**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to treat residents with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 2 of 8 residents (Resident #2 and #3) reviewed for respect. CNA D failed to treat residents with respect and dignity when she told Resident #2 and Resident #3, she did not have to take them out to smoke, on an unknown date in July 2025. These failures could place the residents at risk of feeling disrespected.Findings included: Record review of Resident #2's undated face sheet revealed a [AGE] year-old male admitted on [DATE]. Resident #2 had a medical history of COPD (a group of lung diseases that cause airflow obstruction and breathing difficulties), alcohol induce dementia (a type of alcohol-related brain damage), and muscle weakness. Record review of Resident #2's quarterly MDS dated [DATE], Section C-Cognitive Patterns revealed a BIMS score of 06, which indicated Resident #2 had severe cognitive deficit. Record review of Resident #3's undated face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #3 had a medical history of schizophrenia (a serious mental health condition that affects how people think, feel and behave), HIV (a virus that attacks the body's immune system), insomnia (persistent problems falling and staying asleep), and alcoholic cirrhosis of liver (a chronic liver disease caused by excessive alcohol consumption over many years). Record review of Resident #3's admission MDS dated [DATE], Section C-Cognitive Patterns revealed a BIMS score of 09, which indicated Resident #3 had moderate cognitive deficit. Record review of facility document titled Grievance Decision Report, dated 7/30/2025 revealed: .Detail of Complaint/Grievance: Resident showed [ADM] + [and] DON video of employee having an interaction with another resident and threatened to take away his smoking privilege. Date complaint/grievance occurred: unknown.Summary statement of grievance: Resident [Resident #3] reported concerns of how an employee spoke to him and another resident. Steps taken to investigate the grievance: other resident [Resident #2] interviewed that had the interaction with the employee, resident [Resident #2] didn't report concerns. Summary of pertinent findings of conclusions: prior to employee [CNA D] working another shift, employee will have one on one conversation on expectations. During an interview on 9/2/2025 at 12:23pm with Resident #3, he stated CNA D had been telling another resident that she was not going to take him to smoke. He stated he did not remember what resident it was but that she did not have the right to refuse to take anyone out to smoke. He stated he did record her because he felt that she was violating their rights to smoke. Resident #3 stated CNA D did take them to smoke a few moments later but that he felt she did not treat them with respect and was rude. Resident #3 was unable to recall the date of the incident but stated he did do a grievance report a few days later.During an interview on 9/2/2025 at 2:23pm with LVN B, he stated he does not remember there being any incidents between CNA D, Resident #3 or Resident #2. He stated there was only one night when CNA D told him Resident #2 was cussing and yelling at her because they were running behind on their smoke break and CNA D had told Resident #2 to give her a minute and she would take them out. LVN B stated CNA D did not mention denying the residents their smoke break. He stated there were no reports made to him by any residents. LVN B stated if he had to guess which resident was cussing at CNA D, he would guess [Resident #2] because he can be aggressive if staff are late with smoke breaks. During an interview on 9/2/2025 at 5:02pm with CNA D, she stated she did not recall the date but that she remembers the night shift being busy and running behind. She stated they were running a little behind on going to smoke and had told the smoking residents they would be late taking them to smoke. She stated Resident #2 was mumbling something, and she told him she would not take him to smoke and that they are not always going to be able to take them at the same time. CNA D stated she did ask Resident #3 if he was recording her, and he stated yes. She stated she did take the residents out to smoke within a few seconds of saying she would not. CNA D stated her behavior was inappropriate and she had just been irritated from being behind on schedule. She stated she understood how she spoke to the residents was not how they were trained and that she had been in serviced on resident rights and customer service. She stated she does have a strong voice, and it is often mistaken for yelling, even when she is not. She stated all residents had a right to be treated with respect and she felt she did not treat the residents with respect when she spoke to them in that manner. She stated she will not do that again and will treat all residents with respect. During an interview on 9/3/2025 at 9:30AM with Resident #2, he stated he did not remember the time or date of that incident. He stated he does not remember what started it or why she was telling him he couldn't go smoke. He stated he did not remember how it made him feel but he guessed not good. He stated he felt like he was not treated with respect. He stated he had been a fire fighter and an officer for many years and knew he had rights. He stated he felt safe at the facility and did not have any ongoing concerns with staff members or with his care. He stated that incident had passed, and it was over with. During an observation and review of a 36 second video provided by the ADM on 9/3/2025 at 10:32AM, the undated video revealed CNA D being recorded by Resident #3. The video revealed CNA D standing in front of Resident #3 but looking in a different direction. CNA D stated No you're not to a resident not shown in the video. CNA D turned to look at Resident #3 when he spoke to her. Resident #3 stated You can't take his privilege ma'am. CNA D replied, Yes I can, are you recording me? Resident #3 replied Mhm [yes]. CNA D replied, Let me see. CNA D did not reach for the phone and did not yell at Resident #3. CNA D's tone of voice was stern and argumentative. Resident #3 replied I don't have to let you see; this is my phone. CNA D stated, And I don't have to let y'all [you all] go smoke [LVN B]!. CNA D did not yell at residents but did yell out for LVN B. CNA D walked away from Resident #3 and leaned against the hallway wall after calling for LVN B. Resident #3 stated Do what you want to do ma'am. CNA D was seen leaning against the wall with bag on her shoulder. After a few seconds CNA D walked back down the hall shaking her head and stated, that's alright, I'll talk to administration about it.y'all should be glad someone is taking y'all. CNA D walked towards smoking door exit, and door is heard opening. Resident #3 followed a few seconds later, video ended. During an interview on 9/3/2025 at 2:39pm with the DON, she stated she was not sure what date the interaction had occurred, but they had received a grievance from Resident #3 on 7/30/2025. She stated from her understanding, smoke break had run a little behind on schedule one night. She stated Resident #2 got defensive and was cussing at the staff member. She stated the staff member told him she didn't have to take him out to smoke and that's when the other resident started recording. The DON stated Resident #3 told CNA D that she could not take away his [Resident #2's] smoke break away and she [CNA D] said yea I can. The DON stated she did feel CNA D violated the residents right for respect and she did not have the authority to refuse to take any resident out to smoke. She stated CNA D did take the residents out to smoke. She stated CNA D was in-serviced on customer service training and educated on not speaking to residents rudely. She stated CNA D was educated that she can not deny or revoke residents right to smoke and that if smoke break is going to run late, to let the ADON, or DON know, and they can notify the residents in a timely manner. She stated the potential negative outcome of residents not being treated with respect could be the residents having emotional distress and fearful of not being able to do things freely in the facility. Record review of facility document titled Employee Corrective Action form dated 8/7/2025 revealed; Type of action taken: Final WarningState subject of code of conduct rule violated: Conduct, attitude and behavior.Incident: A resident presented to both the DON and ADM that [CNA D] engaged in an unprofessional verbal exchange with a resident. In the exchange [CNA D] is speaking inappropriately to the resident and implying that smoking privileges could be taken away.Follow up review date: 9/7/2025.Consequences: Could lead to further disciplinary action up to or include termination. Signed by CNA D, DON and ADM on 8/7/2025.Record review of facility policy titled Conduct, attitude and behavior last revised December 2019, revealed; .Employees must maintain good attitude toward his/her job positions, co-workers, residents and visitors. All employees will treat residents, visitors and co-workers with respect kindness and dignity.6. Examples of conduct and behavior that are considered inappropriate and are therefore prohibited by this policy include, but are not limited to the following: a. Failure to treat all residents, visitors and fellow employees with kindness respect and dignity.Record review of facility policy titled Resident Rights implemented 7/2025 revealed; .Respect and Dignity: The resident has the right to be treated with respect and dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promoted the maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility failed to protect and promote the rights of the resident for 1 of 7 (Resident #1) residents reviewed for resident rights. CNA B failed to allow Resident #1 to call her Family Member when Resident #1 requested to make that call at approximately 2:30 AM on 01/24/25. This failure could place residents at risk for diminished quality of life and loss of dignity and self-worth. Findings included: Record review of Resident #1's undated face sheet revealed a [AGE] year-old female originally admitted to the facility on [DATE]. Resident #1 had a medical history of type 2 Diabetes Mellitus (inability of the body to use insulin properly), altered mental status (change in a person's awareness and alertness), major depressive disorder (feelings of sadness), urinary tract infection (bacteria in the urinary tract), anxiety disorder (intense, excessive, persistent worry and fear), restlessness and agitation (feeling uneasy, anxious), insomnia (problems falling or staying asleep), cognitive communication deficit (communication difficultly caused by cognitive impairment) Record review of Resident #1's MDS dated [DATE] revealed Section C- Cognitive patterns a BIMS score of 13 which indicated Resident #1 was cognitively intact. Section D - Mood: B. Feeling down, depressed, or hopeless - yes, 7-11 days. D. Feeling tired or little energy - yes, 7-11 days. Section F - daily preferences - F. how important is it to you to have your family or a close friend involved in discussions about your care? 1-Very important Record review of Resident #1's comprehensive care plan dated 12/05/25 revised on 01/24/25, revealed the resident has history of verbal outbursts and physical aggression when getting care done. Goal: Resident #1 will demonstrate a reduction in aggressive behaviors during care. Approach: Staff will maintain a calm, non-threatening presence. Talk the resident through the whole care process. Psychosocial well-being, Goal: Resident #1 will express/exhibit satisfaction. Approach: Allow to express feelings, keep topics of conversation light and cheerful, listen carefully and be non-judgmental. Mood state: Resident #1 has history of depression and anxiety. Goal: Resident #1 will express/exhibit satisfaction. Approach: Be reassuring and listen to concerns. Record review of Resident #1's psychological evaluation visit note dated 01/03/25, revealed Resident #1 was seen for adjustment difficulty, anxiety, depression/sadness, long-term memory problems, short-term memory problems and sleep disturbance. Resident #1 reported she was very nervous and anxious all the time, and nothing helped to calm her nervous. Resident #1 reported she felt on edge, and highly irritable, she only slept about three hours a night. Resident #1 contributed her uncontrolled anxiety with separation from her son and home. Record review of written statement dated 01/24/25 from CNA B, revealed Resident #1 was screaming and asking for her Family Member. I stated that it was 2:30 AM and that Family Member was sleeping. I reassured Resident #1 that Family Member would be back as soon as Family Member woke up. During an interview on 2/4/2025 at 3:15 PM with Resident #1, she was unable to answer any questions regarding the events from the night of 01/24/25. During an interview on 02/05/25 at 12:26 PM with the ADM, she stated Resident #1 had the right to call Family Member at 2:00 AM and CNA B should have let Resident #1 call her Family Member. During an interview on 02/05/25 at 2:50 PM with Family Member, he stated if Resident #1 wanted to call him at 2:00 AM, 3:00 AM, 4:00 AM, he would be fine with that, he wanted the facility to let her call him at any time. He stated Resident #1 could not recall the incident however thought if she could, it would have bothered her that CNA B did not let her call him. He stated that Resident #1 usually wanted to call him because she was afraid when away from him and needed reassurance from him. During an interview on 02/05/25 at 3:50 PM with CNA B, she stated on 01/24/25 around 2:00 AM she was doing her rounds and heard Resident # 1 yelling out. She stated she entered Resident #1 room and Resident #1 yelled she wanted to call (Family Member) . She stated she told Resident #1 no because (Family Member) is at home and asleep. CNA B stated Family Member had never told her not to call in the night, and in the past, they had called Family Member when Resident #1 was upset or refusing care. During an interview on 02/05/25 at 5:24 PM with NP, she stated Resident #1 should have been allowed to call Family Member. Family Member was awake and there for Resident #1. She stated the situation could have been handled differently, and not allowing Resident #1 to call her Family Member could have increased her anxiety. During an interview on 02/05/25 at 6:21 PM with LVN E, she stated she was in the room, providing care for Resident #1 with CNA D . She stated Resident #1 yells out during care because she is afraid, she will fall. She stated CNA B entered the room and started to talk to Resident #1. She stated Resident #1 wanted to call her Family Member, and CNA B stated not at this hour it's 2:00 in the morning. Record review of a progress notes dated 01/24/25 revealed LSBW observed Resident #1 in her room. She was resting peacefully with no signs of distress. Family Member was also in room. Family Member advised that Resident #1 reported that she had no recollection of any problems or concerns during the previous night. Family Member reported that Resident #1 had been refusing medication and that she resists care and at times becomes combative during care, especially in the mornings. Family Member stated Resident #1 is hard of hearing and tonal adjustment is required in order for Resident #1 to hear. Record review of the facility's policy titled; Resident Rights dated 2001 revised date February 2021 Policy Statement Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to b. be treated with respect, kindness, and dignity e. self-determination f. communication with and access to people and services, both inside and outside the facility. aa. visit and be visited by others from outside the facility. cc. access to a telephone, mail, email.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 of 7 residents (Resident #1) reviewed for hygiene, in that. 1. The facility failed to provide incontinence care on three separate opportunities for Resident #1 on 1/26/2025. These failures could place residents at risk for skin breakdown and infections. Findings include: Record Review of Resident #1's undated face sheet revealed a [AGE] year-old female originally admitted to the facility on [DATE]. Resident #1 had a medical history of nondisplaced fracture of third cervical vertebra (fracture of bones in the neck), anxiety disorder, major depressive disorder, restlessness and agitation, type 2 diabetes, hypertension (high blood pressure) and chronic pain. Record Review of Resident #1's MDS dated [DATE] revealed Section C- Cognitive patterns a BIMS score of 13 which indicated Resident #1 was cognitively intact. Section GG- Functional Abilities revealed resident was Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity, for personal hygiene, toileting hygiene and toilet transfer. Section GG- Functional Abilities revealed Resident #1 required Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort for rolling left to right, sit to lying and lying to sitting on side of bed. Record Review of Resident #1's care plan revealed a problem of Functional urinary incontinence R/T Dementia created on 1/28/2025. Resident #1's care plan revealed an approach of apply moisture barrier to skin and Provide incontinence care after each incontinent episode. Record Review of Resident #1's grievance form dated 01/27/2025 revealed: Person making complaint and relationship to resident: Resident #1's family member. Detail of Complaint/Grievance: Stated Resident #1 sat in poop for about two hours. Date Complaint/Grievance occurred: 01/26/2025. What shift did the complaint/grievance occur? 3-11pm . .Summary statement of grievance: Resident #1's family member was disappointed in call light response time and stated Resident #1 needed to go to the restroom and had BM (bowel movement) on her for about 2 hours . Summary of pertinent findings or conclusions: Resident #1 pushed the call light three times before Resident #1's needs were met . .Decision: Grievance was confirmed: In service conducted with staff by ADM and DON over call light response time, not turning off call light until service is completed. During an interview with Resident #1's family member on 2/4/2025 at 11:21 AM, he stated the other day, he had called to have Resident# 1 go to the bathroom and the CNA stated she would be right back and turned off the call light. He stated about 15 minutes later he called again, and the CNA stated they were pretty busy, but she would try to find somebody to help her. He stated she did eventually come back but he was not sure how long it had been. He stated the first time he called Resident #1 was not wet and did not have a bowel movement. He stated after that, she was wet and did have a bowel movement and at that point she needed to be changed. During a second interview with Resident #1's family member on 2/5/2025 at 2:50pm he stated he remembers calling the first time around 7pm, it may have been 6:45pm, and the CNA did not come back. He stated she came into the room said, I'll be right back and turned off the call light. He stated he hit the call light again, and she came back and said, I'm going to turn off the call light and be back in a minute. He stated it took her longer to come back after the second time he pushed the call light button. He stated he rang it a third time and she was already on her way back with a second person and the CNA had stated they were pretty busy. He stated they changed her around 8:45pm- 8:50pm. He stated that day Resident #1 was telling him she needed to use the bathroom. Resident #1's family member stated Resident #1 does not remember how she felt but he believes she would have been upset because she does not like to sit in a dirty brief. He stated he felt that this was neglect. He stated he did not remember the CNA's name and did not recall the exact date. During an interview with Resident #1 on 2/4/2025 at 3:15pm, Resident #1 was unable to answer any questions regarding the events from night 1/26/2025. During an interview with the ADM on 2/5/2025 at 12:28pm, she stated Resident #1's call light was pushed by the son. The ADM stated, CNA A had stated she was getting her rounds together and she would try to find a second person. The ADM stated she was told that he called again and at that time, the CNA's were under the impression that she had not gone yet, and CNA A was trying to find someone. CNA A was then pulled by the smoking residents to be taken outside to smoke. She stated, then CNA C told CNA A that Resident #1 had a bowel movement and when CNA A came back from smoking, they went to change her. The ADM stated staff were not trained to prioritize resident smoke breaks over providing resident care. She stated she expected the CNA's to find assistance in a timely manner. She stated when she spoke to CNA A, she said she was doing the best she could, and CNA A apologized several times and stated every resident was just as important. The ADM stated there had been three opportunities for Resident #1's needs to be met. The ADM stated they did in-services on call lights and abuse and neglect on 1/27/2025. During an interview with FNP on 2/5/2025 at 5:24pm, she stated she expected the staff at the facility to provide resident care immediately. She stated she was aware it was not always possible to attend to residents immediately but being left in a dirty brief was unacceptable. She stated residents being left in a dirty brief could increase the risk of infection or skin breakdown. During an interview with CNA C on 2/5/2025 at 7:49 pm, she stated she was working on 1/26/2025. She stated she was working with three other CNA's including CNA A. CNA C stated she had been working 100 hall that night and saw the call light going off in 200 hall. She stated CNA A asked if CNA C could assist her in changing Resident #1. CNA C stated she was unable to at that moment because she had another resident, she was providing care for. She stated she did see the call light go off again for hall 200 and about 30 minutes later she saw it go off again. She stated she went to answer the call light and Resident #1's family member stated, she needs to be changed. CNA C stated she told him they would come change Resident #1, but they were very busy. She stated CNA A was assigned to do the 8:30pm smoke break, and CNA A did take the residents out to smoke. She stated around the time of the smoke break, she became available to assist CNA A with her residents. CNA C stated her, and CNA A went into the room to change Resident #1 and Resident #1 was happy and Resident #1's family member was okay. CNA C stated they did apologize and Resident #1's brief was barely dirty and wet. CNA C stated CNA A's Hall is very heavy, and the other CNAs don't always offer to help. CNA C stated everyone was busy that night with call lights and resident care. CNA C stated she does not believe Resident #1 can tell when she has to go to the bathroom. She sated stated there have been times when Resident #1's family member will state Resident #1 needs to go to the bathroom and when they go in, Resident #1 will ask What are you doing? I don't need to go to the bathroom. CNA C stated Resident #1 does not use the bedpan or the bedside commode because she does not always know when she has to go. CNA C stated resident was incontinent and wears briefs. CNA C stated she has been trained on abuse and neglect and did not feel that CNA A's actions were neglectful. Record Review of document titled Provider Investigation Report dated 1/31/2025 revealed the following statement by CNA A, CNA C and LVN F: Interviewee's Name: CNA A . .2. Please explain fully what you know of the incident: Resident #1's family member stated that Resident #1 needed to go to the restroom. I informed him I had to wait for a 2nd person. Call light went off again and Resident #1 was saying she needed to go to restroom. CNA A stated the smokers then wanted to be taken out. When CNA A came inside, CNA C stated Resident #1 had a BM. We then changed her. 3.About what time did it happen? Around 7ish .5. Do you have any knowledge about possible causes of the incident? It was a cluster of events. Interviewee's Name: CNA C . .2. Please explain fully what you know of the incident: I was working my hall when I answered Resident #1's call light since CNA A was with the smokers. Resident #1's family member stated Resident #1 had a BM. When CNA A came back inside and I saw her, I asked her if she needed help with Resident #1. We then change her. The BM was fresh. 3.About what time did it happen? during 1st rounds. .5. Do you have any knowledge about possible causes of the incident? We are all busy during shift changes and getting residents ready for bed and changed. We did the best we could. Interviewee's Name: LVN F . .2. Please explain fully what you know of the incident: When I was doing my PM med pass, I went into Resident #1's room and did my assessment with her. She didn't voice any concerns. Call light was not on .Resident #1's family member stated Resident #1 had BM and needed to be changed .LVN F stated the aid is in the next room and if Resident #1's family member would like the door left open or closed he stated closed, and I told CNA A. 3.About what time did it happen? Around 8 pm Record review of facility document titled Topic: Call Light response time/Grievances/Abuse Instructor: ADM/DON, Date Inservice initiated: 1/27/2025 revealed: Call light response time. Anyone is able to answer a call light, no one should walk past a call light going off. If you go into a room and are unable to provide the service, you need to make sure the leave the call light on. Do not turn off the call light if the resident still needs help. Record review of facility policy titled Answering the Call Light last revised on March 2021, revealed: Purpose The purpose of this procedure is to ensure timely responses to the resident's requests and needs. .Steps in the Procedure . 2. a. If the resident needs assistance, indicate the approximate time it will take for you to respond. b. If the resident's request requires another staff member, notify the individual. c. If the resident's request is something you can fulfill, complete the task within five minutes if possible. d. If you are uncertain as to whether or not a request can be fulfilled or if you cannot fulfill the resident's request, ask the nurse supervisor for assistance.

Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 7 of 15 confidential residents. The facility failed to ensure 7 confidential residents were provided, through postings in prominent locations, the Grievance Procedure, was provided access to the Grievance form, was provided information who the facility grievance official was, their contact information, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings include: Interviews and record review during Resident Council on, 10/28/2024 at 10:00 a.m., 7 confidential residents, stated they did not know the grievance process, they did not know where to obtain or submit a grievance form, they did not know they could file a Grievance anonymously, the Grievance procedure had never been discussed in Resident Council, and they had not observed a posting of the Grievance procedure in prominent locations. Residents attending the group meeting did not know how to file a grievance. Residents did not know where to acquire a grievance form, who to turn the form into, and what happens once a grievance was filed. The residents did not know they had the right to receive a written decision once their grievance was resolved. Seven residents in attendance had all been residents of the facility for 6 plus months. Record review of the facility Grievance policy on 10/29/2024 at 11:05 a.m., revealed a copy of the Grievance/complaint procedure should be posted on the prominently in the facility. Observation of prominent postings on 10/29/2024 at 11:30 a.m., indicated the facility did not include instructions regarding the Grievance procedure with any of the prominent postings. Grievance forms were not available to residents and there was no access to submit a Grievance anonymously. Interview with the ADM on 10/29/2024 at 12:05 p.m., the ADM stated she was the Grievance Officer for the facility. The ADM stated the Grievance form was kept in her office and the office of the Social Worker. The ADM stated she had been employed at the facility for 6 days; therefore, she has not addressed any Grievances to date. The ADM stated from reviewing the Grievance notebook it was apparent to her the Social Worker and the ADM address the Grievances. The Grievances were completed when a Resident comes to her or another staff member with a complaint, and/or if complaints were voiced in Resident Council. The ADM stated the Grievance Procedure was not posted for residents. The ADM stated the residents cannot file a Grievance anonymously due to the residents not having access to the Grievance form and having no means of submitting a Grievance form anonymously. The ADM stated she was responsible for assigning a Grievance to a staff member to address, she stated her expectation was Grievances be resolved as soon as possible. The ADM stated residents who voice a complaint were interviewed by the staff member assigned to resolve the Grievance; she stated this was the first step in resolving the Grievance. These interviews were documented on the Grievance form. The ADM stated the resolution to the Grievances were documented on the Grievance form. The ADM stated the resolution to Grievances was discussed with residents face to face. The ADM stated would monitor the Grievance process for success by following up with the staff member assigned to resolve the Grievance, the ADM stated she would also meet with the complainant to ensure they were satisfied with the resolution. The ADM stated she was responsible for ensuring staff were trained on the Grievance process. The ADM stated she was not aware the Grievance procedure was not being discussed in Resident Council. Interview with the Social Worker on 10/29/2024 at 1:25 p.m., the SW stated process for completing a Grievance included talking to the resident with a complaint, the SW completing the Grievance form, assigning the Grievance to the appropriate Department head, that Department head investigating and solving the Grievance, and emailing the ADM a copy of the Grievance with the interviews documented as well as the resolution. The SW stated the Grievance form was available at the nurses' station, the SW's office, and the ADM's office if the residents ask for the form. The SW stated the forms were not available for the residents to complete without asking the staff for a form. The SW stated there was no confidential manner for a Grievance to be submitted anonymously. The SW stated the timeframe for addressing a Grievance was as soon as possible, she stated Grievances were discussed at every morning meeting. The SW stated the resident who filed a Grievance should be interviewed by the Department hired to complete the Grievance and this interview would be documented on the Grievance form. The SW stated the resolution to the Grievance should be documented on the Grievance form by the Department head who addressed the Grievance. The SW stated the ADM was responsible for ensuring the Grievance was addressed. The SW stated the ADM was responsible for the education of staff on. the Grievance procedure. The SW stated there was no potential harm to residents if the Grievance procedure was not discussed in Resident Council, there was no potential harm to residents if Grievances were ignored, there was no potential harm to residents if they were not offered an avenue to file a Grievance anonymously, and there was no potential harm to residents if the Grievance procedure was not displayed for residents. The SW stated there was an open-door policy throughout the facility; therefore, residents can discuss any issues they have with staff informally, a formal Grievance does not need to be filed. Record review of the Grievance Policy revised 1/12/2023 indicated: Policy Statement: All grievances filed with the facility will be investigated and corrective action will be taken to resolve the grievances. Policy Interpretation and Implementation: The facility will make the information for filing a grievance available to residents and their representatives. The ADM will assign the responsibility of investigating the grievance. Each Resident Grievance form will include the date, time, and details of the grievance. The Grievance forms will be maintained all Grievances and evidence related to the Grievance for three years. The Grievance will be resolved within three working days. The Resident or their Representative will be informed of the finding of the Grievance and any corrective action taken within three working days of the filing of the Grievance.

Based on observations, interviews, and record review the facility failed to, in accordance with State and Federal laws, ensure all drugs and biologicals were stored properly in the treatment cart for 1 of 1 treatment carts observed for drug storage. The facility failed to ensure 2 bottles of wound cleaners was not left on top of the treatment cart unattended. This failure could place residents at risk of access and ingestion of non-narcotic medications. The findings were: During an observation on 10/28/24 at 03:45 PM, LVN A prepared wound care supplies on the treatment cart outside of resident's room. LVN A gathered supplies leaving 2 bottles of wound cleaners on top of treatment cart and entered resident's room. LVN A closed the door to resident's room. During an observation on 10/28/24 at 03:50 PM, the wound cleanser bottle on top of treatment care reflected the following warnings: Keep out of reach of children. If swallowed seek medical attention or call a Poison Control Center. During an interview on 10/28/24 at 03:52 PM, LVN A stated she should not have left the wound cleaners on top of the treatment cart. She stated the wound cleaner's bottle did state Keep out of reach of children. She stated she did not have a reason for leaving the 2 bottles of wound cleaners on top of treatment cart except she just forgot to put it back in the treatment cart. She stated she had been trained on proper medication and supply storage. She stated the potential negative outcome could be a resident opening the bottle and drinking the solution. She stated some could also tamper with the solution adding to it or pouring the solution out. During an interview on 10/29/24 at 10:15 AM, the DON stated the wound cleaner was considered a medication. She stated the nurse was responsible for making sure they store medication and supplies in a locked cart. She stated they all have been trained. She stated the potential negative outcome could be someone drinking the solution, contaminating the solution, or spraying the solution on someone. During an interview on 10/29/24 at 10:35 AM, the ADM stated the wound cleaner should not be stored on top of the treatment cart. She stated all staff have been trained. She stated the DON and ADON were responsible for monitoring storage of medications and wound care supplies. She stated the potential negative outcome could be a resident ingest the solution and could cause harm. Record review of facility policy titled Storage of Medications revised November 2020 reflected the following: Policy: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only persons authorized to prepare and administer medications have access to locked medications .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care, were provided such care, consistent with professional standards of practice for 2 (Residents #40 and #114) of 2 residents reviewed for respiratory care. 1. The facility failed to ensure that Resident #40 and Resident #114's oxygen tubing was replaced every week on Sunday, according to physician's orders. These failures could place residents at risk for respiratory compromise and infection. Findings included: Resident #40 Record review of Resident #40's clinical record reflected a face sheet, dated 10/28/24, which indicated the resident was an [AGE] year-old female admitted to the facility on [DATE]. Resident #40's diagnoses included chronic obstructive pulmonary disease (lung disease) and dementia (memory loss). Record review of Resident #40's annual MDS dated [DATE] revealed a BIMS score of 04, indicating the resident had severe cognitive impairment. Section O - Special Treatments, Procedures and Programs revealed Resident #40 used oxygen therapy while a resident. Record review of Resident #40's comprehensive care plan, dated 09/26/24, revealed Resident #40 required oxygen therapy related to COPD. Record review of Resident #40's current Physician Orders dated 10/28/24 revealed an order to change oxygen tubing, cannula/mask once a week on Sunday. During an observation on 10/28/27 at 11:10 AM, Resident #40 had oxygen being administered at 3 liters/minute via nasal cannula. Oxygen tubing was not dated. Ziplock bag on oxygen concentrator was dated 10/20/24. Resident #114 Record review of Resident #114's clinical record reflected a face sheet, dated 10/28/24, which indicated the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #114's diagnoses included congestive heart failure (decrease pumping power of the heart muscle), chronic respiratory failure, diabetes (high blood sugar), and lung cancer. Record review of Resident #114's annual MDS dated [DATE] revealed a BIMS score of 14, indicating the resident had no cognitive impairment. Section O - Special Treatments, Procedures and Programs revealed Resident #40 used oxygen therapy while a resident. Record review of Resident #114's comprehensive care plan, dated 10/15/24, revealed Resident #114 required oxygen therapy related to decreased cardiac output. Record review of Resident #40's current Physician Orders dated 10/28/24 revealed an order to change oxygen tubing, cannula/mask once a week on Sunday. During an observation on 10/28/27 at 10:32 AM, Resident #114 had oxygen being administered at 4 liters/minute via nasal cannula. Oxygen tubing was not dated. During an interview on 10/29/24 at 10:15 AM with the DON, she stated oxygen tubing should be changed and dated weekly on Sunday. She stated she had agency nurses working on Sunday. She stated all staff have been trained. She stated the ADON and DON were responsible for monitoring compliance. She stated the potential negative outcome was infection control. During an interview on 10/29/24 at 10:35 AM with the ADM, she stated oxygen tubing should be changed according to the physician orders. She stated the tubing should be changed. She stated the nurses, ADON and DON were responsible for monitoring compliance with changing tubing and dating the tubing. She stated the potential negative outcome could be increase negative consequences to the resident related to infection. Record review facility policy titled Departmental (Respiratory Therapy) - Prevention of Infection, revised November 2011 reflected the following: Purpose - The purpose of this procedure is to guide prevention of infection associated with respiratory therapy tasks and equipment, including ventilators, among residents and staff . Infection Control Considerations Related to Oxygen Administration . 7. Change the oxygen cannulae and tubing every seven (7) days, or as needed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that its medication error rates are not 5 percent (%) or greater. The facility had a medication error rate of 20% based on 6 out of 30 opportunities, which involved 2 of 4 residents (Residents #58 and #55) reviewed for medication administration, in that: 1. The facility failed to ensure Resident #55 had Xifaxa n (helps prevent a brain condition that can occur with severe liver disease )550mg, available for administration, resulting in a missed dose. 2. Med Aide C failed to verify the dosage and amount on Resident #55's Lactulos e (treats constipation) resulting in Resident #55 being underdosed. 3. Med Aide C failed to verify the dosage for Resident #58's Magnesium 200mg (treats low magnesium levels), and thiamin B1 (treats low thiamine) 50mg resulting in an incorrect dose given. 4. Med Aid C failed to verify physician order for Resident #58's Multivitamin resulting in the incorrect multivitamin given. 5. Med Aid C administered Ferrous Sulfate (treats low iron) 325mg, without a physician order to Resident #58. These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health. Findings included: Resident #55 During a medication administration observation for Resident #55 on 10/28/2024 at 7:30 AM, Med Ai d C poured 15mL of Lactulose into a measuring cup and administered, she did not give Xifaxan 550 mg tablet, it was unavailable. Record review of Resident #55's undated face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #55 had a medical history of toxic encephalopathy (a neurologic disorder caused by exposure to neurotoxic organic solvents), hypertension (high blood pressure), and alcoholic cirrhosis of liver with ascites (a condition where the liver is scarred due to chronic alcohol use, and fluid builds up in the abdomen). Record review of Resident #55's physician orders revealed an order for lactulose solution 10 gram/15 mL (15 mL); amt: 30 mL BID; oral with a start date of 9/11/2024 to be given between 7AM-10AM and 7PM-10PM. Physician orders also revealed an order for Xifaxan (rifaximin) tablet; 550 mg; amt: 1 tab PO BID; oral with a start date of 9/12/2024 to be given 7AM-10AM and 7PM-10PM. Resident #58 During a medication administration observation on 10/28/2024 at 7:41 AM , Med Aid C administered the following medications to Resident #58: - One-Daily multi-vitamin, 1 tablet -ferrous sulfate 325mg, 1 tablet; -Magnesium 400mg, 1 tablet; and -thiamine 100mg, 1 tablet. Record review of Resident #58's undated face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #58 had a medical history of disorders of phosphorus metabolism (abnormal levels of phosphorus which can result in various other conditions), schizophreniform disorder (short-term mental health condition that causes psychosis), and hypomagnesemia (low magnesium levels). Record review of Resident #58's physician orders revealed the following active orders: thiamine HCl (vitamin B1) 50 mg, 1 tab PO, QD with a start date of 12/09/2023. magnesium 200mg, 1 tablet, twice a day with a start date of 1/1/2024. Adults Multivitamin (multivitamin-min-iron-fa-vit k) 18 mg iron-400 mcg-25 mcg with a start date of 12/09/2023. Record review of Resident #58's physician orders did not reveal an order for Ferrous Sulfate 325mg. During an interview on 10/28/2024 at 12:03 PM, the Med Aid C stated she gave 15mL of Lactulose to Resident #55 and verified the order stated 30mL. The Med Aid C stated she gave Resident #58 Magnesium 400mg and verified the order was for 200mg of Magnesium. The Med Aid C stated she gave Resident #58 Thiamin 100mg and verified the order was for 50mg. The Med Aid C stated she gave Resident #58 the One Daily multivitamin and added the iron pill because the facility did not have the ordered Adults Multivitamin (multivitamin-min-iron-fa-vit k) 18 mg iron-400 mcg-25 mcg. The Med Aid C stated she had been trained to verify orders and on medication administration rights. She stated her last training was in March 2024 when she was hired. She stated the DON is responsible for her training, but she had been trained by the last med aid who no longer worked at the facility. She stated the previous med aid told her she could supplement the ferrous sulfate 325mg to Resident #58's multi-vitamin since they did not have the right one. The Med Aid C stated she could have cut the Magnesium and Thiamin pills in half to give him the correct dose, but she was nervous and forgot. She stated she had been trained to cut the pills in half if needed. The Med Aid C stated did not know what the potential negative outcome of giving a medication without an order could be. The Med Aid C was unable to verbalize the potential negative outcomes for medication errors. She stated she knew her five rights of medication administration which were the name, time, pill, dose, and documentation. The Med Aid C stated she had been trained to report medication errors to the DON. The Med Aid C reported the medication errors to the ADON. During an interview on 10/29/2024 at 10:26 AM, the ADM stated the ADON and DON were responsible for training the nurses and med aides on medication administration. She stated the potential negative outcome of medication errors and residents not receiving their medication regimen could be any adverse effect and a negative consequence on the resident's health. The ADM stated she was not aware of the Med Aid C giving an iron tablet without an order. She stated staff is not trained to give any medication without an order. The ADM stated the nurses and med aids should follow their five rights of medication administration. During an interview on 10/29/2024 at 10:54 AM with the Clinical Resource Nurse and the ADON, the ADON stated the DON and ADON were responsible for training the nurses and med aids on medication administration. The ADON stated she was not sure when the last training was as she had just been hired at this facility, but she would be providing in-services on medication administration. The Clinical Resource Nurse stated that nursing staff and med aids were trained on the five rights of medication administration and the Med Aid C would be doing a training on medication administration. The Clinical Resource Nurse and ADON stated that a potential negative outcome of residents not receiving their ordered medication could be any adverse effect such as, depending on the type of medication, could be low blood pressure if it's a blood pressure mediation. The ADON stated she was not aware that the Med Aid C had been adding any supplemental medication to Resident #58's multi-vitamin. The ADON stated the nursing staff is not trained to do that without a physician order. The ADON stated the nursing staff and med aids were trained to verify the order and medication and if they do not match, they were to let the charge nurses, ADON and DON know in order to notify the physician for verification or to obtain the correct medication. Record review of facility policy titled MEDICATION ADMINISTRATION-GENERAL GUIDELINES dated 6/1/2022 revealed: A .4) FIVE RIGHTS - Right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. A triple check of these 5 Rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away . 6) Tablet Splitting: Splitting of tablets should be avoided and every attempt should be made to obtain an alternative dosage form, medication, or dosing schedule to avoid splitting. If breaking tablets is ultimately necessary to administer the proper dose, hands are washed with soap and water or alcohol gel (and examination gloves worn) prior to handling tablets and examination gloves must be worn to prevent touching of tablets during the process. The following guidelines are followed: a. Assure the tablet is appropriate and able to be split . b. A tablet-splitter is used to ensure accuracy and to minimize contact with the tablet. The splitter blade and surface contacting tablet are cleaned before and after each use. If the tablet is scored, every attempt is made to break along score lines . B .2.) Medications are administered in accordance with written orders of the prescriber.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: 1. The facility failed to store and date foods stored in the refrigerator. 2. The facility failed to store pans upside down on shelfs. These failures could place residents at risk for food contamination and foodborne illness. The findings included: The following observations were made on 10/27/24 at 09:45 AM, during initial observation of the kitchen: Observed the following: Inside the Refrigerator: Three trays with individual deserts in bowl uncovered and no date. -A bowl of puree food covered with plastic wrap with no date. -Two half sandwiches in plastic wrap with no date. Shelf: -One large pot laying on side on bottom shelf in pantry. -Three small pans stored right side up on shelf in kitchen. During an interview on 10/29/24 at 10:35 AM with the ADM, she stated all food should be stored covered and dated. She stated pots/pans should be stored upside down. She stated all kitchen staff have been trained. She stated the DM was responsible for monitoring the kitchen. She stated the potential negative outcome could be harm to the resident. During an interview on 10/29/24 at 10:45 AM with the DM, she stated all food items in the refrigerator needs to be dated and in a sealed container. She stated all pots and pans should be stored upside down on the shelf. She stated all staff have been trained. She stated the DM was responsible for monitoring storage of food and pots and pans. She stated the potential negative outcome of not properly storing food was you do not know how long it has been in refrigerator and could be given to a resident causing them to get sick. She stated the potential negative outcome for not properly storing pots/pans could be the pots/pans could get debris in them and mix with the food. Record review of the facility policy, titled Food Storage, undated reflected the following: Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. Procedure: . 2. d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approve for food storage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 2 of 2 residents (Residents #4 and #38) and 2 of 2 (LVN A and LVN B) staff reviewed for infection control. LVN A failed to wash hands between glove changes during wound care for Resident #38. LVN B failed to wash or sanitize hands after reaching in his pocket and prior to starting wound care. These failures could place residents at risk for spread of infection and cross contamination. Findings include: Resident #4 Record review of Resident #4's clinical record reflected a face sheet, dated 10/29/24, which indicated the resident was a [AGE] year-old female admitted to the facility on [DATE]. Resident #4's diagnoses included dementia (loss of cognitive functioning, thinking, remembering, and reasoning) unspecified open wound right foot (break in the skin exposing underlying tissue), and cellulitis of lower limbs (bacterial infection that affects the deep layers of the skin and underlying tissue). Review of Resident #4s Comprehensive MDS Assessment, dated 09/20/24, reflected the resident was cognitively intact with a BIMS score of 12 . Resident #4 functional abilities and goals reflected resident #4 required substantial/maximum assistance with toileting, upper body dressing and personal hygiene. Resident #4 skin conditions reflected number of stage 4 pressure ulcers as 1, and number of pressure ulcers present at time of admission/entry or reentry as 1. Record review of Resident #4's care plan dated 09/23/24 reflected resident had a pressure ulcer infection on right heel. Approach - use aseptic techniques (disease-free, sterile, uninfected) when preforming dressing changes. Dress and cover wound before dressing other wounds, washing hands and observe aseptic technique. Record review of Resident #4's physician orders dated 10/28/24 reflected Wound Treatment Order: Location: Right heel - clean with wound cleanser, apply calcium alginate, cover with Silicone Foam Dressing once a day on Mon., Wed., Fri., dated 10/24/24. During an observation on 10/28/24 at 3:35 PM, reflected LVN B provided wound care for Resident #4. LVN B reached in his pocket with the gloves on and removed alcohol packets from his pocket and tossed them on the over bed table on the clean alginate. He opened an alcohol pad cleaned around the wound where the previous bandage was. He reached over and moved the alcohol prep packets off the alginate and placed the alginate on the adhesive bandage and placed it over the wound. During an interview on 10/28/2024 at 4:05PM, LVN B stated he performed wound care when the wound care nurse was not at the facility or if he noticed wound care needs to be completed. He stated that he should have changed gloves and sanitized his hands after he reached in his pocket and removed the alcohol wipe packages. He stated that when he tossed the alcohol wipe packages on the over bed table on the parchment paper and alginate, then placed the alginate over the wound it could have caused an infection. He stated he should have stopped the wound care procedure after he reached in his pocket and grabbed the alcohol wipe packets , then washed his hands and started the wound care over. He stated he was an agency nurse and had not received training on wound care form the facility. Resident #38 Record review of Resident #38's clinical record reflected a face sheet, dated 10/28/24, which indicated the resident was a [AGE] year-old male admitted to the facility on [DATE]. Resident #38's diagnoses included osteomyelitis of vertebra (bone infection), spinal stenosis (narrowing of the spinal canal), hypertension (high blood pressure), and congested heart failure (decrease pumping power of the heart muscle). Review of Resident #38s Comprehensive MDS Assessment, dated 09/26/24, reflected the resident was cognitively intact with a BIMS score of 14 . Resident #38 functional abilities and goals reflected resident had impairment on one side upper and lower. Resident #38 used a wheelchair. Resident #38 requires substantial/maximal assistance with toileting, showering, dressing and personal hygiene. MDS skin conditions reflected Resident #38 had a risk for developing pressure ulcers and had one diabetic ulcer and 1 surgical wound. Record review of Resident #38's care plan dated 09/23/24 reflected no care plan for wounds. Record review of Resident #38's physician orders dated 10/28/24 reflected Wound Treatment Order: Location: Right buttocks clean with normal saline/wound cleanser, pat dry, apply calcium alginate, cover with Opti foam once a day on Tue., Thu., Sat., dated 10/22/24. During an observation on 10/28/24 at 03:45 PM, revealed LVN A cleaned Resident #38's right buttock wound with wound cleanser and gauze and patted dry with gauze. LVN A removed gloves and donned new gloves. LVN A did not wash hands or use ABHR when changing gloves between dirty and clean. LVN A applied calcium alginate to wound bed and covered with Opti foam. During an interview on 10/28/24 at 03:52 PM with LVN A, she stated she should have washed her hands with soap and water or ABHR between gloves changes. She stated there was no reason why she did not wash her hands or use ABHR. She stated she had been trained on infection control and hand washing. She stated the potential negative outcome could be spread of infection to the resident or herself. During an interview on 10/29/24 at 10:40 AM with the Interim DON, she stated hands should be washed with soap and water or ABHR between glove changes. She stated the staff have been trained on handwashing and infection control. She stated the ADON was the infection preventionist. She stated the DON and ADON was responsible for monitoring staff for infection control. She stated the potential negative outcome could be spreading infection . Record review Hand Hygiene Competency Validation, dated 09/11/24 for LVN A, reflected competency goals met. Record review facility policy titled Handwashing/Hand Hygiene, undated reflected the following: Policy statement - This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation . 5. Hand hygiene must be performed prior to donning and after doffing gloves.

Based on interviews and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week in the facility for 10 (4/13, 4/14, 4/28, 5/18, 5/19, 5/26, 6/15, 6/16, 6/23, and 6/29/2024) of 91 days reviewed for RN coverage. The facility failed to maintain RN coverage of eight hours a day for 10 days 4/13, 4/14, 4/28, 5/18, 5/19, 5/26, 6/15, 6/16, 6/23, and 6/29/2024). This failure could place residents at risk of not having their nursing and medical needs met and receiving improper care. Findings included: Record review of the CMS report PBJ Staffing Data Report dated 10/23/24 reflected no RN hours for 4/13, 4/14, 4/28, 5/18, 5/19, 5/26, 6/15, 6/16, 6/23, and 6/29/2024. Record review of the facility''s employee survey roster undated reflected there were seven RNs employed at the facility. Record review of Schedule Sheet dated April 2024 reflected RN A was scheduled to work on (4/13, 4/14, and 4/28/2024). Record review of Schedule Sheet dated May 2024 reflected RN A was scheduled to work on (5/18, 5/19, and 5/26/2024). Record review of Schedule Sheet dated June 2024 reflected RN A was scheduled to work on (6/15, 6/16, 6/23, and 6/29/2024). During an interview on 10/29/24 at 01:00 PM with HR, she stated the previous DON did not clock in or out because she was salary. She stated she was not sure how her time was reported. She stated corporate submits time to CMS for the PBJ but she was not sure how it was done or submits it. During an interview on 10/29/24 at 02:00 PM, the DON stated the previous DON was scheduled to work 4/13, 4/14, 4/28, 5/18, 5/19, 5/26, 6/15, 6/16, 6/23, and 6/29/2024. She stated she was not sure why her hours were not reported. She stated there had been several turnovers in staff at the corporate level and someone just dropped the ball. She stated the ADON and DON were responsible for scheduling the RN coverage. She stated the potential negative outcome for not having an RN eight hours a day could be not having someone to lead and direct the LVN staff related to resident assessment who might need to be sent out to the ER. During an interview on 10/29/24 at 02:00 PM, the corporate resource nurse stated he was not aware there was no RN coverage for 4/13, 4/14, 4/28, 5/18, 5/19, 5/26, 6/15, 6/16, 6/23, and 6/29/2024. He stated the previous ADM did tell him she was worried about RN coverage because there were several days, they did not have coverage. He stated he did not know what days she was referring to. During an interview on 10/29/24 at 02:15 PM, the ADM stated it was the policy to have an RN 8 hours a day 7 days a week. She stated she was not aware of not having RN coverage as she was not in the building at that time. She stated they currently have RN coverage. She stated she was currently working on a new system to track RN hours when the coverage was done by a salaried RN that does not clock in. She stated the potential negative our come of not having an RN in the building 8 hours a day 7 days a week could be missing assessments and not having leadership for the LVN staff. Record review of the policy provided by the facility titled, Staffing, revised 9/28/23 revealed in part the following: Policy Statement - Our center provides sufficient nursing staff with the appropriate skills and competencies necessary to provide care and related services to ensure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with resident care plans and the facility assessment. Policy and Implementation . 4. The facility utilizes the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week . 7. Direct care staffing information per day (including agency and contract staff) is submitted to the CMS payroll-based journal system on the schedule specified by CMS, but no less than once a quarter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 6 residents (Resident #1 and Resident #2) reviewed for care plans. The facility failed to have a care plan in place to accurately address Resident #1's wound care. The facility failed to have a care plan in place to accurately address Resident #2's oxygen use. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included: Resident #1 Record review of Resident #1's Face Sheet revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Resident #1's diagnoses included Stroke (damage to brain from interruption of blood supply), Traumatic Brain Dysfunction (a disruption in the normal function of the brain), Amputation (surgical removal of a limb), Diabetes Mellitus (a metabolic disease involving inappropriately elevated blood glucose levels), Hypertension (persistently elevated blood pressure), Non-Alzheimer's Dementia (impaired cognition not related to Alzheimer's Disease). Record review of Resident #1's admission MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating Resident #1 was cognitively intact. Section M-Skin Conditions indicated she had surgical wounds and open lesions and requiring wound care, dressings and application of ointments and medications. Record review of Resident #1's Care Plan dated 06/20/24 indicated wound care was not included on this plan. Record review of Resident #1's Physician's Orders dated 06/20/24 revealed order to cleanse bilateral labial (skin folds on each side of vagina) wounds with wound cleanser and apply silver alginate and cover with abdominal pad daily. During an interview on 08/15/24 at 2:30 p.m., the hospital's Registered Nurse, indicated Resident #1 was diagnosed with vaginal cancer upon her admission to the hospital on [DATE], and was scheduled for wound debride on 08/15/24. Observation on 08/15/24 at 3:01 pm of Resident #1, who was awake, revealed she was lying in her bed. Resident #1's wounds were not observed because she was waiting to go to surgery for wound debride. During an interview on 08/15/24 at 3:01 p.m., Resident #1 indicated she responded to the questions asked of her by nodding her head but did not seem to understand the questions . During an interview on 08/16/24 at 12:55 p.m., LVN A indicated Resident #1 upon admission [DATE]) completed a skin assessment, which included an unstageable wound to her labial that was covered with slough. Resident #1 was seen at the wound care clinic on 06/25/24, 07/03/24, 07/09/24, 08/05/24, and 08/06/24. This clinic referred Resident #1 to the oncologist on 08/12/24 who sent her to the hospital. LVN A said Resident 1's wounds were addressed through the wound care clinic, wound care at the facility, and an air mattress was offered to this resident; however, her family refused. During an interview on 08/16/24 at 2:36 p.m., LVN B indicated she assessed and measured Resident #1's wound and provided wound care per physician's orders; however, the wounds did not improve. During a phone interview on 08/16/24 at 3:48 PM, the DON indicated she did not know why the care plan did not address wound care and that she or the MDS Coordinator was responsible for initiating and updating care plans. She stated a potential negative outcome for failure to ensure accuracy of care plans was missing the goal for informed care of residents. During an interview on 08/16/24 at 5:03 PM, the Clinical Resource RN indicated any resident condition or change of condition should have been included in Resident #1's care plan. The RN said the order for wound care, should have been added to the care plan. Resident #2 Record review of Resident #2's Face Sheet she was [AGE] year-old female admitted to the facility 11/28/22. Resident #2's diagnoses included Dementia (thinking and social symptoms that interferes with daily functioning), chronic obstructive pulmonary disease (lung diseases that blocks airflow and makes it difficult to breathe), pneumonia (infection that inflames air sacs in one or both lungs, which may fill with fluid), shortness of breath, altered mental status (changes in awareness, and movement) systolic heart failure (left ventricle is weak and can't contract normally when the heart beats). Record review of Resident #2's Physician Order Report dated 07/22/24 - 08/22/24 indicated the order was changed on 06/18/24 to nasal cannula (continuous) with oxygen at 2 liters a minute on every shift day and night. Record review of Resident #2's Quarterly MDS dated [DATE] revealed she scored a 12 on her BIMS. Section E-Behavior of this MDS indicated she had not displayed behaviors of rejecting her care. Record review of Resident #2's Care Plan dated 06/27/24 and reviewed/revised by the DON on 07/22/24 revealed oxygen therapy via nasal cannula was not included on this plan. Observation and attempted interview on 08/15/24 at 10:34 a.m., indicated Resident #2 was sitting in her wheelchair in her room, she was not wearing her nasal cannula, because she was sitting on the tubing. Resident #2 could not respond to questions asked her about her nasal cannula. During an interview on 08/15/24 at 11:21 a.m., CNA D indicated she assisted Resident #2 from her bed where she was wearing her nasal cannula from the oxygen concentrator. After, she transferred Resident #2 to her wheelchair she switched her to the nasal cannula from her e-tank (aluminum tank that stores supplemental oxygen) that was on her wheelchair. CNA D said Resident #2 had a history of removing her nasal cannula. During an interview on 08/15/24 at 11:51 a.m., CNA E indicated Resident #2 had a history of removing her nasal cannula. During an interview on 08/15/24 at 12:07 p.m., CNA G indicated Resident #2 had a history of removing her nasal cannula. During an interview on 08/16/24 at 3:45 p.m., the DON indicated upon admission of a resident using oxygen, this would be care planned, but if the oxygen was ordered after admission, she would add it to the plan. The DON said she was not sure why it had not been added to the plan. During an interview on 08/16/24 at 3:51 p.m., the Clinical Resource RN, indicated Resident #2's order for using oxygen, should have been added to the care plan. Review of the facility's policy and procedure for Comprehensive Care Plans dated 01/26/24 indicated it was the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the resident's comprehensive assessment. Qualified staff responsible for carrying out the interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. The services provided or arranged by the facility, as outlined in the comprehensive care plan, will meet professional standards of quality, and will be provided by qualified persons in accordance with each resident's written plan of care. Review of the facility's policy and procedure for Care Plans, Comprehensive Person-Centered dated 2001 indicated The care planning process will: describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; incorporate risk factors associated with identified problems; incorporate identified problem areas and incorporate risk factors associated with identified problems. The Interdisciplinary Team must review and updated the care plan: when there has been a significant change in the resident's condition and when the desired outcome is not met.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to ensure assessments accurately reflected the resident status for 1 of 7 residents (Resident #1) reviewed for MDS assessment accuracy. Resident #1's quarterly MDS assessment dated [DATE] was coded incorrectly for wandering reflecting that she did not wander when she had a consistent presence of the behavior (wandering). Resident #1's quarterly Significant Change assessment dated [DATE] was coded incorrectly for wandering reflecting that she did not wander when she had a consistent presence of the behavior (wandering). Resident #1's quarterly and comprehensive assessment did not reflect the behavior for wandering even though staff (ADM, DON, LVN A, LVN B, The Activity Director, CNA C, CNA D, the MDS Coordinator and CNA E) had witnessed her wandering since her admission [DATE]) into other resident room and specifically Resident #2's room. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Review of Resident #1's face sheet (undated) indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had a diagnosis of dementia with agitation (loss of cognitive functioning), generalized anxiety disorder (feelings of worry, tension and fear), and intermittent explosive disorder (repeated, sudden bouts of impulsive of physical or verbal outburst). Resident #1 resided on Hall 100. Review of Resident #1's quarterly MDS dated [DATE] revealed Resident #1 had a BIMS score of 99 which indicated Resident #1 was unable to complete the interview. The MDS Assessment for Resident #1 revealed in section E0900 that the Resident #1 had not exhibited the behavior of wandering. Review of Resident #1's Significant Change MDS dated [DATE] revealed Resident #1 had a BIMS score of 03 which indicated Resident #1's cognition was severely impaired. The MDS Assessment for Resident #1 revealed in section E0900 that the Resident #1 had not exhibited the behavior of wandering. Section E100 did not contain any data regarding the impact of Resident #1 wandering on others. Section E1100 did not capture if Resident #1's wandering had remained the same, worsened or improved. Review of Resident #1's care plan dated 2/15/24 did not reveal a care plan for the behavior of wandering. Review of Resident #1's progress notes did not reveal any ongoing prevention or intervention about Resident #1 wandering. Review of Resident #2's face sheet (undated) indicated Resident #2 was a [AGE] year-old male admitted to the facility on [DATE]. Resident #2 had a diagnosis of hemiplegia and hemiparesis following cerebral infarction (paralysis of partial or total body function and aphasia (language disorder making it difficult to communicate). Resident #2 resided on Hall 500. Review of Resident #2's MDS dated [DATE] revealed Resident #2 had a BIMS score of 06 which indicated Resident #2 cognition was severely impaired. An interview on 03/06/24 at 10:32 AM with the ADM revealed an incident between Resident #1 and Resident #2 in the hall of 400. She said she was unsure what provoked Resident #2 but that it resulted in Resident #2 hitting Resident #1. She said that Resident #1 would reach out and try to hug and or stick out her hands to others. She said she was curious to know if Resident #1 did either of these things to provoke Resident #2. She said she could not interview Resident #2 because he was upset the day the incident happened. She stated the physical incident between Resident #1 and Resident #2 had not happened before. An Interview on 03/06/24 at 10:33 AM with the DON revealed that there was a physical incident that occurred between Resident #1 and Resident #2 but this had not happened before. An interview on 03/06/24 at 11:18 AM with LVN A revealed that she did not have much information about the physical altercation between Resident #1 and Resident #2, but that Resident #1 wanders the halls. She said Resident #1 would sometimes bump into other people and enter their rooms. An interview on 03/06/24 at 11:31 AM with LVN B revealed that an incident occurred in the hallway between Resident #1 and Resident #2. She was unsure of the date and time. She said they must have been crossing paths, she observed Resident #2 with Resident #1 wrist in his hand, and Resident #2 was screaming. She said she broke them apart and could not get what happened from Resident #1 because he was upset. She said Resident #1 was confused all the time and wanders over the facility. An interview on 03/06/24 at 11:48 AM with the Activity Director revealed that she had not been present for the physical incident with Resident #1 and #2. She said she does know there have been at least two incidents. She said one occurred by his room door, and he kicked her. The second incident she witnessed was when they were near the nurse's station, and she observed Resident #2 hand go up in the air and Resident #1 was near him. She said she yelled for LVN B to look and ran to get Resident #1 away from Resident #2. She said she could not remember the exact date of the incident, but it was about two months ago. An interview on 03/06/24 at 12:01 PM with CNA C revealed that she was not present when the physical altercation occurred between Resident #1 and Resident #2, but that report was given to her that Resident #1 was attempting to wander into Resident #2 room and Resident #1 kicked her. She said Resident #1 had a history of wandering all over the facility. An interview on 03/06/24 at 12:06 PM with the CNA D revealed that Resident #1 does try to go in other resident's room. She said she tried to go in Resident #2 room Resident #2 did not like it. An interview on 03/06/24 at 12:28 PM with CNA E revealed that she did not have any information regarding the physical altercation between Resident #1 and Resident #2 but that she had worked with both residents. She said Resident #1 has a history of wandering around the facility. She said she repeatedly tried to keep Resident #1 off 500 Hall. An interview on 03/06/24 at 1:26 PM with Resident #2 revealed that Resident #1 tried to come into his room multiple times. He said she had tried to come into his room at least five times. He said that he did not know the exact date and time. He said he had not reported these attempts to staff but that there was always staff around when Resident #1 tried to come into his room. He said that he does not like it when residents come into his room. He said Resident #1 entered his room because she wanted to steal from him. An observation was made on 03/06/24 at 1:55 of Resident #1 self-propelled slowly near the nurse's station. An observation was made on 03/06/24 at 2:03 PM, Resident #1 self-propelled slowly down the hall. She entered room [ROOM NUMBER]. Another resident (unknown) propelled behind her, telling her not to go into the room. Resident #1 enter room [ROOM NUMBER] in her wheelchair. She went to the nightstand in the room and began to rummage. The Investigator notified the DON, and she and another staff (unknown) intervened. They redirected her physically out of the resident's room. An interview on 03/06/24 at 2:38 PM with the MDS Coordinator revealed that Resident #1 likes to wander around the facility. She said sometimes Resident #1 would go into the wrong room. She said Resident #1 had wandered since being admitted to the facility. She said usually, staff intervene. She said when Resident #1 gets into the room across from hers, the resident in that room will yell at her, and then staff will get her. She said that she was responsible for completing the MDS assessments for all the residents in the facility. She said the DON was responsible for the resident care plans. She said she believed that Resident #1 behavior for wandering was in the care plan but was not sure. She said the behavior should be captured in the care plan. She said she did not believe there was a potential negative outcome for Resident #1's wandering behavior not being reflected in the care plan. She said the only potential negative outcome that she could think of for the wandering not being reflected in the MDS assessment was there could be a monetary penalty. She said the staff that provide direct care do not look at the MDS assessment to provide care, but they do look at the care plan. She said Resident #1's wandering was not reflected in the MDS assessments because she did not consider her wandering up and down the halls without a purpose significant enough to put in the MDS. She said Resident #1 was not trying to leave the facility or bother other residents. She said she does obtain information from staff for her assessments. She said she knew that a male resident became upset about Resident #1 going into his room, but she did not know when. She said she had been trained on how to complete MDS assessments. She said she taught herself. She said another reason the wandering may not have been in the MDS assessments was that there was a time when Resident #1 did not wander. An interview on 03/06/24 at 2:54 PM with the DON revealed the potential negative outcome for the inaccurate MDS that could affect the care plan. She said it could cause the care plan to not be appropriate for the resident. Regarding Resident #1, all the staff knew her very well. She said she was unaware that the quarterly or the latest comprehensive MDS assessment did not capture Resident #1's wandering behavior. She said she had been trained regarding the accuracy of MDS assessments. She said her training was 3-4 years ago. She said Resident #1 does wander and had exhibited the behavior since she had been employed at the facility. She said Resident #1 was intentional when she wanders. She said Resident #1 would go to the same people daily to see staff she knew. She said she expected that the MDS be completed accurately and reflect current information. She said the MDS Coordinator was responsible for completing the MDS assessments. An interview on 03/06/24 at 3:24 PM with CNA E revealed Resident #1 had always had a history of wandering around the facility and into other residents' rooms since she had been employed at the facility. She said she had been employed at the facility for six months. She said that when she stated in her earlier interview that she tried to keep Resident #1 from Hall 500, it was because of Resident #2. She said she had observed him kick Resident #1 out of his room. She said she did not know what a care plan was and had not looked to see if wandering was on it. She said she had not been specifically trained on what to do about Resident #1's wandering behavior. She said she knew about Resident #1 behavior from working with her. An interview on 03/06/24 at 3:32 PM with the LVN A revealed Resident #1 had always exhibited wandering behavior. She said the only time Resident #1 does not wander was if she does not feel well or was in bed. An interview on 03/06/24 at 3:37 PM with the ADM revealed the potential negative outcome for the MDS not being accurate was billing could be off or skewed. She said she was unaware that Resident #1's wandering behavior was not reflected in her most recent quarterly and Significant Change MDS assessment. She said there was no specific system in place to monitor MDS assessments. She said they do not look at the assessment's individual sections but look at if there was an overall decline. She said she had not been trained in completing accurate MDS Assessments. She said she expected MDS assessments to be accurate and reflect current information regarding residents. She said she had observed Resident #1 wandering around the facility. She said the MDS Coordinator was responsible for accurately completing the MDS assessments. She said she had no reason the MDS was not completed accurately. She said the potential negative outcome of not reflecting Resident #1's behavior of wandering or current behaviors in the care plan was that she or other residents may not receive the care they need. She said Resident #1 had exhibited wandering behavior the entire time she had known her. She said she was unaware that Resident #1 had been in Resident #2's room multiple times. An interview on 03/06/24 at 03:51 PM with CNA D revealed that Resident #1 had always wandered around the facility and in other residents' rooms. She stated she had seen Resident #1 enter Resident #2 room more than once. An interview on 03/06/24 at 03:52 PM with CNA C revealed that Resident #1 had always wandered around the facility and in other residents' rooms. She stated she had seen Resident #1 enter Resident #2 room more than once. She said she observed Resident #2 blocking Resident #1 and attempting to wave her out of his room because he could not speak. An interview on 03/06/24 at 04:20 PM with the ADM revealed that there was no specific policy for the MDS assessments but that they use the Long-Term Care RAI manual. An interview on 03/06/24 at 04:19 PM with the DON revealed she stated she was unaware if Resident #1's wandering was tracked. An interview on 03/11/24 at 05:08 PM with the social worker revealed that on 01/29/24, there was a physical altercation between Resident #1 and Resident #2. She said she could not interview Resident #1 because of her cognitive status. She said she was able to interview Resident #2 through the use of his communication board. She said Resident #2 told her he grabbed Resident #1's arm because she grabbed his leg as she rolled by. She said he motioned that the incident happened in the hallway. She said she did not, and he did not clarify if the incident specifically happened in Hall 500 or where it happened. She assumed it was outside his room because of how he motioned. She said Resident #1 goes up and down the hallways and wanders throughout the facility. She said sometimes she would go into other residents' rooms, but some residents were familiar with her. She said she could not answer the potential negative outcome if Resident #1 went into a room where she was unwanted. She said she could not say what risks Resident #1 would be at if she went into a resident's room that she was unwanted in because it would all depend on the other resident. She said she hoped they would tell Resident #1 to leave, and she would listen and leave. Review of the Intake Investigation Worksheet 480251, dated 01/29, revealed the following: The incident occurred on 01/29/24 at 10:00 AM. LVN B witnessed Resident #2 grabbing Resident #1's arm and twisting it. The Social Worker was told by Resident #2 that Resident #1 touched his leg when she rolled by. Review of the Intake Investigation Worksheet 480251, dated 01/29, revealed the following: The incident occurred on 01/29/24 at 10:00 AM. LVN B witnessed Resident #2 grabbing Resident #1's arm and twisting it. The Social Worker was told by Resident #2 that Resident #1 touched his leg when she rolled by. Review of the facility policy, Behavioral, Intervention and Monitoring, Revised December 2021, revealed the following: Policy Statement: The center will provide, and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Behavioral symptoms will be identified using center-approved behavioral screening tools and the comprehensive assessment. The center will comply with regulatory requirements related to the use of medications to manage behavioral changes. Policy Interpretation and Implementation General Guidelines 1. Behavior is the response of an individual to a wide variety of factors. These factors may include medical, physical, functional, psychosocial, emotional, psychiatric, or environmental causes. a. Behavior is regulated by the brain and is influenced by past experiences, personality traits, environment, and interactions with other people. b. Behavior can be a way for an individual in distress to communicate unmet needs, indicate discomfort, or express thoughts that cannot be articulated. As part of the comprehensive assessment, staff will evaluate, based on input from the resident, family and caregivers, review of medical record and general observations: a. The resident's usual patterns of cognition, mood and behavior; 4. New onset or changes in behavior will be documented regardless of the degree of risk to the resident or others. Cause Identification 1. The interdisciplinary team will evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition, including: Management 1. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. a. Atypical behavior will be differentiated from behavior that is dangerous or problematic for the resident(s) or staff, or behavior that signals underlying distress. b. If the behavior is atypical but not problematic or dangerous and the resident does not appear to be in distress, then the IDT will monitor for changes but not necessarily intervene to normalize the behavior. 2. The care plan will incorporate findings from the comprehensive assessment and PASRR Level II determinations (as appropriate), and be consistent with current standards of practice. 3. The resident and family or representative will be involved in the development and implementation of the care plan. Resident and family involvement, or attempts to include the resident and family in care planning and treatment, will be documented. 4. The resident and family/representatives will be informed of the resident's condition as well as the potential risks and benefits or proposed interventions. 5. The resident and/or resident surrogate will have the right to refuse treatment. 6. Interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities. 7. Interventions and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior. The care plan will include, as a minimum: a. A description of the behavioral symptoms, including: (1) Frequency; (2) Intensity; (3) Duration; (4) Outcomes; (5) Location; (6) Environment; and (7) Precipitating factors or situations. b. Targeted and individualized interventions for the behavioral and/or psychosocial symptoms; c. The rationale for the interventions and approaches; d. Specific and measurable goals for targeted behaviors; and e. How the staff will monitor for effectiveness of the interventions. Monitoring 1. If the resident is being treated for altered behavior or mood, the IDT will seek and document any improvements or worsening in the individual's behavior, mood, and function. 2. The IDT will monitor the progress of individuals with impaired cognition and behavior until stable. New or emergent symptoms will be documented and reported. 3. Interventions will be adjusted based on the impact on behavior and other symptoms, including any adverse consequences related to treatment. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, October 2023, revealed the following: an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for 1 of 7 residents (Resident #1) reviewed for care plans as follows: 1. Resident #1 did not have a care plan for her ongoing behavior for wandering that had occurred since her admission on [DATE]. These failures could place residents at risk of not receiving the care required to meet their Individualized needs. Findings include: Review of Resident #1's face sheet (undated) indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had a diagnoses of dementia with agitation (loss of cognitive functioning), generalized anxiety disorder (feelings of worry, tension and fear), and intermittent explosive disorder (repeated , sudden bouts of impulsive of physical or verbal outburst). Resident #1 resided on Hall 100. Review of Resident #1's quarterly MDS dated [DATE] revealed Resident #1 had a BIMS score of 99 which indicated Resident #1 was unable to complete the interview. The MDS Assessment for Resident #1 revealed in section E0900 that the Resident #1 had not exhibited the behavior of wandering. Review of Resident #1's Significant Change MDS dated [DATE] revealed Resident #1 had a BIMS score of 03 which indicated Resident #1's cognition was severely impaired. The MDS Assessment for Resident #1 revealed in section E0900 that the Resident #1 had not exhibited the behavior of wandering. Section E100 did not contain any data regarding the impact of Resident #1 wandering on others. Section E1100 did not capture if Resident #1's wandering had remain the same, worsened or improved. Review of Resident #1's care plan, dated 2/15/24 did not reveal a care plan for the behavior of wandering. Review of Resident #1's progress notes did not reveal any ongoing prevention or intervention about Resident #1 wandering. An interview on 03/06/24 at 11:18 AM with LVN A revealed Resident #1 wanders the halls. She said Resident #1 would sometimes bump into other people and enter their rooms. An interview on 03/06/24 at 11:31 AM with LVN B revealed Resident #1 was confused all the time and wanders over the facility. An interview on 03/06/24 at 12:01 PM with CNA C Resident #1 had a history of wandering all over the facility. An interview on 03/06/24 at 12:06 PM with the CNA D revealed that Resident #1 does try to go in other resident's room. An interview on 03/06/24 at 12:28 PM with CNA E revealed Resident #1 had a history of wandering around the facility. She said she repeatedly tried to keep Resident #1 off 500 Hall. An observation was made on 03/06/24 at 1:55 of Resident #1 self-propelled slowly near the nurse's station. An observation was made on 03/06/24 at 2:03 PM, Resident #1 self-propelled slowly down the hall. She entered room [ROOM NUMBER]. Another resident (unknown) propelled behind her, telling her not to go into the room. Resident #1 entered room [ROOM NUMBER] in her wheelchair. She went to the nightstand in the room and began to rummage. The Investigator notified the DON, and she and another staff (unknown) intervened. They redirected her physically out of the resident's room. An interview on 03/06/24 at 2:38 PM with the MDS Coordinator revealed that Resident #1 likes to wander around the facility. She said sometimes Resident #1 would go into the wrong room. She said Resident #1 had wandered since being admitted to the facility. She said usually, staff intervene. She said when Resident #1 gets into the room across from hers, the resident in that room will yell at her, and then staff will get her. She said the DON was responsible for the resident care plans. She said she believed that Resident #1 behavior for wandering was in the care plan but was not sure. She said the behavior should be captured in the care plan. She said she did not believe there was a potential negative outcome for Resident #1's wandering behavior not being reflected in the care plan. She said the staff that provide direct care do not look at the MDS assessment to provide care, but they do look at the care plan. She said she knew that a male resident became upset about Resident #1 coming into his room, but she did not know when. An interview on 03/06/24 at 2:54 PM with the DON revealed the potential negative outcome for behaviors not being reflected in the residents' plan was that they may need the care and not receive it. She said she was unaware that Resident #1 care plan did not reflect the wandering behavior. She said the system they use to monitor care plans was the level of care meetings. She said that during these meetings, they talk about resident transfer and how many people it takes to complete the transfer. She said she had been trained regarding the completion of care plans, and this was a part of being a registered nurse. She said the MDS Coordinator was responsible for long-term care plans, and the DON was responsible for acute care plans. She said anything that triggered on the CAAs should be care planned. She said specific things that were risk areas should also be care planned. She said she does not know why Resident #1 wandering was not care planned but that the MDS Coordinator would have been responsible. She said the MDS Coordinator had been trained to complete care plans. An interview on 03/06/24 at 3:24 PM with CNA E revealed Resident #1 had always had a history of wandering around the facility and into other residents' rooms since she had been employed at the facility. She said she had been employed at the facility for six months. She said that when she stated in her earlier interview that she tried to keep Resident #1 from Hall 500, it was because of Resident #2. She said she had observed him kick Resident #1 out of his room. She said she did not know what a care plan was and had not looked to see if wandering was on it. She said she had not been specifically trained on what to do about Resident #1's wandering behavior. She said she knew about Resident #1 behavior from working with her. An Interview on 03/06/24 at 3:32 PM with the LVN A revealed Resident #1 had always exhibited wandering behavior. She said the only time Resident #1 does not wander was if she does not feel well or was in bed. She said she was unsure how to access the care plan and if wandering was on the care plan. An interview on 03/06/24 at 3:37 PM with the ADM revealed the potential negative outcome of not reflecting Resident #1's behavior of wandering or current behaviors in the care plan was that she or other residents may not receive the care they need. She said the information in the kiosk that the CNAs use comes from the care plan. She said she was unaware that Resident #1 behavior of wandering had not been care planned. She said regarding a system to monitor care plans, they review care plans quarterly, and the absence of the behavior should have been caught. She said she was unaware of why Resident #1's wandering behavior was not care planned. She said multiple disciplines are responsible for different areas of the care plan. She said the DON was overall responsible as she ultimately signs off. She said Resident #1 had exhibited wandering behavior the entire time she had known her. She said she was unaware that Resident #1 had been in Resident #2's room multiple times. An interview on 03/06/24 at 03:51 PM with CNA D revealed that Resident #1 had always wandered around the facility and in other residents' rooms. She stated she had seen Resident #1 enter other residents room more than once. She said she used the care plan and had never received specific training for Resident #1's wandering but that she naturally redirected her because she knew her. She confirmed that she did not see a care plan on the kiosk they use for Resident #1's wandering. An interview on 03/06/24 at 03:52 PM with CNA C revealed that Resident #1 had always wandered around the facility and in other residents' rooms. She stated she had seen Resident #1 enter other residents' room more than once. She stated she used the care plan and had never received specific training for Resident #1's wandering but that she naturally redirected her because she knew her. She confirmed that she did not see a care plan on the kiosk they use for Resident #1's wandering. An interview on 03/06/24 at 04:19 PM with the DON revealed that all staff use the care plan. She stated she was unaware if Resident #1's wandering was tracked. An interview on 03/11/24 at 04:19 PM with the DON revealed that all staff use the care plan. She stated she was unaware if Resident #1's wandering was tracked. An interview on 03/11/24 at 05:08 PM with the social worker revealed that on 01/29/24, there was a physical altercation between Resident #1 and Resident #2. She said she could not interview Resident #1 because of her cognitive status. She said she could not answer the potential negative outcome if Resident #1 went into a room where she was unwanted. She said she could not say what risks Resident #1 would be at if she went into a resident's room that she was unwanted in because it would all depend on the other resident. She said she hoped they would tell Resident #1 to leave, and she would listen and leave. Review of the facility policy, Behavioral, Intervention and Monitoring, Revised December 2021, revealed the following: Policy Statement The center will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Behavioral symptoms will be identified using center-approved behavioral screening tools and the comprehensive assessment. The center will comply with regulatory requirements related to the use of medications to manage behavioral changes. Cause Identification 1. The interdisciplinary team will evaluate new or changing behavioral symptoms in order to identify underlying causes and address any modifiable factors that may have contributed to the resident's change in condition, including: Management 1. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. a. Atypical behavior will be differentiated from behavior that is dangerous or problematic for the resident(s) or staff, or behavior that signals underlying distress. b. If the behavior is atypical but not problematic or dangerous and the resident does not appear to be in distress, then the IDT will monitor for changes but not necessarily intervene to normalize the behavior. 2. The care plan will incorporate findings from the comprehensive assessment and PASRR Level II determinations (as appropriate), and be consistent with current standards of practice. 3. The resident and family or representative will be involved in the development and implementation of the care plan. Resident and family involvement, or attempts to include the resident and family in care planning and treatment, will be documented. 4. The resident and family/representatives will be informed of the resident's condition as well as the potential risks and benefits or proposed interventions. 5. The resident and/or resident surrogate will have the right to refuse treatment. 6. Interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs, and strives to understand, prevent or relieve the resident's distress or loss of abilities. 7. Interventions and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior. The care plan will include, as a minimum: a. A description of the behavioral symptoms, including: (1) Frequency; (2) Intensity; (3) Duration; (4) Outcomes; (5) Location; (6) Environment; and (7) Precipitating factors or situations. b. Targeted and individualized interventions for the behavioral and/or psychosocial symptoms; c. The rationale for the interventions and approaches; d. Specific and measurable goals for targeted behaviors; and e. How the staff will monitor for effectiveness of the interventions. Monitoring 1. If the resident is being treated for altered behavior or mood, the IDT will seek and document any improvements or worsening in the individual's behavior, mood, and function. 2. The IDT will monitor the progress of individuals with impaired cognition and behavior until stable. New or emergent symptoms will be documented and reported. 3. Interventions will be adjusted based on the impact on behavior and other symptoms, including any adverse consequences related to treatment. Review of the facility policy, Comprehensive Care Plan, dated 1/27/24, revealed the following: Policy It is the policy of this facility to develop and implement A comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and time frames to meet a residence medical, nursing, mental and psychosocial needs that are identified in the residents comprehensive assessment. The comprehensive care plan will describe, at a minimum of the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical mental and psychosocial well-being. Any services that would otherwise be furnished but are not provided due to the residents exercise of his or her right to refuse treatment. Resident specific interventions that reflect the residents needs and preferences and align with the residents cultural identity, as indicated. Individualized interventions for trauma survivors that recognize the interrelation between trauma and symptoms of trauma as directed. Trigger specific interventions will be used to identify ways to decrease the residents exposure to triggers which read traumatize the resident, as well as identify ways to mitigate or decrease the effect of trigger on the resident. The comprehensive care plan will be prepared by the interdisciplinary team, that includes, but is not limited to: a registered nurse with the responsibility for the resident a nurse aide with responsibility for the resident The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly and BS assessment. The comprehensive care plan will include measurable objectives and time frames to meet the residents needs as identified in the residence comprehensive assessment. The objectives will be utilized to monitor the residents progress. Alternative interventions will be documented as needed. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. The services provided were arranged by the facility, as outlined in the comprehensive care plan will meet professional standards of quality, and will be provided by qualified persons and recordings with each resident's written plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility failed to protect and promote the rights of the resident for 1 of 20 (Resident #19) residents in that: CNA A failed to provide Resident #19 privacy during incontinent care. This could place residents at risk for diminished quality of life and loss of dignity and self-worth. The findings included: A record review of Resident #19's face sheet, dated 09/20/23, revealed a [AGE] year-old female was admitted to the facility on [DATE] with diagnoses to include COPD (lung disease), muscle weakness, major depressive disorder (mental illness), heart disease, dementia (cognitive loss), and hypertension (high blood pressure). Record review of Resident #19's Comprehensive Minimum Data Set assessment, dated 01/18/23, revealed Resident#19 had a BIMS of 07 which indicated the resident's cognition was severely impaired. Resident #19 required total dependence with one person assist with personal hygiene and toilet use. Resident #19 was always incontinent of bladder and bowel. Record review of Resident #19's care plan, dated 0/27/23, revealed Resident #19 required assist x 1 with hygiene and toilet use. The care plan further revealed resident had incontinence with interventions to offer toileting every 2 hours and provide incontinence care after each incontinent episode. During an observation on 09/19/23 at 02:09 PM CNA A was providing incontinent care for Resident #19. CNA A went to wash her hands between glove changes in resident bathroom, she did not cover Resident #19 leaving residents bottom exposed. During an interview on 09/19/23 at 04:00 PM with CNA A, she stated she should have provided privacy when she went to the bathroom to wash her hands. She stated the reason why the resident was left exposed was my mistake I got in a hurry. She stated the potential negative outcome was a dignity issue. She stated the resident would lose dignity not providing privacy. She stated she had been trained and she does skills checkoffs every 3 to 4 months. During an interview on 09/20/23 at 01:35 PM with the ADM, she stated staff should have provided privacy when they leave bedside to wash hands. She stated all staff have been trained on privacy. She stated the ADON does training and skills checkoffs quarterly. She stated the potential negative outcome could be a dignity issue being exposed. She stated her expectations were to provide privacy on all occasions. During an interview on 09/20/23 at 01:50 PM with the DON, she stated the resident should be covered with a towel or sheet when the CNA leaves to wash hands. She stated the ADON was responsible for training and monitoring CNA's using the skills checkoffs. She stated the CNA's do skills checkoffs every 3-4 months. She stated the potential negative outcome of not providing resident privacy could be someone walking in room, resident embarrassed or frightened. She stated her expectations were for staff to provide privacy and not expose the resident to the world. During an interview on 09/20/23 at 02:03 PM with the ADON, she stated when asked if resident should be provided privacy when a CNA leaves to wash hands Absolutely. She stated the CNA's should pull the curtain and closed the door to residents' room. She stated the staff had been trained to provide privacy during incontinent care. She stated she does skills checkoffs with CNA's every 3-4 months. She stated her expectations were for everyone to provide privacy. She stated the potential negative outcome could be a dignity issue. Record review Perineal Care (cleaning the private areas of a resident) Return Demonstration dated 2022 revealed CNA B completed skills demonstration on 07/21/23. Record review of the following policy labelled Resident Rights dated 02/21 revealed the following: Policy Statement: Employees shall treat all residents with kindness, respect and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; . Record review of the following policy labelled Resident Rights Guidelines for All Nursing Procedures dated 10/10 revealed the following: Purpose: To provide general guidelines for resident rights while caring for the resident. Preparation: l. Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on resident rights, including: . b. Resident dignity and respect; . f. Close the room entrance door and provide for the resident's privacy . Record review of policy labelled Perineal Care dated 01/20/23 revealed the following: Policy Statement: Perineal Care is providing cleanliness and comfort to the resident, to prevent infections, skin irritation, and to observe the resident's skin condition. Steps in the Procedure . 2. Provide privacy. i.e., pull curtain, close door . 5. Adjust bedding to resident's comfort and provide dignity during care .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment for 2 of 18 residents (Residents #35 and #45) reviewed for PASRR screening, in that: Residents #35 and #45 did not have an accurate PASRR Level 1 assessments when they had a diagnosis of mental illness. These failures could place residents with an inaccurate PASRR Level 1 Evaluation at risk for not receiving care and services to meet their needs. The findings were: Resident #35: Record review of Resident #35's electronic face sheet revealed a [AGE] year-old male most recently admitted to the facility on [DATE]. The face sheet listed under Diagnoses Information, Schizoaffective Disorder, Bipolar type. Record review of Resident #35's Quarterly MDS dated [DATE], revealed under section I Active Diagnoses, a diagnosis of Schizoaffective Disorder, Bipolar type. Additionally, under Section C Cognitive Patterns, the MDS revealed a BIMS of 1 indicating the resident was severely cognitively impaired. Record review of Resident #35 most recent care plan, undated, revealed a focus area and diagnosis of Schizoaffective Disorder, Bipolar type, this problem started 06/21/2021. Resident #35 is on Hospice and currently not prescribed psychotropics. Record review of Resident #35's Preadmission Screening and Resident Review Level One (PL1) form dated 3/16/2021 revealed under section C0100 Mental Illness an answer of No, indicating the resident did not have a mental illness. Resident #45: Record review of Resident #45's electronic face sheet revealed a [AGE] year-old female most recently admitted to the facility on [DATE]. The face sheet listed under Diagnosis Information a diagnosis of Catatonic Schizophrenia. Record review of Resident #45's Quarterly MDS dated [DATE], revealed under section I Active Diagnoses, a diagnosis of Catatonic Schizophrenia. Additionally, under Section C Cognitive Patterns, the MDS revealed a BIMS of 99 indicating the resident was severely cognitively impaired. Record review of Resident #45's most recent care plan, undated, revealed a focus area and diagnosis of Catatonic Schizophrenia, this problem started 03/09/2023. Resident #45 was prescribed Trazadone 100mg once a day to address this diagnosis. Record review of Physician progress notes for Resident #45 dated 09/20/2023 revealed under current medications, Resident #45 was prescribed Trazadone 100mg once a day to address his diagnosis of Catatonic Schizophrenia. Record review of Resident #45's Preadmission Screening and Resident Review Level One (PL1) form dated 3/09/2023 revealed under section C0100 Mental Illness an answer of No, indicating the resident did not have a mental illness. During an interview conducted on 09/20/23 at 11:07AM with the Administrator, she verified Residents #35 and #45 had a diagnosis of mental illness. The ADM verified Residents #35, and #45 had inaccurate PASRR 1 Evaluations and no subsequent PASRR 2 Evaluations. The ADM stated it was the MDS nurses' responsibility to ensure every resident admitted to the facility has an accurate PASRR 1 Evaluation. The ADM also stated it was the MDS nurses' responsibility to ensure PASRR 1 Evaluation are completed accurately by comparing them to the residents' medical records. The ADM stated the potential harm if a resident with a diagnosis of a mental illness who had a negative PASRR 1 Evaluation, and no subsequent level two evaluation was the residents could potentially go without services. During an interview with the DON on 09/20/23 at 1:52PM, she verified Residents #35 and #45 had diagnosis of mental illnesses. The DON confirmed Residents #35 and #45 did not have PASRR 2 Evaluation as their PASRR 1 Evaluations were negative after review. The DON stated it was the MDS nurses' responsibility to ensure every resident admitted to the facility has an accurate PASRR 1 Evaluation. The DON also stated it was the MDS nurses' responsibility to ensure PASRR 1 Evaluation are completed accurately by comparing them to the residents' medical records. The DON stated the potential harm to a resident without an accurate PASRR 1 Evaluation and a subsequent PASRR 2 Evaluation was the residents will not receive the services they need. During an interview with the MDS nurse on 9/20/23 at 10:25am, she stated Residents #35 and #45 did not have PASRR 2 Evaluations as their PASRR 1 Evaluations were inaccurately negative. The MDS nurse stated Residents #35 and #45 did not have accurate PASRR 1 Evaluations as both residents have a diagnosed mental illness. The MDS nurse stated it was her responsibility to ensure every resident entering the facility had a completed and accurate PASRR 1 Evaluation. The MDS nurse also stated it was her responsibility to ensure any new mental health diagnosis added after entry to the facility that warranted a new PASRR 1 Evaluation were completed. The MDS nurse stated she did not know why #35 and #45 did not have positive PASRR 1 Evaluation due to having had a mental illness diagnosis. The MDS nurse stated the potential negative outcome for residents not having an accurate PASRR 1 Evaluation and subsequent PASRR 2 Evaluation are the residents may not be offered the services they may need for their diagnosis. [NAME] Oaks Preadmission Screening and Resident Review (PASRR) Policy Revised 2/1/2023: The facility policy for PASARR states all applicants to a Medicaid-certified nursing facility are evaluated for mental health prior to admissions and offered the most appropriate setting for their needs. If the PASARR level one screening indicated the individual may have an Intellectual Disability or a Mental Illness diagnosis the facility will confer with local mental health providers to complete a PASARR level two screening. Following the completion of the level two screening a care plan will be developed by the facility in order to meet the needs of a resident with an Intellectual Disability or a Mental Illness diagnosis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder or had a urinary catheter received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 3 Residents (Resident #24 and #32) reviewed for incontinent care. 1. CNA B failed to properly clean labia (middle of vaginal area) and wash hands between glove changes while providing incontinent care to Resident #24. 2. CNA C failed to change gloves and wash hands when going from dirty to clean while providing incontinent care to Resident #32. This failure had the potential to affect residents by placing them at an increased risk of exposure to communicable diseases and infections. Findings include: Resident #24 Record review of face sheet for Resident #24, dated 09/20/23, revealed an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: dementia (cognitive loss), atrial fibrillation (irregular heartbeat), muscle weakness, anxiety (feeling of fear and worry), hypertension (high blood pressure) and diabetes (high blood sugar). Review of Resident #24's MDS, dated [DATE] revealed Resident #24 had a BIMS of 04 which indicated the resident's cognition was severely impaired. The MDS revealed Resident #24 required extensive one person assist with toilet use and limited one person assist with personal hygiene. The MDS further revealed Resident #24 was always incontinent of bladder and bowel. Record review of Resident #24's Comprehensive Care Plan dated 09/12/23 revealed the resident required assist x 1 with bathing/hygiene and toileting. The Resident #24 was incontinent of bowel and bladder. The interventions included check for incontinence every 2 hours and toilet every 2 hours. Resident #24 was at risk for pressures ulcers related to incontinence. The interventions included keep clean and dry as possible, provide incontinence care after each episode and report redness or skin breakdown immediately. During an observation on 09/19/23 at 02:27 PM CNA B was providing incontinent care for Resident #24. CNA B did not clean the labia (middle of resident's vaginal area). CNA B removed gloves then turned around and picked up clean brief off bed side table, opened brief and placed brief beside Resident #24. CNA B donned new gloves and put brief on Resident #24. CNA B did not wash hands after doffing gloves or before donning new gloves. During an interview on 09/19/23 at 04:18 PM with CNA B, she stated she should have washed her hands after removing dirty gloves, before touching clean items and donning new gloves. CNA B stated she forgot to wash her hands and close the resident's door. She stated the potential negative outcome could be spread of germs. She stated the potential negative outcome of not properly cleaning a resident could cause skin irritation, infections and UTI's. She stated she had been trained on proper incontinent care, resident privacy and infection control. She stated she does skills checkoffs every 3 to 4 months. Resident #32 Record review of face sheet for Resident #32, dated 09/20/23, revealed an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: dementia (cognitive loss), muscle weakness, hypertension (high blood pressure), and anxiety (feeling of fear or worry). Review of Resident #32's MDS, dated [DATE] revealed Resident #32 had a BIMS of 05 which indicated the resident's cognition was severely impaired. Resident #32 required total dependence with one person assist with personal hygiene and dressing. Resident #32 was frequently incontinent of bladder and bowel. Record review of Resident #32's Comprehensive Care Plan dated 06/23/23 revealed Resident #32 experiences bladder incontinence related to dementia with interventions to ensure adequate bowel elimination and provide incontinence care after each episode. The care plan further revealed Resident #32 required assist x 1 with hygiene and toileting. During an observation on 09/19/23 at 02:52 PM CNA C was providing incontinent care for Resident #32. CNA C cleaned front side of Resident #32 and then turned resident #32 touching her arm and leg with dirty gloves. During an interview on 09/19/23 at 04:41 PM with CNA C, she stated she should have changed her gloves before turning resident #32. She stated the potential negative outcome could be spread bacteria and infection. She stated she had been trained and did skills checkoffs every 3-4 months. During an interview on 09/20/23 at 01:35 PM with the ADM, she stated she does not know the proper steps in incontinent care and defers that to the DON and ADON. She stated gloves should be changed when going from dirty to clean. She stated the ADON trains and monitors CNA's with skill checkoffs every 3-4 months. She stated the DON, ADON and CN were responsible for monitoring staff to ensure they were following proper infection control. She stated the potential negative outcome could be infection. She stated the common infection seen in the facility was occasionally UTI's. She stated the importance of following infection control guidelines was to prevent infections. During an interview on 09/20/23 at 01:50 PM with the DON, she stated the proper way to clean the front side of a resident was down the middle and then side to side. She stated gloves should be changed when visible soiled and before turning resident on their side. She stated hands should be washed with soap and water or ABHR (alcohol based hand rub) if not visible soiled. She stated CNA's do skills checkoffs every 3-4 months with the ADON. She states she was responsible for monitoring CNA's to ensure they were following proper infection control. She stated the potential negative outcome could be spread of infection and UTI's. She stated some common infections in the facility were UTI's. She stated improper incontinent care and infection control could contribute to the infections. During an interview on 09/20/23 at 02:03 PM with the ADON, she stated the proper steps in incontinent care was clean the labia first then side to side. She stated there was no reason the labia would not be cleaned. She stated she was responsible for training the staff and providing skills checkoffs. She stated skills checkoffs were done quarterly. She stated the possible negative outcome could be spread of infections and UTI's. She stated the facility currently has no common infections. Record review Perineal Care (cleaning the private areas of a resident) Return Demonstration dated 2022 revealed CNA B completed skills demonstration on 07/21/23. Record review Perineal Care (cleaning the private areas of a resident) Return Demonstration dated 2022 revealed CNA C completed skills demonstration on 07/24/23. Record review Perineal Care (cleaning the private areas of a resident) Return Demonstration dated 2022 revealed the following: Procedure Steps: . Used correct technique for peri-care on female vs. male residents. Female: Spread labia, (maintain separation of labia, clean center, then each groin areas/each side - dirty to clean) wipe one side, then the other, and then the middle, wiping toward the rectal area and never wiping back and forth. Dispose of gloves and perform hand hygiene, don new gloves and roll resident to side then proceed to clean the rectal and buttocks area . Maintained resident dignity and privacy throughout entire procedure. Record review policy labelled Perineal Care dated 01/20/23 revealed the following: Policy Statement: Perineal Care is providing cleanliness and comfort to the resident, to prevent infections, skin irritation, and to observe the resident's skin condition. Steps in the Procedure . 2. Provide privacy. i.e., pull curtain, close door . 5. Adjust bedding to resident's comfort and provide dignity during care . A. For a Female Resident: . (2) Separate labia and wash area downward from front to back. (Note: If the resident has an indwelling catheter gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area.) (3) Continue to clean the perineum moving from inside outward to the thighs, cleanse the perineum thoroughly in same direction, using a new cleansing wipe, as needed .

Based on observation, interview and record review, the facility failed to dispose of garbage and refuse properly in 1 of 4 dumpsters (#1) and 2 of 2 grease barrels, in that: The facility failed to maintain the dumpster/refuse disposal containers in a manner that effectively prevented the harborage and attraction of pest. These failures could result in providing harborage and breeding areas for insects, rodents and other pests which could infest the facility. The findings include: On 9/18/23 at 10:06 AM an observation was made of the dumpster area. The exterior of two of two grease barrels revealed that they had a heavy buildup of grease and food debris. The ground surrounding the two barrels had an accumulation of grease spillage on the dirt. It was approximately a 1' to 2' perimeter all the way around the two barrels that had the hardened grease and food debris buildup on the ground. The barrels were located away from concrete slab. On 9/19/23 at 8:29 AM an observation of the dumpster area. One of 4 had one of two lids open (#1). The grease barrels, 2 of 2, were heavily coated with grease and debris and there was hardened grease spillage on the dirt surrounding the barrels. The barrels were not on the concrete slab. On 9/20/23 at 9:00 AM an observation was made, and an interview was conducted with the Maintenance Supervisor. Observation of the dumpster area revealed that 1 of 4 dumpsters (#1) was open and there was a fly in the area. There was hardened grease on the ground surrounding the 2 heavily coated grease barrels. The soiled ground area ranged from 1'to 2'. The Maintenance Supervisor stated that he was not aware that the grease barrels and surrounding ground area had a heavy accumulation of grease on the ground. He stated, he would contact the grease vendor and get new barrels. Regarding whom was responsible for ensuring that the grease barrel area was maintained, and the dumpsters were in good condition, he stated, he would think that the dietary department and himself on the grease. He added the dumpster vendor should monitor the condition of the dumpsters. Regarding why he felt this situation happened, he stated lack of staff knowledge. He added the previous Maintenance Supervisor was gone before he was hired. Regarding what he expected staff to have done, he stated staff should have closed the dumpster lids. He stated he had checked the dumpster area this morning (9/20/23) and the lids were closed. Regarding what could result from the dumpster and grease situation he stated, attraction of flies, disease and parasites. He stated that the dumpsters were emptied daily, or at least six days out of the week. Regarding the grease barrels, he stated that they were emptied every three months or every six months. On 9/20/23 at 3:50 PM an interview was conducted with the Administrator regarding issues found in the facility. Regarding the dumpsters being open, and the grease area that was not maintained, she stated the grease, over time, accumulated and staff failed to close the lids. Regarding what she expected staff to have done, she stated to shut the dumpster lids and the grease barrels needed to be moved back onto the concrete slab. Regarding whom was responsible for maintaining the dumpster and grease disposal area, she stated maintenance, and everyone should close the lids. Regarding what could result from the dumpster and grease barrel situation, she stated there could be a potential for pest accumulation. Record review of the facility policy title Maintenance Service, Revised November 2021, review of the following documentation, Policy Statement. Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation, and Implementation. 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include but are not limited to: a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. b. Maintain the building in good repair and free from hazards. f. Establishing priorities in providing repair services . h. Maintaining the grounds, sidewalks, parking lots, etc., in good order. i. Providing routinely schedule maintenance service to all areas. j. Others that may become necessary or appropriate. 3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 10. Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned

Based on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specification established by CMS for 1 of 1 facility reviewed for administration (Fiscal year 2023 for the third quarter April 1, 2023, to June 30, 2023). The facility failed to submit PBJ (Payroll Based Journal) staffing information to CMS for the third quarter of the fiscal year 2023. This failure could place residents at risk for personal needs not being identified and met. Findings included: Record review of the CMS 672 form dated 9/18/23 and signed by the DON that was provided by the Administrator indicated a total of 64 residents in the facility. Record review of the CMS PBJ Staffing Data Report (payroll based staffing), CASPER Report (Certification and Survey Provider Enhanced Report)1705 D FY Quarter 3 2023 (April 1- June 30), dated 09/14/2023, indicated the following entry: Failed to Submit Data for the Quarter Triggered .Triggered=No Data Submitted for the Quarter. During an interview with the DON on 09/20/23 at 02:00 PM, she said the Compliance Officer with corporate was responsible for submitting the PBJ data. She said she knew the facility must submit the data but was not too familiar with the process. She said corporate has always been responsible for all the payroll, and they provided the information to be submitted to CMS. She said she had not been trained in PBJ. When asked why reporting the information was important, she said that her understanding was the submission was important to monitor staffing. She said PBJ was necessary to ensure nursing facilities have the appropriate staffing. When asked about the potential negative outcome, she said it affects their Star rating. She said the facility did not have any issues with staffing. She said failure to report might give the state inaccurate information, but she could not think of how it would affect the residents negatively because they don't have staffing issues. She said she was unaware of when the PBJ was supposed to be submitted During an interview with the ADM on 09/20/2023 at 2:48PM, she said the Compliance Officer with corporate was responsible for submitting the PBJ data. When asked why the information was not submitted timely, she said she did not know as this task is not her responsibility. When asked if there was a system for monitoring a timely and accurate submission, she said the PBJ submission was usually reported to her after it was completed. She said the Compliance Officer would typically report it directly to her. She said she was aware of the reporting regulation. She said she had been trained in this area because she completed the submission at her previous ADM position. When asked about her understanding of the importance of reporting PBJ data, she said the purpose was to ensure the facility was accurately staffed to care for the residents. She said the facility was fully staffed at this time, there were no nursing issues. When asked what the potential negative outcome was for not submitting the PBJ data, she said failure to report would be that it would not reflect the accuracy of staffing in connection to the census. During an interview with the Compliance Officer on 09/20/23 at 3:15PM, he said he was responsible for PBJ data submission. He said he had been trained, he was responsible for entering the data, he stated he had no doubt the hours were not entered, and it was his mistake. He stated he has been trained to enter the hours; however, he stated there is definitely room for more training. He said he knew he was supposed to complete the data submission. He said it was important so people could see adequate staffing in facilities. He stated he submits the data on the CMS website. When asked if he was aware of the submission deadlines, he said he was aware. When asked what the potential negative outcome was, he said the lack of submission could affect their Star rating. On 9/20/23 at 5:30PM Surveyor requested the facility's policy for record review, the DON stated the facility follows CMS guidelines for Direct-Care Staffing Information (Payroll-Based Journal), a policy was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable and sanitary environment to help prevent the development and transmission of diseases for 2 of 3 (Residents #24 and #32) and 1 of 1 (CNA B) staff reviewed for infection control. 1. CNA B failed to properly serve residents meals by touching the rim of glasses and bowls. 2. CNA B failed to perform hand hygiene between glove changes when providing incontinent care for Resident #24. 3. CNA C failed to perform hand hygiene between glove changes when providing incontinent care for Resident #32. These failures could place residents at risk for spread of infection and cross contamination. Findings include: Observation on 09/18/23 at 12:10 PM CNA B was observed serving residents meal by picking the glass and bowl up off tray by the rim with bare hands. Observation on 09/19/23 at 05:20 PM CNA B was observed serving residents meal by picking the glass and bowl up off the tray by the rim with bare hands. Observation on 09/20/23 at 12:15 PM CNA B was observed serving residents meal by picking the glass and bowl up off the tray by the rim with bare hands. During an interview on 09/20/23 at 01:00 PM with CNA B, she stated she should have served the residents drinks by grabbing the side of cup not the top. She stated, I just forgot. She stated the potential negative outcome was spreading germs. She states she had been trained on how to serve residents drinks. Resident #24 Record review of face sheet for Resident #24, dated 09/20/23, revealed an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: dementia (cognitive loss), atrial fibrillation (irregular heartbeat), muscle weakness, anxiety (feeling of fear and worry), hypertension (high blood pressure) and diabetes (high blood sugar). Review of Resident #24's MDS, dated [DATE] revealed Resident #24 had a BIMS of 04 which indicated the resident's cognition was severely impaired. The MDS revealed Resident #24 required extensive one person assist with toilet use and limited one person assist with personal hygiene. The MDS further revealed Resident #24 was always incontinent of bladder and bowel. Record review of Resident #24's Comprehensive Care Plan dated 09/12/23 revealed the resident required assist x 1 with bathing/hygiene and toileting. The Resident #24 was incontinent of bowel and bladder. The interventions included check for incontinence every 2 hours and toilet every 2 hours. Resident #24 was at risk for pressures ulcers related to incontinence. The interventions included keep clean and dry as possible, provide incontinence care after each episode and report redness or skin breakdown immediately. During an observation on 09/19/23 at 02:27 PM CNA B was providing incontinent care for Resident #24. CNA B did not clean the labia (middle of resident's vaginal area). CNA B removed gloves then turned around and picked up clean brief off bed side table, opened brief and placed brief beside Resident #24. CNA B donned new gloves and put brief on Resident #24. No observation of CNA B washing hands after doffing gloves, before touching clean brief and before donning new gloves. During an interview on 09/19/23 at 04:18 PM with CNA B, she stated she should have washed her hands after doffing gloves, before touching clean items and donning new gloves. CNA B stated she forgot to wash her hands and close the resident's door. She stated the potential negative outcome could be spread of germs. She stated the potential negative outcome of not properly cleaning a resident could cause skin irritation, infections and UTI's. She stated she had been trained on proper incontinent care, resident privacy and infection control. She stated she does skills checkoffs every 3 to 4 months. Resident #32 Record review of face sheet for Resident #32, dated 09/20/23, revealed an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: dementia (cognitive loss), muscle weakness, hypertension (high blood pressure), and anxiety (feeling of fear or worry). Review of Resident #32's MDS, dated [DATE] revealed Resident #32 had a BIMS of 05 which indicated the resident's cognition was severely impaired. Resident #32 required total dependence with one person assist with personal hygiene and dressing. Resident #32 was frequently incontinent of bladder and bowel. Record review of Resident #32's Comprehensive Care Plan dated 06/23/23 revealed Resident #32 experiences bladder incontinence related to dementia with interventions to ensure adequate bowel elimination and provide incontinence care after each episode. The care plan further revealed Resident #32 required assist x 1 with hygiene and toileting. During an observation on 09/19/23 at 02:52 PM CNA C was providing incontinent care for Resident #32. CNA C cleaned front side of Resident #32 and then turned resident #32 touching her arm and leg with dirty gloves. During an interview on 09/19/23 at 04:41 PM with CNA C, she stated she should have changed her gloves before turning resident #32. She stated the potential negative outcome could be spread bacteria and infection. She stated she had been trained and did skills checkoffs every 3-4 months. During an interview on 09/20/23 at 01:35 PM with the ADM, she stated staff should not touch the rim of glasses or bowls. She stated the ADON was responsible for training and monitoring staff. She stated the potential negative outcome could be passing germs or bacteria. She stated her expectations were for staff to handle food containers properly. She stated all staff have been trained. She stated she does not know the proper steps in incontinent care and defers that to the DON and ADON. She stated gloves should be changed when going from dirty to clean. She stated the ADON trains and monitors CNA's with skill checkoffs every 3-4 months. She stated the DON, ADON and CN were responsible for monitoring staff to ensure they were following proper infection control. She stated the potential negative outcome could be infection. She stated the common infection seen in the facility was occasionally UTI's. She stated the importance of following infection control guidelines was to prevent infections. During an interview on 09/20/23 at 01:50 PM with the DON, she stated drink glasses and bowls should not be picked up by the rim, they should be picked up by the side. She stated the DON and ADON were responsible for training and monitoring staff passing drinks and meal trays. She stated the potential negative outcome could be spread of infection. She stated her expectations were for the staff to pass meals and drinks properly. She states all staff had been trained on how to serve food containers. She stated gloves should be changed when visibly soiled and before turning resident on their side. She stated hands should be washed with soap and water or ABHR (alcohol based hand rub) if not visible soiled. She stated CNA's do skills checkoffs every 3-4 months with the ADON. She states she was responsible for monitoring CNA's to ensure they were following proper infection control. She stated the potential negative outcome could be spread of infection and UTI's. She stated some common infections in the facility were UTI's. She stated improper incontinent care and infection control could contribute to the infections. During an interview on 09/20/23 at 02:03 PM with the ADON, she stated drink glasses and bowls should be picked up by the side not the rim. She stated the CN, DON and ADON were responsible for training and monitoring staff passing drinks and meal trays. She stated the potential negative outcome could be spread of infection. She stated her expectations were for the staff to handle all food containers properly. She states all staff had been trained. She stated hands should be washed between glove changes and gloves should be changed between cleaning the front and back of residents. She stated she was responsible for training the staff and providing skills checkoffs. She stated skills checkoffs were done quarterly. She stated the possible negative outcome could be spread of infections and UTI's. She stated the facility currently has no common infections. Record review of the facility's policy titled Kitchen Sanitation to Prevent the Spread of Viral Illness dated 03/03/20 revealed the following: Policy: The Nutrition & Foodservice employees of the facility will practice good sanitation practices in accordance with the state and US Food Codes in order to minimize the risk of cross contamination and potential illness such as influenza and COVID-19 . ii. Cups, glasses and bowls must be handled so that fingers or thumbs do not contact inside surfaces or lip-contact outer surfaces. Record review of the facility's Perineal Care Return Demonstration dated 2022 revealed the following: Procedure Steps: . Used correct technique for peri-care on female vs. male residents. Female: Spread labia, (maintain separation of labia, clean center, then each groin areas/each side - dirty to clean) wipe one side, then the other, and then the middle, wiping toward the rectal area and never wiping back and forth. Dispose of gloves and perform hand hygiene, don new gloves and roll resident to side then proceed to clean the rectal and buttocks area . Record review of the facility's policy titled Standard Precautions, dated 10/18 revealed: Policy Statement - Standard Precautions are used in the care of all residents regardless of their diagnoses or suspected or confirmed infection status. Standard Precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents . Standard precautions include the following practices: 1. Hand hygiene a. Hand hygiene refers to handwashing with soap (anti-microbial or non-antimicrobial) or the use of alcohol-based hand rub (ABHR), which does not require access to water. b. Hand hygiene is performed with ABHR or soap and water: (I) before and after contact with the resident; (2) before performing an aseptic (clean) task; (3) after contact with items in the resident's room; and (4) after removing PPE (personal protective equipment). c. Hands are washed with soap and water whenever: (1) visibly soiled with dirt, blood, or body fluids; (2) after direct or indirect contact with dirt, blood or body fluids; (3) after removing gloves; . 2. Gloves a. Gloves (clean, non-sterile) are worn when in direct contact with blood, body fluids, mucous membranes, non-intact skin, and other potentially infected material. b. Gloves are worn when in direct contact with a resident who is infected or colonized with organisms that are transmitted by direct contact. (For specific pathogens, refer to current CDC isolation precautions guidelines.) c. Gloves are worn when handling or touching resident-care equipment that is visibly soiled or potentially contaminated with blood, body fluids, or infectious organisms. e. Gloves are changed as necessary, during the care of a resident to prevent cross-contamination from one body site to another (when moving from a dirty site to a clean'' one). g. Gloves are removed promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident. h. After gloves are removed, wash hands immediately to avoid transfer of microorganisms to other residents or environments.

Based on observation, interview and record review, the facility failed to ensure sure each resident had a right to a safe, clean, comfortable, and homelike environment in the facility and failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in 4 of 5 common baths (100/200, 300, 500 and 600), reviewed for environment, in that: The facility failed to ensure resident use common areas were clean, safe and did not need repair. These failures could place residents at risk for living in an unsafe, unclean, uncomfortable, and unhomelike environment which could cause a decline in resident psychosocial well-being. The findings include: On 9/18/23 at 4:27 PM an observation was made of the 100/200 bath. The shower chair in the room had a heavy buildup of residue and dirt on the mesh back. There were three dried brown mounds on the floor in the shower stall. The mounds were approximately an inch in diameter. On 9/18/23 at 4:32 PM an observation was made of the hall 300 bath. The shower chair had a buildup of residue on the mesh back and there was a gallon of body wash, stored on the floor. There was a bag of clean folded linens in the sink. On 9/18/23 at 4:49 PM an observation and interview were conducted in the hall 500 bath with CNA D. She stated that the shower chairs were cleaned after each resident. Regarding any deep cleaning of shower chair, she stated, CNAs were not responsible for this duty. She added she was unsure who deep cleaned the shower chairs. There was also a dirty unlabeled hairbrush. On 9/18/23 at 5:07 PM an observation was made of the hall 600 shower. The shower chair mesh back had a buildup of residue, and the mesh was frayed and pulling apart. There was a large bag of clean folded linens in the chair. There was a gallon jug of body wash on the floor with no cap on. The light was not operational in the toilet area. On 9/18/23 at 6:01 PM an interview was conducted with the DON regarding cleaning of the baths. She stated the nursing department had new aides. Regarding any deep cleaning of the shower chairs, she stated staff should conduct deep cleaning. Regarding what could result from unclean shower chairs, she stated infection control. On 9/19/23 at 9:27 AM an observation was made of the hall 600 shower. The pink shower chair had mesh back that was frayed and pulling from the frame. The light was out at the toilet area. There was a large amount of towels that were bagged and clean and placed in a chair. On 9/19/23 at 11:31 AM an observation was made of the hall 100/200 bath. One of one shower chair had heavy buildup residue on the mesh back. There was a heavy accumulation of dirt on one of two ceiling vents. The privacy curtain was missing at the toilet. On 9/19/23 at 10:38 AM an interview was conducted with Housekeeper A, regarding housekeeping duties in the baths. She stated, they take out the trash, wipe down the shower, sweep and clean shower chairs. She stated that they conduct deep cleaning every other day. For deep cleaning they use DC 33 and use a scrub brush. She stated, she was new and had only been here a week and a half. On 9/20/23 at 1:38 PM an interview was conducted with the Housekeeping Supervisor. Regarding shower cleaning duties, she stated, housekeeping staff only cleaned the shower room and brought soap and towels. She added housekeeping staff did not clean the shower chairs, but wheelchairs and shower chairs were cleaned by nurse aides on the night shift. Observation on 9/20/23 at 1:52 PM in the hall 100/200 bath revealed the wall cabinet bottom shelf had an unlabeled dirty brush. On 9/20/23 at 3:50 PM an interview was conducted with the Administrator regarding issues found in the facility. Regarding the cleanliness of resident baths, she stated the cleanliness issues occurred because staff were not doing as good a job cleaning. Regarding what she expected staff to have done, she stated staff should have cleaned the entire shower chairs between residents and label the hairbrushes. Regarding whom was responsible for ensuring that the baths and shower chairs were clean, she stated nursing staff was responsible. Regarding what could result from the cleaning issues, she stated possible contamination and the spread of bacteria. On 9/20/23 at 3:03 PM an interview was conducted with the DON regarding the resident shower chairs. Regarding whom was responsible for ensuring the shower chairs were clean, she stated the DON. Regarding why the situation happened with the shower chairs being dirty, she stated nursing staff were paying attention to what was seen (shower chair front area) and not the things not seen (shower chair mesh backs). She added she expected staff to clean the equipment. She further stated she had not had a chance to train this rotation staff shift (9/20/23) regarding the cleaning of shower chairs. Record review of the In-Service Attendance Record dated 9/18/23 revealed staff were given an in-service with the Subject: Cleaning and Disinfection of Resident Care Equipment. Further record review of the in-service attendance record revealed the attached guidelines did not cover specifics of cleaning shower chairs. Record review of the facility policy titled Cleaning and Disinfecting Non-Critical Resident Care Equipment, Revised April 2020, revealed the following documentation, Purpose. The purpose of this procedure is to provide guidelines for disinfection of non-critical resident care items. Preparation. General Guidelines. 1. Discard resident care items when damaged or so grossly soiled that a disinfection process is not effective in rendering the item clean. 3. The following categories are used to distinguish the levels of sterilization/disinfection necessary for items used in resident care. c. Non-critical items are those that come in contact with intact skin but not mucous membranes. d. Reusable items are cleaned and disinfected are sterilized between residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible in 4 of 5 Baths (100/200, 300, 400 and 500) and 1 of 22 resident rooms (room [ROOM NUMBER]) reviewed, in that: The facility failed to maintain resident use hot water at safe and comfortable temperatures. Resident-use hot water was not reliably controlled. Hot water temperatures ranged from 113.5 to 117.9 F, and The facility failed to ensure chemicals were stored in a manner to prevent contamination of resident use items. This failure could place residents at risk for injuries related to chemical contact and could place residents at risk for sustaining scalding injuries when using resident-use/resident accessible hot water. The findings include: Observation on 9/18/23 at 2:09 PM in room [ROOM NUMBER] revealed the hot water at the room's hand sink was 117.5°F. Observation on 9/18/23 at 2:15 PM revealed the hot water in room [ROOM NUMBER] tested at 117.9°F and the Activity Director was a witness at this time. On 9/18/23 at 4:27 PM an observation was made of the 100/200 bath, and it was unlocked. There was a spray bottle of Peroxide Multi Surface Cleaner and Disinfectant on the top shelf of the wall cabinet which was locked. The key to the cabinet lock was attached to the side of the cabinet. This cleaner was stored next to hair moisturizer and disposable briefs. The cleaner was also stored above resident toiletries, dirty razors, and lotion. The peroxide cleaner was labeled, Causes moderate irritation. Harmful if inhaled. Avoid contact with eyes or clothing. On 9/18/23 at 4:32 PM an observation was made of the hall 300 bath. It was unlocked. There was a spray bottle of DC 33 Spray Disinfectant that was leaning at a slant and stored next to hair conditioner, shampoo and body wash, and on the top cabinet shelf. The shelf was located above disposable gloves, deodorant and toothbrushes. This disinfectant was stored in a locked wall cabinet with the key attached to a chain on the side of the cabinet. The hot water in the room was 113.5°F. On 9/18/23 at 4:49 PM an observation was made of the hall 500 bath with CNA D. The locked wall cabinet had a spray bottle of Peroxide Multi Surface Cleaner stored next to disposable briefs and toothbrushes on the top shelf. On the bottom shelf was another spray bottle of the same peroxide cleaner that was labeled, Causes moderate irritation. Harmful if inhaled. Avoid contact with eyes or clothing. Also on the bottom shelf was an aerosol can of Disinfectant Spray label with the name Resident #44. Further labeling on the can was as follows, May cause irritation. Avoid contact with the eyes and skin. There was also an aerosol can of Monterey Mist Odor Eliminator and Air Freshener that was labeled, Danger. Extremely flammable aerosol. Causes serious irritation. May cause allergic skin reaction. May cause drowsiness or dizziness. The lower shelf also had body wash, baby oil cream that was labeled with the name Resident #41, razors, lotion, and disposable briefs. During an interview on 9/18/23 at 5:06 PM, CNA D stated shower 100/200, had the cleaners stored on the top shelf. Regarding why the cleaners were stored on the top shelf, she stated, when she started working in the facility, that was where they were stored. She stated she was not told anything differently as far as storing chemicals. Regarding what could result from storing chemicals with and above resident use items, she stated, skin breakdown, and chemicals could get in residents' mouths via the toothbrush. Observation on 9/18/23 at 5:12 PM the hall 400 shower was unlocked. The hot water at the sink was 115.9°F. The wall cabinet was empty, but there was a sign on the outside of the cabinets stating, Please do not place disinfectant in cabinet. Observation on 9/18/23 at 5:26 PM in room [ROOM NUMBER] the hot water was still 117.9°F. On 9/18/23 at 5:30 PM an interview was conducted with the Maintenance Supervisor. He stated that he looked for a range of 100 to 110°F as being correct for resident use hot water. He stated that he had never checked the water in room [ROOM NUMBER] on the 400 hall. Regarding his water temperature monitoring routine, he stated he checked rooms randomly every week. Normally he checked temperatures in the morning, and at times later in the day. He added that room [ROOM NUMBER] was closest to the water heater and Halls 300 and 400 were on the same water heater. He stated, everyone was using water in the mornings which could decrease the water temperature readings. Regarding what could result from water temperatures being elevated, he stated, the water could scald residents. He further stated that he had been working in the facility two months. He added that the TELS (online maintenance documentation and scheduling) system was used for the facility. On 9/18/23 at 6:01 PM an interview was conducted with the DON regarding chemical storage in the baths. Regarding what CNA's had been instructed to do regarding the storage of chemicals, she stated, toiletries should not be stored with chemicals. She stated she had conducted in-services on chemical storage, but not recently. She added, the facility had new aides. Regarding when aides would have been instructed about chemical storage, she stated it was probably conducted on hire. Regarding what could result from the storage of chemicals with resident items, she stated, the chemicals could spill on resident items and could hurt somebody. Observation on 9/19/23 at 9:32 AM, revealed bath 300 had DC 33 disinfectant spray stored in the wall cabinet on a lower shelf next to an open box of gloves. On 9/19/23 at 9:37 AM an interview was conducted with TNA A, regarding the hall 300 bath chemical storage. She stated the gloves were used by staff when bathing resident's backs and bodies. She added that chemicals should be stored on the bottom shelf and personal items on the top shelf. She further stated, the DON did not address glove storage related chemical storage. She added, she had asked the DON about chemical storage this morning (9/19/23). She stated she usually used the hall 500 bath and the gloves were stored in a bin and not the cabinet. Regarding what could result from storing chemicals next to the gloves, she stated, chemicals could irritate resident's skin. On 9/19/23 at 4:10 PM an interview was conducted with the Maintenance Supervisor regarding the Water Temperature Log documentation that revealed water temperatures had reached 117 degrees F in previous weeks. He stated he was not sure of what was causing the water temperature fluctuations. He added it could be resident use and the recirculating pumps. He stated the fluctuations seemed random. He also stated that he had not contacted a plumber about the situation. He added, he flushed out a water heater last month. Regarding his reaction when he got temperatures above 110°F, he stated, he just kept track of the temperatures and checked the rooms again. He added he adjusted the water heaters a couple of times when temperatures were high and he would go back and retest, and it usually went down. He added, if the water got excessively high, he would shut off the hot water heater and call the facility's regional corporate staff. On 9/20/23 at 9:00 AM an interview was conducted with the Maintenance Supervisor regarding hot water. He stated the plumber came to the facility today (9/20/23) and explained how the water circulates up one side of the hall and down the other with one recirculating pump. He added the facility replaced a recirculating pump before his employment. He stated the plumber told him that the water temperatures would fluctuate. On 9/20/23 at 1:40 PM an observation and interview were conducted with the Housekeeping Supervisor of the hall 400 janitors closet and the DC 33 Disinfectant. The label documented, Danger. Corrosive. Causes irreversible damage and skin burns. At that time The Housekeeping Supervisor stated, staff should use the tackle boxes (to store the DC 33); each shower room should have one with a bottle of DC 33 and a brush. She added when she checked the showers, the tackle boxes were gone. She further stated all the chemical bottles should have a label. Regarding chemicals being stored with resident toiletries, she stated, staff could not store chemicals with resident use items. Regarding the baths, she stated there may be tackle boxes in the baths, but nothing in the tackle boxes. Observation on 9/20/23 at 1:46 PM, the hall 400 bath tacklebox was empty. Observation on 9/20/23 at 1:49 PM, the hall 500 bath had no tacklebox in the Bath. Observation on 9/20/23 at 1:52 PM in the hall 100/200 bath, the tacklebox only had a brush in it. Observation of the locked wall cabinet revealed the bottom shelf had an unlabeled dirty brush, hair conditioner, foot powder, and deodorant on the shelf next to a spray bottle labeled Peroxide Multi Surface Disinfectant and Cleaner. An Interview was conducted with the Housekeeping Supervisor on 9/20/23 at 1:53 PM. She stated regarding the 100/200 bath peroxide cleaner, That's not even the right bottle. We don't have Peroxide Multi-Surface Cleaner anymore. We have DC 33 Disinfectant Cleaner. I have given nursing staff the correct bottles; I don't know how many times. On 9/20/23 at 3:50 PM an interview was conducted with the Administrator regarding chemical storage in the resident baths and hot water being over 110 degrees F. Regarding why these issues happened, she stated for the chemicals it was an education issue. Regarding the hot water, she stated it was a possible recirculating pump issue. Regarding what she expected staff to have done, she stated chemicals should be stored separately and the plumber should have been called about the hot water. Regarding whom was responsible in these cases, she stated chemicals was Nursing and the hot water was the Maintenance Supervisor. Regarding what could result from these issues she stated the chemicals could have chemical spillage and the water had a potential for burns. On 9/20/23 at 3:03 PM an interview was conducted with the DON. Regarding why staff had issues with the storage of chemicals with resident items, she stated, the regional nurse told her that there was no policy on the storage of chemicals as to what goes where. Their facility guidance just said that all chemicals should be locked and not accessible to residents. Regarding whom was responsible for ensuring that chemicals were stored properly and not with resident items, she stated, she would check showers on supervisory rounds. She stated that she expected staff to store chemicals correctly. She also added that she had not gotten this staff rotation/shift (9/20/23) trained yet regarding the storage of chemicals in baths. Record review of the facility's current undated guidelines titled TELS Masters, F689 Accidents - Water Temperatures, revealed the following documentation, F689 - Description - the facility must ensure that the resident environment remains free of accident hazards as is possible, and each resident receives adequate supervision and assistance devices to prevent accidents. Purpose - the purpose of recording your water temperatures is to assure the surveyor that your facility is remaining as free from accidental burns and scalds as possible, and that any issues are addressed in a prompt and consistent manner. Surveyors will often test water temperatures at hand sinks, and bathing tubs with a thermometer if they hold their hands under the water and feel it is too hot or note their skin turning red. Common causes - a common cause of tap water burns to the elderly, include slipping and falling in the bathing tub and not being able to get back up. Residents may also not check the water before touching it. Other causes could come from mechanical issues such as temperature changes that occur when the water is being used in other areas of the building, or a plumbing malfunction that causes a sudden burst of scalding water. Please note that long-term care residents may be more susceptible to burns than other individuals due to several factors. These include decreased skin sensitivity, communication abilities, and the inability to react quickly when exposed to hot water. State Regulations - F689 is typically enforced by the state department of health. Each state will have its own regulations on maximum water, temperature allowed, but it typically will fall between 105 to 115° F. Check with your surveyor . To gain even more efficiencies, TELS recommends using TELS mobile to record your water temperatures as you perform the testing. After you've tested the water, record the temperature readings in the attached log and note any concerns in the comment section. You can continue this process until all areas requiring testing are complete. Task Instructions. The rest of the temperature location suggested below may not apply to your type of facility. Please check with your regional support staff. 1. For burn prevention, federal guidelines advise that you keep domestic water temperature is below 120°F, although this temperature can still cause burns if exposure reaches five minutes. Many states have even stricter standards that set maximum temperatures lower than 120°F. Although 100°F is considered a safe water temperature for bathing. 2. Test temperature in shower areas. 3. Test temperatures at the mixing valve. 4. Check resident rooms at the end of each wing on a rotating basis or per facility policy. 5. Common area bathrooms, public bathrooms, and any other area having sinks should be checked and recorded as well. Record results in the water temperature log. 1. Note any discrepancies. 2. Adjust water heater settings as required. 3. Read test is necessary. Record review of the Logbook Documentation, for water temperatures from 6/19/23 through 9/14/23 revealed of the 12 approximately weekly water temperature checks, eight of the weeks documented water temperatures in the facility above 113°F in resident rooms and resident use areas. Further record review of the 12 weeks of testing revealed that when temperatures were in the range of 113 or above there was no documentation or comments as to any interventions that were taken. Additional Record review of the facility Water Temperature Logs revealed that there were no times documented as to when the temperatures were taken. The documentation was as follows: On 8/28/23, room [ROOM NUMBER], 307 and 308 had hot water temperatures at 115°F. There was no documentation of checking any rooms on Halls 200, 400 and 600. On 8/24/23 rooms [ROOM NUMBERS] had hot water temperatures at 116°F. There was no documentation that water temperatures were taken in resident rooms are baths on hall 400. On 8/14/23 one shower room on hall 100 and one room on halls 100, 200, 300, 400, 500 and 600 were tested. The temperatures range from 113°F to 115°F in the resident rooms tested on hall 100, 300, 400, 500 and 600. On 8/9/23 water temperatures were tested on all six halls except hall 400. Hot water tested in rooms 108, 201 and the 100/200 shower were 113°F. The hot water in room [ROOM NUMBER] was 114°F and the hot water in the 100 hall restroom was 117°F. On 8/3/23 the resident hot water was tested on all six halls except for hall 400. The hot water in the 100/200 bath was 113°F. On 7/18/23 one resident room was tested on all six halls and the shower room on 100 and 600. The hot water in room [ROOM NUMBER] was 113°F. On 7/3/23 temperatures were documented as tested on all six halls, but no specific rooms were documented. On hall 400 the hot water was 114°F. On 6/26/23 the water was tested on all six halls. There were no specific resident rooms documented. On hall 100 the hot water was 113°F. Review of the current American Burn Association Scald Injury Prevention Educator ' s Guide provided the following information: .although scald burns can happen to anyone, .older adults and people with disabilities are the most likely to incur such injuries .High Risk groups .Older Adults .Older adults, .have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults . People With Disabilities or Special Needs .Individuals who may have physical, mental or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds sensory impairments can result in decreased sensation especially to the hands .so the person may not realize if something is too hot. Changes in a person ' s perception, memory, judgment or awareness may hinder the person ' s ability to recognize a dangerous situation .or respond appropriately to remove themselves from danger . Further review of the Guide revealed that 100 degree F. water was a safe temperature for bathing. Water at 120 degrees F. would cause a third degree burn (full thickness burn) in 5 minutes and 124 degrees F. water would cause a third degree burn in 3 minutes. The Guide further documented that water at 127 degrees F. caused third degree burns in 1 minute and water at 133 degrees F. caused third degree burns within 15 seconds. Water temperatures at 140 degrees F. caused third degree burns within 5 seconds. Record review of the facility policy title Maintenance Service, Revised November 2021, revealed the following documentation, Policy Statement. Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation, and Implementation. 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include but are not limited to: a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. b. Maintain the building in good repair and free from hazards. f. Establishing priorities in providing repair services . i. Providing routinely scheduled maintenance service to all areas. j. Others that may become necessary or appropriate. 3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 10. Maintenance personnel shall follow, establish safety regulations to ensure the safety and well-being of all concerned

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide food that was palatable, and at a safe and appetizing temperature for 1 of 1 meal reviewed for palatability. 1) The facility failed to provide food that was palatable for 3 of 3 food forms served (Regular, Mechanical soft and pureed) at 1 of 1 meal observed (9/20/23 lunch). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss. The findings included: During confidential individual interviews, 4 of 14 residents voiced concerns related to the palatability of the foods served. On 9/18/23 At 10:44 AM a resident stated the food was too salty and too cold. On 9/18/23 at 1:30 PM another Resident stated the food was not good and had no seasoning. On 9/19/23 at 9:11 AM one other Resident stated the food is horrible and bland. On 9/19/23 at 9:30 AM yet another Resident stated the food had no flavor. On 9/20/23 at 11:37 AM, an interview was conducted with the Dietary Manager and she was informed of a test tray request for both the hall carts. Observation on 9/20/23 at 11:37 AM revealed Dietary staff C took temperatures on the service line with the following results: Rolls were room temperature. Spaghetti 158°F Meat sauce 197°F. Puréed spaghetti 176°F Puréed meat sauce 170°F Mashed potatoes 174°F Tomato purée 184°F Stewed tomatoes 199° Ground chicken nuggets 173°F Chicken nuggets 206°F. Observation revealed Cart #1 serviced halls 100, 200 and 300 and the tray preparation for it started at 11:50 AM on 9/20/23. This cart was metal and not heated and the plates were not in a warming unit. The last tray was prepared at 11:56 AM and the test trays were prepared 11:56 AM through 11:59 AM. Cart #1 left the kitchen at 12:01 PM and arrived on hall 200 at 12:02 PM. The last person was served from the Cart #1 was at 12:07 PM and the resident began eating at 12:08 PM. The test for Cart #1 began at 12:14 PM with the following results: Spaghetti and meat sauce - bland, 134°F. Chicken nuggets - cold 97° Ground nuggets - cold 97°F. Puréed spaghetti - bland 108°F. Puréed meat sauce - bland, 108°F. Mashed potatoes - salty/high salt content - flavor 106°F. The tray preparation for Cart #2, which service halls 400, 500 and 600, began at 12:00 PM. This cart was insulated. The last tray was prepared for Cart #2 at 12:07 PM. The test trays were prepared at 12:07 PM and left the kitchen at 12:08 PM. Nursing were checking the cart and the cart left the dining room at 12:13 PM and arrived on hall 500 at 12:13 PM. The cart arrived on hall 600 at 12:22 PM and the last person was served in room [ROOM NUMBER] at 12:23 PM. The resident started eating at 12:25 PM. Observation on 9/19/23 at 12:27 PM, the Cart #2 test tray was sampled with the following results: Spaghetti and meat sauce - bland 135°F. Seven of 17 foods tested had palatability issues related to temperature and flavor On 9/20/23 at 2:20 PM an interview was conducted with the Dietary Manager. Regarding food resident input on food palatability, she stated after resident council meetings, the Activity Director brings any dietary issues to her or any food related issues. She added that she was invited to a resident council meeting one time during COVID (pandemic), and it was about not being able to get eggs. She stated that she does get input from residents one on one verbally. She added a gentleman, about two weeks ago, wanted salt. Regarding why these issues occurred with food being bland and cold, she stated the cart (Cart #1) was not insulated and their plates were not heated. Regarding the food being bland, she stated staff were not testing and tasting the foods for flavor quality. Regarding whom was responsible for ensuring that foods were palatable, she stated it started with the Dietary Manager and includes staff. Regarding what she expected her staff to have done, she stated to add more seasoning. Regarding what could result from the food palatability issues, she stated residents would not eat and it could cause weight loss. Regarding any in services conducted in the last three months, and she stated that she had not conducted any. On 9/20/23 at 3:50 PM an interview was conducted with the Administrator. Regarding food palatability, she stated foods being bland were due to the amount of seasoning and cold foods could possibly be due to carts not being insulated. Regarding what she expected staff to have done, she stated staff should get food to the residents hot and follow the recipes. Regarding whom was responsible for the palatability of foods, she stated the Dietary Manager. Regarding what could result from these issues, she stated residents might not eat and could lose weight. Record review of the Resident Council meeting notes dated 6/13/23, revealed the following documentation, . Dietary: Hall trays are cold. Record review of the Resident Council meeting notes dated 7/12/23 revealed the following documentation, . Food needs help with taste. Record review of the facility policy titled Food and Nutrition Services, Revised September 2021, revealed the following documentation, Policy Statement. Each resident is provided within nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Policy Interpretation and Implementation. 6. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. a. If an incorrect meal is provided to a resident, or meal does not appear palatable, nursing staff will report it to the dietary staff, so that the new food tray can be issued.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: 1)The facility failed to ensure foods were processed and pureed under sanitary conditions, 2) The facility failed to ensure Dietary staff ensured food and non-food contact surfaces were clean, and 3) The facility failed to ensure foods were stored in a manner to prevent contamination, These failures could place residents at risk for food contamination and foodborne illness. The findings included: - The following observations were made during a kitchen tour on 9/18/23 that began at 9:44 AM and concluded at 10:12 AM: 4 of 4 cutting boards had black smears and stored in a rack as clean. There was an unshielded light bulb in the vegetable refrigerator. - The following observations were made, and interviews conducted during a kitchen tour on 9/18/23 that began at 10:53 AM and concluded at 12:24 PM: The underside of the stove upper shelf had a heavy buildup of dry food. Two of two dark blue carts were cracked on the top shelf. One had an approximately 8 x 6 area that was spider patterned cracked. The other had a crack on the top side handle. This cart had a box of lids stored on top. Both carts had a buildup of brown debris in the crevices and grooves. The black cart had brown debris in the grooved areas of the handles. The gray cart had brown debris at the handles and had a buildup of dirt. There were two white bowls, stored on the rack with clean dishes that have black smudges and smears. On the service line, there were six of 25 insulated plate covers and 4 of 25 insulated plate bottoms, ready to use, and were soiled with debris and were dirty. There was dried splatter on the underside of the shelf above the processor area counter. The surveyor checked the processor lid and pot after the processor assembly had gone through the dishwasher and prior to Dietary staff B starting to puree greens. There was an accumulation of food debris in the lid assembly. The Dietary Manager took the parts back to wash in the dishwasher. During an interview on 9/18/23 at 11:33 AM the Dietary Manager stated, they had a second processor assembly to use. Observation at this time of the second processor lid assembly revealed it had a buildup of dry food on the shoot, lid, and rubber seal assembly of the lid. This second processor lid assembly was stored as clean in the processor storage area. On 9/18/23 at 11:36 AM an interview was conducted with a Dietary staff A, dishwasher, regarding the soiled insulated lids and bottoms and processor assembly. She stated, she normally rinsed the food equipment and then placed them in the dishwasher. She added she was trained on how to wash food equipment and had been working in the facility a year. Regarding how she cleaned the processor pot and lid assembly she stated, she removed the seals when cleaning. She added, I do my part. The surveyor checked the processor and lid assembly prior to Dietary staff B pureeing of the corn bread. The processor seals on the lid were again dirty with food debris and were re-washed again. - The following observations were made during a kitchen tour on 9/19/23 that began at 8:18 AM and concluded at 8:35 AM: The rear refrigerator had a broken lightbulb inside that had some remaining glass on the bulb. The vegetable refrigerator had an unshielded light. Three of four kitchen carts had brown debris and buildup. Four of 4 cutting boards were dirty with smears and stored as clean in a rack. - The following observations were made during a kitchen tour on 9/20/23 that began at 11:37 AM and concluded at 12:13 PM: The rear refrigerator had a broken lightbulb inside that had some remaining glass on the bulb. There was an unshielded lightbulb in the vegetable refrigerator. Two to 4 carts (a white and a blue cart) had brown debris in crevices and grooved areas. On 9/20/23 at 2:20 PM an interview and observations were conducted with the Dietary Manager regarding dietary sanitation issues. It was also observed at the time that one of two processor lid units had dried food and debris in the lid assembly. She stated, dietary staff conduct deep cleaning in the kitchen every Sunday and do regular cleaning daily. Regarding why the situations happened regarding dietary sanitation, she stated staff did not check the processors. Regarding whom was responsible to ensure dietary staff perform their duties correctly, she stated the supervisor and employees. Regarding if she had conducted any in-services in the last three months, she stated that she had not. Regarding what she expected staff to have done, she stated she expected staff to have cleaned properly, continuously. She added that she was not aware of the broken light and the unshielded light in the refrigerators. She stated, the carts were wiped with sanitizer, but not scrubbed. Regarding what could result from the issues related to dietary sanitation, she stated residents could get sick. On 9/20/23 at 3:50 PM an interview was conducted with the Administrator regarding issues found in the facility. Regarding why the dietary sanitation problems occurred, she stated staff got used to a routine; it was an oversight. Regarding what she expected staff to have done, she stated to clean the processor and make notes for the maintenance supervisor to replace the lights. Regarding whom was responsible for dietary sanitation, she stated the Dietary Manager. Regarding what could result from the dietary sanitation issues, she stated possible contamination. Record review of the facility policy, titled Nutrition and Food Service Policies and Procedures Manual, 2018, Section 4-5, Policy: General Kitchen, Sanitation, Policy Number: 04.003, Date approved: October 1, 2018, revealed the following documentation, Policy: the facility recognizes that foodborne illness has the potential to harm, elderly and frail residents. All nutrition and food service employees will maintain clean, sanitary, kitchen facilities, in accordance with the state and US Food Codes in order to minimize the risk of infection and foodborne illness. Procedure: 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, except cooking surfaces of equipment in pots and pans that are not used to hold or store food and are used solely for cooking purposes. 3. Keep food contact surfaces of all cooking equipment free of encrusted grease deposits and other accumulated soil. 5. After cleaning and until use, store and handle all food contact surfaces of equipment and multi-use utensils in a manner that protects the surfaces from manual contact, splash, dust, dirt, insects and other contaminants. 6. Clean non-food contact surfaces of equipment at intervals, as necessary to keep them free of dust, dirt, and food particles and otherwise in a clean and sanitary condition. Record review of the facility policy, titled Nutrition and Food, Service Policies and Procedures. Manual, 2018, Section 4-35, Policy: Mixers, Blenders and Food Processors. Policy number: 04.024, Date approved: October 1, 2018, review of the following documentation, Policy: the facility will maintain mixers, blenders and food processors in a sanitary manner to minimize the risk of food hazards. Mixers, blenders, and food processors will be cleaned after each use. Procedure: . 2. Remove all removable parts. 3. Wash removable parts (including meat grinder attachments and guards) in dishwashing machine or in sink filled with warm water and detergent. 6. Air dry.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to accommodate the needs and preferences of 6 of 21 residents (Residents #1, #2, #3, #4, #5, #6) reviewed for accommodation of needs. The facility failed to provide effective accommodations to notify staff when needing help due to call light malfunction. This failure could place residents at risk of not having their needs and preferences met and a decreased quality of life. Findings included: Resident #1: Record review of Resident #1s face-sheet revealed a [AGE] year-old female, admitted to the facility on [DATE] with a readmit date of 11/09/2020 with a diagnosis of: hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) following a stroke, muscle weakness, stenosis of vertebral artery (a condition in which the lumen of the vertebral artery is condensed and narrowed) , acute respiratory disease, Basal cell carcinoma of skin on ear (a type of skin cancer that begins in the basal cells), abnormal weight loss, acute kidney failure, congestive heart failure, history of urinary tract infections, type 2 diabetes, high blood pressure, aphasia (loss of ability to understand or express speech), cognitive communication deficit, abnormalities of gait and mobility, hypocalcemia (a condition in which the blood has too little calcium), iron deficiency, hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone). Record Review of Resident #1s admission MDS dated [DATE] revealed that Resident #1 BIMS (Brief Interview Mental Status) of 12 meaning moderately impairment. Under section G for Functional Status indicated that Resident #1 was listed as total dependence with one-person physical assist for bed mobility, transfer, dressing, toilet use, and hygiene. Resident #1 was listed as independent with no assistance for locomotion on and off unit. Record Review of Resident #1 Care Plan dated 04/30/2023 revealed that Resident #1indicated that Resident #1's ADL Functional Status/Rehabilitation Potential, Resident #1 uses ¼ bed rails for assist with interventions of keep call bell in reach of resident. Record Review of Resident #1 Care Plan dated 03/28/2018 revealed that Resident #1 was at risk for falls with interventions of transfer resident with 2 staff members, keep areas free of clutter and monitor for proper body alignment while utilizing current mobility devices, keep call light in reach Record Review of Resident #1 Care Plan dated 03/28/2018 revealed that Resident #1 has a visual function impairment, blind in left eye and tunnel vision in right eye with interventions of assure that the lenses of the glasses are clean and in good repair, keep call light in reach at all times Record Review of Resident #1 Care Plan dated 03/28/2018 revealed that Resident #1 has urinary incontinence requiring assist with transfers to toilet with interventions of apply moisture barrier to skin as needed and as ordered, keep call light in reach, provide assistance for toileting transfer with staff x2, provide incontinence care after each incontinent episode, report any signs of skin breakdown such as soreness, tenderness, redness, and/or broken areas. Interview with Resident #1 on 05/01/2023 at 4:00 pm. Resident #1 stated that she was given small bells and a plastic whistle to use to call staff when she needs help. Resident #1 stated that she has tried to use both, and the staff do not come because they do not hear the bells or whistles. Resident #1 stated that she has to go to the restroom to use the call light in there to get help. Resident #1 stated that it is hard for her to get to the restroom to do that every time so sometimes she just has to wait until a staff member just comes in the room. Resident #1 stated that it makes her frustrated because when she needs something, and she cannot get help then she feels helpless. Resident #2: Record review of Resident #2s face-sheet revealed a [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis of: congestive heart failure, pressure ulcer on the left buttock, iron deficiency anemia, depression, insomnia, high blood pressure, type 2 diabetes, hyperlipidemia, anxiety, muscle weakness, acute kidney failure, stroke. Record Review of Resident #2s admission MDS dated [DATE] revealed that Resident #2 has a BIMS (Brief Interview Mental Status) of 7 meaning severe impairment. Under Section G for Functional Status indicated that Resident #2 was listed at extensive assistance with one-person physical assist for bed mobility, transfers, dressing, and toilet use. Resident #2 was listed as supervision with set up only for walk in room and corridor, Resident #2 was listed as limited assistance with one person physical assist for locomotion on and off unit. Record Review of Resident #2 Care Plan dated 04/30/2023 revealed that Resident #2 had an actual fall with interventions of bed in low position, orthostatic hypotension precautions, encourage use of call light, instruct resident on safety measures, keep call light within reach. Record Review of Resident #2 Care Plan dated 03/07/2022 revealed that Resident #2 has a cardiac problem with interventions of access heart rate, blood pressure, respiratory, diet restrictions. Interview with Resident #2 on 05/01/2023 at 2:41. Resident #2 stated that she does not get the help she needs from staff since the call lights have been out. Resident #2 stated that she is mostly independent but does still need help because she gets weak often. Resident #2 stated that she has used her whistle and bells and none of the staff come help and then she will have to just walk to the nurse's station to get someone to come help her. Resident #2 stated that it was not like this when the call lights worked. Resident #2 stated that she has even had a hard time getting water. Resident #2 stated that the call lights have been broken for a while. Resident #2 was not sure how long it had been broken. Resident #2 stated that she [NAME] like she is not going to get help when she needs it. Resident #2 stated, Like I said, I get weak a lot. Resident #3: Record review of Resident #3s face-sheet revealed a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis of: hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) following a stroke, hypokalemia (low potassium), anxiety, inflammation, dysphagia (difficulty swallowing), aphasia (loss of ability to understand or express speech), acid reflux disease, muscle wasting and atrophy (is the thinning of muscle mass), muscle weakness, insomnia, high blood pressure, stroke, depressive episodes, hypercalcemia (too much calcium in the blood), vitamin deficiency. Record Review of Resident #4s admission MDS dated [DATE] revealed that Resident #4 has a BIMS (Brief Interview Mental Status) of 7 meaning severe impairment. Under section G for Functional Status indicated that Resident #3 is listed as total dependent with one-person physical assist for bed mobility, transfers, dressing, and toilet use. For bathing is listed as physical help in part of bathing activity with two-person physical assist. Record Review of Resident #3 Care Plan dated 03/26/2021 revealed that Resident #3 is at risk for falls with the interventions of Resident #3 will use call light and wait for staff to assist resident with all transfers. Record Review of Resident #3 Care Plan dated 01/11/2021 revealed that Resident #3 is needs assistance with ADLS, Resident #3 has hemiplegia related to cerebrovascular accident (stroke) with interventions of approach resident from affected side t promote attention to the affected side, give resident verbal reminders not to ambulate/transfer without assistance, keep call light in reach at all times, observe frequently and place in supervised area when out of bed. Observation in Resident#3's room on 05/01/2023 at 2:15 pm of open area on the wall with wires hanging out. Observed no face plate on the wall where call light system is supposed to go. Surveyor went to go get DON to show her the open area on the wall with the wires hanging out. DON observed the open area on the wall. DON stated that she would get the maintenance man to cover the open area. Interview with Resident #3 on 05/01/2023 at 2:22 pm. Resident #3 is not able to talk but has a card with letters on it and was able to spell out or use hand gestures to communicate with Surveyor. When Resident #3 was asked if he was able to use the bells or whistle to call for help, Resident #3 shook his head no. Observed the string of bells and a whistle on the bedside table across the room from Resident #3. Resident #3 appeared frustrated by putting his hands up and waving away at the bells and whistles and shaking his head no. When Resident #3 was asked if this is frustrating him, he shook his head yes. When Resident #3 was asked if he was offered to change rooms, he shook his head no. Resident #3 then spelled out on his alphabet card, Three Weeks. When Resident #3 was asked if it had been three weeks of not having a call light, he shook his head yes. Resident #4: Record review of Resident #4s face-sheet revealed an [AGE] year-old female, originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of: absence of right knee, lower abdominal pain, abnormal weight loss, high blood pressure, Chronic obstructive pulmonary disease, hypothyroidism, hyperlipidemia, anxiety disorder, lack of coordination, cognitive communication deficit, muscle weakness, osteoporosis, stroke. Record Review of Resident #4s admission MDS dated [DATE] revealed that Resident #4 has a BIMS (Brief Interview Mental Status) of 11 meaning moderately impaired. Under Section G for Functional Status indicates that Resident #4 is listed for supervision with one person assist for bed mobility, transfers, dressing and toilet use. For locomotion on and off the unit Resident #4 Is listed as independent with no assistance. For walking in room and corridor, Resident #4 is listed as activity occurring only once or twice with one-person physical assist. For bathing Resident #4 is listed as physical assistance for transfer only with one person assist. Record Review of Resident #4 Care Plan dated 05/04/2022 revealed that Resident #4 is incontinent with interventions of apply moisture barrier to skin as needed, check for incontinent episodes at least every 2 hours, provide incontinence care after each incontinent episode. Record Review of Resident #4 Care Plan dated 04/25/2022 revealed ADL Functional Status/Rehabilitation Potential with interventions of assess residents' mobility, keep call light in reach, re-evaluate the need for bed rails every 3 months. Ambulation/Transfers amount of assist x1, bathing/hygiene amount of assist x1, dressing/grooming amount of assist x1, eating amount of assist for setup only, Record Review of Resident #4 Care Plan dated 04/24/2022 revealed Resident #4 is at risk for falls with interventions of encourage use of call light, keep call light within reach. Interview with Resident #4 on 05/01/2023 at 2:28 pm. Resident #4 stated that the staff do not come around often to check on the residents since the call lights have not been working. Resident #4 stated that the call lights have been out for about 2 to 3 weeks, and she is not sure when they will be working. Resident #4 stated that she was not offered another room, but she was given the bells and whistles. Resident #4 stated that the staff cannot hear them when she uses them because she asks the staff when they come in the room finally why they did not come in earlier when she used the bells or whistle, and they say that they did not hear them. Resident #4 stated that it does not make sense to her why the call lights have not been fixed yet because it should not have taken so long. Resident #4 stated that it makes her worry because if she were to have an accident, she would have no way to get help. Resident #5: Record review of Resident #5s face-sheet revealed a [AGE] year-old female, originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of: congestive heart failure, upper respiratory infection, dysuria (night time wetting), pain, urinary tract infection, bradycardia (slow heartrate), morbid obesity, atrial fibrillation, schizoaffective disorder, bipolar, urinary incontinence, chronic obstructive pulmonary disease, high blood pressure, anxiety, type 2 diabetes, hyperlipidemia, chronic respiratory failure, hypoxia, muscle weakness, coronary artery disease. Record Review of Resident #5s admission MDS dated [DATE] revealed that Resident #5 has a BIMS (Brief Interview Mental Status) of 14 meaning cognitively intact. Under Section G for Functional Status indicated that Resident #5 is listed as extensive assistance with 2-person physical assist for bed mobility, transfers, walk in room, walk in corridor, and toilet use. Resident #4 is listed as total dependent with 2-person physical assist for locomotion on and off of unit, dressing, and bathing. Record Review of Resident #5's Care Plan dated 05/13/2021 indicated that Resident #5 is at risk for fall with interventions of encourage use of call light, keep call light within reach. Record Review of Resident #5's Care Plan dated 05/13/2021 indicated that Resident #5 is incontinent with interventions of apply moisture barrier to skin, check for incontinent episodes at least every 2 hours, provide incontinent care after each incontinent episode, report signs of skin breakdown Interview with Resident #5 on 05/01/2023 at 10:50 am. Resident #5 stated that she was given small bells and whistles, but they do not work well, and the staff does not come when you use the bells because they can't hear them. Resident #5 stated that she can not use the whistle because she is on oxygen, and it is too hard for her to use. Resident #5 stated that she has just started using her cell phone to call the facility when she needs help because the bells and whistles do not work. Resident #5 stated that it makes her feel like she has to make her own accommodations if she needs help. Resident #5 stated what about the residents that do not have cell phones and do not have that option. Resident #6: Record review of Resident #6s face-sheet revealed a -year-old female, originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of: dementia, anxiety, constipation, wedge compression fracture of T11-T12 vertebra, pain in thoracic spine, insomnia, acute respiratory disease, depression, acid reflux, alcoholic cirrhosis of liver, muscle weakness, type 2 diabetes, hypothyroidism, hypotension, hypothyroidism, iron deficiency, hypothyroidism, hyperglyceridemia, low blood pressure. Record Review of Resident #6's annual MDS revealed Resident #6 has a BIMs (Brief Interview Mental Status) of 7 indicating severe impairment. Under Section G for Functional Status indicated Resident #6 was listed as independent with no physical help in the areas of bed mobility, transfer, walk in room, locomotion on unit, locomotion off unit, dressing, eating, toilet use and hygiene. Under Section G for Functional Status for bathing is listed as physical help transfer only with one person assist. Record Review of Resident #6s Care Plan dated 09/1/2021 indicated Resident #6 was at risk for falls with the interventions of encourage use of call light, keep call light within reach. Record Review of Resident #6s Care Plan dated 09/17/2021 indicated Resident #6 indicated that Resident #6 had urinary incontinence with catheter care with interventions of check for incontinence, keep call light in reach, toileting every 2 hours. Record Review of Resident #6s Care Plan dated 09/17/2021 indicated Resident #6 indicated for ADLs that Resident #6 was listed as assistance with one-person physical assist for ambulation/transfers, bathing/hygiene, dressing/grooming, Record review of progress notes for Resident #6 revealed under additional notes: Resident #6's daughter called the nurses station and stated that her mother was on the floor and couldn't get to her whistle or bell. The nurse along with LVN F, went to assess Resident #6 and found her laying on the right side in the bed. Water pitcher was spilt on the floor and Resident #6's gown was wet. This nurse asked Resident #6 what happened, and she stated, I went to the restroom and fell trying to get back in bed, I guess I slipped and landed on my back. Head to toe assessment completed, no injuries noted. No redness or bruising. Resident denies hitting her head. Assistant out of bed so wet clothes and bedding could be changed. Unable to interview Resident #6 because she was in the hospital. Interview with Administrator on 05/01/2023 at 10:15 am. Administrator stated the call light system has been out approximately 2 or 2.5 weeks. Administrator stated that the system has not been fixed yet because parts are on back order. Administrator stated that the fire panel was giving an error. Administrator stated that the vendor was contacted by the maintenance man and the vendor did a reset on the call system. Administrator stated that when the maintenance man checked the resident rooms they were not working. Administrator stated that the vendor stated that the best determination that they could come up with is that it may be a power surge. Administrator stated that an order has been placed to replace the base to the call light system, but the parts are on back order and might be here on 05/05/2023. Administrator stated that is not a guarantee. Administrator stated that for the rooms that were affected, the staff has been doing 30 minutes rounds for the 21 rooms. Administrator stated that the resident's seem okay with the small ball bells and the plastic whistles. Administrator stated that the residents that were affected by the call light system have the option to move to another room. Administrator stated that only one resident wanted to move to another room temporarily. Administrator stated that an electrician had been out to the facility prior to the call light system failing for a different reason. Administrator stated that for the intake with Resident #6 having a fall had suffered no injuries. Administrator stated that she would have to look at the notes but does not believe that it was due to not having the call light system not working. Interview with Maintenance Supervisor on 05/01/2023 at 11:02 am. Maintenance Supervisor stated that he had gotten a call at 1:25 on the day of 04/12/2023. Maintenance Supervisor stated that he went to the facility to check on it and it just kept beeping. Maintenance Supervisor stated that he reset it and then the system showed a yellow light and gave a trouble code. Maintenance Supervisor stated that he reset it again and at that time it was good. Maintenance Supervisor stated that he went to all the rooms and started to check and realized that they were not working. Maintenance Supervisor stated that he called the vendor for electrical work to come look at the system. Maintenance Supervisor stated that the vendor was not able to go look at it until the next day on 04/13/2023. Maintenance Supervisor stated that he was not sure if the system had a short of what the problem was. Maintenance Supervisor stated that the vendor was at the facility on 04/06/2023 for another situation and he is thinking that this was a result of the vendor doing something that made this happen. Maintenance Supervisor stated that the call light system was working on 04/06/2023 and thereafter until 04/12/2023 when it started to malfunction. Maintenance Supervisor stated that he has contacted the vendor every other day and was told that it should be fixed on Friday 05/05/2023. Maintenance Supervisor stated he is not positive if it will definitely be fixed on Friday or not because the parts were on back order. Maintenance Supervisor stated that this is the only place that carries the part because the system is so old. Maintenance Supervisor stated that the day that the call system malfunctioned he reached out to the charge nurse and told her to go ahead and start 30-minute rounds. Maintenance Supervisor stated that he told the administrator and DON that this is an electrical issue because of the burnt wires and stated that an electrician needed to look at it. Maintenance Supervisor stated that he is not sure how it could a power surge because the weather is not bad. Interview with ADON on 05/01/2023 at 12:14 pm. ADON stated that she mainly works in the office, but she is aware that the call light system has stopped working and that the residents were supplied with small bell balls and whistles. ADON stated that she can only hear if the Residents are using the bells or whistles if she is close to the resident's rooms. ADON stated that she guesses it just depends on how well someone could hear. ADON stated that she does not think that is an effective way to call for help because the staff don't really know where the noise is coming from. Interview with Administrator on 05/01/2023 at 3:29 pm. Administrator stated the parts are on back order and had to get the parts from the vendor because they are the only place to get the parts. Administrator stated that it is an older system, and this is the only place to get the parts. Administrator stated that she had gotten the small bells when the call light system went out but quickly realized that you could not hear the small bells. Administrator stated that she went and got the plastic whistles and then she realized that the whistles were not loud, she went out and got better whistles. Administrator stated that she did not assess every resident with their health issues and if they had the capability of using the whistle. Administrator stated that the staff would be able to see if a resident had fallen or were in respiratory distress when the staff the made their 30-minute rounds. Administrator stated that is why she gave the residents bells so they could notify the staff. Administrator stated that she did notify the corporate and they had told her if they can help in any way to let them know. Administrator stated that corporate knew about the bells and whistles. Administrator stated that corporate had told her to make sure to do the 30-minute resident rounds. Administrator stated that she feels that the residents had an effective means of communication to get the help that they need. Administrator stated that the policy states that the facility must have a working call light system. Administrator stated that the way she monitors the 30 minutes rounds is because the staff will initial the paper indicating that they have made the rounds. Administrator stated that when they take resident's in they are accepting the responsibility to take care of their needs. When asked if it is possible that it could make the resident's feel helpless when they are not getting their needs met by answering the call lights? Administrator stated, yes, probably so. Interview with CNA C on 05/01/2023 at 4:18 pm. CNA C stated that she usually makes her rounds every two hours. CNA C stated that every 30-minute rounds are unreasonable and impossible because if they are changing a resident, it may take 15 to 20 minutes. CNA C stated that they usually have 2 to 3 CNAs for 6 halls, and it is impossible to do every 30-minute rounds for the 21 rooms that do not have call lights. CNA C stated she can hear the bells and it depends if she is able to find where the bells or whistles are coming from because there are 6 halls. CNA C stated that she does not feel that this is an effective method. CNA C stated that the facility needed to get a better method for the call system. CNA C stated that she is sure that some residents have gone without help because it is difficult to find where the noise is and there is no light so you can not see where it is coming from, you just have to kind of hunt for it. CNA C stated that some residents can not even use the whistles or bells or may get overly exhausted trying to use the bells or whistles. CNA C stated that the negative potential outcome for residents is that they may get injured or fall trying to help themselves because the can not call for help when they need it. Interview with CNA D on 05/01/2023 at 4:31 pm. CNA D stated that she makes her rounds approximately every two hours. CNA D stated that she has not been told or notified that she needs to be making 30-minute rounds for the residents that are without a call light. CNA D stated that she cannot hear the bells or the whistle, but she can sometimes hear the whistles. CNA D stated that it gets frustrating because she has to run around trying to find where the whistle is coming from and if the resident stops blowing the whistle, it is impossible to find which resident was using the whistle. CNA D stated that some of the residents cannot even use the whistle because of the oxygen and it is too much for them. CNA D stated that she does not think this method is effective because many residents are getting skipped because the staff cannot find where the whistle is coming from. CNA D stated that the call light system has been out for weeks and does not know how much longer it will be until it is fixed. CNA D stated that even with the call lights it takes some time to get to the resident because there is not many staff that are there to work, so can you imagine having no light and trying to hunt down a whistle sound when there is only 3 or 4 staff members that are trying to locate the resident needing help. CNA D stated that makes it impossible to do 30-minute rounds and that is beside trying to provide care for all residents. CNA D stated that the negative potential outcome for not having effective call light system would be that the resident is not getting the needed care they deserve, or they could get injured. Interview with DON on 05/01/2023 at 4:47 pm. DON stated that she can hear the bells and whistles at night. DON stated that she does not usually work nights, but she has from time to time. DON stated that in order to find where the bells and whistles are coming from, she would have to go look for where the noise is coming from. DON stated that she does not guess that would be an effective means of notifying staff that a resident needs help or for a long period of time. When asked if she is willing to work nights until the call light system Is fixed since she can hear the bells and whistles at night when the rest of the staff can not hear it, her response was that she is not willing to work every day until then. DON stated that she does not know other than getting cow bells what they can do. DON stated that the negative potential outcome for residents not being able to get staff attention when they need help is they could possibly get hurt or not get what they need taken care of. DON stated that she can not speak for her staff, but she can only speak for herself, and she believes that she could hear the whistles and bells. DON stated that the way that she monitors the staff making the 30-minute rounds is by checking the log to see if they have initialed the 30-minute round log. DON stated that the parts to fix the call light system are on back order and she does not know if that is the only vendor that is available for the parts or not. When asked why the staff have not made 30-minute rounds while Surveyor has been in the building, DON stated she was not sure why they have not done this. DON stated that the system that they have in place is effective when the staff can hear the whistles or bells and the staff work together and do what they need to do. The DON stated it is the responsibility of the facility to make sure to provide for the needs of the residents. Interview with Maintenance Supervisor on 05/01/2023 at 5:40 pm. Maintenance Supervisor stated that the open area in Resident #3's room should not have been exposed and open with wiring hanging out. Maintenance Supervisor stated that it should be fine though because the wiring is not hot. Maintenance Supervisor stated that there would be a potential for injury if the wiring was hot. When the Maintenance Supervisor was asked, Could one of the wires potentially poke the resident's finger if the resident was touching it? Maintenance Supervisor stated that that could possibly happen but why would a resident be messing with the wires even if it uncovered. Maintenance Supervisor stated that he is aware that he is responsible for coving the exposed wiring and opened wall. Maintenance Supervisor then questioned surveyor if she was talking with a resident that was his family member. Surveyor stated that information is confidential. Maintenance Supervisor got hostile verbally and ended the interview. Record Review of facility provided policy on 05/01/2023, labeled, Resident Call System, dated December 2019, revealed: Policy: The facility is equipped with a functioning communication system from rooms, toilets, and bathing facilities in which the resident calls are received and answered by staff. Procedure: 1). Resident calls are relayed directly to a staff member or to a centralized staff work area. 2). The communication may be through audible or visual signals and may include wireless systems. 3). All portions of the system are functioning a). Systems are on at nursing station, b). Staff are available at the nursing station, c). The volume is loud enough to be heard by the nursing staff, d). Th light above the room or rooms is working, e). calls are being answered, f). For wireless systems, staff who answer resident calls, have functioning devices in their possession, and are answering resident calls. 4). If a resident has disabilities that make use of the facility's communication system inaccessible, alternative, auxiliary aids, or services are provided to meet the resident's needs as identified in the resident's assessment or plan of care. Record Review of facility provided policy on 05/01/2023, labeled, Dignity, date Revised on February 2021, revealed: Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation: 1. Residents are treated with dignity and respect at all times. Record Review of in-service provided by facility on 05/01/2023 dated 04/12/2023, labeled, Call Light Malfunction, revealed: Under topic: Due to the malfunction of the call light system, Staff will do every 30-minute checks on residents who's call light is not working. Whistle and bells have been provided to each resident until the system I fixed. The signature sheets showed 30 employee signatures. Record Review of 30-minute resident check sheet provided on 05/01/2023, dates provided for 04/13/2023-04/30/2023 revealed: Each sheet indicated the resident name at the top and 30-minute increment times on the side with employee initialed signed to each slot. The sheet did not indicate what was the resident being check, if the resident needed anything. There was no documentation on what was done. The sheets do not indicate that the staff was checking due to call light system malfunction. No receipt provided for call light system repair or estimated time of arrival upon request of receipt from facility. Record Review of falls for facility provided on 05/01/2023 revealed: Resident #6 had a fall on 04/15/2023 stated unwitnessed fall with no injuries. Resident #6 call light is not working. Resident #7 had a fall on 04/12/2023 stated sitting on floor, near wheelchair and room entrance. It was listed that Resident #7 was one of the residents with no working call light in this timeframe. Was not able to interview resident. Record Review of facility provided list for non-working call lights and map on 05/01/2023 revealed: Not-Working Call lights: 103, 104, 105, 106, 107, 108, 205, 206, 207[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the facility was adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area in 19 of 51 of resident call light systems that resident in the facility: 1)The facility failed to ensure that 19 of 51 had operable call systems in their rooms. The facility provided ball bells and plastic whistles in which could not be heard by staff. One resident had a fall and could not reach the whistle or ball bells to call for help because they were on the bedside table. Other residents state they could not get assistance or help from staff. These failures could place residents at risk of not receiving assistance when needed as well as possible injury. The findings included: Resident #1: Record review of Resident #1s face-sheet revealed a [AGE] year-old female, admitted to the facility on [DATE] with a readmit date of 11/09/2020 with a diagnosis of: hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) following a stroke, muscle weakness, stenosis of vertebral artery (a condition in which the lumen of the vertebral artery is condensed and narrowed) , acute respiratory disease, Basal cell carcinoma of skin on ear (a type of skin cancer that begins in the basal cells), abnormal weight loss, acute kidney failure, congestive heart failure, history of urinary tract infections, type 2 diabetes, high blood pressure, aphasia (loss of ability to understand or express speech), cognitive communication deficit, abnormalities of gait and mobility, hypocalcemia (a condition in which the blood has too little calcium), iron deficiency, hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone). Record Review of Resident #1 Care Plan dated 03/28/2018 revealed that Resident #1 was at risk for falls with interventions of transfer resident with 2 staff members, keep areas free of clutter and monitor for proper body alignment while utilizing current mobility devices, Keep call light in reach. Record Review of Resident #1 Care Plan dated 03/28/2018 revealed that Resident #1 has a visual function impairment, blind in left eye and tunnel vision in right eye with interventions of assure that the lenses of the glasses are clean and in good repair, Keep call light in reach at all times. Record Review of Resident #1 Care Plan dated 03/28/2018 revealed that Resident #1 has urinary incontinence requiring assist with transfers to toilet with interventions of apply moisture barrier to skin as needed and as ordered, keep call light in reach, provide assistance for toileting transfer with staff x2, provide incontinence care after each incontinent episode, report any signs of skin breakdown such as soreness, tenderness, redness, and/or broken areas. Record Review of Resident #1 Care Plan dated 04/30/2023 revealed that Resident #1indicated that Resident #1's ADL Functional Status/Rehabilitation Potential, Resident #1 uses ¼ bed rails for assist with interventions of keep call bell in reach of resident. Record Review of Resident #1s admission MDS dated [DATE] revealed that Resident #1 had a BIMS (Brief Interview Mental Status) of 12 meaning moderately impairment. Under section G for Functional Status indicated that Resident #1 was listed as total dependence with one-person physical assist for bed mobility, transfer, dressing, toilet use, and hygiene. Resident #1 was listed as independent with no assistance for locomotion on and off unit. Interview with Resident #1 on 05/01/2023 at 4:00 pm. Resident #1 stated that she was given small bells and a plastic whistle to use to call staff when she needs help. Resident #1 stated that she has tried to use both, and the staff do not come because they do not hear the bells or whistles. Resident #1 stated that she has to go to the restroom to use the call light in there to get help. Resident #1 stated that it is hard for her to get to the restroom to do that every time so sometimes she just has to wait until a staff member just comes in the room. Resident #1 stated that it makes her frustrated because when she needs something, and she cannot get help then she feels helpless. Resident #2: Record review of Resident #2s face-sheet revealed a [AGE] year-old female, admitted to the facility on [DATE] with a diagnosis of: congestive heart failure, pressure ulcer on the left buttock, iron deficiency anemia, depression, insomnia, high blood pressure, type 2 diabetes, hyperlipidemia, anxiety, muscle weakness, acute kidney failure, stroke. Record Review of Resident #2 Care Plan dated 03/07/2022 revealed that Resident #2 had a cardiac problem with interventions of assess heart rate, blood pressure, respiratory, diet restrictions. Record Review of Resident #2 Care Plan dated 04/30/2023 revealed that Resident #2 had an actual fall with interventions of bed in low position, orthostatic hypotension precautions, encourage use of call light, instruct resident on safety measures, Keep call light within reach. Record Review of Resident #2s admission MDS dated [DATE] revealed that Resident #2 had a BIMS (Brief Interview Mental Status) of 7 meaning severe impairment. Under Section G for Functional Status indicated that Resident #2 was listed at extensive assistance with one-person physical assist for bed mobility, transfers, dressing, and toilet use. Resident #2 was listed as supervision with set up only for walk in room and corridor, Resident #2 was listed as limited assistance with one-person physical assist for locomotion on and off unit. Interview with Resident #2 on 05/01/2023 at 2:41. Resident #2 stated that she does not get the help she needs from staff since the call lights have been out. Resident #2 stated that she is mostly independent but does still need help because she gets weak often. Resident #2 stated that she has used her whistle and bells and none of the staff come help and then she will have to just walk to the nurse's station to get someone to come help her. Resident #2 stated that it was not like this when the call lights worked. Resident #2 stated that she has even had a hard time getting water. Resident #2 stated that the call lights have been broken for a while. Resident #2 was not sure how long it had been broken. Resident #2 stated that she feels like she is not going to get help when she needs it. Resident #2 stated, Like I said, I get weak a lot. Resident #3: Record review of Resident #3s face-sheet revealed a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis of: hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) following a stroke, hypokalemia (low potassium), anxiety, inflammation, dysphagia (difficulty swallowing), aphasia (loss of ability to understand or express speech), acid reflux disease, muscle wasting and atrophy (is the thinning of muscle mass), muscle weakness, insomnia, high blood pressure, stroke, depressive episodes, hypercalcemia (too much calcium in the blood), vitamin deficiency. Record Review of Resident #3 Care Plan dated 01/11/2021 revealed that Resident #3 needed assistance with ADLS, Resident #3 has hemiplegia related to cerebrovascular accident (stroke) with interventions of approach resident from affected side t promote attention to the affected side, give resident verbal reminders not to ambulate/transfer without assistance, Keep call light in reach at all times, Observe frequently and place in supervised area when out of bed. Record Review of Resident #3 Care Plan dated 03/26/2021 revealed that Resident #3 was at risk for falls with the interventions of Resident #3 will use call light and wait for staff to assist resident with all transfers. Record Review of Resident #3s admission MDS dated [DATE] revealed that Resident #3 has a BIMS (Brief Interview Mental Status) of 7 meaning severe impairment. Under section G for Functional Status indicated that Resident #3 is listed as total dependent with one-person physical assist for bed mobility, transfers, dressing, and toilet use. For bathing is listed as physical help in part of bathing activity with two-person physical assist. Observation in Resident#3's room on 05/01/2023 at 2:15 pm of open area on the wall with wires hanging out. Observed no face plate on the wall where call light system is supposed to go. Surveyor went to go get DON to show her the open area on the wall with the wires hanging out. DON observed the open area on the wall. DON stated that she would get the maintenance man to cover the open area. Interview with Resident #3 on 05/01/2023 at 2:22 pm. Resident #3 was not able to talk but had a card with letters on it and was able to spell out or use hand gestures to communicate with Surveyor. When Resident #3 was asked if he was able to use the bells or whistle to call for help, Resident #3 shook his head no. Observed the string of bells and a whistle on the bedside table across the room from Resident #3. Resident #3 appeared frustrated by putting his hands up and waving away at the bells and whistles and shaking his head no. When Resident #3 was asked if this is frustrating him, he shook his head yes. When Resident #3 was asked if he was offered to change rooms, he shook his head no. Resident #3 then spelled out on his alphabet card, Three Weeks. When Resident #3 was asked if it had been three weeks of not having a call light, he shook his head yes. Resident #4: Record review of Resident #4s face-sheet revealed an [AGE] year-old female, originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of: absence of right knee, lower abdominal pain, abnormal weight loss, high blood pressure, Chronic obstructive pulmonary disease, hypothyroidism, hyperlipidemia, anxiety disorder, lack of coordination, cognitive communication deficit, muscle weakness, osteoporosis, stroke. Record Review of Resident #4s admission MDS dated [DATE] revealed that Resident #4 had a BIMS (Brief Interview Mental Status) of 11 meaning moderately impaired. Under Section G for Functional Status indicates that Resident #4 is listed for supervision with one person assist for bed mobility, transfers, dressing and toilet use. For locomotion on and off the unit Resident #4 Is listed as independent with no assistance. For walking in room and corridor, Resident #4 was listed as activity occurring only once or twice with one-person physical assist. For bathing Resident #4 was listed as physical assistance for transfer only with one person assist. Record Review of Resident #4 Care Plan dated 05/04/2022 revealed that Resident #4 was incontinent with interventions of apply moisture barrier to skin as needed, check for incontinent episodes at least every 2 hours, provide incontinence care after each incontinent episode. Record Review of Resident #4 Care Plan dated 04/25/2022 revealed ADL Functional Status/Rehabilitation Potential with interventions of assess residents' mobility, keep call light in reach, re-evaluate the need for bed rails every 3 months. Ambulation/Transfers amount of assist x1, bathing/hygiene amount of assist x1, dressing/grooming amount of assist x1, eating amount of assist for setup only, Record Review of Resident #4 Care Plan dated 04/24/2022 revealed Resident #4 was at risk for falls with interventions of encourage use of call light, keep call light within reach. Interview with Resident #4 on 05/01/2023 at 2:28 pm. Resident #4 stated that the staff do not come around often to check on the residents since the call lights have not been working. Resident #4 stated that the call lights have been out for about 2 to 3 weeks, and she is not sure when they will be working. Resident #4 stated that she was not offered another room, but she was given the bells and whistles. Resident #4 stated that the staff cannot hear them when she uses them because she asks the staff when they come in the room finally why they did not come in earlier when she used the bells or whistle, and they say that they did not hear them. Resident #4 stated that it does not make sense to her why the call lights have not been fixed yet because it should not have taken so long. Resident #4 stated that it makes her worry because if she were to have an accident, she would have no way to get help. Resident #5: Record review of Resident #5s face-sheet revealed a [AGE] year-old female, originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of: congestive heart failure, upper respiratory infection, dysuria (night time wetting), pain, urinary tract infection, bradycardia (slow heartrate), morbid obesity, atrial fibrillation, schizoaffective disorder, bipolar, urinary incontinence, chronic obstructive pulmonary disease, high blood pressure, anxiety, type 2 diabetes, hyperlipidemia, chronic respiratory failure, hypoxia, muscle weakness, coronary artery disease. Record Review of Resident #5s admission MDS dated [DATE] revealed that Resident #5 had a BIMS (Brief Interview Mental Status) of 14 meaning cognitively intact. Under Section G for Functional Status indicated that Resident #5 is listed as extensive assistance with 2-person physical assist for bed mobility, transfers, walk in room, walk in corridor, and toilet use. Resident #4 is listed as total dependent with 2-person physical assist for locomotion on and off of unit, dressing, and bathing. Record Review of Resident #5's Care Plan dated 05/13/2021 indicated that Resident #5 was at risk for fall with interventions of encourage use of call light, keep call light within reach. Record Review of Resident #5's Care Plan dated 05/13/2021 indicated that Resident #5 was incontinent with interventions of apply moisture barrier to skin, check for incontinent episodes at least every 2 hours, provide incontinent care after each incontinent episode, report signs of skin breakdown Interview with Resident #5 on 05/01/2023 at 10:50 am. Resident #5 stated that she was given small bells and whistles, but they do not work well, and the staff does not come when you use the bells because they can't hear them. Resident #5 stated that she cannot use the whistle because she was on oxygen, and it is too hard for her to use. Resident #5 stated that she has just started using her cell phone to call the facility when she needs help because the bells and whistles do not work. Resident #5 stated that it makes her feel like she had to make her own accommodations if she needs help. Resident #5 stated what about the residents that do not have cell phones and do not have that option. Resident #6: Record review of Resident #6s face-sheet revealed a -year-old female, originally admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of: dementia, anxiety, constipation, wedge compression fracture of T11-T12 vertebra, pain in thoracic spine, insomnia, acute respiratory disease, depression, acid reflux, alcoholic cirrhosis of liver, muscle weakness, type 2 diabetes, hypothyroidism, hypotension, hypothyroidism, iron deficiency, hypothyroidism, hyperglyceridemia, low blood pressure. Record Review of Resident #6's annual MDS revealed Resident #6 had a BIMs (Brief Interview Mental Status) of 7 indicating severe impairment. Under Section G for Functional Status indicated Resident #6 was listed as independent with no physical help in the areas of bed mobility, transfer, walk in room, locomotion on unit, locomotion off unit, dressing, eating, toilet use and hygiene. Under Section G for Functional Status for bathing is listed as physical help transfer only with one person assist. Record Review of Resident #6s Care Plan dated 09/1/2021 indicated Resident #6 was at risk for falls with the interventions of encourage use of call light, keep call light within reach. Record Review of Resident #6s Care Plan dated 09/17/2021 indicated Resident #6 indicated that Resident #6 had urinary incontinence with catheter care with interventions of check for incontinence, keep call light in reach, toileting every 2 hours. Record Review of Resident #6s Care Plan dated 09/17/2021 indicated Resident #6 indicated for ADLs that Resident #6 was listed as assistance with one-person physical assist for ambulation/transfers, bathing/hygiene, dressing/grooming, Record review of progress notes dated 04/15/2023 for Resident #6 revealed under additional notes: Resident #6's daughter called the nurses station and stated that her mother was on the floor and couldn't get to her whistle or bell. The nurse along with LVN F, went to assess Resident #6 and found her laying on the right side in the bed. Water pitcher was spilt on the floor and Resident #6's gown was wet. This nurse asked Resident #6 what happened, and she stated, I went to the restroom and fell trying to get back in bed, I guess I slipped and landed on my back. Head to toe assessment completed, no injuries noted. No redness or bruising. Resident denies hitting her head. Assistant out of bed so wet clothes and bedding could be changed. Unable to interview Resident #6 prior to exit because she was in the hospital. Interview with Administrator on 05/01/2023 at 10:15 am. Administrator stated the call light system has been out approximately 2 or 2.5 weeks. Administrator stated that the system has not been fixed yet because parts are on back order. Administrator stated that the fire panel was giving an error. Administrator stated that the vendor was contacted by the maintenance man and the vendor did a reset on the call system. Administrator stated that when the maintenance man checked the resident rooms they were not working. Administrator stated that the vendor stated that the best determination that they could come up with was that it may be a power surge. Administrator stated that an order has been placed to replace the base to the call light system, but the parts are on back order and might be here on 05/05/2023. Administrator stated that was not a guarantee. Administrator stated that for the rooms that were affected, the staff has been doing 30 minutes rounds for the 21 rooms. Administrator stated that the resident's seem okay with the small ball bells and the plastic whistles. Administrator stated that the residents that were affected by the call light system have the option to move to another room. Administrator stated that only one resident wanted to move to another room temporarily. Administrator stated that an electrician had been out to the facility prior to the call light system failing for a different reason. Administrator stated that for the intake with Resident #6 having a fall had suffered no injuries. Administrator stated that she would have to look at the notes but does not believe that it was due to not having the call light system not working. Interview with Maintenance Supervisor on 05/01/2023 at 11:02 am. Maintenance Supervisor stated that he had gotten a call at 1:25 PM on the day of 04/12/2023. Maintenance Supervisor stated that he went to the facility to check on it and it just kept beeping. Maintenance Supervisor stated that he reset it and then the system showed a yellow light and gave a trouble code. Maintenance Supervisor stated that he reset it again and at that time it was good. Maintenance Supervisor stated that he went to all the rooms and started to check and realized that they were not working. Maintenance Supervisor stated that he called the vendor for electrical work to come look at the system. Maintenance Supervisor stated that the vendor was not able to go look at it until the next day on 04/13/2023. Maintenance Supervisor stated that he was not sure if the system had a short of what the problem was. Maintenance Supervisor stated that the vendor was at the facility on 04/06/2023 for another situation and he is thinking that this was a result of the vendor doing something that made this happen. Maintenance Supervisor stated that the call light system was working on 04/06/2023 and thereafter until 04/12/2023 when it started to malfunction. Maintenance Supervisor stated that he has contacted the vendor every other day and was told that it should be fixed on Friday 05/05/2023. Maintenance Supervisor stated he is not positive if it will definitely be fixed on Friday or not because the parts were on back order. Maintenance Supervisor stated that this is the only place that carries the part because the system is so old. Maintenance Supervisor stated that the day that the call system malfunctioned he reached out to the charge nurse and told her to go ahead and start 30-minute rounds. Maintenance Supervisor stated that he told the administrator and DON that this is an electrical issue because of the burnt wires and stated that an electrician needed to look at it. Maintenance Supervisor stated that he is not sure how it could a power surge because the weather is not bad. Interview with ADON on 05/01/2023 at 12:14 pm. ADON stated that she mainly works in the office, but she was aware that the call light system has stopped working and that the residents were supplied with small bell balls and whistles. ADON stated that she can only hear if the Residents are using the bells or whistles if she is close to the resident's rooms. ADON stated that she guesses it just depends on how well someone could hear. ADON stated that she does not think that is an effective way to call for help because the staff don't really know where the noise is coming from. Interview with Administrator on 05/01/2023 at 3:29 pm. Administrator stated the parts are on back order and had to get the parts from the vendor because they are the only place to get the parts. Administrator stated that it is an older system, and this is the only place to get the parts. Administrator stated that she had gotten the small bells when the call light system went out but quickly realized that you could not hear the small bells. Administrator stated that she went and got the plastic whistles and then she realized that the whistles were not loud, she went out and got better whistles. Administrator stated that she did not assess every resident with their health issues and if they had the capability of using the whistle. Administrator stated that the staff would be able to see if a resident had fallen or were in respiratory distress when the staff the made their 30-minute rounds. Administrator stated that is why she gave the residents bells so they could notify the staff. Administrator stated that she did notify the corporate and they had told her if they can help in any way to let them know. Administrator stated that corporate knew about the bells and whistles. Administrator stated that corporate had told her to make sure to do the 30-minute resident rounds. Administrator stated that she feels that the residents had an effective means of communication to get the help that they need. Administrator stated that the policy states that the facility must have a working call light system. Administrator stated that the way she monitors the 30 minutes rounds is because the staff will initial the paper indicating that they have made the rounds. Administrator stated that when they take resident's in, they are accepting the responsibility to take care of their needs. When asked if it was possible that it could make the resident's feel helpless when they are not getting their needs met by answering the call lights? Administrator stated, yes, probably so. Interview with CNA C on 05/01/2023 at 4:18 pm. CNA C stated that she usually makes her rounds every two hours. CNA C stated that every 30-minute rounds are unreasonable and impossible because if they are changing a resident, it may take 15 to 20 minutes. CNA C stated that they usually have 2 to 3 CNAs for 6 halls, and it is impossible to do every 30-minute rounds for the 21 rooms that do not have call lights. CNA C stated she can hear the bells and it depends if she is able to find where the bells or whistles are coming from because there are 6 halls. CNA C stated that she does not feel that this is an effective method. CNA C stated that the facility needed to get a better method for the call system. CNA C stated that she is sure that some residents have gone without help because it is difficult to find where the noise is and there is no light so you cannot see where it is coming from, you just have to kind of hunt for it. CNA C stated that some residents cannot even use the whistles or bells or may get overly exhausted trying to use the bells or whistles. CNA C stated that the negative potential outcome for residents is that they may get injured or fall trying to help themselves because the cannot call for help when they need it. Interview with CNA D on 05/01/2023 at 4:31 pm. CNA D stated that she makes her rounds approximately every two hours. CNA D stated that she has not been told or notified that she needs to be making 30-minute rounds for the residents that are without a call light. CNA D stated that she cannot hear the bells or the whistle, but she can sometimes hear the whistles. CNA D stated that it gets frustrating because she had to run around trying to find where the whistle is coming from and if the resident stops blowing the whistle, it is impossible to find which resident was using the whistle. CNA D stated that some of the residents cannot even use the whistle because of the oxygen and it is too much for them. CNA D stated that she does not think this method is effective because many residents are getting skipped because the staff cannot find where the whistle is coming from. CNA D stated that the call light system has been out for weeks and does not know how much longer it will be until it is fixed. CNA D stated that even with the call lights it takes some time to get to the resident because there is not many staff that are there to work, so can you imagine having no light and trying to hunt down a whistle sound when there is only 3 or 4 staff members that are trying to locate the resident needing help. CNA D stated that makes it impossible to do 30-minute rounds and that is beside trying to provide care for all residents. CNA D stated that the negative potential outcome for not having effective call light system would be that the resident is not getting the needed care they deserve, or they could get injured. Interview with DON on 05/01/2023 at 4:47 pm. DON stated that she can hear the bells and whistles at night. DON stated that she does not usually work nights, but she has from time to time. DON stated that in order to find where the bells and whistles are coming from, she would have to go look for where the noise was coming from. DON stated that she does not guess that would be an effective means of notifying staff that a resident needs help or for a long period of time. When asked if she is willing to work nights until the call light system Is fixed since she can hear the bells and whistles at night when the rest of the staff cannot hear it, her response was that she is not willing to work every day until then. DON stated that she does not know other than getting cow bells what they can do. DON stated that the negative potential outcome for residents not being able to get staff attention when they need help is they could possibly get hurt or not get what they need taken care of. DON stated that she cannot speak for her staff, but she can only speak for herself, and she believes that she could hear the whistles and bells. DON stated that the way that she monitors the staff making the 30-minute rounds is by checking the log to see if they have initialed the 30-minute round log. DON stated that the parts to fix the call light system are on back order and she does not know if that is the only vendor that is available for the parts or not. When asked why the staff have not made 30-minute rounds while Surveyor has been in the building, DON stated she was not sure why they have not done this. DON stated that the system that they have in place is effective when the staff can hear the whistles or bells and the staff work together and do what they need to do. The DON stated it is the responsibility of the facility to make sure to provide for the needs of the residents. Interview with Maintenance Supervisor on 05/01/2023 beginning at 5:40 pm. Maintenance Supervisor stated that the open area in Resident #3's room should not have been exposed and open with wiring hanging out. Maintenance Supervisor stated that it should be fine though because the wiring is not hot. Maintenance Supervisor stated that there would be a potential for injury if the wiring was hot. When the Maintenance Supervisor was asked, Could one of the wires potentially poke the resident's finger if the resident was touching it? Maintenance Supervisor stated that that could possibly happen but why would a resident be messing with the wires even if it uncovered. Maintenance Supervisor stated that he is aware that he is responsible for coving the exposed wiring and opened wall. Maintenance Supervisor then questioned surveyor if she was talking with a resident that was his family member. Surveyor stated that information was confidential. Maintenance Supervisor got hostile verbally and ended the interview. Record Review of facility provided policy on 05/01/2023, labeled, Resident Call System, dated December 2019, revealed: Policy: The facility is equipped with a functioning communication system from rooms, toilets, and bathing facilities in which the resident calls are received and answered by staff. Procedure: 1). Resident calls are relayed directly to a staff member or to a centralized staff work area. 2). The communication may be through audible or visual signals and may include wireless systems. 3). All portions of the system are functioning a). Systems are on at nursing station, b). Staff are available at the nursing station, c). The volume is loud enough to be heard by the nursing staff, d). Th light above the room or rooms is working, e). calls are being answered, f). For wireless systems, staff who answer resident calls, have functioning devices in their possession, and are answering resident calls. 4). If a resident has disabilities that make use of the facility's communication system inaccessible, alternative, auxiliary aids, or services are provided to meet the resident's needs as identified in the resident's assessment or plan of care. Record Review of in-service provided by facility on 05/01/2023 dated 04/12/2023, labeled, Call Light Malfunction, revealed: Under topic: Due to the malfunction of the call light system, Staff will do every 30-minute checks on residents who's call light is not working. Whistle and bells have been provided to each resident until the system I fixed. The signature sheets showed 30 employee signatures. Record Review of 30-minute resident check sheet provided on 05/01/2023, dates provided for 04/13/2023-04/30/2023 revealed: Each sheet indicated the resident name at the top and 30-minute increment times on the side with employee initialed signed to each slot. There was no documentation on what was done. The sheets do not indicate that the staff was checking due to call light system malfunction. No receipt provided for call light system repair or estimated time of vendor arrival time provided by the facility prior to exit. Record Review of falls for facility provided on 05/01/2023 revealed: Resident #6 had a fall on 04/15/2023 stated unwitnessed fall with no injuries. Resident #6 call light is not working. Resident #7 had a fall on 04/12/2023 stated sitting on floor, near wheelchair and room entrance. It was listed that Resident #7 was one of the residents with no working call light in this timeframe. Interview with Resident #6 could not be conducted on 05/01/2023 due to Resident #6 being in the hospital. Record Review of facility provided list for non-working call lights and map on 05/01/2023 revealed: Not-Working Call lights: 103, 104, 105, 106, 107, 108[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure Residents had the right to formulate an advance directive and determine the choice to receive or not receive CPR (cardiopulmonary resuscitation) in the event of cardiac or respiratory arrest for 1 of 24 Residents (Resident #52) reviewed for advanced directives. The facility failed to ensure Resident #52's physician orders, recorded in her medical records, reflected the Resident's code status was Do Not Resuscitate. This failure could affect any of the 15 Residents who were a DNR status in the facility by not honoring the Residents' choice regarding their CPR status, delay emergency treatment which could result in death, as well as resuscitation against a Resident's wishes. Findings included: Review of Resident #52's undated Face Sheet reflected she was a [AGE] year-old female admitted on [DATE] with diagnosis that included HTN (high blood pressure), falls, pain, impulse disorder and muscle weakness. It also reflected she was a DNR Status. Record review of Resident #52's Monthly Physician Orders reflected the following: Code Status: Do Not Resuscitate (DNR) with a start date of 12-3-21. Code Status: Full Code with a start date of 3-25-22. Review of Resident #52's Out of Hospital Do Not Resuscitate (OOH-DNR) advance directive dated [DATE] reflected it was accurately completed and signed by her responsible party and her primary physician. During an interview on 8-4-22 at 1:45 PM with RN A about Advance directives, she was asked what Resident #52's code status was. After checking the electronic medical record (EMR), she said 'DNR. When she was asked what order was right below the DNR order, she looked, hesitated, then said Full Code. RN A was asked what the potential negative outcome could be with there being an order for both code status', she said they will die, or we thought she was a DNR. I usually go by the status at the top of the profile on the EMR. RN A looked at the details of the 2 code status orders and said the DNR order was written on 12-3-21 by ADON B and the Full Code order was written on 3-25-22 by the DON. When asked, RN A said she probably wouldn't have scrolled down the other orders one she saw the DNR order. RN A said there also was a code status book, which she opened and looked up Resident #52's status. When asked what was in the code status book, she said DNR. She was asked where she was trained to find Resident code status, she said in the code status book or in the computer. She said there was also a code status book on the crash cart. When asked who trained her where to find code status, she said ADON B orientated her. During an interview on 8-4-22 at 2:45 PM with LVN B about Resident Advance directives. When asked where she would look for a Resident code status in the event a Resident coded (required lifesaving measures), she said I can look them up on the computer under their profile, we have a book to make sure it's signed by a doctor. When asked if both code statuses were listed on the computer what would she do, she said she would treat the Resident as a full code until the doctor or family tells her to stop. When asked what the potential negative outcome could be for the Resident, she said you could hurt them while reviving them, put them through aggressive technique such as chest compressions, put them through a lot physically. During an interview on 8-4-22 at 3:10 PM with the DON about Resident #52's Code Status. When asked what Resident #52's Code Status was, she looked in the EMR at the top dashboard area and said DNR. When asked what Resident #52's physician order was for related to her code status, she looked up the orders on the EMR and said DNR. She was asked what was below the DNR order and she said, Full Code, that one wasn't deleted. When asked if the full code status order had the more recent date, she said yes. The DON said Resident #52 went to the hospital and came back and when this occurs, physician orders automatically get thrown back into the system (Matrix application). When asked if that is what happened, she said I don't know, I'm looking. We put her on palliative care with the family's permission. I know she is a DNR. I don't know how it got in there, it's an oops and I put it in there. She was asked if the full code order would override the DNR order, she said by looking at the orders, yes because it had the more recent date. The DON was asked what the potential negative outcome could be for the Resident, she said they would follow the most recent order and it could be not what the Resident wished. When asked what the process was for determining Resident advance directives, she said on admission the facility speaks with the Resident and family about which code status they want. She said if it is a full code status, she puts the status in the computer when putting in the admit orders. If there's a change in condition or wishes of the family or Resident, the family brings her the OOH DNR (out of hospital) then she goes into the computer and uploads it into the documents section of the EMR, then changes the orders for code status, changes the code status on the face sheet, care plan, and changes it in the code status book. The DON calls Resident #52's son on the telephone and clarifies what the Resident/family wants as far as code status then she deleted the full code order and made a progress note. She was asked who is responsible for ensuring the Resident code status was accurate, she said um I don't know if it's designated to anybody, but we'll make sure it is a priority, it will be handled and checked monthly. She said she wondered if it was done on the admit order section, she was asked if Resident #52 was re-admitted on [DATE] from the hospital, she said no. As she was looking at Resident #52 orders on the EMR, she said she wondered if she went into this section and clicked on the code status on accident when she was entering an order for physical therapy to evaluate and treat her. She said, I'll bet you $20 that's what happened which is not an excuse but now I know why it was in the order set. when asked what would have happened if Resident #52 coded between 3-25-22 (when the full code order was entered) and today, she said we'd have to use the full code status. When asked what would've happened if the facility treated her as a full code when she was a DNR, she said it would've been a negative outcome. For one, the Resident could've been injured from CPR, if she lived, she'd probably have broken ribs and that stuff, but if she didn't live (after CPR) we still put her through that, which she or her family didn't want. During an interview on 8-4-22 at 3:25 PM with the Administrator about Resident code status. He was asked what his expectation was of the staff as far as ensuring the Resident code status was accurate, he said he expected the staff to make sure everything is in place for whichever code status the Resident or family wanted. He stated the nurses have to take their time to not click the wrong code status. He said the facility needed to do a full audit today of all Resident code status and make sure they only have one order. If there was more than one order for code status, to get clarification from the Resident and family. He said the facility would do a staff in service after the full audit of Resident code status. He said this issue would have to go to the QA (Quality Assurance) committee to find out the cause of this failure and then how to fix it. He was asked what the potential negative outcome could be for the Resident if the code status was inaccurate, he said we wouldn't code, we would have let her die, we would have not done CPR, or we would have gone against her advance directives and put her through all that pain, cracked ribs, then have to call the family and tell them we did CPR when they didn't want it. Facility policy titled Emergency Procedure - Cardiopulmonary Resuscitation, revision date of [DATE] did not have any information related to this deficiency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, the facility failed to ensure a medication error rate of less than or equal to 5%. The medication error rate was 16% with 4 errors in 25 opportunities involving 2 staff (LVN C and LVN D) and 2 Residents (Resident #38 and #56) reviewed for medication pass. This facility failure can cause residents to not receive their medications as prescribed according to physician's orders and facility policy and procedures, and potentially cause harm to a resident if not given their medication as ordered. Findings Include: Record review of Resident #38's undated face sheet revealed a [AGE] year-old female admitted to facility on 9-20-21 with the following diagnoses: HTN (high blood pressure), pain, Type 2 Diabetes Mellitus (high blood sugar), dementia without behaviors (poor memory), vitamin deficiency, and dysuria (painful urination). Observation of medication pass with LVN C on 8-2-21 at 8:30 am revealed Resident #38 was given one multivitamin with minerals, however, record review of Resident #38's MAR (medication administration record) she was prescribed daily multivitamin (mv-mn-fa-vit k-lycop-lut-coq10) capsule 200-100-500 mcg; amount; 1 tab PO (by mouth) QD (everyday) with a start date of 9-20-21. The multivitamin she was given did not contain the following: fa (folic acid), vit k (vitamin k), lycop (lycopene), lut (lutein), coq10 (coenzyme Q10). Interview with LVN C on 8-2-22 at 3:15 pm revealed she looked at the multivitamins bottle she gave the medication from and said mv-mn-fa-vit k-lycop-lut-coq10 were not on the bottle label. She said she would call the doctor and get clarification. Record review of Resident #56 's undated face sheet revealed an [AGE] year-old female admitted to facility on 6-22-22 and re-admitted on [DATE] with the following diagnosis: HTN (high blood pressure), pain, glaucoma (decrease in vision), COPD (difficulty breathing), arthritis (pain in the joints), and osteoporosis (weakened bones). Medication pass with LVN D observed on 8-2-22 at 9:14 am revealed Resident #56 was not given the following prescribed medications: Brimonidine drops 0.2%, 1gtt each eye BID (twice daily), Dorzolamide drops 2%, 1gtt each eye BID (twice daily) and Vancomycin Rcon Soln 500mg/100ml, IV (intravenously), QD (every day). Record review revealed Resident #56 was prescribed Brimonidine drops 0.2%, 1gtt each eye BID (twice daily) with a start date of 6-22-22, Dorzolamide drops 2%, 1gtt each eye BID (twice daily) with a start date of 7-5-22, and Vancomycin Rcon Soln 500mg/100ml, IV (intravenously), QD (every day) with a start date of 7-14-22. Record review of Resident #56's order reflected the morning dose could be given between 7:00 AM and 10:00AM. Interview with LVN D on 8-2-22 at 3:00 pm she stated Um, I have to wait 5 minutes between the eye drops. If I gave one, then I wouldn't have been able to give the other one (record review of Resident #56's orders reflected these eye drops were both prescribed for the AM dose which was between 7:00 AM and 10:00 AM). She was already heading out (of facility) for her appointment. Transportation was in a hurry. She said she had no idea Resident #56 had a doctor's appointment. When asked if she received nurse to nurse report when she started her shift, she said I don't really get report. I come on at 8:00 am, the other nurses come in at 6:00 am. I generally don't get report because I'm here to be the med nurse. When asked what the potential negative outcome could be for Resident #56 not receiving her missed 3 medications, LVN D said Um, well the IV, it could prolong her infection. Mmm, her eyes could not heal properly from her cataract surgery. When asked if she notified the physician of Resident #56 not receiving these medications, she replied No, ma'am. Normally when stuff like this happens, I'll notify the nurse on that side (hall the resident lived on). When asked if she notified LVN C, she said yes, she thought she did because she told me to go ahead and administer the IV medication. She said she administered the IV medication at 11:50 am. In an interview on 8/2/22 at 3:15 PM with LVN C, she stated she didn't get it (she was not told that this resident had a doctor's appointment) in report either. She said it's in the book. When asked how she knew Resident #56 had a doctor's appointment, she said Resident #56 asked for her medications before she went to the doctor. When asked what the potential negative outcome could be for Resident #56 if she did not receive these missed medications, she said that the Resident was on the antibiotic to get rid of her infection in her knee. She said Resident #56 had cataract surgery recently, she needed the eye drops for optimal healing. In an interview on 8-2-22 at 3:30 PM with the DON, she said she was notified of the reasons or the medication error rate including Resident #56 not receiving her two eye drops and her intravenous antibiotic. She was asked what her expectation of her staff was as far as not giving medications, she said that she expected the nurse to give the medications as ordered. if they were not able to do this, then they needed to notify the doctor about it. When asked about Resident #38 not getting the proper multivitamin, she said they needed to call the doctor to clarify the order. Record review of the facility's policy and procedure dated 4-1-21 and titled Medication Administration General Guidelines documented the following: Policy: Medications are administered as prescribed in accordance with manufacturers specification, good nursing principles and practices and only by persons legally authorized to do so. Procedures: Medication Administration: 1. Medications are administered in accordance with written orders of the prescriber. 14. Medications are administered within 60 minutes of scheduled time Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the nursing care center.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to offer, based on a resident's comprehensive assessment, a therapeutic diet when there was a nutritional problem, and the health care provider orders a therapeutic diet for 10 of 10 residents with physician orders for fortified foods (Residents #10, 14, 16, 30, 32, 37, 40, 47, 50 and 51), in that: The facility failed to provide Residents #10, 14, 16, 30, 32, 37, 40, 47, 50 and 51 with their physician ordered therapeutic diet that included fortified foods for 2 meals (8/2/22 - noon, and 8/3/22 - noon meal). This failure could place residents at risk for hunger, weight loss and chemical imbalances. The findings include: -Resident #30 Record review of the Physician Order Report: 7/3/22-8/3/22 for Resident #30 revealed that the female resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of cerebral infarct due to unspecified occlusion or stenosis of unspecified vertebral artery (stroke) -primary diagnosis, personal history of COVID-19, abnormal weight loss, and diarrhea unspecified. Further record review of the Physician Order Report revealed that the resident had an order dated 5/2/22 stating, diet: regular diet with fortified foods. Record review of the annual MDS assessment for Resident #30 dated 11/16/21 and the quarterly MDS assessment dated [DATE] revealed that the resident had no issues related to nutrition status. Record review of the care plan for Resident #30 dated 7/7/22 revealed the following problem, Problem Start Date: 3/28/18. Category: Nutritional Status. I am on a low concentrated sweet diet due to diabetes mellitus. Edited: 7/7/22. Approaches listed were . Approach start date: 3/28/18. Serve diet as ordered and offer substitution if less than 50% is eaten, monitor intake . Record review of the Weight Variance Report dated 7/31/22 revealed Resident #30 had a 1.2% weight loss between 5/5/22 and 6/3/22, where the resident went from 161 pounds to 158 pounds. Record review of the Comprehensive Metabolic Panel lab for Resident #30 dated 2/15/21 revealed that the resident had an albumin level of 3.0 g/dL which was indicated low. The reference range was 3.4-5.0 g/dL. Record review of the printed tray cards for Resident #30 for Lunch: Tuesday, August 2, 2022, Supper: Tuesday, August 2, 2022 and Lunch: Wednesday, August 3, 2022 revealed the resident had the following order: Regular . fortified foods During an interview on 8/3/22 at 3:57 PM, the DON stated that Resident #30 was on a fortified diet due to weight loss, CVA and it was a long-standing order. -Resident #51 Record review of the Physician Order Report: 7/3/22-8/3/22 for Resident #51 revealed that the female resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of unilateral primary osteoarthritis (arthritis), right knee (primary diagnosis), Alzheimer's disease unspecified, abnormal weight loss, dehydration, COVID-19 acute respiratory disease, vitamin deficiency unspecified. Further record review of the Physician Order Report revealed that the resident had an order dated 5/2/22 that stated, diet: regular diet with fortified foods . Record review of the annual MDS assessment for Resident #51 dated 8/10/21 and the quarterly MDS assessment dated [DATE] revealed no issues related to nutritional status. Record review of the current care plan for Resident #51 dated 7/6/22 document a problem start date: 7/6/22, category: nutritional status, nutritional status diet, edited: 7/6/22. An approach listed was documented as, approach start date: 7/6/22. Diet as ordered: regular with fortified foods. Created: 7/6/22 . Record review of the Dietitian's progress notes dated 4/15/22 for Resident #51 revealed the following, Reason: weight loss, consult Diet: regular/regular/thin/fortified Summary: resident with significant weight loss x 30 days and a consult. Noted resident with fortified foods Record review of the Weight Variance Report dated 7/31/22 for Resident #51 revealed that the resident had a 4.5% weight loss between 5/5/22 and 6/3/22 where the resident went from 110 pounds to 105 pounds. The resident also experienced a downward trend in weight between 2/10/22 and 4/18/22 where the resident went from 115 pounds to 105 pounds. Record review of the Comprehensive Metabolic Panel lab for Resident #51 dated 9/01/20 revealed that the resident had an albumin level of 3.9 g/dL. The reference range was 3.4-5.0 g/dL. Record review of the printed tray cards for Resident #51 for Lunch: Tuesday, August 2, 2022, Supper: Tuesday, August 2, 2022 and Lunch: Wednesday, August 3, 2022 revealed the resident had the following order: Regular . fortified foods During an interview on 8/3/22 at 3:57 PM, the DON stated that Resident #51 was on a fortified diet due to weight loss -Resident #10 Record review of the Physician Order Report: 7/3/22-8/3/22 for Resident #10 revealed that the female resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of malignant neoplasm of rectum (primary) (rectum cancer), abnormal weight loss, other iron deficiency anemias, hypokalemia (low potassium level) and age-related cognitive decline. Further record review of the Physician Order Report revealed that the resident had an order dated 4/17/22 for a diet: regular diet with fortified foods . Record review of the admission MDS assessment for Resident #10 dated 1/11/22 and quarterly MDS assessment dated [DATE] documented that the resident had experienced a weight loss of 5% or more and was not on a physician prescribed weight loss regimen. Further record review of the admission MDS assessment revealed that the resident had an active diagnosis of malnutrition or at risk for malnutrition. Record review of the current care plan for Resident #10 dated 7/20/22 revealed a problem that stated, problem start date: 4/8/22, resident has experienced weight loss related to malignant neoplasm of rectum. Edited: 7/20/22 . The goal listed was as follows, resident will not exhibit signs of malnutrition or dehydration . Record review of the Dietitian's progress notes dated 6/24/22 for Resident #10 revealed the following, resident triggered for significant weight loss x 90 days (7.8% weight loss) Resident on a regular diet. With fortified foods Record review of the Weight Variance Report dated 7/31/22 revealed Resident #10 had an 8.5% weight loss between 3/4/22 and 4/11/22 from 141 to 129 pounds. Record review of the labs for a Resident #10 dated 2/27/22 revealed that the resident had a Comprehensive Metabolic Panel lab and her albumin level was 2.7 g/dL and was indicated low. The reference range was 3.4-5.0 g/dL. Record review of the printed tray cards for Resident #10 for Lunch: Tuesday, August 2, 2022, Supper: Tuesday, August 2, 2022 and Lunch: Wednesday, August 3, 2022 revealed the resident had the following order: Regular . fortified foods. During an interview on 8/3/22 at 3:57 PM, the DON stated that Resident #10 was on a fortified diet due to weight loss and a diagnosis of rectal cancer. -Resident #14 Record review of the Physician Order Report: 7/3/22-8/3/22 for Resident #14 revealed that the female resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of chronic obstructive pulmonary disease with acute exacerbation (breathing disorder) (primary diagnosis), abnormal weight loss, dysphagia, oral pharyngeal phase (swallowing disorder), other dysphagia, personal history of COVID-19, and malignant neoplasm of cervix uteri unspecified (cervix cancer)). Further record review of the Physician Order Report revealed an order dated 5/2/22 stated, Diet: regular diet fortified foods. Texture: mechanical soft . Fluid consistency: nectar . Record review of the annual MDS assessment for Resident #14 dated 1/17/22 and quarterly MDS assessment dated [DATE] revealed no nutritional status issues. Record review of the current care plan for Resident #14 dated 8/1/22 revealed a problem with a start date: 5/18/18, category: nutritional status, Further review of the approaches revealed an approach that documented, approach start date: 12/4/20, obtain a dietary consult as needed and follow recommendations. Edited: 1/6/21 . Record review of the Dietitian progress notes dated 6/24/22 for Resident #14 documented, resident on fortified, mechanical soft diet Record review of a Dietitian's dietary progress note dated 4/15/22 for Resident #14 revealed the following, Reason: consult, insidious . Summary: resident is a consult with noted insidious weight loss. Resident at this time with poor appetite for nursing related to mental status, resident consuming 26 to 75% of most meals and supplements. Recommendations: recommend adding fortified foods with meals . Record review of the Weight Variance Report dated 7/31/22 revealed that Resident #14 had a 2.7% weight loss between 6/14/22 and 7/1/22 from 148 pounds to 144 pounds. Further record review of the weight report revealed that the resident had a downward trend in weight from 3/4/22 through 5/5/22 from 153 pounds to 145 pounds (5.2% weight loss). Record review of the Comprehensive Metabolic Panel lab for Resident #14 dated 2/01/20 revealed that the resident had an albumin level of 3.1 g/dL which was indicated as low. The reference range was 3.4-5.0 g/dL Record review of the printed tray cards for Resident #14 for Lunch: Tuesday, August 2, 2022, Supper: Tuesday, August 2, 2022 and Lunch: Wednesday, August 3, 2022 revealed the resident had the following order: regular/mechanical soft . fortified foods. During an interview on 8/3/22 at 3:57 PM, the DON stated that Resident #14 was on a fortified diet due to weight loss and had a swallowing issues and dietary recommendation. -Resident #37 Record review of the Physician Order Report: 7/3/22-08/03/22 for Resident #37 revealed that the female resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of generalized anxiety disorder (primary), and abnormal weight loss and anorexia (eating disorder). Further record review of the Physician Order Report revealed at the resident had a diet order dated 5/2/22 stating: regular with fortified foods Record review of the annual MDS assessment for Resident #37 dated 12/2/21 and quarterly MDS assessment dated [DATE] revealed no documented nutritional status issues. Record review of the current care plan for Resident #37 dated 7/11/22 revealed a problem stating problems start date: 9/10/18, category: nutritional status, I am at risk for weight loss due to diagnosis of anorexia. Edited: 7/11/22. Record review of approaches for this problem revealed the following approach start date: 9/10/18, I am on a regular diet with med pass b.i.d. and super cereal for breakfast. Created: 7/29/20. Another approach documented an approach start date: 9/10/18. Obtain dietary consult as needed and follow recommendations . Record review of the Weight Variance Report dated 7/31/22 revealed that Resident #37 had a 2.1% weight loss between 3/21/22 and 3/31/22 where the resident went from 95 pounds to 93 pounds. Record review of the Comprehensive Metabolic Panel lab for Resident #37 dated 9/01/20 revealed that the resident had an albumin level of 3.4 g/dL. The reference range was 3.4-5.0 g/dL. Record review of the printed tray cards for Resident #37 for Lunch: Tuesday, August 2, 2022, Supper: Tuesday, August 2, 2022 and Lunch: Wednesday, August 3, 2022 revealed the resident had the following order: regular . fortified foods During an interview on 8/3/22 at 3:57 PM, the DON stated that Resident #37 was on a fortified diet due to a diagnosis of anorexia. -Resident #16 Record review of the Physician Order Report: 7/3/22-8/3/22 for Resident #16 revealed that the female resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of chronic obstructive pulmonary disease with acute exacerbation (breathing disorder) (primary diagnosis), schizophrenia, personal history of COVID-19, and abnormal weight loss. Further record review of the Physician Order Report revealed that the resident had a diet order dated 5/2/22 that stated, Diet: low concentrated sweets with fortified foods. Texture: mechanical soft . Record review of the significant change MDS assessment for Resident #16 dated 9/9/21 and the quarterly MDS assessment dated [DATE] revealed no nutritional status issues. Record review of the current care plan for Resident #16 dated 7/7/22 revealed a problem titled problems start date: 2/14/19. Category: nutritional status, I require a therapeutic diet related to diagnosis of diabetes mellitus, Edited: 7/7/22. Approaches documented revealed the following, approach start date: 12/2/20. Obtain dietary consult and follow recommendations. Edited: 9/6/20 . Record review of the Dietitian's progress notes for Resident #16 dated 1/13/22 revealed the following, Reason: weight loss Diet: low concentrated sweets/mechanical/thin/fortified foods Recommendations: continue plan of care . Record review of the Weight Variance Report dated 7/31/22 revealed that Resident #16 had a 1.8% weight loss between 2/10/22 3/4/22 where she went from 114 pounds to 112 pounds. Record review of the Comprehensive Metabolic Panel for Resident #16 dated 7/31/22 revealed that she had an albumin level of 3.1 g/dL indicating it was low. The reference range for albumin was 3.4-5.0 g/dL. Record review of the printed tray cards for Resident #16 for Lunch: Tuesday, August 2, 2022, Supper: Tuesday, August 2, 2022 and Lunch: Wednesday, August 3, 2022 revealed the resident had the following order: low concentrated sweets/mechanical soft . fortified food. During an interview on 8/3/22 at 3:57 PM, the DON stated that Resident #16 was on a fortified diet due to weight loss. -Resident #32 Record review of the Physician Order Report: 7/3/22-8/3/22 for Resident #32 revealed that the female resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnosis of chronic obstructive pulmonary disease (breathing disorder) (primary diagnosis), dysphasia, oral pharyngeal phase (swallowing disorder), vomiting unspecified, personal history of COVID-19, diarrhea unspecified, hypokalemia (low potassium level). Further record review of the Physician Order Report revealed that the resident had an order dating 4/8/22 that stated, diet: regular diet with fortified foods. Texture: mechanical soft . Record review of the quarterly MDS assessment dated [DATE] and quarterly MDS assessment dated [DATE] for Resident #32 revealed no documented nutritional status issues. Record review of the current care plan for Resident #32 dated 6/16/22 revealed a problem titled, problem start date: 9/24/20. Category: nutritional status. Nutritional status diet regular diet with fortified foods, mechanical soft texture, thin liquids. Edited: 6/16/22. It further documented approaches that stated, approach start date: 9/24/20. Diet as ordered . Record review of the dietitian's progress note dated 4/15/22 for Resident #32 revealed the following, Reason: weight loss . Diet: regular/mechanical soft/thin/fortified foods Summary: resident with significant weight loss and a consult related to poor appetite Record review of the Weight Variance Report dated 7/31/22 revealed that Resident #32 had an 8.2% weight loss between 2/10/22 and 4/6/22 where the resident went from 109 pounds to 100 pounds. Record review of the Comprehensive Metabolic Panel for Resident #32 dated 5/26/22 revealed that the resident had an albumin level of 3.5 g/dL. The reference range was 3.4-5.0 g/dL. Record review of the printed tray cards for Resident #32 for Lunch: Tuesday, August 2, 2022, Supper: Tuesday, August 2, 2022 and Lunch: Wednesday, August 3, 2022 revealed the resident had the following order: regular/mechanical soft . fortified food During an interview on 8/3/22 at 3:57 PM, the DON stated that Resident #32 was on a fortified diet due to weight loss. -Resident #50 Record review of the Physician Order Report: 7/3/22-8/3/22 for Resident #50 revealed that the female resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnosis of other asthma (primary diagnosis), unspecified dementia without behavioral disturbances, abnormal weight loss, vitamin B deficiency, vitamin D deficiency and hyperlipidemia (high cholesterol). Further record review of the Physician Order Report revealed that the resident had an order dated 4/17/22 stating diet: regular diet with fortified foods . Record review of the annual MDS assessment dated [DATE] and the quarterly MDS assessment dated [DATE] for Resident #50 revealed no documented nutritional status issues. Record review of the care plan for Resident #50 dated 7/6/22 revealed a problem titled problem start date: 4/13/21. Category: nutritional status. Nutritional status diet. Edited: 7/6/22 revealed a goal of maintaining stable weight. Approaches listed were documented as, approach start date: 4/13/21. Diet as ordered . Record review of the Dietitian's progress notes for Resident #50 dated 5/31/22 revealed the following, resident is a new admit. Resident tolerating regular, fortified diet with regular texture and thin liquids Record review of the Dietitian's progress notes for Resident #50 dated 4/15/22 revealed the following Summary: resident is a consult with insidious weight loss Recommendations: recommend adding fortified foods with meals Record review of the Weight Variance Report dated 7/31/22 revealed Resident #50 had a 2.5% weight loss between 6/3/22 and 7/1/22 from 161 pounds to 157 pounds. Record review of the Comprehensive Metabolic Panel lab for Resident #50 dated 6/23/21 revealed that the resident had an albumin level of 3.7 g/dL. The reference range was 3.4-5.0 g/dL. Record review of the printed tray cards for Resident #50 for Lunch: Tuesday, August 2, 2022, Supper: Tuesday, August 2, 2022 and Lunch: Wednesday, August 3, 2022 revealed the resident had the following order: regular . fortified food -Resident #47 Record review of the Physician Order Report: 7/3/22-8/3/22 for Resident #47 revealed that the female resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of peripheral vascular disease unspecified (poor blood circulation) (primary diagnosis), abnormal weight loss, unspecified open wound, unspecified lower leg, initial encounter, iron deficiency anemia unspecified, and nausea. Further record review of the Physician Order Report revealed that there was an order dated 5/2/22 that stated, diet: regular diet with fortified foods . Texture: mechanical soft . Record review of Resident #47 admission MDS assessment dated [DATE] and quarterly MDS assessment dated [DATE] revealed no issues associated with nutritional status. Record review of the current care plan for Resident #47 revealed a care plan dated 7/20/22 stating a problem listed as, problem start date: 9/12/21. Category: nutritional status. Nutritional status diet. Edited: 7/20/22 revealed a goal stating maintain stable weight. Approaches listed were approach start date: 9/12/21. Diet as ordered Record review of the Dietitian's progress note dated 7/26/22 for Resident #47 revealed the following, significant weight loss occur x 30 and x 180 days Reason: weight loss Record review of the Dietitian's progress note dated 4/15/22 for Resident #47 revealed the following . Summary.: Resident with significant weight loss x 90 days Recommendations: recommend adding fortified foods with meals Record review of the Weight Variance Report dated 7/31/22 revealed that Resident #47 had a 6.5% weight loss between 6/3/22 to 7/20/22. The resident went from 124 pounds to 116 pounds. Record review of the Comprehensive Metabolic Panel lab for Resident #47 dated 12/23/21 revealed that she had an albumin level of 2.8 g/dL which was indicated as low. The reference range was 3.4-5.0 g/dL. Record review of the printed tray cards for Resident #47 for Lunch: Tuesday, August 2, 2022, Supper: Tuesday, August 2, 2022 and Lunch: Wednesday, August 3, 2022 revealed the resident had the following order: regular diet mechanical soft . fortified foods During an interview on 8/3/22 at 3:57 PM, the DON stated that Resident #47 was on a fortified diet due to weight loss. -Resident #40 Record review of the Physician Order Report: 7/3/22-8/3/22 for Resident #40 revealed that the female resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of cardiac arrhythmia unspecified (irregular heart beat) (primary diagnosis), diverticulitis of large intestine without perforation or abscess with bleeding (large intestine irritation), vitamin deficiency unspecified, and abnormality of albumin (abnormal protein level in blood plasma). Further record review of the Physician Order Report revealed that the resident had a diet order dated 5/2/22 that stated, diet: regular diet with fortified foods Record review of the annual MDS assessment dated [DATE] and quarterly MDS assessment dated [DATE] for Resident #40 revealed that there were no documented nutritional status issues. Record review of the current care plan for Resident #40 dated 6/15/22 revealed a problem titled problem start date: 12/16/21. Category: Nutritional status, resident requires a therapeutic diet related to abnormality of albumin. Edited: 6/15/22. Approaches listed revealed the following, approach start date: 12/16/21. Provide the resident with as much control as possible in routines, food preferences, etc. Created: 12/16/21. An additional care plan problem was listed as problem start date: 12/16/21. Category: nutritional status, resident requires a regular diet with fortified foods. Edited: 6/15/22. The approach listed the following, approach start date: 6/21/21. Provide the resident with as much control as possible in routines, food preferences, etc . Record review of the dietitian's progress note dated 3/4/22 for Resident #40 revealed the following, resident continues on a fortified food diet with regular texture . Record review of the Weight Variance Report dated 7/31/22 for Resident #40 revealed that the resident had a 1.4% weight loss between 3/4/22 and 4/1/22. The resident went from 220 pounds to 217 pounds. Record review of the Comprehensive Metabolic Panel for Resident #40 dated 5/26/22 revealed that the resident had an albumin level of 3.2 g/dL which was indicated low. The reference range was 3.4-5.0 g/dL. During an interview on 8/3/22 at 3:57 PM, the DON stated that Resident #40 was on a fortified diet due to a dietary recommendation, and she was unsure why she was on it. The following observations and interviews were made during a kitchen tour beginning on 8/02/22 at 11:05 AM and concluded at 12:24 PM: Service line temperatures were taken at 11:25 AM by Dietary staff A. During an interview at this time Dietary staff A did not identify any of the foods as fortified. The foods served were as follows: Shepherd's pie, Cream corn, Puréed Shepherd's pie, Puréed corn cream corn, Rolls, Tomato soup, and Puréed roll. Also ham sandwiches were also served as an alternate. On 8/2/22 at 12:11 PM, Resident #30 was served two scoops of Shepherd's pie, roll, cream corn, cake and milk. None were identified as fortified foods. On 8/2/22 at 12:13 PM Resident #51 was served two scoops of Shepherd's pie, cream corn, roll, and cake. None were identified as fortified foods. On 8/2/22 at 12:23 PM Resident #10 was served two scoops of Shepherd's pie, cream corn, roll, cake, water. None were identified as fortified foods. On 8/2/22 at 12:15 PM Resident #14 was served two scoops of shepherd's pie, cream corn, purée dessert, puréed bread. None were identified as fortified foods. On 8/2/22 at 12:15 PM Resident #37 was served two scoops of shepherd's pie, cream corn, roll, and cake. None were identified as fortified foods. On 8/2/22 at 12:14 PM Resident #16 was served two scoops of shepherd's pie, cream corn, roll, and cake. None were identified as fortified foods. On 8/2/22 at 12:02 PM Resident #32 was served shepherd's pie, a roll, corn, cake. None were identified as fortified foods. On 8/2/22 at 12:16 PM Resident #50 was served two scoops of shepherd's pie, corn creamed, roll, and cake. None were identified as fortified foods. On 8/2/22 at 12:07 PM Resident #47 was served shepherd's pie, cream corn, and roll. None were identified as fortified foods. On 8/2/22 at 12:21 PM Resident #51 was served a ham sandwich, tomato soup, apple juice, milk, and cake. None were identified as fortified foods. The following observations and interviews were made during a kitchen tour beginning on 8/03/22 at 10:54 AM and concluded at 12:20 PM: -8/3/22 at 11:00 AM temperatures were taken on the service line by Dietary staff A. During an interview at that time, none of the foods were identified as fortified. The foods served were as follows: Puréed green beans, green beans, rolls, Chicken Fettuccine Alfredo, Puréed Chicken Fettuccine Alfredo, Salisbury steak, Mashed potatoes (alternate meal), Mechanically altered Chicken Fettuccine Alfredo, Lettuce and tomatoes, Tomatoes, Ground beef, Puréed bread, Stewed tomatoes, and Puréed stewed tomatoes. On 8/3/22 at 12:06 PM Resident #16 was served green beans, Chicken Fettuccine [NAME] two scoops, roll, stewed tomatoes, and pudding. None were identified as fortified foods. Her Tray card stated that she was on a fortified diet. On 8/3/22 at 12:07 PM Resident #37 was served two scoops Chicken Fettuccine Alfredo, green beans, rolls, salad, salad dressing, and pudding. None were identified as fortified foods. Her Tray card stated that she was on a fortified diet. On 8/3/22 at 12:09 PM Resident #40 was served two scoops of Chicken Fettuccine Alfredo, green beans, rolls, salad, salad dressing, milk, apple juice, and pudding. None were identified as fortified foods. Her tray card stated fortified diet. On 8/3/22 at 12:10 PM Resident #50 was served two scoops Chicken Fettuccine Alfredo, green beans, roll, salad dressing, salad, and pudding. Her tray card stated fortified diet. None were identified as fortified foods. On 8/3/22 at 2:16 PM, an interview was conducted with the Dietary Manager regarding fortified diets. She stated if a resident had a fortified foods diet, they would either receive super cereal in the morning or super pudding or super mashed potatoes. She added that it would be served with the meal and prepared in the kitchen. She further stated that the tray card indicated which meal the fortified food should be served. She was then asked why she thought the fortified foods were not served. She stated that Dietary staff A forgot or may have been nervous. She added that failure to serve fortified foods as ordered could result in weight loss for residents. She stated that any training regarding fortified diet was provided online. She also stated that she had not conducted any in-services with staff in the last three months. On 8/3/22 at 2:38 PM, an interview was conducted with Dietary staff A. She stated that the fortified food was usually mashed potatoes and that she forgot to prepare any fortified foods for the 3 meals observed. She stated that the failure to provide fortified foods as ordered could result in hunger and weight loss for residents. She stated she had been trained on fortified foods in the past. On 8/4/22 at 8:54 AM, an interview was conducted with the Dietary Manager regarding fortified diets. She was asked who was responsible for ensuring that fortified diets were served. She stated that she was. She added that she ensured fortified foods were served by checking the steam table versus the menus and monitor. She was then asked why the ordered fortified foods were not served. She stated staff focused on other dietary issues and forgot the easy things. She added that serving the fortified foods was overlooked. On 8/4/22 at 10:49 AM, an interview was conducted with the Administrator regarding the omission of ordered fortified foods. He stated he expected dietary staff to have corrected the issues and in-service the staff. He added that the omission of ordered fortified foods could result in resident weight loss. On 8/8/22 at 11:15 AM, an interview was conducted with the Dietary Manager, and she stated that the purpose of fortified foods was to prevent resident weight loss and to add calories to their diets. Record review of the facility policy titled Nutrition and Food Service Policies and Procedures Manual, 2018, Section 7-2, Policy: Nutrition Supplementation, Policy Number: 07.002 . Date Approved: October 1, 2018, Date Revised: June 1, 2019, revealed the following documentation, Policy: the facility is committed to assisting residents and maintaining and maximizing their nutritional status. Supplemental nutrition will be provided in a manner that maximizes intake of the oral diet before adding other supplementation. When oral diet intake alone is insufficient, supplements may be added in a stepwise manner to achieve the maximum result. Procedures: 1. Food first will be used to meet the needs of residents with weight loss, poor intake or increasing nutrient needs whenever possible. For residents with fair to good intake, provide additional calories using high calorie, high protein foods at meal times and as snacks. Examples include peanut butter or meat sandwiches, ice cream, whole or skim milk, boiled eggs, and extra servings of meat with meals. Use high calorie, high protein snacks and foods during activities and on the snack carts to increase daily calories and protein. Sample Fortified recipes are available in menu matrix . 3. Use of fortified foods at each meal should be used to provide additional calories and protein for residents unable to meet estimated calorie and/or protein needs with current intake. Increasing the number and types of fortified food may result in greater acceptance of fortified foods. Additionally, creating a cycle menu of fortified foods each week may also help increase acceptance. Recipes for fortified foods and a sample weekly cycle are available from vendor . Record review of the National Institutes of Health website, National Library of Medicine .Medline Plus (https://medlineplus.gov/lab-tests/albumin-blood-test/) revealed the following documentation, . Albumin Blood Test. What is an Albumin Blood Test? An albumin blood test measures the amount of albumin in your blood. Low albumin levels can be a sign of liver or kidney disease or another medical condition . Albumin is a protein made by your liver. Albumin enters your bloodstream and helps keep fluid from leaking out of your blood vessels into other tissues. It is also carries hormones, vitamins, and enzymes throughout your body. Without enough albumin, fluid can leak out of your blood and build up in your lungs, abdomen (belly), or other parts of your body . Lower than normal albumin levels may be a sign of: Liver disease, including severe cirrhosis, hepatitis, and fatty liver disease Kidney disease Malnutrition Infection Digestive diseases that involve problems using protein from food, such as Croh[TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure that the menu was followed for four of four residents (Resident #20, 28, 36 and 46), in that: The facility failed to ensure four of four residents received the correct portions that were called for on the menu. These failures could place residents at risk for unwanted weight loss and hunger. The findings include: Record review of the Order Report by Category: 6/27/22-7/27/22 revealed that Resident #20 had an order dated 12/19/18 that stated, Diet: regular diet. Texture: puree . Record review of the Order Report by Category: 6/27/22-7/27/22 revealed that Resident #28 had an order dated 7/6/22 that stated, Diet: regular diet. Texture: puree . Record review of the Order Report by Category: 6/27/22-7/27/22 revealed that Resident #36 had an order dated 8/16/21 stated, Diet: regular diet. Record review of the Order Report by Category: 6/27/22-7/27/22 revealed that Resident #46 had an order dated 5/2/22 that stated, Diet: regular diet. The following observations were made during a kitchen tour beginning on 8/02/22 at 11:05 AM and concluded at 12:24 PM: Service line temperatures were taken on 8/02/22 at 11:25 AM by Dietary staff A: Shepherd's pie served with a #8 scoop Cream corn served with a 4 ounce ladle Puréed Shepherd's pie served with a #8 scoop Puréed corn cream corn served with a #12 scoop Rolls at room temperature Tomato soup served with a 6 ounce ladle Puréed roll room temperature and served with a #16 scoop Record review of the Tuesday Facility SS 2022 5 Week - Week - 4 noon menu revealed that residents on regular puréed diet should have received 1 cup (8 ounces) puréed Shepherd's pie, 1/3 cup puréed vegetables, 1/4 cup purée dinner roll and 1/4 cup puréed frosted orange cake. On 8/2/22 at 11:58 AM, Resident #20 was served a #12 (1/3 cup) scoop of purée corn, #8 scoop (1/2 cup) pureed Shepherd's pie, #16 scoop (1/4 cup) pureed bread and pureed cake by Dietary staff A. The resident should have received 1 cup of pureed Shepherd's pie. On 8/2/22 at 12:03 PM, Resident #28 was served a #12 (1/3 cup) scoop of purée corn, #8 scoop (1/2 cup) Shepherd's pie, #16 scoop (1/4 cup) pureed bread and pureed cake by Dietary staff A. The resident should have received 1 cup of pureed Shepherd's pie. On 8/2/22 at 12:41 PM, an interview was conducted with Dietary Staff A regarding the puréed meal service revealed she served only one scoop of each puréed food per meal tray (#12 (1/3 cup) scoop of purée corn, #8 scoop (1/2 cup) Shepherd's pie, and #16 scoop (1/4 cup) pureed bread). The following observations were made during a kitchen tour beginning on 8/02/22 at 5:06 PM and concluded at 5:10 PM: Steamtable observations were as follows on 8/02/22 at 5:06 PM: Mixed vegetables served with a 4 ounce ladle Puréed tuna melt sandwich served with a 4 ounce ladle Purée vegetable served with a 4 ounce ladle Puréed macaroni salad served with a #8 scoop Macaroni salad served with the #8 scoop Tuna salad sandwiches, Ham sandwich (alternate meal) The meal was served by Dietary staff A. Record review of the Tuesday Facility SS 2020 for 5 Week - Week - 4 dinner menu revealed that Residents on a regular purée diet should have received 3/4 (6 ounces) cup puréed tuna melt sandwich, 1/2 cup puréed macaroni salad, 1/3 cup puréed vegetable and 1/3 cup puréed peach slices. On 8/2/22 at 5:10 PM, an interview was conducted with Dietary staff A revealed she stated that she served residents on pureed diets one scoop of each puréed food (4 ounces of puréed tuna melt sandwich, 4 ounces of Purée vegetable, and a #8 scoop (1/2 cup) of Puréed macaroni salad served with a #8 scoop). The residents should have received ¾ cup pureed tuna sandwich. On 8/2/22 at 5:10 PM, an observation of Resident #28's meal tray revealed she received puréed macaroni salad, puréed tuna salad sandwich, puréed vegetables, which was in a bowl, tea and applesauce in a bowl. She was served one scoop of each food on the plate. The resident should have received 6 ounces of pureed tuna sandwich instead of 4 ounces (1/2 cup). The following observations were made during a kitchen tour beginning on 8/03/22 at 10:54 AM and concluded at 12:20 PM: On 8/3/22 at 11:00 AM temperatures were taken on the service line by Dietary staff A with the following results: Puréed green beans served with a #12 scoop. Green beans served with a 4 ounce ladle Rolls at room temperature Chicken Fettuccine [NAME] served with a #8 scoop Puréed Chicken Fettuccine [NAME] served with a #8 scoop Salisbury steak Mashed potatoes Mechanically altered Chicken Fettuccine [NAME] and served with a #8 scoop Lettuce and tomatoes served with a 4 ounce ladle and on ice Tomatoes served with a 4 ounce ladle and on ice. Ground beef served with a #10 scoop Puréed bread served with a #16 scoop and was on ice Stewed tomatoes Puréed stewed tomatoes Record review of the Wednesday Facility SS 2022 5 Week - Week - 4 noon menu revealed the following diet: Residents on a regular diet should have received 8 ounces (1 cup) Chicken Fettuccine Alfredo, 1/2 cup Italian green beans, 1/2 cup toss salad with dressing, One dinner roll and One strawberry bar. Residents on regular puréed diet should have received 1 cup puréed Chicken Fettuccine Alfredo, 1/3 cup puréed Italian green beans, 1/3 cup puréed cold diced tomatoes, 1/4 cup puréed dinner roll and 1/2 cup puréed strawberry bar. On 8/3/22 at 11:30 AM, Resident #36 was served a #8 scoop (1/2 cup) of regular Chicken Fettuccine Alfredo, salad greens and #4 ounces green beans by Dietary staff A. The resident should have received 1 cup (8 ounces) regular Chicken Fettuccine Alfredo. On 8/3/22 at 11:33 AM, Resident #20 received puréed tomatoes, #12 scoop (1/3 cup) purée green beans, #8 scoop (1/2 cup) purée Chicken Fettuccine [NAME] and pudding. The resident should have received 1 cup (8 ounces) purée Chicken Fettuccine Alfredo. On 8/3/22 at 11:39 AM, Resident #42 was served #8 scoop (1/2 cup) of regular Chicken Fettuccine Alfredo, salad greens, roll and 4 ounces green beans. The resident should have received 1 cup (8 ounces) regular Chicken Fettuccine Alfredo. Record review of the order report by category: 6/27/22-7/27/22 revealed that Resident #42 had an order dated 5/2/22 that stated, Diet: Low Concentrated Sweets, No Salt on Tray. Texture: regular On 8/3/22 at 11:40 AM Resident #46 was served #8 scoop (1/2 cup) of regular Chicken Fettuccine Alfredo, salad greens and 4 ounces green beans. The resident should have received 1 cup (8 ounces) regular Chicken Fettuccine Alfredo. On 8/3/22 at 11:50 AM the surveyor intervened and informed Dietary staff A of the incorrect scoop sizes that she was using for the regular and pureed portions of Chicken Fettuccine Alfredo. Dietary Manager was also informed. During an interview at this time, Dietary staff A stated she served one scoop of Chicken Fettuccine [NAME] to regular diets, two scoops to mechanically altered diet and two scoops to purée diets. Dietary staff A was informed by the surveyor that she served only 1 scoop of the puree to Resident #20 then served 2 scoops to pureed diets after Resident #20. The meal tray for Resident #20 was not corrected prior to serving. Observation at this time of the scoop, used for the regular Chicken Fettuccine Alfredo, revealed that it was a #8 scoop which was a 1/2 cup. She confirmed that it was a #8 (1/2 cup) scoop. On 8/3/22 at 2:16 PM, an interview was conducted with the Dietary Manager. She stated staff failed to follow the menu because they could have been in a hurry and did not read the diet spreadsheet correctly. She was asked how not following the menu could affect residents. She stated it could result in weight loss. She stated that the online dietary training reviewed scoop sizes. She was also asked if she had conducted any in-services in the last three months with staff. She stated she had not. On 8/3/22 at 2:38 PM, an interview was conducted with Dietary staff A and she was asked why she had not followed the menu. She stated she misread the menu. She added that not following the menu could result in resident weight loss. She stated she had been trained on using the correct scoop sizes in the past. On 8/4/22 at 8:54 AM, an interview was conducted with the Dietary Manager regarding following the menu. She stated that she was responsible for ensuring that menus were followed. She was also asked how she ensured that the menu was followed. She stated that she checked the steam table versus the menus and monitors and checked the scoop sizes. She stated that the menu was not followed due to staff focusing on other dietary duties and forgetting the easy things. She stated that following the menu had been overlooked. On 8/4/22 at 10:49 AM, an interview was conducted with the Administrator regarding following the menu. He stated he expected the staff to have corrected the issues, use the correct scoops and in-service the staff. He added that residents could lose weight as a result of the menu not being followed. Record review of the facility policy titled Nutrition and Food Service Policies and Procedures Manual, 2018, Section 3-13, Policy: Portion Control, Policy Number: 03.007, Date Approved: October 1, 2018, revealed the following documentation, Policy: the facility will use standard portion control procedures and utensils to ensure that adequate portions are served to residents. Procedures . 3. Portions for each food item should follow the specific portion sizes listed on the menus. 4. Food items should be served using standard size labels, scoops, spoons and spoons .

Based on observation, interview and record review, the facility failed to establish and maintain an Infection Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection for 3 of 11 residents observed for Covid positive status/Covid recovered status on the Secure Unit and for 2 of 25 residents (Resident #28 and 50) observed for medication pass. The facility staff failed to use proper infection control precautions when providing care for Residents who were Covid positive (Resident #20, #36 and #53). The facility failed to follow infection control practices when passing medications for Resident #28 and 50. This deficient practice affected 3 of 11 residents, (Resident #20, #36, and #53) observed on the Secure Unit due Covid positive status and 2 of 25 residents, (Resident #28 and 50) observed for medication pass. Findings include: Observation on 8-2-22 at 8:15 AM of the Secure Unit which had Covid positive Residents revealed staff were not wearing proper PPE (personal protective equipment). CNA C was not wearing a gown while assisting residents with breakfast on the warm unit. Observation on 8-2-22 at 8:30 AM, LVN B was not wearing a gown or protective eyewear (face shield, goggles) while passing medications to Resident #53 in a warm (quarantine) room. Interview on 8-2-22 at 8:35 AM, LVN B was asked about not wearing a gown or protective eyewear when she entered Resident #53's warm zone room. She said that the Residents in the warm room had never been Covid positive, that she was instructed by the DON that wearing a gown or protective eyewear was not required in this area. When asked what the hallway was considered that had Residents with a recovered Covid status were on, she said it should be a warm zone. This unit is not a warm unit, the way we have it set up. CNA C overheard the conversation with Surveyor and LVN B about what the hallway was considered; cold, warm, or hot zone. CNA C answered from the dining room cold zone, it'll be the area without Covid positive residents or just got over Covid. Surveyor showed LVN B a sign that was posted outside the dining room that showed Secured Unit Protocol. All staff that enter the unit will wear full PPE. LVN B said, they just put the sign up, it changes all the time. Observation on 8-2-22 at 8:39 AM, LVN B put on proper PPE when she passed medications to Covid positive Resident (#36) in the hot zone but then left the hot zone without doffing PPE, walking to the warm room to get gloves, with the same PPE as she had on in the hot zone. In an interview at the same time, LVN B said she should have taken off all the PPE, cleaned her hands, then went to get gloves. When asked what the potential negative outcome could be for the residents, she said she could get other people infected with Covid. Observation on 8-2-22 at 12:35 PM revealed there were three residents eating at the table in the hot zone. Resident #20 who is on the Covid recovered unit also considered as the cold zone per staff interview, goes into a Resident's room that is in the hot zone; Covid positive zone. Therapy staff try to redirect Resident #20, but he continues to go into this room. Covid positive Resident #36 was observed leaving the hot zone area and went into the dining room, which was considered a cold zone per staff interview, while recovered Covid Residents were in the dining room as well. CNA C was assisting other Residents down the hall. During an interview on 8-2-22 at 2:55 PM with CNA D, she said that Administration had told staff that they didn't have to wear anything but a mask while in the warm zone area on the secure unit. She said that today the Administrator instructed staff that they were to wear a gown, mask, protective eyewear at all times because the Residents were wandering around on the unit due to their memory loss. When asked what the potential negative outcome could be for the Resident if staff did not wear proper PPE, she said that the Residents probably could get Covid again or she could get Covid. In an interview on 8-3-22 at 11:22 AM with the DON about staff not wearing proper PPE on the secure unit where some residents were Covid positive. When she was told that staff were observed only wearing a mask, no gown or protective eyewear she said I probably told them in fact I did. I misunderstood it so I got an in-service going on about the proper way to use PPE with the cold, warm, and hot zone and about being told that the recovered Residents was a cold zone. When notified of the observation of LVN B leaving the hot zone without removing PPE to go get gloves, the DON said, that's on her, she should know better. When asked if LVN B had been trained on proper donning and doffing procedures, she said they are trained that anytime you come out of the hot zone, you are donning and doffing. when asked what the potential negative outcome could be for residents, the DON said staff could possibly spread Covid to the residents in the quarantine area. She said technically the Residents who are recovered, shouldn't be able to be reinfected. When asked what her expectation was of staff was concerning proper use of PPE, she said, to do things properly, we'll do an in service and they will follow policy and procedure that has been put in place. If not, we'll start disciplinary action. In an interview on 8-3-22 at 11:35 AM with ADON and Infection Preventionist about staff not properly wearing PPE. When asked what her expectation was of staff regarding infection control practices were, she said that she expected them to be in compliance. She said she did an infection control in-service at the beginning of the Covid outbreak which was in July. When asked what she was doing to ensure staff were following PPE guidelines and infection control practices, she said um, watching them and making sure they are doing it correctly. Observation on 8-2-22 at 8:55 AM during medication pass for Resident #28 revealed LVN D dropped a Zofran pill on the top of the medication cart. She gets a glove, picks the pill up off the cart, then puts it into the pill cup and administers the medication to the Resident. LVN D did not clean the top of the medication cart prior to the medication pass. Observation on 8-2-22 at 9:07 AM during medication pass for Resident #50 revealed LVN D dropped a folic acid pill and a pravastatin pill on the top of the medication cart. She gets a glove, pics the two pills up off the cart, then put them into the pill cup and administers the medications to the Resident. LVN D did not clean the top of the medication cart prior to the medication pass. In an interview on 8-2-22 at 1:05 PM with LVN D about picking the dropped pills up off the top of the medication cart and administering them to the Residents without cleaning the top of the cart. She said that she thought that she could pick the pills up as long as she did not touch them with her bare hands. When asked if this was an infection control issue, she said yes, she should have discarded the dropped pill and got a new one. When asked if she has been trained on what to do if she drops a pill, she said yes, she should have discarded the pill in the sharps container. When asked what the potential negative outcome could be for the resident, she said that the resident could get an infection from the top of the medication cart not being cleaned. Record review of the facility undated protocol titled Secure Unit Protocol reflected the following: All staff that enter the unit will wear full PPE. Cold zone: you may wear your gown and gloves and face covering when you walk up and down the hall. Warm zone: (Quarantine) pink taped area. You may wear your PPE in the room; Must change your gown, gloves and mask, eye protection when you exit the room and put on new gown, gloves, mask (disinfect eye protection) Hot zone (COVID positive) red taped area. You may wear your PPE in the rooms; must change your gown, gloves and mask and (disinfect eye protection) when you exit the room and put on new gown, gloves, mask. Record review of the e-mail sent to a Health and Human Service Compliance Reviewer on 7-28-22 from the Administrator documented The entire unit will be considered hot until all has recovered! Record review of the facility policy and procedure dated October 2020 and titled Infection Prevention and Control Program reflected the following: Policy Statement: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Each center should refer to and follow CDC guidelines and their state guidance for infection prevention and control. Texas Health and Human Services, COVID-19 response for nursing facilities most current version, should be referred to and followed by centers located in the state of Texas. Record review of the COVID-19 response for nursing facilities guide version 4.3 dated 6-27-22 reflected the following: Page 40; Personal protective equipment (PPE)- Full PPE is required (NIOSH-approved N-95 or equivalent or higher-level respirator, gown, gloves, and eye protection) for health care personnel working inside the Isolation (COVID-19 positive) zone and Quarantine (Unknown COVIDp-19) zone.