Based upon observation, interview, and record review, the facility failed to provide Activities of Daily Living [ADL] care and assistance to maintain good nutrition for 1 dependent resident [Res.#39] of 3 sampled residents dependent on ADL assistance. Findings include: Per review of Res.#39's Care Plan, the resident is identified as having as having Dysphagia [Dysphagia is a medical term for difficulty swallowing. Difficulty swallowing can lead to: Malnutrition, weight loss and dehydration. ]*, has risk for weight loss and malnutrition due to variable meal intake and dysphagia as well as cognitive impairment, at risk for dehydration, has impaired cognitive function/dementia or impaired thought processes, has an ADL [Activities of Daily Living] self-care performance deficit related to dementia, and has impaired visual function related to left eye blindness. Care Plan interventions to counteract Res.#39's nutritional risks include EATING: Continual supervision, May need more cues/assist, Provide feeding/dining assistance as needed. Set up for meals, Ensure the resident has access to Beverage of choice, and Ensure all meals and fluid intake occur under staff supervision. A meal observation was conducted on 9/9/24 at 11:45 AM. During the lunch meal observation, Res.#39 was observed seated in a wheelchair with h/her eyes closed at a table with 4 other residents. At 11:45 AM, a meal platter and a drink were placed in front of Res.#39, along with platters in front of the other 4 residents, including a resident seated next to Res.#39. Per observation, a staff Licensed Nursing Assistant [LNA] sat down next to the resident seated next to Res.#39, and the LNA began to feed that resident. Res.#39 was positioned in front of h/her meal and drink and made no attempt to feed h/herself or was cued or assisted by staff for approximately 10 minutes, while the other residents at the table ate their meal and the resident seated next to Res.#39 was being fed by the LNA. At 11:55 AM, another resident, Res.#34, approached the table in their wheelchair, took the drink from in front of Res.#39, drank from it, then wheeled away from the table carrying the drink with them. The LNA seated at the table said nothing to Res.#34 and did nothing to intervene. Res. #39 remained seated at the table in front of h/her meal for another 11 minutes without cueing or assistance, when a second LNA came over to the table and replaced the drink that the other resident had taken. Res.#39 was not offered the drink or cued to drink. At 12:10 PM, 25 minutes after the meal platter was placed in front of Res.#39, after the LNA had finished feeding the resident seated next to Res.#39 and the other residents at the table had finished their meals, the LNA moved their chair next to Res.#39 and offered h/her a bite of the meal. Res.#39 took a spoonful of the food and shook h/her head. The LNA did not question the resident as to why they disliked it, if they wanted an alternative, or if the meal needed reheating after sitting uncovered for 25 minutes. An interview was conducted with the facility's Director of Nursing [DON] on 9/10/24 at 9:30 AM. The DON confirmed that Res.#39 was identified as at risk for weight loss, malnutrition and dehydration, and diagnosed with impaired cognition and dementia along with difficulty swallowing. The DON confirmed Res.#39 is dependent on staff for cueing and assistance with meals, and agreed that based on the observation on 9/9/24 at 11:45 AM, Res.#39 was not offered either while the other residents at the table ate and/or were being fed, another resident took Res.#39's drink with no staff intervention, and after being offered their meal after 25 minutes and declining it, was not offered to re-heat the meal or an alternative.

Based on interview and record review the facility failed to provide services that included supervision, monitoring, and ADL (Activities of Daily Living) care necessary to prevent a fall from a wheelchair for 1 of 10 residents in the applicable sample (Resident #19). Findings include: Per record review Resident #19 was found on the floor of her/his room at 1:45 AM on 8/7/24. Review of Resident #19's care plan reveals that s/he is totally dependent on two staff with a mechanical lift for transfers to and from a wheelchair. The care plan also indicates that s/he has an ADL self-care performance deficit, with interventions that include, ensure resident is assisted to bed by 11 PM unless resident requests otherwise, intentional rounding every 1 hour for repositioning, and monitor positioning while in room. A Health Status Note written on 8/7/2024 states that the Resident was found on the floor next to her/his wheelchair in her/his room at 1:45 AM. The note further states that the call light was out of reach and the mechanical lift was in the room. Another Health Status Note written on 8/7/24 at 3:45 PM states that it appears that the Resident slid out of her/his wheelchair and was on the floor before being found by staff. Review of the facility incident summary written by the Administrator dated 8/7/2024 reveals that Resident #19 was assisted from the dining room to her/his room and was not assisted to bed or reevaluated until s/he was found on the floor by staff at approximately 1:45 AM. The summary also states that the Resident was to be turned and repositioned every 2 hours. Per interview with the facility Administrator on 9/11/24 at 11:36 AM the facility internal investigation of the incident determined that a staff member brought the Resident to her/his room sometime after the evening meal. The Licensed Nursing Assistant (LNA) who was assigned to Resident #19's care had signed documentation that s/he had performed safety checks however, s/he had not. The evening and night shift staff had not done walking rounds at change of shift as is expected. During the onsite survey, it was determined that the facility had implemented actions to correct the noncompliance prior to the start of the re-certification survey, which included evaluation of Resident #19, staff education regarding safety checks, repositioning, intentional walking rounds, and increased monitoring of assistance provided to the residents. The facility was able to demonstrate monitoring of the corrective action and sustained compliance.

Based upon observation and interview, the facility failed to meet food service safety requirements. Findings include: 1.) Per observation on 9/8/24 at 9:30 PM and again on 9/11/24 at 9:45 AM, a fan located above the clean dish drying area in the facility's kitchen was noted to have a notable covering of dark gray dust-like material on the fan blades and the outer surface of the fan guard/grill. On 9/11/24 at 9:45 AM, the fan was noted to be circulating air directly above a tray of clean flatware. The dirt on the fan guard was noted to include a strand of dark, stringlike material extended from the guard while the fan was operating. The observation on 9/11/24 was conducted with the facility's Dietary Manager, who confirmed the fan blowing on the clean flatware represented an unsanitary condition, and stated that Maintenance had been notified about the fan needing cleaning the day before, on 9/10/24, but the cleaning had not been done. 2.) Per observation on 9/9/24 at 12:31 PM, a bag of white bread slices was noted to have visible green mold on it in the facility's 2nd floor kitchenette. Per interview on 9/11/24 at 9:45 AM the Dietary Manager confirmed the bread in the 2nd floor kitchenette was moldy and stated that the facility did not have a process for monitoring and dating bread to ensure it was not used beyond its expiration date.

Based on observation, interview and record review the facility failed to ensure that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 3 residents in a standard survey sample. Per record review for Resident #76, admitted in late June, 2022, the resident had unstageable pressure ulcers to the right and left buttocks on the admission assessment. Interview with unit LPN on 7/12/22 at 10:25 AM, the LPN was unaware of resident #76 having any open skin areas. On 7/12/22 at 10:30 AM, the Unit Manager and Director of Nursing (DON) confirmed the resident did currently have open areas on both right and left buttocks and that these areas were being treated. They were unable to locate any provider orders to treat the pressure ulcers or documentation that the ulcers had been receiving any treatment. On 7/12/22 at 3:45 PM, the DON reported a verbal order for treatment had been previously received; however, it had not been documented in the electronic health record nor had it been put on either the Medication Administration Record (MAR) or the Treatment Administration Record (TAR). Therefore, there was no documentation to substantiate the receipt of an order for treatment or record of treatment having been completed.