**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 3 of 6 resident (Residents #11, #13, #14) reviewed for respiratory care. 1. The facility failed to ensure Resident #11, #13, #14's nebulizer/Mask and tubing were kept in a bag while not in use. These failures could place residents at risk for infections and transmission of communicable diseases. Findings include: Record review of Resident #11's face sheet, dated 3/26/25, reflected an [AGE] year-old female, who was admitted to the facility on [DATE]. Resident #11 had diagnoses which included, cerebral infarction (stroke), diverticular disease of intestine (abnormal pouches form in the bowl wall), dementia (cognitive decline), encephalopathy (disease of the brain), asthma (inflammatory disease in the lungs). Record review of Resident #11's MDS quarterly assessment dated [DATE], reflected a BIMS score of 3 which indicated severe cognitive impairment. Section O of the MDS reflected: respiratory therapy. Record review of Resident #11's Physician Orders, revealed, 3 ML INHALE ORALLY EVERY 4 HOURS AS NEEDED FOR SHORTNESS OF BREATH OR WHEEZING VIA NEBULIZER. Record review of Resident #11's MAR date 3/26/25 revealed the last breathing treatment was 3/26/25 at 10:50am. Record review of Resident #11's quarterly Care Plan, dated 2/2/25, revealed Resident #11 had a diagnosis of asthma and to give nebulizer treatments and oxygen therapy as ordered. In an observation on 3/26/25 at 12:55pm, revealed Resident's #11 was lying in bed, and sleeping. Observed the nebulizer/mask and tubing sitting on the bedside table with the tubing touching the floor, and the nebulizer and tubing not bagged. Record review of Resident #13's face sheet, dated 3/26/25, reflected a [AGE] year-old female, who was admitted to facility 9/2/23, with diagnoses which include, Fracture of right femur (thigh bone), atrial fibrillation (abnormal heart rhythm), Chronic Obstructive Pulmonary Disease (damage to lungs). Record review of Resident #13's MDS quarterly assessment dated [DATE] reflected a BIMS score of 13 which indicated the resident was cognitively intact. Record review of Resident #13's Physician Orders, revealed, Ipratropium-Albuterol 0.5-2.5 (3) MG/3ML Solution, 1 vial inhale orally every 4 hours as needed for SHORTNESS OF BREATH. Record review of Resident #13's quarterly Care Plan, dated 3/15/25, revealed Resident #13 was diagnosed with Chronic Obstructive Pulmonary Disease and medications were to be administered as ordered. In an observation on 3/26/25 at 1:03pm, revealed Resident's #13 in her room sitting in wheelchair visiting with family. Observed the nebulizer mouthpiece hanging on a hook on the wall behind a recliner and not bagged. The resident stated that staff hung the nebulizer mouthpiece on the hook to keep it off the floor. The resident could not recall the last breathing treatment, stating it was sometime yesterday 3/25/25. Record review of Resident #14's face sheet, dated 3/26/25, reflected an [AGE] year-old male, admitted to the facility 4/29/22, readmit 2/27/25, with diagnoses which include, nontraumatic subarachnoid hemorrhage (type of stroke), Heart failure, edema (fluid retention), atrial fibrillation (abnormal heart rhythm). Record review of Resident #14's MDS re-admit assessment dated [DATE], reflects a BIMS score of 1, which indicated severe cognitive impairment. Record review of Resident #14's Physician Orders, Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML 1 VIAL INHALE ORALLY EVERY 6 HOURS AS NEEDED FOR SHORTNESS OF BREATH. Record review of Resident #11's MAR, revealed the last Breathing treatment was 3/26/25 at 8:00 am. In an observation on 3/26/25 at 1:15pm, revealed Resident #14 was lying in bed sleeping. The nebulizer/mask and tubing observed sitting on the bedside table not bagged. Interview on 3/26/25 at 3:20pm, the DON stated that her expectation was that staff were to bag nebulizer masks and tubing in a plastic bag after use. The DON stated that placing a nebulizer mask and tubing in bag could prevent equipment from getting dirty and damaged and helped with infection control. Review of Facility policy: Departmental (Respiratory Therapy) Nursing Prevention of Infection, Med-Pass date 2001 (Revised April 2007) revealed: Steps in procedure: Infection Control Considerations related to Medication Nebulizer/Continuous Aerosol: 7. Store the circuit in plastic bag, marked with date and resident's name, between uses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, and interview and record review the facility failed to ensure that drugs and biologicals were secured and stored in locked compartments, and permit only authorized personnel to have access to the keys for 1 of 2 treatment and medication carts (Hall 200 treatment cart ) observed for medication storage, The treatment cart on hall 200 was left unlocked in the hallway by room # 216. This failure placed the residents at risk for medications being misappropriated or for potential harm and adverse reactions from access to medications not prescribed for them. The findings included: In an observation and interview on hall 200 on 12/31/24 at 9:16 AM a treatment cart was left unlocked in the hallway beside room [ROOM NUMBER]. There were no staff members or residents in view of the cart. The State Surveyor walked down the hallway and around a corner . The Administrator was observed sitting at a table doing paperwork at a table located in a sitting area. The cart was not in view by the administrator. The surveyor informed the administrator of the unlocked treatment cart on the 200 hall. The administrator stated it should be locked, and she would take care of it. The administrator then escorted the surveyor to the conference room and left . In an observation on hall 200 and interview at 9:20 AM on 12/31/24, the cart was still unlocked and parked beside the wall next to the door of room [ROOM NUMBER] with the drawers facing the hallway . There were no staff or residents in the hallway at that time. The DON came down the hallway and locked the cart . She stated, I locked the cart and started to walk away. The surveyor asked her to come back and open the cart. She turned around to come back, and as she started back toward the cart the Wound Care Nurse and the Wound Care Physician came out of a resident room. In an interview and observation on 12/31/24 at 9:23 AM the Wound Care Nurse stated the DON had told her she left the cart unlocked. She stated she was not sure how long she was in the room to do wound care. She stated the cart should be locked and never left unattended in order to prevent residents from getting a medication that was not meant for them. She stated there were all sorts of adverse outcomes that could occur, but she really couldn not think at the moment. She then stated Well, they could get into something that was not meant for them. She opened the cart at the surveyor's request. There were several tubes of topical prescription and non- prescription creams which included antifungal creams, prescription antibiotic cream, nonsteroidal anti-inflammatory gels, and different dressing supplies and topical medication used for wound care. There was also a pair of scissors in a drawer beneath that drawer. In an interview with the DON at 9:45 AM on 12/31/24 She stated her expectation was that the medication and treatment cart should be kept locked at all times. She stated she had talked to the treatment nurse, and she would do an Inservice with staff on the importance of keeping the carts locked. She stated not locking medication and treatments could lead to a resident getting a medication that was not intended for them and having an adverse reaction. The security of the treatment cart was not specifically addressed in the policy provided. Record review of the facility policy Security of Medication Cart, dated revised April 2024, revealed the following [in part]: The medication cart shall be secured during medication passes. 1. The nurse must secure the cart during the medication pass to prevent unauthorized entry. 2. The medication cart should be parked in the doorway of the resident's room during the medication pass. The cart and doors and drawers should be facing the resident's room. 3. When it is not possible to park the medication cart in the doorway, the cart should be parked in the hallway with the doors facing the wall. The cart must be locked before the nurse enters the resident's room. 4. Medication carts must be securely locked at all times when out of the nurse's view. 5. When the medication cart is not in use it must be locked and parked at the nurse's station. Or inside the medication room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents have the right to formulate an advance directive for 1 of 24 residents (Resident #279) reviewed for advanced directives. The facility failed to maintain medical records on each resident that are complete, and accurately documented for Resident #279. This failure could affect residents by not having their preferences honored concerning advanced directives . Findings included: Record review on [DATE] of Resident #297's electronic face sheet revealed an [AGE] year-old female, admitted on [DATE] with a DNR status and a diagnosis of, unspecified fracture of right femur, and heart disease. Resident #297's Record Review on [DATE] of Resident #297's MDS Section C Cognitive Status, indicated the residents BIMS was 13 (cognitively intact). Record review on [DATE] of Resident #297's physician's orders dated [DATE] revealed there was an order for DNR. Resident #297's CP (Care Plan) dated [DATE] revealed she had a MPA (Medical Power of Attorney) on file with a Full Code status. Record review on [DATE] of Resident #297's electronic health record from [DATE] through [DATE] revealed there was no evidence of the following: *Advanced Directive for Out of Hospital Do Not Resuscitate Order (OOH-DNR) form; *Progress notes related to the DNR status; *Preadmission Advanced Directive Information form; *Advanced Directive for Out of Hospital Do Not Resuscitate Order (OOH-DNR) verbal assessment. During an interview and Record Review on [DATE] at 10:30 AM the DON stated Resident #297's code status was DNR and had documentation of the Physician order in the electronic chart. The DON stated there was a book at the nurse's station that revealed if residents had a DNR code status DNR, indicated by a RED paper, and Full code status, indicated by a green paper. She stated the SW may have the signed consent on her desk if she was a new admission. The DON reviewed Resident #297's CP and stated the resident was a Full Code status, she must have placed the DNR order on the wrong resident and would go take it out of PCC (electronic charting) immediately. During an interview on [DATE] at 10:48 AM the SW stated Resident #297 was a Full Code and did not have a DNR status or a consent form for her. She stated Resident #297's CP also revealed a Full Code status. The SW stated she did not know what the floor nurses looked at during a code, whether it be the book at the nurse's station or the electronic charting. Record Review of the DNR book dated [DATE] revealed Resident #297 had a green paper that indicated a full code status. During an interview on [DATE] at 11:05 AM, LVN A stated when a resident had a code she looks at the electronic charting for that resident. She revealed in PCC where she would have looked for the resident code status (DNR/Full code) under resident name. LVNA stated, if the resident was sent to the ER, the code status would then have looked at the code status book. She stated if there was a DNR status for that resident there would have also been an order, which would verify a consent that the status would be correct. LVN A stated there would be a negative impact to resident with time lost to being resuscitated. During an interview on [DATE] at 1:15 PM the DON stated she was at home and misunderstood her SW when she called to place the code status order and was a mistake on her part. The DON stated the negative impact for resident would have been, residents have not gotten the correct medical treatment such as CPR if a Full code. She stated it was a typo on her (DON) part, as she misunderstood the SW's text message to place an order for DNR status for Resident #297. The DON stated her expectations was for the resident to fill out the paperwork on admission as well as not relying on texts. She stated the nurse placing the order for the DNR status would be present to verify the consent form. Record review of the facility's undated DNR policy on [DATE] revealed there was no evidence that addressed entering the wrong code status on a Resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident care plans were updated timely after completion of comprehensive assessments for 1 of 6 (Resident #38) reviewed for care plan timing and revision, in that: Resident #38's comprehensive care plan was not updated within seven days after completion of his comprehensive MDS Assessment on 6/28/2023. The facility's failure placed residents at risk of not having their needs met due to lack of direction related to care area triggers. The findings included: Record review of Resident #38 revealed a [AGE] year-old male with the following diagnosis: chronic kidney disease, Type 2 Diabetes Mellitus, Major Depressive Disorder, Vascular Dementia, Anxiety Disorders, Hypertension (high blood pressure) and constipation. Record review of Resident #38's MDS Nursing Home Comprehensive (NC) Item Set started June 14, 2023 and completed June 28, 2023 (date RN Assessment Coordinator signed assessment as complete) revealed CAA triggers for the following: 02. Cognitive Loss/Dementia 06/14/2023 04. Communication 06/14/2023 05. ADL Functional/Rehabilitation Potential 06/14/2023 06. Urinary Incontinence and Indwelling Catheter 06/14/2023 11. Falls 06/14/2023 12. Nutritional Status 06/14/2023 16 Pressure Ulcer 06/14/2023 17 Psychotropic Drug Use 06/14/2023 Record review of Resident #38's care plan revealed the following: - Cognitive Loss/Dementia, care plan was not updated to show it had been reviewed based on CAA trigger (06/14/2023) since the last revision dated 07/19/2019. - Communication, care plan was not updated to show it had been reviewed based on CAA trigger (06/14/2023) since the last revision dated 07/19/2019. - ADL/Functional/Rehabilitation Potential, care plan was not updated to show it had been reviewed based on CAA trigger (06/14/2023) since the last revision dated 07/19/2019. - Urinary Incontinence and Indwelling Catheter, care plan was not updated to show it had been reviewed based on CAA trigger (06/14/2023) since the last revision dated 07/19/2019. - Falls, care plan was not updated to show it had been reviewed based on CAA trigger (06/14/2023) since the last revision dated 07/19/2019. - Nutritional Status, no care plan for this issue found. - Pressure Ulcer, care plan was not updated to show it had been reviewed based on CAA trigger (06/14/2023) since the last revision dated 07/19/2019. - Psychotropic Drug Use, care plan was not updated to show it had been reviewed based on CAA trigger (06/14/2023) since the last revision dated 07/17/2019. In an interview on 08/29/2023 at 2:30 PM, the DON said that care plans should be updated no later than seven days after a comprehensive MDS assessment has been completed. The DON did not know why this one was not done and offered no resident outcomes. The facility supplied three policies related to care plans and comprehensive assessments, none of which indicated the number of days after a comprehensive assessment that a care plan should be completed or updated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for one of two residents (Resident #1) reviewed for infection control practices, in that: CNA A failed to perform proper hand before resident contact and after glove changes while providing incontinence care to Resident #10. This failure could place residents at risk for the spread of infection. The findings included: Review of Resident #10's face sheet dated 8/31/23, revealed an [AGE] year-old male admitted to the facility on [DATE] whose diagnoses included: high blood pressure, kidney disease, and malnutrition. Review of Resident #1's Significant Change MDS assessment dated [DATE] revealed Resident #10 required total dependence of ADL's and she was incontinent of both bowel and bladder. Observation of incontinence care performed by CNA A and CNA B for Resident #10 on 8/29/23 at 10:30 revealed CNA A did not perform hand hygiene after entering Resident 10 s room and prior to donning gloves to begin incontinent care. CNA A removed Resident #1's brief that was soiled with urine and feces. CNA A wiped the resident from front to back. CNA A did not perform hand hygiene after changing gloves and before positioning Resident #10 on her left side and cleaning her buttocks. He changed gloves and performed hand hygiene before placing a new brief on Resident # 10. He removed his gloves and performed hand hygiene before leaving the room. In an interview on 08/29/23 at 10:45 a.m. with CNA A, he revealed he should have washed his hands before starting care and performed hand hygiene between each glove change during care. CNA A stated he had infection control training. He said the resident could acquire an infection when he did not follow good infection control practices including washing hands before commencing care. He stated he was nervous and there were several knocks on the resident's door during incontinent care which cause him to become distracted. 29/23 During an interview with the DON on 8/29/23 at 1:00 PM., she revealed she was aware of some of the concerns raised about infection control. She stated she expected the aides to follow the facility protocols during care, one of which was to ensure hand hygiene when entering the residents' room before beginning care, between glove changes and when completing care and leaving the room. and change of gloves as needed. She stated the LVN's were responsible for monitoring the aides on a shift-to-shift basis. And the ADON's performed proficiency exams on the aides when they began employment and annually. She stated she intended to start inservicing her staff immediately. Review of the facility's infection control policy titled Hand washing/Hand Hygiene, dated August 2015, reflected the following [in part]: The facility considers hand hygiene the primary means to prevent the spread of infections. Use an alcohol-based hand rub or alternatively soap and water Before and after coming on duty, Before and after direct contact with residents and after removing gloves

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the health status for 4 of 26 residents (Residents #7, #35, #45, and #63) whose MDS assessments were reviewed, in that: 1. Resident #7 had contractures in two fingers of her right hand. Her MDS documented no limitations in ROM. 2. Resident #35 had contractures in the fingers of both hands. His MDS assessments documented no limitations in range of motion in his upper extremities. 3. Resident #45 had contractures in both of her legs. Her MDS assessments documented no limitations in range of motion in her lower extremities. 4. Resident #63 had contractures in two fingers of his left hand. His MDS assessments documented no limitations in range of motion in his upper extremities. This failure placed residents at risk for not receiving care and services to meet their physical needs and promote feelings of well-being and quality of life. The findings included: 1. Resident #7 Review of Resident #7's admission Record, dated 8/31/23, revealed a [AGE] year-old female admitted to the facility on [DATE] diagnoses included: hypertension (high blood pressure); muscle weakness, generalized; muscle wasting and atrophy (progressive and degenerative shrinkage of muscles or nerve tissues); dysphagia (difficulty swallowing), congestive heart failure (failure of the heart to adequately pump blood to the body) and mitral valve insufficiency( failure of the mitral valve to close which causes a back flow of blood to into heart). Review of Resident #7's Annual MDS Assessment, dated 6/10/23, revealed she was independent with personal hygiene and ADL's, and she had no limitations in ROM to her upper extremities and hands. Her BIMS score was 7 (moderate cognitive impairment) During an observation and interview on 8/29/23 at 10:26 AM, Resident #7 sitting up in her bed. She was noted to have contractures to the 3rd and 4th fingers of her right hand. Her fingernails were approximately ¼ inch long. She stated she would like them trimmed and filled, but she was unable to do it herself due to her arthritis in her hands. In an interview on 8/31/23 at 10:40 AM, the LVN MDS Coordinator stated she did not have a facility policy for completing MDS assessments. She stated she followed the guidelines of the RAI Manual. When questioned by the surveyor why she did not code the contractures to Resident #7's fingers as a limitation in ROM in her upper extremities, she stated Section G0400 of the RAI Manual defined upper extremity as the shoulder, elbow, wrist, and hand. The MDS nurse she talked to her company MDS consultant, and she stated if the limitation did not affect the resident's ability to feed himself, it could not be coded on the MDS. She stated Resident #7's functional status was not impaired. 2. Resident #35 Review of Resident #35's admission Record, dated 8/31/23, revealed a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of metabolic encephalopathy (brain dysfunction caused by problems with body metabolism). Additional diagnoses included: anxiety disorder; constipation; hereditary and idiopathic neuropathy (nervous system disorders that interfere with normal nerve function); major depressive disorder, recurrent; pseudobulbar affect (nervous system disorder that causes inappropriate involuntary laughing and crying); vascular dementia, unspecified (cognitive impairment caused by lack of blood flow to the brain); atherosclerotic heart disease (hardened arteries due to plaque build-up); dysphagia (swallowing problem); essential (primary) hypertension (high blood pressure); gastro-esophageal reflux disease (liquid content of the stomach refluxes into the esophagus); heart failure, unspecified; muscle wasting and atrophy; generalized muscle weakness; Parkinson's disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves); Type 2 diabetes mellitus (high blood sugar - adult onset). Review of Resident #35's Contracture Potential Assessment - Full Assessment, dated 5/04/23, revealed a score of 11 indicating the resident was at risk for contractures. The assessment documented the resident's state of health was poor/declining; he was confused; he had limited mobility in upper and lower extremities; he was chairfast; and had a diagnosis of Parkinson's disease. Review of Resident #35's Quarterly Contracture Potential Assessment, dated 8/05/23, revealed a score of 12 indicating the resident was at risk for contractures. The assessment documented the resident's state of health was poor/declining; he was confused; he had limited mobility in upper and lower extremities; he was chairfast; and had a diagnosis of Parkinson's disease. Review of Resident #35's admission MDS Assessment, dated 3/30/23, revealed a BIMS score of 00 out of 15 (severe cognitive impairment); he required extensive to total assistance with ADLs with 1 to 2 persons assisting, including extensive assistance with eating with one person assisting; did not walk; had no functional limitation in ROM in upper extremities or lower extremities; and used a wheelchair for mobility. Review of Resident #35's Significant Change in Status MDS Assessment, dated 4/27/23, revealed a BIMS score of 00 out of 15 (severe cognitive impairment); he required extensive to total assistance with ADLs with 1 to 2 persons assisting, including extensive assistance with eating with one person assisting; did not walk; had no functional limitation in ROM in upper extremities or lower extremities; and used a wheelchair for mobility. The assessment documented the resident was receiving hospice care services. Review of Resident #35's Quarterly MDS Assessment, dated 7/27/23, he required extensive to total assistance with ADLs with 1 to 2 persons assisting, including extensive assistance with eating with one person assisting; did not walk; had no functional limitation in ROM in upper extremities or lower extremities; and used a wheelchair for mobility. Observation on 8/28/23 at 11:16 AM revealed Resident #5 was lying on his back in bed on a foam mattress with the room call light in reach of his right hand. The resident was observed to have contractures in the fingers of both, with his hands closed in fists. Resident #35 was able to demonstrate use of his right thumb to activate the call light button. The resident was not using hand splints or soft hand rolls. In an interview on 8/31/23 at 5:40 PM, the LVN MDS Coordinator stated she did not have a facility policy for completing MDS assessments. She stated she followed the guidelines of the RAI Manual. She stated Section G0400 of the RAI Manual defined upper extremity as the shoulder, elbow, wrist, and hand. The LVN stated if the limitation did not affect the resident's ability to feed himself, it could not be coded on the MDS. She stated Resident #35 could eat finger foods. 3. Resident #45 Review of Resident #45's admission Record, dated 8/31/23, revealed a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted [DATE] with a primary diagnosis of post-laminectomy syndrome (failed back syndrome - a condition characterized by chronic pain following back surgeries). Additional diagnoses included: spinal stenosis, cervical region (abnormal narrowing of the spinal canal that puts pressure on the spinal cord and causes pain, numbness or weakness in the arms or legs); muscle wasting and atrophy (progressive and degenerative shrinkage of muscles or nerve tissues); generalized muscle weakness; chronic pain; unspecified dementia (impaired cognition); major depressive disorder, recurrent; insomnia; anxiety disorder; hyperlipidemia; essential (primary) hypertension (high blood pressure); hereditary and idiopathic neuropathy (nervous system disorders that interfere with normal nerve function); acute embolism and thrombosis of unspecified deep veins of right lower extremity (blood clot in right leg); gastro-esophageal reflux disease (liquid content of the stomach refluxes into the esophagus); chronic kidney disease, stage 3 unspecified (moderate loss of kidney function). Review of Resident #45's admission Contracture Potential Assessment, 1/06/23, revealed a score of 4 (not at risk for contractures); and assessed the resident as being alert, well nourished, having a general state of health of fair, full mobility in upper and lower extremities, and needs help with cane/walker. Review of Resident #45's Quarterly Contracture Potential Assessment, dated 8/05/23, revealed a score of 13 (at risk for contractures); and assessed the resident as being alert, thin, having a general state of health of fair, very limited mobility in upper and lower extremities; chairfast; and the documented comment: Limited mobility due to spinal stenosis. Review of Resident #45's Physician Progress Note, dated 7/05/23, revealed documentation of a physical examination and review of systems. The physician documented a note for review of the resident's Musculoskeletal system and documented contractures: flexion contractures bilateral lower extremities and left upper extremity. Review of Resident #45's Initial admission MDS Assessment, dated 12/18/22, revealed the resident required extensive assistance with 1 person assisting for transfers and bed mobility, required supervision with 1 person assisting while walking in-room, there were no functional limitations in range of motion in upper extremities or lower extremities, and mobility devices used were a walker and a wheelchair. Review of Resident #45's admission MDS Assessment, dated 1/10/23, revealed the resident required extensive assistance with 1 person assisting for transfers and extensive assistance with 2 persons assisting for bed mobility, there were no functional limitations in range of motion in upper extremities or lower extremities, and a wheelchair was used for mobility. Review of Resident #45's Quarterly MDS Assessment, dated 3/28/23, and Significant Change in Status MDS Assessment, dated 5/01/23, revealed there were no functional limitations in range of motion in upper extremities or lower extremities, and a wheelchair was used for mobility. Review of Resident #45's Quarterly MDS Assessment, dated 8/01/23, revealed the resident required extensive assistance with 2 persons assisting for transfers and bed mobility, there were no functional limitations in range of motion in upper extremities or lower extremities, and a wheelchair was used for mobility. Observation on 8/28/23 at 4:12 PM revealed Resident #45 was seated in a wheelchair. The resident appeared to have contractures in legs and had a small pillow between her knees. In an interview on 8/31/23 at 5:34 PM, the LVN MDS Coordinator stated she did not have a facility policy for completing MDS assessments. She stated she followed the guidelines of the RAI Manual. The LVN stated Section G0400 of the RAI Manual defined lower extremities as the hip, knee, ankle, and foot. The LVN stated if the limitation in Resident 45's knees did not limit her functional ability, she could not code a limitation in range of motion. She stated Resident #45 had walked a little during her first stay, from 12/12/22 to 1/02/23. She stated Resident #45 had been discharged home and after a few days decided she needed help and was readmitted on [DATE]. The LVN stated Resident #45 had back surgery during April 2023 and she did not walk any more. She stated the resident's feet were on foot pedals when she was in the wheelchair. 4. Resident #63 Review of Resident #63's admission Record, dated 8/31/23, revealed an [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of cerebral infarction, unspecified (a type of stroke caused by impaired blood flow to the brain). Additional diagnoses included: transient cerebral ischemic attack, unspecified (mini-stroke); unspecified atrial fibrillation (irregular heart beat); depression; essential (primary) hypertension (high blood pressure); gastro-esophageal reflux (liquid content of the stomach refluxes into the esophagus); muscle weakness, generalized; muscle wasting and atrophy (progressive and degenerative shrinkage of muscles or nerve tissues); hemiplegia and hemiparesis following cerebral infarction affecting the dominant right side (left sided weakness); chronic obstructive pulmonary disease (a type of progressive lung disease with shortness of breath and cough); schizoaffective disorder, depressive type (a mental disorder with psychotic symptoms and abnormal thought processes, and an unstable mood - schizophrenia with bipolar disorder or depression); dysphagia (difficulty swallowing), polyneuropathy (damage or disease affecting peripheral nerves in areas on both sides of the body, featuring weakness, numbness, and burning pain); and abnormal weight loss. Review of Resident #63's admission Contracture Potential Assessment, dated 9/10/22, revealed a score of 8 (not at risk for contractures), and he was alert, well nourished, his general state of health was fair, he had full mobility of upper and lower extremities, he was chairfast, and had a history of stroke. Review Resident #63's Contracture Potential Assessment - Full Assessment, dated 2/09/23, revealed a score of 14 (at risk for contractures), and he was confused, thin, his general state of health was poor/declining, he had full mobility of upper extremities and limited mobility of lower extremities, was bedfast, and had a history of stroke. Review Resident #63's Quarterly Contracture Potential Assessment, dated 6/07/23, revealed a score of 15 (at risk for contractures), and he was confused, thin, his general state of health was poor/declining, he had limited mobility of the upper and lower extremities, was bedfast, and had a history of stroke. Review of Resident #63's admission MDS Assessment, dated 9/16/22, revealed a BIMS score of 14 out of 15 (cognitively intact), and he required extensive assistance with ADLs with 2 persons assisting for transfers, bed mobility, dressing, personal hygiene, and toileting. He was independent with eating with set up help. He was assessed as having functional limitation in range of motion with impairment on one side in upper and lower extremities and used a wheelchair for mobility. Review of Resident #63's Quarterly MDS Assessment, dated 12/17/22, revealed a BIMS score of 11 out of 15 (moderate cognitive impairment) and he was assessed as having functional limitation in range of motion with impairment on one side in upper and lower extremities and used a wheelchair for mobility. Review of Resident #63's Significant Change in Status MDS Assessment, dated 2/07/23, revealed a BIMS score of 00 out of 15 (severe cognitive impairment), and he was assessed as having no functional limitation in range of motion with no impairment on either side in upper and lower extremities and used a wheelchair for mobility. Review of Resident #63's Quarterly MDS Assessments, dated 5/10/23 and 8/01/23, revealed a BIMS score of 00 out of 15 (severe cognitive impairment), and he required extensive assistance with ADLs with 2 persons assisting for transfers, bed mobility, dressing, personal hygiene, and toileting. He was independent with eating with set up help. He was assessed as having no functional limitation in range of motion with no impairment on either side in upper and lower extremities and used a wheelchair for mobility. Review of Resident #63's comprehensive care plan, dated as initiated 9/17/22, revealed it addressed ADL self-care deficit related to fatigue and impaired balance. The care plan had not been revised to address the limited range of motion and contractures in his left-hand fingers. During an interview and observation on 8/29/23 at 3:26 PM, Resident #63 stated he could not raise his left arm. The resident's left hand small finger and ring finger were contracted. Resident #63 stated his left-hand fingers hurt. He stated he had not had a hand splint or hand roll to place in his left hand. Resident #63 stated he had a little ball to hold in his hand and he did not know what happened to it. In an interview on 8/31/23 at 5:26 PM, the LVN MDS Coordinator stated she did not have a facility policy for completing MDS assessments. She stated she followed the guidelines of the RAI Manual. She stated Section G0400 of the RAI Manual defined upper extremity as shoulder, elbow, wrist, and hand. The LVN stated if the limitation in Resident #63's hand did not interfere with his abilities to perform ADLs or eating, she could not code a limitation in range of motion. She stated Resident #63 ate with his right hand. Review of the facility's policy and procedure for Resident Mobility and Range of Motion, dated as revised July 2017, revealed the following [in part]: Policy Statement 1. Residents will not experience an avoidable reduction in range of motion (ROM). 2. Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. 3. Resident with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. Policy Interpretation and Implementation 1. As part of the resident's comprehensive assessment, the nurse will identify the resident's: a. Current range of motion of his or her joints. b. Current mobility status (per current MDS assessment tool), including his or her ability to: (1) Move to and from the lying position; (2) Turn and move side-to-side in bed; (3) Change body positions; (4) Transfer to and from bed or chair; and (5) Walk. c. Limitations in movement or mobility; d. Opportunities for improvement; and e. Previous treatment and services for mobility. 2. As part of the comprehensive assessment, the nurse will also identify conditions that place the resident at risk for complications related to ROM and mobility, including: a. Pain; b. Skin integrity; c. Muscle wasting and atrophy; d. Gait and balance issues that may lead to falls or fractures; e. Contractures; or f. Other complications that could cause or contribute to immobility, impaired ROM or injury from falls . 3. During the resident's assessment, the nurse will identify the underlying factors that contribute to his or her range of motion or mobility problems, if any, including: a. Immobilization (bedfast, chair or wheelchair usage); b. Neurological conditions (e.g., cerebral palsy, cerebral vascular accident, etc.); c. Conditions in which movement may lead to pain; and/or d. Conditions that limit or immobilize movement of limbs or digits (e.g., splints). 4. The care plan will be developed by the interdisciplinary team based on the comprehensive assessment, and will be revised as needed. 5. The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. 6. Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received adequate care to maintain the highest practical physical and psychosocial well-being for 5 of 26 residents (Residents #7, #21, #33, #63, and #68) reviewed for ADL care, in that: 1. The facility failed to ensure Resident #7's right hand fingernails were trimmed and filed. 2. The facility failed to ensure Resident #21's fingernails on both hands were cleaned and her toenails on both feet were filed or trimmed. 3. The facility failed to ensure Resident #33 had his fingernails on both hands trimmed and filed. 4. The facility failed to ensure Resident #63's left hand fingernails were trimmed and filed. 5. The facility failed to ensure Resident #68 had her toenails on both feet cut and filed. This failure placed residents at risk for experiencing a decreased quality of life and an increased risk for infection and injury. The findings included: 1. Resident #7 Review of Resident #7's admission Record, dated 8/31/23, revealed a [AGE] year-old female admitted to the facility on [DATE] her diagnoses included: hypertension (high blood pressure); muscle weakness, generalized; muscle wasting and atrophy (progressive and degenerative shrinkage of muscles or nerve tissues); dysphagia (difficulty swallowing), congestive heart failure (failure of the heart to adequately pump blood to the body) and mitral valve insufficiency( failure of the mitral valve to close which causes a back flow of blood to into heart). Review of Resident #7's Annual MDS Assessment, dated 8/10/23, revealed she was independent with personal hygiene. During an observation and interview on 8/29/23 at 10:26 AM, Resident #7 was sitting up in her bed. She was noted to have contractures to the 3rd and 4th fingers of her right hand and her fingernails were ¼ inch long. The resident stated she would like to have her fingernails cut, but she could not do it herself. She stated she had asked someone to do it, but she could not recall who she asked. In an interview with the ADON on 8/30/21 at 11:00 AM she stated it was the responsibility of the CNAs to keep resident's fingernails clean, cut and filed. She stated the charge nurses were responsible to monitor to see that the residents' nails were clean and cut. She stated the nurses were responsible to keep the Diabetics Nails cut. She stated nail care did not necessarily mean the nails were cut, just that they were clean. She stated toenails were not cut by the aides or the nurses. She stated the podiatrist cut residents toenails. Interview with CNA G revealed that CNAs should do nail care when they bathed the residents unless they were diabetic, and then they were cut by the LVN. 2. Resident #21 Review of Resident #21's admission Record, dated 8/31/23, revealed a [AGE] year-old female admitted to the facility on [DATE] her diagnoses included: Diabetes; congestive heart failure (failure of the heart to adequately pump blood to the body); pruritus (an uncomfortable, irritating sensation that creates an urge to scratch that can involve any part of the body); muscle wasting and atrophy (progressive and degenerative shrinkage of muscles or nerve tissues) and schizoaffective disorder (a mental disorder with cycles of improvement that may include the symptoms of delusions, hallucinations, depressed episodes, and periods of manic energy). Review of Resident #21's Quarterly MDS Assessment, with an ARD of 8/12/23, revealed she required extensive assistance of one person physically assisting for personal hygiene. In an interview and observation on 8/28/23 beginning at 11:30 AM Resident #21 was in her room. She had a visible scabbed rash that she stated covered her entire body. She stated she had seen a dermatologist and had another appointment on 8//29/23. Her toenails were unkempt and approximately 1/4 inch in length. She stated she would like them to cut. She stated she did not remember when they were last cut. Her fingernails were dirty. She stated she scratched constantly until the rash bleeds, and nobody ever offered to wash her hands before she eats. She stated she feels like the aides get irritated because she gets her nails and sheets dirty, but she can help herself. A deep brown substance was noted underneath her fingernails. Spots of old dried blood was noted on resident #7's sheets. In an interview with the ADON on 8/28/23 at 1:00 pm she stated Resident #7 scratched her skin constantly. She stated that she had been seen by a dermatologist and had another appointment was scheduled the following day. She stated Resident #21 should have nail care every shift because she constantly scratches the rash until it bleeds. She stated the nurses were responsible for cutting the nails of a diabetic resident, but an aide could clean the nails. She stated it was the LVN's responsibility to monitor to see that the resident's nails were clean. In an observation on 8/30/23 at 10:00 AM an unidentified CNA who stated she was in training was observed in Resident #21's room with a bath basin containing water cleaning and filing resident #21's nails. In an interview with the DON on 8/30/23 at 1:30 PM she stated it would be impossible to do nailcare on Resident #21 every time she got her nails dirty because she constantly scratched and made herself bleed. She stated she would purchase gloves to see if this kept the resident from making herself bleed. 3. Resident #33 Review of Resident #33's admission Record, dated 8/31/23, revealed a [AGE] year-old male admitted to the facility on [DATE] his diagnoses included muscle weakness, intellectual disability; full incontinence of feces; difficulty in walking; unspecified urinary incontinence. Review of Resident #33's Quarterly MDS Assessment, with an ARD of 8/10/23, revealed he required extensive assistance of one person physically assisting for personal hygiene. Observation on 8/28/23 at 10:38 AM revealed Resident #33 was up in his wheelchair and was returning from therapy. He was transferred to his bed with extensive assistance by a therapist. The resident's nails were chipped, with sharp edges. In an interview with the ADON on 8/30/21 at 11:00 AM she stated it was the responsibility of the CNAs to keep resident's fingernails clean, cut and filed. She observed Resident #33's nails and agreed they needed to be trimmed and filed. She stated he could injure himself with his jagged chipped nails She stated the charge nurses were responsible to monitor to see that the residents' nails were clean and cut. 4. Resident #63 Review of Resident #63's admission Record, dated 8/31/23, revealed an [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of cerebral infarction, unspecified (a type of stroke caused by impaired blood flow to the brain). Additional diagnoses included: transient cerebral ischemic attack, unspecified (mini-stroke); unspecified atrial fibrillation (irregular heart beat); depression; essential (primary) hypertension (high blood pressure); gastro-esophageal reflux disease (chronic digestive disease where the liquid content of the stomach refluxes into the esophagus); muscle weakness, generalized; muscle wasting and atrophy (progressive and degenerative shrinkage of muscles or nerve tissues); hemiplegia and hemiparesis following cerebral infarction affecting the dominant right side (right sided weakness); chronic obstructive pulmonary disease (a type of progressive lung disease with shortness of breath and cough); schizoaffective disorder, depressive type (a mental disorder with psychotic symptoms and abnormal thought processes, and an unstable mood - schizophrenia with bipolar disorder or depression); dysphagia (difficulty swallowing), polyneuropathy (damage or disease affecting peripheral nerves in roughly the same areas on both sides of the body, featuring weakness, numbness, and burning pain); and abnormal weight loss. Review of Resident #63's Quarterly MDS Assessment, with an ARD of 8/10/23, revealed he required extensive assistance with two persons physically assisting for personal hygiene. During an observation and interview on 8/28/23 at 10:25 AM, Resident #63 was resting on his back in bed on an air mattress with a pillow under his knees. The resident stated he did not get out of bed except for showers. During and observation and interview on 8/29/23 at 3:26 PM, Resident #63 was not able to raise his left arm and his left-hand fingers were contracted. Resident #63 stated his left-hand fingers hurt. In an interview on 8/30/23 at 2:59 PM, the Hospice RN stated she had noticed Resident #63's left hand fingers were contracted, swollen, and very tender. She stated the resident had severe arthritis and he yelled out when she barely touched his finger. The Hospice RN stated Resident #63's fingernails were long, and her aides could cut and file his nails. She stated ultimately the facility was responsible for the care of the resident. During an interview and observation on 8/30/23 at 3:23 PM, Resident #63's family members were seated in chairs in the resident's room. The family stated they had come to meet with the Hospice nurse. The family stated Resident #63 had a stroke and he could not use his left side. The family stated the resident's left hand did not have contractures when he was admitted to the facility about a year ago in September 2022. They stated his fingers had gradually contracted over the course of the past 8 months or so. Resident #63 attempted to open his left-hand fingers and he could not open or move the small finger (digit 5) and the ring finger (digit 4). His left-hand fingernails appeared to extend an approximate ¼ inch over the tip of his fingers, and his fingers were contracted toward the palm of his left hand. 5. Resident #68 Review of Resident #68's admission Record, dated 8/31/23, revealed an [AGE] year-old male admitted to the facility on [DATE] her diagnoses included: muscle weakness, generalized; muscle wasting and atrophy (progressive and degenerative shrinkage of muscles or nerve tissues). morbid obesity (weight 80 to 100 lbs. over ideal body weight); high blood pressure; age related cognitive decline; generalized weakness. Review of Resident #68's Quarterly MDS Assessment, with an ARD of 8/12/23, revealed she was independent with personal hygiene with supervision only. She had a BIMS score of 13 (cognitively intact). In an interview and observation on 08/28/23 at 10:09 AM resident #68's left foot was uncovered on her bed. Her toenails on her left foot were ¼ inch in length. She stated she would like to have them cut or filed and had asked to see the podiatrist. She stated she was able to cut them herself before she came to facility, but now she needed someone else to do it because she could not do it herself. She stated she had asked a nurse for someone to cut them, but nobody had. She did not remember who she asked, but it was when she was in a room on the other side of the building. She stated the social worker stated she would put on a list to see the podiatrist. In an interview with the social worker on 8/31/23 at 2:00 PM the social worker revealed she had placed Resident #68 on the list for the podiatrist. She stated she did not normally place any resident on the list to be seen by the podiatrist until she was sure that the resident was going to be a long-term resident. She stated when it was determined a resident was going to be long- term and remain in the facility she talked with the resident to see if they needed referrals to see a podiatrist, optometrist, dentist, etc. She stated she normally does then when she does this when she completes her section of the MDS assessment. Review of the document titled: Care of Fingernails/Toenails provided by the Administrator on 8/31/23 revealed the following [in part]: Purpose The purpose of this procedure is to clean the nail bed, to keep nails trimmed and to prevent infections. General guidelines: 1. Nail care includes daily cleaning and regular trimming. 4. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who entered the facility without limited range of motion did not experience a reduction in range of motion; residents with limited range of motion received appropriate treatment and services to increase range of motion or prevent further decrease in range of motion; and residents received appropriate services, equipment, and assistance to maintain or improve mobility for 3 of 15 residents (Residents #34, #45, and #63) who were reviewed for care and assistive devices to maintain mobility and avoid further contractures. 1. Resident #35 had contracted fingers in both hands and did not use assistive devices to prevent further contractures. 2. Resident #45 had contractures in both legs and did not use positioning devices to avoid pressure applied between her knees and protect her feet and ankles while seated in a wheelchair. 3. Resident #63 had contractures in the small finger and ring finger of his left hand and did not use an assistive device to prevent further contractures. The facility's failure placed residents at risk for developing avoidable and worsening contractures, decreased functional mobility and range of motion in extremities, and decreased feelings of well-being and quality of life. The findings included: 1. Resident #35 Review of Resident #35's admission Record, dated 8/31/23, revealed a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of metabolic encephalopathy (brain dysfunction caused by problems with body metabolism). Additional diagnoses included: anxiety disorder; constipation; hereditary and idiopathic neuropathy (nervous system disorders that interfere with normal nerve function); major depressive disorder, recurrent; pseudobulbar affect (nervous system disorder that causes inappropriate involuntary laughing and crying); vascular dementia, unspecified (cognitive impairment caused by lack of blood flow to the brain); atherosclerotic heart disease (hardened arteries due to plaque build-up); dysphagia (swallowing problem); essential (primary) hypertension (high blood pressure); gastro-esophageal reflux disease (liquid content of the stomach refluxes into the esophagus); heart failure, unspecified; muscle wasting and atrophy; generalized muscle weakness; Parkinson's disease (progressive disorder that affects the nervous system and the parts of the body controlled by the nerves); Type 2 diabetes mellitus (high blood sugar - adult onset). Review of Resident #35's Contracture Potential Assessment - Full Assessment, dated 5/04/23, revealed a score of 11 indicating the resident was at risk for contractures. The assessment documented the resident's state of health was poor/declining; he was confused; he had limited mobility in upper and lower extremities; he was chairfast; and had a diagnosis of Parkinson's disease. Review of Resident #35's Quarterly Contracture Potential Assessment, dated 8/05/23, revealed a score of 12 indicating the resident was at risk for contractures. The assessment documented the resident's state of health was poor/declining; he was confused; he had limited mobility in upper and lower extremities; he was chairfast; and had a diagnosis of Parkinson's disease. Observation on 8/28/23 at 11:16 AM revealed Resident #35 was lying on his back in bed on a foam mattress with the room call light in reach of his right hand. The resident was observed to have contractures in the fingers of both, with his hands closed in fists. Resident #35 was able to demonstrate use of his right thumb to activate the call light button. The resident was not using hand splints or soft hand rolls. In an interview on 8/31/23 at 3:01 PM, the LVN Treatment Nurse stated she did weekly skin assessments on Wednesdays. She stated she saw Resident #35 for maceration (redness and excoriation) on his buttocks. She stated the resident's fingers had been a little swollen this week. She stated he could open his fingers, but it depended what mood he was in. During an observation and interview on 8/31/23 beginning 3:16 PM, accompanied by the LVN Treatment Nurse, revealed Resident #35 was resting on his back in bed with the room light off. The resident's hands were closed in fists. The LVN donned gloves and asked Resident #35 if he could open his left hand fingers. The resident moved his left thumb and index finger and was unable to open his other left hand fingers. Resident #35 was able to open right hand thumb and was unable to open his remaining right hand fingers. Resident #35 stated his hands and fingers hurt a little. The LVN noted a red area on the inner crease of the right thumb. 2. Resident #45 Review of Resident #45's admission Record, dated 8/31/23, revealed a [AGE] year-old female initially admitted to the facility on [DATE] and re-admitted [DATE] with a primary diagnosis of post-laminectomy syndrome (failed back syndrome - a condition characterized by chronic pain following back surgeries). Additional diagnoses included: spinal stenosis, cervical region (abnormal narrowing of the spinal canal that puts pressure on the spinal cord and causes pain, numbness or weakness in the arms or legs); muscle wasting and atrophy (progressive and degenerative shrinkage of muscles or nerve tissues); generalized muscle weakness; chronic pain; unspecified dementia (impaired cognition); major depressive disorder, recurrent; insomnia; anxiety disorder; hyperlipidemia; essential (primary) hypertension (high blood pressure); hereditary and idiopathic neuropathy (nervous system disorders that interfere with normal nerve function); acute embolism and thrombosis of unspecified deep veins of right lower extremity (blood clot in right leg); gastro-esophageal reflux disease (liquid content of the stomach refluxes into the esophagus); chronic kidney disease, stage 3 unspecified (moderate loss of kidney function). Review of Resident #45's admission Contracture Potential Assessment, 1/06/23, revealed a score of 4 (not at risk for contractures); and assessed the resident as being alert, well nourished, having a general state of health of fair, full mobility in upper and lower extremities, and needs help with cane/walker. Review of Resident #45's Quarterly Contracture Potential Assessment, dated 8/05/23, revealed a score of 13 (at risk for contractures); and assessed the resident as being alert, thin, having a general state of health of fair, very limited mobility in upper and lower extremities; chairfast; and the documented comment: Limited mobility due to spinal stenosis. Review of Resident #45's Physician Progress Note, dated 7/05/23, revealed documentation of a physical examination and review of systems. The physician documented a note for review of the resident's Musculoskeletal system - contractures: flexion contractures bilateral lower extremities and left upper extremity. Observation on 8/28/23 at 4:12 PM revealed Resident #45 was seated in a wheelchair. The resident appeared to have contractures in legs and had a small pillow between her knees. During an interview and observation on 8/29/23 beginning at 1:44 PM, Resident #45 stated she could move her right leg and stated she could not move her left leg. She stated she could move left arm but could not lift it. Resident #45 stated she thought she may have had a stroke during the past. Resident #45 was seated in a wheelchair with her feet in an awkward position on the foot pedals. The resident's knees appeared contracted and touching, and her feet were at an angle toward the outer sides of the foot pedals, with the outer sides of her feet and ankles against the extension bars connected to the foot pedals. No protective padding or positioning pillows were observed between her knees or between her outer feet and wheelchair foot pedal extension bars. In an interview on 8/31/23 at 5:34 PM, the LVN MDS Coordinator stated Resident #45 had walked a little during her first stay, from 12/12/22 to 1/02/23. She stated Resident #45 had been discharged home and after a few days decided she needed help and was readmitted on [DATE]. The LVN stated Resident #45 had back surgery during April 2023 and she did not walk any more. She stated the resident's feet were on foot pedals when she was in the wheelchair. 3. Resident #63 Review of Resident #63's admission Record, dated 8/31/23, revealed an [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of cerebral infarction, unspecified (a type of stroke caused by impaired blood flow to the brain). Additional diagnoses included: transient cerebral ischemic attack, unspecified (mini-stroke); unspecified atrial fibrillation (irregular heart beat); depression; essential (primary) hypertension (high blood pressure); gastro-esophageal reflux (liquid content of the stomach refluxes into the esophagus); muscle weakness, generalized; muscle wasting and atrophy (progressive and degenerative shrinkage of muscles or nerve tissues); hemiplegia and hemiparesis following cerebral infarction affecting the dominant right side (left sided weakness); chronic obstructive pulmonary disease (a type of progressive lung disease with shortness of breath and cough); schizoaffective disorder, depressive type (a mental disorder with psychotic symptoms and abnormal thought processes, and an unstable mood - schizophrenia with bipolar disorder or depression); dysphagia (difficulty swallowing), polyneuropathy (damage or disease affecting peripheral nerves in areas on both sides of the body, featuring weakness, numbness, and burning pain); and abnormal weight loss. Review of Resident #63's admission Contracture Potential Assessment, dated 9/10/22, revealed a score of 8 (not at risk for contractures), and he was alert, well nourished, his general state of health was fair, he had full mobility of upper and lower extremities, he was chairfast, and had a history of stroke. Review Resident #63's Contracture Potential Assessment - Full Assessment, dated 2/09/23, revealed a score of 14 (at risk for contractures), and he was confused, thin, his general state of health was poor/declining, he had full mobility of upper extremities and limited mobility of lower extremities, was bedfast, and had a history of stroke. Review Resident #63's Quarterly Contracture Potential Assessment, dated 6/07/23, revealed a score of 15 (at risk for contractures), and he was confused, thin, his general state of health was poor/declining, he had limited mobility of the upper and lower extremities, was bedfast, and had a history of stroke. Review of Resident #63's comprehensive care plan, dated as initiated 9/17/22, revealed it addressed ADL self-care deficit related to fatigue and impaired balance. The care plan had not been revised to address the limited range of motion and contractures in his left hand fingers. During an interview and observation on 8/29/23 beginning at 3:26 PM, Resident #63 stated he could not raise his left arm. The resident's left hand small finger and ring finger were contracted. Resident #63 stated his left hand fingers hurt. He stated he had not had a hand splint or hand roll to place in his left hand. Resident #63 stated he had a little ball to hold in his hand and he did not know what happened to it. In an interview on 8/30/23 at 2:59 PM, the Hospice RN stated she was at the facility to evaluate Resident #63 for services per his family's request for a change in hospice agencies. The RN stated she had noticed the resident's left hand fingers were contracted, swollen, and very tender. She stated Resident #63 had severe arthritis and he yelled out when she barely touched his finger. The RN stated he would benefit from soft hand rolls. She stated ultimately the facility was responsible for the care of the resident. In an interview on 8/30/23 at 3:23 PM, Resident #63's family members stated they had come to meet with the nurse from Hospice. The family stated Resident #63 had a stroke and he could not use his left side. The family stated Resident #63 had received therapy and they did not recall the resident having a hand splint or hand roll for his left hand. The family stated Resident #63's left hand did not have contractures when he was admitted to the facility about a year ago in September 2022. They stated his fingers had gradually contracted over the course of the past 8 months or so. They family stated they brought small balls for the resident to have in his hands and they did not know what happened to them. Resident #63 attempted to open his left hand fingers and he could not open or move the small finger and ring finger. In an interview on 8/31/23 at 3:09 PM, the LVN Treatment Nurse stated she did not know anything about Resident #63's hands. She stated she knew his hands shook and he had tremors. During an observation and interview on 8/31/23 beginning at 3:31 PM, accompanied by the LVN Treatment Nurse, revealed Resident #63 was resting in bed. His family members were seated in chairs in the room and were visiting with him. Resident #63 was unable to open his left hand small finger and ring finger. The resident's family stated the resident's left hand had been getting progressively worse since he had his stroke. The family did not recall seeing Resident #63 use a hand roll. The LVN stated a contraction device for Resident #63's hand could be ordered by the therapy department. In an interview on 8/31/23 at 5:26 PM, the LVN MDS Coordinator stated she did not have a facility policy for completing MDS assessments. She stated she followed the guidelines of the RAI Manual. She stated Section G0400 of the RAI Manual defined upper extremity as shoulder, elbow, wrist, and hand. The LVN stated if the limitation in Resident #63's hand did not interfere with his abilities to perform ADLs or eating, she could not code a limitation in range of motion. She stated Resident #63 ate with his right hand. Review of the facility's policy and procedure for Resident Mobility and Range of Motion, dated as revised July 2017, revealed the following [in part]: Policy Statement 1. Residents will not experience an avoidable reduction in range of motion (ROM). 2. Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. 3. Resident with limited mobility will receive appropriate services, equipment, and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. Policy Interpretation and Implementation 1. As part of the resident's comprehensive assessment, the nurse will identify the resident's: a. Current range of motion of his or her joints; b. Current mobility status (per current MDS assessment tool), including his or her ability to: (1) Move to and from the lying position; (2) Turn and move side-to-side in bed; (3) Change body positions; (4) Transfer to and from bed or chair; and (5) Walk. c. Limitations in movement or mobility; d. Opportunities for improvement; and e. Previous treatment and services for mobility. 2. As part of the comprehensive assessment, the nurse will also identify conditions that place the resident at risk for complications related to ROM and mobility, including: a. Pain; b. Skin integrity; c. Muscle wasting and atrophy; d. Gait and balance issues that may lead to falls or fractures; e. Contractures; or f. Other complications that could cause or contribute to immobility, impaired ROM or injury from falls . 3. During the resident's assessment, the nurse will identify the underlying factors that contribute to his or her range of motion or mobility problems, if any, including: a. Immobilization (bedfast, chair or wheelchair usage); b. Neurological conditions (e.g., cerebral palsy, cerebral vascular accident, etc.); c. Conditions in which movement may lead to pain; and/or d. Conditions that limit or immobilize movement of limbs or digits (e.g., splints). 4. The care plan will be developed by the interdisciplinary team based on the comprehensive assessment, and will be revised as needed. 5. The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. 6. Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts .

Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, in that: 1. The lids to the bulk storage containers were soiled with food particles. 2. Opened gravy mix and breaded chicken patties were not stored in sealed bags. 3. The vent-a-hood was soiled with grease and the interior surface of the deep fryer unit was soiled with fried food crumbs. 4. Sanitized cooking utensils and pans were stored on hooks suspended in the air from a frame located near the ceiling air duct vents and the sanitized surfaces were not protected from contaminants in the air. 5. Knives were stored on a magnetic strip rack and in a metal box holder mounted on a wall with the sanitized knife blades exposed to the air and potential contaminants. 6. The service delivery door to the outside of the building was not kept securely closed. The facility's failure placed residents at risk for foodborne illness and a decline in health status. The findings included: Observation on 8/28/23 at 8:35 AM, during the initial tour of the facility kitchen, revealed the following: 1 - the dry food storage area had plastic bulk storage bins containing granulated sugar and flour; the lids to the bins were lightly soiled with sugar crystals, food crumbs, and flour dust; 2 - the dry food storage area had wire rack shelf units; a shelf held an open paper package of gravy mix that had been rolled closed and wrapped with plastic cellophane wrap that was not labeled and dated; the CDM removed the wrapped package from the shelf; 3 - the freezer unit contained an open cardboard box with breaded chicken patties that were in a bag that was open to the air and not securely closed; the CDM removed the box from the freezer and handed it to the Dietary Supervisor and told her to throw it away; 4 - the vent-a-hood located above the oven unit and grill was soiled with grease; 5 - the deep fryer unit was covered with a rectangular metal sheet pan; the interior surface of the deep fryer had dried fried food crumbs and was filled with dark colored cooking oil; 6 - cooking utensils and pans were hanging from hooks on a metal frame above the food preparation counter, with the sanitized food surfaces of the utensils and pans exposed to potential contaminants in the air; ceiling air duct vents were located near the metal frame; 7 - a magnetic knife rack was mounted to a wall with knife blades stuck to it; 8 - a knife holder box, with knives stored blade end down inside the box, was mounted on the wall next to the magnetic knife rack. During an observation and interview on 8/30/23 beginning at 1:27 PM, the service delivery door to the outside of the building was observed located near the Dietary Supervisor's office. The door was self-closing and self-locking and also had a deadbolt lock. The deadbolt lock had been turned, preventing the door from closing completely and leaving a small gap of space between the door and the door frame, which could allow the entrance of pests. The CDM stated she thought the staff had taken the trash out to the dumpster and had turned the deadbolt to prevent the door from locking so they could get back into the kitchen without using a key. In an interview on 8/31/23 at 3:59 PM, the CDM stated she would provide a policy for storing sanitized pans and food preparation utensils. Review of the facility's policy and procedure for Manual Warewashing, dated as revised September 2017, provided by the CDM, revealed it did not include the storage of sanitized pans and food preparation utensils. A policy and procedure for the storage of sanitized pans and utensils used for food preparation was not provided before the completion of the survey and exit from the facility on 8/31/23. The Food and Drug Administration Food Code 2022 specified [in part]: Chapter 3 Food 3-202.15 Package Integrity. FOOD packages shall be in good condition and protect the integrity of the contents so that the FOOD is not exposed to ADULTERATION or potential contaminants. Chapter 4 Equipment, Utensils, and Linens 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles. (A) Except as specified in (D) of this section, cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES shall be stored: (1) In a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) Clean EQUIPMENT and UTENSILS shall be stored as specified under (A) of this section and shall be stored: (1) In a self-draining position that allows air drying; and (2) Covered or inverted.

Based on interview and record review, the facility failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups for Resident Council Meetings reviewed for grievances consisting 7 residents who regularly attend the meetings and complain about the temperature, taste, and lateness of the food. The facility failed to comply with grievances voiced by residents #12, #32,#46, #3, #20, #15 and #33 in the resident council meeting held in January 2022, February 2022, March 2022, April 2022, and May 2022 consisting of residents , These failures could place residents at risk unresolved grievances, a decreased sense of self-worth, and a decline in quality of life. Findings Included: Review of Grievances followed up by the Resident Council meetings reveal the following: Review of Monthly Grievance Log for January, February, March. April, and May 2022 revealed the following dietary complaints: 1. On January 30, 2022 a resident complained that she was unhappy with breakfast - facility response: showed Dietary Manager note of the complaint. 2. February 7 and 8 2022 four residents complained about the quality of the food service - facility response: They have new contract dietary service. 3. March 17, 2022established food committee with 6 residents complaining to the dietary manager regarding taste, cold, and late service and not alternatives- facility response: Dietary Manager met with residents to discuss concerns and work with the food committee. 4. March 19, 2022 resident complained regarding food service - facility response will talk to the dietary manager 5. April 28, 2022 Resident Council expressed concerns with dietary department with staffing in department - facility response - Dietary manager to attend next resident council meeting to work on resolving issues and work on staffing. 6. May 12, 2022 Food Committee express concerns to the Dietary Manager regarding taste, cold and late service - Facility response - follow up with Resident group and happy with progress made. 7. May 17, 2022 May 20 Concerns expressed regarding dietary services and unhappy with substitutes - facility response - happy with response if there no excuses moving forward. During a Confidential Group Interview on 6/28/22 at 11:00 p.m., residents (#12, 32,46,3,20,15 and33 ) stated the food was cold and gross. One resident stated, there wasn't enough food to feed a baby. The residents stated there were no snacks. They stated if they asked for the substitute, they were not going to get it and sandwiches had no condiments. When asked if they could pick one thing, they wanted surveyor to work on, they unanimously stated the food, which was terrible always late and frequently cold. During an interview on 06/28/2022 at 4:45 PM, Dietary Manager said that the previous dietary manager was let go (Present DM was not specific when she was let go) and they had been working with the Resident Council and the Food Committee, but had not had a chance to get together since she was terminated. She said they had been short-handed, and the food time is posted at 12:00 Noon and she said they must deliver the first tray by 12:00 Noon and the first tray was delivered by that time. Sometimes the hall trays do not get delivered until after 12:00 Noon and the dining room was delivered after all the hall trays are delivered. During an interview with Administrator on 06/30/2022 at 3:00 PM, she said food was the major topic and they tried to work with the residents. The kitchen was contracted out and they have made it known about the issues and were trying to resolve them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents of the facility ( Resident #'s 212, 56,and the North Eas [NAME] had the right to a safe, clean, comfortable, and homelike environment. The facility failed to ensure : A. The floor was clean and free of soiled areas in Resident #212's room. B. The bedside table, infusion pole, and floor were cleaned and free of spills and debris in Resident #56's room C. Residents' equipment (Hoyer lift, wheel chairs, walkers and other pieces of heavy equipment) were stored in a way to ensure cleanliness, order, and resident/visitor safety. These failures could affect the residents, by placing them at risk for unsafe, unclean, and uncomfortable environment, low self-esteem, and a diminished quality of life. Findings included: An observation on 06/27/22 at 12:06 PM, and 6/29/22 at 3:37 PM revealed the floor of Resident # 212 was soiled with feces. The resident refused an interview. An observation of Resident # 56's room revealed a bedside table and an infusion pole sitting in the resident's room, had built up dust/grime and spilled tube feeding formula on the metal frames. There were multiple syringe caps littering the carpet of the room. The carpet in the room was soiled with stains. The resident was not interviewable due to cognitive impairment and aphasia. In interviews during the Resident council meeting on the 6/28/22 at 11:15 AM Resident #' s 12, 32, 28, 3, 20, 15, 2, and 33 complained about the housekeeping staff only pulling trash from the public bathrooms and living room areas of the facility, and never vacuuming or mopping the floors of the resident rooms. They concurred that the bathrooms sinks are never cleaned, and they had cleaned the sinks themselves. They stated they found this disgusting and stated it happened on a regular basis. An interview with the Housekeeping Supervisor on 06/29/22 4:30 PM, revealed the floors in the resident's rooms were to be mopped daily. She also stated she mopped Resident #212's floor on 6/28/22 and must have missed seeing the feces that was left on the floor. She stated she was responsible for monitoring to ensure the resident's rooms were cleaned and another housekeeper(who not available for an interview) should have mopped the room on 06/29/22. An interview on 06/29/22 at 3:46 with a facility nursing staff member that wished to remain anonymous, revealed the staff member felt Resident #56's room was always dirty. She stated the room was horrible and housekeeping did not keep the resident's room clean. She stated it was housekeeping's responsibility to clean the resident's bedside tables and Infusion poles. In an interview on 06/29/22 at 4:30 PM, the DON witnessed the condition of resident #'s 212 and #56's rooms. She stated the nurses were responsible for cleaning up anything that they spill, or for picking up any equipment or trash that they drop in a resident's room. She stated she was not aware that resident #'s 212 and 56 rooms needed cleaning. In an observation on 06/029/2022 at 03: 51 PM, of the North East hall revealed the area in front of the therapy room, at the end of the hall, had several walkers hanging from the walls on brackets. There were several walkers on each bracket. There were also several wheelchairs, a Hoyer lift, a weight chair, and various other pieces of unused resident equipment in the open hallway in direct view and access of residents and visitors. In an interview on 01/10/2019 at 12:00 PM, the Administrator stated she was aware of the equipment stored at the end of the Northeast Hallway in front of the therapy room. She stated she could see that it did not contribute to a safe and home-like environment now that she had been made aware of it. She stated it has just been there so long; I didn't notice it being there. She stated she would move the equipment immediately. In a record review, the facility's policy, titled Quality of life - Home Like Environment dated revised October 2009 revealed in part: 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 depersonalized, institutional setting. There characteristics include cleanliness and order, comfortable noise levels.

Based on observation, interview, and record review, the facility failed to post the actual hours worked by the licensed and unlicensed nursing staff directly responsible for direct resident care per shift on a daily basis. The daily nursing staffing information was posted but did not include the total numbers of actual hours worked for RNs, LVNs, CNAs, and RNAs. The facility's failure could place residents at risk of not knowing the daily nurse staffing data. The findings included: Observation on 06/27/22 to 06/30/22 revealed the daily nursing staffing hours form was posted on the wall outside the Director of Nurses (DON) office on the main hallway entrance. Review of the Facility's staffing form titled Senor Care Centers dated 6/27/22 at 10:00 AM and posted outside of the DON's office revealed the following Scheduled Hours 6 AM - 2 PM, RN - 32 Hrs. LVN - 32 Hrs. CNA - 45 Hrs. 6 AM - 2 PM Hours Worked. RN - 32 Hrs. LVN - 32 Hrs. CNA - 45 Hrs. 2 PM - 10 PM Scheduled Hours RN - 8 Hrs. LVN - 24 Hrs. CNA - 45 Hrs. 2 PM - 10 PM Hours Worked. RN - 8 Hrs. LVN - 24 Hrs. CNA - 45 Hrs. Scheduled Hours 10 PM - 6 AM, RN - 0 Hrs. LVN - 16 Hrs. CNA - 32 Hrs. 10 PM - 6 AM Hours Worked. RN - 0 Hrs. LVN - 16 Hrs. CNA - 32 Hrs. Resident Census: 65 Review of the Facility's staffing form titled Senor Care Centers dated 6/28/22 at 11:00 AM and posted outside of the DON's office revealed the following Scheduled Hours 6 AM - 2 PM, RN - 32 Hrs. LVN - 32 Hrs. CNA - 45 Hrs. 6 AM - 2 PM Hours Worked. RN - 32 Hrs. LVN - 32 Hrs. CNA - 45 Hrs. 2 PM - 10 PM Scheduled Hours RN - 8 Hrs. LVN - 24 Hrs. CNA - 45 Hrs. 2 PM - 10 PM Hours Worked. RN - 8 Hrs. LVN - 24 Hrs. CNA - 45 Hrs. Scheduled Hours 10 PM - 6 AM, RN - 0 Hrs. LVN - 16 Hrs. CNA - 32 Hrs. 10 PM - 6 AM Hours Worked. RN - 0 Hrs. LVN - 16 Hrs. CNA - 32 Hrs. Resident Census: 65 Review of the Facility's staffing form titled Senor Care Centers dated 6/29/22 at 10:30 AM and posted outside of the DON's office revealed the following Scheduled Hours 6 AM - 2 PM, RN - 32 Hrs. LVN - 32 Hrs. CNA - 45 Hrs. 6 AM - 2 PM Hours Worked. RN - 32 Hrs. LVN - 32 Hrs. CNA - 45 Hrs. 2 PM - 10 PM Scheduled Hours RN - 8 Hrs. LVN - 24 Hrs. CNA - 45 Hrs. 2 PM - 10 PM Hours Worked. RN - 8 Hrs. LVN - 24 Hrs. CNA - 45 Hrs. Scheduled Hours 10 PM - 6 AM, RN - 0 Hrs. LVN - 16 Hrs. CNA - 32 Hrs. 10 PM - 6 AM Hours Worked. RN - 0 Hrs. LVN - 16 Hrs. CNA - 32 Hrs. Resident Census: 65 Observation on 6/29/22 at 10: 40 AM revealed the daily nursing staff posted hours and resident census had not been modified to reflect the actual staff present on each shift nor a change in the resident census from 6/27/22 - 6/29/22. In an interview on 6/29/22 at 1:50 PM, the DON stated she completed the daily staffing sheets every morning for all three shifts, morning 6 AM - 2 PM, evening 2 PM - 10 PM, and night 10 PM - 6 AM. According to the scheduled staff, not the actual staff and posts it outside her door. She further stated she was not aware the staffing sheets were supposed to be completed at the beginning of each shift and reflect the actual number of staff on the floor. And could negatively affect resident care and give anyone inquiring about the number of staff present inaccurate information. In an interview on 6/29/22 at 2:00 PM, the Administrator stated, the DON was responsible for posting the daily nursing staffing hours. And the posting of the actual staff present is a new one on me. The administrator further stated, not having the actual hours posted could negatively affect resident care and give anyone inquiring about the number of staff present inaccurate information. Review of the facility policy titled Posting Direct Care Daily Staffing Numbers, revised July 2016, showed: Policy Interpretation and Implementation 1. Within two (2) hours of the beginning of each shift .will be posted in a prominent location (accessible to residents and visitors) and in a clear and readable format . 3 .The information recorded on the form shall include: a. The name of the facility. b. The date for which the information is posted. c. The resident census at the beginning of the shift for which the information is posted. d. Twenty-four (24)-hour shift schedule operated by the facility. e. The shift for which the information is posted. f. Type (RN [registered Nurse], LPN [Licensed Practical Nurse], LVN [Licensed Vocational Nurse], or CNA [Certified Nursing Assistant]) and category (licensed or non-licensed) of nursing staff working during that shift. g. The actual time worked during that shift for each category and type of nursing staff. h. Total number of licensed and non-licensed nursing staff working for the posted shift

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 7 residents reviewed for palatable food. (Residents #2, #3, #12,#15, #28, #32 and #33 residents in a Residence Council Meeting) This failure could place residents at risk of diminished nutrition and quality of life Findings included: During the resident council meeting on 06/28/2022 at 11:00 AM, residents attending (residents #2, #3, 12,15, 28, 32 and 33) stated that frequently, the food taste is terrible, cold, and always late. Resident #3 stated they have complained on several occasions and it would improve for a while then return to the food late cold and taste terrible. Review of Monthly Grievance Log for January, February, March. April, and May revealed complaints regarding food taste, cold and late. 1 January 30 resident complained regarding she was unhappy with breakfast - facility response showed Dietary Manager note of the complaint. 2. February 7 and 8 four residents complained about the quality of the food service - facility response - They have new contract dietary service. 3. March 17 established food committee with 6 residents complaining to the dietary manager regarding taste, cold, and late service and not alternatives- facility response: Dietary Manager met with residents to discuss concerns and work with the food committee. 4. March 19 resident complained regarding food service - facility response will talk to the dietary manager 5. April 28 Resident Council expressed concerns with dietary department with staffing in department - facility response - Dietary manager to attend next resident council meeting to work on resolving issues and work on staffing. 6. May 12 Food Committee express concerns to the Dietary Manager regarding taste, cold and late service - Facility response - follow up with Resident group and happy with progress made. 7. May 17, May 20 Concerns expressed regarding dietary services and unhappy with substitutes - facility response - happy with response if there no excuses moving forward. During a Confidential Group Interview on 6/28/22 at 11:00 p.m., the residents stated the food was cold and gross. One resident stated, there wasn't enough food to feed a baby. The residents stated there were no snacks. They stated if they asked for the substitute, they were not going to get it and sandwiches had no condiments. When asked if they could pick one thing, they wanted surveyor to work on, they unanimously stated the food which is terrible always late and frequently cold. Observation of a test tray evaluation on 06/28/2022 at 1:00 PM, revealed the test tray consisted of 1 cup of collard greens, 1 corn bread square, a bowl of beans and bacon, and a fruit cup Three surveyors evaluated the test tray. The collard greens [NAME]-warm corn bread, [NAME]-warm, beans [NAME]-warm residents complain about food being cold taste during meal service. Interview on 06/28/2022 at 1:00 PM, revealed the Admissions Manager (Administrator unavailable) stated corn bread [NAME]-warm collard greens [NAME]-warm beans warm. Flavor was good. During an interview on 06/28/2022 at 4:45 PM, the Dietary Manager said that the previous Dietary Manager was let go and they have been working with the Resident Council and the Food Committee, but have not had a chance to get together since she was terminated. She said we had been short-handed, and the food time is posted at 12:00 Noon and as I understand , we must deliver the first tray by 12:00 Noon and the first tray is delivered by that time. Sometimes the hall trays do not get delivered till after 12:00 Noon and the dining room is delivered after all the hall trays are delivered. She also said water should not be added to puree food. Observation of staff during diner food service on 06/28/2022 at 4:30 PM reveals 1 Cook 1 Dietary Aide 1 Dietary Manager Staff to provide meals for 63 residents who eat in the facility's only dining room. Observation of food delivered to the dining room 06/27/22 - 12:50 PM 06/28/22 - 1:00 PM 06/29/2022 request dietary policy and procedure and food times revealed Lunch meals time begin at 12:00 Noon. No dietary policy and procedure regarding delivery was provided.

Based on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for one of one kitchen. The facility failed to ensure a kitchen staff changed their gloves and washed their hands after putting hand within the trash can. This failure could place residents at increased risk of exposure to food-borne illnesses. Findings included: During meal service observation 06/28/2022 at 4:30 PM, Dietary Aide was observed moving a large garbage can out of his path by placing his fingers within the inside of a garbage can used near the stove. This staff failed to change gloves or wash hands prior to walking over to a reach in refrigerator moving three pitchers consisting of water, orange juice and cranberry juice. This staff removed a case of milk cartons and placed ten milk cartons in a pan with ice, and placing the pitchers and milk carton on a cart and took to the residents on the facility halls and dining room. During an interview with Dietary Aide on 06/29/2022 at 1:40 PM, he said he was confused about when to change gloves and wash hands and did not realize he needed to change gloves or wash hands after touching the inside of the garbage can. (Dietary Aide had not completed his Safe Serve Certification training at this time) During an interview with the Dietary Manager on 06/29/2022 at 1:45 PM, she said the Dietary Aide had only been working there for about a week and undergoing training on the Safe Serve Certification and they were required to complete it within 30 days. She said he was supposed to complete it on Monday 6/27/2022 and not sure he has completed it yet. The Dietary manager said he should have removed his gloves and washed his hands before providing food service to the residents. Review of the kitchen policy and procedures dated 2020 titled, Proper Hand Hygiene: Dining Services Employees. Handwashing with soap and water is required in a Dining Services Setting in the following situations: - After handling dirty dishes or trash