ORCHARD PARK HEALTH CARE CENTER

A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed.

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is a Type V (111), single story existing structure separated by two-hour rated construction from a two-story Type II (111) addition (A2) completed early 2013; the entire building is equipped with wet and dry NFPA 13 automatic sprinkler systems. This survey that was conducted June 5, 2024 included an inspection for compliance with the fire safety requirements of Chapter 19 of NFPA 101-Life Safety Code (2012 edition). An exit conference was conducted at the end of the on-site survey with the Administrator and Director of Maintenance. The Administrator reported the current census to be 116 on June 5, 2024.

Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 1. This was evidenced by the following:1. 5-year fire sprinkler internal obstruction testing is overdue (Last performed 9/13/2018). NFPA 25 section 14.2.1, in part, inspection of piping and branch line conditions shall be inspected every 5 years for the purpose of inspecting for the presence of foreign organic and inorganic material. NFPA 25 14.2.1 Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the Administrator and Maintenance Director at the exit conference.

A recertification survey with complaint #CO35853, #CO35861, #CO35866, #CO35877 and Incident #35719 was completed 5/6/24 to 5/9/24. Two deficiencies were cited.

An Emergency Preparedness survey was conducted from 5/6/24 to 5/9/24. No deficiencies were cited.

Based upon observations, interviews and record review, the facility failed to ensure two (#65 and #69) of five residents reviewed for assistance with activities of daily living (ADL) received fingernail care out of 45 sample residents. Specifically, the facility failed to:-Ensure Resident #65 fingernails were trimmed and clean; and,-Ensure Resident #69 received staff assistance with fingernail care, applying lotion on his dry skin and showering assistance. Findings include: I. Facility policy and procedure The Fingernails policy, revised June 2008, was provided by the nursing home administrator (NHA) on 5/9/24 at 5:00 p.m. It revealed in pertinent part, "The purpose of this procedure is to promote circulation to the hands and to clean fingernails. "Procedure includes, assisting residents into comfortable positions, cleaning under the fingernails with an orange stick if indicated and using nail clippers to cut the fingernails if permitted." II. Resident #65 A. Resident status Resident #65, age greater than 65, was admitted on 9/12/23. According to the May 2024 computerized physician orders (CPO), diagnoses included dementia, blindness right and left eye category three, chronic pain, unspecified osteoarthritis, muscle weakness and the need for assistance with personal care. The 3/23/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. He required set-up assistance with transfers, dressing, eating, toileting and personal hygiene. B. Observations and interview Resident #65 was interviewed on 5/6/24 at 9:12 a.m. Resident #65 was sitting on his bed in his room. His fingernails were long, chipped and cracked. Resident #65 said he needed assistance to get his fingernails cut and filed. He said his fingernails were too long and that bothered him. The resident said, although he received showers twice a week, the certified nurse aides (CNA) did not cut and trim his fingernails. At 2:35 p.m. Resident #65 returned to his room from an activity and sat on his bed. His fingernails were long and chipped. On 5/7/24 at 4:15 p.m. Resident #65 sat in his wheelchair in his room with long, chipped and cracked fingernails. On 5/8/24 at 9:40 a.m. Resident #65 was escorted to the shower room by CNA #1 for a shower. The resident returned to his room with CNA #1 following the shower. At 10:00 a.m. CNA #1 left Resident #65' s room after assisting the resident with the shower and escorting him back to his room. Resident #65' s nails remained long, cracked and chipped.-CNA #1 failed to provide fingernail care to the resident even though she assisted the resident with a shower. C. Record review The ADL care plan, initiated on 9/12/23 and revised on 4/1/24, identified Resident #65 had an activities of daily living (ADL) self-care performance deficit related to his diagnosis of dementia. -The care plan did not include interventions for fingernail care. III. Interviews Certified nurse aide (CNA) #1 was interviewed on 5/8/24 at 10:25 a.m. CNA #1 said Resident #65 required one person extensive assistance with his activities of daily living (ADL), including cutting and trimming his fingernails. She said she noticed during the resident' s shower that his fingernails were long but she did not have fingernail clippers to cut them. CNA #1 said long fingernails could cause injuries such as skin tears and could carry bacteria that could cause infections. Registered nurse (RN) #1 was interviewed on 5/8/24 at 10:35 a.m. RN #1 said Resident #65 was dependent on staff and required extensive assistance with his ADLs. RN #1 said the nurses were responsible for providing fingernail care for all dependent residents. She said she was not sure if CNAs could provide nail care for residents. She said Resident #65' s nails were long and chipped. RN #1 said the resident' s fi

Based on interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures. Specifically, the facility failed to ensure resident food was palatable in taste, temperature and texture. Findings include: I. Resident interviews Resident #108 was interviewed on 5/6/24 at 1:37 a.m. Resident #108 said his meal trays were often missing an ordered item. He said he was served a hamburger for lunch with no lettuce and tomatoes and sugar and creamer and no tea. The resident said warm food was usually cold when it was delivered. Resident #215 was interviewed on 5/6/24 at 2:02 p.m. Resident #215 said the food in the facility was not good. He said he had not had a good meal in so long he could not remember when the last good meal was. He said he told the kitchen not to serve him rice anymore because it was always served with hard pieces in it and the pork and beans that were served recently as a main meal was hardly a meal. He said instead, it was a cup of beans with one small piece of a hotdog weiner. Staff served his food with plastic utensils that usually broke off in his food and food that was supposed to be hot was often served cold. The last cheeseburger he was served was not only cold but was hard like it had been sitting around. Resident #22 was interviewed on 5/7/24 at 9:07 a.m. Resident #22 said the food tasted terrible, that it was dry and tasteless, especially the chicken. He said his meal trays were often missing an ordered item and the hot foods were served cold most of the time. Resident #69 was interviewed on 5/8/24 at 12:13 p.m. Resident #69 said he was served salisbury steak, green beans and mashed potatoes for lunch and it was terrible and the temperature was cold. He said he could only eat a few bites of food. He said he tried to get staff to bring him something else but staff did not return until the meal service was over so he just went without. Resident #69 said if you ate in the main dining room there were no good alternative foods offered. II. Observations On 5/8/24 at 12:37 p.m. five surveyors evaluated a test tray for a regular textured diet and a pureed textured diet immediately after the last resident had been served their lunch. The regular textured meal consisted of chicken pot pie, carrots, mashed potatoes and and individual cheesecake pudding pie with a graham cracker crust.-The mashed potatoes had a chicken stock flavor.-The chicken pot pie was present in a messy scooped pile that was unidentifiable as a pot pie and was way too salty.-The carrots were not seasoned but tasted like a cooked carrot. -The cheesecake pudding pie with a graham cracker crust had a strange slightly floral taste and was warm and not cold as you would expect. The pureed consistency meal consisted of chicken pot pie, carrots and an individual crustless cheesecake pudding.-The chicken pot pie was too salty.-The carrots tasted bland and had a gritty slightly chunky texture.-The crustless pie was bland and warm tasting. When the temperature was taken both the cheesecake crusted and crustless pies temperatures were over the acceptable temperature range for safe and palatable foot temperature. The test tray crusted cheesecake pie temperature was 52 degrees Fahrenheit (F) and the crustless cheesecake pie temperature was 73 degrees F.-In both cases the cheesecake pudding pies were removed from the refrigerator and placed directly on the meal trays and then taken shortly after to be delivered to the resident and delivered as the test tray. At 1:05 p.m., after testing the meal trays, the temperature was taken of the leftover cheesecake pudding pies that remained in the facility's main kitchen refrigerators. The temperature of the individualized cheesecake pudding pies that remained in the refrigerators was 49 degrees F. On 6/8/24 at 4:30 p.m., dietary manager (DM) #2 provided the cheesecake pie recipe. The recipe revealed the cheesecake pudding pies were made of a milk product containing cream cheese, canned vanilla pudding, and a graham cracker pie shell. The ingredients were to be mixed together and chilled for two to three hours before serving. The pie was to be held and served cold at or below 40 degrees F.III. Staff interviews DM #1 and DM #2 were interviewed on 5/8/24 at 2:50 p.m. DM #1 said the kitchen staff should have obtained the temperature of the cheesecake before serving it to the residents. DM #1 said it was important to ensure food items were kept at a safe temperature to avoid bacteria growth, which could lead to food-borne illnesses. DM #1 said the chicken pot pie might have been salty due to the chicken base the cooks used. DM #1 said he would try a different chicken base the next time pot pie was on the menu. DM #2 said the pureed carrots did not reach the proper pureed texture. She said inconsistent diet texture could result in aspiration and possible weight loss when residents did not eat due to an incorrect diet texture. DM #2 said the facility immediately provided education on proper pureed textures for all kitchen staff.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 04/01/2024 and 04/07/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 02/05/2024 and 02/11/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 01/22/2024 and 01/28/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 08/21/2023 and 08/27/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.

A complaint survey, prompted by #CO32356 was conducted on 6/8/23 to 6/13/23. No deficiencies were cited.

A revisit survey was completed on 4/24/23 for all previous deficiencies cited on 1/26/23. The facility is in compliance with all regulations surveyed.

A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed.

INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility's general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). The facility is a Type V (111), single story existing structure separated by two-hour rated construction from a two-story Type II (111) addition (A2) completed early 2013; the entire building is equipped with wet and dry NFPA 13 automatic sprinkler system. This survey that was conducted February 7, 2023 included an inspection for compliance with the fire safety requirements of Chapter 19 of NFPA 101-Life Safety Code (2012 edition). An exit conference was conducted at the end on-site survey with the Administrator and Director of Maintenance.

Based on observation during the survey, it was determined that the facility failed to maintain the Exits in accordance with NFPA 101, Life Safety Code, Sections 7.10.1.2.1, 7.10.1.5.1, 7.10.8.3.1This was evidence by the following:1. Main exit doors say delayed entry and they are not 2. No exit signage in court yardNFPA 101 7.10.1.2.1* Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign that is readily visible from any direction of exit access. NFPA 101 7.10.1.5.1 Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. NFPA 101 7.10.8.3.1 Any door, passage, or stairway that is neither an exit nor a way of exit access and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows:These deficient practices could affect all residents, staff, and visitors during an emergency. These deficiencies were discussed during the exit conference.

Through observation during the survey, it was determined that the facility failed to meet the kitchen hood requirements in accordance with NFPA NFPA 96, (Chapter 12, Section 12.1.2.3.1) and cooking appliance restraint as required by NFPA 54, 9.6.1.4. This was evidence by the following:1. Kitchen appliances need wheel chock 2. Kitchen appliances not restrainedNFPA 96, 12.1.2.3.1 An approved method shall be provided that will ensure the appliance is returned to an approved design location. NFPA 54, 9.6.1.4 Restraint. Movement of appliances with casters shall be limited by a restraining device installed in accordance with the connector and appliance manufacturer's installation instructions. A.13.1.2.3.1 Wheel chocks that can be fastened to the floor should be installed to ensure that an appliance with casters is returned to its approved design location. These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within this smoke compartment. Deficient items were discussed with the Maintenance Director during the survey and again during the exit conference with the Administrator.

Based on observation during the survey, it was determined that the facility failed to maintain the Alarm system in accordance with NFPA 101, Life Safety Code, Section 9.6.1.3This was evident by:1. Fire Alarm in troubleNFPA 101 9.6.1.3 A fire alarm system required for life safety shall be installed, tested, and maintained in accordance with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code, unless it is an approved existing installation, which shall be permitted to be continued in use. This deficient practice could affect all residents, staff, and visitors during an emergency. This deficiency was discussed during the exit conference.

Based on observation, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25, 13.2.5.2 and NFPA 101, Section 19.7.6, 4.6.12This was evidence by the following:1. Gauges in riser room have no date on them 2. Rms 112, 214, and 309 escutcheons needs repair3.18 in of clearance needed for sprinkler head in closet in bathroom NFPA 101 5.2.1.2.1* Unless greater distances are required by 5.2.1.2.2, 5.2.1.2.3, or 5.2.1.2.4, or lesser distances are permitted by 5.2.1.2.6, clearance between the deflector and the top of storage shall be 18 in. (457 mm) or greater. NFPA 101 19.7.6, 4.6.12 Standards required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. Section, NFPA 25, 13.2.5.2 Gauges shall be replaced every 5 years or tested every 5 years by comparison with a calibrated gauge. NFPA 25 5.2.1.1.5 Escutcheons and coverplates for recessed, flush, and concealed sprinklers shall be replaced with their listed escutcheon or coverplate if found missing during the inspection. NFPA 25 5.2.1.1.5.1 Where the listed escutcheon or coverplate from a listed assembly is missing and is no longer commercially available, the sprinkler shall be replaced. These deficient practices could affect all residents, staff, and visitors during an emergency. These deficiencies was discussed during the exit conference.

Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain corridor doors in accordance with the Life Safety Code Section 19.3.6.3This was evidenced by the following: 1.300 wing fire doors not work 2. Door to rm 312 does not latch NFPA 101, 19.3.6.3.1 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of smoke. NFPA 101, 19.3.6.3.2, (2) In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7, the door construction materials requirements of 19.3.6.3.1 shall not be mandatory, but the doors shall be constructed to resist the passage of smoke. This deficient practice could affect all residents within the smoke compartments should the egress become untenable, due to smoke and heat transfer via the non-latching corridor doors and gaps in the door smoke seal. This was discussed during exit conference.

K511Based on observation during the survey, it was determined that the facility failed to maintain proper gas valve protection in accordance with Life Safety Section 9.1 and NFPA 54, 7.9.2.1. and NFPA 54, 10.4.5.2 This was evidenced by the following:1. Gas orifice on dryer rated for 0-2000 feet in elevation in basement laundry room. NFPA 101, 9.1.1 Gas. Equipment using gas and related gas piping shall be in accordance with NFPA 54, National Fuel Gas Code. NFPA 54, 11.1.2 High Altitude. Gas input ratings of appliances shall be used for elevations up to 2000 ft (600 m). The input ratings of appliances operating at elevations above 2000 ft (600 m) shall be reduced in accordance with one of the following methods:(1) At the rate of 4 percent for each 1000 ft (300 m) above sea level before selecting appropriately sized appliance(2) As permitted by the authority having jurisdiction.(3) In accordance with the manufacturer's installation instructions. NFPA 54, 10.4.5.2 Ducts for exhausting clothes dryers shall not be assembled with screws or other fastening means that extend into the duct and that would catch lint and reduce the efficiency of the exhaust system. This deficient practice could affect all residents, staff, and visitors during an emergency. This deficiency was discussed during the exit conference.

Based on record review and staff interview during the survey, the facility failed to perform and document the exercising of all fire and smoke dampers at least every four years, in accordance with NFPA 101, Life Safety Code, Section 7.5.2.2.1 & 7.5.2.2This was evidence by the following:1.3 dampers were not inspected due to accessNFPA 7.5.2.2.1 Each damper shall be inspected and tested 1 year after the completion of acceptance testing. NFPA 7.5.2.2.2* After the inspection and test required by 7.5.2.2.1, the test and inspection frequency shall then be every 4 years, except in buildings containing a hospital, where the frequency shall be every 6 years. This deficient practice could affect all residents, staff, and visitors during an emergency. These deficiencies were discussed during the exit conference.

Based on observation and staff interview during the survey, it was determined that the facility failed to maintain proper electrical practices in accordance with NFPA 70, 110.26 (A)(1)This was evident by:1. Storage in front of electrical panel in business office NFPA 70 (2011) - NATIONAL ELECTRICAL CODE110.26(A)(1) Depth of Working Space. The depth of the working space in the direction of live parts shall not be less than that specified in Table 110.26(A)(1) unless the requirements of 110.26(A)(1)(a), (A)(1)(b), or (A)(1)(c) are met. Distances shall be measured from the exposed live parts or from the enclosure or opening if the live parts are enclosed. This deficient practice could affect all residents, staff, and visitors during an emergency. This deficiency was discussed during the exit conference.

A recertification survey with complaint #CO30627 was completed from 1/23/23-1/26/23. Six deficiencies were cited.

An Emergency Preparedness survey was conducted from 1/23/22 to 1/26/22. No deficiencies were cited.

Based on interviews and record review, the facility failed to honor resident choices for one (#357) of three out of 50 sample residents. Specifically, the facility provide Resident #357 bathing according to her preference. Findings include:I. Resident #357 statusResident #357, age 71, was admitted on 11/4/22. According to the January 2023 computerized physician orders (CPO), the diagnoses included unilateral primary osteoarthritis, left knee, strain of other muscles and tendons at lower leg level, unspecified fracture of left patella (kneecap), subsequent encounter for closed fracture with routine healing and presence of left artificial knee joint. The 11/11/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required extensive assistance of one person with bed mobility and toileting and extensive assistance with transfers, dressing and personal hygiene. A. Resident interviewResident #357 was interviewed on 1/23/23 at 3:13 p.m. She said she received a bed bath in the late evening, sometimes at 8:00 p.m. The resident said she preferred to receive bathing during the daytime. She said she had informed the facility staff of her preference several times, however she still received bathing at night. B. Record reviewThe resident specific to the tasks for the certified nursing assistant (CNA) read that Resident #357's bathing days were documented as Tuesdays and Fridays, during the day shift. The shower book, located at the nursing station, was provided by CNA #1 on 1/26/23 at 5:07 p.m. It documented Resident #357's bathing schedule was on Tuesdays and Fridays, during the night shift. III. Staff interviews CNA #1 was interviewed on 1/26/23 at 5:07 p.m. She said each resident's bathing schedule was listed on the front of the shower book. She said the facility staff followed the schedule that was documented in the shower book. She said Resident #357's bathing schedule was Tuesdays and Fridays, during the evening shift. Registered nurse (RN#1) was interviewed on 1/26/23 at 5:11 p.m. She said Resident #357 received bathing in the evening. The director of nursing (DON) was interviewed on 1/26/23 at 5:45 p.m. She said bathing schedule preferences were discussed with residents as part of the admission process. She said the resident's preference was documented in the resident's tasks in the point of care (POC) electronic medical record system. She said the bathing schedule was also documented in the shower book kept at the nursing station. She said the unit manager was responsible for updating the shower book if the resident preferences changed.

Based on record review and interviews, the facility failed to develop a comprehensive care plan for two (#82 and #51) out of 50 sample residents for services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed to ensure the comprehensive care plan addressed Resident #82 and Resident #51's nutritional status and needs. Findings include:I. Facility policy and procedureThe Baseline, Resident Centered Comprehensive Care Plans, and Care Plan Summary policy and procedure, undated, was received by the nursing home administrator (NHA) on 1/26/23 at 6:00 p.m. It read in pertinent part, "Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to primer continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services by receiving a written summary. "Within the first 48 hours of admission. The facility staff must implement the interventions to assist the resident to achieve care plan goals and objectives period."Baseline care plans must be updated to reflect changes to approaches, as necessary, resulting from significant changes in condition or needs, occurring prior to development of the comprehensive care plan."II. Resident #82A. Resident statusResident #82, age 85, was admitted on 12/16/22. According to the January 2023 computerized physician orders (CPO), the diagnoses included unspecified protein calorie malnutrition. The 12/23/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 11 out of 15. He required supervision of one person with mobility, transfers, dressing, personal hygiene and toileting. B. Record reviewThe 12/22/22 nutritional assessment documented Resident #82 reported he had a "fair" appetite. The registered dietitian (RD) put a Boost Plus supplement once per day in place to provide nutritional support. It indicated the resident's weight was 189 lbs (pounds). Resident #82's weights were documented as:-189 lbs (pounds) on 12/16/22; and,-174.2 lbs on 1/11/23. The 1/24/23 nutrition progress note documented the resident sustained a weight loss and now weighed 174.2 lbs. It documented that the resident was on a regular diet with Boost plus twice daily and Magic cup once daily, which had been recently added due to the resident's weight loss. The RD recommended a reweigh in order to track for accuracy and changes to the resident's weight. It indicated that the resident was on an antidepressant which could cause a decreased appetite. The January 2023 CPO documented:-Regular diet with thin liquids;-Boost Plus nutritional supplement-give in the afternoon for malnutrition and skin integrity - ordered 12/19/22 and then changed to two time per day on 1/17/23; and-Magic Cup nutritional supplement-give a chocolate cup with lunch for malnutrition - ordered 1/18/23. A review of the resident's electronic medical record did not reveal documentation the facility had developed or implemented a comprehensive care plan that included and addressed the resident's nutritional status to include goals and person-centered interventions. C. Staff interviews The registered dietitian (RD) was interviewed on 1/26/23 at 4:44 p.m. She said a nutritional care plan was developed upon each resident's admission and was revised quarterly and as needed. She said the comprehensive care plan was developed once the initial nutritional assessment was completed. She said the nutritional care plan should address the resident's nutritional status, document the resident's nutritional goals and personalized interventions to assist the resident in meeting the identified goals. She said Resident #82 had experienced some weight loss since his admission to the facility. She said she had reviewed the resident's weights, met with the resident and put Boost Plus and a Magic Cup supplements in place to address the weight loss. The RD confirmed Resident #82's medical record did not contain a nutritional care plan. The director of nursing (DON) was interviewed on 1/26/23 at 6:00 p.m. She said that a care plan for the resident's nutritional status, to include goals and interventions, should be included in a comprehensive care plan. She said it was the responsibility of the dietitian to develop the comprehensive care plan. She said the care plan should be completed after the dietary assessment had been conducted. III. Resident #51A. Resident statusResident #51, age 84, was admitted on 1/8/22 and readmitted on 9/30/22. According to the January 2023 CPO, the diagnoses included type two diabetes and unspecified protein calorie malnutrition. The 1/13/23 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required extensive assistance of one person with bed mobility, transfers, dressing, toileting and personal hygiene. He was independent with eating. It indicated the resident was on a prescribed weight loss regimen. B. Record review The January 2023 CPO revealed the following physician orders:-Regular no added salt diet, mechanical soft texture with thin consistency; extra moisture with meats-ordered 10/3/22. The 1/24/23 nutrition progress note documented the resident had a recent weight loss of 11.2 lbs (pounds) in 30 days, from 220 lbs to 209.2 lbs. It indicated the weight loss was attributed to the resident being placed on a diuretic medication and was beneficial due to the resident's obese status. The resident had good meal intake ranges between 75 %-100%. The resident had declined any nutritional supplements and was agreeable with the weight loss. A review of the resident's electronic medical record did not reveal documentation that the facility had developed or implemented a care plan that addressed the resident's nutritional status and needs, established goals and person-centered interventions. C. Staff interviews The RD was interviewed on 1/26/23 at 2:25 p.m. She said Resident #51 was in the obesity range and a gradual weight loss was medically beneficial for the resident. She said the resident had asked that all nutritional supplements be discontinued and was agreeable with the weight loss. She said she was responsible for developing a care plan to address the resident's nutritional status, goals and implement person centered interventions. She confirmed a nutritional care plan had not been developed for Resident #51, who had resided at the facility for over a year.

Based on observation, record review and interviews, the facility failed to ensure two (#5 and #23) of two residents reviewed for communication out of 50 sample residents were provided appropriate treatment and services to maintain or improve their abilities. Specifically, the facility failed to ensure strategies were in place to effectively communicate with Resident #5 and Resident #23, who spoke a language other than English. Findings include:I. Facility policy and procedureThe Auxiliary Aide and Services Assessment policy and procedure, revised 2019, was provided by the nursing home administrator (NHA) on 1/26/23 at 6:02 p.m. It documented, in pertinent part,"Appropriate auxiliary aids and services are necessary for effective communication will be provided by the facility as soon as practicable without compromising resident care to residents and their companions who are deaf, hard of hearing. Effective communication is communication with people with disabilities that is as effective as communication with others, that is provided in an accessible format, in a reasonably timely manner, and that protects privacy and independence."The determination of appropriate auxiliary aids or services and the timing, duration, and frequency with which they will be provided will be made by the facility staff in consultation with the resident and or companion with a disability or where appropriate, the Resident's responsible party. The assessment made by the facility will take into account the relevant facts and circumstances, including the individual's communication skills and knowledge, and the nature and complexity of the communication needs at issue. The facility will not rely on an adult accompanying an individual with a disability to interpret or facilitate communication, except: in an emergency involving an imminent threat to the safety or welfare of an individual or the public or where the individual with the disability specifically requests that the accompanying adult interpret or facilitate communication, the accompanying adult agrees to provide such assistance, and reliance on the that adult is appropriate under the circumstances."The following are examples of issues that have arisen where a facility has not provided effective communication: Enlisting family members, friends and/or staff members to facilitate communication."Our facility complies with applicable federal civil rights laws, provides free language services to people whose primary language is not English such as: qualified interpreters and information written in other languages."II. Resident #5 A. Resident statusResident #5, age 86, was admitted on 3/23/21. According to the January 2023, computerized physician orders (CPO), the resident's diagnoses included depressive episodes and encephalopathy (functional and/or structural disorder of the brain caused by diseases). According to the 12/27/22 minimum data set (MDS) assessment, the resident had short-term and long-term memory impairment with severe impairment in making decisions regarding tasks of daily life. The resident had unclear speech and sometimes understood and responded adequately to simple and direct communication. She required extensive assistance of two people with bed mobility and transfers and extensive assistance from one person with dressing, toileting and personal hygiene. B. ObservationsOn 1/23/23 at 2:15 p.m. the residents room did not have signs indicating communication needs or interventions staff could use. C. Family interviewResident #5's family member was interviewed on 1/23/23 at 2:15 p.m. She said her mom did not always understand English and preferred to communicate in Hindi. She said that staff often misunderstood what her mom was trying to say. She said that she stayed in the facility around ten hours per day and had only missed 12 days in two years because she was afraid staff would not understand her mom's needs. D. Record reviewThe communication care plan, revised on 10/2/22, documented Resident #5 had a language barrier and that her primary language was Hindu. It indicated the resident preferred to communicate in Hindi. The interventions included discussing concerns or feelings regarding the resident's communication difficulty with the resident's family, providing a translator as necessary to communicate with the resident. It indicated that the resident's daughter was the translator. E. Staff interviews Certified nursing assistant (CNA) #1 was interviewed on 1/25/23 at 11:40 a.m. He said that Resident #5's needed help with communicating with staff. He said the resident's daughter helped with communication. He said that he was unaware of any communication tools at the facility. The social worker (SW) was interviewed on 1/26/23 at 3:45 p.m. She said that Resident #5 understood English. She said there were no signs in Resident #5's room to indicate that the resident may have a communication impairment. She said that the care plan would indicate if the resident had communication concerns and interventions to address the concern. She said Resident #5's daughter was at the facility every day and she was able to help translate. She said that there was a Stratus (translation device) available for staff to use. She said that staff would know to use the Stratus or other communication tools by looking at the resident's care plan. -However, according to the comprehensive care plan and resident's medical record, the Stratus device was not included nor instructions on how to use the device to assist in communicating with the resident in her preferred language. The director of nursing (DON) was interviewed on 1/26/23 at 5:38 p.m. She said individuals who had a primary language other than English, should be provided with communication tools like the Stratus machine. She said staff could also use Google Translate. She said Resident #5's daughter was in the facility everyday and her daughter translated for her. She said that Resident #5 seemed to understand her when she communicated with her. III. Resident #23A. Resident statusResident #23, age over 80, was admitted on 4/27/21 and readmitted on 4/18/22. According to the January 2023 computerized physician orders (CPO), the diagnoses included Alzheimer's Disease, dementia, chronic obstructive pulmonary disease (COPD), unspecified mood disorder, dysphagia in oropharyngeal stage (which causes the inability to swallow), sleep disorder, and difficulty in walking. The 11/3/22 minimum data set (MDS) assessment revealed the resident was unable to provide a brief interview for his mental status score (BIMS). The resident had short and long term memory problems. The resident had severely impaired cognitive skills for daily decision making. The resident did not have disorganized thinking or problems with focused attention. The resident required extensive assistance with dressing, toilet use, and personal hygiene. He was totally dependent on staff for bathing. He required supervision with bed mobility, walking in his room, and locomotion on and off the unit. It was somewhat important for the resident to have books or magazines to read, listen to music that he liked, keep up with the news, do things with groups of people, go outside when the weather was good, and participate in religious activities. B. Resident interviewResident #23 was interviewed on 1/23/23 at 2:46 p.m. He was asked if he spoke English. He shook his head no several times. He said "Mandarin." (Mandarin is the official state language of China)C. ObservationsOn 1/23/23 at 2:50 p.m. the resident had a book on his bedside table in his room titled Christmas and it was in English. His room did not have any translation boards, flash cards, communication papers, magazines, or books in his primary language of Mandarin. During the observation his roommate said "He doesn't speak English so we can't talk. I think he only speaks Chinese."On 1/24/23 at 12:39 p.m. an unidentified certified nurse aide (CNA) sat next to Resident #23 in the diningroom and used a fork to assist the resident Mexican food. The CNA did not speak to the resident before she assisted him for 10 minutes. The CNA then said in English, "Do you want something else? Are you sure? Are you done eating?" The resident did not answer and stared straight ahead. The CNA then spoke Spanish to the resident and said loudly, "Mas, mas? Mas, mas?" (The word "mas" in Spanish translated to mean more). The resident did not answer the CNA and looked at his plate. The CNA then propelled the resident in his wheelchair out of the dining room. D. Record reviewThe comprehensive care plan on 4/28/21 and revised on 1/19/23 revealed,-Focus: The resident's primary language was Mandarin. He had a communication problem with a language barrier. The resident had impaired cognition.-Interventions: The resident preferred to communicate in Mandarin. (The facility to) Provide (a) translator as necessary to communicate with the resident. The nurse practitioner (NP) progress note on 11/17/22 revealed that due to dementia and language limitations the resident did not answer some (yes/no) questions during the visit with the NP. The NP progress note on 1/13/23 revealed the NP tried to communicate with the resident's wife but English was not her primary language and the NP was not sure the wife understood even with several communication attempts. -There was no documentation of an interpreter being provided for the resident or his wife during either visit with the NP. E. Staff interviewsCertified nurse aide (CNA) #4 was interviewed on 1/24/23 at 4:20 p.m. CNA #4 said she did not know what language the resident spoke. She said she just talked to him and maybe he understood but she could not be certain. She said she did not carry any translation cards with her or use her phone to find words to communicate with him. She said when she worked in a hospital a translator service was used but the facility did not use a service like that for the residents. She said menu cards were provided every day in English only. She said she did not know if the resident could read a menu card in English. CNA #5 was interviewed on 1/24/23 at 4:45 p.m. He said when the wife came into the facility she would circle the menu card in English what food her husband would want. He said the wife had not been in recently so CNA #5 circled food items he thought the resident would like but did not ask him personally. CNA #5 said the resident seemed depressed and kept to himself. He said the facility had a translator type service but the facility did not have it anymore. He said he did not know where the translator machine went or where it would be in the facility if it was still in the building. He said the resident spoke Mandarin and he could not speak English. The CNA said one time the resident's wife brought a newspaper that was written in Mandarin and the resident was very happy when he could read in his own language. The dietary manager (DM) was interviewed on 1/25/23 at 9:25 a.m. She said she did not know what language Resident #23 spoke nor did she know how to communicate with him. She said the dietary staff did not communicate with him. She said the dietary staff did not have any translation cards to use to communicate with him. She said she relied on the CNAs to fill out menu cards for each person and turn the menu cards into the kitchen. She said she had met the resident's wife about three months ago but they did not speak about food, or what the resident liked to eat. The DM said she never called the family to discuss what the resident liked to eat or what foods the resident disliked. She said she was unaware that today in the morning for breakfast the resident had a large portion of scrambled eggs on his plate that he did not eat. She said she thought he liked hard boiled eggs. She said maybe he had both scrambled and hard boiled eggs on his plate but she was not sure. She said the CNAs brought him to the dining room but the dietary staff did not speak to him once he was in the dining room. She said the dietary staff did not use a translator service to communicate with the resident. She said he liked oatmeal for breakfast and she did not know how to communicate with him if he changed his mind and wanted something besides oatmeal to eat. The social service director (SSD) was interviewed on 1/25/23 at 12:23 p.m. She said the facility had a translator service machine but she did not know where it was in the building. She said she did not know who was responsible to print out flashcards or to make a communication board in a foreign language to communicate with residents who did not speak English. She said she was unaware the facility staff did not have a way to communicate with Resident #23. She said she could get him reading materials, flash cards, a flip book in Mandarin, a translator dictionary, and a basic communication board put up on the wall in his room. She said today she would get speech cards printed up and laminated, and put in his room so the facility staff could communicate with him. The nursing home administrator (NHA) was interviewed on 1/25/23 at 3:19 p.m. The NHA said the resident's wife had been out sick and had not been in the facility recently. He said he would make sure the staff were trained on how to use the translator service machine that was in the facility. He said the management team would come up with strategies and ideas on how to fix the communication situation for Resident #23. He said the SSD today would print out laminated flash cards and put them in the resident's room for the staff to utilize to help communicate with the resident in Mandarin Chinese.

Based on observations, record review and interviews, the facility failed to ensure activities designed to support residents' physical, mental, and psychosocial well-being were provided for one (#36) of four out of 50 sample residents. Specifically, the facility failed to meet Resident #36's socialization needs. Findings include:I. Facility policy and procedureThe Group Activities policy and procedure, undated, was provided by the nursing home administrator (NHA) on 1/26/23 at 6:02 p.m. It revealed, in pertinent part, "Group activities assist residents with social interaction. Group activities, the involvement of a number of people in physical and mental interactions, are vital to the effectiveness of the facility's activity program. Group activities maximize resources, involve many people, and promote social interactions. Group activities are encouraged to assist residents in overcoming feelings of loneliness and/or isolation, which often accompanies long-term care and illness. Group activities are divided into these categories: spectator group activities; performing group activities; independent group activities; and interdependent group activities. Residents are encouraged to participate in all group activities, but especially those in which they are best able to participate physically, mentally, and emotionally."II. Resident #36 status Resident #36, age 70, was admitted on 12/8/22. According to the December 2022 computerized physician orders (CPO), the diagnoses included depression and anxiety. The 12/20/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 12 out of 15. She required supervision of one person with mobility, transfers, toileting, dressing and personal hygiene. A. Resident interviewResident #36 was interviewed on 1/24/23 at 12:14 p.m. She said she did not prefer to participate in group activities. She said the facility staff did not offer her any activities to do in her room. She said she only engaged with staff when they provided her medication or meals. B. ObservationsDuring continuous observation on 1/25/23 beginning at 9:30 a.m. and ended at 4:14 p.m. Resident #36 was observed lying in bed, watching television.-At 12:00 p.m. Resident #36 was provided with a lunch tray.-At 2:28 p.m the resident remained lying in bed with the television on. There were no meaningful activities observed in the resident's room. -At 4:14 p.m. Resident #36 remained in the same position, with the television on. The resident did not have any staff interaction since 12:00 p.m., when the lunch meal tray was delivered to her room. During continuous observation on 1/26/23 beginning at 9:06 a.m. and ended at 1:36 p.m. Resident #36 was observed lying in bed. -At 9:06 a.m an unidentified physical therapist entered the resident's room to converse with Resident #36 regarding her therapy time for that day. The resident did not have any meaningful activities observed in her room.-At 12:00 p.m. the lunch meal tray was delivered to the resident.-At 1:36 p.m. the same unidentified physical therapist returned to room of Resident #36 and assisted the resident to ambulate in the hallway. Aside from lunch tray being delivered and picked up from Resident #36's room, the resident's only interaction was with the physical therapist. C. Record reviewThe 12/27/22 activity evaluation revealed the resident enjoyed games, arts and crafts, music, writing, conversation, watching tv (television) or movies, and cooking. It documented that her preferred social contact was visits, telephone, or mail. It documented the resident's preferred activity environment was independent in her own room, and she had no interest in participating in group activities. The mood care plan, initiated on 12/8/22, documented the resident had depression. The interventions included providing one to one conversations with the resident, providing hand massages, offering the resident music or going outside,offering the resident food or drinks, providing redirection and reassurance and facilitating deep breathing exercises. A review of the resident's medical record on 1/25/23 revealed the facility had failed to develop and implement a care plan with person-centered interventions to meet the resident's socialization needs. III. Staff interviews The activities director (AD) was interviewed on 1/26/23 at 5:02 p.m. He said he was not familiar with Resident #36. He said he did not realize he had completed an activity assessment for the resident because he did not remember meeting her. He said he had not provided any one-to-one activities or independent activities for the resident. The director of nursing (DON) was interviewed on 1/26/23 at 6:00 p.m. She said that every resident should be evaluated for their socialization needs upon admission to the facility. She said the activity director was responsible for developing a care plan to meet each resident's socialization needs. She said if the resident did not enjoy attending group events, the activities department should provide independent activities for the resident, of their preference, in their room and one-to-one activities with an activity staff member.

Based on observations, record review and interviews, the facility failed to ensure one (#62) of seven out of 50 sampled residents with a pressure ulcer received the necessary treatment and services according to professional standards of practice. Specifically, the facility failed to ensure that Resident #62 received a prescribed wound treatment after every incontinence episode on a coccyx wound. Findings include:I. Professional referenceThe Joint Commision (March 2022). Quick Safety 25: Preventing pressure injuries. The European Pressure Ulcer Advisory Panel (EPUAP) and the National Pressure Injury Advisory Panel (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) (2019). The International Guideline (Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline). https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-25-preventing-pressure-injuries/preventing-pressure-injuries/#.Y9gDenbMI2w retrieved on 1/30/23 at 11:09 a.m."Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist and may represent as an intact or ruptured serum filled blister, adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage cannot be used to describe moisture associated skin damage (MASD), including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns and abrasions)."Skin Care. Protecting and monitoring the condition of the patient's skin is important for preventing pressure sores and identifying Stage 1 sores early so they can be treated before they worsen. Inspect the skin upon admission and at least daily for signs of pressure injuries, assess pressure points temperature, and the skin beneath medical devices, clean the skin promptly after episodes of incontinence, use skin cleanser that are pH (a measure of how acidic or basic a solution) balanced for the skin, and use skin moisturizers, avoid positioning the patient on an area of pressure injury."II. Facility policy and procedure The Skin Integrity policy and procedure, last revised September 2017, was provided by the nursing home administrator (NHA) on 1/26/23 at 6:00 p.m. It read in pertinent part,"To provide consistent assessment and evaluation, monitoring, documentation, and implementation of therapeutic interventions to heal and maintain skin integrity, unless clinically unavoidable."To promote the prevention of pressure ulcer/injury development."To promote the healing of existing pressure ulcers/injuries (including prevention of infection to the extent possible), and to prevent development of additional pressure ulcer/injury."III. Resident #62A. Resident statusResident #62, age 90, was admitted on 11/30/22. According to the January 2023 computerized physician order (CPO), the diagnoses included chronic osteomyelitis of the left ankle and foot, peripheral vascular disease (PVD) and protein calorie malnutrition. The 12/5/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 13 out of 15. He was totally dependent with the assistance of one person for dressing and toileting, required extensive assistance of two people with bed mobility and transfers and extensive assistance with one person for personal hygiene and the supervision of one person for eating. The resident was admitted with two unstageable pressure ulcers. B. ObservationsOn 1/26/23 at 10:45 a.m. Resident #62 was observed in bed and positioned on the left side for incontinence care.-Licensed practical nurse (LPN) #1 donned gloves and unfastened the resident's brief. The resident was incontinent of a moderateamount of soft brown stool and barrier cream residue was not observed over resident sacrum or coccyx.-LPN #1 cleaned the resident's rectal area and buttocks using incontinence wipes.-Three scattered reddened non open areas and excoriation to the left ischial area were observed. One small open, round circumscribed (a clearly defined edge) area was observed on coccyx. The wound edges were pink with a wound bed that had a small white area in the center.-LPN #1 disposed of dirty incontinence wipes and briefs, donned new gloves and applied a new brief. LPN #1 did not apply wound cleanser or barrier cream, as was directed in the physician's treatment order. C. Record reviewThe January 2023 CPOs documented a physician's order to cleanse the right upper buttock with normal saline or wound cleanser and apply Triad cream three times a day and as necessary. The skin integrity care plan, initiated on 12/2/22 and revised on 1/11/23, documented the resident was at risk for potential skin impairment due to the resident's impaired mobility. The interventions included treating the resident's skin, per facility protocol and notifying the physician, if skin breakdown occurred, providing a specialty air mattress for the resident's bed and providing a cushion while the resident was sitting up in a chair.-No personalized interventions were care planned for incontinence or wound care for sacral MASD (moisture associated skin disease). The 1/17/23 wound care physician note revealed the resident had MASD located on the coccyx. The wound measurements were 1 cm (centimeter) x 0.5cm x 0.1 cm. The prior wound measurements on 1/10/23 (when it was first identified) were 1.0 cm x 1.0 cm x 0 cm. The wound had 100% epithelialization (formation of skin tissue) with scant serosanguinous (yellow blood tinged) drainage. The treatment orders indicated Triad cream should be applied three times per day and as needed. IV. Staff interviewsCertified nurse assistant (CNA) #3 was interviewed on 1/26/23 at 11:00 a.m. She said that Resident #62 had skin issues on his buttocks and was incontinent of stool. She said he needed to be cleaned with a wound cleanser and a barrier cream applied. She said the barrier cream was kept at the resident's bedside and should be applied after every incontinent episode. LPN #1 was interviewed on 1/26/23 at 10:50 a.m. She said Resident #62 had skin issues on his sacrum. She said that she was not aware of any physician ordered treatment for Resident #62's skin issues for his sacrum or coccyx. The wound care specialist (WCS) was interviewed on 1/26/23 at 1:30 p.m. She confirmed, after assessing the coccyx wound, that the wound was no longer considered MASD and appeared to be a pressure injury. She confirmed that the Triad cream was ordered to be applied three times a day and as needed after incontinent episodes. Unit manager (UM) #2,was interviewed on 1/26/23 at 1:45 p.m. She said, after observing the coccyx wound, that the wound was no longer MASD and it was "something more." She confirmed that the Triad cream should be applied after each incontinence episode and three times per day. The director of nursing (DON) was interviewed on 1/26/23 at 5:40 p.m. She said when there were wound care orders in place the orders were to be followed. She said a barrier cream treatment order was in place for every resident. She said Triad cream was to be applied according to the physician's order three times a day and as needed for Resident #62. The wound care physician was interviewed on 1/26/23 at 2:00 p.m. He said Resident #62's coccyx wound now had defined edges which was the definition of a pressure ulcer. He said that he would be speaking with the current wound physician regarding the staging of the wound. He confirmed that the Triad cream was ordered to be applied three times a day and after each incontinence episode as needed. He said all treatments should be applied as directed to ensure skin breakdown and wounds healed.

Based on observations, interviews, and record review the facility failed to honor food preferences for one (#28) of four residents reviewed out of 50 sample residents. Specifically the facility failed to ensure Resident #28's requests and preferences for gluten free foods were served to her. Findings include:I. Facility policy and procedureThe Dietary Diet Orders policy, dated 2008, was provided by the nursing home administrator (NHA) on 1/26/23 at 5:00 p.m. It revealed in pertinent part,"Diets will be served per physician order."II. Resident #28A. Resident statusResident #28, age under 70, was admitted on 6/11/21. According to the January 2023 computerized physician orders (CPO), the diagnoses included multiple sclerosis, vascular dementia, cerebral infarction (stroke), mood disorder, depression, reduced mobility, dysphagia (difficulty swallowing), anemia, and prediabetes. The resident was allergic to gluten. The 12/21/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of nine out of 15. She required extensive assistance with bed mobility and dressing. She required total dependence on staff for toilet use and transfers. She required supervision (oversight, encouragement, cueing) from staff for eating. The resident did not reject care from staff. B. Resident interviewResident # 28 was interviewed on 1/23/23 at 1:07 p.m. She said she was allergic to gluten. She said she had multiple sclerosis. She said her body felt better when she did not eat foods with gluten. She said she could tell the difference in how she felt when she would eat gluten. She said she did not want to eat food items which contained gluten. She said she felt the facility staff would not listen to her about her desire to have gluten free food items. She said she had told anybody who would listen to her. She said when she lived in a previous hallway in the facility, a dietary manager who no longer worked in the facility, always provided her gluten free items for her diet. She said she had lived in her current room for about a year and she no longer received gluten free items except some very dry gluten free sandwich bread, but not on a consistent basis. She said she never received gluten free desserts. C. ObservationsOn 1/24/23 at 5:27 p.m. the resident was provided a room tray on her bedside table with her evening meal. The tray contained a piece of cake with pink frosting. Licensed practical nurse (LPN) #2 came into her room and asked what she needed. Resident #28 held up the piece of cake and asked for a dessert that was gluten free. LPN #2 took away the cake and said she would try to find a dessert that was gluten free. D. Record reviewAn allergy progress note on 7/20/22 revealed in the category of food that the resident had a gluten allergy. The comprehensive care plan 8/24/22 and revised 9/20/22 documented:-Special instructions: Gluten free-Allergies: GlutenThe January 2023 medication and treatment administration record (MAR and TAR) documented the resident had an allergy to gluten. The MAR and TAR documented the resident had a dietary preference for gluten free with her diagnosis of multiple sclerosis.. III. Staff interviewsThe dietary manager (DM) was interviewed on 1/25/23 at 9:25 a.m. She said she was not sure how many people in the facility had gluten free diets but she thought it was three or four residents. She said for some people it was just a fad to eat a gluten free diet. She said other people had medical reasons. She said she knew she was responsible to serve gluten free items if that was what the resident preferred or it was a medical order. She said she was aware Resident #28 was to receive a gluten free diet. She said she was unaware Resident #28 had not had gluten free items to eat. She said she did not have any gluten free desserts in the facility kitchen. She said she did not have any premade dessert items such as gluten free brownies or gluten free cookies. She said she was unaware yesterday Resident #28 was served the strawberry cake that was made with gluten and was not offered a gluten free alternative. She said she had spoken to the NHA recently about expanding special diet options with gluten free items. She said she did not buy gluten free pasta either but said she would look into how to purchase gluten free pasta. The corporate consultant (CC) and the registered dietitian (RD) were interviewed together on 1/25/23 at 10:06 a.m. The CC said the facility was looking into an action plan today on how to train the kitchen staff to read gluten free on menu cards and place the correct gluten free items on the resident's meal trays. She said the facility would honor the gluten free diets. She said if there were substitute food items on the menus the facility would also offer gluten free alternatives. She said "We're on it, and we're going to fix it."The RD said she did not feel the resident needed gluten free foods. The RD said she would call the physician and ask that the sentence on the diagnosis which read allergic to gluten be discontinued in the resident's medical record. She said she would honor the resident's preference for gluten free items whether the food preference was a physician's order or a resident's taste preference. She said the resident had a right to choose to eat gluten free foods and the facility must offer the items of their preference. During the survey on 1/25/23 at 5:15 p.m. a progress note written by the assistant director of nursing (ADON) revealed, "MD (physician) notified and gave verbal order to remove gluten free from (the) patient's (medical) record."-However, the gluten free was removed from the resident's record, she preferred to have gluten free foods due to them making her feel better with her multiple sclerosis (see resident interview). The NHA was interviewed on 1/25/23 at 3:19 p.m. He said a lot of staff changes had happened in the kitchen over the past year. He said because of a kitchen management change, the gluten free items were not served. He said he and the management had begun work today on the gluten free items being purchased and served. He said he had begun an education with the kitchen staff on how to read the meal tickets correctly for gluten free. He said he put a performance plan in place with the admissions department. The plan was to ensure the admissions staff correctly communicated what a new resident's diet preferences or medical diagnoses were for foods. He said a list of items were purchased today at the local grocery store that were gluten free items, which included pastas and desserts. He said today Resident #28 would receive gluten free pasta for her meal along with others who had regular pasta with gluten. He said the facility would fix the situation and offer and provide gluten free items.