Every finding on record at UNC Rockingham Rehab & Nursing Care Center

Based on observations, record review, and staff interviews, the facility failed to ensure food was stored in a sanitary manner and failed to have functioning water temperature gauges for the dish machine. The facility failed to label food stored for use and failed to discard expired food in 1 of 3 reach-in refrigerators (Refrigerator #1 used to store milk) and 3 of 3 nourishment refrigerators (East hall, [NAME] hall, and South hall nourishment refrigerators). The facility also failed to maintain hot food above 135 degrees Fahrenheit ( F) on the tray line. The facility used a low temperature dishwasher to wash and rinse dishes; The dishwasher used chlorine based chemical sanitation. The temperature gauge for the rinse cycle was providing results which were outside of the recommended range for the rinse cycle, and the chemical sanitizer test strips did not indicate that sanitation occurred. The failure to maintain water temperature and chlorine sanitation could compromise effective dishware sanitation. These failures had the potential to affect the safety and quality of food served to residents. Findings included:1. An observation of reach in refrigerator #1 with the Dietary Supervisor on 8/3/26 at 10:30 AM revealed an opened 32 fluid ounce carton containing honey thickened milk and an opened 42 fluid ounce carton containing honey thickened tea that were not labeled or dated with an opened date or a discard date.During an interview on 8/3/26 at 10:33 AM, the Dietary Supervisor stated the reach in refrigerator was used to store milk and thickened liquids for residents' use. She stated she was unsure when the thickened liquid cartons were opened. She indicated all opened thickened liquid containers should be labeled and dated, and they should be discarded within 3 days (72 hours) after opening.2a. An observation of the locked nourishment room, refrigerator #1 (East hallway) with the Dietary Supervisor on 8/3/26 at 10:48 AM revealed an opened 32 fluid ounce carton containing honey thickened cranberry juice that was not labeled or dated with an opened date or a discard date.During an interview on 8/3/26 at 10:50 AM, the Dietary Supervisor stated the nursing staff should label and date any opened thickened liquid carton. She stated these should be discarded within 72 hours after opening.2b. An observation of the locked nourishment room, refrigerator #2 (West hallway) with the Dietary Supervisor on 8/3/26 at 10:56 AM revealed the following: A clear plastic gallon bag containing sliced watermelon with no label or date. A clear plastic gallon bag containing yellow colored mushy food with no label or date. A clear plastic quart bag containing red grapes with no label or date. There was reddish liquid in the bag. A plastic container with a red-colored lid containing brown colored food and some bread with no label or date. A takeout container dated 7/3/26 with no name, containing restaurant food that appeared mushy and watery. The nourishment freezer contained the following:A 20 ounce cup from a fast food establishment. The contents in the cup had a frozen drink and the cup was covered with brown paper napkins. There was no label or date on the cup.An opened plastic bag containing 3 mini corn dogs with no label or opened date.An opened plastic bag containing 4 mini sausages and biscuits with no label or opened date.An individually wrapped hot pocket sandwich with no label or date.During an interview on 8/3/26 at 11:00 AM, the Dietary Supervisor stated the plastic container with the red colored lid in the refrigerator contained pinto beans and cornbread. She stated the nursing staff should label and date all foods brought in by families before placing them in the nourishment refrigerator. She stated all fresh fruit, salads, and other home prepared food could be kept in the refrigerator for up to 72 hours and then were to be discarded by nursing or dietary staff. She indicated the dietary staff stocking the nourishment refrigerator were responsible for discarding any food that was expired and/or not dated or labeled. The Dietary Supervisor explained she did not know who the various food items belonged to. She indicated staff do not store personal food in the nourishment room refrigerators and thought it was food [NAME] in by family members for residents.2c. An observation of the locked nourishment room, refrigerator #3 (South hallway) with the Dietary Supervisor on 8/3/26 at 11:04 AM revealed the following: A clear plastic container containing brown colored food with round brown balls with no label or date. A black plastic container with a clear top containing a brown patty and bun with no label or date. A clear plastic bag containing cooked chicken wings with no label or date. A 16 ounce opened soda bottle with no label or opened date. The nourishment freezer contained the following: A frozen dinner with no label or date. During an interview on 8/3/26 at 11:06 AM, the Dietary Supervisor stated the black plastic container contained a chicken patty with a hamburger bun. She indicated she was unsure why the nursing staff had not labeled nor dated the food brought in by family members. She further stated the nourishment rooms were locked and only the nursing and dietary staff had access to them.During an interview on 8/6/26 at 9:05 AM, the Director of Nursing (DON) stated nursing staff who accepted food brought in for residents and placed the food in the refrigerator in one of the nourishment rooms were required to label it with the resident's name and the date it was placed in the refrigerator. The DON explained perishable food in the nourishment room refrigerators should be discarded within 72 hours of placing them in the nourishment refrigerator. The DON indicated both dietary and nursing staff were responsible for discarding expired food which had been in the food for 72 hours or longer. The DON stated dietary staff were expected to discard any expired or unlabeled food when stocking the nourishment refrigerator, and Nurse Aides assigned to clean and check the nourishment refrigerator were also expected to discard any food which had been in the food for 72 hours or longer.During an interview on 8/6/26 at 12:00 PM, the Administrator stated the nourishment refrigerator should be checked by both dietary and nursing staff, and any expired or unlabeled food should be discarded.3. The hospital kitchen was across the nursing home parking lot and operated separately from both the nursing home and its kitchen. The hospital kitchen served as the main kitchen where food was prepared.On 8/4/25 at 11:30 AM the food cart containing the food prepared by the hospital was observed to arrive to the nursing home kitchen. Hospital dietary staff transported the food in a blue, closed, insulated hot holding cart by pushing it across the parking lot. The food was held in steam table pans, and nursing home dietary staff removed the pans from the carts and placed them on the hot steam table.During an interview on 8/4/26 at 11:35 AM, the Dietary Supervisor stated the facility received prepared food in an insulated cart from the hospital kitchen, which was separate from the nursing home kitchen. Hospital dietary staff pushed the insulated hot holding cart across the parking lot, and it arrived at the nursing home kitchen at 11:30 AM so the tray line could start by 11:55 AM and the first meal cart could be sent to the dining room by 12:00 PM. She stated she filled the steam table with water and turned it on at 10:30 AM so it would be hot enough to maintain food temperatures. She stated the hospital cook took meal temperatures before sending the food to the nursing home. She reported that transporting the food took approximately five minutes.The Dietary Supervisor stated the food was to remain on the steam table until the tray line started at 11:50 AM. The temperatures of food on the tray line were taken by the Dietary Supervisor using a calibrated thermometer on 8/4/26 at 11:56 AM. The observation revealed the following food temperatures:Chicken tenders: 130 FBaked boneless chicken with barbeque (BBQ) sauce: 134 FGrilled chicken breast: 120 FMinced carrots: 124 FSquash: 131.9 FHotdogs: 120 FChili: 127 [NAME] 8/4/26 at 12:00 PM, an observation revealed the Dietary Supervisor remove the food items from the tray line steam table and place them back into the carts. The cook called the hospital kitchen to report that the food needed to be picked up and reheated. A hospital staff member arrived, collected the food, and returned it to the hospital kitchen to be reheated. The Dietary Supervisor sent the food back because the nursing home only had a microwave, which could not reheat food to an internal temperature above 135 F.An observation on 8/4/26 at 12:35 PM revealed the hospital staff brought the food to the nursing home after reheating. Nursing home dietary staff removed the food from the carts, placed it in the steam table, and the Dietary Supervisor checked the temperatures of all items. All temperatures were above 135 F. After confirming temperatures, dietary staff resumed the tray line to plate meals for nursing home residents.During an interview on 8/4/26 at 12:57 PM, the Dietary Supervisor stated the facility received prepared food from the hospital kitchen in a hot holding buggy at 11:30 AM so the tray line could start by 11:55 AM. She explained the first tray cart should be sent to the dining hall by 12:00 PM. She stated she filled and heated the steam table at 10:30 AM so it would be hot enough to maintain food temperatures when the food arrived. She stated she was unsure why the food temperatures dropped below recommended levels.During an interview on 8/6/26 at 11:30 AM, the Food Service General Manager stated the hospital cook checked food temperatures before dispatching the food to the nursing home kitchen. He reported that all food items temperatures were above 135 F when the food was sent from the hospital kitchen. He stated he was unsure why the temperatures were below recommended levels on the tray line. The Food Service General Manager indicated the food temperatures needed to be rechecked on the tray line and if the temperatures were below the recommend 135 F, the food should be sent back to the main hospital kitchen to be reheated to the recommended temperature.During an interview on 8/6/26 at 12:00 PM, the Administrator stated all hot food items should be above the recommended temperatures so residents could be served warm meal trays.4. A review of the instructions provided on the sanitizer (chlorine) solution container revealed the final rinse concentration of chlorine sanitizer should be at a concentration of 100 parts per million (ppm) (a standard unit for measuring very small concentrations) for chlorine for sanitation. A review of the Low Temperature Mechanical Warewashing instructions from the manufacturer of the dish machine read, in part. In addition to checking the temperature, employees must also check the concentration of sanitizer (chlorine) using a chlorine test strip. The standard/critical limits indicated in the document were a minimum wash temperature of 120 degrees ( ) Fahrenheit (F) and a chlorine rinse concentration for sanitation between 50-100 ppm.On 8/5/26 at 10:07 AM, the dishwashing process was observed with the Dietary Supervisor at the nursing home. The temperature gauge located on top of the dishwasher and indicated a wash cycle temperature of 140 F and a rinse cycle temperature of 100 F as read by the Dietary Supervisor. The Dietary Supervisor tested sanitation using a (chlorine) test strip. The (chlorine) test strip was tested on the clean dish crater that just came out of the rinse cycle. The test strip did not change color, indicating no chemical sanitation occurred. The Supervisor ran the dishwasher at least 5-6times in total. The temperature gauge readings remained consistent at 100 F. The Dietary Supervisor changed the chlorine sanitation container, and a new container was placed. The dishwasher was run a few times and the test strip results continued to indicate no chlorine in the sanitizer cycle of the dish machine. A posted sign on the dishwasher read, in part, Dish machine temperatures to be taken every meal daily. Wash temp and rinse temp for each meal.During an interview on 8/5/26 at 10:11 AM, the Dietary Supervisor stated the facility used a low temperature dish machine, and the minimum wash temperature should be 120 F or above. She stated the rinse temperature should also be 120 F. The dish machine used chlorine concentration during the rinse cycle for sanitation, and the test strip should be touched to the wet surface of a clean dish after one cycle. The strip color should match the chart on the strip container to verify a concentration between 50-100 ppm. She stated she was unsure why the test strip was not changing color. The Dietary Supervisor stated the dietary aide handling clean dishes should check ppm using the test strip. She further stated she also checked the ppm using the test strips to ensure the dishes were clean and sanitized for all meals. The Dietary Supervisor was unable to produce a record of the dish machine sanitizer levels having been tested. However, she did state the machine had been tested after supper the previous evening. Once it was discovered the dish machine was not sanitizing dishware, the facility stopped using dishware and utilized disposable meal containers.During an interview on 8/5/26 at 10:20 AM, Dietary Aide #1, who stated she had been working at the facility for 2 years, explained she was usually assigned to the clean dish area and ensured dishes were stacked on clean racks for air drying. She stated she had never used a chlorine test strip and was not aware she was required to do so. She indicated she did not check wash or rinse temperatures. She stated she thought the other dietary aides assigned to dirty dishes were responsible for checking temperatures.During an interview on 8/6/26 at 10:00 AM, Dietary Aide #2 stated she usually rinsed dirty dishes and stacked them on the racks before washing. She stated she did not check dishwasher temperatures. She indicated she thought the dietary aide assigned to load the dishes into the dishwasher was responsible for checking the dishwashing temperatures.On 8/6/26 at 10:10 AM, a review of the Weekly High Temperature Mechanical Warewashing Log for Week 1 of August (covering 8/3/26 through 8/4/26) revealed the following: On 8/3/26, the breakfast wash temperature was documented as 140 F and the rinse temperature was 100 F; at lunch, the wash temperature was documented as 110 F and the rinse temperature was 125 F; and at dinner, the wash temperature was documented as 120 F and the rinse temperature as 140 F. On 8/4/26, the breakfast wash temperature was documented as 110 F and the rinse temperature was 140 F; the lunch wash temperature was documented was 125 F and the rinse temperature as 140 F; and the dinner wash temperature was documented as 100 F with a rinse temperature of 140 F. The temperatures for 8/5/26 were not documented as the facility was not using the dish machine. The log contained the Dietary Supervisor's initials.An observation on 8/5/26 at 10:15 AM revealed the dishwasher was not in use; however, the wash temperature gauge continued to indicate 140 F. During an interview on 8/6/26 at 10:23 AM, the Dietary Supervisor stated she had recorded the dishwasher water temperatures for the week as the dietary aide assigned to check the temperatures was nervous with the surveyors in the facility. She indicated she documented the wash and rinse temperature on the log sheet and placed her initials. Dietary Supervisor stated the recommended wash temperatures should be 120 F or above. She reiterated she was using the test strips to check the chlorine ppm daily when the dishwasher was used after each meal when the dishes were washed. The Supervisor indicated she logged the temperature as the dietary aides were stressed that the surveyors were in the building. The Supervisor also stated she did not know when the gauges stopped working.During an interview on 8/6/26 at 11:30 AM, the Food Service General Manager (for both the hospital and the nursing home) stated he had not been made aware of the water temperatures in the dish machine were less than 120 degrees F. He stated earlier on 8/5/26, while reviewing the temperature log, he observed the temperatures for the dish machine were less than 120 degrees F on the weekly sheets for August. He indicated he was not aware the chemical sanitation was not occurring and the test strip was not showing any change in color, which would indicate a lack of sanitizer. He stated he had educated the Dietary Supervisor to notify him and the dish machine service company when the temperature of dishwasher was below 120 F. He stated the wash temperature should be above 120 F and the sanitation strip should read 50-100 ppm after the rinse cycle.During an interview on 8/6/26 at 12:06 PM, the Administrator stated she was not aware the dishwasher was not functioning according to the manufacturer's recommendations. She stated she should have been notified so food could be served in disposable containers and alternate arrangements made if needed.

Based on observations, staff interviews and manufacturer recommendations, the facility failed to date opened multi-dose vials of insulin medications, and failed to remove expired medications from the medication cart drawers for 4 of 4 medication administration carts reviewed (cart number 2 on South Hall, carts number 1 and 2 on [NAME] Hall, and cart number 2 on East Hall).Findings Included: A review of the manufacturer's recommendations, dated December 1st, 2023, indicated to discard Lantus insulin multi-dose vial 28 days after opening. a. On 8/4/6 at 7:45 AM, an observation of the medication administration cart #2 on South Hall with Nurse #1 revealed in the first drawer, one opened and undated multi-dose vial of Lantus insulin.On 8/4/6 at 7:50 AM, during an interview, Nurse #1 indicated that the nurses assigned to the medication carts were responsible for discarding opened and undated or expired multi-dose vials and insulin pens. She mentioned that training requires nurses to date multi dose medications upon opening. Nurse #1 stated that she had not checked the opened date on insulin vials or pens in her medication cart at the beginning of her shift and confirmed she had not administered expired medication this shift.b. On 8/4/6 at 7:55 AM, an observation of the medication administration cart #2 on East Hall with Nurse #2 revealed in the second drawer: one half empty plastic vial of Nitroglycerine Solution 0.4 mg (milligram), marked on the package as expired on 5/17/26.On 8/4/6 at 8:10 AM, during an interview, Nurse #2 indicated that the nurses assigned to the medication carts were responsible for discarding expired medications. She mentioned that training requires nurses to remove expired medications from medication administration carts. Nurse #2 stated that she had not checked the expiration dates of medications in her medication cart at the beginning of her shift and confirmed she had not administered the expired medication this shift.c. On 8/4/6 at 8:20 AM, an observation of the medication administration cart #1 on [NAME] Hall with Nurse #3 revealed in the second drawer, one opened carton of Fish Oil, 1000 mcg (microgram) soft gels, marked on the package as expired on 7/3/26.On 8/4/6 at 8:25 AM, during an interview, Nurse #3 indicated that the nurses assigned to the medication carts were responsible for discarding expired medications. She reported that training required nurses to remove expired medications from medication carts. Nurse #3 stated that she had not checked the expiration date of medications in her medication cart at the beginning of her shift and confirmed she had not administered the expired medication this shift.d. On 8/4/6 at 8:30 AM, an observation of the medication administration cart #2 on [NAME] Hall with Nurse #4 revealed in the first drawer, one opened and undated multi-dose vial of Lantus insulin.On 8/4/6 at 7:50 AM, during an interview, the nurses assigned to the medication carts were responsible for discarding opened and undated multi dose vials and insulin pens. He reported that training required nurses to date multi dose medications upon opening. Nurse #4 stated that he had not checked the date of the opened insulin vials or pens in his medication cart at the beginning of his shift and confirmed he had not administered the expired medication this shift.On 8/4/26 at 1:25 PM, during an interview, the Director of Nursing indicated that all the nurses were responsible each shift for checking assigned medication carts for dating of multi-dose vials opening, expiration dates, and removing expired medications. She expected that no expired or undated items would be left in the medication carts.On 8/4/26 at 2:05 PM, during an interview, the Administrator stated that no expired items were expected to remain in the medication administration carts.

Based on record review, observations, and resident and staff interviews and a test tray, the facility failed to provide food that was appetizing in texture and palatability for 5 of 5 residents (Residents #16, #18, #20, #40, and #57) reviewed for food palatability and preferences. The findings included: In a Resident Council meeting on 6/18/25 at 12:04 PM, Residents #16, #18, #20, #40, and #57 reported the food was bland, they did not receive seasoning packets on their trays everyday, and they said the meat served was too tough to cut or chew. On 06/19/2025 beginning at 11:25 AM, all foods on the steam table were checked for safe temperatures by the Dietary Manager, and a test tray was followed from the serving line with the Dietary Manager to the serving cart on the 200- hall. At 12:54 PM on 06/19/2025, after all the resident trays were delivered, a regular diet test tray was sampled. The tray consisted of a portion of baked breaded fish, steamed white rice, and boiled zucchini. The edges of the fish were tough, difficult to cut with a fork, and were chewy and rubbery. There were no spices or seasonings tasted on the steamed white rice and the boiled zucchini. When the Dietary Manager tasted the tray at 12:54 PM as well, she agreed that the fish was tough and chewy on the outside edges. She said the facility did not use any seasonings when cooking the food. She stated because the residents all prefer different amounts of seasonings, they add salt and pepper packets to the trays for the residents, which were present on the test tray. In an interview on 06/19/25 2:43 PM, the Dietary Manager said she was aware of the resident concerns of tough meat and had worked with the main hospital kitchen, where the food was cooked, to ensure the meat was cooked so it would be tender when served to the residents after the residents started to express the concern in February 2025. She said gravy was also available at all meals to soften the meat when a resident requested it. In an interview on 06/19/25 at 3:38 PM, the Administrator said when a resident has a concern about the palatability of the food, the kitchen tried to resolve the concern with the resident as best as possible. She said she worked with the main hospital kitchen to adjust the menu to reflect resident preferences.

Based on a lunch meal tray line observation, staff interviews and record review, the facility failed to follow the approved menu when 5 of 5 residents on a moist and minced diet only received 2 ounces of fish instead of 4 ounces as per the menu. In addition, the facility served 2 ounces of mashed potatoes instead of 4 ounces per the menu to 54 of 61 residents who ate a regular or mechanically altered diet. The findings included: 1. The daily diet menu for 6/19/25 revealed residents on a moist and minced diet (a mechanically altered diet where all foods were soft, moist, and finely minced or mashed into very small pieces) should have received 4 ounces of fish. Continuous observation on 6/19/25 from 11:54 AM - 12:40 PM of the complete lunch service revealed the Dietary Supervisor plated all 5 residents on a moist and minced diet 1.75 ounces (one red handled #24 sized scoop) of mechanically altered fish. The Dietary Supervisor scooped inconsistent amounts of fish per scoop, some were overfilled, and some were level with the scoop The facility Diet Order Roster dated 6/19/25 revealed there were 5 residents on a moist and minced diet. In an interview on 6/19/25 at 1:32 PM with the Dietary Supervisor, she said she used the facility Production Sheet to determine how large a portion should be served to each resident on that meal. She provided the Production Sheet and reviewed it during the interview. She said the portion sizes were not on the menu like she had believed. The Dietary Supervisor stated she had been in-serviced that the appropriate scoop size for the meat in a meal was 4 ounces. She said she wasn't sure if she had a 4-ounce scoop available at the time of service, so she used the red handled scoop, which she examined during the interview and was noted it was a #24 or 1.75-ounce scoop. She stated she knew it was a smaller scoop but tried to make each scoop overfull. The Dietary Supervisor looked at all the scoops she had available during the interview and confirmed she did have a 4-ounce scoop available and should have used it. 2. Review of the facility's pre-approved Week 3 cycle menu revealed residents on a regular and mechanically altered meal should have received 4 ounces of mashed potatoes for the lunch meal served on 6/19/25. Continuous observation on 6/19/25 from 11:54 AM - 12:40 PM of the complete lunch service revealed the Dietary Supervisor plated mashed potatoes using one light blue handled scoop onto the plates for all residents on a regular or mechanically altered diets. In an interview on 6/19/25 at 1:32 PM, the Dietary Supervisor confirmed she used one light blue handled scoop, which was labeled as a #16 or 2-ounce scoop for the mashed potatoes served to the residents on a regular or mechanically altered diet. She said she did not know the menu called for 4 ounces of the mashed potatoes since it wasn't listed on the production report. The Dietary Supervisor stated she did not know the production report did not list the portion sizes for the items on the menu and she did not review the menu. In an interview on 6/19/25 at 3:38 PM, the Administrator said she will need to educate dietary staff to make sure they know what portion sizes utensil to use and to make sure the menu was followed. She said she would need to discuss with the main hospital kitchen any concerns or changes to diets to make sure the correct portions were served.

Based on record review, and interviews of staff, residents, and the hospital Food Service Director, the facility failed to act promptly to resolve grievances reported about the resident's food preferences, missing food items, and meats that were hard to cut and chew since the March 2025 Resident Council Meeting for five residents that regularly attended. This deficient practice affected 5 of 11 residents present during the Resident Council Meetings of 3/26/25, 4/30/25, and 5/28/25 (Residents #16, #18, #20, #40, and #57). Findings included: The Resident Council Concern Form was completed on 2/10/25 by the Administrator that Resident #40 was receiving food that she could not eat, and meats were tough to cut. The Administrator responded: the resident had a food preference change and replaced tough meat with sandwich. The food preference questionnaire was completed on 3/31/25 by the Dietary Manager. Resident council meeting minutes dated 3/26/25 were reviewed and the following resident concerns were documented. There were 11 residents present including Residents #16, # 18, #20, #40, and #57. Old business did not include meal concerns. Current residents' concerns requested kitchen staff meet with the residents to change their likes and dislikes and listen to their food requests. Resident Council Concern Form dated 3/26/25 indicated Residents #16 and #40 had their likes and dislikes completed by the Dietary Manager on 4/3/25. Resident council meeting minutes dated 4/30/25 were reviewed and the following resident concerns were documented. There were 11 residents present including Residents #16, #18, #20, #40, and #57. Old business did not include meal concerns. Current residents' concerns included meal preferences, cold food, failure to provide coffee when requested, and missing silverware. A Resident Council Concern Form was not completed in April 2025. Resident council meeting minutes dated 5/28/25 were reviewed and the resident concerns were documented. There were 11 residents present including Residents #16, #18, #20, #40, and #57. Old business did not include meal concerns. Current residents' concerns were none. On 6/18/25 at 12:00 pm a Resident Council Meeting was held. Residents #16, #18, #20, #40, and #57 were the only residents in attendance. All of the residents provided input that the food provided (breakfast, lunch or dinner) was not always the same as what was put on their meal ticket and preferences were not always followed. All of the Residents stated these food problems had been going on for months, even after some of the residents completed a preference request. All of the residents also stated that the meat, specifically, pork and beef, was hard to cut and chew and there was no other meat substitute. Residents #18, #20, and #57 stated their meat was to be in small bites according to their diet order. Resident #57 stated she was eating hot dogs frequently because she cannot chew the beef and the pork because it was too hard. All residents felt the food was bland and the seasonings were sometimes left off the tray. Some of the residents had a chicken salad sandwich from the unit refrigerator when there were missing food items. Resident #16 and #40 both stated that they had completed a preference form with the Dietary Manager a couple of months ago when the concern was brought up at the March 2025 resident council meeting. Resident #40 stated the management at the hospital had planned to attend the Resident Council Meeting to address their concerns but had not attended the April and May 2025 meetings. Resident #40 commented that she had recently received very dry rice instead of mashed potatoes which was on her meal ticket, and she could not eat the rice. This happened after she completed the preference form with the Dietary Manager back in April 2025 and informed the Dietary Manager food items were missing from her tray or not correct when on her meal ticket. Resident #40 had informed the nurse of the wrong food items on many occasions, and this was brought up in the prior Resident Council Meetings. Resident #40 stated the Activities Director was aware of food concerns and was supposed to document and report to the Administrator. Resident #16 stated she was provided with a hamburger for lunch with no cheese or condiments and these were on the meal ticket but not provided. Resident #16 could not remember the date she had to wait for the Nurse Aide (NA) to bring ketchup and there was no cheese provided. The NA was aware of the missing food items. On 6/18/25 at 1:54 PM an interview was conducted with the Activities Directo (AD). The AD stated she was responsible for coordinating the Resident Council Meeting each month and documenting the minutes. The minutes included the residents' concerns. The concerns were reported verbally to the Administrator and the Administrator completes the Resident Council Concern Forms. The AD stated she did not document the previous month's resident concerns and whether they were resolved after reporting them to the Adminstrator. The AD stated she was aware of the food preferences concerns. When the kitchen ran out of the food item preference there was less food on the tray because the preference was not the menu item, and the hospital provided the menu items. The resident's reported meat was tough, and residents were unable to cut and chew it for the past couple of months and this was reported to the Administrator. When the residents reported back in March 2025 they didn't get their preferences, the AD informed the Dietary Manager and the Administrator. The AD stated the hospital Food Services Director was informed by the Dietary Manager of the residents' concerns for preferences and the hospital Food Services Director had not attended the April or May 2025 resident council meeting as promised. The residents were aware management from the hospital was expected to attend the Resident Council in June 2025 regarding the residents' meal concerns. The AD stated preferred food was provided when available and if there was not a substitute, nothing else was provided. This was where the missing food concern came from. The concern was not brought forward as old business into April 2025 meeting minutes. The Administrator was made aware of the resident's food concerns. The AD stated the Administrator was getting a lunch tray each day and was made aware of the residents' concern of tough meat. The AD had not checked back with the Administrator to follow up but she thought the tough meat was addressed after it was reported months ago. The AD stated at the May 2025 Resident Council meeting, the residents reported they were still not getting their preferences which was reported to the Administrator again. The AD also commented she had prior complaints that the meat was hard, and the residents were unable to identify it. She had reported this information to the Administrator again and thought it was addressed. On 06/18/25 at 1:09 PM an interview was conducted with the Dietician. The Dietician stated he was not aware that food was missing from the resident's meal but was aware that food ran out and substitutes were given (i.e. sausage for bacon). All food was cooked and prepared at the hospital. The hospital has all food and drink stocked. The cooked food was sent from the hospital to the facility (across the street) and placed on the steam table and plated. The chef at the hospital was new and the Dietician thought things were getting better with the correct amount/type of food when concerns came up. The Dietician stated he was not aware food documented on the meal ticket was not on the plate, and there was no substitute, and pork and beef was difficult to cut and chew. He was not sure where the breakdown in communication was to provide enough food, and the preferences. On 6/19/25 at 2:43 PM an interview was conducted with the Dietary Manager. The Dietary Manager stated she was aware from the AD of the concern about tough meat. She reported the concern to the hospital Food Service Director a while ago where the food was cooked. The Dietary Manager explained food was transported from the hospital to the nursing home and placed on a steam table. The food was plated in the nursing home. The residents requested gravy on their meat for beef and pork to soften it but gravy was not automatically placed on the meat unless requested. On 6/18/25 at 4:06 PM an interview was conducted with the Dietary Manager and hospital Food Service Director. The Food Service Director stated he was aware of the residents not getting their preferences from March 2025. This problem could be a breakdown in communication. The Dietary Manager stated that when there's a preference and the resident disliked the alternate as well as the menu protein, nothing was provided. On 6/18/25 at 3:00 PM an interview was conducted with the Administrator. The Administrator stated she received concerns from the AD back in February 2025 that the residents had not received their preference items, and the meat was tough. The Administrator completed a concern form. The Administrator stated that the resident food preferences were addressed after the March 2025 meeting and there was a pending Resident Council Meeting where the hospital Foods Service Director was to attend. The Administrator stated she was aware of the residents' preferences and the Dietary Manager interviewed all the Resident Council members (documentation provided for 3 residents). The Administrator further commented that the residents' diets were input into the system every day for dietary staff to plate the meal and information was missing. The Administrator explained when information was missing the residents had not received their food items.

Based on record review, observation, and resident and staff interview, the facility failed to provide a resident her food preferences (Resident #365). The deficient practice affected 1 of 3 residents reviewed for food. Findings included: Resident #365 was admitted to the facility on [DATE] with the diagnoses of osteomyelitis (infection of the bone) of the left foot and ankle, anemia, and diabetes. Resident #365 had a food preference form completed by the Dietary Manager dated 6/3/25. The form included chocolate nutritional supplement and hot grits as a preference. Breakfast was to include eggs, bacon, and biscuits with gravy every day. The form had choices to pick, and the resident liked lima beans and mashed potatoes with gravy all the time. The resident had chosen not to have veal, liver, fish, shellfish, tuna, oatmeal, pancakes, pasta, asparagus, beets, broccoli, brussels sprouts, cauliflower, and onions. The admission Minimum Data Set, dated [DATE] for Resident #365 documented her cognition was intact. The resident required moderate assistance for all activities of daily living with a set up for meals. Her diagnoses were osteomyelitis of left foot and ankle, anemia, and diabetes. The resident had no dental or swallowing deficit. The care plan for Resident #365 dated 6/6/25 documented that she was at risk for nutritional deficit and was receiving a nutritional supplement. On 6/16/25 at 10:05 AM an observation was completed of Resident #365 and her meal tray. The tray was on her tray table open and there was no food remaining. A review of the meal ticket revealed eggs and bacon were on the list. An interview with the resident revealed she had not received all her food that was on her ticket. She had not received the eggs and bacon. She had received a small sausage. The resident stated she was supposed to receive bacon and eggs with gravy every morning and this was not the first time food was missing from her tray that was on her meal ticket. The resident was concerned because she had lost weight at home, and she was hungry. The resident had received a nutritional supplement. The resident also commented she had received macaroni and cheese and green beans for lunch with no meat the other day. The resident stated she had reported the missing food items to the Nursing Assistants (NA) who were bringing her tray. On 6/16/25 at 10:07 AM an interview was conducted with NA #1. NA #1 had entered the room to retrieve Resident #365's tray during the interview. NA #1 stated she was aware there were missing food items on the resident's tray this morning. NA #1 thought there was no more bacon. The food was cooked at the hospital and brought over to the facility and the facility may not have been provided enough for all residents. NA #1 stated some residents had not received their preferences before. There were missing food items that were listed on the meal ticket. NA #1 stated other residents were affected, and she had informed the nurse. On 6/16/25 at 2:40 PM an interview was conducted with Nurse #1. Nurse #1 stated she was aware from the NAs that occasionally there were preferences missing off the resident's tray but not on a regular basis. Nurse #1 was not aware that Resident #365 was missing food items on her tray and there was no substitute. Nurse #1 stated that there were chicken salad sandwiches and pimento cheese for the residents in the nourishment refrigerator available all the time as well as snacks. Nurse #1 was not aware that any residents went hungry when there were missing food items. On 6/18/25 at 8:45 AM an observation was done of Resident #365's breakfast tray and the resident was interviewed. The resident stated she received toast that was hard and cold instead of the english muffin that was on her ticket. The ticket was observed to include an english muffin. The resident stated she was not getting her preferences and not always getting gravy for the eggs as requested. On 06/18/25 at 1:09 PM an interview was conducted with the Dietician. The Dietician stated he was not aware that resident's food item(s) were missing from the plate but was aware that food ran out and substitutes were given (i.e. sausage for bacon). All food was cooked and prepared at the hospital. The hospital had all the food and drink stock for the residents. The cooked food was sent to the facility (from across the street) and placed on the steam table and plated. The Chef at the hospital was new and the Dietician thought things were getting better with the correct amount/type of food. The Dietician stated he was not aware that the food that was documented on the meal ticket was not on the resident's plate and there was no substitute. The Dietician stated he was not sure where the breakdown was. On 6/18/25 at 2:40 pm the Dietary Manager (DM) and hospital Food Services Director were interviewed. The Food Services Director stated there was bacon and biscuits with gravy made every day at the hospital and available for the facility. He was informed by the DM that bacon was requested but not provided to 4 residents. The amount of food sent to the facility depended on the diets input into the system. The Food Services Director stated Resident #365 was receiving what was on the menu and not her preferences. The menu system was set up so that each resident's diet and preferences had to be entered each day. There was no carry over of the information. The Food Services Director stated the preferences may have been omitted from being entered. This was human error. If additional food items were needed, the kitchen staff could call the hospital, and additional food would be sent. The DM indicated that when a particular food was out on the steam table a substitute was used. If the substitute was not wanted by the resident, there was no replacement. The DM stated she had not called the hospital to request additional food. There was chicken salad and pimento cheese for the residents on each hall as well as snacks. The DM stated she was familiar with Resident #365 and her preferences chosen upon admission.

Based on record review and staff interviews, the facility failed to complete Minimum Data Set (MDS) discharge assessments within the regulated time frame for 2 of 2 residents reviewed for resident assessment (Residents #64 and #43). The findings included: 1. Resident #64 had been admitted on [DATE]. Diagnoses included Parkinsonism and repeated falls. A Social Work note dated 12/18/2023 indicated Resident #64 had a plan to discharge to her home tomorrow. A PPS (Prospective Payment System, a Medicare Part A required MDS assessment) 5-day and end of PPS assessment dated [DATE] had been completed. Nursing documentation dated 12/19/2023 noted Resident #64 was discharged to her home at 5:10 PM. No MDS discharge assessment had been completed for Resident #64. On 5/21/24 at 2:46 PM an interview with the MDS coordinator was conducted. She stated the discharge assessment should have been included with the 5-day PPS assessment but had been missed being included. This had been a data entry error. On 5/22/24 at 11:06 AM an interview with the Administrator was conducted. She stated she would expect discharge assessments to be completed on time. 2. Resident #43 had re-entered the facility on 1/11/2024. Her diagnoses included chronic respiratory failure and pulmonary hypertension. A Social Work note dated 1/12/2024 indicated Resident #43 had a plan to discharge to her home on 1/17/2024. A PPS (Prospective Payment System, a Medicare Part A required MDS assessment) 5-day and end of PPS assessment dated [DATE] had been completed. Nursing documentation dated 1/17/2024 at 11:00 AM noted Resident #43 had been discharged to her home. No MDS discharge assessment had been completed for Resident #43. On 5/21/24 at 2:46 PM an interview with the MDS coordinator was conducted. She stated the discharge assessment should have been included with the 5-day PPS assessment but had been missed being included. This had been a data entry error. On 5/22/24 at 11:06 AM an interview with the Administrator was conducted. She stated she would expect discharge assessments to be completed on time.

Based on staff and consultant pharmacist interviews and record reviews, the facility's consultant pharmacist failed to conduct a review of each resident's drug regimen at least once a month for 4 of 5 residents reviewed for unnecessary medications (Resident #16, #34, #11 and #10). The findings included: 1. Resident #16 was admitted to the facility on [DATE]. Her cumulative diagnoses included adult failure to thrive, major depressive disorder and anxiety disorder. Resident #16's electronic medical record (EMR) included the reviews of the resident's drug regimen (known as Medication Regimen Reviews or MRRs) completed by the facility's consultant pharmacist from April 2022 through March 2023. Review of the resident's EMR revealed the pharmacist did not document an MRR was completed for Resident #16 during the month of October 2022. A telephone interview was conducted on 3/22/23 at 4:00 PM with the facility's consultant pharmacist. During the interview, an inquiry was made regarding the missing documentation for several residents' MRRs (including Resident #16's) from October of 2022. The pharmacist confirmed she failed to conduct October 2022 MRRs due to a severe pharmacy staff shortage in [the pharmacy] department. The pharmacist stated the failure to conduct the monthly MRRs in October 2022 was reported to the facility's Administrator, Director of Nursing (DON), and Medical Director in a monthly Quality Assurance (QA) meeting held during the first week of November 2022. The consultant pharmacist reported she was only able to complete an initial MRR for newly admitted and readmitted residents at the facility during the month of October 2022. An interview was conducted on 3/23/23 at 12:40 PM with the facility's Director of Nurses (DON). During the interview, concern regarding failure of the facility's consultant pharmacist to conduct an MRR during October 2022 for residents was discussed. The DON reported she had not been aware of the October 2022 MRRs not being completed for all residents. She stated she would have wanted to know ahead of time if completing the monthly MRRs were a problem so she could have requested assistance from the facility's contracted pharmacy to complete the missing MRRs. An interview was conducted on 3/23/23 at 1:05 PM with the facility's Administrator. During the interview, the Administrator reported the DON had shared the concern regarding the failure to conduct residents' MRRs during the month of October 2022. The Administrator reported their consultant pharmacist did not notify the facility there were difficulties with completing the medication reviews for October until November 2022. At that time, it was too late to remedy the situation. The Administrator reported if they had known completion of the MRRs was going to be a problem in October, they could have made alternative arrangements to get the reviews done by another pharmacist. 2. Resident #34 was admitted to the facility on [DATE]. Her cumulative diagnoses included dementia with agitation, depression, hypothyroidism (an underactive thyroid gland) and hypertension (high blood pressure). Resident #34's electronic medical record (EMR) included the reviews of the resident's drug regimen (known as Medication Regimen Reviews or MRRs) completed by the facility's consultant pharmacist from April 2022 through March 2023. Review of the resident's EMR revealed the pharmacist did not document an MRR was completed for Resident #34 during the month of October 2022. A telephone interview was conducted on 3/22/23 at 4:00 PM with the facility's consultant pharmacist. During the interview, an inquiry was made regarding the missing documentation for several residents' MRRs (including Resident #34's) from October of 2022. The pharmacist confirmed she failed to conduct October 2022 MRRs due to a severe pharmacy staff shortage in [the pharmacy] department. The pharmacist stated the failure to conduct the monthly MRRs in October 2022 was reported to the facility's Administrator, Director of Nursing (DON), and Medical Director in a monthly Quality Assurance (QA) meeting held during the first week of November 2022. The consultant pharmacist reported she was only able to complete an initial MRR for newly admitted and readmitted residents at the facility during the month of October 2022. An interview was conducted on 3/23/23 at 12:40 PM with the facility's Director of Nurses (DON). During the interview, concern regarding failure of the facility's consultant pharmacist to conduct an MRR during October 2022 for residents was discussed. The DON reported she had not been aware of the October 2022 MRRs not being completed for all residents. She stated she would have wanted to know ahead of time if completing the monthly MRRs were a problem so she could have requested assistance from the facility's contracted pharmacy to complete the missing MRRs. An interview was conducted on 3/23/23 at 1:05 PM with the facility's Administrator. During the interview, the Administrator reported the DON had shared the concern regarding the failure to conduct residents' MRRs during the month of October 2022. The Administrator reported their consultant pharmacist did not notify the facility there were difficulties with completing the medication reviews for October until November 2022. At that time, it was too late to remedy the situation. The Administrator reported if they had known completion of the MRRs was going to be a problem in October, they could have made alternative arrangements to get the reviews done by another pharmacist. 20906 3.Resident #11 was admitted to the facility on [DATE]. Her cumulative diagnoses included, bipolar depressive disorder and anxiety disorder. Resident #11's electronic medical record (EMR) included the reviews of the resident's drug regimen (known as Medication Regimen Reviews or MRRs) completed by the facility's consultant pharmacist from April 2022 through March 2023. Review of the resident's EMR revealed the pharmacist did not document an MRR was completed for Resident #11 during the month of October 2022. A telephone interview was conducted on 3/22/23 at 4:00 PM with the facility's consultant pharmacist. During the interview, an inquiry was made regarding the missing documentation for several residents' MRRs (including Resident #11's) from October of 2022. The pharmacist confirmed she failed to conduct October 2022 MRRs due to a severe pharmacy staff shortage in [the pharmacy] department. The pharmacist stated the failure to conduct the monthly MRRs in October 2022 was reported to the facility's Administrator, Director of Nursing (DON), and Medical Director in a monthly Quality Assurance (QA) meeting held during the first week of November 2022. The consultant pharmacist reported she was only able to complete an initial MRR for newly admitted and readmitted residents at the facility during the month of October 2022. An interview was conducted on 3/23/23 at 12:40 PM with the facility's Director of Nurses (DON). During the interview, concern regarding failure of the facility's consultant pharmacist to conduct an MRR during October 2022 for residents was discussed. The DON reported she had not been aware of the October 2022 MRRs not being completed for all residents. She stated she would have wanted to know ahead of time if completing the monthly MRRs were a problem so she could have requested assistance from the facility's contracted pharmacy to complete the missing MRRs. An interview was conducted on 3/23/23 at 1:05 PM with the facility's Administrator. During the interview, the Administrator reported the DON had shared the concern regarding the failure to conduct residents' MRRs during the month of October 2022. The Administrator reported their consultant pharmacist did not notify the facility there were difficulties with completing the medication reviews for October until November 2022. At that time, it was too late to remedy the situation. The Administrator reported if they had known completion of the MRRs was going to be a problem in October, they could have made alternative arrangements to get the reviews done by another pharmacist. 43332 4. Resident #10 was admitted to the facility on [DATE]. His cumulative diagnoses included Parkinson's disease, seizure disorder, anxiety disorder, depression, bipolar, and schizophrenia. Resident #10's electronic medical record (EMR) included the reviews of the resident's drug regimen (known as Medication Regimen Reviews or MRRs) completed by the facility's consultant pharmacist from July 2022 through March 2023. Review of the resident's EMR revealed the pharmacist did not document an MRR was completed for Resident #10 during the month of October 2022. A telephone interview was conducted on 3/22/23 at 4:00 PM with the facility's consultant pharmacist. During the interview, an inquiry was made regarding the missing documentation for several residents' MRRs (including Resident #16's) from October of 2022. The pharmacist confirmed she failed to conduct October 2022 MRRs due to a severe pharmacy staff shortage in [the pharmacy] department. The pharmacist stated the failure to conduct the monthly MRRs in October 2022 was reported to the facility's Administrator, Director of Nursing (DON), and Medical Director in a monthly Quality Assurance (QA) meeting held during the first week of November 2022. The consultant pharmacist reported she was only able to complete an initial MRR for newly admitted and readmitted residents at the facility during the month of October 2022. An interview was conducted on 3/23/23 at 12:40 PM with the facility's Director of Nurses (DON). During the interview, concern regarding failure of the facility's consultant pharmacist to conduct an MRR during October 2022 for residents was discussed. The DON reported she had not been aware of the October 2022 MRRs not being completed for all residents. She stated she would have wanted to know ahead of time if completing the monthly MRRs were a problem so she could have requested assistance from the facility's contracted pharmacy to complete the missing MRRs. An interview was conducted on 3/23/23 at 1:05 PM with the facility's Administrator. During the interview, the Administrator reported the DON had shared the concern regarding the failure to conduct residents' MRRs during the month of October 2022. The Administrator reported their consultant pharmacist did not notify the facility there were difficulties with completing the medication reviews for October until November 2022. At that time, it was too late to remedy the situation. The Administrator reported if they had known completion of the MRRs was going to be a problem in October, they could have made alternative arrangements to get the reviews done by another pharmacist.

Based on observations, staff interviews and record review, the facility failed to provide an adaptive eating utensil in accordance with the resident's care plan for 1 of 1 resident (Resident #9) requiring adaptive equipment at mealtime. The findings included: Resident #9 was admitted to the facility on [DATE]. His cumulative diagnoses included dysphagia (difficulty swallowing) and left hemiparesis (mild or partial weakness or loss of strength on one side of the body). The resident's current diet order indicated he was on a pureed diet with mildly thick liquids. Resident #9's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The resident was reported as being sometimes understood and sometimes understanding others. He had moderately impaired cognition. The MDS indicated Resident #9 required supervision only for eating. A review of the resident's current care plan included an area of focus related to nutrition (initiated 8/30/16). The planned interventions included, in part: Built up handled spoon for all meals and a divided plate (updated on 3/6/23). Resident #9's care plan also included an area of focus related to his impaired Activities of Daily Living (ADLs) function due to his diagnoses (updated 3/6/23). The planned interventions included, in part: 2- handled cup with lid. An observation was conducted on 3/20/23 at 12:47 PM as Resident #9 was eating his noon meal. The resident's meal consisted of pureed foods served on a divided plate and a beverage in a 2-handled cup with lid. The only eating utensil observed on the meal tray was a plastic spoon. Resident #9 appeared to have some difficulty eating the pureed foods with the plastic spoon as evidenced by a significant amount of pureed food observed to have been spilled onto his clothing protector. A second observation was conducted on 3/21/23 at 12:30 PM of Resident #9 as he fed himself his noon meal. The resident had his meal served on a divided plate and beverage in a 2-handled cup with lid. However, the only eating utensil observed on the meal tray was a plastic spoon. An interview was attempted with the resident on 3/21/23 at 12:30 PM with only yes/no questions asked. When Resident #9 was asked if it was hard for him to eat with a plastic spoon, he nodded his head to indicate yes. He was then asked if it was easier for him to use a spoon with a larger handle (a built-up handled spoon). The resident responded by nodding his head to indicate yes. An interview was conducted on 3/21/23 at 12:50 PM with Nurse #4. Nurse #4 was the hall nurse assigned to care for Resident #9 on 1st shift. During the interview, inquiry was made as to whether Resident #9 typically received a built-up handled spoon (an adaptive utensil) with his meals. The nurse stated she thought he did. Accompanied by the nurse, an observation was made of the resident's meal tray placed on his bedside tray table in front of him. Nurse #4 confirmed the only utensil on Resident #9's meal tray was a plastic spoon. An interview was conducted on 3/21/23 at 12:55 PM with Nurse #1. Nurse #1 was identified as the Nurse Manager for Resident #9's hallway. During the interview, Nurse #1 was asked whether the resident typically received a built-up handled spoon instead of a plastic spoon with his meals. The nurse stated she would need to check on the built-up handled spoon for Resident #9. An observation was conducted on 3/22/23 at 9:00 AM of the resident. The resident was observed to have finished eating breakfast with his intake estimated to be 75 - 100 percent (%) of the meal. A built up handled spoon was placed on his meal tray. The spoon had apparently been used during the meal as it was observed to have food particles remaining on it. At that time, Resident #9 was asked if the built-up handled spoon was easier for him to use. The resident nodded to indicate yes. An interview was conducted on 3/22/23 at 11:12 AM with the facility's Registered Dietitian (RD). During the interview, concerns regarding Resident #9's difficulty using a plastic spoon to eat his pureed food at mealtime was discussed. Upon review of his electronic medical records, the RD reported use of a built up handled spoon was initiated for Resident #9 on 4/23/21. The RD confirmed the resident's meal ticket (placed on his tray at mealtime) indicated a sectional plate and 2-handled cup with lid needed to be sent with his meals. However, there was no notation on the meal ticket to indicate the resident needed to have a built-up handled spoon. The RD reported she would add the built-up handled spoon to the resident's meal ticket to ensure it would be sent on each of his meal trays. An interview was conducted on 3/23/23 at 12:40 PM with the facility's Director of Nursing (DON). During the interview, the DON reported she was aware of the concern identified when Resident #9 did not have his built-up handled spoon at mealtime. She confirmed the resident had used a built-up handled spoon for quite a long time and was unsure how long he had gone without it. The DON stated she understood this concern was brought to the staff's attention on 3/21/23 and that the built-up handled spoon was provided for Resident #9 to use at his next meal.

Based on staff interviews and record reviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of pressure ulcers, pain and vision/use of corrective lenses for 1 of 1 resident reviewed for MDS accuracy (Resident #1). The findings included: 1) Resident #1 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. A review of Resident #1's Admission wound assessment dated [DATE] revealed resident had a left heal unstageable pressure ulcer due to deep tissue injury (DTI) with slough and eschar. Resident #1 had an additional right heel unstageable pressure ulcer due to DTI. Resident #1 had an additional right bottom foot and right lateral side of foot unstageable pressure ulcer due to DTI. A review of Resident#1's quarterly MDS assessment dated [DATE] was conducted. The assessment revealed the resident was coded as having two stage 2 pressure ulcers with one present upon admission, 1 stage 3 pressure ulcer that were present upon admission and 1 unstageable pressure ulcer due to coverage of wound bed by slough and or eschar that were not present upon admission. An interview was conducted on 5/19/21 at 2:00 pm with MDS nurse #2. MDS Nurse #2 reviewed Resident #1's MDS 12/17/20. Upon review MDS nurse #2 reported that the units charge nurse manager (CNM) completed the skin sections of the MDS due to the CNM were responsible for wound management for the residents. The wound assessment completed on 11/24/20 revealed that resident #1 had a right heel unstageable pressure ulcer that was present upon admission, a left heel stage 2 pressure ulcer with open blister that was not present on admission and a sacrum abscess that was not present on admission. When asked for clarification of pressure ulcers listed on the 12/17/20 MDS, the MDS Nurse #2 stated that the MDS was coded incorrectly for pressure ulcers and there was no supporting documentation for a stage 2 pressure ulcer present on admissions and a stage 3 pressure ulcer that was present on admission. An interview was conducted on 5/19/21 at 4:00 PM with the facility's Director of Nursing (DON). During the interview, the Administrator stated the MDS should have been coded correctly for Resident #1. b. A review of Resident #1's quarterly Minimum Data Set (MDS) assessment dated [DATE] was conducted. Section B of the MDS reported the resident was able to make herself understood and had the ability to understand others (clear comprehension). Section C indicated the resident had intact cognitive skills for daily decision making. Section J (J0200) of the MDS assessment was coded to indicate a Pain Assessment Interview should not be conducted (resident is rarely/never understood). Instructions in this section of the MDS read in part, Attempt to conduct interview with all residents. An interview was conducted on 5/19/21 at 1:05 PM with MDS Nurse #1. Upon request, the nurse reviewed Resident #1's quarterly MDS dated [DATE] and reported the person who usually conducted the pain assessment interview did not complete it. When asked, MDS Nurse #1 reported she herself was responsible to complete Section J after she received the information from the pain assessment interview. The MDS nurse stated the pain interview should have been completed and confirmed this was an error on Resident #1's MDS assessment. An interview was conducted on 5/19/21 at 2:00 PM with the facility's Director of Nursing (DON). During the interview, the MDS coding errors for Resident #1 were discussed. When asked, the DON stated she would have expected Resident #1's pain assessment interview to have been completed and the MDS assessment to have been coded accordingly. c. A review of Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] was conducted. Section B of the MDS revealed the resident ' s ability to see in adequate light was impaired (sees large print, but not regular print in newspapers/books). Resident #1 was reported to wear corrective lenses. A Care Area Assessment (CAA) worksheet for Vision was dated 7/1/20. Notes on the CAA read, in part: Impaired vision (sees large print) but she wears glasses. Resident #1's quarterly MDS assessment dated [DATE] was also reviewed. Section B of the MDS revealed the resident's ability to see in adequate light was impaired (sees large print, but not regular print in newspapers/books). She was reported to wear corrective lenses. Section B of Resident #1's quarterly MDS assessment dated [DATE] reported her vision was adequate (sees fine detail, including regular print in newspapers/books). This MDS assessment was also coded to indicate Resident #1 did not wear corrective lenses. An interview was conducted on 5/19/21 at 1:05 PM with MDS Nurse #1. Upon request, the nurse reviewed Section B of Resident #1 ' s quarterly MDS dated [DATE]. Upon review, MDS Nurse #1 stated she based the coding for this portion of the MDS on the 12/11/20 Weekly Nursing Summary which reported Resident #1 ' s vision was adequate. However, MDS Nurse #1 also stated the Weekly Nursing Summary dated one day after the quarterly MDS assessment reported the resident had adequate vision but did wear glasses. When asked if the coding for Resident #1's vision and corrective lenses in Section B of the 12/17/20 MDS was an error, MDS Nurse #1 stated, It probably was .I should have coded it differently and put her glasses on here. An interview was conducted on 5/19/21 at 2:00 PM with the facility's Director of Nursing (DON). During the interview, the MDS coding errors for Resident #1 were discussed. When asked, the DON stated she would expect the MDS assessments to be coded accurately.

Based on observation, resident interviews, and staff interview, and record review the facility failed to offer or deliver bedtime snacks to 11 of 11 residents who expressed preference to receive a bedtime snack when interviewed for snacks. (Resident #5, Resident # 20, Resident # 29, Resident # 38, Resident # 51, Resident # 54, Resident # 55, Resident # 56, Resident # 71, Resident # 93, and Resident #96). Finding include: During an observation on 9/25/18 from 8:20 PM to 9:20 PM staff was not observed passing out and/or offering snacks to the residents in south, east and north hallway of the facility. a. Record review revealed Resident # 20 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent Minimum Data Set (MDS) assessment dated [DATE] marked as a quarterly assessment, revealed resident was assessed as moderately cognitively impaired. During an observation and interview on 9/25/18 at 8:23 PM, Resident #20 was identified as alert and oriented. Observation revealed the resident was up in bed. Resident # 20 stated bed time snack were not offered. b. Record review revealed Resident # 51 was readmitted on [DATE] with [DIAGNOSES REDACTED]. During an observation and interview on 9/25/18 at 8:28 PM, Resident # 51 was identified as alert and oriented. Observation revealed resident was lying in her bed. Resident # 51 stated bed time snack were not offered, and her family usually provides her with snacks. Resident further stated she must ask staff for snacks if she wanted one. During an interview on 09/25/18 at 08:30 PM, Nurse # 9 indicated the residents were provided snacks immediately after supper. Nurse #9 further stated snacks were provided if residents requested one. During an interview on 09/25/18 at 08:33 PM, NA # 5 indicated the residents were provided snacks after they were assisted with bed time routine later in the night. NA # 5 further stated showers were provided to assigned residents and other assigned tasks completed before any snacks were offered to residents who were awake and request one. c. Record review revealed Resident # 38 was readmitted on [DATE] with [DIAGNOSES REDACTED]. During an observation and interview on 9/25/18 at 8:35 PM, Resident # 38 was sitting in her wheelchair and talking to visitors. Resident # 38 stated bed time snack were not offered. Resident further stated she gets hungry at night, making it hard to get a good night sleep. d. Record review revealed Resident # 5 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent MDS assessment dated [DATE] marked as a quarterly assessment, revealed resident was assessed as cognitively intact. During an interview on 9/25/18 at 8:37 PM, Resident # 5 stated bed time snack were not offered, and she had to ask for a snack if she needed one. There was no snack or remainder of snack on the bedside table. e. Record review revealed Resident # 56 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent MDS assessment dated [DATE] marked as a quarterly assessment, revealed resident was assessed as cognitively impaired. During an observation and interview on 9/25/18 at 8:37 PM, Resident # 56 was identified as alert. Observation revealed resident was sitting in her wheelchair near her bed. Resident stated she was a diabetic and bed time snacks were not offered. Observation of the nourishment room ( between east and north hallway) and nourishment room refrigerator and interview with Nurse # 10 on 09/25/18 at 08:40 PM revealed refrigerator was well stocked with snacks like pudding, jello (including sugar free), thickened fluids, beverages like soda, juices, milk supplements and few 12 oz Styrofoam cups 3 /4 filled and labeled pimento cheese and chicken salad with date 9/24/18 and use by date 9/26/18. Freezer contained multiple cups of ice cream. Observation of the nourishment room cupboards revealed a loaf of bread, multiple single serving of cereal cups, soups cans and a bowl of graham crackers and saltine crackers. Nurse # 10 stated the nourishment room had snacks that residents like. Nurse #10 indicated residents were offered sandwiches like chicken salad or pimento cheese, soups, cereals or peanut butter and crackers if they requested. Nurse # 10 stated the residents were offered snack only if they requested a snack during their medication administration. During an interview and observation of the nourishment room refrigerator (near the west hallway) on 09/25/18 at 08:45 PM, Nurse #11 stated residents were offered snack at 8:30 PM by staff. Nurse #11 indicated staff were required to provide snacks upon request. Observation of the nourishment room refrigerator revealed multiple snacks like pudding, jello, supplements, milk, thickened liquids, 5 Styrofoam cups 12 oz each (approximately 3 /4 filled) labeled pimento and few labeled chicken salad with a use by date 9/26/18. The refrigerator and freezer were well stocked with ice cream, snacks and beverages. During an interview on 09/25/18 at 08:50 PM, NA # 6 indicated snacks were offered to residents at 10 PM. She stated residents were offered snacks upon request. She further stated the residents who were asleep were not offered one. During an interview on 09/25/18 at 08:52 PM, Nurse #12 indicated residents were offered snacks at 10 PM, if residents were hungry and /or request one. During an interview on 09/25/18 at 08:55 PM, NA # 7 indicated residents were offered snacks at 7 :30 PM and at 9:30 PM. She also stated snacks were offered only to the residents who had requested them. f. Record review revealed Resident # 29 was readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent MDS assessment dated [DATE] marked as a quarterly assessment, revealed resident was assessed as cognitively intact. During an observation and interview on 09/25/18 at 09:00 PM, Resident # 29 was identified as alert and oriented. Observation revealed resident was lying in her bed. Resident stated she was never offered any snack at bed time. g. Record review revealed Resident # 96 was readmitted on [DATE] with [DIAGNOSES REDACTED]. During an observation and interview on 09/25/18 at 09:03 PM, Resident # 96 was lying in her bed. Resident stated she was never offered any snack and her family brings in some bedtime snacks for her. During an interview on 09/25/18 at 09:05 PM, NA #8 stated residents were offered snacks before residents were put to bed and upon request. h. Record review revealed Resident # 54 was readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent MDS assessment dated [DATE] marked as a quarterly assessment revealed resident was assessed as moderately cognitively impaired. During an interview on 09/25/18 at 09:09 PM, Resident # 54 stated was not offered a snack. She indicated staff just offered her roommate snacks and walks out of the room. There was no snack or remainder of snack on the bedside table. During an interview on 09/25/18 at 09:12 PM, Nurse #13 stated residents were offered snacks upon request. Nurse was unsure if Resident # 54 was offered one. Observation of nourishment refrigerators on 9/26/18 at 8:14 AM (West hallway and between east and north hallway) revealed the refrigerators were filled with snacks and were not depleted per visual observations made on 9/25/18 night. During an interview on 09/27/18 at 08:30 AM, the Dietitian indicated the nourishment refrigerators were stocked by food service staff around 12 Noon daily, however the nursing staff were responsible to maintaining the refrigerator clean and at appropriate temperature. Dietitian stated NAs were supposed to offer snacks to the residents at night. During an interview on 09/27/18 at 03:39 PM, the Director of Nursing (DON) stated all diets and snacks were liberalized. DON further stated the residents with medical conditions that required an assigned snack were provide one. DON also stated it was her expectation for staff to offers snacks to all residents. i. Record review revealed that Resident #93 was admitted [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] indicated the resident was cognitively intact. During an observation and interview on 09/25/18 at 8:30 p.m., Resident #93 was resting in bed with eyes opened. When asked, the resident and two visiting family members responded that staff members did not offer a snack this evening. The family members indicated that a snack would be provided if the resident requested one. They stated they were aware of the procedure because Resident #93 had had a prior admission on another unit and the handling of snacks on the current unit was like that of the other unit. There was no snack or remainder of a snack on the bedside table. j. Record review revealed that Resident #55 was admitted [DATE] with [DIAGNOSES REDACTED]. The admission MDS dated [DATE] indicated the resident had moderate cognitive impairment. During an observation and interview on 09/25/18 at 8:35 p.m., Resident #55 was resting in bed with eyes opened. When asked, the resident and a visiting family member responded that staff members did not provide a snack this evening. Resident #55 and the family member stated that receiving a snack in the evening depends on who is working. There was no snack or remainder of a snack on the bedside table. k. Record review revealed that Resident #71 was admitted [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated the resident had moderate cognitive impairment. During an observation and interview on 09/25/18 at 8:40 p.m., Resident #71 was sitting in a wheelchair with eyes opened. When asked, the resident responded that staff members did not offer snacks this evening. He indicated that snacks had not been offered in the evening since his admission several weeks ago. There was no snack or remainder of a snack on the bedside table. In an interview on 09/25/18 at 9:10 p.m., Nurse #16 indicated that residents were not automatically provided snacks in the evening. She stated that residents with dementia though, were always asked if they wanted a snack. The Nourishment Room on the South Unit was inspected 09/25/18 at 9:00 p.m. The refrigerator was well stocked with a variety of snack-sized containers of pudding, Jello, applesauce, beverages and nutritional supplements. Two 12-ounce Styrofoam cups were present, one labeled chicken salad hand-dated 09/24/18-09/26/18 and one labeled pimento cheese hand-dated 09/24/18-09/26/18. In the cupboard there were snack-sized packages of cookies, graham crackers and other items as well as a loaf of fresh bread. The Nourishment Room on the South Unit was inspected 09/26/18 at 8:35 a.m. The quantity of food items present from the previous evening was not depleted by visual inspection. The cups of chicken salad and pimento cheese remained in the refrigerator. The Nourishment Room on the North Unit was inspected 09/26/18 at 8:45 a.m. The quantity of food items present from the previous evening was not depleted by visual inspection. The cups of chicken salad and pimento cheese remained in the refrigerator.

Based on observations and staff interviews the facility failed to remove 136 containers of expired [MEDICATION NAME] 1.5 Cal (Calorie) (Nutritional supplement/medication for tube feeding) from 1 of 3 medication storage rooms on South-West hall. Findings Included: On 9/25/18 at 11:55 AM, during the observation of the medication storage room on South-West hall, there were expired medications found: 1. 13 cans of [MEDICATION NAME] 1.5 Cal, 237 ml (milliliter) each, expired in (MONTH) (YEAR). 2. 5 paper boxes (two opened and three closed) with 24 packets of [MEDICATION NAME] 1.5 Cal, 237 ml in each box and 3 paper packets of [MEDICATION NAME] 1.5 Cal, 237 ml without boxes, totally 123 packets, expired in (MONTH) (YEAR). On 9/25/18 at 12:15 PM, during an interview, Nurse # 1 indicated that all the nurses checked the expiration date while restocking the medication storage rooms. All the expired medications, including tube-feeding nutrition, needed to be removed from the medication storage room. On 9/25/18 at 1:00 PM, during an interview, the Director of Nursing indicated that all the nurses were responsible to check all the medications. Her expectation was no expired items be left in medication storage rooms.

Based on record review and a staff interview, the facility failed to report an allegation of a staff member verbally threatening to slap a resident to the appropriate state agency within two hours of the administrator being made aware of the allegation for one of one resident reviewed for abuse (Resident #41). Findings included: Resident #41 was admitted [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set ((MDS) dated [DATE] indicated the resident was cognitively intact, independent for activities of daily living and continent. The current care plan (09/26/18) for Resident #41 identified the resident with [MEDICAL CONDITION], obesity, and at risk for falls and skin breakdown. In an interview 09/26/18 at 1:45 p.m., Resident #41 shared an incident that she stated occurred several weeks ago. The resident recounted that she mentioned to a nurse aide that she (Resident #41) did not understand why Laundry Aide #1 didn ' t talk to her. She told the nurse aide she thought that the laundry aide didn ' t like her. The next morning Laundry Aide #1 entered her room and said, If you ever tell anyone that I don ' t talk to you, I ' m going to slap you. Resident #41 stated that Laundry Aide #1 was within inches of her face when she allegedly threatened her. The resident added in the interview that I ' m blind, I couldn ' t tell if she had her hand raised and was going to hit me. She stated she was fearful that Laundry Aide #1 might return to hurt her. Resident #41 was unable to identify the nurse aide she initially spoke with or the date of the encounter with the laundry aide. She stated that she had not told anyone about the incident until the current interview. In an interview on 09/26/18 at 3:45 p.m., Laundry Aide #1 denied that the incident with Resident #41 had occurred. In a meeting on 09/26/18 at 2:15 p.m., the Administrator and Director of Nursing were notified of the allegation of abuse. In an interview on 09/27/18 at 9:10 a.m., the Administrator stated that he faxed a 24-hour Report to the state earlier that morning. He provided the report and a fax cover sheet that indicated the information was transmitted 09/27/18 at 9:04 a.m. When informed of the requirement to report an allegation of abuse to the state agency within two hours, he stated that he was not aware of this or of the use of new reporting forms. He shared his expectation that any staff member who suspected abuse should report it immediately to management and that the allegation be faxed to the state within two hours on the appropriate forms.

Based on record review and a staff interview, the facility failed to develop a written policy on reporting abuse that included a timeframe for reporting allegations of abuse to the state agency and a timeframe for reporting allegations to the Administrator for one of one residents reviewed for abuse (Resident #41). Findings included: A review of the facility policy and procedure titled Abuse Reporting dated 6/2018 revealed the following language: 3. When an alleged or suspected case of mistreatment .is reported, the facility administrator, or his/her designee, will notify the following persons or agencies of such incident: a. State Licensing and Certification Agency . The policy did not include a timeframe for reporting the abuse allegation to the state agency as required by regulatory statute, i.e., immediately but not later than two hours after the allegation is made. The Abuse Reporting policy also included the following language: 2. Any alleged violations involving mistreatment .must be reported to the administrator. 6. The person(s) observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the charge nurse. 8. The charge nurse must complete a Resident Abuse Report Form. 9. A completed copy of the Resident Abuse Report Form .must be provided to the administrator within 24 hours. The policy did not include a timeframe for reporting the abuse allegation to the administrator as required by regulatory statute, i.e., immediately but not later than two hours after the allegation is made. The policy listed an Original Issue Date of 10/97 and a Date Reviewed of 6/2018. The review of 06/2018 included formatting changes. The date of the previous review/revision was 1/08. In an interview on 09/27/18 at 2:36 p.m., the Administrator stated that the facility was brought under the control of a new healthcare system earlier this year (2018). The facility ' s current policies and procedures were transferred from the new system. He acknowledged that the policy and procedure for Abuse Reporting failed to incorporate reporting accurate timeframes for abuse allegations for the administrator and the state agency. He was unsure if the Abuse Reporting policy had been reviewed for potential substantive changes in (MONTH) (YEAR) but stated that policies and procedures were generally updated annually or when new regulations were released.

Based on observations, interviews and record review, the facility failed to honor food preferences for 1 of 1 sampled resident (Resident # 51). The findings included: Resident #51 was admitted to the facility on [DATE]. The [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] indicated Resident #51 ' s cognition was intact and she was on a regular diet with no added salt. The MDS coded Resident #51 as requiring set up assistance only for meals. The care plan updated 8/20/18 identified a problem as the resident was at nutritional risk with variable intake for possible weight loss. The goal included resident ' s weight would be stable plus or minus 3 pounds. The approaches included diet as ordered, (HS)evening snack offered by staff, Boost daily at lunch, maintain accurate and current listing of resident food likes and dislikes, ensure that meal trays are served with foods at appropriate temperatures, appropriate seasonings and attractive, document food intake at each meal and evaluate trend, promptly offer resident food alternatives when appropriate for any meal served, provide verbal encouragement with ingesting meals, allow sufficient time for resident to feed self and weigh and record as ordered or as deemed appropriate. During dining observation on 9/24/18 at 12:00 PM, residents were observed in dining rooms and resident rooms. The lunch meal included lasagna, green beans/broccoli, chef salad, sweet potatoes, chopped beef. During an observation on 9/24/18 at 12:30 PM, Resident #51 was in the dining room and the meal of the day was lasagna, but Resident #51 did not eat the lasagna. Resident #51 stated I have told them several times I don ' t eat lasagna and they continue to send it. It is on the meal card along with other stuff I don ' t eat. Why do I have to keep reminding folks? The other staff don ' t ask me if I want something different, I just eat what ' s on my plate or nothing at all. Staff did not offer Resident #51 an alternate. Review of Resident #51 ' s meal card revealed the dislikes as, lasagna with pork, squash, brussels sprouts, chicken breast, tuna fish and mashed potatoes at dinner. During an observation on 9/26/18 at 12:29 PM, Resident #51 was eating in dining room and the meal of the day included fried chicken, squash and boiled potatoes. Resident #51 stated she did not like squash and was not going to eat it. Resident #51 stated the problem is I have told them I did not like certain things and they continue to send it on my tray, just like the lasagna they sent me the other day. If I have already told them several times what I didn ' t like why doesn ' t anyone check the card to make sure they don ' t send me the foods on my dislikes. During an interview on 9/26/18 at 12: 35PM, Nurse #14 and Nurse #15 stated it was the expectation of the kitchen staff to check the tray cards before the food was delivered to the dining area. Nurse #14 stated staff should also check to make sure residents were being offered alternative likes snacks, sandwiches, soup or something different. Both Nurses reviewed the meal card and confirmed that the resident had squash on the plate and no one had offered the resident an alternate or checked the meal card for dislikes. During observation on 9/27/18 at 11:45 AM, the Registered Dietician stated the expectation was for the kitchen staff to check the meal cards prior to delivery to unit and to ensure resident preferences and/or dislikes were honored.

Based on observation, staff interview and record reviews the facility failed to provide a dignified dining experience for 1 of 21 residents (Resident # 27) who was not provided meals at the same time as other residents in the dining hall during meal observation. Findings included: Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the most recent Minimum Data Set (MDS) assessment dated [DATE] marked as an annual assessment, revealed resident was assessed as cognitively impaired. Assessment indicated resident was total dependence with one-person assistance for eating. Resident was coded as receiving mechanically altered diet. Review of the recent updated care plan dated 7/30/18 revealed resident was care planned for underweight and for activities of daily living (ADL) needing total to extensive assistance due to cognitive loss and poor body control related to Parkinson. Goal was to not have weight loss, no complication related to ADL dependence. Interventions included were providing high protein supplements, document meal intake and report decline to dietitian, encourage resident to dine in the dining room to provide opportunity to socialize. Provide extensive/ total assistance with all ADL's. Resident was on pureed meals and required feeding assistance and cueing at all meals. During lunch observation on 9/24/18 from 12:05 PM to 12:30 PM, Resident # 27 was observed sitting in a wheel chair in the dining hall. Resident #27 was observing other residents being assisted with eating their meals while she waited to be served her meal. During an interview on 09/24/18 at 12:25 PM, Nurse Aide (NA) # 3 indicated she was assisting another resident and would feed the resident once completed with her task. NA # 3 stated Resident #27 had to wait to be fed as staff were assisting other residents with feeding. NA # 3 also stated she was unsure why restorative NA's were not in the dining room to assist residents with feeding. Observations on 9/24/18 at 12:30 PM revealed NA #3 served Resident #27 her lunch meal and began assisting the resident to eat her meal. During an interview on 09/24/18 at 12:35 PM, NA # 4 stated she was not sure why restorative aides were unavailable to help. NA # 4 further stated Resident # 27 was not assisted with feeding as there were no staff in the dining hall available to feed. During an interview on 09/26/18 at 04:45 PM, Director of Nursing(DON) indicated Resident # 27 had been declining and had poor meal intake. DON stated she expected the staff should ask for help when needed. DON also stated it was her expectation that all residents who needed feeding assistance be fed approximately at the same time in the dining room.

Based on record review, observation and staff interviews, the facility failed to monitor the development and treatment of [REDACTED].#139). Findings included: Resident #139 was admitted [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] was completed for a significant change in resident ' s condition (a new medical [DIAGNOSES REDACTED]. The MDS indicated that the resident had severe cognitive impairment and was totally dependent for all activities of daily living. The following pressure ulcers were documented: one Stage 2, one unstageable area, and three unstageable deep tissue injuries. No skin integrity issues were recorded on the previous MDS, a quarterly review dated 05/30/17. The care plan for Resident #139 updated 08/22/17 listed measures to address pressure ulcer development such as repositioning the resident, placing bunny boots while in bed, applying skin prep to heels twice a day, and using a pressure-relieving mattress and chair cushion. A nursing progress note dated 06/23/17 documented the discovery of and initial assessment and measurement of two Stage 2 wounds to the sacrum and left buttocks. A medical order to initiate the Stage 2 protocol to sacrum and left buttocks for Resident #139 was dated 06/23/17 and signed by the physician on 07/02/17. The Stage 2 protocol directed nurses to measure (in centimeters) the area weekly. Note wound bed tissue appearance, amount/type of drainage and peri-wound details .skin condition every shift. No measurements or descriptions of wound status were present on the Pressure Ulcer Assessment sheets labeled with Resident #139 ' s name. A review of nursing progress notes revealed two notes after the initial assessment on 06/23/17 that included measurements and/or descriptions of the wound beds, one dated 08/01/17 and one dated 08/08/17. The 08/01/17 nursing progress note documented the sacral wound as now unstageable and the presence of a new Stage 2 wound to the right buttocks. The 08/08/17 nursing progress note recorded the merging of the right buttock wound with the sacral wound. Measurements were present in the medical record progress notes for the following pressure ulcers: 1) Sacral – 06/23/17 initial assessment: 2.0 centimeters (cm) x 0.5 cm, 08/01/17 measurement of 1.5 cm x 2.3 cm x 0.1 cm, 08/08/17 measurement of 4.0 cm x 6.5 cm x 1.0 cm. 2) Left buttock – 06/23/17 initial assessment: 1.0 cm x 1.0 cm, 08/08/17 measurement of 1.0 cm x 1.0 cm. 3) Right buttock – 08/01/17 initial assessment 1.0 cm x 1.0 cm. The nursing progress note dated 08/08/17 recorded the presence of purulent drainage with a foul odor. A wound culture was performed for Resident #139 and she was subsequently treated with an oral antibiotic. A physician order [REDACTED]. Pat dry. Apply [MEDICATION NAME] Extra AG+. Cover with [MEDICATION NAME]. Change dressing only when dressing becomes saturated with drainage. Dressing may be left in place up to 7 days. The wound dressing for Resident #139 was observed on 08/24/17 at 4:33 p.m. Nurse #4 lifted the sacral dressing on the corner so the wound could be examined. A large ulcerated area on the sacrum with depth was present. Measurements were not taken. Nurse #4 acknowledged that the sacral dressing currently applied (dated and initialed 08/22/17) was saturated and needed replacement. In an interview on 08/24/17 at 10:59 a.m., Clinical Nurse Manager #1 confirmed that two measurements of the sacral area (dated 08/01/17 and 08/08/17) had been taken in the nine weeks following the discovery and initial assessment of the skin breakdown on 06/23/17. Documentation of wound status was missing for seven weeks. She indicated that residents ' wound progression was monitored through the weekly weight and wound meeting attended by the two clinical nurse managers, the Director of Nursing and the dietician. In an interview on 08/24/17 at 5:05 p.m., the Medical Director acknowledged that he visited Resident #139 on 07/21/17 but did not view or evaluate the pressure ulcers. He shared his expectation that nurses contact him if the wound treatment ordered is not working, if there are complications, or if they feel a hospital evaluation is needed. He stated that wound measurements recorded weekly are very helpful in determining wound progression and/or improvement. In an interview on 08/24/17 at 5:54 p.m., the Director of Nursing stated her understanding of the use of pressure ulcer protocols in monitoring the development and treatment of [REDACTED]. She shared her expectation that nurses followed the pressure ulcer protocols by measuring wounds, recording observations weekly, and notifying the physician promptly of changes in wound condition.

Based on record review and staff interviews, the facility failed to maintain complete and accurate records for pressure ulcer status for one of one residents reviewed for pressure ulcers (Resident #139). Findings included: Stage 2 protocols dated 06/23/17 for wounds on the sacrum and left buttocks were present in the Treatment Administration Record (TAR) for Resident #139. The multipage protocols consisted of instructions for the care and treatment of [REDACTED]. The final page titled Pressure Ulcer Assessment Sheet consisted of rows for documenting wound characteristics such as stage; size and depth; appearance; and the presence of drainage, odor or tunneling. Each sheet could record observations and comparisons for 22 weeks. The Stage 2 protocol directed nurses to measure (in centimeters) the area weekly. Note wound bed tissue appearance, amount/type of drainage and peri-wound details .skin condition every shift. Resident #139 was admitted [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] was completed for a significant change in resident ' s condition (a new medical [DIAGNOSES REDACTED]. The MDS indicated that the resident had severe cognitive impairment and was totally dependent for all activities of daily living. The following pressure ulcers were documented: one Stage 2, one unstageable area, and three unstageable deep tissue injuries. No skin integrity issues were recorded on the previous MDS, a quarterly review dated 05/30/17. The care plan for Resident #139 listed measures to address pressure ulcer development such as repositioning the resident, placing bunny boots while in bed, applying skin prep to heels twice a day, and using a pressure-relieving mattress and chair cushion. A nursing progress dated 06/23/17 documented the initial assessment and measurement of Stage 2 wounds to the sacrum and left buttocks. There were no progress notes or weekly skin assessments present in the medical record for Resident #139 prior to this date that indicated skin breakdown to this area. A medical order to initiate the Stage 2 protocol to sacrum and left buttocks for Resident #139 was dated 06/23/17 and signed by the physician on 07/02/17. No measurements or descriptions of wound status were present on the Pressure Ulcer Assessment sheets for either the Stage 2 sacral or left buttock wounds for Resident #139. A review of nursing progress notes revealed two notes after the initial assessment on 06/23/17 that included measurements and/or descriptions of the wound beds, one dated 08/01/17 and one dated 08/08/17. In an interview on 08/24/17 at 3:09 p.m., Nurse #3 indicated that the clinical nurse manager completed initial measurements when a new pressure ulcer developed. When asked, Nurse #3 was unable to identify who was responsible for measuring wounds on a weekly basis. She stated that unit nurses could chart measurements on either the Pressure Ulcer Assessment sheets or in the nursing progress notes. She indicated that the Pressure Ulcer Assessment sheets were not used much anymore since the facility no longer employed a wound treatment nurse. In an interview on 08/24/17 at 10:59 a.m., Clinical Nurse Manager #1 explained that the unit nurse assigned treatments documented wound measurements. She confirmed that there were no electronic wound treatment forms or notes for Resident #139. In an interview on 08/24/17 at 5:54 p.m., the Director of Nursing shared her expectation that nurses followed the pressure ulcer protocols by assessing and measuring wounds weekly and recording the observations in the resident ' s medical record.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment to reflect the hospice care and indwelling urinary catheter for 1 of 12 sampled residents (Resident #93), reviewed for MDS assessment. Findings Included: Resident# 93 was admitted on [DATE] with [DIAGNOSES REDACTED]. 1. Review of Minimum Data Set (MDS) assessment for significant changes, dated 6/13/17, reveled that Resident 93 ' s cognition was severely impaired, and she was not coded for hospice services. Review of Resident 93 ' s plan of care, dated on 6/2/17, revealed that the resident had significant changes in condition and received hospice service. Review of Resident 93 ' s hospice comprehensive assessment and care plan, dated 6/1/17, indicated that based on the [DIAGNOSES REDACTED]. Record review of the multiple nurses ' notes for June – August 2017 revealed that Resident #93 received hospice service, provided by hospice team from 6/1/17 three times a week, according to hospice plan of care. Record review of the hospice progress notes for June – August 2017 revealed that hospice aides came three times a week and hospice nurse came weekly to provided hospice care for Resident #93. On 8/23/17 at 10:40 AM, during an interview, Nurse Aide #1 indicated that Resident #93 received hospice program. The hospice aides came to the facility three times a week to provide morning and comfort care. The hospice nurse came weekly. The facility ' s nurse aides communicated with hospice team to provide the care. On 8/23/17 at 10:50 AM, during an interview, Nurse #1 indicated that Resident #93 received hospice program from the beginning of June 2017. The hospice aides came three times a week and the hospice nurse came weekly or more often to coordinate the care. The aides communicated with hospice nurse and floor nurse in regards to resident ' s care. On 8/23/17 at 10:55 AM, during an interview, Hospice Nurse, indicated that Resident #93 began hospice program on 6/1/17. Hospice Nurse came to Resident #93 weekly to provide care, according to care plan. The hospice team coordinated hospice plan of care with nursing care plan weekly. On 8/23/17 at 11:15 AM, during an interview, MDS Nurse #1 indicated that she was notified about hospice program for Resident #93 on 6/1/17. Another MDS nurse, who was responsible for significant change MDS assessment, did not complete hospice section on 6/13/17 MDS assessment, which was an error. On 8/23/17 at 21:25 AM, during an interview, Director of Nursing , indicated that she expected the MDS nurses to complete the assessments accurately and on time. 2. Review of Minimum Data Set (MDS) assessment for significant changes, dated 6/13/17, reveled that Resident 93 ' s cognition was severely impaired, and she was not coded for indwelling urinary catheter. Record review revealed the initial physician's order [REDACTED].#93 ' to use Foley (indwelling urinary catheter) catheter due to [MEDICAL CONDITION]. Record review of the care tracker for Resident #93 revealed that from 6/7/17 to 6/13/17 the resident received catheter care, provided by the nurse aides daily. On 8/23/17 at 10:35 AM, Resident #93 was observed in bed with Foley catheter in place, connected to the covered drainage bag. On 8/23/17 at 10:40 AM, during an interview, Nurse Aide #1 indicated that it was her responsibility to provide catheter care for Resident #93 and empty the urinary drainage bag during the shift. On 8/23/17 at 11:15 AM, during an interview, Nurse #2 indicated that Resident #93 had indwelling urinary catheter for two-three months, including the period from 6/7/17 to 6/13/17. On 8/23/17 at 11:15 AM, during an interview, MDS Nurse #1 indicated that she observes residents seven days prior to complete MDS assessment for urinary catheter. Another MDS nurse, who was responsible for the assessment of Resident #93, marked he was always urinary incontinent with indwelling catheter section not coded, which was an error. On 8/23/17 at 21:25 AM, during an interview, Director of Nursing, indicated that indwelling urinary catheter MDS section should reflect the actual situation with Foley catheter for seven previous days.

Based on observations and staff interviews, the facility failed to discard 3 out of 3 blocks of expired three pound blocks of cream cheese, 1 out of 1 case of expired one ounce cream cheese containers, 1 out 3 containers of expired five pound container of cottage cheese. The facility also failed to dispose of 1 out 1 case of spoiled lemons. Findings Included: An observation during the initial kitchen tour on 10/5/15 at 9:35 am of the produce cooler and the dairy cooler revealed the following: 1. Three pound blocks of Cream Cheese (3 out 3 blocks) was expired on 7/9/15 2. One ounce individual containers of Cream Cheese (1 out of 1 case) was expired on 9/9/15 3. Five pound container of Cottage Cheese (1 out of 3 containers) was expired on 10/1/15 4. One case of spoiled/rotten lemons During an observation on 10/5/15 at 9:35 am, the Chef discarded the expired items and spoiled lemons. An interview was conducted with the Chef on 10/8/15 at 12:15 pm. The Chef revealed a chart, which was in place for the dietary staff members responsible for checking their assigned coolers. The chart indicated that coolers are to be checked daily for expired products and soiled produce, and to be sure everything is dated and labeled. His expectations of his staff is to check their assigned coolers daily and to be sure to pull out any product that is expired or spoiled and to ensure everything is dated is labeled. The Chef was responsible for the dairy cooler and the produce cooler. He stated that the expired and spoiled products should have been discarded. The Chef further added the staff is to follow the first in, first out rule, which is the products with the most recent expiration date need to be pulled forward to be the first product out. The Chef stated the expired products were not used often and they were over looked. An interview was conducted with the Dietary Manager on 10/8/15 at 12:20 pm. The Dietary Manager revealed the expectation of the staff is to follow the first in, first out rule. Expects the staff to pull product forward with the most recent date and to monitor for expired product. The expired product should be pulled from the area immediately. An interview with the Administrator on 10/8/15 at 2:15 pm revealed the Administrator ' s expectation of his dietary staff is to monitor all food products for expiration dates and to discard it they are expired.