**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that the medication error rate was not 5% or greater. The facility had a medication error rate of 9.38% based on 3 errors out of 32 opportunities, which involved 2 of 4 residents (Resident #3 and #13) reviewed for medication errors. The facility failed to ensure LVN-A administered medications according to physician's order and manufactured guidelines for resident #13 when LVN-A crushed an extended release medication and failed to ensure a medication was in the medication cup. LVN-A failed to give resident #03 the correct number of tablets. This failure could place residents at risk for incorrect dosages resulting in reduced healing and unnecessary hospitalizations. Findings include: 1. Record review of Resident #13's undated face sheet, revealed she was an [AGE] year-old female admitted [DATE] with diagnoses of Senile degeneration of brain, Anxiety disorder, Congestive Heart Failure, and Respiratory Failure. Record review of Resident #13's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 11, which indicated the resident's cognitive ability was moderately impaired. Record review of Resident #13's Care Plan, reflected a Focus area was initiated on 1/22/2025 for resident having impaired cognitive function/dementia. Her goal was to improve current level of cognitive function. Record review of Resident #13's orders reflected a 10/30/24 order for Desvenlafaxine Succinate (antidepressant) Tablet Extended Release 24 hour: 100mg oral tablet daily. Order reflects Do Not Crush. Record review of Resident #13's orders reflected a 11/05/2024 order for Lorazepam-Schedule IV tablet: 0.5mg: 1 orally twice daily. 2. Record review of Resident #3's undated face sheet, revealed she was a [AGE] year-old female admitted [DATE] with diagnoses of Chronic pain, Repeated falls, Diabetes Type II, Chronic Obstructive Pulmonary Disease (lung disease), and Bipolar disease. Record review of Resident #3's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated the resident's cognitive ability was intact. Record review of Resident #3's orders reflected a 4/19/2024 order for Torsemide tablet (fluid pill) 20mg-3 tablets once daily. Observation of medication pass on 3/12/2025 at 8:43 AM, revealed the following for Resident #13: 1. LVN-A crushed a Desvenlafaxine succinate Tablet Extended Release 24-hour 100mg tablet and administered it to Resident #13. 2. LVN-A failed to ensure a Lorazepam 0.5mg tablet was in the medication cup. Examination revealed the tablet had not fallen out of the packaging. Observation that the narcotic count was 3 versus the 4 seen in the pack by the surveyor revealed the error and it was corrected. Observation of medication pass on 3/12/2025 at 9:28 AM, revealed the following for Resident #03: 1. LVN-A placed 2 Torsemide 20mg tablets into Resident #3's medication cup. When her medications were completed and count was verified by Surveyor, the cup was short 1 Torsemide. Observed LVN-A correcting the error and adding the 3rd Torsemide to the cup . In an interview with LVN-A on 03/12/25 at 09:06 AM, he stated that the medications in the cup for Resident #13 were completed and he was ready to give the medications. He stated, he Desvenlafaxine ER 100 was allowed to be crushed, he stated the resident has to have all medications either crushed or capsules opened. When he was asked by surveyor if crushing the medication could affect the medication time release, he stated unsure and proceeded to give the medication. In an interview with LVN-B on 3/13/2025 at 1:18 PM, she stated, the policy was to administer medications exactly as the order was written and that was important to maintain patient safety. She stated that administering a fluid tablet incorrectly could cause a resident to have fluid overload, electrolyte imbalances, or respiratory problems. She further stated that administering an anti-anxiety medication incorrectly could cause a resident to withdraw (socially) and refuse therapy. She stated it was standard practice not to crush extended-release medications and that it could cause the resident to get medications release too fast and have burning. She stated the dose would be changed if crushed. In an interview with DON on 3/13/25 at 1:44 PM, she stated the policy for is that when a nurse receives an order, she is to put them in the computer and follow the order. She said changing an order must be clarified with a physician. She stated it was important to follow doctor's orders exactly to prevent medication errors, prevent harm to the resident and so the medication could fix what it was intended for. She stated that administering a fluid tablet incorrectly could cause a resident to retain fluid and could cause a hospitalization. She further stated that administering an anti-anxiety medication incorrectly could cause a resident emotional harm or could cause them to harm themselves or others. She stated it was standard practice not to crush extended-release medications, but an alternative medication should be obtained for the resident if required. In an interview with the ADM on 3/13/25 at 1:28 PM, he stated the policy was to follow physician's orders exactly to administer medication as indicated on the Medication Administration Record. He stated this was important because the physician was the person overseeing the clinical care of the resident and if the order was not followed, the medication wouldn't have the intended effect on the resident. He stated the resident's health outcome could be changed and an example if a fluid pill was not given correctly, was that a resident could have fluid retention. Interview attempted with RPH (Pharmacy Rep) on 3/13/25 at 2:05 PM. A message was left but no return call received. A record review of the facility policy titled, Nursing Policy and Procedure-Medication Administration dated 10-2020 reflected the following: It is the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations. If it is safe to do so, medication tablets may be crushed. Record review of manufacture package insert for Desvenlafaxine-Extended-Release tablets reflected the following: Take tablets whole; do not divide, crush, chew, or dissolve.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the transmission of communicable diseases and infections for 4 of 4 residents (Resident #1, #3, #13, and #51) reviewed for infection control. The facility failed to ensure LVNA sanitized equipment/work surfaces between Residents #1, #3, #13, and #51. This failure could place residents at risk for development of communicable diseases and infections. Findings included: 1. Record review of Resident #1's undated face sheet, revealed she was an [AGE] year-old female admitted [DATE] with diagnoses of Vascular Dementia, High Blood Pressure, Stroke affecting Right dominant side, Alzheimer's disease and lack of coordination. Record review of Resident 01's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 10, which indicated the resident's cognitive ability was moderately impaired. Record review of Resident #01's Care Plan, reflected a Focus area was initiated on 4/22/2021 for resident having Cognitive Loss/Dementia. The goal was set to maintain current level of cognitive function by maximizing her involvement in daily decision making. 2. Record review of Resident #03's undated face sheet, revealed she was a [AGE] year-old female admitted [DATE] with diagnoses of Chronic pain, Repeated falls, Diabetes Type II, Chronic Obstructive Pulmonary Disease (lung disease), and Bipolar disease. Record review of Resident #03's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, which indicated the resident's cognitive ability was intact. Record review of Resident #03's Care Plan, reflected a Focus area was initiated 12/6/2024 for resident being at risk for infection related to Covid-19. Her goal was to remain free from serious infection. 3. Record review of Resident 13's undated face sheet, revealed she was an [AGE] year-old female admitted [DATE] with diagnoses of Senile degeneration of brain, Anxiety disorder, Congestive Heart Failure, and Respiratory Failure. Record review of Resident 13's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 11, which indicated the resident's cognitive ability was moderately impaired. Record review of Resident 13's Care Plan, reflected a Focus area was initiated on 1/22/2025 for resident having impaired cognitive function/dementia. Her goal was to improve current level of cognitive function. 4. Record review of Resident 51's undated face sheet, revealed he was a [AGE] year-old male admitted [DATE] with diagnoses of Colon Cancer, Open wounds, Hyponatremia (low sodium), and Congestive Heart Failure. Record review of Resident 51's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 11, which indicated the resident's cognitive ability was moderately impaired. Record review of Resident 51's Care Plan, reflected a Focus area was initiated on 12/5/2024 for resident requiring Hospice for terminal disease. The goal was to maintain dignity and keep pain free. Observation on 3/12/2025 at 8:43 AM, during medication pass, LVN-A removed a blood pressure cuff from the top of the medication cart and used it to take Resident #13's blood pressure. After taking the blood pressure, the cuff was replaced on the top of the medication cart without being sanitized. LVN-A proceeded to prepare Resident #13's medications on the cart then administered them to her. The blood pressure cuff remained on the top of the cart. Hand hygiene was done after leaving Resident #13's room Observation on 3/12/2025 at 9:08 AM, revealed LVN-A moved the medication cart to Resident #01's room and picked up the unclean blood pressure cuff. He proceeded to take Resident 01's blood pressure then returned the unclean blood pressure cuff to the top of the medication cart without sanitizing it. He then proceeded to prepare and administer the medications. LVN A performed hand hygiene but did not clean the medication cart surface or the blood pressure cuff on the medication cart. His hands had contact with both areas. Observation on 3/12/2025 at 9:17 AM, revealed LVN-A moved the medication cart to Resident #51's room and picked up the unclean blood pressure cuff. He proceeded to take Resident 51's blood pressure then returned the unclean blood pressure cuff to the medication cart without sanitizing it. He then proceeded to prepare the medications for Resident #51 and to administer the medications. When Resident 51's medications were completed he performed hand hygiene but did not clean the medication cart surface or the blood pressure cuff on the medication cart. His hands had contact with both areas. Observation on 3/12/2025 at 9:28 AM revealed LVN-A moved the medication cart to Resident #03's room The unclean blood pressure cuff remained on the medication cart. LVN-A then proceeded to prepare the medications for Resident #03 on the unclean medication cart surface and to administer the medications. When Resident 03's medications were complete he performed hand hygiene but did not clean the medication cart surface or the blood pressure cuff on the medication cart. In an interview with LVN-A on 03/12/25 at 09:39 AM, he stated that per policy he should have cleaned the blood pressure cuff between residents. He stated that equipment was cleaned to prevent cross contamination between residents. He also stated that the negative outcome to residents if equipment was not cleaned would be the spread of diseases and germs. In an interview with CNA-A on 3/13/2025 at 1:14 PM she stated, the policy for sanitizing between residents was to wear gloves and wipe the blood pressure cuff with sanitizing wipes. She stated this has to be done between every resident. She stated, it was important to sanitize equipment/work surfaces for infection control to prevent the spread of germs. She also stated that failure to sanitize could make the residents sick or potentially kill them if they can't fight off infections. In an interview with LVN-B on 3/13/2025 at 1:18 PM she stated, the policy was to sanitize hands and blood pressure cuffs between residents. She stated it is important to sanitized equipment and work surfaces for infection control on wounds, lesions or anything else that a resident could have. She further stated the negative outcome if equipment/work surfaces are not sanitized was germs could go from one resident to another and make them sick. In an interview with DON on 3/13/25 at 1:44 PM she stated, the policy for sanitizing equipment /work surfaces between residents was they should be wiped with sanitizing wipes between residents for any multiple use items. She stated it was important to sanitize equipment/work surfaces to prevent the spread of contaminates and the negative outcome to residents if this was not done is was you could spread contaminates from resident to resident and cause illnesses. In an interview with the ADM on 3/13/25 at 1:28 PM he stated, the policy for sanitizing equipment /work surfaces between residents was to use specific sanitizers between use. He stated it was important to sanitize equipment/work surfaces because if not you could potentially spread an infection to another resident and the negative outcome if equipment/work surfaces are not sanitized was that residents could get a virus, or an infection transmitted to them. A record review of the facility policy titled, Nursing Policy and Procedure-Infection Control-Cleaning and Disinfecting Resident Care Items and Equipment dated 10-2020, reflected the following: Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). Non-critical items (blood pressure cuffs) can be decontaminated where they are used.

Based on observation, interview and record review the facility failed to ensure all drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 1 of 1 medication rooms reviewed for medication storage. The facility failed to ensure expired medications were removed from the over-the-counter medication supply cabinet in the medication storage room. This failure placed residents at risk of not receiving the intended therapeutic effects of their medications. Findings included: An observation on 01/30/24 at 12:35 PM, revealed five bottles of Saccharomyces Boulardii Probiotics (a nutritional supplement used for gut health), with an expiration date of 12/23, in the cabinet of the medication storage room. During an interview on 01/30/24 at 12:35 PM, the DON stated, MRD was just there the other day, and she cleared all the expired medication. When the medication was found, she was shocked as she stated the MRD supposedly had pulled all the expired medications. After all other medications were checked, that appeared to be the only medication that was expired in the med room. During an interview on 01/31/24 at 08:10 AM, RN A stated the MRD was responsible for ordering and stocking the OTC medications in the med room. She stated the MRD checked expiration dates on the medication bottles. She stated the pharmacist is responsible for getting in the electronic medications that has expired. She stated it is the nurse's responsibility to check the expiration date when they take a bottle of medication from the medication room. She stated the nurses were responsible for monitoring the prescription medications that were stored in the medication room. She stated whoever is using the med cart is responsible for getting rid of the expired medications. She stated she checks them herself. She stated the additives in expired medications could cause adverse reactions. She stated expired meds could not be potent or have no effect, or they could be too strong. She stated residents may not get the desired effectiveness from expired medications. During an interview on 01/31/24 at 08:36 AM, the DON stated, the MRD was responsible for ordering over-the counter-medications. She stated the MRD rotated the stock and checked expiration dates routinely. She stated the pharmacy consultant was in monthly and completed checks of the medication room and medication carts. She stated if the meds are expired or DC, they put the meds in a box. The DC control meds are placed in a lock box in her office and when the pharmacist come in, they destroy them together. She stated there should not have any expired medication in the med room. The nurses are responsible for meds in the fridge. She stated ultimately the nursing staff was responsible for checking expiration dates on all medications. She stated the ADON does a spot check randomly. She stated expired medications may have lost their effectiveness and the resident may not receive the therapeutic benefits of the medication, the medication can be too strong, and the medication can have a reverse reaction, and the resident can die. The DON stated having expired medication in the cabinet did not meet her expectations. Record review of the facility policy titled, Medication Storage - in the Home dated 10/20, reflected in part, It is the policy of this home that medications will be stored appropriately as to be secure from tampering, exposure, or misuse . 12. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of per procedures for medications destruction, and reordered from the pharmacy, if a current order exists.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that each resident with pureed diet orders receivedfood that was palatable, attractive, and at a safe and appetizing temperature for 11 of 11 residents on pureed diets and 1 of 1 lunch meal tested for nutritive value, flavor, and appearance. The facility failed to provide palatable food served at an appetizing temperature to residents. The facility failed to ensure residents received their meals according to the menu. This deficient practice could place the residents who ate food from the facility kitchen by placing them at risk of poor food intake, weight loss and/or dissatisfaction of the meals served. Findings include: During an observation and interview with CK 1 on 01/29/2024 between 11:15 a.m. to 12:05 p.m. revealed CK 1 she was going to prepare pureed food for 11 residents that were getting pureed Diets. CK 1 prepared by getting her fried chicken patties for the residents. She stated she normally puts an extra 1 or 2 in just to make sure there is enough. CK 1 did not measure portions of chicken patties according to the recipe. CK 1 broke the patties up in the blender and added chicken broth/stock to the blender. CK 1 poured the liquid into the blender, and she let it blend for one to two minutes. She then took the top off the blender to check the consistency and stated she needed a little more stock to thin the chicken out a little more. She took the measuring cup and added some hot water from the coffee maker, and then she put some powder broth/stock mix into the water and stirred it. She added the stock to the chicken and let it blend for another one to two minutes or until it was the consistency she wanted. CK 1 was satisfied with the consistency, so she placed the puree chicken in a metal container and put it on the stem table to keep it hot. She tempted the chicken, and it was at 155 degrees. CK 1 took apart the blender and she brought it over to the washing station and she washed it then placed it in the dishwasher. Once that was done, she got the blender and brought it back and assembled it. The next item she prepared was carrots. She again got the measuring cup and eye-balled how much she thought would be enough for the 11 residents. She placed the carrots in the blender and blended them about two and a half to three minutes. She then checked the consistency of the carrots and figured it needed some more liquid to thin them out and make them smoother. She took the measuring cup, and she got some water and placed into the blender. She blended it for about two minutes, and she still was not satisfied with the consistency. DM got a plate and spoon and advised her to put a spoon of the carrots on the plate and slide it across the plate and see if it still not grainy or do you think its smooth enough for someone who cannot swallow can eat it without having to chew? CK 1 said she thought so. DM then retrieved another spoon and had her to taste it. DM asked her was she able to just swallow it? CK 1 stated she could, but it still felt a little grainy. CK 1 stated she felt it was not going to get any smoother. DM advised her blended a little more and then see how it comes out. CK 1 was headed to get some more water when DM stated I would have used the juice from the carrots to make sure the food still had its nutritive value. CK 1 got the juice from the carrots, and she poured it in the blender and let it go for about two to three minutes pouring the liquid in the blender. CK 1 checked the carrots again and she stated it appear to be the same texture to her. DM them advised CK 1 to use the other blender and see if it smooths out the texture. CK 1at this time was agitated. She poured the carrots into the other blender and blended it for about two minutes. Once again, CK 1 stated that blender still didn't change the texture. DM advised her to throw the carrots out and prepare the squash for the puree diet. DM took and dumped the carrots and advised CK 1 she needed to hurry up because they were falling behind. CK 1 brought the dishes over to the washing station and DS washed it out and placed in the dishwasher. CK 1 got a towel from the sanitizer bucket, and she wiped the counter off. Once the blender finish washing, DS brought it to her. CK 1 gathered the squash and placed it into the blender and blended for about a minute until she thought the texture was right for the pureed diet. The squash appeared to be loose, but CK 1 and the DM figured it was fine. DM advised her she would use a thickener to thicken it up. CK 1 stated the temp was reading at 122 degrees and it needed to be hotter. DM advised CK 1 to warm it up. CK 1 placed the squash in a bowl and warmed it up. And then it read 160 degrees. CK 1 then placed the squash in the metal pan and placed on the steam table. It was already pass serving time which trays started going out in the hall at noon. Carrots was on the board, and it was not updated due to the change. There were rolls on the steam table and they were supposed to be served with lunch. DM stated the rolls were not proofed so she changed to bread. The bread however was update on the menu board. DM placed the first pan of rolls on the counter and the second pan of rolls on a cart by the little hallway. Dining observation was observed by Surveyors, and it was revealed several residents stated the food was horrible. While Surveyors did interviews with residents in their rooms along with residents in a confidential meeting, they complained about the food also. In an interview with CK 2 on 01/31/2024 at or around 9:55 a.m., CK 2 stated her expectations for the quality of the food must taste good. She stated she tasted her food and the texture must be right. She stated she gets a spoonful of puree item, and she tries to swallow it and if she can chew it, it is not the right texture and it is not ready for a puree resident. CK 2 stated she also checks the puree to see if it ready by lifting the food through the spaces in the fork, and if it does it is ready. CK 2 stated she gets feedback from the residents the DM. CK 2 stated DM talks about concerns in the morning meetings. Also, the residents will ring the bell and let them know. CK 2 stated they have gotten complaints about a month ago regarding the food being cold. She stated they were not using the hot plate. She stated when the temps were taken for the food in the kitchen, the temps it was hot, but by the time the residents received their food on the last hallways the food is called. She stated she was advised to not put the hot plate when she started. She stated she was just as she was told. CK 2 stated she has not received any complaints regarding her food being nasty. She stated she tastes her food She stated she cannot speak for the other cooks. She stated she follows the menu. If they do not have an item, they sign a sheet of paper and use an alternate item if it is approved. In an interview on 1/31/2024 at 1:10 p.m. the DM stated she follow the menus per the guidelines. For puree diets she will add the stock from the food if that is available. If not, she will use a broth and a thickener if it is to lose. She tells her employees that you can always add but you cannot take out. She checks the quality and palatability of the food by getting a spoon and tasting it. She stated if it is good to her, it is good to them. She stated her expectations is for the food to be [NAME] and for the staff to follow the recipes. She stated she talks with the residents to find out about their likes and dislikes and to see how she can change the menu. She stated when the resident is admitted into the facility, she will go to their room and introduce herself and talk with them. The dietician makes sure the diets are correct for residents with special diets. Review of the facilities diet manual unknown date provided 3.1 D-1 Pureed Texture. The Pureed texture is a mechanical modification of the Regular Diet or any therapeutic diet, designed for people with moderate to severe swallowing difficulty and a poor ability to protect their airway. This texture allows pureed food (pudding like consistency) that is smooth and easily stays together. Food should be avoided if they require chewing. Coarse and dry textures, raw fruits and vegetables, breads and nuts should also be avoided. Beverages should be Thin (regular), Nectar-like, Honey-like, or Pudding-like. It is critical that standardized recipes be followed when preparing pureed foods to ensure nutritional quality is maintained. A record review of the facility's policy titled Menu Substitutions dated 10/2018 reflected the following: The facility believes that a well-balanced menu, planned in advanced and served as posted is important to the well-being of their residents. The menu will be served as planned except emergency situations when a food item is unavailable.

FACILITY Based on observation, interview, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. The facility failed to ensure CK #1 properly sanitized her hands between tasks. The facility failed to ensure DS used the ice scooper when scooping ice out of the ice machine. The facility failed to ensure DM and [NAME] 1 properly wore a hair restraint while in the kitchen. These failures could place residents who were served from the kitchen at risk for health complications, foodborne illnesses, and decreased quality of life. Findings included: Observation on 01/29/2024 between 11:15 a.m. to 12:05 p.m. revealed CK 1 placed her hand in the sanitizing bucket under the counter and retrieved a towel and wiped the counter down. CK #1 returned the towel back into the sanitizing bucket while another staff brought back her blender. CK #1 was observed placing a glove on her hand without properly washing her hands. She began to puree squash. CK #1 had a hairnet on that was worn inappropriately. CK #1 had hair hanging from under the hairnet. Observation on 01/29/2024 between 11:15 a.m. to 12:05 p.m. revealed the DM was observing along with Surveyor. CK #1 beganto puree the vegetables. Surveyor observed DM wearing hairnet inappropriately, her hair was hanging from under the hairnet. Observation on 01/29/2024 between 11:15 a.m. to 12:05 p.m. revealed the DS scooping ice from the ice machine with a what would be residents drinking cup. It was observed the DS picked up a stack of cups, touching the rims of the cups and scooping the ice out of the ice machine. She did not use the ice scooper. In an attempt to interview CK #1 on 01/30/2024 at and around 9:30, CK #2 stated she knows all hair should be in a hairnet. CK #2 stated she washed her hands frequently and changed her gloves. CK #2 stated she knows while in the kitchen everything should always be sanitized. In an interview with DS on 01/30/2024 at or around 9:55 a.m., the DS stated she knew she should have used the ice scooper. She stated she was just trying to cut the time and get it done. Surveyor asked her if she was aware she also was touching the rim of the cups. She denied putting her hands on the rim of the cups. DS said she was not aware she was touching the rim of the cup. In an interview on 1/31/2024 at 1:10 p.m. the DM stated she thought all her hair was in the hairnet. DM stated DS advised her the Surveyor asked her about taking ice out of the machine with the residents cup and she stated she knew better than to scoop the ice with the cup, but she was trying to save time. DM stated she admitted knowing it was not the proper way to get the ice out of the machine and she should have used the scoop. The DM stated her expectations is for her staff is to operate the kitchen properly and how they have been trained. A record review of the facility's policy titled Employee Sanitation dated 10/2018 reflected the following: Employee Cleanliness Requirements: Hairnets, headbands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food-contact surfaces. A record review of the facility's policy titled Employee Sanitation dated 10/2018 reflected the following: Other Practices: Cups, glasses and bowls must be handled so that fingers or thumbs did not contact inside surfaces or lip-contact outer surfaces. A record review of the facility's policy titled Employee Sanitation dated 10/2018 reflected the following: Employee Cleanliness Requirements: Handwashing: Gloves are not a substitute for thorough and frequent hand washing. When using gloves always wash hands before touching or putting on new gloves. A record review of the facility's policy titled Ice Machines dated 10/2018 reflected the following: The facility will maintain the ice machine, scoop, and storage container, in a sanitary manner to minimize to risk of food hazards. The ice machine will be cleaned once per month or more often than needed. The scoop and storage container will be cleaned once each day. Review of the FDA Food Code 2022, Section 2-402 Hair Restraints, 2-402.11 Effectiveness reflected Food employees shall wear hair restraints such as hair coverings or nets, beard restraints . that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils and linens and unwrapped single service and single-use articles. Review of the FDA Food Code 2022 Section 2-301.14 When to wash reflected Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils and unwrapped single service and single use articles and: A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; E) After handling soiled equipment or utensils F) During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. Review of the FDA Food Code 2022 Section 4-602.11 Surfaces of utensils and equipment contacting food that is not time/temperature control for safety food such as iced tea dispensers, carbonated beverage dispenser nozzles, beverage dispensing circuits or lines, water vending equipment, coffee bean grinders, ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. Some equipment manufacturers and industry associations, e.g., within the tea industry, develop guidelines for regular cleaning and sanitizing of equipment. If the manufacturer does not provide cleaning specifications for food-contact surfaces of equipment that are not readily visible, the person in charge should develop a cleaning regimen that is based on the soil that may accumulate in those items of equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to promptly resolve grievances for Resident #7 and 10 of 10 anonymous residents reviewed for grievances during a confidential meeting. The facility failed to ensure Anonymous resident 1 - Anonymous resident 10's grievances related to call lights being answered were promptly resolved. The facility failed to ensure Resident #17's grievance of staff failure to speak appropriate language in front of the resident was resolved promptly. This deficient practice could place the residents at risk for decreased quality of life and feelings of neglect or hopelessness. The findings included: Record review of Resident #7's face sheet (undated) and consolidated physician orders dated 10/26/22 indicated she admitted to the facility on [DATE] with diagnoses of pneumonia (an infection that inflames the air sacs in one or both lungs), acute respiratory failure (often caused by a disease or injury that affects your breathing, such as pneumonia), and COPD-chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #7's comprehensive MDS dated [DATE] indicated she was understood by staff and able to understand others. Her BIMS score is 15/15 which indicated Resident #7 is cognitively intact. The MDS indicated Resident #7 required extensive assistance with bed mobility, dressing, and personal hygiene. The MDS indicated she was always incontinent of bowel and bladder. Record review of Resident #7's comprehensive care plan last revised on 4/19/22 indicated no behaviors or cognitive decline. During a confidential interview on 5/25/22 at 3:00 PM Anonymous residents 1 - Anonymous resident 10 indicated grievances were not addressed or resolved promptly. Anonymous residents 1 - 10 indicated they had made complaints about call lights being answered, turned off, and staff not returning. Anonymous residents 1 - 10 indicated the activity director was present during the resident council meetings and was aware of complaints about the call lights. Anonymous residents 1 - 10 stated the Activity Director told them she was aware of the issue regarding call lights but did not offer a resolution or a plan to resolve the problem. Anonymous residents 1 - Anonymous resident 10 stated it was still happening across all shifts and made them feel forgotten, angry, and degraded. During an interview with Resident #7 on 5/26/22 at 8:06 AM Resident #7 stated she reported an incident in September 2022 about two CNAs speaking Spanish while providing care to her. Resident #7 stated it was better for about a week and then it was right back to where it started. Resident #7 stated CNAs during the night shift were still speaking Spanish while providing care for her. Resident #7 stated the last time it happened was on the night of 10/24/22. Resident #7 stated she did not tell anyone about the CNAs speaking Spanish in front of her, because she did not want to get anyone in trouble. Resident #7 stated it made her feel sad, angry, and like they were talking about her. Resident #7 stated she did not feel the grievance was resolved. Resident #7 stated the facility did not discuss the grievance with her after she reported it. Resident #7 stated a reasonable time frame to her for a grievance to be resolved would be about a week. Record review of resident council minutes for 8/4/22, 9/6/22, and 10/6/22 indicated Call lights are being answered and residents told I'll be back, and never return. Record review of grievance logs for May 2022 - September 2022 indicated no grievances for call lights being answered, turned off, and staff not returning. Record review of a grievance report dated 9/14/22 indicated Resident #7 reported two night shift CNAs were only speaking Spanish when in her room and she was unable to understand them. Grievance report indicated staff were educated to speak appropriate language when providing patient care. Record review of in-service dated 9/14/22 indicated staff was educated on the use of foul language or inappropriate conversation during patient care. During an interview on 10/26/22 at 3:38 PM The Activity Director stated she believed that complaints during resident council were considered grievances. The Activity Director stated grievances were started by the person who took the complaint and then given to the Social Worker. The Activity Director stated the failure for unresolved grievances could make the residents believe nothing ever got solved and it hurts them because they must continue to deal with the problem. During an interview on 10/26/22 at 3:43 PM the Social Worker stated some complaints made during resident council would be considered a grievance. The Social Worker stated that answering the call lights, turning them off and saying they will return, and not returning would be considered a grievance. The Social Worker stated grievances were started by the person taking the grievance, then they discussed it in the morning meeting or with the Administrator. The Social Worker stated they would talk to residents, staff, or supervisors to resolve the complaint. The Social Worker stated they follow up on grievances by talking to residents to see if they are satisfied or if it is resolved. The Social Worker stated they follow up for a few days after the grievance and then periodically afterward. The Social Worker stated Resident #7's grievance was resolved by having the CNAs relocated to another area and those CNAs were educated on the use of appropriate language during resident care. The Social Worker stated the failure to resolve grievances for residents would make them feel disrespected, unheard, and not cared about. During an interview on 8/26/22 at 3:54 PM the DON stated anyone could take a grievance. The DON stated it was usually documented by a department head and the form is turned into the Social Worker, then it is discussed in the morning meeting. The DON stated the department in which the grievance originated would then perform the investigation, corrective action, and follow-up. The DON stated she was unaware of the grievance report for Resident #7 and the resident council complaints. The DON stated the residents could feel disrespected, unheard, and dehumanized when grievances are not resolved or reported. During an interview on 8/26/22 at 4:06 PM the ADMIN stated that complaints during resident council were absolutely considered grievances. The ADMIN stated he expected department heads to document grievances and then discuss them during the morning meeting. The ADMIN stated the investigation, corrective action, and follow up would be completed as an interdisciplinary team. The ADMIN stated he was unaware of Resident #17's grievances or the resident council complaints. The ADMIN stated the residents would not feel cared for or disconnected and could lead to physical needs not being met or the environment not being secured. Record review of Grievances Standard of Practice policy revised on November 2017 revealed Standard of Practice: . The facility will make prompt efforts to resolve grievances. Record review of Grievances Standard of Practice policy revised on November 2017 revealed Standard of Practice Explanation and Compliance Guidelines: 6. C An initial response is expected within 72 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to implement their written policies and procedures that prohibit and prevent abuse for 1 of 20 residents reviewed for abuse. (Resident #24) The facility failed to follow their policy on abuse and reportable events by not reporting allegations of abuse to the administrator for Resident #24. This failure could place residents at risk of not having incidents of abuse, being reviewed, and investigated which could place residents at risk of continued and/or unrecognized abuse. Findings Included: Record Review of Resident #24's face sheet (no date) indicated a [AGE] year-old female admitted to the facility on [DATE]. Resident #24 had diagnoses of dementia (impaired ability to remember), psychosis (disconnection from reality) and dysphagia (difficulty swallowing). Record Review of the progress note dated 09/29/2022 at 4:01 pm by LVN C indicated Resident #24, was hit on the head by another resident. No injuries noted, no complaints of pain or discomfort. The Administrator, nursing management and MD were notified. Progress note at 6:28 pm by LVN C indicated the responsible party had been called and LVN C had left a voicemail to return call. LVN C was not available for interview. Record review of Resident #24's chart indicated no incident report was completed on 09/29/2022 for a resident-to-resident altercation. Record Review of Resident #24's MDS dated [DATE] indicated a BIMS score of 2 indicating severe impairment. Section I of the MDS for active diagnosis indicated Resident #24 had Non-Alzheimer's dementia, anxiety, and psychotic disorder. Record Review of Resident #24's care plan dated 8/29/2022 indicated Resident #24 was in the secure unit related to dementia. The Approach dated 8/29/2022 indicated to keep environment free of possible hazards and monitor to assure residents safety. Record Review of Resident #24's care plan indicated on 4/21/2022 that Resident #24 exhibits verbally abusive behavioral symptoms. The approach (dated 3/1/2021) indicated to allow distance in seating other residents around resident and to assess whether the behavior endangered Resident #24 and others. Another approach indicated to avoid over-stimulation of other physically aggressive residents. During an interview on 10/26/22 at 2:08 p.m. LVN A stated, The Charge nurse was responsible for filling out incident reports when resident altercations had occurred and notifying the Administrator. Incident reports were important because they had the correct steps to follow to make sure the residents were safe. During an interview on 10/26/22 at 3:07 p.m. with the MDS Coordinator and the DON interim, the interim DON stated, the charge nurse was responsible for filling out an incident report for any resident altercations and the Administrator was the abuse coordinator. Resident to resident altercations should have been reported because the resident could have continued with an aggressive pattern and the state needed to know that steps had been followed to prevent future incidents. The interim DON was not aware of the alleged incident involving Resident #24. During an interview with the Administrator on 10/26/22 at 2:45 p.m., the Administrator stated he was never notified of the resident-to-resident altercation on 9/26/22 or he would have completed an investigation. The Administrator stated he should have been notified immediately to investigate and the violator should have been determined for possible interventions. The Administrator stated he made daily rounds in the unit and the charge nurses were responsible for notifying him of any incidents that had happened. The Administrator stated if the incident was not investigated, the possible violator could have endangered another resident. Record review of the policy dated September 2020 on Abuse/Reportable Events indicated all residents had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Residents should not be subjected to abuse by anyone, including facility staff, other residents, consultants or volunteers, or staff of other agencies serving the resident. It was everyone's responsibility to recognize, report and promptly investigate actual or alleged abuse, neglect, exploitation, or mistreatment of resident's property abuse and situations that may constitute abuse or neglect to any resident in the facility. Facility employees must report all allegations of abuse, neglect, exploitation, mistreatment of residents, misappropriation of resident property or injury of unknown source to the facility administrator. Comprehensive investigations will be the responsibility of the administrator. The administrator will report cases to HHSC.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screening for 1 of 20 residents (Resident #24) reviewed for PASRR. The facility failed to review Resident #24's PASRR level 1 assessment for accuracy. Resident #24 was diagnosed for psychosis on 02/16/2022 prior to his diagnosis of dementia on 10/18/2022. This failure could place resident at risk of not receiving needed assessments (PASRR Evaluation), individualized care and specialized services to meet their needs. Findings include: Record Review of Resident #24's face sheet (no date) indicated a [AGE] year-old female admitted to the facility on [DATE]. Resident #24 had a diagnosis of dementia (impaired ability to remember), psychosis (disconnection from reality) and dysphagia (difficulty swallowing). Record review of Resident #24's care plan dated 4/25/2022 indicated on 8/29/2022 the resident resided in the secure unit related to dementia. The care plan indicated on 4/25/22 that Resident #24 had a diagnosis of depression and was at risk for mood decline and side effects of medication. The care plan dated 4/21/2022 indicated Resident #24 was taking psychotropic drugs Xanax, Abilify and Seroquel for psychotic disorder with delusions. Record Review of Resident #24 MDS dated [DATE] indicated Resident #24 had a BIMS score of 2 indicating severe cognitive impairment. Section I of the MDS indicated Resident #24 had an active diagnosis of anxiety, non-Alzheimer's dementia, and psychotic disorder. Section N of the MDS indicated Resident #24 had received antipsychotic medications for the last 7 days and antidepressants for the last 7 days. Record Review of Resident #24's PASRR Level 1 Screening completed on 10/31/2020 indicated in Section C0100 resident had no mental illness. During an interview on 10/26/22 at 3:07 p.m. with the MDS nurse, who was also the interim DON, stated the PASRR was completed by the MDS nurse, so it would have been her responsibility to review the PASRR. The MDS nurse stated she was not aware that the PASRR should have been marked yes on the mental illness section (C0100) because the resident had a diagnosis of dementia. The MDS nurse stated the failure could have resulted in Resident #24 not receiving the correct services or it could have impacted her quality of life. During an interview on 10/26/22 at 2:45 p.m. the Administrator stated he expected the MDS nurse to notify the state authority when residents had a mental illness. During an interview on 10/26/22 at 1:32 p.m., a policy for PASRR was requested from the ADON but was not provided upon exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure a gradual dose reduction was attempted for 1 of 5 residents (Resident #31) reviewed for unnecessary medications. The facility failed to do a gradual dose reduction or document contraindication for a gradual dose reduction for Resident #31's Seroquel 25 mg at bedtime started on 06/09/21. This failure could place residents at risk for possible psychotropic medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Findings included: Record review of the face sheet for Resident #31 revealed a [AGE] year-old-female admitted on [DATE] with diagnoses including dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life), Aphasia following other cerebrovascular disease (loss of ability to understand or express speech, caused by brain damage), dysphagia following other cerebrovascular disease (difficulty swallowing foods or liquids), Fall from bed, and essential (primary) hypertension (force of the blood against the artery walls is too high). Record review of the most recent MDS dated [DATE] revealed Resident #31 was unable to complete the BIMS interview, and staff assessment indicated cognitive skills for daily decision making were severely impaired. The MDS revealed Resident #31 sometimes understood. The MDS revealed Resident #31 required limited to extensive assistance with ADLS. The MDS revealed Resident #31 had no hallucinations, delusions, behavior, rejection of care or wandering. The MDS revealed in section N0410 medications received Resident #31 received an antipsychotic 7 days. Record review of the care plan last revised 06/15/21 revealed Resident #31 required psychotropic drugs for the treatment of depression, behavior management. The short-term goal target date of 07/21/22 indicated Resident #31 will reduce the use of psychoactive medication through the review date. Record review of Resident #31 physician order report dated 09/26/22-10/26/22 revealed an order for Seroquel 25 mg 1 tab by mouth at bedtime with start date of 06/09/21 for diagnosis of Dementia. Record review of Resident #31 medical records revealed no record of a gradual dose reduction or documentation of a contraindication for gradual dose reduction. During an observation and interview on 10/24/22 at 1217 Resident #31 sitting up in bed with eyes open. Resident #31 was alert, pleasant and voiced no concerns. During an interview on 10/26/22 at 1:33 PM, the pharmacy consultant indicated she did not know why the gradual dose reductions for Resident #31 were not done. The pharmacy consultant indicated she provided the facility the recommendations for gradual dose reductions for Resident #31 on the dates of 06/25/21, 08/25/21, 02/23/22, and 09/22/22. The pharmacy consultant provided surveyor with copies of the previously provided recommendations for Resident #31. Record review of the pharmacy recommendation dated 06/25/21 for Resident #31 indicated, Please consider a trial dose reduction to assess continued need for treatment and check one of the following: () Medication to be continued as ordered. Discontinuation of therapy likely will be harmful to resident and/or others or it will interfere significantly with the provision of care for others. () reduce the current order to Seroquel 12.5 mg at bedtime x 1 week, then dc. () Other: Record review of the pharmacy recommendation dated 08/25/21 for Resident #31 indicated, Please consider a trial dose reduction to assess continued need for treatment and check one of the following: () Medication to be continued as ordered. Discontinuation of therapy likely will be harmful to resident and/or others or it will interfere significantly with the provision of care for others. () reduce the current order to Seroquel 12.5 mg at bedtime x 1 week, then dc. () Other: Record review of the pharmacy recommendation dated 02/23/22 for Resident #31 indicated, The resident has been taking the antipsychotic Seroquel 25 mg at bedtime since 6/2021. Please evaluate the current dose and consider a dose reduction. () Condition stable: attempt dose reduction to () Resident with good response, maintain the current dose () Previous dose reduction failed: Date of failed GDR: _____ () Condition is not well controlled. Record review of the pharmacy recommendation dated 09/22/22 for Resident #31 indicated, The resident has been taking the antipsychotic Seroquel 25 mg at bedtime since 6/2021. Please evaluate the current dose and consider a dose reduction. () Condition stable: attempt dose reduction to () Resident with good response, maintain the current dose () Previous dose reduction failed: Date of failed GDR: _____ () Condition is not well controlled. The pharmacy consultant indicated after performing the medication reviews, she would send the recommendations to the facility email and the DON would provide the recommendations to the facility doctor. During an interview on 10/26/22 at 2:51 PM, the corporate nurse indicated if pharmacy recommendations for gradual dose reduction for Resident #31 were not in the binder the facility did not have them. The corporate nurse indicated it was the DON's responsibility to ensure gradual dose reductions were being attempted or contraindication for gradual dose reductions was documented. During an interview on 10/26/22 at 4:31 PM, the ADON indicated she had started in September 2022, and she did not know why the gradual dose reductions had not been attempted. The ADON indicated she is currently working with the corporate nurse to develop a monitoring system to ensure gradual dose reductions are attempted or contraindications for gradual dose reductions are documented. The ADON indicated not attempting gradual dose reductions could cause residents to have dizziness, memory loss and negatively affect them. During and interview on 10/26/22 at 4:41 PM, the DON indicated the DON's office was responsible for gradual dose reductions or documentation of contraindication for gradual dose reductions. The DON indicated the pharmacist gave recommendations for gradual dose reductions and these were then given to the doctor to see if he agreed. The DON indicated 5 months ago she was monitoring the gradual dose reductions with a binder, but she had moved to be the MDS nurse and had not been following through with the pharmacist recommendations. The DON indicated she assumed the ADON took over the gradual dose reductions. The DON indicated a gradual dose reduction not being attempted was part of a system failure. The DON indicated not attempting gradual dose reductions placed the residents at risk for being over medicated and keeping them more sedated than they needed to be. Record review of the facility's policy and procedure for Medication-Drug Regimen Review with effective date of 10-2020 revealed, .5. The Pharmacy Consultant drug regimen review and nursing medication documentation review reports are processed as follows: a. Drug Regimen Review recommendations to physician: The report is provided by the Pharmacy Consultant upon exit from the home, the physician provides a written response to the home after the report is sent, a copy of the report is kept by the home until the physician's signed response is returned, the physician's response is provided to the Pharmacy Consultant for review and then filed by the home, the home maintains copies of signed reports on file for at least two years .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 2 of 20 residents reviewed for laboratory services. (Resident #157 and Resident #16) The facility did not ensure Resident #157's electrolyte panel was drawn daily for five days. The facility did not obtain a physician's ordered CBC (test that measures red blood cells, white blood cells, and platelets), CMP (test that measures different substances in blood), Hemoglobin (test that measures for low or high levels of red blood cells), Lipid Panel (test that measure the amount of fats in blood), TSH (test that measures the thyroid gland), and Vitamin D levels for Resident #16. These failures could place the residents at risk of not receiving lab services as ordered and not managing medications at a therapeutic level. Findings Include: 1. Record review of the consolidated physician orders dated 10/26/2022 indicated Resident #157 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including hyponatremia (decreased sodium level), cardiac pacemaker, atrial fibrillation (irregular, often rapid heart rate that commonly causes poor blood flow), and hypertension (high blood pressure). The physician orders did not indicate Resident #157 had an order for an electrolyte panel to be drawn. The physician orders indicated Resident #157 had an order for sodium chloride 1 gram by mouth twice a day starting 10/20/2022 Record review of the baseline care plan completed by LVN D dated 10/22/2022 indicated Resident #157's diagnosis that contributed to admission was low sodium. Record review of the comprehensive care plan dated 10/25/2022 indicated Resident #157 was at risk for alteration in sodium levels/abnormal lab values related to hyponatremia with an intervention of monitor labs per physician orders. Record review of the hospital discharge orders dated 10/20/2022 indicated Resident #157 had a discharge order to draw an electrolyte panel (A blood test that measures if there is an electrolyte imbalance in the body. Electrolytes such as sodium, potassium, chloride, and bicarbonate are found in the blood.) daily for five days. Record review of the hospital lab results dated 10/17/2022 indicated Resident #157's sodium level was 128 milliequivalent/Liter (meq/L). The hospital lab results indicated Resident #157's sodium level of 128 meq/L was low, but did not provide a reference range. During an interview on 10/25/22 at 8:17 a.m. the Regional Reimbursement Consultant Nurse said Resident #157 had not had a lab drawn since she admitted to the facility on [DATE]. The Regional Reimbursement Consultant Nurse said the nurse practioner would be making rounds on 10/25/2022 and would order labs for Resident #157. The Regional Reimbursement Consultant Nurse viewed the discharge lab orders with the surveyor. The Regional Reimbursement Consultant Nurse said the lab order was not carried over at the facility. The Regional Reimbursement Consultant Nurse said she was unsure why the lab order was not carried over. The Regional Reimbursement Consultant Nurse said she did not enter the primary diagnosis of hyponatremia, but had saw that was Resident #157's primary diagnosis in the electronic medical records. The Regional Reimbursement Consultant Nurse said the hospital documentation indicated the resident had not been maintaining her sodium levels. The Regional Reimbursement Consultant Nurse said it was important to have drawn the labs to monitor her sodium levels. The Regional Reimbursement Consultant Nurse said decreased sodium levels could lead to cardiac issues and muscle cramps. Record review of the lab results dated 10/25/2022 indicated Resident #157's sodium level was 135 meq/L. The lab results indicated the refence range for sodium was 136-145 meq/L. During an interview on 10/26/22 at 1:33 p.m. LVN D said she no longer worked at the facility. LVN D said she had been the nurse who put in the admission orders for Resident #157. LVN D said she had not been given the complete set of discharge orders from the nursing management for Resident #157. LVN D said the orders were supposed to be verified by a second nurse and the ADON. LVN D said the orders were not verified by a second nurse or the ADON. LVN D said she could not remember who the second nurse was that day. LVN D said not having sodium levels drawn as ordered could result in having cramps, dehydration, lethargy, and weakness. During an interview on 10/26/22 at 2:20 p.m. the ADON said the charge nurse was responsible for entering admission orders. The ADON said she verified admission orders after the charge nurse entered the orders initially. The ADON said the negative effect for labs not being drawn as order on Resident #157 could be not monitoring for signs and symptoms of hypo-natremia such as low blood pressure, cramps, or dehydration. 2. Record review of Resident #16's physician order report, dated 09/26/2022-10/26/2022, indicated Resident #16 was an [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis which included acute respiratory disease, essential hypertension (high blood pressure), and Alzheimer's (progressive disease that destroys memory and other important mental functions). Record review of Resident 16's physician order report, dated 09/26/2022-10/26/2022, indicated Resident #16 had a one-time order for CBC, CMP, Hemoglobin, Lipid Panel, TSH, and Vitamin D levels to be drawn with a start date of 09/22/2022. Record review of Resident #16's annual MDS, dated [DATE], indicated Resident #16 understood others and made herself understood. The assessment indicated Resident #16 was moderately cognitively impaired with a BIMS score of 7. The assessment indicated Resident #16 did not reject care or evaluation. The assessment indicated Resident #16 did not require help or staff oversight at any time with bed mobility, transfers, dressing, eating, toileting, personal hygiene, and bathing. Record review of Resident #16's care plan, dated 06/07/2022, did not address physician lab orders. During an interview on 10/25/2022 at 10:05 a.m., the ADON stated Resident #16 had not had her labs drawn that was ordered on 09/22/2022. During an observation and interview on 10/26/2022 at 9:15 a.m., Resident #16 stated she did not know how often her lab work should be drawn. She was unable to recall the last time her labs were drawn. Resident #16 did not have any negatives outcomes from the labs not being done. During an interview on 10/26/2022 at 2:07 p.m., the DON stated the ADON was responsible for ensuring labs were drawn and ordered were completed. The DON stated the ADON walked out around 09/30/2022. The DON stated she was not aware that Residents #157 and #16 had orders for labs until surveyor intervention. The DON stated Resident #157 admission nurse was responsible for inputting all new lab orders. The DON stated the ADON should had done an audit to ensure all orders were placed in the computer. The DON stated she was responsible for checking/monitoring orders. The DON stated she monitors by pulling a facility activity report every morning. The DON stated she was depending on the ADON to assist with completion of lab orders by reviewing the activity report because the DON was also fulfilling the role of a MDS nurse. The DON stated the important of having labs drawn was so that the values could be monitored on a more consistent basis. The DON stated the failure of not knowing the lab values could potentially be critical and life threating. Record review of the facility's Lab Order policy, dated 10-2020, indicated, It is the policy of this home to provide or obtain laboratory services to meet the needs of its resident . 2. The DON/designee will be responsible to monitor lab orders to assure that all ordered labs have been drawn as ordered by the physician. 3.The DON/designee will be responsible to input all new lab orders as they were received. 7. Laboratory results will be maintained in the resident's clinical record Record review of the facility's Lab Monitoring-Therapeutic Levels policy, dated 10-2020, indicated It is the policy if this home that physician ordered laboratory services will be provided and monitored . 4. All lab result will be reviewed by a nurse. The nurse will date and document the time the result was received

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure food was provided that accommodated resident allergies, intolerances, and preferences of 1 of 20 residents (Resident #24) reviewed for food allergies. The facility failed to ensure that Resident #24 did not receive a tray that accommodated her allergies or dislikes. This failure could place resident at risk for poor intake, weight loss, and unmet nutritional needs. Findings include: Record Review of Resident #24's face sheet (undated) indicated a [AGE] year-old female admitted on [DATE]. Resident #24 had a diagnosis of dementia (impaired ability to remember), psychosis (disconnection from reality) and dysphagia (difficulty swallowing). Record Review of Resident #24's physician orders (undated) indicated a mechanical soft diet with thin liquids, avoid all milk products lactose intolerance. Record Review of Resident #24's care plan dated 10/25/2022 indicated a mech soft diet with thin liquids. The approach included mechanical soft, chopped/moistened meats. Record Review of Resident #24's MDS dated [DATE] indicated a BIMS score of 2 indicating cognitively impaired. Section I of the MDS indicated a diagnosis of dysphagia. Section K0510 for swallowing/nutritional status indicated a mechanically altered diet. Section G of the MDS under function status indicated Resident #12 required supervision with eating and one-person physical assist. Record Review of Resident #24's meal ticket on 10/25/2022 indicated double portion/mechsoft. Allergies include milk (lactose). Dislikes include cheese, cottage cheese, milk beverages, and cream cheese. Special notes indicated resident is lactose intolerant and avoid all milk products. During observation on 10/25/2022 at 12:06 pm, Resident #24 was given a tray with a grilled cheese sandwich and wavy lays potato chips. Resident interview was attempted and resident #24 was not interviewable. Resident #24 was eating the potato chips with her hands and no choking or coughing occurred. During an interview on 10/26/22 at 4:20 p.m. [NAME] C stated the cook was responsible for checking diets on the tray. Stated kitchen staff they would go over the plate changes or substitutes as a group and break the trays down together. [NAME] C stated the CNAs were responsible for looking at the trays prior to serving and making sure nothing was missed. [NAME] C stated receiving a plate that was chopped and not mechanical soft could affect the resident's health. [NAME] C stated they used a puree machine on the pulse setting to make a mechanical soft diet and they did not use breaded meats because they turn to mush. [NAME] C stated if the meat is not less than 1 inch thick, it was considered diced and not mechanical soft. During an interview on 10/26/22 at 2:08 p.m. LVN A stated the charge nurses were responsible for checking trays before they give them to the residents. LVN A stated she skimmed over the meal ticket and did not realize she gave Resident #24 the wrong tray. LVN A stated that giving the wrong tray could have caused the resident to have diarrhea due to lactose intolerance. During an interview on 10/26/11 at 1:33 p.m. the ADON stated dietary was responsible for serving the correct trays and the charge nurses were responsible for checking the trays prior to giving them out. The ADON stated receiving the wrong tray could have resulted in the resident having an allergic reaction. During an interview on 10/26/22 at 3:07 p.m. the DON stated the food trays were dietary's responsibility. The nurses and CNAs were responsible for checking the trays on the floor to make sure they were correct. The DON stated she expected the nurses and CNAs to check the trays prior to giving them out every time. The DON stated giving the wrong trays and not following the listed allergies could have resulted in anaphylaxis. During an interview on 10/26/22 at 1:33 p.m. a policy for therapeutic diets was requested from the ADON but was not provided upon exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure an accurate MDS was completed for 3 of 20 residents reviewed for MDS assessment accuracy. (Resident #24, #8 and #13). The facility failed to accurately reflect Resident #24, #8 and #13's medications on the MDS assessment. This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: 1.Record Review of Resident #24's face sheet indicated a [AGE] year-old female admitted on [DATE]. Resident #24 had a diagnosis of dementia (impaired ability to remember), psychosis (disconnection from reality) and dysphagia (difficulty swallowing). Record Review of Resident #24's physician orders (9/1/2022-9/20/2022) indicated Resident #24 was taking buspirone 10mg daily from 8/23/2022 until 10/20/2022. No indication that Resident #24 was taking Seroquel, Lexapro, Abilify and Mirtazapine were found on the orders. Record Review of Resident #24's care plan dated 4/25/2022 indicated she was taking Lexapro and Mirtazapine for depression. Care plan dated 4/21/2022 indicated Resident #24 was taking psychotropic drugs Xanax, Abilify and Seroquel. Record Review of Resident #24 MDS dated [DATE] indicated she had a BIMS score of 2 indicating mildly impaired. Section I of the MDS indicated Resident #24 had an active diagnosis of anxiety and psychotic disorder. Section N of the MDS indicated Resident #24 had received antipsychotic medications for the last 7 days and antidepressants for the last 7 days. Section N0450 indicated that a GDR had been documented from the physician as clinically contraindicated. 2. Record Review of Resident #8 indicated she was an [AGE] year-old female admitted to the facility on [DATE]. Resident #8 had a diagnosis of stage 3 chronic kidney disease, dementia (brain disorder) and hypertension (high blood pressure). Resident #8 did not have a diagnosis of diabetes. Record Review of the physician orders dated 7/15/22 until 8/5/22 indicated Resident #8 was not taking any insulin. Record Review of Resident #8's care plan did not indicate she was taking insulin or have a diagnosis of diabetes. Record Review of the MDS dated [DATE] indicated Resident #8 had a BIMS score of 2 indicating mildly impaired. Section I of the MDS for active diagnosis did not indicate a diagnosis of diabetes. Section N0300 of the MDS under medications indicated Resident #8 had 4 days of injections in the last 7 days. Section N0350 indicated she had insulin injections 4 of 7 days since admission. 3. Record Review of Resident #13's face sheet indicated a [AGE] year-old male admitted on [DATE]. Resident #13 had a diagnosis of HTN (high blood pressure), Alzheimer's (brain disorder) and chronic pain. Record Review of Resident #13's Physician orders dated 8/31/22 indicated Resident #13 was taking clopidogrel 75mg po qd. Physician orders did not indicate Resident #13 was taking anticoagulants. Record Review of care plan dated 08/10/2022 indicated Resident #13 was taking Plavix for clot prevention. Care plan did not indicate Resident #13 was taking anticoagulants. Record Review of the MDS dated [DATE] indicated a BIMS score of 1, indicating mildly impaired. Section N of the MDS under medications indicated Resident #13 had taken anticoagulants 7 of 7 days. Interview on 10/26/22 at 2:08 pm with LVN A, LVN A stated the MDS nurse is responsible for completing the MDS. LVN A stated the MDS nurse will ask the nurses if there are any changes in resident's conditions. LVN A stated the charge nurses will list resident changes in their 24-hour report and the day shift charge nurse will notify the MDS nurse. Interview on 10/26/11 at 1:32 pm with the ADON. The ADON stated the charge nurses are responsible for notifying the MDS nurse of any changes that need to be updated on the MDS. Interview on 10/26/22 at 3:07 pm interview with the MDS coordinator, the MDS coordinator stated she is responsible for completing the MDS's accurately. MDS coordinator stated if it was not done correctly it could result in false information and inaccurate care planning. Interview on 10/26/22 at 2:45 pm with the Administrator. Administrator reported it was the responsibility of the MDS nurse to complete the MDS's. Stated he expected the MDS to be completed correctly. The policy on Nursing Policy and Procedures dated 10/2020 under #4 concerns and problems indicated to review care Area Assessment triggers on the MDS and list the problems. Sources include diagnosis, problems related to physician orders, and all problems identified on all assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 4 of 20 residents reviewed for care plans. (Resident #14, Resident #47, Resident #4, and Resident #24) The facility failed to ensure Resident #14 received his daily showers as ordered by the physician. The facility failed to ensure Resident #47 received oxygen at rate ordered by the physician and the facility failed to develop and implement plan of care for oxygen therapy. The facility failed to update Resident #4's care plan to indicate he no longer was receiving hospice services. The facility failed to ensure Resident #24's care plan was updated and revised to reflect she was not taking any antidepressant medications. The facility failed to ensure Resident #24's care plan was updated and revised to reflect she was not taking any antipsychotic medications. These failures could place the residents at increased risk of injury or infection and not having their individual needs met. The findings included: 1. Record review of the face sheet (undated) indicated Resident #47 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of COVID-19 (Contagious disease caused by severe acute respiratory syndrome coronavirus 2), dyspnea (difficult or labored breathing), and vascular dementia (A condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain. It causes problems with reasoning, planning, judgment, and memory.) Record review of Resident #47's consolidated physician orders dated 10/26/22 indicated an as needed order for oxygen at 2 liters per minute via nasal cannula for shortness of breath which started on 12/7/21. Record review of the comprehensive MDS dated [DATE] indicated Resident #47 had a BIMS score of 14 and was cognitively intact. The MDS revealed no shortness of breath. The MDS revealed no oxygen in the last 14 days while a resident. Record review of the comprehensive care plan, last revised 10/25/22, indicated no comprehensive care plan for Resident #47's oxygen therapy. During an observation on 10/24/22 at 10:48 AM Resident #47 was receiving oxygen at 3 liters per minute via nasal cannula. Resident #47 was non-interviewable. During an observation on 10/25/22 at 8:20 AM Resident #47 was receiving oxygen at 3 liters per minute via nasal cannula. During an observation on 10/26/22 at 8:00 AM Resident #47 was receiving oxygen at 3 liters per minute via nasal cannula. During an interview on 10/26/22 at 4:19 PM LVN F indicated the charge nurses were responsible for monitoring and checking oxygen concentrators. LVN F stated the charge nurses must sign off on residents receiving oxygen therapy on the electronic health record one time per shift. LVN F stated Resident #47 had an order for oxygen at 2 liters per minute via nasal cannula. LVN F stated the charge nurses were responsible for putting the orders in the electronic health record. LVN F stated receiving a higher dose of oxygen than ordered can be bad for your brain. During an interview on 10/26/22 at 2:20 p.m. the ADON stated it was the charge nurse's responsibility for entering orders. The ADON said she verified orders after the charge nurse enters the orders. The ADON said the charge nurse could update the care plan, but it was the MDS Coordinator responsibility to update the care plans. The ADON said if oxygen was being administered at a higher rate than ordered the nurse should notify physician a. Running to and receive an order to administer the oxygen at a higher rate. The ADON said oxygen being administered at a higher rate than ordered could inadvertently damage the lungs. The ADON said it was important to have supplemental oxygen on the care plan so the nurses would know what the resident's oxygen fluctuation was, whether the resident had a diagnosis of COPD, or determine if the resident needed a diagnosis changed. The ADON said the care plan ensured proper interventions were in place to care for residents. 2. Record review of the consolidated physician orders dated 10/26/2022 indicated Resident #14 was a [AGE] year-old male, admitted on [DATE] with diagnoses including pressure ulcer of the sacral region, local infection of the skin, muscle wasting and atrophy, pilonidal cyst with abscess (an abnormal pocket in the skin at the tailbone that usually contains hair and skin debris that drains pus or blood), and rash. The physician orders indicated Resident #14 was to have a daily shower as part of his wound care starting 10/09/2022. Record review of the most recent MDS dated [DATE] indicated Resident #14 understood others and was understood by others. The MDS indicated Resident #14 had a BIMS score of 13 and was cognitively intact. The MDS indicated Resident #14 was not resistive to evaluation or care. The MDS indicated Resident #14 required total dependency with bed mobility, transferring, dressing, personal hygiene, and toileting. Record review of the care plan updated on 8/29/2022 indicated Resident #14 had an activities of daily living (ADL) deficit. The care plan interventions included total assistance with showers. The care plan indicated Resident #14 was at risk for skin breakdown related to amyotrophic lateral sclerosis (a nervous system disease that weakens muscles and impacts physical function) and quadriplegia (paralysis of all four limbs). The care plan interventions included to keep the resident clean and dry as much as possible. Record review of Resident #14's shower sheet for October 2022 indicated he was provided a shower on 10/10/2022, 10/12/2022, and 10/19/2022. Record review of a progress note dated 10/13/22 at 12:30 p.m. indicated Resident #14 had gone out on pass with family. Record review of a progress noted dated 10/17/22 at 12:19 a.m. indicated Resident #14 has returned to the facility on [DATE] at 11:30 p.m. During an observation and interview on 10/24/22 at 10:55 a.m. Resident #14 was clean and without offensive odor. Resident #14 said he was not receiving his showers as often as he should. During an interview on 10/25/22 at 9:28 a.m. Resident #14 said he had not been receiving his showers. Resident #14 said it depended on what staff member was working as to whether or not he received his showers. Resident #14 said he had only been receiving his showers once a week. 3. Record review of the consolidated physician orders dated 10/26/2022 indicated Resident #4 was [AGE] year-old male, re-admitted [DATE] with diagnoses including acute respiratory failure, COPD, alcohol dependence in remission, bipolar disorder, shortness of breath, and muscle weakness. Record review of the most recent MDS dated [DATE] indicated Resident #4 usually understood other and was usually understood by others. The MDS indicated Resident #4 was severely cognitively impaired with a BIMS of 06. The MDS indicated Resident #4 required total assistance with bed mobility, transferring, eating, and toileting. Record review of the most recent care plan updated on 7/13/2022 indicated Resident #4 required hospice as evident by terminal illness of COPD. Record review of a progress note dated 5/23/2022 indicated Resident #'s wife had requested him to be taken off hospice services. Record review of a progress note dated 5/30/2022 indicated the Nurse Practioner would have been notified on 5/31/2022 when making rounds of Resident #4 no longer receiving hospice services. During an interview on 10/25/22 at 3:20 p.m. LVN D said Resident #4 was not receiving hospice services. LVN D said she was unsure when Resident #4 discharged from hospice services. 4. Record Review of Resident #24's face sheet (no date) indicated a [AGE] year-old female admitted to the facility on [DATE]. Resident #24 had a diagnosis of dementia (impaired ability to remember), psychosis (disconnection from reality) and dysphagia (difficulty swallowing). Record Review of Resident #24's physician's orders (no date) indicated Resident #24 was taking buspirone 10mg daily from 8/23/2022 until 10/20/2022. There was no indication Resident #24 was taking Seroquel, Lexapro, Abilify and Mirtazapine were found on the orders. Record Review of the Care plan dated 4/21/2022 indicated Resident #24 was taking psychotropic drugs Xanax, Abilify and Seroquel. The goal included Resident #24 will remain free of drug related complications. The approach included to administer medications as ordered, pharmacy consult, and discuss with the MD and family the need for use of medication. Record Review of Resident #24's care plan dated 4/25/2022 indicated the problem was taking Lexapro and Mirtazapine for depression. The goal indicated Resident #24 would remain free of signs or symptoms of distress, symptoms of depression, anxiety, or sad mood. The approaches included administering medications as ordered, pharmacist consultant, and monitor and report to the MD risk for harming others. Record Review of Resident #24's MDS dated [DATE] indicated she had a BIMS score of 2 indicating mildly impaired. Section I of the MDS indicated Resident #24 had an active diagnosis of anxiety and a psychotic disorder. During interview on 10/26/22 at 2:08 p.m. LVN A stated the charge nurses were responsible for updating the care plan when medications were discontinued. LVN A stated the MDS nurse was responsible for updating the care plan when residents are discharged from hospice services. LVN A stated the charge nurses should document resident changes on their 24-hour report and notify the MDS nurse the next morning or the MDS nurse would ask the nurses if there were any changes to update the MDS. LVN A stated care plans should be updated for medication changes to prevent mistakes or confusion. LVN A stated if care plans were not complete, nurses might think the care plan was ongoing. During an interview on 10/26/11 at 1:32 p.m. the ADON stated the charge nurse was responsible for updating the care plan if medication or hospice services had been discontinued. The ADON stated the care plans were important to ensure resident changes in medications and when to monitor for side effects. During an interview on 10/26/22 at 2:47 p.m. the DON/MDS Coordinator said the charge nurse should input orders and the ADON ensured the orders are input correctly. The DON/MDS Coordinator said the showers sheets and point of care system was how CNAs were aware of showers needing to be done. The DON/MDS Coordinator checked shower sheets to ensure resident showers were done as ordered or scheduled. The DON/MDS Coordinator said residents with orders for showers daily with a wound and not receiving them were at risk for infection, odor, and maceration (occurs when the skin is in contact with moisture for too long. The skin becomes soft, wet, soggy, wrinkly, and lighter in color). The DON/MDS Coordinator said the nurses should monitor to ensure the oxygen was being administered at the correct rate. The DON/MDS Coordinator said oxygen administered at too high of a rate could affect the resident's eyes and hyperventilate them. The DON/MDS Coordinator said she was responsible for ensuring care plans were updated. The DON/MDS Coordinator said acute issues and a new onset of chronic issues for a resident was reported on the facility activity report. The DON/MDS Coordinator said the facility activity report triggered what needed to be added to the resident's care plan. The DON/MDS Coordinator said chronic issues that a resident was admitted with would be triggered by the MDS to put on the care plan. The DON/MDS Coordinator said oxygen therapy should be care planned. The DON/MDS Coordinator said oxygen therapy should be care planned intervention and should be accessible for the nurse to review and apply necessary interventions to aid the resident receiving oxygen. During an interview on 10/26/22 at 3:07 pm interview with the MDS coordinator/Interim DON, the DON stated she should have updated the care plans and she was responsible for making sure the changes were made. The DON stated the charge nurses were responsible for updating the care plan when medications were discontinued and the MDS nurse was responsible for updating the care plan when hospice care was discontinued. The DON stated if care plans were not correct, the nurses could get false information. During an interview on 10/26/2022 at 4:45 p.m. the ADON said the facility's Chart-readmission policy was the policy to refer to for physician orders. Record review of the facility's Care Plan-Resident policy dated 10/2022 indicated, .Resident Care Plan Documentation and Use of The Plan .a. The resident care plan is used to plan and assign care for all disciplines .c. The resident care plan must be kept current at all times . Record review of the facility's Chart-readmission policy dated 10/2022 indicated, .New physician orders will be completed .Update medication administration record (MAR)/treatment administration record (TAR) as appropriate .Update MAR/TAR with med/treatment changes . The policy on Nursing Policy and Procedures dated October 2020 under #8 (b) the care plan must be reviewed and revised at least every 90 days. Problems, goals, and approaches may be reviewed and revised when appropriate and necessary. When the goal is resolved the date should be entered in the appropriate are on the care plan. #12 (d) indicated all residents receiving Hospice are to have care plans developed in conjunction with the organizations.

Based on interview and record review, the facility failed to ensure their activities program was directed by a qualified professional for 1 of 1 facility reviewed for Activity Director. The facility did not ensure the Activity Director was qualified to serve as the director of the activities program. This failure could place residents at risk of not receiving a program of activities that meets their assessed activity needs. Findings include: Record review of a Personnel File Review Sheet, undated, revealed a staff member listed as Activity Director with a hire date 8/12/2022. Record review of the Activity Director employee file revealed no documentation of certification or CEU's as an Activity Director. During an interview on 10/26/2022 at 1:30 p.m., the Activity Director stated she had been in the position for the past two months. The Activity Director stated she was responsible for providing activities in room and in a group setting. The Activity Director stated she did not have a certification or license to qualify as an Activities Director. The Activity Director stated her background was as a caregiver. The Activity Director stated she was not aware that a certification was needed. The Activity Director stated she thought she had up to a year to become certified. The Activity Director stated she was told by the previous Administrator she did not have to be certified prior to her taking the position. The Activity Director stated the failure of not being certified was residents not receiving activities that meet their activity needs. During an interview on 10/26/2022 at 4:51 p.m., the Interim Administrator stated he had only been at the facility for seven weeks. The Interim Administrator stated the Activity Director did not have a certification or license to qualify as an Activity Director. The Interim Administrator stated he was not aware that the Activity Director was not certified until the surveyor brought it to his attention. The Interim Administrator stated it was important for the Activity Director to be certified to ensure she was following a plan that would be conducive to residents. When asked how residents could be negatively affected, he said, I do not see a potential harm since the residents were being provided activities. Record review of an undated Job Description Activity Director sheet, indicated will be responsible for the planning, developing, organizing, implementing, evaluating, and directing of Activity Programs in accordance with current existing federal, state, and local standards, as well as our established policies and procedures, to ensure that the spiritual development, emotional, recreational and social needs of the patient/resident are maintained on an individual basis . Certificates, Licenses, Registrations: Activity Professional Certification required .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 3 of 20 residents (Resident #24, Resident #12, and Resident #50). Resident #24, who required a mechanical soft diet with ground meat was served wavy lays potato chips at lunch. Resident #12 who required a mechanical soft diet with ground meat was served a chopped pork chop at lunch and cornbread. Resident #50 who required a mechanical soft diet with ground meat was served diced pork chop with rice at lunch. These failures could place residents on a mechanical soft ground meat diet at risk for poor intake, weight loss, not meeting their nutritional needs and choking. The findings included: 1. Record Review of Resident #24's face sheet (undated) indicated a [AGE] year-old female admitted on [DATE]. Resident #24 had a diagnosis of dementia (impaired ability to remember), psychosis (disconnection from reality) and dysphagia (difficulty swallowing). Record Review of Resident #24's physician orders (no date) indicated a mechanical soft diet with thin liquids, avoid all milk products lactose intolerance. Interventions included offering substitutes if less than 75% is eaten and monitoring intake. Record Review of Resident #24's care plan dated 10/25/2022 indicated a mech soft diet with thin liquids Record Review of Resident #24's MDS dated [DATE] indicated a BIMS score of 2 indicating the resident was cognitively impaired. Section I of the MDS indicated a diagnosis of dysphagia. Section K0510 for swallowing/nutritional status indicated a mechanically altered diet. Section G of the MDS for functional status indicated Resident #24 required supervision for eating and setup help only. During observation/interview on 10/25/2022 at 12:06 pm, Resident #24 was given a tray with a grilled cheese sandwich and wavy lays potato chips. Interview was attempted and resident was not interviewable. Resident #24 was eating the potato chips with her hands and no choking or coughing occurred. The meal ticket indicated Resident #24 was on a mech soft diet with thin liquids. During an interview on 10/26/22 at 2:08 pm LVN A stated the charge nurses were responsible for checking trays before they give them to the residents. LVN A stated giving the wrong texture of meat could cause choking or aspiration. LVN A stated she skimmed over the meal ticket and did not realize she gave Resident #24 the wrong tray. 2. Record Review of Resident #12's face sheet (undated) indicated he was a [AGE] year-old male admitted on [DATE]. Resident #12 had a diagnosis of depression, HTN (high blood pressure) and dysphagia (difficulty with swallowing). Record Review of Resident #24's care plan dated 4/14/2022 indicated a problem with nutritional status. Approach included mechanical soft, chopped/moistened meats. Record Review of Resident #12's MDS dated [DATE] indicated he had a BIMS score of 4 indicating severely impaired cognition. Section K0510 of the MDS under Nutritional Approaches indicated Resident #12 received a mechanically altered diet. Section G of the MDS under function status indicated Resident #12 required supervision with eating and one-person physical assist. During observation on 10/26/2022 at 1:18 pm, Resident #12 was given a chopped pork chop with rice, greens, and cornbread. Meal ticket read mech soft diet. Interview was attempted and resident #12 was not interviewable. 3. Record review of Resident #50's face sheet (undated) indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #50 had diagnoses of Dementia (impaired ability to remember), dysphagia (difficulty with swallowing), and aphasia (affects a person's ability to express and understand written and spoken language). Record review of Resident #50's consolidated physician order for diet dated 10/18/22 indicated Regular, Mechanical soft diet with thin liquids and fortified food with all meals. Special instructions revealed ice cream with lunch and dinner. Record review of the comprehensive MDS dated [DATE] indicated Resident #50 was usually understood and usually understands others. The BIMS was 00 which indicated severe cognitive impairment. The MDS revealed Resident #50 required set up help with eating. Record review of the comprehensive care plan last revised on 8/17/22 revealed Resident #50 would receive a mechanical soft diet with thin liquids and fortified foods with breakfast for problem with nutritional status. During observation, interview, and record review on 10/24/22 at 12:50 PM Resident #50 received smothered pork chop that was cut in approximately 1 - 2-inch cubes on top of regular rice. There was no ice cream. The meal ticket with tray indicated Resident #50 should have received ground smothered pork chop, pureed rice, and ice cream with lunch and supper meals. Resident #50 was observed in her room eating the pork chops and rice with no coughing, eyes watering, or nose running. Resident #50 was able to use utensils without any difficulty observed. Resident #50 stated she does not usually get ice cream with her meals, but she doesn't like it much anyways. Resident #50 stated the food was good and she was not having trouble eating or swallowing. During an interview on 10/25/22 at 11:57 AM CNA E stated charge nurse and dietary staff were responsible for checking the trays. CNA E stated he just passes them out. CNA E stated if something was missing from the meal tray, he goes to kitchen to get it. During an interview on 10/26/22 at 4:19 PM, LVN F stated dietary, charge nurses, then CNAs were responsible for checking meal trays. LVN F stated Resident #50 was on a mechanical soft diet. LVN F stated residents on a mechanical soft diet cannot have chips, bacon, or rice. LVN F stated meat should be ground up not chopped or diced. LVN F stated residents could choke or aspirate if given the wrong diet texture. During an interview on 10/26/22 at 4:20 p.m. [NAME] C stated the cook was responsible for checking diets on the tray. [NAME] C stated kitchen staff goes over any plate changes or substitutes together as a group and breaks the trays down together. [NAME] C stated the CNAs were responsible for looking at the trays prior to serving and making sure nothing was missed. [NAME] C stated receiving a plate that was chopped and not mechanical soft can affect the resident's health. [NAME] C stated they use a puree machine on the pulse setting to make a mechanical soft diet and they do not use breaded meats because they turn to mush. [NAME] C stated if the meat was not less than 1 inch thick, it was considered diced and not mechanical soft. During an interview on 10/26/11 at 1:15 PM, The Dietary Manager stated he printed the meal tickets and put them in the daily folder for the cook. The Dietary Manager stated the cook read the meal tickets and prepared the meal tray, then the dietary aid read the meal tickets, then the nurse verified the trays were correct against the meal ticket. The Dietary Manager stated the dietician gave him the recommendation summary report and the nurses gave him communication forms and then he updated the meal tickets with correct diet. The dietary manager said he was responsible for ensuring meal tickets get updated with correct diet. During an interview on 10/26/11 at 1:33 p.m. the ADON stated dietary was responsible for serving the correct trays and the charge nurses were responsible for checking the trays prior to giving them out. The ADON stated the wrong texture of meat could result in aspiration. During an interview on 10/26/22 at 3:07 pm with the DON interim, the DON stated the food trays were dietary's responsibility. The nurses and CNAs were responsible for checking the trays on the floor to make sure they were correct. The DON stated she expected the nurses and CNAs to check the trays prior to giving them out every time. The DON stated giving the wrong texture of meat can cause choking or aspiration. During an interview on 10/26/2022 at 1:32 p.m. the Administrator stated dietary and nursing staff were responsible for checking the dietary trays. The Administrator stated he expected the trays to be checked daily and serving the wrong tray could cause a resident to aspirate. Record Review of the Policy provided on mechanical soft diet (undated) indicated a mechanical soft diet was ground meat with gravy. No chunks or large pieces.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure: o food items were dated, labeled, and sealed appropriately. o hair restraints were worn by dietary staff. o expired food item was discarded. o the juice dispenser nozzle was clean. o the toaster was free of food debris. This failure could place residents at risk for foodborne illness. Findings included: During an observation on 10/24/22 starting at 10:22 AM revealed: Freezer #2 large, opened bag of chicken tenders 1/4 full unlabeled and not dated Freezer #3 large box of hamburger patties that were in an unsealed bag inside the box exposed to the air with no open date 36 lb. bag of dinner rolls with no open date Refrigerator #1 12 oz can of cranberry juice cocktail undated, the can was rusted and completely thawed the label read should be kept frozen 46 oz carton of thickened water with no open date 1 pitcher half full of lemonade undated Refrigerator #2 large piece of ham in a Ziploc bag dated 10/08/22 3 boiled eggs in a Ziploc bag dated 10/17/22 1 gallon Worcestershire sauce approximately 1/4 remaining expired 7/12/22 Refrigerator #3 1 large bag of lettuce dated 10/08/22 the lettuce throughout the bag appeared soggy and the lettuce was brown During an observation in the dry storage room on 10/24/22 starting at 11:04 AM revealed: On the shelves 36 oz box of rice pilaf expired 07/13/21 4 packs of 12 hot dog buns all had green areas and fuzzy white spots 1 loaf of bread with fuzzy white areas During an observation on 10/24/22 at 11:37 AM, the toaster had food particles and the juice dispenser nozzle had gunky dark colored residue. During an observation on 10/25/22 at 11:14 AM, the Dietary Aide G was preparing drinks. Dietary Aide G had hair extending below the collar and freely displayed. Dietary Aide G was wearing a baseball cap with no hair restraint. During an interview on 10/26/22 at 1:21 PM, the Dietary Manager indicated it was his responsibility to ensure the kitchen was clean, staff wore hair restraints, food was labeled, dated and sealed appropriately, and expired items were discarded. The Dietary Manager indicated all food should be labeled and dated when it came in the facility and when it was opened. The Dietary Manager indicated he made rounds every Monday morning to ensure the kitchen was clean, food in the freezers and refrigerator were labeled, dated, and sealed appropriately, and items were discarded if expired. The Dietary Manager indicated he did not do the rounds this past Monday due to being in a hurry to help the kitchen staff to cook. The Dietary Manager indicated it was important for the kitchen to be clean and equipment to be sanitized adequately to prevent cross contamination and prevent food borne illnesses. The Dietary manager indicated it was important to keep food labeled, dated, and sealed appropriately and to discard of expired items to prevent the resident's from getting sick and dying. The Dietary Manager indicated it was his responsibility to ensure all staff in the kitchen wore hairnets. The Dietary Manager indicated he was not aware Dietary Aide G needed to wear a hairnet. The Dietary Manager indicated he believed a baseball cap would suffice. The Dietary Manager indicated the use of hair nets in the kitchen was important to prevent hair from getting in the food and to prevent particles from contaminating the food. During an interview with the administrator on 10/26/22 at 4:53 PM, the administrator indicated he expected the Dietary Manager to ensure all staff wore hairnets, food was dated, labeled, and sealed appropriately, expired food items were discarded, and the kitchen was adequately cleaned and sanitized. The administrator indicated not doing this could cause food-borne illnesses. Phone interview attempted with the Dietician on 10/26/22 at 4:58 PM with no success. Record review of the facility's policy titled, Sanitizing Equipment In-Place, dated October 1, 2018, revealed . 2. Remove any fallen food particles and scraps. 3. Wash, rinse, and sanitize removable parts using the manual immersion method described in Policy 04.005. 4. Wash remaining food-contact surfaces, and rinse with clean water. Wipe down with chemical sanitizing solution mixed according to the manufacturer's directions . Record review of the facility's policy titled, General Kitchen Sanitation, dated October 1, 2018, revealed . 1. Clean and sanitize all food preparation areas, food-contact surfaces, dining facilities and equipment. After each use, clean and sanitize all tableware, kitchenware and food-contact surfaces of equipment . Record review of the facility's policy titles, Food Storage, dated October 1, 2018, revealed . 2. (d) Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. (e) Use all leftovers within 72 hours. Discard items that are over 72 hours old . 3. (e) Store frozen foods in moisture-proof wrap or containers that are labeled and dated .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records on each resident that are complete and accurately documented for 3 of 17 residents (Resident #10, Resident #23, Resident #43) reviewed for clinical records. Resident #10 and Resident #43 had Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms that were missing a date by the physician. Resident #23 had an Out-of-Hospital Do Not Resuscitate (OOH-DNR) form that was missing the physician's signature. This failure could place the residents at risk for not having their end of life wishes honored. Findings included: Record review of an undated face sheet for Resident #10 revealed an [AGE] year-old male re-admitted to the facility on [DATE] with diagnoses including viral pneumonia (infection of the lungs caused by a virus), major depressive disorder, recurrent severe without psychotic features (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), Alzheimer's disease with late onset (progressive disease that destroys memory and other important mental functions). Record review of the MDS dated [DATE] revealed Resident #10 was unable to complete the BIMS interview. Resident #10's electronic health record under the miscellaneous tab contained an Out-of-Hospital Do Not Resuscitate form that was not dated by the physician. Record review of Resident #10's care plan last revised on 08/31/22 revealed Resident #10 had an order for Do Not Resuscitate (DNR). Record review of Resident #10's Physicians Orders revealed an active physician's order for Code Status: DNR with start date of 03/04/22. Record review of an undated face sheet for Resident #43 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including 2019-nCoV acute respiratory disease (virus that causes respiratory illness), ischemic cardiomyopathy (disease in which the body cannot pump enough blood to the rest of the body), cerebral infarction (lack of adequate blood supply to the brain which causes parts of the brain to die off) and paroxysmal atrial fibrillation (irregular, rapid heart rate that causes poor blood flow). Record review of the MDS dated [DATE] revealed Resident #43 was unable to complete the BIMS interview. Record review of Resident #43's electronic health record under the miscellaneous tab contained an Out-of-Hospital Do Not Resuscitate form that was not dated by the physician. Record review of Resident #43's care plan last revised on 06/28/22 revealed Resident #43 had an order for Do Not Resuscitate (DNR). Record review of Resident #43's Physicians Orders revealed an active physician's order for Code Status: DNR with start date of 04/21/22. Record review of an undated face sheet for Resident #23 revealed an [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses including pathological fracture, right femur, sequela (fracture of the right femur caused by weakened bone), gastro-esophageal reflux disease without esophagitis (disease in which stomach acid or bile flows into the food pipe and irritates the lining), Alzheimer's disease with late onset (progressive disease that destroys memory and other important mental functions), Parkinson's disease (brain disorder that causes unintended or uncontrollable movements) and Dementia in other diseases classified elsewhere with behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of the MDS dated [DATE] revealed Resident #23 was unable to complete the BIMS interview. Record review of Resident #23's electronic health record under the miscellaneous tab contained an Out-of-Hospital Do Not Resuscitate form that was not signed by the physician. Record review of Resident #23's care plan last revised on 10/25/22 revealed no indication that Resident #23 had an order for Do Not Resuscitate (DNR). Record review of Resident #23's Physicians Orders revealed an active physician's order for Code Status: DNR with start date of 10/25/22. During an interview with the social worker on 10/26/22 at 4:23 PM, the social worker indicated she was responsible for ensuring DNRs were accurately completed and documented. The social worker indicated she did not know why the DNRs for Residents #10, #43, and #23 were not completed. The social worker indicated she started August 8th and had been working with medical records to get everything organized by looking at all the electronic health records one by one to see who had a DNR. The social worker indicated she was starting a system to monitor the DNRs by keeping a binder with all the residents who were DNR. The social worker stated it was important that all DNRs be accurately documented and completed to ensure the residents and families wishes were honored. The social worker indicated not having the DNRs accurately documented and completed would cause more stress in an already stressful situation and could unnecessarily make end of life care more stressful. During an interview with the Administrator on 10/26/22 at 4:51 PM, the Administrator indicated the social worker was responsible for ensuring the DNRs were accurately completed and documented. The Administrator indicated not having the DNRs accurately completed and documented could cause confusion and the families wishes not to be followed. During an interview with the ADON on 10/26/22 at 4:37 PM, the policy regarding advanced directives was requested and not provided.