**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined there was a delay in care for a resident complaining of leg numbness and weakness for 1 of 4 sampled residents. Resident identifier: 1. Findings Include: Resident 1 was admitted to the facility on [DATE] and discharged on 6/30/2024 with diagnoses of wedge compression fracture of the thoracic (t) vertebra of t7-t8 , multiple rib fractures, muscle weakness, cognitive communication deficit, and schizophrenia. On 6/26/2024 at 12:38 PM, a provider documented a cranial nerve exam and neurological exam was conducted on resident 1 due to complaints of being unable to move or feel their legs for the last day. The provider documented no abnormalities were noted. Resident 1 had been able to feel and move their lower extremities at the time of the exam. On 6/29/2024 at 4:48 AM and 11:54 AM, licensed practical nurses documented resident 1 had complained of lower extremity paralysis. There was no provider documentation or communication located to indicate the provider had been made aware of resident 1's change of condition. On 6/30/2024, a registered nurse documented resident 1 had been seen by the provider and sent to the emergency room due to hypoxia, nausea, and new onset paralysis to lower extremities. At 1:30 PM, the provider documented resident 1 had been sent to the emergency room due to a new diagnosis of peripheral neuropathy and no movement to their lower extremities post vertebral compression fracture. It should be noted resident 1 had a 5 day hospital admission with diagnoses including but not limited to Cauda equina compression, epidural abscess, and osteomyelitius of the thoracic vertebra. On 10/7/2024 at 2:19 PM, an interview was conducted with the Administrator (ADM). The ADM stated they were recently made aware that resident 1 had made claims of a fall at the facility and staff had not been taking care of them. The ADM stated there was no documented incident of a fall and there had been no report of a fall. On 10/7/2024 at 2:42 PM, an interview was conducted with the Nurse Practitioner (NP). The NP stated the last encounter they had with resident 1 was when resident 1 voiced they were unable to move or feel their legs and the NP observed a lack of movement in resident 1's lower extremities. The NP stated they sent resident 1 to the hospital but they were unsure if resident 1 was faking or exaggerating their symptoms. The NP stated they remembered they rounded on resident 1 on a Sunday and immediately sent them out that day due to their symptoms and their past medical history. The NP stated resident 1's lumbar back all of a sudden got worse and they were unable to move their legs and with their history, they knew this was going to happen eventually. On 10/8/2024 at 9:48 AM, a follow up interview was conducted with the ADM. The ADM stated they were unable to provided further documentation to show the provider had been notified of resident 1's condition on 6/29/2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined for 1 out of 36 sampled residents, the facility did not treat each resident with respect and dignity and care for each resident in a manner in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. Specifically, a resident was covered in towels in a shower chair with the sides of her buttocks exposed and being pulled backwards through the hallway. Resident Identifier: 56. Findings included: Resident 56 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included, but were not limited to, hemiplegia and hemiparesis following cerebral infarction, type 2 diabetes mellitus, chronic obstructive pulmonary disease, bipolar disorder, major depressive disorder, adjustment disorder with anxiety, cognitive communication deficit, and muscle weakness. On 8/26/24 at 11:16 AM, an observation was made of resident 56 being pulled backwards in a shower chair by Certified Nursing Assistant (CNA) 3. Resident 56 was observed to be covered in towels with the sides of her buttocks exposed in the 200 hallway. A care plan Focus revealed ADL [activities of daily living] Self Care Performance Deficit r/t [related to] hemiplegia, stroke, weakness, edema, COPD [chronic obstructive pulmonary disease]. An intervention initiated on 7/18/24, included BATHING Requires staff participation with bathing. On 8/26/24 at 11:21 AM, an interview was conducted with resident 56. Resident 56 stated that this was the first time she had been pulled backwards through the hallway. Resident 56 stated that she had always been dressed in a shirt and at least a brief before she exited the shower room. Resident 56 stated she would prefer to be fully dressed after her shower before she was brought back to her room. On 8/26/24 at 11:42 AM, an interview was conducted with CNA 3. CNA 3 stated that it was not unusual for him to bring residents back to their rooms covered in towels to prevent the resident from getting their clothes wet. On 8/27/24 at 12:10 PM, an interview was conducted with Director of Nursing (DON). DON stated that it was not standard practice for residents to be wheeled backwards through the hallway covered in towels. DON stated that residents should be fully clothed with no sensitive area exposed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility did not provide, 4 of 36 sampled residents, the right to have secured and confidential personal and medical records. Specifically, the computer screen was left open on the medication carts with resident personal information and a nurse report paper was left face up on the medication cart with resident personal information. Resident identifiers: 4, 8, 70, and 76. Findings included: On 8/25/24 at 1:46 PM, an observation was made of Licensed Practical Nurse (LPN) 2. LPN 2 was observed to leave the computer screen open on the medication cart in the 200 hallway and walked away from the computer down the hallway. Residents 8, 70, and 76 were observed to be near the medication cart. On 8/26/24 at 7:23 AM, an observation was made of Registered Nurse (RN) 5. RN 5 was observed to leave the computer screen open on the medication cart in the 200 hallway and walked into resident room [ROOM NUMBER]. Resident 4 was observed to be walking by the medication cart. On 8/27/24 at 7:30 AM, an observation was made of a nurse shift report left on top of a medication cart in the 200 hallway face up with resident personal information and unattended. An observation was made that the medication cart was left unattended for a period of 15 minutes. It was observed that resident 4 was walking the 200 hallway. On 8/29/24 at 11:07 AM, an interview was conducted with Director of Nursing (DON) 1. DON 1 stated that nurses should lock their computer screen any time they leave the medication cart unattended. DON 1 stated that nurse reports with any resident information should never be left out in the open.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure that the transfer or discharge was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider. Specifically, for 1 out of 36 sampled residents, a resident did not have any transfer documentation in their medical record when they were transferred to the hospital. Resident identifier: 8. Findings included: Resident 8 was admitted to the facility on [DATE] with diagnoses that include, but were not limited to, hereditary and idiopathic neuropathy, asthma, cognitive communication deficit, weakness, reduced mobility, borderline personality disorder, major depressive disorder, anxiety disorder, chronic obstructive pulmonary disease, malingerer, and panic disorder. Resident 8's medical record was reviewed from 8/25/24 to 8/29/24. Resident 8's progress notes revealed the following: a. On 7/26/24 at 12:12 AM, a nursing note documented, Resident's roommate came out into the hall asking for help and stating that [resident name redacted] was on the floor. When I walked in, she was lying on the floor in front of her TV, lying on her R [right] side. I tried to assess for any injury. [Resident name redacted] was making intelligible comments, and she was unable to help get herself into a sitting position. Her roommate reported that 'she hit her head pretty hard'. She also said that she thinks that 'she may have been knocked out, she wouldn't answer me for several minutes'. EMS [emergency medical services] called and Resident transported via ambulance to [name of hospital redacted]. b. On 7/26/24 at 2:00 AM, a nursing note documented, returned from [name of hospital redacted] ED [emergency department] 7/26/24: Diagnosis from Today's Visit: 1. Altered Mental Status 2. Compression Fracture of L5 [fifth lumbar vertebra] vertebra 3. T12 [twelfth thoracic vertebra compression fracture f/u [follow up] Dr. [doctor] [name redacted] (Neurosurgery). On 8/27/24 at 11:58 AM, an interview was completed with the Corporate Resource Nurse (CRN). The CRN stated that when a resident was discharged or transferred to a hospital a face sheet, a list of resident's medications, and a copy of the bed hold agreement would go with the resident. The CRN stated that there was no information on resident 8's transfer to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2 Resident 8 was admitted to the facility on [DATE] with diagnoses that include, but were not limited to, hereditary and idiopathic neuropathy, asthma, cognitive communication deficit, weakness, reduced mobility, borderline personality disorder, major depressive disorder, anxiety disorder, chronic obstructive pulmonary disease, malingerer, and panic disorder. Resident 8's medical record was reviewed on 8/25/24 to 8/29/24. Resident 8's progress notes revealed the following: a. On 7/26/24 at 12:12 AM, a nursing note documented, Resident's roommate came out into the hall asking for help and stating that [resident name redacted] was on the floor. When I walked in, she was lying on the floor in front of her TV, lying on her R [right] side. I tried to assess for any injury. [Resident name redacted] was making intelligible comments, and she was unable to help get herself into a sitting position. Her roommate reported that 'she hit her head pretty hard'. She also said that she thinks that 'she may have been knocked out, she wouldn't answer me for several minutes'. EMS [emergency medical services] called and Resident transported via ambulance to [name of hospital redacted]. b. On 7/26/24 at 2:00 AM, a nursing note documented, returned from [name of hospital redacted] ED [emergency department] 7/26/24: Diagnosis from Today's Visit: 1. Altered Mental Status 2. Compression Fracture of L5 [fifth lumbar vertebra] vertebra 3. T12 [twelfth thoracic vertebra compression fracture f/u [follow up] Dr. [doctor] [name redacted] (Neurosurgery). There was no information regarding a bed hold agreement found in resident 8's medical record. On 8/27/24 at 11:58 AM, an interview was conducted with the CRN. The CRN stated that when a resident was discharged or transferred to a hospital a face sheet, a list of the resident's medications, and a copy of the bed hold agreement would go with the resident. The CRN stated the packet with the bed hold agreement was given to EMS, but it never came back with the resident from the hospital. Based on interview and record review, the facility did not provide written information to the resident or resident representative that specifies the duration of the state bed-hold policy, if any, during which the resident was permitted to return and resume residence in the nursing facility. Specifically, for 2 out of 36 sampled residents, resident's were transported to the hospital and were not informed of the facility bed-hold policy. Resident identifiers: 8 and 56. Findings included: 1. Resident 56 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, type 2 diabetes mellitus with diabetic neuropathy, chronic obstructive pulmonary disease, bipolar disease, and anemia. Resident 56's medical record was reviewed on 8/25/24 through 8/29/24. Resident 56's progress notes revealed on 4/5/24 at 6:20 PM, Called to residents' room by her mother stating her daughter doesn't seem right, I entered the room and noticed residents' right side of mouth drooping, resident slurring her words, very dry mouth, unable to tell me her name, could not tell me what day it was or who the president was, she was able to recognize her mother, extremely drowsy falling asleep while attempting to speak, unable to hold her eyes open but does respond to painful stimuli, all sedating medication have been held all day d/t [due to] lethargy and excessive sleepiness per nursing report, . 911 called resident transported to hospital, mother was here and aware, another nurse called on call provider and on call nursing. There was no information regarding a bed hold agreement in resident 56's medical record. On 8/29/24 at 8:32 AM, an interview was conducted with the Corporate Resource Nurse (CRN). The CRN stated that there was an envelope with paperwork the nurse sent to the hospital with the resident. The CRN stated the bed hold form was given in the envelope that was sent with the resident to the hospital. The CRN stated there was a form on the envelope that had the information provided on it. The CRN stated that form was then scanned into the residents medical record. The CRN stated that there were no bed holds in resident 56's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents. Specifically, for 2 out of 36 sampled residents, a resident that was considered an elopement risk with a wandergaurd left the facility unattended and the resident was a smoker without a smoking assessment. In addition, another resident that had an unwitnessed fall and did not have neurological checks completed. Resident identifiers: 59 and 185. Findings included: 1. Resident 185 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, acute on chronic systolic congestive heart failure, moderate protein-calorie malnutrition, chronic obstructive pulmonary disease, mild intellectual disabilities, cognitive communication deficit, urinary tract infection, dementia, alcohol abuse, and essential hypertension. Resident 185's medical record was reviewed on 8/25/24. On 7/8/23 at 6:22 PM, the Elopement/Wandering Evaluation documented that resident 185 was a High Risk for wandering with a score of 11. A resident with a score of 10 to 55 was considered a High Risk. On 7/9/23 at 10:29 AM, a Nursing progress note documented Note Text: Pt. [patient] attempt to check out stating that he want [sic] to go home and get his money and shoes. Pt. was assist back to his room and friend on his contact was called. Pt. exhibit confusion. A care plan Focus initiated on 7/10/23, documented Elopement risk/wanderer r/t [relate to] History of attempts to leave facility unattended. The intervention initiated on 7/10/23, documented Document wandering behavior and attempted diversional interventions. On 7/10/23 at 3:22 PM, a Nursing progress note documented Note Text: Verbal Consent for Wander Guard and Patient Education This progress note documents an important discussion and intervention with the patient regarding their desire to leave the facility and concerns about their safety. The patient expressed a willingness to leave, even mentioning the possibility of exiting through a window if necessary. The nurse . [name redacted] and I obtained verbal consent from the patient to implement a wander guard system, and we also provided education on the importance of following the medical team's orders and ensuring a safe departure if and when it becomes appropriate. During a conversation with the patient, they expressed a strong desire to leave the facility, stating that they were ready to leave by any means necessary, including through a window. Recognizing the potential risk to their safety, the nurse . director and I engaged in a discussion with the patient to address their concerns and explore alternative solutions. We explained the concept of a wander guard system, which is designed to enhance patient safety by preventing unauthorized exits from the facility. After providing a clear explanation of the purpose and functionality of the wander guard, we obtained verbal consent from the patient to implement this measure. The patient demonstrated understanding of the purpose of the system and agreed to its implementation. Additionally, we took the opportunity to educate the patient on the importance of following the medical team's orders and completing the full course of antibiotics as prescribed. We emphasized that staying in the facility and receiving proper treatment would enhance their overall well-being and increase the chances of a successful recovery. We addressed any concerns or questions the patient had, ensuring they were well-informed and involved in their care decisions. A physician's order dated 7/10/23 at 3:41 PM, documented Check Wandergaurd Placement at the beginning of every Shift every shift for wander guard. Discontinued on 9/23/23. On 7/13/23, a St. Louis University Mental Status (SLUMS) Examination documented that resident 185 had dementia with a score of 1 to 20. An admission Minimum Data Set assessment dated [DATE], documented that resident 185 had a Brief Interview for Mental Status (BIMS) score of 11. A BIMS score of 8 to 12 indicated moderate impairment. On 7/25/23, a SLUMS Examination documented that resident 185 had dementia with a score of 1 to 20. On 7/26/23 at 4:01 PM, a Nursing progress note documented Note Text: Resident removed wander guard on NOC [night] shift, wander guard was found on bed table, Wander guard reapplied to right wrist. On 8/26/23 at 1:47 PM, a Nursing progress note documented Note Text: Resident removed wander guard this afternoon and returned it to his nurse stating that 'it slows him down.' New straps are pending delivery so there is no wander guard on at this time. Resident is currently lying down in his bed. Provider notified. Staff notified. Will reapply wander guard as soon as able to. On 8/26/23 at 8:10 PM, a Nursing progress note documented Note Text: Resident cut his wandergaurd off today. It was placed in the top drawer of the nurses cart, we are awaiting a delivery of new bands. Resident has been compliant with staying in the facility today. Will continue to monitor closely. On 9/16/23 at 2:55 PM, a Nursing progress note documented Note Text: Resident asked if he could go out this morning. When asked who he was going with he said no one. He was told that he couldn't leave the building by himself. He said he thought so, but he wanted to try. On 9/22/23 at 3:48 PM, a Nursing progress note documented Note Text: Resident called a friend this morning and she came to the facility and signed him out. They have not returned yet. He did take all medicaiton [sic] this morning. He has the wander guard on the right ankle. He has his belongings packed in boxes and sitting in front of his bed. On 9/23/23 at 2:42 PM, a Nursing progress note documented Note Text: resident went out to smoke with other residents. CNA [Certified Nursing Assistant] called saying resident was down by [name redacted] gas station refusing to come back to facility. Resident stated to CNA that Resident was 'going to get on the bus and go were the homeless people are.' ON callnursing [sic] manger [sic] reported above. On call nursing manager to call back with plan. (Note: Resident 185 did not have a smoking evaluation completed and a care plan that addressed smoking had not been developed.) On 9/23/23 at 2:52 PM, a Nursing progress note documented Note Text: on call nursing manger said to go over to [name redacted] store and try to get resident back. If resident will not come then call the police. on my way to store another floor nurse will watch my patients. On 9/23/23 at 3:19 PM, a Nursing progress note documented Note Text: Returned from [name redacted] store. On Call nursing supervisor called and reported that there was no sign of CNA or resident at [name redacted] and on my way back to facility. There [sic] The CNA who saw the resident at [name redacted] store was on his way home from work. 911 called reported protected patient missing last seen at [name redacted] store to catch a bus to where the homeless people are. Police officer to come to the facility. On 9/23/23 at 3:53 PM, a Nursing progress note documented Note Text: Police Officer [name redacted] came and got the information needed, looked at chart picture we have of resident. Policer [sic] is going to look for resident and bring him back if he can. On 9/23/23 at 10:35 PM, a Nursing progress note documented Note Text: R [resident] returned to facility tonight. R was alert and oriented X3 [person, place, and time]. Head to toe assessment done. No apparent signs of injuries noted. Skin looked intact. Vitals taken BP [blood pressure]: 131/76, Pulse 94, Resp [respirations] 18, Temp [temperature] 98. R was compliant and pleasant. Wander guard noted to hisL [sic] [left] foot. On 9/23/23 at 10:42 PM, a Skin Evaluation documented no apparent signs of injuries noted. Skin looked dry, warm and intact. No edema noted. A care plan Focus initiated on 7/10/23, documented Elopement risk/wanderer r/t History of attempts to leave facility unattended. The interventions initiated on 9/23/23, documented Q15 [every fifteen] minute checks, Supervision when outside of building and Wander Guard to left ankle. A physician's order dated 9/24/23 at 6:00 AM, documented Wander Guard placement and function every shift for wander guard. On 9/24/23 at 2:46 PM, the Elopement/Wandering Evaluation documented that resident 185 was a low risk for elopement with a score of 6. A resident with a score of 0 to 9 was considered a Low Risk. On 9/24/23 at 6:29 PM, an Alert Note progress note documented Note Text: Resident is alert, ox4 [oriented times four to person, place, time, and event], follows all commands, answers questions appropriately. Resident has not tried to leave facility grounds this shift. Resident was placed on Q [every] 15min [fifteen minute] watch while in building, 1:1 [one on one] while out smoking at approximately 15:00 [3:00 PM]. Reported to on coming nurse the above restrictions and gave her the q 15min monitor sheet. On 9/25/23 at 9:00 AM, an Interdisciplinary Team (IDT) Note progress note documented Text: IDT reviewed incident that occurred 9/23/2023. At approximately 2:30 pm, it was identified that resident had left the facility alone. Resident reported to a staff member that he 'wanted to live with the homeless people'. Facility was thoroughly searched, as well as, surrounding areas. Emergency response was issued to locate the resident (Police, UTA [Utah Transit Authority], Emergency Rooms, Homeless Shelters convenience stores) were all notified. Emergency contact and primary physician were notified as well. Employees searched the streets of [NAME] for 6 hours until dark. At approximately 2122 [9:22 PM], resident returned to facility. Head to toe assessment completed, no injury noted. Wander guard placement/functionality assessed and found to be in working order. Provider notified. Police were also notified of residents return. Intervention: Resident was placed on Q15 minute visual checks and supervision when resident is outside of the building. On 9/25/23 at 6:36 PM, a Nursing progress note documented Note Text: Resident has had 15 minute checks and has been present for them. He walked past the nurse on the 200 hall way and the nurse followed behind. He went out the 200 side door and the door did not alarm. He had taken his wander guard off. He was followed inthem [sic] parking lot and the nurse was talking with him and asking him to stop and talk with her. He did go with a staff member and back into the building. He then became one on one in nurse management office. He has been watched closely. A new wander guard was put on his left ankle. On 9/25/23 at 8:49 PM, a Therapy progress note documented Note Text: The patient is experiencing difficulties remembering how to check himself out of the SNF [Skilled Nursing Facility] and has presented with increased memory loss that adversely impacts his safety, independence and well-being. He could benefit from ST [Speech Therapy] sessions implementing compensatory strategies so that he can return to his PLOF [prior level of functioning] successfully. On 9/26/23 at 7:38 PM, an Alert Note progress note documented Note Text: Resident remain on Q 15 minute checks, 1:1 when he goes out to smoke. Resident has stayed all day in his room. Resident is withdrawn, not interacting with staff or residents as before. On 9/28/23 at 2:21 PM, an Alert Note progress note documented Note Text: Resident continues to be Q15 minute checks. Resident has remained mostly in room except to smoke. Resident stated today that he wants to get on a bus and go to [NAME], Utah. Resident 1:1 when he is out smoking. On 9/29/23 at 4:51 PM, an Alert Note progress note documented Note Text: Resident remains on Q 15 minute check. Resident caught smoking in his restroom by night shift staff. Resident has tried to use the back door exit at end of hall to go smoke. Resident is 1:1 when he smokes. Resident expresses desire to 'leave this place'. On 10/5/23 at 5:00 PM, a Nursing progress note documented Note Text: Resident transferred to [Long Term Care Facility name redacted] with all belongings, medications (controlled and scheduled)via [name redacted] transportation. The exhibit 358 form submitted to the State Survey Agency (SSA) was reviewed. On 9/23/23 at 2:30 PM, it was identified that resident 185 had left the facility alone with mild cognitive impairment. He had last been heard to say that he wanted to live with the homeless people. Emergency response was issued to locate the resident were all notified. Resident 185 did not have any emergency need for medications and the weather was favorable. Emergency contact and primary physician were notified as well. Eight individuals employed by the facility searched the streets of [NAME] for six hours until dark to find resident 185. The facility pulled the eight individuals off of the search for the day around 8:30 PM, when it was no longer light outside. The facility anticipated continuing the search on Sunday morning. All the while, the plan was to have Police, UTA, Emergency rooms, etc. keep an eye out for resident 185 through the night. On 9/23/23 at 9:22 PM, resident 185 showed back up to the facility stating that he was cold so he came back. Resident 185's evaluation will be performed to make sure there were no injuries as well as to determine careplan adjustments going forward. The exhibit 359 form submitted to the SSA was reviewed. The Summary of interviews with witnesses documented that there were no witnesses to the incident. It was identified that resident 185 had gotten out of the facility when a CNA left the building to go home at 2:40 PM, and resident 185 was walking down the sidewalk behind the gas station in close proximity to the facility. The CNA attempted to get resident 185 to go back to the building but resident 185 refused. The CNA alerted staff at the facility that resident 185 had gotten out of the building. The CNA was off the clock and did not feel like he needed to stay with resident 185 so he left. From that time forward the facility was not able to locate resident 185. The Unit Manager had noted that resident 185 in the past had expressed desires to leave the facility, but had never acted on that desire. Resident 185 had times when he had been more lucid than others. Resident 185 was a supervised smoker and had a wandergaurd anklet on. As much as the facility could ascertain, resident 185 slipped away while out on supervised smoking when the staff member was taking another resident back. On 8/26/24 at 11:41 AM, an interview was conducted with CNA 4. CNA 4 stated that he was off shift driving home when he saw resident 185 at the bus stop by the local convenient store. CNA 4 stated that he called the facility to let them know. CNA 4 stated that he asked resident 185 to get in the vehicle so he could take him back to the facility but resident 185 would not get in the vehicle. CNA 4 stated that resident 185 was a supervised smoker and resident 185 had a wander guard on his ankle. CNA 4 stated that resident 185 liked to cut off the wandergaurd and would use a butter knife. CNA 4 stated if a resident was a supervised smoker he would put a smoking apron on the resident, make sure the resident was ashing their cigarette appropriately, watch the resident for safety, and dispose of their cigarette. CNA 4 stated that he was unsure if resident 185 had the wandergaurd on or not the day of the elopement. CNA 4 stated that resident 185 liked to hang around the exit door of the facility and staff would try to keep resident 185 occupied in the activities room. CNA 4 stated that the distraction would work sometimes to keep resident 185 away from the doors. CNA 4 stated that he should have stayed with resident 185 at the bus stop and it had been a learning experience. On 8/26/24 at 11:43 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she was on call the night that resident 185 had eloped and she got the call from the floor nurse. LPN 1 stated that resident 185 was always trying to get to the bank or had a destination in mind. LPN 1 stated that resident 185 was a supervised smoker the day he eloped and she believed that resident 185 had snuck away. LPN 1 stated that resident 185 had been homeless before and thought he might be headed back there. LPN 1 stated that she spent the day looking for resident 185, like six hours. LPN 1 stated that the floor nurses did the elopement assessments. LPN 1 stated there were things to consider if the resident was a high risk. LPN 1 stated if the resident could actively leave the facility then yes they would put in a process. LPN 1 stated the high risk would depend on the resident's cognition and history. LPN 1 stated that she could not remember what interventions were in place for resident 185. On 8/26/24 at 2:18 PM, an interview was conducted with CNA 5. CNA 5 stated if a resident was a supervised smoker she would get the residents ready by the door. CNA 5 stated that some CNAs would let the residents get their cigarettes prior to going out or the CNA would take the box out with them. CNA 5 stated that two staff would take the residents all out and we would make sure the residents got their smokes. CNA 5 stated that she would watch the residents all smoke and when the resident were finished the staff would take the residents back in the facility. CNA 5 stated if the resident was a wander risk the resident usually would have a wandergaurd on and the alarm would go off if the resident went out the door. CNA 5 stated the wandergaurd was an extra check. CNA 5 stated that usually their was someone outside during the smoke break while the other staff member was bringing the residents in. CNA 5 stated if there was only one staff member during the smoke break it was usually at night when there was less staff. CNA 5 stated she would monitor the smoke break the entire time until the residents were all finished. CNA 5 stated that there were also smoke aprons for the residents. On 8/26/24 at 3:01 PM, an interview was conducted with the Administrator (ADM). The ADM stated that CNA 4 was driving down the road and saw resident 185 and CNA 4 thought he would check it out. The ADM stated that CNA 4 stopped to check on resident 185 to see if he was okay. The ADM stated that CNA 4 asked resident 185 if he wanted to get in his van and go back to the facility and resident 185 replied no. The ADM stated that CNA 4 stated that the situation felt weird but CNA 4 thought it was okay for resident 185 to be out there. The ADM stated that CNA 4 left and called the nurse. The ADM stated that resident 185 had said that he was going to the ghetto so the ADM called resident 185's family to see where that might be. The ADM stated that resident 185 walked into the building on his own right as they called off the search. The ADM stated the staff increased monitoring and needed to get resident 185 to a better environment. The ADM stated that resident 185 had the wandergaurd on and 15 min checks. The ADM stated the wandergaurd system for the facility would alarm but it would not lock the doors. The ADM stated that resident 185 continued to try and leave the facility. The ADM stated that education with the staff members was provided. The ADM stated when resident 185 admitted to the facility he was not a wander risk and there were no notes that indicated he was a wander risk. The ADM stated that resident 185 was not exit seeking but anxious and staff would walk the building with resident 185. The ADM stated that staff met as a team after resident 185 had eloped and decided that resident 185 was able to leave the building and get himself back was he really a risk. The ADM stated that resident 185 was reassessed as a low elopement risk. On 8/26/24 at 4:35 PM, an interview was conducted with CNA 6. CNA 6 stated that she could not remember any circumstances regarding resident 185. CNA 6 stated that she thought she worked on a hall that resident 185 was not on so she did not have much interaction with resident 185. CNA 6 stated any resident who was deemed unsafe to smoke for any reason would be a supervised smoker. CNA 6 stated there was a list of residents that were smokers so the staff did not miss anyone. CNA 6 stated the staff did not have time to take the smokers out extra if their smoke time was missed. CNA 6 stated whom ever was assigned to the smoke break and that resident would ensure the resident got their smoke break. CNA 6 stated that the residents were gathered by the door by the nurses station on the 200 hall. CNA 6 stated the staff would make sure the resident was wearing a smoking apron and would get the residents ready to go outside. CNA 6 stated there was a coded lock box due to residents complaining of missing smokes. CNA 6 stated another staff member would assist to get everyone outside. CNA 6 stated that staff would control the lighter for the residents depending on the circumstances. CNA 6 stated that sometimes the extra staff member would stay outside if the staff member was able. CNA 6 stated if there were two staff one would push the residents into the facility and the other staff member would stay outside while the residents finished smoking. CNA 6 stated if there was one staff member then technically yes there might be a moment when the residents were unsupervised outside but she would push the residents just inside the door so she could watch the residents that were still outside. CNA 6 stated if there was a resident with a wandergaurd or the resident was an elopement risk she would push them into the facility first so she knew that they were safe. The facility policy and procedure Elopement/Unsafe Wandering was reviewed. The policy and procedure had a revision/review date of 1/2022. Policy It is the policy of this facility to provide a safe environment for all residents through appropriate assessment and interventions to prevent accidents related to unsafe wandering or elopement. Purpose This facility is committed to promoting resident autonomy by providing an environment that remains as free of accident hazards as possible. Each resident is assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision and diversional programs to prevent unsafe wandering while maintaining the least restrictive environment for those at risk for elopement. Procedure 1. Residents with capabilities of ambulation and/or mobility in wheelchair will have an Elopement/Wandering Evaluation completed to determine risks for elopement and unsafe wandering on admission and with observed behaviors of wandering or attempting to elope. 2. Residents with high risk factors will be identified as At Risk and will have an individualized care plan developed that includes measurable objectives and timeframes. a. Care plan interventions will consider the elements of the evaluation or behavior observations that identified the resident at risk. b. Interventions will address the individualized level of supervision needed to prevent elopement/unsafe wandering. 3. Staff shall promptly report any resident who is trying to leave the premises or is suspected of being missing to the Charge Nurse or Supervisor to evaluate the need for further interventions. 5. When the resident has been located and/or returns to the facility: a. An assessment of the resident will be completed to determine if medical attention is required and provide interventions as indicated. b. Notify search teams that the resident has been located. c. The attending Physician and Resident Representative will be notified of the resident's return and the resident status. d. Document relevant information in the resident's medical record. 6. Complete an Elopement/Wandering Evaluation of the resident post elopement incident with continued follow ip documentation for a minimum of 72 hours following the incident. 7. The Interdisciplinary Team will review of [sic] the elopement incident, to include an investigation to determine safety of the environment and probable causal factors leading to the elopement. A summary of the investigation and recommendations will be documented in the resident's medical record. 8. The resident's care plan will be updated and include interventions to address the possible need for the increased level of supervision. The facility policy and procedure Smoking Policy was reviewed. The policy and procedure had a revision date of 12/2019. POLICY: It is the policy of this facility to provide to its' residents a smoke free environment. It is also policy to provide those residents who choose to smoke a means in which to do so that does not jeopardize their safety or the safety of others residing in the facility. PURPOSE: To satisfactorily address the wishes of both smoking and non-smoking residents without compromising the safety of either. PROCEDURES: 1. This facility does not allow smoking of any kind to occur within the facility. Designated smoking areas outside the building are available for this purpose. No lighting materials (e.g. matches, lighters), tobacco products, or smoking devices will be allowed to be kept in the possession of the residents, either on their person or in the facility. 2. Upon admission (7-10 days), residents who desire to smoke will be assessed as well as their ability to do so safely. All new admissions will be on supervised smoking until assessment is reviewed by the interdisciplinary team. The Interdisciplinary Team will accomplish this using the Smoking Assessment form and a review of the resident's clinical record. At the end of this period it will be determined if the resident will be allowed to smoke either under supervision or independently with or without protective devices. In either case, no lighting materials (e.g., matches, lighters), tobacco products, or smoking devices will be allowed to be kept in the possession of the resident, either on their person or in the facility 3. The results of the evaluation will be placed in the resident's chart and the IDT recommendations will be care planned. 4. Upon quarterly review by the IDT, or at any time a significant change of condition occurs, smoking residents will be re-assessed as to their ability to smoke safely, either independently or under supervision, and their ability to understand and comply with facility non-smoking policy using the Smoking Assessment form. 5. If a resident decides to begin smoking after initially being assessed as a non-smoker, the facility will follow the above procedures. 6. The frequency of smoking for residents that are determined not safe will be the following times with staff supervision 06:30 [6:30 AM] 11:30 [AM] 15:30 [3:30 PM] 20:30 [8:30 PM] 09:30 [9:30 AM] 13:30 [1:30 PM] 18:30 [6:30 PM] 22:30 [10:30 PM] These times will be no more than twenty (20) minute increments or 2 cigarettes 7. If it is determined that a resident is a safe smoker, smoking materials will still be retained by nursing staff and they may come and request 1 or 2 cigarettes at the time they desire to go out to smoke unsupervised There will be no smoking between the hours of 23:00 [11:00 PM] and 6:30 [AM] by any resident even if they are deemed safe 8. The facility reserves the right to immediately confiscate smoking materials as well as to rescind the individual smoking privileges if failing to take such measures would jeopardize resident safety. 9. If a resident continues to be non-compliant with the smoking policy set forth they will be given a written thirty (30) day notice and placed on fifteen (15) minute checks until they leave the facility 10. The facility reserves the right at any time to modify or change the smoking policy to maintain the safety of the facility and the residents. All smokers will be advised and given a copy of the new policy. 2. Resident 59 was admitted to the facility on [DATE] and readmission dated 2/27/24 with diagnoses which included erosive arthritis, type 2 diabetes mellitus, protein-calorie malnutrition, hyperkalemia, depression, pain left knee, fatigue, need assistance with personal care, fracture of one rib left side, and history of falling. On 8/25/24 at 12:23 PM, an interview was conducted with resident 59's family member. Resident 59's family member stated resident 59 had fallen three or four times and had been hurt. Resident 59's medical record was reviewed on 8/25/24 through 8/29/24. Fall risk assessments revealed that resident 59 was at medium risk for falls on 1/30/24 and 2/25/24. Resident 56 was assessed as a high risk for falls on 4/7/24. A care plan dated 1/30/24, revealed that resident 56 Has had an actual fall: 1/30/2024 no injury 2/25/2024 no injury 2/29/2024 no injury 4/6/2024 rib fracture 7/5/2024 slight left rib fracture. The goal was Will resume usual activities without further incident through the review date. The interventions included 4/6/2024 Intervention: Therapy to evaluate and treat as appropriate; 7/5/24: Bed in lowest position and; Continue interventions on the at-risk plan. On 1/30/24 at 8:55 AM a nursing progress note revealed, Resident had a fall today while in the shower. He slipped and fell on his right knee. He was in the shower with [name removed], his wife. The CNA was not present at the time of the fall. Both the resident and his wife deny that he hit his head. They stated he slipped while ambulating on the wet floor to get to his walker. He c/o [complaints of] right knee tenderness. No other injuries were noted upon assessment. No bruising was noted. He does have 2 small abrasions, these were cleaned and dried and left open to air. NP [Nurse Practitioner] [name removed] was notified and she responded, 'knee x-ray please if still in pain.' Resident denies any pain at this time and stated he does not want an x-ray. Will continue to monitor. Will notify family. There were no neurological assessments located in resident 56's medical record after the fall on 1/30/24. On 8/29/24 at 8:40 AM, an interview was conducted with Director of Nursing (DON) 1 and Corporate Resource Nurse (CRN). The CRN stated if the fall was unwitnessed, then neurological assessments were completed. The CRN stated if a resident was found on the floor, the nurse should conduct a full body assessment. The CRN stated after a fall the nursing staff notified the Medical Doctor and the resident's representative. The CRN stated alert charting was implemented for 72 hours. The CRN stated within 24 business hours the Interdisciplinary Team reviewed the fall and looked for a more permanent intervention. The CRN stated there were no neurological assessments completed after the fall on 1/5/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not provide pharmaceutical services which included procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident. Specifically, for 1 out of 36 sampled residents, the resident did not have gabapentin available. Resident identifier: 14. Findings included: Resident 14 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included acute on chronic combined systolic and diastolic heart failure, type 2 diabetes mellitus, morbid obesity, reduced mobility, and muscle weakness. On 8/25/24 at 11:36 AM, an interview was conducted with resident 14. Resident 14 stated she had a sciatica problem and it flared up in the morning. Resident 14 stated she had requested to see the physician regarding changing times of her muscle relaxer. Resident 14 stated her pain was 10 out of 10 every morning and the pain woke her up at night. Resident 14's medical record was reviewed on 8/25/24 through 8/28/24. Resident 14 had physician's orders for gabapentin 400 milligrams (mg) three times a day for neuropathy. According to the nursing progress notes on 8/25/24 at 8:35 AM, gabapentin was not administered because Resident out. According to nursing progress notes on 8/25/24 at 1:20 PM, gabapentin was not administered because Needs RX [prescription] from pharmacy. The August 2024 Mediation Administration Record revealed resident 14 was not administered gabapentin on 8/25/24 at 8:00 AM and 2:00 PM. Resident 14 was administered cyclobenzaprine 10 mg every eight hours as needed for spasms on 8/25/24 at 6:43 AM. In addition, a Lidocaine External Patch 5% was applied at 7:30 AM on 8/25/24, to resident 14's lower back. A care plan dated 5/8/24, revealed Has chronic pain r/t [related to] DM [diabetes mellitus], CHF [congestive heart failure], morbid obesity. The goal was Will not have an interruption in normal activities due to pain through the review date. Interventions included Will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date; Will voice a level of comfort through the review date; Follow pain scale to medicate as ordered; and Pain assessment every shift. On 8/29/24 at 9:35 AM, an interview was conducted with Nursing Assistant (NA) 1. NA 1 stated resident 14 did not ask for a lot of assistance. NA 1 stated she had complained of pain and NA 1 reported the pain to the nurse. NA 1 stated resident 14 was waiting for the medication to kick in. NA 1 stated resident 14 had neuropathy in her feet. NA 1 stated resident 14 was able to verbalize her needs. On 8/27/24 at 3:19 PM, an interview was conducted with Certified Nursing Assistant (CNA) 6. CNA 6 stated that resident 14 walked to the nurses cart and asked the nurse for pain medications if she was in pain. CNA 6 stated resident 14 was alert and oriented to be able to verbalize her pain. On 8/27/24 at 1:13 PM, an interview was conducted with Director of Nursing (DON) 2. DON 2 stated that gabapentin needed a prescription from the physician. DON 2 stated that was why resident 14 did not have the gabapentin available. DON 2 stated other interventions were used for pain on 8/25/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 34 was admitted to the facility on [DATE] and readmitted [DATE] with diagnoses including primary osteoarthritis left shoulder, type 1 diabetes mellitus with diabetic neuropathy, type 1 diabetes mellitus with diabetic chronic kidney disease, hypothyroidism, Alzheimer's disease, dementia, end stage renal disease, and mood disorder due to known physiological condition with depressive features. Resident 34's medical record was reviewed from 8/25/24 through 8/29/24. Resident 34's Medication MAR and Treatment Administration Record (TAR) were reviewed for the months of June, July, and August 2024. The following orders were noted to have irregularities: a. Abilify Oral Tablet 2 milligram Give 1 tablet by mouth one time a day for anxirty [sic] /depression. This order was placed on 6/20/24 with a start date of 6/21/24. It should be noted that the order was listed as being scheduled for 7:00 AM, administration. For the month of July 2024, resident 34's MAR showed that resident 34 missed 12 doses of Abilify. The dates that resident 34 missed doses were 7/1/24, 7/3/24, 7/5/24, 7/9/24, 7/10/24, 7/12/24, 7/15/24, 7/19/24, 7/23/24, 7/24/24, 7/26/24, and 7/29/24. The reason documented on the MAR for the 12 missed doses was, Absent from facility. For the month of August 2024, resident 34's MAR showed that resident 34 missed ten doses of Abilify. The dates that resident 34 missed the doses were 8/2/24, 8/7/24, 8/9/24, 8/12/24, 8/14/24, 8/16/24, 8/19/14, 8/21/24, 8/22/24, and 8/26/24. The reason documented for the missed doses on the MAR was, Absent from facility. The reason documented for the missed doses on 8/7/24 and 8/12/24, was as other/see nurse notes. Resident 34's progress notes were reviewed. There were no nursing progress notes that documented a reason for the missed doses of the medication. It should be noted that resident 34 had orders to attend hemodialysis Mondays, Wednesdays, and Fridays at an offsite location. Resident 34's listed pickup and transport time was 6:00 AM. b. Torsemide Tablet Give 80 milligram by mouth one time a day for edema. This order was placed on 6/11/22. It should be noted that the order was listed as being scheduled for 7:00 AM, administration. For the month of July 2024, resident 34's MAR showed that resident 34 missed 12 doses of Torsemide. The dates that resident 34 missed the doses were 7/1/24, 7/3/24, 7/5/24, 7/9/24, 7/10/24, 7/12/24, 7/15/24, 7/19/24, 7/23/24, 7/24/24,7/26/24, and 7/29/24. The reason documented on the MAR for the 12 missed doses was, Absent from facility. For the month of August 2024, resident 34's MAR showed that resident 34 missed nine doses of Torsemide. The dates that resident 34 missed the doses were 8/2/24, 8/8/24, 8/12/24, 8/14/24, 8/16/24, 8/19/24, 8/21/24, 8/22/24, and 8/26/24. The reason documented for the missed dotes on the MAR was, Absent from facility. The reason documented for the missed dose on the 8/12/24 was, other/see nurse notes. Resident 34's progress notes were reviewed. There were no nursing progress notes documented for 8/12/24. It should be noted that resident 34 had orders to attend hemodialysis Mondays, Wednesdays, and Fridays at an offsite location. Resident 34's listed pickup and transport time was 6:00 AM. c. Novolog Injection Solution 100 Unit/milliliters (Insulin Aspart) Inject as per sliding scale: if 180-230 = 2; 231-280 =4; 281-330 = 6; 331-380 = 8; 381-430 = 10 below 60 or above 400, notify provider, subcutaneously at bedtime for DM II [type 2 diabetes mellitus].This order was placed on 6/11/24. For the month of June 2024, resident 34's MAR showed that resident 34 received 2 units of insulin on 6/30/24. Resident 34's blood glucose had been reported as 156, which was outside the listed parameters of 180-230 that would indicate a need for 2 units of insulin to be administered. On 8/28/24 at 3:50 PM, an interview was conducted with the Corporate Resource Nurse (CRN). The CRN stated that resident 34 should not have missed his Abilify or Torsemide. The CRN stated that the facility should have communicated with the facility physician to determine if the scheduled medication times could be adjusted on the days that resident 34 went to dialysis. The CRN stated that the facility did not follow resident 34's insulin parameters for the dose given on 6/30/24. The CRN stated that the facility was on a four step action plan for this reason. Based on interview and record review it was determined, for 2 of 36 sampled resident, that the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug was any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, blood pressure medication was administered when a residents blood pressure was outside of the physician ordered parameters. In addition, another resident missed his antipsychotic and diuretic medication because he was scheduled for dialysis during the scheduled administration time. The same resident was not administered insulin according to physician's orders. Resident identifiers: 22 and 34. Findings included: 1. Resident 22 was admitted to the facility on [DATE] with diagnoses which included spastic hemiplegia affecting right dominate side, intracranial injury without loss of consciousness, muscle weakness, hypothyroidism, hypertension, pressure hydrocephalus, epilepsy, schizophrenia and major depressive disorder. Resident 22's medical record was reviewed 8/25/24 through 8/28/24. Resident 22 had a physician's order dated 7/3/2020 for Propranolol 20 MG (milligrams) once daily. The parameters were to Give 20 mg by mouth one time a day . Hold if BP [blood pressure] < [less than] 120/70 or HR [heart rate] <60 related to essential hypertension. *HOLD IF BP <120/60, OR HR<60. According to the August 2024 Medication Administration Record (MAR) the Propranolol 20 MG was administered to resident 22 when blood pressure was outside of parameters: a. On 8/3/24, 111/80 b. On 8/21/24, 117/75 c. On 8/22/24, 117/75 According to the August 2024 MAR the Propranolol 20 MG was held and not administered when the blood pressures were: a. On 8/1/24, 11/86 b. On 8/6/24, 112/73 c. On 8/8/24, 109/71 d. On 8/10/24, 119/91 e. On 8/14/24, 108/78 f. On 8/28/24, 98/60 According to the July 2024 MAR the Propranolol 20 MG was administered with the following blood pressures: a. On 7/3/24, 117/89 b. On 7/11/24, 118/70 c. On 7/17/24, 101/67 d. On 7/19/24, 101/67 e. On 7/20/24, 101/67 According to the July 2024 MAR the Propranolol 20 MG was held and not administered with the following blood pressures: a. On 7/1/24, 116/66 b. On 7/6/24, 110/81 c. On 7/8/24, 106/71 d. On 7/18/24, 101/67 e. On 7/21/24, 102/83 f. On 7/29/24, 107/71 On 8/28/24 at 8:27 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated blood pressure medications were administered according to the physician ordered parameters. LPN 1 stated usually the physician's parameters were to hold if the diastolic number was less than a certain number. LPN 1 stated she did not understand the parameters for resident 22's blood pressures and would need to clarify with the physician before administering the Propranolol. On 8/28/24 at 8:38 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated when a resident had blood pressure medications, parameters were checked prior to administering the medications. RN 1 stated if the blood pressure was within parameters then she would administer the medication. RN 1 stated she would hold the medication if the blood pressure was outside parameters. RN 1 stated with resident 22's parameter orders she would hold the medication if either systolic or diastolic were under the parameters. RN 1 stated she would hold if the heart rate was less than 60. On 8/28/24 at 8:41 AM, an interview was conducted with LPN 3. LPN 3 stated if a resident had blood pressure medications with parameters, she would check the blood pressure and heart rate. LPN 3 stated then she would administer or hold the medication according to parameters. LPN 3 stated she would document why medications were not administered. LPN 3 stated she administered resident 22's medications on 8/28/24. LPN 3 stated resident 22's blood pressure was 98/60 so she held the Propranolol. LPN 3 stated typically physician ordered parameters would say to hold if the systolic was under a certain number. LPN 3 stated according to resident 22's parameters she would hold the Propranolol if either systolic was under 120 or diastolic was below 60. LPN 3 stated she did not understand the parameters for resident 22 and should have clarified the physician ordered parameters. On 8/28/24 at 8:44 AM, an interview was conducted with Director of Nursing (DON) 1. DON 1 stated for blood pressure medications with physician ordered parameters, the nurses should take the residents blood pressure and heart rate then compare those to the parameters. DON 1 stated the nurse would then administer or hold the medication. DON 1 stated with resident 22's medication should be held if any of the numbers were low. DON 1 stated she would have to verify the parameters for resident 22 because there were 2 different blood pressure parameters. DON 1 stated the physician was to be notified if the blood pressure or heart rate were below the parameters. DON 1 stated that the parameters should have been to hold the medication if blood pressure was less than 120/60. DON 1 stated there was a free text area in the physician's order and the nurse must have accidentally wrote 120/70 and it should have been 120/60.

Based on observation and interview, the facility did not ensure safe and secure storage of drugs and biologicals in accordance with accepted professional principles; or include the appropriate accessory and cautionary instructions, and the expiration date on the medication. Specifically, an opened multi-dose vial in the medication cart had exceeded the 28 day expiration date, an insulin pen was not dated with the date it was opened, and bubble packs had medication taped back in. Resident identifiers: 28. Findings included: 1. On 8/27/24 at 7:00 AM, the medication cart at the top of the 100 hallway was inspected. An observation was made that the medication cart contained a Lispro insulin vial with an open date of 7/21/24, and a used glargine insulin pen with no open or expiration date on it. An interview was conducted with Registered Nurse (RN) 3. RN 3 stated that opened insulin was good for 28 days and then it must be discarded. RN 3 stated she was unsure when the insulin pen was opened and the vial of insulin needed to be removed from the cart. 2. On 8/27/24 at 7:44 AM, an observation was made of RN 4 during medication pass. RN 4 was observed to untape the back of a medication bubble pack and administered the medication to resident 28. On 8/27/24 at 7:50 AM, an interview was conducted with RN 4. RN 4 stated that she would not tape medications back into the bubble pack. RN 4 stated she would discard the medication and should not have given the medication to the resident. On 8/27/24 at 8:57 AM, an interview was conducted with Director of Nursing (DON) 1. DON 1 stated she personally did not know that the nurses taped medications back into the bubble packs. DON 1 stated that the nurses should not be taping medications back into the bubble packs and the medications should be discarded. DON 1 stated that all undated open medications needed to be discarded. DON 1 stated that insulin needed to be replaced after 28 days of it being opened. 3. On 8/25/24 at 8:15 AM, an observation was made of the medication cart in the 100 hallway. There was a ball with intravenous antibiotic on top of the medication cart. The antibiotic was observed to be unattended on the medication cart. On 8/29/24 at 11:05 AM, an interview was conducted with DON 1. DON 1 stated medications should not be left unattended at anytime.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not establish an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use. Specifically, for 1 out of 36 sampled resident, staff were not aware of who and why a resident was ordered prophylaxis antibiotics. Resident identifier: 56. Findings included: Resident 56 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis, type 2 diabetes mellitus, chronic obstructive pulmonary disease, bipolar disorder, major depressive disorder, and anxiety. Resident 56's medical record was reviewed on 8/25/24 through 8/29/24. A care plan dated 3/3/24, revealed Is on Antibiotic Therapy r/t [related to] UTI. The goal was Will be free of any discomfort or adverse side effects of antibiotic therapy through the review date. The interventions included Administer medication as ordered and Observe for possible side effects every shift. On 6/2/24 at 1:48 PM, a Nurse Practitioner / Physician's Assistant Progress Note revealed, She has had recurrent UTI. She wants prophylaxis abx [antibiotic] to help prevent recurrence. ASSESSMENT AND PLAN: Recurrent UTI: Start Florastor 1 by mouth every morning. Start Keflex 500 mg [milligrams] by mouth every morning no intake, vitamin C at thousand milligrams by mouth every morning as prophylaxis to help prevent recurrence of UTI. A nursing progress note dated 6/2/24 at 3:09 PM, revealed Resident c/o [complained of] UTI like s/s [signs and symptoms]. Per provider request resident to have 1000mg q [every] AM, Florastor q AM and Keflex 500mg q AM. A physician's order dated 6/3/24, revealed Keflex Oral Capsule 500 MG (Cephalexin) Give 1 capsule by mouth in the morning for Prophylaxis. On 8/27/24 at 12:59 PM, an interview was conducted with Director of Nursing (DON) 2. DON 2 stated resident 56 had history of reoccurring UTI's. DON 2 stated her last UTI was on 2/27/24. On 8/28/24 at 3:44 PM, an interview was conducted with the Corporate Resource Nurse (CRN). The CRN stated she was unsure which provider started the Keflex. The CRN stated that there was no information from a urologist regarding the Keflex.

Based on interview and record review, the facility did not develop and implement written policies and procedures that; prohibit and prevent abuse, neglect, and exploitation of residents. Specifically, for 2 out of 5 sampled staff members, the facility did not follow their abuse policy by screening prospective employees licenses prior to employee working with residents. Findings included: A review of employee records revealed the following: Employee 1 was a Nursing Assistant (NA) hired by the facility on 7/31/23, and started working on the floor on 8/10/23. There was no record of Employee 1's license being checked to verify that a previous license had not been obtained. Employee 2 was a Certified Nursing Assistant (CNA) was hired by the facility on 2/2/23, and started working on the floor on 3/6/23. Employee 2's license was verified on 7/28/23. A review of the facility's abuse policy and procedures revealed the following: . a. Screening: Prospective Employees 1. Prior to hire, the Facility will screen potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property in order to prohibit such abuse, neglect, exploitation, or misappropriation of resident property. This screening will include but not be limited to: Attempting to obtain information from previous employers and/or current employers, whether favorable or unfavorable Documentation of status and any disciplinary actions from licensing or registration boards and other registries. Reviewing the prospective employee's employment history, especially when there is or may be a pattern of inconsistency. 4. All CNAs and licensed employees will have their certificates or licenses verified through the State Board of Nursing. On 8/27/24 at 2:02 PM, an interview was conducted with the Human Resources (HR). The HR stated that a staff member's license or certification verification form was completed upon hire and then the CNA registry was checked. The HR stated that all licenses and certifications were to be checked prior to working with residents. The HR stated that the license check was printed off and then uploaded into the employee file. On 8/29/24 at 11:34 AM, an interview was conducted with the Administrator (ADM). The ADM stated that HR was the department that verified licenses for employees. The ADM stated that before staff could access the computers their licenses must be checked. The ADM stated that employee license verification must be done prior to the employee working with residents. The ADM stated that when a NA was hired, the process was to always check to see if they had a previous license. The ADM stated that he did not have any proof that the license was checked for Employee 1. The ADM stated he was not sure why it took several months for verification of Employee 2's license.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Resident Council Minutes: a. A review of the facility's resident council notes for March 2024 revealed complaints that nurses were good, but residents felt they were overwhelmed. Medication delivery was rushed. b. A review of the facility's resident council notes for April 2024 revealed complaints about call lights during night shift were struggling again. Complaints of new CNAs, residents saying they did not seem to understand what to do and ongoing complaints of evening shift. c. A review of the facility's resident council notes for May 2024 revealed complaints that call lights were sometimes good and sometimes not good on night shift. They have seen an improvement on evening shifts call light responds. d. A review of the facility's resident council notes for July 2024 revealed night shifts call lights were getting better but sometimes still long. There was still room for improvement, issues with CNAs and night shift but were getting better. On 8/28/24 at 11:16 AM, an interview was conducted with the Administrator (ADM). The ADM that the facility was always hiring new staff, even when it was not needed. The ADM stated that the nursing staff numbers remained the same on the weekdays and the weekends, but the difference is that the leadership staff were not in the building to help with the overflow of resident requests. The ADM stated that the facility did utilize agency nursing staff for approximately 3 to 4 shifts a week. The ADM stated that he was aware that some residents have complained about the long call light wait times. Based on interview, observation and record review it was determined, for 12 of 36 sampled residents, that the facility did not have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment. Specifically, there were observations of resident's call lights alarming up to 30 minutes before assistance was provided, residents complained of long call light wait time and resident council minutes revealed resident concerns with staffing. Resident identifiers: 10, 12, 14, 20, 29, 34, 38, 56, 58, 70, 133 and 383. Findings include: 1. Observations of Call lights: a. On 8/25/24 at 8:26 AM, an observation was made of a call light on in room [ROOM NUMBER]. The call light was answered by staff at 8:54 AM. b. On 8/25/24 at 8:27 AM, an observation was made of a call light on in room [ROOM NUMBER]. The call light was answered by staff at 8:57 AM. c. On 8/25/24 at 11:04 AM, an observation was made of a call light on in room [ROOM NUMBER]. The call light was answered by the Administrator at 11:36 AM. d. On 8/25/24 at 8:27 AM, an observation was made of a call light on in room [ROOM NUMBER]. The call light was answered by staff at 8/25/24 at 8:35 AM. e. On 8/25/24 at 11:06 AM, an observation was made of resident 56's call light alarming. Resident 56's call light was answered at 11:21 AM. 2. Resident interviews: a. On 8/25/24 at 11:26 AM, an interview was conducted with resident 56. Resident 56 stated she did not feel like there was enough staff. Resident 56 stated at night time it took a long time for her call light to be answered. Resident 56 stated her call light was on for about 20 minutes before the surveyor entered the residents room. Resident 56 stated that morning before breakfast she waited an hour and a half for her call light to be answered. Resident 56 stated she needed a liner in her brief changed because it was wet. Resident 56 stated staff were unable to change her before breakfast. Resident 56 stated she had to eat breakfast with a wet liner in her brief. Resident 56 stated half of the time, staff told her that she needed to wait till after the meal trays were picked up to be changed. Resident 56 stated some staff were doing a really good job and others were not good. Resident 56 stated she reported staffing concerns to a nurse manager who was no longer employed at the facility. b. On 8/25/24 at 10:04 AM, an interview was conducted with resident 70. Resident 70 stated that he did not like using the call light because staff did not respond all the time or it took over 30 minutes for staff to come and help him. c. On 8/25/24 at 11:20 AM, an interview was conducted with resident 58. Resident 58 stated he felt like there was a long wait for the call lights to be answered. d. On 8/25/24 at 11:24 AM, an interview was conducted with resident 38. Resident 38 stated staff did not get to her roommate as quickly as they should. Resident 38 stated her roommate called for a nurse last night and it took staff a long time to respond. e. On 8/25/24 at 11:38 AM, an interview was conducted with resident 14. Resident 14 stated sometimes she felt there needed to be more staff. Resident 14 stated sometimes it took a while depending on the situations that were going on with other residents. Resident 14 stated she needed assistance getting out of bed first thing in the morning and pushed her call light. Resident 14 stated staff tried to get there as quickly as they could but she had an incontinent episode a could weeks ago. Resident 14 stated she wanted to make sure she was getting the same attention as other residents. f. On 8/25/24 at 11:55 AM, an interview was conducted with resident 383. Resident 383 stated the facility needed more Certified Nursing Assistants (CNA) because they were overworked and unable to answer call lights in a timely manor. Resident 383 stated a staff member could only do what they could do. g. On 8/25/24 at 11:57 AM, an interview was conducted with resident 133. Resident 133 stated staff were over worked. Resident 133 stated on Friday he turned on the call light, then had to get the phone in his room and call the front desk for assistance. Resident 133 stated he needed to use the urinal and was unable to get up by himself. Resident 133 stated he was going to have a shower and get his face shaved on 8/24/24 but he did not get the shower or his face shaved because there were not enough staff. h. On 8/25/24 12:21 PM, an interview was conducted with resident 20. Resident 20 stated her call light was on for a long time and staff did not come answer the call light. Resident 20 stated staff were on their phones a lot. i. On 8/25/24 at 12:58 PM, an interview was conducted with resident 34. Resident 34 stated there was not enough staff. Resident 34 stated the weekends seemed to be the worse and for the most part the CNA's were doing the work of two people. Resident 34 stated one time he had to wait over four hours to get changed. j. On 8/25/24 at 1:50 PM, an interview was conducted with resident 12. Resident 12 stated that the call lights were never answered and he had to wait a long time before staff would come in. Resident 12 stated that it was worse on the weekends. k. On 8/25/24 at 2:06 PM, an interview was conducted with resident 10. Resident 10 stated that the night staff did not answer call lights. l. On 8/25/24 at 2:30 PM, an interview was conducted with resident 29. Resident 29 stated on the weekends there were longer response times to call lights. Resident 29 stated sometimes he had to wait up to an hour for the call light to be answered. 3. Staff Interviews: a. On 8/27/24 at 3:11 PM, an interview was conducted with CNA 6. CNA 6 stated staffing was usually pretty good. CNA 6 stated if staff were looking at what they needed to do during shift and planned their day, then staff were able to get everything done. CNA 6 stated answering call lights were hard during meal times. CNA 6 stated residents call lights alarmed at the same time and it was hard to answer all the call lights. b. On 8/28/24 at 10:42 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that she had been asked to pick up an open shift at the facility weekly do to staff shortages. RN 1 stated that she knew that residents had complained about long call light wait times. RN 1 stated she tried to help out with answering the call lights, but she had her own job to complete. RN 1 stated she did not believe there was enough staff to work the halls. c. On 8/28/24 at 10:52 AM, an interview was conducted with RN 2. RN 2 stated that she did not feel like she was able to complete all of her duties in the facility due to staffing shortages. RN 2 stated she had been asked to stay late, come in early, or work overtime the last few months. d. On 8/28/24 at 10:55 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she had been asked to come in early, stay late after her shift, and to pick up overtime. LPN 1 stated that weekend staffing was poor as management was not in the building to help answer call lights and assist residents. LPN 1 stated residents complain about the long call light wait times. e. On 8/29/24 at 9:35 AM, an interview was conducted with Nursing Assistant (NA) 1. NA 1 stated resident's were frustrated because there were a lot of call lights on at one time. NA 1 stated residents will think they have been waiting a long time when it had only been a couple of minutes. NA 1 stated weekend staffing was different. NA 1 stated management was not in the facility on the weekends, so staff were not as on top of things as they needed to be. NA 1 stated it was harder to work on the weekends. NA 1 stated sometimes it was hard to get all the residents changed because there were back to back call lights and no one else was able to help. NA 1 stated she was left in the dining room by herself over the weekend because another CNA needed to use the bathroom. f. On 8/29/24 at 9:47 AM, an interview was conducted with CNA 7. CNA 7 stated staffing was good and the nurses were helpful to CNA's. CNA 7 stated there might be a day that the floor was short a CNA but there was a nurse on call that called another CNA into work. CNA 7 stated the the nurse on call had helped fill in at times. CNA 7 stated there were some residents that complained of long call light times. CNA 7 stated usually during meals when staff were passing meal trays in the hallway and staff answered call lights when they were done passing meal trays.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 34 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including primary osteoarthritis left shoulder, type 1 diabetes mellitus with diabetic neuropathy, type 1 diabetes mellitus with diabetic chronic kidney disease, hypothyroidism, Alzheimer's disease, dementia, and mood disorder due to known physiological condition with depressive features. Resident 34's medical record was reviewed from 8/25/24 through 8/29/24. Resident 34's Medication Administration Record (MAR) and Treatment Administration Record were reviewed for the months of June, July, and August 2024. Resident 34 had an order placed on 6/3/24, that revealed, TSH and Lipid Panel on 6/5/24 (send to dialysis with pt [patient]) one time only for spin and call for lab p/u [pick up] when he returns for 1 day. Resident 34's June 2024 MAR documented that this order was never completed. This order was discontinued on 6/5/24. Resident 34 had an order placed on 6/5/24, that revealed, TSH and Lipid Panel on 6/7/24 (send to dialysis with pt) one time only for spin and call for lab p/u when he returns for 1 Day. Resident 34's June 2024 MAR documented that this order was never completed. This order was discontinued on 6/7/24. Resident 34 had an order placed on 6/7/24 that revealed, TSH and Lipid Panel on 6/7/24 (send to dialysis with pt) one time only for spin and call for lab p/u when he turns for 1 Day. Resident 34's June 2024 MAR documented that this order was not not completed until 6/10/24 at 9:41 AM. The lab report for the labs drawn on 6/10/24, was reviewed. According to the lab report, the sample was not collected until 6/14/24, was received by the laboratory on 6/15/24, and the results were reported to the facility on 6/18/24. On 6/19/24 at 4:27 PM, a nursing progress note revealed, Provider reviewed the labs for 6/14/24 and the [sic] let the following new orders: Draw a T3 and T4. The lab report for the labs ordered on 6/19/24, was reviewed. According to the lab report, the sample was collected on 6/20/24, was received by the laboratory on 6/22/24, and the results were reported to the facility on 6/25/24. On 6/24/24 at 10:15 AM, a nursing progress note revealed, NP [nurse practitioner] looked over t4 and t3 labs that came back. she gave new order to increases [sic] Synthroid from 125 mcg to 150 mcg q [every] daily. she also has a [sic] order for TSH to be recheck [sic] in 6 weeks resident notified of new orders. There were no orders for Resident 34's TSH to be rechecked in six weeks located in the in the medical record. On 8/28/24 at 12:48 PM, an interview was conducted with the CRN. The CRN stated that the facility had a four step action plan for labs as of 8/8/24. The CRN stated that Resident 34's TSH should have been rechecked six weeks after the t3 and t4 labs were drawn. The facility Laboratory Testing Policy/Procedure revised 11/2016 revealed, POLICY: It is the policy of this facility to obtain laboratory and radiology services when ordered by a physician, PA [Physician's Assistant], NP or clinical nurse specialist and to promptly notify the ordering entity of test results. PROCEDURES: 1. Laboratory and radiology services will be arranged as ordered. 2. Results of laboratory, radiological, and diagnostic tests outside the clinical reference ranges shall be reported to the resident's attending physician, PA NP or clinical nurse specialist promptly or as specified in the order. 3. Notification of test results will be documented in the resident's clinical record. 4. Results of all diagnostic services shall be made a part of the resident's medical record. Based on interview and record review, the facility did not obtain laboratory services to meet the needs of its residents. Specifically, for 3 of 36 sampled residents, a resident did not have a Valproic acid level, thyroid-stimulating hormone (TSH), complete blood count (CBC), and a comprehensive metabolic panel (CMP) completed as ordered by the physician. Another resident did not have a TSH redrawn six weeks after the June levels were drawn. In addition, another resident did not have a urinalysis (UA) with culture and sensitivity (C&S) obtained that was orded by the physician. Resident identifiers: 22, 34, and 58. Findings included: 1. Resident 58 was admitted to the facility on [DATE] with diagnoses which included bipolar disorder, disorder of urea cycle metabolism, disorientation, unspecified psychosis not due to a substance or known physiological condition, and personal history of urinary tract infections. Review of records was completed on 8/25/24 through 8/29/24. An admission Minimum Data Set assessment dated [DATE], revealed that resident 58 had a Brief Interview of Mental Status score of 9 which indicated moderately impaired cognition. A review of physician's orders revealed an order started on 8/7/24, for a UA C&S one time only related to disorientation, unspecified until 8/7/24 at 11:59 PM, to obtain urine was marked completed on 8/7/24. On 8/7/24 at 2:14 PM, a Nursing Progress Notes revealed the following. Nurse went in the resident's room for morning medication pass and the resident was lying on the side of his bed. His emergency contact was notified, and the provider was notified. Resident had a new order for a UA due to some confusion. On 8/8/24 at 5:56 PM, a Fall Committee Interdisciplinary Team progress note revealed the following, Resident was currently resting in bed. Resident denied pain or discomfort related to fall. His emergency contact was notified, and the provider was notified. Resident has a new order for a UA C&S due to some confusion. The UA C&S results were unable to be located. On 8/27/24 at 3:30 PM, an interview with Director of Nursing (DON) 2 was conducted. DON 2 stated she was unable to locate the lab results for the UA C&S or any progress notes from 8/7/24. 2. Resident 22 was admitted to the facility on [DATE] with diagnoses which included spastic hemiplegia affecting right dominate side, intracranial injury without loss of consciousness, muscle weakness, hypothyroidism, hypertension, pressure hydrocephalus, epilepsy, schizophrenia, and major depressive disorder. Resident 22's medical record was reviewed on 8/25/24 through 8/28/24. On 10/23/23, resident 22's TSH level was 0.079 which was low. It was written on the laboratory results Reduce Levothyroxine to 125 mcg [micrograms] recheck in 6 weeks. Signed with a date of 10/26/23. A physician's order dated 10/26/23, revealed TSH one time a day for lab. On 12/7/23, there was a laboratory results that revealed Test not performed. Insufficient specimen to perform or complete. A physician's order dated 2/4/24, revealed CBC and CMP urgently for lethargy. On 2/5/24, there was a laboratory results form that revealed Test not performed. The required specimen for the test ordered was not received . Comp. [comprehensive] Metabolic Panel . The CBC revealed Test not performed. Whole blood specimen partially or completely clotted. A common cause is insufficient mixing upon collection. A physician's order dated 3/29/24, revealed TSH 4/1/24 one time only for 2 days only signs off if obtained. A physician's order dated 4/3/24, revealed T3 [Triiodothyronine] and T4 [Thyroxine] one time only for lab for 1 day. A physician's order dated 7/12/24, revealed Valproic Acid one time only related to epilepsy. On 7/15/24, there was a laboratory results form that revealed A lavender top tube was received with no test indicated. On 7/22/24 at 2:30 PM, Valproic Acid 105 microgram per milliliter which was high. There was a signature dated 7/26/24, and revealed to recheck in two weeks. A physician's order dated 7/24/24, revealed Valproic Acid one time only related to epilepsy. A physician's order dated 7/27/24, revealed Valproic Acid one time only related to epilepsy. On 7/28/24, Valproic Acid was . not performed. No serum received. A physician's order dated 8/9/24, revealed Valproic Acid one time only related to epilepsy. A nursing progress note dated 8/9/24 at 7:31 AM, revealed Date for Valproic acid draw changed to 8/12 as phlebotomist will be here that day, provider notified and is ok with having lab drawn on Monday On 8/15/24, Valproic Acid was not performed. Gel barrier tube was unsuitable for test orders. On 8/22/24, Valproic acid was not performed. No serum received. On 8/27/24 at approximately 2:00 PM, an interview was conducted with DON 1. DON 1 stated from 7/28/24, the wrong tube was sent to the laboratory and there was a physician's order to redraw in two weeks. DON 1 stated there was a note that the Valproic acid was not performed in two weeks and the provider was notified. DON 1 stated the nursing note revealed no new orders. DON 1 stated the laboratory note from the 8/22/24, that Valproic was not done and provider was notified. DON 1 stated that since they notified the physician that the Valproic acid was not done, there were no new orders, so there was no need to follow-up on the Valproic Acid after 7/22/24, even though it had been attempted twice. On 8/28/24 at 12:19 PM, a follow-up interview was conducted with DON 1. DON 1 stated the laboratory process started with nursing staff communicating with the physician for an order. DON 1 stated all physician's orders were entered into the medical record. DON 1 stated there was a phlebotomists who worked at the facility and drew the residents specimen. DON 1 stated then the laboratory was called to pick up the specimen. DON 1 stated the results were in the residents medical record. On 8/28/24 at 12:48 PM, an interview was conducted with the Corporate Resource Nurse (CRN). The CRN stated there was a four step action plan for the laboratory process. The CRN stated the action plan was started on 8/8/24. The CRN stated the policy was reviewed. The CRN stated there was now an in house phlebotomist and staff were auditing five random charts per week for laboratory orders and results. The CRN stated the TSH was not done 12/7/23, because the specimen was insufficient and the TSH was not rechecked.

. Based on observation, interview, and record review, it was determined that the facility did not provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Specifically, surveyors made multiple observations of the lunch and meal services being served and delivered later than the posted meal times, there were multiple resident complaints about food being served late and cold, and there were multiple recent resident council notes documenting resident complaints about food being served cold and late. Resident Identifiers: 12 and 28. Findings Include: The following meal times were provided upon entrance: Breakfast 7:30 AM Residents to dining hall by 7:15 AM Food comes out by 7:30 AM Hall 100 trays served at 8:00 AM Hall 200 trays served at 8:30 AM Hall 100 trays back to kitchen by 9:00 AM Hall 200 trays back to kitchen by 9:30 AM Lunch 11:30 AM Residents to dining hall by 11:15 AM Food comes out by 11:30 AM Hall 100 trays served at 12:00 PM Hall 200 trays served at 12:30 PM Hall 100 trays back to kitchen by 1:00 PM Hall 200 trays back to kitchen by 1:30 PM Dinner 5:30 PM Residents to dining hall by 5:15 PM Food comes out by 5:30 PM Hall 100 trays served at 6:00 PM Hall 200 trays served at 6:30 PM Hall 100 trays back to kitchen by 7:00 PM Hall 200 trays back to kitchen by 7:30 PM. The following meal times were posted outside of the facility dining room: Breakfast: Hall 100 served by 7:50 AM Hall 200 served by 8:10 AM Lunch food came out in the dining room by 11:30 AM Hall 100 trays served at 11:50 PM Hall 200 trays served at 12:10 PM [It should be noted the posted meal times were different from the ones provided upon entrance.] On 8/25/24 at 1:53 PM, an interview was conducted with Resident 12. Resident 12 stated that sometimes the food was not served hot. On 8/25/24 at 10:21 AM, an interview was conducted with Resident 28. Resident 28 stated that the food served was not always served hot. On 8/25/24, an observation was made of the lunch time meal service in the dining room and hallways. The first resident was served in the dining room at 11:55 AM. The first resident in the 100 hall was served at 12:21 PM. The first resident was served in the 200 A hallway at 12:39 PM and 200 B hall was 12:58 PM. On 8/28/24, an observation was made of the lunch meal. The 100 hallway cart was observed to leave the kitchen at 8:10 AM. The 200 hallway meal cart was delivered at 8:23 AM. On 8/28/24, the last cart was delivered to the 200 hallway at 12:44 PM. According to the posted meal times at the facility, the latest any meals should be delivered is to the 200 hall at 12:30 PM. Meals were served to the dining room starting at 11:54 AM. According to the posted meal times at the facility, meals should have started being served at 11:30 AM. According to the posted meal times at the facility, trays for the 100 hall should have been delivered starting at 12:00 PM. Residents in this hall did not start to receive their meals until 12:15 PM. A review of the facility's resident council notes for March 2024 revealed complaints about cold food being served at the facility. A review of the facility's resident council notes for April 2024 revealed complaints about cold food being served at the facility. A review of the facility's resident council notes for May 2024 revealed complaints about cold food being served at the facility. A review of the facility's resident council notes for July 2024 revealed complaints about cold food being served at the facility. A review of the facility's resident council notes for August 2024 revealed complaints from residents that one roommate in a double bed room will receive their meal while the other roommate does not. On 8/29/24 at 9:21 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that kitchen staff always delivered meals out of the kitchen on time and that if meals were late, it was likely that nursing staff that were behind on passing trays. [It should be noted observations were made of the meals leaving the kitchen after the posted meal times]. On 9/29/24 at 10:27 AM, an interview was conducted with the facility administrator (ADM). The ADM stated that he expected meals to be sent out to residents on time within a 5-10 minute window of the posted meal times.

Based on observation, interview, and record review it was determined, for 10 of 36 sampled residents, that the facility did not provide food prepared by methods that conserve flavor and appearance or provide food and drink that was palatable, attractive, and at an appetizing temperature. Specifically, there were multiple complaints from residents about the quality of the food, there were multiple resident council complaints about the flavor of the food, and a test tray was bland to the taste with overcooked foods. Resident identifiers: 10, 12, 14, 20, 28, 34, 38, 56, 59, and 68. Findings Include: On 8/25/24 at 12:51 PM, an interview was conducted with resident 10. Resident 10 stated that the food served at the facility was not good. Resident 10 stated that the food served gave her diarrhea. Resident 10 stated that the eggs and oatmeal served were not good and caused her to have constipation. At 2:02 PM, an additional interview was conducted with Resident 10. Resident 10 stated that the food served was so bad that she had called her son to bring her food from fast food for lunch. On 8/25/24 at 1:53 PM, an interview was conducted with resident 12. Resident 12 stated that the food served at the facility did not taste good. Resident 12 stated that sometimes the food was served hot. On 8/25/24 at 11:35 AM, an interview was conducted with resident 14. Resident 14 stated that the food served at the facility was bland. On 8/25/24 at 12:16 PM, an interview was conducted with resident 20. Resident 20 stated that the food served at the facility was not good and causes her to have diarrhea. On 8/25/24 at 10:21 AM, an interview was conducted with resident 28. Resident 28 stated that the food served at the facility did not always taste good and that the food served was not always served hot. On 8/25/24 at 12:06 PM, an interview was conducted with resident 34. Resident 34 stated that the kitchen staff had a tendency to be lazy and served the same foods frequently. On 8/25/24 at 11:24 AM, an interview was conducted with resident 38. Resident 38 stated that the food served was not good. Resident 38 stated that the food served was too spicy. On 8/25/24 at 11:24 AM, an interview was conducted with resident 56. Resident 56 stated that the food served at the facility was bland to the taste. On 8/25/24 at 12:25 PM, an interview was conducted with resident 59. Resident 59 stated that he did not like the food served at the facility. Resident 59 stated that he had friends bring food into the facility for him and his wife. On 8/25/24 at 2:51 PM, an interview was conducted with resident 68. Resident 68 stated that the food served at the facility was terrible. Resident 68 stated that anything served that required preparation tended to not be good. On 8/28/24 at 8:21 AM until 8:50 AM, an observation was made of the 200 hallway. Trays were observed to be served to residents. Plates were observed without the heating pellet system. The pellet heating system was used to keep meals warm while they were delivered to residents. On 8/28/24, a test tray was obtained from the kitchen. The last try plated was at 12:44 PM. According to the menu posted at the facility, the entree should have been breaded chicken. The entree received was not breaded and had a slight purple color when cut into. The meat was try and chewy. The carrots were overcooked and mushy. A review of the facility's resident council notes for the month of March 2024 revealed complaints about cold food being served at the facility. A review of the facility's resident council notes for the month of April 2024 revealed complaints about cold food being served at the facility. A review of the facility's resident council notes for the month of May 2024 revealed complaints about cold food being served at the facility. A review of the facility's resident council notes for the month of July 2024 revealed complaints about cold food being served at the facility. A review of the facility's resident council notes for the month of August 2024 revealed complaints about the salads served at the facility. The resident council notes had complaints of items being out of stock in the kitchen. On 8/29/24 at 9:21 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that the facility used a pellet system to keep meal trays warm for residents who ate in their rooms. The DM stated that the pellet system should always be used to keep meals warm. On 8/29/24 at 10:27 AM, an interview was conducted with the facility administrator (ADM). The ADM stated that meals should be served within a 5-10 minute window. The ADM stated that the pellet system was recently purchased to help keep meals warm prior to being served to address resident and resident council complaints of cold food. The ADM stated that the only reason the pellet system would not be used was if the kitchen ran out of pellets before they finished serving meals or if residents did not return their trays timely prior to the next meal service. The ADM stated that the facility purchased 110 pellets for a facility census of 80. The ADM stated that his expectation for kitchen staff was that the food starts improving and gets better. The ADM stated that he had seen food quality improve with new kitchen staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility did not 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. Specifically, for 1 out of 36 sampled residents, a medication was touched by bare hands and administered to a resident and hallway meal trays were not delivered in a sanitary manner. Resident identifier: 28. Findings Included: 1. On 8/27/24 at 7:44 AM, an observation was made of Registered Nurse (RN) 4 during medication pass. RN 4 removed a pill that was taped back into a bubble pack. RN 4 was unable to remove the pill from the tape and pulled the pill off the tape and dropped the pill into the medication cup. RN 4 administered the pill to resident 28. On 8/27/24 at 7:50 AM, an interview was conducted with RN 4. RN 4 stated that she would not tape medications back into the bubble pack. RN 4 stated she would discard the medication and should not have given the medication to the resident. On 8/27/24 at 8:57 AM, an interview was conducted with Director of Nursing (DON) 1. DON 1 stated she personally did not know that the nurses taped medications back into the bubble packs. DON 1 stated that the nurses should not be taping medications back into the bubble packs and the medications should be discarded. 2. During the lunch meal service on 8/25/24, the following observations were conducted. a. At 12:23 PM, Certified Nursing Assistant (CNA) 6 was observed to place the lid of the chocolate milk in the palm of their hand to pour a resident a cup of the chocolate milk. CNA 6 was observed to place the lid back on the jug of chocolate milk. b. At 12:26 PM, CNA 5 was observed to serve a meal tray to resident room [ROOM NUMBER] bed B. CNA 5 did not perform hand hygiene upon exiting room [ROOM NUMBER] and obtained another meal tray from the meal cart. c. At 12:30 PM, a staff member was observed to serve a meal tray to resident room [ROOM NUMBER]. The staff member did not perform hand hygiene upon exiting room [ROOM NUMBER] and obtained another meal try from the meal cart from resident room [ROOM NUMBER]. d. At 12:34 PM, a staff member was observed to serve a meal tray to resident room [ROOM NUMBER]. The resident in room [ROOM NUMBER] was on enhanced barrier precautions. The staff member did not perform hand hygiene upon exiting room [ROOM NUMBER]. e. At 12:42 PM, an observation was made of CNA 1. CNA 1 delivered a food tray into a resident room, handed the resident their utensils and did not perform hand hygiene after exiting the room and picking up another tray. f. At 12:43 PM, an observation was made of CNA 2. CNA 2 delivered a food tray to a resident and then picked up a different tray and served the tray without hand hygiene being performed. g. At 12:44 PM, an observation was made of CNA 1. CNA 1 delivered a food tray and did not perform hand hygiene before delivering a food tray to a resident. h. At 12:45 PM, an observation was made of CNA 1. CNA 1 delivered a food tray and did not perform hand hygiene after exiting the room. i. At 12:47 PM, an observation was made of CNA 1. CNA 1 delivered a food tray and did not perform hand hygiene after exiting the room. j. At 1:02 PM, an observation was made of CNA 1. CNA 1 delivered a food tray and did not perform hand hygiene after exiting the room. k. At 1:04 PM, an observation was made of CNA 1. CNA 1 delivered a food tray and did not perform hand hygiene after exiting the room. l. At 1:05 PM, an observation was made of CNA 1. CNA 1 touched their face, picked up a food tray, delivered the food tray to a resident and did not perform hand hygiene. 3. During the breakfast meal service on 8/28/24, the following observations were conducted. a. At 8:24 AM, an observation was made of CNA 3. CNA 3 did not perform hand hygiene after he delivered a tray to a resident. b. At 8:30 AM, an observation was made CNA 3. CNA 3 did not perform hand hygiene after he delivered a tray to a resident and assisted the resident to sit up in bed. On 8/28/24 at 8:27 AM, an interview was conducted with CNA 4. CNA 4 stated that the received training on how to pass food trays to residents in the halls. CNA 4 stated that after a tray was given to a resident hand hygiene should be performed. CNA 4 stated that if at any time you assisted the resident or came into contact with the resident then hand hygiene should be performed. On 8/28/24 at 8:55 AM, an interview was conducted with CNA 3. CNA 3 stated that before meal service hand hygiene should be performed. CNA 3 stated that hand hygiene should be performed before and after entering a residents room. CNA 3 stated that hand hygiene should be performed after delivering a meal tray to a resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 3 sampled residents, that the facility did not ensure that the resident had the right to be free from abuse, neglect, and misappropriation of resident property. Specifically, a resident reported an unauthorized bank transaction in the amount of $300 that was done by Nurse Assistant (NA) 1. Resident identifier 1. Findings included: Resident 1 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, spondylopathy lumbar region, cognitive communication deficit, osteoporosis, chronic kidney disease, type 2 diabetes mellitus, agoraphobia with panic disorder, schizoaffective disorder, major depressive disorder, anxiety disorder, insomnia, and hypertension. On 3/16/23 resident 1's medical records were reviewed. On 11/24/22, the Annual Minimum Data Set (MDS) Assessment documented that resident 1 had a Brief Interview for Mental Status (BIMS) score of 10, which would indicate a moderate cognitive impairment. The assessment documented that resident 1 did not have any hallucinations or delusions. The assessment documented that resident 1 required one person extensive assistance for bed mobility, transfers, locomotion on and off the unit, dressing, toilet use and personal hygiene. On 11/4/22 at 10:30 AM, a grievance form documented that resident 1 reported that her bank account was short roughly $1400. Resident 1 called her banking institution and discovered several fraudulent charges to DoorDash, Amazon, [NAME], and other food services. The form documented that resident 1 reported that her bank was investigating the matter. The conclusion documented on the form was to allow resident 1 and their family representative to work with the bank to investigate the incident. On 3/1/23 at 10:30 AM, a grievance form documented that resident 1 reported that NA 1 stole a check and cased it for $300 on 11/15/22. The grievance form documented that resident 1 denied writing the check. The conclusion documented that the facility would reimburse resident 1 the $300, and NA 1 was no longer employed by the facility. On 3/1/23 at 10:30 AM, the facility investigation documented that resident 1 reported to the Administrator (ADM) that she had a check cashed by someone that she did not know. The date the alleged incident occurred was on 11/15/22. The report documented that the name written on the check was identified as NA 1, and that NA 1 was employed at the facility during the time the check was cashed. The report documented that resident 1 had no recollection of writing the check and that there was no record of the check on her carbon copy. Resident 1 denied knowledge of or giving permission to NA 1 to take the check. The report verified that a check for $300 with NA 1's name was cashed. The report documented that NA 1 was terminated for other reasons prior to the identification of the misappropriation of property on 3/1/23. The report documented that the Director of Nursing (DON) noted that NA 1 was not dependable and did not show up for shifts, and was subsequently terminated for a no call no show. The report documented that the local police department was notified of the incident. Review of NA 1's personnel file documented a date of hire as 11/3/22. Review of NA 1's timecard revealed the following: a. On 11/7/22 clocked in at 5:55 PM, clocked out at 6:10 AM. b. On 11/8/22 clocked in at 5:55 PM, clocked out at 6:30 AM. c. On 11/9/22 clocked in at 5:45 PM, clocked out at 6:15 AM. d. On 11/10/22 clocked in at 9:50 PM, clocked out at 6:10 AM. e. On 11/11/22 clocked in at 5:54 PM, clocked out at 10:11 PM. f. On 11/13/22 clocked in at 6:23 PM, clocked out at 5:18 AM. g. On 11/17/22 clocked in at 9:12 PM, clocked out at 6:08 AM. h. On 11/22/22 clocked in at 5:59 PM, clocked out at 9:52 PM. i. On 11/23/22 clocked in at 10:11 PM, clocked out at 6:03 AM. j. On 11/24/22 clocked in at 10:04 PM, clocked out at 6:06 AM. k. On 11/25/22 clocked in at 6:54 PM, clocked out at 6:11 AM. On 11/30/22, NA 1 was terminated from the facility. Review of the facility Policy and Procedures for Abuse: Prevention of and Prohibition Against documented that each resident had the right to be free from misappropriation of property. The policy documented that misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful temporary, or permanent use of a resident's belongings or money without the resident's consent. The policy documented that if an allegation of abuse, neglect, or misappropriation of property involved an employee that the facility would immediately remove the employee from the care of any resident and suspend the employee pending the investigation. The policy was last revised in October 2022. On 3/16/23 at 11:16 AM, an interview was conducted with the ADM. The ADM stated that at the time of the incident NA 1 was not yet certified. The ADM stated that NA 1 was terminated for performance reasons, and that this was prior to him being made aware of the cashed check. The ADM stated that when he was informed of the incident by resident 1 he started an investigation. The ADM stated that resident 1 showed him a copy of the check that was cashed online and it was written out to NA 1. The ADM stated that resident 1 denied writing the check and did not have any information on the duplicate check carbon copy. The ADM stated that the facility reimbursed resident 1 for the missing funds and reported the incident to the police department. On 3/16/23 at 11:56 AM, the ADM stated that resident 1's bank reimbursed the resident for all the unauthorized transactions in November 2022. The Administrator in Training (AIT) stated that there were two cases opened with the police department, one for the fraudulent charges and another for the check. On 3/16/23 at 12:51 PM, an interview was conducted with resident 1. Resident 1 stated that an aide had made some transactions on her bank account in November 2022. Resident 1 stated that her debit card went missing and she did not know until she went to the bank to get her balance. Resident 1 stated that this was when she noticed that money was missing. Resident 1 stated that the bank helped her setup her banking account online and that was when she noted all the unauthorized transactions. Resident 1 stated that she just noticed a week ago that 3 checks were missing and NA 1 cashed one of them. Resident 1 stated that she suspected someone that worked at the facility for taking her debit card but did not know who until the check was cashed. Resident 1 stated that she did not think to check on her belongings as everyone was nice. Resident 1 stated that at night after she takes her sleep aide she was out and did not know what was going on. Resident 1 stated that she believed the debit card and checks were taken when she was sleeping. Resident 1 stated that the check was dated 11/14/22 and was posted on 11/15/22. Resident 1 stated that she looked in her checkbook and the check was not there. Resident 1 stated that when she informed the bank they said they could not pay her back because it was after 90 days. Resident 1 stated that at first she could not remember the aide but she recognized the name. Resident 1 stated that the facility reimbursed her the money. Resident 1 stated that NA 1 took advantage of her situation because she was difficult to wake up. Resident 1 stated that she spoke to the police and they were opening an investigation. Resident 1 stated that the police wanted information on the debit charges and the check. Resident 1 stated that she had a copy of the cashed check on her computer. Resident 1 stated that NA 1 had only worked at the facility for a few months. Resident 1 stated that at the time of the incident her debit card and checks were located in her wallet in the top drawer of the night stand. Resident 1 stated that this was really upsetting, because she had no money and then owed money to the bank for the overdraft that this caused. Resident 1 stated that there were a lot of charges. Resident 1 stated she asked the bank why the clerk cashed the check because it was not her signature or writing. Resident 1 stated that she put a hold on the other missing checks and the bank changed her account number. Resident 1 stated that the bank reimbursed her for all the debit card transactions including all the overdraft charges. Resident 1 stated that it was stressful at the time because she had to wait for the bank to put the money back in the account. Resident 1 stated it took about 72 hours for the bank to reimburse her.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 1 of 27 sampled residents, that based on the comprehensive assessment residents were not provided the necessary care and services to ensure that a resident's abilities in activities of daily living did not diminish. Specifically, a resident was not provided oral care and was observed with build up on her teeth. Resident identifier: 33. Findings include: Resident 33 was admitted to the facility on [DATE] with diagnoses which included unspecified dementia, anxiety, mood disorder, major depressive disorder, contractures to right shoulder, left hip and right hip, left hand contracture, left shoulder, left elbow, left wrist, right knee, left ankle, and right hand. On 12/13/22 at 1:45 PM, an observation of resident 33 was made. Resident 33 was observed to have white and yellow build up substance on her teeth around the gum line. Resident 33's medical record was reviewed on 12/15/22. A quarterly Minimum Data Set (MDS) dated [DATE] revealed resident 33 no dental issues. The MDS further revealed that resident 33 required 1 person extensive assistance with personal hygiene. A care plan dated 4/23/20 revealed [resident 33] has ADL (activities of daily living) Self Care Performance Deficit r/t (related to) weakness, impaired cognition. The goals was Will safely perform Bed Mobility, Transfers, Eating, Dressing, Grooming, Toilet Use and Personal Hygiene)with staff assistance as needed. Interventions included Converse with resident while providing care; Explain all procedures/tasks before starting; Praise all efforts at self care; Encourage to discuss feelings about self-care deficit; and Encourage to participate to the fullest extent possible with each interaction. The Certified Nursing Assistant (CNA) documentation in the tasks section of resident 33's medical record revealed PERSONAL HYGIENE: SELF PERFORMANCE - How resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths and showers) was completed on 11/17/22, 12/1/22, 12/2/22, 12/4/22 and 12/10/22 in the last 30 days. On 12/15/22 at 10:22 AM, an interview was conducted with CNA 1. CNA 1 stated he did not know about resident 33's teeth. CNA 1 stated that occasionally staff did oral care. CNA 1 stated he was not sure if there was a specific process for oral care. CNA 1 stated when staff got residents up in the morning, and would then brush residents' teeth. CNA 1 stated resident 33 did not refuse help with her activities of daily living with him but had refused for some female CNAs. On 12/15/22 at 10:25 AM, an interview was conducted with CNA 2. CNA 2 stated oral care depended on the type of assistance a resident needed. CNA 2 stated when she assisted resident 33 with oral care, she needed to tell her what to do and had to remind her by doing the oral care. CNA 2 stated resident 33 had her own teeth. CNA 2 stated she cared for her once and resident 33 did not refuse oral care. On 12/15/22 at 12:29 PM, an interview was conducted with CNA 3. CNA 3 stated oral care should be done in the morning and at night. CNA 3 stated some residents were able to do their own oral care but she assisted residents who needed help. CNA 3 stated resident 33 needed help with oral care and staff had to complete full oral care. CNA 3 stated resident 33 did not have dentures. CNA 3 stated sometimes resident 33 refused oral care, so staff tried again at a later time. CNA 3 stated sometimes resident 33 bit down on the tooth brush and staff were unable to brush her teeth. CNA 3 stated she had not worked with resident 33 much so had not noticed build up on her teeth. On 12/15/22 at 12:42 PM, an observation of resident 33's teeth was conducted with CNA 1. CNA 1 was observed to put gloves on and ask resident 33 if we could see her teeth. Resident 33's teeth had a white and yellow substance at the gum line and on the front right teeth there was a large bump. Resident 33 stated she did not know if staff cleaned her teeth. On 12/15/22 at 1:03 PM, an interview was conducted with the Director of Nursing (DON). The DON stated residents' oral care was completed when the CNAs got the residents up in the morning and when the residents went to bed at night. The DON stated resident 33 had severe dementia and pushed staff away and said no, no, no. The DON stated with oral care resident 33 bit down on the tooth brush. It should be noted there were no notes or care plans regarding resident 33 refusing assistance with activities of daily living.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 27 sample residents, that the facility did not ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. Specifically, a resident did not receive brief changes, skin checks, and toileting services in coordination with good nursing care and outlined in the resident's care plan. Resident identifier: 24. Findings include: Resident 24 was admitted to the facility on [DATE] with diagnoses that included rheumatoid arthritis (RA), hemiplegia, cerebral infarction, left hand, shoulder and elbow contractures, osteoarthritis, depression, bilateral knee contractures, depression, and cognitive communication deficit. Resident 30's medical record review was completed on 12/15/22. On 12/13/22 at 12:30 PM, resident 24 was observed in the activity room. Resident 24 was able to answer in yes and no answers to a few questions. On 12/14/22 at 10:48 AM, a continuous watch was initiated. Resident 24 was observed to be in the activity room with 16 residents and one activity staff during an activity. Resident 24's wheelchair back appeared to be at approximately an 80 degree angle. At 10:50 AM, resident 24 was observed to be taken to the hallway and was provided a smoking apron. At 11:00 AM, resident 24 was taken outside with other residents to smoke. Resident 24 smoked approximately half her cigarette and was brought back inside at 11:14 AM and was pushed to the dining room. Resident 24 was observed sitting in the dining room until 11:49 AM when she was served lunch. Resident 24 was asked if she required her casserole to be cut, to which she shook her head no. Resident 24 was observed feeding herself and drank coffee and orange juice. At 12:05 PM, resident 24 was observed to finish eating and was served a gelatin-salad appearing dessert at 12:07 PM. At 12:24 PM, resident 24 was pushed to the activity room where a total of five residents were watching a [NAME] western. At 1:01 PM, resident 24 was taken outside for a smoking break. At 1:10 PM, resident 24 was pushed back into the activity room where she was placed in front of Bonanza with three other residents. At 1:35 PM, resident 24 asked staff when she would be taken to BINGO. Resident 24 asked activity staff (AS) 1 for a root beer. At 1:41 PM, AS 1 retrieved a root beer for resident 24. At 2:00 PM, another western started, and resident 24 began calling out for staff. At 2:07 PM, the other residents left the activity room to go prepare for BINGO. At 2:18 PM, resident 24 was taken to BINGO in the dining room, which began at 2:30 PM. Resident 24 continued to play BINGO when the continuous watch ended at 2:48 PM. An immediate interview was conducted with the Recreation Therapist (RT), who stated that BINGO would continue until 4:00 PM. Resident 24's latest Minimum Data Set (MDS) evaluation was a quarterly assessment performed on 10/27/22. Resident 24's MDS revealed the following: a. Resident 24 had a BIMS (Brief interview for Mental Stats) score of 5/15, which indicates severe cognitive impairment. b. Resident 24 had no exhibited rejection of care. c. Resident 24 required two person assistance for bed mobility, transferring, and toilet use. d. Resident 24 was dependent for toileting and the helper performed all the physical effort. e. Resident 24 required substantial/maximal assistance for rolling left and right, moving for sitting to lying or lying to sitting, and transferring, including toilet transferring. f. Resident 24 did not have a toileting program. g. Resident 24 was always incontinent of urine and bowel. h. Resident 24 was at risk for developing pressure ulcers. Resident 24's care plan revealed the following: a. Has potential for pressure ulcer development and skin impairment r/t (related to) immobility, muscle weakness, cerebral infarction, hemiplegia, RA (rheumatoid arthritis), contractures, incontinence. Initiated: 2/3/20 with interventions that included Needs monitoring/reminding/assistance to turn/reposition. b. Resident 24 Has Hemiplegia/Hemiparesis (paralysis) r/t Stroke with interventions that included Provide assistance with turning and repositioning to keep body in good alignment and to prevent skin breakdown. On 11/28/22 at 2:05 PM, a Nurse Practitioner (NP)/ Physician Assistant (PA) note revealed that resident 24 . is severely debilitated from history of a stroke with hemiplegia and multiple contractures. She is totally dependent for transferring [and] positioning. She has no ability to reposition . in wheelchair and has issues with past and current skin breakdown Ordered a Tilt-In-Space wheelchair with pressure relieving cushion to reduce risk of skin breakdown. [Note: Resident 24 was in a tilt-in-space wheelchair during the observation listed above on 12/14/22, but was not observed to be tilted in any other angle than approximately 80 degrees.] Nursing notes revealed the following: a. On 8/19/22 at 6:00 PM, .Turning/repositioning program is being used to maintain skin integrity. Other observations and interventions include Resident is turned and repositioned q 2 (every two) hours and PRN (as needed), resident is provided peri care q 2 hours and PRN . b. On 8/23/22 at 11:00 AM, .Pressure Relief: Repositioning, offloading per facility protocol. Dietary Interventions: Facility protein supplement with meals twice daily until wound closure. IMPRESSION: Based on today's evaluation, wound healing potential is fair, and may be delayed. Current and future wounds may be unavoidable due to the following comorbidities impairing wound healing c. On 8/24/22 at 11:00 PM, .Turning/repositioning program is being used to maintain skin integrity. Other observations and interventions include Resident is turned and repositioned q2 hours and PRN d. On 10/23/22 at 10:00 AM, .Turning/repositioning program is being used to maintain skin integrity . e. On 11/8/22 at 11:21 AM, a nursing note revealed .Repositioning, offloading per facility protocol The Certified Nursing Aide (CNA) task checklist for the previous 30 days revealed that CNAs documented toilet use for resident 24 on the following dates and times: a. 11/14/22, did not occur b. 11/15/22 at 9:17 AM c. 11/16/22, did not occur d. 11/17/22 at 12:51 AM e. 11/18/22, did not occur f. 11/19/22 at 1:59 PM g. 11/20/22 at 10:42 AM h. 11/21/22 at 12:39 AM i. 11/22/22, did not occur j. 11/23/22 at 1:20 AM and 11:29 PM k. 11/24/22, did not occur l. 11/25/22 at 1:59 PM m. 11/26/22, did not occur n. 11/27/22 at 11:00 AM o. 11/28/22, did not occur p. 11/29/22, did not occur q. 11/30/22 at 3:07 PM r. 12/1/22, did not occur s. 12/2/22, did not occur t. 12/3/22 at 1:18 AM u. 12/4/22, did not occur v. 12/5/22 at 12:03 PM w. 12/6/22, did not occur x. 12/7/22 at 9:22 AM y. 12/8/22 at 12:27 AM z. 12/9/22 at 3:23 AM and 7:25 PM aa. 12/10/22, did not occur bb. 12/11/22 at 4:27 AM cc. 12/12/22 at 10:30 AM On 12/15/22 at 9:42 AM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated that CNAs were to chart for tasks by the end of their shift for all activities that were completed. CNA 2 stated that for residents who could not move, the CNAs were to rotate them every two hours. CNA 2 stated that the only residents that were rotated were those who were in bed and not those who were up in a wheelchair. CNA 2 stated that resident 24 was not on the reposition list. CNA 2 stated that resident 24 could not reposition herself in her wheelchair. CNA 2 stated that residents' briefs were checked when the resident got out of bed, after meals, after activities, and/or if there was any sign that they were soiled or wet. CNA 2 stated that resident 24 had told CNA 2 when her brief was wet in the past, but had not expressed wetness in the past month. On 12/15/22 at 9:50 AM, CNA 1 was interviewed. CNA 1 stated that some of the residents needed to be repositioned every two hours, and reported that 4 residents who stayed in bed needed repositioning. CNA 4 stated that resident 24 was not on a repositioning checklist. CNA 1 stated that CNAs were to check briefs every two hours. CNA 1 stated that resident 24 was a little tricky because she liked to remain in her wheelchair all day. CNA 1 stated that resident 24 did not report when her brief was wet, and required two people to change her and the use of the Hoyer lift. CNA 1 stated that it was difficult to change resident 24's brief because the sling was required. CNA 1 stated that resident 24 did not want to go back to bed, so CNAs did not usually change her during the day unless she had a bowel movement. CNA 1 stated that often, resident 24 remained in her wheelchair all day. CNA 1 stated that she did not know if there was a cushion in resident 24's wheelchair. CNA 1 stated that when the CNAs changed resident 24's brief, they looked for red marks that looked like pressure injuries, because resident 24 had pressure injuries in the past. CNA 1 stated that resident 24's skin was usually intact. CNA 1 stated that resident 24's brief could not be checked while resident 24 was in a common area, so the CNAs would have to take resident 24 to her room to check her brief. CNA 1 stated that resident 24 usually got out of bed just before breakfast, between 7:00 AM and 7:30 AM, and would not return to bed until after dinner. On 12/15/22 at 10:03 AM, Registered Nurse (RN) 2 was interviewed. RN 2 stated that resident 24 could hold a cup of water and feed herself, but otherwise required staff assistance for all cares and tasks. RN 2 stated that resident 24 could not adjust herself in her wheelchair. RN 2 stated that resident 24 required two people and a Hoyer lift to transfer into bed for brief changes. RN 2 stated that resident 24 liked to sit all day long. RN 2 stated that resident 24 should have been repositioned, but will sometimes yell and scream at staff. RN 2 stated that resident 24 did not like to have her brief changed, but when staff educated her about the importance of having regular brief changes, resident 24 would let staff assist her. RN 2 stated that resident 24's cares should be charted in the CNA tasks for repositioning and brief changes. On 12/15/22 at approximately 3:00 PM, the Director of Nursing (DON) and Corporate Resource Nurse (CRN) were interviewed. The CRN stated that resident 24 should have been repositioned every two to three hours. The DON stated that resident 24's care plan stated that resident 24 required frequent repositioning. The DON stated that some staff did not know that residents in wheelchairs required repositioning.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined for 1 of 27 residents that the facility failed to reevaluate the risks versus benefits of the installed side rails for a resident. Specifically, one resident had a skin tear occur from the use of the current side rail. Resident identifier: 3. Findings Include: Resident 3 was admitted to the facility on [DATE] with diagnoses which included heart failure, type 2 diabetes mellitus, morbid obesity, and reduced mobility. On 12/13/22 at 12:01 PM, an interview was conducted with resident 3. Resident 3 stated she injured her left forearm on the inside of the side rail. Resident 3 stated that the inside of her side rail had something that stuck out for her to put her remote in. Resident 3 stated that her arm slid off the side of the rail and scraped the part for the remote-control holder. Resident 3 stated this happened on a day she wasn't coordinated and couldn't control her upper body. Resident 3's medical records were reviewed on 12/14/22 A Minimum Data Set (MDS) - section P restraints and alarms dated 10/25/22 documented that resident 3 did not use any bed rails. Bed rail/ transfer bar safety assessment dated [DATE] documented that physical therapy (PT) recommended bed rails to allow resident 3 to pull herself up in bed into a sitting position. Bed rail/ transfer bar safety initial assessment dated [DATE] and 8/17/22 revealed that resident 3 did have difficulty with balance/poor trunk control. A nursing progress note on 11/10/22 at 10:00 PM stated, Resident has a new skin tear to L (left) forearm. CNA's (certified nursing assistants) were doing cares and when resident was turned onto her right side, her left arm got caught up in the bed rail and left a skin tear. Site was cleansed and covered. Hospice was notified. Will have AM (morning) shift f/u (follow up) with family in the morning regarding the incident. Per November and December 2022 progress notes, resident 3 required wound care to her left forearm skin tear from 11/11/22 through 12/9/22. Resident 3's care plan was reviewed and revealed a care area for actual impairment to skin integrity. The goal identified was skin tear to left forearm will be healed. Interventions were identified and included as follows: 1. Education done with staff on safe bed positioning and turning to prevent possible injury. 2. Encourage good nutrition and hydration in order to promote healthier skin. This care plan was initiated on 11/11/22. Another care area identified was the use of ¼ bed side rail for positioning and ease in mobility. The goal identified was that resident 3 would remain free of complication related to side rail use through the review date. Intervention identified included: 1. Discuss with resident, family/caregivers, the risk and benefits of side rail use, when side rails should be used, and any concerns or issues regarding side rail use. 2. Evaluate/record continuing risks/benefits of side rail use, alternatives, need for ongoing use, reason for use. 3. Monitor/document/report to Medical doctor as needed changes regarding effectiveness of side rail use, if appropriate; any negative or adverse effects noted from side rail use. This care plan was initiated on 12/14/22. On 12/15/22 at 11:43 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 3's skin was really frail. RN 1 stated that at the beginning of November 2022, resident 3's left arm got stuck in between the mattress and the side rail resulting in a skin tear. RN 1 stated the first time she saw the skin tear, she recalled it being a good size and having steri strips on it. RN 1 stated that the skin tear took a long time to heal and it looked like that resident had a scar as a result of that skin tear. On 12/15/22 at 12:26 PM, an interview was conducted with CNA 5. CNA 5 stated that it took two people to clean resident 3 since she was unable to turn herself at all. CNA 5 stated that resident 3 crossed her arms during brief changes and when turned to either side, resident 3 sometimes got pinched in between the bed rails. On 12/15/22 at 12:39 PM, an interview was conducted with CNA 6. CNA 6 stated that resident 3 was able to hold onto the bedrail during brief changes. CNA 6 stated that resident 3 had a hard time breathing when turned onto her right side and that was why they mostly turned her to her left side. CNA 6 stated that resident 3 liked to lean towards her left side so they usually wedged a pillow or a blanket in between resident 3 and the siderails to prevent skin breakdown. On 12/15/22 at 2:20 PM, an interview was conducted with the Director of nursing (DON) and the corporate resource nurse (CRN). The DON and CRN stated that resident 3 used the siderail to pull herself up. The DON and CRN stated that physical therapy did an evaluation on resident 3 on the use of side rails and recommended that resident 3 use them for bed mobility. The DON and CRN stated resident 3 signed a consent form for use of the bed rails. The CN stated there was one instance where resident 3 was turned in bed and bumped her arm against the bed rails. That was the only issue she was aware of resident 3 had with the bed rail. The DON and CRN stated they did staff education on bed rail safety and repositioning. The DON and CRN stated they were unaware the resident 3 had been pinched between the bed rail multiple times. The DON and CRN stated they would have therapy look into it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined, for 5 of 27 sampled residents, that the facility did not provide a safe, clean comfortable and homelike environment. Specifically, resident wheelchairs were dirty and a lift was dirty. Resident identifiers: 13, 17, 33, 34, and 52. Findings include: 1. On 12/13/22 at 1:45 PM, resident 33 was observed in her wheelchair. Resident 33 wheelchair was observed to have a soiled wheelchair cushion, the sides and wheels of her wheelchair were soiled. On 12/15/22 at 12:46 PM, an observation was made of resident 33's wheelchair. Resident 33's wheelchair was observed to have a soiled cushion. In addition, the sides and wheels of her wheelchair were soiled. 2. On 12/15/22 at 12:26 PM, an observation was made of resident 52's wheelchair. Resident 52's wheelchair was observed to have a green pad on it. There was food and debris on the pad. There was a strong urine odor. There was debris on the sides of the cushion and the wheels were soiled. 3. On 12/15/22 at 12:55 PM, an observation was made of resident 34. Resident 34's wheelchair was observed to be soiled on the cushion and on the sides and the back where the motor was. 4. On 12/15/22 at 12:47 PM, an observation was made of resident 17's electric wheelchair. Resident 17's wheelchair was observed to be soiled on the arm rests, and there was crumbs and debris under the joystick. Resident 17's cushion had debris and a white substance dried on it. 5. On 12/13/22 at 1:35 PM, an observation was made or resident 13's room. Resident 13's dresser had 3 of the 6 handles broken. Resident 13 stated the handles will just break again anyway. Resident 13's wheelchair was observed to be dirty. Resident 13 stated the Certified Nursing Assistants (CNA) cleaned wheelchairs at night. 6. On 12/15/22 at 12:45 PM, an observation was made of a sit to stand lift outside room [ROOM NUMBER] and 134. The lift was observed to be soiled on the foot rests. On 12/15/22 at 12:15 PM, an interview was conducted with CNA 4. CNA 4 stated the night shift CNAs should be cleaning the wheelchairs. On 12/15/22 at 12:28 PM, an interview was conducted with CNA 3. CNA 3 stated there was a nightly list for CNAs to be cleaning wheelchairs on night shift. CNA 3 stated there was a list in the CNA binder at the nurses station. CNA 3 was unable to find a list of wheelchairs cleaned. CNA 3 stated there was nothing specifically signed off when the wheelchair was cleaned. On 12/15/22 at 12:57 PM, an interview was conducted with the Director of Nursing (DON). The DON stated there was an assignment book with which wheelchairs were cleaned on which days. The DON stated there was no log or anything because it had not been a problem having the wheelchairs cleaned. The DON stated if staff noticed a dirty wheelchair, they cleaned it. The DON stated CNAs were to wipe the lifts down between each resident.

Based on observation, interview, and record review it was determined, for 12 of 27 sampled residents, that the facility did not serve food that was prepared by methods that conserved nutritive value, flavor, and appearance or serve food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, residents complained of cold and unappetizing food. In addition, green beans and peas were overcooked and resident council minutes revealed residents' complaints of food quality. Resident identifiers: 1, 7, 13, 20, 34, 37, 41, 45, 49, 55, 59, and 61. Findings Included: 1. On 12/13/22 at 2:56 PM, resident 1 was interviewed. Resident 1 stated that the eggs were usually cold and not good. 2. On 12/13/22 at 3:01 PM, resident 7 was interviewed. Resident 7 stated that the food was always cold by the time they received it. 3. On 12/13/22 at 1:35 PM, resident 13 was interviewed. Resident 13 stated that the food was cold. 4. On 12/13/22 at 1:08 PM, resident 20 was interviewed. Resident 20 stated that the food was the worst part of the facility. The food was always pancakes and eggs, and that the food was always cold. The resident stated that the tortilla they received for lunch was cold and they did not like the menu. 5. On 12/13/22 at 1:35 PM, resident 34 was interviewed. Resident 34 stated that the food needed improvement; they were served potatoes or pancakes every day. 6. On 12/13/22 at 2:20 PM, resident 37 was interviewed. Resident 37 stated that they were served too many beans; the food tasted like Miralax and it had the same effect as Miralax. 7. On 12/13/22 at 1:25 PM, resident 41 was interviewed. Resident 41 stated that the food was cold all the time, though it usually tasted good, and that the coffee was always hot. 8. On 12/13/22 at 1:43 PM, resident 45 was interviewed. Resident 45 stated that the foods served were repetitive and frequently served with gravy. 9. On 12/14/22 at 8:40 AM, resident 49 was interviewed. Resident 49 stated that the food had no flavor; the resident did not receive coffee or orange juice this morning. 10. On 12/13/22 at 1:29 PM, resident 55 was interviewed. Resident 55 stated that the food was not great and was usually cold. 11. On 12/13/2022 at 2:21 PM, resident 59 was interviewed. Resident 59 stated that the meat tasted freezer burnt, and the resident does not eat it. 12. On 12/13/2022 at 1:12 PM, resident 61 was interviewed. Resident 61 stated that all of the food served was cold, the tortillas were cold at lunch, and that the food served was not good. On 12/14/2022 at 11:32 AM, a test lunch tray was requested after observing the trayline. At 11:39 AM the test tray was placed onto the 200 hallway delivery cart. At 11:47 AM, the meal trays were served to the 200 hallway. An observation was made of the meal trays. There were no hot pellets observed between the base and the meal plate prior to serving. The following temperatures were obtained: [Note: All temperatures were in degrees Fahrenheit.] a. Chicken King Casserole was 162 b. Peas were 121 c. [NAME] Beans were 115 d. Salad was 52 e. Gelatin Dessert was 59. Resident council minutes revealed the following complaints of food: a. 8/9/2022 .mentioned they do not like Sausage Patties, or French toast sticks . b. 9/13/2022 Residents would like more protein options for breakfast besides sausage c. 10/11/2022 Residents would appreciate grilled cheeses to not be pre-cooked d. 11/08/2022 .Food has been cold but staff is being replaced so hopefully food quality will improve . On 12/15/22 at 1:40 PM, an interview was conducted with the Dietary Manager (DM). The DM stated the facility recently purchased a new plate warmer. The DM stated that the plate warmer was broken for about 4 weeks and residents complained of cold food. The DM stated kitchen staff warmed plates in the oven and steamer during that time. The DM stated she had never seen pellet warmers between the plate and the base.

Based on observations and interviews, it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, uncooked meats were stored above ready to eat foods, there were soiled areas in the kitchen, cracked paint, missing grout and broken tiles. Findings Include: 1. On 12/13/2022 at 9:46 AM, an initial tour of the kitchen was conducted. The following was observed: a. In the walk-in refrigerator, a box of raw hamburger patties was found stored above breadsticks. b. Inside the walk-in freezer there were large chunks of ice on the floor and ice circles hanging from the ceiling. c. The door handle from the kitchen to the dining room was observed to have crumbs and debris in it. d. There was cracked paint and drywall under the vents above the stove. e. Underneath the prep sink a tile was missing. f. There was missing grout on the tile in front of the oven. g. Crumbs and debris were found around the edges of the flooring. 2. On 12/15/2022 at 1:37 PM, a follow up tour of the kitchen was conducted. The following was observed: a. There was raw bacon and sausage stored above oatmeal, mixed vegetables, and rolls in walk-in refrigerator. b. There was a container labeled egg salad with no date in the walk-in refrigerator. c. Inside the walk-in freezer there were large chunks of ice on the floor and ice circles hanging from the ceiling. d. A three drawer plastic compartment with serving utensils was observed to be soiled with food on both the inside and outside of the drawers. e. The shelf above trayline basins was observed to be soiled under the shelf. f. Dietary Aide (DA) 1 was observed to be standing by the trayline rolling silverware in napkins. DA 1 was observed to not have her hair restrained. DA 1 was observed to put on a beanie right after the surveyors entered. g. There was cracked paint and drywall observed under the vents above the stove. h. Underneath the prep sink a tile was missing. i. There was missing grout on the tile in front of the oven. j. Crumbs and debris were observed around the edges of the flooring. k. The door handle on the door from the kitchen to the dining room was observed to have crumbs and debris on its surface. On 12/15/22 at 1:37 PM, [NAME] 1 was interviewed. [NAME] 1 stated the inside and outside of the 3 drawers with the utensils in it was cleaned weekly with soap. On 12/15/22 at 1:40 PM, the Dietary Manager (DM) was interviewed. The DM stated the 3 drawers with the utensils were to be cleaned on a weekly basis. The DM stated the drawers were not on the cleaning schedule so she did not know what day they were cleaned. The DM stated uncooked meats were supposed to be stored on the bottom right shelf of the walk-in refrigerator to prevent meat juices from dripping and contaminating ready-to-eat foods. The DM stated the kitchen was supposed to be swept every night. The DM stated that the ice in the freezer was from the defrost cycle. The DM stated she had not noticed the missing grout and cracked tile. The DM stated the door handles were scheduled to be cleaned nightly. The DM stated the tray line was cleaned nightly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 2 of 22 sample residents, that the facility did not assist residents in obtaining routine and 24-hour emergency dental services and did not promptly, within 3 days, refer residents with lost or damaged dentures for dental services. Specifically, the facility did not follow-up when a resident's dentures did not fit properly and were painful to wear and another resident had painful teeth with bleeding gums. Resident identifiers: 1 and 49. Findings include: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, functional quadriplegia, anxiety disorder, major depressive disorder, cognitive communication deficit, and protein-calorie malnutrition. On 5/3/21 at 9:29 AM, resident 1 was observed without her dentures in her mouth. Resident 1 was interviewed and stated that her dentures were too big and she could not get a dental appointment. On 5/6/21 at 8:58 AM, an interview was conducted with resident 1. Resident 1 stated she was not wearing her dentures because they did not fit and she had not been able to get an appointment with a dentist. Resident 1's medical record was reviewed on 5/5/21. Resident 1's physician's orders were reviewed and revealed the following: a. On 1/11/21, Dental consultation and treatment as needed. b. On 1/12/21, Regular diet, Regular texture, Thin liquids consistency. The diet order was discontinued on 1/21/21. c. On 1/21/21, Fortified diet, Mechanical soft texture, Thin liquids consistency. An admission Minimum Data Set (MDS) dated [DATE] revealed resident 1 did not have natural teeth. Resident 1 had missing, artificial upper and lower teeth. In addition, resident 1 had dentures or a partical that was broken or lose fitting. An admission Inventory list dated 1/11/21 revealed that resident had upper and lower dentures that didn't fit her. An admission Nutrition Evaluation dated 1/18/21 revealed resident was on a regular diet and she had upper and lower dentures that did not fit. The evaluation further revealed, She has ill fitting dentures and does not use them. Would like to try mech (mechanical) soft texture., difficulty chewing, . Will send trial mech soft tray at lunch and if tolerated better will recommend texture change to optimize intake. Will monitor wt (weight) trends/po (by mouth) intakes for changes and follow as needed. Resident 1's progress notes revealed the following entries: a. On 1/11/21 at 7:16 PM, Resident has dentures but states they are too big. b. On 1/15/21 at 12:00 AM, States that she has dentures, but they are too big and hurt mouth' so she doesn't wear them by personal choice. Lack of teeth make it hard for resident to enunciate. No GI (gastro-intestinal) changes observed. No GI appliance(s) used Active SX (symptoms): difficulty chewing. The secition other observations and interventions revealed, Dislikes wearing personal dentures. Soft foods preferred. c. On 1/21/21 at 4:04 PM, Weight Committee IDT (Interdisciplinary Team) Weekly weight reviewed by RD (Registered Dietitian) and ADON (Assistant Director of Nursing). Resident with 10.9% wt gain [times] 1 week. Possible wt error this week. RD (Registered Dietitian) recommendations: fortified diet with shakes BID (twice-a-day) with meals. Resident states she had wt loss prior to admit. Dentures are loose fitting. Will change to mechanical soft texture. SLP (Speech Language Pathology) notified of diet texture change. Will continue to monitor. Provider notified. d. On 1/21/21 at 4:54 PM MDS Notes, No evidence of swallow disorder but has loosely fitting dentures. RD in today and changed diet to fortified, mechanical soft textures. e. On 1/27/21 Nursing: Mouth continues painful so dentures no [sic] in. On 5/6/21 at approximately 9:05 AM, an interview was conducted with CNA (Certified Nursing Assistant) 4. CNA 4 stated she knew that resident 1 had dentures, but did not know why she did not wear them. On 5/6/21 at approximately 9:15 AM, an interview was conducted with the CNA Coordinator. The CNA Coordinator stated she knew that the resident had dentures but did not know why she did not wear them. On 5/6/21 at approximately 9:21 AM, an interview was conducted with RN (Registered Nurse) 2. RN 2 stated she had worked with resident 1 last Sunday (5/2/21) and that resident 1 had told her that her dentures hurt. RN 2 stated that she passed that information on to the night nurse, who replaced her and requested that the night nurse tell facility leadership about resident 1's dentures hurting Monday morning. On 5/6/21 at approximately 9:27 AM, an interview was conducted with RN 3, who was a Clinical Care Coordinator. RN 3 stated that the facility had a dentist, who regularly came every 3 months to the facility. RN 3 stated that with COVID-19, the dentist had not been able to come as frequently as he had in the past. RN 3 stated that if a resident had mouth or teeth pain, the dentist ordered antibiotics and then schedule an appointment for the resident to go to his office for treatment. RN 3 stated she had not heard about resident 1 having problems with her dentures and that an appointment with a dentist had not been scheduled. On 5/6/21 at approximately 9:44 AM, an interview was conducted with the Director of Nursing (DON) and Clinical Resource Nurse (CRN) 2. The DON and CRN 2 stated they had not heard about resident 1's dentures not fitting. The DON stated that she would make sure a dental appointment is made for resident 1 to have her dentures checked. 2. Resident 49 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease, dementia, artificial knee, anxiety, major depressive disorder order, pain in left knee, and epilepsy. On 5/3/21 at 2:57 PM, an interview was conducted with resident 49. Resident 49 stated that were teeth were painful and it hurt to eat food. On 5/6/21 at 12:44 PM, an interview was conducted with resident 49. Resident 49 stated that her teeth still hurt. Resident 49 stated she thought the staff knew they hurt. Resident 49's teeth were observed to be brown colored with some silver on her back teeth. Resident 49's medical record was reviewed on 5/4/21. An annual MDS dated [DATE] revealed that resident 49 did not have problems with teeth and had her own teeth. A care plan dated 4/5/2020 and revised 11/2/2020 revealed that resident 49 had ADL (activities of daily living) Self Care Performance deficit related to muscle weakness. The goal developed was Will safely perform .Personal Hygiene with staff assistance through review date. The intervention developed was personal hygiene/oral care required 1 person staff participation and Has oral/dental health problems: gums bleeding after brushing teeth. Another intervention was Will comply with mouth care at least daily through review date and Coordinate arrangements for dental care, transportation as needed/as ordered. An intervention revealed Monitor/document/report to MD (Medical Doctor) PRN (as needed) s/sx (signs and symptoms) of oral/dental problems needing attention: Pain (gums, toothache, palate), Abscess, Debris in mouth, Lips cracked or bleeding, Teeth missing, loose, broken, eroded, decayed, Tongue (black, coated, inflamed, white, smooth), Ulcers in mouth, Lesions. A nursing progress note dated 4/25/21 revealed, Gums began bleeding after brushing her teeth this morning. Provider notified. Resident is worried about it. [Note: There were no additional notes in resident 49's medical record regarding follow up.] On 5/6/21 at 10:30 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated resident tooth brushes were stored in the resident's closet. CNA 1 stated that oral care was completed prior to breakfast. CNA 1 stated that resident 49 required assistance with her teeth brushing. CNA 1 stated that sometimes resident 49 refused to have teeth brushed. CNA 1 stated she was not aware of resident 49's gums bleeding or any mouth pain. On 5/6/21 at 11:00 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that oral care was performed after getting the resident out of bed in the morning. The DON stated that oral care was done at night. The DON stated that nurse assessed residents mouth and notified the physician and obtained a dental consult. The DON stated that the transportation staff member made dental appointments. On 5/6/21 at 11:42 AM, a follow-up interview as conducted with the DON. The DON stated that resident 49 did not have a dental appointment scheduled. The DON stated that resident 49 had not been to a dentist appointment since her gums had bleed on 4/25/21. The DON stated that prior to COVID-19 outbreak, a dentist came to the facility quarterly and examined all the residents. The DON stated that the dentist was scheduled to examine the residents at the facility on 6/3/21.

Based on interview and record review it was determined that the facility did not employ a clinically qualified full-time dietitian or another clinically qualified nutrition professional to serve as the director of food and nutrition services. Specifically, the facility did not a employee a full time Registered Dietitian (RD) and the Dietary Manager (DM) did not meet the requirements to serve as the director of food and nutrition services. Findings include: On 5/6/21 at 12:27 PM, an interview was conducted with the Dietary Manager (DM). The DM stated that she would complete her Certified Dietary Manger course in October, 2021. The DM stated that the Registered Dietitian (RD) was in the building every Thursday. The DM stated that the RD was available by phone anytime.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined for 5 of 22 sample residents, that the facility did not ensure the resident's environment remained as free from accident hazards as possible and that each resident received adequate supervision and assistance to prevent accidents. Specifically, residents were observed to not be using smoking equipment and a resident sustained feet injuries while operating an electric wheelchair without a follow-up assessment or intervention. In addition, a resident did not have items available to prevent falls. Resident identifiers: 22, 34, 35, 50 and 58. Findings include: 1. On 5/3/21 at 11:00 AM, three smoking aprons were observed hanging on the south wall next to the east exit, where the residents exited the building to the smoking area. An observation was made of resident's smoking outside under a tent. There were no residents observed to have a smoking apron or other smoking equipment. There was one staff member with the residents. a. Resident 22 was admitted to the facility on [DATE] with diagnoses which included cerebral infarction, hemiplegia, rheumatoid arthritis, generalized weakness, osteoarthritis and contractures. On 5/3/21 at 11:05 AM, an observation was made of resident 22 outside smoking. Resident 22 was observed to not be wearing a smoking apron. On 5/4/21 at 9:00 AM, an observation was made of resident 22 outside smoking. Resident 22 was observed to not be wearing a smoking apron. On 5/4/21 at 11:05 AM, an observation was made of resident 22 outside smoking. Resident 22 was holding a cigarette in her right hand and appeared to be shaking. Resident 22 was not observed to be wearing a smoking apron. On 5/5/21 at 11:02 AM, an observation was made of resident 22 outside smoking. Resident 22 was observed to be wearing a smoking apron. On 5/6/21, resident 22's electronic medical record was reviewed. Resident 22's smoking care plan revealed that resident 22 had potential for injury r/t (related to) smoking. She is supervised smoker and has an apron while smoking. This was created on 12/13/19. The intervention to utilize smoking apron during smoking activities was initiated on 4/12/21. A smoking evaluation was completed for resident 22 on 2/24/21 at 12:25 PM. The resident had a dexterity problem and required adaptive clothing in the form of a smoking apron. A note was included that stated resident 22 continued with supervised smoking. Resident 22's Treatment Administration Record (TAR) revealed Smoking Apron: Resident must wear smoking apron with supervised smoking every shift. This was signed in the TAR by the nurse on May 1st, 2nd and 3rd. Wearing a smoking apron was ordered on 7/30/19. b. Resident 34 was admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis, cerebral infarction affecting dominant side, end stage renal disease, toxic encephalopathy, and diabetes mellitus type II. On 5/3/21 at 11:05 AM, an observation was made of resident 34 outside smoking. Resident 34 was observed to not be wearing a smoking apron. On 5/4/21 at 9:00 AM, an observation was made of resident 34 outside smoking. Resident 34 was observed to not be wearing a smoking apron. On 5/4/21 at approximately 1:40 PM, resident 34 was observed outside alone in the smoking area. The Administrator was observed to approach resident 34. Another staff member was observed to go out to the smoking area and stay with resident 34 while he smoked. The Administrator was interviewed, and stated that resident 34 wanted to smoke, but had missed his smoking time due to a family visit. On 5/5/21, resident 34's electronic medical record review was completed. Nursing notes for resident 34 revealed that on 2/7/21, resident 34 did not have cigarettes and was very anxious wanted to leave .Later was waiting for smoke break and then was outside knocking on the door the other residents answered and let [Resident 34] in. I went out and ask why (he) was out said thought was smoke break and reminded him that was not till 8 and no one else had gone out with him. Then (he) tells me that he lost phone outside .I feel that [resident 34] needs to have more supervision since last hospital stay and has had increased forgetfulness and confusion. Resident 34's care plan had a focus for .potential for injury r/t smoking. He is on supervised smoker at this time. This was initiated on 12/13/19. On 4/13/21, a goal was initiated that stated resident 34 will be compliant with smoking protocols and wear a smoking apron until next review. An intervention was initiated on 4/14/21 to Utilize smoking apron during smoking activities. c. Resident 58 was admitted to the facility on [DATE] with diagnoses which included peripheral vascular disease, muscle weakness, lack of coordination, malaise, left hand contracture, diabetes, cognitive communication deficit, anxiety, contracture right knee, social phobia, and major depressive disorder. On 5/3/21 at 9:51 AM, an interview was conducted with resident 58. Resident 58 stated that she smoked 1 cigarette every time she went out to smoke with staff. On 5/3/21 at 11:00 AM, an observation was made of resident 58. Resident 58 was observed in the smoking area in a tilt back wheelchair. Resident 58 was not observed to have a smoking apron or other smoking equipment. On 5/4/21 at 9:00 AM, resident 58 observed to have a smoking apron placed on her on the way out the door. Resident 58 was observed to smoke with a smoking apron over her. Resident 58's medical record was reviewed on 5/3/21. Resident 58's smoking assessment dated [DATE] revealed that resident 58 had cognitive loss, falls, leans sideways, smokes five times per day, lit her own cigarette, needed a smoking apron, and required supervision. A care plan dated 10/14/19 revealed that resident 58 was at risk for potential injury related to smoking. The care plan further revealed resident 58 may smoke with supervision per smoking assessment. The goal developed was [Resident 58] will be compliant with smoking protocols and individual smoking plan until next review. An intervention developed on 3/13/2020 and revised on 8/4/2020 revealed to Utilize smoking apron during smoking activities. On 5/4/21 at 9:06 AM, an interview was conducted with Certified Nurses Assistant (CNA) 2. CNA 2 stated smoking assessment were completed by the nurses. CNA 2 stated if she noticed a change when a resident was smoking she reported the change to the nurse for a smoking re-evaluation. CNA 2 stated when she was observing the smoking break, she observed residents for flicking or dropping ashes. CNA 2 stated that she made sure residents were not burning themselves and were able to get back into the building safely. On 5/5/21 at 9:29 AM, an interview was conducted with an Activities Assistant (AA) 1. AA 1 stated that resident 22, 34 and 58 should have worn smoking aprons on while smoking because they were not safe to smoke without them. AA 1 stated that management staff had reminded her and the other staff that assisted the residents with smoking about the residents who needed smoking aprons. AA 1 stated that staff were outside with residents and lit the resident's cigarettes. On 5/5/21 at approximately 9:40 AM, an interview was conducted with CNA 4. CNA 4 stated that resident 34 had required more assistance with his cares since his return from the hospital. CNA 4 stated that staff had recently assessed that resident 34 required a smoking apron because he was weak. On 5/5/21 at 9:33 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that there were scheduled times for residents to smoke. The DON stated that CNAs took residents out, lit the cigarettes and monitored for social distance between resident. The DON stated that resident 58, resident 34, and resident 22 required smoking aprons. The DON stated that a safe smoking assessment was completed by the nursing staff for all resident's that smoked. The DON stated that if a resident was unsafe during smoking, then therapy also evaluated the resident. The DON stated that resident 34 was evaluated for a smoking apron recently. The DON stated that resident 58 and 22 had smoking aprons since August 2020. The DON stated that on 5/4/21 CNAs told her that resident 22 did not have a smoking apron on. The DON stated she was not aware that resident's did not have smoking aprons on 5/3/21. The DON stated that CNAs placed the smoking aprons on the resident's prior to exiting the facility. The DON stated that resident 22 was able to apply her own apron. The DON stated that resident 34 sometimes refused to wear a smoking apron. The DON stated that if resident 34 refused an apron, then the nurse talked to him about it. The DON stated that if he continued to refuse, then a CNA stood by him and watched to make sure he was safe. The DON stated that she wrote up education on 5/4/21 and discussed with all CNAs and Nurses about the 3 resident's that needed to have an apron on. The DON stated there was a list of resident's that needed smoking aprons in the box with the cigarettes. On 5/5/21 at 9:40 AM, Corporate Resource Nurse (CRN) 2 was interviewed. CRN 2 stated that all staff were in-serviced about which residents required smoking aprons. The three residents who were assessed as requiring smoking aprons were resident 22, resident 34 and resident 58. On 5/5/21 at 9:40 AM, CRN 1 was interviewed. CRN 1 stated that nurses completed the smoking assessments, and therapy assisted with the assessments. CRN 1 stated that resident 34 had a decline in condition, and afterward required a smoking apron. CRN 1 stated that everyone was supervised when smoking, but the staff who were assisting the residents to smoke told the management staff that they had forgotten to put aprons on the residents. CRN 1 stated that resident 34 often had to be convinced to wear it, and if he refused, staff would stand right next to him to monitor. CRN 1 stated that staff checked the residents clothing and skin to make sure they had no burn marks. The facility provided a smoking policy, effective 8/3/2020. Policy: It is the policy of this facility to provide to its residents a smoke free environment. It is also the policy to provide those residents who choose to smoke a means in which to do so that does not jeopardize their safety or the safety of others residing in the facility Procedures: 1. Upon admission, residents who desire to smoke will be assessed as well as their ability to do so safely. Smoking agreement will be reviewed with resident that wish to smoke . 2. The results of the evaluation will be in the resident's chart and the IDT (interdisciplinary team) recommendations will be care planned. 3. Upon quarterly review by the IDT, or at any time a significant change of condition occurs, smoking residents will be re-assessed as to their ability to smoke safely and their ability to understand and comply with facility smoking policy Smoking rules: 1. All smokers will be accompanied by a member of staff during the 5 daily smoking times . 2. Resident 50 was admitted to the facility on [DATE] with diagnoses which included morbid obesity, spinal stenosis, type II diabetes, peripheral neuropathy, cellulitis, and cognitive communication deficit. On 5/4/21 at 9:28 AM, resident 50 was observed in his power chair. Resident 50's feet turned outward, beyond the foot rests of the chair. On 5/5/21, a review of resident 50's electronic medical record was completed. On 9/29/2020, a physician's order for podiatry consultations as needed was initiated for resident 50. Resident 50 had a Power Wheelchair Training Checklist, with an initial evaluation date of 12/11/2020 and a final evaluation date of 12/29/2020. The evaluation stated that resident 50 .is appropriately trained on the proper use and function, and demonstrated the ability to safely and efficiently operate this wheelchair. On 3/15/21, a physician's order was initiated for Therapy to assess balance and gait strength. On 3/17/21, a physical therapy evaluation revealed that resident 50 frequently asked to return to bed, yelled for help, and needed additional balance and strength training. Resident 50 had two falls, muscle tightness, and tenderness. On 4/12/21 at 12:48 PM, a nursing note revealed that resident 50 complained of left foot pain and was examined by the nurse practitioner. On 4/12/21 an x-ray revealed that resident 50 had degenerative changes in the left foot and osteopenia. Resident 50 also had soft tissue swelling. On 4/15/21, resident 50 continued with moderate persistent edema to bilateral lower extremities (BLE) with unna boot treatment (for compression). Resident 50 was receiving wound care due to venous ulcers of the bilateral lower extremities. On 4/16/21 at 11:25 AM, a nursing note revealed that resident [50] was going into restroom with his power chair and caught his 3rd toe of left foot on bathroom door. he (sic) has a small cut just above toenail and scraped the skin off knuckle of toe. Areas were cleaned . On 4/16/21, an incident report revealed that resident 50 was wheeling into the restroom when a toe was caught on the bathroom door. There were no identified predisposing physiological or situational factors. On 4/16/21 at 12:13 PM, a nursing note revealed that the nurse practitioner (NP) examined resident 50. On 4/16/21 at 2:38 PM, an IDT note for resident 50 revealed that .Resident is currently on therapy services; therapy towork (sic) on safety awareness. On 4/17/21, a physician's order was created that stated: 3rd toe on left foot, cleanse with NS (normal saline) cover with border gauze. monitor for s/s (signs/symptoms) of infection. On 4/20/21 at 1:52 PM, a skin/wound note revealed that resident 50 had a left 3rd toe trauma/skin tear times two. Medial wound 0.4 cm (centimeter) x 1 cm with scant sero-sanguineous (clear) drainage. Distal wound 0.6 cm x 1.3 cm with scant sero-sanguineous drainage. Skin flap rolled. 4th toe bruised on side next to 3rd toe. Both tender to the (sic) touch. Wounds cleansed and dressed per orders . On 4/28/21 at 1:32 AM, a nursing note revealed that resident 50 .was using his chair to go to sink and hurt his toes on left foot. They bent back slightly. No sign of serious injury . On 4/28/21 at 5:41 PM, a nursing note revealed that the NP (Nurse Practitioner) assessed resident 50 and ordered xrays of both knees and the right foot. On 4/29/21, an incident report revealed that resident 50 rubbed his foot under the wardrobe closet door next to the sink when maneuvering in his electronic wheelchair. Resident 50 required first aide to a 3x3 cm skin flap. Resident 50's predisposing situation factors included ambulating without assistance and improper footwear. On 4/30/21 a physician's order was created that stated: Right great toe; Cleanse area gently pat dry, apply Neosporin ointment to edges of skin affected. Cover with non-adherent dressing . On 5/3/21 at 5:42 AM, a nursing note revealed that resident 50 continued to receive wound care to both great toes. On 5/5/21 at approximately 12:00 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 50 hit his feet because his legs and feet were swollen and resident 50's feet were not aligned with the pedals of his electric wheelchair. RN 1 stated that she thought resident 50 drove the wheelchair safely, but his feet stuck out too far so he bumped them. 3. Resident 35 was admitted to the facility on [DATE] with diagnoses which included spastic hemiplegia affecting right dominant side, urinary tract infection, epilepsy, abnormalities of gait and mobility, left shoulder contracture, right elbow contracture, right shoulder contracture, right wrist contracture and right hand contracture. On 5/4/21 at 9:40 AM, an interview and observation was conducted with resident 35. Resident 35 was observed in her bed with a bedside table next to her. Resident 35's over bed table was observed to have a phone and a mug on it. Resident 35's bed was about 3 feet above of the ground. Resident 35 did not have a fall mat next to her bed. Resident 35 stated she did not remember falling or sustaining any injuries from falling. On 5/6/21 at approximately 12:45 PM, an observation was made of resident 35. Resident 35 was observed in a wheelchair propelling herself through the activity room. Resident 35 was observed to be leaned forward in her wheelchair. Resident 35 was observed to ask staff to assist her into bed. Resident 35 had an alarm box on the back of her wheelchair with a pressure pad under her. On 5/6/21 at 1:59 PM, an observation was made of resident 35. Resident 35 was laying in bed approximately 2 feet off the ground. There was no fall mat next to her bed. An alarm was observed at the foot of her bed. Resident 35's wheelchair was observed to have an alarm on top of a cushion and no dysom was observed. Resident 35 was observed to have a call light by left hand. Resident 35's medical record was reviewed on 5/5/21. Resident 35's fall risk evaluations revealed on 12/8/2020 resident 35 was at a high risk for falls. On 4/29/2021 a fall risk evaluation was completed. Resident 35 was at a high risk for falls. A care plan dated 3/9/2020 and updated on 3/17/2020 revealed, [Resident 35] is at risk for falls due to her history of falls, actual falls, TBI (traumatic brain injury), increased weakness, poor safety awareness and poor impulse control. Per family [resident 35] sleeps with her legs hanging off the bed and often slides out at night due to her impulsive body movements. The goal developed was [Resident 35] ill (sic) be free of minor injury through the review date. Interventions developed on 3/9/2020 were avoid rearranging furniture, bed against the wall per resident/family request, bed in lowest position, and floor mat at bedside at night. An intervention developed on 3/10/2020 was room assignment close to the nurses station. An intervention dated 3/16/2020 was to use right 1/4 side rails as an enabler for bed mobility and safety. An intervention to provide supervision while in restroom was developed on 3/20/2020. Interventions developed on 5/1/2020 revealed pressure alarm placed under cushion in wheelchair and dysom in wheelchair to prevent resident from slipping forward. An intervention developed on 5/20/2020 revealed to ensure appropriate footwear. An intervention dated 7/20/2020 revealed to replace bed alarm with a new one. An intervention developed on 7/23/2020 was to ensure call light was clipped where resident can reach it and remind resident to use call light. An intervention for a reacher on her bedside table was developed on 6/29/2020. An intervention developed on 1/12/21 revealed for Restorative Nursing Aide to work with resident. An intervention dated 1/22/2021 was a boppy pillow for wheelchair to remind resident to ask for assistance with transfers. An intervention for 2/9/2021 revealed to provide education about waiting for staff to assist with toileting cares. An intervention developed on 2/25/2021 Therapy to work on safety awareness. Resident 35's progress notes revealed the following falls since January 2021: a. On 1/11/21 at 6:41 PM, [Resident 35] yelled and this nurse went into the room and resident was on the floor.Resident had glasses on and their (sic) is a bruise along the side of her head where the glasses were. A very superficial wound on the lateral side of her head. No other deformities noted. Encouraged resident to use call light and she demonstrated understanding. Call light within reach. Will continue to monitor. An IDT note dated 1/12/21 revealed, Intervention: Resident has hx (history) of TBI, she is impulsive and has poor safety awareness. RNA (Restorative Nurses Assistant) to work with resident and walk with her TID (three times a day). b. On 1/19/21 at 6:23 PM, Resident had a fall in the dining room this afternoon. She did not put her brakes on the w/c (wheelchair), stood to get hot cocoa and down on her butt. No injuries and no c/o (complaints of) pain or discomfort. Resident was educated to put brakes on the w/c and not to stand without assistance. An IDT note dated 1/20/21 revealed, Intervention: Continue with current POC (plan of care) to maintain resident safety, continuing to interest resident with activities, RNA to walk with resident TID. Resident has TBI, is impulsive and has poor safety awareness. c. On 1/29/21 at 2:37 PM, A noise was heard coming from resident's room. Nurse and aid ran in and resident was on the floor just outside the bathroom door and in front of the bed. Resident stated that she was leaning toward the floor to pick her phone up. The alarm was not sounding . An IDT note dated 2/1/21 revealed . Interventions: Boppy pillow to be used to help remind resident to ask for assistance; resident will be able to move pillow away at all times. Will continue with current POC as well, to maintain resident safety d/t (due to) impulsivity and poor safety awareness r/t TBI. d. On 2/5/21 at 8:47 AM, The resident was on the toilet when the aid realized there was no wipes. The aid went to get wipes and when she walked in the resident had gotten toilet paper and was leaned over wiping and fell off the toilet.Bump on right lateral forehead. Encouraged resident to use call light and ask for assistance. Call light within reach. Will continue to monitor. An IDT note dated 2/8/21 revealed interventions Reminded resident of importance to wait for staff to assist with toileting cares. Resident has TBI and is impulsive and has poor safety awareness. Continue with POC to maintain resident safety. e. On 2/9/2021 at 9:31 AM, IDT reviewed incident that occurred 2/8/2021. Resident was leaning to far forward in her w/c to pick something up and fell forward onto her knees. Provider, nursing and family notified. Intervention: Education provided to staff about the importance of utilizing boppy pillow to remind resident to ask for assistance. [Note: There was no progress note regarding a fall on 2/8/21.] f. On 2/19/21 at 2:11 PM, Resident was in the activity room and the alarm to her w/c started to go off and 'help me' was heard coming from that room. Two nurses and two aides ran in and found resident on the floor lying on her right side. She had blood coming from her right ear. Gauze was held to apply slight pressure. local hospital ER (Emergency Room) was called to inform that resident was on her way. Non emergency transport just returned resident and transferred her to her bed. She has 7 dissolvable sutures inside and outside of the right ear. An IDT note dated 2/22/21 revealed Ensure that resident has eye glasses repaired and replaced. [Note: There was no new intervention developed after the fall.] g. On 2/25/21 at 1:18 AM, Fall for resident. Resident had witnessed fall by me and others from wheelchair on 02/24/21 at approximately 17:09 (5:09 PM). Resident alert and oriented to baseline with no changes in cognition or physical status. Resident verbalized no pain at this time. Fall alarm sounded at fall. Fall alarm tested, checked, and placed once returning to wheel chair. An IDT note dated 2/26/2021 revealed .Resident picked up on therapy services; therapy to work on safety awareness. h. On 4/20/2021 at 9:45 PM, CNA stated, 'I was getting [resident 35] back in bed from using the bathroom. While stepping onto her bed, she missed her mattress and landed on the floor. I guided her to the floor using her gait belt, so she didn't hit anything. [Resident 35] was able to get back up and in bed with no issues.' No injuries were noted. An IDT notes dated 4/21/2021 revealed a new intervention for therapy to evaluate resident for safety. i. On 4/29/2021 at 5:55 PM, Resident had an unwitnessed fall. Resident stated she was attempting to get into bed. She fell forward onto knees, and did not hit head. Assessment completed with no noted injuries at this time. Neuro charting started. [There were no documented new interventions developed.] On 5/6/21 at 10:35 AM, an interview was conducted with CNA 2. CNA 2 stated that that resident 35 had not used a boppy pillow in her wheelchair for a while because it was really big for her wheelchair. CNA 2 stated that she made sure there was nothing on the floor because resident 35 tried to pick things up off the floor and had fallen. CNA 2 stated resident 35's was assisted to bed after meals because she liked her bed. CNA 2 stated resident 35's bed was in the lowest position and usually had a mat placed on the floor next to her bed. On 5/6/21 at 1:56 PM, an interview was conducted with CNA 3. CNA 3 stated that nurses verbally informed CNAs regarding resident's that sustained falls. CNA 3 stated that nurse's informed CNAs of new interventions for residents. CNA 3 stated that CNAs verbally reported falls to the oncoming CNAs. CNA 3 stated that resident 35 had a low bed and a mattress next to the bed and alarms in wheelchair and bed. On 5/6/21 at 2:13 PM, an interview was conducted with the DON andCRN 1. CRN 1 stated that education for resident 35 was to use a continual repetitive reminder to use the call light and education provided on 2/9/21 was for the staff not the resident. The DON stated that resident 35 used a [NAME] pillow in her wheelchair when she wanted to. The DON stated that somedays resident 35 refused to have the boppy pillow. The DON stated that the reacher was stored on the resident's bedside table. On 5/6/21 at 2:26 PM, an observation was made of resident 35 with CRN 2. CRN 2 was unable to find a boppy pillow, reacher, dysom or fall mat in resident 35's room. CRN 2 stated that it looked like resident 35 had a new wheelchair so she did not need the dysom. On 5/6/21 at approximately 3:00 PM, a follow up interview was conducted with CRN 2. CRN 2 stated that she found the boppy pillow and reacher in resident 35's other room. CRN 2 stated that she had moved rooms because her roommate was passing away. CRN 2 stated that the equipment should have been taken with resident 35 to the other room when she was moved on 5/2/21.

Based on observation, interview and record review it was determined that the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, recently-washed dishes were observed to be placed with clean dishes when the dishmachine did not reach the manufacture required temperatures for sanitation. In addition, there was no process to track when health shakes were removed from the freezer and placed in the refrigerator. Findings include: 1. On 5/6/21 at 1:14 PM, an observation was made of the facility dishmachine. Dietary Aide (DA) 1 was observed to be scraping dishes, loading the dishmachine and putting dishes away. The following temperatures was observed: [Note: All temperatures were in degrees Fahrenheit.] a. At 1:14 PM, the washing cycle was 100 and the rinse cycle was 110. DA 1 stated it usually takes a few times running it to get to temp (temperature). b. At 1:22 PM, the washing cycle was 110 and the rinse cycle was 120. There were 2 dish machine baskets removed from the dishmachine. In the baskets was a plastic bin, 3 dessert bowls, 8 dinner plates and 8 plate bases. DA 1 was observed to put away the dishes in the dishmachine baskets. c. At 1:24 PM, the washing cycle was 109 and the rinse cycle was 118. There were 8 plates, 8 bases, 8 domes, 3 bases and 3 plates put away with the clean dishes by DA 1. d. At 1:27 PM, the washing cycle was 105 and the rinse cycle was 118. There were plates, domes and bases put away with the clean dishes. DA 1 was observed to place plates, domes, and bases with the clean dishes. e. At 1:30 PM, DA 1 was observed to check the sanitizer. The DA stated that the sanitizer should be 120 parts per million (PPM). The sanitizer strip changed to a light purple color. DA 1 compared the sanitizer strip to the color coding for sanitizer amount. The DA stated that the sanitizer was 50 PPM. The test strips were observed to have an expiration date November 1, 2020. The DA was observed to check the sanitizer solution a second time and it was the same color. DA 1 stated it was 50 PPM. f. At 1:42 PM, the washing cycle was 100 and rinse cycle was 110. DA 1 was observed to put plates, bases, dessert bowls, cups and mugs away with the clean dishes. g. At 1:45 PM, the washing cycle was 100 and the rinse cycle was 115. h. At 1:47 PM, an observation was made with the Dietary Manager (DM) of the dishmachine. The washing cycle was 115 and the rinse cycle was 119. DA 1 and DM confirmed the temperatures using the outside thermometer on the dishmachine. The DM was observed to check the sanitizer solution. The DM stated that it was 50 PPM chlorine for sanitizer. A sign on the dishmachine revealed, Minimum wash temperature 120. Wash cycle time 35 seconds. Minimum rinse temperature 120. Rinse cycle time 20 sec. Minimum Chlorine 50 PPM. A form titled Low Temp (temperature) Dishwasher Log for April 2021 and May 2021 were reviewed. The form revealed that the washing temperature was 120 and the sanitizer was 150 PPM three times a day for April 2021. The May 2021 log revealed a washing temperature of 120 with the sanitizer at 150 PPM three times a day from 5/1/21 through 5/5/21. On 5/6/21 the temperature documented at 8:30 AM was 120 for the washing temperature and 150 for the sanitizer. There was no documented rinse temperature on the April and May form. At the bottom of the form the following was hand written, Wash cycle min 120-140, Rinse cycle min 120-140, Sanitizer 150-400 PPM. An interview was conducted immediately with DA 1. DA 1 stated that if the temperatures were below 120 she reported it to the Maintenance Director. DA 1 was observed to continue replacing dishes from the dishmachine into the clean dish area. An interview was conducted immediately with the DM. The DM stated that the dishmachine had received maintenance. The DM stated there had been talk with the managers about a new high temperature dishmachine. The DM stated that she notified the Maintenance Director when the temperatures were low. On 5/06/21 at 2:04 PM, an interview was conducted with the Registered Dietitian (RD). The RD stated that she was at the facility weekly. The RD stated that she went into the kitchen every time and touch base with the DM. The RD stated she completed a kitchen sanitization audit monthly. The RD stated that last month the dishmachine was not working the day of the audit and facility was using paper products because there were no chemicals. The RD stated that the month prior the dishmachine was not in use because there was a leak in the ceiling. The RD stated that she had talked to the DM about the dishmachine temperature log because it was always the same numbers. The RD stated that she encouraged the DM to train her staff to use the actual number from the dishmachine temperature sensor. The Dietary Checklist and Sanitation Survey completed by the RD on 4/29/21 revealed, .temp log remind staff of importance of accurate taking temps. 2. On 5/3/21 at 10:28 AM, an observation was made of the facility kitchen. There was a reach-in refrigerator with a tray of drinks. There were cartons of health shake supplements on 3 different trays. There were no dates or labels on the health shakes regarding the date the supplements were removed from the freezer. A label on the carton revealed Use thawed product within 14 days. An interview was immediately conducted with the DM. The DM stated that the beverage trays were prepared prior to each meal. The DM stated that the health shake supplements were removed from the freezer the night before to use the next day. The DM stated that if there were left over health shakes from the meal, the cartons were placed on the tray for the next meal. The DM stated she was not sure when the health supplements were removed from the freezer.