Every finding on record at Camelot Brookside

Based on observations, interviews, and record reviews, the facility failed to have a system in place to ensure coffee was served at a safe temperature to prevent scalds/burns for 1 (#79) resident. 112 residents consumed meals and beverages prepared by the facility's kitchen.Findings:Review of the American Burn Association Scald Injury Prevention Educator's Guide revealed in part: The severity of a scald injury depends on the temperature to which the skin is exposed and how long it is exposed. Older adults, identified as a high risk group, have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications .Scald injuries result in considerable pain, prolonged treatment, possible lifelong scarring, and even death. Third degree burns can occur within 1 second with hot water temperatures at 155 degrees Fahrenheit (F), within 2 seconds at 148 degrees F, within 5 seconds at 140 degrees F, within 15 seconds at 133 degrees F, and within 1 minute at 127 degrees F.On 04/19/2026, a review of the facility's policy titled, Safety of Hot Liquids with a revised date of October 2014 read in part: Policy Statement: Residents risk factors for safety concerns and potential for injury from hot liquids once identified, appropriate precautions will be implemented to maximize choice of beverages while minimizing the potential for injury. Policy interpretation and implementation: 1. The potential for burns from hot liquids is considered an ongoing concern among residents with weakened motor skills, balance issues, impaired cognition, and nerve or musculoskeletal conditions. 3. Once risk factors for injury from hot liquids are identified, appropriate interventions will be implemented to minimize the risk from burns. Such interventions may include: a. Maintaining a hot liquids serving temperature of not more than 180 degrees F. 4. Food service staff will monitor and maintain foods temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding. A review of the facility's incident report #810, dated 02/24/2026, revealed in part: During med pass, the certified nurse aid notified the nurse that Resident #79 spilled coffee while in bed and arm is red. Upon entering the room, noted empty coffee cup with lid applied .Coffee noted on the resident's bed pad. Assessed resident, redness noted to resident's left arm and buttocks area. The resident states she was trying to get her coffee from the table when she bumped the table and it fell. Non spill cup to be given to the resident for coffee. The dietary manager made aware. Coffee temp analysis performed and within policy .On 04/19/2026 at 10:17 a.m., an interview was conducted with Resident #79. She stated that she had burns on her left forearm and left hip after she spilled hot coffee on herself when she was placing the Styrofoam cup with a lid on her over the bed table. On 04/20/2026 at 1:30 p.m., during an interview, S1ADM stated that on 02/24/2026 at 2:00 p.m., after learning about the Resident #79's burn, a test pot of coffee was brewed into a thermal insulated carafe, with the spigot, and the lid. Coffee temperatures were obtained from 2:30 p.m. to 4:30 p.m. The coffee temperature at 2:30 p.m. was 160 degrees and continued to lower to 118 degrees by 4:30 p.m. In response to the incident, a non-spill cup was given to resident #79 for her coffee. He reported that no further coffee temperatures were taken after the day of the incident.On 04/19/2026 at 2:00 p.m., an interview and observation was conducted with S2DM. S2DM was asked if the kitchen staff documented coffee temperatures prior to providing coffee to the residents. She stated that the staff did not check the temperatures of the coffee prior to sending the coffee out to the floor to be served to the residents. S2DM brewed a canister of coffee and the temperature was obtained. The reading was 158.1 degrees F (Fahrenheit). S1DM replaced the lid on the canister and set it aside to go out to the floor.

Based on observations, interviews, and record review, the facility failed to honor and accommodate food preferences for 1 (#68) out of 9 residents reviewed for dining. This deficient practice had the potential to affect 112 residents who consumed meals from the kitchen.Review of Resident #68's medical record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, unspecified dementia and unspecified protein-calorie malnutrition. Review of the facility's policy titled Resident Food Preferences, with a last review date of 10/29/2025, read in part, Policy Statement: Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative's consent. Review of Resident #68's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 12, indicating her cognition was moderately impaired. Review of Resident #68's meal ticket, read in part, Special Notes: dislikes breakfast sausage.On 04/20/2026 at 8:18 a.m., and observation and interview was conducted with Resident #68. Resident #68 was observed to have a breakfast sausage patty cut up on her breakfast plate. Resident #68 stated that she did not eat breakfast sausage. On 04/21/2026 at 8:24 a.m., a second observation and interview was conducted with Resident #68. Resident #68 was again observed to have a breakfast sausage patty cut up on her breakfast plate. Resident #68 stated again that she did not eat breakfast sausage. On 04/21/2026 at 8:39 a.m., an observation of Resident #68's breakfast tray and interview was conducted with S2DM who was responsible for dietary services at the facility. S2DM confirmed that breakfast sausage was listed as a dislike on the resident's meal ticket and had been served on her breakfast tray. She further confirmed that because breakfast sausage was listed as a dislike, it should not have been served to the resident. On 04/21/2026 11:30 a.m., an interview was conducted with S1ADM. S1ADM confirmed that because breakfast sausage was listed as a dislike on Resident #68's meal ticket, she should not have been served breakfast sausage.

Based on record review, observations, and interviews, the facility failed to ensure dishware was clean and stored under sanitary conditions to prevent the likelihood of foodborne illness. This had the potential to affect the 112 residents who ate meals from the facility's kitchen. Findings: Review of the facility's policy, titled Sanitization, with a last revised date of 10/2008, read in part, Policy Statement: The food service area shall be maintained in a clean and sanitary manner. 2. All utensils, counters, shelves and equipment shall be kept clean, maintained in good repair. 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. 16. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. On 04/19/2026 at 10:43 a.m., an observation in the kitchen was conducted. An observation of an open shelf next to the food serving line revealed stacked plate warmers, that were all soiled. Many of the plate warmers had grease and pieces of egg and others had fragments of other food items and crumbs. Further observation revealed Styrofoam plates stacked on the top shelf facing up. Observation of the Styrofoam plates revealed the first plate had a piece of egg inside of it. On 04/19/2026 at 10:44 a.m., an observation and interview of the open shelf was conducted with S2DM. S2DM stated the dishwashing staff were responsible for stacking the plates and the plate warmers on the shelf for the lunch meal. Further observation revealed Styrofoam plates which were stored on the top of the open shelf. S2DM removed the Styrofoam plates from the top shelf and observed a piece of egg inside the unused Styrofoam plate. S2DM confirmed that the plate warmers were soiled with grease, pieces of egg, crumbs from other food items and should have been sanitized prior to stacking them on the clean shelf. She also confirmed the Styrofoam plates should have been stored face down.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection by failing to ensure: 1. staff removed soiled gloves and performed hand hygiene before exiting a resident's room; and 2. staff did not use soiled gloves to open the door of Room A Findings: Review of the facility's policy entitled, Isolation - Categories of Transmission-Based Precautions, revised on 03/20/2025, revealed, in part, gloves were to be removed and hand hygiene performed before leaving a resident's room. An observation on 03/25/2025 at 9:00 AM revealed S8CNA (Certified Nursing Assistant) exited a resident's room, wearing gloves and carrying soiled linens. She walked down the hallway, and then used her gloved hand to open the door of Room A. An interview with S8CNA on 03/25/2025 at 11:19 AM revealed soiled gloves were to be removed and hand hygiene performed prior to exiting a resident's room. S8CNA stated soiled gloves should not be used to open the door of Room A. S8CNA confirmed she did not remove her soiled gloves and perform hand hygiene before exiting the resident room, but should have. S8CNA confirmed she used soiled gloves to open the door of Room A, but should not have. Interview with S7IP (Infection Preventionist) on 03/26/2025 at 10:50 AM confirmed staff were to remove gloves and perform hand hygiene prior to exiting a resident room. S7IP confirmed staff should not wear soiled gloves when exiting a resident's room, and should not have used soiled gloves to open the door of Room A.

Based on observations, interviews, and record review, the facility failed to maintain a clean and homelike environment for 1 (#10) out of 5 (#4, #10, #35, #66, and #77) investigated for environment. Findings: On 03/26/2025, a review of the facility's policy titled, Cleaning and Disinfecting Residents' Rooms with a last reviewed date of 11/15/2025, read in part, The purpose of this procedure guidelines for cleaning and disinfecting residents' room. The policy also indicated housekeeping general guidelines, Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. On 03/24/2025 at 10:30 AM, a first observation was conducted of Resident #10's room. One large stain red stain was noted on the floor next to the right side of her bed. Multiple red circular stains were observed on her bedside table. On 03/25/2025 at 12:07 PM, a second observation was made of Resident #10's room. One large stain red stain was noted on the floor next to the right side of her bed. Multiple red circular stains were observed on her bedside table. On 03/25/2025 at 2:07 PM, a third observation made of Resident #10's room. One large stain red stain was noted on the floor next to the right side of her bed. Multiple red circular stains were observed on her bedside table. On 03/25/2025 at 2:40 PM, a fourth observation and interview was conducted with S4HSKPSup (Housekeeping Supervisor). S4HSKPSup stated housekeeping was supposed to clean each room daily which included mopping the floors and cleaning the bedside table. She stated the housekeeper then initials on another form next to the room number indicating that everything on the daily cleaning inspection form was completed for that room. An observation was made of Resident #10's room with S4HSKPSup confirmed there was a large red stain on the floor next to the right side of the resident's bed and multiple red circular stains on the resident's bedside table. On 03/26/2025 at 9:50 AM, a record review and interview was conducted with S4HSKPSup who provided the housekeeping checkoff list from 03/24/2025 and Resident #10's room number was initialed indicating the room should have been cleaned on 03/24/2025. She confirmed the housekeeper should have cleaned the room on 03/24/2025 and she did not.

Based on record reviews, observations, and interviews, the facility failed to ensure a resident's comprehensive person-centered care plan was implemented by failing to administer oxygen as ordered for 2 (#55, #102) of 2 (#55 and #102) residents reviewed for oxygen therapy. Review of the facility's policy titled Oxygen Administration, with a last revised date of February 2025, read in part: 3. Turn on the oxygen. Unless otherwise ordered, the flow of oxygen per Physician orders. Resident #55 Review of Resident #55's medical record revealed she was admitted to the facility on [DATE] with diagnoses including, but not limited to, chronic obstructive pulmonary disease, acute and chronic respiratory failure, and acute on chronic diastolic congestive heart failure. Review of Section C.: Cognitive Patterns of Resident #55's quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed the resident had a BIMS (Brief Interview for Mental Status) score of 14, indicating she was cognitively intact. Review of Resident #55's Physician's Orders revealed an order dated 11/07/2023 that read: Oxygen: May have oxygen at 3LPM (Liters Per Minute) per nasal cannula; may remove for ADLs (Activities of Daily Living ) ; Keep HOB (Head of Bed) elevated for SOB (Shortness of Breath) while laying flat. Review of Resident #55's plan of care with an initiation date of 11/07/2023 read in part: Provide oxygen therapy as ordered. On 03/25/2025 at 2:38 PM, an observation and interview was conducted with Resident #55 in her room. The resident stated that she wears her oxygen continuously, and her oxygen concentrator should be set at 3 liters. She stated that she had been experiencing some slight shortness of breath on today while wearing her oxygen. An observation was then made of the resident's oxygen concentrator. The oxygen concentrator was set at 2.5 liters per minute. On 03/25/2025 at 2:40 PM, an interview was conducted with S3LPN (Licensed Practical Nurse). She stated Resident #55 had to wear oxygen continuously and had an order for 3 liters per minute. At 2:47 P.M., an observation was made of the resident's oxygen concentrator with S3LPN. She confirmed that the indicator ball within the flow meter was below three liters. 41419 Resident #102 Review of Resident #102's medical record revealed she was admitted on [DATE] with diagnoses including, but not limited to, chronic obstructive pulmonary disease, hypertensive heart disease with heart failure, and emphysema. She was admitted to hospice on 03/14/2025. Review of Resident #102's physician orders dated 03/24/2025 read in part .administer continuous oxygen at 3 Liters per nasal cannula. Review of Resident #102's plan of care with an initiation date of 03/12/2025 read in part .oxygen settings - oxygen via nasal cannula at 3 liters continuously. On 03/24/2025 at 1:18 PM, an observation of Resident #102's oxygen concentrator revealed an oxygen flow rate of 2 liters via nasal cannula. On 03/25/2025 at 7:45 AM, a follow up observation was conducted. Resident #102's concentrator revealed an oxygen flow rate of 3.5 liters via nasal cannula. On 03/25/2025 at 1:10 PM, an observation and immediate interview was conducted with S10LPN (Licensed Practical Nurse) who confirmed the oxygen flow rate was currently set on 3.5 liters which was not the current physician order. S10LPN stated the resident was not physically capable of changing the oxygen flow rate, and the oxygen flow rate should have been set at 3 liters. On 03/26/2025 at 10:05 AM, an observation of Resident #102's oxygen concentrator and immediate interview was conducted with S12LPN, who stated the oxygen flow rate for Resident #102 was set at 4 liters. She confirmed the oxygen flow rate should have been set at 3 liters. Any confirmation from the nurse saying the resident could have not have changed the settings herself?

Based on interviews and record review, the facility failed to ensure that a resident and/or a resident's RP (Responsible Party) was invited to the resident's care planning meeting for 1 (Resident #111) out of a total sample of 32 residents. This deficient practice had the potential to affect a census of 112. Findings: On 03/26/2025, a review of the facility's policy titled Care Planning-Interdisciplinary Team with a review date of 01/21/2024 and an annual review date of 11/15/2024, read in part: Policy Statement. The Interdisciplinary team is responsible for the development of resident care plans. Policy Interpretation and Implementation .4. The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. 7. If it is determined that participation of the resident or representative is not practicable for the development of the care plan, an explanation is documented in the medical record. Review of Resident #111's electronic medical record revealed an admitted [DATE] with diagnoses that included colostomy, congestive heart failure, anxiety, cognitive communication deficits, depression, Diabetes Mellitus II and chronic kidney disease. A review of Resident #111's quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 04/24/2024 revealed he had a BIMS (Brief Interview for Mental Status) score of 11, suggesting moderate cognitive impairment. On 03/24/2025 at 10:28 AM, an interview was conducted with Resident #111. The resident stated she had never been invited to a care plan meeting. On 03/25/2025 at 1:45 PM, an interview was conducted with S5SSD (Social Service Director). S5SSD stated she was responsible for resident's care planning meetings. She stated they invite the residents to attend the care plan meetings and send a letter to the RP (Responsible Party). A review of the sign in sheet, dated 12/11/2024, for Resident #111 revealed only staff members signed the sign in and the resident or RP had not signed the sign in sheet. Further review revealed the additional comments section on the sign in sheet was blank. On 03/26/2025 at 11:30 AM, during an interview with Resident #111's RP, he stated he had not received a letter from the facility to invite him to any meeting for his wife.

Based on record review, observations, and interviews, the facility failed to ensure an activity program was being conducted for 1 (#38) out of 1 (#38) residents investigated for activities. This had the potential to affect 112 residents. Findings: Review of the facility document titled Individual Activities and Room Visit Program, with a review date of 11/15/2024, read in part .Individual activities will be provided for those residents whose situation or condition prevents participation in other types of activities. Policy Interpretation and Implementation: 3. Residents on a full room visit program will receive, at a minimum, three room visits per week. Documentation of the room visit will be documented on the Bed Bound Activity Assessment. Resident #38 was admitted to the facility on [DATE] with diagnoses that included, unspecified dementia without behavioral disturbances, aphasia following cerebral infarction, cerebral infarction, and dysphagia. Review of Resident #38's MDS (Minimum Data Set) dated 01/20/2025 revealed her cognitive status was 99 which indicated severely impaired. Under the Section F- Preferences for Customary Routine and Activities-Staff assessment of daily and activity preferences, the resident prefers to listen to music. Review of the facility document titled tasks read in part .Programs - Bed Bound Activity with a look back date of 30 days, failed to reveal any activities were completed with Resident #38. Further review of a task titled Programs - 1:1 with a look back date of 30 days, failed to reveal any 1:1 activities were completed with the resident. Review of Resident #38's Care Plan dated 03/21/2024 read in part I have little or no activity involvement related to immobility. Interventions were to provide cues and assist with improving orientation, and staff to provide 1:1 visits regularly. Review of Progress Notes dated 03/04/2025 thru 03/17/2025 written by S14AA (Activity Aide) read in part .resident (doesn't participate in activities) activities will come twice a week to remind and encourage resident to participate in activities. On 03/24/2025 at 8:50 AM, an observation was made of Resident #38 lying in bed, tv was on, and staff was not observed engaging in activities with the resident. On 03/24/2025 at 10:00 AM, a follow up observation was made of Resident #38 lying in bed tv was on, and no staff was observed in the room engaging in activities with the resident. On 03/24/2025 at 1:00 PM, another observation was made of Resident #38 lying in bed with her tv on, and no staff was observed in the room engaging in activities with the resident. On 03/24/2025 at 3:15 PM, observation was made of Resident #38 lying in bed with her tv on, and no staff was observed in the room engaging in activities with the resident. On 03/25/2025 at 8:10 AM, an interview was conducted with S9AD (Activity Director) who stated she goes in the resident's room and reads scripture to her. When asked if she documented in the progress notes when she had interactions with the resident, she stated she did chart on the resident. Further review of the last 3 months of activities she had completed with the resident, did not reveal any documented evidence S9AD had completed any 1:1 activities with Resident #38. After review of the documentation S9AD stated that was all the documentation she could provide. On 03/26/2025 at 8:12 AM, a phone interview was conducted with Resident #38's daughter, and substitute decision maker. The resident's husband is the responsible party, but passed away two days ago according to the resident's daughter. The resident's daughter stated she visits her mother every weekend, and she had not observed staff interacting with her mother by reading to her, massaging her, playing spiritual music for her, or performing any range of motion on her.

Based on observation and interviews, the facility failed to ensure that medications were stored and labeled properly in accordance with current accepted professional standards by having loose medications in the bottom of 2 drawers for 1 medication cart (Cart A) of 2 (Cart A, Cart B) medication carts observed in a facility with a census of 112 residents. Findings: The facility's policy titled Storage of Medications with a last reviewed date of 11/15/2024 read in part .2. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. On 03/25/2025 at 1:00 PM, an observation was conducted of the Med Cart A with S3LPN (Licensed Practical Nurse). One oval orange colored pill was observed loose in the bottom of the second drawer and a one round peach colored pill was observed out of the package, loose on the bottom of the third drawer. S3LPN confirmed they should not have loose pills in the medication carts. On 03/26/2025 at 1:30 PM, during an interview S2DON (Director of Nursing) confirmed medications should not be left loose in any of the medication carts.

Based on observations and interviews, the facility failed to provide a clean, comfortable, and homelike environment for 3 (#1, #2, #3) out of 3 (#1, #2, #3) sampled residents. The deficient practice had the potential to affect a total census of 108. Findings: Resident #1 On 10/28/2024 at 11:30 a.m., an observation of Resident #1's bathroom revealed a urinal hanging on the back of the safety bar of the toilet. The urinal was labeled with Resident #1's initials, did not have a lid, and was not stored in a bag. On 10/28/2024 at 12:46 p.m., a second observation of Resident #1's bathroom revealed the same urinal in the same place it was last seen. On 10/29/2024 at 1:55 p.m., an observation of Resident #1's bathroom and urinal was conducted with S6LPN (Licensed Practical Nurse). S6LPN confirmed a urinal with Resident #1's initials was hanging on the back of the toilet safety rail with no lid and was not stored in a bag She stated the urinal should have been stored in a bag. Resident #2 On 10/28/2024 at 12:06 p.m., an observation of Resident #2's room was conducted with S5CNA (Certified Nursing Assistant) who confirmed there was bedpan on the floor under the resident's bed. She confirmed the bedpan should have been placed in a bag and stored in the bathroom and not on the floor under the resident's bed. On 10/29/2024 at 9:45 a.m., a second observation was conducted of Resident #2's bathroom. Two bedpans were stacked on the floor between the toilet and the wall. The bedpan on the top was soiled with a yellow liquid, open to air, and were not stored in a bag. Further observation of the bathroom revealed a trash can without a liner that contained soiled incontinence briefs and incontinence underwear. The restroom had a strong urine odor. Further observation revealed a light brown substance on the toilet seat and the rim. On 10/29/2024 at 9:57 a.m., an observation of the resident's bathroom was conducted with S5CNA. She confirmed two soiled bedpans were on the floor next to the toilet and not stored in a bag. S5CNA confirmed the bedpans should have been stored in a bag with the resident's initials on them. S5CNA also confirmed the trash can contained soiled incontinence briefs and incontinence underwear and there was no trash can liner in the trash can and stated the trash can should have a liner in it. She also confirmed the soiled incontinence briefs and incontinence underwear should have been removed from the bathroom and the toilet seat and the rim should have been cleaned of the light brown substance on it. On 10/29/2024 at 10:05 a.m., an observation of the Resident #2's bathroom was conducted with S1DON (Director of Nursing). She confirmed there were two soiled bedpans on the floor and they were not stored in bags. S1DON confirmed the toilet seat and rim was soiled with a light brown substance and the trash can contained soiled incontinence briefs and incontinence underwear with no trash can liner. She stated the bedpans should be in a bag, the trash should have been removed from the restroom, a liner should have been in the trash can and the toilet seat and rim needed to be cleaned. 44418 Resident #3 On 10/28/2024 at 1:15 p.m., observation of a shared bathroom for Resident #3 and Resident #R6 was done. There were three unlabeled urinals hanging on the hand rail on the side of the toilet. A bedpan that contained stool and toilet paper was sitting on the shower bench in the shower. The bathroom had a strong odor of stool. On 10/28/2024 at 1:30 p.m., an observation and interview was conducted with S5CNA. S5CNA observed and confirmed the the unlabeled urinals hanging in the bathroom on the hand rail should have been labeled and stored in a bag. She also observed and confirmed the dirty bedpan, in the shower. S5CNA stated the urinal and bedpan should have been emptied and cleaned. S5CNA stated she did not know how long the bedpan had been in the shower. She confirmed Resident #R6 was continent of bowel and bladder and uses did not require assistance with toileting. She reported Resident #3 had been out of the facility since last week. On 10/28/2024 at 1:45 p.m., and observation of Resident #3 and Resident #R6's shared bathroom was conducted with S1DON. She confirmed there were three unlabeled urinals that should have been labeled with a name and stored in a bag. She also confirmed there was a bedpan in the shower, with stool and toilet paper in it. She confirmed the dirty bedpan should not have been left in the shower, it should have been emptied, cleaned, and then stored in a bag. On 10/29/2024 at 1:30 p.m., an interview was conducted with Resident #R6, who shared a bathroom with Resident #3. He reported he used the toilet. He reported the bathroom was often dirty, with stool on the floor and the toilet seat. He stated there had been a dirty bedpan in the shower that was causing a foul odor for about a week.

Based on record reviews, and interviews, the facility failed to implement the resident's comprehensive plan of care to provide the necessary care and services for 1 (#3) out of 3 (#1, #2, and #3) sampled residents as evidenced by the nursing staff failing to administer nine doses of a medication ordered by Resident #3's physician. Findings: Review of Resident #3's EHR (electronic health record) revealed the resident was admitted to the facility on [DATE] with the following diagnoses in part: Osteomyelitis of Vertebra, and Thoracic Region. Review of Resident #3's admission MDS (Minimum Data Set) assessment dated [DATE], revealed under Section C a BIMS (Brief Interview for Mental Status) score of 8, indicating the resident's cognition was moderately impaired. Review of Resident #3's Comprehensive Care Plan revealed on 09/04/2024 the resident was at risk for alteration in comfort with an intervention to administer analgesia (pain medication) as ordered. Review of Resident #3's physician's orders revealed an order entry dated 09/12/2024 for Hydrocodone-Acetaminophen (APAP) 5-325 mg (milligrams) tablet, one tablet by mouth three times a day with a discontinued date of 09/23/2024. Another order was written on 09/23/2024 for Hydrocodone-APAP 5-325 mg tablet one tablet by mouth four times a day. Review of the resident's September 2024 medication administration history for Hydrocodone-APAP 5-325 mg tablet one tablet three times a day with a discontinued date and time of 09/23/2024 at 1:01 p.m., scheduled for morning, late, and HS revealed: 09/20/2024 the late and HS (at night) were signed as hold-see progress notes, and other-see progress notes. 09/21/2024 morning and HS were signed as other-see progress notes, and late dose was signed as hold-see progress notes. 09/22/2024 the late dose was signed as hold-see progress notes and HS dose signed as other-see progress notes, 09/23/2024 the morning dose was signed as other-see progress notes. Review of Hydrocodone-APAP 5-325 mg tablet one tablet three times a day with a start date and time of 09/23/2024 at 6:00 p.m. revealed the 6:00 p.m. dose was signed as other-see progress notes. Review of Resident #3's progress notes revealed in part: 09/20/2024 at 2:16 p.m., Hydrocodone-APAP Oral Tablet 5-325 MG. Give 1 tablet by mouth three times a day for pain (EMAR revealed held - see progress note) signed by S3LPN (Licensed Practical Nurse) 09/20/2024 at 8:12 p.m., Hydrocodone-APAP Oral Tablet 5-325 MG Give 1 tablet by mouth three times a day for Pain, On order signed by S8LPN 09/21/2024 at 7:07 a.m., Hydrocodone-APAP Oral Tablet 5-325 MG Give 1 tablet by mouth three times a day for Pain, Awaiting from pharmacy. signed by S3LPN 09/21/2024 at 2:31 p.m., Hydrocodone-APAP Oral Tablet 5-325 MG Give 1 tablet by mouth three times a day for Pain. Awaiting from pharmacy. signed by S3LPN 09/21/2024 at 8:38 p.m., Hydrocodone-APAP Oral Tablet 5-325 MG Give 1 tablet by mouth three times a day for Pain. On order. signed by S8LPN 09/22/2024 at 2:01 p.m., Hydrocodone-APAP Oral Tablet 5-325 MG Give 1 tablet by mouth three times a day for Pain, awaiting from pharmacy. signed by S3LPN 09/22/2024 at 8:05 p.m., Hydrocodone-APAP Oral Tablet 5-325 MG Give 1 tablet by mouth three times a day for Pain. (Signed as other-see progress notes) signed by S8LPN 09/23/2024 at 11:48 a.m., Hydrocodone-APAP Oral Tablet 5-325 MG Give 1 tablet by mouth three times a day for Pain, waiting for medication to come in. signed by S9LPN 09/23/2024 at 11:23 p.m., Hydrocodone-APAP Oral Tablet 5-325 MG Give 1 tablet by mouth four times a day for Pain, waiting on pharmacy. signed by S10LPN On 10/28/2024 at 1:50 p.m., an interview was conducted with S2LPN (Licensed Practical Nurse). She stated the facility had an emergency drug kit that contained Hydrocodone-APAP 5-325 mg, the pain medication Resident #3 was prescribed, locked in a secured dispensing system. She confirmed that if a medication was needed while waiting on the medication to come from the pharmacy, it could be obtained from the emergency drug kit to be administered to residents. On 10/28/2024 at 2:00 p.m., an interview was conducted with S3LPN. She reported she recalled that Resident #3 ran out of his Hydrocodone-APAP, but did not know the exact date it was out of stock. S3LPN confirmed while waiting on the medication to come from the pharmacy, Resident #3 did not receive the medication as ordered. She confirmed she was knowledgeable about the facility's emergency kit, but she was not aware the Hydrocodone-APAP was available in the emergency drug kit/secured dispensing system for use while waiting on medication from pharmacy. On 10/28/2024 at 2:25 p.m., an interview was conducted with S1DON (Director of Nursing). She stated the secured drug dispensing system was available for medications needed if the resident had a new order, or was out of a medication until the medication could be delivered. S1DON also confirmed the nurses should have been aware of the emergency drug kit and should have utilized it when Resident #3 was out of his Hydrocodone-APAP 5-325mg.

Based on observation, interview and record review, the facility failed to ensure pureed menus and recipes were followed. This failure had the potential to contribute to an unpleasant dining experience, decreased intake, altered nutritional needs and weight loss. Findings: Review of the facility's diet manual revealed . Guidelines for Preparing Pureed Food with basic instructions that read: 1. Measure number of servings. 2. Drain well. Reserve liquid for use after blending, if needed . 5. Add 1/3 of measured liquid, no more than 1/2 to 1 oz (ounce) per serving is recommended . 8. Measure final product. Divide by number of original servings (step #1). Review of the facility's menu for 02/06/2024 for the lunch meal revealed, in part: P (Puree) dinner roll On 02/06/2024 at 10:30 a.m., an observation was made of S10Cook preparing the lunch meal. S10Cook confirmed he was responsible for preparing the pureed diets. S10Cook was unable to provide the number of servings needed for residents who consumed pureed diets. S10Cook was observed removing a total of 10 slices of white sandwich bread from the loaf and placing all 10 slices inside the electric 2 1/2 quart food processor. S10Cook then added milk, by pouring an unmeasured amount directly from the plastic 1 gallon milk jug. After blending the mixture, S10Cook was then observed adding thickening powder to the mixture by shaking the container of powder over the mixture. S10Cook stated he had pureed about 10 slices of bread. S10Cook denied having knowledge of recipes to be followed. S10Cook confirmed he had not used the dinner rolls as listed on the lunch meal menu. On 02/06/2024 at 10:38 a.m., an interview was conducted with S4DM (Dietary Manager). S4DM verified there were 7 total residents in the facility who consumed pureed diets. S4DM confirmed recipes were not being used for pureed diets nor were measurements being used when adding liquid to the mixture. S4DM further confirmed that S10Cook had not followed the lunch menu by using white sandwich bread instead of the listed dinner rolls.

Based on observations, record review or review of policy and procedure and interviews, the facility failed to store, distribute, and serve food in accordance with professional standards for food service safety by failing to follow appropriate food handling practices as evidenced by: 1. Failing to ensure foods stored in the freezer were labeled and dated and 2. Failing to ensure staff present in the kitchen wore hairnets at all times and covered facial hair. The total census was 113 residents. Findings: A review of the facility's policy titled, Food Receiving and Storage, revealed in part: 1. Food Services, or other designated staff, will maintain clean food storage areas at all times . 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). On 02/05/2024 at 8:57 a.m., an initial tour of the facility's kitchen was conducted with S14DA (Dietary Aide). S10Cook and S11DA were observed in the kitchen without a hairnet or facial hair covering in place. On 02/05/2024 at 9:07 a.m., an observation was made of the facility's walk in freezer with S14DA. The following items were observed in separate plastic storage bags without labeling or dates: Frozen filets, frozen precooked dark meat and frozen crinkled cut fries. S14DA then requested for S10Cook to verify what the unlabeled meats were and he confirmed the above mentioned items were not labeled or dated and should have been. On 02/05/2024 at 10:55 a.m., a follow up visit to the kitchen was made. An observation was made of S10Cook and S11DA preparing food for lunch without hairnets or facial hair coverings in place. On 02/05/2024 at 11:30 a.m., an interview was conducted with S4DM (Dietary Manager) who confirmed all kitchen staff must wear hairnets at all times and a separate covering for facial hair. S4DM also confirmed all foods stored in the freezer must be labeled and dated.

Based on observation, record review and interview, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections as evidenced by staff: 1. Failing to put on PPE (Personal Protective Equipment ) prior to entering Resident #94's room who was on contact isolation precautions; 2. Failing to sanitize hands upon exiting Resident #94's room and 3. Failing to ensure staff performed hand hygiene according to accepted standards of practice during wound care observation for 1 (Resident #98) out of 2 (Resident #33 and #98) residents sampled for wound care. Findings: Resident #94 Review of the facility's policy titled, Isolation - Categories of Transmission - Based Precautions, read in part .Contact Precautions .7. Staff and visitors wear gloves when entering the room b. Gloves are removed and hand hygiene performed before leaving the room [ROOM NUMBER]. Staff and visitors wear a disposable gown upon entering the room . Review of Resident #94's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses in part .Methicillin Resistant Staphylococcus Aureus (MRSA) Infection as the Cause of Diseases Classified Elsewhere, Type 2 Diabetes Mellitus, and Bacteremia. Review of Resident #94's current physician's orders revealed an order dated 1/23/2024 that read: Strict isolation to room, all services provided within room. On 02/06/2024 at 11:37 a.m., an observation was made of S9CNA (Certified Nursing Assistant) distributing meal trays to residents on Hall A. Observations of Hall A and Resident #94's room revealed a door caddy containing PPE mounted on the resident's door and a sign that read Isolation Until 02/10/2024. A second sign posted on the door read in part, Contact Precautions, Everyone must: clean their hands including before entering and when leaving the room. Providers and staff must also: put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. At this time, an observation was made of S1CNA entering Resident #94's room. She placed Resident #94's lunch tray on his bedside table then exited the resident's room. S1CNA did not put on PPE prior to entering Resident #94's room and did not sanitize her hands upon exiting the resident's room. S9CNA proceeded to the meal cart, pushed it down the hallway, and prepared to remove the next resident's meal tray. An interview was then conducted with S1CNA. S1CNA confirmed that she did not put on PPE prior to entering Resident #94's room because she only went to give the resident his lunch tray, and she didn't think she needed to despite the sign outside the door instructing to do so upon entry. S1CNA further confirmed that she did not sanitize her hands upon exiting the resident's room because she did not have any hand sanitizer. On 02/06/2024 at 11:42 a.m., an interview was conducted with S3ADONIP (Assistant Director of Nursing/Infection Preventionist). S3ADONIP stated that staff members were required to put on PPE prior to entering the room of residents who were in isolation and also confirmed staff members were required to sanitize their hands after exiting an isolation room. 47540 Resident #98 Review of the facility's policy, Wound Care, revealed in part, the following: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing . Steps in the Procedure . 4. Put on exam glove . remove dressing. 5. Pull over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves . Review of Resident #98's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Muscle Wasting and Atrophy, and Unspecified Protein-Calorie Malnutrition. Review of Resident #98's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 8 indicating her cognition was moderately impaired. Review of Resident #98's physician's orders revealed an order written on 02/05/2024 Venous stasis ulcer to left lower leg cleanse with wound cleanser apply ca ag (Calcium Alginate) cover with abd (Abdominal) pad, wrap with kerlix q day (everyday). On 02/06/2024 at 8:55 a.m., an observation was made of S6WCLPN (Wound Care Licensed Practical Nurse) providing wound care to Resident #98. A t-shirt was wrapped around Resident #98's left lower extremity covering the wound. S6WCLPN applied clean gloves, removed the t-shirt that was covering the wound and cleaned the wound bed with wound cleanser and gauze. S6WCLPN was not observed changing her dirty gloves, performing hand hygiene, or donning clean gloves after she removed the t-shirt that was covering the wound. On 02/06/2024 at 9:15 a.m., an interview was conducted with S6WCLPN. S6WCLPN confirmed that after removing the t-shirt that was around Resident #98's left lower extremity wound her gloves were considered dirty, but she continued to perform wound care. She confirmed that she should have changed her gloves, performed hand hygiene, and donned clean gloves after removing the t-shirt that was around the wound site. On 02/06/2024 at 10:41 a.m., an interview was conducted with S2DON (Director of Nursing). S2DON confirmed that after S6WCLPN removed the t-shirt that was around Resident #98's wound site on the left lower extremity, she should have removed her gloves, performed hand hygiene and donned clean gloves.

Based on observation, interviews and record reviews the facility failed to ensure a resident was treated with respect and dignity as evidenced by staff failing to intervene and replace Resident #43's meal tray after her food was touched by Resident #66. Findings: Review of the facility's policy, Resident Rights, revealed in part, the following: Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Resident #66 Review of Resident #66's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Bipolar Disease, Essential Hypertension, and Systemic Lupus Erythematosus. Review of Resident #66's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 99 indicating the resident was unable to participate. Review of Resident #66's Comprehensive Care Plan revealed a focus dated on 02/05/2024: Reached in another resident's plate during lunch. Resident #43 Review of Resident #43's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Type 2 Diabetes Mellitus, Iron Deficiency Anemia, and Hyperlipidemia. Review of Resident #43's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 3 indicating her cognition was severely impaired. An observation was conducted on 02/05/2024 at 11:49 a.m. of Resident #66 and Resident #43 during lunch. Resident #66 was being fed by S8CNA (Certified Nursing Assistant) at this time. Resident #66 reached over to Resident #43's meal tray and touched her food. Resident #43 started eating her food that was on the meal tray. On 02/05/2024 at 12:01 p.m., an interview was conducted with S8CNA. S8CNA stated she did observed Resident #66 reach over to Resident #43's meal tray and touch her food and Resident #43 started to eat her food. S8CNA confirmed that she did not replace Resident #43's meal tray when she observed Resident #66 touch her food. On 02/05/2024 at 12:05 p.m., an interview was conducted with S7LPN (Licensed Practical Nurse). S7LPN confirmed that after Resident #66 touched Resident #43's food on her meal tray, it should have been replaced with a new meal tray. On 02/06/2024 at 10:43 a.m., an interview was conducted with S2DON. S2DON confirmed that Resident #43's meal tray should have been replaced with a new meal tray by S8CNA after she observed Resident #66 touched Resident #43's food on her meal tray.

Based on record review, review of the facility's policy and procedure, and interviews, the facility failed to develop a comprehensive person-centered care plan within 7 days of the completion of the required comprehensive assessment MDS (Minimum Data Set) for 1 (Resident #43) out of 1 (Resident #43). The final sample size was 49. Findings: Review of the facility's policy, Care Plans, Comprehensive Person-Centered, revealed in part, the following: Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . Policy Interpretation and Implementation . 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment MDS. Resident #43 Review of Resident #43's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Type 2 Diabetes Mellitus With Other Specified Complication, Chronic Obstructive Pulmonary Disease, and Gastro-Esophageal Reflux Disease Without Esophagitis. Review of Resident #43's Annual MDS was dated 12/28/2023. Review of Resident #43's comprehensive person-centered care plan revealed it was incomplete. On 02/06/2024 at 10:58 a.m., an interview was conducted with S5MDS. S5MDS stated that Resident #43 was admitted on [DATE] and the comprehensive care plan should have been completed by 01/04/2024. She confirmed she did not have Resident #43's comprehensive care plan completed by 01/04/2024 and confirmed she completed Resident #43's comprehensive care plan on 02/06/2024. On 02/06/24 at 11:05 a.m., an interview with S2DON (Director of Nursing). S2DON confirmed Resident #43 was admitted on [DATE] and she confirmed the comprehensive care plan should have been completed by 01/04/2024 and it was not completed until 02/06/2024.

Based on observations and interviews, the facility failed to serve palatable food at an appetizing temperature for 1 (#115) of 49 sampled residents. Findings: Review of the facility's grievance log revealed a grievance had been filed on behalf of Resident #115 on 01/18/2024 about his meal trays not being hot enough. Review of Resident #115's electronic medical record (EMR) revealed the resident was admitted to facility on 01/10/2024. He had diagnoses in part: Muscle Weakness, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Shortness of Breath and Edema. Review of the Resident #115's admission MDS (Minimum Data Set) assessment, dated 01/16/2024 revealed he had a BIMS (Brief Interview for Mental Status) score of 14, indicating his cognition was intact. On 02/05/2024 at 9:54 a.m., an interview was conducted with Resident #115 and he reported the food on his meal trays was always served cold. On 02/06/2024 at 10:27 a.m., an interview was conducted with S9LPN (Licensed Practical Nurse), she stated the Resident #115 had complained his food was cold at times. On 02/06/2024 at 12:30 p.m., an observation was made of lunch trays being delivered from the kitchen area to the residents who resided on Hall W. The lunch trays were transported on a covered rolling cart. On 02/06/2024 at 12:35 p.m., an interview was conducted with Resident #115 and he stated his food was cold when he received his tray. On 02/06/2024 at 12:40 p.m., the surveyor received a test lunch meal tray from Hall W, after all residents on Hall W had been served. Upon removing the lid from the tray, there was no condensation or steam observed from the food and there was no ice noted in the served beverages. The surveyor then took a bite of the red beans and rice that was on the tray. The red beans and rice tasted cold and dry. The tray was returned to the kitchen, to check the temperature of the food. On 02/06/2024 at 12:42 p.m., an observation was made in the kitchen of S4DM (Dietary Manager) use a food thermometer to obtain the temperature of the returned lunch tray that the surveyor had tasted. The temperature of the red beans and rice failed to register on the thermometer. S4DM then touched the food and confirmed it was cold. She stated the food should be warm when served to the resident's.

Based on record review, observation, review of the facility's policy and procedure, and interviews, the facility failed to ensure resident's medical record contained documentation of a newly identified skin concern for 1 (Resident #98) out of 2 (Resident #33 and #98) residents investigated for skin conditions. The facility same size was 49. Findings: Review of the facility's policy, Pressure Ulcers/Skin Breakdown - Clinical Protocol, revealed in part, the following: . Documentation: . 3. Newly identified skin concerns will be added to the EMR (Electronic Medical Record) . Resident # 98 Review of Resident #98's record revealed she was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Muscle Wasting and Atrophy, and Unspecified Protein-Calorie Malnutrition. Review of Resident #98's Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 8 indicating her cognition was moderately impaired. An observation of Resident #98 was conducted on 02/05/2024 at 10:46 a.m. of Resident #98's left lower extremity wrapped in a Kerlix dressing. On 02/06/2024 at 8:53 a.m., an interview was conducted with S6WCLPN (Wound Care Licensed Practical Nurse). S6WCLPN stated that Resident #98 had a facility acquired ruptured blister to her left lower extremity that was discovered on 01/25/2024. S6WCLPN confirmed she completed the assessment but there was no documentation in Resident #98's EMR of the initial assessment of the newly identified ruptured blister. On 02/06/2024 at 10:15 a.m. an interview with conducted with S6WCLPN and S2DON (Director of Nursing). S6WCLPN stated that the initial wound care assessment of Resident #98's facility acquired ruptured blister to her left lower extremity should have been documented into the EMR after the assessment was completed. S6WCLPN and S2DON confirmed there was no documentation in the EMR of Resident #98's initial assessment of the newly identified ruptured blister and there should have been documentation of the assessment in the EMR.

Based on record review and interview, the facility failed to refer residents with newly diagnosed mental disorders or had a significant change in their mental condition to the appropriate state-designated authority for Level II PASARR (Preadmission Screening and Resident Review) for evaluation and determination for 2 (#8, #13) of 2 residents investigated for PASARR in a final sample of 43 residents. Findings: Review of the facility's policy titled, Behavioral Assessment, Intervention and Monitoring read in part: The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. New onset or changes in behavior that indicate newly evident or possible serious mental disorder, intellectual disability, or a related disorder will be referred for a PASARR Level II evaluation. Resident #8 Review of Resident #8's diagnosis list revealed on 3/23/2022 she was diagnosed with Bipolar Disorder. Review of Resident #8's records revealed no evidence of a Level II PASARR (Preadmission Screening and Resident Review) had been submitted to the appropriate state-designated authority until 11/29/2022. On 02/14/2023 at 12:20 p.m., an interview conducted with S3SW. She stated Resident #8 was diagnosed with Bipolar Disorder on 3/23/2022. S3SW stated she was not in charge of PASSAR's until November of 2022 when the role was handed to her. She confirmed the resident's last PASSAR (Level1) was done in 2015. S3SW provided a Notice of Medical Certification from Office of Behavioral Health, showing the letter H box was checked which stated Resident #8 approved for admission by Level 11 Authority for a temporary period effective 11/29/2022 through 11/28/2023. She also confirmed that a Level 2 PASSAR should have been completed when the Resident was diagnosed with Bipolar Disorder on 3/23/2022. 41824 Resident #13 Review of Resident #13's records revealed he was admitted to the facility on [DATE] with diagnoses including Bipolar Disorder and Dementia. He was diagnosed with Schizoaffective disorder (a combination of symptoms of Schizophrenia and mood disorder) on 10/6/22. Review of the resident's progress notes August 2022 - October 2022 revealed in part: 8/6/22 1:54 p.m. Behavior -- CNA (Certified Nursing Assistant) came to nurse explaining that resident was sexually inappropriate with her. Resident hit his call bell and when she went in his room to answer it, resident was sitting up masturbating and asked her to have sex with him. Nurse explained to resident the inappropriateness of his behavior and he claims he was going to continue to do it. 8/6/22 4:59 p.m. Behavior -- CNA was trying to obtain vital signs on resident when he stuck his hands in between her legs and tried to grab her. 10/5/22 CNA Supervisor reported resident had been exhibiting sexually inappropriate behavior with CNAs. Resident had a history of periodically grabbing at CNAs in private areas. Had begun to expose himself to CNAs and grope himself in their presence. He does not respond to attempts to redirect this behavior or their attempts to give him privacy. He repeatedly calls CNAs to his room. NP (Nurse Practitioner Note) and ADON (Assistant Director of Nursing) made aware. ADON to contact family and psychiatrist to notify of these behaviors. Review of the resident's NP note dated 10/12/22 revealed Resident #13 was evaluated by the Psychiatric NP on 10/5/22. The resident was started on Seroquel due to his behaviors and was newly diagnosed with Schizoaffective disorder. Review of the resident's PASARR records revealed a request for Level II evaluation submitted on 11/25/22 and 1/26/23. Review of the requested forms revealed, If the resident has not received an OBH (Office of Behavioral Health) PASRR Level II evaluation (include residents regardless of whether or not they were previously identified by the Level I Screen and Determination as having primary dementia); please check which of the following apply: Diagnosis (tier 1): the resident has a diagnosis of Schizophrenia, Bipolar d/o, major depressive d/o, schizoaffective or other psychotic disorder was not checked off. Further review revealed a resident review is required if the following apply: resident has tier 1 diagnosis. There was no evidence that OBH had made a determination for Level II services for the reviews submitted. On 02/14/23 at 11:27 a.m., an interview and record review was conducted with S3SW who stated she was responsible for resident PASARR evaluations. She stated that the facility's DON (Director of Nursing) had given her a list of residents in November 2022 who needed to have reviews sent to OBH (Office of Behavior Health). She then revealed a large file box filled with papers which she said was all the files she sent to OBH. S3SW stated she sent Resident #13's Level II evaluation on 11/25/22 when she sent the mass number of requests to OBH per the DON's list. OBH called her and said that she sent too many resident requests that it was impossible for them to review all of them. OBH instructed her to send only the residents who needed to be reviewed. S3SW failed to provide written evidence that Resident #13's evaluation was resent during the review of the resident's record with S3SW. S3SW stated that she had not received a written notice of determination nor any response from OBH regarding Resident #13's evaluation dated 11/25/22. She further stated that she had not contacted OBH for a follow-up when she had not received a response. She reviewed the evaluation form she sent to OBH dated 11/25/22 and confirmed she had not marked that the resident had a tier 1 diagnosis. She confirmed that according to the resident's record, he was diagnosed with Schizoaffective disorder on 10/6/22. S3SW stated that she was aware Resident #13 had a history of behaviors, but was not made aware that the resident was diagnosed with Schizoaffective disorder until January 2023. Once aware of his diagnosis she sent another referral to OBH on 1/26/23 who determined the resident qualified for Level II services on 2/8/22.She stated that the facility did not have a system in place of communicating changes in diagnoses or conditions to ensure evaluations were submitted to OBH when required. S3SW confirmed that had she followed up with OBH in November 2022 that the resident could have possibly received services sooner. She confirmed that an evaluation for Level II services should have been submitted to OBH in October 2022 when Resident #13 was diagnosed with Schizoaffective disorder.

Based on observations and interviews the facility failed to 1) ensure food was palatable and attractive for 5 (#48, #55, 90, #93, #98) of 10 (#5, #48, #52, #55, #58, #59, #89, #90, #93, #99 ) residents reviewed for food. 2) serve food palatable and at an appetizing temperature for 3 (#5, #52, and #59) of 3 sampled residents. Findings: 1) Resident #48 Resident #48 was admitted to the facility on [DATE] with diagnoses including Atherosclerotic Heart Disease, Stage 3 Kidney Disease and Hypertension. Review of the Resident #48's quarterly MDS (Minimum Data Set), dated 1/5/23, revealed she had a BIMS (Brief Interview for Mental Status) score of 13, indicating her cognition was intact. On 02/13/2023 at 11:48 a.m., during an interview, Resident #48 reported the food was not tasty, appealing, or attractive. She gave the example that the peas look like they go from a can to the plate. On 02/13/2023 at 12:15 p.m., Resident #48 stated she was not eating lunch in the facility because on Monday's it is always beans. She reported her daughter brought her lunch from outside. On 02/14/2023 at 08:45 a.m., an observation of Resident #48's breakfast tray revealed she ate 25%. When surveyor asked why she ate so little she responded it was not tasty. On 02/14/2023 at 1:15 p.m., Resident #48, reported the lunch was not good, the rice was not cooked, she could not identify what the main course was, then stated it just looked like some green and yellow something. She added the soup only had bay leaves in it, there were no beans, and it was not appealing to the eye. Resident #55 Resident #55 was admitted to the facility on [DATE] with diagnoses including Hyperlipidemia, Vitamin Deficiency, Heart Failure, Morbid Obesity, and Type 2 Diabetes Mellitus. Review of the resident's quarterly MDS dated [DATE] revealed she had a BIMS score of 12 indicating her cognition was moderately intact. On 02/13/2023 at 11:23 a.m., Resident #55 reported the food had decreased in quality, flavor, and was unappealing. On 02/15/2023 at 10:03 a.m., during an interview S13LPN reported Resident #55 had complained about the food when she was served fish, because she does not like fish. Resident #90 Resident #90 was admitted to the facility on [DATE] with diagnoses including Anemia, Coronary Artery Disease, Hypertension, Hyperlipidemia, Parkinson's and Depression. Review of the resident's quarterly MDS dated [DATE] revealed she had a BIMS score of 15 indicating her cognition was intact. On 02/15/2023 at 10:28 a.m., an interview with S12CNA, she reported Resident #90 often tells her the food served is slop. Most of time, Resident #90 picks over her food then tells the CNA to take the tray, and had not hardly eaten anything. On 02/15/2023 at 10:40 a.m., during an interview Resident #90 reported the food here was not good, the lunch served yesterday was terrible and looked like c***. Resident #93 Resident #93 was admitted to the facility on [DATE] with diagnoses including Cerebral Vascular Accident, Anemia, Congestive Heart Failure, Hypertension, Diabetes Mellitus II and Hyperlipidemia. Review of Resident #93's quarterly MDS dated [DATE] revealed she had a BIMS score of 14 indicating her cognition was intact. On 02/14/2023 at 3:08 p.m., an interview was conducted with Resident #93. At this time Resident #93 stated the lunch food was not good today and he could not identify what the main course was. He described it as a green blob with some kind of rice dish that tasted bland, like plain white rice. Review of the grievance/complaint investigation log revealed the sister of Resident #93 had filed a complaint about the food on 12/6/2022. She reported the resident did not care for the food to the administrator. Resident #99 Resident #99 was admitted to the facility on [DATE] with diagnoses including Viral Hepatitis, Anxiety, Depression and Chronic Obstructive Pulmonary Disease. Review of the resident's quarterly MDS dated [DATE] revealed he had a BIMS score of 15 indicating his cognition was intact. On 02/15/2023 at 10:30 a.m., an interview was conducted with S12CNA. She reported Resident #99 had often complained about the food. . On 02/15/2023 at 10:47 a.m., during an interview, Resident #99 stated the food was not good and looked bad. He also stated, a lot of times it is not cooked enough, and the chicken is sometimes pink at the bones. On 02/14/2023 menu read: Italian Wedding Soup, Chicken Chablis, Creamy Lemon Risotto, Honey Roasted Dill Carrots, Honey Kissed Roll and Cloud Nine Salad. On 02/14/2023 at 12:30 p.m., surveyor was provided a lunch tray. The main course was not easily identified the rice in the Creamy Lemon Risotto was not completely cooked, and the carrots were dry and shriveled. On 02/14/2023 at 1:05 p.m., an interview and observation of the tray was conducted with S5DM. S5DM confirmed the rice in the Creamy Lemon Risotto, had the appearance of not being completed cooked. 47354 On 02/13/2023 during interviews with Residents #5, #52, and #59, they stated they were served cold food at meal times. On 02/14/2023 at 11:32 a.m., an observation revealed residents' lunch trays were brought from the kitchen area to Hallway A on an uncovered rolling cart. S4CNA (Certified Nursing Assistant) began passing out lunch trays 11:32 a.m. On 02/14/2023 at 11:38 a.m., an observation and testing of food temperature was conducted with S5DM (Dietary manager) when Resident #52 received her lunch tray. Resident #52's soup was served at 98 degrees Fahrenheit, chicken was served at 92.4 degrees Fahrenheit, and rice was served at 95.5 degrees Fahrenheit. On 02/14/2023 at 11:50 a.m., Resident #52 stated that her lunch was cold when she received her lunch tray. On 02/14/2023 at 11:43 a.m., a second observation and testing of food temperature was conducted with S5DM when Resident #5 received his. Resident #5's soup was served at 91 degrees Fahrenheit, chicken served at 102 degrees Fahrenheit, and rice was served at 109.5 degrees Fahrenheit. On 02/14/2023 at 12:05 p.m., Resident #5 stated her lunch was not warm enough when she received her lunch tray and requested a sandwich. On 02/14/2023 at 11:45 a.m., a third observation and testing of food temperature was conducted with S5DM when Resident #59 received his lunch tray. Resident #59's soup was served at 90 degrees Fahrenheit, chicken was served at 90 degrees Fahrenheit, and rice was served at 112 degrees Fahrenheit. An interview on 02/14/2023 at 11:55 a.m., with S5DM confirmed the above findings and stated that meal tray temperatures are not routinely checked once on the hallway and is not aware of food holding temperatures. S5DM stated that the facility does not have or use plate warmers for hall tray delivery.