THE VILLAGE AT HERITAGE OAKS

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 1 of 4 residents (Residents #1) reviewed for resident rights in that: <BR/>The facility failed to ensure Residents #1's call light was within reach on 03/22/2025. <BR/>This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met. <BR/>Findings included: <BR/>Record review of Resident #1's admission record dated 03/22/2025 documented an [AGE] year-old female admitted on [DATE]. Resident #1 had diagnoses which included: hypertensive heart disease with heart failure(high blood pressure damage the heart and blood vessels), hyperlipidemia(high levels of fat particles in the blood),hypokalemia(blood level that s below normal that result in fatigue, muscle cramps, and abnormal heart rhythms),parkinsonism(cause tremors and slow movements, and depression(sadness).<BR/>Record review of Resident #1's Quarterly MDS assessment, dated 02/05/2025, revealed the resident had a BIMS score of 12 indicating the resident had moderate cognitive impairment. The MDS also revealed Resident #1 required partial/moderate assistance in the areas of Toileting hygiene, shower/bathe self, lower body dressing, and putting on /taking off footwear.<BR/>Record review of Resident #1's care plan, dated 03/22/2025, revealed Resident #1 was care planned for ADL self-care performance deficit r/t impaired balance, stroke, and PD. Resident # 1 had an intervention of: Encourage Resident #1 to use call light for assistance.<BR/>Observation on 03/22/2025 at 12:50 PM., revealed Resident #1's call light was under her bed, in the middle, not in reach. <BR/>During an interview on 03/22/2025 at 12:50 PM, Resident #1 stated it had been out of reach since early morning. Resident # 1 was not able to recall how long the call light was not in reach or the last time staff had come in to assist her. Resident # 1 stated she needed to be changed and was waiting on staff to pass by her room to call out for staff to assist her. Resident # 1 stated when the call light was not in reach, she would just wait for staff to come to her room. Resident # 1 stated she really didn't want to say too much because she had to stay there and did not want the facility to retaliate against her<BR/>During an interview on 03/22/2025 at 2:29 PM, CNA A stated CNAs should make rounds at least every two hours or as needed. CNA A stated that CNAs should be checking to see if call lights were in reach. CNA A stated she had left Resident # 1's room around 12:30 PM, and the call light was in place when she had entered the room (time entered not recalled). CNA A stated the call light may have fell of when she made Resident #1's bed. CNA A stated she could not recall if the call light was tied to the bed rail when she had left Resident #1's room. CNA A stated if a resident's call light was not within reach, then the resident needs would not have been met.<BR/>During an interview on 03/22/2025 at 3:10 PM, the DON stated that anyone that entered the resident's room was responsible for ensuring the call light was within reach. The DON stated the purpose of a call light was for resident to notify staff when they needed assistance. The DON stated if a resident's call light was not in reach, then the resident could have an unmet need. The DON stated her expectation was that all resident's call lights were always within reach so the resident could notify staff they need assistance. <BR/>During an interview on 03/23/2025 at 1:45 PM, the ADM stated the purpose of call light was for the residents to alert staff when they needed assistance. The ADM stated it was everyone's responsibility to ensure call lights were always within reach. The ADM stated that if a call light was not within reach, then a resident desired need would not be met. The ADM stated that she expected for call lights to be always within reach and answered timely.<BR/>Review of the facility's Call Lights: Accessibility and Timely Response policy, implemented 05/01/2024 and revised 05/01/2024, reflected, Purpose: The purpose of this policy is to assure the facility is adequately equipped with a call light to allow residents to call for assistance.<BR/>Policy Explanation and Compliance Guidelines<BR/>1. <BR/>All staff will be educated on the proper use of the resident call system, including how the system works and ensuring resident access to the call light.<BR/>5. <BR/> .Staff will ensure the call light is within reach of the resident and secured, as needed.

Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for four of four halls (Halls 100, 200, 300, and 400) and the nurse's station, conference room, lobby, and main dining room reviewed for pest control program. <BR/>The facility had live flies and gnats in areas of the facility including the nurse's station, Halls 100, 200, 300, 400, nurse's station, conference room, lobby, and the main dining room. <BR/>This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life.<BR/>Findings included:<BR/>An observation on 09/16/24 at 9:00 a.m., revealed in the front lobby there were three gnats flying around the front door. The food service carts were sitting outside of the kitchen door. There were three flies flying around the closed food carts. The flies landed and started crawling on the closed food carts. <BR/>An observation on 09/16/24 at 9:15 a.m., revealed a live fly and a gnat flying in the conference room.<BR/>An observation on 09/16/24 at 9:20 a.m., revealed a gnat crawling on top of the nurse's station.<BR/>An observation on 09/16/24 at 9:20 a.m., revealed as the surveyor entered Hall 400 a live fly flew past down the hallway.<BR/>An observation on 09/16/24 at 9:30 a.m., revealed three live flies flying down Hall 300 and a group of five gnats at the end of Hall 300. <BR/>An observation on 09/16/24 at 10:00 a.m., revealed a live fly flying down Hall 100 and at the end of the hallway a live fly was crawling on the exit door. <BR/>An observation on 09/16/24 at 10:45 a.m., revealed a live mosquito flying in the Administrators office.<BR/>An observation and interview on 09/16/24 at 12:15 p.m., revealed a live fly crawling on a table in the dining room with a glass of juice on it. The fly lit on the lip of the glass. The resident returned to the table. The surveyor informed the staff in the dining room there had been a fly on the lip of the glass, the staff got a new glass of juice. Interview with MA A revealed it was the time of the year for the flies to be bad, the MA stated they come in the door that is in the dining room that goes outside and the front door. MA A stated there was a book at the nurses' station to write the fly sightings in, but she had not written anything in it lately. <BR/>An observation on 09/16/2024 at 12:25 p.m., revealed a live fly flew out the main door of the dining room. <BR/>An observation on 09/17/24 at 8:20 a.m., revealed a live fly crawling on the linen cart on Hall 100. <BR/>In a confidential group meeting on 09/17/24 at 10:10 a.m., revealed a resident stated there were mosquitoes in the facility. <BR/>An interview on 09/17/24 at 2:40 p.m., CNA B revealed there was a pest control book at the nurse's station, as she took the surveyor and showed her the book. CNA B stated if we see any pest we are to write in here. CNA B stated she had not seen any pest, but she had seen the pest control man here. <BR/>An interview on 09/17/24 at 3:15 p.m., CNA C revealed there was a pest control log at the nurse's station. CNA C stated she would write in that book if she saw pest. CNA C stated she had not seen any flies. <BR/>Record review of the pest control book reflected a log with no notations of flies, gnats, or mosquitoes. <BR/>An observation on 09/17/24 at 4:00 p.m., in the men's bathroom located near the nurse's station revealed a large cloud of gnats swarmed in and out of the drain located in the middle of the bathroom. <BR/>An interview on 09/17/24 at 7:45 a.m., LVN D revealed there was a pest control book at the nurse's station. LVN D stated she had seen some bugs recently and had documented in the pest control book and the pest control man had come. The pest was not flies, they were roaches, she stated she had not seen any more of them lately. LVN D stated the residents will also tell us and we will document in the pest control logs. <BR/>An interview on 09/18/2024 at 1:21 p.m., Resident #47 revealed she had seen a mosquito in her room, she could not recall when that was, but she knew it was a mosquito, buzzing around her face. Resident #47 stated she did not think to tell anyone, it went away, and she did not see it anymore.<BR/>An interview on 09/18/24 at 1:27 p.m., the Administrator revealed the pest control services was just here on the past Monday. The Administrator stated the pest control company would be contacted to come. The staff is supposed to document in the pest control log at the nurse's station. The Administrator stated if the pest were not controlled, they could spread germs. <BR/>Record review of facility provided pest control visits revealed, in part, dates and treatments as follows:<BR/>Treatment dates and services performed:<BR/>-09-04-2024-after inspection . verified active fruit fly and gnat activity in kitchen, drains need to be cleaned better, built up food . treated the kitchen drains. <BR/>-8-23-2024- after inspection . treated hallways, in kitchen . dish sink area drains flies .<BR/>-06-28-2023- after inspection . targeted pest throughout the facility treated . drain flies, flies, gnats, fruit flies, and mosquitoes . treated hallways, reception, office areas, laundry, kitchen storage sink area, restrooms, recreation storage area for small and large flies, serviced fly light station.<BR/>Record review of the facility's policy revised, April 2024 and titled Pest control Program reflected it is the policy of this facility to maintain an effective Pest control program that eradicates and contains common household pest and rodents .definition . effective pest control program is defined as measures to eradicate and contain common household pests (e.g., bed bugs, lice, roaches, ants, mosquitoes, flies, mice, and rats).

Based on interviews and record review, the facility failed to ensure the Activity Program was directed by a qualified professional for one (Activity Director) of one activity-directing professional reviewed for quality of life.<BR/>The facility failed to ensure Activity Director was qualified to direct the activities program.<BR/>This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident.<BR/>Findings included:<BR/>Review of personnel records on 05/06/22 revealed no evidence that Activity Director had completed the required activity director course. <BR/>Interview on 05/06/22 at 12:54 PM with Activity Director revealed she had not completed the required activity director course. She stated her anticipated completion date was in three weeks. She stated the Social Worker and herself provide activities to the residents daily. She stated there was a May 2022 activity calendar posted on a wall near the nurse's station. She stated the purpose of an activity director was to keep residents entertained and to give them something to do every day. <BR/>Interview on 05/06/22 at 1:53 PM with Social worker revealed she had been assisting the Activity Director with activities for three weeks. She stated the facility did not have a certified activity director. She stated the residents participate in activities every day. She stated the importance of a qualified activity director was to improve a resident's quality of life. <BR/>Interview on 05/06/22 at 1:51 PM with Administrator revealed the facility did not have a qualified activity director. She stated the facility has not had an activity director since 04/15/22. She stated she had given the Activity Director until 05/16/2022 to complete required activity director courses. She stated the Activity Director and Social Worker have been assisting residents with activities. She stated the importance of an activity director was to assist residents with their psycho-social needs. She stated the facility did not have a policy for regarding a qualified activity director.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide treatment and services to prevent complications of enteral feeding for one (Resident #41) of three residents reviewed for feeding tubes.<BR/>LVN A failed to follow the facility's policy regarding administering medications via g-tube (gastrostomy tube). LVN A crushed seven medications together and administered them all at once to Resident #41. <BR/>The failure placed residents at risk of obstruction of the g-tube and adverse drug interactions. <BR/>Findings included:<BR/>Record review of Resident #41's admission Record, dated 07/07/21, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #41's diagnoses included dysphagia, cerebral infarction, muscle weakness, unspecified dementia and anxiety disorder.<BR/>Record review of Resident #41's Annual MDS assessment, dated 04/08/22, revealed that Resident #41 had a feeding tube.<BR/>Review of the Resident #41's May 2022 Medication Administration Record revealed the following medications were scheduled to be administered at 12:00 PM every day: Norco 5-325mg tablet, Amlodipine 500mg tablet, Aspirin 81mg tablet, Gabapentin 100mg Capsule, Lisinopril 20mg tablet, Carvedilol 12.5mg tablet and Miralax Powder 17gm. <BR/>Review of the Resident #41's May 2022 Medication Administration Record revealed a doctor's order dated 05/04/22 may crush and mix all meds and dissolve in 4-6oz of water to administer via g-tube unless contraindicated.<BR/>Observation on 05/05/22 at 12:00 PM revealed LVN A crushed Resident #41's medications and placed them in a medication cup. LVN A entered Resident #41's room and positioned the resident. LVN A checked the Resident #41's g-tube (gastrostomy tube) placement and residual and flushed the g-tube with 30 cc of water. LVN A mixed the medications in the cup with 30 cc of water and placed a syringe in the cup and pulled the plunger, pulling all of the crushed medications in the cup along with the water into the syringe. LVN A attached the syringe to the g-tube port and pushed the plunger, pushing the medications in via the syringe. LVN A then flushed the g-tube with 30 cc of water. <BR/>In an interview on 05/05/22 at 12:30PM LVN A stated she crushes and mixes all of the medications together because that is the way she was trained, and she has an order from the doctor to cocktail the medications together. LVN A stated that she feels administering the medications one by one is best practice and mixing medications together may cause an adverse reaction. LVN A also stated that medications should be administered via gravity to prevent stomach pain or discomfort. <BR/>In an interview with the DON on 05/05/22 at 1:14 PM revealed that nursing staff have been trained to administer medications upon hire. The DON stated that the facility policy stated to follow the doctor's order. The DON stated she felt best practice was to administer medications via g-tube separately and via gravity to avoid adverse reactions. Further interview revealed that the DON is responisble for ensuring proper medication administration is practiced within the facility. The DON was unable to provide a policy that stated to follow the doctor's orders over the facility policy. <BR/>Review of LVN A's g-tube medication administration training dated 11/01/21 revealed she was trained to administer medications one at a time. <BR/>Review of facility policy, revised March 2015 titled Administering Medications through an Enteral Tube, revealed, General Guidelines 3. Do not mix medications together prior to administering through an enteral tube. Administer each medication separately. Steps in the Procedure, 26. If administering more than one medication, flush with 15ml warm sterile or purified water between medications.

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation.<BR/>1. The facility failed to ensure food was properly stored in the facility's refrigerator, freezer, and dry storage.<BR/>2. The facility failed to ensure expired/spoiled foods were discarded. <BR/>3. The facility failed to ensure the floor in the freezer was free from spills and unpackaged food.<BR/>4. The facility failed to ensure food on the steam table reached the appropriate temperature before plating food for resident consumption. <BR/>These failures could place residents at risk for food-borne illness. <BR/>Findings included: <BR/>Observation of the facility's refrigerator on 05/04/22 at 10:44 AM revealed: <BR/>- 1 plastic bag of meat open and exposed to air. <BR/>Observation of the facility's walk-in freezer on 05/04/22 at 10:50 AM revealed: <BR/>- A red spill on the floor<BR/>- 3 individually packaged containers of butter on the floor <BR/>- 2 sausage links on the floor <BR/>Observation of the facility's smaller freezer on 05/04/22 at 10:55 AM revealed: <BR/>- 1 box of Salisbury patties open and exposed to air.<BR/>Observation of the facility's dry storage on 05/04/22 at 11:00 AM revealed: <BR/>- 1 bag of Japanese style breadcrumbs open and exposed to air<BR/>- 1 bag and box of thickener open and exposed to air<BR/>Observation of the main area in the kitchen under a prep table on 05/04/22 at 11:10 AM revealed: <BR/>- 1 white onion with black and fuzzy white spots<BR/>Observation of milk storage in the main area in the kitchen on 05/04/22 at 11:15 AM revealed: <BR/>- Spilt milk on the top of three boxes containing gallons of milk. <BR/>Observation of Dietary [NAME] D checking food temperatures on the steam table on 05/05/22 at 11:45 AM revealed: <BR/>- Ground beef with peppers were temped at 132F and again at 121F.<BR/>- Puree ground beef with peppers were temped at 125F; and <BR/>- Chicken strips were tempted at 150F<BR/>Interview with substitute Dietary Manager on 05/05/22 at 12:20 PM revealed the ground beef with peppers and chicken strips were safe for residents to consume. She stated residents' trays would not be pulled and they will eat the food that has been temped and plated. <BR/>Interview with DON and Administrator on 05/05/22 at 12:30 PM revealed the food temperatures were safe for residents to consume. They stated their facility policy revealed food could be served at a temperature of 115F. They stated there would be no adverse reaction to residents consuming chicken strips at 150F and ground beef with peppers at 132F, 125F, and 121F. <BR/>Interview with Dietary [NAME] D on 05/05/22 at 3:06 PM revealed the ground beef with peppers should not have been served to residents because the temperature was too low and not safe to consume. She stated the temperature of the chicken strips were safe to serve residents. She stated beef and chicken must reach a temperature of 135F on the steam table before they are served to residents. She stated the substitute Dietary Manager was responsible for determining the accurate temperature for food to be served to residents. She stated the the substitute Dietary manager monitors temperatures for breakfast, lunch, and dinner. She stated the substitute Dietary Manager informed her the ground beef with peppers and chicken strips were at an appropriate temperature to serve to residents. She stated she received an in-serviced regarding food temperatures in March 2022. She stated residents could become sick if food was consumed at the wrong temperature.<BR/>In an interview with the substitute Dietary Manager on 05/06/22 at 12:43 PM revealed she had been the substitute dietary manager for one month. She stated she has ten years of experience as a cook, possesses her food handler's certificate, and educated regarding food temperatures and kitchen sanitation. She stated she was not classified as a qualified dietary manager because she had not completed her dietary manager courses. She stated she was responsible for overseeing the kitchen. She stated she completes walk throughs of the kitchen upon arrival to work, in between meals, and Thursdays on food truck arrival. She stated dietary staff have a cleaning chore list in the kitchen. She stated she ensured the dietary staff were educated and reeducated regarding the kitchen. She stated proper food storage and cleanliness of floors was important. She stated residents could be at risk of food borne illnesses. <BR/>Review of the facility policy titled Food Receiving and Storage, dated July 2014, revealed, Foods shall be received and stored in a manner that complies with safe food handling practices.(5) The following internal cooking temperatures/times for specific foods must be reached to kill or sufficiently inactivate pathogenic microorganisms: (a) poultry and stuffed foods - 165F. Ground meat, ground fish and eggs held for service - at least 115F.<BR/>Review of facility policy titled Food Handling and Service, dated 06/01/2019, revealed, To ensure that all food served by the facility is of good quality and safe for consumption, all food will be held and served according to the state and US Food Codes and HACCP guidelines. (1) Serve all hot foods at a temperature of 135F or greater and all cold food at 41F or less. (2) If hot foods drop below 135F, reheat to 165F for a minimum of 15 seconds.<BR/>Review of U.S Department of Health and Human Services Food Code, dated 2017, revealed, 3-202.15 Package Integrity reflected: Food packages shall be in good condition and protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants.<BR/>Review of the Food and Drug Administration Food Code, dated 2017, reflected, .3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11 Food Storage. (A) .food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety <BR/>Review of the Texas Food Establishment Rules, dated 2015, reflected, Time/temperature controlled for safety food that is cooked, cooled, and reheated for hot holding shall be reheated so that all parts of the food reach a temperature of at least 74 degrees Celsius(165 degrees Fahrenheit) for 15 seconds.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for one (Resident #25) of four residents reviewed for environment.<BR/>1. <BR/>The facility failed to ensure Resident #25's personal items were unpacked in her new room.<BR/>2. <BR/>The facility failed to ensure Resident #25's recliner was moved into her new room.<BR/>This failure could place residents at risk for diminished quality of life due to the lack of a homelike environment. <BR/>Findings included: <BR/>Review of Resident #25's MDS dated [DATE] revealed she was a [AGE] year-old female and admitted to the facility on [DATE]. Her diagnoses were anemia, peripheral vascular disease, seizure disorder, anxiety disorder, and insomnia. <BR/>Observation and interview in Resident #25's room on 05/04/22 at 11:15 AM revealed she had two boxes filled with personal items. She stated she had been in her new room for two weeks. She stated she returned from the hospital and was moved to a new room. She stated she did not remember why she was moved from her previous room. She stated she has asked staff to assist with unpacking her personal items and moving her recliner in her new room. She stated she does not feel like her room has a homelike experience because she does not have access to her personal items. <BR/>Observation of Resident #25's previous room on 05/04/22 at 11:30 AM revealed there was an unused blue recliner. <BR/>Review of Resident #25's electronic medical record on 05/05/22 revealed she had previously resided in a different room.<BR/>Interview with CNA C and CNA D on 05/06/22 at 11:02 AM revealed they assist residents with room changes by moving their personal items. They stated Resident #25 has been in her new room for two weeks. They stated some of her personal items were in boxes and her recliner was not in her room. They stated she did not have enough space in her new room for all her items. They stated the resident had not asked them to assist with unpacking her items but requested her recliner be moved into her new room. They stated Resident #25 was moving into a new room with more space on 05/06/22. They stated Resident #25's room was not homelike because her items were not unpacked, and she did not have her recliner. They stated a homelike environment was important because the nursing facility was Resident #25's home. <BR/>Interview with LVN B on 05/06/22 at 9:25 AM revealed Resident #25's recliner was moved into her new room on 05/04/22. She stated Resident #25 had personal items in boxes because there was not enough space to unpack her items. She stated CNAs assist with moving the resident's items and maintenance assists with moving resident's furniture. She stated Resident #25's recliner and personal items unpacked would help her have a home like environment. She stated residents need a home like environment to feel safe and enjoy living in the facility. <BR/>Interview with DON on 05/06/22 at 1:09 PM revealed the Resident #25's requested a new room upon arrival from hospital and did not want to return to old room. She stated Resident #25 had a lot of personal items and her current room does not have enough space for the items. She stated Resident #25 was being moved from her current room to her previous room on 05/06/22. She stated Resident #25's items would be unboxed and her recliner would be in the new room. She stated Resident #25's items personal items boxed and not having her recliner did not affect her homelike environment. She stated a homelike environment was important for residents to feel at home and comfortable at the facility. <BR/>Review of the facility policy titled Quality of Life - Homelike Environment, dated 04/2014, revealed, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for one (Resident #25) of four residents reviewed for environment.<BR/>1. <BR/>The facility failed to ensure Resident #25's personal items were unpacked in her new room.<BR/>2. <BR/>The facility failed to ensure Resident #25's recliner was moved into her new room.<BR/>This failure could place residents at risk for diminished quality of life due to the lack of a homelike environment. <BR/>Findings included: <BR/>Review of Resident #25's MDS dated [DATE] revealed she was a [AGE] year-old female and admitted to the facility on [DATE]. Her diagnoses were anemia, peripheral vascular disease, seizure disorder, anxiety disorder, and insomnia. <BR/>Observation and interview in Resident #25's room on 05/04/22 at 11:15 AM revealed she had two boxes filled with personal items. She stated she had been in her new room for two weeks. She stated she returned from the hospital and was moved to a new room. She stated she did not remember why she was moved from her previous room. She stated she has asked staff to assist with unpacking her personal items and moving her recliner in her new room. She stated she does not feel like her room has a homelike experience because she does not have access to her personal items. <BR/>Observation of Resident #25's previous room on 05/04/22 at 11:30 AM revealed there was an unused blue recliner. <BR/>Review of Resident #25's electronic medical record on 05/05/22 revealed she had previously resided in a different room.<BR/>Interview with CNA C and CNA D on 05/06/22 at 11:02 AM revealed they assist residents with room changes by moving their personal items. They stated Resident #25 has been in her new room for two weeks. They stated some of her personal items were in boxes and her recliner was not in her room. They stated she did not have enough space in her new room for all her items. They stated the resident had not asked them to assist with unpacking her items but requested her recliner be moved into her new room. They stated Resident #25 was moving into a new room with more space on 05/06/22. They stated Resident #25's room was not homelike because her items were not unpacked, and she did not have her recliner. They stated a homelike environment was important because the nursing facility was Resident #25's home. <BR/>Interview with LVN B on 05/06/22 at 9:25 AM revealed Resident #25's recliner was moved into her new room on 05/04/22. She stated Resident #25 had personal items in boxes because there was not enough space to unpack her items. She stated CNAs assist with moving the resident's items and maintenance assists with moving resident's furniture. She stated Resident #25's recliner and personal items unpacked would help her have a home like environment. She stated residents need a home like environment to feel safe and enjoy living in the facility. <BR/>Interview with DON on 05/06/22 at 1:09 PM revealed the Resident #25's requested a new room upon arrival from hospital and did not want to return to old room. She stated Resident #25 had a lot of personal items and her current room does not have enough space for the items. She stated Resident #25 was being moved from her current room to her previous room on 05/06/22. She stated Resident #25's items would be unboxed and her recliner would be in the new room. She stated Resident #25's items personal items boxed and not having her recliner did not affect her homelike environment. She stated a homelike environment was important for residents to feel at home and comfortable at the facility. <BR/>Review of the facility policy titled Quality of Life - Homelike Environment, dated 04/2014, revealed, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised as appropriate for one (Resident #20) of four residents reviewed for care plans. <BR/>The facility failed to revise Resident #20's care plan to reflect she slept in a recliner. <BR/>This failure could place residents at risk of not receiving needed services and care. <BR/>Findings Included: <BR/>Review of Resident #20's MDS dated [DATE] revealed she was a [AGE] year-old female and admitted to the facility on [DATE]. Her diagnoses were hypertension, renal insufficiency, diabetes, hyperlipidemia, non-Alzheimer's dementia, malnutrition, anxiety disorder, depression, psychotic disorder, and hyperthyroidism.<BR/>Review of Resident #20's most recent care plan, undated, revealed her care plan had not been revised to include she preferred to sleep in a recliner and not a bed. <BR/>Observation on 05/04/22 at 11:35 AM revealed Resident #20 did not have a bed in her room. <BR/>Interview with Resident #20 on 05/04/22 at 12:00 PM revealed she slept in a recliner instead of a bed. She stated she did not have a bed in her room and could not remember if she ever had a bed in her room. She stated her preference was to sleep in her recliner because is was more comfortable. <BR/>Interview with LVN B on 05/06/22 at 9:25 AM revealed Resident #20 prefers to sleep in a recliner because her bed was uncomfortable. She stated Resident #20's bed was removed because she refused to sleep in the bed. She stated Resident #20 should be care planned to sleep in her recliner. She stated the MDS coordinator was responsible for revising resident care plans. <BR/>Interview with MDS Coordinator on 05/06/22 at 11:22 AM revealed she was responsible for updating care plans. She stated Resident #20's care plan should have been updated once her plan of care changed. Resident #20 was sleeping in a bed upon admission to the facility then requested to sleep in a recliner. She stated she did not know when Resident #20 requested to sleep in a recliner. She stated Resident #20 should have been care planned to sleep in a recliner. She stated the purpose of a care plan was to educate staff about a resident's disease process and intervention. She stated Resident #20's care plan not being revised did not pose any risks.<BR/>Interview with ADON on 05/06/22 at 1:44 PM revealed she was responsible for overseeing the MDS coordinator's completion and revision of care plans. She stated care plans were audited every week. She stated she reviewed Resident #20's care plan a few months ago. She stated Resident #20 slept in a recliner. She stated Resident #20 should have been care planned for a recliner. She stated she was not aware Resident #20's care plan had not been revised to include her recliner. She stated the importance of revising Resident #20's care plan was to educate everyone that her preferred method of sleeping was in a recliner. <BR/>Review of facility policy, Care plans, Comprehensive Person-Centered, dated 12/2016, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on interview and record review, the facility failed to ensure that the facility's Medical Director attended the QAA/QAPI Committee meetings, for 3 of 3 quarterly meetings ( July, August, September 2022, October, November, December 2022 and January,February, March 2023), reviewed for QAA/QAPI.<BR/>The facility failed to ensure the Medical Director attended their QAA and QAPI meetings for the months of July 2022 through March 2023. <BR/>This failure could place residents at risk for quality deficiencies being unidentified and no appropriate plans of actions developed or implemented, and no appropriate guidance developed.<BR/>Findings included: <BR/>Review of the facility's QAA/QAPI meeting signature logs for the months of July 2022 through May 2023, revealed the Medical Director had not attended any of the meetings for the QAA/QAPI Committee, during those months. There were no notation indicating the Medical Director had attended any of the meetings by telephone or zoom. <BR/>During an interview on 07/25/2023 at 11:35 AM, the Administrator said the QAA/QAPI met monthly, but no less than once per quarter. She said she realized the Medical Director was not in attendance for the QAA/QAPI meetings for the months of July 2022 through May 2023, but she could not say why he was not in attendance. She said she was not the Administrator at that time, she became the Administrator in September 2022 and could not speak to anything prior to that. She said there was no indication the Medical Director had attended any of the meetings between July 2022 and May 2023, nor by telephone or zoom, nor did he have a designee assigned to attend in his place. <BR/>During an interview on 07/25/2023 at 12:15 PM, the medical director said he thought he had attended at lease two QAA/QAPI meetings. He was shown the sign in sheets and agreed that if he had not signed in there was no proof that he was there, he said if it wasn't signed it wasn't done. He also said he did not attend via telephone and did not have a designee assigned to attend in his place.<BR/>Review of the facility's Quality Assurance and Performance Improvement (QAPI Plan Revised April 2014) revealed, Policy Statement: This facility shall develop, implement, and maintain an ongoing, facility-wide, QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems. Authority: 1. The owner and/or governing board(body) of our facility shall be ultimately responsible for the QAPI Program. 2. The Administrator is responsible for assuring that this facility's QAPI Program complies with federal,state and local regulatory agency requirements. Implementation: 2. This committee shall meet monthly to review reports, evaluate the significance of data, and monitor quality-related activities of all departments, services, or committees<BR/>.&sect;483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of: <BR/>(i) The director of nursing services; <BR/>(ii) The Medical Director or his/her designee;<BR/>(iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and <BR/>(iv) The infection preventionist.

Based on observation, interview, and record review, the facility failed to ensure that the menus were followed for one of three meals reviewed for meal accuracy:<BR/>The facility failed to follow the menu or the meal ticket that was based off the lunch menu for 05/04/22.<BR/>This failure could affect residents by contributing to dissatisfaction, poor intake, and weight loss.<BR/>The findings included:<BR/>Review of the daily lunch menu for 05/04/22 reflected the date of Tuesday, sliced turkey with gravy, sweet potato, veggies, dinner roll, and salted caramel apples. <BR/>Review of the residents' meal tickets, dated 05/04/22, revealed chicken pot pie, mixed green salad, saltine crackers, dressing of choice, and pumpkin pie. <BR/>Observation on 05/04/22 at 12:30 PM revealed there were 15 residents eating lunch in the dining room. All 15 of the resident's meal tickets did not match the food they received or the daily menu. The residents were served pork loin, sliced steamed carrots, beans, and pie.<BR/>Interview with substitute dietary manager on 05/06/22 at 12:43 PM revealed she had been the substitute dietary manager for one month. She stated the residents' meal tickets and daily menu on 05/04/22 were not updated because the system took a while to update to the current menu. She stated the meal tickets, and the daily menu were supposed to reflect the food the residents were served. She stated she was responsible for updating meal tickets and menus. She stated accurate meal tickets and daily menus were important because residents need to know what they will be eating.<BR/>Interview with Administrator on 05/06/22 at 1:51 PM reflected the facility did not have a policy regarding meal tickets and menus.