**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs as identified in the comprehensive assessment for 1 of 16 (Resident #5) reviewed for care plans. This facility failed to implement the comprehensive care plan for Resident #5, resulting in a fall with injury. This failure could place residents at risk of not receiving the care needed to live at their highest practicable level of health and mental well-being. Findings included: A review of Resident #5's clinical face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE] with a BIMS of 02 indicating severe cognitive impairment with a diagnosis of, but not limited to, Neurocognitive Disorder with Lewy Bodies (clumps of abnormal protein that, for reasons unknown, accumulate in the brain), Dementia in Other Diseases Classified Elsewhere (loss of cognitive function), Unspecified Severity with Other Behavioral Disturbance, Agitation and Anxiety, Parkinsonism (a clinical syndrome which manifests with motor symptoms such as rigidity, tremors, slow movements, unstable posture and gait impairment), Unspecified, Muscle Weakness, (Generalized), Cognitive Communication Deficit, Other Lack of Coordination, Delirium ( a mental state in which you are confused, disoriented, and not able to think clearly) Due to Known Physiological Condition and History of Falling. A review of Resident #5's MDS dated [DATE] revealed bilateral Functional Limitation in Range of Motion in both the upper and lower extremities. Resident #5 used a wheelchair for ambulation and needed Substantial (helper does more than half) to Dependent help (2 or more helpers) with ADLs. Review of Resident #5's Care Plan dated 09/09/2024 revealed Resident #5 had an actual fall with injury prior to admission and continued to be a fall risk since admission. The goal for Resident #5 was to be free of injury related to falls, and a decrease the number of falls. The interventions for Resident #5 were bed in lowest position with fall mat on floor, shoes, or non-skid socks at all times, especially during transfers and keep resident within line of sight at all times, as he would constantly try to stand alone. Record review of facility incidents revealed on 10/15/2024, Resident #5 sustained an unwitnessed fall. An observation of Resident #5 on 10/22/2024 revealed a large bruise in various stages of healing to the right side of Resident #5's face, and a skin tear to the bridge of the nose. Review of progress notes for Resident #5 from 10/15/2024 revealed he was assessed by facility staff, and it was determined Resident #5 did not need to seek medical attention. Neuro checks were performed by licensed staff every 2 hours for the first 24 hours after the fall, and Resident #5 continued to perform within normal limits. An interview with Resident #5's family member on 10/22/24 at 6:37PM revealed the facility called him immediately after Resident #5 fell. The facility surveillance tape from 10/15/2024 was reviewed by the family member and it was determined Resident #5 fell at or around 7pm. The family member stated Resident #5 sustained injuries which in his opinion might have required x-rays, but Resident #5 was not sent out for x-ray, nor was the mobile x-ray unit called. The family member stated Resident #5 is never to be out of eyesight of staff, yet Resident #5 was on the floor for 6-7 minutes before staff found him, according to the surveillance tape. An interview with Resident #5's POA on 10/24/24 at 12:27PM revealed she was called immediately after the fall. The POA stated she was told by staff Resident #5 fell out of his wheelchair and onto the floor. The POA stated she was told by staff x-rays were not required and Resident #5 had been treated for any injury to his face. The POA stated she had spoken with the Rounding Provider and was told x-rays were not needed for Resident #5. The POA stated Resident #5 was to be in eyesight of staff at all times, but felt the facility was not at fault for the fall, as Resident #5 tried to stand alone regularly. Review of facility Policy and Procedure for Person-Centered Care Plans revealed the following: 4. Each resident's comprehensive person-centered care plan will be consistent with the resident's rights to participate in the development and implementation of his or her care plan, including the right to: (g.) Receive the services and/or items included in the care plan. 8. The comprehensive, person-centered care plan will: (a.) Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; (g.) Incorporate identified problem areas; (h.) Incorporate risk factors associated with identified problems; (m.) Aid in preventing or reducing decline in the resident's functional status and/or functional levels; (n.) Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and (o) Reflect currently recognized standards of practice for problem areas and conditions. 11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making (a.) When possible, interventions address the underlying source(s) of the problem(s), not just addressing the only the symptoms and triggers.

Based on interviews, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 (10/12/2024) of the 90 days reviewed. The facility did not have an RN working in the facility on 10/12/2024. This failure has the potential to affect the residents in the facility and place them at risk of not having staff with advance care skills available to assist in their care needs. Findings included: Record review of the facility's last 90 days (07/22/2024-10/22/2024) of RN coverage provided by the BOM revealed the facility had no RN working in the facility for the following date: 10/12/2024. During an interview on 10/22/24 at 12:20 PM, the BOM verified that the facility did not have an RN working in the facility on 10/12/24. During an interview on 10/24/24 at 9:15 AM, the ADON stated that a possible negative outcome for not having an RN working for 8 hours/day would be that if something bad happened, the staff would not know what to do and would not have anyone to go to. During an interview on 10/24/24 at 10:20 AM, LVN A stated that a negative outcome for not having an RN on staff every day would be that if a major clinical issue came up in the facility, the correct treatment might not be given. During an interview on 10/24/24 at 10:24 AM, the DON stated that a negative outcome for not having an RN on staff each day would be that management or direction would not be there and there could be a lack of care due to that. Policy for RN coverage was requested on 7/24/24 at 8:14 AM but was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, and misappropriation of resident property are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 of 16 residents (Residents #5 and #27) reviewed for abuse and neglect. The facility failed to report to the Administrator and State Survey Agency an allegation of abuse involving Residents #5 and #27 within 2 hours of the allegation. This failure could place residents at risk of not having incidents of abuse, neglect, exploitation, and misappropriation of resident property being reviewed and investigated in a timely manner by the facility and state survey agency. Findings included: 1. Record review of Resident # 5's face sheet dated 10/23/2024, revealed that the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses, included but not limited to, Neurocognitive Disorder with Lewy Bodies (cognitive decline in thinking abilities, visual perception, and visual hallucinations), Dementia (cognitive loss) with anxiety and agitation, Parkinsonism (slowness of movement, tremor, difficulty walking, or rigidity). Record review of Resident # 5's significant change of status MDS, dated [DATE], revealed a BIMS score of 2 out of 15 which indicated his cognition was severely impaired and he required substantial/maximal physical assistance from 1 staff member in most ADLs including moving between surface to and from bed, chair, and wheelchair. Record review of Resident #5's Care Plan dated 09/09/2024 revealed that resident was care planned for falls with an intervention that stated to keep resident in line of sight, because he will try to try to constantly stand. Record review of Resident #5's progress notes dated 10/16/2024 revealed that at approximately 7:00 PM on 10/15/2024 agency staff reported to nursing staff that Resident #5 was noted on the floor in the dining room on his belly with left side of face on the floor and w/c beside him. Upon assessment resident noted with small skin tear to bridge of nose and superficial abrasion to left side of forehead. Minimal bleeding noted to skin tear on bridge of nose. Resident assisted back to w/c with assistance x 2 and was not able to move all extremities without complaint of pain or discomfort. Unable to provide description of fall due to cognitive status. POA, physician, RN, and ADM notified of resident's fall. 2. Record review of Resident #27's face sheet dated 10/24/2024 revealed that the resident was an [AGE] year-old female admitted to the facility on [DATE] with an original admission date of 01/03/2024 with diagnoses, included but not limited to, Alzheimer's disease (memory loss). Record review of Resident #27's quarterly MDS, dated [DATE], revealed a BIMS score of 99 which revealed that the resident was unable to complete the interview and she required complete dependence on 2 or more helpers in most ADLs including toileting and personal hygiene. Record review of Resident #27's progress notes dated 9/1/2024 at 7:45 AM fell while eating breakfast in dining room and was found lying on her left side with blood coming out of her head. EMS was called and resident transported to ER, POA, physician, and ADM notified of fall. During an observation on 10/23/2024 at 9:21 AM, Resident #27 had stiches to the head and leg. Resident was non interview able. Interview with Resident's family member on 10/23/2024 at 9:22 AM, stated that she had an unwitnessed fall on 09/01/2024 which resulted in a laceration to the head and required a hospital visit. During an observation on 10/23/2024 at 11:08 AM, Resident #5 was sitting in w/c in common area with 2 wounds on his arms, both had bandages on arms with dates of 10/21/2024 on them. Resident was observed to have wounds on cheeks and nose, neither were bandaged. Resident was non interview able. During a phone interview on 10/23/2024 at 6:40 PM, Resident #5's family member stated that the resident fell on [DATE] because he was left alone and was always supposed to have someone with him or be in their line of sight. Resident's family member did not think this incident was investigated or reported to the state. During an interview on 10/24/2024 at 9:14 AM, the ADON revealed to surveyor that falls were not investigated and/or reported to the state for investigation. During an observation on 10/24/2024 at 11:45 AM, CE showed surveyor video footage of a fall for Resident #27 on 09/01/2024 around 8:11 AM. No witnesses were observed in footage. During an observation on 10/24/2024 at 12:18 PM, CE showed surveyor video footage of Resident #5 without staff present. Video footage revealed at 7:06 PM on 10/15/2024 that Resident #5 fell from chair to his left side. Further footage of the video revealed at 7:08 PM on 10/15/2024, 2 unidentified staff walked away from Resident #5. During an interview on 10/24/2024 at 2:10 PM, the ADM stated that a negative outcome for not investigating a fall would be that they would not be able to find the root cause of the incident and to prevent future incidents of the same nature from happening and a negative outcome for failing to report a fall would be that it is required and expected . Record review of facility provided policy titled Abuse and Neglect - Clinical Protocol, dated 2001 and revised November 2018 , revealed the following in part: Assessment and Recognition, #4. Significant injuries in physically dependent individuals. Cause Identification, #1. The staff, with the physician's input as needed, will investigate alleged abuse and neglect to clarify what happened and identify possible causes. Record review of facility provided policy title Accidents and Incidents - Investigating and Reporting, dated 2001 and revised July 2017, revealed the following in part: Policy Statement. All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Record review of facility employee in service training records revealed Falls-Prevention of Falls and Interventions training was conducted 08/09/2024 and 10/21/2024. Record Review of Tulip for intakes for this facility, revealed no incidents reported on either fall for Resident #5 or Resident #27.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated for 2 of 16 (Residents #5 & #27) residents reviewed for abuse and neglect. The facility failed to conduct a thorough investigation when Resident #5 fell from his wheelchair unobserved and obtained a skin tear to the bridge of nose and abrasion to left side of forehead. The facility failed to conduct a thorough investigation when Resident #27 fall leading to a head wound on her left side. This failure could place residents at risk of abuse and neglect. Findings included: Record review of Resident # 5's face sheet dated 10/23/2024, revealed that the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses, included but not limited to, Neurocognitive Disorder with Lewy Bodies (cognitive decline in thinking abilities, visual perception, and visual hallucinations), Dementia (cognitive loss) with anxiety and agitation, Parkinsonism (slowness of movement, tremor, difficulty walking, or rigidity). Record review of Resident # 5's significant change of status MDS, dated [DATE], revealed a BIMS score of 2 out of 15 which indicated his cognition was severely impaired and he required substantial/maximal physical assistance from 1 staff member in most ADLs including moving between surface to and from bed, chair, and wheelchair. Record review of Resident #5's Care Plan dated 09/09/2024 revealed that resident was care planned for falls with an intervention that stated to keep resident in line of sight, because he will try to try to constantly stand. Record review of Resident #5's progress notes dated 10/16/2024 revealed that at approximately 7:00 PM on 10/15/2024 agency staff reported to nursing staff that Resident #5 was noted on the floor in the dining room on his belly with left side of face on the floor and w/c beside him. Upon assessment resident noted with small skin tear to bridge of nose and superficial abrasion to left side of forehead. Minimal bleeding noted to skin tear on bridge of nose. Resident assisted back to w/c with assistance x 2 and was not able to move all extremities without complaint of pain or discomfort. Unable to provide description of fall due to cognitive status. POA, physician, RN, and ADM notified of resident's fall. Record review of Resident #27's face sheet dated 10/24/2024 revealed that the resident was an [AGE] year-old female admitted to the facility on [DATE] with an original admission date of 01/03/2024 with diagnoses, included but not limited to, Alzheimer's disease (memory loss). Record review of Resident #27's quarterly MDS, dated [DATE], revealed a BIMS score of 99 which revealed that the resident was unable to complete the interview and she required complete dependence on 2 or more helpers in most ADLs including toileting and personal hygiene. Record review of Resident #27's progress notes dated 9/1/2024 at 7:45 AM, fell while eating breakfast in dining room and was found lying on her left side with blood coming out of her head. EMS was called and resident transported to ER, POA, physician, and ADM notified of fall. During an observation on 10/23/2024 at 9:21 AM, Resident #27 had stiches to the head and leg. Resident was non interview able. Interview with Resident's family member on 10/23/2024 at 9:22 AM stated that she had an unwitnessed fall on 09/01/2024 which resulted in a laceration to the head and required a hospital visit. During an observation on 10/23/2024 at 11:08 AM, Resident #5 was sitting in w/c in common area with 2 wounds on his arms, both had bandages on arms with dates of 10/21/2024 on them. Resident was observed to have wounds on cheeks and nose, neither were bandaged. Resident was non interview able. During a phone interview on 10/23/2024 at 6:40 PM, Resident #5's family member stated that the resident fell on [DATE] because he was left alone and was always supposed to have someone with him or be in their line of sight. Resident's family member did not think this incident was investigated or reported to the state. During an interview on 10/24/2024 at 9:14 AM, the ADON revealed to surveyor that falls were not investigated and/or reported to the state for investigation. Footage of the falls were reviewed but that is the extent of the investigation. During an observation on 10/24/2024 at 11:45 AM, CE showed surveyor video footage of a fall for Resident #27 that happened on 09/01/2024 around 8:11 AM. No witnesses were observed in footage . During an observation on 10/24/2024 at 12:18 PM, CE showed surveyor video footage of Resident #5 without staff present. Video footage revealed at 7:06 PM on 10/15/2024 that Resident #5 fell from chair to his left side. Further footage of the video revealed at 7:08 PM on 10/15/2024, 2 unidentified staff walked away from Resident #5. During an interview on 10/24/2024 at 2:10 PM, ADM stated that a negative outcome for not investigating a fall would be that they would not be able to find the root cause of the incident and to prevent future incidents of the same nature from happening and a negative outcome for failing to report a fall would be that it is required and expected . Record review of facility provided policy titled Abuse and Neglect - Clinical Protocol, dated 2001 and revised November 2018, revealed the following in part: Assessment and Recognition, #4. Significant injuries in physically dependent individuals. Cause Identification, #1. The staff, with the physician's input as needed, will investigate alleged abuse and neglect to clarify what happened and identify possible causes. Record review of facility provided policy title Accidents and Incidents - Investigating and Reporting, dated 2001 and revised July 2017, revealed the following in part: Policy Statement. All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Record review of facility employee in service training records revealed Falls-Prevention of Falls and Interventions training was conducted 08/09/2024 and 10/21/2024. Record review of Tulip for intakes for this facility, revealed no incidents reported on either fall for Resident #5 or Resident #27.

Based on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff and individuals providing services under a contractual agreement, consistent with their expected roles for 4 of 11 (interim DON, LVN B, CNA C and CNA D) staff reviewed for nursing home training. The facility failed to ensure Interim DON, LVN B, CNA C and CNA D were trained in the prevention of Resident Abuse, Neglect and Exploitation, HIV Policy and Procedures, Fall Prevention, Use of Restraints, Emergency Procedures and Dementia. This failure could place residents at risk for a diminished quality of life and diminished psychosocial well-being, due to lack of training in essential resident care and facility practice. Findings included: Record review of employee files revealed the following staff did not have training in the prevention of Resident Abuse, Neglect and Exploitation, HIV Policy and Procedures, Fall Prevention, Use of Restraints, Emergency Procedures and Dementia prior to interacting with and caring for residents in the facility: Record review of the interim DON's employment file revealed a hire date of 10/14/2024, and no training in the prevention of Resident Abuse, Neglect and Exploitation, HIV Policy and Procedures, Fall Prevention, Use of Restraints, Emergency Procedures and Dementia prior to interacting with and caring for residents in the facility. Record review of the LVN B's employment file revealed a hire date of 10/20/2024, and no training in the prevention of Resident Abuse, Neglect and Exploitation, HIV Policy and Procedures, Fall Prevention, Use of Restraints, Emergency Procedures and Dementia prior to interacting with and caring for residents in the facility. Record review of the CNA C's employment file revealed a hire date of 10/11/2024, and no training in the prevention of Resident Abuse, Neglect and Exploitation, HIV Policy and Procedures, Fall Prevention, Use of Restraints, Emergency Procedures and Dementia prior to interacting with and caring for residents in the facility. Record review of the CNA D's employment file revealed hire date of 10/01/2024, and no training in the prevention of Resident Abuse, Neglect and Exploitation, HIV Policy and Procedures, Fall Prevention, Use of Restraints, Emergency Procedures and Dementia prior to interacting with and caring for residents in the facility. An interview with the Administrator on 10/24/2024 at 11:28 AM, revealed she was not aware there were 4 employees who had been caring for residents without any prior training. She was unaware it was the facility's responsibility to train contract employees prior to employment. She stated she assumed the agency providing the employees had trained them prior to their employment with the agency. She stated she had a notebook of PowerPoint slides which covered the training information regarding Abuse/Neglect/Exploitation, HIV, Fall Prevention, Use of Restraints, Emergency Procedures and Dementia that employees were welcome to read at any time. She stated she had not confirmed the competency of these 4 employees in Abuse/Neglect/Exploitation, HIV, Fall Prevention, Use of Restraints, Emergency Procedures and Dementia prior to their employment. An interview with the Administrator on 10/24/2024 at 2:36 PM, revealed she could not define a negative outcome of these 4 employees caring for residents with no training. An interview with the Administrator on 10/24/2024 at 2:51 PM, revealed the negative outcome of the Interim DON mentoring LVN B and LVN B mentoring CNA's C and D would be the potential hinderance of health and safety of residents. The Administrator could not provide the facility's policy and procedures regarding training and stated she followed the regulation guidance provided by the State Operations Manual (SOM).

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety for 1 of 1 kitchen reviewed for food safety. The facility failed to ensure all food in the dry pantry and cold storage were properly sealed, labeled and dated. The facility failed to ensure all foods in the dry pantry were at least 18 inches off the floor as required by facility policy for dry pantry storage. These failures could place residents at risk of residents at risk of food-borne illness and a diminished quality of life. Findings included: On 10/22/2024 at 10:04AM an initial observation of the kitchen was conducted, and the following was noted: Dry Pantry: (3) partial 5lb. bags corn tortillas with no received date and one bag open to air. (1) partial 10lb. bag elbow macaroni with no received date and open to air. (1) partial 50lb. bag white rice with no received date and open to air. (2) 3oz. boxes dry raspberry gelatin with no received date. (1) partial 2lb. 3oz. bag frosted flake cereal with no received date and open to air. (1) 1gal. zip top bag crisp rice cereal with no received date and open to air. (1) partial 16oz. bag mini marshmallows open to air. (1) 1lb. box corn starch with no received date. (17) 3.2oz. packages dry Ranch dressing with no received date. (44) 4oz. cans pineapple juice with no received date. (36) 4oz. cans vegetable juice with no received date. (19) 4oz. cans chicken noodle soup with no received date. (4) 4oz. containers Thick-n-Easy Clear, Cranberry Flavored Drink with no received date. (10) 4oz containers Thick-n-Easy Clear, Orange flavored drink with no received date (12) 4oz. containers Thick-n-Easy Clear, Red Tea Flavored Drink with no received date. Dry pantry foods were not stored at least 18-inches above the floor as required by facility policy. Cold Storage Unit: ½ fresh tomato in a bowl with no label, no use by date and open to air. (3) 6oz. cups prepared thickened drink mix with no label, no use by date and open to air. 1qt. enchilada sauce with no received date. (4) 5lb. bags chicken breasts with no received date. 2 fresh cantaloupes with no received date. (1) 50lb. box fresh potatoes with no received date. (1) 1gal. container barbeque sauce with no received date. (1) 9lb 14oz box individual serving margarine cups with no received date. (4) 48-count fresh eggs in cardboard pallets with no received date. An interview with the Head [NAME] 10/23/2024 at 11:12AM revealed there was no Dietary Manager working for the facility at that time. She stated the negative outcome of residents eating foods which were not labeled and dated was they could become sick if they ate foods which were expired. She stated there was no facility policy regarding Recommended Maximum Storage Periods for dry or cold storage foods. Review of facility policy for Food Receiving and Storage dated October 2017 revealed the following: (6.) Food stored in designated dry storage areas shall be kept off the floor (at least 18 inches) and clear of sprinkler heads, sewage/waste disposal pipes and vents. (8.) All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by date) (14.) d. Beverages must be dated when opened and discarded after twenty-four (24) hours. e. Other opened containers must be dated and sealed or covered during storage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents had the right to and the facility promoted and facilitated resident self-determination through support of resident choice, which included but not limited to the right to make choices about aspects of his or her life in the facility that were significant to the resident for 1 of 16 residents (Resident #3) reviewed for self-determination. The facility failed to ensure Resident #3 was allowed to choose the type of foods he preferred when he expressed he would like all the foods the other residents were served. This failure could place residents at risk for being denied the opportunity to exercise his or her autonomy regarding things that were important in their life and a decrease in their quality of life. Findings include: Record review of Resident # 3's face sheet revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include vascular dementia (defective memory), dysphagia (difficulty swallowing), and anxiety. Record review of comprehensive MDS assessment dated [DATE] revealed Resident # 3 was usually understood. The MDS revealed Resident # 3 had a BIMS of 10 which indicated the resident's cognition was moderately impaired. Section K indicated Mechanically altered diet: Require change in texture of food or liquids. Record review of a care plan, dated 08/28/23 for Resident # 3 revealed the following: Category: Nutritional Status The resident was on regular pureed diet with thin liquids. Record review of Resident # 3's order summary report dated 10/18/23 revealed the following orders: Diet ordered 07/09/23: Regular diet, Pureed texture, thin liquids consistency. Record view of Resident # 3 weight log, August- October 2023, indicated there was no significant weight loss at the time of survey. An observation was made on 10/16/23 at 12:20 PM of Resident #3 lunch tray and it did not have any puree bread on the plate. During an interview on10/16/23 at 12:05 pm, the DM said she had pureed everything that she had to for the meal. During an interview on 10/17/23 at 9:00 am Resident # 3 stated he would like all the same foods as the other residents receive. Resident #3 stated he does not receive bread or desserts (cake, pie cookies or churros) for meals when the other residents are served desserts or bread. Resident #3 stated he felt sad and left out when he sees other residents eating desserts and he was not served the same foods. Resident #3 stated he wanted the same foods as other resident's receive. During a confidential interview on 10/17/23 at 9:30 am an employee stated Resident # 3 was never given bread or desserts (cake pie cookies or churros) when residents who are not on a pureed diet are served bread or desserts. The employee stated Resident #3 gets pudding or applesauce when desserts are served. The employee stated Resident #3 also gets pudding or applesauce when snacks are served in the morning and the afternoon snack times. The employee stated Resident #3 has seen other residents get desserts (cake pie cookies and churros) and has asked for the desserts when he sees the other residents eating them. The employee stated when he asks for bread and dessert, the staff tell him he cannot have the bread or desserts. The employee stated Resident #3 always looks sad that he is told he cannot have the same foods as other residents. During an interview on 10/17/23 at 9:45 am Resident #3 family member stated Resident #3 liked anything sweet. The family member stated Resident #3 loved to eat, and he will eat anything he was served. The family member stated Resident #3 loved pie and cake. The family member stated Resident #3 loves pumpkin pie and in the past at Thanksgiving, the facility would give Resident #3 pumpkin pie The family member stated she used to take Resident #3 candy bars and the previous food manager would puree the candy bars for him. The family member stated Resident #3 would feel sad and left out if he saw other residents with pie and cake and he was told he could not have any desserts. The family member stated she was not aware Resident #3 was not being given bread or sweets for meals. During an interview on 10/17/23 at 12:10 pm the DM said none of the residents who receive a pureed diet were served bread or pureed desserts. She stated when the menu listed desserts( cake, pie, cookies or churros ) for residents with regular diets, she does not puree desserts (cake, pie, churros or cookies.) She stated the RD told her not to puree desserts as well as bread for Resident #3. During an interview on 10/17/23 at 1 :45 pm, the facility MD stated he was not aware Resident #3 who was on a pureed diet were not receiving pureed bread or desserts. He stated there was no reason Resident #3 could not have bread or desserts. The MD stated there was no reason residents with pureed meals should not get bread or desserts like everyone else. The MD further stated Resident #3 should get whatever he wants. During an interview on 10/17/23 at 3:00 pm the RD stated she has trained the DM to not serve pureed bread or desserts to residents on a pureed diet. The RD stated We do not puree bread. You have to puree it with milk, and it ends up really gross and was not appetizing. The RD was asked about pureeing cake, pie, and cookies. The RD stated she has trained the DM to not give residents with a pureed diet any cakes, cookies, or pies either. She stated even if the residents ask for pureed bread, cake, pie or cookies they cannot have it. During an interview on 10/18/23 at 10:00 am the DON stated he was not aware Resident #3 was not receiving pureed bread or desserts. The DON stated residents would feel left out and caloric intake is lacking if Resident #3 was not provided the same diet as the rest of the residents. Record review of the facility's policy titled, Menus, revised October 2008 revealed: [NAME] will provide a variety of foods from the basic daily food groups and will indicate standard portions at each meal. If a food group is missing from a resident's daily diet (e.g. diary products) the resident will be provided an alternate means of meeting the residents nutritional needs. Menus will be varied for the same day of consecutive weeks. Record review of the facility policy titled, Therapeutic Diets, dated November 2015 revealed: Diet will be determined in accordance with the resident's informed choices, preferences, and wishes. The resident has a right not to comply with therapeutic diets. Snacks will be compatible with the therapeutic diet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the menu was followed, for 2 out of 3 residents that received pureed food (Resident #3 & Resident # 29), in that: 1. The facility failed to ensure Resident # 3 received pureed bread on 10/16/23. 2. The facility failed to ensure Resident # 29 received pureed bread on 10/16/23. These failures could place residents at risk for unwanted weight loss, hunger, unwanted weight gain, and metabolic imbalances. The findings include: Resident # 3 Record review of Resident # 3's face sheet revealed a [AGE] year-old-male admitted to the facility on [DATE] with diagnoses to include vascular dementia (defective memory), dysphagia (difficulty swallowing), and anxiety. Record review of comprehensive MDS assessment dated [DATE] revealed Resident # 3 was usually understood. The MDS revealed Resident # 3 had a BIMS of 10 which indicated the resident's cognition was moderately impaired. Section K indicated Mechanically altered diet: Require change in texture of food or liquids. Record review of a care plan, dated 08/28/23 for Resident # 3 revealed the following: Category: Nutritional Status Resident was on regular pureed diet with thin liquids. Record review of Resident # 3's order summary report dated 10/18/23 revealed the following orders: Diet ordered 07/09/23: Regular diet, Pureed texture, thin liquids consistency. Resident # 29 Record review of Resident #29's face sheet revealed a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses to include dementia, anxiety and psychotic disorder. Record review of comprehensive MDS assessment dated [DATE] revealed Resident #29 was rarely or never understood. The MDS revealed Resident # 29 had a BIMS of 0 which indicated the resident's cognition was severely impaired. Section K indicated Mechanically altered diet: Require change in texture of food or liquids. Record review of a care plan, dated 09/26/23 for Resident # 29 revealed the following: Category: Nutritional Status Resident was on regular pureed diet with thin liquids. Record review of Resident # 29's order summary report dated 9/8/23 revealed the following orders: Diet ordered 07/09/23: Regular diet, Pureed texture, thin liquids consistency. On 10/16/23 at 11:41 AM an observation of the pureed process was conducted. The DM began the process at 11:41 am. No bread or rolls were pureed during this process. During an interview on10/16/23 at 12:05 pm, the DM said she had pureed everything that she had to for the meal Record review of Resident #3's diet card dated Wednesday 10/16/23 revealed he should have received a bread or roll. An observation was made on 10/16/23 at 12:20 PM of Resident #3 lunch tray and it did not have any puree bread on the plate. Record review of Resident # 29's diet card dated Wednesday 10/16/23 revealed he should have received a bread or roll. An observation was made on 10/16/23 at 12:31pm of Resident #29's lunch tray and it did not have any puree bread on the plate. During an interview on 10/17/23 at 1:45 pm the DM said she did not puree any bread because the dietician had told her not to give any of the residents with pureed diets bread. She stated the substitute for bread was mashed potatoes. The dietary manager further stated residents were not served pureed desserts. She stated she did not puree cake, pie churros or cookies. She stated the RD told her not to puree desserts as well as bread. During an interview on 10/17/23 at 1 :45 pm, the facility MD stated he was not aware residents who are on a pureed diet were not receiving pureed bread. He stated there was no reason the residents with pureed diets could not have bread. During an interview on 10/17/23 at 3:00 pm the RD stated she has trained the DM to not serve pureed bread to residents on a pureed diet. The RD stated We do not puree bread. You have to puree it with milk, and it ends up really gross and is not appetizing. The RD stated she has trained the DM to not give residents with a pureed diet any cakes, cookies, or pies either. She stated even if the residents ask for pureed bread, cake, pie or cookies they cannot have it. During an interview on 10/18/23 at 10:00 am the DON stated he was not aware residents on a pureed diet were not receiving pureed bread or desserts. The DON stated residents would feel left out and caloric intake would be lacking if residents on a pureed diet were not provided the same diet as the rest of the residents. Record review of the facility's policy titled, Menus, revised October 2008 revealed: [NAME] will provide a variety of foods from the basic daily food groups and will indicate standard portions at each meal. If a food group is missing from a resident's daily diet (e.g. diary products) the resident will be provided an alternate means of meeting the residents nutritional needs. Menus will be varied for the same day of consecutive weeks. Record review of the facility policy titled, Therapeutic Diets, dated November 2015 revealed: Diets will be determined in accordance with the resident's informed choices, preferences, and wishes. The resident has a right not to comply with therapeutic diets. Snacks will be compatible with the therapeutic diet.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1of 1 kitchen observed for kitchen sanitation. The facility failed to: A. Ensure general cleanliness was maintained. B. Ensure food items were properly stored. These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings include: Observations on 10/16/23 at 10:15 am of the pantry revealed: 1. An opened jar of jelly with a label that stated refrigerate after opening. Observations on 10/16/23 at 10:20 am of the walk-in cooler revealed: 1. A package of shredded cheese, open to air. 2. A package of sliced cheese, open to air. 3. A large bottle of Coffee Mate liquid creamer on the shelf. Label stated do not refrigerate or freeze. Observations on 10/16/23 at 10:20 am of the walk-in freezer revealed: 1. A box of frozen burritos, open to air. Observation of the lunch meal service on 10/16/23 at 12:05 pm revealed the following: The DM was observed with gloved hands touching various kitchen workstation surfaces, rolling a hot box to the steam table, and picking up utensils and a plate to begin plating the lunch meal. The DM did not change her gloves or wash her hands. The DM picked up a roll with her gloved hand and placed the roll on the plate. The DM set the plate cover on the plate and put the plate into the hot box. The DM then separated all the rolls from each other using her gloved hands to pull all the rolls apart. The DM was stopped by the surveyor and asked if she was supposed to use tongs when touching the rolls. The DM stated she did not know that she was supposed to use tongs to serve the rolls. Observations on 10/17/23 at 9:30 am of the pantry revealed: 2. An opened jar of jelly with a label that stated refrigerate after opening. Observations on 10/17/23 at 10:20 am of the walk-in cooler revealed: 4. A package of shredded cheese, open to air. 5. A package of sliced cheese, open to air. 6. A large bottle of Coffee Mate liquid creamer on the shelf. Label stated do not refrigerate or freeze. Observations on 10/17/23 at 10:20 am of the walk-in freezer revealed: 2. A box of frozen burritos, open to air. In an interview and observation of the issues in the kitchen on 10/ 17/23 at 11:00 AM, the DM was shown the opened jar of jelly in the pantry and told the label stated jelly needed to be refrigerated. The DM stated she did not know why the jelly was on the shelf. The DM was shown the creamer in the refrigerator and the label for storage was reviewed. The DM stated she did not know why the creamer was in the cooler. The DM stated the shredded cheese and sliced cheese should be closed to air. The DM was shown the box of burritos in the walk-in freezer and stated the burritos should be closed to air. The DM stated cross contamination could occur when foods were not stored and served properly. The DM stated all kitchen employees are supposed to change gloves and use tongs when handling food. The DM stated the dietician trained the staff in kitchen sanitation. Record review of the facility policy titled, Food Receiving and Storage, dated October 2017, documented all foods stored in the refrigerator will be covered labeled and dated. Wrappers of frozen food must stay intact until thawing. Record review of the facility policy titled, ' Preventing Food Borne Illness- Food Handling with a revision date of July 2014 , documented all employees who handle prepare or serve food will be trained in the practices of safe handling and preventing food borne illnesses. Employees must wash their hands after handling soiled equipment or utensils, before coming into contact with any food surfaces, during food preparation as often as necessary to remove soil and contamination and to prevent cross contamination. Food service employees will be trained in the proper use of utensils such as tongs, gloves, deli paper and spatulas to prevent food borne illness. Gloves are considered single use items and must be discarded after completing the task for which they are used. The use of gloves does not substitute for proper handwashing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to implement a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #4) of 16 Residents reviewed for comprehensive care plans. -The facility failed to include care plans for Resident #4's C-PAP. This failure could affect residents in the facility receiving care per comprehensive person-centered care plans resulting in resident not being able to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Finding include: Record review of Resident #4's clinical record revealed he was admitted to the facility on [DATE] with diagnoses to include unspecified dementia, cerebellar ataxia, recurrent depressive disorder, benign prostatic hyperplasia, anemia, cognitive communication deficit, difficulty in walking, and a history of falling. Record review of Resident #4's annual MDS completed 3/8/2022 revealed the following: Section C-C0500-BIMS Summary Score-15 (indicating he is cognitively intact). Section G-Functional Status-indicated that Resident #4 required set-up assistance with most activities of daily living. Section O-Special Treatment, Procedures, and Programs-G Non-Invasive Mechanical Ventilator (BiPAP/CPAP)-Resident #4 is marked While a Resident. Record review of Resident #4 Active Orders as of: 08/31/2022 revealed an order for C-PAP at HS at bedtime with an active date of 4-26-2021. Record review of Resident #4's care plans with date initiated of 4/26/21 and a Last Care Plan Review Completed of 6/21/2022 revealed no care plan for C-PAP. During an observation on 08/29/22 at 10:43 AM Resident #4 was in his room sitting in his recliner. He had his C-PAP on his bedside dresser that he stated he has used for 3-4 years. Resident #4 verified that staff do help him with the use of his C-PAP at night and help him care for his equipment. During an interview on 08/31/22 at 10:49 AM the MDS Coordinator verified that she is responsible for completing the care plans and that she completes the care plans from MDS information, 24 hours reports, and resident chart information. When questioned if she could verify that Resident #4 had his C-PAP addressed on his current care plan the MDS Coordinator reviewed his care plan and stated, I'm not seeing it. When questioned if the C-PAP should be care planned, the MDS Coordinator stated, I know it should be in his care plan. When questioned if there were any consequences of not addressing the use of C-PAP in Resident #4's care plans the MDS Coordinator stated, It is on his ETAR so the nurses know to put in on him at night but no I do not feel like there could be any problems. I'm sure there could be, but I can't think of any. I know it should be there. The MDS Coordinator continued to state, I will put that in the care plan right now. I'm disappointed I missed that. During an interview on 08/31/22 at 11:57 AM when questioned if Resident #4's C-PAP should have been addressed in his care plans the DON stated, It probably should have been, but I don't think it would have affected the outcome. When asked if not having the C-PAP addressed in Resident #4's care plan could affect his care the DON stated, I don't think it would have affected his care because it is in his orders and his ETAR, so it was addressed. When asked if there were any adverse consequences from not addressing a residents needs in the comprehensive care plans the DON stated, I don't think there would be any consequences from not having this in the care plan. Record review of facility provided policy titled Care Plans, Comprehensive Person-Centered, revised December 2016, reflected in part: Policy Statement-A comprehensive, person-centered care pan that included measurable objectives and timetables to meet the resident's physical and functional needs is developed and implemented for each resident. Policy interpretation and Implementation- 3. The comprehensive, person-centered care plan will: b. Describe the service that are to be furnished to attain or maintain the resident highest practicable physical, mental, and psychosocial well-being. 9. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan.