Every finding on record at Pontotoc Health & Rehab Center

Based on observation, resident and staff interview, record review and facility policy review the facility failed to ensure that a urinary catheter and urinary leg bag were secured correctly and maintained below the level of the bladder, resulting in the potential for backflow of urine, catheter dislodgement, and compromised urinary drainage for one (1) of two (2) residents reviewed with an indwelling catheter (Resident #9). Findings Include:Review of the facility policy titled Bladder and Bowel Habits, Urinary Incontinence and Catheter Care. with a revision date of 9/15/2022 revealed under Catheter Care; Catheter care shall follow these guidelines: The catheter bag must be kept in a patent position (below the level of the bladder). During an observation and interview on 12/01/2025 at 10:45 AM, an observation revealed a Velcro strap secured around Resident #9's left ankle, anchoring a urinary catheter tubing and a 600 cubic centimeter (cc) urinary leg bag, which was noted hanging off the lower left side of the bed and had approximately 300 cc of urine in the bag. Resident #9 revealed she has a catheter, and she had no idea why the strap was on her ankle. In an observation and interview on 12/01/2025 at 11:20 AM, Resident #9 was observed lying in bed with the Velcro strap securing the urinary tubing and the emptied urinary leg bag attached to the upper left positioning bar. The resident revealed they just came in, moved it from my ankle, and put it up here. The urinary drainage bag was positioned above Resident #9's bladder level. Resident #9 removed her covers to expose her left leg, and no urinary tube securement device was observed in place. An observation on 12/02/2025 at 8:35 AM, and again at 10:23 AM, revealed the white catheter leg strap remained secured to the upper left positioning bar, with the urinary leg bag hanging above the bladder level. During an observation and interview on 12/02/2025 at 11:30 AM, the urinary leg drainage bag remained suspended from the upper left positioning bar above the resident's bladder level and contained approximately 500 cc of yellow urine. The Director of Nurses (DON) stated, Oh, this bag needs to be emptied, and confirmed the drainage bag was improperly positioned above the bladder and not securely anchored. Resident #9 stated that she was instructed during a recent hospital stay that The bag was supposed to be kept low. The DON acknowledged that failing to secure the drainage bag and keeping it below bladder level could cause backflow of urine and increase the risk of catheter dislodgement. During an interview on 12/02/2025 at 3:24 PM, the Nurse Consultant confirmed that the urinary drainage bag must always be positioned below the bladder to ensure proper urine flow and that the catheter tubing must be properly secured to ensure proper placement. Record review of the admission Record revealed the facility admitted Resident #9 on 7/9/2024 with medical diagnoses that include Chronic Kidney Disease, Stage 3A, and retention of urine. Record review of Resident #9's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/18/25, revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident was cognitively intact.

Based on observation, staff interviews, record review and facility policy review the facility failed to provide Activities of Daily Living (ADL) care to maintain personal hygiene for one (1) of 45 residents observed. (Resident #22) Findings Include: Review of facility policy titled, Activities of Daily Living (ADL) with revision date 9/15/2022, revealed, .Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming, and oral care .A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . During an observation on 12/01/2025 at 10:43 AM, with Resident #22 revealed the resident had hair on her upper lip measuring approximately one-half inch (1/2) in length and also on her chin measuring approximately one inch to one and one-half inches in length. During an interview on 12/02/2025 at 10:19 AM, with Licensed Practical Nurse (LPN) #1 revealed Certified Nursing Assistants (CNAs) are responsible for ensuring that facial hair is removed from female residents unless the resident or their responsible party refuses. During an interview on 12/02/2025 at 10:23 AM, with Certified Nursing Assistant (CNA) #1, revealed Resident #22 did have very long facial hair on her chin and upper lip yesterday, 12/01/25. She stated that she did shave the resident today. She verified that removing facial hair on female residents was part of daily ADL care and that CNAs were responsible for that. She verbalized that Resident #22's family wanted her to be free from facial hair. She further verbalized that female residents should not have unwanted facial hair and it should be removed daily as needed. During an interview on 12/02/2025 at 10:36 AM with the Director of Nursing (DON), she confirmed that CNAs were responsible for daily ADL care which included removal of facial hair for female residents unless resident/family refused. She further verbalized that unwanted facial hair on female residents should be taken care of on a daily basis. Record review of the admission Record revealed Resident #22 was admitted to the facility on [DATE] with medical diagnoses that included Cerebrovascular Disease, Tremor, and Unspecified Lack of Coordination. Record review of the MDS assessment with Assessment Reference Date (ARD) of 11/26/25, revealed under section C, a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact.

Based on observation, staff interviews, facility policy review, and record review, the facility failed to implement the Activities of Daily Living (ADL) care plan for one (1) of 45 residents observed. (Resident #22) Findings Include: Review of facility policy titled, Comprehensive Plan of Care with revision date 2/17/25, revealed, It is the policy of this facility to .implement a comprehensive person-centered care plan for each resident .that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality . An observation on 12/01/2025 at 10:43 AM, with Resident #22 revealed the resident had hair on her upper lip measuring approximately one-half inch (1/2) in length and also on her chin measuring approximately one inch to one and one-half inches in length. Record review of the ADL care plan revealed, The resident has an ADL self-care performance deficit . Interview on 12/03/2025 at 12:15 PM with the Minimum Data Set (MDS) Coordinator confirmed that care plans are created as a guide for staff to ensure resident specific care. She further confirmed that the ADL care plan was not implemented for Resident #22. Record review of the admission Record revealed Resident #22 was admitted to the facility on [DATE] with medical diagnoses that included Cerebrovascular Disease, Tremor, and Unspecified Lack of Coordination. Record review of the MDS assessment with Assessment Reference Date (ARD) of 11/26/25, revealed under section C, a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact.

Based on observation, staff interview, record review and facility policy review, the facility failed to remove facial hair on a resident requiring assistance with Activities of Daily Living (ADL) for one (1) of 17 residents sampled. Resident #41 Findings Include: Record review of the facility policy titled, Activities of Daily Living (ADL) with a revision date of 9/15/22 revealed . Policy Explanation and Compliance Guidelines .3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene . During an observation on 07/23/24 at 10:28 AM, revealed Resident #41 sitting up in her wheelchair with 6-8 white hairs on both sides of her chin that were approximately 1/8- 1/4 inch long. During an observation and interview on 7/24/24 at 9:15 AM with Certified Nurse Assistant (CNA) #1 confirmed that Resident #41 had chin hairs on both sides of her chin that should have already been removed. She stated the resident had a doctor's appointment yesterday and she got in a hurry and did not remove them when she gave the resident her shower. She stated most women don't want hair on their face. CNA #1 then stated I know I would not. An observation and interview on 7/24/24 at 9:25 AM, with the Director of Nurses (DON) confirmed Resident #41 had facial hair that should have been removed with her bath and should have been documented correctly under whether the resident had facial hair. She stated that facial hair removal is part of bathing and she expected it to be done. Record review of Resident #41's documented baths revealed the resident received a bath on 7/23/24 at 10:51 AM. Record review of Resident #41's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Dementia. Record review of Resident #41's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/11/24 revealed in Section GG the resident was totally dependent on staff for bathing and personal hygiene.

Based on observation, staff interview, record review and facility policy review the facility failed to implement a care plan regarding a resident needing assistance with Activities of Daily Living (ADL) for one (1) of 17 care plans reviewed. Resident #41 Findings Include Review of the facility policy titled, Comprehensive Plan of Care with a revision date of 10/10/22 revealed Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . Record review of the Care Plan Detail for Resident #41 revealed Focus: Res (Resident) requires assist with all ADL's .Interventions/Task .Assist with all .Bathing .Personal Hygiene . An observation on 07/23/24 at 10:28 AM, revealed Resident #41 sitting up in her wheelchair with 6-8 white hairs on both sides of her chin that were approximately 1/8- 1/4 inch long. An observation and interview on 7/24/24 at 9:15 AM, with Certified Nurse Assistant (CNA) #1 confirmed Resident #41 had chin hairs on both sides of her chin that should have already been removed. She stated the resident had a doctor's appointment yesterday and she got in a hurry and did not remove them when she gave the resident her shower. She stated most women don't want hair on their face. CNA #1 stated, I know I would not. An interview on 7/24/24 at 9:40 AM, with the Minimum Data Set/Registered Nurse (MDS/RN) revealed she develops the care plans for ADL's and confirmed that Resident #41 needed assistance with her ADL's that included her facial hair removal. She agreed that the care plan was not implemented if the resident had a shower, and the facial hair was not removed. An interview on 7/24/24 at 1:30 PM, with the Director of Nurses (DON) confirmed Resident #41 needed assistance removing the hair from her chin and therefore her ADL care plan was not implemented. Record review of Resident #41's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses which included Unspecified Dementia. Record review of Resident #41's MDS with an Assessment Reference Date (ARD) of 6/11/24 revealed in Section GG the resident was totally dependent on staff for bathing and personal hygiene.

Based on resident and staff interviews, record review and facility policy review, the facility failed to provide weekend activities for three (3) of eight (8) residents reviewed in the resident council meeting. Resident # 7, Resident #29, and Resident #40. Findings include: A record review of the facility policy titled Activities with a revised date of 11/28/2017 revealed, Policy: This facility shall provide ongoing activities in accordance with the interest, physical, mental, and psychosocial well-being of each resident During the resident council meeting held on 7/24/24 at 1:30 PM, with 8 residents in attendance, 3 residents revealed that they do not have activities on the weekend and stated there is really nothing for them to do. They stated they wished they had more things to do like they do during the week. Resident #7 During an interview in the resident council meeting, Resident #7, who is also the resident council president, revealed we don't have activities on the weekends. We have a preacher who comes in at 10 AM on Sundays and has Sunday School, but other than that, we really don't have anything to do. She revealed it would be nice to have something to do. Record review of Resident #7's Admission Record revealed an admitted [DATE]. Record review of Resident #7's Minimum Data Set (MDS) with an Assessment reference date (ARD) of [DATE], Section C, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #7 is cognitively intact. Review of Section F Preferences for Customary Routine and Activities F0500 revealed While you are in this facility how important is it to you to do things with groups of people? And how important is it to you to do your favorite activities? revealed that Resident #7 considered this to be Somewhat Important. Resident #29 Resident #29 revealed in an interview, during the resident council meeting, We don't have activities on the weekend. There's really nothing to do. We understand the Activities Director must spend time with her family, but it would be nice to have something to do. Record review of Resident #29's Admission Record revealed an admitted [DATE]. Record review of Resident #29's MDS with an ARD of [DATE], Section C, revealed a BIMS score of 15, which indicated Resident #29 is cognitively intact. Review of Section F Preferences for Customary Routine and Activities F0500 revealed While you are in this facility how important is it to you to do things with groups of people? And how important is it to you to do your favorite activities? revealed that Resident #29 considered this to be Somewhat Important. Resident #40 Resident #40 revealed in an interview during the resident council meeting, We have coloring books and games that we can come in here and do by ourselves, but we don't have something to do as a group. She revealed that a lot of times, families come and visit on the weekends. Resident #40 stated,I guess that's why we don't have any activities. We just mainly stay in our rooms. Record review of Resident #40's Admission Record revealed an admitted [DATE]. Record review of Resident #40's MDS with an ARD of 06/24/24, Section C, revealed a BIMS score of 15, which indicated Resident #40 is cognitively intact. Review of Section F Preferences for Customary Routine and Activities F0500 revealed While you are in this facility how important is it to you to do things with groups of people? And how important is it to you to do your favorite activities? revealed that Resident #40 considered this to be Very Important. In an interview on 7/24/24 at 3:08 PM, the Activities Director revealed she is aware the weekend activities are lacking and confirmed the residents could benefit from organized activities. She revealed the residents have complained to her that there is nothing to do on the weekends, and she tried to come in at times and do activities with them, but it is not consistent. She revealed Resident #40 specifically voiced to her again recently that there is nothing to do on the weekends and has told her that it's boring on the weekends and the only thing they do is sit in their rooms. In an interview on 7/24/24 at 3:32 PM, the Director of Nurses (DON) revealed she was aware there had been complaints in the past from some residents wanting more activities on the weekend. She revealed she thought that the Activities Director was leaving stuff with the charge nurse at the desk for them to do on the weekends, but she admitted she was not sure. In an interview on 7/24/24 at 4:40 PM, the Administrator confirmed the weekend activities are lacking. She revealed that we recently added an extra nurse to help with weekend activities but confirmed that they had not fully implemented it yet.

Based on observation, staff interview, record review and facility policy review, the facility failed to administer a medication according to the physician orders for one (1) of 31 medication administration opportunities. Resident #23 Findings Include: Review of the facility policy titled, Medication Administration with a revision date of 6/8/23 revealed Policy .Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection . An observation and interview on 7/24/24 at 8:15 AM, revealed Licensed Practical Nurse (LPN) #1 allowed Resident #23 to self administer an inhaler with no instructions to rinse and spit afterwards according to physician orders. LPN #1 stated, Well I messed that up. She revealed the resident refuses to rinse and spit, but I should have reminded her of the need to do so. She stated she was not sure the purpose of rinsing and spitting after the inhaler, unless it was just to get the taste out of their mouth. She confirmed Resident #23's order indicated the resident needed to rinse and spit following the administration of the inhaler, so therefore she did not follow the physician orders. An interview on 7/24/24 at 10:30 AM, with the Director of Nurses (DON) confirmed the nurse did not follow the physician orders and the nurse did not instruct the resident to rinse and spit after the administration of the inhaler. She stated that the purpose of rinsing and spitting after the inhaler was to prevent yeast and sores in the residents' mouth. Record review of physicianOrder Details revealed the following: 8/7/23 BREO ELLIPTA Inhaler 100-25-1 puff inhale orally one time a day related to Mild Intermittent Asthma, Uncomplicated, Rinse mouth with water (H2O) and spit after use. Record review of Resident #23's Admission Record revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Mild intermittent asthma, uncomplicated and Acute Cough.

Based on observations, staff interviews, record review and facility policy review the facility failed to prevent the possible spread of infection during medication pass for two (2) of 35 medication administrations observed (Resident #18 and Resident #21) and by not storing a nebulizer mask properly when not in use for one (1) of five (5) residents reviewed for respiratory care (Resident #16). Findings Include: Review of the facility policy titled, Infection Prevention and Control with a revision date of 5/12/23 revealed, Policy .This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. Review of the typed statement on facility letterhead revealed the facility did not have a policy on utilizing a barrier when administering medications and was signed by the Administrator dated 6/7/23. Review of the typed statement on facility letterhead revealed the facility did not have a policy on nebulizer storage when not in use that was signed by the Administrator and dated 6/7/23. Resident #18 An observation on 6/7/23 at 9:18 AM with Resident #18 revealed Licensed Practical Nurse (LPN) #2 entered the resident's room to administer medications and eye drops to the resident and placed a bottle of eye drops on the resident's bedside table with no barrier and did not wipe down the table prior to placing the eye drops on the table. LPN #2 then administered the resident's other medications, followed by the eye drops. After administering the eye drops, LPN #2 returned the eye drop bottle to her medication cart and placed them back in the drawer of the medication cart. An interview on 6/7/23 at 9:30 AM, with LPN #2 confirmed that she should have put a barrier down to set the eye drops on instead of setting them directly on the resident's bedside table, because there was no way to know what could have been on that table. She stated that the barrier would have prevented the possible spread of infection. Record review of Resident #18's June 2023 Physician Orders revealed an order dated 12/27/18 for Artificial Tears one drop each eye twice per day for Dry Eyes. Record review of Resident #18's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Dry Eye Syndrome. Record review of Resident #18's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/16/23 revealed in Section C a Brief Interview for Mental Status (BIMS) of 15, which indicated the resident was cognitively intact. Resident #21 An observation on 6/7/23 at 8:57 AM, with Resident # 21 revealed that LPN #1 entered the resident's room, set the resident's ordered eye drop bottle on the overbed table with no barrier, administered the residents by mouth (PO) medications and then picked the eye drop bottle up off of the overbed table and administered the eye drops. LPN #1 then left the residents room and returned the eye drop bottle to the medication cart drawer. An interview on 6/7/23 at 9:15 AM, with LPN #1 confirmed she set Resident #21's eye drops on the overbed table with no barrier before administering and then returned them to the medication cart. She revealed that she should have used a barrier under the eye drops before setting them on the overbed table to prevent the possible spread of infection and she stated that she knew better. An interview on 6/7/23 at 9:50 AM, with the Infection Preventionist (IP) confirmed that the nurses should have placed a barrier down to place the eye drop bottle on instead of setting them directly on the resident's furniture. She stated that they are absolutely supposed to use a barrier and that the nurses are trained in using a barrier for infection control purposes when they are hired and during annual in-services. An interview on 6/7/23 at 2:10 PM, with the Director of Nurses (DON) confirmed that the nurses should not set an eye drop bottle down in the resident's room without using a barrier to prevent the spread of infection. Record review of Resident #21's Physician Orders List revealed an order dated 3/31/21 for Olopatadine HCL 0.1% eye drops, administer one drop in both eyes daily for Allergies. Record review of Resident #21's Face Sheet revealed the resident was admitted to the facility on [DATE] with medical diagnoses that included Unspecified Dementia, Unspecified Severity with behavioral disturbances and Allergic Rhinitis Unspecified. Record review of Resident # 21's MDS with an ARD of 5/30/23 revealed in Section C a BIMS of 11 which indicated the resident was moderately cognitively impaired. Record review of the facility in-services regarding infection control revealed the facility had an in-service on 7/22/22 and 2/16/23 that was attended by all nursing staff including LPN #1 and LPN #2. 47874 Resident #16 An observation and interview on 06/05/23 at 11:05 AM, with Resident #16 revealed his nebulizer machine and mask were located on the bedside table with no storage bag placed over the nebulization mask. The resident revealed he used the nebulizer several times a day. An observation on 06/06/23 at 9:05 AM, revealed Resident #16's nebulizer mask lying on the bedside table with no storage bag over the mask. An observation on 06/07/23 at 9:30 AM, revealed Resident #16's nebulizer mask clipped onto the nebulizer machine located on the bedside table with no storage bag placed over the mask. An interview on 06/07/23 at 9:40 AM, with Licensed Practical Nurse (LPN) #2 confirmed that Resident #16's nebulizer mask was not placed in a storage bag. She revealed that not placing the mask in a storage bag could cause the mask to become contaminated with germs and could lead to respiratory issues. An interview on 06/07/23 at 9:55 AM, with the Infection Preventionist (IP) revealed that staff are supposed to keep the nebulizer mask bagged if not in use. She revealed that leaving Resident #16's mask out of the storage bag could cause bacteria to enter the mask and could cause respiratory infection. An interview with the Director of Nursing (DON) on 06/07/23 at 10:10 AM, acknowledged that Resident #16's nebulizer mask should not be left out in the environment and doing so could lead to respiratory infection. She stated that the facility has IP's (in pouches) that the mask should be stored in between usage. Record review of the medical record revealed Resident #16 was readmitted to the facility on [DATE] with diagnoses that included Personal history of COVID-19, Centrilobular Emphysema, Anxiety Disorder, and Shortness of Breath. Record Review of Resident #16's Physician Orders List revealed an order dated 01/12/23, DUO-NEB 0.5-2.5MG(milligrams)/3ML(milliliter) neb (nebulizer) give 3ML inhalation via nebulizer QID (four times a day); Emphysema Record review of the MDS with an ARD of 04/04/23 revealed under section C a Brief Interview for Mental Status (BIMS) score of 13, which indicates Resident #16 is cognitively intact.

Based on family interview, staff interviews, facility policy review, and record review, the facility failed to treat, monitor, and manage the resident's pain for one (1) of three (3) residents assessed for pain. Resident #143. Findings include: Review of the facility policy titled, Pain: Assessment, Scale and Management, dated 11/28/2017, revealed, POLICY: .facilities shall provide management of pain to ensure that residents attain or maintain the highest practicable physical, mental, and psychosocial well-being .PROCEDURE: .attempts to control pain shall be employed until the resident reaches an acceptable comfort level . A phone interview on 12/28/2021 at 8:25 AM, with Resident #143's daughter, revealed her mother had a [CONDITION(S)] on 2/1/2019, and was admitted to the facility on [DATE], for therapy with the plan to return home. She revealed that the resident's condition deteriorated, and she was admitted to the hospital on 5/5/2021 and was discharged to a hospice center after hospitalization . She revealed her mother passed away on 5/20/2021. She revealed she attended a dental appointment with her mother on 4/19/2021 and was horrified when she observed her mother's teeth had deteriorated and several were broken off at the gum line and caused her pain when she ate. She revealed her mother's teeth were not in that condition the last time she was able to see them. She revealed when COVID-19 started, she was only allowed to visit through the window, and during the few in person visits she had with her mother, both she and her mother were required to wear masks and remain at a distance, therefore, her mother's teeth were not visible to her. She revealed the staff did not give her mother the ordered pain medications that would have eased the pain and allowed less discomfort during meals. An interview on 12/29/2021 at 8:45 AM, with the Speech Therapist (ST) revealed she had worked with the resident on swallowing. She revealed the resident had discomfort in her teeth when she ate the mechanical soft diet and the diet was changed to a pureed diet to ease the pressure during meals. She revealed that during the assessment of the resident's mouth, she noted the resident's bottom front tooth was present, but decayed and biting down caused her discomfort. ST stated she thinks a dental consult was postponed when the resident had COVID-19. A phone interview on 12/29/2021 at 10:45 AM, with Registered Nurse (RN) #1, revealed she had taken care of Resident #143. She revealed the resident complained of pain in her mouth, and when she evaluated her mouth, she noted several teeth were broken off at the gum line. She revealed she did not remember if she gave the resident anything for pain or if she offered other comfort measures, but if she had given pain medication, it would have been documented. She revealed if pain medication was not documented, she did not give. She revealed pain medication should have been given when resident was having pain. An interview on 12/29/2021 at 12:40 PM, with the Director of Nursing (DON), revealed when Resident #143 complained of pain, interventions to alleviate pain should have been implemented. She revealed the pain medication should have been given, the physician should have been notified concerning findings in resident's mouth, and a follow up for pain evaluation should have been done. She revealed the resident should have received treatment and been closely monitored to ensure comfort and well-being and her pain should not have been left untreated. The DON confirmed the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She confirmed the resident's pain was not treated and the facility failed to ensure the resident's pain was monitored and treated appropriately. An interview on 12/29/2021 at 12:45 PM, with the Administrator, revealed there was documentation the resident was in pain and no treatment was given. She confirmed the facility failed to ensure the resident's pain was monitored and treated appropriately. The Administrator confirmed that by pain medication not being administered as ordered and by the delay in obtaining a dental consult, the resident's pain was not managed properly. Record review of ST Progress Note, dated 3/24/2021, revealed, Patient unable to tolerate mechanical soft consistencies due to signs and symptoms (s/s) of dysphagia and reported pain with teeth during mastification. Record review of nurses note on 3/5/2021 at 01:54 PM, revealed, Resident complains of mouth pain, pointed to left side of mouth. Noted upon view resident has a molar broken off and noted decay. And also bottom teeth are broken off to the gums. Resident unable to eat and drink due to intolerance of heat and cold on tooth . Record review of the March 2021 Physician's Orders revealed an order dated 2/7/2021 for Acetaminophen 325 milligram tablet and give two tablets to equal 650 milligrams by mouth every four hours as needed for mild pain 1-3. Record review of electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #143 ' s electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #143's care plan revealed a care plan was not developed for the resident for mouth pain. Record review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/2/2021, Section C - Cognitive, revealed a Brief Interview for Mental Status (BIMS) score of 2, which indicated severe cognitive impairment. Record review of the Face Sheet revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, interview, record review and facility policy review, the facility failed to provide a safe and clean environment for preparing and storage of food for two (2) of three (3) kitchen/nourishment room tours. Findings include: Review of facility policy, titled, Cleaning Instructions: Oven, dated 2017, revealed Policy: Ovens will be cleaned as needed and according to the cleaning schedule (at least once every two weeks). Spills and food particles will be removed after each use . Review of facility policy, titled, Cleaning Instructions: Ranges, dated 2017, revealed, Policy: The cook/chef on each shift is responsible for keeping for range as clean as possible during the preparation of the meal. The range will be cleaned after each use. Spills and food particles will be wiped up as the occur . Review of facility policy, titled, Cleaning Instructions: Fryers, dated 2017, revealed Policy: Fryers will be cleaned on a regular basis and cared for in such a way to maintain optimum production . Review of facility policy, titled, Food from Outside Sources, dated 2008, revealed, .Procedure: 5. Food brought in should be labeled with the individual's name and dated if it must be stored. An observation, on 12/28/21 at 2:00 PM, revealed there was a yellow and brown build up on a large steam table pan lid, a flat/thin silver sheet of metal, and two (2) cookie sheets, that were being used to cover the deep fryer. There were four (4) deep fryer baskets, sitting on top of the deep fryer covers, covered with yellow and brown build up. The stove top had black colored build up on the areas surrounding the eyes. There was black, crusty, build up on the pipes under each stove eye. The inside of the convection oven doors was covered with a dark brown build up that had run down on the ledge on the outside of the stove under the oven doors. The back wall of the convection oven was covered in a dark brown build up. There was a dark and thick, yellow and brown, build up on the silver panel located behind the stove. There were six (6) baking pans and five (5) pots covered with a dark brown and black build up on the outside. The baking pans had a dark brown build around the sides on the inside of the pans. An observation and interview, on 12/28/21 at 2:12 PM, with Dietary Cook #1, confirmed that there was grease build up on the stove top, that there was black crusty build on the pipes under the stove eyes, that there was a yellow and brown build up on the 4 deep fryer baskets, that there was a yellow and brown grease build up on the large steam table pan lid, a flat piece of silver metal, and two (2) cookie sheets, that were being used to cover the deep fryer, that there was a brown build up inside the doors of the convection oven, that there was a dark brown build up on the ledge of the convection oven on the outside under the doors, that there was a brown build up on the back wall inside of the convection oven, and that there was a yellow and dark brown build up on the silver panel located behind the stove. Dietary Cook #1 stated all of the appliance's should have been cleaned and were supposed to be cleaned every week. Dietary Cook #1 stated she did not know when the last time the deep fryer was used or cleaned. An observation and interview, on 12/28/21 at 02:20 PM, with Dietary Staff #2, confirmed the stove top, the deep fryer covers, and the 4 deep fryer pans had grease build up and had not been cleaned. Dietary Staff #2 revealed she did not know who was assigned to clean the stove and she did not know how long the fryer basket had been dirty. Dietary Staff #2 confirmed the baking pans and the pots had yellow and black build on the outside and the baking pans has dark brown build up on the inside. An interview, on 12/28/21 at 02:25 PM, with Dietary Staff #3, revealed the deep fryer had not been used in a very long time, and she could not give a specific time frame. Dietary Staff #3 stated there were plenty of cleaning supplies available to clean the kitchen appliances, but did not know who was supposed to be cleaning the fryer. An observation and interview, on 12/28/21 at 03:30 PM, with the Administrator, confirmed there was a brown and yellow grease build up on a large steam table pan lid, a flat piece of silver metal, and two (2) cookie sheets, that were being used to cover the deep fryer, that there were four (4) deep fryer baskets covered with yellow and brown build up, that the stove top had grease build on the areas surrounding the eyes, that there was black, crusty, build up on the pipes under each stove eye, that there was a thick, yellow and brown build up on the silver panel behind the stove, that the inside of the convection oven doors were covered with a dark brown build up that had run down on the ledge on the outside of the convection oven under the oven doors, that the back wall of the convection oven was covered in a dark brown build up, that there was a yellow and dark brown build up on the silver panel located behind the stove, and that the baking pans and pots were covered with a brown and black build up on the outside, that the baking pans had a dark brown build around the sides on the inside of the pans. The Administrator stated the grease build up on the stove top, on the stove pipes, and on the deep fryer could possibly cause a fire. The Administrator revealed she only had a copy, for one week, of the December 2021 kitchen cleaning schedule, that showed kitchen staff cleaning task assignments. The Administrator revealed that the December 2021 kitchen cleaning schedule did not have a date that indicated which week in December the cleaning took place. The Administrator confirmed there has been no in-services done on the cleaning of the kitchen. An observation, on 12/28/21 at 04:00 PM, revealed the resident nourishment refrigerator had an excessive amount of yellow and dark tan build up inside at the bottom of the refrigerator. The entire bottom of the inside of the refrigerator had yellow and tan spillage, that was dried and run out of the bottom under the door. There was also spillage down the lower part of the back wall inside of the refrigerator. Observation also revealed there were several outside food items and drinks in the resident nourishment refrigerator that were not labeled with a resident's name or dated, to show when they were placed in the resident nourishment refrigerator. Items observered included two (2 ) plastic containers with food, cold cut tray, two (2) zip lock bags and three (3 ) opened partially empty drink bottles in the nourishment refrigerator that were not labeled or dated. An observation and interview, on 12/28/21 at 04:05 PM, with Licensed Practical Nurse (LPN) #1, confirmed the resident nourishment refrigerator had an excessive amount of yellow and dark tan build in the bottom and the nourishment refrigerator should have been cleaned. LPN #1 stated the nourishment refrigerator was supposed to be cleaned by the night shift staff, but not sure how often the refrigerator was to be cleaned. LPN #1 stated the outside food, not being labeled and dated in the resident nourishment refrigerator, could cause a resident to have been given the wrong food or old food, and a resident could get sick. An observation and interview, on 12/28/21 at 04:14 PM, with Director of Nursing (DON), revealed the resident nourishment refrigerator at the nurses station had an excessive amount of yellow and dark tan build up, in the bottom of the refrigerator, on the inside, and there was several food items, two (2 ) plastic containers with food, cold cut tray, two (2) zip lock bags and three (3 ) opened partially empty drink bottles in the nourishment refrigerator that were not labeled or dated. The DON confirmed the resident nourishment refrigerator should have been cleaned. The DON confirmed the 11:00 PM to 7:00 AM shift's nursing staff were responsible for the nourishment refrigerator cleaning task. DON confirmed a resident could get sick if they were given the unlabeled food or drinks. A telephone interview, on 12/29/21 at 11:50 AM, with Dietary Staff #4, revealed she last cleaned the stove top and the convection oven, on Saturday, 12/18/21. Dietary Staff #4 stated it was not her job to clean the stove and oven and the Kitchen Cook was responsible for cleaning the stove. Record review of the December kitchen cleaning schedule title, Daily Cleaning Schedule Form, dated December 2021 revealed the schedule covered one week and did not indicate which week in December it represented. The cleaning schedule revealed the cleaning of the stove top and the convection oven were to be done weekly. There was no indication of how often the fryer was to be cleaned. The December kitchen cleaning schedule revealed Dietary Staff #4's initials, that indicated she was the last one to clean the stove top and the convection oven, on a Saturday, with no specific date noting which Saturday in December the cleaning took place. Record review of the cleaning schedule for the nourishment refrigerator titled, 11-7 Cleaning Schedule, dated 04/23/14 revealed the nourishment refrigerator was to be defrosted and cleaned every Thursday, and all Certified Nursing Assistants were to work together to complete the task.

Based on staff interview and record review the facility failed to correctly complete a Level I Pre-Admission Screening (PAS) for a resident requiring a Level II Pre-Admission Screening and Resident Review (PASRR) for major mental illness for one (1) of three (3) residents reviewed for no PASRR with diagnosis. Resident #42. Findings include: An interview and record review of Resident #42's admission paperwork and Level I Pre-Admission Screening (PAS), on 12/28/21 at 10:00 AM, with the Social Worker (SW), confirmed Resident #42 was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The SW confirmed that she answered PAS questions incorrectly related to person has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #42 to have a Level II Pre-Admission Screening and Resident Review (PASRR). SW confirmed it was important for a PAS to be completed correctly, to ensure Resident #42 received appropriate mental health services while in the nursing facility. An interview, on 12/28/21 at 02:35 PM, with the Administrator, confirmed the PAS submitted for Resident #42, on 6/7/21, had questions answered incorrectly. The Administrator confirmed the questions being answered incorrectly on the PAS, caused Resident #42 to not receive a Level II PASRR. The Administrator confirmed she was aware that Resident #42 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator confirmed it was important for Resident #42 to have received a Level II PASRR to ensure the facility provided appropriate mental health services while in the nursing facility. The Administrator stated the facility did not have a policy regarding completion of a PAS. Record review, of the PAS, for Resident #42, revealed it was submitted on 6/7/21. The PAS was answered, no, for person has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Face Sheet revealed Resident #42 was admitted to the facility on [DATE]. Record review of the Diagnosis/History revealed a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review the June 2021 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) Significant Change in Status Assessment, dated 12/17/21, noted Resident #42 had a Brief Interview for Mental Status (BIMS) score of 05, which indicated the resident had severe cognitive impairment.

Based on observation, staff interview, and facility policy review, the facility staff failed to lock the medication cart during medication pass for one (1) of three (3) nurses observed during medication pass. Findings include: Review of the facility policy titled, Drug Aquisition, Storage and Inspection, revised 11/28/2017, revealed responsibility for control of medications within this facility shall rest with nursing services. Policies and procedures shall be designed to ensure the safe and accurate dispensing of medications throughout the facility. The procedure for storage revealed lockable medication carts shall be used to store unit-of-use medications in the resident medication dose system. These carts shall be locked when not attended. On 05/08/19 at 11:22 AM, an observation during medication pass with Licensed Practical Nurse (LPN) #1 revealed the medication cart sitting in the A-wing hallway unlocked. LPN #1 pushed the medication cart to the end of the hall and set up an Insulin injection. While in the resident's room, the cart remained unlocked in the hallway out of LPN #1's sight. LPN #1 administered medications to two (2) other Residents leaving the medication cart unlocked and unattended. During this time, housekeeping staff, nursing staff, therapy and residents were observed in the hallway. On 05/08/19 at 11:33 AM, an interview with LPN #1 revealed she did not think the medication cart was supposed to be locked just going from room to room giving medications but it should be locked when it is parked and medications are not being given. LPN #1 confirmed she could see why it should be locked because some one could take some medications from it. On 05/08/19 at 3:36 PM, an interview with the Administrator (ADM) confirmed the medication cart should be locked during medication pass if it is in the hallway because anybody could take something off of it. The ADM stated there were no residents on the A-hall that wander without purpose. On 05/08/19 at 04:03 PM, an interview with the Director of Nursing (DON) stated the nurses have been in-serviced on the medication cart, and that is not the way we are supposed to do that. The medication cart is supposed to be locked any time the nurse is away from it. The DON stated a confused resident or a visitor or employee or anybody could get into the cart and this could be a major problem. The DON stated the nurse is not supposed to leave the cart unlocked. Record review revealed LPN #1 attended an in-service on 10/29/18, in which documentation included in #15, to keep medication cart locked at all times when away from it. Facility Policy and Procedure on Drug Acquisition, Storage and Inspection (Revised 11.28.2017) which was also listed in the in-service included under Procedure: Storage: Lockable medication carts shall be used to store unit-of-use medications in the resident medication dose system. These carts shall be locked when not attended.

Based on observation, staff interview, record review, and facility policy review, the facility failed to maintain a medication error rate less than five percent (5%) as evidenced by failure to flush between medications administered through a Percutaneous Endoscopic Gastrostomy (PEG) tube for four (4) of 35 medication administration opportunities observed. Findings include:. Review of the facility's policy titled, Medication Administration, with a revision date of 6/15/18, revealed medications administered through a PEG tube should be administered individually, flushing with 5 cc (cubic centimeter) after each medicaiton. On 6/14/18 at 4:28 PM, an observation of Resident #25's medication administration revealed Licensed Practical Nurse (LPN) #1 administered four (4) medications via the resident's PEG tube. LPN #1 crushed an Eliquis five (5) milligram (mg.) tablet, and [MEDICATION NAME] 25 mg., one half (1/2) tablet, and poured each medication into separate medication cups. LPN #1 added five (5) milliliters (ml) of water into each cup. LPN #1 poured up liquid Potassium 15 ml mixed in four (4) ounces of water, and liquid [MEDICATION NAME] 10 ml. LPN #1 flushed the PEG tube with 30 cubic centimeters (cc) of water, and then administered the liquid [MEDICATION NAME], followed by the Eliquis five milligrams (5 mg.). LPN #1 did not flush with water between the [MEDICATION NAME] and the Eliquis. LPN #1 administered the liquid Potassium 15 milliliters (ml) in four (4) ounces of water, followed by the [MEDICATION NAME] one half (1/2) of the 25 mg. tablet. LPN #1 did not flush with water after the Eliquis, or between the Eliquis and the liquid Potassium, or between the liquid Potassium and the [MEDICATION NAME]. On 06/14/18 at 4:59 PM, an interview with LPN #1 confirmed she did not flush between any of the medications administered via Resident #25's PEG tube. LPN #1 revealed she knew she was supposed to flush between the medications, and she did not. LPN #1 revealed she just forgot, and has been inserviced on this. LPN #1 stated she always flushed between each medication, but she forgot today. Review of Resident #25's (MONTH) (YEAR) physician's orders [REDACTED]. tablet, give 1/2 (one half) tablet per PEG tube BID, Potassim Chloride 10% (percent) 20 meq (milliequivalent) per 15 ml per PEG tube BID, and Eliquis 5 (five) mg. tablet, 1 (one) per PEG tube BID. On 06/15/18 at 3:40 PM, an interview with the Director of Nursing (DON) revealed the facility does all inservices with the medication nurses related to medication administration. The DON stated she was going to ask the Pharmacist to do an inservice with the nurses. She stated she was aware that there should be a flush between the medications administered through the PEG tube, and she did not cover that part of the medication through the PEG tube in any inservice. Review of the facility's Inservice Training Class Attendance Sheet revealed an inservice, dated 10/24/17, for Crushing Medications, either oral or via PEG tube, must give these medications one at a time. Review of the attached copy of Crushing Oral Medications New Regulation from the website http://allnurses.com/geriatric-nurses-ltc/oral-crushing-oral-medications, revealed: Crushed medications should not be combined and given all at once either orally (e.g. in pudding or similar food) or via feeding tube. LPN #1's signature was written on the attendance sheet. Review of the Face Sheet revealed Resident #25 was admitted by the facility, on 8/16/17. The Face Sheet included curent [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED].

Based on observation, and staff interview, the facility failed to provide Resident #13's fingernail care for one (1) of 19 residents reviewed for Activities of Daily Living (ADL) care. Findings include: An observation, on 06/13/18 at 12:59 PM, revealed a brown colored material under Resident #13's fingernails on both hands. An observation, on 06/14/18 at 8:35 AM, revealed Resident #13's fingernails continued to be dirty with a brownish material under the nails. An observation and interview with the Director of Nurses (DON) regarding Resident #13's fingernails, on 06/14/18 at 2:00 PM, the DON confirmed Resident #13's fingernails were dirty, and needed to be cleaned and trimmed. Review of Resident #13's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 4/16/18, revealed a Basic Interview for Mental Status (BIMS) score was 00, which indicated severe cognitive impairment. Further review of the MDS revealed Resident #13 required extensive assistance with two person physical assist with bed mobility, was totally dependent on staff with one person physical assist with dressing, and extensive assistance with one person physical assist with toilet use and personal hygiene. The MDS also revealed Resident #13 was admitted by the facility on 10/19/15.

Based on observation, staff interview, and facility policy review the facility failed to store enteral products per manufacturer guidelines as evidenced by expired nutritional feeding in one (1) of one (1) enteral storage rooms. Findings Include: Review of the facility's policy, Drug Acquisition, Storage and Inspection, with an effective date, [DATE], revealed, All drug storage areas within the facility shall be inspected monthly by the Consultant Pharmacist. Expired, damaged and or contaminated medications shall be removed from drug storage areas within the facility during the Pharmacy inspection. Observation of the enteral storage room on [DATE] at 2:30 PM with Licensed Practical Nurse (LPN) #1 revealed four cases of Two Calorie HN with an expiration date of ,[DATE]. Interview on [DATE] at 3:00 PM with the Director of Nursing (DON) revealed the Enteral supplier checks the enteral feedings monthly when they make new deliveries. The DON stated the nursing department needs to be responsible for checking the expiration dates and plans to have the Quality Assurance Nurse perform this task.

Based on observation, interview and policy review, the facility failed to ensure one of two medications carts were kept locked when the nurse was away from the cart. Findings Include: On 03/18/14 at 11:53 AM, the medication cart was observed unlocked near room A 15. LPN #1 was in the resident's room across the hall and at the time the cart was observed unlocked, she was in the restroom washing her hands. Interview with LPN #1 on 3/18/14 at 11:53 AM revealed she had left the cart unlocked and she confirmed it was out of her sight while she was in the restroom washing her hands. Review of the facility policy entitled, "Medication Set Up, Administration and Documentation Policy" documented, "The medication cart is to be locked when the nurse is away from it".

Based on observation and policy review the facility failed to ensure the dumpster was closed to prevent potential infestation on 2 of 3 days of the survey. Findings Include: On 03/18/14 at 6:58 AM the dumpster was observed with one of the two lids open. On 03/19/14 at 7:00 AM the dumpster was observed with a bag of garbage hanging over the side and the lid was not completely closed. On 03/19/14 at 3:00 PM, the Administrator was informed of the two observations of the dumpster being left open. She revealed she would take care of it right away. She further revealed there was not policy regarding the dumpsters.

Based on observation, resident interview, staff interview, and policy review, the facility failed to provide a functioning call light system for two (2) of three (3) days of survey and on both halls for one (1) of three (3) days of survey. Findings include: Observation and resident interview during initial tour on 1/28/2013 at 11:10 a.m. revealed Resident #11 stated, "My call light (is) not showing up. I told the CNAs (Certified Nurse Aides). It's been that way since the other night." Observation and interview on 1/28/13 at 11:10 a.m. confirmed the call light was working over the door but not at the nurse call panel system at the nurse's station. Observation on 1/29/13 at 2:15 p.m. revealed a repairperson was working on the nurse call panel system. Observation on 1/30/13 at 11:05 a.m. of call light system revealed the following: Rooms 3A, 7A, 11B and 18A on Hall A and Hall B had Rooms 1B, 3A, 5A, and 16B were tested and the call lights would light up over the room door but not at the nurse call panel system. Interview on 1/30/2013 at 11:05 a.m. with Housekeeping/Maintenance Staff #1 revealed none of the call lights on Halls A & B were working since 1/29/13 later that night. Interview on 1/30/2013 at 11:45 a.m. revealed Resident #11 stated, "I noticed it late Friday afternoon, the 3 - 7 p.m. crew. I had just got back from the hospital. The staff that was here, everybody had gone home. They told me they had been working on it since." Interview on 1/30/2013 at 12:00 noon with Housekeeping/Maintenance Staff #2 confirmed that Resident #11 light was working on 1/29/2013. Housekeeping/Maintenance Staff #2 stated, "They were working before the man came. The first man came and we got A# hall working on Monday morning. Yesterday, we called them back, and that was a different man that came yesterday. After then everything started messing up." Interview on 1/30/2013 at 1:55 p.m. revealed Housekeeping/Maintenance Staff #1 stated, "He said we had a shortage somewhere in the panel. We went down both halls and checked. They were working. He was here until 8:00 p.m. The emergency lights were not working on the panel for the bathrooms. It would blink but it wouldn't identify which room. He told us to call (name of company). They came out here and checked it. They recommended for us to replace the board. I have contacted them and they are doing that. (Name of company) had three (3) companies looking into it. We talked at 10:00 a.m." Interview on 1/30/2013 at 2:07 p.m. with Certified Nurse Aide (CNA) #2 confirmed the lights were not working. CNA #2 stated, "It started with one (1) resident light. I found out after I came to work. I work second shift. One of the nurses told me her call light was on. I got in there and she said she had her light on and I told her the nurse at the desk told me her light was on, and they weren't working on the board. I was off Friday. It must have been Thursday. Review of the facility's "Alternate Call Light System Policy", dated 1/12/07, noted, "It is the policy of this facility that an alternative call light system will be provided as follows: In the event of mal-function of existing call light system. Staff will check residents every 15 minutes and document on Resident Visual Monitoring Sheet. Mal-functioning call light will be reported to Maintenance as soon as possible." Record review and interview with Administrator on 1/30/2013 at 12:30 p.m. revealed staff was in-serviced on 1/28/2013 at 8:05 p.m. to monitor lights closely in the hallways and at the nurses desk and to report any problems to administration.

Based on observation, staff interview, and policy review, the facility failed to store refrigerated foods under sanitary conditions and failed to ensure that food storage equipment was clean on one (1) of two (2) dietary observations. Findings include: Observation on 1/28/2013 at 11:01 a.m. revealed there was opened one (1) one-half gallon of Buttermilk and one (1) opened gallon of Vitamin D Whole Milk stored in the refrigerator without an open date. Interview with Dietary Staff #1 on 1/28/12 at 11:01 a.m. confirmed there was no open date on the two containers of milk. Dietary Staff #1 stated, "We just go by the use by date." Observation on 1/28/13 at 11:05 a.m. revealed there were black colored spots around the seal of the milk cooler. Interview with Dietary Staff #1, at this time, confirmed the black colored spots around the seal of the milk cooler. Dietary Staff #1 stated, "We clean it all the time." Review of the facility's "Food Storage" policy, dated 2008, noted, "...15. Refrigeration: ... e. All foods should be covered, labeled and dated ...g. Refrigerated foods should be stored upon deliver and careful rotation procedures should be followed ..." Review of the facility's "Cleaning Instructions: Cleaning Refrigerators" policy, dated 2008, noted, "The refrigerators will be washed thoroughly inside and outside with a detergent and followed by a sanitizer at least once every month, or as needed. Spills and leaks will be wiped up as they are noticed ..."

Based on observation, policy review and staff interview, the facility failed to promote a home-like environment for two (2) of three (3) days of meal observations in dining room which included resident meals being served on trays, and tables with no table covering or decorations. Findings include: Observation on 1/29/13 at 5:30 p.m. revealed there were six (6) residents being served the supper meal in the main dining room on trays. 14 of 14 tables in the dining room were not covered with tablecloths and did not have any type of table decorations. Observation of the lunch meal on 1/30/13 at 11:30 a.m. revealed 12 residents being served the lunch meal in the main dining room on trays. 14 of 14 tables in the dining room were not covered with tablecloths and did not have any type of table decorations. Interview on 1/30/13 with the Dietary Manager #1 regarding residents observed eating from plates on trays in the dining room, stated, "The majority of residents do eat off of plates, the trays are primarily for the feeders." When asked if residents being fed could benefit from eating off plates on tables instead of trays, stated, "We could do that." When asked about the lack of table decorations, the Dietary Manager stated, "The Activity Director is responsible for that." Interview on 1/30/13 at 2:10 p.m. with the Activity Director #1 regarding the lack of decorations on the tables in the dining room, revealed, "We usually have something on the tables, just not this week." Review of the facility's "A Matter of Rights A Guide to your Rights and Responsibilities" policy, dated 1/30/13, noted, "... It is our policy to provide the kind of care to our residents that will maintain and enhance their dignity, individuality, and quality of life..." Review of the facility's "Environment Policy", not dated, noted, "... A "homelike" environment is one that demphasizes (de-emphasizes) the institutional character of the setting, to the extent possible ..." Interview on 1/30/13 at 2:45 p.m. with the Administrator regarding the lack of a home-like appearance of the dining experience confirmed that there were no decorations on the tables I the dining room and stated, "They could remove the plates from the trays ...The Activity Department is responsible for providing table decorations. They often use the resident's crafts to decorate with."