**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 5 residents (Resident #19) reviewed for care plans. The facility failed to ensure Resident #19's care plan dated 05/31/2024 reflected the resident's recent left below knee amputation which had been updated/changed on 09/30/2024. This failure could place residents at risk of not receiving appropriate care to meet their current needs. Findings include: Record review of a facility face sheet for Resident #19 dated 11/21/24 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included peripheral vascular disease (also known as peripheral artery disease, is a condition that occurs when blood vessels narrow or become blocked, reducing blood flow to the body) (peripheral vascular disease can affect any blood vessel outside of the heart, but it most commonly affects the legs and feet), atrial fibrillation (irregular, often rapid heart that causes poor blood flow), osteoarthritis (a degenerative joint disease that causes the cartilage and bone in a joint to break down over time), cerebrovascular disease (a general term for conditions that affect the blood vessels in the brain and spinal cord, which can lead to serious complication), and white matter disease (a progressive disorder that occurs when the white matter in the brain is damaged.) Record review of Resident #19's Quarterly MDS assessment dated [DATE], reflected under Section C Cognitive Patterns, a BIMS score of 15 indicating Resident #15 was cognitively intact. Further review of the MDS assessment under Section K - Swallowing/Nutritional Status reflected resident required set-up or clean up assistance with eating, substantial/maximal assistance with toileting and showering, and partial/moderate assistance with personal hygiene. MDS reflected under Section I reflected Resident #19 had active diagnoses of peripheral vascular disease and acquired absence of left foot. Record review of Resident #19's Care Plan initiated 05/31/24 revealed a problem: Impaired physical Mobility r/t loss of balance and coordination Secondary to CVA; Muscle weakness Goal: Resident's needs will be met daily over the next 90 days. Interventions include: assist with mobility as needed daily, encourage ROM exercises as needed, may provide therapy as needed. Problem: Has an ADL self-care performance deficit r/t pain, S/P Fracture, weakness. Resident chooses to sleep in recliner at times. Goal: Will demonstrate the appropriate use of adaptive device to increase ability in ADLS. Interventions include: MOBILITY: Requires moderate assist to ambulate x 1 staff, TRANSFER: Resident requires maximal assistance for all transfers. Record review of physician orders dated 11/08/24 for Resident #19 revealed an order for Float right heel when in bed every shift. In an interview on 11/19/24 at 11:07 AM, Resident #19 stated she was doing fine. She stated she recently had her left leg amputated below her knee. She stated staff took care of everything and all treated her well. She stated she used a call light and staff got to her quickly when she called for them. She stated she participated in therapy and had learned a lot from them. She stated she had no concerns. In an interview on 11/21/24 at 11:30 AM, the MDS stated the purpose of a care plan was to explain what they treated a resident for and informed staff of the residents plan of care. She stated she was responsible for completing and revising care plans. She stated the DON, or a corporate nurse were responsible for ensuring the accuracy of the care plans. She stated she had been trained on completing and revision of care plans. She stated if a resident had an amputation, it should have been included on their care plan and it could have affected the residents ADL's. She stated she was not aware that Resident #19's care plan did not include that Resident #19 had an amputation to her left leg below her knee. She stated Resident #19's amputated left leg below the knee should have been care planned. She stated if an amputation was not care planned it could have affected how the staff knew what to do for the resident or could have affected the care or transfer of a resident. In an interview on 11/21/24 11:40 AM, the DON stated the purpose of a care plan was to have known the plan of care for the residents. She stated the MDS nurse was responsible for completing and revising care plans. She stated they had care plan meetings and revised the care plans as needed and they also had care plan meetings and went over the care plans during the meetings and made changes as needed. She stated the corporate nurse was responsible for ensuring the accuracy of the care plans. She stated the MDS nurse was trained on completing and revision of care plans. She stated if a resident had an amputation, it should be included in the care plan. She stated she was not aware that Resident #19's left below knee amputation was not included in her care plan, but that it should have been in the care plan. She stated if an amputation was not included in a care plan, staff may not know a residents correct status, and it could have affected the safety awareness or transfers. In an interview on 11/21/24 11:55 AM, the ADM stated the purpose of a care plan was to inform nursing staff of how to properly care for the resident. She stated the MDS nurse was responsible for completing and revising the care plans and she had been trained on how to complete and revise the care plans accurately. She stated the IDT reviewed the care plans quarterly and initially the MDS nurse should ensure the care plans were done correctly. She stated any amputation should be care planned. She stated she was not aware that Resident #19's left below knee amputation was not care planned. She stated Resident #19 was one of their long-term residents and she had recently gone out to have the amputation done and then to a rehabilitation hospital. She stated Resident #19's amputation should have been care planned upon her re-admission. She stated if an amputation was not care planned it may have caused confusion for the staff and if the care plan had been done, it could have provided more direction for resident positioning. Record review of the facility policy titled Comprehensive Care Plans dated 04/14/24 reflected the following documentation: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Policy Explanation and Compliance Guidelines: 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally competent and trauma informed. 2. The comprehensive care plan will be developed along with the comprehensive MDS assessment. All Care Assessment Areas (CAAs) triggered by the MDS will be considered in developing the plan of care. Other factors identified by the interdisciplinary team, or in accordance with the resident's preferences, will also be addressed in the plan of care. The facility's rationale for deciding whether to proceed with care planning will be evidenced in the clinical record. 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. d. The resident's goals for admission, desired outcomes, and preferences for future discharge. f. Resident specific interventions that reflect the resident's needs and preferences and align with the resident's cultural identity, as indicated. If the resident is non-English speaking, the facility will identify how communication will occur with the resident. The care plan will identify the language spoken and tools used to communicate. g. Individualized interventions for trauma survivors that recognizes the interrelation between trauma and symptoms of trauma, as indicated. Trigger-specific interventions will be used to identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. 7. The physician, other practitioner, or professional will inform the resident and/or resident representative of the risks and benefits of proposed care, of treatment, and treatment alternatives/options. The facility will attempt alternate methods for refusal of treatment and services and document such attempts in the clinical record, including discussions with the resident and/or resident representative. 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to immediately report allegations that involved abuse, neglect, exploitation or mistreatment, including injuries of unknown source or misappropriation of resident property to HHSC, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse, or result in serious bodily injury for one of five residents (Resident #1) reviewed for injury of unknown origin. The facility failed to report to HHSC, an unwitnessed fall that resulted in major injuries. Resident #1 sustained two fractures, one to her right hip (Pelvis CT shows proximal right femoral fracture with moderate displacement) and one to her right wrist (X-Ray shows right distal radius and ulnar fracture). Resident #1 was unable to provide details of how she fell. This failure placed residents at risk of not having abuse or neglect reported promptly to HHSC and being subjected to further abuse or neglect. Findings included: Review of the undated face sheet for Resident #1 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia (loss of thinking, remembering, and reasoning skills), other frontotemporal neurocognitive disorder (damage to neurons in the frontal and temporal lobes of the brain), cognitive communication deficit (difficulty with thinking and how someone uses language), and muscle weakness. Review of the Annual MDS for Resident #1 dated 01/24/2024 reflected a BIMS score of 4, which indicated a severe cognitive impairment. In Section GG - Functional Abilities and Goals reflected Resident #1 ambulated independently and had no limitation in range of motion. In Section I - Active Diagnoses reflected Resident #1 was diagnosed with Non-Alzheimer's Dementia. Review of the undated care plan for Resident #1 reflected the following: The Resident is an elopement risk/wanderer related to impaired safety awareness, Resident wanders aimlessly, Resident sleeps in others rooms/beds due to cognitive impairment. The Resident's safety will be maintained through the review date. Redirect resident when found in others' rooms/beds. The resident is at risk for falls related to confusion, wandering - actual falls: 6/4/23, 6/13/23, 8/10/23, 11/28/23, 12/1/23, 1/12/24 and 2/4/24. The resident will be free of falls through the review date. The resident will be free of minor injury through the review date. The resident will not sustain serious injury through the review date. Educate the resident about safety reminders and what to do if a fall occurs. Review of a Fall Risk Evaluation dated 02/04/2024 for Resident #1 reflected the total number of falls within the last 3 months were 1 or 2 times. Under Memory and Recall Ability it reflected in the last 7 days, Resident #1 never recalled three out of four of the following: current season, he/she is in a nursing home, location of room, staff names/faces. Under Gait, it revealed, Resident #1 gait was normal. Under Mobility, it revealed Resident #1 had no limitations. Review of an un-witnessed fall incident report for Resident #1 dated 02/04/24 at 05:40 PM completed by LVN A reflected, This nurse entered Resident's room with meal tray and noted Resident laying on her right side in her roommate's bed. Attempted to assist Resident to upright position in bed, ineffective. Requested assistance from CNA staff. Upon standing, Resident immediately called out related to right hip and leg pain as well as right arm pain. Upon questioning Resident regarding pain Resident stated, I accidentally fell and hurt myself. Resident was unable to describe how fell happened. Her level of Pain was 9. Review of the progress notes for Resident #1 dated 02/04/2024 at 05:53 PM written by LVN A reflected, This nurse entered Resident's room with evening meal tray. Noted Resident laying on side in roommate's bed, shoes on floor beside bed. Attempted to help Resident sit up for mealtime. Resident unable to stand with assistance x1. Help requested from CNA staff with transfer. Upon attempted standing Resident, she called out right leg and hip pain. Resident also stated, my arm hurts too, regarding right arm. Upon questioning about what caused pain, Resident stated, I accidentally fell and hurt myself. Vitals were taken and within normal limits. Resident assisted to lying position in bed. Medical Director notified for emergency room transport due to pain and symptoms. EMS personnel arrived at the facility and Resident transported to NRH emergency room for evaluation and treatment. Review of the progress notes for Resident #1 dated 02/12/2024 at 06:36 PM written by LVN B reflected, Resident returned to facility via ambulance. Resident was diagnosed with right hip fracture and right wrist fracture. Resident had a wound vac to her right hip and a sling placed on her right wrist. Resident denies pain. Resident presented to facility with blisters and bruising to right thigh. Review of the hospital paperwork dated 02/04/2024 at 11:58 PM under Physical Summary for Resident #1 revealed, [AGE] year-old female, with advanced dementia, apparently had a fall at the nursing home on her right side. In the ER, she was noted to have both a femoral neck fracture as well as a wrist fracture on the right, currently splinted. Patient is unable to give any history secondary to dementia. The Imaging Results revealed, Pelvis CT shows proximal right femoral fracture and Wrist X-Ray shows right distal radius and ulnar fracture. During an attempted interview on 02/21/2024 at 12:45 PM with Resident #1, she was unable to explain how she sustained the multiple fractures. During an interview on 2/21/2024 at 3:20 PM with LVN A, she stated she went to assist with the trays and realized Resident #1 was not in the dining room. LVN A stated she took Resident #1's tray to her room and when she opened the door, Resident #1 was laying in her roommate's bed on her right side. LVN A stated she went to assist Resident #1 up because she was not getting up on her own. LVN A stated she realized Resident #1 was not sitting up as she normally does. LVN A stated she and CNA A attempted to sit Resident #1 up in bed and when they tried to stand her up, Resident #1 said her right leg and wrist hurt. LVN A stated there was swelling around Resident #1's wrist. LVN A stated Resident #1 was making vocal complaints of pain and they assisted her to lay back down. LVN A stated Resident #1 said she fell and hurt herself but could not tell her what happened or how she fell. LVN A stated she took Resident #1's vital signs and assessed her pain level. LVN A stated she notified everyone and called for transport to the Emergency Room. LVN A stated when the emergency personnel questioned Resident #1, she started talking about her grandmother which was not relevant to the questioning. LVN A stated the incident started around 5PM and she left work at 6PM and found out about the fracture when she returned to work the next morning. LVN A stated per policy, they must complete an Unwitnessed Fall Incident Report and complete notifications. LVN A stated they continue to treat any injuries or send the Resident out for further evaluation if necessary. LVN A stated by this incident not being reported to the State, there could possibly be things not being followed through or handled appropriately. LVN A stated she knows this is the purpose of reporting things to the State. LVN A stated she has never been in a situation where incidents were not reported to the State. During an interview on 02/16/2024 at 03:50 PM, CNA A stated she saw LVN A in Resident #1's room and asked if she needed help. CNA A stated LVN A said yes because she was having a hard time standing Resident #1 up. CNA A stated they both took an arm to assist Resident #1 up and Resident #1 yelled out it hurts. CNA A stated Resident #1 pointed to her right side. CNA A stated LVN A asked Resident #1 what happened, and Resident #1 said she fell. CNA A stated they repositioned Resident #1 into the bed she was already sitting. CNA A stated then LVN A sent Resident #1 out to the hospital for further evaluation. During an interview on 02/16/2024 at 04:20 PM, the DON stated she was informed by LVN A that Resident #1 told her she fell and when LVN A tried to help Resident #1 up, she could not stand, so she sent her out. The DON stated LVN A told her Resident #1 said, I did not tell anyone, but I fell and hurt myself earlier today. The DON stated she interviewed the CNAs, and no one saw or heard Resident #1 fall. The DON stated Resident #1 did not have any bruising or bleeding. The DON stated they follow the guidelines and depending on the severity and the scope, if the resident was not able to give an account, or it is an area of suspicion, it needs to be reported to the State. The DON stated everything is reported to the ADM, they complete an internal investigation, and all major injuries of a suspicious nature need to be reported to the State. During an interview on 02/16/2024 at 05:45 PM, the ADON stated in the group text she was informed Resident #1 informed LVN A she fell and due to her crying out in pain, LVN A sent Resident #1 out to the hospital for further evaluation. The ADON stated they later learned Resident #1 had sustained a fractured right hip and a fractured right wrist. The ADON stated the alleged fall was unwitnessed. The ADON stated when a Resident experiences an unwitnessed fall, you assess them and call EMS if necessary. The ADON stated a report should have been called into the Stated due to the fall being unwitnessed with major injuries and the resident not being able to say exactly what happened. During an interview on 02/16/2024 at 06:10 PM, the ADM stated at the time of the incident, Resident #1 was found laying on her right arm crooked in her roommate's bed. The ADM stated Resident #1 ambulates independently. The ADM stated LVN A reported she tried to get Resident #1 up for dinner and walk her over to her own bed. The ADM stated when LVN A and CNA A attempted to stand Resident #1 up, Resident #1 responded, Ow ow, I had an accident and fell. The ADM stated LVN A called the DON and herself to inform them Resident #1 was being sent out. The ADM stated the family member texted her on 02/4/2024 at 10:37 PM and informed her Resident #1's wrist and hip was broken. The ADM stated she did not report it as an unwitnessed fall with injury due to it not being suspicious. The ADM stated Resident #1 told LVN A she fell. The ADM stated there was no allegation of abuse or neglect. The ADM stated she conducted an internal investigation and discovered there was no foul play and the resident fell. The ADM stated she did not report the injury to the State because she did not deem it suspicious. Review of facility policy titled, Abuse Prohibition Guideline 2023 reflected the following: Injuries of Unknown Source: An injury should be classified as an injury of unknown source when both of the following conditions are met: 1. The source of the injury was not observed by any person, or the source of the injury could not be explained by the resident; and 2. The injury is suspicious because of the extent of the injury or the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of injuries over time. Investigations The Health Care Center will thoroughly investigate all alleged violations/allegations and take appropriate actions. No later than 2 hours if the allegation involves abuse or results in serious bodily injury, and no later than 24 hours if the allegation does not involve abuse and does not result in serious bodily injury. Reporting 4. The Health Care Center will report allegations to the state agency in accordance with state law. (Note timeframe requirement)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure residents had the right to be free from exploitation and misappropriation of property for 1 of 8 residents (Resident #2) who were reviewed for misappropriation of resident property. The facility failed to protect RES #2 from CNA A stealing two items of personal jewelry on 11/20/2023 at 9:50 PM. This failure placed residents at risk for loss of possessions and the feeling of loss. Findings include: Record review of RES #2's AR indicated RES #2 was a [AGE] year-old-male who was admitted to the facility on [DATE]. RES #2 was diagnosed with Dementia, which was an impaired ability to remember, think, or make decisions that interfere with doing everyday activities. Record Review of RES #2's Quarterly MDS assessment, dated 10/24/2023, indicated RES #2 had a BIMS Score of 2. A BIMS Score of 2 indicated RES #2 had severe cognitive impairment. Record review of RES #2's CP indicated a Focus Area, initiated on 11/20/2023, which pertained to keeping valuable personal belongings in a lockbox or with family. The Goal, with a target date of 12/13/2023, was to keep valuable belongings in a lockbox, or with family members. Record review of RES #1' AR indicated RES #1 was an [AGE] year-old woman who was admitted to the facility on [DATE]. RES #1 was diagnosed with Unspecified Degeneration of Eyes. Record review of RES #1's Quarterly MDS assessment, dated 11/30/2023, indicated RES #1 had a BIMS Score of 15. A BIMS Score of 15 indicated RES #1 had intact cognition. Interview on 12/7/2023 at 10:30 AM with RES #1 revealed CNA A was in her, and RES #2's, room on the night of 11/20/2023 at 9:50 PM. CNA A was looking at RES #1's jewelry and took RES #1's rings and bracelet off her hand and wrist. CNA A was looking at the jewelry under a lamp when RES #1 demanded CNA A return her jewelry. CNA A returned RES #1's jewelry and asked RES #1 where RES #2's rings were. RES #1 told CNA A the rings were on RES #2's fingers. CNA A stopped talking to RES #1 and approached RES #2 in the hallway, just outside of RES #1 and RES #2's room. RES # 1 stated CNA A spoke to RES #2 and offered to take and clean RES #2's rings. CNA A took two rings off RES #2's fingers and proceeded to leave the facility. RES #1 stated she felt odd about the situation, reported the matter to staff, and called the police. The police responded, investigated, and recovered RES #2's rings at a pawn shop. RES #2's rings were returned on 11/27/2023. Interview on observation on 12/7/2023 at 10:35 AM with RES #2 revealed he stated he was disappointed in himself and wished he had been able to respond differently and tell CNA A she could not take his rings. RES #2 thought he could trust CNA A because she was an employee; furthermore, he did not think someone who worked at the facility would commit such an act. RES # 2 felt like he lost some ability to trust people. RES #2 was observed wearing his rings at the time of the interview. Record review of the Facility's PIR for Misappropriation of Property, dated 11/27/2023, indicated CNA A, an employee with a TA, exploited RES #2 on 11/20/2023 at 9:50 PM when she stole two gold rings. CNA A approached RES # 2 in the hallway, outside of his room, and told RES # 2 she would take 2 of his rings and have them cleaned. RES #2 handed over his jewelry, which he was wearing, and gave them to CNA A. CNA A left the facility with RES #2's property and did not return the jewelry. The PIR indicated CNA A did not respond to phone call attempts from the facility administration. Interview on 12/7/2023 at 9:05 AM with DET revealed she was the investigating officer to the report of misappropriation of property at the facility on 11/20/2023. DET stated the case was still open, but that the police department was able to track down CNA A to a local pawn shop. The DET stated CNA A was recorded on video having entered the pawn shop and sold RES #2's rings. The property was returned to RES #2 on 11/27/2023. A warrant for CNA A's arrest was initiated. Record review of CNA B written statement, undated, described she learned of the incident between CNA A and RES #2 right after it happened on 11/20/2023. CNA B walked to the parking lot and confronted CNA A about RES #2's rings and asked CNA A to come back inside to speak with the charge nurse. CNA A stated she would come back inside but did not return. It was reported that CNA A left the parking lot in her vehicle. Interview on 12/7/2023 at 2:10 PM with the [NAME] revealed the TA contracted with members of the medical field and provided them with a platform to pick up shifts from local agencies. The [NAME] stated each employee was considered a private contractor that each had to pass background checks and possess a current license in their field to be eligible for the platform. On the date of the interview, the [NAME] stated he had already removed CNA A from the TA platform, based on what he learned about CNA A having misappropriated property from RES #2 on 11/20/2023. Interview on 12/7/2023 at 2: 23 PM with the DON reflected the facility was responsible for the resident's welfare and it was the facility's responsibility to protect RES #1 and RES #2. The DON stated that the facility performed background checks before hiring an employee. Interview on 12/7/2023 at 12:45 PM with CNA B revealed she was an employee with the TA. CNA B stated the TA required drug tests, background checks, and a current license to pick up shifts on the platform. CNA B stated that TA employees do not always get to participate in regular employee trainings at the facility, but she knows to report misappropriation of property to the charge nurse and the ADM. Interview on 12/7/2023 at 3:05 PM with RN A revealed all staff must go through a background check before hired and must pass yearly employee misconduct checks. RN A stated that criminal background checks only worked if an employee had a documented criminal history, and the facility could not tell what an employee might do. RN A stated that the facility trained its employees to recognize suspicious employee behavior and report misappropriation of a resident's property to the charge nurse and the ADM immediately. Interview on 12/7/2023 at 3:10 PM with HK A revealed the facility trained housekeeping staff to respect resident's property and it was never ok to take something from a resident. HK A stated any incidents of misappropriation of property were reported to her supervisor immediately. Interview on 12/7/2023 at 3:30 PM with LVN B revealed she was trained on Misappropriation of Property as a part of facility training. Most recently, an in-service was given for Resident Rights. LVN B stated she would report suspicious behavior of an employee and misappropriation of property to the ADM. Interview on 12/7/2023 at 4:30 PM with the facility SW revealed she spoke with RES #1 and RES #2 on 11/21/2023, the morning after the incident on 11/20/2023. The SW stated that RES #1 and RES #2 were pleased with how the facility was overseeing the incident with CNA A and RES #2. The SW described RES #1 and RES #2's mood as a little sad and stated RES #1 and RES #2 were a resilient couple and did not let things get them down. Interview on 12/7/23 at 5:00 PM with the ADM revealed CNA A's first day as a TA employee at the facility was on 11/20/2023, which was the same day of the incident of Misappropriation of Property. CNA A's last date of eligibility for employment was on 11/20/2023 and CNA A has not been allowed to return to the facility. The ADM felt she did everything she could do to get RES #2's jewelry back. She stated she spoke to the police, provided pictures of the rings to the police, and kept RES #1 and RES #2 informed every step of the way. The ADM called the TA, with which CNA A contracted, and told the [NAME] what occurred. She stated the [NAME] decided to remove CNA A from the platform. The ADM stated she spent at least 30 minutes a day with RES # 1 and RES #2 since the incident on 11/20/2023 and did not notice any decline, changes in behaviors, or deviation from normal routine. The ADM stated the facility policy for valuable items was covered in Abuse Prohibition Guideline and RES #2 was counseled on wearing expensive jewelry and encouraged to keep expensive jewelry locked up or sent home with family. Record review of RES #2's PN from a clinical counseling service performed by PSY D, dated 11/27/2023, reflected a counseling session, where RES #1 and RES #2 shared grief regarding an incident, which resulted in the loss of the resident's jewelry. Support was provided and both residents stated they felt confident and appreciated how the administration oversaw the situation. Both residents reported they enjoyed living at the facility and felt safe. Record review of the facility Abuse Prohibition Guideline in-services, dated 2023, reflected Misappropriation of Property includes but is not limited to the deliberate misplacement, exploitation, or wrongful temporary or permanent use of your residents' belongings or money without the resident's consent. The Abuse Prohibition Guideline identified procedures for prevention of misappropriation of resident's property by (1) upon admission, the health care center will assist the resident and resident family to identify and mark personal possessions; and (8) the healthcare center will educate the family and residents on risks associated with keeping valuable items and options for safe keeping, such as taking them home or storing them in a lockbox.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 3 of 23 residents (Resident #73, Resident #25, and Resident #51) reviewed for resident rights; in that: The facility failed to ensure Resident #73, Resident #25, and Resident #51 call lights were within reach. This failure could place residents at risk of needs not being met. Findings included: Resident #73 Record review of Resident #73's admission record, dated 09/27/23, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #73 had diagnoses which included: dementia (general decline in cognitive abilities), muscle wasting and atrophy (wasting [thinning] or loss of muscle), gross hematuria (visible blood in urine), need for assist with personal care, and acute myocardial infarction (heart attack). Record review of Resident #73's quarterly MDS assessment, dated 08/15/23, reflected Resident #73 had a BIMS score of 02, which indicated the resident was cognitively impaired. The resident required extensive assistance in various areas of activities of daily living such as bed mobility, transfer, toilet use. Resident #73 required limited assist for locomotion on unit, dressing, eating, and personal hygiene. Record review of Resident #73's care plan, initiated 05/24/23 and revised 07/07/23, reflected Resident #73 was care planned for has an ADL self-care performance deficit r/t Confusion, Dementia, Impaired balance with a goal of [Resident #73] will demonstrate the appropriate use of adaptive device(s) to increase ability through the review date. and had an intervention of be sure [Resident #73's] Encourage the resident to use bell to call for assistance. In an observation on 09/25/23 at 1:30 PM, observed Resident #73's call light out of reach. Resident #73's call light was sitting on a recliner behind where Resident #73 was sitting in a wheelchair. Resident #73 attempted to stand and get the call light but was unable to reach call light. In an interview on 09/25/23 at 1:32 PM, Resident #73 stated he used a call light to call for help when he needed it. Resident #73 stated he could get up and get the call light if he needed to. Resident #25 Record review of Resident #25's admission record, dated 07/27/23, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #25 had diagnoses which included: type 2 diabetes mellitus (a chronic condition that affects the way the body processes the blood sugar), muscle wasting and atrophy (wasting [thinning] or loss of muscle), history of falling, need for assistance with personal care, and dysphagia (difficulty swallowing). Record review of Resident #25's quarterly MDS assessment, dated 09/07/23, reflected the resident had a BIMS score of 02, which indicated the resident was cognitively impaired. The resident required extensive assistance for dressing and supervision in various areas of activities of daily living such as bed mobility, transfer, locomotion on and off unit, eating, toilet use, and personal hygiene. Record review of Resident #25's care plan, initiated 02/21/20 and revised 09/24/23, reflected Resident #25 was care planned for at risk for falls r/t confusion, gait/balance problems, poor communication/comprehension, psychoactive drug use, unaware of safety needs, vision/hearing problems with a goal of [Resident #25] will be free of falls through the review date and had an intervention of be sure [Resident #25's] call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. In an observation on 09/26/23 at 11:59 AM, observed Resident #25's call light not in reach and on the floor beside his bed. In an interview on 09/26/23 at 12:01 PM, Resident #25 stated the staff come quick when needed. Resident #51 Record review of Resident #51's admission record, dated 09/26/23, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #51 had diagnoses which included: type 2 diabetes mellitus (a chronic condition that affects the way the body processes the blood sugar), dementia (general decline in cognitive abilities), muscle wasting and atrophy (wasting [thinning] or loss of muscle), need for assistance with personal care, cognitive communication deficit (difficulty thinking and using language) Record review of Resident #51's Annual MDS assessment, dated 07/21/23, reflected Resident # 51 required extensive assistance for dressing and supervision in various areas of activities of daily living such as bed mobility, transfer, locomotion on and off unit, eating, toilet use, and personal hygiene. Record review of Resident #51's care plan, initiated 02/21/20 and revised 09/24/23, reflected Resident #51 was care planned for at risk for falls r/t confusion, gait and balance problems, unaware of safety needs, wandering, Dementia with a goal of [Resident #51] will be free of falls through the review date and had an intervention of be sure [Resident #51's] call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance. In an observation 9/25/23 1:41PM Resident #51 was lying in bed sleeping with call light on floor rolled up next to head of the bed on the floor. In an observation 09/26/23 10:22 AM Resident #51 observed resident lying in bed, call light remains rolled up next to the head of the bed on the floor In an interview on 09/27/23 10:34 AM with Resident #51 she stated I do not know how to call for help if needed. Resident #51 appeared confused. In an Interview on 09/27/23 10:47 AM CNA B stated call lights needed to be within reach in case the resident's needed assistance. Everyone that works should have made sure the call light was within reach of the resident. Staff were educated to keep them within reach. Risk to the resident for not having call light in reach is the resident would not be able to get help if needed. In an interview on 09/27/23 10:38 AM LVN A stated call lights should be attached to beds and within reach for safety. Staff are educated on keeping the call lights within reach in the form of reminders and in-services from DON and ADON. The Certified Nurse's Aides were responsible for making sure the call lights are attached. The risk to the resident for not having access to their call light is the inability to obtain staff assistance when needed. In an interview on 09/27/23 11:41AM with DON stated all residents should have had access to a call light while in bed. All staff are responsible and should have placed call lights within reach of the residents . In an interview on 09/27/23 at 10:38 AM, the ADM stated the purpose of a residents call light was for residents to notify staff that they needed assistance. He stated if a residents call light was out of reach and the resident needed help, the time could be extended for staff to provide assistance to residents. He stated staff should have made sure residents call lights were in reach when they did their rounds because residents could knock it off the bed or something. He stated they did angel rounds every morning and they checked for the call lights being in reach. The ADM stated the staff has not been in-serviced since he had been there, and they had not had the need to in-service staff because there had been no issues with call lights. Record review of the facility's Answering the Call Light policy dated 10/2010 revealed General Guidelines bullet #5 When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #26) of 8 residents reviewed for reasonable accommodations. The facility failed to ensure Residents #26 received a shower chair for his personal bathroom after the shower bench in his shower broke. This failure could place residents at risk of injuries, health complications and decreased quality of life. Findings included: Review of Resident #26's face sheet dated 08/10/2022 revealed Resident #26 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of epilepsy (seizure disorder), chronic obstructive pulmonary disease (lung disorder that makes breathing difficult), high blood pressure, alcohol dependence disorder and alcoholic polyneuropathy (nerve damage from alcohol abuse that causes pain in the extremities). Review of Resident #26's annual MDS assessment dated [DATE] revealed Resident #26 had a BIMS score of 15 to indicate intact cognition. Resident #26 required supervision and one person assistance with ADL's including physical help, in part, with bathing. Review of Resident #26's care plan dated 05/10/2021 revealed Resident #26 required assistance by one staff member for bathing and showering. In an interview on 08/10/2022 at 8:30 AM, Resident #26 stated he had not showered in almost two weeks because the shower bench in his shower broke while he was sitting on it. He said the facility had not provided him with a shower chair since the bench broke and he was unable to safely take a shower without a shower chair. He said the bench broke because the hardware had corroded, and it snapped off the wall. He said when the bench broke, he fell and had a bruise and skin tear on his left arm. He said the maintenance man told him they would either replace the shower bench or he would have a shower chair for showers. Review of Resident #26's progress notes dated 08/01/2022 - 08/10/2022 did not reveal a progress note regarding the broken bench or skin tear. Review of Resident #26's electronic medical record dated 08/01/2022 - 08/10/2022 did not reveal an incident report for the broken bench or skin tear. Review of Resident #26's shower records dated 07/29/2022 - 08/09/2022 revealed Resident #26 did not shower during this time period An observation on 08/10/2022 at 8:40 AM revealed Resident #26 did not have a shower chair or shower bench in his shower. Resident #26 had a bandage on his left upper arm. In an interview on 08/10/2022 at 8:45 AM MAINT DIR said Resident #26's shower bench broke and they had not replaced it with anything because Resident #26 would not sit on shower chair that had a toilet seat that had been previously used by another resident. He said he removed the broken shower bench and the facility would not be replacing it because finding a replacement to fit the hardware in the shower wall would be costly and difficult. He said he thought a family member of Resident #26 was bringing a shower chair from his home but did not know when or if his family member had brought the shower chair to the facility. He said he was looking at ordering a different shower chair for Resident #26 but had not ordered one. In an interview on 08/10/2022 at 10:41 AM, the DON knew of Resident #26's shower bench breaking last week and thought a family member was bringing him a shower chair from home. She said she was not sure of the exact date of when it broke or how long the resident had been without a shower. She said she would have to check to see if the family member was able to bring the shower chair to the facility. In an interview on 08/10/2022 at 1:28 PM, RN C stated one of the nurse aides, CNA D, told her Resident #26's shower bench broke. She said she went to check on Resident #26 and he reported to her the bench broke. She said he did not report he fell when the bench broke. She treated a skin tear on his arm and thought he had it from hitting arm on wall or toilet when the bench broke. She said Resident #26 was not taking a shower when the bench broke. Resident #26 was sitting on the bench looking at an issue with his toilet. She said Resident #26 did not request a shower chair from her and thought maintenance was taking care of a new shower chair or bench. She said other residents who did not have a shower bench in their shower used a shower chair, and the facility provided the shower chair to them. In an interview on 08/10/2022 at 1:37 PM, CNA D stated Resident #26 called her into his bathroom because his shower bench broke, and he had skin tear to his arm. She said he made a mess in his bathroom when he was looking at something on the toilet and sat on the shower bench to look at it. She was not aware Resident #26 fell when the bench broke. She said she immediately reported the broken bench and skin tear to RN C. RN C reported the broken bench to the MAINT DIR . Resident #26 did not ask her for a shower chair, and one had not been brought to him. She said for other residents without a shower bench, they have a shower chair that wheels in and out of the shower in their bathroom. In a follow-up interview and observation on 08/10/2022 at 2:45 PM, Resident #26 said they brought a shower chair in today. Shower chair observed in his shower. He wanted the bench back but MAINT DIR said they would not be replacing it. He was not aware of a discussion in which his family member was going to bring a shower chair from home for him. In a follow-up interview on 08/11/2022 at 11:21 AM, the ADMIN stated Resident #26 should have had a shower within the next day after the bench broke on 08/01/2022. She said facility staff should have followed up with the family member regarding a shower chair from home and provided Resident #26 with a shower chair if the one from home was not brought. Review of the facility's policy Equipment - General Use for All Residents (undated) revealed our facility should provide routine equipment for the general use of the resident population.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to conduct an accurate comprehensive assessment of each resident's functional capacity for 2 of 16 residents reviewed for MDS accuracy (Resident #4 and Resident # 219). 1. The facility failed to ensure Resident # 4's annual assessment was completed. 2. The facility failed to ensure Resident #219's admission assessment was completed by the 14th day of admission. These failures placed residents not receiving the proper care required to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Findings included: Review of Resident's # 4's Face Sheet, dated 08/11/2022, reflected an [AGE] year-old female admitted to the facility on [DATE] with a diagnoses cardiac pacemaker ( an electronic device that is implanted in the body to monitor heart rate and rhythm), chronic diastolic heart failure ( a condition in which your heart's main pumping chamber becomes still and unable to fill properly), cholecystitis, unspecified (when gallstones block this tube, bile builds up in your gall bladder), thyrotoxicosis without thyrotoxic crisis or storm ( have too much thyroid hormone in your body), muscle weakness - generalized ( when your full effort doesn't produce a normal muscle contraction or movement), need for assistance with personal care ( nursing staff assistance), morbid obesity ( if their weight was more than 80 to 100 pounds above their ideal body weight), age-related cataract, morgagnian type, bilateral ( a type of hypermature cataract in which the nucleus sings within the fluid cortex) and muscle wasting and atrophy, not elsewhere classified ( decrease in size and wasting of muscle tissue. Muscles that lose their nerve supply can atrophy and simply waste away). Review of Resident #4's MDS assessments dates reflected the last MDS completed was a Quarterly MDS on 04/06/2022. Her Annual MDS was due in July 2022. Her last annual assessment was completed on 07/26/2021 Her Annual MDS was approximately 417 days late. Review of Resident #219's face sheet dated 08/11/2022 revealed Resident #219 was a [AGE] year-old male admitted to the facility on [DATE] with a diagnoses of cancer, post-surgical recovery from neck and spinal surgery, high blood pressure and sepsis . Review of Resident #219's electronic medical record as of 08/10/2022 revealed Resident #219 did not have a completed admission MDS Assessment. In an interview on 08/11/2022 at 10:23 AM the MDS NURSE stated she had been on leave beginning 07/20/2022 and would need to refer to her calendar of the exact date she returned to work. She stated the corporate MDS nurse was to assist with MDS' assessments when the MDS nurse was not working for a long period of time. She stated the admission MDS Assessment for Resident #219 would have been due to be completed and exported by 08/02/2022, 14 days after his admission. She stated it was not completed by the due date. In an interview on 08/11/2022 at 11:27 AM, the ADMIN stated the MDS assessments should have been completed within the required time frames, and due to the MDS NURSE being out on leave, they were not completed. She stated the facility had a back-up plan for the corporate MDS nurse to complete MDS assessments if the facility's MDS NURSE was out, but the corporate MDS nurse was out on vacation as well. The ADMIN did not answer the question of the potential consequences if the MDS assessments were not completed within the required time frames. Review of the RAI manua,l dated October 2019, reflected admission assessments are completed no later than the 14th calendar day of the resident's admission. Annual assessments were to be completed within 366 calendar days of previous annual assessment and within 92 days of previous quarterly assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess each residents quarterly (every 3 months) using the Minimum Date Set form specified by the state and approved by CMS for 2 of 20 residents (Resident #3, Resident #34 ) reviewed for assessments. The facility failed to ensure Residents #3's and #34's MDS assessments were completed quarterly. This failure could place residents at risk of not receiving necessary care or receiving inappropriate care for their conditions. Findings included: Review of Resident #3's Face sheet dated 08/11/2022 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: Type 2 Diabetes Mellitus (a condition results from insufficient production of insulin, causing high blood sugar), and Hypertension (high blood pressure). Review of Resident #3's last completed Quarterly assessment dated [DATE] reflected a BIMS score was not conducted indicating she had severe cognitive impairment. Resident #3 was further assessed to require extensive assistance with ADLs. Review of Resident #3's EMR on 08/11/2022 reflected Resident #3's quarterly assessment was due on 07/05/2022 and was 22 days overdue. Review of Resident #34's Face Sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including: Unspecified Dementia (without behavioral disturbance), Schizophrenia (unspecified), and Vascular Dementia (without behavior disturbance). Review of Resident #34's Quarterly MDS Assessment, dated 4/6/2022, reflected a BIMS of 12, indicating she is capable of being interviewed and providing input regarding her care. Review of Resident #34's MDS Assessment (ARD (Q4)) reflected it was started on 7/5/2022. It has not been completed and is now 21 days overdue. On the last day of the Survey, the MDS Assessment is still showing In Progress. In an interview on 08/11/2022 at 10:39 AM, the MDS Coordinator stated that Resident #3 and #34's MDS Assessments were overdue. The MDS Coordinator stated she was out sick starting on 07/20/2022 and had been in and out of the facility the month of August due to health issues. She stated the care plan is always there, and they have access to it, regardless if the MDS is late or not. The MDS Coordinator stated she knew the MDS's were late, and she is working on getting them completed. She further stated it is the IDT Team and her responsibility to ensure the Assessments are completed timely. She is not sure why the Corporate office did not assist in completing the Assessments, but they are working on the issue now. In an interview on 08/11/2022 at 11:22 AM with the Administrator regarding Care Plans and MDS Assessments, she stated the MDS Coordinator had a medical emergency that prevented her from coming to work. They had someone from the corporate office that assists, but they are still playing catch up. The Administrator stated she was able to provide the MDS Coordinator a laptop for a few days, unfortunately, they are still not caught up. In an interview on 8/11/22 at 11:45 AM, the DON stated she expected the resident's MDS assessments to be timely and further stated the consequences of care plans and MDS Assessments not being completed timely was that staff could miss something crucial that was going on with the residents' health. The DON stated the facility did not have a policy regarding MDS completion timelines. She stated the facility used the RAI manual. Review of the RAI manual dated October 2019 reflected quarterly assessments are completed by calculating from the ARD (assessment reference date) of the previous assessment plus 92 calendar days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to use the results of an assessment to develop, review and revise a comprehensive care plan of each resident that included measurable objectives and timetables to meet a resident's medical and nursing needs for two of eight residents reviewed for care plans (Resident's # 37 and # 45). 1. The facility failed to ensure Resident #37's care plan accurately reflected her diabetic status. 2. The facility failed to ensure Resident #45's care plan was updated and revised after completion of annual MDS assessment on 06/27/2022. The following was not reviewed/ revised and/ or added to the care plan: cognitive patterns, mood, behaviors, preferences for customary routine and activities, ADL status, active diagnosis, health conditions, skin conditions, special treatment, urinary incontinence, falls, dehydration/ fluid maintenance, pain and new diagnosis of UTI. These failures could place residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in injury, a decline in physical, mental, quality of life and/ or psychosocial well-being. Findings included: Review of Resident #37's Face Sheet, dated 08/10/2022, reflected an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of type 2 diabetes mellitus without complications (a disease that prevents someone from properly regulating their blood glucose levels). Review of Resident #37's Quarterly MDS assessment, dated 06/16/2022, reflected resident had a BIMS score of 15 indicating her cognition was intact. Resident required assistance with ADL's. Review of Resident #37's Comprehensive Care Plan dated 07/19/2022 reflected Review of Resident #37's Diagnosis Report dated 08/10/2022 reflected resident had diagnosis of type 2 diabetes mellitus without complications onset was 08/01/2022. Review of Resident #37's Physician Orders dated 08/01/2022 thru 08/05/2022 reflected resident began Humalog solution 100 unit/ml (insulin Lispro) start date on 08/01/2022, Metformin HCl tablet 500 mg start date 08/01/2022, NovoLog solution (insulin aspart) start dated 08/05/2022 and Lantus Solution (insulin glargine) start date 08/05/2022. Review of Resident #37's Blood Sugar Report dated 08/10/2022 reflected resident blood sugar was checked 2-4 times per day from 08/01/2022 thru 08/10/2022. During this period resident blood sugar was the following: - 08/01/2022 563.0 mg/dL - 08/02/2022 thru 08/03/2022 was between 302.0 - 485.0 mg/dL - 08/04/2022 thru 08/05/2022 was between 309.0- 460.0 mg/dL - 08/06/2022 thru 08/07/2022 was between 117.0- 340.0 mg/dL - 08/08/2022 thru 08/10/2022 was between 173.0- 258.0 mg/dL Observation on 08/09/2022 at 9:57 AM revealed Resident # 37 was in her room sitting in wheelchair. Her breakfast tray was on her bedside table. Resident # 37 did not eat her breakfast. In an interview on 08/09/2022 at 10:00 AM, Resident #37 stated she did not like any of the food on her tray. She stated she wanted cheerios and they brought her frosted flakes. She stated cheerios was going to be delivered to the facility on the food truck today. She also stated she was a diabetic and was not happy about it. She stated getting shots every day was the only information she knew about being a diabetic. She stated she was frustrated and a little sad about being a diabetic. She also stated she was seeing a counselor and she would talk to the counselor about her feelings. In an interview on 08/09/2022 at 12:35 PM, LVN A stated Resident #37 was a new diabetic. She stated Resident #37 was refusing her lunch and she attempted four times to persuade resident to eat her lunch. She also stated resident was upset with the new diagnosis of diabetes. She stated resident did not inform her why she was upset. She also stated resident told her she ate her breakfast today and when she went to resident's room, she did not eat her breakfast. She stated this could affect Resident #37's blood sugar if she begins to refuse to eat her meals and prefers to eat snacks for meal substitute. In an interview on 08/09/2022 at 12:45 PM CNA B stated she did not realize Resident #37 was a diabetic. She stated they do have a guide of what type of care residents require and it is on the electronic medical record. She also stated Resident #37 refused her lunch and breakfast today. She stated Resident #37 would eat snacks in her room. Review of Resident # 45's Face Sheet, dated 08/09/2022, reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with a diagnoses functional quadriplegia ( the complete inability to move due to severe disability or frailty caused by another medical condition without physical injury or damage to spinal cord), unspecified protein-calorie malnutrition ( a condition caused by not getting enough calories or the right amount of key nutrients, such as vitamins and minerals in the diet or when the body cannot absorb nutrients from food), flaccid hemiplegia affecting the left dominant side ( paralysis on one side), moderate intellectual disabilities ( delays in reaching developmental verbal and communication skills, cannot typically communicate on complex levels. Have difficulty in social situations and problems with social cues and judgement) and autonomic dysreflexia (an abnormal, overreaction of the involuntary nervous system to stimulation. This reaction may include change in heart rate and high blood pressure). Review of Resident #45's Annual MDS Assessment, dated 06/27/2022, reflected resident had a BIMS score of 4 indicating his cognition was severely impaired. Resident required assistance with all ADLs and required the use of a mechanical lift for transfers. Resident #45 was assessed as having an indwelling catheter and had malnutrition. Resident was also assessed for pain. The MDS further reflected resident's height was 66 inches. He weighed 168 pounds. Review of Resident #45's Comprehensive Care Plan dated 03/09/2022 reflected the care plan was not reviewed/ updated/ revised after the comprehensive assessment on 06/27/2022. The care plan team failed to add Resident #45's UTI with start date 06/23/2022 to the care plan. Review of Resident #45's Physician Order dated August 2022 reflected resident admitted to skilled nursing services for UTI- start date 06/23/2022. House Supplement 2.0 two times a day for weight loss start date 07/28/2022. Regular Diet, regular texture and consistency and add fortified food with meals revision date 7/28/2022. Review of Resident #45's Director of Nurses note in the electronic medical record dated 08/10/2022 reflected weight loss follow-up. On 06/23/2022 resident was started on IV antibiotic for a UTI. He had a poor appetite. On 07/28/2022 resident started on Levaquin for UTI, house supplement two times per day and fortified foods with diet order. The Dietary consultant reviewed today see note for more details related to weight . Will continue to monitor weekly weights. Review of Resident #45's Nutrition Service Note dated 08/10/2022 reflected Resident had significant weight loss 8% x 90 days. No recent labs to access. Resident receives fortified foods with meals and house supplements 2.0 60 cc x 30 days for weight loss. Med review for possible appetite stimulants. Resident PO intake varies from 0-100% but usually 51 % - 75 %. No recent reports of chewing and swallowing problems. Review of Resident #45's Nutrition Service Note dated 07/22/2022 reflected Resident had a weight loss of 6.5 % x 30 days and 8.4 % x 90 days. PO intake varies 0-100 %. Resident does not have any chewing or swallowing problems. Will monitor weights. Recommend fortified foods with meals, Med pass 2.0 BID x 30 days to maximize weights, PO intakes and fluid intakes and will remain available PRN. Review of Resident #45's Electronic Medical Weight Record dated from 03/03/2022 thru 08/09/2022 reflected resident weight: 03/03/2022- 169.0 pounds 07/03/2022- 155.0 pounds 08/09/2022- 147.5 pounds In an interview on 08/11/2022 at 10:23 AM , MDS Nurse stated if there was something pertinent that could change the residents' care, it would need to be on the care plan. She stated a new diagnosis of diabetes would be considered pertinent. She also stated if the resident with diabetes had new medications, the mediations needed to be care planned. She stated this could interfere with resident's care if a new diagnosis of diabetes was not on the care plan. She stated if a resident had a new UTI and weight loss his care plan was expected to be updated. She stated if a resident's care plan was last completed on 03/09/2022, the resident's care plan was required to be reviewed/ revised/ updated in June of 2022. She stated Resident #45's care plan was considered late. In an interview on 08/11/2022 at 11:45 AM, the ADMIN stated resident care plans were expected to be updated after 90 days or before the 90 days if there were any changes in resident's condition. In an interview on 08/11/2022 at 12:08 PM, the DON stated she would need to refer to the care plan policy to determine when a care plan was required to be updated, reviewed and/or revised She stated if Resident #37 had concerns about her diabetes, it would be discussed with the resident. She also stated Resident # 45's weight loss was after being diagnosed with a UTI in June. Review of the facility's policy Care Plans, Comprehensive Person-Centered dated 12/2016 reflected assessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change. Reflect the resident's expressed wishes regarding care and treatment goals .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure resident weights were completed consistently with the same method, and variances were verified with interventions documented in the resident's EMR to ensure residents were maintaining acceptable parameters of nutritional status for one residents (Resident #61) out of four residents reviewed for accurate weights. 1. The facility failed to establish a consistent method of weighing Resident #61 to ensure accuracy of resident weights and did not follow facility policy to re-weigh within one day to verify the significant weight variance. 2. The facility failed to document interventions in Resident #61 who experienced a severe weight loss. These failures put residents at risk for undetectable weight loss, malnutrition, and poor quality of life. Findings included: Review of Resident #61's face sheet revealed Resident #61 was a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses of acute pyelonephritis (infection of the kidneys), Clostridium Difficile (C-Diff - germ that causes diarrhea), Type 2 Diabetes Mellitus, asthma, chronic kidney disease stage 3 (disease in which resident experiences decreased kidney function) and high blood pressure. Review of Resident #61's quarterly MDS assessment dated [DATE] revealed Resident #61had a BIMS score of five to indicate severely impaired cognitive status. Resident #61 required total assistance by two or staff members for ADL's. Resident #61 was not noted to have experience significant weight gain or loss. Review of Resident #61's care plan dated 08/10/2022 revealed Resident #61 had a nutritional problem or potential nutrition problem related to weight loss. Resident #61's interventions included the facility would provide and serve regular diet with fortified foods as ordered by the MD. The plan stated that the facility should notify the MD of further weight loss. Review of Resident #61's physician orders dated 07/06/2022 revealed Resident #61 was ordered to have weekly weights for four weeks. Review of Resident #61 Weight Summary dated 08/11/2022 revealed Resident #61's weight as follows dated: 08/09/2022 248.0 lbs Sitting 08/04/2022 248.8 lbs No method recorded 07/27/2022 254.0 lbs Sitting 07/20/2022 271.0 lbs Sitting 07/13/2022 280.0 lbs Wheelchair 07/06/2022 282.0 lbs Wheelchair 12.05% weight loss in 30 days Review of Resident #61's Nursing Progress notes dated 07/06/2022 - 08/09/2022 did not reveal documentation regarding Resident #61's weight variances or MD notification for weight loss. Review of Resident #61's Medical Nutrition Therapy assessment dated [DATE] revealed Resident #61 was obese with poor oral intake. RD recommended Resident #61 to have fortified foods related to poor appetite and weekly weights. Review of Resident #61's physician orders revealed the following diet orders dated: 07/06/2022 Regular diet, regular texture 07/14/2022 Regular diet, pureed texture with fortified foods 07/21/2022 Regular diet, mechanical soft texture 08/05/2022 Regular diet, regular texture In an interview on 08/09/2022 at 4:00 PM, the DON stated she monitored the resident weights for accuracy and consistency. She stated the transport aide at the facility weighed the residents and she entered the weights into the EMR. She stated they had three scales they use for weighing residents and she tried to ensure the method used was documented along with the weight. She said they had a standing scale that a resident in a wheelchair could be weighed on, a scale with a chair that residents could sit on and be weighed, and mechanical lift with a scale. She stated she had several weights from 08/04/2022 that required a re-weigh because there was a large variance including Resident #61. She said Resident #61 was one of the residents that needed to be re-weighed. An observation on 08/10/2022 at 3:30 PM revealed a standing scale that was large enough for a resident in a wheelchair to be weighed on and a scale with a chair that a resident could sit on and be weighed. There was a mechanical lift observed that had the ability to weigh a resident when being transferred via mechanical lift. In an interview on 08/10/2022 at 1:28 PM, RN H stated she did not weigh residents routinely and that a transport aide weighed all residents and the DON monitored resident weights. She stated if she noted a large variance in a weight, she would notify the DON. She stated a sitting weight could be either the resident sitting on the chair scale or a resident sitting in their wheelchair on the standing scale. She stated she was unsure of whether a sitting weight documented in the EMR meant sitting scale or wheelchair on the standing scale. In an interview on 08/10/2022 at 4:00 PM, RD stated she monitored resident weights and would request a re-weigh if there was a large variance or inconsistent weight. She stated there were three scales. She stated she did not know if sitting weight was for the chair scale or a wheelchair on the standing scale. She stated residents should be weighed using the same method consistently to ensure accuracy of the weight. She stated she will make recommendations based upon resident weights and if a resident was not weighed accurately, it could put the resident at risk for unaddressed weight loss or gain and malnutrition. She stated for Resident #61 she noted the large decrease in the month of July and had them re-weigh her. She stated the drop was largely due to Resident #61 started on a diuretic and had fluid loss with reduced edema therefore some part of the weight loss was unavoidable, She stated Resident #61 reported a decreased appetite in July and she recommended an appetite stimulant and dietary supplement if her oral intake was poor. She stated the facility implemented the interventions to prevent further dramatic weight loss. In an interview on 08/11/2022 at 9:40 AM, RN K stated they weigh residents at the scales in hallway near the dining room or the mechanical lift scale. She stated she would then add the weight in the EMR and if there was a big change, she would notify the resident's MD for orders. She stated they should chart a progress note for weight variance and MD notification. She said the sitting method documented in the weight record could mean sitting on chair scale or sitting in wheelchair on standing scale . She stated Resident #61 did not eat well when she was first admitted to the facility due to having trouble chewing her food and she was downgraded to pureed. She said Resident #61 continued to not eat well and did not like the pureed textured food. She said they upgraded her to mechanical soft and her intake improved slightly. She said she was recently changed to regular texture food at the resident's request and since she was stronger and more alert she was able to chew her food without issues. In a follow-up interview on 08/11/2022 at 12:33 PM, the DON stated she monitored all resident weights weekly/monthly depending on the resident's orders. She stated new admissions were weighed weekly for four weeks or until stable after four weeks. She stated a resident who experienced a significant weight loss or gain would be weighed weekly for four weeks until stable. She stated when she added the weights to the EMR, she should be adding the method of weighing the resident each time and it should be consistent to ensure accuracy of the weight. She stated she kept her records in a separate binder and made notes there about the method used and was not fully transferring the record into the EMR. She stated she also kept her notes, MD notifications and interventions for residents who experienced significant weight loss or gain in her separate binder. She stated the documentation should also be in the residents' EMR. She stated she would need to clarify sitting weights to ensure residents who are weighed in their wheelchair on the standing scale were identified differently than residents who were weighed using the chair scale. She stated interventions were completed for Resident #61 as she was losing weight including liberalizing her diet, adding fortified foods, adding an appetite stimulant and accounting for some of the weight loss related to diuretic use. She stated Resident #61 was admitted on a regular diet but then downgraded to a pureed diet due to trouble chewing. She stated her intake was poor so her diet was upgraded to mechanical soft. As Resident #61 became stronger and able to chew easier, the physician assistant upgraded her diet to a regular diet to improve her intake from 10%-25% of meal to greater than 70% of meals. She stated Resident #61 had expressed wanting to lose some weight, but they did not want her losing weight too fast which could complicate other health issues. She stated Resident #61 was admitted with C-Diff which could also account for some of the weight loss. She stated the variance of her weight should have been documented in her EMR and the facility's response also noted. Review of Weight Assessment and Intervention Policy dated September 2008 revealed the nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. Weights will be recorded in each unit's Weight Record chart or notebook and in the individual's medical record. Any weight changes of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent or greater when the facility had a medication error rate of 7.14% based on 2 of 28 opportunities, for 1 of 4 residents (Resident #31) reviewed for medication administration. 1. The facility failed to ensure Resident #31's Potassium Chloride was not crushed before administration. 2. The facility failed to ensure Resident #31 was administered Pepcid instead of omeprazole (Prilosec). These deficient practices could place residents at risk of not receiving therapeutic dosage of medications. Findings Include: Review of Resident #31's Face Sheet dated 08/10/2022 reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnosis Gastro-Esophageal Reflux Disease (heart burn), Cardiac Arrhythmia (irregular heartbeat), and Hypokalemia (low potassium level). Review of Resident #31's Quarterly MDS assessment dated [DATE], reflected Resident #31 was assessed to have a BIMS score of 14 indicating he was cognitively intact. Review of Resident #31's Comprehensive Care Plan dated 02/28/2022 reflected no plan of care for his diagnoses of hypokalemia or GERD. Observation and interview on 08/10/2022 at 8:38 AM revealed MA C preparing Resident #31's AM medication. MA C placed Resident #31's Potassium CL ER 20 mg into a medication bag used for crushing medications. MA C was asked if she should crush the medication she stated, I don't know why they want it like that since it dissolves in water, it is the only pill he has problems with. MA C then proceeded to crush the potassium and placed the crushed tablet into a small amount of pudding. MA C then removed a bottle of Prilosec (omeprazole) 20 mg from the cart and placed two tablets in the medication cup with Resident #31's other medications. MA C then prepared the rest of Resident #31's medication and entered his room and administered the medications to Resident #31. Review of Resident #31's Consolidated Physician Orders dated 08/01/2022 reflected an order for Klor-Con M20 tablet extended release (potassium chloride crystal ER) give one tablet by mouth one time a day every other day for hypokalemia take with 4-8 oz of water and do not crush the medication with a start date of 05/16/2020. Further review of his consolidated physician orders reflected an order for Pepcid (Famotidine) table 20 mg give 2 tablets by mouth one time a day for GERD with a start date of 06/28/2022. Review of the Resident #31's MAR dated August 2022 reflected an entry for Klor-Con M20 tablet extended release (potassium chloride crystal ER) give one tablet by mouth one time a day every other day for hypokalemia take with 4-8 oz of water and do not crush. Further review revealed an order for Pepcid table 20 mg (Famotidine) give 2 tablets by mouth one time a day for GERD. The MAR reflected Resident #31 was being administered the medication. Observation and interview on 08/10/2022 at 9:30 AM revealed MA C was asked to remove the medication Prilosec (omeprazole) 20 mg from the medication cart and was asked if it was the medication, she gave to Resident #31 during his morning medication pass, she stated Yes. MA C was asked why she gave Prilosec (omeprazole) 20 mg two tablets when Resident #31's physician order was for Pepcid (Famotidine) tablet 20 mg two tablets. MA C stated that was what they give for Pepcid. Surveyor then pointed to the Pepcid bottle in the cart which was located next to the Prilosec bottle and asked why she did not give the Pepcid instead. The MA C looked at both bottles and stated she did not notice that. When MA C was asked why she crushed the potassium tablet when Resident #31's order stated not to crush the medication, she stated she did not notice that and then pulled out a list of do not crush medications that was on her cart which reflected the potassium should not be crushed. MA C then stated she should not have crushed the medication since it was on the do not crush list and his order stated not to crush it. In an interview on 08/10/2022 at 9:50 AM, the DON stated she expected the medication aide to follow medication instructions for administration and to ensure they administered the right medications and follow the right procedures for crushing medications. In an interview on 08/10/2022 at 10:10 AM, Resident #31 was asked if the potassium he took this morning upset his stomach. Resident #31 stated he has had an upset stomach for a long time and been on medications for it and was not able to tell if the potassium had anything to do with. In an interview on 08/10/2022 at 4:30 PM, the Pharmacy Consultant stated that potassium, when crushed, can cause the stomach to become upset. She stated Resident #31 had GERD before starting the potassium, so she did not feel like the potassium caused the GERD. She stated it will cause discomfort but the pill does dissolve fast so she did not feel it would cause damage to his stomach lining. In an interview on 08/11/2022 at 11:44 AM, the Administrator stated, regarding MA C's errors during medication pass, that it must have been a training issue with MA C. She stated she had been a MA for a long time and should have known better. She stated when she talked with MA C, MA C was not able to tell her why she made the errors. The Administrator further stated she expected the medication aides to follow the policy and ensure residents receive their medications as ordered. Review of the facility's policy Administering Medications dated 12/2012 reflected Medications shall be administered in a safe and timely manner, and as prescribed .The individual administering the medication must check the label three times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication . Review of the facility's policy Crushing Medications dated 04/2007 reflected Medications shall be crushed only when it is appropriate and safe to do so, consistent with physician orders .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received food that is palatable and attractive for the facility's only1 kitchen reviewed for palatable and attractive food. 1. The facility failed to provide an entrée at lunch that was palatable as residents were unable to eat the pork chop served because it was tough to chew. 2. The facility failed to provide an entrée at dinner that was attractive and palatable in that the meal color was brown and yellow and the potato salad had an odor. These failures could lead to a diminished quality of life and expose residents to food borne pathogens and illness. Findings included: In an interview on 08/09/22 at 9:57 AM, Resident #37 stated the food is lousy and they did get enough to eat. She said when the food was good, they only gave you a little food. She said she complained to the DM, but it didn't do any good. An observation on 08/09/2022 at 10:00 AM revealed the menu for lunch and dinner was not posted in the menu frames in the dining room. There was a menu posted titled Everyday Menu with instructions to please order 2 hours before. In an interview on 08/09/2022 at 11:23 AM, the DM stated they were serving pork chops with brown gravy, green beans, black-eyed peas and dinner roll. For dessert she served [NAME] mousse. She said the alternative meal if residents did not like the entrée would be from the Everyday Menu posted outside. She said alternatives included chicken tenders, cheeseburger or a chef salad. When asked where those items were for serving, DM stated she would have to cook them to order they were not prepared until a resident did not like their meal. She was cooking today because they had a cook quit and had not replaced her yet. An observation on 08/09/2022 at 12:00 PM revealed no menu posted outside dining room except Everyday Menu. An observation and interview on 08/09/2022 at 12:20 PM revealed Resident #36's plate with a pork chop on it and black-eyed peas. He said the pork chop was tough because the cook boils them and he could not chew it. He said he doesn't have problems with his teeth or anything, the pork chop was just bad. He said if he asked for something else they would not bring him anything. He did not eat the black-eyed peas either because he did not like them. He ate green beans only for lunch because the [NAME] mousse dessert was an odd color and did not taste good. He said sometimes the food was good, but it depended on who was cooking. An observation and interview on 08/09/2022 at 12:30 PM revealed Resident #57 had a pork chop on her plate with chewed up pieces of meat in her napkin. She said the pork chop was too tough to eat and she spit it out. When asked if she asked for something else, she said she didn't know she could ask for other food. In an interview on 08/09/2022 at 12:39 PM, LVN F stated if a resident did not eat their food, they could pre-order food off the Everyday Menu or have a sandwich as an alternative. She said most of the time the food was good at the facility, but it depended on who was cooking. She said the residents preferred when COOK G prepared the food rather than DM. She said they rarely had complaints when COOK G was the cook but she was off this week. In a confidential group meeting on 08/10/2022 at 10:00 AM, the residents stated the food was not good and they have complained without much change. One resident stated they sent out my meal yesterday and the pork was hard, and I couldn't cut it . They take the plates out of plate warmer and put it under the food warmer and the food was cold by time it got to their room. One resident stated he didn't know they had anything else to eat if you don't like the meal. Another resident stated they will say they have hot dogs or corn dogs to eat and they did not have it to choose if you don't like the meal. The group stated when we asked for something else to eat, they did not have it and say they ran out of the food. They stated you can get a hamburger or cheeseburger, but you had to order it ahead of time. They did not post what the meals were in the facility and the residents did not know to order a hamburger or cheeseburger two hours ahead of time because they did not know what the meal would be. One resident stated they will post the menu ahead of time, but then the actual meal served was not the same as the one posted. They stated the variety they serve you is poor, and they will serve 2 starches at meals. For instance, yesterday they had black eye peas and green beans. An observation on 08/10/2022 at 5:30 PM reflected the dinner entrée for 08/10/2022 which was bratwurst, cooked cabbage and potato salad with a slice of white bread. Banana pudding with vanilla wafers was for dessert. The color of the meal was brown and yellow and lacked appeal. The bratwurst was served alone on the plate with no condiments. It was tough to chew the outer membrane of the bratwurst. The cabbage was slimy and lacked flavor. The potato salad was unusually yellow and had an unappealing odor. In an interview on 08/10/2022 at 5:32 PM, DM stated she had not received complaints about the food recently. She said if residents did not like what was served, they could order food from the Everyday Menu as a substitute. She said the bratwurst, cabbage and potato salad were usually well-received. An observation on 08/10/2022 at 5:50 PM revealed 12 resident trays in the dining room and four had the cabbage left on the tray and other foods eaten. Six trays had the potato salad and cabbage left on the tray. Two trays had the whole entrée remaining on the tray with only the dessert and bread eaten by the resident. In an interview on 08/11/2022 at 9:40 AM, RN C stated residents will sometimes complain about the food, but it depended on the cook. She said some cooks were better than others. In an interview on 08/12/2022 at 9:50 AM, MA H stated the food was gross depending on the cook. It's cold sometimes and there were not options offered to residents. When COOK G prepared the food, it was good, and residents can get something else if they did not like what was served. She stated when the DM prepared the food, they received a lot of complaints and residents refused to eat the food. She stated the residents would then eat snacks or they would offer them a health shake. In an interview on 08/12/2022 at 10:00 AM, LVN J stated food quality was dependent on who was cooking. COOK G gets it right and [DM] doesn't. Last night, they ran out of sausage and not all residents got a sausage. She said it was usually just sliced white bread with meals not rolls or other type of bread. She said COOK G customized food for residents and honored food preferences. They had to check trays closely when DM was cooking and doing trays because residents received the wrong diet orders. If residents did not like food, they might get a sandwich from the kitchen, but the Everyday Menu was not always available. In an interview on 08/12/2022 at 11:21 AM, the ADMIN stated she had not received complaints recently regarding food quality. She said the current complaints and food quality was more related to who was cooking, and they are down to one cook, so the DM was cooking. She stated residents preferred COOK G's cooking. In an interview on 08/12/2022 at 12:33 PM, the DON said, every once in a while, they received complaints regarding the food. She said most of the time food was well plated and appealing. She has heard the biscuits are too hard. She stated the facility's kitchen needed to improve upon serving quality food all the time and not be cook dependent. In an interview on 8/11/22 at 11:21 AM, the ADMIN stated the facility did not have a policy regarding food quality and/or monitoring of meal quality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided appealing options of similar nutritive value to residents who chose not to eat food that was initially served or who requested a different meal choice for 15 of 20 residents (Residents#36, Resident #57 and 13 residents in a confidential group setting) reviewed for resident preferences and substitutes. The facility failed to ensure an alternative entrée was available when residents did not eat the meal they were served. These failures put residents at risk for poor oral intake, weight loss, and poor quality of life. Findings included: An observation on 08/09/2022 at 11:30 AM revealed the steam table with the food for lunch with one entree which inlcuded pork chops, black-eyed peas, green beans with a roll. In an interview on 08/09/2022 at 11:32 AM, the ADMIN stated there was not an additional entree available on the steam table. In an interview on 08/09/2022 at 11:35 AM, the DM stated there was an alternate choice of entrees and resident's could order from the Everyday Menu if they did not like the food. In an interview on 08/09/22 at 9:57 AM Resident #36 said she was not offered an alternative entrée choice if she did not like the main entrée served. She said if you wanted something else besides what was served, you had to order it two hours before the meal. She said if the menu was not posted in advance to know what was being served, how would a resident know to order two hours before the meal. An observation and record review on 08/09/2022 at 10:00 AM revealed the menu for lunch and dinner dated 08/09/2022 was not posted in the menu frames in the dining room. There was a menu posted titled Everyday Menu with instructions to please order 2 hours before. The Everyday Menu included: Breakfast: Eggs made to order scrambled, fried, hard boiled Assorted Cereals Hot or Cold Pancakes Creamy Butter or Maple Syrup Toast Creamy Butter or Jelly Preserves Lunch and Dinner: Soup and Sandwich of the day Hamburger with Assorted Chips Chef Salad Cottage Cheese and Fruit Plate Dessert: Fruit Cup: Always available as a healthy alternative to the menu dessert In an interview on 08/09/2022 at 11:23 AM, the DM stated they were serving pork chops with brown gravy, green beans, black-eyed peas, and dinner roll. For dessert she served [NAME] mousse. She said the alternative meal, if residents did not like the entrée, would be from the Everyday Menu posted outside. She said alternatives included chicken tenders, cheeseburger, or a chef salad. When asked where those items were for serving, DM stated she would have to cook them to order they were not prepared until a resident did not like their meal. She was cooking today, because they had a cook quit and had not replaced her yet. An observation and interview on 08/09/2022 at 12:20 PM revealed Resident #36's plate with a pork chop on it and black-eyed peas. He said the pork chop was tough because the cook boils them and he could not chew it. He said he did not have problems with his teeth or anything, the pork chop was just bad. He said if he asked for something else they would not bring him anything. He did not eat the black-eyed peas either because he did not like them. He ate green beans only for lunch because the [NAME] mousse dessert was an odd color and did not taste good. He said sometimes the food was good, but it depended on who was cooking. When asked if he wanted to ask for something else today, he said no. An observation and interview on 08/09/2022 at 12:30 PM revealed Resident #57 to have a pork chop on her plate with chewed up pieces of meat in her napkin. She said the pork chop was too tough to eat and she spit it out. When asked if she asked for something else, she said she didn't know she could ask for other food. In an interview on 08/09/2022 at 12:39 PM, LVN F stated if a resident did not eat their food they could pre-order food off the Everyday Menu or have a sandwich as an alternative. She said most of the time the food was good at the facility, but it depended on who was cooking. She said the residents preferred when COOK G prepared the food rather than the DM. She said they rarely had complaints when COOK G was the cook, but she was off this week. In a confidential group meeting, of 13 residents, on 08/10/2022 at 10:00 AM, the residents stated the food was not good and they have complained without much change. One resident stated they sent out my meal yesterday and the pork was hard and I couldn't cut itOne resident stated he did not know they had anything else to eat if you don't like the meal. Another resident stated they will say they had hot dogs or corn dogs to eat and they did not have it to choose, if you did not like the meal. The group stated when we asked for something else to eat the staff said they did not have it and say they ran out of the food. They stated you can get a hamburger or cheeseburger, but you have to order ahead of time. They did not post the menu in the facility and the residents did not know to order a hamburger or cheeseburger two hours ahead of time because they did not know what the meal would be. One resident stated they will post the daily menu ahead of time sometimes, but then the actual meal served was not the same as the one posted. They stated the variety they serve was poor and they often serve two starches at meals. For instance, yesterday they had black eye peas and green beans. In an interview on 08/10/2022 at 10:30 AM, the RD stated residents should be able to order from the Everday Menu if they want a different entrée from what was on the menu. She said she was unaware of the rule that the resident had to order from the Everyday Menu two hours in advance of mealtime. In an interview on 08/10/2022 at 5:32 PM, DM stated she had not received complaints about the food recently. She said if residents did not like what was served, they could order food from the Everyday Menu as a substitute. She said the bratwurst, cabbage and potato salad were usually well-received. She usually posted the menu first thing in the morning but due to having to cook because of being short staffed she did not get the menu posted yesterday or today. In an interview on 08/11/2022 at 9:40 AM RN C stated residents will sometimes complain about the food, but it depended on the cook. She said some cooks were better than others. In an interview on 08/12/2022 at 9:50 AM, MA H stated the food was gross depending on the cook. It's cold sometimes and there were not options or alternatives offered to residents except a sandwich. When COOK G prepared the food, it was good and residents could get something else if they did not like what was served. She stated when the DM prepared the food they received a lot of complaints and residents refused to eat the food. She stated the resident would then eat snacks or they would offer them a health shake. She said residents had to order two hours before the meal if they wanted a sandwich or burger. She said the menu was posted sometimes outside dining room and no other place. She said she would not know how a resident would know to order alternative entree if the menu was not posted. In an interview on 08/12/2022 at 10:00 AM LVN J stated food quality was dependent on who was cooking. COOK G gets it right and DM doesn't. Last night they ran out of sausage and not all residents got a sausage. She said it was usually just sliced white bread with meals and not rolls or other types of bread. She said COOK G customized food for residents and honored food preferences. She said the menu was not posted in advance because the kitchen was constantly changing what was served. If resident did not like food, they might get a sandwich from the kitchen. The Everyday Menu was not always available. In an interview on 08/12/2022 at 11:21 AM ADMIN stated if residents did not like the entrée served at a meal, they could request food from Everyday Menu. She stated the DM should post the menu daily outside the kitchen in the dining room. She said the kitchen was short-staffed in the kitchen right now and that was likely why it was not posted. She stated residents should be offered an alternative if they did not like the entrée served or eat the entrée well. She stated she was under the impression the Everyday Menu could be prepared at any time, if a resident requested it. She said the process of ordering in advance of the meal needed to be worked out by posting the menus. In an interview on 08/12/2022 at 12:33 PM, the DON said occasionally they received complaints regarding the food. She said most of the time food was well plated and appealing. She stated menus should be posted next to kitchen in the dining room. The DM should be posting it daily. She stated she was not sure why a second entrée was not offered or served at meals. She said other facilities she worked at had a hot second entree but not here. She said they serve from the Everyday menu if residents want an alternative. She said she could see the problem of not posting the menu so residents would know whether to order from Everyday menu. She said staff should offer residents an alternate should be offered if a resident did not eat well. She stated the facility needed to fix the process of posting the menu and making alternatives available to residents. In an interview on 8/11/22 at 11:21 AM, the Administrator stated the facility did not have a policy regarding food choices for residents.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for two (NTR REF #1 and NTR REF #2) out of two resident nourishment refrigerators. 1. The facility failed to ensure expired nutritional supplements were not available for distribution to residents in the NTR REF #2. 2. The facility failed to ensure labeling and dating of resident leftover food kept in NTR REF #1 and that the refrigerator was clean without dried liquid and debris in the bottom of the refrigerator. 3. The facility failed to ensure staff food and drinks were not stored with resident snacks, drinks and supplements in NTR REF #1 and NTR REF #2. These failures could place residents who received snacks and supplements from the nourishment storage area and refrigerator at risk of foodborne illness. Findings included: An observation on 08/09/2022 at 2:00 PM revealed in NTR REF #1 in a night pantry at the nurse's station between the 400 and 500 hallway with unlabeled food in containers. There were cut-up tomatoes in a resealable bag, three plastic containers with food and an open Gatorade bottle with no label or date. There was mustard, ketchup, grape jelly and salad dressing opened with no label or date. Dried liquid and debris was observed at the bottom of refrigerator. An observation on 08/09/2022 at 2:10 PM revealed in NTR REF #2 in a night pantry at the nurses' station between the 100, 200 and 300 hallway, a Ready shake that expired 05/10/2022 and milk that was past best buy date of 08/04/2022. There was an open unlabeled coffee drink and a cup with liquid and no lid or label. In an interview on 08/09/2022 at 2:25 PM, CNA E stated she did not know who maintained the nourishment refrigerators. She stated she did not know who the containers in the refrigerator on the 400 and 500 hallway night pantry belonged to or whether the containers were from staff or residents. She stated she thought the refrigerators in the night pantry were for residents who did not have a refrigerator in their room. She stated food should be labeled and dated in the refrigerator. In an interview on 08/09/2022 at 4:00 PM, the DON stated there should not be expired or products in the nourishment refrigerators past their best by or expiration date. She stated staff on each hallway should maintain the nourishment refrigerators. She stated there should not be staff food or drinks in the refrigerators with resident food and drinks as it could expose the residents to cross contamination. In an interview on 08/10/2022 at 1:28 PM, RN C stated she did not know who maintained the nourishment refrigerators for resident food and drinks. She stated the refrigerator in the night pantry was for residents who did not have a refrigerator in their room. She stated products in the refrigerator should be labeled with the resident's name with a date of when opened and when to throw away. In an interview on 08/10/2022 at 1:40 PM, CNA D stated residents who did not have a refrigerator in their room, could store their food in the refrigerator. She said they labeled the food with the resident's name. She said she did not know who was supposed to ensure the refrigerator was cleaned out and dispose of expired foods. In an interview on 08/11/2022 at 12:01 PM, the ADON stated the charge nurses should check the refrigerators in the night pantries for food to be labeled and dated and dispose of expired food and drinks. She stated staff should not keep their food or drinks as it could expose the residents to germs from cross contamination. She said products past their best buy should be thrown away and not given to residents. In a follow-up interview on 08/11/2022 at 12:33 PM, the DON stated the charge nurses should check the nourishment refrigerators each shift to ensure no food was expired and no food or drinks from staff were kept in the refrigerator with resident food. She stated all food and drinks should be labeled with the resident's name and throw away date. She stated staff threw away the expired Ready shake and milk that was past its best buy date. Review of the facility's Foods Brought by Family/Visitors policy dated February 2014, revealed perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers will be labeled with the resident's name, the item and the use by date. The nursing staff is responsible for discarding perishable foods on or before the use by date. Review of the facility's Refrigerators and Freezers policy dated December 2014 revealed this facility will ensure safe refrigerator and freezer maintenance, temperatures and sanitation, and will observe food expiration guidelines. The policy noted all food shall be appropriately dated to ensure proper rotation by expiration date.