Hampshire Center

Inspectors wroteBased on record review and staff interviews, the facility failed to provide care and services in accordance with professional standards of practice by crushing extended-release medications. This failed practice was found true for (1) one of (3) residents reviewed for weight loss during the complaint survey process. Resident identifier #45. Facility Census: 59. Findings Include:a) Resident #45A record review, completed on 05/05/26 at 10:30 AM, revealed a physician order for Resident #45, dated 09/24/19, that read as follows: Generic substitution is authorized unless otherwise indicated. Center may participate in therapeutic interchange program, where permitted by state regulations. May crush crushable meds. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to maintain complete and accurate medical records in accordance with standards of practice. This was a random opportunity for discovery during a complaint survey process, with the ability to affect more than a limted amount of residents. Resident Identifier: Resident #45. Census 59. Findings Included: a) Resident #45 During the routine complaint investigation process, performed on 05/04/26, it was discovered that the physician orders, care plan, and Kardex for Resident #45 did not contain the same information. They (orders, care plan and Kardex) were updated as the status of the resident changed, however, they simply added the new information to what was already there and did not remove outdated information. The care areas that were not matching were the sections pertaining to transfers, eating and hygiene. [...]

Inspectors wroteBased on observation, resident interview, and staff interview, this facility failed to ensure a safe, comfortable homelike environment. This failed process was a random opportunity of discovery during Long Term Care Survey Process. Facility census: 61.

Inspectors wroteBased on staff record review, staff interview, the facility failed to ensure all kitchen staff were up to date with their food handler cards. Two (2) of Eight (8) employees did not have food handler's cards. Interview with Dietary Manager, he confirmed these food handler cards were not obtained by expiration dates. This failed practice was a random opportunity for discovery during the Long Term Care Survey Process. Employee identifiers: #20 and #7. Facility census: 61.

Inspectors wroteBased on observation, resident interview, and staff interview, this facility failed to ensure menus were properly displayed with correct meal and that residents receiving meals were given the correct diet type. This failed practice had the potential to affect more than an isolated number of residents. Resident identifier: #49. Facility census: 67.

Inspectors wroteBased on observation, resident interviews, and staff interview, the facility failed to ensure food was prepared and served in a palatable, and attractive appearance for the residents that received their nutrition from the kitchen. This failed practice had the potential to affect more than an isolated number of residents. Facility census: 61.

Inspectors wroteBased observation and staff interview, this facility failed to ensure food was procured, stored, served in a sanitary way, this failed practice was a random opportunity for discovery during the Long Term Care survey process. Facility census: 61.

Inspectors wroteBased on observations and interviews, the facility failed to maintain and provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections. Areas of concern were the dirty laundry room, Hallway 100, Hallway 300/400, and the Shared bathroom for room [ROOM NUMBER]/109. Facility Census: 61. b) 300 and 400 hall soiled lift slings On 12/07/25 at approximately 11:40 AM upon entrance to the facility, it was observed that four slings were left draped over lifts and chairs in both the 300 and 400 hallways. The 300-hall had one (1) sling that was visibly dirty left hooked to the lift and thrown over the main lifting arm left in hall. The 400-hall had one (1) sling left out draped over the lift after being used, as well as lift slings that were dirty left in chairs down at the end of the 400 hallways. [...]

Inspectors wroteBased on medical record review and staff interview, this facility failed to ensure care plans were updated to reflect current resident needs. This practice affected (1) of 20 care plans reviewed during Long Term Care Survey. Resident identifier #10. Census 61.

Inspectors wroteBased on record review and interview, the facility failed to follow a physician's order for the administration of insulin. This was a random opportunity for discovery. Resident identifier: #3. Facility Census: 61. Findings Includea) Resident #3During record review on 12/10/25 it was noted that Resident #3 had been administered fifty-four (54) units of short-acting insulin, instead of the prescribed fifty-four (54) units of long-acting insulin on 01/20/25 at approximately 8:00 pm. The Change-in-Condition documentation noted that the Clinician was notified at 8:40 PM.The record review also revealed that the resident had been prescribed the following medications:A short-acting insulin -NovoLog Flex Pen Subcutaneous Solution Pen-Injector 100/Unit/ML. (Insulin Aspart). Inject subcutaneusly before meals for DM (diabetes mellitus). [...]

Inspectors wroteBased on observation and interview the facility failed to ensure the resident environment over which it had control was as free from accident hazards as possible. This was a random opportunity for discovery of Resident #7's bed safety. Resident Identifier: #7. Facility census: 61. a) Resident #7 During an observation of Resident #7's bed, a 6-inch gap was found between footboard & mattress. Resident #7 was observed in bed with a blanket rolled up and put on one side of the footboard and a mattress gap for his feet to rest on. During an interview 12/09/25 at 1:35 PM the DON verified the footboard and mattress gap could cause entrapment. She stated that she would call the maintenance department to get it fixed immediately. No further information was provided prior to the end of the survey on 12/10/25 at 11:30 AM.

Inspectors wroteBased on observation, resident interview, staff interview the facility failed to ensure diet needs were being provided correctly (1) one of (7) seven reviewed for diets and nutrition. Resident identifier: #49. Facility census: 61.

Inspectors wroteBased on observation, and staff interview, the facility failed to provide privacy to residents when providing assistance for showers. This was a random opportunity for discovery during the Survey process. Resident identifier #8. Facility Census 62. Findings Included: a) Resident #8 An observation on 08/12/24 at 9:45 AM, of the shower room located on hall 200 revealed the shower room had no lock or in use signage. Noticing there was no sign or lock the Surveyor knocked on the door. There was no answer, so the Surveyor entered the shower room. Further observation of the shower room revealed Nurse Aide (NA) #38 standing undressing Resident #8, who only had a brief on at this time. During an interview on 08/12/24 at 9:50 AM, NA #59, Stated, We just usually knock. I agree there isn't much privacy. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to follow physician's orders regarding wound care for Resident #9 and #36, follow a physician's order regarding adaptive equipment for Resident #8, and completing an intervention per the physician for a possible resident to resident altercation for Resident #35. This was true for three (3) of 16 residents reviewed during the survey process. Resident Identifiers: #9, #36, #8 and #35. Facility Census: 62. Findings Included: a) Resident #9 On 08/13/24 at 10:30 AM, a record review was completed for Resident #9. The review found physician's orders were not being followed regarding treatments, including wound care. The following physician's orders were not completed on the following dates: --Clotrimazole-Betamethasone External Cream 1-0.05% apply to affected area topically every day shift for itching. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to serve meals at a palatable temperature. This failed practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents during the survey process. Resident identifiers #54 and #60. Facility Census 62. Findings Included: a) Food temperatures Resident #53 and #60 According to the meal timesheet hall 400 trays were brought out to the hallway at 7:45 AM During an observation on 08/13/24 at 8:00 AM, of hallway 400 it was revealed, Resident #54 and #60 were sitting in the hallway in reclining wheelchairs and their breakfast meal trays were still on the food cart. No staff were noted to be nearby and were down hall 200 passing breakfast trays. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to provide an accurate and complete record for an acute transfer for Resident #9 and meal intake for Resident #8. This was true for two (2) of 16 residents reviewed during the survey process. Resident Identifiers: #9 and #8. Facility Census: 62. Findings Include: a) Resident #9 On 08/12/24 at 12:00 PM, a record review was completed for Resident #9. The review found the resident had been transferred to an acute care facility on 02/22/24 . The transfer form listed the date as 07/08/23. On 08/12/24 at 12:30 PM, the Director of Nursing was notified of the incorrect transfer date. The DON stated, I will have to look into this. b) Resident #8 During a record review on 08/14/24 at 12:30 PM of Resident #8's meal intake from 06/16/24 to 08/12/24, it revealed that out of a possible 174 meals, 42 of those had no documentation. [...]

Inspectors wroteBased on record review, and staff interview, the facility failed to do a complete and thorough investigation on a possible resident to resident altercation resulting in death. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers #63 and #35. Facility Census 62. Findings Included: a) Resident # 63 A record review on 08/13/24 at 9:00 AM, of Resident # 63's E Interact Change in Condition dated 01/20/24 read as follows: Another resident grabbed at this resident's sleeve and this resident lost balance and fell down. Resident landed on buttocks and the staff member caught head in hands before hitting the floor. Four staff members witnessed the fall. Further record review revealed another E Interact Change in Condition form dated 02/14/24 that read as follows: Found resident on floor in room [ROOM NUMBER], blood noted from back of head. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to implement an intervention regarding pressure ulcers for Resident #54 and implement an intervention of wearing personal protective equipment (PPE) for Resident #50. This was true for two (2) of 16 residents reviewed during the survey process. Resident Identifiers: #54 and #50. Facility Census: 62. Findings Included: a) Resident #54 On 08/13/24 at 11:00 AM, a record review was completed for Resident #54. The review found the resident was receiving wound care for an unstagable pressure ulcer on the left heel. The care plan was reviewed regarding the wound care and pressure ulcer. The care plan listed an intervention of assist resident in turning and repositioning every 1 (one) hrs (hours) and PRN (as needed). The Director of Nursing (DON) was interviewed regarding this intervention on 08/13/24 at 1:00 PM. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to update a care plan regarding an actual fall for Resident #42. This was true for one (1) of three (3) residents reviewed during the survey process. Resident Identifier: #42. Facility Census: 62. Findings Included: a) Resident #42 On 08/14/24 at 9:20 AM, a record review was completed for Resident #42. The review found the resident had an actual fall on 07/10/24 due to the bathroom floor being slippery from powder which is being used with another resident who shares the bathroom. The care plan was reviewed at this time. The care plan focus area stated, Resident is at risk for falls, R/T (related to) Weakness, Osteoarthritis, Chronic Pain, HTN (hypertension). The need for assistance with ADLs, (activities of daily living) use of meds (medications) that could cause drowsiness/dizziness. [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to provide Activities of Daily Living (ADL) care to dependent residents. This failed practice was found true for (1) one of (4) four residents reviewed for ADL care during the survey process. Resident identifier #50. Facility Census 62. Findings Included: a) Resident #50 During an Observation on 08/14/24 at 5:00 PM, Resident #50's call light came on. Further observation at 5:10 PM, shows Resident #50's call light continues to be on. During an interview on 08/14/24 at 5:15 PM, Resident #50 stated, I need changed, I feel wet. An observation on 08/14/24 at 5:16 PM, shows Nurse Aide (NA) #71 and NA #17 entering Resident #50's room. The NA's asked Resident #50 what he needed. Resident #50 stated, I want changed NA #17 stated, I'll be back in a few minutes with your tray. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to provide an ongoing program of activities to meet the needs and interest of the residents. This was a random opportunity for discovery during the survey process. Resident identifier #36. Facility Census 62. Findings Included: a) Resident #36 An observation on 08/12/24 at 12:20 PM, showed Resident #36 eating her lunch in a common area in front of the nurses station. Further observation showed Resident #36 continuing to sit in the common area in front of the nurse's station with no television and/or music on at 1:30 PM, 1:45 PM, 2:25 PM and 3:00 PM. An observation on 08/13/24 at 8:30AM showed Resident #36 eating her breakfast in a common area in front of the nurses station. Further observation of Resident #36 at 10:00AM revealed Resident #36 crying in the common area in front of the nurses station. [...]

Inspectors wroteBased on observation, resident interview and staff interview, the facility failed to provide appropriate treatment to prevent further decrease in range-of-motion for Resident #11. This was a random opportunity for discovery. Resident Identifier: #11. Facility Census: 62. Findings Included: a) Resident #11 On 08/14/24 at 3:30 PM, an interview was held with Resident #11. During the interview, Resident #11 stated, I had my shower earlier and they didn't put my splint on my hand (right). On 08/14/24 at 4:00 PM, a record review was completed for Resident #11. The review found a physician's order stating, SoftPro resting hand splint (WHFO) (wrist/hand/finger orthosis) to be applied to right hand in the morning, when patient is in her wheelchair, and to be removed in the evening, at bedtime. Skin checks to be performed pre/post WHFO application two times a day. [...]

Inspectors wroteBased on observation, record review, resident interview and staff interview, the facility failed to ensure the resident environment, over which it has control, was as free from accident hazards as possible. This was a random opportunity for discovery. Resident Identifier: #9. Facility Census: 62. Findings Include: a) Resident #9 On 08/12/24 at 9:00 AM, the initial interview was held with Resident #9. Observations made during the interview, found multiple medications sitting on the over-the-bed table and laying on the resident's bed. Resident #9 was asked, are you allowed to have these medications in your room? The resident responded, it is okay .it is no big deal. On 08/12/24 at 9:28 AM, Registered Nurse (RN) #41 entered into the resident's room. [...]

Inspectors wroteBased on record review, resident interview and staff interview, the facility failed to ensure physician's visits were completed every 30 days for the first 90 days for Resident #9. This was a random opportunity for discovery. Resident Identifier: #9. Facility Census: 62. Findings Included: a) Resident #9 On 08/12/24 at 9:00 AM, an interview was held with Resident #9. The resident stated, I want to talk to the physician about certain things and I can never see him .it's usually the nurse practitioner .sometimes it's things I want to discuss with a physician. On 08/12/24 at 11:30 AM, a record review was completed for Resident #9. The findings of the review were unclear as to when the facility physician visited the resident versus the nurse practitioner. The DON was asked for a list of the provider's visits to Resident #9. The resident was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, staff interview and record review the facility failed to provide an effective infection control program which meets current standards of practice. This failed practice was found true for (3) of (3) residents reviewed for infection control practices during the survey process. Resident identifiers #9, #54, and #50. Facility Census 62.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. This had the potential to affect any residents receiving nourishment from the kitchen. Facility census: 59.

Inspectors wroteBased on observation, facility record review, Centers for Disease Control and Prevention (CDC) review, and staff interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. These failed practices were discovered during observation of medication administration, and review if the Infection Preventionist surveillance had the potential to affect more than a limited number of residents currently residing in the facility. Resident identifiers: #39, #43, #165, 38, #6, #113, #5, and #112. Facility census 59.

Inspectors wroteBased on facility record review and staff interview the facility failed to establish an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. This was true for six (6) out of nine (9) residents reviewed for antibiotic stewardship. Resident identifiers: Resident #9, #23. #4 #34, #113, and #11. Facility census 59.

Inspectors wroteBased on observation record review and staff interview, the facility failed to ensure residents were treated with dignity and respect. These failed practices were a random opportunity for discovery and were true for Resident #9. Resident identifier: #9. Facility census: 59.

Inspectors wroteBased on observation, resident interview, medical record review and staff interview, the facility failed to ensure residents were free from physical restraints and evaluate resident's ability to remove physical restraints easily. This was true for two (2) of two (2) residents reviewed for restraints. Resident Identifier: #51 and #49. Facility census: 59.

Inspectors wroteBased on observation, resident Interview and staff interview, the facility failed to ensure an allegation of neglect was reported when Resident #55 was burned from an e-stim patch. This was a random opportunity for discovery. Resident identifier #55. Facility Census 59.

Inspectors wroteBased on resident interview, staff interview, and operation policy the facility failed to take actions to thoroughly investigate an alleged neglect when Resident #55 received a burn from an e-stim unit. This was a random opportunity for discovery. Resident identifier #55. Facility census: 59.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to capture diagnoses upon admission and complete an updated Preadmission Screening and Resident Review (PASARR) This was true for three (3) of three (3) residents reviewed for the area of PASARR. Resident identifiers: #112, #51, and #39. Facility census: 59.

Inspectors wroteBased on record review and staff interview the facility failed to develop a person-centered 48 hour baseline care plan for urinary tract infection (UTI). This was true for one (1) of one (1) reviewed for the care area of UTI during the Long-Term Care Survey Process. Resident identifier: #56. Facility census: 59.

Inspectors wroteBased on observation, resident interview, record review and staff interview the facility failed to develop or implement a comprehensive person-centered care plan with measurable objectives for each resident. This was true for three (3) of 17 residents reviewed during the Long-Term Care Survey Process. Resident Identifiers: Resident #58, Resident #49, and Resident #40. Facility Census: 59 Findings Include: a) Resident #58 On 01/15/24 at 10:10AM during a tour of the facility, Resident #58 was seen to in a wheelchair with a chair alarm. A review of the medical record on 01/16/24 at 8:54 AM, found Resident # 58 was admitted on [DATE] with a Brief Interview of Mental Status (BIMS) score of 06 and lacked capacity long term. The residents comprehensive care plan review did not identify a person centered comprehensive care plan per the standards of practice for the use of the chair alarm. [...]

Inspectors wroteBased on record review and staff interview the facility failed to revise the residents care plan in regard to tube feeding. This failed practice was true one (1) out of one (1) reviewed for tube feeding. Resident identifier: #45. Facility census 59.

Inspectors wroteBased on observation and staff interview the facility failed to ensure the resident was correctly positioned to maximize eating abilities. These failed practices were a random opportunity for discovery and was true for Resident #9. Resident Identifier: #9. Facility census 59.

Inspectors wroteBased on observation, record review, family interview and staff interview the facility failed to provide Activities of Daily Living (ADL) care for dependent residents in the care area of bathing/showers and assisting during mealtime. This was true for two (2) out of two (2) residents reviewed for ADLs. Resident identifiers: #45, and #9. Facility census 59. Findings Include: a) Resident #45 A medical record review found Resident #45 suffered a Cerebral Infarction, which left her totally dependent for ADL care. During a family phone interview on 01/15/24 at 12:03 PM, with the husband of Resident #45, he stated he often must bush her hair and when she was first admitted he had to cut the hair on the back of her head almost to the scalp because it was so matted up. He also stated she did not have dandruff before coming here. [...]

Inspectors wroteBased on medical record review, resident interview and staff interview, the facility failed to ensure one (1) resident received treatment and care in accordance with professional standards of practice. The facility failed to ensure a change in condition was completed or a skin issue was monitored for progression. This was a random opportunity for discovery. Resident Identifier: Resident #55. Facility Census: 59. Findings Include: a) Resident #55 An observation and interview with Resident #55 on 01/15/24 at 8:39 AM, revealed a scabbed area to her right lower leg. She stated it got burnt from an Electrical Stimulation (E-stim) patch in therapy which was defective. Resident #55's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/04/23 noted the resident had a score on the Brief Interview for Mental Status (BIMS) of 15. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to use a psychotropic medication to treat a specific, diagnosed, and documented condition. This was found for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #58.

Inspectors wroteBased on record review and staff interview the facility failed to have a complete order for hospice services for Resident #40. This was true for one (1) of one (1) resident reviewed for the care area of hospice, during the Long-Term Care Survey Process. Resident #40 did not have a complete order for hospice. Resident identifier: 40. Facility census: 59.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure the call light system device was accessible for a resident while in bed. This was a random opportunity for discovery and was true for Resident #30. Resident identifier: #30 Facility census: 59.

Inspectors wroteBased on observation, medical record review, resident interview and staff interview, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. The facility failed to provide activities according to their interest for Resident #47 and Resident #48 and failed to develop a care plan in a timely manner for Resident #110. This practice was found true for three(3) of five (5) Residents reviewed for the Activity Care Area during the Long term care survey process. Resident Identifier: Resident #47, Resident #48 and Resident #110 Facility Census: 62 Findings Included: [...]

Inspectors wroteBased on record review, resident interview and staff interview, the facility failed to ensure sufficient qualified nursing staff were available at all times to provide nursing and related services to meet the residents' needs safely and in a manner that promoted resident rights, physical, mental and psychosocial well-being in accordance with the facility assessment. This failed practice has the potential to affect more than an isolated number of residents currently resding in the facility. Resident Identifiers: Resident #53. Facility census: 62 Findings Included: a) Resident Council meeting During a resident council meeting held on 10/04/22 at 10:02 AM the following concerns were presented: Confidential interviews with the Resident group found the following concerns related to call lights: -Depends on how many is working how long it takes them to answer the call lights. [...]

Inspectors wroteBased on observation, policy review and staff interview the facility failed to store food in accordance with professional standards for food safety. The facility failed to label and date food items that were open and failed to dispose of expired food items. The facility also failed to accurately record dishwasher and resident refrigerator temperature logs. The facility also failed to keep the kitchen equipment sanitary. The facility also failed to have a one (1) inch space between the floor and ice machine drain in the kitchen and nourishment room ice machines. These failed practices had the potential to affect more than a limited number of residents currently receiving nourishment from the facility's kitchen and nourishment room. Facility census: 62. Findings Included: The Food Service Director (FSD) was not present upon entering the facility. [...]

Inspectors wroteBased on record review, resident and staff interview, the facility failed to ensure a resident was included in all aspects of person-centered care planning, which supported the resident's goals, choices, and preferences including, but not limited to, goals related to the their daily routines. This was true for one (1) of 22 residents reviewed for care plan involvement during the survey process. Resident identifier: Resident #15 Census

Inspectors wroteBased on observation, record review, resident and staff interview, the facility failed to ensure when a resident self administered medications, the interdisciplinary team had determined this practice was clinically appropriate. This deficient practice was identified during a random opportunity for discovery when Resident #53 was observed in the resident's room with an inhaler on the bedside table. Resident identifier: Resident #53. Census: 62.

Inspectors wroteBased on resident interview, record review, and staff interview the facility failed to provide showers according to the residents preferences. This failed practice was true for one (1) of twenty-two (22) sampled residents. Resident Identifier: #26 Facility Census: 62 Findings Included: a) During the initial interview phase of the long term survey process Resident #26 complained of getting bed baths instead of showers as she preferred. According to her care plan, it is important for her to choose between a shower or a bed bath and she prefers a shower. Records indicate that she is schedule for a shower every Monday, Wednesday and Friday. Documentation shows she received seven (7) out of fourteen (14) showers schedule for the last thirty-four (34) days. She received twenty-seven (27) bed baths during this time. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility failed to assist residents to carry out Activities of Daily living (ADL's) including grooming and eating , when the resident was assessed to require assistance. This was true for one (1) of nine (9) residents reviewed for ADLs during the Long Term Care Survey Process (LTCSP). Resident #50 did not receive assitance with grooming as required. Resident identifier : Resident #50. Census: 62.

Inspectors wroteBased on observation, record review, ,and staff interview, the facility failed to ensure respiratory care was provided in accordance with professional standards of practice for one (1) of three (3) residents who was reviewed for oxygen therapy. Physician's orders for the oxygen administration flow rate was not followed for Resident #53. Resident identifier: Resident #53. Census:

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a Registered (RN) was present at the facility for at least eight (8) consecutive hours a day seven (7) days a week. This had the potential to affect a limited number of residents residing at the facility. Facility census: 62. Findings Included: a) Registered Nursing hours During a review on 10/05/22 of the daily nurse staffing hours revealed on 10/02/22 there was no RN scheduled for that date. A review of the payroll time sheet for RN #64, revealed on 10/01/22 clocked in at 10:45 PM and clocked out at 7:30 AM. During an interview on 10/05/22 at 2:37 PM the Scheduling and Payroll Manager #68 stated there was no RN scheduled for Sunday because the RN # 64's name worked Saturday 11 PM to 7:15 AM. She acknowledged it was not 8 consecutive hours on Sunday 10/02/22. .

Inspectors wroteBased on observations, resident interview and staff interview the facility failed to provide menu items according to resident preference and the facility also failed to provide notification of changes of the menu by not noting or updating on the menu and/or residents were not notified of the change, when substituting foods. This had a potential to affect all residents receiving nourishment from the facility kitchen. Resident Identifiers: Resident #13, and Resident # 18. Facility Census: 62 Findings Included: a) Resident #13 During an interview on 10/03/22 at 10:39 AM Resident #13 stated We get a lot of soup and sandwiches, the food is never good. We never receive what we are supposed to. If the menu says chicken noodle soup we get tomato soup. The menu might say hamburger and we get a ham sandwich. [...]

Inspectors wroteBased on observation, record review and staff interview the facility failed to accurately document the percentage of meal intake for the Resident. This was true for one (1) of twenty-two (22) records reviewed. Resident Identifier: #30 Facility Census: 62 Findings Included: a) According to Resident #30's care plan she is independent to extensive assistance with eating. The care plan also has interventions for participation in the restorative feeding program twice (2) a day, three (3) times a week as well as monitor intake of all meals. On 10/04/22 this surveyor witnessed Restorative Aid (RA) #9 attempt to feed Resident #30. The Resident would not wake up enough to eat. After attempting to feed the Resident for approximately fifteen (15) minutes the RA took the resident back to her room. The Resident did not eat anything. [...]