**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility did not ensure residents received treatment and care in accordance with professional standards of practice. Specifically, for 1 of 27 sampled residents, the facility did not ensure the resident's physician was contacted timely regarding side effects of a medication change, and the facility did not ensure the physician's orders were transcribed and executed accurately. Resident identifier: 28. Findings included: Resident 28 was admitted to the facility on [DATE], with medical diagnoses which included, but not limited to, generalized epilepsy and epileptic syndromes, myoclonus, agoraphobia with panic disorder, major depressive disorder, herpesviral dermatitis, chronic pain syndrome, age-related osteoporosis, gastro-esophageal reflux disease, tremors, reduced mobility, chronic migraine, and low back pain. On 7/12/21 at 3:35 PM, resident 28 was interviewed and exhibited a delayed response in speech when asked questions. Certified Nursing Assistant (CNA) 2 reported resident 28 began having more seizures and tremors a couple months ago. CNA 2 reported, since that time, resident 28 had a decline in her ability to communicate and resident 28 never fully recovered. On 7/14/21, a review of resident 28's medical record was completed. On 3/26/21, resident 28 had a visit with the neurologist; at which time a change was made to the medication Zonisamide. A nursing progress note dated 3/26/21, written by Registered Nurse (RN) 1 read, Note Text: telehealth visit with [neurologist] due to COVID-19 (coronavirus disease 2019) restrictions. labs (sic) and drug therapeutic levels reviewed. New orders to decrease Zonisamide to 1 capsule for 2 weeks and then discontinue Zonisamide after 2 weeks and monitor increase in tremors. [Note: The neurologist's visit note dated 3/26/21 was unable to be located within resident 28's medical record.] Resident 28's medication regimen regarding an anti-seizure medication, zonisamide, was reviewed. The following was included; a. Prior to 3/26/21, resident 28's order for zonisamide medication read, Zonisamide Capsule 100 MG (milligrams) Give 2 capsule by mouth in the evening related to OTHER GENERALIZED EPILEPSY AND EPILEPTIC SYNDROMES. b. As of 3/26/21, the medication order read, Zonisamide Capsule 100 MG Give 1 capsule by mouth in the evening related to OTHER GENERALIZED EPILEPSY AND EPILEPTIC SYNDROMES; Start date: 03/26/2021. End Date: 04/09/2021. c. Other orders included, Complete Progress Note Every Shift about resident condition, and monitor for tremors due to decrease in Zonisamide. every shift related to OTHER GENERALIZED EPILEPSY. every shift for 3 Days -Start Date- 03/26/2021, and, Complete Progress Note Every Shift about resident condition, and monitor for tremors due to discontinuation of Zonisamide. every shift for 3 Days -Start Date- 04/09/2021. [Note: No progress notes about resident 28's condition and monitor for tremors were found within resident 28's medical record from the time period of 3/27/21 through 3/30/21 or from the time period of 4/9/21 to 4/13/21.] Within resident 28's progress notes the following occurrences were documented regarding resident 28's tremor and medication change side effects; a. 4/6/21: Note Text: Reported that resident had some difficulty in fully swallowing some food at breakfast. After a few sips of water resident was able to swallow food with out difficulty. Lungs clear bilaterally. No other concerns noted at this time. Will continue to monitor. b. 4/6/21: Body tremors have seemed to have increased. Did leave message with [neurologist's] office concerning recent medication change possibly contributing to tremors. Will continue to monitor and f/u (follow up) with [neurologist's] office. c. 4/16/21: Note Text: Left message with [neurologist's] office concerning resident's increase in tremors and correlation with recent medication change of Zonisomide (sic). Will continue to monitor and f/u with [neurologist's] office or house MD (Medical Director) if tremors increase. d. 4/17/21: Note Text: Resident has had an increase in tremors to the point that she is having a hard time eating and drinking. Unable to reach [in-house doctor], notified [other in-house doctor], he ordered the Zonisamide to be resumed at 100mg and tapered for now until [neurologist] can be notified on Monday. [Note: no progress notes regarding staff having attempted to reach resident 28's neurologist were documented from 4/6/21 to 4/16/21. Per resident's progress notes resident was noticed with increased tremors as of 4/6/21; when current medication dose of zonisamide was at 100 mg rather than 200 mg daily. The zonesamide medication was then discontinued on 4/9/21, per RN 1's telephone order.] Per resident 28's weight history, resident 28 experienced a 4.4% weight reduction between the time period of 3/30/21 through 4/27/21. On 3/30/21, resident 28 had a documented weight of 158.6 pounds. On 4/27/21, resident 28 had a documented weight of 151.7 pounds. A physician's note from resident 28's neurologist dated 4/29/21, documented the following; a. Telephone note, 04/12/2021. The patient did worse after her zonisamide was decreased from 200mg nightly to 100mg. Because of the tremor it was difficult to swallow. I changed the dose back to 200mg once daily. Refill sent [Note: No progress note was found within resident 28's medical record indicating neurologist's change in medication dose on 4/12/21, and no documentation of a telephone encounter was noted from 4/12/21.] b. We have tried to reduce polypharmacy with [resident 28], and lately I tried to reduce the zonisamide, and had given instructions to restart the medicine if [resident 28] had tremor [sic] or myoclonus or seizures. However that masses (sic) [message] did not get through .I talked with staff to make it clear that my notes do indicate what should be done in case there are problems with medication changes that I make. In addition I am happy to receive calls and make adjustments. The issue with the last set of phone calls was that I was asked to refill prescriptions following instructions that I did not know about. In the future, a phone call to the office or just looking back at my last clinic note would be the best course of action, and could potentially avoid a lot of confusion. On 7/14/21 at 4:06 PM, the Charge Nurse was interviewed. The Charge Nurse reported the neurologist visit note dated 3/26/21 was not within resident 28's chart, and the Charge Nurse would have to contact the physician's office to locate documentation. When the Charge Nurse was asked about the zonisamide medication, the Charge Nurse reported being unsure why staff would discontinue the anti-seizure medication on 4/9/21 if resident 28 had been experiencing increased tremors as of 4/6/21. On 7/15/21 at 11:02 PM, RN 1 was interviewed. RN 1 reported, I was in the visit with [resident 28] and the neurologist. The doctor said to monitor for tremors, and call if [resident 28] had any tremors. [The neurologist] did not say [resident 28] could be restarted on the medication. On 7/15/21, the neurologist's visit note dated 3/26/21 was now available for review. The physician's visit note included orders for resident 28's medication change, which read, decrease zonisamide to 1 capsule in the evening for 2 weeks, then stop. If there are seizures, or more myoclonus (twitching) then okay to . restart zonisamide. On 7/15/21 at 10:35 AM, the Director of Nursing (DON) was interviewed. The DON reported, [Physician visit notes] can come late because it takes a while for the doctor to transcribe the note. It should not take 4 months to get a note. The visit note should have been in [resident 28's] chart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined the facility did not maintain medical records on each resident that were complete and readily accessible. Specifically, for 1 of 27 sampled residents, the facility did not have a complete and accessible record of a resident's physician visits with the neurologist. Resident identifier: 28. Findings included: Resident 28 was admitted to the facility on [DATE], with medical diagnoses which included, but not limited to, generalized epilepsy and epileptic syndromes, myoclonus, agoraphobia with panic disorder, major depressive disorder, herpesviral dermatitis, chronic pain syndrome, age-related osteoporosis, gastro-esophageal reflux disease, tremors, reduced mobility, chronic migraine, and low back pain. On 7/14/21, resident 28's medical record was reviewed. Prior to 3/26/21, resident 28's order for Zonisamide medication read, Zonisamide Capsule 100 MG (milligrams) Give 2 capsule by mouth in the evening related to OTHER GENERALIZED EPILEPSY AND EPILEPTIC SYNDROMES. Following resident 28's neurologist visit on 3/26/21, this medication order was adjusted. On 3/26/21, resident 28 had a visit with the neurologist; at which time a change was made to the medication Zonisamide. A nursing progress note dated 3/26/21, written by Registered Nurse (RN) 1 read, Note Text: telehealth visit with [neurologist] due to COVID-19 (coronavirus disease 2019) restrictions. labs (sic) and drug therapeutic levels reviewed. New orders to decrease Zonisamide to 1 capsule for 2 weeks and then discontinue Zonisamide after 2 weeks and monitor increase in tremors. [Note: The neurologist visit note dated 3/26/21 was unable to be located within resident 28's medical record.] Resident 28's medication regimen regarding an anti-seizure medication, zonisamide, was reviewed. The orders placed on 3/26/21, by RN 1 for changes in Zonisamide medication included the following: a. Zonisamide Capsule 100 MG Give 1 capsule by mouth in the evening related to OTHER GENERALIZED EPILEPSY AND EPILEPTIC SYNDROMES, Start date: 03/26/2021, and, End Date: 04/09/2021. b. Complete Progress Note Every Shift about resident condition, and monitor for tremors due to decrease in Zonisamide. every shift related to OTHER GENERALIZED EPILEPSY . for 3 Days -Start Date- 03/26/2021. c. Complete Progress Note Every Shift about resident condition, and monitor for tremors due to discontinuation of Zonisamide. every shift for 3 Days -Start Date- 04/09/2021 A physician's note from resident 28's neurologist dated 4/29/21, was reviewed. Documentation read; a. Telephone note, 04/21/2021. The patient did worse after her zonisamide was decreased from 200 mg nightly to 100 mg. Because of the tremor it was difficult to swallow. I changed the dose back to 200 mg once daily. Refill sent [Note: No progress note was found within resident 28's medical record indicating neurologist change in medication dose on 4/21/21, and no documentation of a telephone encounter was noted from 4/21/21.] b. We have tried to reduce polypharmacy with [resident 28], and lately I tried to reduce the zonisamide, and had given instructions to restart the medicine if [resident 28] had tremor [sic] or myoclonus or seizures. However that masses (sic) [message] did not get through .I talked with staff to make it clear that my notes do indicate what should be done in case there are problems with medication changes that I make. In addition I am happy to receive calls and make adjustments. The issue with the last set of phone calls was that I was asked to refill prescriptions following instructions that I did not know about. In the future, a phone call to the office or just looking back at my last clinic note would be the best course of action, and could potentially avoid a lot of confusion. [Note: Within resident 28's medical record there was no documentation of the neurologist's conditional restart of anti-seizure medication if resident 28 had tremors or myoclonus or seizures]. On 7/14/21 at 4:06 PM, the Charge Nurse was interviewed regarding the location of resident 28's neurologist visit from 3/26/21. The Charge Nurse reported the visit note was not within resident 28's chart, and the Charge Nurse would have to contact the physician's office to locate documentation. On 7/15/21, the 3/26/21 neurologist visit note was now available. The neurologist visit note included orders for resident 28's medication change, which read, decrease zonisamide to 1 capsule in the evening for 2 weeks, then stop. If there are seizures, or more myoclonus (twitching) then okay to . restart zonisamide. On 7/15/21 at 10:35 AM, the Director of Nursing (DON) was interviewed. The DON stated, [Physician visit notes] can come late because it takes a while for the doctor to transcribe the note. It should not take 4 months to get a note. The visit note should have been in [resident 28's] chart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 5 of 27 sampled residents, the facility assessment did not accurately reflect the resident's status. Specifically, the facility did not ensure that all participants in the assessment process had the requisite knowledge to complete an accurate assessment for resident's documented with limited range of motion, a resident documented with nutritional concerns, and a resident documented with wandering behaviors. Resident identifiers: 3, 13, 15, 23, and 30. Findings include: 1. Resident 3 was admitted to the facility on [DATE] and readmitted in 10/26/2020 with diagnoses that included but not limited to type 2 diabetes mellitus with diabetic neuropathy, end stage renal disease, benign prostatic hyperplasia without lower urinary tract symptoms, anemia in chronic kidney disease, gastro-esophageal reflux disease, hypertension, vitamin deficiency, repeated falls, weakness, and dependence on renal dialysis. On 7/14/21, resident 3's medical record was reviewed. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed in Section G - Functional Status: Functional Limitation in Range of Motion (ROM): a. Upper extremity (shoulder, elbow, wrist, hand): 1. Impairment on one side b. Lower extremity (hip, knee, ankle, foot): 0. No impairment The Centers for Medicare & Medicaid Service's Resident Assessment Instrument (RAI) Version 3.0 Manual's definition of Functional Limitation in Range of Motion was, Limited ability to move a joint that interferes with daily functioning (particularly with activities of daily living) or places the resident at risk for injury. The Hospital Emergency Department (ED) Medical Doctor Note dated 3/12/21, revealed on the Physical Exam Extremities Upper extremities exhibit normal ROM. Review of the nurses' Patient Driven Payment Model (PDPM) Assessment during the look back period 3/14/21 to 3/20/21 for resident 3 revealed the following: a. On 3/14/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 1. Impairment on one side 2. Lower extremity (hip, knee, ankle, foot): 0. No impairment b. On 3/15/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 1. Impairment on one side 2. Lower extremity (hip, knee, ankle, foot): 0. No impairment c. On 3/16/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 1. Impairment on one side 2. Lower extremity (hip, knee, ankle, foot): 0. No impairment d. On 3/17/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 1. Impairment on one side 2. Lower extremity (hip, knee, ankle, foot): 0. No impairment e. On 3/18/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 1. Impairment on one side 2. Lower extremity (hip, knee, ankle, foot): 0. No impairment f. On 3/19/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 1. Impairment on one side 2. Lower extremity (hip, knee, ankle, foot): 0. No impairment g. On 3/20/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 1. Impairment on one side 2. Lower extremity (hip, knee, ankle, foot): 0. No impairment On 7/14/21 at approximately 4:06 PM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated she had coded resident 3 as having limited ROM due to resident 3 had gone to the Hospital's ED on 3/12/21, and was diagnosed with right upper arm cellulitis, which the MDS Coordinator thought restricted resident 3's right arm ROM. 2. Resident 13 was admitted to the facility on [DATE] with diagnoses which included but not limited to type 2 diabetes mellitus with diabetic neuropathy, dementia with behavioral disturbance, major depressive disorder, essential hypertension, muscle weakness, chronic pain syndrome, edema, other reduced mobility, difficulty in walking, and need for assistance with personal care. On 7/15/21, resident 13's medical record was reviewed. A Quarterly MDS assessment dated [DATE], revealed in Section G - Functional Status: Functional Limitation in ROM: a. Upper extremity (shoulder, elbow, wrist, hand): 2. Impairment on both sides b. Lower extremity (hip, knee, ankle, foot): 2. Impairment on both sides Review of the nurses' PDPM Assessment during the look back period 4/12/21 to 4/18/21 for resident 13 revealed the following: a. On 4/12/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 0. No impairment 2. Lower extremity (hip, knee, ankle, foot): 2. Impairment on both sides b. On 4/13/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 0. No impairment 2. Lower extremity (hip, knee, ankle, foot): 2. Impairment on both sides c. On 4/14/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 0. No impairment 2. Lower extremity (hip, knee, ankle, foot): 2. Impairment on both sides d. On 4/15/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 2. Impairment on both sides 2. Lower extremity (hip, knee, ankle, foot): 2. Impairment on both sides e. On 4/16/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 2. Impairment on both sides 2. Lower extremity (hip, knee, ankle, foot): 2. Impairment on both sides f. On 4/17/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 2. Impairment on both sides 2. Lower extremity (hip, knee, ankle, foot): 2. Impairment on both sides g. On 4/18/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 2. Impairment on both sides 2. Lower extremity (hip, knee, ankle, foot): 2. Impairment on both sides [Note: The nurses' PDPM Assessments were inconsistent. Upper extremities were assessed as 0. No impairment for three days and 2. Impairment on both sides for four days during the look back period.] 3. Resident 15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that include but not limited to protein-calorie malnutrition, weakness, and hypertension. On 7/15/21, resident 15's medical record was reviewed. An admission MDS assessment dated [DATE], revealed in Section K - Swallowing/Nutritional Status: Weight Loss. Loss of 5% or more in the last month or loss of 10% or more in the last 6 months: 2. Yes, not on prescribed weight-loss regimen. Resident 15's admission weight on 4/13/21, was documented as 78.2 pounds (lbs). Resident 15's admission MDS assessment weight on 4/25/21, was documented as 79.6 lbs. [Note: Resident 15 had a weight gain of 1.4 lbs.] On 7/15/21 at approximately 10:53 AM, an interview was conducted with the MDS Coordinator. Resident 15's weights were reviewed with the MDS Coordinator. The MDS Coordinator stated she would have to research why she had coded resident 15 as losing weight on the admission MDS assessment. On 7/15/21 at approximately 11:08 AM, the MDS Coordinator emailed a Physician's Clinic Note dated 4/8/21. The Physician's Clinic Note revealed in the History of Present Illness section of the note, Patient has been losing weight. In the Assessment/Plan section, the note revealed, Patient's kids have had a hard time finding things that the patient will eat. She is losing a lot of weight and getting weaker. In the Exam section, the note revealed a weight of 49.9 kilograms (kg) [109.8 lbs]. The MDS Coordinator stated resident 15's weight during the clinic visit on 4/8/21, was 109.8 lbs. The MDS Coordinator stated resident 15's admission MDS assessment weight on 4/25/21, was 79.6 lbs. The MDS Coordinator stated resident 15 had a weight loss of 30.2 lbs [-27.5%]. [Note: The 4/8/21 Physician's Clinic Note dated 4/8/21, included a History and Physical exam dated 9/2/20. Resident 15's weight 49.9 kg was from the H&P exam performed on 9/2/20. Resident 15's weight from the H&P exam was not within the 6 month look back period.] 4. Resident 23 was admitted to the facility on [DATE] with diagnoses which included but not limited to Parkinson's disease, weakness, dementia without behavioral disturbance, anxiety disorders, essential hypertension, spinal stenosis, pulmonary heart disease, low back pain, history of falling, unsteadiness on feet, dysphagia, insomnia, and type 2 diabetes mellitus with diabetic neuropathy. On 7/15/21, resident 23's medical record was reviewed. A Quarterly MDS assessment dated [DATE], revealed in Section E Wandering - Presence & Frequency: Has the resident wandered? 2. Behavior of this type occurred 4 to 6 days, but less than daily. Review of the nurses' PDPM Assessment during the look back period 5/20/21 to 5/26/21 for resident 23 revealed the following: a. On 5/20/21, PDPM Assessment: Section E - Wandering - Presence & Frequency 8. Has the resident wandered? 1. Yes 9. Has the wandering placed the resident at risk of getting to a potentially dangerous place? (e.g stairs, outside of the facility. etc.) 2. No 10. Does the wandering intrude of the privacy or activity others? 2. No b. On 5/21/21, PDPM Assessment: Section E - E0900. Wandering - Presence & Frequency 8. Has the resident wandered? 1. Yes 9. Has the wandering placed the resident at risk of getting to a potentially dangerous place? (e.g stairs, outside of the facility. etc.) 2. No 10. Does the wandering intrude of the privacy or activity others? 2. No c. On 5/22/21, PDPM Assessment: Section E - E0900. Wandering - Presence & Frequency 8. Has the resident wandered? 1. Yes 9. Has the wandering placed the resident at risk of getting to a potentially dangerous place? (e.g stairs, outside of the facility. etc.) 2. No 10. Does the wandering intrude of the privacy or activity others? 2. No d. On 5/23/21, PDPM Assessment: Section E - E0900. Wandering - Presence & Frequency 8. Has the resident wandered? 1. Yes 9. Has the wandering placed the resident at risk of getting to a potentially dangerous place? (e.g stairs, outside of the facility. etc.) 2. No 10. Does the wandering intrude of the privacy or activity others? 2. No e. On 5/24/21, PDPM Assessment: Section E - E0900. Wandering - Presence & Frequency 8. Has the resident wandered? 1. Yes 9. Has the wandering placed the resident at risk of getting to a potentially dangerous place? (e.g stairs, outside of the facility. etc.) 2. No 10. Does the wandering intrude of the privacy or activity others? 2. No f. On 5/25/21, PDPM Assessment: Section E - E0900. Wandering - Presence & Frequency 8. Has the resident wandered? 1. Yes 9. Has the wandering placed the resident at risk of getting to a potentially dangerous place? (e.g stairs, outside of the facility. etc.) 2. No 10. Does the wandering intrude of the privacy or activity others? 2. No g. On 5/26/21, PDPM Assessment: Section E - E0900. Wandering - Presence & Frequency 8. Has the resident wandered? 1. Yes 9. Has the wandering placed the resident at risk of getting to a potentially dangerous place? (e.g stairs, outside of the facility. etc.) 2. No 10. Does the wandering intrude of the privacy or activity others? 2. No 5. Resident 30 was admitted to the facility on [DATE] with diagnoses that include but not limited to type 2 diabetes mellitus with diabetic neuropathy, atrial fibrillation, chronic pain syndrome, peripheral vascular disease, osteoarthritis, restless leg syndrome, gastro-esophageal reflux disease, and hypothyroidism. On 7/15/21, resident 30's medical record was reviewed. An Annual MDS assessment dated [DATE], revealed in Section G - Functional Status: Functional Limitation in ROM: a. Upper extremity (shoulder, elbow, wrist, hand): 2. Impairment on both sides b. Lower extremity (hip, knee, ankle, foot): 2. Impairment on both sides Review of the nurses' PDPM Assessment during the look back period 2/21/21 to 2/28/21 for resident 30 revealed the following: a. On 2/21/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 0. No impairment 2. Lower extremity (hip, knee, ankle, foot): 2. Impairment on both sides b. On 2/22/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 0. No impairment 2. Lower extremity (hip, knee, ankle, foot): 2. Impairment on both sides c. On 2/23/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 2. Impairment on both sides 2. Lower extremity (hip, knee, ankle, foot): 2. Impairment on both sides d. On 2/24/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 0. No impairment 2. Lower extremity (hip, knee, ankle, foot): 2. Impairment on both sides e. On 2/25/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 2. Impairment on both sides 2. Lower extremity (hip, knee, ankle, foot): 2. Impairment on both sides f. On 2/26/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 2. Impairment on both sides 2. Lower extremity (hip, knee, ankle, foot): 2. Impairment on both sides g. On 2/27/21, PDPM Assessment: Section G 1. Upper extremity (shoulder, elbow, wrist hand): 2. Impairment on both sides 2. Lower extremity (hip, knee, ankle, foot): 2. Impairment on both sides [Note: The nurses' PDPM Assessments were inconsistent. Upper extremities were assessed as 0. No impairment for three days and 2. Impairment on both sides for four days during the look back period.] On 7/15/21 at approximately 12:18 PM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated she used the PDPM assessment that the facility nurses' complete during the MDS Assessment look back period to determine how to code a resident's MDS Assessment. The MDS Coordinator stated the look back period was seven days prior to the assessment. The MDS Coordinator stated she had not trained the nursing staff on the specific RAI definition for ROM and she needed to do more training to ensure accurate coding of the assessments. The MDS Coordinator further stated that she was confident the nursing staff knew how to assess ROM and wandering. The MDS Coordinator stated she also included her own observations of the residents when coding the MDS assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined the facility did not develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs. Specifically, for 4 of 27 sampled residents, following witnessed and unwitnessed falls the facility did not maintain and update the comprehensive care plan to include the services that were to be furnished. Resident identifiers: 1, 3, 13, and 23. Findings included: 1. Resident 1 was admitted to the facility on [DATE] with medical diagnoses that included, but not limited to, spinal stenosis, major depressive disorder, congestive heart failure, low back pain, essential hypertension, chronic obstructive pulmonary disease, benign prostatic hyperplasia, edema, gastro-esophageal reflux disease, peripheral vascular disease, generalized anxiety disorder, asthma, reduced mobility, anemia, hypercholesterolemia, agoraphobia with panic disorder, hypothyroidism, intervertebral disc degeneration, acquired absence of left leg below knee, insomnia, and pseudarthrosis after fusion of spine. On 7/12/21 at 1:25 PM, resident 1 was interviewed. Resident 1 stated, I fell last week. Tripped over my feet going around my wheelchair. I was alone in my room. On 7/14/21, a review of resident 1's medical record was completed. Resident 1 had a care plan that revealed, [Resident 1] is a high risk for falls with an actual fall related to generalized weakness, acquired absence of left leg below knee and difficulty walking. Date Initiated: 09/06/2017, Revision on: 04/01/2020. Interventions included; a. Anticipate and meet needs. Bed in lowest position. Date Initiated: 09/06/2017, Revision on: 01/15/2020 b. Be sure call light is within reach and encourage use as needed for assistance. Keep personal items within reach. Date Initiated: 09/06/2017, Revision on: 12/20/2019 c. Encourage participation in activities that minimize the potential for falls while providing diversion and distraction. Date Initiated: 12/20/2019 d. Encourage participation in activities that promote exercise, physical activity for strengthening and improved mobility such as: Physical Therapy (PT), Occupational Therapy (OT), Restorative Program, and/or Recreation Therapy with physical activity. Date Initiated: 12/20/2019 e. Ensure proper footwear is worn (such as non-skid socks, slippers with rubber bottom or shoes when ambulating or mobilizing, transferring, or ambulating. Date Initiated: 12/20/2019 f. Evaluate the need for and supply with mobility devices as needed for continued appropriateness for safety PRN (as needed). Date Initiated: 12/20/2019, Revision on: 01/15/2020 g. Follow facility fall protocol. Date Initiated: 09/06/2017 h. Offer and assist PRN with a safe environment with even surfacing free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; and rails on walls, personal items within reach. Date Initiated: 12/20/2019, Revision on: 01/15/2020 i. PT and/or OT evaluate and treat as ordered or PRN. Date Initiated: 12/20/2019, Revision on: 01/15/2020 The facility incident report dated 6/26/21, revealed CNA (Certified Nursing Assistant) . found resident in his room on the floor. Resident was transferring himself from his electric wheelchair to his push wheelchair. Resident fell backwards onto his bottom. Resident had proper foot wear (shoes) on, prosthesis was on his left leg, call light was not in reach due to him being on the floor up against the wall . Resident states that he was just trying to get from his electric w/c (wheelchair) to his manual w/c and tripped and then fell backward onto his bottom. Once he hit the ground his head bumped the wall. [Note: no interventions were initiated or revised following fall on 6/26/21.] On 7/14/21 at 2:21 PM, CNA 6 was interviewed. CNA 6 reported she was not at work the day resident 1 fell. CNA 6 reported being unaware of any new interventions put in place following resident 1's fall to help prevent future falls. CNA 6 reported new interventions were placed in the fall intervention book at the nurses' station, and that was typically where she gathered instructions on how to work with residents for fall prevention. On 7/14/21 at 2:23 PM, the fall intervention book was reviewed. Regarding resident 1, the fall prevention book read, Actual Fall intervention: 1. Re-educate [Resident 1] to call for assistance when transferring. 2. PT will continue with wheelchair safety training. On 7/14/21 at 2:28 PM, the Physical Therapy Assistant (PTA) was interviewed. The PTA reported resident 1 was on therapy caseload for occupational and restorative therapy, but not physical therapy at that time. On 7/14/21 at 2:32 PM, the Physical Therapy (PT) Director was interviewed. The PT Director reported, No, [resident 1] is not on physical therapy for wheelchair training. He completed that already. I did not receive a referral after he fell recently because he doesn't fall often. 2. Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included type 2 diabetes mellitus with diabetic neuropathy, end stage renal disease, anemia in chronic kidney disease, repeated falls, weakness, and dependence on renal dialysis. On 7/13/21 at approximately 8:29 AM, resident 3 was observed sitting in the recliner in his room. Resident 3 was dressed and well groomed. The call light button was within reach. Resident 3 stated that staff had responded well when he had pushed the call light button for help. Resident 3 stated he had used his walker when he needed to get up and walk. Resident 3 stated that he had fallen recently. On 7/13/21, resident 3's medical record was reviewed. Resident 3's current Care Plan was reviewed and revealed a Focus Area, [Resident 3] is a high risk for falls with diagnoses of weakness, a history of repeated falls and unsteadiness on feet and a recent fall. Date Initiated: 09/23/2019 Revision on: 04/29/2021 Fall Prevention interventions on the Care Plan included: a. Anticipate and meet needs. Bed in lowest position. Date Initiated: 9/23/19 Revision on: 1/15/20 b. Be sure call light is within reach and encourage use as needed for assistance. Keep personal items within reach. Date Initiated: 9/23/19 Revision on: 12/20/19 c. Encourage participation in activities that minimize the potential for falls while providing diversion and distraction. Date Initiated: 12/20/19 d. Encourage participation in activities that promote exercise, physical activity for strengthening and improved mobility such as: Physical Therapy, Occupational Therapy, Restorative Program, and/or Recreation Therapy with physical activity. Date Initiated: 12/20/19 e. Ensure proper footwear is worn (such as non-skid socks, slippers with rubber bottom or shoes when ambulating or mobilizing, transferring, or ambulating. Date Initiated: 12/20/19 f. Evaluate the need for and supply with mobility devices as needed for continued appropriateness for safety PRN. Date Initiated: 12/20/19 Revision on: 1/15/20 g. Follow facility fall protocol. Date Initiated: 09/23/2019 h. Offer and assist PRN with a safe environment with even surfacing free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach. Date Initiated: 12/20/19 Revision on: 01/15/20 i. PT and/or OT evaluate and treat as ordered or PRN. Date Initiated: 09/23/2019 Revision on: 1/15/20 Review of resident 3's 2021 Progress Notes revealed that resident 3 had a fall on 4/27/21 and another fall on 6/5/21. [Note: There were no new fall prevention interventions initiated or revised following resident 3's falls.] On 7/13/21 at approximately 10:28 AM an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that she would fill out an incident report and included fall prevention interventions to prevent future falls. LPN 1 stated she was aware that resident 3 had fallen in the past. LPN 1 stated she had reminded resident 1 to ask for help when getting up but that he was not complaint and continues to get up on his own. On 7/14/21 at approximately 9:58 AM, an interview was conducted with the Director of Nursing (DON). The DON stated the nurse completed an Incident Report after a resident fall and the report would include new fall prevention interventions. The DON stated that she or the Minimum Data Set (MDS) Coordinator reviewed the Fall Incident Reports to determine if the fall prevention interventions noted by nursing staff were appropriate or not and then update the resident's Care Plan. When asked why resident 3's Care Plan had no new interventions following his fall on 4/27/21, the DON stated that OT completed an Activities of Daily Living evaluation. When asked if OT made any fall prevention recommendations, the DON said there were no new interventions recommended after the OT evaluation. When asked why there were no new fall prevention interventions following resident 3's fall on 6/5/21, the DON stated they had a meeting with resident 3 and a family member to reinforce following safety measures. The DON stated there were no new fall prevention interventions that came from that meeting. The DON was asked how fall prevention interventions were communicated to staff. The DON stated there was a Fall Intervention Book at the Nurses' Station that included fall prevention interventions specific to each resident, which was updated every 90 days. The DON stated that new fall prevention interventions were also discussed daily as needed with clinical staff at the beginning of every shift in their group huddles. 3. Resident 23 was admitted to the facility on [DATE] with diagnoses which included but not limited to Parkinson's disease, weakness, dementia without behavioral disturbance, anxiety disorders, essential hypertension, spinal stenosis, pulmonary heart disease, low back pain, history of falling, unsteadiness on feet, dysphagia, insomnia, and type 2 diabetes mellitus with diabetic neuropathy. Resident 23's medical record was reviewed on 7/13/21. A Care Plan Problem initiated on 5/14/21 and revised on 7/13/21, documented (Resident 23) is high risk for falls with the diagnoses of Parkinson's Disease, low back pain, weakness and a recent fall. The Goals initiated on 5/17/21 with a review date 8/25/21, documented To be free of falls through the review date. To not sustain serious injury from a fall through the review date. Side effects of medications contributing to gait disturbance, balance disturbance, syncope, movement disorders and increasing fall risk will be reduced by the reviewed in Psychotropic meeting with a GDR (Gradual Dose Reduction) if appropriate. The Interventions initiated on 5/14/21, included the following: a. Anticipate and meet needs. b. Bed in lowest position. c. Be sure call light was within reach and encourage use as needed for assistance. d. Keep personal items within reach. e. Electronic Motion Sensor in use. Ensure the device was in place and working. Initiated on 5/14/21 and revision on 5/17/21. f. Encourage participation in activities that minimize the potential for falls while providing diversion and distraction. g. Encourage participation in activities that promote exercise, physical activity for strengthening and improved mobility such as: PT, OT, Restorative Program, and/or Recreation Therapy with physical activity. h. Ensure proper footwear was worn such as non-skid socks, slippers with rubber bottom or shoes when ambulating or mobilizing, transferring, or ambulating. i. Evaluate the need for and supply with mobility devices as needed for continued appropriateness for safety PRN. j. Follow facility fall protocol. k. Keep personal items within reach. l. Offer and assist PRN with a safe environment with even surfacing free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach. m. PT and/or OT evaluate and treat as ordered or PRN. Resident 23's fall interventions were located in the Fall Intervention book at the nurses' station. The form documented Actual Fall Intervention: 1- Q (every) 1 (hour) Resident Current Status checks. 2-Electronic Motion Sensor in use. Ensure the device is in place and working. Standard Fall Interventions: Anticipate and meet needs. Bed in the lowest position. Be sure call light is within reach and encourage use as needed for assistance. Keep personal items within reach. Encourage participation in activities that minimize the potential for falls while providing diversion and distraction. Encourage participation in activities that promote exercise, physical activity for strengthening and improved mobility such as: Physical Therapy, Occupational Therapy, Restorative Program, and/or Recreation Therapy with physical activity. Ensure proper footwear is worn (such (sic) as non-skid socks, slippers with rubber bottom or shoes when ambulating or mobilizing, transferring, or ambulating. Evaluate the need for and supply with mobility devices as needed for continued appropriateness for safety PRN. Follow facility fall protocol. Offer and assist PRN with a safe environment with even surfacing free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach. PT and/or OT evaluate and treat as ordered or PRN. On 5/29/21 at 8:20 AM, an Incident Description documented, Resident was found by [name removed] CNA sitting on the floor in front of her recliner next to her bed, she was in her night gown and brief, was continent. Was last checked on 20 minutes before at 0600 (6:00 AM). Call light was not on. Resident was self transferring from bed to recliner, became weak and sat on floor. Her statement 'I was trying to get to my recliner and sat down on the floor'. The Notes section of the report documented, 5/29/2021 Interventions 1. Every hour toileting. 5/31/2021 Resident placed on every hour toileting. No injuries noted. [Resident 23] is confused and frequently attempts to get up unassisted. [Note: The care plan was not updated with the fall intervention.] On 6/28/21 at 7:25 PM, an Incident Description documented, I was called to room [ROOM NUMBER] at 1925 (7:25 PM), resident was sitting upright in front of her recliner. Resident had non-skid socks on. her call light was attached to her recliner within reach and not on, motion sensor in place and working. Resident was last check (sic) on at 1910 (7:10 PM). When asked what happened, resident stated 'I was trying to get from my chair to my bed'. The Notes section of the report documented, 6/29/21 Intervention: Staff education initiated to encourage resident to be in the lobby doing activities/watching tv until she is ready for bed. [Note: The care plan was not updated with the fall intervention.] On 7/13/21 at 1:41 PM, an interview was conducted with CNA 1. CNA 1 stated she also worked as the Medical Records Manager at the facility. CNA 1 stated fall interventions were listed in the electronic medical record under the Individualized Support Plan (ISP) tab. CNA 1 stated interventions in place for resident 23 were a low bed, non skid socks, motion sensor, and one hour checks. CNA 1 stated she would chart on the tablet if a resident was a one hour check. CNA 1 showed this surveyor in the electronic medical record that resident 23 was a one hour check. CNA 1 further stated that resident 23 required 2 people for a transfer. 4. Resident 13 was admitted to the facility on [DATE] with diagnoses which included but not limited to type 2 diabetes mellitus with diabetic neuropathy, dementia with behavioral disturbance, major depressive disorder, essential hypertension, muscle weakness, chronic pain syndrome, edema, other reduced mobility, difficulty in walking, and need for assistance with personal care. Resident 13's medical record was reviewed on 7/14/21. A Care Plan Problem initiated on 10/26/17 and revised on 5/22/21, documented [Resident 13] is a High risk for falls with an actual fall) (sic) with the diagnosis of dementia with behavioral disturbance. The Goal initiated on 12/20/19 and revised on 2/25/21, documented To not sustain serious injury from a fall through the review date. The Interventions initiated on 10/26/17, included the following: a. Bed in lowest position. Revision date 1/15/20. Be sure call light is within reach and encourage use as needed for assistance. b. Keep personal items within reach. Revision date 12/20/19. c. Encourage participation in activities that promote exercise, physical activity for strengthening and improved mobility such as: PT, OT, Restorative Program, and/or Recreation Therapy with physical activity. Revision date 12/20/19. d. Ensure proper footwear was worn (such as non-skid socks, slippers with rubber bottom or shoes when ambulating or mobilizing, transferring, or ambulating. Revision date 12/20/19. e. Follow facility fall protocol. f. Offer and assist PRN with a safe environment with even surfacing free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach. Revision date 1/15/20. g. Actual Fall Interventions: 1- Every hour Resident Status checks 2-Encourage resident to get into bed at bed time. Date initiated 2/3/20 and revision on 6/22/21. Anticipate and meet needs. h. Encourage participation in activities that minimize the potential for falls while providing diversion and distraction. Date initiated 12/20/19. i. Evaluate the need for and supply with mobility devices as needed for continued appropriateness for safety PRN. Date initiated 12/20/19 and revision on 1/15/20. j. PT and/or OT evaluate and treat as ordered or PRN. Date initiated 12/20/19 and revision on 1/15/20. On 4/3/21 at 7:40 PM, an Incident Description documented, Resident found by [name removed] RN (Registered Nurse) sitting on the floor at the nurses station with her legs extended in front of her with her brief wet. No injuries noted. Resident does not c/o (complain of) pain. Resident last toileted at 1847 (6:47 PM). Wheelchair next to resident and there was a stool next to resident. Resident said she sat down. The Notes section of the report documented, 4/12/2021 1.Rolling stool locked in Charge nurse office. 2.Staff education that resident to be in site of staff when in common area. 4/16/2021 No injuries noted from incident. Staff encouraged to toilet resident if restless and monitor in common area. [Note: The care plan was not updated with the fall intervention.] On 6/20/21 at 2:31 PM, an Incident Description documented, Resident was in her room on the floor laying on her left side next to her recliner that was up in the highest position. Resident had non skid socks on and call light was hooked on recliner. Resident was last checked on 10 minutes earlier at 1420 (2:20 PM). Resident did not have any injuries after assessment. Started neuros. Resident Unable to give Description. The Notes section of the report documented, Recliner removed from room for safety. [Note: The care plan was not updated with the fall intervention.] On 7/13/21 at 2:02 PM, an interview was conducted with RN 2. RN 2 stated fall interventions were communicated to staff in the fall intervention book that was located at the nurses' station, huddles at shift change, and the meetings where interventions were discussed. RN 2 stated the MDS Coordinator, DON, and Assistant Director of Nursing (ADON) updated care plans with interventions. On 7/13/21 at 2:31 PM, an interview was conducted CNA 7. CNA 7 stated the fall intervention book at the nurses' station had the fall interventions for all residents. CNA 7 stated the residents were alphabetical in the fall book and had their own individualized plan. CNA 7 also stated the brains paper she carried in her pocket had resident interventions listed. On 7/13/21 at 2:33 PM, an interview was conducted with CNA 8. CNA 8 stated resident fall interventions were on the resident care plans. CNA 8 stated she able to access the resident care plans on her Tablet. CNA 8 showed this surveyor her Tablet and how she was able to access the resident care plans. On 7/14/21 at 11:11 AM, an interview was conducted with the Charge Nurse. The Charge Nurse stated the DON would update the care plans with interventions. The Charge Nurse stated the DON would print the care plan interventions and she would update the fall intervention books with the printed interventions. On 7/14/21 at 2:04 PM, an interview was conducted the Administrator. The Administrator stated Resident 13 had standard fall interventions in place. On 7/14/21 at 2:24 PM, an interview was conducted with CNA 6. CNA 6 stated resident 13 required assistance with all activities of daily living. CNA 6 stated resident 13 was very confused. CNA 6 stated she was unsure what fall interventions were in place for resident 13. CNA 6 showed this surveyor the Fall Interventions book at the nurses station and resident 13 did not have a sheet in the book indicating fall interventions implemented. On 7/15/21 at 8:56 AM, an interview was conducted with the DON and ADON. The DON stated that herself or the MDS coordinator would update the care plans with interventions. The DON stated at the time of the fall the nurse would come up with the interventions. The DON stated if an intervention was not monitored the intervention was not added to the care plan. On 7/15/21 at 10:39 AM, an interview was conducted with the DON and ADON. The DON stated staff were educated about resident fall interventions during clinical stand up with the nursing staff and at shift change group huddle with nursing staff and CNA's. The DON stated the CNA on the resident hall that had a fall would know right away the fall interventions. The DON stated the CNA's get initial training snap shots of the resident. The DON stated ongoing interventions were on the resident care plan and in the Fall Interventions book at the nurses station.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 3 was admitted to the facility on [DATE] and readmitted in 10/26/2020 with diagnoses that included but not limited to type 2 diabetes mellitus with diabetic neuropathy, end stage renal disease, anemia in chronic kidney disease, repeated falls, weakness, and dependence on renal dialysis. On 7/13/21 at approximately 8:29 AM, resident 3 was observed sitting in the recliner in his room. Resident 3 was dressed and well groomed. The call light button was within reach. Resident 3 stated that staff have responded well when he has pushed the call light button for help. Resident 3 stated he has used his walker when he needed to get up and walk. Resident 3 stated that he had fallen recently. On 7/13/21, resident 3's medical record was reviewed and revealed the following: Review of the resident's 2021 Progress Notes revealed that resident 3 had fallen twice. Resident 3 had one fall on 4/27/21 and another fall on 6/5/21. Resident 3' current Care Plan was reviewed and revealed a Focus Area, [Resident 3] is a high risk for falls with diagnoses of weakness, a history of repeated falls and unsteadiness on feet and a recent fall. Date Initiated: 09/23/2019 Revision on: 04/29/2021 Fall Prevention interventions on the Care Plan included: a. Anticipate and meet needs. Bed in lowest position. Date Initiated: 9/23/19 Revision on: 1/15/20 b. Be sure call light is within reach and encourage use as needed for assistance. Keep personal items within reach. Date Initiated: 9/23/19 Revision on: 12/20/19 c. Encourage participation in activities that minimize the potential for falls while providing diversion and distraction. Date Initiated: 12/20/19 d. Encourage participation in activities that promote exercise, physical activity for strengthening and improved mobility such as: PT, OT, Restorative Program, and/or Recreation Therapy with physical activity. Date Initiated: 12/20/19 e. Ensure proper footwear is worn (such as non-skid socks, slippers with rubber bottom or shoes when ambulating or mobilizing, transferring, or ambulating. Date Initiated: 12/20/19 f. Evaluate the need for and supply with mobility devices as needed for continued appropriateness for safety PRN. Date Initiated: 12/20/19 Revision on: 1/15/20 g. Follow facility fall protocol. Date Initiated: 09/23/19 h. Offer and assist PRN with a safe environment with even surfacing free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach. Date Initiated: 12/20/19 Revision on: 01/15/20 i. PT and/or OT evaluate and treat as ordered or PRN. Date Initiated: 09/23/19 Revision on: 1/15/20 Review of resident 3's 2021 Progress Notes revealed that resident 3 had a fall on 4/27/21 and another fall on 6/5/21. [Note: There were no new fall prevention interventions initiated or revised following resident 3's falls.] The Incident Reports completed following resident 3's fall on 4/27/21 and 6/5/21 were reviewed and revealed the following: a. On 4/27/21, Nursing Description: Resident found by RN 3 lying on his left side in front of his recliner. 2 skin tears noted to left elbow. Call light within reach but not in use. No footwear in use. Resident was last checked on by CNA 3 at 12:18 AM. Resident Description: I was trying to put my pajama pants back on to go sit back in my chair and got my feet stuck in the same pant leg. Resident denies hitting head states he just hit his elbow and side. Immediate Action Taken: Head to toe assessment completed by RN 3. Three person assist by Hoyer lift to chair by RN 3, CNA 3, and CNA 4. Skin tears to left elbow cleansed with normal saline adaptic and protective dressing applied. [NAME] checks started, DON, family and Physician notified. Injury: Left elbow skin tear. Resident 3 oriented to person, place, time and situation. DON Note: Resident resistant to assistance with cares. Resident 3 was educated on the risk of falls and asking for assistance. The fall interventions implemented on 4/27/21, revealed the following. Resident educated to ask for assistance with ADL's and to wear provided non skid footwear. OT to evaluate for ADL dependence. [Note: Fall intervention to wear non skid footwear was initiated on the care plan on 12/20/19. Fall intervention to have OT evaluate was initiated on the care plan on 9/23/19 and revised on 1/15/20. The care plan was not updated with additional fall interventions.] b. On 6/5/21, Nursing Description: Resident was found on floor next to the side of his bed on his bottom with back against bed by CNA 5. Non slip socks were on feet, pants on with no shirt, call light was not on when he fell resident turned call light on after he fell. Was last checked on by CNA at 12:13 PM was sitting in recliner watching television (TV). Checked by nurse at approximately 2:00 PM and was sitting in recliner watching TV. Resident Description: Resident said he was putting some clothes away getting ready to take a shower and his foot slipped out from under him and he fell down. Resident hit his back against the bed but did not hit his head. Immediate Action Taken: Vital Signs Blood Pressure 144/72, Heart Rate 77, Respirations 20, Temperature 97.3, Oxygen Saturation 95. Licensed Practical Nurse (LPN 2) did assessment. LPN 2 and CNA 5 used lift to get resident off of the floor and into his recliner. Injury: Bruising. Resident 3 oriented to person, place, time and situation. DON Note: Plan made to discuss resident falls and resistance to safety measures with family and resident for possible solution. Resident was encouraged to ask for assistance. The fall interventions implemented on 6/5/21, revealed the following. Encouraged resident to ask for assistance. [Note: Fall intervention was implemented after resident 3 fell on 4/27/21]. Staff to discuss with resident and family during Interdisciplinary meeting to reduce increased falls and resistance to safety precautions. On 7/13/21 at approximately 10:17 AM, an interview was conducted with CNA 1. CNA 1 was asked to describe the process when a resident had a fall. CNA 1 stated that when a resident fell, she would quickly check to see if the resident was okay and then immediately notified the nurse. CNA 1 stated the resident was not moved until the nurse came and assessed the resident for injury. CNA 1 stated after the nurse had assessed the resident and the resident was okay, she would assist the nurse with helping the resident up off the floor. CNA 1 further stated she would get the resident's vital signs and start neuro checks for the next 72 hours. CNA 1 stated she was aware that resident 3 had fallen in the past and she had reminded resident 3 to ask for help when getting up to go to the bathroom. On 7/13/21 at approximately 10:26 AM, resident 3 was observed sleeping in the recliner in his room. Resident 3's feet were elevated in the recliner. The call light button was within reach. Resident 3 had non-skid socks on both feet. On 7/13/21 at approximately 10:31 AM, an interview was conducted with LPN 1. LPN 1 was asked to describe the process when a resident had a fall. LPN 1 stated when a CNA notified her that a resident had fallen, she would immediately assess the resident, checking for fractures, and neurological signs and symptoms. LPN 1 stated that neuro checks were done for 72 hours. LPN 1 stated she would notify the DON, MD, and the resident's family. LPN 1 stated that she would fill out an incident report and would include fall prevention interventions to prevent future falls. LPN 1 stated that fall prevention strategies could include; checking on the resident hourly for toileting, asking the resident to call for help when getting up to walk, having the resident wear non-skid socks, and sometimes using a motion detector which would alert the CNA if the resident was trying to get out of bed. LPN 1 stated she was aware that resident 3 had fallen in the past. LPN 1 stated she had reminded resident 3 to ask for help when getting up but resident 3 was not complaint and continued to get up on his own. On 7/14/21 at approximately 8:31 AM, resident 3 was observed sleeping in his recliner in his room. Resident 3's feet were elevated but he had no non skid socks on his feet. Resident 3's call light button was within reach. On 7/14/21 at approximately 9:58 AM, an interview was conducted with the DON. The DON was asked to describe the process when a resident had a fall. The DON stated when a resident had a fall, the nurse would complete an assessment and if appropriate, the resident would be helped up off the floor using a Hoyer lift. The DON stated the nurse would contact the DON, MD and family. The DON further stated that the nurse would complete an Incident Report that included new fall prevention interventions. The DON stated herself or the MDS Coordinator review the Fall Incident Reports to determine if the fall prevention interventions noted by nursing were appropriate or not and then updated the resident's Care Plan. When asked why resident 3's Care Plan had no new interventions following his fall on 4/27/21, the DON stated she had OT complete an ADL evaluation. When asked if OT made any fall prevention recommendations, the DON stated there were no new interventions recommended after the OT evaluation. When asked why there were no fall prevention interventions following resident 3's fall on 6/5/21, the DON stated they had a meeting with resident 3 and a family member to reinforce following safety measures. The DON stated there were no new fall prevention interventions that came from that meeting. The DON was asked how fall prevention interventions were communicated to staff. The DON stated there was a Fall Intervention Book at the nurses' station that included fall prevention interventions specific to each resident, which was updated every 90 days. The DON stated that new fall prevention interventions were also discussed daily as needed with clinical staff at the beginning of every shift in group huddles. On 7/14/21 at approximately 10:17 AM, an interview was conducted with the SW. The SW stated that during resident 3's 6/15/21, Care Conference which included resident 3, resident 3's family member, and facility clinicians, resident 3 was encouraged to use his call light and allow staff to help him when up doing ADL's. On 7/14/21 at approximately 10:41 AM, the Fall Intervention Book at the Nurses' Station was reviewed with the ADON. There were no fall prevention interventions for resident 3 in the book. The ADON stated there would only be fall prevention interventions for resident 3 in the book if there had been new fall prevention interventions initiated or revised in the last 90 days. Based on observation, interview, and record review it was determined, for 3 of 27 sampled residents, the facility did not ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, residents that had multiple falls were not provided interventions or adequate supervision to prevent falls from occurring. Resident identifiers: 3, 13, and 23. Findings include: 1. Resident 23 was admitted to the facility on [DATE] with diagnoses which included but not limited to Parkinson's disease, weakness, dementia without behavioral disturbance, anxiety disorders, essential hypertension, spinal stenosis, pulmonary heart disease, low back pain, history of falling, unsteadiness on feet, dysphagia, insomnia, and type 2 diabetes mellitus with diabetic neuropathy. On 7/12/21 at 12:25 PM, a staff member was observed in resident 23's room and the staff member was heard asking resident 23 about falling out of her chair that morning. On 7/12/21 at 2:58 PM, resident 23 was observed in the day room. Resident 23 was observed to have a large hematoma on the left side of her forehead that appeared to be bruising. The hematoma was covered with a bandage. Resident 23's medical record was reviewed on 7/13/21. An admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 23 required extensive assistance of one person for bed mobility, transfers, walk in room and corridor, locomotion on and off the unit, dressing, and personal hygiene. Resident 23 required extensive assistance of two persons for toilet use. Resident 23 was not steady and only able to stabilize with staff assistance when moving from a seated to standing position, walking with assistive devices, moving off and on toilet, surface to surface transfer, and turning around to face the opposite direction while walking. An admission MDS assessment dated [DATE], documented that resident 23 had a Brief Interview for Mental Status (BIMS) score of a 2. A BIMS score of 0 to 7 indicates a severe cognitive impairment. A Care Plan Problem initiated on 5/14/21 and revised on 7/13/21, documented (Resident 23) is high risk for falls with the diagnoses of Parkinson's Disease, low back pain, weakness and a recent fall. The Goals initiated on 5/17/21 with a review date 8/25/21, documented To be free of falls through the review date. To not sustain serious injury from a fall through the review date. Side effects of medications contributing to gait disturbance, balance disturbance, syncope, movement disorders and increasing fall risk will be reduced by the reviewed in Psychotropic meeting with a GDR (Gradual Dose Reduction) if appropriate. The Interventions initiated on 5/14/21, included the following: a. Anticipate and meet needs. b. Bed in lowest position. c. Be sure call light was within reach and encourage use as needed for assistance. d. Keep personal items within reach. e. Electronic Motion Sensor in use. Ensure the device was in place and working. Initiated on 5/14/21 and revision on 5/17/21. f. Encourage participation in activities that minimize the potential for falls while providing diversion and distraction. g. Encourage participation in activities that promote exercise, physical activity for strengthening and improved mobility such as: Physical Therapy (PT), Occupational Therapy (OT), Restorative Program, and/or Recreation Therapy with physical activity. h. Ensure proper footwear was worn such as non-skid socks, slippers with rubber bottom or shoes when ambulating or mobilizing, transferring, or ambulating. i. Evaluate the need for and supply with mobility devices as needed for continued appropriateness for safety as needed (PRN). j. Follow facility fall protocol. k. Keep personal items within reach. l. Offer and assist PRN with a safe environment with even surfacing free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach. m. PT and/or OT evaluate and treat as ordered or PRN. Resident 23's fall interventions were located in the Fall Intervention book at the nurses' station. The form documented Actual Fall Intervention: 1- Q (every) 1 (hour) Resident Current Status checks. 2-Electronic Motion Sensor in use. Ensure the device is in place and working. Standard Fall Interventions: Anticipate and meet needs. Bed in the lowest position. Be sure call light is within reach and encourage use as needed for assistance. Keep personal items within reach. Encourage participation in activities that minimize the potential for falls while providing diversion and distraction. Encourage participation in activities that promote exercise, physical activity for strengthening and improved mobility such as: Physical Therapy, Occupational Therapy, Restorative Program, and/or Recreation Therapy with physical activity. Ensure proper footwear is worn (such (sic) as non-skid socks, slippers with rubber bottom or shoes when ambulating or mobilizing, transferring, or ambulating. Evaluate the need for and supply with mobility devices as needed for continued appropriateness for safety PRN. Follow facility fall protocol. Offer and assist PRN with a safe environment with even surfacing free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach. PT and/or OT evaluate and treat as ordered or PRN. On 5/14/21, resident 23 was categorized high risk for falling with a score of 105 on the Morse Fall Scale form. A Morse Fall Scoring 45 and higher was categorized high risk. On 5/17/21 at 10:00 PM, an Incident Description documented, Nurse observed resident on the floor in front of her room with her legs extended in front of her. Foot wear in place resident in street clothes [NAME] in front of patient. Nurses aide at resident's side. Nurses aide stated that resident was leaning to the left side and was losing her balance so she assisted resident to the floor CNA (Certified Nursing Assistant) reacted urgently to prevent injury which did not provide time for gait belt use. Resident was up trying to ambulate on her own. Nurses aide had motion sensor and was behind resident at the time of incident. No injuries noted. Resident denies pain or discomfort. The Notes section of the report documented, 5/18/2021 PT to evaluate for restorative program. 5/27/2021 Evaluated by physical therapy and will receive physical therapy for strengthening. [Note: Intervention was implemented on the care plan on 5/14/21, prior to resident 23's fall. No new fall interventions were implemented.] On 5/29/21 at 8:20 AM, an Incident Description documented, Resident was found by [name removed] CNA sitting on the floor in front of her recliner next to her bed, she was in her night gown and brief, was continent. Was last checked on 20 minutes before at 0600 (6:00 AM). Call light was not on. Resident was self transferring from bed to recliner, became weak and sat on floor. Her statement 'I was trying to get to my recliner and sat down on the floor'. The Notes section of the report documented, 5/29/2021 Interventions 1. Every hour toileting. 5/31/2021 Resident placed on every hour toileting. No injuries noted. [Resident 23] is confused and frequently attempts to get up unassisted. [Note: The care plan was not updated with the fall intervention.] On 6/17/21 at 7:40 AM, an Incident Description documented, Called to the resident room by [name removed] CNA. I arrived to find the resident sitting on the floor between her recliner and walker with legs stretched out in front of her. Resident stated she was trying to go to breakfast. Resident was wearing street clothes with non slip socks. Resident was dry with no incontinence noted. Last checked on at 0655 (6:55 AM). Resident stated 'I was going to breakfast'. The Notes section of the report documented, 6/17/2021 intervention 1 - social work to contact family in order to obtain resident hobbies/likes. Recreational therapy to encourage participation in activities and or hobbies of choice to decrease restless impulsive behaviors. [Note: Intervention was implemented on the care plan on 5/14/21, prior to resident 23's fall. No new fall interventions were implemented.] On 6/28/21 at 7:25 PM, an Incident Description documented, I was called to room [ROOM NUMBER] at 1925 (7:25 PM), resident was sitting upright in front of her recliner. Resident had non-skid socks on. her call light was attached to her recliner within reach and not on, motion sensor in place and working. Resident was last check (sic) on at 1910 (7:10 PM). When asked what happened, resident stated 'I was trying to get from my chair to my bed'. The Notes section of the report documented, 6/29/21 Intervention: Staff education initiated to encourage resident to be in the lobby doing activities/watching tv until she is ready for bed. [Note: The care plan and Fall Intervention book was not updated with the fall intervention. Intervention Encourage participation in activities that minimize the potential for falls while providing diversion and distraction. was implemented on the care plan on 5/14/21.] On 7/12/21 at 11:10 AM, an Incident Description documented, . I looked down the hall to see [resident 23] on the floor with [name removed] RN (Registered Nurse) and [name removed] next to her. Resident was outside her doorway in prone position slightly tilted to her left facing the wall with wheelchair at her feet. Resident wearing day clothes and nonskid socks. Resident with no incontinence noted. Resident last checked at 1102 (11:02 AM) watching television. AAOx3 (awake, alert, and oriented to person, place, or time) unable to state name but was able to state her birthday. Resident states, 'I have a bump on my head. I don't know what happened'. Mental Status section of the form documented, . Resident at baseline LOC (Level of consciousness). 2.8cm (centimeters) x 2.2.cm abrasion to left knee without bleeding. 0.5 bruise and abrasion to right thumb knuckle without bleeding. 0.8cm in length skin tear to left side of forehead. 4.2cm hematoma to left side of forehead moderate bleeding. Cleaned with gauze, spot dressing applied. resident reported head pain, ICE was attempted per resident tolerance. PRN Tramadol 50mg administered. The Notes section of the report documented, 7/12/2021 Intervention #1: Switched out wheelchair for a smaller and taller wheelchair with PT recommendation. On 7/13/21 at 1:38 PM, Resident 23 was observed in bed sleeping. Resident 23 had a bandage on the hematoma located on the left side of her forehead. Resident 23's left eye was bruised. On 7/13/21 at 1:41 PM, an interview was conducted with CNA 1. CNA 1 stated she also worked as the Medical Records Manager at the facility. CNA 1 stated fall interventions were listed in the electronic medical record under the Individualized Support Plan tab. CNA 1 stated fall interventions in place for resident 23 were a low bed, non skid socks, motion sensor, and one hour checks. CNA 1 stated she would chart on the tablet if a resident was a one hour check. CNA 1 showed this surveyor in the electronic medical record that resident 23 was a one hour check. CNA 1 further stated that resident 23 required 2 people for a transfer. On 7/13/21 at 1:56 PM, an interview was conducted with the PT Director. The PT Director stated resident 23 was in a wider wheelchair and resident 23 fidgets. The PT Director stated resident 23 was evaluated for a smaller wheelchair yesterday and one was provided for her. The PT Director stated he had been working with resident 23 on balance to help prevent falls. On 7/13/21 at 2:02 PM, an interview was conducted with RN 2. RN 2 stated fall interventions were communicated to staff in the Fall Intervention book that was located at the nurses' station, huddles at shift change, and in the meetings where interventions were discussed. RN 2 stated the MDS Coordinator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) updated care plans with interventions. RN 2 stated after a resident had a fall the nurse would check the resident and assess for injury, after the resident was assessed the resident would be moved with the Hoyer lift, the resident would be treated for pain if necessary, and if needed the resident would be further assessed at the hospital. RN 2 stated she would inform the Medical Director (MD), DON, and the resident's family of the fall. RN 2 stated at first she was concerned that resident 23 was not further assessed by the MD after the fall yesterday. RN 2 stated resident 23 was confused to begin with and at her baseline prior to the fall. RN 2 stated after resident 23 fell yesterday the staff provided one to one monitoring and resident 23 was monitored and further assessed throughout the day. RN 2 stated resident 23 had a face time visit with family that was familiar with resident 23's baseline. On 7/13/21 at 2:19 PM, an interview was conducted with the Social Worker (SW) and the Recreational Therapy staff member. The SW stated she spoke to resident 23's daughter in law but had not made a progress note of the conversation. The SW stated resident 23 enjoyed reading but Recreational Therapy was already reading to resident 23. The Recreational Therapy staff member stated resident 23 liked to visit, fold items, and ball yarn. The Recreational Therapy staff member stated resident 23 needed to be kept busy. On 7/13/21 at 2:31 PM, an interview was conducted CNA 7. CNA 7 stated the Fall Intervention book at the nurses' station had the fall interventions for all residents. CNA 7 stated the residents were alphabetical in the Fall Intervention book and residents had their own individualized plan. CNA 7 also stated the brains paper she carried in her pocket had resident interventions listed. On 7/13/21 at 2:33 PM, an interview was conducted with CNA 8. CNA 8 stated resident fall interventions were on the resident care plans. CNA 8 stated she was able to access the resident care plans on her Tablet. CNA 8 showed this surveyor her Tablet and how she was able to access the resident care plans. On 7/13/21 at 2:39 PM, Resident 23 was observed in bed sleeping. Resident 23 had a bandage on the hematoma located on the left side of her forehead. Resident 23's left eye and cheek were bruised. On 7/13/21 at 3:03 PM, an interview was conducted with the Physical Therapy Assistant (PTA). The PTA stated that she had assessed resident 23 for a different wheelchair after the fall yesterday. The PTA stated the new wheelchair was a little narrower for resident 23 and was a better fit. The PTA stated she tried to work with resident 23 on balance yesterday but resident 23 was busy all day and today resident 23 had been in bed all day. On 7/14/21 at 11:11 AM, an interview was conducted with the Charge Nurse. The Charge Nurse stated the DON would update the care plans with interventions. The Charge Nurse stated the DON would print the care plan interventions and she would update the Fall Intervention books with the printed interventions. The Charge Nurse stated there was a Fall Intervention book at each nurses' station. On 7/15/21 at 8:56 AM, an interview was conducted with the DON and ADON. The DON stated that herself or the MDS Coordinator would update the care plans with interventions. The DON stated at the time of the fall the nurse would come up with the interventions. The DON stated they had tried to call resident 23's family regarding additional interventions and there were no additional helpful things offered. The ADON stated she had asked Recreational Therapy to increase their time with resident 23. The DON stated if an intervention was not monitored the intervention was not added to the care plan. 2. Resident 13 was admitted to the facility on [DATE] with diagnoses which included but not limited to type 2 diabetes mellitus with diabetic neuropathy, dementia with behavioral disturbance, major depressive disorder, essential hypertension, muscle weakness, chronic pain syndrome, edema, other reduced mobility, difficulty in walking, and need for assistance with personal care. Resident 13's medical record was reviewed on 7/14/21. A Quarterly MDS assessment dated [DATE], documented that resident 13 required extensive assistance of one person for bed mobility, transfers, walk in room and corridor, dressing, toilet use, and personal hygiene. Resident 13 was not steady and only able to stabilize with staff assistance when moving from a seated to standing position, walking with assistive devices, moving off and on toilet, surface to surface transfer, and turning around to face the opposite direction while walking. A Quarterly MDS assessment dated [DATE], documented that resident 13 did not have a BIMS conducted due to resident 13 rarely or never understood. A Care Plan Problem initiated on 10/26/17 and revised on 5/22/21, documented [Resident 13] is a High risk for falls with an actual fall) (sic) with the diagnosis of dementia with behavioral disturbance. The Goal initiated on 12/20/19 and revised on 2/25/21, documented To not sustain serious injury from a fall through the review date. The Interventions initiated on 10/26/17, included the following: a. Bed in lowest position. Revision date 1/15/20. Be sure call light is within reach and encourage use as needed for assistance. b. Keep personal items within reach. Revision date 12/20/19. c. Encourage participation in activities that promote exercise, physical activity for strengthening and improved mobility such as: PT, OT, Restorative Program, and/or Recreation Therapy with physical activity. Revision date 12/20/19. d. Ensure proper footwear was worn such as non-skid socks, slippers with rubber bottom or shoes when ambulating or mobilizing, transferring, or ambulating. Revision date 12/20/19. e. Follow facility fall protocol. f. Offer and assist PRN with a safe environment with even surfacing free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night; handrails on walls, personal items within reach. Revision date 1/15/20. g. Actual Fall Interventions: 1- Every hour Resident Status checks 2-Encourage resident to get into bed at bed time (HS). Date initiated 2/3/20 and revision on 6/22/21. Anticipate and meet needs. h. Encourage participation in activities that minimize the potential for falls while providing diversion and distraction. Date initiated 12/20/19. i. Evaluate the need for and supply with mobility devices as needed for continued appropriateness for safety PRN. Date initiated 12/20/19 and revision on 1/15/20. j. PT and/or OT evaluate and treat as ordered or PRN. Date initiated 12/20/19 and revision on 1/15/20. On 12/11/20 at 12:22 AM, an Incident Description documented, I was called to come to room [ROOM NUMBER] at 0022 (12:22 AM), when I entered the room [resident 13] was sitting straight up on the floor in the front of her recliner. There was a maroon blanket under her and she did have on non-skid socks and she was in her nightgown. Call light was clipped to the chair and was not used for assistance. Last checked on and offered toileting at midnight. Resident stated she wanted us to help her up. Resident unable to verbalize[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined the facility did not store, distribute and serve food in accordance with professional standards for food service safety. Specifically, meal tray items were uncovered when delivered by staff and uncovered meal tray items were placed at nurses' stations for extended periods; snacks with packaging that read Keep Refrigerated were stored at room temperature; food within the kitchen fridge and freezer were observed unlabeled and left open to air; food was stored at ground level in the walk-in refrigerator; and kitchen staff were unable to demonstrate an ability to check the concentration of sanitizer within sanitation buckets and the dish washing machine. Findings included: 1. Meal trays, which included, uncovered desserts and cups of canned fruit were transported through halls or placed at nurses' stations. On 7/12/21 at 11:31 AM, Kitchen Aide 1 carried a lunch tray, which included uncovered cake, from the tray line in the main dining room to the nurses' station. The tray was placed at the nurses' station. The lunch tray sat at the nurses' station until 11:34 AM, at which time a Certified Nursing Assistant (CNA) delivered the tray by walking to the far end of the 300 hall. On 7/12/21 at 11:31 AM, staff carried two lunch trays, which included uncovered cake and peaches, from the tray line in the main dining room to the nurses' station. The trays were placed at the nurses' station. The lunch tray with the uncovered peaches sat at the nurses' station until 11:39 AM, at which time a CNA delivered the tray to resident room [ROOM NUMBER]. The lunch tray with the uncovered cake sat at the nurses' station until 11:42 AM, at which time a CNA delivered the tray to resident room [ROOM NUMBER]. On 7/12/21 at 12:13 PM, the hall lunch tray cart was delivered to the 300 hall. A CNA was observed to deliver lunch trays to resident rooms [ROOM NUMBERS]. The cake was observed to be uncovered and the lunch trays were walked through the 300 hall. On 7/12/21 at 12:22 PM, the hall lunch tray cart was moved to the 600 hall. A CNA was observed to deliver lunch trays to resident rooms [ROOM NUMBER]. The cake and peaches were observed to be uncovered and the lunch trays were walked through the halls from the 600 hall. On 7/13/21 at 8:22 AM, a breakfast meal tray was placed at the nurses' station with an uncovered cup of canned fruit. The meal tray had been transported by a Kitchen Aide from the main dining room to the nurses' station. At 8:25 AM, the breakfast tray, with an uncovered cup of fruit, was transported by a CNA to the far end of the 300 hall. On 7/14/21 at 7:29 AM, a breakfast meal tray, with an uncovered cup of canned fruit, was observed at the nurses' station. At 7:31 AM, a CNA transported the breakfast meal tray to the far end of the 600 hall; the cup of fruit remained uncovered. On 7/14/21 at 7:38 AM, a breakfast meal tray with an uncovered cup of canned fruit was observed sitting at the nurses' station. At 7:41 AM, a CNA transported the breakfast meal tray to the far end of the 300 hall; the cup of fruit remained uncovered. On 7/14/21 at 8:07 AM, the Charge Nurse collected a breakfast tray from the tray cart. The breakfast tray included an uncovered cup of fruit. The charge nurse then walked with the tray from the beginning of the 500 hall to the far end of the hall. On 7/14/21 at 9:12 AM, the Dietary Manager (DM) was interviewed. The DM reported her kitchen staff should know to cover all tray items when the trays were placed at the nurses' station. The DM stated she had thought tray items which were delivered within a covered tray cart could be uncovered. The DM was not aware, that during delivery, the tray cart would be parked at one end of the resident hall, and then nursing staff would be walking through the unit to deliver trays. The DM had thought staff were pushing the meal tray cart from doorway to doorway when delivering trays. 2. Snacks with packaging that indicated Keep Refrigerated were observed stored at room temperature. On 7/12/21 at 1:47 PM, the snack cart was observed to be parked near the nurses' station. On the second shelf of the cart was an assortment of cookies, chips, and string cheese. The string cheese packaging read, Keep Refrigerated. On 7/14/21 at 9:12 AM, the DM was interviewed. The DM reported her staff should have placed the Keep Refrigerated snacks on ice when delivering them to the nursing units. 3. On 7/12/21, an initial tour of the kitchen was completed, and a follow-up tour was concluded on 7/14/21. During the initial and follow-up kitchen tours, food items were found not stored in accordance with professional standards for food service safety. On 7/12/21 at 11:09 AM, a package of frozen pancakes and a package of a frozen fried item were found within the walk-in freezer. The packages were observed to not be labeled with a date or description. An open package of frozen, cubed chicken and frozen edamame were not labeled with a date. On 7/12/21 at 11:13 AM, the walk-in fridge was observed. In the walk-in refrigerator, small service bowls filled with canned peaches were stored uncovered and unlabeled. Also, cartons of milk were stored in crates on the floor of the walk-in fridge. A container of unlabeled, condiment squeeze bottles were identified in the walk-in fridge. The condiment bottles were not labeled with a description or date. On 7/14/21 at 8:21 AM, the refrigerator located near tray line in the main dining room was observed. Within the fridge was a magic cup frozen dessert. The packaging of the magic cup frozen dessert read, Consume within 5 days of thawing, under refrigeration. The magic cup within the fridge was not labeled with the date it had been thawed. Kitchen Aide 1 was interviewed and asked why the magic cup frozen dessert was not labeled. Kitchen Aide 1 stated, That should not be in there. On 7/14/21 at 8:34 AM, the walk-in fridge contained a pan of diced potatoes submerged in water unlabeled with a date or description. The milk cartons continued to be stored on the floor of the walk-in fridge. On 7/14/21 at 10:38 AM, the refrigerator at the nurses' station was observed. Within the nurses' station refrigerator, 2 yogurts were identified with use by date of July 9, 2021. On 7/14/21 at 9:12 AM, the DM was interviewed. The DM stated staff should have known to place the milk cartons on the shelving unit and should have labeled items that enter the fridge or freezer with a date and description. The DM stated the kitchen staff clean the resident refrigerator located at the nurses' station, and the kitchen staff discard any expired items. 4. When kitchen aide staff were asked to demonstrate how they check the sanitizer concentration of the dish washing machine and sanitizer buckets, the staff were unable to locate working test strips. On 7/14/21 at 8:48 AM, Kitchen Aide 1 ran the dishwasher to demonstrate functionality. Kitchen Aide 1 attempted to check the amount of sanitizer through utilizing a sanitizer test strip. The test strip did not change in coloration. Kitchen Aide 1 reported being in charge of washing dishes today, and Kitchen Aide 1 reported being unaware of what to do if the sanitizer strips were not working. Kitchen Aide 1 reported having just started recently, and Kitchen Aide 1 reported needing more training on how to use the dishwasher. On 7/14/21 at 9:11 AM, the DM was interviewed. The DM reported being unaware of any trouble with the dishwasher. The DM attempted to test the sanitizer concentration of the dish washing machine and reported, These are not the right test strips. We do not have the right ones. The DM stated she typically relied on staff to inform her when more sanitizer test strips were needed, and the DM reported, I will have to re-educate the staff.