDS assessment indicated Resident #4 had received an anticoagulant and a diuretic within the last 7 days of the 7-day look back period. Record review of Resident #4's comprehensive care plan dated 10/04/24, indicated Resident #4 had polyosteoarthritis (arthritis that affects multiple joints simultaneously) and was at risk for increased discomfort. The comprehensive care plan also indicated Resident #4 had congestive heart failure and hypertension. The care plan interventions included to administer medications as prescribed. Record review of Resident #4's physician order report dated 10/06/24-11/06/24, indicated Resident #4 had the following orders: *Eliquis (anticoagulant medication) 2.5mg give one tablet twice a day with a start date of 05/26/23. *Ranolazine (used to treat chronic chest pain) 500mg give one tablet twice a day with a start date of 10/16/23. During an observation and interview on 11/04/24 at 12:36 PM, LVN A said the medications she was about to prepare for Resident #4 were late because she was the only person who gave medications in the entire building. LVN A prepared and administered Resident #4's medications. An Eliquis 2.5mg tablet and a ranolazine 500mg tablet were included in Resident #4's medications. LVN A administered Resident #4's medications 1 hour and 36 minutes late from the scheduled time of 6:00 AM-10:00 AM after the 1-hour grace period. Record review of Resident #4's medication administration record dated 11/01/24-11/06/24, indicated the following medications were scheduled to have been administered from 6:00 AM-10:00 AM on 11/04/24: *Eliquis 2.5mg one tablet *Ranolazine 500mg one tablet The medication administration history also indicated on 11/05/24 the following medications were scheduled to be received from 6:00 AM to 10:00 AM and 5:00 PM- 10:00 PM. LVN A charted the medications as being late for the 6:00AM- 10:00 dose: *Eliquis 2.5mg one tablet twice a day was charted at as being administered at 3:55 PM. *Ranolazine 500mg one tablet twice a day was charted as being administered at 3:54 PM . LVN A administered Resident #4's medications 4 hours and 55 minutes late from the scheduled time of 6:00 AM-10:00 AM after the 1-hour grace period. During an interview on 11/06/24 at 1:27 PM, LVN A said she was responsible for administering the medications to the entire facility. LVN A said by administering medications late could cause the medications to be less effective. LVN A said if medications were ordered more than one time a day, it could cause medications to be administered to close to the second dose. LVN A said she was responsible for ensuring medications were administered as scheduled. LVN A said the medications rights were the right time, right dosage, right amount, right resident and right route. LVN A said no one trained her on the medication pass when she started in October of 2024. LVN A said had told the DON and the Administrator the medication load was too heavy for one person and medications were not being given on time. LVN A said they had the liberalized medication pass and the one-hour rule before and after still applied. LVN A said she was responsible for ensuring the correct dosage was administered. During an interview on 11/07/24 at 9:30 AM, the DON said she had not received any reports that LVN A was having any issues. The DON said the pharmacy consultant had reported LVN A was doing great. The DON said she was unable to answer the risks of what could occur with medication being administered late. The DON said the medication aide, nurse, and herself were responsible for ensuring the medications were given on time and by physician orders. During an interview on 11/07/24 at 9:48 AM, the Administrator said she expected medications to be given correctly and in a timely manner. The Administrator said the DON and the clinical staff oversaw the medication pass. The Administrator said she was unable to answer the risks of what could happen for medications not being administered on time. The Administrator said the medication aide was responsible for ensuring medications were being administered as scheduled and per physician orders. Record review of the facility's policy Medication Administration- General Guidelines dated 06/01/22, indicated . Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so . 4. Five rights- right resident, right drug, right dose, and right time are applied for each medication being administered . 12) Medications are administered within [60 minutes] of scheduled time, except before, with, or after meal orders, which are administered [based on mealtimes]. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel, and labeled and dated correctly for 1 of 4 medication carts (south nurse's treatment cart) and 2 of 7 residents (Resident #3) observed for medication storage. 1. The facility did not ensure the south side nurse's treatment cart was secured and unable to be accessed by unauthorized personnel on 11/05/24. 2. The facility failed to ensure Resident #3's insulin lispro pen was properly secured when LVN B left it on top of the nurse's treatment cart on 11/05/24. 3. The facility failed to ensure Resident #38 wound care supplies was properly safe and secured. These failures could place residents at risk for not receiving drugs and biologicals as needed and a drug diversion. Findings included: Record review of Resident #3's face sheet dated 11/06/24, indicated a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included cerebral palsy (movement disorder that appears in early childhood), type 2 diabetes mellitus (body has trouble controlling blood sugar and using it for energy), essential hypertension (high blood pressure), and weakness. Record review of Resident #3's quarterly MDS assessment dated [DATE], indicated Resident #3 was able to be understood and understood others. The MDS assessment indicated Resident #3 had a BIMS score of 15 which indicated her cognition was intact. The MDS assessment indicated Resident #3 received insulin 7 days out of the 7-day look back period. Record review of Resident #3's comprehensive care plan dated 08/15/24, indicated Resident #3 had diabetes mellitus with interventions to administer medications per ordered and received insulin. Record review of Resident #3's physician order report dated 10/06/24- 11/06/24, indicated Resident #3 had an order for insulin lispro 100 unit/ml pen per sliding scale before meals and at bedtime with a start date of 05/20/24. Record review of Resident #3's medication administration record dated 11/01/24-11/06/24, indicated Resident #3 received insulin lispro pen per sliding scale before meals and at bedtime. During an observation and interview on 11/05/24 at 11:30 AM, LVN B obtained the glucometer, a small gauze, an alcohol pad, a lancet and a glucometer test strip from inside the nurse's cart and placed them on top of the cart on a piece of wax paper. LVN B then obtained Resident #3's insulin lispro pen from inside the cart and placed it on the wax paper on top the cart. LVN B proceeded to enter Resident #3's room to obtain her blood sugar. LVN B left the nurse's treatment cart unlocked with the insulin pen on top of cart and closed Resident #3's door. LVN B proceeded to obtain Resident #3's blood sugar. LVN B said she had thought about not locking the nurse's cart but since she was right inside the room, she said she could have heard someone getting inside the cart. LVN B said she was responsible for ensuring the cart was locked when left unattended and medications secured. LVN B said by leaving the cart unlocked and the insulin pen on top of the cart, someone could have taken medications from inside the cart or taken the insulin pen. During an interview on 11/07/24 at 9:30 AM, the DON said she expected the medications cart to be locked when not in view of the nurse. The DON said she expected medications to be always secured. The DON said by leaving the medication cart and the insulin pen unsecured, someone could have taken medications or could have potentially administered the insulin. The DON said the person in charge of the medication cart was responsible for ensuring the medication cart and medications were properly secured when not in view. During an interview on 11/07/24 at 9:48 AM, the Administrator said she expected the medication carts to be locked when the staff stepped away from them. The Administrator said she expected medications to be properly always secured. The Administrator said she was unable to answer what risks could occur when leaving the cart unlocked or the insulin pen unsecured. The Administrator said the nurse providing the medications was responsible for ensuring the cart was locked when left unattended and ensuring medications were properly secured. 3. Record review of Resident #38's face sheet, dated 11/6/24, indicated Resident #38 was a [AGE] year-old female, originally to the facility on [DATE] with diagnoses which included pressure ulcer of sacral (bone of the spine that connects the spine to the lower body) region. Record review of Resident #38's physician order report, dated 10/6/24-11/6/24, indicated an active physician's order for: wound Treatment Order: Location: Coccyx, Clean with Normal Saline/Wound Cleanser, Apply: Wound Vac at 150 mmhg. Once A Day on Mon, Wed, Fri with a start date 10/24/24. Record review of Resident #38's quarterly MDS, dated [DATE], indicated Resident #38 made himself understood, usually understood others. Resident #38's BIMS score was a 15, which indicated his cognition was intact. Resident #38 had a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device that required treatment. Record review of the comprehensive care plan, dated 09/14/23, indicated Resident #38 had a stage IV pressure wound to her coccyx (tailbone). The care plan interventions included staff to apply treatment to stage IV as ordered via physician, monitor and document size, drainage, infection, appearance of wound peri wound and pain and notify doctor of worsening of wound. During an observation and interview on 11/5/24 at 8:45 a.m., Resident #38 was sitting in her wheelchair. There was a bottle labeled Gentell dermal wound cleanser (wound care supplies) and a tube labeled Anasept skin and wound gel (wound care supplies) sitting on her dresser. Resident #38 stated those items were used for her wound to her bottom. Resident #38 stated staff had brought it in her room when they performed wound care. During a telephone interview on 11/7/24 at 9:56 a.m., LVN B stated she was the charge nurse for Resident #38 on 11/5/24. LVN B stated she did not see the wound care supplies on her dresser. LVN B stated wound care supplies should be stored in the nurse's cart when not in use. LVN B stated this failure could potentially residents at risk for their safety. During an observation and interview on 11/7/24 at 10:15 a.m., with the Regional Compliance Nurse a tube labeled Anasept skin and wound gel was noted sitting on Resident #38's dresser. The Regional Compliance Nurse stated wound care supplies should be stored in the nurse's treatment cart. The Regional Compliance Nurse stated it was important to ensure wound care supplies were stored properly for the safety of residents. During an interview on 11/7/24 at 12:14 p.m., the DON stated she expected the wound cleanser to be labeled with the resident name. The DON stated all wound care supplies should be stored in the treatment cart. The DON stated during angel rounds the staff should be ensuring wound care items were stored in the treatment cart. The DON stated the MDS Coordinator was responsible for Resident #38 angel rounds. The DON stated it was important that wound care supplies were not left at bedside for overall safety. During an interview on 11/7/24 at 12:20 p.m., the MDS Coordinator stated she conducted rounds for Resident #38. The MDS Coordinator stated she was only there a couple days a week. The MDS Coordinator stated she did make rounds this week, but she did not actually go in Resident #38 room. The MDS Coordinator stated she should have gone in the room and inpect. The MDS Coordinator stated it was ensuring items were stored properly for resident safety. During an interview on 11/7/24 at 12:39 p.m., the Administrator stated she expected wound care items to be stored in the treatment cart. The Administrator stated she expected the nurse that was providing the wound care to take the items and store back in the treatment cart. The Administrator stated she expected the individual that was assigned for angel rounds to keep an eye out also. The Administrator stated it was important to ensure wound care supplies were stored properly for resident safety. Record review of the facility's policy Medication Administration- General Guidelines dated 06/01/22, indicated . 16) During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. No medications are kept on top of the cart . Record review of the facility's policy titled Storage of Medications revised 11/20 indicated . the facility stores all drugs and biologicals in a safe, secure, and orderly manner 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner 6. Compartment (including, but not limited to, drawers, cabinets, rooms, refrigerator, carts, and boxes) containing drugs and biologicals are locked when not in use . unlocked medication carts are not left unattended .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 2 residents (Resident #1) reviewed for hospice services. The facility did not ensure Resident #1's updated plan of care and most recent medication list from the hospice were a part of their current medical records in the facility. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. The findings included: Record review of the face sheet, dated 11/07/24, reflected Resident #1 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis that included Alzheimer's disease (neurological disorder that involves irreversible worsening changes in the ability to think and remember). Record review of the quarterly MDS assessment, dated 08/29/24, reflected Resident #1 had clear speech and was usually understood by others. The MDS reflected Resident #1 was usually able to understand others. The MDS reflected Resident #1 had a BIMS score of 1, which indicated severe cognitive impairment. The MDS reflected Resident #1 had no behaviors or refusal of care. The MDS reflected Resident #1 received hospice services while a resident at the facility. Record review of the comprehensive care plan, revised 10/04/24, reflected Resident #1 had a terminal illness and was receiving hospice services. Record review of the general order, start date 06/30/23, reflected Resident #1 had an order for hospices care and services. Record review of the hospice binder, accessed on 11/07/24, reflected Resident #1's most current plan of care update report was on 10/02/24, the plan of care update report should have been completed every 2 weeks. Record review of the hospice binder, accessed on 11/07/24, reflected Resident #1's most current hospice medication report was completed on 09/17/24. During an interview on 11/07/24 beginning at 11:48 AM, LVN D said hospice binders were kept at the nurses' station. LVN D stated the hospice paperwork was kept on the tablets brought in by the hospice staff. LVN D stated she was required to sign the hospice tablet when the hospice staff came to the facility. LVN was unsure if physical copies of the information was kept at the facility. LVN D stated she only signed the tablets and did not really deal with the paperwork in the hospice binders. LVN D stated someone in management probably dealt with that. During an interview on 11/07/24 beginning at 11:54 AM, the DON said the ADON was responsible for ensure the hospice binder had updated information. The DON stated the ADON walked out the first of last month (October 2024). The DON stated she had recently started working at the facility and had not had a chance to ensure the hospice binders were updated. The DON stated it was important to ensure the hospice paperwork was up to date for continuity and coordination of care. During an interview on 11/07/24 beginning at 12:20 PM, the Administrator stated she expected the hospice binder to have updated paperwork. The Administrator stated nursing management was responsible for ensuring the hospice binders had the most updated paperwork. The Administrator stated it was important to ensure the hospice paperwork was up to date to promote communication and continuity of care between the teams. Record review of the hospice contract signed 06/20/23, reflected the facility shall maintain an accurate patient medical record. Required documentation provided by hospice will be included in a designated area/section. Facility will ensure that these forms are not removed facility will keep accurate, detailed, and complete accounts and records of all services and events provided . Record review of the Hospice Program policy, revised July 2017, reflected .obtaining the following information from the hospice: the most recent hospice plan of care specific to each resident .hospice medication information specified to each resident .

Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 3 doors reviewed for a safe environment. The facility failed to ensure the wander guard system operated correctly on the north side door when the Maintenance Supervisor tested the door on 11/07/24. This failure could place residents at risk of elopement, injury, or harm. Findings included: During an observation on 11/07/24 at 9:54 a.m., the Maintenance Supervisor checked the wander guard door on the north side hall and the alarm did not activate. He then checked the other 2 wander guard doors, and they were functioning properly. During an observation on 11/07/24 at 10:08 a.m., LVN D checked 2 different residents' wander guards using their handheld system and they both worked properly. During an interview on 11/07/24 at 10:13 a.m., the Maintenance Supervisor said he checked the door for functionality last week (unknown day). He said the doors were functioning properly during the inspection. He said he checked the doors weekly as part of his duties. He said he would call {name of company} and have them come out to look at the wander guard system. During an observation on 11/07/24 at 10:15 a.m., reflected the Human resource personnel standing by the north side door. During an interview on 11/07/24 at 10:20 a.m., the Administrator said if the wander guard system was not functioning properly, she was supposed to have a staff member on the door watching and making sure no resident left the facility until the doors were fixed. The Administrator said the maintenance Supervisor was responsible for ensuring the wander guard system was always working for the safety of the residents. During an interview on 11/07/24 at 10:25 a.m., the DON said the Maintenance Supervisor was responsible for checking the wander guard system doors. She said if the doors were not functioning properly then a staff member was to be placed at the doors until the doors were fixed for the safety of residents. The DON said they had 6 residents who were at risk of elopement and wore wander guards. During an observation and interview on 11/07/24 at 10:28 a.m., the Maintenance Supervisor said the doors were fixed. He placed a wander guard up to the door and it activated the shutdown system. He said he called {name of company} and they told him to check the batteries first and he did and then the door started working. He said the doors needed to work properly for the safety of the residents. During an interview on 11/07/24 at 11:00 a.m., the Regional Nurse Consultant said they did not have a policy on checking the doors. Record review of the TELS (a building maintenance Platform that is a leading web-based technology designed to tackle the day-to-day challenges of building operations) logbook on 10/31/24 the north side door was checked and working properly. Record review of the facility policy titled, Wandering and Elopements, dated 09/01/23, indicated Policy Statement: The facility will ensure that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care. 2. For those facilities equipped, each resident that is noted to be a risk per the elopement observation will have a roam alert device placed after: o An order is obtained from a physician. The order will include placement of the device, behavior monitoring q shift, check placement q shift, functionality daily, and monthly check of the expiration date of the sensor.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure residents have the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives and to choose the option he or she prefers for 2 of 5 residents reviewed for the right to be informed. (Resident's #1 and #9) 1. The facility failed to ensure Resident #1's psychotropic consent for trazadone (antidepressant), Xanax (antianxiety), lorazepam (antianxiety), and sertraline (antidepressant) reflected the clinical indication for use, the benefits of the medication, and the statement of consent. 2. The facility failed to ensure Resident #9's psychotropic consent form for Zyprexa (antipsychotic) reflected the resident or resident representative's signature for consent. These failures could place residents at risk for treatment or services provided without their informed consent. The findings included: 1. Record review of the face sheet, dated 11/07/24, reflected Resident #1 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease (neurological disorder that involves irreversible worsening changes in the ability to think and remember), anxiety disorder, and depression. Record review of the quarterly MDS assessment, dated 08/29/24, reflected Resident #1 had clear speech and was usually understood by others. The MDS reflected Resident #1 was usually able to understand others. The MDS reflected Resident #1 had a BIMS score of 1, which indicated severe cognitive impairment. The MDS reflected Resident #1 had no behaviors or refusal of care. The MDS reflected Resident #1 received an antianxiety medication and an antidepressant medication during the 7-day look back period. Record review of the comprehensive care plan, edited 10/04/24, reflected Resident #1 received an antianxiety medication related to a diagnosis of anxiety disorder. The care plan further reflected Resident #1 received an antidepressant medication related to a diagnosis of depression. Record review of the general order received and started on 09/28/23, reflected Resident #1 had an order for trazadone (antidepressant) 100 mg - give one tablet by mouth at bedtime. Record review of Resident #1's informed consent for use of psychotropic medication form for trazadone (antidepressant), dated 02/09/24, had no clinical indications for use, no benefits from medications, and no statement of consent (I DO, or I DO NOT) checked or filled out. Record review of the general order received and started on 11/29/23, reflected Resident #1 had an order for Xanax (antianxiety) 0.25 mg - give one tablet by mouth twice daily. Record review of Resident #1's informed consent for use of psychotropic medication form for Xanax (antianxiety), dated 03/11/24, had no clinical indications for use, no benefits from medications, and no statement of consent (I DO, or I DO NOT) checked or filled out. Record review of the general order received and started on 02/01/24, reflected Resident #1 had an order for sertraline (antidepressant) 50 mg - give 2 tablets by mouth once per day. Record review of Resident #1's informed consent for use of psychotropic medication form for sertraline (antidepressant), dated 02/09/24, had no clinical indications for use, no benefits from medications, and no statement of consent (I DO, or I DO NOT) checked or filled out. Record review of the general order received and started on 10/14/24, reflected Resident #1 had an order for lorazepam (antianxiety) 0.5 mg - give one tablet by mouth every 6 hours as needed. Record review of Resident #1's informed consent for use of psychotropic medication form for lorazepam (antianxiety), dated 03/11/24, had no clinical indications for use, no benefits from medications, and no statement of consent (I DO, or I DO NOT) checked or filled out. During an observation and attempted interview on 11/04/24 beginning at 1:36 PM, Resident #1 was wheeling herself down the hallway. Resident #1 had a WanderGauard to her left ankle. Resident #1 had Geri-sleeves to both arms and non-skid socks to both feet. Resident #1 was non-interviewable as evidenced by confused conversation. 2. Record review of the face sheet, dated 11/06/24, reflected Resident #9 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis of bipolar disorder (serious mental illness characterized by extreme mood swings). Record review of the significant change MDS assessment, dated 10/01/24, reflected Resident #9 had clear speech and was usually understood by others. The MDS reflected Resident #9 was usually able to understand others. The MDS reflected Resident #9 had a BIMS score of 15, which indicated he was cognitively intact. The MDS reflected Resident #9 had no behaviors or refusal of care. The MDS reflected Resident #9 received an antipsychotic medication during the 7-day look back period. Record review of the comprehensive care plan, edited 09/24/24, reflected Resident #9 had bipolar and was currently taking an antipsychotic medication. Record review of the general order received and started on 06/05/24, reflected Resident #9 had an order for Zyprexa (antipsychotic) 5 mg - give one tablet by mouth at bedtime. Record review of the Consent for Antipsychotic or Neuroleptic Medication Treatment form, dated 03/13/24, reflected Resident #9 had not signed the form. During an interview on 11/04/24 beginning at 1:45 PM, Resident #9 said he knew he was taking an antipsychotic for his bipolar disorder. Resident #9 said he knew and understood the risks and benefits, but he needed the medication. Resident #9 stated he had not signed a consent form. During an interview on 11/07/24 beginning at 11:48 AM, LVN D stated when the nurse received an order for a psychotropic medication, it was their responsibility to ensure a consent form was completed. LVN D stated consent forms should have been filled out completely. LVN D stated consent forms should have had a signature from the resident or responsible party. LVN D was unsure why Resident #1's consent forms were missing the clinical indication for use, the benefits from use, and a statement of consent. LVN D was unsure why Resident #9's psychotropic consent form was missing his signature. LVN D stated it was important to ensure psychotropic consent forms were filled out completely so the facility could prove the resident, or the responsible party made an informed decision. During an interview on 11/07/24 beginning at 11:54 AM, the DON stated the ADON was previously responsible for ensuring the psychotropic consent forms were completely filled out and placed in a binder. The DON stated the ADON walked out of the facility at the beginning of last month (October 2024). The DON stated she was to be responsible for ensure psychotropic consent forms were completely filled out and uploaded in the electronic health record moving forward. The DON stated she expected the nurses to have completed or filled out every part of the psychotropic consent forms. The DON stated it was important to ensure consent forms were completely filled out and signatures were in place, so the resident or responsible party were fully aware of the risks and benefits. The DON said so they could have made an informed decision. During an interview on 11/07/24 beginning at 12:20 PM, the Administrator stated she did not have a clinical background. The Administrator stated she expected the nursing management to monitor to ensure psychotropic consent forms were filled out completely with all required signatures. The Administrator stated it was important to ensure consent forms were completely filled out with all required signatures for good documentation and so the resident or responsible party clearly understood the risk and benefits of the psychotropic medication. Record review of the Psychoactive Medications policy, dated July 2024, reflected Consent must be obtained from the resident or resident representative prior to administering a psychotropic medication A consent from for antipsychotic medication .must be completed and signed by the resident or resident representative .consent must be obtained in writing .a consent form for other psychotropic medications must be completed and signed by the resident or resident representative using the psychotropic consent form

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to promptly resolve grievances for 3 out of 24 residents (Resident's #42, #44, #47) reviewed for grievances. The facility did not ensure Resident's #42, #44, and #47 grievances concerning coffee temperature were addressed. This deficient practice could place the residents at risk for decreased quality of life and feelings of neglect. The findings included: 1. Record review of the face sheet, dated 11/07/24, reflected Resident #42 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of COPD (an ongoing lung condition caused by damage to the lungs resulting in limited air flow into and out of the lungs). Record review of the quarterly MDS assessment, dated 10/16/24, reflected Resident #42 had clear speech and usually understood others. The MDS reflected Resident #42 was usually able to understand others. The MDS reflected Resident #42 had a BIMS score of 12, which indicated moderately impaired cognition. The MDS reflected Resident #12 was independent eating, which included bringing liquid to the mouth. Record review of Resident #42's comprehensive care plan, edited 08/26/24, reflected she was at risk for nutritional impairment. The interventions included: determine likes/dislikes; regular diet with thin liquids; monitor meal percentages. Record review of the general order, start date 04/21/23, reflected Resident #42 had an order for a regular diet texture with a thin fluid consistency. Record review of the grievance form dated 07/16/24, reflected all residents complained of the coffee temperatures being lukewarm. During an interview on 11/04/24 beginning at 11:28 AM, Resident #42 stated the coffee was served cold. Resident #42 said the facility staff said it was the state's fault. Resident #42 said everyone gripes about the coffee. Resident #42 stated she wanted hot coffee. Resident #42 said the facility staff were aware of the coffee being served cold, but they have not addressed the issue. 2. Record review of the face sheet, dated 11/06/24, reflected Resident #47 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease (neurological disorder that involves irreversible worsening changes in the ability to think and remember). Record review of the quarterly MDS assessment, dated 10/20/24, reflected Resident #47 had clear speech and was understood by others. The MDS reflected Resident #47 was able to understand others. The MDS reflected Resident #47 had a BIMS score of 9, which indicated moderately impaired cognition. The MDS reflected Resident #47 was independent with eating, which included bringing liquid to the mouth. Record review of the comprehensive care plan, edited 10/04/24, reflected Resident #47 was at risk for nutritional impairment. The interventions included: determine likes/dislikes; regular diet with thin liquids; and monitor meal percentages. Record review of the general order, start date 03/06/24, reflected Resident #47 had an order for regular diet texture with a thin fluid consistency. Record review of the grievance form dated 07/29/24, reflected Resident #47 complained that the coffee was cold. During an interview on 11/04/24 beginning at 12:06 PM, Resident #47 stated the coffee was served cold. Resident #47 stated multiple complaints had been made but it has not gotten better. Resident #47 said she has drunk hot coffee her whole adult life and wanted her coffee to have been served hot, not cold. During an observation and interview on 11/05/24 beginning at 8:28 AM, Resident #47 was standing at the coffee thermos outside the dining room. Resident #47 said she was getting some coffee. Resident #47 took a sip of the coffee and said it was cold. 3. Record review of the face sheet, dated 11/05/24, reflected Resident #44 was a [AGE] year-old male who admitted to the facility on [DATE] with a diagnosis of liver cell carcinoma (liver cancer). Record review of the quarterly MDS assessment, dated 09/17/24, reflected Resident #44 had clear speech and was understood by others. The MDS reflected Resident #44 was able to understand others. The MDS reflected Resident #44 had a BIMS score of 15, which indicated he was cognitively intact. The MDS reflected Resident #44 was independent with eating, which included bringing liquids to his mouth. Record review of the comprehensive care plan, edited 10/30/24, reflected Resident #44 was on a regular diet with a thin fluid consistency. The interventions included: determine likes/dislikes. Record review of the general order, start date 08/09/24, reflected Resident #44 had an order for regular diet texture with a thin fluid consistency. Record review of the grievance form dated 08/22/24, reflected Resident #44 complained that the coffee was cold. During an interview on 11/04/24 beginning at 1:10 PM, Resident #44 said the coffee was cold. Resident #44 said someone burnt themselves on the coffee so they could not serve it unless it was at 140 degrees or less. Resident #44 said it would be fine if by the time they got it was actually at 130 - 140 degrees. Resident #44 said by the time it got to his room it was much colder. Resident #44 said he liked drinking hot coffee and it was not pleasurable drinking cold coffee. Resident #44 stated when he has complained or filed a grievance, it was not addressed. During an observation and interview on 11/05/24 beginning at 8:34 AM, DA C temped the coffee in the thermos outside the dining room. DA C read the thermometer at 119.8 degrees F. DA C stated the coffee could have been hotter. DA C stated the temperature should have been at 140 degrees F or below. DA C stated she waited until the coffee was at least 135 degrees F before she served it. DA C stated she had received numerous complaints about the coffee being too cold. DA C said, the residents were always on her back about the coffee. DA C stated the residents were used to having coffee that was scalding hot. DA C stated she did not have a set schedule for checking the coffee, but she checked it periodically for temperature and refreshed it when it became cold. DA C stated she made coffee throughout the day. DA C stated the CNAs placed the coffee on the trays before they were passed out. DA C stated she had to follow the policy and she was not allowed to serve the coffee above 140 degrees F. During an interview on 11/06/24 beginning at 12:33 PM, the DM stated she had received complaints about the coffee being too cold. The DM said the coffee had to be served between 130- and 140-degrees F. The DM stated the residents hate it and she did not blame them. The DM stated coffee served at 119.8 degrees F could have been considered luke warm. She said it could have been warmer. The DM stated when the residents complained she took the policy to educate them or had the Administrator or Social Worker talk to them. During an interview on 11/07/24 beginning at 12:20 PM, the Administrator stated she had received grievances on the coffee temperature being too cold. The Administrator stated when she received a grievance regarding coffee temperatures, she notified the DM and the DM started monitoring the coffee temperatures. The Administrator stated random temperatures were obtained to ensure the coffee was staying hot in thermos. The Administrator stated she had not identified any problems with the coffee temperatures. The Administrator stated she expected coffee to be served at 140 degrees F or less. The Administrator stated coffee served at 119.8 degrees could have been warmer. The Administrator stated it was important to ensure grievances were resolved or addressed for the residents so they could feel satisfied with the temperature of the coffee. Record review of the Grievances, Recording and Investigating policy, revised 01/12/23, reflected the resident grievance form will be filed with the Administrator of designee and the resolution will be identified within three working days of the concern .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents who required dialysis (treatment that filters water and waste from the blood when the kidneys are no longer able to do so) received such services, consistent with professional standards of practice for 1 of 1 resident (Resident #49) reviewed for dialysis. The facility failed to ensure all pre and post-dialysis assessments were completed for Resident #49. This deficient practice could affect residents who received dialysis treatments and place them at risk for complications and not receiving adequate care and treatment to meet their needs. Findings included: Record review of Resident #49's face sheet, dated 11/06/24, revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including fluid overload (which happens when there is too much fluid in your body. It can raise blood pressure, cause swelling, and impact organ function), End-Stage Renal Disease also known as ESRD (a permanent condition that occurs when the kidneys stop working and require dialysis or a kidney transplant to sustain life), high blood pressure, and depression (sadness). Record review of Resident #49's 5-day MDS Assessment, dated 10/14/24 indicated Resident #49 usually made himself understood and usually understood others. Resident #49 had a BIMS score of 01 indicating his cognition was severely impaired. The MDS indicated Resident #49 required assistance with transfers, dressing, toileting, bed mobility, personal hygiene, bathing, and set-up for eating. The MDS for Resident #49 indicated he received hemodialysis (while a resident and on admission). Record review of the care plan initiated on 10/27/24 indicated he had a diagnosis of ESRD and was dependent on dialysis. He went to dialysis on Tuesday, Thursday, and Saturday. He had a left fistula on his inner arm. The interventions were for staff to administer medications as ordered, monitor the fistula site, and report any abnormalities to the physician. Record review of Resident #49's Order Summary, dated 10/17/24, revealed orders: Hemodialysis: AV Fistula/AV Graft to the left upper arm. Auscultate bruits and palpate thrill every shift. Hemodialysis performed on Tuesday, Thursday, and Saturday with a chair time of 6 a.m. Special Instructions: Fill out the form (Pre-Dialysis Assessment), and send medications, snacks, and a blanket with the resident. Record review of Resident #49's Dialysis Notebook undated revealed the following: *10/10/24 Pre-dialysis and post-dialysis assessment completed. *10/12/24 Pre-dialysis and post-dialysis assessment completed. *10/19/24 Pre-dialysis and post-dialysis assessment completed. *10/29/24 Pre-dialysis and post-dialysis assessment completed. Further review revealed there were no pre-dialysis or post-dialysis communication sheets located for following dates: 10/10/24, 10/15/24, 10/17/24, 10/22/24, 10/24/24, 10/26/24, 10/31/24 and 11/2/24. Record review of Resident #49's electronic medical records revealed there were no pre-dialysis or post-dialysis assessments for the following dates: 10/10/24, 10/15/24, 10/17/24, 10/22/24, 10/24/24, 10/26/24, 10/31/24 and 11/2/24. During an interview on 11/05/24 at 9:07 a.m., LVN E said Resident #49 had a dialysis communication book. She said sometimes Resident #49 did not bring back the communication sheets. She said if he did not bring back the communication sheet, she would assess him, but she did not place the assessment (communication sheet) in his book or document the assessment his electronic medical records. She said it was reported (unknown source) to her that Resident #49 had thrown his communication sheets in the trash or out the window of the van. She said she had never called the dialysis center to inquire about his communication sheets, any new orders, or any concerns during dialysis. During an interview on 11/05/24 at 12:24 p.m., Resident #49 was sitting on the side of his bed eating lunch. He said the staff usually gave him some paperwork to take to dialysis and he brought it back. He said he sometimes gave it to the van person or someone at the facility. During an interview on 11/07/24 at 10:37 a.m., the DON said the nurses sent communication forms with Resident #49 to dialysis. She said she expected the nurses to do the pre and post-dialysis assessment to ensure the resident was okay before and after dialysis. She said Resident #49 had a communication book, but she wanted to change the process and start scanning them into his electronic medical records. During an interview on 11/07/24 at 11:22 a.m., the Administrator said all dialysis residents should have communication sheets for any changes. She said the DON was the overseer of Dialysis. Record review of the facility policy titled, End-Stage Renal Disease, Care of a Resident with . revised date of September 2010, indicated, Policy Interpretation and Implementation: 1. Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents. 2. Education and training of staff includes, specifically: The type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis. Signs and symptoms of worsening condition and/or complications of ESRD; Timing and administration of medications, particularly those before and after dialysis; The care of grafts and fistulas; and the handling of waste. 3. Education and training of staff in the care of ESRD/dialysis residents may be managed by the contracted dialysis facility or by a clinician with special training in ESRD and dialysis care. 4. Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including: How the care plan will be developed and implemented and how information will be exchanged between the facilities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 1 storage area reviewed for expired and discontinued medications. The facility failed to keep a record of receipt of controlled medications awaiting disposition to allow accurate and periodic reconciliation. This failure could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion. Findings included: During an observation and interview on [DATE] at 09:54 AM, the following medications were observed in a basket located inside the controlled medication closet located inside the DONs office, and were awaiting to be disposed: *Ativan/Benadryl 1mg/25mg/ml gel- 25 mls RX# 363926/001 *Hydrocodone-apap 5-325mg tablet (label 1 of 3)- 8 tablets RX# 400219 *Hydrocodone-apap 5-325mg tablet (label 2 of 3)- 60 tablets RX# 400219 *Alprazolam 0.25mg tablet- 52 tablets RX# 423615 *Tramadol 50mg tablet- 6 tablets RX 123278 The DON said the controlled medications awaiting to be disposed were kept in the closet behind the locked door and lock. The DON said she was the only one with the key to the door and lock. The DON said her process when she reconciled medications that need to be disposed of was as follows: when medications were brought to her, she checked the narcotic medication count and verified the count with the nurse, the nurse and herself signed the narcotic sheet, logged the medication on the destruction log that was kept with the medications, then she placed the medication in the double locked closet. The DON said she had not found where the facility kept a copy of the blank destruction log so she could log the medications. The DON said she was the only person with the keys therefore medications would not come up missing. The DON said she was responsible for ensuring narcotic medications were being logged. During an interview on [DATE] at 09:48 AM, the Administrator said she expected narcotic medications to be logged and locked up appropriately. The Administrator said she expected the narcotic medications to be logged so they were appropriately accounted for. The Administrator said there were no risks for not logging the narcotic medications as the DON was the only one with the key. The Administrator said the DON was responsible for accurately reconciling the narcotic medications. Record review of the facility's policy Controlled Substance Storage dated [DATE], indicated . Controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are retained in the facility in a securely locked area with restricted access until destroyed. Accountability records for discontinued controlled substances are maintained with the unused supply until it destroyed or disposed of, and then store for 5 years or as required by applicable law or regulation. The consultant pharmacist or designee routinely controlled substance storage, records [i.e., change if shift sheets, individual controlled substance accountability sheets, MARs, delivery confirmation sheets], and expiration dates during routine medication storage inspec

Based on observations, interviews, and record review, the facility failed to ensure the meals served met the nutritional needs of residents for 1 of 1 meal (the lunch meal) reviewed for nutritional adequacy. The facility did not ensure an 8 oz scoop size was used to serve the chicken alfredo during the lunch meal on 11/05/24. This failure could affect all residents in the facility by placing them at risk of not receiving adequate nutritive food value needed to promote/maintain health. Findings included: Record review of the facility dietary spreadsheet dated 06/04/24, indicated an 8 oz scoop size should be used to serve chicken alfredo. During an observation on 11/05/24 at 11:52 AM, a 6 oz scoop was being used to serve chicken alfredo. Approximately 10 resident trays had already been served and delivered. During an observation and interview on 11/05/24 at 11:56 AM, the Dietary Manager said the size of the scoop that was needed was documented on the dietary spreadsheet. The Dietary Manager said she posted the colors of each scoop size on the window in front of the serving table. The Dietary Manager looked at the scoop size that was being used to serve the chicken alfredo and said a 6oz scoop was being used. The Dietary Manager said an 8 oz scoop was needed to be used instead of the 6 oz per the spreadsheet. The Dietary Manager said she was responsible for ensuring the correct scoop size was being used and failure to do so placed the residents at risk for receiving less food. During an observation and interview on 11/05/24 at 11:59 AM, [NAME] E said she when had looked at the spreadsheet she saw it said to use a 6oz scoop for the chicken alfredo. [NAME] E went and looked at the spreadsheet again and said it indicated to use an 8 oz scoop. [NAME] E said she was responsible for ensuring the correct scoop was being used and failure to do so placed the residents at risk for not receiving enough food. During an interview on 11/07/24 at 9:30 AM, the DON said she expected the Dietary staff to use the correct size scoop so residents could receive the correct portions. The DON said failure to use the correct scoop size placed residents at risk for not receiving the nutrition intended. The DON said the Dietary Manager and the Dietician Consultant were responsible for ensuring the correct scoop size was being used to serve the resident's meals. During an interview on 11/07/24 at 9:48 AM, the Administrator said she expected the dietary staff to read the menu and use the correct scoop size. The Administrator said if the dietary staff noticed an error, they needed to correct it immediately so the residents could receive the correct amount of food. The Administrator said all residents were provided with the correct nutritional value of their food and they could always provide an alternate or give them more food if necessary. The Administrator said the Dietary Manager and the [NAME] were responsible for ensuring the correct scoop size was being used when serving the meals. Record review of the facility's policy and procedure Tray Service dated 2018, indicated . The facility believes that accurate tray service and adequate portion sizes are essential to the resident's wellbeing and safety. The facility will ensure that diets are serviced accurately and in the correct portions and that resident preferences are met . Record review of the facility's policy and procedure Portion Control dated 2018, indicated . The facility will use standard portion control procedures and utensils to ensure that adequate portions are served to residents . 3. Portions for each food group should follow the specific portion sizes listed om the menu .

Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 4 of 19 residents (Resident's #22, #42, #44, and #47) reviewed for palatable food. The facility failed to provide palatable food served at an appetizing temperature or taste to Resident #22, #42, #44, and #47 who complained the food was served cold, was bland, and did not taste good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. The findings included: During an interview on 11/04/24 at 11:28 AM, Resident #42 stated the food was cold and did not have flavor. During an interview on 11/04/24 at 12:02 PM, Resident #22 said she wished the facility had better food. Resident #22 said the food was bland. During an interview on 11/04/24 at 12:06 PM, Resident #47 stated she did not like the food. Resident #47 stated the vegetables were musty and very bland. Resident #47 said the food was cold when she received it. During an interview on 11/04/24 at 1:10 PM, Resident #44 stated he was getting hungrier and hungrier. Resident #44 said he has had traumatic experiences with the food at the facility. Resident #44 said gravy had the consistency of milk, eggs were dry like popcorn. Resident #44 said the food was nasty. Resident #44 said he breakfast meal was cold most of the time. During an observation and interview on 11/05/24 at 12:40 PM, a lunch tray was sampled by the Dietary Manager and 4 surveyors. The sample tray consisted of fettuccini alfredo, capri vegetables, and a roll. The Dietary Manager said the lunch meal did not look appetizing and it was hard to tell what the fettuccini alfredo was. The Dietary Manager said the vegetables were bland, warm, and mushy. The Dietary Manager said it was always an ordeal with complaints from the residents. During an interview on 11/06/24 beginning at 12:33 PM, the DM stated she received food complaints constantly. The DM stated the food complaints were mainly about having the same things over and over again. The DM stated she had not received any complaints about the temperature of the food being too cold recently. The DM stated resident council complained of the food being over seasoned so in response they used less seasoning. The DM stated she was unaware of any complaints the food was bland or the vegetables were over-cooked until she tasted it on the test tray. The DM stated it was important to ensure food was served at an appropriate temperature and looked appetizing to ensure residents ate and received the appropriate nutrition. During an interview on 11/06/24 beginning at 12:20 PM, the Administrator stated she received food complaints at least monthly. The Administrator stated she was unaware of complaints regarding the food being bland. The Administrator stated expected the food to have been served at the appropriate temperature. The Administrator she expected the food to have an appetizing appearance. The Administrator stated the DM was responsible for monitoring to ensure the food was served correctly. The Administrator stated it was important to ensure the food was appetizing and served at the appropriate temperature to prevent weight loss from the residents not eating. Record review of the Food and Nutrition Services policy, revised September 2021, reflected Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3.Record review of Resident #3's face sheet dated 11/06/24, indicated a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses which included cerebral palsy (movement disorder that appears in early childhood), type 2 diabetes mellitus (body has trouble controlling blood sugar and using it for energy), essential hypertension (high blood pressure), and weakness. Record review of Resident #3's quarterly MDS assessment dated [DATE], indicated Resident #3 was able to be understood and understood others. The MDS assessment indicated Resident #3 had a BIMS score of 15 which indicated her cognition was intact. The MDS assessment indicated Resident #3 received insulin 7 days out of the 7-day look back period. Record review of Resident #3's comprehensive care plan dated 08/15/24, indicated Resident #3 had diabetes mellitus with interventions to administer medications per ordered and received insulin. Record review of Resident #3's physician order report dated 10/06/24- 11/06/24, indicated Resident #3 had an order for insulin lispro 100 unit/ml pen per sliding scale before meals and at bedtime with a start date of 05/20/24. Record review of Resident #3's medication administration record dated 11/01/24-11/06/24, indicated Resident #3 received insulin lispro pen per sliding scale before meals and at bedtime. During an observation and interview on 11/05/24 at 11:30 AM, LVN B sanitized her hands and applied gloves. LVN B entered Resident #3's room and obtained Resident #3's blood sugar. LVN B removed her dirty gloves and applied clean gloves. LVN B did not hand sanitize in between glove changes. LVN B then went to the nurse's cart and obtained Resident #3's insulin pen. LVN B proceeded to administer Resident #3 her insulin. LVN B said she should have performed hand hygiene in between glove changes. She said she did not perform hand hygiene because of the loud alarm going off and her brain was fried. LVN B said she was responsible for performing hand hygiene and failure to do so was an infection control issue. During an interview on 11/07/24 at 09:30 AM, the DON said she expected her staff to perform hand hygiene once gloves were removed and prior to donning on clean gloves. The DON said failure to perform hand hygiene after removing dirty gloves placed the residents at risk for infection. The DON said the nurse performing the task was responsible for ensuring hand hygiene was performed. During an interview on 11/07/24 at 09:48 AM, the Administrator said she expected she expected hand hygiene to be performed in between glove changes. The Administrator said there were no risks to the residents because LVN B was dealing with the same resident, and she would have expected her to perform hand hygiene when LVN B went to another resident. Record review of the facility's policy handwashing/hand hygiene revised 01/20/23, indicated . This facility considers hand hygiene the primary means to prevent the spread of infections .1. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 5. Hand hygiene must be performed prior to donning and after doffing gloves . Record review of the facility policy titled, Transmission Precautions, date revised August 2016 indicated, Use Standard Precautions (SP) with transmission-based isolation. Cohort: *the door may remain open, wash hands after every resident contact, wear gloves when in contact with the resident environment, wear gowns if you anticipate that your clothing may become contaminated, wear masks or face shields if you come within 3 feet of the resident and resident wears a mask during transport, dedicate equipment to the infected resident, contain or cover site of infection before resident transport, ensure all environmental surfaces washed at least daily and as needed. Record review of the facility policy titled, Wound care, Revised June 2022, indicated Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Preparation:1. Verify that there is a physician's order for this procedure. 3. Assemble the equipment and supplies as needed. Date and initial all bottles and jars upon opening. (Note: This may be performed at the treatment cart.) Equipment and Supplies: The following equipment and supplies will be necessary when performing this procedure. 1. Dressing material, as indicated (i.e., gauze, tape, scissors, etc.);2. Disposable cloths, as indicated;3. Antiseptic (as ordered); and 4. Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed). Steps in Procedure:4. Put on clean gloves. Loosen the tape and remove the dressing. 5. Pull the glove over the dressing and discard it into an appropriate receptacle. Perform hand hygiene. 6. Put on clean gloves. Gowns will only be necessary if soiling of your skin or clothing with blood, urine, feces, or other body fluids is likely. Masks and eyewear will only be necessary if splashing of blood or other body fluids into your eyes or mouth is likely.10. Apply treatments and dress the wound as ordered by physician 11. [NAME] tape with initials, time, and date and apply to dressing.12. Remove the disposable cloth next to the resident and discard into the designated container. 13. Discard disposable items into the designated container. Discard all soiled laundry, linen, towels, and washcloths into the soiled laundry container. Remove disposable gloves and discard into a designated container. Perform hand hygiene. Based on observation, interview, and record review the facility failed to effectively maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including hand hygiene for 3 of 7 residents (Resident #48, Resident #44 and Resident#3) reviewed for infection control. 1. The facility failed to ensure LVN H changed gloves or performed hand hygiene while providing wound care for Resident #48's coccyx area. 2. The facility failed to ensure CNA F did not wear Personal protective equipment and gloves in the hallway after assisting Resident #44 with his breakfast tray who was in contact isolation. 3. The facility failed to ensure LVN B performed hand hygiene when she removed her gloves after she obtained Resident #3's blood sugar on 11/05/24 These deficient practices could place residents at risk for infection due to improper care practices. Findings included: 1.Record review of a face sheet dated 11/06/24 indicated Resident #48 was an [AGE] year-old female admitted on [DATE] with the diagnosis of Dementia (the loss of cognitive functioning) pressure ulcer also known as bedsore (a skin injury caused by constant pressure on an area of the body), high blood pressure, and anxiety (a feeling of fear, dread, and uneasiness that can be a normal reaction to stress). Record review of a significant change in status MDS assessment dated [DATE] indicated Resident #48 was usually understood and usually understood others. The MDS indicated Resident #48 required assistance with bed mobility, dressing, personal hygiene, transfers, toilet use, and supervision with eating. The MDS indicated Resident #48 had a stage 3 pressure ulcer. Record review of the comprehensive care plan dated 09/26/24 indicated Resident #48 had an open stage 3 area to the coccyx. The interventions were for staff to treat as ordered, always tilt her off the coccyx, and use a pillow or a wedge for positioning. Record review of Resident #48's physician's order dated 10/31/24 indicated: Cleanse area to coccyx with normal saline or wound cleanser, pat dry, apply Collagen, cover with silicone dressing daily, and PRN spoilage. During an observation on 11/07/24 at 12:52 p.m., LVN H provided wound treatment for Resident #48. Resident #48 was on enhanced barrier precautions. LVN A washed her hands and applied her gown and gloves. LVN H then cleaned the area of the coccyx and patted the wound dry. LVN H did not change her gloves and then attempted to apply dressing but had forgotten some supplies, so she removed her gloves but not her gown and went outside to her treatment cart and gathered her equipment. LVN H came back into the room applied her gloves without hand hygiene and proceeded with the treatment of applied collagen and the clean dressing on the wound and secured it. LVN H then went outside the room with her gloves and gown on looking for a biohazard bag to put her soiled dressing in. LVN H did not remove her Personal protective equipment or hand hygiene before leaving the room. LVN H then re-entered the room removed the soiled trash, removed her Personal protective equipment, and performed hand hygiene. During an interview on 11/07/24 at 1:15 p.m. with LVN H, she said she realized she had not changed her gloves or performed hand hygiene after cleaning the wound for Resident #48. LVN H said she should have removed her PPE and hand hygiene before leaving Resident #48's room. She said failure to properly hand hygiene or remove PPE before exiting a room could cause infection control issues. 2.Record review of Resident #44's face sheet dated 11/06/24, indicated a [AGE] year-old male who was admitted to the facility on [DATE], with diagnoses which included Liver cancer ( a disease that can start in the liver or spread to the liver from another part of the body), Zoster, also known as shingles or herpes zoster (a painful rash caused by the varicella-zoster virus (VZV,) stroke, and type 2 diabetes mellitus (body has trouble controlling blood sugar and using it for energy. Record review of Resident #44's quarterly MDS assessment dated [DATE], indicated Resident #44 was able to be understood and sometimes understood others. The MDS assessment indicated Resident #44 had a BIMS score of 15 which indicated his cognition was intact. The MDS assessment indicated Resident #44 required supervision for his ADL care. Record review of Resident #44's comprehensive care plan dated 11/05/24, indicated Resident #44 had a rash with a diagnosis of shingles. The interventions were for staff to administer medications per ordered, contact precautions with ADL care, and keep his shingles clean and dry as possible. Record review of Resident #44's physician order report dated 11/04/24- 11/11/24, indicated Resident #44 had an order for Valtrex (valacyclovir) tablet; 500 mg; amt: 2 tabs; oral Special Instructions: 1000mg every 8 hours times 7days, for diagnosis of Shingles. During an observation and interview on 11/05/24 at 8:44 a.m., CNA F was coming out of Resident #48's room wearing a gown and gloves. She then placed his tray on the dish cart in the middle of the hallway, walked 2 doors down, and removed her personal protective equipment without hand hygiene. She then walked to Resident #43's room, talked with her, and removed her tray. The surveyor stopped CNA F and asked why she was wearing her gown and gloves in the hallway. She said Resident #48 was on isolation precautions, but since he did not have any boxes or containers in his room, she walked down 2 doors to remove the personal protective equipment. She said she did not wash her hands when she took off her personal protective equipment or before entering Resident #43's room. CNA F said she was supposed to remove her personal protective equipment and hand hygiene before leaving Resident #44's room. She said she would go and do hand hygiene. She said she knew she could cause the spread of infection by not hand hygiene or removing her Personal protective equipment properly. During an interview on 11/05/24 at 1:54 p.m., LVN D said Resident #43 was on contact isolation for shingles. She said she had received in report of his shingles from the night nurse. She said the night shift did not get a chance to put the boxes or containers in his room before they left. She said she did not think about the boxes again until the aide came to her. She said she had placed boxes in his room after the aide mentioned it to her. She said she did not expect staff to walk in the hallway with personal protective equipment on or not hand hygiene before leaving a contact isolation room because of the risk of spreading infection. During an interview on 11/07/24 at 10:37 a.m., the DON said she expected wound care to be performed correctly. She said she expected staff to perform hand hygiene before, during, and after providing wound care. She said they should change their gloves when going from dirty to clean, and in between glove changes. The DON said anytime a staff member performed care with a resident that required enhanced barriers or contact isolation should have on a gown and gloves. She said she did not expect any staff member to go into the hallway with Personal protective equipmenton. She said they should remove all PPE and hand hygiene before leaving the room. The DON said wearing Personal protective equipment in the hallway, not providing hand hygiene when needed, and performing wound care incorrectly could lead to infection control issues. During an interview on 11/07/24 at 11:22 a.m., the Administrator said she expected staff to perform wound care and hand hygiene properly. She said residents on enhanced barrier and contact isolation should have a sign outside the room and carts and staff should follow the guidelines for their PPE. She said staff should remove their personal protective equipment and hand hygiene before they leave the room. She said improper wound care, hand hygiene, and not following the enhanced barrier and contact precautions correctly could lead to infection control issues.

Based on observation, interview, and record review, the facility failed to follow established policy regarding smoking areas, and smoking safety for 1 of 1 smoking area. The facility failed to ensure flammable paper products (empty cigarette box, piece of a paper towel, blue sticky note, and a sonic cup) were not discarded in the red metal trash can designed for the disposing of cigarette butts. This failure could place residents who smoke at risk of physical harm and lead to an unsafe smoking environment. Findings Included: During an observation on 11/5/24 at 8:24 a.m., 4 residents were outside in the smoking area smoking with staff present. There was a red smoking can with cigarette butts, an empty cigarette box, piece of a paper towel, blue sticky note, and a sonic cup. During an interview on 11/7/24 at 10:34 a.m., the HR Coordinator stated whoever take the residents out to smoke should check the red smoking can for trash. The HR Coordinator stated the red can should not have any trash inside, only ashes and butts. The HR Coordinator stated it was important to ensure trash was kept out of the red metal trash can to prevent a fire. During an interview on 11/7/24 at 11:11 a.m., the Maintenance Supervisor stated all staff were responsible for ensuring trash was not in the red can. The Maintenance Supervisor stated he check the red can weekly to ensure only ashes and cigarette butts were in there. The Maintenance Supervisor stated this risk could potentially cause a fire. During an interview on 11/7/24 at 11/7/24 at 12:14 p.m., the Administrator stated she expected trash to be put in the correct receptacles. The Administrator stated the Maintenance Supervisor was responsible for checking the red can daily to ensure only ashes and cigarettes butts were in there. The Administrator stated this failure could potentially cause a fire. Record review of a facility's policy titled Smoking Policy-Residents, revised 2019, indicated . this facility shall establish and maintain safe residents smoking practices .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide residents with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 1 of 1 meal (the lunch meal) reviewed for nutritional adequacy. The facility failed to prepare an adequate amount of food for the lunch meal on 10/29/24. This failure could affect all residents in the facility by placing them at risk of not receiving adequate nutritive food value needed to promote/maintain health. Findings included: 1. Record review of Resident #1's face sheet dated 10/29/24, indicated a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included liver cancer, cerebral vascular disease (a group of conditions that affect blood flow and the blood vessels in the brain, congestive heart failure (a serious condition that occurs when the heart cannot pump enough blood to meet the body's needs), and anemia (a condition in which the blood doesn't have enough healthy blood cells and hemoglobin, a protein found in red blood cells, to carry oxygen all through the body). Record review of Resident #1's quarterly MDS assessment dated [DATE], indicated he was understood and understood others. The MDS assessment indicated Resident #1 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #1 was independent with eating, did not have swallowing disorders, and did not have a weight loss or weight gain of 5 percent in the last 6 months. Record review of Resident #1's comprehensive care plan dated 05/14/24 and revised on 10/04/24, indicated Resident #1 had an order for a regular diet, double portions, with thin liquids. The care plan interventions indicated diet: regular, texture: regular fluids, consistency: thin double portions, special instructions: may chop or puree meat at request. Record review of Resident #1's physician order report dated 09/29/24- 10/29/24, indicated Resident #1 had an order for regular diet with thin liquid double portions. During an interview on 10/29/24 at 11:04 AM, Resident #1 said the facility has frequently run out of food. Resident #1 said he has had to send out for food. Resident #1 said there was not enough food at the facility if he wanted extra. Resident #1 said staff had told him before that there was not enough for extras, you get what you get. Resident # 1 said he received one egg, one strip of bacon, and one biscuit that morning. Resident #1 said he has asked before for an extra biscuit, but they had told him there was no more and not to be selfish that there were more residents at the facility, so he quit asking . 2. Record review of Resident #2's face sheet dated 10/29/24, indicated a [AGE] year-old male who admitted to the facility on [DATE] and discharged home on [DATE]. Resident #2 had diagnoses which included cerebral ischemic attack (occurs when blood flow to the brain is reduced or blocked), essential hypertension (high blood pressure), protein-calorie malnutrition (inadequate intake of proteins and calories in diet), and end stage renal disease (permanent condition that occurs when the kidneys are no longer able to function and require dialysis or a kidney transplant to sustain life). Record review of Resident #2's quarterly MDS assessment dated [DATE], indicated Resident #2 was usually understood and usually understood others. The MDS assessment indicated Resident #2 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment did not indicate Resident #2 had a swallowing disorder or a significant weight loss/gain of 5 percent in the last 6 months. Record review of Resident #2's comprehensive care plan revised 04/18/24, indicated Resident #2 was on a regular diet with thin liquids. The care plan interventions indicated Resident #2 will follow diet orders. Record review of Resident #2's physician order report dated 12/28/23-05/17/24, indicated Resident #2 had an order for regular diet with a start date of 12/18/23. Record review of a grievance form dated 04/03/24, indicated Resident #2 made the complaint himself. The grievance form indicated under detail of complaint of grievance [Resident #2] feels like dietary department is frequently running low on food or out of a certain items ie: eggs, biscuit. During an observation of facility lunch menu on 10/29/24 at 11:35 AM, that was displayed at the entrance of the dining room, indicated lunch meal was as followed: Baked pork steak lyonnaise, potatoes, sliced carrots, cornbread, and applesauce . During an observation and interview on 10/29/24 at 12:40 PM, the test tray was placed on the cart. The test tray portion size appeared to be adequate. [NAME] A said they had ran out of cornbread so none were placed on the test tray. During an observation and interview on 10/29/24 at 12:51 PM, the Dietary Supervisor said they had run out of the main lunch meal and the alternate meat and needed to take the test tray for a resident that had requested he wanted what was served for lunch . The Dietary Supervisor said that running out of food usually did not happen. During an interview on 10/29/24 at 12:55 PM, the Dietary Supervisor said if a resident requested for extra servings of the meal they would have to fix an alternate meal. The Dietary Supervisor said depending on what the resident wanted, they could fix them sandwiches or a grilled cheese sandwich. The Dietary Supervisor said if the resident wanted what they had for lunch and they did not have extras, then the cook would have to make more. The Dietary Supervisor said she would not let a resident be without eating. The Dietary Supervisor said she had ready to cook meats that could be cooked quickly if needed. The Dietary Supervisor said the cook and herself were responsible for ensuring the residents had enough food . During an interview on 10/29/24 at 12:59 PM, [NAME] A said she had worked at the facility for 13 years. [NAME] A said the Dietary Supervisor and herself were responsible for ensuring there was enough food cooked if the residents requested for extra portions. The Dietary Supervisor said she usually cooked an extra kind of meat as an alternate. [NAME] A said there were residents at the facility that required double portions. [NAME] A said if a resident requested extra food, she would ask them what they wanted, and she would cook it for them . So, this would not affect the residents. [NAME] A was unable to give a reason as to why they ran out of food. During an interview on 10/30/24 at 12:13 PM, LVN B said she had not received any complaints of not having enough food from residents. LVN B said she had not seen the facility run out of food. LVN B said if a resident requested extra food, during their meal, they had the right to receive more food. LVN B said if a resident requested extra food and there was not enough extra made, they could go hungry. LVN B said they Dietary Supervisor and the Administrator were responsible for ensuring there was an adequate amount of food made with each meal . During an interview on 10/30/24 at 2:14 PM, the DON said there should be enough food made for seconds as well as an alternate meal. The DON said she had not heard or seen any issues of running out of food. The DON said it was important for there to be an adequate amount of food because if a resident said they were still hungry then they must accommodate. The DON said if they ran out of food, then the cook was responsible for making more food. The DON said the Dietary Supervisor and the Administrator were responsible for ensuring there was an adequate amount of food made with each meal. The DON said the residents were not at any risk because they had already received some food and there were no risks to that. The Administrator was not available for interview. Record review of the facility's policy titled Food and Nutrition Services revised September 2021, indicated . Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. 1. The multidisciplinary staff, including nursing staff, the attending physician and the dietician will assess each resident's nutritional needs, food likes, dislikes, and eating habits, as well as physical functional, and psychosocial factors that affect eating and nutritional intake and utilization. 4. Reasonable efforts will be made to accommodate resident choices and preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical and mental status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 6 (Resident #2) residents reviewed for notification of change. The facility failed to notify Resident #2's physician of a weight loss of 9.8 lbs. in 8 days. These failures could result in residents with weight loss not receiving treatments, supplements, or nutrition needed to maintain acceptable and desired weight and nutritional needs for healing. Findings Include: 1. Record review of a face sheet dated [DATE] indicated Resident #2 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses pressure ulcer (injury to the skin and underlying tissue resulting from prolonged pressure on the skin) of the sacral region (area located below the lumbar spine and above the tailbone), dementia, muscle weakness, muscle wasting, and lack of coordination. Record review of the MDS dated [DATE] indicated Resident #2 was usually understood by others and usually understood others. The MDS indicated Resident #2 had a BIMS of 05 and was severely cognitively impaired. The MDS indicated Resident #2 required set-up assistance with eating. The MDS indicated Resident #2 did not have any swallowing issues. The MDS indicated Resident #2 had a weight of 180 lbs. The MDS indicated Resident #2 had not had a weight loss of 5% or more in a month. Record review of the care plan last updated [DATE] indicated Resident #2 was admitted to the facility with a stage IV pressure ulcer (pressure sore that extends below the subcutaneous fat into the deep tissues, including muscle, tendons, and ligaments) to the sacrum. Record review of the vital report dated [DATE] through [DATE] indicated Resident #2 had the following weights: *173.3 lbs. - [DATE]. *173 lbs. - [DATE]. *163.5 lbs. - [DATE]. Record review of the progress notes dated [DATE] through [DATE] indicated the physician was not notified of Resident #2's weight loss. The progress notes indicated there was not a dietician consult requested for Resident #2. During an interview on [DATE] at 11:12 a.m. the DON said the ADON received the weights and if a significant weight loss was noted the ADON should notify the physician, ensure supplements and snacks were in place, and request a dietician consult. The DON said the dietician came to the facility monthly. The DON said notifications to the physician and requests for consults should be documented. During an interview on [DATE] at 1:50 p.m. the ADON said she assisted with performing weights on residents. The ADON said she entered weights into the computer except for weekly weights and it was the responsibility of the charge nurses to enter weekly weights into the computer. The ADON said if a resident had a significant weight loss it would be the responsibility of whoever discovered the weight loss to notify the physician. The ADON said physician notification and dietician consult requests should be documented in the progress notes. The ADON said she was not aware of Resident #2 having a weight loss and did not know why a notification to the physician had not been done. During an interview on [DATE] at 2:15 p.m. the ADON said she was unsure about the weight loss on Resident #2. The ADON said she could not confirm whether the recorded weight loss for Resident #2 was a clinical error or not. The ADON said she had performed the weight on Resident #2 on [DATE]. The ADON said she thought she had weighed Resident #2 via mechanical lift (a device used to assist with transfers and movement of individuals who require support for mobility beyond the manual support provided by caregivers alone). The ADON said Resident #2 had been weight via wheelchair and the wheelchair weight not figured properly it could have been a clinical error. The ADON said all wheelchairs in the facility should be marked with their weight to properly calculate a resident's weight who was weighed in a wheelchair. The ADON said the weight of a resident in a wheelchair might fluctuate depending if the foot pieces were on the wheelchair when the resident was weighed or not. The ADON said there should not be a 9.5 lb. weight difference between a wheelchair weight and a mechanical lift weight. The ADON said Resident #2's family had been at the facility on [DATE] and informed her he had expired. During an interview on [DATE] at 2:32 pm LVN D said she remembered Resident #2. LVN D said she performed Resident #2's weights on [DATE] and [DATE]. LVN D said she had used the same wheelchair and scale when weighing Resident #2 on both days. LVN D she did notice Resident #2's weight loss from [DATE] to [DATE]. LVN D said she had planned on speaking with Resident #2's physician regarding his weight loss, but the physician did not return her call. LVN D said there was no way to prove she had attempted to contact the physician as she did not document it. LVN D said she did not notify anyone else regarding Resident #2's weight loss. LVN D said the importance of reporting the weight loss was that it was a significant change. During an interview on [DATE] at 9:10 a.m. the DON said weight loss was monitored monthly. The DON said once all the weights were entered into the system a monthly report was printed to review any significant weight changes. The DON said if a nurse noticed a significant weight loss, she would expect the nurse to reweigh the resident to determine there was not a discrepancy and to notify the physician. The DON said the importance in recognizing weight losses and reporting weight losses to the physician was to aide in the resident maintaining good nutrition. The DON said maintaining good nutrition could possibly aide in wound healing. Record review of the facility's Weight Management Policy revised on [DATE] indicated, Based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicated otherwise .The following should be documents in the medical record: a. The physician should be informed of a significant change in weight gain or loss and may order nutritional interventions .d. The Registered Dietician or Dietary Manager should be consulted to assist with interventions related to unplanned or undesirable weight gain or loss and subsequent interventions or actions documented in the medical record . Record review of the facility's Change in a Resident's Condition or Status policy revised [DATE] indicated, Our facility promptly modifies the resident, his or her physician, health care provider, and the resident representative of changes in the resident's medical/mental condition and/or status .The nurse will record in the resident's medical record information relative to the changes in the resident's medical/mental condition or status .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation , interview, and record review the facility failed to ensure parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician ordersto help prevent the development and transmission of communicable diseases and infections were maintained for the facility for 1 of 2 (Resident #1) residents reviewed for parenteral fluids. The facility did not ensure Resident #1's central line (a tube that is inserted into a large vein in the neck, chest, groin, or arm to give fluids, blood, medications, or to do medical tests quickly) dressing was changed every seven days per the physician's order. This failure could place residents at risk for central line associated bloodstream infections. Findings Included: 1. Record review of the face sheet dated 1/18/24 indicated Resident #1 was a [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses including pressure ulcer (injury to the skin and underlying tissue resulting from prolonged pressure on the skin) of the sacral region (area located below the lumbar spine and above the tailbone), stroke, reduced mobility, lack of coordination, and COPD. Record review of the MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS of 9 and was moderately cognitively impaired. The MDS indicated Resident #1 was dependent for toileting, showering/bathing, personal hygiene, and transfers. The MDS indicated Resident #1 was receiving antibiotics through her central line. Record review of the care plan updated on 12/14/23 indicated Resident #1 was re-admitted to the facility with a stage IV pressure ulcer (pressure sore that extends below the subcutaneous fat into the deep tissues, including muscle, tendons, and ligaments) to the sacral area with interventions including staff to apply treatment as ordered via physician. Record review of the physician orders dated 1/16/24 through 1/18/24 indicated Resident #1 had an order to change the central line dressing every 7 days starting 12/20/23. The physician orders indicated Resident #1 had an order to change the central line dressing as needed starting 12/20/23. Record review of the MAR dated 1/1/24 through 1/18/24 indicated Resident #1's central line dressing was changed on 1/1/24, 1/8/24, and 1/15/24. During an observation on 1/17/24 at 10:58 a.m. Resident #1's central line dressing was dated 1/1/24. During an interview and observation on 1/17/24 at 11:35 a.m. RN A said nursing was responsible for changing central line dressings. RN A said central line dressings should be changed every 7 days. RN A observed Resident #1's central line dressing with surveyor present. RN A said Resident #1's central line dressing was dated 1/1/24. RN A said Resident #1's central line dressing had not been changed in over 2 weeks. RN A said the importance of changing a central line dressing every 7 days was for infection control. During an interview on 1/17/24 at 3:21 p.m. LVN B usually worked day shift on Sundays, Mondays, and Tuesdays. LVN B said she was familiar with Resident #1. LVN B said she could not remember the last time she changed Resident #1's central line dressing. LVN B said on 1/8/24 she just added a tegaderm (thin clear sterile dressing) to the central line dressing due to the dressing lifting and not having a dressing change kit available. LVN B said the central line dressing change kit was supposed to be delivered in the evening of 1/8/24. LVN B said she probably did not document changing the central line and should not have signed off the central line dressing was changed on the MAR. LVN B said the importance of changing central line dressing weekly was to prevent infection. During an interview on 1/17/24 at 3:26 p.m. RN C said she worked as needed at the facility. RN C said she was a graduate nurse. RN C said she had not touched Resident #1's central line dressing. RN C said she had changed Resident #1's central line dressing with her preceptor on 1/15/24. RN C said she dated Resident #1's central line dressing when she changed the dressing. RN C said she did not do any central line dressing change on 1/15/24. RN C said central line dressing changes were done on Tuesdays. RN C said the importance of performing central line dressing changes weekly was for infection control. During an interview on 1/18/24 at 9:10 a.m. the DON said the nurses were responsible for central line dressing changes. The DON said she expected the nurses to change the central line dressing weekly. The DON said the importance of changing the central line dressings weekly was to prevent infection and maintain skin integrity. The DON said the nurses should not sign off on the MAR a central line dressing change was completed when it was not. The DON said if a central line dressing change was signed off on the MAR as completed when it was not then the dressing change would not get done as ordered. Record review of the facility's Infusion Therapy Procedures Dressing Changes for Vascular Access Devices dated 2011 indicated, To prevent local and systemic infection related to the IV (Intravenous) catheter .Central venous access device and midline dressing changes will be done at established intervals and immediately if the integrity of the dressing is compromised, if moisture, drainage or blood is present or for further assessment if infection is suspected. Transparent semi-permeable membrane dressings are changed every 7 days and PRN (Pro re nata (as needed)) . Record review of the facility's Employee Training on Infection Control policy revised January 2022 indicated, The facility shall provide staff with appropriate information and instruction about infection control through various means, including initial orientation and ongoing training programs. Personnel are required to attend and participate in task and job-specific infection control training programs .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 14 residents (Resident #33) reviewed for MDS assessment accuracy. The facility did not ensure Resident #33's quarterly MDS identified a medication as an anti-platelet instead of an anticoagulant. These failures could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of Resident #33's face sheet, dated 10/11/23, indicated he was a [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included cerebral infarction (the pathologic process that results in an area of necrotic tissue in the brain). Record review of Resident #33's quarterly MDS assessment, dated 07/20/23, indicated in Section N0410 Medications Received item E. Anticoagulant was marked as having been given for the last 7 days. The instructions for this section read, Indicate the number of DAYS the resident received the following medications by pharmacological classification, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7 days. Record review of Resident #33's care plan, last edited on 08/28/23, indicated a problem of [Resident #33] has had recent cerebrovascular accident (stroke) with [left] sided weakness and dysphagia, takes [aspirin]. Approaches included administer medications per physician's orders. The antiplatelet medication Aggrenox (an anti-platelet medication used to reduce the risk of stroke) was not addressed in the care plan. Record review of Resident #33's physician's orders, dated 10/11/23, indicated an order for Aggrenox (an anti-platelet medication used to reduce the risk of stroke) 25-500mg, 1 capsule, twice a day. The start date was 09/28/22. During an interview on 10/11/23 at 08:36 AM, the MDS Coordinator said she thought the Aggrenox medication was an anticoagulant. She said she looked up the medication just before this surveyor came to interview her and she said and the MDS should not have been coded for anticoagulants . She said the Aggrenox medication was an antiplatelet medication. She said she would correct the MDS. She said there was a corporate nurse that audited the MDS assessments occasionally. During an interview on 10/11/23 at 09:10 AM, the Regional Reimbursement Manager said she did MDS audits for accuracy. She said she did not review all the MDS assessments. She said Resident #33's MDS should not have been coded for anticoagulant. She said they would correct the inaccurate MDS. During an interview on 10/11/23 at 10:37 AM, RN B said she signed the MDS assessments after the MDS coordinator sometimes. She said it was an oversight that the Aggrenox was coded as an anticoagulant and it should have been coded as a anti platelet. She said the risk to the resident was that it could possibly cause the care plan to have an anticoagulant care area when it should not have. During an interview on 10/11/23 at 11:08 AM, ADON C said Resident #33's MDS assessment should not have been coded for an anticoagulant. She said the MDS coordinator was responsible for ensuring the MDS assessment was accurate. She said they will now discuss the MDS assessments with all the administration staff before sending in the MDS. She said there was no risk to the resident because of the MDS being inaccurate. During an interview on 10/11/23 at 11:17 AM, the DON said the Aggrenox medication was an antiplatelet medication. She said Resident #33's MDS assessment should not have been coded for an anticoagulant. She said there was no risk to the resident because of the MDS being inaccurate. She said the MDS coordinator was responsible for checking that the MDS assessment was accurate. She said the corporate MDS nurse was also responsible for ensuring the MDS was accurate . During an interview on 10/11/23 at 11:24 AM, the Administrator said she expected the MDS assessments to be completed accurately. She said there was no risk to the resident because of it being inaccurate. She said the MDS coordinator was responsible for ensuring that the MDS assessment was accurate. She said the RN that signs the MDS assessments was responsible for ensuring the accuracy of the assessment as well. Record review of the Facility's policy, Certifying Accuracy of the Resident Assessment, last revised November 2019, stated: .Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment . .2. Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of the assessment . .4. The Resident Assessment Coordinator is responsible for ensuring that an MDS assessment has been completed for each resident. Each assessment is coordinated and certified as complete by the Resident Assessment Coordinator, who is a registered nurse

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure respiratory care was provided with professional standards of practice for 1 of 2 resident reviewed for respiratory care and services. (Resident #142) The facility failed to administer oxygen at 3 liters via nasal cannula as prescribed by the physician for Resident #142. This failure could place residents who receive respiratory care at risk for developing respiratory complications. Findings included: Record review of Resident #142's face sheet dated 10/10/23, indicated a [AGE] year-old male who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #142's diagnoses included pneumonia (infection of the air sacs in one or both lungs), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), chronic respiratory failure with hypoxia (not enough oxygen in the blood), and malignant neoplasm of mandible (jaw cancer). Record review of Resident #142's admission MDS assessment dated [DATE], indicated he usually made himself understood and usually understood others. The MDS assessment indicated Resident #142 had a BIMS score of 11, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #142 required extensive assistance with bed mobility, dressing, eating, toileting, and personal hygiene. Resident #142 was totally dependent on staff with bathing. The MDS indicated Resident #142 was receiving oxygen therapy. Record review of Resident #142's physician summary reported dated 09/17/23-10/10/23, indicated he had an order for oxygen at 3 liters per minute via nasal cannula continuous with a start date of 09/17/23. Record review of Resident #142's care plan dated 10/04/23, indicated he had chronic hypoxic respiratory failure, chronic obstructive pulmonary disease, and a lung mass. Resident #142 required the use of oxygen. The care plan interventions indicated to administer oxygen as ordered. Record review of Resident #142's MAR dated 10/01/23- 10/10/23, indicated he had been receiving oxygen at 3 liters per min via nasal cannula daily. During an observation on 10/09/23 at 10:08 AM, Resident #142 was receiving oxygen at 4 liters per minute via nasal cannula. During an observation on 10/10/23 at 09:01 AM, Resident #142 was receiving oxygen at 4 liters per minute via nasal cannula. During an observation and interview on 10/10/23 at 4:07 PM, Resident #142 was receiving oxygen at 4 liters per minute via nasal cannula. Resident #142 said he did not know who set the oxygen at 4 liters and he said he had not changed the settings on the oxygen concentrator. During an interview and observation on 10/10/23 at 4:08 PM, RN A said the oxygen setting was checked every morning. RN A went to Resident #142 and said the oxygen was set at 4 liters per minute. RN A said Resident #142 oxygen was usually set at 4 liters per minute via nasal cannula. RN A said the physician had given an order for oxygen 2-5 liters per minute to keep Resident #142's oxygen saturation above 92 percent. RN A reviewed Resident #142's physician's orders and said Resident #142 had an order for oxygen 3 liters per minute via nasal cannula and could not find the order for when the oxygen was changed. RN A reviewed Resident #142's progress notes and could not find when the physician had given the order for oxygen 2-5 liters. RN A said the nurse who received the order was responsible for ensuring the new oxygen order was transcribed in Resident #142's medical records. RN A said the nurse could administer oxygen without a physician's order . RN A said the Resident #142 was at risk for receiving more than the prescribed dose of oxygen which was considered a medication error. During an interview on 10/11/23 at 10:57 AM, ADON C said she expected the physician's orders to be followed when administering oxygen. ADON C said oxygen was considered a medication. ADON C said Resident #142 should have been receiving oxygen at 3 liters per minute via nasal cannula as prescribed. ADON C said the nurses were responsible for ensuring the oxygen was set as ordered when it was signed off on the MAR. ADON C said by not setting the oxygen at the prescribed rate could cause residents to receive too much or not enough oxygen. During an interview on 10/11/23 at 11:05 AM, the DON said she expected oxygen to be set at the prescribed rate. The DON said the nurses were responsible for ensuring the oxygen was set at the correct rate. The DON said not following the physician's order could cause residents to not receive proper oxygenation. During an interview on 10/11/23 at 11:13 AM, the ADM said she expected oxygen to be administered as per the physician's orders. The ADM said the nurse was responsible for following the physician's orders and ensuring the correct oxygen dose was being administered. The ADM said by not setting Resident #142's oxygen as ordered he was at risk for hyperoxygenation (too much oxygen) or could cause him to end up back in the hospital. The ADM said oxygen did require a physician's order. Record review of the facility's policy Oxygen Administration revised October 2010 indicated .The purpose of this procedure is to provide guidelines for safe oxygen administration. 1. Verify that there is a physician's order for this procedure. Review the physical's orders or facility protocol for oxygen administration .

Based on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for one of one medication room reviewed for medications storage (North Side Medication Room). The facility failed to remove an expired medication from the North Side Medication Room. These failures could place residents at risk for not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings included: During an observation on 10/11/23 at 09:47 AM, this surveyor reviewed the North Side Medication Room with RN A. A 2mL vial of Lidocaine HCL injection 1% (a medication used to alleviate pain and discomfort by numbing the targeted area of the body) was found with an expiration date of September 2013. During an interview on 01/11/23 at 09:55 AM, RN A said the expired lidocaine vial should not have been in the medication room. She said it was missed because it was in the back area of the cabinet. During an interview on 10/11/23 at 11:08 AM, ADON C said the medication aides, nurses, ADON, and DON were responsible for checking the medication room for expired medications. She said the nurses check the medication room each shift. She said if a resident received the medication there would be risk of infection to the resident. During an interview on 10/11/23 at 11:17 AM, the DON said that the Lidocaine vial should not have been in the medication room. She said all nursing staff were responsible for checking the medication room for expired medications. She said it was possible that someone could accidentally grab that medication and give it to a resident. She said if it was given to a resident that it could have been ineffective. During an interview on 10/11/23 at 11:24 AM, the Administrator said she expected the expired medications to be removed from the med room. She said the nursing staff were responsible for ensuring that the medication rooms were checked. She said the risk was possible adverse effects if the medication was given to a resident. Record review of the Facility's policy, Storage of Medications, last revised November 2020, stated: .The facility stores all drugs and biologicals in a safe, secure, and orderly manner . .4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure the use of psychotropic medications was documented in the clinical record for 1 of 5 residents reviewed for unnecessary psychotropic drugs (Resident #30). The facility failed to adequately monitor Resident #30's side effects regarding her antidepressant medication. This failure could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings included: Record review of Resident #30's face sheet dated 10/10/23, indicated a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #30's diagnoses included depression, anxiety, congestive heart failure (condition in which the heart does not pump blood as well as it should), and essential hypertension (high blood pressure). Record review of Resident #30's quarterly MDS assessment dated [DATE], indicated she usually made herself understood and usually understood others. The MDS assessment indicated Resident #30 had a BIMS score of 13, which indicated her cognition was intact. The MDS assessment indicated Resident #30 required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #30 was totally dependent on staff for bathing. The MDS assessment indicated Resident #30 received antidepressant medications 6 days out of the 7 days of the look back period. Record review of Resident #30's care plan dated 08/18/23 did not indicate Resident #30 was receiving antidepressant medications. Record review of the performance improvement dated 10/04/23, indicated the facility had identified issues with the residents comprehensive centered care plans and were in the process of updating all care plans. Record review of Resident #30's physician order report dated 09/10/23- 10/10/23, indicated she had the following orders for antidepressant medications: *Duloxetine 30mg: one tablet by mouth once a day with a start date of 07/28/23 *Paxil 10mg: one tablet at bedtime with a start date of 08/30/23 Record review of Resident #30 MAR dated 10/01/23- 10/11/23, indicated she had been receiving Duloxetine 30mg one tablet in the morning ad Paxil 10mg one tablet at bedtime. Record review of Resident #30's Treatments Administration History dated 10/01/23-10/11/23 did not indicate Resident #30's antidepressant side effects were being monitored. During an interview on 10/11/23 at 10:57 AM, ADON C said residents who received psychotropic medications should be monitored for side effects. ADON C said the nurses, DON, and herself were responsible for ensuring the side effect monitoring nursing order was in place. ADON C said not monitoring the side effects could cause residents to receive medications for no reason or could cause residents to be over sedated. ADON C said side effect monitoring was documented on the nurse's administration record. ADON C said the DON and herself reviewed the orders upon admission. During an interview on 10/11/23 at 11:05 AM, the DON said she expected residents who received psychotropic medications to have side effect monitoring in place. The DON said the nurses were responsible for ensuring the residents were being monitored for side effects or adverse reactions. The DON said by not monitoring the residents side effects regarding psychotropic medication use could cause them to miss a resident's side effect to that medication and may cause harm to them. During an interview on 10/11/23 at 11:13 AM, the ADM said she expected resident who received psychotropic medications to have documentation on medication side effects. The ADM said the nurse was responsible for ensuring side effect monitoring was in place. The ADM said not monitoring side effects for psychotropic medications could cause residents to be over medicated. The ADM said by not monitoring the effectiveness of the medications the physician will not know when to adjust the medication. Record review of the facility's policy Medication Monitoring Medication Management dated January 2022, indicated . Each resident's drug regimen is reviewed to ensure it is free from unnecessary drugs. This includes any drug .without adequate monitoring .The facility's medication management support and promotes: .the monitoring of medications for efficacy and adverse consequences .4. The interdisciplinary team reviews the resident's medication regimen for efficacy and actual or potential medication-related problems on an ongoing bases and with the consideration of resident preferences .Monitoring of Psychotropic Medications: When monitoring a resident receiving psychotropic medications, the facility must evaluate the effectiveness of the medications as well as look for potential adverse consequences .Potential Adverse Consequences: The facility assures that residents are being adequately monitored for adverse consequences such as: anticholinergic effects which may include flushing, blurred vision, dry mouth, altered mental status, difficulty urinating, falls, excessive sedation, constipation, signs and symptoms of cardiac arrythmias such as irregular heart beat or pulse palpitations unstable or poorly controlled blood sugar, weight gain .agitation, distress, tardive dyskinesia (neurological syndrome that results in involuntary and repetitive body movements), cerebral vascular accident (stroke) .

Based on observation, interviews 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 kitchen sanitation in that: 1. Expired food was not disposed of. 2. Food was not labeled or dated. 3. Kitchen equipment was not kept free of carbon buildup. These deficient practices could place residents who received meals from the kitchen at risk for food borne illness. The findings were: During an observation on 10/09/23 at 9:00 a.m., a cast iron skillet was on the stove that was used to cook breakfast. The cast iron skillet was observed with a thick layer of carbon buildup. The cast iron stove top had a thick layer of carbon buildup. Inside the refrigerator it was observed that a tub of cottage cheese was out of date, 10/04/2023. It was observed 8 bags of hotdog buns without dates or labels and no expiration date was printed on bag. It was observed that a loaf of bread was opened and laying on a serving table with no date or label and no expiration date printed on the bag. During an interview on 10/11/23 at 9:30 a.m., with the Dietary Manager she stated she expects that all her kitchen staff throw away expired food or food past its best use by date. She stated that her staff are not allowed to serve expired food as it could cause foodborne illness. She stated staff are supposed to label and date all items so that they do not serve expired items and if there is no label or date nor an expiration date then there is no way to tell when the food expired. She stated cooking equipment should not have carbon buildup. She stated their cast iron skillet will be replaced after a new skillet they have ordered comes in. She stated their corporate resource staff also told her that some of her skillets and pans needed to be replaced due to age and carbon buildup. During an interview on 10/11/23 at 10:20 a.m., with the Administrator she stated she expected staff to throw away expired food. She stated residents could be placed at risk for foodborne illness and food poisoning. She stated all kitchen staff are responsible to throw away expired food. She stated food should be labeled and dated. She stated staff should label and date food so they know the date ranges of how long the food has been in the kitchen and when to discard it. She stated she expects her kitchen staff to maintain their cooking equipment and ensure it is free from carbon buildup. She stated she expects that if a skillet or pan had carbon buildup it should be cleaned or replaced. Review of the facility document revised April of 2022, Preventing Foodborne Illness - Food Handling provided by the Dietary Manager revealed: Food will be stored, prepared, handled, and served so that the risk of foodborne illness is minimized. The Resident agrees to consult with Nursing and Dietary staff regarding food or beverages brought into the Center. This facility recognizes that the critical factors implicated in foodborne illness are: a. Poor personal hygiene of food service employees; b. Inadequate cooking and improper holding temperatures; c. Contaminated equipment; and d. Unsafe food sources. All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents. This facility only accepts prepared foods from suppliers subject to federal, state or local food service inspections and who remain in good standing with such agencies. Review of the facility document dated 2018, Food Storage provided by the Dietary Manager revealed: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. g. Use the first-in, first-out (FIFO) rotation method. Date packages and place new items behind existing supplies, so that the older items are used first.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure an accurate MDS was completed for 1 of 17 residents reviewed for MDS assessment accuracy. (Resident #13). The facility failed to accurately reflect Resident #13's weight on the MDS assessment. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Record review of the physician summary report indicated a [AGE] year-old female admitted on [DATE] with a diagnosis of congestive heart failure (excessive fluid in the lungs that causes weakness in the heart), Type 2 diabetes mellitus (sugar in the blood) and hypertension (high blood pressure). Record review of the quarterly MDS assessment dated [DATE] indicated that Resident #13 had a weight of 233 lbs in section K0200 and section K0300 is marked #1 for loss of 5% or more in the last month or loss of 10% or more in last 6 months. Record Review of the weight variance report dated 02/01/22-08/22/22 indicated that Resident #13 weighted 264 lbs on 05/03/22 and weighted 268 lbs on 06/01/22. Record review of Resident #13 care plan dated 4-13-22 indicated that she had a problem with nutritional status and fluctuations in weight, but loss was desired. Goals indicated, I will continue to have good nutritional status with my weight loss. Approaches included: decline in status due to nutrition notify the MD immediately, labs per order, monitor for fluid intake ensuring resident does not show s/s of dehydration and notify MD if noted and monitor percent of meals eaten. During an interview on 8-24-22 at 9:14 AM with LVN D, LVN D stated they do monthly weights on all residents. LVN D stated that the facility scales were messed up and not working correctly. LVN D stated that, if we got a weird weight, we would assist the aides with weighing residents 4-5 x in the same day. During an interview on 8-24-22 at 2:00 PM with the MDS Coordinator. MDS coordinator stated that if there is a weight fluctuation, she will let the DON and treatment nurse know because the treatment nurse was the one that gets the weights. MDS Coordinator said that if the MDS must be done in 14 days, then she would not have time to re-weigh the resident prior to submitting and she would just use the weight she was given. MDS Coordinator stated she looks back at 30- and 180-day log of weights to compare. MDS Coordinator stated that if the weight was submitted wrong on the MDS, it could impact the MDS, and the resident could stop eating if they weighted more than expected because they might think it was too much. MDS coordinator stated that the wrong weight can also psychologically impact the resident. During interview on 8-24-22 at 10:39 AM with the DON, DON stated there was a problem with their scales. DON stated that if there was a weight fluctuation the nurses would document it in the nursing notes that the resident's weight is off and notify the MD. DON stated that she notified corporate of the scale problem. Stated they received a new scale on 8-19-22, but they have not started using it yet. DON stated they plan on doing weekly weights on every resident starting on 8-29-22 and re-establishing baselines. DON stated the MDS coordinator should have called and questioned someone about the weight difference prior to submitting the MDS. DON stated that the wrong weight could have resulted in adding supplements to someone that did not need the weight gain or residents could have been cut back on calories when they did not need to be cut back. During an interview on 08-24-22 at 1:01 PM with the Administrator, the Administrator stated that she expected staff to reweigh residents if there is a major change in weight. Administrator stated that the facility scale has been off, and even reweights have been off.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASRR) to the maximum extent practicable to avoid duplicative testing and effort for 1 of 10 (Resident #50) residents reviewed for PASRR. The facility failed to refer Resident #50 for PASRR Level ll assessment when a diagnosis of Bipolar disorder, current episode manic severe with psychotic features was diagnosed after admission on [DATE]. This failure could affect residents with mental illnesses and place them at risk of not being assessed to receive needed services. Findings include: Record review of a face sheet dated 08/24/22 revealed Resident #50 was [AGE] years old and was admitted on [DATE] with diagnoses including major depressive disorder, recurrent, unspecified (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), bipolar disorder, current episode manic severe with psychotic features (a disorder associated with episodes of mood swings ranging from depression lows to manic highs), and anxiety disorder, unspecified (mental illness defined by feelings of uneasiness, worry and fear). Record review of the most recent MDS assessment, dated 08/11/2022, indicated Resident #50 was understood and understood others. The MDS indicated Resident #50 had a Brief Interview for Mental Status (BIMS) of 7. This score indicated severe cognitive impairment for Resident #50. The MDS section, Preadmission Screening and Resident Review indicated Resident #50 did not have a serious mental illness. The section named Level II Preadmission Screening and Resident Review Conditions did not reflect a mental illness. The MDS section of Psychiatric/mood disorder indicated diagnoses of anxiety disorder, depression, and bipolar disorder. Record review of the care plan problem start date 04/20/22 indicated Resident #50 had a diagnosis of maniac depression (bipolar) and can have mood swings from euphoria to depression and was prescribed to take Depakote (anticonvulsant used to treat bipolar disorder). Record review of Resident #50's PASRR Level 1 Screening completed on 05/07/21 indicated in section C0100 no evidence of this individual having mental illness. During an interview on 08/24/2022 at 4:15 PM, the DON indicated the MDS Coordinator was responsible for all the PASRR Level 1 Screenings and for coordinating the appropriate PASRR services. The DON said she did not know why Resident #50's PASRR was not updated after the new diagnosis of bipolar disorder was made. The DON indicated she did not monitor PASRR. The DON reported the MDS coordinator was the only one responsible for PASRR. The DON said residents not receiving the adequate PASRR services could negatively affect their mental status, ADL function, and quality of life. During an interview on 08/24/2022 at 4:50 PM, the MDS Coordinator stated that she was responsible for ensuring all residents had a PASRR Level 1 screening and if necessary, the PASRR Level 2 assessment. The MDS Coordinator said that she was responsible for ensuring residents received the appropriate PASRR services as recommended. The MDS coordinator indicated if, after admission, a resident had a new mental illness diagnosis, she was responsible for submitting a new PASRR Level 1 Screening. The MDS coordinator said she was not made aware of the new mental illness diagnosis for Resident #50. The MDS coordinator said it must have been missed since she was not at the facility every day. The MDS coordinator said she did not currently have a system in place to monitor that the PASRR Level 1 Screenings were accurately completed and updated as needed. The MDS coordinator said not completing the PASRR accurately could result in residents not having the services they require to help with their mental illness. Record review of the facility's policy for PASRR did not address the process for updating PASRR Level 1 Screening after admission for residents with newly diagnosed mental illness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to 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, mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 17 residents (Resident #50) reviewed for comprehensive person-centered care plans. The facility failed to care plan Resident #50's communication deficits related to hearing impairment and use of hearing aids. This failure could place residents at risk of not having individual needs met, a decreased quality of life, and communication deficits. Findings include: Record review of a face sheet dated 08/24/22 revealed Resident #50 was [AGE] years old and was admitted on [DATE] with diagnoses including urinary tract infection (infection in any part of the urinary system including the kidneys, ureters, bladder, and urethra), type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), cognitive communication deficit (difficulty with thinking and how someone uses language),and need for assistance with personal care (needing help with day-to-day activities of daily living). Record review of the most recent MDS assessment, dated 08/11/22 indicated Resident #50 used a hearing aid or other hearing appliances. The MDS indicated Resident #50 was understood and understood others. The MDS indicated Resident #50 had a Brief Interview for Mental Status (BIMS) of 7. This score indicated severe cognitive impairment for Resident #50. The MDS indicated Resident #50 required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Record review of the MDS Section V Care Area Assessment (CAA) Summary signed 08/12/22 by the DON and the MDS Coordinator revealed that communication would be addressed in the care plan. Record review of Resident #50's comprehensive care plan, last reviewed 08/11/22 revealed no record to indicate Resident #50's communication deficits related to hearing impairment and the need for hearing aids. During an observation on 08/22/22 at 11:37 AM. Resident #50 did not have hearing aids to either ear. During an observation and interview on 08/23/22 at 9:40 AM, Resident #50 did not have hearing aids to either ear. Resident #50 indicated she had hearing aids, but they were lost. Resident #50 indicated she needed the hearing aids because she could not hear adequately without them. During an interview on 08/24/22 at 4:15 PM, the DON indicated she was responsible for the development of the 48-hour care plans, and the MDS Coordinator was responsible for the development of the comprehensive care plan and updating the care plan. The DON indicated she was not aware Resident #50's care plan did not address her communication deficits related to hearing impairment and the need for hearing aids. The DON said audits were done quarterly by herself and the MDS Coordinator to ensure care plans are adequate for each residents needs. The DON said Resident #50's care plan not addressing her communication deficit, related to hearing impairment and the need for hearing aids, could place the resident at risk for impaired and improper communication. The DON said Resident #50's quality of life and ADLs could be diminished. During an interview on 08/24/22 at 4:50 PM, the MDS Coordinator indicated she was responsible for completing and updating the care plans. The MDS Coordinator initially said she care planned Resident #50's communication deficits related to hearing impairment and the need for hearing aids, but then said to let her review the care plan briefly to verify. After, she looked at the care plan she said it was not on the care plan and she did not know why it was not, but she would add it. The MDS Coordinator said because Resident #50's communication deficits related to hearing impairment and the need for hearing aids were not on the care plan staff would not know Resident #50 was hard of hearing and would not be able to communicate effectively with her. Additionally, staff would not know to clean and put on Resident #50's hearing aids. Record review of the facility's care plan policy titled Care Plans, Comprehensive Person-Centered revised December 2020 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 . 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and time frames; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .g. Incorporate identified problem areas . m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels . 9. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. 10. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process . 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents received, and consumed foods as prescribed by the physician for 1 of 17 residents (Resident #50) reviewed for therapeutic diets. The facility did not ensure Resident #50 had ice cream and soup with her lunch for 2 days as ordered by the physician. This failure could place residents at risk for poor intake, weight loss, and unmet nutritional needs. Findings include: Record review of the face sheet dated 08/24/22 revealed Resident #50 was an [AGE] years old female and was admitted on [DATE] with diagnoses including urinary tract infection (infection in any part of the urinary system including the kidneys, ureters, bladder, and urethra), type 2 diabetes mellitus without complications (chronic condition that affects the way the body processes blood sugar), cognitive communication deficit (difficulty with thinking and how someone uses language), need for assistance with personal care (needing help with day-to-day activities), and abnormal weight loss (unexpected loss of body weight). Record review of the most recent MDS assessment, dated 08/11/22 indicated Resident #50 was understood and understood others. The MDS indicated Resident #50 had a Brief Interview for Mental Status (BIMS) of 7. This score indicated severe cognitive impairment for Resident #50. The MDS indicated Resident #50 required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. Record review of the care plan las revised 08/11/22 indicated Resident #50 had experienced un-intentional weight loss related to change in condition with oral intake and current body weight at 186.5 down 21 pounds. The care plan goal was for Resident #50 to not have any further weight loss through the next evaluation period. Record review of the physician order report dated 07/01/22-08/24/22 indicated Resident #50 had an order to add ice cream and soup to lunch and dinner for diagnosis of abnormal weight loss with a start date of 08/11/22. During an observation on 08/22/22 at 12:50 PM, Resident #50 was not given soup and ice cream with her lunch meal. Resident #50 meal ticket did not indicate she was ordered ice cream and soup with lunch and dinner. During an observation on 08/23/22 at 12:35 PM, Resident #50 was not given soup and ice cream with her lunch meal. Resident #50 did not indicate she was ordered ice cream and soup with lunch and dinner. During an interview on 08/23/22 at 9:40 AM, Resident #50 indicated that the previous day she had not received soup and ice cream with her lunch and dinner. Record review of meal tickets dated 08/22/22, 08/23/22, 08/24/22, did not indicate to give Resident #50 soup and ice cream with lunch and dinner. During an interview on 08/24/22 at 2:15 PM, LVN C indicated Resident #50 was not receiving soup and ice cream with lunch. LVN C said she was not aware Resident #50 had an order to receive soup and ice cream with lunch and dinner. LVN C reported nurses were responsible for entering diet orders and giving the kitchen a communication form indicating new diet orders for the Dietary Manager to update the meal tickets. LVN C said that prior to serving meals the nurse was responsible for checking the tray with the meal ticket. LVN C said that Resident #50 not receiving the soup and ice cream with lunch and dinner could cause Resident #50 to be weak, not feel full, and experience further weight loss. During an interview on 08/24/22 at 3:05 PM, the Dietary Manager indicated the dietician was responsible for checking orders with meal tickets once a month to ensure the diet orders matched with the residents' meal tickets. The Dietary Manager indicated changes to diet and new diet orders were communicated to her through a communication form that were given to her by the nurses, and then she would update the meal tickets. The Dietary Manager indicated Resident # 50's meal ticket was not updated due to her not receiving a communication form. The Dietary Manager said the nurses were responsible for checking the trays with the meal tickets prior to serving meals. The Dietary Manager indicated Resident #50 not receiving soup and ice cream with lunch and dinner could lead to weight loss. During an interview on 08/24/22 at 3:19 PM, the Dietician indicated she checked the diet orders once a month by printing a list of all the diets. The Dietician said the Dietary Manager was responsible for making changes when new diet orders were given and ensuring changes were made on meal tickets. The Dietician indicated she might have been aware of Resident #50 order for soup and ice cream with lunch and dinner, but she was not sure because she went to multiple facilities. The Dietician said she was not sure how this could harm Resident #50 because she was not sure what other dietary interventions were in place for Resident #50. During an interview on 08/24/22 at 4:10 PM, the DON indicated the charge nurse was responsible for implementing new diet orders and communication them to the kitchen through a communication form. The DON indicated when the communication form went to the kitchen the Dietary Manager was responsible for updating the meal tickets. The meal tickets are used for the nurses to check meal trays prior to serving meals. The DON indicated she was aware of Resident #50 order to receive soup and ice cream with lunch and dinner because she was the one who put the order in. The DON indicated she did not fill out a communication form because the diet order was given during a monthly weight loss meeting and the Dietary Manager was present during the meeting. The DON said she expected nurses to implement new orders and communicate new diet orders to the Dietary Manager. The DON said currently there was no monitoring in place to ensure new and changed diet orders were accurately reflected on the meal tickets, but something needed to be in place to monitor this. The DON indicated that Resident #50 not receiving soup and ice cream for lunch and dinner could lead to further weight loss, lack of nutrition, and furthermore impaired skin integrity. During an interview on 08/24/22 at 4:40 PM, the ADON indicated the nurses were responsible for implementing new diet orders and communicating new and changed diet orders to the Dietary Manager for the Dietary Manager to update meal tickets. The ADON said the nurses were responsible for checking the diet with the meal ticket before serving meals. The ADON indicated she did not know why the order for Resident #50 to have ice cream and soup with lunch and dinner was not communicated to the Dietary Manager. The ADON said that she expected nurses to communicate new diet orders to the Dietary Manager and that this was supposed to be monitored by a monthly weight meeting. The ADON indicated Resident #50 not receiving the soup and ice cream with lunch and dinner could cause Resident #50 to lose a couple pounds. Record review of the facilities Therapeutic Diets policy las revised October 2017 revealed, Therapeutic Diets are prescribed by the Attending Physician to support the resident's treatment and plan of care and in accordance with his or her goals and preferences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure safe and sanitary storage of resident's food items for 1 of 28 residents reviewed for personal food safety. (Residents #25) The facility did not implement their own foods brought by family/visitor's policy by discarding foods that shows obvious signs of potential foodborne danger. This failure could place the residents at risk for food borne illnesses. Findings include: Record review of the face sheet and consolidated physician orders dated 08/24/2022-08/24/2022 indicated Resident #25 was a [AGE] year-old male, admitted to the facility on [DATE] with diagnoses including cerebral infarction (a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) due to unspecified occlusion or stenosis of unspecified cerebral artery, chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and hyperlipidemia (blood has too many lipids (or fats)). Record review of the quarterly MDS assessment dated [DATE] indicated Resident #25 understood others and made herself understood. The MDS indicated Resident #25 was moderately cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 10. The MDS indicated Resident#25 did not reject care necessary to achieve the resident's goals for health or well-being. The MDS indicated he required supervision with bed mobility, transfers, eating, and toileting: and required limited assistance with personal hygiene and extensive assistance with bathing. Record review of the care plan dated 07/25/2022 did not address refrigerator checks until surveyors' intervention on 08/24/2022. During an observation on 08/22/2022 at 2:25 p.m., Resident #25's personal refrigerator was noted to have two plastic Ziploc bags with two slices of pizza dated 05/18/2022. The pizzas were covered with a green-blackish thick substance. There was also a container of meat loaf and macaroni and cheese dated 05/22/2022. The macaroni and cheese had a thick white film noted on top. During an observation on 08/23/2022 at 10:15 a.m., Resident #25's personal refrigerator was noted to have two plastic Ziploc bags with two slices of pizza dated 05/18/2022. The pizzas were covered with a green-blackish thick substance. There was also a container of meat loaf and macaroni and cheese dated 05/22/2022. The macaroni and cheese had a thick white film noted on top. During an observation and interview on 08/24/2022 at 9:48 a.m., the DON and ADM went into Resident #25 room with the surveyor to look in his personal refrigerator. The ADM asked Resident #25 if she could remove the pizzas and the container with the meat loaf and macaroni cheese. Resident #25 nodded yes. The ADM removed the items from the refrigerator. The DON said the Maintenance Director was responsible for checking Resident #25's refrigerator weekly and discarding any food that showed mold growth. During an interview on 08/24/2022 at 2:50 p.m., the Maintenance Director said he was responsible for removing any food that showed obvious signs of mod growth from Resident #25's personal refrigerator. He said he look at the refrigerator last week but was unable to give exact day. He stated, I did not actually look through the refrigerator for expired food, which I should have. He said this failure could place residents at risk for food borne illness. During an interview on 08/24/2022 at 3:34 p.m., the ADM said the Maintenance Director was responsible for checking Resident #25's personal refrigerator weekly. She said Resident #25 did not allow staff to check his refrigerator sometimes. She was not able to tell the surveyor the last time it was attempted or documentation where he refused. She said the Angel Rounds was put in place around June 2022. She said moving forward her, and the administrative department will establish a process to maintain refrigerators. She said this failure could potentially place residents at risk for food borne illness. Record review of the facility's policy titled Foods Brought by Family/Visitors dated 03/2022 indicated . the nursing staff will discard perishable foods on or before the use by date . the nursing staff and/or food service staff will disregard any foods prepared for the resident that shows obvious signs of potential foodborne danger (for example, mold growth .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure necessary services to maintain grooming and personal hygiene were provided for 4 of 17 residents (Resident #52, Resident #12, Resident #30, and Resident #19) reviewed for ADLs. The facility did not provided assistance with nail care for Resident #52. The facility did not provide assistance with facial hair removal for Resident #12, Resident #30, and Resident #19. These failures could place residents at risk of not receiving services/care, skin tears, decreased self-esteem, and decreased quality of life. Findings Included: 1. Record review of the consolidated physician orders dated 8/24/2022 indicated Resident #52 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), lack of coordination, reduced mobility, need for assistance with personal care, optic atrophy (a condition that affects the optic nerve, which carries impulses from the eye to the brain), and diabetes type 2. Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #52 understood others and was understood by others. The MDS indicated Resident #52 had a BIMS score of 12 and moderately cognitive impairment. The MDS indicated Resident #52 was not resistive to evaluation or care. The MDS indicated Resident #52 required supervision with bed mobility, transferring, and toileting. The MDS indicated Resident #52 required limited assistance with dressing and personal hygiene. Record review of the care plan updated on 7/26/22 indicated Resident #52's specific tasks would be documented in the plan of care assist program including nail care. The care plan indicated Resident #52 was at risk for impaired skin integrity related to poor safety awareness and Resident #52 getting skin tears and bruises periodically Record review of skilled nursing point of care compliance sheets dated 8/01/22 through 8/24/22 indicated Resident #52 had not missed any of her scheduled showers or nail care scheduled for Mondays, Wednesdays, and Fridays. During an observation and interview on 8/22/22 at 11:54 a.m. Resident #52 was observed with jagged nails on both hands. Resident #52 said sometimes staff help her cut and groom her nails. Resident #52 said she would allow staff to assist her with grooming her nails. During an observation and interview on 8/23/22 at 8:31 a.m. Resident #52 was observed with jagged nails on both hands. Resident #52 said she would like them to be cut and groomed. During an observation on 8/24/22 at 9:12 a.m Resident #52 was observed with jagged nails on both hands. During an interview on 8/24/22 at 1:45 p.m. LVN E said residents should be assisted nail care during their showers and as needed. LVN E said it was important to groom nails and keep them from being jagged to prevent skin tears. LVN E said Resident #52 did not refuse care. During an interview on 8/24/22 at 1:55 p.m. LVN D said residents should be assisted with nail grooming during showers and as needed. LVN D said the importance of nail grooming was to prevent skin tears. LVN D said Resident #52 did not resist care. During an interview on 8/24/22 at 3:16 p.m. NA V said nail grooming was provided as needed and at least weekly. NA V said the importance of grooming jagged nails was to prevent residents from cutting themselves. 2. Record review of the consolidated physician orders dated 8/24/2022 indicated Resident #12 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including diabetes type 1, unspecified disorder of adult personality and behavior, cerebral palsy (a congenital disorder of movement, muscle tone, or posture), muscle wasting and atrophy (the decrease in size and wasting of muscle tissue), lack of coordination, and need for assistance with personal care. Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #12 usually understood others and was understood by others. The MDS indicated Resident #12 had a BIMS score of 05 and severely cognitive impairment. The MDS indicated Resident #12 was not resistive to evaluation or care. The MDS indicated Resident #12 required extensive assistance with bed mobility, transferring, dressing, personal hygiene, and toileting. Record review of the care plan updated on 8/08/22 indicated Resident #12 had an impaired ADL function with interventions including bathing/hygiene and dressing/grooming required maximum assistance of 1 staff member. Record review of skilled nursing point of care compliance sheets dated 8/01/22 through 8/24/22 indicated Resident #12 had not missed any of her scheduled showers scheduled for Mondays, Wednesdays, and Fridays. During an observation and interview attempt on 8/22/22 at 10:31 a.m. Resident #12 was observed with thick, silver/white colored chin hair approximately 0.5cm in length. Resident #12 was not interviewable. During an observation on 8/23/22 at 8:21 a.m. Resident #12 was observed with thick, silver/white colored chin hair approximately 0.5cm in length. During an observation on 8/23/22 at 12:30 p.m. Resident #12 was observed with thick, silver/white colored chin hair approximately 0.5cm in length. During an observation on 8/24/22 at 9:09 a.m. Resident #12 was observed with thick, silver/white colored chin hair approximately 0.5cm in length. 3. Record review of the consolidated physician orders dated 8/24/2022 indicated Resident #30 was a [AGE] year-old female, re-admitted to the facility on [DATE] with diagnoses including muscle weakness, lack of coordination, reduced mobility, ataxia (impaired balance or coordination), need for assistance with personal care, bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Record review of the most recent comprehensive MDS dated [DATE] indicated Resident #30 usually understood others and was usually understood by others. The MDS indicated Resident #30 had a BIMS score of 07 and severely cognitive impairment. The MDS indicated Resident #30 was not resistive to evaluation or care. The MDS indicated Resident #30 required supervision with bed mobility, transferring, and toileting. The MDS indicated Resident #30 required limited assistance with dressing and personal hygiene. Record review of the care plan updated on 8/08/22 indicated Resident #30 had impaired physical mobility related to decreased muscle control and strength with interventions including needed assistance with bathing with assist of one staff member. The care plan indicated Resident #30 was limited in ability to maintain grooming/personal hygiene related to brain cyst with interventions including assist with showers three times a week and provide assistance with grooming hair. Record review of skilled nursing point of care compliance sheets dated 8/01/22 through 8/24/22 indicated Resident #30 had not missed any of her scheduled showers scheduled for Mondays, Wednesdays, and Fridays. During an observation on 8/22/22 at 10:40 a.m. Resident #30 was observed with chin hair approximately 1-2cm in length. During an observation on 8/23/22 at 8:28 a.m. Resident #30 was observed with chin hair approximately 1-2cm in length. During an observation on 8/23/22 at 12:28 p.m. Resident #30 was observed with chin hair approximately 1-2cm in length. During an interview attempt on 8/23/22 at 2:33 p.m. Resident #30 was not interviewable and unable to answer the surveyor's questions. During an observation on 8/24/22 at 9:11 a.m. Resident #30 was observed with chin hair approximately 1-2cm in length. During an interview on 8/24/22 at 1:45 p.m. LVN E said residents should be assisted with facial hair removal showers and as needed. LVN E said it was important to assist female residents with facial hair removal for dignity. LVN E said residents Resident #12 and Resident #30 both sometimes refuse care. During an interview on 8/24/22 at 1:55 p.m. LVN D said residents should be assisted with facial hair removal showers and as needed. LVN D said the importance of assisting female residents with facial hair removal was dignity. LVN D said Resident #12 sometimes refused care. LVN D said Resident #30 would only allow certain staff members to assist her with facial hair removal. During an interview on 8/24/22 at 3:16 p.m. NA V said facial hair removal was performed during showers. NA V said it was important to assist female residents with facial hair removal for their self-esteem. NA V said assisting women with facial hair removal would overall make them feel better. 4. Record review of the face sheet and consolidated physician orders, dated 07/24/2022-08/24/2022, indicated Resident #19 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including cerebellar stroke syndrome (a blood vessel is blocked or bleeding, causing complete interruption to a portion of the brain), essential hypertension (force of the blood against the artery walls is too high), and acute kidney failure (condition in which the kidneys suddenly cannot filter waste from the blood). Record review of the quarterly MDS assessment dated [DATE], indicated Resident #19 understood others and made herself understood. The MDS indicated Resident #19 was moderately cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 11. The MDS indicated Resident#19 did not reject care necessary to achieve the resident's goals for health or well-being. The MDS indicated she required extensive assistance with bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS indicated bathing did not occur or family and/or non-facility staff provided care 100% of the time for that activity over the entire 7-day period. Record review of the care plan dated 08/27/2020 indicated, Resident #19 had an impaired physical mobility related to history of stroke. There were interventions that she preferred to take a bath/shower on Monday, Wednesday, and Friday between 6a-2p. The care plan indicated she had a history of stroke and she required assistance with ADLs such as toileting, transfer, bed mobility, eating, and personal hygiene when needed. Record review of skilled nursing point of care compliance sheets dated 08/01/2022-08/24/2022 indicated Resident #19 received all her scheduled showers. During an observation on 08/22/2022 at 2:30 p.m., Resident #19 was observed with white chin hair approximately 0.5 centimeter (cm) in length and white upper lip hair approximately 1.0 centimeter (cm) in length. During an interview and observation on 8/23/2022 at 2:34 p.m., Resident #19 was observed with white chin hair approximately 0.5 centimeter (cm) in length and white upper lip hair approximately 1.0 centimeter (cm) in length. Resident #19 said she was told by an aide last week, but she does not remember her name, that she would come and remove the hair. Resident #19 stated I feel like a man. During an observation on 08/24/2022 at 9:08 a.m., Resident #19 was observed with white chin hair approximately 0.5 centimeter (cm) in length and white upper lip hair approximately 1.0 centimeter (cm) in length. During an interview on 08/24/2022 at 11:21 a.m., CNA G said she was the 6a-2p CNA for Resident #19. CNA G said facial hair removal was performed during showers and as needed. CNA G said Resident #19 would allow the staff assist in facial hair removal, but sometimes it took time to talk her into it. CNA G said Resident #19 was assisted with facial hair removal last Monday (08/15/2022) due to noticeable chin hair. CNA G said it was important to assist women with facial hair removal for their dignity. During an interview and observation on 08/24/2022 at 11:35 a.m., LVN C said facial hair removal should be performed on residents during their showers and as needed. LVN C said Resident #19 would allow the staff assist in facial hair removal, but sometimes it took several attempts. LVN C said it was the charge nurse's responsibility to ensure residents received their showers and assistance with facial hair removal. LVN C went and asked Resident #19 if she would like her facial hair removed and she stated yes. LVN C assisted Resident #19 with facial hair removal. LVN C said it was important to assist women with the removal of facial hair to protect their integrity. During an interview on 8/24/22 at 3:47 p.m., the DON said she expected staff to assist residents with facial hair and nail grooming with showers and as needed. The DON said it was the responsibility of the charge nurse to ensure facial hair and nail grooming was performed or offered. The DON said the department heads checked for facial hair removal and nail care during angel rounds. The DON said the importance of providing facial hair removal to female residents was dignity. The DON said the importance of ensuring fingernails were not jagged was dignity and skin protection. Record review of the facility policy Fingernails/Toenails, Care of, supporting revised February 2018 indicated, The purpose of this procedure was to clean the nail bed, to keep nails trimmed, and prevent infection. Nail care includes daily cleaning and regular trimming .Trimmed and smooth nails prevent the resident from accidently scratching and injuring his or her skin .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 3 of 19 residents reviewed for palatable food. (Residents #35, #45, and #50) The facility failed to provide palatable food served at an appetizing temperature or taste to Residents #35, #45 and #50 who complained the food was served cold and did not taste good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. Findings include: 1. Record review of the face sheet and consolidated physician orders dated 07/24/2022-08/24/2022 indicated Resident #35 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including acute kidney failure (condition in which the kidneys suddenly cannot filter waste from the blood), Alzheimer's (progressive disease that destroys memory and other important mental functions), and essential hypertension (force of the blood against the artery walls is too high). Record review of the admission MDS assessment dated [DATE] indicated Resident #35 understood others and made herself understood. The MDS indicated Resident #35 was cognitively intact with a BIMS (Brief Interview for Mental Status) score of 13. The MDS indicated Resident #35 required a therapeutic diet. Record review of the care plan dated 06/17/2022 indicated Resident #35 was at risk for nutritional status impairment related to diagnosis of obesity, type 2 diabetes (chronic condition that affects the way the body processes blood sugar) and a therapeutic diet as ordered by the MD. There were interventions to determine likes/dislikes and to provide diet as ordered; regular. During an interview on 08/22/2022 at 2:25 p.m., Resident #35 said sometimes the food was overcooked and cold. She said she reported this to staff but could not remember the names. 2. Record review of the face sheet and consolidated physician orders dated 07/24/2022-08/24/2022 indicated Resident #45 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including essential hypertension (force of the blood against the artery walls is too high), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), and GERD (gastro-esophageal reflux disease-) (stomach acid or bile irritates the food pipe lining). Record review of the quarterly MDS assessment dated [DATE] indicated Resident #45 understood others and made herself understood. The MDS indicated Resident #45 was moderately cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 11. The MDS did not indicated what diet was required for Resident #45. Record review of the care plan dated 08/11/2022 indicated Resident #45 had experienced weight loss related to decreased oral intake. There were interventions to offer available substitutes if residents have problems with the food being served, monitor/record weight monthly, and notify the MD and family of significant weight change. During an observation and interview on 8/22/2022 at 11:53 a.m., Resident #45 was eating a bowl of chicken noodle soup. She said she preferred the chicken noodle soup most of the time because the other food did not have enough seasoning. Resident #45 said she reported this to staff but could not remember the names. 3. Record review of the face sheet and consolidated physician orders dated 07/24/2022-08/24/2022 indicated Resident #50 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including urinary tract infection, essential hypertension (force of the blood against the artery walls is too high), and dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of the annual MDS assessment dated [DATE] indicated Resident #50 understood others and made herself understood. The MDS indicated Resident #50 was severely cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 7. The MDS indicated the resident required mechanically altered food. Record review of the care plan dated 08/11/2022 indicated Resident #50 had experienced un-intentional weight loss related to change in condition with decreased oral intake. There were interventions to offer available substitutes if residents have problems with the food being served, monitor need for changing diet consistency to increase ease of eating and assist with meals as needed. During an interview on 08/22/2022 at 2:10 p.m., Resident #50 said the food was cold and did not taste good. She said she reported this to staff but could not remember the names. 4. During an observation and interview on 8/23/22 at 12:44 p.m., a lunch tray was sampled by the Dietary Manager and four surveyors. The sample tray consisted of chef salad, baked potato, and peach cobbler. The baked potato was slightly warm. The chef salad was slightly warm. The peaches in the peach cobbler were tough. The Dietary Manager said the baked potatoes was not hot enough, salad should had been cooler, and the peaches should had been cooked more. During an interview on 08/24/2022 at 11:21 a.m., CNA G said she had heard a lot of food complaints. She said the residents told her the food was cold, overcooked, and not enough seasonings. She said she has taken trays back to the kitchen and requested a new tray for residents. She said she reported all food complaints to the charge nurse and Dietary Manager. She said residents not eating their food could potentially cause weight loss. During an interview on 08/24/2022 at 11:35 a.m., LVN C said she heard a lot of food complaints. She said she had been told the food did not taste good, the food was cold, and I don't like that. She said she has offered the residents an alternative when they complain to her. She said she reported all food complaints to the Dietary Manager. She said residents not eating their food could potentially cause depression, decreased quality of life and weight loss. During an interview on 08/24/2022 at 2:14 p.m., the Dietary Manager said she heard complaints by word of mouth from the residents and staff. She said then she went to the resident to try to solve the problem. The Dietary Manager said she monitored the kitchen/food to ensure it was palatable by sampling test trays four to five times a month. She said in July she sampled a test tray with the Dietician and there were concerns of the carrots not been seasoned. She said it was noticed that the aides were taking too long to pass out trays on the halls which cause the food to be cold. She said she reported it to the DON/ADON, and aides were instructed to pass trays first before assisting residents who required assistance with feeding. She said residents not eating their food could potentially cause weight loss. During an interview on 08/24/2022 at 3:34 p.m., the Administrator said staff should address food complaints by offering alternatives. She said staff should report all complaints to her and the Dietary Manager. She said she was not aware of any food complaints. She said if she had a complaint, a grievance would be filed, and she would follow up with the resident. She said residents not eating their food could potentially cause weight loss. Record review of the facility's policy titled Food and Nutrition Services Staff dated 10/2017 indicated .food will be palatable, attractive, and served in a timely manner at proper temperatures .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure: food items were dated, labeled, and sealed appropriately. expired food item was discarded. the was toaster clean and free of food debris. Damaged cans were stored in a designated area for return to vendor. Chlorine test strips were not expired Refrigerators were free of leaks the juice machine spigot was clean These failures could place residents at risk for foodborne illness. Findings include: During an observation in the refrigerators and freezers on 08/22/2022 starting at 10:15 a.m. revealed 1 opened gallon of ranch was undated; 1 clear container of yellow substance identified by the [NAME] H as chicken noodle soup; 3 tubs of Cowboy barbecue sauce were undated; 1 box of frozen vanilla was undated; and 1 box of orange sherbet ice cream was undated. During an observation in the dry storage room on 08/22/2022 starting at 10:20 a.m. revealed 1 bags of rippled potatoes chips were undated; 1 dented can of mandarin oranges noted on rack; and 2 unopened bags of hot dogs' buns with a thick green substance noted on them. During an observation in the kitchen on 08/22/2022 at 10:25 a.m., revealed food particles observed inside of toaster, a brown gooey substance was observed in the juice machine spigot and the 3-compartment sink chlorine test strips expired on 03/2022. Record review of the daily cleaning schedule dated 08/15/2022-08/21/2022 indicated the juice machine was cleaned one time by Dietary Aide W and the toaster was cleaned twice by [NAME] H. Record review of a dining services and sanitation audit dated 06/22/2022 completed by the Dietician indicated items were undated and there no was signage regarding dented cans during her visit. Record review of an undated in-serviced titled State Readiness Kitchen Expectation indicated all dietary staff attended. During a telephone interview on 08/24/2022 at 1:51 p.m., [NAME] H stated all staff were responsible for labeling and dating food products. She said the cook was responsible for cleaning the toaster daily and the aide aides were responsible for cleaning the juice nozzle daily. She said the last time she cleaned the toaster was last Thursday (08/18/2022). She said the toaster was cleaned after surveyor intervention. She stated the dented cans should be stored in the dry storage room by the dented can signage. She said the bread should have been discarded prior to mold. [NAME] H said these failures could potentially alter the taste of food and cause food borne illness. [NAME] said she was in serviced on kitchen sanitation last month. [NAME] H said she has told the Maintenance Director personally the freezer was leaking. During an interview on 08/24/2022 at 2:05 p.m., Dietary Aide K said all food products should be labeled and dated. Dietary Aide K said all food should be discarded prior to signs of mold. She said all staff were responsible for ensuring this was done. She said the cooks were responsible for cleaning the toaster daily and the aides were responsible for cleaning the juice nozzle daily. She said she cleaned the nozzle last Wednesday (08/17/2022). She said the bread should have been discarded before mold appears. Dietary K said she was in serviced on kitchen sanitation last month. She said these failures could cause food borne illness. Dietary Aide K said she has reported the freezer leak to the Dietary Manager but could not recall when. During an interview on 08/24/2022 at 2:14 p.m., the Dietary Manager said cleanliness was important in the kitchen, so they were not spreading germs or contaminating anything. She said she was responsible for making sure the kitchen was cleaned appropriately. She said all food should have been labeled with date received and the date it was opened. She said when freight was put up, whoever touched the item needs to label and date the item as to when it was opened. She said if it was taken out of the original box then it should be labeled with what it was, the date received, and when they opened it. She said it should be dated so they know the food was not old and know how long it had been opened. She said the aides were responsible for cleaning the juice spigot daily, and the cooks were responsible for cleaning the toaster after each use. She said the dented can should go under the dented cans sign. She indicated she told her staff several times to leave the dry storage room door open to keep air circulating to prevent the bread molding so quickly. She said these failures could cause food borne illness. She said the cooks were responsible for checking the test strips to ensure there not expired. She said test strips should not be expired that way you will know you have the right sanitation level when cleaning. She said she did daily sweeps during the day and address any issues. She said staff were in-service last month of kitchen sanitization and they also must complete a corporate monthly in-service on kitchen sanitation. She stated, I did not do any spot checks this week due to state been in the building. The Dietary Manager said maintenance was responsible for fixing the refrigerator leak. She said she reported to him verbally several times about the leak. She said she thrown out food that did not need to be threw out due to this issue. During an interview on 08/24/2022 at 2:50 p.m., The Maintenance Director said he was responsible for maintaining the equipment in the facility. He said he made rounds throughout the facility weekly to see if anyone has any issues and it had not been reported to him that the refrigerator was leaking. He said he has a maintenance log, but issues were also reported to him verbally. During an interview on 08/24/2022 at 3:34 p.m., the ADM said she expected the kitchen to be cleaned and staff preventing cross contamination. She said she expected all food to be labeled and dated. She said food items should be discarded prior to mold. She said she did not know how often the toaster and juice spigot should be clean, but she would expect at least daily. She said she does weekly rounds with the Maintenance Director and did not notice any issues with the refrigerator. She said these failures could potentially cause a food borne illness. Record review of the facility's policy titled General Kitchen Sanitation dated 2018 indicated . facility recognizes that food-bone illness has the potential to harm elderly and frail residents . will maintain clean, sanitary kitchen facilities in accordance with the state and US Food Codes in order to minimize the risk of infection and food borne illness . clean and sanitize food contact surfaces of equipment and multi-use utensils for preparation of potentially hazardous foods on a continuous or production line basis at scheduled intervals .