Every finding on record at Memorial Manor

Based on observation, interview, and record review, the facility failed to follow physician's orders for 2 of 2 sampled residents reviewed for ventilators (Resident #9 and Resident #149); failure to follow physician orders for oxygen therapy for 2 of 2 sampled residents reviewed for oxygen (Resident #154 and Resident #52); and failure to monitor a resident during nebulizer therapy for 1 of 1 sampled resident reviewed for nebulizer therapy (Resident #52). The findings included: A record review of the facility's policy titled, Oxygen Administration PH 180-426, with an effective date of 04/2026, documented under procedure that: Oxygen is administered under orders of a physician. Personnel authorized to initiate oxygen therapy include physicians, Registered Nurses (RN), Licensed Practical Nurses (LPN), and Respiratory Therapist (RT). 1. Record review revealed Resident #149 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented Resident #1 had severe cognitive impairment and was dependent for activities of daily living. The assessment further documented the resident had a tracheostomy (hole in neck to breath) and was mechanical ventilator dependent (required a machine to breathe). A tracheostomy (trach) care observation was conducted with Staff C, a Respiratory Therapist (RT) on 04/22/26 at 12:00 PM for Resident #149. During trach care, Staff C confirmed with surveyor the current ventilator (vent) settings for Resident #149 was observed at a rate of 22 (number of breaths a minute). A review of Resident #149's physician orders revealed an order dated 04/10/26 for a vent rate of 20. An interview was conducted with Staff C on 04/22/26 at 3:00 PM. Staff C confirmed Resident #149's was not receiving the ordered vent rate settings. 2. Record review revealed Resident #9 was admitted to the facility on [DATE] with the last readmission date on 02/05/26. A comprehensive assessment dated [DATE] documented Resident #9 had severe cognitive impairment and was dependent for activities of daily living. The assessment further documented the resident had a tracheostomy (hole in neck to breath) and was mechanical ventilator dependent (required a machine to breathe). A review of Resident #9's care plans revealed a care plan dated 05/26/20 for inadequate airway patency/ ineffective clearance. Interventions included administer oxygen as ordered and as needed, position resident for maximum ventilatory efficiency, and monitor ventilator settings and oxygen. A review of Resident #9's orders revealed an order dated 01/18/23 for vent settings for rate 24, tidal volume of 450 (amount of air volume), and oxygen at 35%. An observation of Resident #9 was conducted on 04/21/26 at 10:00 AM and again on 04/22/26 at 12:30 PM. Resident #9's vent settings were as follows: rate 22, tidal volume 400, and oxygen at 40%. An interview was conducted with Staff C, a Respiratory Therapist (RT) on 04/22/26 at 3:00 PM. Staff C confirmed Resident #9 was not receiving the ordered vent settings. Staff C stated Resident #9 went out to the hospital and came back on hospital vent settings. Staff C stated it was nursing responsibility to assure correct orders are input into the system. An interview was conducted with the Director of Nursing (DON) on 04/22/26 at 4:00 PM. The DON stated a resident's vent settings should match the physician's orders. The DON acknowledged the above. 3. A record review for Resident #154 revealed the resident was admitted to the facility on [DATE]. The following diagnoses were included: Pulmonary Embolism and Lung Cancer. The 5-day Medicare Minimum Data Set (MDS) assessment dated [DATE], documented a Brief Interview of Mental Status (BIMS) with a score of 15, on a scale of 0 to 15, which indicated that Resident #154's cognition was intact. It also documented that the resident required substantial to maximum assistance while in bed to roll left or right and to reposition himself from laying on his back to sitting on the side of the bed. Record review revealed a Physician's Order dated 04/14/26 was noted for continuous oxygen therapy via nasal cannula at 3 liters per minute (L/min). It specified to keep the resident's oxygen saturation percentage at greater than 90%. Record review revealed Resident #154 had a Baseline Care Plan that identified the resident at risk for respiratory distress and to maintain the resident's oxygen saturation at 90% and above. Further record review revealed Resident #154's oxygen saturation was recorded in the vitals section of the health record. His oxygen saturation results were never observed to be equal to or below 90%. Some of the results were as follows: 04/20/26 at 09:26 AM- 96% 04/21/26 at 08:27 AM- 97% 04/22/26 at 09:24 AM- 96%. On 04/21/2026 at 9:28 AM, Resident #154 was observed in bed wearing a nasal canula. The oxygen concentrator was observed with the flow meter set at 4.5 L/min. On 04/22/26 at 8:40 AM, Resident #154 was observed consuming his breakfast meal in bed. He was wearing a nasal cannula, and the oxygen concentrator was observed with the flow meter set at 3.75 L/min. The resident denied ever adjusting the concentrator setting and stated he could not reach it. On 04/23/26 at 11:10 AM Resident #154 was observed in the Occupational Therapy room about to begin his upper body exercises. He was wearing a nasal cannula, and a portable oxygen tank was observed in use. The setting of the tank was 4.0 L/min. On 04/23/26 at 11:34 AM an interview was conducted with Staff C, a Respiratory Therapist (RT), who had been employed by the facility for about 2.5 years. She stated RT's were responsible for providing breathing treatments that were administered via a nebulizer, and they also managed oxygen concentrators. She stated the concentrator flow meter should be set to the amount ordered. She explained oxygen orders were written to help wean a resident off oxygen and the only time oxygen would be provided at a higher rate was when oxygen levels were below the goal. The RT also stated that a resident's oxygen levels were not increased during therapy unless a resident had sign/symptoms of respiratory distress or verbalized they were short of breath. The oxygen levels then would be taken and if the results were below the goal, the oxygen then could be increased temporarily and the physician would be alerted. On 04/23/26 at 11:47 AM an interview was conducted with Staff G, Registered Nurse (RN), who had been employed by the facility for 1 year and 4 months. She stated when a resident is prepared to go to therapy, either the RN or the Certified Nursing Assistant (CNA) would set a resident's oxygen tank setting according to the physician's order. She stated she was not sure of Resident #154's oxygen order and looked it up in his record. She confirmed the order was 3 L/min. She stated she had helped prepare the resident for therapy that day and had set the oxygen tank to 3 L/min. On 04/23/26 at 11:53 AM an interview was conducted with Resident #154's family member while in his room. She stated she never touched Resident #154's oxygen equipment and did not prior to sending him to therapy that day. On 04/23/26 at about 12:00 PM an interview was conducted with Staff H, Therapy Assistant, who had been employed by the facility for 10 years. She stated she was the person who brought the resident to therapy and did not adjust the oxygen setting. Photographic evidence was obtained. 4. Record review documented Resident #52 was admitted to the facility on [DATE] with diagnoses which included Facial Fracture, Traumatic Brain Injury, and Chronic Respiratory Insufficiency. A review of Resident #52's Minimum Data Set assessment dated [DATE] documented under the Brief Interview for Mental Status (BIMS), revealed that a current score is still in progress. Section O dated 04/20/26, documented oxygen (O2) at two (2) liters per minute via nasal cannula. A review of physician orders dated 02/05/26 revealed oxygen therapy, with a routine method of O2 administration via nasal cannula at 2 Liters per minute. An additional record review documented by a Physician Assistant (PA), dated 04/14/26, revealed oxygen at 2 liters per minute for Chronic Respiratory Insufficiency. A review of the most recent nursing progress notes dated 04/13/26, documented by a Licensed Practical Nurse (LPN), revealed Resident #52 was receiving oxygen at 2 liters per minute through nasal cannula as ordered. There were no other nursing progress notes documenting increased oxygen flow amount. During an observation conducted on 04/20/26 at 2:51 PM, Resident # 52 was observed in bed with a nasal cannula on both nares. The oxygen concentrator on the floor located at the left side of her bed was observed delivering oxygen flow at 3 liters per minute. When Resident #52 was asked if staff had adjusted her oxygen by touching the machine, she responded, no, no one has touched the machine. When she was asked if she gets out of bed, she responded, no she does not get up without staff assistance. During an observation conducted on 04/21/26 at 11:45 AM, Resident #52 was observed with a nasal cannula on both nares, and the oxygen flow meter was at 3.5 Liters per minute. When the resident was asked if staff had checked and adjusted her oxygen, she responded, no. During an observation conducted on 04/22/26 at 8:44 AM, resident was inside the room lying on the bed with a nasal cannula on both nares. The oxygen flow meter was at level 3.5 Liters per minute. When the resident was asked if staff adjusted her oxygen level, she responded, no one touched the oxygen machine. An electronic review of flowsheet records from 04/13/26 until 04/22/26, documented Resident #52's oxygen flow rate was at 2 liters per minute. In an interview conducted with Staff F, a Certified Nursing Assistant (CNA), who has been working in the facility for 4 years. She stated that only staff Respiratory Therapist may adjust the oxygen flow meter. They do not touch the nasal cannula, but during cleaning of the resident's face, they sometimes have to remove it for few a seconds to clean the nose area. She added no CNAs touch the oxygen concentrators to adjust the oxygen amount delivered to the resident. In an interview conducted with Staff A, a Registered Nurse (RN), on 04/22/26 at 9:45 AM, she stated that she has been working in the facility for 20 years. When asked who is responsible for adjusting the oxygen flow meter for residents, responded, only respiratory therapists are adjusting the oxygen flow. When asked if Nurses check and document the oxygen flow amount residents are receiving during their shifts, she responded, yes, they check and document the correct physician ordered delivery flow amount with the method of oxygen delivery. When asked how often they check the oxygen if it is according to the physician order, she responded multiple times during their shifts. A review of the facility's policy titled, Nebulizer Therapy PH 180-425, with an effective date of 04/2026, documented the following under the care of resident: Assist the resident into a comfortable position. If possible, place resident in an upright position to encourage full lung expansion and promote aerosol dispersion (8). Keep nebulizer vertical during treatment (12). Observe resident during the procedure for any change in condition (13). During observation and interview conducted with Staff C, a Respiratory Therapist (RT) on 04/22/26 at 9:45 AM, she was observed with all her supplies inside a plastic bag. She entered Resident #52's room without knocking, and immediately sanitized her hands, then donned gloves. She informed Resident #52 about the nebulizer therapy, measured the oxygen saturation by placing an oximeter on Resident #52's finger, and started opening the plastic bag with the medication. Staff C did not read and check the medication label but immediately instilled the solution into the bottom part of the nebulizing equipment. She tossed the medication into the trash afterwards. When asked about the expiration date of the medication, she responded, she did not check. Observation revealed Staff C then placed the face mask on the resident and left the room from 9:45 AM until 9:48 AM. The resident, after a facemask was strapped onto her was observed having trouble and decided to adjust her position. While raising her head up using a bed control, the tubing came off the bottom part of the face mask. The resident tried hard to put the tubing back on, but to no avail. When the resident was asked if Staff C, usually leaves her during the treatment, she responded, she usually does not come back until after the treatment is over. Observations revealed Staff C returned to Resident #52's room after 3 minutes. She then helped the resident attach the tubing on the bottom part of the face mask. When asked if the resident received the physician ordered dose for this nebulizing treatment after the tubing got disconnected for few minutes, she did not respond. In an interview conducted with the Director of Nursing (DON) on 04/22/26 at 10:18 AM, when asked if staff may leave the resident during inhalation and nebulizing treatment, she responded, as long as they have direct vision of the resident in case of any untoward reactions, it is ok. When asked if staff can have a direct vision of a resident located on the window side and is separated from the door bed with privacy curtain and a wall, would Staff have direct vision of that resident, she did not respond.

Based on observation and interview, the facility failed to failure to ensure the infection control program was implemented by providing equipment for proper hand hygiene in the soiled linen area of the laundry room. The findings included:A review of a facility policy titled, Laundry PH 180-886, with an effective date of 04/2026, revealed the following: The facility launders linens and clothing in accordance with current Center for Disease Control and Prevention (CDC) guidelines to prevent transmission of pathogens.Memorial Manor's laundry area will provide hand washing facilities and products as well as personal protective equipment (PPE). A review of the facility's policy titled, Handling Soiled Linen, implemented on 07/01/23, documented to wash hands after contact with soiled linen (8). During an observation conducted on 04/22/26 at 8:45 AM with Staff D, a laundry staff, who stated she has been working in the facility for 8 years, when asked to show the hand-washing station inside the soiled linen area, she pointed at a sink with no trash bin underneath or next to it, and no paper towel dispenser. Staff D stated they have a soap dispenser, but no paper towel dispenser for hand drying, and no trash collection inside this room. When she was asked how long they had been sorting soiled linen without proper equipment to perform hand hygiene, she stated she does not remember. When she was asked if she had reported the issue to the Facilities Director, she did not respond. Staff D then called an electrician who installed the liquid soap dispenser behind the washing machines. The electrician stated that he was not aware the soiled linen area has no paper towel dispenser or a trash bin. In an interview conducted with Staff E who has been working in the facility for 5 years, when she was asked to demonstrate hand hygiene, she motioned that after dispensing soap into her hands, and rinsing them under running tap water, she turns off the faucet using one of her wet hands, and wiggle them (hands) to air dry. When she was asked if she is following the proper hand hygiene technique by doing these processes, she responded, no. In an interview conducted with the Facilities Director on 04/22/26 at 9:28 AM, when he was asked who is responsible for ensuring there are equipment available for staff inside the laundry room to perform proper hand hygiene, he responded, he is. When he was asked when the paper towel dispenser was removed inside the soiled linen area inside the laundry room, he responded it was removed because the facility had installed a new soap dispenser system for the washing machines, but he did not know why the paper towel dispenser was not put back. He stated he would ask another staff for a log or documentation of a date when the paper towel dispenser was removed. The DON (Director of Nursing) presented documentation later that day, but it did not include any record of when the towel dispenser was removed. When the electrician and the Facilities Director were both asked where would staff throw any trash inside the soiled linen area in the laundry room, the Facilities Director responded, he did not know there was no trash bin under the sink. He stated it is the first time he was informed by the electrician that there is no trash bin inside the soiled linen area of the laundry room. In an interview conducted with the Infection Control Nurse on 04/22/26 at 5:08 PM, when she was asked if laundry staff had attended the hand hygiene in service training, she responded, yes.

Based on record review and interview, the facility failed to respond to a change in a resident's condition in a timely manner for 1 of 3 sampled residents reviewed for hospitalizations (Resident #1), as evidenced by failing to assess a resident with symptoms of a Gastrointestinal (GI) Bleed, and notification to the physician for over 6.5 hours later. The findings included:| A review of the facility's policy titled Change In A Resident's Condition Or Status, dated October 1990 and last revised in January of 2026, documented it is the policy of the facility to consult with the resident immediately and notify the attending physician of the following: an accident/fall or any injury; a significant change in the resident's physical, mental or psychosocial status; a need to alter treatment significantly; a decision to transfer or discharge the resident from the facility. The procedure was noted as the following:The charge nurse/designee on duty is responsible for notifying the resident's physician and family member/legal representative of a change in the resident's condition, accident/fall or any injury, significant treatment alteration or discharge/transfer from the facility.Family members/legal representative is to be notified as soon as possible.Nurse assessment/evaluation and document findings.Carry out orders received if patient is remaining in the facility.Monitor and update.Notifications are to be charted in the nurse's progress notes.If the charge nurses are unable to contact the resident's family/legal representative, the director of patient care services is to be notified. Record review revealed Resident #1 was admitted to the facility on [DATE]. A comprehensive assessment dated [DATE] documented the resident had severe cognitive impairment and was dependent for activities of daily living. The assessment further documented the resident received tube feedings for nutritional support. A review of Resident #1's care plans revealed a care plan dated 09/10/25 that documented the resident was at risk for aspiration (feedings inhaled into the lungs) due to tube feeding dependency. An intervention included to report abnormal findings to the physician. A review of Resident #1's orders revealed an order dated 02/24/26 for tube feedings (TF) to run at 60 millimeters an hour for 16 hours daily. A review of Resident #1's nursing progress note dated 04/19/26 at 12:33 AM, which documented Resident #1 was noted with nausea and was medicated with Zofran (antinausea medication). Resident #1's TF was documented to be held for 30 minutes and to continue to monitor. A progress note dated 04/19/26 at 1:42 AM documented Resident #1 had a large amount of coffee ground vomitus (indicative of a gastrointestinal bleed). The note documented the Zofran administered earlier was ineffective, the resident's feedings were off, and the physician was called and a message was left with return call pending. Further review of Resident #1's records did not reveal any assessment of the resident's condition, or vital signs at the time. A progress note dated 04/19/26 at 4:19 AM (over 2.5 hours later) documented Resident #1's head of bed was elevated, no more episode of vomiting, was resting quietly in bed with no distress. The note documented, will continue to monitor. Further record review did not reveal any vital signs for Resident #1 since the change in the resident's condition. The note did not indicate any notification of a physician order or confirmation the physician was aware of the resident's change in condition at the time. Record review revealed Resident #1 had vital signs recorded on 04/19/26 at 6:43 AM (5 hours after the change in condition) and again at 7:30 AM. The vital signs were within normal limits. A progress note dated 04/19/26 at 8:28 AM documented second call placed to physician service related to large amount of coffee ground emesis (vomiting) earlier this morning (over 6.5 hours after the change in Resident #1's condition). The physician returned call and ordered for the resident to be transferred to the hospital for evaluation and treatment. Further record review revealed Resident #1 was admitted to the hospital for upper GI (gastrointestinal) bleed on 04/19/26. An interview was conducted with the Director of Nursing (DON) on 04/22/26 at 3:00 PM. The DON stated with a change in a resident's condition, the nurse is expected to assess the resident, including evaluating the resident's vital signs, and call the physician. The DON further stated if there was no response from the physician by 2 hours, the nurse should assess the resident, including vital signs, notify a supervisor, place another call to the physician, continue to monitor and send the resident out 911 if need be. The DON acknowledged there was no evidence/documentation of an assessment /vital signs for Resident #1's change in condition. The DON further acknowledged a second attempt to call the physician about a change in the resident's condition was over 6.5 hours later, and there was no documentation of a supervisor being notified in the delay of a physician's response to call, which delayed the treatment of Resident #1's change in condition.

Based on interviews and record review, the facility failed to ensure the resident's physician was notified regarding the resident's blood pressure medications that were held for three consecutive days due to low blood pressure for 1 of 3 sampled residents (Resident #2). The findings included:Review of the facility's Standard Practice policy titled Change in a Resident's Condition Status revised on 01/2025 documents it is the policy of (name of facility) to consult with the resident immediately and notify the Attending Physician of the following:.a significant change in the resident's physical, mental or psychosocial status; a need to alter treatment significantly or a decision to transfer or discharge the resident from the facility. The resident's legal representative or interested family member is to be notified of these changes as soon as possible.Resident/Family/Physician notification is to be documented in the Nurses' progress notes. Review of the facility's policy titled Administration procedures for all medication PH 180-113 revised on 01/2024 documents .notification of Physician/Prescriber: held medications for pulse, blood pressure.resulting in medications being held.Review of Resident #2's clinical record documented a readmission to the facility on [DATE] and a transfer to a local hospital on [DATE]. The resident's admitting diagnosis was Toxic Metabolic Encephalopathy and Hypertension. Review of Resident #2's care plan titled (Resident #2) is at risk for cardiovascular complications related to HTN (hypertension), hypokalemia and Anemia initiated on 07/25/25 with interventions to include: monitor vital signs to include BP (blood pressure) and Pulse. Notify physician of abnormal findings. Review of Resident #2's nurses notes dated 09/13/25 at 1:13 PM, documented a heart rate (HR) of 84, a blood pressure (BP) of 90/55. The nurse note lacked written evidence that the resident's physician was notified of a change of the resident's low BP. Review of Resident #2's nurses note written by Staff B, Registered Nurse (RN) dated 09/14/25 at 9:00 AM documented a HR of 114, a BP of !84/50 (the BP reading was documented in red and had a question mark next to the reading), BP low again this AM, resident denies dizziness, fatigue or blurred vision, but HR of 114. Resident has no appetite for current meal. The clinical record lacks written evidence that the physician was notified of a change of the resident's low BP and elevated HR. Review of Resident #2's nurse note dated 09/15/25 at 8:20 AM documented a HR of 111, a BP of !76/52 (question mark next to the reading noted). Appears weak with poor appetite despite encouragement. PA (Physician Assistant) evaluated. Pending new orders.Review of Resident #2's September 2025's MAR documented that the resident's blood pressure medications:- Irbesartan (Avapro) 150 milligrams (mg) daily at 9:00 AM that was started on 08/04/25, was not given on 09/12/25, 09/13/25 and 09/14/25. -Metoprolol (Toprol XL) 24-hour tablet 50 mg daily at 9:00 AM that was started on 08/02/25, was not given on 09/12/25, 09/13/25 and 09/14/25. - Nifedipine (Adalat) 24-hour tablet 60 mg daily at 9:00 AM that was started on 08/02/25, was not given on 09/12/25, 09/13/25 and 09/14/25. Further review revealed no written evidence of Resident #2's physician notification regarding low BP, elevated HR and not given/held the resident's blood pressure medications on 09/12/25, 09/13/25 and 09/14/25. On 10/27/25 at 11:52 AM, an interview was conducted with Staff A, Registered Nurse (RN), who was asked what do you consider a resident change in condition and stated a mental status change, appetite not as usual and vital signs off from normal. Staff A was asked what would you do then and replied she will call the doctor.On 10/27/25 at 2:10 PM, an interview and a side-by-side review of Resident #2's clinical record was conducted with the Director of Nursing (DON). The review revealed the resident had a low BP on 09/13/25, and on 09/14/25. The DON was apprised the resident's BP readings were off from her baseline, prior documented readings were anywhere from 130's 150's and 160's with HR readings between 70's and 80's and had an elevated HR 144 on 09/14/25. The DON was asked to submit written evidence regarding Resident #2's physician notification of low BP, an elevated HR and not given BP medications for three (3) consecutives days. The DON stated she did not see any written notification to the physician. On 10/27/25 at 3:12 PM, an interview was conducted with Staff B, RN who was asked what would you do if your resident has a change in vital signs and replied, call the supervisor, call the doctors, get new orders, send them out and call the family. Consequently, a side-by-side review of Staff B's nurses note dated 09/14/25 for Resident #2 was conducted. Staff B was asked if she notified Resident #2's low blood pressure reading of 84/50 and the heart rate of 114 to the physician and stated she rechecked the blood pressure one hour later and it was okay. The RN was asked why she did not notify the physician of the changes to the BP and HR and stated she looked at the history and noticed the blood pressure reading was kind of baseline, was asymptomatic, added the resident was not eating, having a low BP and elevated HR she was dehydrated, got report she was not eating very well, but make up by drinking ensure. Staff B was asked if she thought Resident #2 was dehydrated, why did not call the doctor? Staff B stated she would like more proof, rechecked the BP in one hour and it was okay for not calling the doctor. There was no written evidence that Staff B rechecked the resident's elevated HR. Staff B stated the resident was hypertensive and believed she held the medications and stated, critical thinking is thinking on your feet and will call the doctor after she exhausted all of her nursing knowledge, will call the supervisor after all of steps were done, added this where we are, what do I do now. Staff B was asked if she discussed Resident #2's low blood pressure and elevated heart rate with the supervisor and stated she did not. On 10/27/25 at 5:59 PM, during an interview, the DON was asked if the nurse was to call the physician with changes on vital signs and medication held due to low blood pressure and stated a standard of practice is to hold the medication if the BP is low. The DON stated the physician should have been notified and added a low blood pressure could be due to multiple reason, a sustained low BP is a cause to call the physician.

Based on observations, interviews, and record review, the facility failed to monitor the behaviors of residents who are receiving psychotropic medications for 4 of 5 sampled residents reviewed for unnecessary medication (Resident #94, Resident #79, Resident #73, and Resident #1). The findings included: A review of the facility ' s policy titled Use of Psychotropic Medication revised in October 2022 revealed the following: Resident are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnoses and documented in the clinical record, and medication is beneficial to the resident, as demonstrated by monitoring and documentations of the resident ' s response to the medications. 1) Record review revealed that Resident #94 was admitted to the facility on [DATE] with diagnoses of Mild Dementia, Major Depressive Disorder, and Type 2 Diabetes. The Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #94 has a Brief Interview of Mental Status (BIMS) score of 11, indicating moderately cognitively impaired. A review of a Physician 's order revealed an order for Zoloft (antidepressive medication) 25 milligrams daily, which was dated 09/03/24. In an interview conducted on 10/11/24 at 1:00 PM with Resident #94, it was revealed that she did not remember seeing a psychologist for her anxiety and depression. She is currently not having any symptoms of anxiety and anxiousness. Review of the care plan, which started on 09/10/24, revealed the following: Resident #94 had psychosocial anxiety with the goal of not having the anxiety interfere with daily life functions. Interventions are in place to administer appropriate medications as ordered and monitor for effectiveness of medications-a care plan for psychosocial behaviors with interventions to monitor for changes/severity of behavioral symptoms. Further review revealed a care plan, which started on 09/10/24, for psychosocial-mood documented, with interventions in place: Monitor mood state and report changes to appropriate disciplines. Administer medications as ordered. Monitor the effectiveness of medications. A review of the Behavior Monitoring Flow Sheet did not show that any behavior monitoring was done for Resident #94 since admission on 09/03/24. Record review revealed that Resident #94 was seen by a psychologist on 10/9/24 for situational depression and major depressive disorder. A review of the progress notes completed by nursing did not show any documentations regarding behavior monitoring. In an interview conducted on 10/11/24 at 1:05 PM with Staff C, a Registered Nurse (RN) she stated that any behaviors observed of the residents are documented in the progress notes for every medication that was administered to them. This included behavioral examination and observation of the patient for any signs of agitation, anxiety, and extreme depression that she defined as being quiet and sleepy. She further reported that if no behaviors are observed she documents as stable. In this interview, Staff C did not mention any Behavior Monitoring Flow Sheet. In an interview conducted on 10/11/24 at 1:15 PM with Staff A, RN, she stated that residents on psychotropic medications are being monitored for behaviors and documented on a specific behavior flow sheet that she created herself. Nursing supervisors fill out that particular behavior flow sheet, but the bedside nurse observes. In an interview conducted on 10/11/24 at 1:20 PM with the facility's Director of Nursing, the director stated that the behavior flow sheet is completed only when a resident has a present behavior. When behaviors are present, they are documented in the progress notes (narrative) and noted as stable. In an interview conducted on 10/11/24 at 1:23 PM with Staff A, she acknowledged that Resident #94 did not have a completed behavioral flow sheet since admission on 09/03/24. 41837 2) Record review for Resident #79 revealed the resident was admitted to the facility on [DATE] with diagnoses that included in part the following: Paraplegia, Intracranial Injury with Loss of Consciousness, and Sequela. Review of the Minimum Data Set for Resident #79 dated 10/03/24 documented in Section C a Brief Interview of Mental Status score of 15 indicating a cognitive response. Review of the Nurse Progress Notes for Resident #79 from 09/01/24 to 10/14/24 revealed no documentation of behaviors being monitored. Review of the Behavior Monitoring Flow Sheet for Resident #79 from 09/01/24 to 10/14/24 revealed no Behavior Monitoring Flow Sheet. Review of the Physician's Orders for Resident #79 revealed an order dated 06/27/24 for Mirtazapine (Remeron) 15 mg oral at bedtime for Major Depressive Disorder. Review of the Care Plan for Resident #79 dated 10/04/24 with a problem of resident is at risk for adverse side effects related to use of psychotropic medication Diagnoses Anxiety and Depression. The goal was for the resident to have no injury to medication usage/side effects through next review date. The interventions included monitor for confusion and sedation, Monitor moods and behavioral patterns. Notify MD of any significant changes. Gradual dose reduction as needed. During an interview conducted on 10/14/24 at 9:25 AM with the Director of Nursing who stated she has worked at the facility for 6 years. When asked about behavior monitoring for residents on psychotropic medications, she stated If resident is receiving a psychotropic medication, the resident would be monitored for behaviors, and this would be documented on the behavior monitoring flow sheet or it could be documented in the nursing progress notes. They only document if the resident is having behaviors, they do not document if the resident has no behaviors. They chart by exception. When asked about monitoring behaviors for Resident #79 the DON acknowledged there was no Behavior Monitoring Flow Sheet for the resident. The DON also acknowledged there were no Nursing Progress Notes for the resident that document with information specifically pertaining to behaviors. When asked if they have any facility policy indicating they document by exception, she said no. During an interview conducted on 10/14/24 10:44 AM with Staff D Consultant Pharmacist, since May 2024. When asked when a resident is on psychotropic medication, does he check if the resident is being monitored for behaviors, he stated yes, he does, he believes they chart by exception. If they have no Behavior Monitoring Flow Sheet, he would assume the resident is not having any behaviors. When asked about an example of a Behavior Monitoring Flow Sheet for Resident #79 which documented an outcome code as same, and then improved and was asked what this indicates, he said I would not know. It was noted that this improved behavior documentation did not specify which behavior this resident experienced and what had improved. During an interview conducted on 10/14/24 at 11:22 AM with Staff E, Registered Nurse who stated she has worked at the facility for 2.5 years. Staff E was asked if a resident is receiving a psychotropic medication does she document for behaviors. She stated yes, if resident is screaming or fighting with staff, she would document this on the note (Nursing Progress Note) for the day. When asked about documenting on a behavior monitoring flow sheet, she said no she does not use this. 49060 3) Record review for Resident #73 revealed that the resident was admitted to the facility on [DATE] with the following diagnoses: Coronary Artery Disease; Diabetes Mellitus, type II; Venous Insufficiency; Vertigo. Review of Section C of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #73 had a Brief Interview for Mental Status (BIMS) of 13, which indicated that he was cognitively intact. Review of Section N revealed that Resident #73 was on an antidepressant. Review of the Physician's Orders showed that Resident #73 had an order dated 08/22/24 for Cymbalta (Duloxetine) capsule 20mg for Depression. Review of the Physician's Orders showed that Resident #73 had an order dated 09/09/24 for Remeron (Mirtazapine) tablet 7.5mg for Appetite loss. Review of the Physician's Orders for Resident #73 did not include orders for side effects monitoring and no orders for behavior monitoring for psychotropic medications. Review of the Care Plan dated 08/27/24 documented that Resident #73 is at risk for adverse side effects related to (r/t) use of psychotropic medication due to diagnosis: Depression and Adjustment Disorder with Anxiety. The goal for the resident was to have no injury related to the medication usage and/or side effects through the review date. The interventions included: Administer medication as ordered; Report any negative observation to MD; Monitor for confusion and sedation; Monitor moods and behavioral patterns; Gradual dose reduction as needed. Review of the Nursing Note/assessment dated from 08/22/24 to 10/08/24 revealed no documentation of side effects or behavior being monitored for Resident #73. An interview conducted on 10/11/24 at 10:15 AM with DON. She stated residents on psychotropic medications are monitored for behaviors only if the behavior is observed, and then documented by the nursing management under the Behavior Monitoring Flow Sheet (BMFS) in the computer system. She also stated if the resident has not shown any behavior changes, there will not be a BMFS in the resident's chart. 50895 4) A record review on 10/14/24 09:19 AM revealed that Resident#1 was admitted to the facility on [DATE] with diagnoses that included Agitation, Anxiety, Depressive disorder, Mental disorder, Dysphagia, GERD, Intracerebral hemorrhage, Psychosis, Seizures, and Unspecified cerebral artery occlusion with cerebral infarction. The Brief Interview for Mental Status (BIMS) score was 0 on the Minimum Data Set (MDS) assessment Quarterly assessment dated [DATE]; this indicated that Resident #1 had severe cognitive impairment. This MDS assessment also showed that Resident #1 was administered antipsychotics on a routine basis for anxiety and depression. According to Resident #1's Physician's orders, she was on Diazepam since 09/17/24 (5 mg twice a day for anxiety), Mirtazapine since 02/06/24 (30 mg at bedtime for depressive disorder), and Quetiapine since 02/06/24 (50 mg every 8 hours for Depression). These are psychotropic medications. Resident #1's care plan dated 08/08/24 stated that Resident #1 was at risk for adverse side effects related to use of psychotropics. The interventions for that problem included to monitor for confusion and sedation, and to monitor for moods and behavioral patterns. The MD (Medical Doctor) was to be notified of any significant changes. In addition, the care plan stated that Resident #1 has a history of periods of agitation and resistance of care at times. The specified goal was that the resident's mood state would not interfere with daily life functioning. The interventions included to monitor mood state and to report changes to appropriate disciplines. Another care plan for Resident #1 stated that the resident had the potential for symptoms of mood disorders; the interventions included to monitor mood state and to report the changes to the appropriate disciplines. A review of the Behavior Monitoring for Psychotropic Meds report beginning 09/01/24 and ending 10/13/24 showed no documentation of behavior monitoring on 09/03/24, 09/10/24, 09/11/24, 09/16/24, 09/18/24, 09/24/24, 09/25/24, 09/27/24, 09/28/24, 09/29/24, 09/30/24, 10/05/24, 10/06/24, 10/08/24, 10/09/24, and 10/11/24. Photographic evidence obtained.

Based on observations, interviews and chart review, the facility, failed to provide the correct diet consistency, for the Pureed diet observed during 2 of 2 observations for Resident #34. This had the potential to effect 10 residents on a Pureed diet. The findings included: A review of the International Dysphagia Standardization Initiate (IDDSI) Descriptions provided by the facility's Speech Therapy Pathologist revealed the following: Pureed diet level 4: falls off the spoon when tilted. It continues to hold its shape in a plate. It cannot be drunk from a cup or sucked from a straw. It can be molded and does not require chewing. It has no lumps or stickiness. A chart review showed that Resident #34 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Bipolar Disorder, and Depression. The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score indicating Resident #34 is rarely understood. In an observation conducted on 10/07/24 at 12:43 PM, Resident #34 was observed eating her lunch meal in her room. The meal ticket was noted to have the following: pureed chicken, mashed potatoes, pureed broccoli, pureed bread, and pureed cobbler. The meal plated was noted with pureed chicken, mashed potatoes, pureed broccoli, pureed cobbler, and pureed bread, noted with lumpy pieces and not having one uniform consistency (photographic evidence obtained). In an observation conducted on 10/08/24 at 8:43 AM, Resident #34 was eating her breakfast tray in the room. The breakfast tray consisted of pureed fortified oatmeal, pureed cheese omelet, pureed ham, and pureed bread, which was noted to have lumps and not one uniform consistency (photographic evidence obtained). In an interview conducted on 10/14/24 at 8:25 AM with Staff B, the Speech-Language Pathologist, it was stated that the pureed diet should be smooth and creamy with no solid particles. It should not have any lumps or pieces. According to Staff B, most of the pureed foods are bought by an outside company, and only certain food items are prepared in-house. In an interview conducted on 10/14/24 at 9:10 AM, the Food Service Director stated that Pureed bread is not bought from an outside company and is made in-house. She further said that 10 residents are on a pureed diet. When photographic evidence of the pureed diet was shown, she acknowledged that it was not within the guidelines of a pureed diet consistency.

Based on observations, interviews, and record reviews, the facility failed to provide food accommodating resident preferences, choices, and tolerances. The facility did not follow its menu regarding food portion sizes during multiple dining observations for Resident #74, Resident #148, Resident #14, Resident #55, Resident #20, and Resident #71. The findings included: A review of the facility's 4-week menu cycle revealed the following: Tuesday's menu showed lunch served was had roast beef (3 ounces), gratin potatoes, green beans, and a soft roll. For Wednesday, the menu showed lunch served was glazed pork loin, baked potato, and mixed vegetables. 1. Resident #74 was admitted to the facility on [DATE] with a diagnosis of Stroke and Hypertension. The Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview of Mental Status (BIMS) score of 09, indicating mild to severe cognitive impaired. The diet order showed a mechanical soft cardiac heart healthy dated 10/2/122. In an observation conducted on 07/25/23 at 8:07 AM, Resident #74 was eating his breakfast meal. Closer observation revealed a meal ticket, documenting 6 ounces of grits, 2 ounces of eggs, ground ham, and a slice of white bread. Further observation revealed Resident #66's tray did not have the 6 ounces of grits as noted on his meal ticket. 2. Resident #148 was admitted to the facility on [DATE] with a diagnosis of Diabetes and Severe Obesity. The MDS assessment dated [DATE], showed a BIMS score of 15, indicating cognitively intact. Diet order noted for cardiac heart-healthy carbohydrate control dated 07/24/23. In an observation conducted on 07/25/23 at 8:44 AM, Resident #148 was in his room with a breakfast tray. His meal ticket showed a diet for cardiac carbohydrates controlled with eggs, white toast, coffee, and sugar packets. In this observation, Resident #148 stated that they gave him sugar packets on his tray and that he has diabetes. A review of the facility's week-at-a-glance menu breakdown showed that on the carbohydrate-controlled diet, sugar substitutes would be provided instead of sugar packets. 3. Resident #14 was admitted to the facility on [DATE] with diagnoses of Dementia and Parkinson's disease. The MDS dated [DATE] lacked documentation of a BIMS score. The order noted for regular diet dated 03//02/22. In an observation conducted on 07/24/23 at 12:15 PM, Resident #14 was noted with a lunch tray. Closer observation showed a regular diet meal ticket with 3 ounces of roast beef. The lunch plate was noted with two round slices of roast beef. In an interview conducted on 07/25/23 at 3:50 PM, Staff C, Registered Dietitian, stated that for the lunch menu, the roast beef is sliced and placed on the scale to ensure that each slice is 3 ounces. When asked by the surveyor of why some residents received two round pieces of roast beef and some residents received one portion, she said that they might be less than 3 ounces, and if they looked smaller, they would provide two pieces. 4. Resident #55 was admitted to the facility on [DATE] with a diagnosis of Anemia and Diabetes. The MDS assessment dated [DATE] with a BIMS score of 14, which is cognitively intact. Diet order for cardiac, carbohydrate controlled dated 03/01/22. In an observation conducted on 07/24/23 at 12:10 PM, Resident #55 was noted with her lunch tray. Closer observation showed a lunch plate that consisted of 1 slice of round roast beef and potatoes. The meal ticket showed Resident #55 has a cardiac carbohydrate-controlled diet with 3 ounces of roast beef. 5. Resident #20 was admitted to the facility on [DATE] with diagnoses of Diabetes and Hypertension. The MDS assessment dated [DATE] with BIMS score of 13, indicated the resident cognitively intact. Diet order noted for carbohydrate control diet dated 03/01/22. In an observation conducted on 07/24/23 at 12:13 PM, Resident #20 was noted with her lunch tray. Closer observation showed a lunch plate that consisted of 1 slice of round roast beef. The meal ticket showed that Resident #20 has a carbohydrate-controlled diet with 3 ounces of roast beef. Another observation was conducted on 04/26/23 at 8:12 AM, Resident #20 was eating her breakfast meal. The meal ticket showed a diet for carbohydrate control with 4 ounces of juice and sugar substitute. Closer observation showed 4 ounces of juice on the breakfast tray and 8 ounces of regular hot chocolate. 6. Resident #71 was admitted to the facility on [DATE] with a diagnosis of Dementia and Kidney Stones. The MDS assessment dated [DATE] has a BIMS score of 08, indicating moderate to severe cognitive impairment. Diet order noted for a regular diet; send side gravy/sauce with the meal and omit the baked ham and roast pork dated 02/11/23. In an observation conducted on 07/25/23 at 12:25 PM, Resident #71 was noted in the room with his lunch tray. The tray showed a tuna sandwich and one soft roll. Closer observation showed a meal ticket for a tuna salad sandwich, soft roll, and 1/2 cup of mixed vegetables, which was not on the tray. In an interview conducted on 07/25/23 at 3:50 PM with Food Service Director, it was stated that there is one staff member that is assigned to the tray line to ensure that the appropriate food items are placed on the correct diet trays. Any food items listed on the meal ticket will be on the tray unless the resident request something different it will write in pen on the meal ticket.

Based on record review, observations and interviews, the facility failed to ensure a resident's wound dressings were changed timely and as per physician orders for 1 of 1 sampled residents reviewed for skin conditions (Resident #5). The findings included: Review of the facility's policy titled Skin Integrity-Skin Tears implemented on 01/09/23 with no revision date documented, it is the policy of this facility to provide proper treatment and care to maintain skin integrity .licensed nurses will conduct skin assessments .RNs (Registered Nurses) and LPNs (Licensed Practical Nurses) will participate in the management of skin tears .by following physician orders, assessment of residents . Review of Resident #5's clinical record documented an admitted to the facility on [DATE] with no readmissions. The resident diagnoses included Renal Insufficiency, Hypertension, Metabolic Encephalopathy, Chronic Kidney Disease, Anemia, Atrial Fibrillation, Congestive Heart Failure, and Infection of the skin- subcutaneous tissue. Review of Resident #5's Minimum Data Set (MDS) annual assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 15, indicating that the resident had no cognition impairment. The assessment documented under Functional Status that the resident needed extensive assistance with most of his Activities of Daily Living and total assistance from the staff with transfers via a mechanical lift. Review of Resident #5's physician order dated 07/16/23 documented wound care orders dressing /ointment type: dry dressing: wound location and care instructions: cleanse healing skin tear left lower leg and right lower leg with normal saline, pat dry, apply xeroform gauze, cover with dry dressing every third day and as needed (prn) until resolved. Review of Resident #5's care plan titled, Resident's skin will remain without skin integrity compromise initiated on 04/05/23 and revised date on 07/05/23 documented an intervention that read .assess skin daily .monitor skin during care for red or open areas and notify the nurse . The care plan did not address actual wounds. On 07/24/23 at 12:10 PM, an interview was conducted with Resident #5 in his room who stated no concerns with the care provided. The resident was accompanied by an aide and were playing a table game. Resident #5 stated that the aide was his private aide (PA) who had been with him for two years. Observation revealed a dressing on the resident's right leg dated 07/19/23, and a dressing on his left lower leg. The surveyor was unable to see the left leg dressing date because he was sitting and facing the aide. The resident stated that he was taking blood thinners and his skin was thin from the blood thinners. The PA stated the resident loves to put bandages on his skin. The PA was asked to state the date on the resident's left lower leg and stated it was dated 07/19/23. On 07/26/23 at 9:33 AM, observation revealed Resident #5 in bed and he continued to have a right leg dressing dated 07/19/23 and had a dressing on his left lower leg dated 07/25/23. Subsequently, a joint interview was conducted with the resident and his PA. The PA stated that the nurse changed the resident dressing on his left leg but did not see the dressing on the right leg. During the interview, Staff E, Licensed Practical Nurse (LPN) came into Resident #5's room and stated she was there to say hello to the resident. Consequently, an interview was conducted with Staff E who stated that she did not do the resident's dressing change on 07/25/23. Staff E was apprised of the right leg dressing dated 07/19/23 and stated that the dressing was for protection maybe and offered to remove it. Observation revealed Staff E performed hand hygiene, donned gloves, and removed Resident #5's right leg dressing dated 07/19/23. Staff E, LPN stated the skin tear was healed. Observation revealed a small scratch like skin mark. The removed dressing had a piece of xeroform gauze in it. Staff E confirmed that the piece of xeroform gauze was in the dressing removed. 0n 07/26/23 at 9:43 AM, an interview was conducted with Staff B, Registered Nurse (RN) who stated there was nothing on Resident #5's right leg and added that all that the nurse needed to do was remove the dressing and discontinue the order. Staff B was apprised that the dressing on his right upper leg (thigh) and left lower leg, were dated 07/19/23 when the observation was made on 07/24/23. On 07/26/23 at 9:52 AM, a joint interview was conducted with Staff B, RN, Staff E, and the Assistant Director of Nursing (ADON). The ADON confirmed that Resident #5's physician order's frequency for the right leg and left leg was to be changed every third day and should have been changed on 07/22/23. Staff E confirmed that the right leg dressing was dated 07/19/23 and the left leg dressing was dated 07/25/23. The ADON was apprised that the right leg dressing was on for 7 days and the left leg dressing was changed 6 days rather than every third day as ordered. On 07/26/23 at 10:08 AM, a side by side review of Resident #5's clinical record was conducted with Staff B, RN/Unit Manager. Staff B confirmed that the resident's physician orders dated 07/16/23, included wound care orders dressing /ointment type: dry dressing: wound location and care instructions: cleanse healing skin tear left lower leg and right lower leg with normal saline, pat dry, apply xeroform gauze, cover with dry dressing every third day and prn (as needed) until resolved. Continued review revealed that Resident #5's wound care documentation for 07/22/23 documented skipped by the nurse on duty for the day. Staff B stated that the dressing change was not done on 07/22/23. Further review revealed that the resident's dressing changed on 07/25/23 was not documented. On 07/26/23 at 10:27 AM, an interview was conducted with Staff E, LPN who stated she took the physician orders for Resident #5's wound care for the right and the left leg, but that somehow did not prompt the nurses to do it. On 07/26/23 at 3:09 PM, an interview was conducted with the MDS Coordinator who stated that Resident #5's annual assessment dated [DATE] documented that the resident had skin tear (s) during the review. On 07/27/23 12:03 PM, surveyor was approached by the Director of Nursing (DON) who stated that the facility did meet with the managers and the wound care nurse, and that they were addressing the dressing change problem. The DON was apprised that Resident #5's dressing on both legs were in place for over 6 days and the physician orders were to change it every third day. The DON was informed that the dressings were dated 07/19/23 for both legs, and the left leg dressing was changed on 07/25/23 but the right leg dressing was not.

Based on observations, interviews, and record review, the facility failed to provide the tube feeding regimen according to the Physician ' s orders for 1 of 2 sampled residents reviewed for tube feeding (Resident #66). The findings included: In an observation conducted on 07/25/23 at 7:30 AM, Resident #66 was noted with the tube feeding Isosource 1.5 (tube feeding formulary) running at 55 ml (milliliters) an hour. Closer observation showed that the tube feeding was started at 4:00 PM, the night before and was at the 800 ml mark out of a 1500 ml capacity bag. The tube feeding mark showed that 700 ml of tube feeding was infused during the night. In an observation conducted on 07/25/23 at 8:07 AM, the breakfast tray was brought into Resident #66's room. The breakfast tray showed a sliced cheese omelet, ground ham, white toast, and grits. Closer observation showed that the tube feeding was still running with Isosource 1.5 (tube feeding formulary) at 55 ml (milliliters) an hour. In this observation, Resident #66 said, I am not hungry. Upon continued observation at 8:18 AM, Resident #66's tube feeding was still running with Isosource 1.5 at 55 ml an hour. The breakfast tray was noted to be 100% untouched. At 8:50 AM, the tube feeding was still running in the room while Resident #66 was trying to eat her breakfast tray. Resident #66 ate a few bites of her breakfast tray. In an observation conducted on 07/26/23 at 8:13 AM, Resident #66 was trying to eat her breakfast tray in her room. Closer observation showed the tube feeding was still running at 55 ml an hour. The tube feeding bag was at the 800 ml mark out of a 1500 ml capacity bag. This showed that 700 ml of formulary was given instead of the 880 ml as ordered by the Physician. Continued observation at 8:22 AM showed that the tube feeding was turned off, and Resident #66 did not eat anything on her breakfast tray. At 8:40 AM, the breakfast tray was still 100% untouched. A record review showed that Resident #66 was readmitted on [DATE] with severe malnutrition and respiratory failure diagnoses. An order was noted for tube feeding continuously every 16 hours to start at 4:00 PM and stopped at 8:00 AM to provide 880 ml dated 07/14/23-diet order for mechanical soft ground dated 03/30/23. A nutrition progress note dated 06/06/23 showed that the tube feeding order meets 74% (percent) of Resident 66's daily caloric needs and 78% of Resident #66's daily protein needs. Resident #66 ' s estimated caloric requirements range between 1785 to 2024, and estimated protein needs range between 77 to 102 grams of protein. The care plan showed that Resident #66 is at risk of unintended weight loss in nutrition parameters due to total dependence on Enteral Feeding (delivering nutrition straight to your stomach or small intestines) for fluids and hydration. A caloric daily intake was conducted on 04/04/23 for the three daily meals, which showed that Resident #66 was eating 30% of her caloric needs and 38% of her protein needs. In an interview conducted on 07/26/23 at 12:10 PM with Staff A, Registered Nurse (RN), it was stated that Resident #66 tolerates her tube feeding well. The tube feeding runs from 4:00 PM the night before until 8:00 AM the next day for 16 hours. When asked why the tube feeding was running past 8:00 AM while Resident #66 was eating her meals, she said that the tube feeding pump would beep when it was done, and that is when she turned the tube feeding off. Staff A further reported that it is okay for the tube feeding to run while the Resident eats her meals. In an interview conducted on 07/26/23 at 12:20 PM, Staff B Registered Nurse (RN) stated that it is not best practice to run tube feeding while a resident eats. She further said that the tube feeding should have stopped while Resident #66 was eating her lunch meals. In an interview with Staff D, Registered Dietitian, on 07/27/23 at 8:45 AM, stated that Resident #66 Tube feeding runs 16 hours starting at 4:00 PM and stopping at 8:00 AM running at 55 ml an hour. She adjusts the tube feeding based on how well the Resident eats, and Resident #66 sometimes fluctuates. She was only eating 10% to 30% of her meals for a while. This is why she based her needs from the tube feeding on the higher end of needs. She further stated that you should run the tube feeding at a different time than Resident #66 is eating her meals.

Based on observations, interviews, and record review, the facility failed to maintain food safety requirements with storage, preparation, and distribution in accordance with professional standards for food service safety which included: failure to maintain sanitary conditions and failure to maintain adequate holding temperatures. The findings included: 1. During the initial tour of the kitchen conducted on 03/21/22 at 8:45 AM, accompanied by the Executive Chef and Operations Manager, the following were noted: a. A lanyard with about 10 keys was stored on top of the food preparation table. The Executive Chef acknowledged that the keys should not have been stored on top of the food preparation table. b. In the Victory reach-in refrigerator, one plastic container with about 40 hotdogs was missing a label with a use by date. c. In the reach-in cooler, one opened package of Swiss cheese had an open date of 03/03/22. The Executive Chef stated that opened products were to be used within 7 days after opening and that the Swiss cheese should have been discarded. d. In the dry storage area, a coat was stored on top of the shelving racks containing food products. e. In the dry storage area, one 15 ounce can of Gandules Verdes was observed with a dent. f. In the dry storage area, one 18-quart plastic storage bin of dried northern beans was missing a label with a use by date. g. In the walk-in refrigerator, one 6-quart plastic container of peach slices was observed with a use by date of 03/19/22. h. In the walk-in freezer, one package of oven ready whole grain breaded Alaska [NAME] fillet portions was left open and uncovered. The Executive Chef acknowledged that this put the fillet portions at risk of contamination. i. In the paper goods dry storage area, one rolling cart containing clean aprons was stored over a puddle/drain. Closer observation showed that the strings of the clean aprons were hanging out of the cart and laying in the puddle. The Executive Chef acknowledged that this contaminated the clean aprons. j. One light bulb was out over the dishwashing machine. 2. During a tour of the South Wing Nourishment Room conducted on 03/21/22 at 9:15 AM, the flooring underneath the shelving was observed with a moderate amount of debris. In an interview conducted on 03/23/22 at 4:19 PM, the Food Service Director was informed of the findings and acknowledged all findings. 3) During a follow-up observations of the kitchen/Food Service Department on 03/22/22 at 7:30 AM and 03/23/33 at 11:30 AM, the temperatures of the hot and cold foods on the lunch tray assembly line were taken by the use of the facility's calibrated bayonet food thermometer. The temperature testing results noted that hot foods were not being held and the regulatory requirement of 135 degrees F or greater and cold foods were not being held at the regulatory requirement of 41 degrees F or below, as per the following: Fried Eggs (3) = 130 degrees F Dannon Yogurt - (5 individual) = 45 degrees F Hamburger Patties (3) = 120 degrees F Chefs Salad (3) - including ham,turkey, and egg = 50 Degrees F Beet & Onion Salad (28 individual) = 51 degrees F

Based on observations, interviews, and record review, the facility failed to provide fingernail grooming for 1 of 1 sampled residents reviewed for activities of daily living (Resident #38). The findings included: Review of the facility's policy titled, Providing Nail Care, revised on 01/12/21, documented the following: Assessments of resident nails will be conducted on a regular basis to determine condition of the resident's nail condition, needs, and preferences for nail care, if possible. Routine cleaning and inspection of nails will be provided during activities of daily living (ADL) care on an ongoing basis. Routine nail care, to include trimming and filing, will be provided on a regular schedule. Nail care will be provided between scheduled occasions as the need arises. Review of the Certified Nurse Assistant (CNA) job description documented that CNAs were to assist patients with tending to personal care and activities of daily living, including bathing, grooming and eating. Review of the record documented that Resident #38 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Section C of the Admission Minimum Data Set (MDS) dated [DATE] documented that Resident #38 had a Brief Interview for Mental Status score of 15, which indicated that he was cognitively intact. Review of Section G of the Admission MDS dated [DATE] documented that Resident #38 required limited assistance with one person physical assist for personal hygiene. Review of the Care Plan dated 01/19/22 documented that Resident #38 required limited assistance with personal hygiene related to muscle weakness. Goals were for Resident #38 to be cleaned, groomed, and free of odor daily. Interventions were to assist him with ADLs and shower three times a week. During an observation conducted on 03/21/22 at 11:46 AM, Resident #38 was observed with long fingernails that were about 1/4 inch past the tips of his fingers. Closer observation showed that there was black residue underneath his fingernails. When asked about his fingernails, Resident #38 stated, I want them cut. I have asked them so many times but they don't cut them. During an observation conducted on 03/21/22 at 2:04 PM, Resident #38 was still observed with long fingernails that were about 1/4 inch past the tips of his fingers. Closer observation showed that there was still black residue underneath his fingernails. When asked about his fingernails, Resident #38 stated No one came to do anything. During an observation conducted on 03/22/22 at 8:40 AM, Resident #38 was still observed with long fingernails that were about 1/4 inch past the tips of his fingers. Closer observation showed that there was still black residue underneath his fingernails. Resident #38 asked the surveyor to ask a staff member to come cut his fingernails During an observation conducted on 03/22/22 at 2:44 PM, Resident #38 was still observed with long fingernails that were about 1/4 inch past the tips of his fingers. Closer observation showed that there was still black residue underneath his fingernails. During an observation conducted on 03/22/22 at 5:49 PM, Resident #38 was still observed with long fingernails that were about 1/4 inch past the tips of his fingers. Closer observation showed that there was still black residue underneath his fingernails. During an observation conducted on 03/23/22 at 8:56 AM, Resident #38 was still observed with long fingernails that were about 1/4 inch past the tips of his fingers. Closer observation showed that there was still black residue underneath his fingernails. Resident #38 stated that he still wanted his fingernails cut and asked the surveyor if staff were going to cut his fingernails. During an observation conducted on 03/23/22 at 11:21 AM, Resident #38 was still observed with long fingernails that were about 1/4 inch past the tips of his fingers. Closer observation showed that there was still black residue underneath his fingernails. Resident #38 stated that he still wanted his fingernails cut. During an interview conducted on 03/23/22 at 11:32 AM, Staff A, CNA, stated that all CNAs were responsible for cutting/cleaning residents' fingernails. She further stated, If they are in your assignment, then you're responsible for cutting their nails. Staff A stated that she checked fingernails once a week to see if they needed to be cleaned/cut. She further stated that if a resident asked to have their fingernails cut, she would cut them and if she was busy, she would tell the resident that she would come back later in the day to cut their fingernails. According to her, no residents had asked for their nails to be cut. When asked about Resident #38, she stated that he had not asked for his nails to be cut. Staff A then accompanied the surveyor to look at Resident #38's fingernails. Staff A acknowledged that they were long and stated, Yes, they need to be cut. During an interview conducted on 03/23/22 at 12:18 PM, the Director of Nursing (DON) stated that CNAs were responsible for cleaning/cutting fingernails. She stated that documentation of fingernail care refusal was kept at the nursing station on a census. The DON then accompanied surveyor to ask Staff B, Registered Nurse/Unit Manager, for documentation of fingernail care refusal. Staff B stated that she did not have it and that she gave it to the Assistant Director of Nursing (ADON). During an interview conducted on 03/23/22 at 12:40 PM, the ADON reviewed the Nail Care Audit dated 03/08/22 with the surveyor which showed that there was no documentation that Resident #38 refused fingernail care. The surveyor informed the ADON of the findings and the ADON stated that Resident #38 will sometimes refuse fingernail care. When asked for documentation of fingernail care refusal, the ADON stated that the Nail Care Audit dated 03/08/22 was the only form that she had and that if Resident #38 had refused, staff should have documented it on there. Review of all notes under the Notes tab in Epic (electronic charting system) dated 03/01/22 - 03/23/22 showed that there was no documentation of Resident #38 refusing fingernail care. During an interview conducted on 03/23/22 at 12:57 PM, the DON stated that she did not have any notes at this time showing that Resident #38 refused fingernail care. During an interview conducted on 03/23/22 at 2:16 PM, the DON stated that that she did not have any notes at this time showing that Resident #38 refused fingernail care. On 03/24/22 at 8:30 AM, the DON approached the surveyor and provided the surveyor with a handwritten form which documented that Resident #38 refused nail care on Sunday. Closer observation showed that there was no date to indicate on which Sunday nail care was refused. During an interview conducted on 03/24/22 at 8:53 AM, Resident #38 was asked if he refused nail care on Sunday (03/20/22). Resident #38 stated, I actually asked them to cut my nails on Sunday. I didn't refuse. When asked if he refused fingernail care over the weekend, Resident #38 stated that he did not refuse nail care over the weekend and that he has never refused fingernail care.

Based on observation, interview, record review and review of policy and procedure, it was determined that the facility failed to provide dental care services to meet the needs of the resident by not making appointments and arranging for transportation to and from the dental services location for 1 of 1 sampled residents reviewed for dental care (Resident #28). The findings included: Review of facility policy and procedure for Dental Services provided by the Director of Nursing (DON) reviewed May 2016, indicated that Policy: in order to promote good oral hygiene and mouth care to the residents of Memorial Manor, dental services will be made available. Procedure: 1. Residents have the right to use their own community dentist. 2. Residents who have Medicaid Managed Assistance Plans have dental coverage and will be able to receive care and services in accordance with their plan .6. The nursing staff will perform oral assessments. Review of facility licensed Unit Manager Nurse job description on 03/24/22 at 11:47 AM, indicated that manages the daily operations of the assigned departments. Job responsibilities: Assesses the quality of patient care delivered. Evaluates needs of patients and families and provides patient and family centered care . Review of facility licensed nurse job description on 03/24/22 at 12:07 PM, indicated that Job Summary: Provides direct resident care using the nursing process in or/as supervised and delegated by a registered nurse, provides direct resident care in accordance with applicable scope and standards of practice and with the policies, values and mission of the organization. Job responsibilities: plans, implements and evaluates resident care based on assessment to optimize outcomes and maximizes available resources. Monitors, records and communicates resident condition as appropriate or contributes to the assessment of patients by collecting data for analysis. Performs plan of car interventions .Performs treatments and administers medications in accordance with established policies and procedures. Collaborates as needed across disciplines to coordinate resident care .Administers medications .and all treatments in accordance with established policy and procedure. Review of facility policy and procedure on 03/24/22 at 12:19 PM for Social Worker Job Description provided by the (DON) indicated that Job Summary: Provides assessment, planning, counseling and education to patients. Job Responsibilities: .Interviews and assesses patients and/or patient's family, caregivers and/or legal representatives. Determines prioritizes, provides and/or arranges for needed internal and external services/interventions During observational room rounds conducted on 03/21/22 at 12:26 PM of Resident #28, it was observed that he only had approximately eleven (11) portions/remnants of his normally occurring thirty-two (32) full-sized adult teeth, in his mouth. Photographic evidence obtained. A brief interview was conducted with Resident #28, in which he conveyed to this surveyor that he had not been seen by a dentist in over two (2) years and would like to follow-up with one. He added that sometimes when he chews it does hurt. He elaborated by stating that he recalls mentioning this to one of the facility staff members sometime ago, but nothing ever happened. Resident #28 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He had a Brief Interview Mental Status (BIM) score of 15 (cognitively intact). During an interview conducted on 03/23/22 at 2:21 PM with Staff D, a Licensed Practical Nurse (LPN) for Resident #28, she acknowledged that the resident had dental issues that need to be addressed; this was not offered to him by her. And, she added that he has not been to see a dentist, to her knowledge. Further review revealed there were no physician's orders related to/regarding dental services for this resident. Review of the Annual MDS (Minimum Data Set) assessment dated [DATE], revealed the assessment did not indicate whether or not Resident #28's natural teeth or tooth fragments-edentulous, were assessed. The resident's facility computerized quarterly care plan dated 10/11/21 documented to provide resident with necessary dental care on a regular basis and as needed and Problem: Resident #28 is at risk for dental problems due to some missing teeth. Interventions: assist resident with dental hygiene needs, monitor resident's oral cavity for redness, swelling, bleeding, pain, difficulty chewing/eating .Dental evaluation and follow-up as needed (PRN); this was not done. Record review of Resident #28's two (2) most recent Interdisciplinary Team (IDT) meetings dated 10/21/21 and 01/20/22, did not identify or make any references to the resident's current/on-going dental status/ issues, nor whether this was being addressed or discussed, at any point during his facility stay. An interview was conducted with the Social Services Director on 03/23/22 at 1:15 PM regarding the resident's dental insurance coverage and his last dental appointment and she stated that she does not take care of this; she said that the North wing Unit Manager handles this for the residents on her unit. There was no Social Services documentation nor any nursing notes documentation in the record to reflect that Resident #28 had received any dental care/visits during his two and one-half (2.5) year facility stay. On 03/23/22 at 2:20 PM, an interview was conducted with Staff B, a Registered Nurse (RN)/Unit Manager (UM), regarding the Resident #28's dental consults and she indicated that the Resident #28 has not been seen by a dentist during his 2.5- year facility stay. She acknowledged that the resident had dental issues that need to be addressed; this was not offered to him by her. And, she added that he has not been to see a dentist, to her knowledge, since he has been residing in the facility and she also stated that she is responsible for scheduling all of the resident's dental appointments on her unit. Record review of Resident #28's eligibility verification request documentation revealed that Resident #28 has currently had Full-Medicaid insurance coverage effective ever since 03/01/22. An appointment was not scheduled for the resident until April 2022, after surveyor intervention. The (DON) further acknowledged and recognized that dental care and services were to be provided to the resident during his facility stay; this was not done.

Based on observation, record review, interview and review of policy and procedure, it was determined that the facility failed to 1) ensure that it dated and properly labeled the oxygen tubing for 3 of 3 sampled residents observed receiving oxygen therapy (Resident #20, Resident #80 and Resident #52. And, 2) failed to ensure that it properly administered ordered oxygen therapy as per physician order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings included: Review of the facility policy and procedure on 03/24/22 at 10:45 AM for Standard Practice Oxygen Therapy Techniques provided by the Director of Nursing (DON) reviewed February 2021 indicated Policy: Oxygen therapy devices will be set-up and used under the following guidelines. Purpose: to provide safe, effective Oxygen therapy in an effort to therapeutically raise arterial oxygen tension Aerosol Devices. Indications 1) Aerosol devices are employed to deliver a particulate mist to the tracheobronchial tree in an attempt to correct a humidity deficit 11) All aerosol devices from flowmeter to, and including resident connector will be changed once a week. Aerosol device and drainage bag are to be dated when changed Review of the facility policy and procedure on 03/24/22 at 10:51 AM for Medication Administration (Oxygen as a medication for administration) provided by the (DON) effective July 2015 indicated Policy---to administer medications in a safe and effective manner . Review of the facility policy and procedure on 03/24/22 at 11:13 AM for Standard Practice Oxygen Therapy provided by the (DON) updated March 2021 indicated Policy: Oxygen therapy will be provided by the Respiratory Therapy Department to residents in Memorial Manor in response to verbal or written orders from attending physicians under the following guidelines. Purpose: to describe the routine methods of delivery of oxygen and the goals of the Respiratory Therapy Department for providing safe, effective therapy. Procedure: 1. orders for Oxygen therapy must comply with accepted standards set by the policy concerning physicians orders of Respiratory Therapy 3. All aerosol devices will be changed on Monday by the 7-3 shift personnel. Review of facility licensed Respiratory Therapist job description on 03/24/22 at 11:26 AM dated 09/15/21 indicated for patients with Cardiopulmonary Disorders. Responsibilities: delivers and assesses response to ordered therapy per plan of care. Monitors, documents and communicates patient condition as appropriate. Evaluates respiratory care policies and procedures based on patient outcomes, current research, and best practices Assesses patient condition and delivers appropriate treatment. Review of facility licensed Unit Manager Nurse job description on 03/24/22 at 11:47 AM indicated that they manage the daily operations of the assigned departments. Job responsibilities: Assesses the quality of patient care delivered. Evaluates needs of patients and families and provides patient and family centered care . Review of facility licensed nurse job description on 03/24/22 at 12:07 PM revealed a Job Summary: Provides direct resident care using the nursing process in or/as supervised and delegated by a registered nurse, provides direct resident care in accordance with applicable scope and standards of practice and with the policies, values and mission of the organization. Job responsibilities: plans, implements and evaluates resident care based on assessment to optimize outcomes and maximizes available resources. Monitors, records and communicates resident condition as appropriate or contributes to the assessment of patients by collecting data for analysis. Performs plan of car interventions .Performs treatments and administers medications in accordance with established policies and procedures. Collaborates as needed across disciplines to coordinate resident care .Administers medications .and all treatments in accordance with established policy and procedure. 1) During an observational screening tour conducted on 03/21/22 at 12 PM Resident #20 was noted to have oxygen infusing at two (2) liters per minute via oxygen concentrator, but there was no label or date noted on the oxygen tubing as to when it was last changed by facility staff. Photographic evidence obtained of Resident #20's oxygen tubing with no label or date noted. Resident #20 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had a Brief Interview Mental Status (BIM) score of 0. (severely impaired). On 03/21/22 at 1:59 PM, Resident #20 was noted to have oxygen infusing at two (2) liters per min via oxygen concentrator, but there was still no label or date noted on the oxygen tubing as to when it was last changed. On 03/22/22 at 10:14 AM, Resident #20 was noted to have oxygen infusing at two (2) liters per min via oxygen concentrator, but there was still no label or date noted on the oxygen tubing as to when it was last changed. On 03/22/22 at 2:36 PM, Resident #20 was noted to have oxygen infusing at two (2) liters per min via oxygen concentrator, but there was still no label or date noted on the oxygen tubing as to when it was last changed. On 03/23/22 at 9:52 AM, Resident noted to have oxygen infusing at 2 liters per min via oxygen concentrator, but there was still no label or date noted on the tubing as to when it was last changed. On 03/23/22 at 10:02 AM, a computerized record review conducted of the Resident #20's current physician's orders dated 11/26/21 which indicated Oxygen therapy routine method of oxygen administration: Nasal cannula administer two (2) liters/minute; keep oxygen saturation % greater than 92% continuous. On 03/23/22 at 10:24 AM, record review of Resident #20's nursing care plan dated 10/01/19 indicated Problem: the resident was at risk for respiratory difficulties related to limited mobility. Interventions: Administer oxygen as needed. Medications as ordered. Goal: resident will be managed with interventions in place through next review date. 2) During an observational screening tour conducted on 03/21/22 at 12:04 PM Resident #80 was noted to have oxygen infusing at two (2) liters per min via oxygen concentrator, but there was no label or date noted on the oxygen tubing as to when it was last changed by facility staff. Resident #80 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had a Brief Interview Mental Status (BIM) score of 15 (cognitively intact). Photographic evidence obtained of Resident #80's oxygen tubing with no label or date noted on it. On 03/21/22 at 2:01 PM Resident #80 was noted to have oxygen infusing at two (2) liters per min via oxygen concentrator, but there was still no label or date noted on the oxygen tubing as to when it was last changed. On 03/22/22 at 10:15 AM Resident #80 was noted to have oxygen infusing at two (2) liters per min via oxygen concentrator, but there was still no label or date noted on the oxygen tubing as to when it was last changed. On 03/22/22 at 2:38 PM Resident #80 was noted to have oxygen infusing at two (2) liters per min via oxygen concentrator, but there was still no label or date noted on the oxygen tubing as to when it was last changed. On 03/23/22 at 9:57 AM Resident #80 was noted to have oxygen infusing at two (2) liters per min via oxygen concentrator, but there was still no label or date noted on the oxygen tubing as to when it was last changed. On 03/23/22 at 10:07 AM, Resident #80's current physician's orders dated 11/26/21 which indicated Oxygen therapy routine method of oxygen administration: Nasal cannula administer two (2) liters/minute; keep oxygen saturation % greater than 92% continuous. On 03/23/22 at 10:32 AM, record review of Resident #80's nursing care plan dated 10/01/19 indicated Problem: the resident was at risk for respiratory difficulties related to limited mobility. Interventions: Administer oxygen as needed. Medications as ordered. Goal: resident will be managed with interventions in place through next review date. On 03/23/22 at 12:36 PM, an interview was conducted with Staff C, a Licensed Practical Nurse (LPN) and with Staff B, a Registered Nurse (RN)/Unit Manager (UM), regarding the Resident #20 and Resident #80's oxygen tubing undated/unlabeled and they both acknowledged that the resident's oxygen tubings should have been labeled and dated as to when they were last changed by staff; this was not done. 3) During an observational screening tour conducted on 03/21/22 at 12:38 PM Resident #52 was receiving oxygen at two (2) liters via oxygen concentrator, but with no label or date noted as to when the oxygen tubing was last changed by facility staff. Resident #52 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had a Brief Interview Mental Status (BIM) of (severely impaired). Photographic evidence obtained of Resident #52's oxygen tubing with no label or date noted on it. On 03/22/22 at 12:22 PM, Resident #52 was receiving oxygen at two (2) liters via oxygen concentrator, but still with no label or date noted as to when the oxygen tubing was last changed. On 03/22/22 at 3:20 PM, Resident #52 was receiving oxygen at two (2) liters via oxygen concentrator, but still with no label or date noted as to when the oxygen tubing was last changed. On 03/23/22 at 10:28 AM, Resident #52 was receiving oxygen at two (2) liters via oxygen concentrator, but still with no label or date noted as to when the oxygen tubing was last changed. On 03/23/22 at 11:18 AM, an interview was conducted with the facility's Respiratory Therapy Director, regarding the Resident #52's oxygen tubing should be changed every week and he further acknowledged that none of the resident's oxygen tubings had dates on them to directly indicate exactly when they had been changed by Respiratory staff; this was not done. On 03/23/22 at 11:24 AM Resident #52's current physician's orders dated 11/26/21 which indicated Oxygen therapy routine method of oxygen administration: Nasal cannula administer two (2) liters/minute; keep oxygen saturation % greater than 92% continuous. On 03/23/22 at 11:36 AM, record review of Resident #52's nursing care plan dated 10/01/19 indicated Problem: the resident was at risk for respiratory distress due to shortness of breath/wheezing/cough. Interventions: assess respiratory status. Ongoing oxygen and respiratory treatments as needed per medical doctor (MD) order. Goal: will have no respiratory distress through next review date. On 03/23/22 at 12:40 PM, an interview was conducted with Staff E, a Registered Nurse (RN) and with Staff B, a Registered Nurse (RN)/Unit Manager (UM), regarding the Resident #52's oxygen tubing undated/unlabeled and they both acknowledged that the resident's oxygen tubing should have been labeled and dated as to when it was last changed by staff; this was not done. 4) During an observational screening tour conducted on 03/22/22 at 10:14 AM Resident #20's oxygen was not noted to be infusing into the resident as ordered. The end of the resident's oxygen tubing was not attached/connected to the oxygen concentrator to allow the resident to receive her ordered infusion of oxygen therapy from the machine, which was on and currently running. On 03/22/22 at 02:36 PM, Resident #20 was noted to not be receiving her ordered oxygen. The end of the resident's oxygen tubing was still not attached/connected to the oxygen concentrator machine to allow the resident to receive her ordered infusion of oxygen therapy from the machine which was still on and currently running. On 03/23/22 at 10:02 AM, a computerized record review conducted of the Resident #20's current physician's orders dated 11/26/21 which indicated Oxygen therapy routine method of oxygen administration: Nasal cannula administer two (2) liters/minute; keep oxygen saturation % greater than 92% continuous. On 03/23/22 at 10:24 AM, record review of Resident #20's nursing care plan dated 10/01/19 indicated Problem: the resident was at risk for respiratory difficulties related to limited mobility. Interventions: Administer oxygen as needed. Medications as ordered. Goal: resident will be managed with interventions in place through next review date. On 03/23/22 at 10:50 AM, an interview was conducted with the facility's Respiratory Therapy Director, regarding Resident #20's oxygen therapy tubing not connected and not being infused as ordered and he acknowledged that the resident's oxygen should have been connected and administered as ordered by Respiratory staff; this was not done. On 03/23/22 at 11:15 AM, an interview was conducted with Staff C, a Licensed Practical Nurse (LPN) and with Staff B, a Registered Nurse (RN)/Unit Manager (UM), regarding Resident #20's oxygen therapy tubing not connected and not being infused as ordered and they both acknowledged that the resident's oxygen should have been connected and administered as ordered; this was not done. It was noted that Resident #20's ordered oxygen therapy had been off/disconnected/not infusing for more than a minimum of four (4) hours that day, during the survey. The Director of Nursing (DON) further acknowledged that all of the resident's oxygen tubing should have been labeled and dated as to when it was last changed by staff and that the resident's oxygen should have been connected and administered as ordered; this was not done.

Based on observation, interview, record review and review of policy and procedure, it was determined that the facility failed to 1) ensure that it secured over-the-counter (OTC) topical medications for 3 of 27 sampled residents observed, (Resident #297, Resident #9, and Resident #61) and 2) failed to discard resident's expired OTC topical medication left at bedside for 1 of 27 sampled residents observed Resident #297. The findings included: Review of the facility policy and procedure on [DATE] at 2 PM for Storage of Medications provided by the Director of Nursing effective [DATE] indicated that Medications and biologicals are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel or staff members lawfully authorized to administer medications Outdated, contaminated or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal. 1) On [DATE] at 10:21 AM during observational room rounds, it was noted that on Resident #297's bedside dresser there was a used tube of (OTC) topical Menthol 0.44% and [MEDICATION(S)] Ointment 20.625% with an expiration date of ,d+[DATE]; it was visible, accessible and unsecured, to other residents, staff members and visitors. Photographic evidence obtained of tube of (OTC) topical Menthol 0.44% and [MEDICATION(S)] Ointment 20.625%. Resident #297 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She had a Brief Interview Mental Status (BIM) score of 15 (cognitively intact). On [DATE] at 11:34 AM, it was noted that on Resident #297's bedside dresser there was a used tube of (OTC) topical Menthol 0.44% and [MEDICATION(S)] Ointment 20.625% with an expiration date of ,d+[DATE]; it was visible, accessible and unsecured, to other residents, staff members and visitors. Record review of the resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . However, it was noted that there were currently no scheduled doses. 2) On [DATE] at 10:47 AM, during observational room rounds, it was noted on the Resident #9's bedside table that there was a used tube of (OTC) tube of topical Muscle Rub with an expiration date of ,d+[DATE]; it was visible, accessible and unsecured, to other residents, staff members and visitors. Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He had a Brief Interview Mental Status (BIM) score of 14 (cognitively intact). Photographic evidence obtained of tube of (OTC) tube of topical Muscle Rub. On [DATE] at 1:51 PM, it was noted on Resident #9's bedside table that there was a used tube of (OTC) tube of topical Muscle Rub with an expiration date of ,d+[DATE]; it was visible, accessible and unsecured, to other residents, staff members and visitors. Record review revealed that Resident #9 was currently prescribed (OTC) Methly [MEDICATION(S)] 15% and Menthol 10% one (1) topical application twice daily. 3) On [DATE] at 3:04 PM, during observational room rounds, it was noted that on Resident #61's bedside dresser there was a small round used container of (OTC) topical Menthol 0.44% and [MEDICATION(S)] Ointment 20.6% with no expiration date noted; it was visible, accessible and unsecured, to other residents, staff members and visitors. Photographic evidence obtained of (OTC) topical Menthol 0.44% and [MEDICATION(S)] Ointment 20.6%. Resident #61 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He had a Brief Interview Mental Status (BIM) score of 14 (cognitively intact). On [DATE] at 11:07 AM, during a Wound Care Observation conducted with the Wound care nurse for Resident #61, it was noted that there was a thirty-two (32) oz. bottle of liquid [MEDICATION(S)] located in a basket at the bedside, on his bedroom dresser tabletop. Further record review revealed that Resident #61 was currently prescribed (OTC) Methly [MEDICATION(S)] 15% and Menthol 10% one (1) topical application twice daily. However, there was no order noted for the liquid [MEDICATION(S)]. On [DATE] at 12:31 PM an interview was conducted with Staff C, a Licensed Practical Nurse (LPN), regarding the (OTC) topical Menthol 0.44% and [MEDICATION(S)] Ointment 20.625% with an expiration date of ,d+[DATE] for Resident #297 and the (OTC) tube of topical Muscle Rub for Resident #9, left unattended and unsecured at both of the resident's bedsides. She acknowledged that the medications should not have been there and should have been properly secured or discarded, if expired; this was not done. On [DATE] at 12:45 PM an interview was conducted with Staff D, an (LPN), regarding (OTC) topical Menthol 0.44% and [MEDICATION(S)] Ointment 20.6% with no expiration date for Resident #61, left unattended and unsecured at both of the resident's bedsides and she acknowledged that the medication should not have been there and should have been properly secured; this was not done. On [DATE] at 1 PM an interview was conducted with Staff B, a Registered Nurse (RN)/Unit Manager (UM), regarding the (OTC) topical Menthol 0.44% and [MEDICATION(S)] Ointment 20.625% with an expiration date of ,d+[DATE] for Resident #297 and for Resident #61 and the (OTC) tube of topical Muscle Rub for Resident #9, all left unattended and unsecured at each of the resident's bedsides. She further acknowledged that the medications should not have been there and should have been properly secured or discarded, if expired; this was not done. There was no assessment performed for any of these residents to ensure that they were able to administer their own medications at the bedside; the facility administers the medications for them, per Staff B, a Registered Nurse (RN)/Unit Manager (UM). Further review revealed none of three residents were assessed by the facility, as being able to safely and responsibly, self-administer their own medications. Furthermore, the unattended/unsecured OTC medications were removed from the resident's bedsides, after surveyor intervention. The Director of Nursing (DON) further acknowledged and recognized that Resident #297, Resident #61 and Resident #9's, unattended and unsecured medications should not have been left at their bedsides and should have been properly secured or discarded, if expired; this was not done.

Based on observation and interview, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 1 (South Wing) of 2 residential wings. The findings included: During the Environment Tour conducted on 03/21/22 at 8 AM, and 03/22/22 at 3 PM, accompanied with Administrator, and Infection Control Perfectionist, the following were noted: Room #249: (a) Window Shade (1 of 2) - noted to be heavily soiled with large areas dried red/matter. (b) Window (1 of 2) - noted the window film was peeling off the entire surface area . (c) Room Clock- located on wall, noted not to be working - time on clock was 9 AM. (d) Bathroom - noted emergency call cord was wrapped around wall hand rail . Could not be activated when attempting to activate due to the cord wrapping. (e) Bathroom - noted large soaked towel on floor - no staff noted in the room. (f) Above bed wallboard - noted wall board located over B-bed to have large areas of dried tape. (g) Ceiling tiles (2) - located in center of room was noted to have large areas of stained/dried red/brown matter. (h) Room Walls - areas of peeling paint and unknown areas of dried matter. Room #236 - Noted bathroom floor area around the toilet was in disrepair and heavily worn. Room #245 - Noted bathroom floor area around the toilet was in disrepair and heavily worn. Full urinal located on overbed table next to breakfast tray. Room #247 - The over bed light cord was out of reach for the resident residing in the B-bed due to the position of the bed. The bathroom emergency call cord was wrapped twice around the wall hand rail. The light could not be activated due to the cord wrapping. Photographic evidence obtained for all examples.

Based on observations and interviews, the facility failed to maintain a safe, clean, comfortable, and homelike environment in 2 out of 2 supplement storage rooms and the facility failed to maintain food safety requirements with storage, preparation, and distribution in accordance with professional standards for food service safety which included: failure to maintain sanitary conditions in the kitchen and failure to maintain sanitary conditions in 2 out of 2 nourishment rooms. The findings included: During the initial tour of the kitchen conducted on 03/29/21 at 8:52 AM, accompanied by the Food Service Director (FSD) and the Executive Chef, the following were noted: 1. Staff N, Cook, was observed walking through the kitchen without a hairnet. The FSD was observed walking through the kitchen while strands of hair were coming out of her hairnet and falling to her shoulders. The Executive Chef was wearing a chef's hat, however, it did not cover his hair which was sticking out from underneath his hat. The FSD acknowledged that hair must be covered while in the kitchen. 2. One meal cart located inside of the Victory reach-in refrigerator was observed with rusted wheel [NAME]. Two dish [NAME] carts in the food preparation area were observed with rusted wheel [NAME]. One utility cart in the food preparation area was observed with rusted wheel [NAME]. In the dishwashing area, two dish [NAME] carts that contained about 5 racks of clean dishes were observed with rusted wheel [NAME]. Closer observation showed that these dish [NAME] carts had black debris touching the clean dishes. The FSD stated the dishes needed to be re-washed. 3. White and black debris was observed on the bottom of the sugar ingredient bin located in the food preparation area. 4. Plastic, food residue, and brown stains were observed on the floor underneath the ingredient storage bins in the food preparation area. 5. Brown residue was observed underneath the clean dishes on the dish [NAME] cart in the food preparation area. 6. In the walk-in freezer, two frozen bins used for serving ice cream were observed with yellow debris. 7. The floor of the walk-in freezer was observed with white debris. 8. The floor and shelving in the walk-in refrigerator was observed with food residue. 9. In the dry storage area, one 50 ounce can of Campbell's vegetable soup and one 97 fluid ounce can of Glenview Farms evaporated milk were dented. 10. In the dry storage area, about 25 plastic forks were uncovered in an aluminum pan. The FSD stated that the plastic forks should have been covered. 11. The air vent located in the dry storage area was observed with black residue. The air vent located in the paper goods storage area was observed with rust. 12. The dishwashing machine was torn apart from the ceiling and was observed with a heavy amount of brown residue. 13. Used personal protective equipment was observed on the floor next to the outdoor dumpster. 14. One dumpster that was designated for construction items (such as wood and cardboard) was observed with plastic bags of garbage. 15. Two opened plastic water bottles were observed in the employee locker area (which was located inside of the kitchen). Opened personal water bottles and coffee cups were observed inside of the dietitian's office (which was located inside of the kitchen). The FSD acknowledged that employees should not consume beverages while in the kitchen area. She further acknowledged that after consuming a beverage, an employee could have saliva on their hands, walk through the kitchen, and contaminate food items. Following the initial tour, the FSD acknowledged the surveyor's findings. During the tour of the Nourishment Rooms in both the North and South Wings conducted on 03/29/21 at 9:45 AM, accompanied by the FSD and Executive Chef, the following were noted: A. Nourishment Room (North Wing): 16. The floor was observed with white debris. 17. The reach-in freezer for resident items was observed with brown stains on the bottom shelf and on the inner panel of the door. 18. The gasket located on the door of the reach-in refrigerator for resident items was observed with a moderate amount of brown residue. 19. One opened 46 fluid ounce container of cranberry juice cocktail was not labeled with an open date. B. Nourishment Room (South Wing): 20. The floor was observed with white debris and dust. 21. The reach-in freezer for resident items was observed with a moderate ice buildup on the back wall. Closer observation showed a moderate amount of black and orange residue on the bottom shelf. 22. The shelving on the door of the reach-in refrigerator for resident items was observed with yellow residue. 23. The gasket located on the door of the reach-in refrigerator for resident items was observed with a 4-inch tear. Following the tour, the FSD acknowledged the surveyor's findings. 24. During the tour of the supplement storage rooms in the North and South Wings conducted on 03/29/21 at 10:00 AM, accompanied by the Food Service Director (FSD) and the Executive Chef, the following were noted: A. Supplement Storage Room (North Wing): 1. Roach legs, brown residue, and black stains were observed on the flooring. 2. The walls were observed with black stains. 3. One utility cart was observed with brown residue. 4. New personal protective equipment was stored on top of a cardboard box which contained garbage. B. Supplement Storage Room (South Wing): 5. Plastic, brown debris, and black stains were observed on the flooring. 6. The air vent and the ceiling was observed with a black, mold-like substance. 7. The walls were observed with black stains. Following the tour, the FSD acknowledged the surveyor's findings and agreed that the supplement storage rooms in the North and South Wings needed to be cleaned. During an observation conducted on 03/30/21 at 7:13 AM, the Senior Analyst was observed walking through the kitchen without a hairnet. When asked, the Senior Analyst stated that she did not wear a hairnet because she was walking through the kitchen to use the printer that was located in the FSD's office. During an observation conducted on 03/31/21 at 11:17 AM, Staff M, Hostess, was observed walking through the kitchen wearing a hairnet, however, her ponytail was hanging out from underneath. The FSD acknowledged that Staff M's ponytail was hanging out of hairnet. She further stated that hair must be covered while in the kitchen.

Based on interviews, observations, and record review, the facility failed to maintain dignity during dining for 1 out of 1 sampled residents requiring feeding assistance (Resident #47). The findings included: Resident #47 was admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Section C of the Quarterly Minimum Data Set (MDS) dated [DATE] showed that Resident #47 had a Brief Interview for Mental Status of 8, which indicated that he was moderately cognitively impaired. Review of Section G of the Quarterly MDS dated [DATE] showed that Resident #47 required limited assistance with one person physical assist for eating. Review of the Care Plan dated 02/25/21 showed that Resident #47 required assistance with feeding, was at risk for dehydration, and was at risk for unintended weight loss. Interventions were to assist/feed resident at all meals as needed and to set up his food tray and assist as needed during meals. During an observation conducted on 03/29/21 at 12:04 PM, Resident #47 was seated in his wheelchair for his lunch meal. Staff O, Certified Nursing Assistant (CNA), was observed standing over Resident #47 while feeding him his lunch. Closer observation showed that an empty chair was located inside of Resident #47's room across from his bed. During an observation conducted on 03/30/21 at 8:12 AM, Resident #47 was seated in his bed for his breakfast meal. Staff O was observed standing at Resident #47's bedside while feeding him his breakfast. Closer observation showed that an empty chair was located inside of Resident #47's room across from his bed. During an observation conducted on 03/31/21 at 8:13 AM, Resident #47 was seated in his bed for his breakfast meal. Staff O was observed standing at Resident #47's bedside while feeding him his breakfast. Closer observation showed that an empty chair was located inside of Resident #47's room across from his bed. During an interview conducted on 03/31/21 at 8:20 AM, Staff O stated that staff members should be seated when feeding residents to maintain their dignity. When asked why she was not seated while feeding Resident #47, Staff O did not have an answer. Staff O acknowledged that she should have been seated while providing feeding assistance to Resident #47. During an interview conducted on 03/31/21 at 1:29 PM, the Director of Nursing (DON) stated that when a resident required feeding assistance, she would expect staff members to place a chair next to the resident's bed/wheelchair so that they can be seated while providing feeding assistance. The DON acknowledged the surveyor's observations and stated that Staff O should have been seated while providing feeding assistance.

Based on observation, interview, record review and review of the facility's policy and procedure, it was determined that the facility failed to provide care and services with activities of daily living (ADL)including nail grooming for 3 of 3 sampled residents reviewed for ADL care, (Resident #180, Resident #32 and Resident #23). The findings included: Review of the facility's policy and procedure on 04/01/21 at 11:15 AM for Providing Nail Care provided by the DON revised 01/12/21 indicated Policy: The purpose of this procedure is to provide guidelines for the provision of care to a resident's nails for good grooming and health. Policy Explanation and Compliance Guidelines: Assessments of resident nails will be conducted on a regular basis to determine condition of the resident's nail condition, needs, and preferences for nail care, if possible Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. Routine nail care, to include trimming and filing, will be provided on a regular schedule (such as Biweekly on 3-11 shift). Nail care will be provided between scheduled occasions as the need arises. Principles of nail care: Nails should be kept smooth to avoid skin injury Procedure: .Gently clean underneath nails. If trimming is allowed, clip nails using nail clippers straight across and even with tops of the fingers. Shape nails across using nail file, emery board, or the like .Document completion of task. 1) During an observational tour on 03/29/21 at 10:01 AM, Resident#180 was observed with long, sharp, unkempt fingers on both hands. The resident was wearing bilateral hand splints, however, they do not have separations between each finger. Thus, allowing the fingers to touch/come into contact with each other. The long thumb nail of the left hand appeared to be digging/cutting into the middle finger of the left hand with the left index fingernail noted to have some brown matter underneath. There was a small fresh reddened scratch noted on the resident's left index finger (see pix). The right-hand thumb had a small fresh reddened scratch on the right out side of it next to the adjacent right index finger. Resident #180 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #180 is medically fragile with a Ventilator and [CONDITION(S)] in place and totally dependent on staff for care. (Photographic evidence obtained of Resident #180's long, sharp, unkempt fingernails). On 03/29/21 at 1:33 PM, an observation was conducted of Resident #180 who was still noted to have long, sharp, unkempt fingernails on both hands. On 03/29/21 at 4:33 PM, an observation was conducted of Resident #180 who remained with long, sharp, unkempt fingernails on both hands. On 03/30/21 at 9:42 AM, an observation was conducted of Resident #180 who remained with long, sharp, unkempt fingernails on both hands. On 03/30/21 at 2:46 PM, an observation was conducted of Resident #180 still remaining with long, sharp, unkempt fingernails on both hands, with no bilateral hand splints, on at this time. On 03/31/21 at 10:15 AM, an observation was conducted of Resident #180 who remained with long, sharp, unkempt fingernails on both hands, and wearing bilateral hand splints. There were no separations between each finger; thus, allowing the fingers to touch/come into contact with each other. An interview was conducted with Staff A, a certified nursing assistant (CNA) on 04/01/21 at 10:43 AM and on 03/31/21 at 11:30 AM with Staff B, in which they revealed that they had not provided fingernail care to Resident #180 and both said that it is the responsibility of the CNAs to clean and trim the residents fingernails. They further agreed that the resident's fingernails were long, sharp, untrimmed, and unkempt. An interview was conducted with Staff C, a Registered Nurse (RN) on 03/31/21 at 1:51 PM, and on 04/01/21 at 10:50 AM with Staff D, an (RN), regarding Resident #180's long, unkempt nails. They both also agreed that Resident #180's fingernails were long, sharp, untrimmed and unkempt. Record review of the Resident #180's Monthly CNA ADL (Activities of Daily Living) Flowsheet Record dated 03/02/21 thru 04/01/21 revealed that resident's (ADL) for Personal Hygiene indicated that the resident required physical help from one person and total dependence for personal hygiene activities. Record review of Resident #180's Care plan revised 03/28/21 indicated Problem: Total Activities of Daily Living (ADL) care provided by staff Staff will provide total care with his ADLs. Nonetheless, Resident #180's fingernail care had not been done, on the dates from 03/29/21 thru 03/31/21; until after surveyor intervention. 2) On 03/29/21 at 10:27 AM, an observation was conducted of Resident #32 who was observed to have long, sharp and jagged fingernails on both hands. The resident was wearing bilateral hand splints. Resident #32, was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #32 is medically fragile with a Ventilator and [CONDITION(S)] in place and totally dependent on staff for care. (Photographic evidence obtained of Resident #32's long, sharp, jagged fingernails). On 03/29/21 at 1:35 PM, an observation was conducted of Resident #32 who was still observed to have long, sharp and jagged fingernails on both hands. On 03/29/21 at 4:27 PM, an observation was conducted of Resident #32 who again was still observed to have long, sharp and jagged fingernails on both hands. An interview was conducted with Staff E, a certified nursing assistant (CNA) on 03/31/21 at 1:38 PM, which revealed that Staff E, admitted she had not provided fingernail care to Resident #32 and that it is the responsibility of the CNAs to clean and trim the residents nails. She further agreed that the resident's fingernails were long, sharp, jagged and unkempt. An interview was conducted with Staff F, a Registered Nurse (RN) on 03/31/21 at 02:16 PM, regarding Resident #32's long, unkempt fingernails and she also agreed that Resident #32's fingernails were long, sharp and jagged and unkempt. Record review of Resident #32's Monthly CNA ADL (Activities of Daily Living) Flowsheet Record dated 03/02/21 thru 04/01/21 revealed that resident's ADLs for Personal Hygiene indicated that the resident required physical help from one person and total dependence for personal hygiene activities. Record review of Resident #32's Care plan revised 02/15/21 revealed Total care provided with his ADLs Staff will provide total ADL care. Nonetheless, Resident #32's fingernail care had not been done, on the date of 03/29/21. 3) During an observation conducted on 03/29/21 at 11:46 AM, Resident #23 was observed to have long, sharp fingernails on both hands with bilateral clenched fists with the nails observed to be digging into her palms, black matter was noted underneath the middle finger of her right hand. (Photographic evidence obtained of long, sharp fingernails). Resident #23, was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #23 is medically fragile with a [CONDITION(S)] in place and totally dependent on staff for care. On 03/29/21 at 1:39 PM, an observation was conducted of Resident #23 who was observed to have long, sharp fingernails on both hands and a right-hand clenched fist with the nails observed to be pressing/digging into her palm. On 03/29/21 at 4:49 PM, an observation was conducted of Resident #23 who was still observed to have long, sharp fingernails on both hands and with a right-hand clenched fist with the nails observed to be digging into her palm. On 03/30/21 at 10:04 AM, an observation was conducted of Resident #23 who was still observed to have long, sharp fingernails on both hands and with a right-hand clenched fist with the nails observed to be pressing/digging into her palm. On 03/30/21 at 2:53 PM, an observation was conducted of Resident #23 who was still observed to have long, sharp fingernails on both hands. An interview was conducted with Staff A, a certified nursing assistant (CNA) on 04/01/21 at 10:43 AM, and with Staff B, on 03/31/21 at 11:30 AM, which revealed that both Staff A and Staff B, confirmed that they had not provided fingernail care to Resident #23 and both said that it is the responsibility of the CNAs to clean and trim the residents nails. They further agreed that the resident's fingernails were long, sharp, untrimmed, and unkempt. An interview was conducted with Staff G, a Registered Nurse (RN) on 04/01/21 at 11 AM, regarding Resident #23's long, unkempt nails and she also agreed that Resident #23's fingernails were long, sharp, untrimmed and unkempt. Record review of the Resident #23's Monthly CNA ADL (Activities of Daily Living) Flowsheet Record dated 03/02/21 thru 04/01/21 revealed that resident's ADLs for Personal Hygiene indicated that the resident required physical help from one person and total dependence for personal hygiene activities. Record review of Resident #23's Care plan revised 03/09/21 indicated, Problem: She requires total assist with Activities of Daily Living (ADL)s due to functional decline assist as needed with ADLs. Nonetheless, Resident #23's fingernail care had not been done, on the dates from 03/29/21 thru 03/31/21, until after surveyor intervention. An interview was conducted with the Activities Director on 03/31/21 at 12:52 PM in which she stated that her department has been doing fingernail polishing and filing for the residents, but primarily for the long-term residents who have requested it, by either one (1) of her two (2) activities assistants or done by herself. She added that her department is not allowed to cut any of the resident's fingernails. The Activities Director said that her department provided nail care service to Resident #180 in 12/20 and 02/21 and to Resident #32 in 12/20. The Director also acknowledged that Resident #180, Resident #32 and Resident #23's fingernails were all long, untrimmed and unkempt. On 03/31/21 at 12:45 PM, an interview was conducted with Staff H, a (RN) Unit Manager South wing and with Staff I , another (RN) Unit Manager South wing/(RN) and with the Director of Nursing (DON) regarding Resident #180, Resident #32 and Resident #23's fingernails being long, sharp and untrimmed and they both agreed that it is the responsibility of the CNAs to clean and trim the residents nails. They further acknowledged that all of the resident's fingernails were long and that they should have been cleaned/trimmed/cut. On 03/31/21 at 1:15 PM, an interview was conducted with the Director of Nursing (DON) regarding Resident #180, Resident #32 and Resident #23's fingernails being long, sharp and untrimmed and she also acknowledged that it is the responsibility of the CNAs to clean and trim the residents nails and they further acknowledged that all of the resident's fingernails were long and that they should have been cleaned/trimmed/cut. Review of facility job description on 04/01/21 at 2:40 PM for Certified Nursing Assistant (CNA) provided by the DON indicated the following: Job Summary-Under the supervision of an RN or LPN, performs basic patient/resident care activities. Job Responsibilities Assists patients with tending to personal care and activities of daily living, including bathing, grooming and eating.

Based on observation, interview, and record review, it was determined that following the review of 2 of 9 sampled residents reviewed for nutritional status (Resident #130 and Resident #44) , the facility failed to ensure Resident #130 was offered sufficient types of fluids to maintain proper hydration and health; and failed to ensure gastric tube feedings and flushes was administered according to the attending physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] The findings included: 1) During the initial screening of residents on 03/29/21 at 12 PM, it was noted that Resident #130 requested to speak with the surveyor. The resident spoke while finishing the lunch meal. The resident pointed to to the nectar thick beverages that included milk, juice, and water and stated that she does not drink them and throws them in the trash every meal for some time now. The resident further stated that she has informed the facility's Speech Language Therapist (SLP) on numerous occasions that the thickened beverages make her ill and requested to drink regular thin liquids, and that her swallowing issues was due to chronic GERD (Gastroesophageal Relux Disease). She further stated that the SLP would not speak with her or attempt to resolve the thickened liquids issue. The resident further stated that when she drinks thin fluids it will make her feel better and demonstrated to the the surveyor the drinking of non-thickened hot tea which was on her food tray. The resident further stated that the SLP stated that she must have a [MEDICATION(S)] Swallow test to determine her swallowing issues and capabilities, but requested she would take the test only if supervised by a physician. The resident stated the SLP never responded to her request and she was worried about dehydration due to poor intake of fluids. Following the interview and observation of Resident #130 an interview with the SLP was conducted by the surveyor. The SLP stated that the resident had refused the [MEDICATION(S)] Swallow test, and did not respond to the resident if the test was supervised by a physician. The SLP stated that the resident was not re-evaluated for thin liquids and the possibility of discontinuance of thickened liquids Review of the clinical record of Resident #130 on 03/29/21 and 03/30/21 noted an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review noted 3/29/21- Nurse Manager - Progress Note that documented, spoke with patient due to refusal of Speech service. Patient states she has GERD and gets acid reflux which can cause swallowing difficulty. Patient stated that she is being followed by an Ear Nose and Throat Physician when needed. Patient states she does not need thickened liquids. Spoke with attending physician who gave order to discontinue thickened liquids. Patient additionally states she has been drinking regular liquids without difficulty. Patient observed to not be couching or any difficulty breathing Further review noted a Speech Therapy (SLP) Note dated 3/29/21 that documented attempted to re-screen to advance diet to thin liquids. Patient refusing to participate and refusing clinical trials . RN (Registered Nurse) present and to speak with physician concerning patients continued refusal . Review of a physician Assistant Note dated 3/29/21 documented, discussed with nursing as well as nursing supervisor that patient has been observed drinking thin liquids such as water and tea without any cough or signs and symptoms of of aspiration Video on patient was without weakness and no breathy tone . No cough noted. Patient has declined on multiple occasions to have a MBS (Modified [MEDICATION(S)] Swallow) study done. Discussed with nursing supervisor that patient to be on thin liquids as she has tolerated Further noted a Minimum Date Set (MDS) - Admission, 5-Day assessment dated [DATE] that documented, the resident with a BIMS score of15 (no cognitive impairment (Able to make own health care and food preference) and Section G: Eat = Requires on supervision/set-up only with meals. Following the observation, interview, and record review, an interview was discussed with the Director of Nursing and the Administrator that the Speech Therapist failed to act on the resident's request on repeated occasions for the discontinuance of thickened liquids. It was further discussed that the thickened liquids were making the resident ill and resulted in the resident refusing to drink liquids for an approximate 14 day period, which was causing nutritional and hydration issues. 2) During an initial observational tour on 03/29/21 at 11:09 AM, Resident #44 was observed with the head of his bed elevated with a full bottle of [MEDICATION(S)] 1.5 cal tube feeding (TF) hung up on an Intravenous (IV) pole and connected to Resident #44 was set to infuse at 65ml/hr. via pump. The tube feeding Kangaroo pump was sounding in a continuous beeping tone with the message displayed on the front of the pump: Feed error---bag empty, clog in line, valve not loaded and none of the (TF) was observed to be infusing into the resident's Percutaneous Gastrostomy (PEG-tube) line (Photographic evidence obtained). The (TF) is recorded as being hung up on 3/29/21 at 3:30 AM by the facility night shift nurse. However, there was still remaining a full 1500ml bag hanging up on 03/29/21 at 11 AM. Resident #44, was originally admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #44 is medically fragile with a [CONDITION(S)] in place and totally dependent on staff for care, hydration and nutrition. On 03/29/21 at 12:09 PM, a second observation was conducted in Resident #44's room where it was noted that the Kangaroo pump was again making a continuous beeping tone sound with the message displayed on the front of the feeding pump: Feed error---bag empty, clog in line and valve not loaded with 1500 ml of tube feeding still observed as remaining in the (TF) bag and not infusing. On 03/29/21 at 1:32 PM, a third observation conducted in Resident #44's room where it was noted again that the Kangaroo pump was again sounding in a continuous beeping tone with the message: Feed error---bag empty, clog in line and valve not loaded with 1500 ml still remaining in the tube feeding bag and not infusing into the resident; this on-going issue was not being addressed by staff. On 03/29/21 at 4:37 PM, a fourth observation was conducted of Resident #44's Kangaroo pump which was still sounding in a continuous beep tone with the message: Feed error---bag empty, clog in line, valve not loaded. The tube was now noted to be running and there was still a full 1500ml bag hanging up, at this time. This on-going issue was still noted as not being addressed by staff. Record review conducted of the physician Gastrostomy feeding tube (G-tube) order dated 11/29/19 read, TF continuous 1,430 ml via Percutaneous Esophagogastrostomy (PEG) tube every 22 hours @ 65ml/hr over 22 hours; of 2 hours. On 03/30/21 at 11:10 AM, a computerized record review was conducted of the Tube feeding 1,430 ml administration record which revealed that Staff C, a Registered Nurse (RN), had actually recorded inaccurate/incorrect information in the resident's record regarding a received intake of 1,430 ml at 65 milliliters (ml)/hour (hr.) of the G-tube feeding on 03/29/21---timed as action time at 6:04 PM and recorded time at 6:05 PM, as being given/administered; when, in fact, it was not provided at all as recorded, on that day. Record review of the dietary note by the facility's Registered/Licensed Dietician dated 03/24/21, does not indicate that the resident exhibits an intolerance to his tube feeding. However, further record review indicated that none of the 1,500 milliliters (mls) of [MEDICATION(S)] 1.5 kcal was provided out of 1,500 ml net volume, as prescribed by the physician, on 03/29/21. Further record review of the dietary note by the facility's Registered/Licensed Dietician dated, 03/24/21 indicated that Diet NPO (nothing by mouth) .Tube Feeding---[MEDICATION(S)] 1.5 at 65 ml/hr. x 22 hours continuous. Free water at 45 ml/hr. x 22 hours continuous. Providing 2,145 kcal/97 grams Protein/2,083 ml total free water .Feeding Strength: Full .Resident remains dependent of PEG tube feeding for nutrition support and hydration. Resident is status/post (s/p) routine PEG replacement on 03/12/21. Resident is tolerating PEG tube feeding with no signs/symptoms of Gastrointestinal (GI) upset with aspiration precaution in place. Record review of the resident's care plan for G-tube feeding dated 02/15/21, indicated that Resident #44 is NPO and has a G-tube feeding as his sole means of nutrition PEG feed per Medical Doctor (M.D.) order. There was approximately five and one-half (5.5) hours of daytime which passed, with no nutrition or hydration being provided to this resident. Resident #44 only received 536 kcals of tube feeding and 24 grams of protein, in this time frame. However, he should have received: 2,145 kcals. Thus, he was not provided the ordered 1,609 kcals, for the day. Furthermore, Resident #44 should have received 97grams of Protein. But, he was also not provided an additional 73 grams of protein. An interview was conducted with Staff J, a Certified Nursing Assistant (CNA), on 03/30/21 at 12:26 PM, in which she stated that she did hear Resident #44's (TF) pump beeping around 10 or 11 AM and she admitted that she placed the (TF) pump on hold for only 30 minutes on the pump's automatically timer around 10:30 AM, in order to provide care to Resident #44. Staff J, further confirmed that she did not document anywhere in the resident's record as to when she held Resident #44's tube feeding, during his care. An interview was conducted with Staff C, a (RN), on 03/30/21 at 3:02 PM, in which she confirmed that a full bag of tube feeding was hanging up in the resident's room. She stated that she did hear the pump beeping around 10 AM and at that time, Staff C, stated, that she saw flow error on the screen. She confirmed that she only pushed the run button on the machine and then she walked away from the pump, the first time. Staff C, went on to say that another time, she did hear the (TF) pump beep and she said that the machine read, bag empty, but the bag was not empty and it was still a full bag of (TF) hanging with nothing infused around 12 Noon. She confirmed that she had not actually checked to see if the volume of the feeding had actually infused. Staff C, further confirmed that she inaccurately signed off that 1,430 ml (almost the full 1500 ml) had infused into the resident by 6:04 PM. On 12/11/19 at 1:10 PM, an interview was conducted with both Staff I, a (RN), Supervisor of the South wing and with the Director of Nursing (DON) in which they both confirmed and agreed that there was no nursing note entry note from 3/29/21, to indicate that there were any issues with the resident's (TF) infusing. The DON added that the nurse should have documented any issues in the nurses' notes that she was having with regard to Resident #44's tube feeding, in accurate and correct manner. The DON further confirmed and agreed that the nurse should have ensured that this Resident #44's (TF) was administered as ordered; this was not done. Review of the facility's policy and procedure for Care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .---It is the policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Policy Explanation and Compliance Guidelines: Feeding tubes will be utilized according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Periodic evaluation of the amount of feeding being administered for consistency with practitioner's orders. Calibration of enteral feeding pumps to ensure that pump settings accurately provide the rate and volume consistent with the resident's plan. Periodic maintenance of feeding pumps consistent with manufacturer's instructions to ensure prper mechanical functioning .

Based on observation, interview and record review, the facility failed to ensure Gastronomy Tube feeding was provided per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: The facility's Policy for Care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #16 was admitted for current stay on 08/04/16. According to the resident's most recent full assessment, a quarterly Minimum Data Set (MDS), dated [DATE], Resident #16 was dependent upon staff for all Activities of Daily Living (ADLs). Resident #16's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #16 was not interviewable and did not respond in any manner or gesture to this surveyor greeting by name Resident #16's dietary orders dated -01/02/21 included: Tube feed - continuous 1,300 mL every 12 hours - on 2 PM off 10 AM. Resident #16's care plan documents, (Resident) continues at risk for aspiration due to feeding tube dependency. Quarterly Review 7/7/20 - ongoing. 10/08/20 - ongoing s/p small amount of emesis; currently tolerating PEG feeding aspiration precaution in place. 02/06/21 - s/p emisis. The goal of the car plan was documented as, (Resident) will be free from complications from feeding tube Interventions to the care plan were documented as: * Keep head of bed elevated 30-45 degrees * Observe for s/s of complications from feeding tube * Report abnormal findings to Physician * Observe feeding tube tolerance, collaborate to make appropriate modifications * Monitor intake & output as appropriate * Monitor correct tube placement * Collaborate with Speech Therapy * (Resident) is NPO & has a G-tube feeding as his sole means of nutrition. 1/6/21 Quarterly assessment, con't POC. The goal of the care plan was documented as, Will tolerate G-tube feeding without complications. Interventions to the care plan were documented as: * Maintain NPO as ordered * PEG feed per MD order * Placement check as ordered, * Residual check if above 100 notify MD. * PEG site care done per MD order and as needed * Assess for constipation and diarrhea. Medicate per order. Any deviations communicate with MD. * HOB elevated at least 30 degrees during feedings * 9/22/20 Emesis noted x 1, HOB elevated & staff will continue to monitor for any further episodes A progress note, dated 03/28/21 at 7:10 PM, documents, Resident noted vomit x 1 amount indigested feeding. Feeding kept on holdand resumed. No sign of respiratory distress noted. [CONDITION(S)] care done as ordered. Ped tube patent, in place, peg site dressing intact. Care rendered kept clean and dry. Safety reinforced, call light at reach. Will continue to monitor. On 03/29/21 at 1:26 PM Resident #16 was observed in bed with Tube Feeding (TF) initiated at 65 Milliliters per hour (Ml/hr). at the time of the observation, the display on the feeding pump read 524 ml fed. The bag that the supplement was being dispensed from was date marked 03/29/21 at 4:42. Review of the resident's Electronic Health Record (EHR) revealed no documentation to show that the resident was taken off of feeding regimen per order or justifying why the resident's TF was initiated outside parameters dictated the order or had been continuously running. On 03/30/21 at 7:44 AM, Resident #16 was observed in bed with TF initiated at 65 ml/hr. At the time of the observation, the display on the feeding pump read 266 Ml fed. The bag that the supplement was being dispensed from was date marked 03/30/21 at 0400. The resident's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . At a rate of 65 Ml/hr, the resident should have been fed 195 Ml. On 03/30/21 at 10:51 AM, Resident #16 was observed in bed with TF initiated at 65 ml/hr. At the time of the observation, the display on the feeding pump read 395 ml fed. The observation was of the same bag of the supplement as the previous observation. A review of the resident's EHR revealed no documentation to show that the resident was taken off of feeding regimen per order or justifying why Resident #16's TF was initiated outside of the parameters dictated by the order. During an interview, on 03/31/21 at 12:50 PM, with Staff L, LPN, when I turned him off at 10:00 this morning, 367ml of fluid is what he got from 2:00 PM yesterday until 10:00 this morning when I turned it off. I guess when I turn his feeding back on at 2;00 PM, and it's going to run until the next shift takes down the bag. Continuous, he gets 900 ml of water and then 1300 ml of fluid (TF supplement). At 2:00 PM, there will be a column (in the resident's MAR) and I will put Tube feeding start and the rate. It will keep running and at 7:30, the end of my shift, I check to see that it is running. When the next shift comes in they are supposed to zero out the fluid and the feeding so that they can see what he is getting. When I am leaving, I document the amount of feeding. I did not work with (the resident) Monday and Tuesday. During the interview, Staff L confirmed that there was no documentation in the resident's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview, on 04/01/21 at 8:56 AM, with the DON, when asked about the process and order for Resident #16's TF, the DON stated, at the beginning of the shift, the nurse clears the pump in order to track how much he has gotten during her shift. Nothing is in there for today (in the resident's flowsheet) she would put the total amount at the end of her shift On 04/01/21 at 8:13 AM, Resident #16 was observed in bed with TF initiated at 65 ml/hr. At the time of the observation, the display on the feeding pump read 62 ml fed. The bag that the supplement was being dispensed from was date marked 04/01/21 at 4:50 AM. At a rate of 65 Ml/hr the resident should have been fed 227 Ml over the approximately 3.5 hours since being initiated. There was no documentation in Resident #16's record showing that the resident was removed from TF or that it had stopped at any time and no justification as to why the resident had not been fed as dictated by the order. During a follow up interview, on 04/01/21 at 9:12 AM, with Staff L, LPN, she stated, when I come in the morning, I clear his pump at 7:00 AM, at 10:00, I see what he is getting for that time period. at 2:00 he is going back up and I am going to check at 7:30 to see that his pump is working and if he is getting his feeding. During an interview, on 04/01/21 at 9:22 AM, with the Clinical Dietitian, she stated We did his assessment and assessed his nutrition needs quarterly on 01/01/21. His estimated nutrient needs were between 1550 to 1860. The current feeding that he is at is providing 1560 cal.