**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 18 residents (Resident # 14) reviewed for MDS assessment accuracy. The facility failed to code Resident #14's hospice accurately. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of Resident #14's face sheet, dated 12/04/24 indicated Resident #14 was a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia(forgetfulness), seizures, anxiety (uneasiness or fear), and high blood pressure. Record review of Resident #14's physician orders dated 07/27/24 indicated an order for {name} hospice. Record review of Resident #14's quarterly MDS assessment, dated 11/08/24, indicated Resident #14 was not on hospice service. Record review of Resident #14's care plan dated 10/29/24 indicated Resident #14 had a terminal prognosis and was on hospice service. The intervention was to work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met. During an interview on 12/04/24 at 1:42 p.m., the MDS Coordinator N said she was responsible for the completion of the MDS assessments. She looked at section O on Resident # 14 MDS assessment and said she did not code hospice. She said Resident #14 was on hospice services. She said it was important to code the MDS assessment correctly because it reflected their care and reimbursement. During an interview on 12/05/24 at 11:49 a.m. the DON said the MDS Coordinator was responsible for completing the MDS assessments. The DON stated she did not know why the MDS indicated Resident # 14 was not on hospice. The DON stated it was important for the MDS assessments to be accurately coded to make sure they provided the residents with the care they needed. During an interview on 12/05/24 at 12:26 p.m. the Administrator said the MDS Coordinator was responsible for completing the MDS assessments. He said the DON was the overseer. The Administrator said he expected the MDS assessment, for any resident, to be completed thoroughly and correctly based on the resident assessment. During an interview on 12/05/24 at 12:46 p.m., the Regional Nurse Consultant indicated they do not have a policy for MDS coding. She said they follow the CMS RAI manual. Record review for the RAI manual on https://www.cms.gov/medicare/quality/nursing-home-improvement/resident-assessment-instrument-manual: indicated on Section 00110 to code if a resident was on hospice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to review and revise the person-centered care plan to reflect the current condition for 1 of 3 (Resident #49) residents reviewed for care plan revisions. The facility failed to revise Resident #49's care plan to remove her wound care when she no longer had a wound. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings Included: Record review of Resident #49's face sheet dated 12/04/24, indicated an [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), Multiple Sclerosis (a chronic disease that damages the central nervous system), depression(a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily) and high blood pressure. Record review of Resident #49's quarterly MDS assessment dated [DATE], indicated Resident #49 understood and was understood by others. The MDS assessment indicated Resident #49 had a BIMS score of 10 indicating she was moderately cognitively impaired. The MDS indicated she required assistance with ADLs and set up for meals. The MDS did not indicate any wounds. Record review of Resident #49's comprehensive care plan revised on 04/03/24, indicated Resident #49 had a Stage 3 pressure ulcer on the right hip related to decreased mobility. The care plan interventions were for staff to provide wound care as ordered. Record review of Resident #49's order summary report dated 12/04/24, indicated Resident #49 had no wound orders. Record review of Resident #49 wound care note dated 04/24/24 indicated her wound had healed. During an interview on 12/05/24 at 11:14 a.m., MDS Coordinator N said she was responsible for the care plans for the long-term residents. She said the care plan was done so the staff would know how to care for the resident. She said she was made aware of the residents' changes in the morning meeting and at times the floor staff would communicate to her about changes. She said anytime the residents had a change in their care, she should revise the care plan. She said Resident #49's wounds had healed, and the care plan should have been revised. She said care plans were done to reflect the resident's care. During an interview on 12/05/24 at 11:49 a.m., the DON said she expected the care plans to be accurate. She said the MDS Coordinator was responsible for ensuring the care plans were kept current with the resident's care. She said during the morning meetings they discussed any changes with the resident's care, she said they also had weekly and quarterly meetings where the care plan should have been updated. She said Resident #49 did not have any current wounds. She said it was important to have the most updated care plan so that staff would know what care they needed to provide. During an interview on 12/04/24 at 12:46 p.m., the Administrator said the MDS Coordinator was responsible for the care plans. He said the DON was the overseer of the care plans. He said if care plans were not done residents might receive something they do not need or not receive something they do need. Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated December 2016, indicated, Policy statements a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy interpretation and implementation #2 The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment #13 Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. #14 The Interdisciplinary Team must review and update the care plan: a. when there has been a significant change in the resident's condition, b. when the desired outcome is not met, c. when the resident has been readmitted to the facility from a hospital stay and, d. at least quarterly, in conjunction with the required quarterly MDS assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that the resident environment remained as free of accident hazards as possible for 1 of 18 Residents (Resident #37) reviewed for accidents and hazards. The facility failed to ensure Resident #37 had on her wander guard bracelet on 12/2/24 and 12/3/24. This failure could place residents at risk of elopement, injury, or harm. Findings included: 1.Record review of Resident #37's face sheet, dated 12/04/24 indicated he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included dementia (loss of memory), Schizophrenia (a chronic mental disorder that affects a person's ability to think, perceive reality, and interact with others), and depression (sadness). Record review of Resident #37's quarterly MDS assessment, dated 11/21/24, indicated Resident #37 understood and was understood by others. Resident #37's BIMS score was a 10 indicating her cognition was moderately impaired. The MDS indicated Resident #37 required limited assistance with her ADLs including transfers and bed mobility. The MDS indicated she had an elopement/wander alarm. Record review of Resident #37's comprehensive care plan dated 09/30/24 indicated, she was at risk for elopement/wandering related to impaired safety awareness. The interventions were for staff to monitor the wander guard to the left lower leg and distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. Also, remind the resident not to leave the facility without assistance. Record review of Resident 37's Physician order dated 09/16/24 indicated, she had a wander guard to the Left lower leg related to exit-seeking behaviors. Check placement every shift. Record review of Resident #37's Elopement Risk Evaluation dated 09/16/24 indicated she was at risk of elopement. During an observation on 12/02/24 at 11:35 a.m., Resident #37 was in bed with no wander guard bracelet on her left lower leg. During an interview on 12/04/24 at 5:00 p.m., Resident #37 said she did have on her wander guard, but it had been removed a long time ago (unknown date). During an observation and interview on 12/04/24 at 5:18 p.m., Resident #37 was lying in her bed and no wander guard was on her leg. CNA R verified by looking at Resident #37's leg and said she did not have a wander guard bracelet on. During an interview on 12/05/24 at 11:49 a.m., the DON said Resident #37 was supposed to have her wander guard on and the nurses should check for placement each shift. She said Resident #37 had removed her wander guard before but was not sure why Resident #37's wander guard was not in place. She said all staff was responsible for ensuring the residents who had orders for wander guards, had the wander guards on. She said if Resident #37 did not have on her wander guard she was at risk for elopement. During an interview on 12/05/24 at 12:46 p.m., the Administrator said if Resident #37 had an order for a wander guard, then she should have had on her wander guard. He said wander guards were used for residents at risk of wandering. He said all staff were responsible for ensuring the wander guard was in place. Record review of facility policy titled, Wandering and Elopement, dated November 15, 2023, indicated, Policy statement: The facility will identify residents who are at risk of unsafe wandering and implement appropriate protective measures to help guard against a resident wandering from the facility. The facility strives to prevent harm while maintaining the least restrictive environment for residents. Policy interpretation and implementation: identifying residents at risk 1. on admission, readmission, quarterly doing observation period of the MDSs, annual significant changes, and as needed. The nurse will screen each resident for elopement risk using the elopement risk evaluation or equivalent form. After reviewing this information, the nursing staff will determine if the resident is at risk of wandering or elopement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to act upon the recommendations of the pharmacist report of irregularities for 1 of 5 residents (Resident #25) reviewed for (DRR) Drug Regimen Review. The facility failed to implement the pharmacy recommendations for Resident #25's medications that contained acetaminophen. This failure could place residents at risk for adverse side effects and not receiving medications at the most effective dosage. The findings included: Record review of the order summary report, dated 12/04/2024, reflected Resident #25 was a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of Parkinson's disease (age-related degenerative brain condition, meaning it causes parts of your brain to deteriorate) and chronic pain. Record review of the quarterly MDS assessment, dated 11/21/2024, reflected Resident #25 had no speech and was rarely/never understood by others. The MDS reflected Resident #25 was rarely/never able to understand others. The MDS reflected Resident #25 had poor long-term and short-term memory problems. The MDS reflected Resident #25 was unable to recall the current season, location of her own room, staff names and faces, or that she was in a nursing home. The MDS reflected Resident #25 had severely impaired decision making skills. The MDS reflected Resident #25 had an active diagnosis of chronic pain. The MDS reflected Resident #25 had no indicators of pain or possible during the last five days of the look-back period. Record review of the comprehensive care plan, revised 11/08/2024, reflected Resident #25 received pain medication therapy. The interventions included administer medication as ordered by the physician. Record review of the Director of Nursing Report from the pharmacy consultant, dated 08/28/2024, reflected Resident #25 had a pharmacy recommendation that stated Please note this resident has orders for routine and/or prn medications that contain acetaminophen. The FDA believes that limiting the amount of acetaminophen per tablet, capsule, or other dosage unit in prescription products will reduce the risk of severe liver injury from acetaminophen overdosing, an adverse event that can lead to liver failure, liver transplant, and death. Due to the high concern of hepatic injury, the makes or OTC Extra Strength Tylenol (acetaminophen) have voluntarily decided to change the directions on their label to include a revised maximum daily dosage of 3,000 mg (3 gm). Suggest adding to all orders that contain acetaminophen to not exceed 3,000 mg (3 gm) per day. Record review of the Director of Nursing Report from the pharmacy consultant, dated 09/26/2024, reflected Resident #25 had a pharmacy recommendation that stated Please note this resident has orders for routine and/or prn medications that contain acetaminophen. The FDA believes that limiting the amount of acetaminophen per tablet, capsule, or other dosage unit in prescription products will reduce the risk of severe liver injury from acetaminophen overdosing, an adverse event that can lead to liver failure, liver transplant, and death. Due to the high concern of hepatic injury, the makes or OTC Extra Strength Tylenol (acetaminophen) have voluntarily decided to change the directions on their label to include a revised maximum daily dosage of 3,000 mg (3 gm). Suggest adding to all orders that contain acetaminophen to not exceed 3,000 mg (3 gm) per day. Record review of the order audit report, dated 12/04/2024, reflected Resident #25 had an order for acetaminophen - give 500 mg by mouth every 6 hours as needed for pain or fever. The order did not indicate to not exceed 3,000 mg (3 gm) per day. Record review of the order audit report, dated 12/04/2024, reflected Resident #25 had an order for Norco (Hydrocodone-Acetaminophen) 5-325 mg - Give 1 tablet by mouth every 6 hours as needed for pain. The order did not incident to not exceed 3,000 mg (3 gm) per day. During an interview on 12/05/2024 beginning at 10:54 AM, the Pharmacy Consultant stated when she made recommendation, she expected the facility to follow up and address the recommendations. The Pharmacy Consultant stated she expected do not exceed 3,000 mg (3gm) per day on at least one of the orders that contained acetaminophen. The Pharmacy consultant stated it was important to ensure do not exceed 3,000 mg (3 gm) per day was on the orders because it was the manufactures guidelines. The Pharmacy Consultant stated administering acetaminophen in the elderly placed them at risk for liver toxicity if they were to exceed 3,000 mg. The Pharmacy Consultant said it was important to have the information on the orders so the nurses were aware and could have calculated the amount of acetaminophen Resident #25 was getting. During an interview on 12/05/2024 beginning at 12:32 PM, the DON said when the pharmacy recommendations were received, she printed them out. The DON said her and the ADON went through the recommendations and updated the orders. The DON stated she missed Resident #25's recommendation for the acetaminophen. The DON said it was important to ensure pharmacy recommendations were implemented to ensure residents were getting the best care they could. During an interview on 12/05/2024 beginning at 1:11 PM, the Administrator stated he expected the pharmacy recommendations to be addressed and implemented. The Administrator stated nursing leadership was responsible for ensuring pharmacy recommendations were implemented. The Administrator stated failing to implement pharmacy recommendations could have placed residents at risk for side effects from medication or discomfort. Record review of the Pharmacy Services - Role of the Consultant Pharmacist policy, revised April 2007, reflected the consultant pharmacist shall provide consultation on all aspects of pharmacy services in the facility including: .helping identify and evaluate medication-related issues .appropriate communication of information to prescribers and facility leadership about potential or actual problems related to any aspect of medications and pharmacy services, including medication irregularities . The policy did not address implementing pharmacy recommendations.

Based on observation, interview, and record review, the facility failed store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 2 medication carts (Hall 300 nurse medication cart and 300 hall medication cart) of 6 medication carts reviewed for medication storage. The facility failed to ensure MA B secured a controlled narcotic medication when he left a Tramadol inside a medication cup sitting on the 300-hall medication cart when he walked to the nurse's station. The facility failed to ensure RN F secured the 300-hall nurse cart when she entered the room, standing behind the privacy curtain to obtain a blood pressure, then again when she went behind the privacy curtain to obtain the over-the-bed table to prepare the supplies, then lastly when she closed the door and stepped behind the privacy curtain to administer the gastrostomy tube medications. Theseis failures could place residents at risk of ingesting medications not prescribed, and access to sharps (needles and lancets). Findings included: During an observation and interview on 12/03/2024 at 4:30 p.m., MA B had a medication cup in his hand, and a cup of water. MA B was asked about the administration of the medication in the cup. MA B said he needed to retrieve his computer from the nurse's station at the end of the hall 300. MA B placed the medication cup with a Tramadol 50 milligrams on top of the 300-hall medication cart while he went to obtain his computer from the nurse's station. MA B was out of the surveyor's line of site when he left the medication. MA B refused to answer why securing the medication was important. During an observation and interview on 12/03/2024 at 7:00 p.m., RN F took 300-hall cart to the resident's room . RN F opened the cart, obtained a blood pressure cuff, then walked into the room to assess the residents blood pressure. RN F then returned to the unlocked cart, then re-entered the room to obtain the over-the-bed table. After RN F prepared the medications for administration, she entered the room, shut the door, and went around the privacy curtain to administer the medications. RN F said she should have locked her medication cart each time. RN F said any resident can open the cart and obtain medications that were not prescribed to them. During an interview on 12/05/2024 at 11:42 a.m., the DON said she expected the medications and medication carts to be secured when not within site or easy reach. The DON said a resident could get into the cart, obtain medications, and pilfer through the cart. The DON said nurse management monitored with spot checks looking for unlocked carts and unsecured medications. The DON said nurses, medication aides, and nurse management were responsible for ensuring the medication carts remain locked and medications remain secured. During an interview on 12/05/2024 at 1:09 p.m., the Administrator said he expected the medications and medication carts to be always secured. The Administrator said management rounds were made several times during the day to check for compliance. The Administrator said drug diversions and residents could suffer adverse effects from obtaining medications from an unsecured medication cart. Record review of a Storage of Medications policy dated April 2019 indicated the facility stores all drugs and biologicals in a safe, secure, and orderly manner. 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls .3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner 8. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes). 9. Unlocked medication carts are not left unattended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received therapeutic diets that were prescribed by the attending physician for 1 of 3 residents (Resident #49) reviewed for therapeutic diets. The facility did not ensure Resident #49 was given her ice cream as ordered by the physician. This failure could place residents at risk for poor intake, weight loss, unmet nutritional needs, and a loss of dignity. Findings Included: Record review of Resident #49's face sheet dated 12/04/24, indicated an [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), Multiple Sclerosis (a chronic disease that damages the central nervous system), depression(a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily) and high blood pressure. Record review of Resident #49's quarterly MDS assessment dated [DATE], indicated Resident #49 understood and was understood by others. The MDS assessment indicated Resident #49 had a BIMS score of 10 indicating she was moderately cognitively impaired. The MDS indicated she required assistance with ADLs and set up for meals. The MDS assessment indicated Resident #49 had a therapeutic diet. Record review of Resident #49's comprehensive care plan revised on 09/20/24, indicated Resident #49 was at risk for nutrition problems related to the diagnosis of dementia. The care plan interventions were for staff to provide and serve diet as ordered. Record review of Resident #49's order summary report dated 04/03/24, indicated Resident #49 had the following order: Enhanced diet: Regular texture and thin consistency. Divided plate with meals, add butter, salt, and ice cream with lunch, and enhance mashed potatoes with dinner. During an observation and interview on 12/02/24 at 12:43 p.m., Resident #49's lunch meal ticket dated 12/02/24, indicated under meal note add shake and ice cream. Resident #49 did not have her shake or ice cream until the surveyor intervened by asking CNA R where her shake and ice cream were. CNA R said the nurses usually check the trays, but the CNAs should also recheck as they pass the trays to ensure the residents had everything on their trays. CNA R went to get the shake and ice cream. During an observation and interview on 12/04/24 at 1:04 p.m., Resident #49 was in the dining room eating lunch. She did not have her ice cream on her tray. LVN E looked at her meal ticket and said she did not have her ice cream. He said the ice cream should have been passed out with her tray. He said he would get the ice cream. He said he did not realize when he was checking the tray cards that he missed her ice cream. During an interview on 12/05/24 at 11:49 a.m., the DON said the trays were supposed to be checked by the nurses in the dining room and then the aides when they passed the trays. She said it was important for the staff to read the tickets and ensure the residents were receiving the correct diets. She said Resident #49 should be receiving her ice cream when they serve the trays. She said failure to give the ice cream could cause Resident #49 weight loss. During an interview on 12/05/24 at 12:46 p.m., the Administrator said when staff was serving the trays, they were responsible for ensuring the resident had the correct diet and all supplements that were ordered. He said it was important for residents to receive the correct diet/supplement to prevent weight loss. Record review of the facility's policy titled Therapeutic Diet, dated October 2017, indicated Therapeutic diets are prescribed by the attending physician to support the resident treatment and plan of care and in accordance with his or her goals and purposes. Policy interpretation and implementation: #1 Diets will be determined in accordance with the resident's informed choices, preferences, treatment goals, and wishes diagnosis alone will not determine whether the resident is prescribed a therapeutic diet #7 The dietitian, nursing staff, and attending physician will regularly review the needs for, and resident acceptance of, prescribe a therapeutic diet.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals for 1 resident reviewed (Resident #34) for special eating equipment and assistance when consuming meals. The facility failed to provide Resident #34's physician ordered plate guard. Thisese failures could place residents at risk for harm by weight loss, diminished independence, and self-esteem. Findings included: Record review of a face sheet dated 12/04/2024 indicated Resident #34 was an [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnosis of dementia (memory loss), stroke, hemiplegia (paralysis or weakness of one side) and a contracture (shortening or hardening of muscle or tendon leading to rigidity) of the left hand. Record review of a Quarterly MDS dated [DATE] indicated Resident #34 was understood and understood others. The MDS failed to reflect Resident #34's BIMS score. The MDS indicated Resident #34 had a memory problem and was severely impaired on daily decision-making cognitive skills. The MDS indicated Resident #34 required partial/moderate assistance with eating. Record review of the Comprehensive Care Plan dated 2/28/2024 indicated Resident #34 had a potential for nutritional problems related to dementia and poor appetite. The goal of the care plan indicated Resident #34 would maintain adequate nutritional status as evidenced by no symptoms of malnutrition. The Comprehensive Care Plan dated 4/16/2024 indicated Resident #34 had a self-care deficit related to her stroke and limited mobility. The goal of the care plan was Resident #34 would maintain her current level of function. The care plan intervention for eating was to provide the required assistance. The care plan failed to mention the use of a plate guard. Record review of the Consolidated Physician's Orders dated 12/04/2024 indicated on 9/25/2023 Resident #34 was ordered an enhanced diet mechanical soft texture, thin liquids, and use of a plate guard and regular utensils with all meals. During an observation on 12/02/2024 at 4:50 p.m., Resident #34 was eating her evening meal in her room and in her bed. Resident #34 had enchiladas, beans, and broccoli with cauliflower. Resident #34's tray card failed to reveal a plate guard was required, and the plate guard was not present on Resident #34's plate. During an observation and interview on 12/04/2024 at 11:55 a.m., Resident #34 was eating lunch in the dining room. Resident #34's lunch plate failed to have a plate guard. LVN E said he was unaware if Resident #34 required a plate guard. LVN E said Resident #34's tray card had not reflected the need of a plate guard. The DM said he was unaware of Resident #34 requiring a plate guard for her plates. LVN E said when an order was received for a device for meals, an order was provided to the DM. The DM said when he received the order communication, he would place the notice on the tray card in order Resident #34 received the needed plate guard during meal services. During an interview on 12/05/2024 at 11:35 a.m., the DON said she expected Resident #34 to have the plate guard in place with meals. The DON said the plate guard allows Resident #34 to feed herself independently. The DON said the process was the nurse would give the DM a copy of the order to implement the device. The DON said she shared the dietary audit report at least monthly with the DM to audit his diet cards. The DON said nursing was responsible for ensuring Resident #34 and all other residents had the needed devices during meals. During an interview on 12/05/2024 at 12:55 p.m., the Administrator said not having a plate guard could become a dignity and malnutrition issue for Resident #34. The Administrator said the meal was the one main part of the day a resident looked forward to and getting it right was important. The Administrator said the process was when the order was received, the nurse manager also ensured the DM received the orders as part of the review of orders. The Administrator said and the diets were reviewed weekly in the standards of care meetings. Record review of a Quality of Life-Accommodation of Needs policy dated August 2009 indicated our facility's environment and staff behaviors are directed toward assisting he resident in maintaining and/or achieving independent functioning, dignity, and well-being. 1. The resident's individual needs and preferences shall be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. 2. The resident's individual needs and preferences including the need for adaptive devices and modifications to the physician environment, shall be evaluated upon admission and reviewed on an ongoing basis.

Based on observation, interview, and record review, the facility failed to ensure food was prepared and served in a manner that prevented foodborne illness for 1 of 1 kitchen reviewed for food preparation and serving. The facility did not ensure hair restraints were worn appropriately by the Dietary Manager. This failure could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: During an observation on 12/02/24 at 11:10 a.m., revealed the Dietary Manager came into the kitchen and did not apply his hair or beard restraint. The Dietary Manager was in the freezer and storage area without his hair and beard restraint on. The Dietary manager's facial and beard hair was approximately 1/4 to 1/2 inch long. During an interview on 12/02/24 at 11:49 a.m., the Dietary Manager said he had ran to the store and heard that the state was in the facility and he was trying to get back and see what he needed to do. The Dietary Manager said he went into the freezer and the storage room without his hair or beard restraint on. He said he knew it was important to wear his hair and face restraint to prevent hair from getting into the food. During an interview on 12/05/24 at 11:49 a.m., the DON said she expected everyone to wear a hair restraint while in the kitchen area. She said that everyone should wear hair restraints to prevent hair or bacteria from entering the food and for infection control issues. During an interview on 12/05/24 at 12:46 p.m., the Administrator said he expected the kitchen to be clean and staff to prevent cross-contamination. He said the Dietary Manager was the overseer of the kitchen and should have had on his hair and beard restraints while in the kitchen. The Administrator said he expected hair restraints and face restraints (if required) to be worn to prevent hair loss in the food. Record review of the facility policy titled, Food Preparation and Services, dated July 2014, indicated, Policy: Food service employee shall prepare and serve food in a manner that complies with safe food handling practice. Foodservice/Distribution: #7 Dietary staff shall wear hair restraints (hair net, hat, beard restraints, etc ) so that hair does not contact food.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 2 of 18 residents (Resident #14, and Resident #129) reviewed for hospice services. The facility failed to maintain Resident #14's, and Resident #129's hospice binder containing information related to hospice services provided for the resident such as the most recent plan of care, hospice election form, physician recertification, and hospice medication profile. These deficient practices could place residents who receive hospice services at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. The findings included: 1.Record review of Resident #14's face sheet, dated 12/04/24 indicated Resident #14 was a [AGE] year-old male admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included dementia), dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), seizures, anxiety (uneasiness or fear), and high blood pressure. Record review of Resident #14's physician orders dated 07/27/24 indicated an order for {name} hospice. Record review of Resident #14's quarterly MDS assessment, dated 11/08/24, indicated Resident #14 rarely understood and was rarely understood by others. Resident #14 had short and long-term memory loss indicating he was cognitively impaired. The MDS indicated Resident #14 required total or extensive assistance with his ADL's. The MDS indicated Resident #14 was not on hospice services. Record review of Resident #14's comprehensive care plan dated 10/29/24 indicated Resident #14 had a terminal prognosis and was on hospice services. The intervention was to work cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical, and social needs were met. Record review of Resident #14's hospice binder revealed it did not have the Physician certification of the terminal illness, care plan, medication list, or Hospice election form. The last IDT meeting was dated 8/08/24. The last recertification was dated 07/23/24-10/23/24. The resident had new orders for enhanced barriers and therapy added to his orders. During an interview on 12/04/24 at 9:15 a.m., LVN H said she did not look at the hospice folder because she often communicated with hospice for all the changes related to Resident #14's care. She said she was not sure how often the hospice company had a meeting to discuss Resident #14's care or how often his folder should be updated. She said the hospice company was responsible for the upkeep of their folders or binders. She said hospice should have all the information for the resident such as meds and plan of care in the resident's folders or binders. During a phone interview on 12/04/24 at 2:36 p.m., the Hospice Administrator said the binders at the facility should contain a face sheet, the do not resuscitate copy, the IDG meetings, 3074 certifications of hospice, and any supporting notes or documentation needed for Resident #14. She said they met every two weeks for the IDG meetings and said the documentation should be updated at least monthly. She said someone from the office would usually bring all the information needed from the office to the nursing facility. She said it was important to have the binders at the facility to help the facility know why the resident was admitted and to ensure we were providing the care he needed. She said she would have someone drop off the necessary paperwork today (12/04/24). During an interview on 12/05/24 at 11:49 a.m., the DON said she expected the hospice documents to be at the facility with the most recent plan of care and current medication orders. The DON said the failure to ensure those documents were at the facility was due to a lack of communication with the facility and the hospice companies. The DON said it was the responsibility of the hospice company to ensure their documents were to the facility timely and then it was the nurse manager's responsibility to ensure that was being completed. The DON said there had not been any monitoring in place to ensure the hospice documents were being brought to the facility. She said the hospice binders help with medication changes and correlate care. During an interview on 12/05/24 at 12:46 p.m., the Administrator said it was the facility's responsibility to ensure all hospice documents were up to date. He said the nurse managers were the overseers of the process. He said the books should be updated because they reflect the care the resident should be receiving. 2. Record review of a face sheet dated 12/04/2024 indicated Resident #129 was an [AGE] year-old male who admitted on [DATE] with the diagnosis of Alzheimer's Disease (memory loss disease). Record review of the Consolidated Physician's Orders dated 12/04/2024 indicated Resident #129 was orderedhad an order on 11/27/2024 to admit to hospice care. Record review of Resident #129's electronic medical record indicated the admission MDS was in process. Record review of the Baseline Care Plan dated 11/27/2024 indicated in Section 4d.1 Specify home services: on hospice services. Record review of Resident #129's hospice binder and electronic medical record revealed there was not a hospice plan of care, a hospice election form, or a physician's certification of terminal illness. During a telephone interview on 12/03/2024 at 2:57 p.m., the Director of the hospice provider indicated the entire hospice team was responsible for ensuring Resident #129's hospice record had the hospice plan of care, the hospice election form, and the physician's certification of terminal illness. The Director of the hospice provider indicated these forms were pertinent to ensure coordination of care. During an interview on 12/05/2024 at 11:33 a.m., the DON said the hospice provider should supply all the admission paperwork when the resident admitsadmitted to the facility. The DON said the facility had their own orders, and their own plan of care and she believed there would be minimal effect on the quality-of-care Resident #129 received. The DON said the nurse managers were responsible for ensuring the hospice provider updated the clinical records of each hospice resident. The DON said the nurse managers usually checked the hospice records at least with 24-48 hours of admission. During an interview on 12/05/2024 at 11:50 a.m., LVN E said he expected the hospice providers to keep Resident #129's hospice record current. LVN E said it was especially important to ensure coordination of care with medications and comfort. During an interview on 12/05/2024 at 12:50 p.m., the Administrator said he expected the hospice to provide all the required documents at the time of admission to ensure an accurate hand off of care ensuring the coordination of care. The Administrator said the nurse completing the admission was responsible for ensuring the documentation was available. The Administrator said the process was reviewed in the daily meetings to review the admissions, and then again in the weekly standards of care meetings. Record review of the Hospice Program policy dated July 2017 indicated Hospice services are available to residents at the end of life .2. In order for a resident to qualify for the hospice benefit under Medicate, he or she must be: a. Entitled to Medicare Part A; and b. Certified as being terminally ill 12 d. Obtaining the following information from the hospice: 1. The most recent hospice plan of care specific to each resident; 2. Hospice election form; 3. Physician certification and recertification of terminal illness specific to each resident . Record review of the facility's policy titled, Hospice Program, Hospice services are available to residents at the end of life. Policy Interpretation and Implementation: Our facility has an agreement in place with at least one Medicare-certified hospice to ensure that residents who wish to participate in a Hospice program may do so. #5 Hospice providers who contract with this facility must have a written agreement with the facility outlining in detail the responsibilities of the facilities and the Hospice agreement and are held responsible for meeting the same professional standards and timeliness of service as any contracted individual or agency associated with the facility.#12 Our facility has designated hospice and facility staff to collaborate care such as D. #1 Obtaining the following information from the Hospice the most recent hospital plan of care specific to each resident, #2 Hospice election form, #3 Physician certification and recertification of the terminal illness specific to each resident, #4 Names and contact information from Hospice personnel involved in Hospice care of each resident, #5 instructions on how to access the Hospice 24 hour on-call system, #6 Hospice education information Pacific to each resident, #7 hospital physician and attending physician if any order specific to each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections reviewed for 2 of 18 residents (Resident #45, and Resident #49) reviewed for infection control. 1. The facility failed to ensure the Treatment Nurse performed hand hygiene while performing wound care for Resident #45 who had wounds, on 12/03/24. 2. The facility failed to ensure CNA S changed gloves or performed hand hygiene while providing incontinent care for Resident #49 who was incontinent, on 12/03/24. These failures could place residents, and staff at risk of the spread of infections. Findings included: 1.Record review of Resident #45's face sheet, dated 12/05/24 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included pressure wounds (areas of damaged skin and tissue caused by sustained pressure that reduces blood flow to vulnerable areas of the body), dementia (decline in mental abilities that affects a person's daily life) and diabetes. Record review of Resident #45's quarterly MDS assessment, dated 11/25/24, indicated Resident #45 understood and was understood by others. Resident #45 BIMS score was a 04 indicating she was severely cognitively impaired. The MDS indicated she required assistance with her ADL's such as toileting and hygiene. The MDS indicated Resident #45 was always incontinent of bowel and bladder. The MDS indicated Resident #45 had wounds. Record review of Resident #45's Physician order dated 11/18/24 indicated: Cleanse Stage 3 pressure wound to sacrum (a triangular bone located at the base of the spine, which plays a crucial role in providing stability and support to the pelvis) with normal saline, pat dry and apply Iodosorb (medication) cover with a border dressing daily and monitor for any signs of infection. Record review of Resident #45's comprehensive care plan dated 08/29/24 indicated, she had a Stage 3 (open wound) pressure ulcer related to her diagnosis of diabetes, history of ulcers, and immobility. The interventions were for staff to administer treatments as ordered and monitor for effectiveness. Monitor nutritional status. Serve diet as ordered, monitor intake, and record. During an observation on 12/03/24 at 2:09 p.m., revealed the Treatment Nurse provided wound care to Resident #45. She explained what she was going to do and put on her gown and gloves. She cleaned the wound area, then removed her gloves and applied new gloves without hand hygiene. She patted the area dry, put on the Iodoform, and applied the dressing. Afterward, she removed her gown, wiped the table, removed her gloves, and washed her hands. During an interview on 12/03/24 at 2:18 p.m., the Treatment Nurse said she forgot to wash her hands between dirty and clean, she said she knew she was supposed to hand hygiene and could not believe she forgot to hand hygiene. She said without proper hand hygiene it could cause infection. 2. Record review of Resident #49's face sheet dated 12/04/24, indicated an [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included Dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), Multiple Sclerosis (a chronic disease that damages the central nervous system), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily) and high blood pressure. Record review of Resident #49's quarterly MDS assessment dated [DATE], indicated Resident #49 understood and was understood by others. The MDS assessment indicated Resident #49 had a BIMS score of 10 indicating she was moderately cognitively impaired. The MDS indicated she required assistance with ADL's such as toileting and set up for meals. The MDS assessment indicated Resident #49 was always incontinent of bowel and bladder. Record review of Resident #49's comprehensive care plan revised on 09/20/24, indicated Resident #49 had an ADL self-care performance deficit related to activity intolerance, impaired balance, and diagnosis of Dementia. The care plan interventions were for staff to assist with ADL care. During an observation on 12/03/24 at 7:53 p.m., revealed CNA S was providing incontinent care for Resident #49 who had an incontinent episode. She explained what she was going to do provided hand hygiene and applied gloves. CNA S washed Resident #49's peri area side to side and front to back and then turned her over touching her side with the same dirty gloves on, then cleaned her buttock wiping side to side and front to back and back to front. CNA S then changed her gloves but did not hand hygiene, applied new gloves, pulled up the covers, and lowered the bed. During an interview on 12/03/24 at 8:06 p.m., CNA S said she should have used hand hygiene when changing her gloves and when going from dirty to clean. She said she was not supposed to wipe back to front or side to side when performing incontinent care. She said she forgot but knew it was important to wipe front to back to prevent cross-contamination. She said she had been trained on hand hygiene and incontinent care but not at the current facility. She said she was hired in August 2024. During an interview on 12/05/24 at 11:49 a.m., the DON said she expected staff to perform peri-care, wound care, and hand hygiene correctly to prevent infection. The DON said she and the ADON usually did peri-care and wound care checkoffs with staff on hire, annually and as needed. The DON said failure to perform incontinent care, wound care, and hand hygiene properly could lead to infection issues. During an interview on 12/05/24 at 12:46 p.m., the Administrator said all staff were responsible for infection control issues. He said failure to do proper incontinent care, wound care, and hand hygiene could lead to infection. Record review of the facility policy for Handwashing/Hand Hygiene, dated December 22, 2023, indicated, This facility considers hand hygiene the primary means to prevent the spread of infection. Record review of the facility policy for Perineal Care, dated October 2010, indicated, The purpose of this procedure was to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Steps: 9b. Wash the perineal area, wiping from front to back. (1) Separate the labia and wash the area downward from front to back 4e. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttock. Do not reuse the same washcloth or water to clean the labia. Record review of the facility policy for Wound Care, dated November 2017, indicated, The purpose of this procedure is to provide guidelines for the care of wounds to promote wound healing. Steps in procedure: #4 Put on exam gloves, loosen the tape and remove the dressing, #5 Pull gloves over the dressing and discard in appropriate receptacle and wash and dry hands

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, and dispensing of routine drugs and biologicals to meet the needs of each resident for 4 of 4 resident reviewed for pharmacy services. (Resident's #5, #11, #49, and #50) The facility failed to ensure Resident #11's ordered alprazolam (antianxiety) medication was available for administration on 11/26/2024, 11/27/2024, 11/28/2024, and 11/29/2024, which resulted in 11 missed doses of her antianxiety medication. The facility failed to ensure Resident #50's ordered Letrozole (hormone treatment for breast cancer) medication was available for administration 12/03/2024. The facility failed to ensure Resident #49's tramadol (scheduled ll pain medication) was accurately reconciled on 12/03/2024. The facility failed to ensure Resident #5 was not administered Hydrocodone 10/325 milligrams out of the ordered administration times on 12/04/2024. These failures could place residents at risk to have increased symptoms of anxiety, change in hormonal levels affecting breast cancer, medication errors and loss of medications through drug diversion. The findings included: 1. Record review of the face sheet, dated 12/05/2024, reflected Resident #11 was an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of unspecified dementia, without behaviors (a group of symptoms affecting memory, thinking and social abilities that interferes with daily life) and generalized anxiety disorder (a mental and behavioral disorder characterized by excessive, uncontrollable, and often irrational worry about events or activities). Record review of the admission MDS assessment, dated 10/22/2024, reflected Resident #11 had clear speech and was understood by others. The MDS reflected Resident #11 was able to understand others. The MDS reflected Resident #11 had a BIMS score of 12, which indicated moderately impaired cognition. The MDS reflected Resident #11 had no behaviors or refusal of care. The MDS reflected Resident #11 had an active diagnosis of anxiety disorder. The MDS reflected Resident #11 received an antianxiety medication with a noted indication for use. Record review of the comprehensive care plan, revised 10/23/2024, reflected Resident #11 used antianxiety medication related to anxiety disorder. The interventions included: administer antianxiety medication as ordered by the physician. Record review of the order summary report, dated 12/02/2024, reflected Resident #11 had an order, which started on 10/15/2024, for alprazolam (antianxiety medication) 1 mg by mouth three times a day for anxiety. Record review of the MAR, dated November 2024, reflected Resident #11 refused the 3 PM dose of alprazolam on 11/26/2024. The MAR reflected Resident #11 did not receive the alprazolam on 11/27/2024 at 9 AM, 3 PM, or 9 PM; on 11/28/2024 at 9 AM; on 11/28/2024 at 9 AM; and on 11/29/2024 at 9 AM. There were 7 missed doses of alprazolam documented on the MAR. There were no documented behaviors on the MAR. Record review of the controlled drug record sheet, undated, reflected Resident #11 received the last dose of her alprazolam on 11/26/2024 at 9 AM. Record review of the controlled drug record sheet, dated 11/29/24, reflected Resident #11's alprazolam was given at 11/30/2024 at 8 AM. Resident #11 missed 11 doses of her alprazolam (antianxiety medication). Record review of the administration note, signed and dated 11/27/2024 at 9:09 AM by MA G, reflected Resident #11's alprazolam was not administered related to out of stock. The note indicated the nurse was notified. Record review of the administration note, signed and dated 11/28/2024 at 8:59 AM by MA G, reflected Resident #11's alprazolam was not administered related to out of stock. The note indicated the nurse was notified. Record review of the administration note, signed and dated 11/29/2024 at 9:22 AM by MA G, reflected Resident #11's alprazolam was not administered related to out of stock. The note indicated the nurse was notified. During an observation and interview on 12/02/2024 beginning at 11:32 AM, Resident #11 was sitting on her bed. Resident #11 was pleasant and calm during the interview with her hair neatly combed and clothing without stains or odors. Resident #11 stated she had no problems whatsoever with the care she received at the facility. Resident #11 stated she had an issue during the last week (11/25/24 to 11/30/24) with not receiving her antianxiety medication. Resident #11 stated she felt like she had an anxiety attack because her toes went numb. Resident #11 stated she was going to talk to the doctor about it and was waiting on him to come to the facility. During an interview on 12/02/2024 beginning at 5:47 PM, RN A stated he did not normally work on Resident #11's hallway. RN A stated he worked on Resident #11's hallway on 11/29/2024 and was passing medications. RN A stated he realized Resident #11 was out of her alprazolam, so he notified the pharmacy. RN A said the pharmacy reported they were unable to see the order on their side, so RN A stated he re-entered the order in the computer system to fix it. RN A stated Resident #11 did not receive her alprazolam on 11/29/2024 because it was unavailable at the facility. RN A stated he was unsure how long Resident #11 went without her medication. RN A stated he did not notice if Resident #11 had an increased anxiety or signs of a panic attack. RN A stated resident's who did not receive their antianxiety medication could have had increased anxiety. During an interview on 12/03/2024 beginning at 8:01 AM, RN H stated last week on approximately Thursday (11/28/2024) MA G reported Resident #11 had approximately 2 alprazolam left. RN H stated the psychiatric doctor was at the facility and she believed the doctor was going to send in the refills to the pharmacy. RN H stated to her knowledge Resident #11 did not go without her antianxiety medication. RN H stated she did not notice if Resident #11 had any increased anxiety or signs of a panic attack. RN H stated the process for re-ordering narcotic medication was as follows: when the card got down to about 7 or 8 pills, the MA should have notified the charge nurse. The charge nurse then notified the pharmacy to see if there were any refills available. RN H said if the medication had refills left the charge nurse was able to re-order the medication. RN H stated if no refills were available, then the charge nurse would have notified the agent for the doctor so they could have called in the order to the pharmacy. RN H stated the ADONs were agents for the doctors at the facility. RN H stated the facility had a lot of problems with the pharmacy including sending medication timely. RN H said they also had trouble with getting the agents to call in the refill orders. RN H said that if a resident did run out of their antianxiety medication, she would have notified the doctor to get a STAT order or to see if anything could have been put in place. RN H said if a resident did not receive antianxiety medication, it could have caused a panic attack. RN H said signs of a panic attack included increased heart rate, sweating, agitation, and confusion. During an interview on 12/03/2024 beginning at 8:05 AM, MA G said Resident #11 ran out of her antianxiety medication last week. MA G stated she was unsure what day it was and was unsure how long she went without the medication. MA G stated she notified RN H about 3 days before Resident #11 ran out of medication. MA G stated RN H notified LVN K and LVN K called the medication into the pharmacy. MA G said the last she heard about the medication was that it needed a new prescription, and the pharmacy was waiting on the doctor to send it in. MA G stated alprazolam was not in the e-kit. MA G stated she kept asking and reminding the nurses who worked that she was out, but she was unsure if anything was done. MA G said the process for re-ordering controlled medication was to notify the nurse, then the nurse would have notified the pharmacy to see if any refills were available. MA G said if refills were available the pharmacy would have sent the medication. MA G said if refills were unavailable the nurse would have notified the doctor. MA G said medication aides could not have re-ordered controlled medication. MA G said resident who did not receive their antianxiety medication could have cause anxiety, insomnia, and increased moodiness. During an interview on 12/03/2024 beginning at 8:12 AM, LVN K stated she did not believe it was reported that Resident #11 was out of alprazolam. LVN K stated if a resident ran out of medication, the medication aid should have let the charge nurse know. LVN K said the charge nurse should have notified the pharmacy and checked for refills. LVN K said if refills were available then the pharmacy would have sent the medication. LVN K said if refills were unavailable then the charge nurse was supposed to notify her because she was an agent of the doctor. LVN K said she then would call the prescription into the pharmacy. LVN K said she did not work on 11/28/2024 and did not believe the pharmacy was open on 11/27/2024. LVN K said she worked on 11/29/2024 but did not remember being notified Resident #11 was out of medication. LVN K said the nurses should have been able to get the alprazolam out of the e-kit if Resident #11 was out. LVN K said she would have had to call and authorize the prescription as an agent of the doctor. LVN K said then the charge nurses would have been able to call the pharmacy to obtain a code to remove controlled medication out of the e-kit. LVN K stated residents who did not receive antianxiety medication could have caused withdrawal symptoms or a panic attack. LVN K said signs of a panic attack were breathing heavy, and increased anxiety. During an attempted phone interview to gather additional evidence on 12/03/24 at 8:32 AM, LVN L did not answer the phone. A brief message was left with a call back number. No return call received upon exit of the facility. During an interview on 12/05/2024 beginning at 10:39 AM, the Pharmacy Technician said a nurse from the facility called in Resident #11's alprazolam on 11/29/2024. The Pharmacy Technician stated there was no call in to the pharmacy regarding Resident #11's alprazolam before that date. The Pharmacy Technician said it was called in after the first delivery cut off time, so the medication was delivered on the midnight run. The Pharmacy Technician said the medication was delivered on 11/30/2024 at 3:55 AM. The Pharmacy Technician said they were open all the time and was never closed, even during the holidays. The Pharmacy Technician said the facility would have been responsible for calling in the medication because they had no automatic system for refills. During an interview on 12/05/2024 beginning at 11:19 AM, PA M stated the psychiatric doctor typically was responsible for reordering psychotropic medication in residents who had a psychiatric diagnosis, such as anxiety. PA M stated if the facility was unable to get a response from the psychiatric doctor, then the facility could have notified him, and he would have sent in a 14 day order to the pharmacy. PA M stated he expected the facility staff to ensure controlled antianxiety medication was available to administer to the residents. PA M stated he was not notified Resident #11 was out of alprazolam during the last week (11/25/24 - 11/30/24). PA M stated Resident #11 had a true diagnosis of anxiety and histrionic behaviors. PA M stated Resident #11 was already anxious and going without her medication could have caused her to become more anxious. PA M stated it was important to ensure antianxiety medications were administered to keep the residents stable. During an interview on 12/05/2024 beginning at 12:32 PM, the DON said the charge nurse was responsible for monitoring to ensure medications were re-ordered and available at the facility. The DON stated the medication aide should have notified the charge nurse if controlled medications were running low. The DON said the charge nurse would have called the pharmacy to determine if refills were available. The DON said if refills were unavailable then the charge nurse should have notified the agent of the doctor at the facility. The DON stated the nursing management was responsible for monitoring the charge nurses to ensure medication was available. The DON stated she was notified on 11/30/2024 that Resident #11 was out of her medication when the alprazolam arrived at the facility. The DON stated the charge nurses should have gotten the medication out of the e-kit until the medication arrived. The DON said it was important to ensure Resident #11 received her antianxiety medication to keep her at a therapeutic level. The DON said if Resident #11 did not receive her medication it could have caused anxiety. During an interview on 12/09/24 beginning at 1:11 PM, the Administrator said he expected the nursing staff to administer medication as ordered and prescribed by the doctor. The Administrator stated a nurse was notified Resident #11 was out of medication and that nurse did not get the medication out of the e-kit. The Administrator stated he was unable to explain that and Resident #11's alprazolam should have been administered out of the e-kit. The Administrator stated if Resident #11 was on the medication long-term then they have a system in place for ensuring residents did not go without medication. The Administrator stated the medication aide should have notified the charge nurse when there were 8 or 9 pills left, so the charge nurse could have gotten a new order or refill. The Administrator stated nursing management was responsible for monitoring to ensure medication was available at the facility and the nursing staff was following the system for re-ordering medication. The Administrator stated it was important to ensure Resident #11 received her antianxiety medication so it did not increase her anxiety or behaviors. 2. Record review of a face sheet dated 12/04/2024 indicated Resident #50 was a [AGE] year-old female who admitted on [DATE] with the diagnoses of dementia (memory loss), and malignant neoplasm of the female breast (breast cancer). Record review of the comprehensive care plan dated 6/28/2024 failed to indicate Resident #50 was receiving hormonal treatment for her diagnosis of breast cancer. Record review of the Quarterly MDS dated [DATE] indicated Resident #50's BIMS score was 3 indicating severe cognitive impairment, she was usually able to understand and was usually understood. Section I-Active Diagnoses failed to indicate the diagnosis of malignant neoplasm of the female breast as an active diagnosis. Record review of the physician's orders dated 12/04/2024 indicated Resident #50 was ordered Letrozole 2.5 milligram tablet give one tablet daily for breast cancer on 6/18/2024. Record review of the electronic administration record dated December 2024 indicated on 12/03/2024 Resident #50 had a missed dose of Letrozole 2.5 milligrams. During an observation and interview on 12/03/2024 at 8:33 a.m., RN A attempted to prepare Resident #50's ordered Letrozole 2.5 milligrams for administration but there were none available for administration. RN A placed an order for the medication using his computer. RN A said he would notify the physician of the missed dose of medication. RN A said he was unsure why the medication was unavailable. RN A said the nursing staff were responsible for ensuring medications were available for administration. 3. Record review of a face sheet dated 12/03/2024 indicated Resident #49 was a [AGE] year-old female who admitted on [DATE] with the diagnosis of a healing fracture and dementia (memory loss disease). Record review of an admission MDS dated [DATE] indicated Resident #49 was understood and understood others. The MDS indicated Resident #49's BIMS score was a 6 indicating severe cognitive impairment. Section I-Active Diagnoses of the MDS indicated Resident #49 had a diagnosis of fractures or other multiple traumas. The MDS also indicated in Section I8000 Additional active diagnoses indicated pain to the left hip. Section J-Health Conditions in the section J0100 indicated Resident #49 received as needed pain medications. Record review of the comprehensive care plan dated 10/08/2024 indicated Resident #49 received pain medication for a right hip fracture. The goal of the care plan was Resident #49 would be free of any discomfort or adverse side effects from pain medications. The care plan interventions included to administer analgesic medications as ordered by the physician. Record review of the consolidated physician's orders dated 12/03/2024 indicated Resident #49 was ordered Tramadol 50 milligrams one tablet three times daily. Record review of the electronic medication administration record dated December 2024 indicated Resident #49 was administered Tramadol 50 milligrams on 12/03/2024 at 9:00 a.m. and 3:00 p.m. Record review of the undated narcotic administration record on 12/03/2024 at 4:30 p.m., Resident #49's Tramadol 50 milligrams was not signed out for the doses administered at 9:00 a.m. and 3:00 p.m. Record review of a Medication Administration Audit Report dated 12/03/2024 indicated Resident #49 was administered Tramadol 50 milligrams at 9:58 a.m. by RN A, and at 3:56 p.m. by MA B. The Medication Administration Audit Report failed to indicate a Tramadol 50 milligrams was administered at 4:30 p.m. on 12/03/2024 when MA B had the Tramadol 50 milligrams prepared and attempting administration when the surveyor intervened. The Medication Administration Audit Report indicated MA B administered the 9:00 p.m. dose of Tramadol 50 milligrams at 8:16 p.m. During an observation and interview on 12/03/2024 at 4:30 p.m., MA B was walking away from the 300-hall medication cart with a medication cup with one tablet in the cup. MA B said was he was administering Resident #49's Tramadol at this time. MA B provided the narcotic administration sheet for the surveyor to review. The narcotic administration record indicated there had not been any entries of the administration of the Tramadol for 12/03/2024. MA B was then asked to reconcile the narcotic Tramadol with the surveyor. Resident #49's narcotic administration record indicated there was 57 medications on hand. Resident #49's medication card of Tramadol 50 milligrams RX 5505760.00 filled on 11/21/2024 had 54 tablets. Resident #49's narcotic administration record indicated there should be 57 tablets available for administration. MA B said he had not reconciled the narcotics with RN A prior to taking over the medication cart. MA B was unable to explain the risks involved in not accurately reconciling the narcotics. During an interview on 12/03/2024 at 6:00 p.m., RN A said he had administered Resident #49's Tramadol for the 9:00 a.m., and 3:00 p.m. doses but failed to sign out the narcotic sheet. RN A said he was distracted and failed to sign out the administered medication on the narcotic sign out sheet. RN A said the narcotic sign out sheet should be signed when administering the medication. RN A said the risks were medication errors with readministering medications, and drug diversions (missing medications). RN A said the narcotic counts were to be reconciled at the start of a shift and at the end of shift, and/or when changing of nursing staff. Record review of a Medication Administration Observation Report dated 7/19/2024 indicated MA B was observed by the pharmacist in the techniques including correct medication verified by visual check of the medication, label, and MAR (omission, unordered medication, wrong dose, route, dosage form, drug, and time). Record review of a Competency Assessment Administering Oral Medications dated 9/12/2024 indicated RN A was checked off on medication administration by the ADON. The check off included 9b. For Narcotics check the narcotic record for the previous drug count and compare with supply on hand. Report any discrepancies to the nurse supervisor. During an interview on 12/05/2024 at 11:30 a.m., the DON said she expected the medications to be signed out as administered. The DON said the importance of signing out as administered was to prevent re-administration and accurate record keeping. The DON said she expected the nursing staff to reconcile the narcotics each shift prior to accepting the cart and at the end of the shift prior to the next nurse assuming the cart. The DON said spot checks and check offs were used to ensure compliance. During an interview on 12/05/2024 at 11:48 a.m., LVN E said he expected the MAs to sign out the medications as they were administered to ensure medications were not re-administered. LVN E said nursing was responsible for re-ordering medications timely. During an interview on 12/05/2024 at 12:46 p.m., the Administrator said medication counting was a critical part of shift change. The Administrator said medications should be documented as giving as they were administered to ensure nursing was aware the medication was administered. The Administrator said signing out of narcotics was a way to account for the use of the narcotics. The Administrator said he expected the nurse to monitor the MAs, the ADON and DON were responsible for oversight ultimately. 4)Record review of a face sheet dated 12/05/2024 indicated Resident #5 was a [AGE] year-old male who admitted on [DATE] and 3/09/2024 with the diagnoses of cognitive impairment, and low back pain. Record review of the comprehensive care plan dated 4/05/2024 indicated Resident #5 had chronic and acute pain related to diabetic disease and chronic low back pain. The goal of Resident #5's care plan was he would not have an interruption of his normal activities due to pain. The interventions included monitor and document causes of each pain episode, monitor/record/report to the nurse resident complaints of pain or request of pain treatment, notify the physician if interventions were unsuccessful or current complain was a significant change from the resident's past experience of pain. Record review of a Quarterly MDS dated [DATE] indicated Resident #5 was understood and understood others. The MDS indicated Resident #5's BIMS score was 9 indicating moderate cognitive impairment. The MDS in Section J-Health Conditions indicated Resident #5 received routinely scheduled pain medications and had not received as needed pain medications. Record review of the consolidated physician's orders dated 12/05/2024 indicated Resident #5 was ordered Norco Oral Tablet 10/325 milligram (hydrocodone-acetaminophen) give 1 tablet by mouth 4 times daily for pain on 4/05/2024. Record review of the Medication Administration Record dated December 2024 indicated on 12/04/2024 Resident #5 was scheduled to receive Norco 10/325 milligrams one tablet at 1:00 a.m., 7:00 a.m., 1:00 p.m., and 7:00 p.m. Record review of the undated Individual Narcotic Count Sheet indicated Resident #5's Rx N7443372 Norco (hydrocodone) 10/325 milligrams was signed out on 12/04/2024 at 2:00 a.m., 8:00 a.m., 2:00 p.m., and 8:00 p.m. dose indicated was pulled for dosing by MA B but wasted by the DON. Record review of the Medication Administration Audit Report dated 12/02/2024 - 12/04/2024 indicated Resident #5 last administration of Norco 10/325 milligrams at 12:34 p.m. for the scheduled 1:00 p.m. by MA C. During an observation and interview on 12/04/2024 at 3:44 p.m., MA B was standing at the medication cart. MA B was asked to allow the surveyor to review the medication cart for compliance with opened and dated medications, and cleanliness. MA B opened the top drawer of the medication cart and there were 3 medication cups with prepared medications for administration. MA B grabbed the cups and attempted to place them in his jacket pocket. Upon request MA B removed the medications from his pocket and attempted to add applesauce to the medication cup MA B indicated was for Resident #5. MA B indicated Resident #5 was crying in pain and he was administering the 7:00 p.m. scheduled Norco 10/325 milligram at this time. MA B attempted several times to walk inside Resident #5's room to administer the medication but was stopped each time by the surveyor to clarify the administration. MA B said RN D had advised him to administer this medication. RN D who was standing a few feet away was summoned to the medication cart. RN D said he had in fact had not been consulted concerning Resident #5 crying in pain or the need to administer Norco 10/325 milligram at this time. RN D summoned the DON as requested . The DON and Corporate Clinical Nurse arrived at the medication cart. The DON questioned MA B concerning his preparation and attempt of administration of Resident #5's 7:00 p.m. medications at 3:44 p.m. MA B attempted to inform the DON of how Resident #5 was crying in pain and needed the medication early. The DON was noted to inform MA B this was out of his scope of practice and that he was not able to administer any medications without the physician's order. The DON advised MA B to waste the Norco 10/325 milligram medication at this time with her approval. The DON was informed the surveyor intervened in the administration due to the fact Resident #5's narcotic sheet indicated he had received his Norco 10/325 milligram at 2:00 p.m. just 1 hour and 44 minutes earlier. During an interview on 12/04/2024 at 4:32 p.m., the DON indicated Resident #5 was assessed and he denied being in pain and was sitting up in his wheelchair in his room. The DON said Resident #5 probably would not have suffered any adverse effects from the early administration of the Norco 10/325 milligrams, but another resident could suffer adverse effects. The DON said she had validated with MA B no other residents had received medications early off their scheduled times. Record review of a Medication Administration Observation Report dated 7/19/2024 indicated MA B was observed by the pharmacist in the techniques including correct medication verified by visual check of the medication, label, and MAR (omission, unordered medication, wrong dose, route, dosage form, drug, and time). During an interview on 12/05/2024 at 11:39 a.m., the DON said she expected the MAs and nurses to follow the rights of medication administration including right time. The DON said administering pain medications too closely together could adversely affect some residents. The DON said she monitors the medication audit report to monitor for missed doses. The DON said the pharmacist also monitors the nursing staff with medication compliance. The DON said the nurses were responsible for reordering medications timely to ensure the medications were available for administration. The DON said missed medications could affect the residents adverse by not having optimal levels and effectiveness. During an interview on 12/05/2024 at 11:55 a.m., RN E said MAs were unable to assess residents for pain and decide what the course of action should be. RN E said the nurse should assess for pain, evaluate when the last administration of pain medications was provided, evaluate if an as needed dose of medication was required, and notify the physician for further guidance. RN E said nurses and MAs were responsible for reordering timely to ensure no medications were missed due to unavailability. RN E said the physician should be notified and all attempts made to ensure the medication was available for administration. During an interview on 12/05/2024 at 1:00 p.m., the Administrator said the nursing staff should know when the medication was low and order prior to exhausting what was on hand. The Administrator said the nurses have access to the emergency kit and the pharmacy could make a stat (three hour turn around) delivery. The Administrator said MA B made a decision he had never witnessed before. The Administrator said MA B failed to follow the facility's process for medication administration. The Administrator said nursing management was responsible for ensuring monitoring of medication management and administration of staff competencies. Record review of an Adverse Consequences and Medication Error policy dated April 2014 indicated, the interdisciplinary team evaluates medication usage in order to prevent and detect adverse consequences and medication-related problems such as adverse drug reactions and side effects 6. Examples of medication errors included: b. Unauthorized drug is administered without a physician's order g. Wrong time Record review of a Documentation of Medication Administration policy dated April 2007 indicated, the facility shall maintain a medication administration record to document all medications administered. 1. A nurse or Certified Medication Aide shall document all medication administer to each resident on the resident's medication administration record (MAR). Record review of a Controlled Substance policy dated December 2012 indicated, the facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule ll and other controlled substances. 9. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nursing going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services. 10. The director of Nursing Services shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsibility parties and shall give the Administrator a written report of such findings. Record review of Medication Orders and Receipt Record policy, dated April 2007, reflected Medication should be ordered in advance, based on the dispensing pharmacy's required lead time. Record review of the Pharmacy Services - Role of the Provider Pharmacy, dated April 2010, reflected the provider pharmacy shall agree to provide services that comply with applicable facility policies and procedures; accepted professional standards of practice, and laws and regulations, including (but not limited to), the following: .establish a reliable way to notify the facility in a timely fashion of issues and concerns related to medications and prescriptions .provide and maintain the facilities emergency medication supply .deliver medications to the facility . Record review of a Documentation of Medication Administration policy dated April 2007 indicated, the facility shall maintain a medication administration record to document all medications administered. 1. A nurse or Certified Medication Aide shall document all medication administer to each resident on the resident's medication administration record (MAR). Record review of a Controlled Substance policy dated December 2012 indicated, the facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule ll and other controlled substances. 9. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nursing going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services. 10. The director of Nursing Services shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsibility parties and shall give the Administrator a written report of such findings.

Based on observation, interview and record review the facility failed to provide a safe, clean, comfortable and homelike environment allowing the resident to use his or her personal belongings to the extent possible for 1 of 1 shower reviewed for resident rights. The facility failed to ensure the shower did not have trash on the floor on 5/24/24. This failure could place residents at risk of an unsafe or uncomfortable environment and a decrease in quality of life. Findings included: During an observation on 5/24/24 at 9:11 a.m. the facility's central shower had a disposable razor that was on the floor next to the wall and trash in the floor of the shower room. During an observation on 5/24/24 at 10:16 a.m. the central shower room had a disposable razor that was on the floor next to the wall and trash on the floor of the shower room. During an observation on 5/24/24 at 1:00 p.m. the central shower had a disposable razor, used gloves, trash, and popcorn on the floor. During an interview on 6/11/24 at 10:30 a.m., CNA A said the CNAs were responsible for cleaning trash and razors off the floor in the showers. CNA A said trash and razors should not be left on the floor of the showers. CNA A said the importance of ensuing the shower floor was free of debris was for infection control purpose. During an interview on 6/11/24 at 10:32 a.m. LVN B said the CNAs and nurses were responsible for ensuring the showers were cleaned and free of trash on the floor. LVN B said razors and trash should not be left on the shower floors. LVN B said trash left on the shower floors posed a fall risk and razors left on the shower floor posed an injury risk which included a resident getting cut. During an interview on 6/11/24 at 10:42 a.m. the DON said the CNAs were supposed to clean showers as the go. The DON said as a CNA finished a shower, they should be picking up any trash off the floor. The DON said leaving trash on the floor was an accident hazard. Record review of the facility's Quality of Life-Homelike Environment Policy, revised May 2017, reflected, Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible .The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: 1. Clean, sanitary, and orderly environment Record review of the facility's Shower/Tub Bath policy, revised October 2010, reflected, The purposes of this procedure are to promote cleanliness, provide comfort to the resident, and to observe the condition of the resident's skin .Steps in the Procedure .28. Pick up all towels, bath cloths, soiled clothing, etc.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 2 of 6 residents (Resident #1 and Resident #2) reviewed for baseline care plans. The facility failed to ensure Resident #1 and Resident #2 had baseline care plans completed within 48 hours of admission. This failure could place newly admitted residents at risk of receiving inadequate care and services. Findings included: 1. Record review of the face sheet dated 2/28/24 indicated Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including anxiety, diabetes, hypotension (decreased blood pressure, chronic kidney disease, lack of coordination, shortness of breath. Record review of the MDS dated [DATE] indicated Resident #1 admitted to the facility on [DATE]. The MDS indicated Resident #1 was sometimes understood by others and sometimes understood others. The MDS indicated Resident #1 had a BIMS of 10 and was moderately cognitively impaired. The MDS indicated Resident #1 was dependent with toileting, lower body dressing, and putting on and taking off footwear, required maximum assistance with bathing, and moderate assistance with upper body dressing. Record review of the baseline care plan signed 2/13/24 indicated Resident #1 admitted to the facility on [DATE]. The baseline care plan indicated Resident #1 was vision and hearing impaired. The baseline care plan indicated Resident #1 was allergic to Lisinopril (medication to treat elevated blood pressure), Januvia (medication to treat diabetes), and Zosyn (an antibiotic). The baseline care plan indicated Resident #1 was a diabetic. The baseline care plan indicated Resident #1 was receiving IV medication. 2. Record review of the face sheet dated 2/28/24 indicated Resident #2 was a [AGE] year-old female initially admitted to the facility on [DATE] and then re-admitted to the facility on [DATE] with diagnoses including post-traumatic stress disorder, COPD, osteoporosis (a condition in which bones become weak and brittle), and [NAME]-[NAME] syndrome (a rare, serious disorder of the skin and mucus membranes). Record review of the MDS dated [DATE] indicated Resident #2 admitted to the facility on [DATE]. The MDS indicated Resident #2 usually understood by others and usually understood others. The MDS indicated Resident #2 had a BIMS of 15 and was cognitively intact. The MDS indicated Resident #2 was independent with transferring, required set-up with upper body dressing, required supervision with toileting and bathing, and required moderate assistance with lower body dressing and putting on/taking off footwear. Record review of the baseline care plan signed 12/22/23 indicated Resident #2 admitted to the facility on [DATE]. The baseline care plan indicated Resident #2 had adequate vision and hearing. The baseline care plan indicated Resident #2 had no known allergies. The baseline care plan indicated Resident #2 used a wheelchair for mobility and was always incontinent of bladder and bowel. During an interview on 2/27/24 at 1:17 p.m. MDS Coordinator A said baseline care plan could be found under assessments in the electronic medical records. MDS Coordinator A said the date a baseline care plan was signed by the MDS coordinator was the date the baseline care plan was completed. MDS Coordinator A said the facility tried to ensure baseline care plans were completed within 72 hours of admission. MDS Coordinator A said Resident #1s baseline care plan dated 2/13/24 was completed after his 2/9/24 admission. MDS Coordinator A said 2/13/24 was more than 72 hours after admission. MDS Coordinator A said new baseline care plans were not completed upon a re-admission because the facility either used the previous baseline care plan or comprehensive care plan. MDS Coordinator A said if the resident had any change in condition upon re-admission the baseline or comprehensive care plan would be updated. MDS Coordinator A said Resident #2's baseline care plan dated 12/22/23 was from her admission on [DATE]. MDS Coordinator A said Resident #2 discharged to the hospital on 1/10/24 and did not re-admit until 2/9/24. MDS Coordinator A said she did not know if Resident #2 had any changes during her month-long hospital stay that would have needed updated on the care plan. During an interview on 2/28/24 at 10:01 a.m. LVN B said she had worked at the facility for 2 years. LVN B said the MDS nurses were responsible for completing the baseline care plans. LVN B said the baseline care plans were important so staff would know with a new resident how to take care of the resident and what the resident's need were. During an interview on 2/28/24 at 10:19 a.m. LVN C said she had worked at the facility since October 2023. LVN C said the charge nurses were responsible for completing the baseline care plans. LVN C said the importance of the baseline care plan was for a foundation to be started of knowing how to care for the resident, what their likes and dislike were, how to transfer, and how to care for them overall. During an interview on 2/28/24 at 11:26 a.m. the QA Nurse said the admitting nurse was responsible for initiating the baseline care plan and then the MDS nurses completed the baseline care plan. The QA Nurse said baseline care plans should be completed within 48 hours of admission. The QA nurse said the importance of the baseline care plan was to initiate a plan of care for a resident that would inform staff what care the resident required. Record review of the facility's Care Plans-Baseline policy revised 11/14/23 indicated, A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission. To assure the resident's immediate needs are met and maintained, a baseline care plan will be developed within forty-eight (48) hours of the resident's admission .The baseline care plan will be used until staff can conduct the comprehensive assessment and develop an interdisciplinary, person-centered care plan .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to the facility must develop and implement a baseline care plan for 2 of 4 residents reviewed for baseline care plans. (Resident #43 and Resident #33) The facility failed to develop person baseline care plans within 48 hours of admission for Resident #43 and Resident #33. Findings included: 1.Record review of Resident #33's Quarterly MDS dated [DATE] revealed he was an [AGE] year-old male admitted on [DATE]. He had a diagnosis of coronary artery disease, hypertension (high blood pressure), pneumonia, MDRO (multidrug resistant organism), urinary tract infection, and generalized muscle weakness. He had a BIMS of 6 (severe cognitive impairment). He required the use of a wheelchair, extensive assistance, and oxygen therapy. Record review of Resident # 33's clinical assessments log (where baseline care plans can be found) dated from 09/27/23 to 10/12/23 revealed there was no baseline care plans completed. 2.Record review of Resident #43's Quarterly MDS dated [DATE] revealed she was a [AGE] year-old female admitted on [DATE]. She had a diagnosis of hypertension (high blood pressure), cerebral palsy, cerebral vascular accident (stroke), seizure disorder, anxiety, depression, rheumatoid arthritis, and history of falling. She had a BIMS of 00 (severe cognitive impairment). She required the use of a wheelchair and extensive assistance with ADLs. Record review of Resident #43's clinical assessments log dated 09/04/23 to 10/12/23 revealed there was no baseline care plans completed. Interview on 10/11/23 at 06:30 pm with LVN M revealed that the baseline care plans are done by the DON and or the MDS nurse on admission. He stated that the charge nurses do not do the care plans, but they do look at them to see how to care for the residents. He also stated that the care plans include information on how to care for that resident specifically. If there were missing care plans, it could lead to missing the proper care of the resident. Interview on 10/12/23 at 12:04 pm with RN H revealed the DON does the baseline care plans on admission. The importance of the care plans are so all the nurses can see how to care for the resident the best way. She also stated that if there were missing care plans then the residents might not get the care they should be getting. Interview on 10/12/23 at 03:17 pm with the DON revealed there was a miscommunication with the nurses on the process to get the baseline care plans completed and the process should be the charge nurses are the ones who should be opening them and the MDS nurse checked to makes sure they were completed and accurate. She stated the potential harm to the resident if the care plans were missing could be the plan of care could be missed and not followed. She stated the cause of them missing could be related to the transition to a new EMR system and her expectations is that the care plans are accurate and completed. Interview on 10/12/23 at 04:13 pm with the Administrator revealed the breakdown in the baseline care plans had been brought to his attention today(10/12/23).He stated another MDS nurse will start on 11/01/23 to help with the volume of resident charts that need to be reviewed. He stated his expectation is that the care plans are completed on time and accurately. Record review of facilities policy titled Care Plans- Baseline revealed a baseline plan of care is completed to meet the resident within forty-eight hours of admission. To assure that the residents immediate care needs are met and maintained, a baseline care plan will be developed within 48 hours of the resident's admission and include: initial goals based on admission orders, physician orders, dietary orders, therapy services, social services and PASARR recommendations if applicable.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible and received adequate supervision for 3 residents (#8, #36 and #37) of 10 residents reviewed for supervision. The facility failed to have adequate staff supervision in the 300 hall Tea/Bistro room and main dining room, to ensure the pureed and mechanically soft diet residents were not at risk of getting or receiving solid foods from the snack stands. This failure could potentially place residents at risk of eating food not doctor ordered and unsafe for them to eat and drink, which could cause them to choke or aspirate, resulting in a decreased quality of life and psycho-social well-being. Findings included: Resident #8's Quarterly MDS assessment dated [DATE] revealed an [AGE] year old female who admitted on [DATE] her BIMS Score was 03 (severely impaired cognition), extensive one person assistance for eating and upper extremity impairment on one side, used a wheelchair .diagnoses of hypertension, diabetes mellites, aphasia, CVA, Non Alzheimer's Dementia, hemiplegia/hemiparesis, malnutrition and dysphagia with a swallowing disorder: coughing or choking during meals .complaints of difficulty or pain with swallowing with a mechanically altered diet . Record review of Resident #8's Diet order dated 08/29/23 revealed, Enhanced Diet: Pureed texture, regular/thin consistency. Record review of Resident #8's Care Plan dated 10/12/23 revealed the residents care areas: Difficulty making own decisions: please approach from the front in calm, unhurried manner, give verbal cues/reminders when cannot remember .Hypertension: monitor for signs/symptoms of headache, gastrointestinal distress .Hyperlipidemia: monitor for serious side effects headache, fatigue irregular heart rate .ADL assistance: give verbal cues to help prompt .Aphasia: allow a making wants/needs known, allow ample time for residents to respond to what is asked, anticipate needs .Difficulty swallowing: supervise for all oral intake, thicken all my liquids to nectar consistency, remind to tuck chin when swallowing .On pureed diet: diet as order, Monitor meal intake and right side weakness: assess for signs of decreased tissue perfusion. Resident #36's Quarterly MDS assessment dated [DATE] revealed an [AGE] year old female who admitted [DATE] and as of this assessment her BIMS score was 03 (severely impaired cognition), limited one person assistance for eating and upper extremity impairment on one side, used a wheelchair .with diagnoses hypertension, hyperlipidemia, CVA, non - Alzheimer's Dementia, hemiplegia/hemiparesis, malnutrition, depression .loss of liquids/solids from mouth when eating and drinking and coughing or choking during meals. Record review of Resident #36's Diet order dated 09/25/23 revealed, Enhanced Diet: Mechanical soft texture, regular/thin consistency Record review of Resident #36's Care Plan dated 10/12/23 revealed, Dysphagia: Supervise all of my oral intake, thicken my liquids .staff assist for ADL's: Observe resident for pain .Mechanical soft diet order: Monitor food intake and document, assist in eating as needed .Hypertension: Monitor blood pressure as ordered. Resident #37's Quarterly MDS assessment dated [DATE] revealed an [AGE] year old female who admitted [DATE] and as of this assessment her BIMS score was 08 (Moderate impaired cognition) with supervision with setup assist with eating, no upper extremity impairment with use of a walker and wheelchair .diagnoses hypertension, peripheral vascular disease, hyperlipidemia, non- Alzheimer's dementia, malnutrition, dysphagia and swallowing disorder: holding food in mouth/cheek or residual food in mouth after meals. Record review of Resident #37s Diet order dated 09/25/23 revealed, Enhanced Diet: Pureed texture, honey/moderately thick consistency. May have snacks 3 x daily magic cup 3 x daily. Resident #37's Care plan dated 10/12/23 revealed, ADL self-care performance deficit related to dementia: Eating: the resident requires supervision by x1 staff to eat .Dysphagia: monitor/document circumstances surrounding mealtimes/refusals to eat .Impaired cognitive function/dementia or impaired thought processes related to dementia: cue, reorient and supervise as needed .hypertension: Monitor for and document any edema .GERD: avoid coffee, fatty foods, chocolate, citrus juices, [NAME], tomato products .Swallowing problem related to complaints of difficulty or pain with swallowing, coughing, choking during meals: all staff to be informed of resident's special dietary and safety needs, check mouth after meal for pocketed food and debris, resident to eat only with supervision. Observation on 10/10/23 at 11:09 am, in the 300 hall Tea/Bistro room, Residents #8, #36 and #37 were sitting at the tables approximately 3 to 4 feet away from the 3 tier snack stand which had bananas, apples, granola bars and cereal packs on it; and a coffee dispenser was next to it. A female Resident (who had a regular diet order) used a walker to ambulate, went to one of the tables and began to consume her food and drink in front of the other residents and no staff was present watching them. Observation on 10/10/23 at 1:20 pm, in the dining room, there was a 3 tier snack stand with bananas, apples, granola bars and cereal and a coffee dispenser was located on the countertop. Resident #37 was sitting in her wheelchair at a dining room table, by herself approximately 5 feet way from the snack stand and coffee dispenser. Resident #37 was looking around the dining room, looking at the table and chairs and there was no staff watching this resident. Observation on 10/10/23 at 4:15 pm, in the 300 hall Tea/Bistro room there were snacks on the 3-tier snack stand and a coffee dispenser was on the counter. A female resident (who had a regular diet order) was eating a banana with a drink in front of Residents #8 and #36 who were watching tv and no staff was present in the room watching them. Observation on 10/11/23 at 9:15 am, in the 300 hall Tea/Bistro room, there were snacks and a coffee dispenser, and a female resident (who had a regular thin liquid diet order) was standing at the snack stand and walked to a table with a drink in her hand and sat down and started drinking it in front of Residents #36 and #37 present and there was no staff around watching them. Observation on 10/11/23 at 10:30 am, in the 300 hall Tea/Bistro room, Residents #8, #36 and #37 was sitting 3 to 4 feet away from the snack stand with 7 apples, 3 bunches of bananas and a coffee dispenser. And a male resident (who had a regular thin liquid diet order) and ambulated with a walker, was getting a cup of coffee and started drinking it in front of the residents and there was no any staff in the room watching the residents. The snacks were at counter height, within arms reach of the residents. Observation on 10/12/23 at 8:55 am, in the Tea/Bistro room Residents #8, #36 and #37 were sitting in their wheelchairs watching Television and they were not interviewable. Interview on 10/11/23 at 2:37 pm, CNA A stated the dietary department filled the snack stand in the dining room and Tea/Bistro room between 6:00 am or 7:00 am and anyone could get those snacks. She stated they were good about watching the residents in the Tea/Bistro room and dining room, while they were at the nurses' station and walking down the halls, they checked on them. She stated normally the mechanical soft and pureed diet residents did not try to get to the food on the snack stand. Interview on 10/11/23 at 2:55 pm, LVN B stated the snack stands had been in the Tea/Bistro and dining rooms for the past four months she worked at this facility. She stated there was no staff in the Tea/Bistro room at all times when the residents were in there. She stated their eyes could not be everywhere all the time if they were busy they might miss something. She stated if a resident was to get a snack from the snack bar a resident could choke if they were not supposed to eat regular diet consistency food. Interview on 10/11/23 at 4:32 pm, the Dietary Director stated the snacks in the dining room and both Tea/Bistro rooms were always available, which consisted of oranges, apples, peanut butter crackers, apple sauce cups and [NAME] buddy. She stated normally the CNA's watched the residents eating the snacks. But today she was told by her boss to remove the snacks for now and put them out at the nurses station. She stated the snacks being available for anyone to get was not a good idea. She stated if a resident were to get fruit and they were on a pureed diet that would be a choking hazard. She stated she made her staff pickup all of the snack trays until they figured out what to do with them and wanted to put the snacks out the right way. She stated Dietary Aides C and D removed the snacks from the 2 tea/bistro rooms and dining room today (10/11/23) and took them to the nurses' stations to better monitor who was getting what snacks. She stated the CNA's and nurses were responsible for monitoring to ensure the residents were not getting the wrong snacks to eat. Interview on 10/11/23 at 4:56 pm, the DON stated the snack stands usually had crackers, graham crackers that were always out and available for the residents to consume. She stated there were no staff monitoring who was eating in those snack areas when snacks were put out daily and said she really did not have an answer with how they ensured the staff monitored the residents from getting the snacks they were not supposed to get. She stated as of today the snacks were removed from the snack stands in the main dining room and both Tea/Bistro rooms. She stated anybody with any diet order could choke and stated she would look at the policy and get back with the surveyor to clarify. She stated the nurses and CNAs monitored the meal services but not all the time in the tea rooms and dining room and stated now the snacks were kept at the nurses station. She stated her expectation for snack services was for it to be done accordingly. Interview on 10/12/23 at 10:37 am, CNA E stated they used to have snacks in the Tea/Bistro room like graham crackers, apples, granola bars, oatmeal, [NAME] buddies, Oreo cookies, apple sauce that was put out in the mornings for any residents could get who could walk. She stated Residents #8, #36 and #37 were on pureed diets and liked to go to the Tea/Bistro room. She stated she had not ever seen the residents that were pureed and mechanical soft diets trying to get the snacks, and she told them they could not have the snacks by redirecting them because they could choke or stop breathing if they ate the wrong types of food. She stated there were times no staff watched the residents in the Tea/Bistro room but said they checked on the residents often, like Resident #8, every two hours. Interview on 10/12/23 at 11:01 am, Dietary Aide F stated they used to put graham crackers, apples, fruits, peanut butter crackers, pudding and oranges on the snack stands. But stated as of today (10/12/23) the Dietary Director told them they could not put out snacks on the snack stands any longer. He stated the Dietary Director was concerned a pureed person would eat the wrong snacks, and choke. He stated the snacks were currently being taken to the nurses' station to give to the residents. Interview on 10/12/23 at 11:11 am, [NAME] G stated they put snack bars, chips, [NAME] buddy bars, oatmeal pies, apple sauce, bananas, peanut butter crackers and granola bars out daily around 6:00 am and at 12:00 pm and again around 6:45 pm. He stated the nursing department should be watching the residents in the Tea/Bistro room at all times for the resident's safety. He stated if a resident with a pureed diet could choke on the food on the snack stand if they took them or was given to them. Interview on 10/12/23 at 11:22 am, LVN B stated Residents #8 and #37 were on pureed diets, and Resident #36 was on a mechanical soft diet went to the main dining room for meals with the nursing staff present. She stated in the Tea/Bistro room there was no specific person watching the residents, but they often looked in there. She stated they monitored the residents often as she was doing her nursing tasks. She stated they have snack stands in the main dining room and Tea/Bistro room and not ever seen the pureed residents eating the snacks from the snack stands but it they did they could choke or aspirate. Interview on 10/12/23 at 11:43 am, RN H stated Residents #8, #36 and #37 were on pureed diets and also went to many of the activities and in the tea for activities in the morning. She stated #37 could feed herself and Residents #8 and #36 needed staff assist with meals. She stated staff were not always in the Tea/Bistro room, but she worked by the Station #1 and kept an eye on the residents. She stated she never saw the residents with pureed and mechanical soft diets get snacks from the snack stand or residents in their right mind give them snacks. She stated if she saw that she would take the food or drink from the resident and give them something like apple sauce to eat. She stated the residents were at risk of choking if they ate the wrong type of food. She stated the residents with pureed and mechanical diets could not reach the snack bar because the countertop was high. Interview on 10/12/23 at 12:32 pm MDS Coordinator I, stated she did not see an issue with the snacks being in the Tea/Bistro room and main dining room because a nurse would see them and stop them if a resident grabbed the wrong type of food. She stated there was no staff in the actual room the entire time the residents were in the Tea/Bistro room, but the nurses watched them from the nurses' station, when they were at the nurses station. She stated she was not sure who watched the residents when the nurses left the nurses station and stated the staff was not able to watch the residents in the tea/bistro room all the time because of doing patient care in rooms. She stated if a Resident had a pureed diet and ate an apple or banana they could choke and could be harmful and the resident could choke to death. She stated the snack stands were no longer in the main dining room and Tea/Bistro rooms and was not sure why. Interview on 10/12/23 at 3:24 pm, the DON stated the CNAs and nurses monitored the residents in the Tea/Bistro room often and the CNAs knew what the residents diet orders were and if they did not, they could ask the nurse. She stated the resident's snacks were now being stored in the nutrition room for the staff to give to the residents. Interview on 10/12/23 at 3:48 pm, the Administrator stated they had three snack stands with a variety of snacks on them, two were in the Tea/bistro rooms and one was in the main dining room and stated the snacks were no longer in those areas and added after review they planned to put them back out. He stated the Dietary Manager removed them because the HHSC Surveyor said something about them. He stated there was no concern about the residents with pureed diets getting to the snack stand and did not think anyone would give a person a banana unless it was mashed for a resident with a mechanical soft diet. He stated they did not always have staff in the tea/bistro rooms monitoring what snacks and drinks the residents were getting from the snack stand and was not sure if the residents with pureed and mechanical soft diets were even in the bistros. He stated it was a group effort among the nurses and CNA's to ensuring the residents did not get the wrong types of snacks. He stated ultimately the ADON and DON were responsible for ensuring the residents were not getting the wrong types of foods. Interview on 10/12/23 at 4:06 pm, the Dietary director stated she did an Inservice training with the dietary staff today 10/12/23 for them to put the resident's snacks behind the nurses station so the snacks would not be out for all the residents to possibly get to. She stated after they put out the snacks it was out of her hands, and they were nurses responsibility to watch what food the residents ate. Interview on 10/12/23 at 4:13 pm, Dietary Aide D stated he had an Inservice training yesterday 10/11/23 about making sure the resident's snacks were put behind the nurses' station now. He stated the snacks went behind the nurses' station now because the Residents had different diet orders. He stated what if a resident had a different order from what was on the snack stand and was not supposed to eat it, they could choke. Interview on 10/13/23 at 12:49 pm, the Facility's Ombudsman stated unattended snacks was not a good idea if the staff were not monitoring which residents was getting snacks from the snack stands in the Tea/Bistro and Dining room. She stated she saw the snack stands in the tea/bistro rooms and said typically it was nice to have available snack stands, but if the residents had dietary restrictions and somehow got snacks they should not get, could cause a problem if the resident was not to have them. She stated the nurses could see who was getting the snacks better if they were at the nurses' station to ensure the snacks were given to the right residents. She stated at most facility's they usually stored snacks in a refrigerator, and the staff passed the snacks out to the residents. She stated it was better the residents' snacks were closer to the nurses station to better monitor them, otherwise a resident could choke. Record review of the Dietary Department All staff Inservice training dated 10/11/23 revealed, Always Available Resident Snacks on both Tea/Bistro room and Dining Rooming .Presenter: Dietary Director and 8 residents signed it including the dietary director. Record review of the facility's incident/accident policy was requested on 10/12/23 at 5:30 pm but was not provided. Record review of the facility's QAPI Program Policy undated revealed, Policy Interpretation and implementation: The purpose of QAPI in our facility is to take a proactive approach to continually improve the way we care for and engage with our residents .The QAPI program provides a system for objective and systematic monitoring and evaluation of the quality, appropriateness, efficiency and effectiveness of clinical care and service delivered Record review of the facility's Assistance with meals policy dated 2001, revised 2022, Policy Statement: Resident shall receive assistance with meals in a manner that meet the individual needs of each resident .Policy and interpretation and implementation: Dining room residents 1. All residents will be encouraged to eat in the dining room .Residents requiring full assistance: .2. Residents who cannot feed themselves will be fed with attention to safety, comfort dignity

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth, 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 for 3 out of 4 residents reviewed. (Resident #133, Resident # 57, and Resident #33) The facility failed to develop person centered care plans for antibiotic use, medical management of seizure disorder, anxiety, depression and fall prevention for Resident #133. The facility failed to develop interventions/tasks within the person-centered care plans for hypothyroid disease, depression, malnutrition, and shortness of breath. They also failed to develop care plans for medical management of insomnia and allergy to penicillin for Resident # 57. The facility failed to develop person centered care plans for medical management of depression, insomnia, NPO status (nothing by mouth), fall prevention, and allergies to Droperidol, Hydralazine., Ativan, Compazine, Relpax, Topamax, Toradol, Penicillin, Sulfonamide, and wasp venom for Resident #49. The facility failed to develop person centered care plans for medical management of depression, oxygen use, specialized diet, and antibiotic use for Resident #33. This failure could place residents at risk of residents not receiving individualized care to maintain the resident's highest level of practicable physical, mental, and psychosocial wellbeing. Findings included: 1.Record review of Resident # 133's admission MDS dated [DATE] revealed she was a [AGE] year-old female admitted on [DATE]. She had a diagnosis of Diabetes Mellitus (high blood sugar), hypertension (high blood pressure), Cerebral Vascular Accident (stroke) and seizure disorder. She had a BIMS of 6 (severe cognitive impairment). She required the use of a walker and or wheelchair and moderate assistance with ADLs. Record review of Resident # 133's physician order summary dated 10/03/23 revealed the following orders: *Buspirone HCl tablet 5mg give 1 tablet by mouth three times a day for anxiety with a start date of 10/06/23. *Carbamazepine tablet 200mg give 1 tablet by mouth two times a day for seizures with a start date of 10/04/23, *Ceftriaxone sodium intravenous solution reconstituted 2gm one time a day for infection until 11/08/23 with a start date of 10/04/23. *Escitalopram 10mg tablet give 1.5 tablet by mouth one time a day for depression/anxiety 1.5 tab = 15mg with a start date of 10/12/23. *Levetiracetam 750mg tablet give 2 tabs by mouth wo times a day for seizures 2 tabs =1500mg with a start date of 10/04/23. Record review of Resident #133's care plans dated 10/11/23 revealed there was no care plans for medical management of antibiotic use, seizures, anxiety, depression or fall prevention. 2. Record review of Resident #57's Quarterly MDS dated [DATE] revealed he was a [AGE] year old male admitted on [DATE]. He has a diagnosis of hypertension (high blood pressure), Dementia, anxiety, depression, insomnia, Obstructive sleep apnea, malnutrition, and hypothyroidism. He had a BIMS of 6 (severe cognitive impairment). He required the use of a walker and or wheelchair, a CPAP (continuous positive airway pressure) at night and limited assistance with ADLS. Record review of Resident #57's physician order summary dated 10/01/23 revealed the following orders: *Mirtazapine 15mg disintegrating tablet give 1 tablet at bedtime or appetite stimulant with a start date of 10/06/23. *Trazodone HCl 50mg give 0.5 tablet by mouth at bedtime for insomnia with a start date of 10/06/23. Record review of Resident #57s care plan dated 09/22/23 revealed a care area for hypothyroidism initiated on 09/22/23 revealed there were no goals or interventions. Further review revealed the care areas depression, malnutrition, and shortness of breath initiated on 09/22/23 revealed there were no interventions. There was no care area for the medical management of insomnia or allergy to penicillin. 3.Record review of Resident #33's Quarterly MDS dated [DATE] revealed he was a [AGE] year old male admitted on [DATE]. He had a diagnosis of coronary artery disease, hypertension (high blood pressure), pneumonia, MDRO (multidrug resistant organism), urinary tract infection, and generalized muscle weakness. He had a BIMS of 6 (severe cognitive impairment). He required the use of a wheelchair, extensive assistance, and oxygen therapy. Record review of Resident # 33's physician order summary dated 10/01/23 revealed he had the following orders: *No salt on tray, puree texture, regular/thin consistency, no straws. *May have oxygen at 2-4 liters per minute related to shortness of breath as needed with a start date of 10/03/23. *Cefuroxime Axetil oral tablet 500mg give 1 tablet by mouth two times a day for pneumonia for 10 days with a start date of 10/05/23. *Celexa oral tablet 20mg give 1 tablet by mouth one time a day for depression with a start date of 10/10/23. Record review of Resident #33's care plans dated 10/06/23 revealed there was no care plans for medical management of antibiotics use, depression, oxygen use, or specialized diet. 4. Interview on 10/11/23 at 05:53pm with CNA L revealed that they have access in their charting to see interventions on how to care for the residents. Some examples of information found were how to transfer the resident, if they need help eating, and any specialized care needs. She stated this information was pulled from the resident's care plans. Interview on 10/11/23 at 06:30 pm with LVN M revealed the care plans are done by the DON and or the MDS nurse. He stated the charge nurses do not do the care plans, but they do look at them to see how to care for the residents. He also stated the care plans include information on how to care for that resident specifically. If there were missing care plans, it could lead to missing the proper care of the resident. Interview on 10/12/23 at 12:04 pm with RN H revealed the MDS nurse does the comprehensive care plans during reviews and then as needed. The importance of the care plans are so all the nurses can see how to care for the resident the best way. She also stated that if there were missing care plans then the residents might not get the care they should be getting. Interview on 10/12/23 at 12:44 pm with MDS coordinator I revealed she was responsible for doing the comprehensive care plans. She stated all the care plans are in the EMR and if they were not there then they were probably missed. She stated there should be a care plan for all medical diagnosis and specialized medications so that the residents can be properly monitored and to ensure that the care plans were person centered. She stated if there were missing care plans that the potential harm to the residents could be missing interventions to protect the residents. She was unsure why Resident #133, Resident #57, and Resident 33's care plans are not complete. Interview on 10/12/23 at 03:17 pm with the DON revealed the MDS nurse was the one who was responsible for completing the comprehensive care plans. She stated the care plans should include an inclusive look at the residents care some examples were fall prevention, dietary orders, specialized medication such as antibiotics and psychotropic, allergies, and specific medical equipment use. She stated the potential harm to the resident if the care plans were missing could be the plan of care could be missed and not followed. She stated the cause of them missing could be related to the transition to a new electronic medical record system and her expectations was that the care plans are accurate and completed. Interview on 10/12/23 at 04:13 pm with the Administrator revealed the breakdown in the care plans had been [NAME] to his attention today, they have another MDS nurse starting on 11/01/23 to help with the volume of resident charts that need to be reviewed. He stated his expectation was that the care plans are completed on time and accurately. Record review of facilities policy titled Care Plans, Comprehensive Person-Centered revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial, and functional needs is developed and implemented for each resident. The comprehensive person-centered care plan is developed within seven days of the completion of the required comprehensive assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 (Hall 300) of 8 halls and 1(Nurses Station #1) of 2 nurses stations and one resident (#29) of 8 residents and one (confidential meeting) reviewed for Environment. The facility failed to repair or replace the flooring and carpet areas around the 300 hall and nurses' station #1, which was reported to the Maintenance Director months ago by staff and documented in the maintenance logbook. These failures placed residents at risk of being potentially at risk of tripping and falling which could cause injury, pain, and distress, resulting in a decrease in their quality of life and psycho-social well-being. Findings included: Record review of Resident #29's Quarterly MDS assessment dated [DATE] revealed, a [AGE] year-old female who admitted on [DATE] and as of this assessment her BIMS score was 09 (moderate cognitive impairment), supervision with setup help for locomotion off unit, no upper and lower impairment, used a walker and wheelchair,. The resident's diagnoses were CVA, hypertension, Renal Failure (kidney). Observation on 10/11/23 at 2:28 pm, Resident # 29 was having a hard time rolling her wheelchair along the 300 hall, towards Station #1, she used her arms when going down the 300 hall and was moving very, very slowly. Observation on 10/10/23 at 10:37 am, approximately 40 feet of the 300 hall flooring foundation, from rooms 308 to 320 had several ridges, bumpy, and the carpet was loose in some areas. And there was loose carpeting that was arched up in three places in front of rooms [ROOM NUMBERS] and 312. Observation on 10/12/23 at 10:00 am, the carpet around the Nurses Station #1 was torn, coming up and frayed and the white strings of fabric from the carpet was seen. Interview on 10/11/23 in a confidential group meeting, a resident stated the 300-hall carpet was bumpy and hard for him/her to move their wheelchair, most of the residents stated the flooring was uneven and went up and down as they moved along it. A resident stated they had to put more of an effort moving down this hallway and it was hard moving up and down and had to put more effort into moving along the 300 hall. One resident stated the 300 hall had been like that for a year and another resident stated the 300 hall flooring was not leveled and slowed them down. A resident stated the flooring was bumpy and dirty and wished they would fix it and it was frustrating going down that hall. They stated they complained to the staff about the carpet and the staff were aware of the issue. One resident stated the 300 hall flooring went Up a little and bump bump bump and said it would be wonderful if they fixed the flooring. He/She stated, They paid like the rich and lived like the poor and did not understand why the floor had not been fixed and cleaned and said the carpet was old but said maybe it would be too expensive to fix. Observation on 10/12/23 at 10:59 am, the Corporate Maintenance Rep. was on the 300 hall with a glue gun trying to flatten out the raised carpeted areas and placed yellow marker signs in those areas. Observation on 10/12/23 at 11:36 am, the Dietary Aide F rolled a metal meal cart down the 300 hall, and it was vibrating and rattled very loudly as he pushed it down the hallway. Interview on 10/12/23 at 2:30pm, the Housekeeping/laundry Supervisor stated for the past 4 or 5 months she noticed the carpet on the 300 hall was worn, loose, and uneven. She stated she spoke to the nursing department and to the Administrator about it and was told they would look into it. She stated when going down the 300 hall, the housekeeping cart and broom bounce around a lot and she needed to hold on to the broom to prevent it from falling off the housekeeping cart. She stated onetime on a weekend, this past summer, she had to clean up a meal tray off of the 300 hall floor, that fell off the meal cart. Interview on 10/12/23 at 9:24 am, the Maintenance Director stated for a little over a year the carpet was coming up and he guessed it was the glue needing to be redone. He stated the adhesive probably was not sticking to the carpet and pulled in certain areas. He stated the 300 hall carpet needed to be relayed down and was not sure why the flooring under the carpet was bumpy and had not noticed it until it was brought to his attention 2 months ago by the dietary staff. He stated he went to the administrator and they both went to the 300 hall to look at it to come up with a solution and stated they were still trying to come up with repairing the flooring that was cost efficient. He stated he received five estimates that were kind of high and Corporate Maintenance Rep. was also made aware of the 300 hall flooring. He stated the dietary staff complained about having a hard time pulling the meal carts down the hallway and reported it to him and he noticed the carpet was bunched up in some areas. He stated he nor the Corporate Maintenance Representative had not tried to fix the carpet and flooring issue because they were not sure how to fix it. He stated they had not yet determined who was going to fix it and was not aware of any residents falling but knew it was a fall hazard. He stated he was responsible to ensure repairs were completed and stated he was not aware of any problems of worn carpet around Station 1 until the HHSC Surveyor showed it to him today (10/1/23). Interview on 10/12/23 at 11:01 am, Dietary Aide F stated the 300 hall flooring was a little bumpy for as long as he could remember working here and was not sure why he did not notify maintenance director. Interview o 10/12/23 at 11:11 am, the [NAME] G stated he noticed the carpet was raised up in some areas of the 300 hall. He stated he spoke to the Maintenance Director, and the Maintenance Director said he would have someone look at it. He stated he had no problems wheeling the meal carts down the 300 hall, but noticed walking down there how uneven it was. Interview on 10/12/23 at 12:32 pm, MDS Coordinator I stated not being sure when, but she felt the little bumps under the carpet on the 300 hall. She stated she told the maintenance director about it in passing down the hall a few months ago. Interview on 10/12/23 at 3:24 pm, the DON stated she never noticed any issues and had no complaints about the 300 hall flooring being bumpy or rough. She stated the staff did a good job reporting maintenance requests and the Maintenance Director was pretty good fixing things and stated this was a stable building. Interview on 10/12/23 at 3:48 pm, the Administrator stated there were no issues with the 300 hall flooring being bumpy or carpeting being loose. He stated the Corporate Maintenance Representative was using a glue dispenser gun earlier today (10/12/23) because the HHSC surveyor said something about the carpet. He stated there were no bids for the flooring to be repaired and he had not spoken to anyone about repairing the flooring including the Maintenance Director. He stated he had no complaints from anyone about the 300 hall flooring and there had not been any residents who had tripped or fallen on the 300 hallway and stated he was responsible for ensuring maintenance repairs were done. Interview on 10//13/23 at 12:49 pm, the Facility's Ombudsman stated the residents complained to her on 10/11/23 about the 300 hall flooring being bumpy and they showed her where the bumps in the flooring was. She stated one of the residents pointed to an area of the flooring and said that area of the 300 hall they had to put more strength and effort to move their wheelchair. She stated as she walked along the 300 hall she also noticed how uneven the flooring was and could see the carpet was worn and torn in some areas and it needed to be repaired. She stated it was almost like a pipe was underneath the 300 hall that moved the flooring around and stated she tried to discuss this issue with the administrator, but he was not in his office and said she would follow-up with him later. Record or the facility's Maintenance Log sheet dated 09/21/23 by ADON J Carpet coming up Station #1 (Nurse Station #1) with no completed date and initialed - by Maintenance Director. Record review of the facility's Maintenance Service Policy dated 2002 and revised 2009 revealed, Policy Statement: Maintenance services shall be provided to all area of the building, grounds, and equipment .Policy Interpretation and Implementataion: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. Maintaining the building in good repair and free from hazards .f. Establishing priorities in providing repair services .3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings .are maintained in a safe operable manner

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 the facility's only kitchen reviewed for food safety. 1.The facility failed to ensure food items in the refrigerator, freezer and dry storage room were labeled and stored in accordance with the professional standards for food service. 2. The facility failed to ensure the ice machine vent was free from greasy residue buildup with dust. 3. The facility failed to discard items stored in refrigerator, freezers or dry storage that were not properly labeled or past the 'best buy', consume by or expiration dates. 4. The facility failed to ensure the emergency water supply was monitored and changed out as needed 5. The facility failed to ensure handwashing sink #1 was free from debris in the sink. 6. The facility failed to ensure food items stored in the walk-in refrigerator and dry storage room were not left open to air or secured close. 7. The facility failed to ensure hazardous tools were not left out unsecured in the dry storage room. 8. The facility failed to ensure they use and open one food item first before opening another. 9. The facility failed to ensure they separated good useable canned good from dented unusable canned goods. These failures could place residents at risk for food-borne illness and cross contamination. Findings Included: Observation of the kitchen on 10/10/23 at 09:31 AM revealed the following: -Handwashing sink #1 (of 3) had a clear-ish gelatinous like lump of a material in the sink, sitting in the drain. -On the receiving side of the steam table, at the end, there was a small prep. table with plate warmers stacked. The top warmer on the first stack had a dark brown quarter sized piece of debris on it. -Ice Machine plastic vent, located on the left side of the machine, the vent slats had a greasy residue/film with dust on them. Observation of voltage closet in central supply room with the Dietary Manager on 10/10/23 at 09:38 AM revealed the following: -Emergency water supply in 1-gallon jugs (47). One jug in the back of the room against the wall, was half full, the cap still sealed. -Another jug on the 2nd row from the door, had the seal broken and only approximately ¼ of the water remaining. -Several of the jugs were not full as the majority of the jugs, but seals remained intact. Observations of walk-in refrigerator on 10/10/23 at 09:49 AM revealed the following: -Left side: 2nd row from top- 1 whole medium sized watermelon no item of description, no received by date, no consume by or discard by date. -1 Large opened box labeled [NAME] leaf cabbage slaw: 1 large zip top bag dated 10/06/23, label of item description, no consume by or discard by date. -1 Large opened box dated 09/19/23 label premium lettuce has a large plastic bag with romaine lettuce inside. The bag was open to air, there was a medium brown spot not on the left side of the lettuce head. - At the bottom of the bag, there was lettuce as the bottom wilted, brown and soggy, no open date, no consume by or discard by date. -3rd row from the bottom: -1 extra-large stainless-steel bowl with 2 halves of a watermelon, there was plastic wrap on the on the bowl, but it was not completely covering the bowl or the watermelon, dated 09/27/23 after the plastic wrap was stretched to check for label and date, no consume by or discard by date. -4th row from the top: -1 large box with 4 head of cabbage in it, was open to air, dated 09/29/23. The writing was illegible, cook stated the date was 09/27 or 09/29. There was no consume by or discard by date. -Right side shelf, 2nd row from the top: -1 large zip top bag with a small amount of yellow cheese slices, dated 10/10/23 there was no label of item description, no consume by or discard by date. - 1 Large zip top bag, open to air, the bag was sealed but just under the zip top portion the bag had been torn open across the top almost tore the zip top portion off. The bag was dated 10/10/23, it contained a small amount of uncut deli meat, no label of item description, no consume by or discard by date. -1 Large zip top bag dated 10/06/23 with shredded yellow cheese, product label not visible and no written label of description, no consume by or discard by date. -1 Large zip top bag with more than 11 boiled eggs dated 10/06/23, no label of item description, no consume by or discard by date. -3rd row from the top: -1 large metal pan with potato salad dated 10/10/23 for lunch, there was no label of item description, no consume by or discard by date. 4th row form the top: -1 small stainless-steel pan with 5 sausage patties and a small amount of ground/crumbles sausage patties, labeled sausage and dated 10/10/23 had no consume by or discard by date. -Left side, 2nd shelf (had condiments on tip row), 3rd row from the top: - large zip tip bag with 3 thick cut pieces of turkey lunch/deli meat dated 10/07/23, there was no label of item description, no consume by or discard by date. Observations of the walk-in freezer on 10/10/23 at 10:10 AM revealed the following: -On the right side, bottom shelf, there were 3 large bags of potato wedges, no label of item description, no received by date, no consume by or discard by date. -1 Small opened box dated 08/08/23, with a blue plastic bag inside, open to air, that contained breaded squash. The squash was freezer burned- had dried white patches on various pieces of the squash. -1 Large opened box with 2 bags of chicken parts/pieces, no received by date noted on any side of the box. -1 Large beef brisket in its original plastic packaging, no received by date. There was a dried, aged appearance to bottom middle area of the brisket, ice crystals over the middles portion of the packaging. Observations of Dry Storage Room with Dietary Manager on 10/10/23 at 10:21 AM revealed the following: -Left side of the room, near the door there were 2 (usable) canned good racks. 2nd rack, 4th row from the top: -1-6lbs. 6 oz. tomatoes 7 zucchini sliced in juice dated 10/10/23, no manufacturer expiration date, can is dented at the bottom and small dent at the top of the can. -1-6lbs. 6 oz can tomatoes & zucchini sliced in juice dated 20/10/23 no manufacturer expiration date, dented at the bottom of the can. - 3rd shelf, 2nd row from the top: -1-7 ¼ oz can of vegetable beef soup, no received by date, manufacturer expiration date 05/09/24. The can was sitting in the box of a different product (pimentos) that was dated 08/11/23. -1 small box with 8-7 oz cans of unpeeled dried pimentos, dated 08/11/23, when the can was picked up to check the can, it was stuck to bottom of the box as if something had spilled dried and made the can stick to the box. The bottom of the can had rust around it and the other 7 cans. -1-7 oz can of unpeeled dried pimentos with dented bottom. -1 large white bin with individually wrapped saltines dated 10/03/23, no consume by or discard by date. -4th row from the top, left side: 1-7 lbs. can cut yams (sweet potatoes) in syrup, dated 07/28/23, manufacturer's expiration date 09/20/25, medium sized dent at top of can and a large dent at bottom of can. -3- 6 lbs. 12 oz can of Texas rancheros style pinto beans dated 09/22/23, manufacturer's expiration date 06/20/25, dented on top and bottom of cans. -5th shelf (middle of back wall), 2nd row: -when preparing to look at a 2lbs 10 oz. cannister of old-fashioned oatmeal dated 09/29/23, there was a switchblade type knife, in opened position, sitting on top of the oatmeal cannisters. -1 Large zip top bad dated 09/26/23 with 1.99 lbs. bag of potato pearls (dehydrated potato flakes) no clear visible packaging label, no written label of item description, no consume by or discard by date. -3rd row from the top: -1 large zip top bag with 1.86 lbs. bag of refried beans, dated 09/08/23, no open date, no consume by or discard by date. -4th row form the top: -1- 35 lbs. opened box of long grain parboiled rice, dated 09/22/23, in a blue plastic bag, open to air, no opened date, no consume by or discard by date. -1 35 lbs. opened box of long grain parboiled rice, dated 09/12/23, in a blue plastic bag, open to air, no opened date, no consume by or discard by date. -1-10 lbs. previously opened bag of wheat semolina pasta, dated 07/02/23, no opened date, product packaging label no visible, no written item of description, no consume by or discard by date. -1 Extra-large bag of elbow noodles, no visible received by date, previously opened, wrapped in plastic wrap, no opened date, no label of item description, no consume by or discard by date. -1-5 lbs. bag of cornbread mix in zip top bag, dated 09/02/23, no received by date, no label of item description, no consume by or discard by date. Observations of kitchen on 10/12/23 at 11:04 AM revealed the following: -Cook K was standing behind the steam stable and had finished temperatures had grabbed plates to start preparing meals, touched his forehead with the back of his hand and did not go wash his hands or put on gloves before he proceeded to prepare plates for the halls. -Cook G came back to the kitchen with a new food warmer but did not change his gloves or wash his hands when he returned to the kitchen. Cook G went to the kitchen door to answer it and took lunch tickets from a CNA but did not change gloves or wash his hands before going back to receiving side of the steam table. Observations of Dry Storage Room on 10/12/23 at 01:24 PM revealed the following: -On right side, last shelf, 3rd row from the top: -1-25 lbs. bag of non-fat milk powder dated 04/17/21, no consume by or discard by date. Observation of dining room on 10/12/23 at 01: 27 PM revealed the following: -On the counter where juice and coffee items are held under the juice machine, in cabinet nearest the kitchen's main entrance, was a garbage receptacle that was full of trash and had a dark thick dried substance running down the sides of the garbage receptacle. In an interview on 10/10/23 at 09:53 AM with [NAME] K, when asked about the illegible date written on the side of the box of cabbage, he stated it read either 09/27 or 09/29 then he settled on 09/29/23. He stated dating the new products received let staff know when it came into the kitchen and then you can figure out how long you can keep it as well as look or smell of the product. In an interview and observation on 1/11/23 at 11:30 AM with the Dietary Manager, she stated they keep leftovers in the refrigerator for 3 days. There were two sets of sliced cheddar cheese opened with different dates and the Dietary Manager was asked how long is opened cheese kept, the Dietary Manager stated they put an end date on the cheese. She said, it varies on how long opened items are kept in the dry storage room because they do not stay long. The Dietary Manager had entered the dry storge room while the surveyor was doing a round. She asked if there was there any concerns. She was shown the rice and how it was left open to air. She noted the switchblade knife and put it in her pocket. When asked about the open switchblade knife left open sitting on top of the oatmeal, she stated they know they are not supposed to leave that there. She stated the harm could be to staff or any person that came in the kitchen and reached for the product before seeing the knife and get cut/injured. The Dietary Manager was able to show where the dented can were but there was a non-dented can with the dented cans, she stated she did not see that regular can with the dented cans, on the bottom shelf. The Dietary Manager stated she would have to check the policy to see how long they kept canned goods with no expiration date and get back to me. The Dietary Manager stated they kept opened items in the freezer for 6 months to 1 year. She stated she does inventory and rotates the stock. She stated they use First In-First Out system. The Dietary Manager stated the kitchen served 69 residents. In an interview on 10/12/23 at12:12 PM with the Dietary Staff, [NAME] K answered and said, cross contamination was the harm to resident regarding dust on the vent of the ice machine and any other items, could lead to sickness and death of the residents. Review of the Facility's Nutrition Services Food Storage Policy and Procedure, Policy Number: 03.003; Date Approved: October 1, 2018; Date Revised: June 1, 2019; reflected that Policy: To ensure that all 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 HAACCP guidelines. Procedure: 1. Dry storage rooms . e. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated G. Where possible, leave items in the original cartons placed with the date visible. Use the firs-in, first-out (FIFO) rotation method. Date packages and place new items behind existing supplies, so that the older items are used first. 2. Refrigerators . e. Use all leftover within 72 hours. Discard items that are over 72 hours old 3. Freezers . c. Store all foods on racks or shelves off the floor. d. Do not over stock the freezer and leave space between items to further improve air circulation. Review of the U.S. FDA Food Code 2022 reflected: Chapter 3 section 3-501.17 . Commercial processed food: Open and hold cold . B. 1. The day the original container is opened in the food establishment shall be counted as Day 1. 2. The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on FOOD safety. C. 2. Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (A) of this section. 3. Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded as specified under (B) of this section. Definitions 3. Food Receiving and Storage - When food, food products or beverages are delivered to the nursing home, facility staff must inspect these items for safe transport and quality upon receipt and ensure their proper storage, keeping track of when to discard perishable foods and covering, labeling, and dating all PHF/TCS foods stored in the refrigerator or freezer as indicated. www.fda.gov

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record reviews, the facility failed to immediately inform the resident representative(s) when there was- A significant change in the resident's physical, mental, or psychosocial status that was, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications or Resident #1. The facility failed to ensure LVN A notified the residents representative when Resident #1 was sent to the ER (Emergency Room) after a change in condition occurred during dialysis on 6/28/23. This failure placed residents at risk of a delay in resident representative involvement in care, and a worsening of their condition. Findings included: Record review of Resident #1's admission MDS assessment dated [DATE] revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of End Stage Renal Disease, Diabetes Mellitus (high blood sugar), and Acute on Chronic diastolic (congestive) Heart Failure. He had a BIMs of 15 (cognitively intact). Resident #1 required limited to extensive assistance with ADLs. Oxygen usage while a resident and while not a resident was not indicated on the MDS. Record review of Resident #1's progress notes dated 6/27/23 at 1:28pm written by LVN B, revealed Resident #1 reported having SOB and the physician was notified. Oxygen was placed on the resident at 2 Liters. Record review of Resident #1's progress notes from 6/28/23 revealed there were no further progress notes input before, during or after the resident's discharge. Record review of Facility's Resident Availability record revealed Resident #1 was sent to dialysis at 7:30am on 6/28/23. No return was recorded after that entry. Record review of Resident #1's dialysis communication sheets revealed no communication sheet was available for 6/28/23. Record review of Resident #1's Discharge summary dated [DATE] at 5:00pm revealed the reason for discharge was the resident was sent to the hospital from dialysis. Record review of Resident #1's Acute Care Hospital emergency room Clinical Report dated 6/28/23 revealed he was admitted on [DATE] at 10:48 am with a chief complaint of dyspnea (difficulty breathing). That started 2 days ago; Patient was taken to dialysis with an empty oxygen tank. He was picked up from dialysis by EMS (emergency medical services) due to dyspnea. Record review of Resident #1's Dialysis Center Patient Notes dated 6/28/23 at 12:03pm revealed he arrived Resident #1 arrived at around 8:40pm with oxygen in place but visibly short of breath and having trouble catching his breath. Dialysis Center RN C discovered that portable oxygen tank was empty and Resident #1's oxygen saturation was 84%. He was placed on oxygen with a concentrator and his oxygen improved to 96%. After dialysis was attempted, he continued to be visibly short of breath and started complaining of chest pain. Dialysis was ended, and RN C sent him to the ER for evaluation. RN C called the Facility and notified them of transfer to ER due to SOB. Interview on 7/25/23 at 12:43pm with Resident #1 revealed on 6/28/23 he felt breathless, while at dialysis. He stated he felt he needed oxygen and was not sure why he was not getting any from the oxygen tank and felt it was not working or ran out of oxygen. He stated he alerted the Dialysis Center staff and they brought him to the back and started helping him. He ended up going to the Acute Care Hospital emergency room. He was sent to the emergency room within 1 hour of leaving the Facility. He cannot recall if the nurse gave him a full tank of oxygen before leaving the Facility. Interview with the Dialysis Center Administrator on 7/25/23 at 1:37pm, revealed that on 6/28/23, Resident #1 was transported to the Dialysis Facility and brought to the lobby while he awaited his chair to be ready. Shortly after he arrived, he started to complain of SOB, a nurse checked his oxygen levels, and it was low at 84%. This was when it was realized the oxygen tank, he was transported with, was empty. He was immediately brought back and hooked up to Dialysis Center oxygen at 8:40am and his oxygen saturation recovered to 96%. The Resident's dialysis was attempted for 25 minutes, and the resident remained unwell, so it was decided to send him to an Acute Care Hospital. Interview and record review with LVN A on 7/25/23 at 5:11pm revealed on 6/28/23 he helped get Resident #1 on oxygen before he left to dialysis. He stated he got the tank off the charging station and believed it was full. He stated once he was moved from the oxygen concentrator to the tank the resident complained the tank was not working properly. LVN A provided teaching to the resident that he needed to take a breath for the oxygen to be delivered. He stated there should be a progress note stating the resident's condition before going to dialysis. He stated there should be a dialysis communication sheet for 6/28/23 as well. LVN A reviewed the Physician Order List and revealed there was no order for oxygen administration or parameters. He stated there should be a standing order for oxygen. LVN A reviewed Progress Notes and revealed there was no progress notes before going to dialysis. He could not recall why and stated there should be. He said he did not notify Resident #1's family when he didn't return to the Facility. He said the risks of not documenting properly were the next person not knowing what happened. The risks of not having proper oxygen could be respiratory failure. Interview and record review with the DON on 7/25/23 at 7:44pm revealed progress notes would be found in the electronic medical record. Her expectation was that they would include the time and condition the resident was in at the time they left the Facility. She stated that her expectation was that documentation would accurately paint a picture of what was going on with the resident and included the proper information. She stated she did not attempt to communicate with dialysis center because LVN A received a call around 10:30am to 12:00pm that he was sent to ER for unknown reason. She did not call the Acute Care Hospital or Resident #1's family. She stated Facility did not have the Dialysis communication sheet from 6/28/23, she stated she didn't think to ask for it back. The Dialysis center didn't return the communication book back to them despite it being a part of Resident #1's medical records. She stated that all residents have a standing order for oxygen administration. Resident #1's progress notes reviewed and revealed no documentation on 6/28/23 in residents' electronic medical records. Resident #1's Physician Order Lists also reviewed and no standing order for oxygen administration was available. The Dialysis Communication sheet was also reviewed, and DON stated they do not have it. Interview with Administrator on 7/25/23 at 8:10pm revealed that the Resident Availability Record and vital signs record was their documentation that Resident #1 was properly assessed before leaving the Facility. Interview with Resident #1's FM 1 on 7/26/23 at revealed 10:25am revealed she was not notified of Resident #1s transfer from dialysis to the Acute Care Hospital. She was also unaware of why Resident #1 needed oxygen; he did not use oxygen at baseline. She stated there was no communication between the Facility and herself and or her FM 2 during the time Resident #1 was at the Facility. Interview with Resident #1's FM 2 on 7/26/23 at 11:19am revealed Resident was sent to Acute Care Hospital after he was sent to dialysis with an empty oxygen tank. FM 2 stated that the drive from the Facility to the Dialysis Center was about 30 minutes and he was not sure why the tank ran out so fast. He was not informed of Resident #1's hospitalization, or why he was sent with an empty oxygen tank to dialysis. He stated he made several calls before finding him in the Acute Care Hospital where he ended up being admitted for 2 or 3 days. He was not on oxygen at baseline, and he was unsure why he suddenly required oxygen. Record Review of facility policy named Change in a Resident's Condition or Status revised May 2017 revealed the nurse will notify the residents Attending Physician when there has been a significant change in the residents physical/emotional/mental condition, need to transfer the resident to a hospital/treatment center, discharge without proper medical authority. A significant change is described as a major decline or improvement that would not resolve without intervention by staff. It also revealed a nurse will notify the resident's representative when transferred to a hospital/treatment center, a decision has been made to discharge the resident, and for a significant change unless otherwise instructed not to

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety Resident #1. The facility failed to ensure LVN A performed the proper assessment while caring for a resident during oxygen administration and ensure oxygen equipment was in working order. This failure could place residents at risk of not being monitored or assessed properly along with not receiving the proper amount of oxygen which could lead to worsening of residents' condition. Findings included: Record review of Resident #1's admission MDS assessment dated [DATE] revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of End Stage Renal Disease, Diabetes Mellitus (high blood sugar), and Acute on Chronic diastolic (congestive) Heart Failure. He had a BIMs of 15 (cognitively intact). Resident #1 required limited to extensive assistance with ADLs. Oxygen usage while a resident and while not a resident was not indicated on the MDS. Record review of Resident #1s Physician Order List dated 6/19/23 revealed no standing order for oxygen administration. Record review of Resident #1's progress notes dated 6/27/23 at 1:28pm written by LVN B, revealed Resident #1 reported having SOB and the physician was notified. Oxygen was placed on the resident at 2 Liters. Record review of Resident #1's handwritten Physician Telephone Order dated 6/27/23. It read oxygen at 2-4 Lpm via N/C (nasal cannula) as needed to maintain O2 (oxygen) above 92% or for noted SOB. The order had the following missing information: Resident #1's date of birth , room number, attending physician, time ordered, notification of the above treatment change, time receiving order and date of physician signature. Record review of Resident #1's progress notes from 6/28/23 revealed there were no further progress notes input before, during or after the resident's discharge. Record review of Resident #1's Vital Signs Grid on 6/28/23 revealed vitals were entered at 7:27am, 7:46am, and 11:48am, no indication of oxygen use was noted in the note's column on the grid. Record review of Facility's Resident Availability record revealed Resident #1 was sent to dialysis at 7:30am on 6/28/23. No return was recorded after that entry. Record review of Resident #1's dialysis communication sheets revealed no communication sheet was available for 6/28/23. Record review of Resident #1's Discharge summary dated [DATE] at 5:00pm revealed the reason for discharge was the resident was sent to the hospital from dialysis. Record review of Resident #1's Acute Care Hospital emergency room Clinical Report dated 6/28/23 revealed he was admitted on [DATE] at 10:48 am with a chief complaint of dyspnea (difficulty breathing). That started 2 days ago; Patient was taken to dialysis with an empty oxygen tank. He was picked up from dialysis by EMS (emergency medical services) due to dyspnea. Record review of Resident #1's Dialysis Center Patient Notes dated 6/28/23 at 12:03pm revealed he arrived Resident #1 arrived at around 8:40pm with oxygen in place but visibly short of breath and having trouble catching his breath. Dialysis Center RN C discovered that portable oxygen tank was empty and Resident #1's oxygen saturation was 84%. He was placed on oxygen with a concentrator and his oxygen improved to 96%. After dialysis was attempted, he continued to be visibly short of breath and started complaining of chest pain. Dialysis was ended, and RN C sent him to the ER for evaluation. RN C called the Facility and notified them of transfer to ER due to SOB. Interview on 7/25/23 at 12:43pm with Resident #1 revealed on 6/28/23 he felt breathless, while at dialysis. He stated he felt he needed oxygen and was not sure why he was not getting any from the oxygen tank and felt it was not working or ran out of oxygen. He stated he alerted the Dialysis Center staff and they brought him to the back and started helping him. He ended up going to the Acute Care Hospital emergency room. He was sent to the emergency room within 1 hour of leaving the Facility. He cannot recall if the nurse gave him a full tank of oxygen before leaving the Facility. Interview on 7/25/23 at 1:06pm with the DON revealed the portable oxygen tank was a new system where they could be refilled in house. The station was found in the medication room, and they should be refilled by the nurses before they send a resident anywhere outside of the Facility. She stated when full they can last for 6 hours when being used at 2-6 liters. She stated the full tanks were stored in the oxygen room. Interview with the Dialysis Center Administrator on 7/25/23 at 1:37pm, revealed that on 6/28/23, Resident #1 was transported to the Dialysis Facility and brought to the lobby while he awaited his chair to be ready. Shortly after he arrived, he started to complain of SOB, a nurse checked his oxygen levels, and it was low at 84%. This was when it was realized the oxygen tank, he was transported with, was empty. He was immediately brought back and hooked up to Dialysis Center oxygen at 8:40am and his oxygen saturation recovered to 96%. The Resident's dialysis was attempted for 25 minutes, and the resident remained unwell, so it was decided to send him to an Acute Care Hospital. Interview and record review with LVN A on 7/25/23 at 5:11pm revealed on 6/28/23 he helped get Resident #1 on oxygen before he left to dialysis. He stated he got the tank off the charging station and believed it was full. He stated once he was moved from the oxygen concentrator to the tank the resident complained the tank was not working properly. LVN A provided teaching to the resident that he needed to take a breath for the oxygen to be delivered. He stated there should be a progress note stating the resident's condition before going to dialysis. He stated there should be a dialysis communication sheet for 6/28/23 as well. LVN A reviewed the Physician Order List and revealed there was no order for oxygen administration or parameters. He stated there should be a standing order for oxygen. LVN A reviewed Progress Notes and revealed there was no progress notes before going to dialysis. He could not recall why and stated there should be. He stated he received an in-service training within the last two months (May or June 2023) on how to properly use the oxygen tanks. He said the risks of not documenting properly were the next person not knowing what happened. The risks of not having proper oxygen could be respiratory failure. Interview and record review with the DON on 7/25/23 at 7:44pm revealed progress notes would be found in the electronic medical record. Her expectation was that they would include the time and condition the resident was in at the time they left the Facility. She stated that her expectation was that documentation would accurately paint a picture of what was going on with the resident and included the proper information. She stated she did not attempt to communicate with dialysis center because LVN A received a call around 10:30am to 12:00pm that he was sent to ER for unknown reason. She did not call the Acute Care Hospital or Resident #1's family. She stated Facility did not have the Dialysis communication sheet from 6/28/23, she stated she didn't think to ask for it back. The Dialysis center didn't return the communication book back to them despite it being a part of Resident #1's medical records. She stated that all residents have a standing order for oxygen administration. Resident #1's progress notes reviewed and revealed no documentation on 6/28/23 in residents' electronic medical records. Resident #1's Physician Order Lists also reviewed and no standing order for oxygen administration was available. The Dialysis Communication sheet was also reviewed, and DON stated they do not have it. Interview with Administrator on 7/25/23 at 8:10pm revealed that the Resident Availability Record and vital signs record was their documentation that Resident #1 was properly assessed before leaving the Facility. Interview with Resident #1's FM 1 on 7/26/23 at revealed 10:25am revealed she was not notified of Resident #1s transfer from dialysis to the Acute Care Hospital. She was also unaware of why Resident #1 needed oxygen; he did not use oxygen at baseline. She stated there was no communication between the Facility and herself and or her FM 2 during the time Resident #1 was at the Facility. Interview with Resident #1's FM 2 on 7/26/23 at 11:19am revealed Resident was sent to Acute Care Hospital after he was sent to dialysis with an empty oxygen tank. FM 2 stated that the drive from the Facility to the Dialysis Center was about 30 minutes and he was not sure why the tank ran out so fast. He was not informed of Resident #1's hospitalization, or why he was sent with an empty oxygen tank to dialysis. He stated he made several calls before finding him in the Acute Care Hospital where he ended up being admitted for 2 or 3 days. He was not on oxygen at baseline, and he was unsure why he suddenly required oxygen. Record Review of facility policy named Oxygen Administration revised October 2010 revealed after completing oxygen set up or adjustment record in residents medical record the date/time the procedure was performed, the rate of oxygen flow, route, and rationale, the reason for p.r.n administration, and all assessment data obtained before, during, and after procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices, on each resident that are- complete; accurately documented; readily accessible; and, systematically organized for 1 of 2 residents (Resident #1). The facility failed to maintain medical records for Resident #1's progress notes, telephone order, and dialysis communication sheet from 6/28/23 that were complete and accurate. This failure could place residents at risk of not recording a proper account of medical interventions, treatments, and outcomes during a residents' stay. Findings included: Record review of Resident #1's admission MDS assessment dated [DATE] revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of End Stage Renal Disease, Diabetes Mellitus (high blood sugar), and Acute on Chronic diastolic (congestive) Heart Failure. He had a BIMs of 15 (cognitively intact). Resident #1 required limited to extensive assistance with ADLs. Oxygen usage while a resident and while not a resident was not indicated on the MDS. Record review of Resident #1s Physician Order List dated 6/19/23 revealed no standing order for oxygen administration. Record review of Resident #1's progress notes dated 6/27/23 at 1:28pm written by LVN B, revealed Resident #1 reported having SOB and the physician was notified. Oxygen was placed on the resident at 2 Liters. Record review of Resident #1's handwritten Physician Telephone Order dated 6/27/23. It read oxygen at 2-4 Lpm via N/C (nasal cannula) as needed to maintain O2 (oxygen) above 92% or for noted SOB. The order had the following missing information: Resident #1's date of birth , room number, attending physician, time ordered, notification of the above treatment change, time receiving order and date of physician signature. Record review of Resident #1's progress notes from 6/28/23 revealed there were no further progress notes input before, during or after the resident's discharge. Record review of Resident #1's Vital Signs Grid on 6/28/23 revealed vitals were entered at 7:27am, 7:46am, and 11:48am, no indication of oxygen use was noted in the notes column on the grid. Record review of Facility's Resident Availability record revealed Resident #1 was sent to dialysis at 7:30am on 6/28/23. No return was recorded after that entry. Record review of Resident #1's dialysis communication sheets revealed no communication sheet was available for 6/28/23. Record review of Resident #1's Discharge summary dated [DATE] at 5:00pm revealed the reason for discharge was the resident was sent to the hospital from dialysis. Record review of Resident #1's Acute Care Hospital emergency room Clinical Report dated 6/28/23 revealed he was admitted on [DATE] at 10:48 am with a chief complaint of dyspnea (difficulty breathing). That started 2 days ago; Patient was taken to dialysis with an empty oxygen tank. He was picked up from dialysis by EMS (emergency medical services) due to dyspnea. Record review of Resident #1's Dialysis Center Patient Notes dated 6/28/23 at 12:03pm revealed he arrived Resident #1 arrived at around 8:40pm with oxygen in place but visibly short of breath and having trouble catching his breath. Dialysis Center RN C discovered that portable oxygen tank was empty and Resident #1's oxygen saturation was 84%. He was placed on oxygen with a concentrator and his oxygen improved to 96%. After dialysis was attempted, he continued to be visibly short of breath and started complaining of chest pain. Dialysis was ended, and RN C sent him to the ER for evaluation. RN C called the Facility and notified them of transfer to ER due to SOB. Interview on 7/25/23 at 12:43pm with Resident #1 revealed on 6/28/23 he felt breathless, while at dialysis. He stated he felt he needed oxygen and was not sure why he was not getting any from the oxygen tank and felt it was not working or ran out of oxygen. He stated he alerted the Dialysis Center staff and they brought him to the back and started helping him. He ended up going to the Acute Care Hospital emergency room. He was sent to the emergency room within 1 hour of leaving the Facility. He cannot recall if the nurse gave him a full tank of oxygen before leaving the Facility. Interview on 7/25/23 at 1:06pm with the DON revealed the portable oxygen tank was a new system where they could be refilled in house. The station was found in the medication room, and they should be refilled by the nurses before they send a resident anywhere outside of the Facility. She stated when full they can last for 6 hours when being used at 2-6 liters. She stated the full tanks were stored in the oxygen room. Interview with the Dialysis Center Administrator on 7/25/23 at 1:37pm, revealed that on 6/28/23, Resident #1 was transported to the Dialysis Facility and brought to the lobby while he awaited his chair to be ready. Shortly after he arrived, he started to complain of SOB, a nurse checked his oxygen levels, and it was low at 84%. This was when it was realized the oxygen tank, he was transported with, was empty. He was immediately brought back and hooked up to Dialysis Center oxygen at 8:40am and his oxygen saturation recovered to 96%. The Resident's dialysis was attempted for 25 minutes, and the resident remained unwell, so it was decided to send him to an Acute Care Hospital. Interview and record review with LVN A on 7/25/23 at 5:11pm revealed on 6/28/23 he helped get Resident #1 on oxygen before he left to dialysis. He stated he got the tank off the charging station and believed it was full. He stated once he was moved from the oxygen concentrator to the tank the resident complained the tank was not working properly. LVN A provided teaching to the resident that he needed to take a breath for the oxygen to be delivered. He stated there should be a progress note stating the resident's condition before going to dialysis. He stated there should be a dialysis communication sheet for 6/28/23 as well. LVN A reviewed the Physician Order List and revealed there was no order for oxygen administration or parameters. He stated there should be a standing order for oxygen. LVN A reviewed Progress Notes and revealed there was no progress notes before going to dialysis. He could not recall why and stated there should be. He said the risks of not documenting properly were the next person not knowing what happened. The risks of not having proper oxygen could be respiratory failure. Interview and record review with the DON on 7/25/23 at 7:44pm revealed progress notes would be found in the electronic medical record. Her expectation was that they would include the time and condition the resident was in at the time they left the Facility. She stated that her expectation was that documentation would accurately paint a picture of what was going on with the resident and included the proper information. She stated she did not attempt to communicate with dialysis center because LVN A received a call around 10:30am to 12:00pm that he was sent to ER for unknown reason. She did not call the Acute Care Hospital or Resident #1's family. She stated Facility did not have the Dialysis communication sheet from 6/28/23, she stated she didn't think to ask for it back. The Dialysis center didn't return the communication book back to them despite it being a part of Resident #1's medical records. She stated that all residents have a standing order for oxygen administration. Resident #1's progress notes reviewed and revealed no documentation on 6/28/23 in residents' electronic medical records. Resident #1's Physician Order Lists also reviewed and no standing order for oxygen administration was available. The Dialysis Communication sheet was also reviewed, and DON stated they do not have it. Interview with Administrator on 7/25/23 at 8:10pm revealed that the Resident Availability Record and vital signs record was their documentation that Resident #1 was properly assessed before leaving the Facility. Interview with Resident #1's FM 1 on 7/26/23 at revealed 10:25am revealed she was not notified of Resident #1s transfer from dialysis to the Acute Care Hospital. She was also unaware of why Resident #1 needed oxygen; he did not use oxygen at baseline. She stated there was no communication between the Facility and herself and or her FM 2 during the time Resident #1 was at the Facility. Interview with Resident #1's FM 2 on 7/26/23 at 11:19am revealed Resident was sent to Acute Care Hospital after he was sent to dialysis with an empty oxygen tank. FM 2 stated that the drive from the Facility to the Dialysis Center was about 30 minutes and he was not sure why the tank ran out so fast. He was not informed of Resident #1's hospitalization, or why he was sent with an empty oxygen tank to dialysis. He stated he made several calls before finding him in the Acute Care Hospital where he ended up being admitted for 2 or 3 days. He was not on oxygen at baseline, and he was unsure why he suddenly required oxygen. Record review of facility policy named Charting and Documentation revised July 2017 revealed the following information is to be documented in the residents medical record: objective observations, medication administration, treatments or services performed, changes in the resident's condition, events, incidents or accidents involving the residents, and progress or changes in the care plan goals and objectives. It should also be complete and accurate. The policy continues to say that procedures and treatment will include care-specific details including date and time procedure/treatment was provided, the assessment date and any unusual findings, notification of family, etc. Record Review of facility policy named Change in a Resident's Condition or Status revised May 2017 revealed the nurse will notify the residents Attending Physician when there has been a significant change in the residents physical/emotional/mental condition, need to transfer the resident to a hospital/treatment center, discharge without proper medical authority. A significant change is described as a major decline or improvement that would not resolve without intervention by staff. It also revealed a nurse will notify the resident's representative when transferred to a hospital/treatment center, a decision has been made to discharge the resident, and for a significant change unless otherwise instructed not to. Record Review of facility policy named Oxygen Administration revised October 2010 revealed after completing oxygen set up or adjustment record in residents medical record the date/time the procedure was performed, the rate of oxygen flow, route, and rationale, the reason for p.r.n administration, and all assessment data obtained before, during, and after procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident was treated with respect and dignity in a manner and in an environment which promotes maintenance of enhancement of his or her quality of life and recognizing each resident individually for one (Resident #1) five resident reviewed for resident rights. CNA A failed to speak to Resident #1, who was non-verbal and in the end-stages of life, in a respectful and dignified manner. This failure placed residents at risk for diminished quality of life, loss of dignity and self-worth. Findings included: Review of Resident #1's MDS assessment dated [DATE] reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident's diagnoses included cerebral vascular accident (stroke), non-Alzheimer's dementia, hemiplegia (paralysis to one side of the body), depression, and need for assistance with personal care. Resident #1 had severe cognitive impairment with a BIMS of 0. Review of Resident #1's care plan with an onset date of 03/16/23 reflected the resident required staff assistance for all ADLs. The care plan further reflected Resident #1 was on hospice services for a terminal diagnosis of senile degeneration of the brain. Review of Resident #1's Hospice RN-Skilled Nursing Visit Addendum Page, dated 05/19/23, reflected the following: .Upon arrival to the patient's room [Resident #1] today, her granddaughter informed me the aide at the facility had been rude to the patient during the night. There is video evidence. The incident occured on 05/18 around 0400 [4:00 AM]. She emailed the videos to .RN, DON. She showed me the video. The following is from memory. I only seen the videos once (there are two). The aide walks into the room and identifies herself as [CNA A]. She speaks to the patients roommate and then walks towards [Resident #1]. She hears [Resident #1] moan out and immediately throws her head back and groans. [Resident #1] is heard groaning and the aide [CNA A] says something close to, WHat [sic] do you want, I can't understand you, need to stop it. She then closes the curtain for [Resident #1], walks behind the curtain, says something this nurse didn't hear. The roommate begins getting up and says something. The aide then says something like you don't need to worry about this, I'm taking care of it. She then walks towards where the door is an is no longer seen. The facility is aware of the situation. At the time of talking wtih the granddaughter, the facility had not spoken with them about the situation. Upon my departure, the ADON was going into [Resident #1's] room. Prior to that I informed her of the incident. She told me they were aware and had all seen the video. I asked why the aide was once again in charge of her care on the night of 5/18 (reported by the granddaughter). She seemed unaware that had happened. Informed her that it was inappropriate and should not happen again Review of the video on 06/05/23 revealed CNA A entered Resident #1's room on 05/18/23 at 4:00 AM. Resident #1 and her roommate (Resident #2) were both in bed. CNA A walked past Resident #1 and said to Resident #2, You okay [Resident #2[ .It's just me [CNA A]. She proceeded to pull the privacy curtain between Resident #1 and Resident #2. When Resident #1 heard CNA A's voice, she began to make whimpering and moaning sounds. CNA A then dropped her shoulders and looked up at the ceiling in an exasperated motion. CNA A goes over to Resident #1's side of the room and says to Resident #1, Can I help you? Resident #1 whimpers/moans again, and CNA A CNA A responded, I don't understand what that means. CNA A then goes behind the curtain on Resident #1's side of the room outside of direct camera view from the foot of her bed towwards the head of the bed, and Resident #1 whimpers again. CNA A responded loudly, Stop it! Resident #2 hears CNA A and tries to communicate with CNA A. CNA A told her, I'm not talking to you [Resident #2] you just need to lay down and let me take care of it. The rest of the interaction between CNA A and Resident #1 was not visible because of the privacy curtain, and the video ended shortly thereafter. Interview on 06/05/23 at 1:50 PM with the Hospice Nurse revealed a video was brought to her attention by Resident #1's family where CNA A was speaking to the resident in a manner she found inappropriate. The Hospice Nurse said she reported the incident on 05/19/23 to her DON and the facility's ADON, who told her the facility had already been made aware of the situation. Interview on 06/05/23 at 2:00 PM with the Hospice ADON revealed Resident #1 was actively dying (near death) at the time of the incident and was not able to verbal communicate any longer. The Hospice Nurse stated she watched the video. She stated Resident #1's family was upset due to the way CNA A had spoken to the resident. The family decided to stay with the resident until she passed away, the following day after the incident on 05/18/23. Attempts to contact CNA A and Resident #1's family on 06/06/23 were unsuccessful. Interview on 06/06/23 at 1:24 PM with the ADON revealed Resident #1's family brought the video to her attention after the incident 05/19/23. The ADON said the actions in the video were considered poor customer service from CNA A and Resident #1's family had asked the CNA no longer care for the resident. The ADON reported the CNA's actions to the Administrator and the DON. CNA A was brought in and counseled/re-inserviced on proper customer service when providing care to the residents. Review of In-Service Training Report titled Customer Service/Professionalism dated 05/20 /23 provided by the ADON and signed by CNA A reflected the following: .is expected to maintain professionalism as it relates to performance, care of the residents. Customer service skills, language and (body language.) Interview on 06/06/23 at 2:04 PM with the Administrator revealed the video of CNA A and Resident #1's interaction had been brought to his attention by the ADON when she was made aware of the incident, 05/19/23. The Administrator stated the ADON had called in the CNA and re-inserviced her on resident customer service and the aide was removed from the care of Resident #1 at that time. Review of the facility's policy titled Quality of Life - Dignity revised 10/04/22 reflected the following: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. 1. Resident shall be treated with dignity and respect at all times. .7. Staff shall speak respectfully to residents at all times, including addressing the resident by his or her name of choice

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 the facility's only kitchen. 1.The facility failed to ensure food items in the refrigerator were labeled and stored in accordance with the professional standards for food service and the facility's policy. 2.The facility failed to discard items stored in the refrigerator or dry storage that were not properly sealed/secured, damaged or past the 'best use by', consume by or expiration dates. These failures could place residents at risk for food-borne illness and cross contamination. Findings included: Observations of the walk-in refrigerator on 08/21/22 at 9:39 AM -On right shelf, next to door. In a zip top bag, labeled 08/19/20, there was some shredded cheese in its original package that was open to air inside of the zip top bag that was also open to air. There was no item description or use by date reflected. -Diced Honeydew in medium metal container, covered in plastic wrap, dated 8/7/22, no item description or use by date. -Chili in large metal container, covered in plastic wrap, dated 8/16/22 with no use by date. -Vegetable cream-based soup in small metal container, dated 08/18/22, no item description or use by date. -2-4 oz. containers of Peach yogurt, no received date with expiration date of 08/20/22. -On 2nd shelf in the back, was ground meat in a small metal container, no description label or a prepared/opened date or a use by date. - 2 trays of 50-4oz. clear cups with brown liquid with plastic lids on top, on rack, in rear right side of fridge, with no labels on trays of when pulled/prepared date, item description or use by date. -10 bowls of pureed angel food cake with strawberry sauce, there was no label of preparation date, no item description, no use by date, no covering. -There were 3 more trays with a total of 66 bowls of Angel food cake with strawberry sauce, no item description, preparation date, no covering, no use by date. Observations of the dry storage room on 08/21/22 at 10:23 AM revealed the following: -2 bags of [NAME] Gravy mix opened then sealed in plastic wrap, no item description, no open date or use by date reflected. - 1 bag of mashed potato flakes opened, sealed in plastic wrap, no item description, no date opened or use by date reflected. -1 large bag of powdered sugar opened, placed in a zip top bag, no label for item description, no opened date or use by date reflected. - 1 bag of Pepper Biscuit gravy mix opened, then sealed in plastic wrap, no label of item description, no opened date or use by date. - 842 oz containers of Oats, had no received dates. -1 large bag of Grits dated 11/23/21 with an expiration 4/14/22. -2 Boxes of grits dated 12/7/21 with expiration 5/2/22. Observation of reach-in refrigerator on 08/21/22 at 9:44 AM revealed the following: 1-8oz container of 1/3 less fat cream cheese block that expired on 08/12/22. Observation of freezer on 08/21/22 at 10:12 AM revealed the following: -There were two stacks of boxes stacked on the floor to the left side freezer door. One stack was 2 small boxes tall and the other stack 3 boxes high. -There was a large ice formation on the top and 2nd box of the 2 box stack attaching the two boxes and another formation starting on the 3 box stack. Observations and interview of the kitchen on 08/21/22 at 9:39 AM revealed the following: -There was one tray of snacks sitting under the prep table on top of the juice mix boxes, that connected to juice machine. The snack tray was not labeled to reflect the date the snacks were pulled. -A Hanging rack over the food prep table with cooking utensils hanging from it, had greasy residue build up. -The Cleaning Schedule for 8/1/22-8/8/22 was posted on glass of Managers office, and there were several areas left uninitialed. There was not a current cleaning schedule posted -1 potato sitting on top of the steam table, unwrapped and unlabeled, no pulled or use by date. In an interview on 08/21/22 at 10:05 AM, the Dietary Manager stated leftovers are held in the fridge for 3 days. She said, my expectations of staff is to put open dates on dry goods. She said, We have been short staff since January 2022 I have been working as the [NAME] too. She stated it was everyone's job to label food items when they come in. Observation of Lunch Service on 08/24/22 at 11:06 AM revealed the following: Entered kitchen, staff already starting to plate lunch meals. Staff present: Dietary Manager, Dietary Aide C, [NAME] A, and Dietary Aide D. Dietary manager stated Dietary Aide D is new. Dietary Aide D said, I have been here for a week and a half -Trash receptacle for the hand washing sink, next to the walk-in refrigerator, has items other than paper towels inside. There are plastic bags from the mash potato flakes and gloves in the trash receptacle. -At 11:16 AM Dietary Aide D went from prepping trays to starting to break apart the dinner rolls, without removing or changing gloves. Review of the Facility's Nutrition Services Food Storage Policy and Procedure, Policy Number: 03.003; Date Approved: October 1, 2018; Date Revised: June 1, 2019; Approved by: [NAME] Odefey MS, RDN, LD, reflected Policy: To ensure that all 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 HAACCP guidelines. Procedure: 1. Dry storage rooms . e. To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated G. Where possible, leave items in the original cartons placed with the date visible. Use the first-in, first-out (FIFO) rotation method. Date packages and place new items behind existing supplies, so that the older items are used first. 2. Refrigerators . e. Use all leftover within 72 hours. Discard items that are over 72 hours old 3. Freezers . c. Store all foods on racks or shelves off the floor. d. Do not over stock the freezer and leave space between items to further improve air circulation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff for one (Hall 400) of three halls and two of three (main dining and bistro dining area) dining areas observed for environment, in that: The facility failed to ensure furniture (chairs) were in good repair for Rooms #407, #408, #412, #414, #415, and #417, and in the main dining and bistro dining area. These failures could place residents at risk for diminished quality of life due to the lack of a well-kept furniture. Findings included: An observation of Room#415 on 08/21/22 at 10:36 a.m., revealed a straight back sitting chairs seat bottom was frayed and torn with the foam exposed. An observation of room [ROOM NUMBER] on 08/21/22 at 10:42 a.m., revealed a straight back straight back sitting chairs seat bottom was frayed and torn with the foam exposed. An observation of the main dining area on 08/21/22 at 10:50 a.m., revealed six dining chairs seat bottoms was frayed and torn with the foam exposed. An observation of the Bistro dining area on 08/21/22 at 11:05 a.m., revealed four dining chairs seat bottoms was frayed and torn with the foam exposed. An observation of room [ROOM NUMBER] on 08/21/22 at 11:15 a.m., revealed a straight back sitting chairs seat bottom was frayed and torn with the foam exposed. An observation of room [ROOM NUMBER] and interview on 08/21/22 at 11:30 a.m., revealed a straight back sitting chairs seat bottom was frayed and torn with the foam exposed. The family member of Resident #77 was visiting and stated she had asked for another chair to sit in, and the staff provided another chair that was torn. I told the staff I ws not going to sit in a torn chair. The family member said , since they were going to be here every day they had just brought their own folding chair. An observation of room [ROOM NUMBER] and interview on 08/22/22 at 11:45 a.m., revealed a straight back sitting chairs seat bottom was frayed and torn with the foam exposed. Resident #149 stated she was aware the chair was torn, and it did not look nice and she would like it to look nicer, but her visitors usually stood when they came to visit, or we go outside to the gazebo area and visit. An observation of the administrator's office on 08/21/22 at 12:00 p.m., revealed two straight back sitting chairs seat bottom was frayed and torn with the foam exposed. An observation of room [ROOM NUMBER] and interview on 08/22/22 at 1:00 p.m., revealed Resident #153 and his wife were visiting in his room. Resident #153 stated his wife had to get the staff to provide a chair to sit in that did not have a torn bottom. He stated the chair she was sitting in stayed in the room, because the other one was all torn up, just look at it. Interview on 8/21/22 at 10:15 a.m., LVN E revealed if something was broken or needed to be repaired the staff wrote it in the maintenance log. LVN E stated the log was located at the nurse's station. LVN E stated if the furniture was broken she would let the maintenance man know, by writing it in the book at the nurse's station. LVN E stated she was not aware any of the chairs broken, some of them are worn looking, they could use some new material. The LVN said she had not reported to anyone about the worn chairs. In an observation and interview on 08/21/22 at 12:50 p.m., CNA F revealed if something was broken it would be written in the maintenance log at the nurse's station. The CNA went to the nurse's station and the book was at the nurse's station. CNA F stated some of the chairs are worn and if the families or residents complain she finds a chair that does not have material worn out on the bottom. The CNA stated she had not told anyone. Interview on 08/23/22 at 1:00 p.m., the Administrator revealed he was aware that the chairs used for dining and in resident's rooms, needed repair. The Administrator said he was going to have few chairs bottoms reupholstered at a time, as it was expensive, but he had not gotten that started. The Administrator stated he would have the maintenance man remove all the chairs right away and he would complete a quality assurance plan on the replacement of the chairs, he did not want the residents or the families to sit in chairs that required repair. The Administrator stated he was unaware of any complaints concerning the chairs. Review of the Maintenance log report reflected for the months of March, April, May, June and July of 2022, there was no documentation related to the condition of the chairs. The Maintenance Director was unavailable during the visit. Review of the Policy/Procedure Cleaning/Repairing Carpeting and Cloth Furnishings, dated December 2009 reflected .cloth furnishing shall be .repaired promptly .Upholstered furniture shall be kept in good repair and replaced if torn excessively .