**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, observations, and review of Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual, the facility failed to ensure Resident Identifier (RI) 120's Minimum Data Set (MDS), with an Annual Assessment Reference Date (ARD) of 09/07/2022 was accurately coded to reflect RI #120 did not have an indwelling catheter. This deficient practice affected RI #120, one of twenty-six sampled resident's whose MDS's were reviewed. Findings Include: The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual, dated October 2019, revealed: . SECTION H: BLADDER AND BOWEL Intent: The intent of the items in this section is to gather information on the use of bowel and bladder appliances, the use of and response to urinary toileting programs, urinary and bowel continence, bowel training programs, and bowel patterns. Each resident who is incontinent or at risk of developing incontinence should be identified, assessed, and provided with individualized treatment (medications, non-medicinal treatments and/or devices) and services to achieve or maintain as normal elimination function as possible . RI #120 was admitted on [DATE] with no diagnosis that would require RI #120 to have an indwelling catheter. RI #120 Physician's Orders dated 08/31/2021 - 11/30/2022 did not identify an order for an indwelling catheter. RI #120 annual MDS with an Assessment Reference Date of 09/07/2022, Section H .H0100. Appliances. A. Indwelling catheter (including suprapubic catheter and nephrostomy tube) . is coded for an indwelling catheter. On 11/29/2022 at 11:16 AM and 11/30/22 at 02:59 PM, RI #120 lying in bed in a supine position. RI #120 was observed not to have an indwelling catheter. On 12/01/2022 at 8:48 AM, an interview was conducted with Employee Identifier (EI) #6, Licensed Practical Nurse (LPN), who stated RI #120 has never had an indwelling catheter. On 12/01/2022 at 8:55 AM, an interview was conducted with Employee Identifier (EI) #7, MDS Coordinator. He stated that RI #120 being coded for an indwelling catheter was an error. EI #7 stated RI #120 should not have been coded for an indwelling catheter.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) RI #74 was admitted to the facility on [DATE]. A review of a Quarterly Minimum Data Set with an Assessment Reference Date of 10/28/2022 indicated RI #74 was at risk for pressure ulcers and also coded RI #74 had a Stage 3 Pressure Ulcer. A review of RI #74's care plans did not reveal any pressure ulcer care plans. On 11/29/2022 at 3:55 PM, a body audit was conducted on RI #74 which revealed no open areas. On 11/30/2022 at 5:28 PM, an interview was conducted with EI #16, a Registered Nurse (RN). EI #16 was asked if there was a care plan for RI #74 for pressure ulcer; she said there was not. EI #16 was asked, what type care plan should RI #74 have. EI #16 said RI #74 should have an at risk and actual pressure ulcer care plan. EI #16 was asked when should a care plan for pressure have been done. EI #16 said typically when the problem was identified. EI #16 was asked, what was the policy for developing care plans. EI #16 said to follow the RAI manual. EI #16 was asked, why was a care plan not done for pressure ulcers for RI #74. EI #16 said, human error. EI #16 was asked, what was the harm in not having a care plan for a pressure ulcer. EI #16 said, not knowing the resident has a pressure ulcer and not knowing how to care for it. Based on interviews, record review, and review of the Resident Assessment Instrument (RAI) Manual Chapter 4, the facility failed to ensure: 1) a nutritional care plan was implemented for Resident Identifier (RI) #76; and 2) an at risk and actual pressure ulcer care plan was implemented for RI #74. RI #74 developed a pressure ulcer to the sacrum 07/20/2022, which has since healed, however; the facility did not implement an at risk or the actual pressure ulcer care plan. This deficient practice affected RI #74 and 76, two of twenty-six sampled resident's whose plans of care were reviewed. Findings include: A review of the RAI Manual Chapter 4 October 2019 revealed . Chapter 4 Care Area Assessment Process and Care Planning . 4.7 . The care plan is driven not only by identified resident issues and/or conditions but also by a resident's unique characteristics, strengths and needs. Develops and implements a intradisciplinary care lan based on the assessment information gathered throughout the RAI process, with necessary monitoring and follow up .Provides information regarding how the causes and risks associated with issues and or conditions can be addressed to provide for a resident's highest practicable level of well-being (care planning). 1) RI #76 was admitted to the facility on [DATE] and readmitted on [DATE], with a diagnosis of Obesity. A review of RI #76's admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 07/22/2022, Section V: Care Assessment (CAA) Summary, revealed under Nutritional Status RI #76 triggered for a Care Planning Decision. Further review of the CAA worksheet revealed: Care Plan Considerations Will Nutritional Status - Functional Status be addressed in the care plan? Yes If care planning for this problem, what is the overall objective . Avoid complications . Minimize risk (were checked) . On 12/01/2022 at 11:54 AM, the surveyor conducted an interview with Employee Identifier (EI) # 7, the MDS Coordinator. When asked to locate a nutritional care plan for RI #76, EI #7 said he did not see one. The surveyor asked EI #7 how would it be determined if RI #76 needed a nutritional care plan. EI #7 said RI #76's CAAs would indicate that. EI #7 said according to RI #76's CAAs, RI #76 should have a nutritional care plan. When asked what was the rationale for implementing a nutritional care plan for RI #76, EI #7 said you would not want any adverse outcomes and you would want to make sure all of RI #76's nutritional needs were met. The surveyor asked EI #7 who would be responsible for ensuring RI #76's nutritional care plan was implemented. EI #7 said he and the care plan coordinator work together in creating care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review and review of the Unit Managers Duties and Responsibilities, the facility failed to ensure Resident Identifier (RI) #65's nebulizer mask was dated and labeled; and the nebulizer mask was stored in a bag on three of five days of the survey. This deficient practice affected RI #65, one of one resident observed with nebulizer equipment at the bedside. Findings include: Review of an undated UNIT MANAGER DUTIES AND RESPONSIBILITIES, revealed the following: . MONDAY • check rooms for correct dates and storage of 02 and nebulizer tubing. These are changed out, bagged, and dated weekly on Sunday night by night shift . RI #65 was was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Chronic Obstructive Pulmonary Disease, Acute and Chronic Respiratory Failure and Dyspnea. A review of RI #65's November 2022 Order Summary Report (Physician Orders) revealed RI #65 had an order to receive Ipratropium-Albuterol Solution 0.5 -2.5 (3) MG (milligrams)/3 ML (millimeters) 3 ml inhale orally via (by way of) nebulizer every 6 hours related to Acute and Chronic Respiratory Failure with Hypercapnia. On 11/29/2022 at 12:58 PM, RI #65's nebulizer mask was observed on top of the nebulizer machine not in a bag. There was also no date on the nebulizer tubing. On 11/30/2022 at 8:54 AM, RI #65's nebulizer mask remained on top of the nebulizer machine not in a bag. A review of RI #65's November 2022 eMAR revealed RI #65 had received his/her nebulizer treatments as ordered. On 12/01/2022 at 8:25 AM, the nebulizer mask remained on top of the nebulizer machine not in a covering. RI #65 stated he/she had a breathing treatment that morning. A review of RI #65's December 2022 eMAR revealed RI #65 had received his/her nebulizer treatment as ordered that morning. On 12/01/2022 at 10:53 AM, an interview with Employee Identifier (EI) #18, a LPN (Licensed Practical Nurse). EI #18 said RI #65 received breathing treatments ever six hours. When asked where should RI #65's nebulizer mask be stored, EI #18 said at the bedside in a plastic bag. When asked when not stored in this manner what was that considered, EI #18 said an infection control issue because anything could get on the mask. On 12/01/2022 at 10:59 AM, the surveyor entered RI #65's room with EI #18. RI #65's nebulizer mask remained on top of the nebulizer machine not in a covering. On 12/02/2022 at 11:35 AM, the surveyor conducted an interview with EI #2, the Director of Nursing (DON). EI #2 said the resident's nebulizer mask should be stored in a plastic bag at the bedside when not in use. EI #2 said this would prevent contamination. When asked who was responsive for ensuring the mask was stored properly, EI #2 said the nurse. On 12/02/2022 at 12:57 PM, in a follow-up interview with EI #2, the surveyor asked what did the U-SA on RI #65's eMAR for the breathing treatments mean. EI #2 said that meant RI #65 self administers his/her breathing treatments. EI #2 said the nurse is still responsible for putting the nebulize mask in a plastic bag when a resident self administers a breathing treatment. On 12/02/2022 at 2:05 PM, the surveyor conducted an interview with EI #19, the RN (Registered Nurse) Unit manager. EI #19 said the resident's nebulizer should be stored in a plastic Ziploc bag when not is use. EI #19 said when not stored in this manner there was a potential for infection control. EI #19 said the nurse that is giving the treatment is responsible for ensuring this is done. When asked how she as the Unit Manager ensured this was being done by the nurses, EI #19 said the nebulizer mask are changed out on Sunday night; and she as the Unit manger do walking rounds on Monday to make sure this was done. EI #19 said when she made her walking rounds on Monday she did not recall if RI #65's nebulizer mask was stored in a bag or dated.

Based on observation, interviews, record reviews and review of a facility policy titled Storage and Expiration Dating of Medications, Biologicals, the facility to store controlled refrigerated Ativan/Lorazapam in a secured non removable box in the medication room. Findings Include: A review of a facility policy titled Storage and Expiration Dating of Medications, Biologicals with a revision date of 7/21/2022, revealed . Procedure .3.1.1 Store all drugs and biolgicals in locked compartments including Schedule II-V medications in a separately, permanently affixed compartments . On 12/01/2022 at 9:05 AM, an observation was made of the medication room with Employee Identifier (EI) #17, Licensed Practical Nurse (LPN). The refrigerator had a clear secured box on bottom shelf with nothing in the box, two vials of injectable Ativan belonging to a resident was not in any box only in plastic bag on the shelf and in the locked refrigerator. A green box was on the top shelf with a combination lock. EI #17 was asked what was in the green box; she said an oral Ativan and an injectable Ativan. EI #17 was asked how should Ativan be stored in the medication room refrigerator. EI #17 said in a locked box with the refrigerator locked and the medication room locked. EI #17 was asked if the ativan box was secured properly to the refrigerator; she said if the green box was to be secured it was not. On 12/01/2022 at 9:17 AM, an interview was conducted with EI #2, Registered Nurse, Director of Nursing. EI # 2 was asked what did she see; she said the green box on the shelf with a combination lock and a green pharmacy tag with according to packing slip concentrate ativan and ativan injection. EI #2 was asked what were the two vials on the shelf, she said two vials of Ativan two milligrams each, EI #2 opened the green box and was asked what was in the box. EI #2 said one liquid Ativan and one two milliliter vial of injectable Ativan. EI #2 was asked if they were stored properly; she said no they were on the shelf. EI #2 was asked, where should they have been stored. EI #2 said, in the secured non removable box. EI #2 was asked, how should controlled ativan be secured. EI #2 said in a box that cannot be removed, it should be attached to the refrigerator. When asked if the Ativan was secured properly she said no it was not secured to the refrigerator. EI #2 was asked what was the harm in the Ativan not stored properly. EI #2 said the possibility of diversion, the box was double locked, however, not secured to the refrigerator. EI #2 was asked, what was policy for storing the Ativan. EI #2 said in the refrigerator in a secured box attached or non removable box.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review, the facility's Customer Concern / Grievance Communication Form, the facility's Resident Council Meeting minutes, the facility's Food Preference policy, and the facility's former Daily Alternate List; the facility failed to provide Resident Identifier (RI) #65's long-standing request for Chef Salad at supper on Monday nights and Cottage Cheese with Fruit at supper on Wednesday nights, which she had received for years. This affected RI #65, one of 130 residents receiving meals from the kitchen. Findings Include: The facility's Food Preferences policy, dated May 2014, included the following: Policy Statement It is the center policy that individual food preferences are identified for all residents . food and fluid preferences will be entered into the resident profile in menu management software system. Resident Identifier (RI) #65 was originally admitted to the facility on [DATE] and was last readmitted on [DATE]. RI #65's diagnoses included Anxiety Disorder, Type 2 Diabetes Mellitus Without Complications, and Difficulty in Walking. RI #65's Quarterly Minimum Data Set (MDS) Assessment with an ARD (Assessment Reference Date) of 9/13/2022 included a BIMS (Brief Interview for Mental Status) score of 15; indicating the resident was cognitively intact. This MDS also revealed the resident had adequate hearing, clear speech, adequate vision, the ability to make oneself understood, and the ability to understand others. The MDS also revealed RI #65 was independent for eating and only required setup assistance. RI #65's Physician Orders for November 2022 and December 2022 each included the following: . No Salt Packet (NSP) diet Regular Texture . 04/05/2022 . RI #65's RD (Registered Dietitian) Nutritional Assessment's Annual Summary, dated 3/3/2022, included the following: . h/o (history of) moderate protein calorie malnutrition . often requests specific foods and has a limited range of foods . stating . unable to chew due to poor dental status. Continue to provide preferences and requests as able. RI #65's RD Nutritional Assessment's Summary, dated 4/13/2022, included the following: . Resident recently hospitalized . had a significant loss of 6.5% . Wt. (Weight) loss likely r/t (related to) hospitalization. Due to resident's poor dentition, . doesn't eat certain foods. prefers soft foods and soup, but does not want a mechanically altered diet. Continue with plan of care and honor preferences/dislikes. RI #65's RD Nutritional Assessment's Summary, dated 5/16/2022, included the following: . Diabetes mellitus Type 2 diet controlled. h/o chewing problems r/t poor dentition. recently saw a dentist. has multiple food preferences . enjoys soups, hot tea . Continue to honor preferences as facility is able. Customer Concern / Grievance Communication Form, dated 11/28/2022, included the following summary statement for RI #65's expressed concern: Food Preferences not provided - (RI #65) contacted Admin. (Administrator) . regarding the unavailability of salads for several days a week. Resident reports (she/he) has special dental issues and can only tolerate certain foods. During an interview with RI #65 on 11/29/2022 at 12:40 PM, RI #65 said he /she spoke with the Administrator (EI #1) on Tuesday morning (11/29/2022) about not being able to get a Chef Salad like she had been getting. The Administrator was supposed to be following up to see why RI #65 was not getting the Chef Salad. On 11/30/2022 at 3:38 PM, Employee Identifier (EI) #11, the Dietary Manager, was interviewed. EI #11 was asked why were residents no longer able to receive Chef Salads. EI #11 said the facility told us that we were not to do that anymore. My boss, (name of EI #12), told me that about a month ago. When asked why, EI #11 said I am just going on what I was told to do. On 11/30/2022 at 4:06 PM, EI #12, the Regional Dietary Manager for the healthcare foodservice management company contracted by the facilty, was interviewed. When asked why were residents told they would no longer be able to receive Chef Salad, EI #12 said because that is not on the always available menu; it is not on the menu that the facility gave us to follow. EI #12 further said it was not on their order guide. On 12/01/2022 at 4:45 PM, RI #65 was interviewed. When asked about the follow up to the concern voiced to the Administrator (EI #1) on 11/29/2022, RI #65 said he/she received a Chef Salad for lunch and it was wonderful. The resident said he/she was used to receiving Cottage Cheese with Fruit every Wednesday evening and Chef Salad every Monday evening. RI #65 said I don't understand the high-handedness of just stopping it and not allowing something simple like this. The resident further said he/she was fearful that he/she would not be able to get Chef Salad and Cottage Cheese with Fruit after the survey. When asked who told you they were going to stop the Chef Salad and Cottage Cheese with Fruit, RI #65 said no one; they just stopped sending it. RI #65 said when the Aides (CNAs) went down to find out, they were told it was being stopped by Dietary. RI #65 futher said that when the people who now own Dietary, not (the name of the facility), first came; they tried to stop my Chef Salads and Cottage Cheese with Fruit, but the Administrator was able to fix it for a few months. RI #65 said she/he had been at the facility for eight years and had received Chef Salad on Monday nights and Cottage Cheese with Fruit on Wednesday nights for years. On 12/01/2022 at 6:00 PM, EI #11, the Dietary Manager, was interviewed. EI #11 was asked when was the last time she visited RI #65 about food preferences. EI #11 said about three weeks ago. When asked how long RI #65 had been receiving Chef Salad on Monday nights and Cottage Cheese and Fruit on Wednesday Nights; EI #11 said for quite a while, probably years. Upon being asked how and when RI #65 was informed that he/she would no longer be receiving Chef Salad on Monday nights and Cottage Cheese and Fruit on Wednesday Nights; EI #11 said she did not remember telling the resident. When asked if it was unreasonable for a resident to request a Chef Salad or a dish of Cottage Cheese and fruit as a food preference, EI #11 said no. EI #11 was asked if it was possible for the kitchen to provide those items. EI #11 said we can, but it is not my call; (name of EI #12) is my boss. On 12/01/2022, immediately following the 6:00 PM interview with the Dietary Manager; the Registered Dietitian (RD), EI #10, was interviewed. Upon being asked how and when RI #65 was informed that she/he would no longer be receiving Chef Salad on Monday nights and Cottage Cheese and Fruit on Wednesday nights, EI #10 said I do not know. When asked if it was it unreasonable for a resident to request a Chef Salad or a dish of Cottage Cheese and fruit as a food preference; EI #10 said I don't think it is unreasonable to request that. EI #10 was asked if it was possible for the kitchen to provide those items. EI #10 said Cottage Cheese would have to be a special purchase because it is no longer on our menu or order guide anymore. On 12/01/2022 at 7:03 PM, EI #12, the Regional Dietary Manager was interviewed. When asked if it was unreasonable for a resident to request a Chef Salad or a dish of Cottage Cheese and fruit as a food preference; EI #12 said no, it is not unreasonable, but we do not always have it on hand. EI #12 was asked if it was possible for the kitchen to provide those items. EI #12 said if we could get it approved by (name of the facility's company) as one one of their always available menu options, we could do that. EI #12 further said I not sure who wrote the menu or who would be able to change the menu options, but I would take it to my Director of Operations and she would coordinate it. On 12/02/2022 at 9:00 AM, EI #11, the Dietary Manager, was asked when were the residents told about the new menu and what were they told. EI #11 said the residents were told at Resident Council. EI #11 further said Activity had record of the meeting date. EI #11 said she told the residents that the menu was to be changed. There would no longer be a Everyday Meal option (Daily Alternate List), which included items to be offered on designated days; such as Chef Salad on Mondays, Cottage Cheese and Fruit on Wednesdays, Hot Dogs on Fridays, and Hamburgers on Sundays. There would be the Regular menu, an alternate menu choice, and a health care alternate choice; but the Everyday Meal/Daily Alternate List was being discontinued. On 12/02/2022 at 12:10 PM, EI #4, the Activity Supervisor, provided a copy of the Resident Council minutes when the Dietary Manager (EI #11) announced new menus on 10/17/2022. The minutes documented that 20 residents attended the meeting. RI #65 was not listed as attending the meeting. EI #4 said she posts the date and time for the Resident Council Meeting on the facility's hall calendars and goes around to invite the residents to attend the meeting. When asked if information or minutes from the meeting are given to the residents who did not or could not attend; EI #4 said no. On 12/02/2022 at 12:47 PM, the Administrator, EI #1, was interviewed. EI #1 said (name of RI #65) did talk with her on Tuesday, 11/29/22, about not getting Chef Salad and said the resident also talked about Cottage Cheese and Fruit. EI #1 said the resident (RI #65) wanted to file a grievance. EI #1 also said the resident (RI #65) had explained that the Chef Salad with Boiled Eggs and the Cottage Cheese with Fruit was easier to chew and that the resident liked those things. EI #1 said she told RI #65 that she would go to the kitchen and take a list of what the resident desired: two cartons of milk to mix with Slimfast for lunch and for dinner the Cottage Cheese and Fruit. EI #1 said I went to the kitchen to turn in the request and I talked with the (name of healthcare foodservice contract management company's) Regional Dietary Manager, (name of EI #12). There was some discussion and then there was agreement that they would be getting it. EI #1 was asked if she could speak to RI #65's comment that you, the Administrator, were previously able to hold them (the healthcare foodservice contract management company) off from stopping the Chef Salad and Cottage Cheese with Fruit for a few months. EI #1 said their system is that they have a set menu and an alternate that they serve at lunch and at dinner. EI #1 was told that the Regional Dietary Manager, EI #12, had said they were bound to serving the menu, which (the name of the facility's company) had given them to follow. EI #1 said I am not aware of (name of the facility's company) presenting (name of the healthcare foodservice management company) with a menu for them to use. That is their work.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews and facility policies titled Resident Screening Guidelines and Evaluations, the facility failed to initiate an evaluation for Physical Therapy as indicated by a screening for Resident Identifier (RI) #139. This affected one of one resident sampled for Physical Therapy. Findings Include: A Policy titled, Resident Screening Guidelines with a revision date of 03/14/2018, documented, Policy . that screenings be completed . on all new admission, readmissions, or upon referral by the medical and/or nursing department of a facility .This is done to: .2. Help identify indications of functional loss or aptitude that may require the need for a rehabilitation referral to evaluate for additional skilled services .6. The screening process concludes with one of these possible recommendations: referral for evaluation . A policy titled Evaluations with a revision date of 09/05/2017, documented, Policy . all patients identified as needing an assessment of functional status and potential to benefit from rehabilitation services be evaluated in order to determine an appropriate plan of care. Procedure Evaluations will be initiated within a reasonable amount of time of receipt of physician's order or authorization . RI #139 was admitted to the facility on [DATE] with a diagnosis to include Fibromyalgia. RI #139 was ordered PT eval and treat as indicated on 10/25/2022 RI #139's Interdisciplinary Rehabilitation Screening Form dated 11/01/2022, documented, Screening . 3. Recommendations: Request Evaluations (select all that apply) . PT . An interview was conducted with RI #139 on 11/29/2022. RI #139 stated he/she has been at the facility for a month and still had not received therapy. An interview was conducted with Employee Identifier (EI) # 8, Physical Therapist on 12/01/2022. EI #8 stated she conducted a screening for RI #139 on 11/01/2022. EI #8 stated she recommended Physical Therapy indicated to get a baseline. EI #8 stated therapy department must wait on authorization for evaluation to determine frequency of therapy. An interview was conducted with EI #9, Director of Physical Therapy on 12/01/2022. EI #9 stated once screening was completed, and it was determined that Physical Therapy was a need. She completed a Payer Verification Form and sent to administrator for approval. EI #9 stated administrator approves Medicaid residents off her determination. EI #9 stated she is not sure where RI #139's evaluation fell through. EI #9 stated the concern of not receiving therapy when needed is decrease mobility, decrease independence and decrease range of motion. An interview was conducted with EI #2, Director of Nursing (DON) on 12/02/2022. EI #2 stated she was not involved in the evaluation decision that was between the therapist and the administrator. EI #2 stated the concern of a resident not receiving therapy when needed is them not getting better and resident not reaching their maximum potential. An interview was conducted with EI #1, Administrator on 12/02/2022. EI #1 stated the process of Payer Verification Form is resident comes in and are screened and its determined what is needed. EI #1 stated that RI #139's Payer Verification Form was submitted, and she didn't respond to it. EI #1 stated that was her oversight. EI #1 stated the concern of a resident not receiving therapy when needed is a service the facility did not complete.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an observation, interviews and review of [NAME] and Perry's FUNDAMENTALS OF NURSING, the facility failed to ensure a wound bandage was disposed of in a manner to prevent cross contamination. On 12/12/2022, a wound bandage was observed in one of the shower rooms at the facility. This deficient practice has the potential to affect all residents using one of two shower rooms on one of three floors at the facility. Findings include: A review of [NAME] and Perry's FUNDAMENTALS OF NURSING with a copyright date of 2017, Chapter 48 Skin Intergrity and Wound Care, page 1221, revealed the following: SAFETY GUIDELINES FOR NURSING SKILLS . Keep a plastic bag within reach to discard dressings and prevent cross contamination . On 11/30/2022 at 12:27 PM, a blood tinged dressing was observed laying on the shower grab bar in a shower room at the facility. At this time an interview was conducted with Employee Identifier (EI) #19, the RN (Registered Nurse) Unit Manager. When asked what was on the shower bar, EI #19 said it looked like a bandage that might have come off in the shower. EI #19 said when dressing are removed from a resident they are usually put in a bag in the soiled utility room in the red barrel. When asked what type concern it would be when dressing are not place in the appropriate receptacle, EI #19 said infection. On 12/02/2022 at 11:28 AM, an interview with the Director of Nursing, EI #2 who said, when a dressing comes off of a resident it should be disposed of in the trash. EI #2 said when not disposed of in that manner, it would be an infection control issue.

Based on observations, interviews, a copy of Your Resident Rights and Protections Under State and Federal Law, and the facility's Position Description for Maintenance Supervisor, the facility failed to ensure the building was in good repair as evidenced by stained ceiling tiles, loose hand rails, a loose door knob, holes in walls under residents' sinks exposing pipes and adjoining rooms, hole in wall in hallway, broken window with a cut edge open to outside elements/torn window screen, missing sheetrock behind a resident's toilet, toilets leaking/not flushing properly, missing/scraped paint on walls, doors and base boards, detached pieces on residents' doors, black residue under air conditioning (AC) units, sinks and smoke detector, loose baseboards, holes in resident walls, and torn sheetrock under sinks. This affected 3 out of 4 floors of the facility. Findings Include: A review of an undated document titled, Your Resident Rights and Protections Under State and Federal Law, revealed, . A nursing home must care for you in a manner and environment that promotes the maintenance and enhancement of your quality of life. A review of an undated facility's position description for Maintenance Supervisor revealed, . KEY RESPONSIBILITIES: Administrative Functions Supervise, repair, plan, organize, and conduct the day-to-day activities of the physical plan and operations department. Complete routine plant and grounds inspections . Maintenance Functions Maintain/repair/replace-toilets, sinks, faucets, drains . Repair/replace window screens . Repair/replace doors, hinges, handles, and locks . Repair/replace major and minor plumbing systems . Paint walls, ceilings, doors, window and door frames . Replace ceiling and floor tile . The following observations were made regarding Room Locators (RL). RL 1: On 11/29/2022 at 5:14 PM, observed stained area on three ceiling tiles. On 11/30/2022 at 8:27 AM, stained areas remained on three ceiling tiles. On 12/01/2022 at 7:45 AM, stained areas remained on three ceiling tiles. RL 2: On 11/29/2022 at 11:55 AM, observed pipe access panel not replaced behind the toilet and pipe leaked when flushed. RL 3: On 11/29/2022 at 10:27 AM, observed window pane broken on left window and outside window screen torn on right hand side. On 11/30/2022 at 11:26 AM, observed window pane still broken. RL 4: On 11/30/2022 at 11:39 AM, observed base floor boards covering up a hole located under the fire extinguisher. Tiles above the fire extinguisher and above the AC unit appeared to have water damage around AC pipes. RL 5: On 11/29/2022 at 11:05 AM, Observed sign on bathroom door that read Out of Order and dated 08/23. Toilet did not flush properly. RL 6: On 11/29/2022 at 8:12 AM, observed loose door knob on bathroom door. On 11/30/2022 at 8:42 AM, door knob to bathroom remained loose. On 12/01/2022 at 7:55 AM, door knob on bathroom door remained loose. RL 7: On 11/29/2022 at 4:58 PM, observed the bottom of resident's door with missing pieces of paint. Observed area beneath sink in room with loose sheetrock and pipes exposed. On 11/30/2022 at 8:45 AM, observed same missing pieces of paint on resident's door. Area beneath sink observed with same loose sheetrock and pipes exposed. On 12/01/2022 at 7:57 AM, observed same missing pieces of paint on resident's door. Area beneath sink observed with same loose sheetrock and pipes exposed. RL 8: On 11/29/2022 at 4:23 PM, observed missing pieces of paint beneath the door handle to the resident's room. On 11/30/2022 at 8:49 AM, observed same missing pieces of paint beneath the door handle. On 12/01/2022 at 8:08 AM, observed same missing pieces of paint beneath the door handle. RL 9: On 11/29/2022 at 4:22 PM, observed detached piece on left side of resident's door. Observed a small circular stain on one ceiling tile. On 11/30/2022 at 8:48 AM, observed detached area on left side of door. Stain remained on ceiling tile in room. On 12/01/2022 at 8:11 AM, observed detached area on left side of door. Stain remained on ceiling tile in room. RL10: On 11/30/2022 at 11:47 AM, observed loose hand rail. RL 11: On 11/29/2022 at 8:35 AM, observed pieces of paint missing on bottom of resident's door. On 11/30/2022 at 8:52 AM, pieces of paint remained missing from left side on bottom of door. On 12/01/2022 at 8:21 AM, pieces of paint remained missing from bottom of door. RL 12: On 11/29/2022 at 8:45 AM, observed stain on one ceiling tile above the fire extinguisher. On 11/30/2022 at 8:54 AM, stain remained on ceiling tile. On 12/01/2022 at 8:20 AM, stain remained on ceiling tile. RL 13: On 11/29/2022 at 8:32 AM, observed black residue under both AC units, six discolored/stained ceiling tiles, baseboard on floor from plug to end loose and held in place with tv table and blue tape, black residue under AC unit over fire extinguisher, black substance on the rim of the AC unit, plaster on wall bubbled, and black and gray discolored area on ceiling tile at smoke detector. On 11/30/2022 at 4:58 PM, observed black residue on units, same loose baseboard from the wall with blue tape holding it in place, same discolored ceiling tiles. RL 14: On 11/29/2022 at 9:14 AM, observed hole under sink exposing RL 15. Observed scrapes on lower edges of wall. On 11/30/2022 at 5:16 PM, observed same hole under sink. RL 15: On 11/29/2022 at 9:14 AM, observed hole under sink exposing RL 14 and hanging sink plaster/sheetrock. On 11/30/2022 at 5:16 PM, observed same hole under sink. RL 16: On 11/29/2022 at 9:05 AM, observed plaster torn and hanging under sink. On 11/30/2022 at 5:13 PM, observed same plaster torn and hanging under sink. The following observations were made regarding RL 17: On 11/29/2022 at 8:59 AM, observed scrapes and scratches behind bed. On 11/30/2022 at 5:12 PM, observed same scraped and scratched wall. RL 18: On 11/29/2022 at 8:55 AM, observed scratches and holes in wall behind television. On 11/30/2022 at 5:09 PM, observed same scratches and holes on wall behind television. RL 19: On 11/29/2022 at 8:53 AM, observed black residue under the sink. On 11/30/2022 at 5:07 PM, observed same black residue on plaster under sink. RL 20: On 11/29/2022 at 8:50 AM, observed scratches on wall under bed A light. RL 21: On 11/29/2022 at 8:46 AM, observed water dripping on the floor. On 11/30/2022 at 5:03 PM, water continued dripping on floor where toilet was leaking. RL 22: On 11/29/2022 at 8:44 AM, observed large cut out area under sink exposing plumbing. On 11/30/2022 at 5:01 PM, observed same large cut out area under sink exposing plumbing. On 12/01/2022 at 4:58 PM, observation of the following areas was made with Employee Identifier (EI) # 3, Maintenance Director: RL #1-EI #3 stated he observed water spots on three ceiling tiles. RL #2-EI #3 agreed with the observation of pipe access panel not replaced behind the toilet and pipe leaked when flushed. RL#3-EI #3 stated he observed a broken window pane and torn window screen. RL #4-EI #3 stated he observed the wall caved in behind the base board in the wall under the fire extinguisher and stained ceiling tiles above the fire extinguisher and above the AC unit. RL #5-EI #3 stated he observed the out of order sign. EI #3 stated a diaphragm was needed to address the leaking. RL #6-EI #3 acknowledged the door knob to the bathroom was loose. RL #7-EI #3 stated he saw missing paint at the bottom of the door and loose sheetrock beneath the sink, exposing pipes. RL #8-EI #3 stated he observed missing pieces of paint beneath the door handle. RL #9-EI #3 stated he observed a detached piece of the door and a small circular stain on one ceiling tile RL #10-EI #3 stated he observed the loose hand rail. RL #11-EI #3 stated he observed missing pieces of paint on bottom of door. RL #12-EI #3 stated he observed a stain on one ceiling tile. RL #13-EI #3 stated he saw mildew from the unit, tape holding up the baseboard, mildew under one unit on one side, where the wall needed to be sanded down and painted and mildew by the smoke detector. RL #14-EI #3 stated he observed scrapes on the lower edges of wall on baseboards. RL #15-EI #3 stated he observed a hole under the sink and hanging plaster. RL #16-EI #3 stated he observed torn, hanging plaster under the sink. RL #17-EI #3 stated he observed scrapes on the wall from the bed rail. RL #18-EI #3 stated he observed nail holes on the wall that appeared to be from a previous television rack on the wall. RL #19-EI #3 stated he observed a black resident under the sink that appeared to be from when the plumber made a repair and did not clean it. RL #20-EI #3 stated he observed scratches on the wall under the light. RL #21-EI #3 stated he observed the toilet cut off leaking. RL #22-EI #3 stated he observed a cut out area under the sink exposing plumbing. EI #3 stated it was an old building and the cast iron was cracking so the plumbing was being replaced. EI #3 stated replacing plumbing stated before he took that position. EI #3 stated he repaired part of the hole on 12/01/2022. He stated he would fill the rest of the hole with foam and cut to shape. In an interview on 12/01/2022 at 4:58 PM, EI #3 stated he had worked at the facility for three months. He stated his responsibilities included general upkeep of the building and repairs. EI #3 stated the building was older and he tried to keep it clean and in good repair but he had only been in his position a short time. In an interview on 12/02/2022 at 11:50 AM EI #1, Administrator, stated she and Maintenance were responsible to ensure the building was clean and in good repair. EI #1 stated housekeeping and team members were expected to report anything they saw that needed repairs. EI #1 stated that utilized the TELS system for reporting issues and Maintenance was expected to check TELS and make the repairs. EI #1 stated she made rounds throughout the facility weekly. EI #1 stated the items identified by the surveyors and Maintenance were things EI #3 was addressing. EI #1 stated the building that had issues and they were getting things repaired one by one or in groups if they are connected. EI #1 stated they had major plumbing repairs because of the galvanized pipes. This deficiency was written as a result of the investigate on of AL00042272.

Based on interview; document review; the Rules of the Alabama State Board of Health, Alabama Department of Public Health (ADPH), Chapter 420-5-10, Nursing Facilities; and the facility's job description for Dining Services Director/Account Manager; the facility failed to ensure the full time Dietary Manager, Employee Identifier (EI) #11, met the definition of a Dietary Manager per the rules of the State of Alabama. This had the potential to affect 130 of 130 residents receiving meals from the facility kitchen. Findings Include: The Rules of the Alabama State Board of Health, ADPH, Chapter 420-5-10, Nursing Facilities, original rules effective 8/23/1996 and last amendments effective 7/30/2016 included the following: . 420-5-10-.01 Definitions. (1) Definitions - (a list of selected terms often used in connection with these rules): . (b) These Rules - Rules 420-5-10-.01 through 420-5-10-.11, Chapter 420-5-10, Nursing Facilities, Alabama Administrative Code. (l) Director of Food Services/Dietary Manager - . who is a full-time employee, and if not a qualified dietitian, is one who: (1) is a graduate of a dietary manager's training program, approved by the Dietary Manager's Association (name changed to Association of Nutrition & Foodservice Professionals in 2012), or (2) is a graduate of a dietetic technician program approved by the American Dietetic Association (name changed to Academy of Nutrition and Dietetics in 2012), or (3) is a graduate from a college or university who has received a B.S. (Bachelor of Science) degree in the field of dietetics, food and nutrition or food service management which included course work in diet therapy and quantity food production. The facility's job description for Dining Services Director/Account Manager, undated, included the following: . Must hold state . required credential . On 11/29/2022 at 5:10 PM, Employee Identifier (EI) #10, the Registered Dietitian (RD), provided requested documents for Food and Nutrition Services (FNS). EI #10 said the facility's FNS management was recently contracted out to a healthcare foodservice management company. EI #10 said she normally worked about three days per week. EI #10's credentials included the Alabama Board of Dietetics & Nutritionists License, expiring 9/30/2023, and the Commission on Dietetic Registration credential verification, expiring 8/31/2023. EI #11 was identified by the RD (EI #10) as the full-time Dietary Manager (DM). EI #11's credentials included a ServSafe Certification, expiring 5/25/2024, and a Food Safety Education certification from the [NAME] County Department of Health, expiring 5/25/2024. EI #10 was asked if EI #11 had Dietary Manager's training as approved by the Association of Nutrition & Foodservice Professionals (ANFP), formerly named the Dietary Manager's Association. EI #10 said no. When asked if EI #11 was a Dietetic Technician as approved by the Academy of Nutrition and Dietetics, formerly named the American Dietetic Association; EI #10 said no. Upon being asked if EI #11 had a B.S. degree in Dietetics, Food and Nutrition, or Food Service Management; EI #10 said no. EI #10 was asked if EI #11 was currently enrolled in a dietary manager's training program. EI #10 said she did not think so. Also, EI #10 was asked about EI #12's position and credentials. EI #12 was identified by the RD (EI #10) as the Regional Dietary Manager who periodically visits the facility. EI #12's credentials included certification of completing an AFNP approved dietary manager's training program by the University of Florida, dated 1/8/2020; Certified Dietary Manager and Certified Food Protection Professional examination documentation from the Certifying Board for Dietary Managers (CBDM), dated 7/14/2020, and verification of current certification from the CBDM, dated 11/29/2022. When asked if EI #12 was at the facility full time, EI #10 said no. On 11/30/2022 at 8:35 AM, the RD (EI #10) and DM (EI #11) were interviewed in the kitchen. EI #11 was performing AM [NAME] duties today. EI #11 was asked how long she had worked at the facility. EI #11 said she had worked here as a DM for 12 years with another DM; she said there were two since the place was so large. EI #11 said she then left for a year and came back on 1/18/2022 as an Assistant DM and Relief Cook. At 8:45 AM, EI #10 said the previous DM had been gone about two months and that EI #11 was then promoted to DM. EI #10 further said the healthcare foodservice management company started at the facility about February or March of 2022. The RD (EI #10) has been working at the facility for about a year since Oct. 2021; primarily as clinical and, when needed, as an operational consultant. An interview on 11/30/2022 at 3:38 PM, EI #11 said, she had started a dietary manager's training course with the University of North Dakota about a year ago. EI #11 said this was started while she was working at a different nursing home. In addition, EI #11 said her RD proctor was unavailable for health reasons and did not want to come into the building because of COVID so this threw her behind. EI #11 said she was halfway through the training, but her expiration date for her course expired. EI #11 stated she still had the books and contact information for the University of North Dakota. EI #11 confirmed she was not a dietetic technician and she did not have a Bachelor of Science degree.

Based on observation, interview, the Resident Council Meeting on 11/30/2022, and a test tray on 12/01/2022; the facility failed to ensure scrambled eggs were served warm, palatable, and appetizing in appearance. This had the potential to affect 130 of 130 residents receiving meals from the kitchen. Findings Include: A Resident Council Meeting was conducted on 11/30/2022 at 11:00 AM with fourteen residents attending. During this meeting, the residents attending complained that hot foods were being served cold and the food did not taste good. On 12/01/2022 at 6:40 AM, the steamtable was observed to be setup with breakfast food items. The plate warmer not turned on. Employee Identifier (EI) #13, a Dietary Aide, turned on the plate warmer twenty minutes before the start of trayline. At 6:50 AM, the food thermometer was calibrated to 32 degrees Fahrenheit in an ice water slush by Dietary staff. At 6:55 AM, the Scrambled Eggs were 174 degrees Fahrenheit on the steamtable. At 7:00 AM, the Breakfast trayline started. EI #13, a Dietary Aide, was at the starter position, EI #15, a Dietary Aide, was serving from the steamtable, EI #14, a Dietary Aide, was loading trays onto the carts, and EI #11, the DM, was acting AM Cook/Runner/Cart Deliverer. The Regular Diet breakfast had two pancakes, two strips bacon, scrambled eggs, grits, juice, 2% Milk, and a syrup cup. The plates were covered with an insulated lid; but no insulated plate underliners were used, although 74 insulated plate underliners were observed on carts in the kitchen. When a low-profile 4-ounce (oz.) bowl was used directly on the meal plate, the insulated lid covered the plate fully. When a fluted, high-profile 4-oz. bowl was used, as seen for Oatmeal, the insulated lid was tilted askew; causing a gap that allowed heat to escape. At 8:03 AM, the next to last cart was being loaded with breakfast trays, dietary staff started to use insulated plate underliners as plate covers. At 8:10 AM, the surveyor asked for a Regular Diet test tray as the last trays was about to be placed on the last cart. At 8:13 AM, the loading of the last cart began. At 8:25 AM, the plate for the test tray was prepared. At 8:28 AM, the last cart was placed in the elevator for delivery to the 2nd floor. There were 22 trays on the cart, including the test tray. At 8:29 AM, the last cart was removed from the elevator on the 2nd floor by two staff waiting for the cart at the elevator. At 8:29 AM, the first tray was served. Three staff were serving trays from the cart to residents in their rooms. At 8:40 AM, the last resident tray had been served and the test tray was sampled. The Scrambled Eggs had a slight green tinge and air holes on surface. The appearance of the eggs was not attractive. The eggs tasted overcooked and had a slightly rubbery texture. The eggs were not hot. 12/01/2022 09:00 AM Results of the test tray findings were shared with the Dietary Manager, EI #11. EI #11 said there was an issue obtaining insulated plate lids, insulated plate underliners, and 4-oz. low profile bowls. This deficiency was written as a result of the investigate on of AL00042272.

Based on observation, interview, the facility's policy for Food Storage: Cold Foods, and the 2017 Food Code of the United States (U.S.) Public Health Service and U.S. Food and Drug Administration (FDA); the facility failed to ensure: 1.) the dishmachine drain did not extend down into the floor drain, thereby creating the potential for backflow; 2.) food in the Walk-in Cooler was not stored on shelves that were less than six inches from the floor and with accumulated debris on the floor beneath the shelves; and 3.) the surfaces of the dishmachine wall, the shelf beneath the dishtable, and the interior of two food delivery carts were clean. This had the potential to affect 130 of 130 residents receiving meals from the kitchen. Findings Include: 1.) The 2017 Food Code of the U.S. Public Health Service and the FDA included the following: . 5-402.11 BackflowPrevention. (A) . a direct conection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. On 11/30/2022 at 9:10 AM, Employee Identifier (EI) #10, the Registered Dietitian (RD), and EI #11, the Dietary Manager (DM), were present during the observation of the Dishwashing Machine area. The drain pipe from the dishwashing machine was observed to be extending into the floor drain. EI #10 agreed there should be an air-gap to prevent potential back-flow from the sewer into the dishmachine. On 11/30/2022 at 9:21 AM, EI #3, the Maintenance Director, measured the distance that the dishwashing machine drainpipe extended into floor drain. It was three inches from the floor level to the end of the drainpipe. On the same day 2:55 PM, EI #3 said he had checked his book and found that to avoid backflow, there needed to be at least a one inch gap between the drain and floor. 2.) The 2017 Food Code of the U.S. Public Health Service and the FDA included the following: . 3-305.11 Food Storage. (A) . FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm [centimeters] (6 inches) above the floor. The facility's policy for Food Storage: Cold Foods, dated April 20, 2018, included the following: . Policy Statement All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA Food Code. Procedures 1. All food items will be stored 6 inches above the floor . On 11/30/2022 at 12:48 PM, five shelving units in the Walk-in Cooler had bottom shelves at a level that was less than 6 inches from floor. In addition, built-up debris was on the floor underneath the shelving units. At 4:38 PM, EI #12, the Regional Dietary Manager, measured the distance from the Walk-in Cooler floor to the bottom shelving as 2 1/2 inches. 3.) The 2017 Food Code of the U.S. Public Health Service and the FDA included the following: . 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. . (C) NONFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an acculmulation of dust, dirt, FOOD residue, and other debris. On 11/30/2022 at 9:10 AM, EI #10, the RD, and EI #11, the DM, were present in the Dishwashing Machine area during an observation. There was a dark build-up on the wall and sink behind spray/scrap sink. When EI #11 was asked what the dark build-up was, EI #11 said mildew and further said it needed to be cleaned. The shelf beneath the dishtable on the dirty side of the dishwashing machine had a build-up of grime. EI #11 said this area also needed to be cleaned as the grime could attract roaches. On 11/30/2022 at 12:34 PM, during the lunch trayline, the interior of a food delivery cart was observed to have food particles on the bottom of the far left tray holding section and midway up on the door. On 12/01/2022 at 7:50 AM, during the breakfast trayline, four food delivery carts were checked. Some of the carts had stains, but only one had food particles. There were three particles/flakes of an apparent bread product on the inside floor of the cart.

Based on observation, interview, and the 2017 Food Code of the United States (U.S.) Public Health Service and U.S. Food and Drug Administration (FDA); the facility failed to ensure the dumpster area was not littered with unneeded or discarded equipment, which could provide harborage for vermin. This had the potential to affect 138 of 138 residents in the facility. Findings Include: The 2017 Food Code of the U.S. Public Health Service and FDA included the following: . 6-501.114 Maintaining Premises, Unnecessary Items and Litter. The PREMISES shall be free of: (A) Items that are unnecessary to the operation or maintenance of the establishment such as EQUIPMENT that is nonfunctional or no longer used; . On 11/30/2022 at 8:50 AM, the dumpster area was observed with Employee Identifier (EI) #10, the Registered Dietitian (RD). There were nine wooden pallets stacked up by the facility building across from dumpster area. A hospital-style bed frame and mattress were observed beside the garbage dumpsters. A wooden door was observed leaning against the retaining wall behind the dumpsters. EI #10 was asked if the pallets, bed frame, mattress, and door should be there. EI #10 said, No. When asked why those items should not be there, EI #10 said there would be the potential for unwanted critters. On 11/30/2022 at 9:31 AM, EI #3, the Maintenance Supervisor was interviewed. EI #3 said the bed frame, pallets, door, and mattress should not be out by the dumpsters. EI #3 said they were a hazard. EI #3 also agreed pests could harbor in those items.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and facility policy review, the facility failed to notify the responsible party for one of 34 sampled residents (Resident Identifier (RI) #74) of a change in medical treatment and new medical diagnosis. Specifically, an indwelling urinary catheter was inserted without notification of the responsible party. Findings include: Review of the facility's policy titled, Notification of Change in Patient/Resident Health Status dated June 2017 revealed the purpose, to ensure all interested parties are informed of the patient's/resident's change in health status so that a treatment plan can be developed which is in the best interest of the patient/resident. The policy revealed the facility would consult the resident's physician, nurse practitioner or physician assistant, and if known notify the patient representative when there was a change in . (B) Acute illness or a significant change in the resident's physical, mental, or psychosocial status. Notification will be immediate. (i.e., Life threatening conditions are such things as a heart attack or stroke. Clinical complications are such things as development of a new pressure injury, onset or recurrent periods of delirium, recurrent urinary tract infection, or persistent decline in psycho social status) (C) A need to alter treatment significantly (i.e., a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). Depending on the nursing assessment appropriate notification may be immediate to 48 hours. Review of the undated admission Record, in the electronic medical record (EMR) under the Profile tab revealed RI #74 was admitted to the facility on [DATE] with diagnoses including unspecified dementia without behavioral disturbance, mixed incontinence, and weakness. RI #74's responsible party and primary emergency contact was RI #74's family member. Review of the undated admission Record, revealed a diagnosis of neuromuscular dysfunction of the bladder was added on 11/18/20. Review of the Quarterly Minimum Data Set (MDS') with an Assessment Reference Date (ARD) of 03/11/21, in the EMR under the MDS tab, revealed the resident was unable to complete the Brief Interview for Mental Status test. Staff assessed the resident as not having spoken, being rarely/never understood and being rarely/never able to understand. The resident had short and long-term memory impairment and was severely impaired in decision making. RI #74 was totally dependent on one person for toileting assistance. The MDS indicated that an indwelling urinary catheter was in use. Review of Physician's Order in the EMR under the Orders tab revealed a Foley catheter was initially prescribed on 11/18/20 for diagnoses of neurogenic bladder with incontinence and unstageable sacral wound. During an interview on 06/22/21 at 02:25, RI #74's family member stated RI #74 was on hospice, indicating the resident had early onset of Alzheimer's disease and was currently very demented and unable to communicate her needs. RI #74's family member stated she was not informed by the facility when the indwelling urinary catheter was inserted and was not informed why the catheter was necessary. RI#74's family member stated that the resident did not have a history of urinary retention. RI #74's family member stated that he/she wanted to be apprised of changes in the resident's care. Review of the nursing Progress Notes in the EMR under the Progress Notes tab did not include documentation of RI #74's family member being notified of the indwelling urinary catheter placement or of the new diagnoses of neurogenic bladder and neuromuscular dysfunction of the bladder. During an interview on 06/24/21 at 10:38 AM, Employee Identifier (EI) #20, Registered Nurse (RN) (charge nurse) stated she did not remember notifying RI #74's family member of the catheter placement. EI #20 indicated he/she had reviewed RI #74's medical record and stated, We have no documentation we notified the family of the catheter placement. EI#20, indicated the responsible party should have been notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, document review and review of the Long-Term Care Resident Assessment Instrument, the facility coded the MDS incorrectly for two of 34 residents, Resident Identifier (RI) #75 and 32. Specifically, RI#75 was not coded as receiving hospice services and RI#32 was coded as not being administered an antipsychotic medication. Findings include: Review of a document provided by EI#7 dated 06/23/21 revealed, The MDS Department follows the guidelines for Significant Change Assessments and Care plans set forth in the CMS [Center for Medicare and Medicaid Services] RAI [Resident Assessment Instrument] [NAME] (sic). Review of the Long Term Care Resident Assessment Instrument 3.0 User's Manual, dated October 2019, indicated, The RAI process has multiple regulatory requirements. require that (1) the assessment accurately reflects the resident's status. 1. Review of RI#75's admission Record located under the Profile Tab in the electronic medical record (EMR) indicated the resident was admitted to facility on 01/10/14. Review of the resident's Physician Orders located under the Orders tab of the EMR revealed on 02/24/21 the resident was admitted to hospice with a diagnosis of failure to thrive. Review of the Significant Change Minimum Data Set (MDS) with an Assessment Review Date (ARD) of 03/04/21 revealed the resident was not coded as receiving hospice services under Section O Special Treatment, Procedure and Programs. During an interview with the Employee Identifier (EI) #7, MDS Coordinator on 06/24/21 at 3:37 PM, when asked about coding hospice for the March 2021 significant change MDS, he/she stated it should have been coded. 2. Review of RI #32's EMR undated Face Sheet under the face sheet tab revealed RI #32 was admitted to the facility on [DATE] with diagnosis including psychoactive substance dependence, and in 2019 was diagnosed with adjustment disorder with mixed anxiety and depressive mood. Review of RI #32's quarterly MDS with an ARD of 03/19/21 under the MDS tab revealed RI #32 Brief Interview for Mental Status (BIMS) score was 15 which indicated resident was cognitively intact. There were no behaviors or psychosis documented. The MDS indicated that RI #32 had not received antipsychotic medication during the seven-day assessment period from 03/12/21 through 03/19/21. Review of RI #32's EMR Clinical Physician Orders dated from 04/20/12 through June 2021 under the orders tab revealed RI #32 was prescribed Abilify (an antipsychotic medication) routine daily starting 10/01/19 and continued to the current active medication orders (June 2021). Review of RI #32's EMR Medication Administration Record (MAR) dated for the month of March 2021 under the orders tab verified RI #32 had received the antipsychotic medication Abilify daily during the MDS assessment reference period and the entire month of March 2021. During an interview on 06/24/21 at 3:45 PM, EI#7 confirmed she had incorrectly coded the March quarterly MDS and that she should not have documented a zero under antipsychotic medications received during the look back period. EI#7 stated that RI #32 had received seven days of the antipsychotic medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, document review and record review, the facility failed to develop a plan of care for three (Resident Identifier (RI) #32, RI#74 and RI#75) of 34 residents reviewed for care plans. Specifically, RI #32 was prescribed Abilify, an antipsychotic medication without developing and identifying specific target behavior/s and non-pharmacological interventions for the use of the medication. RI#74 care plan did not reflect interventions for the care of the resident with limited Range of Motion (ROM) and contractures. RI#75's care plan did not address that the resident had an indwelling urinary catheter and the intervention that nursing staff were to provide catheter care per shift and PRN (as needed). Findings include: Review of a document provided by EI#7, dated 06/23/21 indicated, The MDS Department follows the guidelines for Significant Change Assessments and Care plans set forth in the CMS [Center for Medicare and Medicaid Services] RAI [Resident Assessment Instrument] Manual (sic). 1. Review of RI #32's electronic medical record (EMR) undated Face Sheet under the face sheet tab revealed RI #32 was admitted to the facility on [DATE] with diagnosis including psychoactive substance dependence, and in 2019 was diagnosed with adjustment disorder with mixed anxiety and depressive mood. Review of RI #32's EMR annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/20/20 under the MDS tab revealed RI #32's Brief Interview for Mental Status (BIMS) score of 14 which indicated he/she was cognitively intact. RI #32 received an antipsychotic medication routinely for seven-days during the assessment period and was indicated to have depression listed under psychiatric/mood disorder. The MDS documented RI #32 had no behaviors or psychosis. Review of RI #32's EMR quarterly MDS with an ARD of 03/19/21 under the MDS tab revealed RI #32's BIMS score was 15 which indicated that he/she was cognitively intact with a psychiatric/mood diagnosis of depression. There were no behaviors or psychosis documented. Review of RI #32's EMR Clinical Physician Orders dated from 04/20/12 through June 2021 under the orders tab revealed RI #32 was prescribed Abilify (an antipsychotic medication) routine daily starting 10/01/19 and continued to the current active medication orders (June 2021). Review of RI #32's EMR Care Plan under the care plan tab with various dates revealed RI #32 had a care plan for the use of an antipsychotic medication. The care plan problem and goal were as follows; .02/03/20 Potential for drug related complications associated with the use of psychotropic medications related to antipsychotic medication .the goal RI #32 will be free of psychotropic drug related complications and the target date was for 01/15/21. The care plan interventions were as follows: . 02/03/20 Observe for side effects and report to physician ., 09/13/19 Psychotropic medication risk/benefit and reduction plan as recommended by physician and pharmacist, 09/13/19 Refer to psychologist/psychiatrist for medication and behavior intervention recommendations . During an interview on 06/24/21 at 3:45 PM, EI#7, MDS Coordinator confirmed RI #32's care plan should have been developed to reflect target behavior/s and non-pharmacological interventions related to the use of psychotropic medications specifically, an antipsychotic medication. 2. Review of the undated admission Record, in the EMR under the Profile tab revealed RI #74 was admitted to the facility on [DATE]. Review of the Clinical Physician's Orders in the EMR under the Orders tab revealed RI #74 was admitted to hospice on 05/19/20. Review of the Significant Change MDS with an ARD of 06/26/20, located in the EMR under the MDS tab, revealed the resident had impaired ROM to both of his/her upper extremities (shoulder, elbow, wrist, hand). The resident was not receiving any physical therapy (PT), or occupational therapy (OT) and he/she was not on a restorative nursing program for provision of ROM exercises or splint/brace assistance. Review of the Quarterly MDS, with an ARD of 03/11/21, located in the EMR under the MDS tab, revealed RI #74 now had impairment in ROM on both sides to the upper and lower extremities. The resident received no therapy (PT or OT) and was not on a restorative nursing program such as the provision of ROM exercises or splint/brace assistance. Review of the Care Plan revised on 08/26/19, in the EMR under the Care Plan tab, revealed a focus of, Physical functioning deficit related to: Mobility impairment, Self-care impairment, Dementia, Contractures present, Osteoarthritis. Although the contractures were identified on the care plan, the location of the contractures was not identified and there were no interventions to address the contractures or to prevent further decline. During an interview on 06/24/21 at 4:01 PM, EI#7 stated there should be interventions care planned for RI#74's limited ROM and contractures. 3. Review of RI#75's Physicians Orders found in the EMR under the Orders Tab indicated on 11/12/20, the Medical Director ordered, Insert straight catheter every 8 hours to monitor for urinary retention. On 01/02/21, the Physician Order, indicated, foley catheter care every shift and PRN. Review of the quarterly MDS with an ARD of 02/04/21 and 06/04/21 indicated that RI#75 had an indwelling urinary catheter. Review of RI#75's care plan, found under the Care Plan tab of the EMR, indicated on 11/06/20 a care plan Focus for Alteration in elimination of bowel and bladder intermittent catheter for urinary retention was initiated. The care plan was not revised when the indwelling foley catheter was inserted. Interview with Employee Identifier (EI) #7 on 06/24/21 03:37 PM, stated the resident received an order for an indwelling urinary catheter in January. When asked should the care plan have been updated, he/she stated, Absolutely it should have been updated in January.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, document review and record review, the facility failed to ensure two of 34 sampled residents requiring assistance with activities of daily living (ADLs) (Resident Identifier (RI) #93 and RI#32) and one supplemental resident who wished to remain anonymous received their scheduled baths. Findings include: 1. Review of the undated admission Record located in the electronic medical record (EMR) under the Profile section, revealed RI #93 was admitted to the facility on [DATE] with diagnoses including multifocal leukoencephalopathy (progressive viral disease of the central nervous system), cerebral infarction (stroke), hemiplegia (complete loss of strength or paralysis on one side of the body), muscle weakness, and lack of coordination. Review of the Care plan dated 04/06/18 in the EMR under the Care Plan tab revealed the focus area of Physical functioning deficit related to: Mobility impairment, Self-care impairment, Progressive Multifocal Leukoencephalopathy, Epilepsy, Muscle weakness, Lack of Coordination, and Paralysis of the lower extremities. The goal was for the resident to maintain his current level of functioning. Approaches included providing extensive assistance with dressing and hygiene, encouraging choices with care, and reporting changes in physical functioning abilities. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/14/21, located in the EMR under the MDS tab, revealed RI #93 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating the resident was cognitively intact. The resident had no mood or behavioral indicators. RI #93 required extensive assistance of one staff for personal hygiene and required physical help from one person for bathing. During an interview on 06/21/21 at 1:22 PM, RI #93 stated that he/she needed assistance with activities of daily living due to a stroke that resulted in weakness to his/her left side. RI #93 stated he/she did not receive baths/showers in accordance with his/her bath/shower schedule. He/she stated he/she preferred three showers a week per the schedule, but might get two. He/she stated if the facility was short of staff, he/she did not get his/her baths/showers. Review of the undated Shower Schedule for Each Unit revealed all residents were to be bathed three times a week either on Monday, Wednesday and Friday or on Tuesday, Thursday and Saturday. Showers were based on the resident's room number and bed assignment. Half of the residents were to be bathed on the 7:00 AM - 3:00 PM shift and half on the 3:00 PM - 11:00 PM shift Review of the Follow Up Question Report dated 04/01/21 - 05/31/21 revealed RI #93 received a total of three bed baths and that he/she received no showers or tub baths during this two-month period. Review of the Follow Up Question Report dated 06/01/21 - 06/24/21 revealed RI #93 received a total of seven bed baths and that he/she did not receive any showers or tub baths during this 24-day period. During an interview on 06/23/21 at 11:44 AM, Employee Identifier (EI)#23, Certified Nurse Assistant (CNA) stated RI #93 had no cognitive impairment. EI#23 stated there were no assigned bath aides and the CNAs gave the residents baths as part of their assignments. EI#23 stated residents were scheduled for three baths/showers per week according to their room numbers, however, when staffing was short, residents might not get their baths. EI#23, stated that the CNAs documented in the kiosk when baths were given. During an interview on 06/24/21 at 4:26 PM, EI#2, Director of Nursing (DON) confirmed that the bath/shower records did not illustrate the resident had received any showers from 04/01/21 - 06/23/21. EI#2 stated, The records are not complete but that is all we have. 2. During an interview on 06/21/21 at 3:38 PM, a resident who requested to remain anonymous stated he/she did not always get her baths, especially on evening shift when the facility was short staffed. This resident resided on the 4th floor. 3. Review of RI #32's EMR undated Face Sheet under the face sheet tab revealed RI #32 was admitted to the facility on [DATE]. Review of RI #32's EMR annual MDS with an ARD of 07/20/20 under the MDS tab revealed RI #32's BIMS score was a 14 which indicated he/she was cognitively intact. It was documented bathing was a very important daily preference to RI #32 and he/she required supervision to limited assist of one staff member for bathing and dressing. Review of RI #32's EMR quarterly MDS with an ARD of 03/19/21 under the MDS tab revealed RI #32's BIMS score was 15 which indicated he/she was cognitively intact with a psychiatric/mood diagnosis of depression. It was documented RI #32 required partial to limited staff assist with daily bathing and dressing. Review of RI #32's EMR Care Plan under the care plan tab with various dates revealed RI #32 had a care plan problem developed for physical functioning deficit dated 09/13/19 with a goal dated 07/17/21 to improve current level of functioning. The interventions were as follows: .Personal hygiene extensive assistance . Review of RI #32's Follow Up Question Report for ADL Bathing documentation provided by the facility dated from April 2021 to June 2021 revealed RI #32 had received no showers and three full bed baths provided. In the month of May 2021 RI #32 had received no showers, one partial, and one full bed bath provided. In the month of June 2021 RI #32 had received one shower, two partial, and four full bed baths provided. During an interview on 06/21/21 at 11:45 AM, RI #32 stated he/she had a complaint that he/she only received showers once weekly if that much and, on most weeks, it was due to short staffing. RI #32 stated his/her preference was evening showers and the evening shift was the shortest staffed. Review of the Shower Schedule undated and provided by the facility (Not located in the EMR) revealed RI #32's shower was scheduled for the evening shift. Further review of RI #32's Follow Up Question Report for ADL Bathing documentation dated from April 2021 through June 2021 revealed no showers or baths completed were provided on the evening shift. During an interview on 06/24/21 at 12:40 PM, EI#20-,Registered Nurse (RN), who was designated the Unit Manager of RI #32's wing, confirmed RI #32 was accurate, he/she had not been receiving showers as scheduled. EI#20 stated RI #32 was independent with staff set up and RI #32 could wash his/her upper body himself/herself with only supervision. EI#20 confirmed the facility considered a bed bath the same as receiving a shower. EI#20 stated according to his/her understanding RI #32 preferred a shower but would accept a bed bath. During an interview on 06/24/21 at 5:05 PM, RI #32 stated that he/she would agree that most of the missed showers were due to agency staff not doing the showers versus them just not getting done in general. RI #32 stated he/she had not in the past informed the Unit Manager when he/she had not received his/her shower. He/she stated he/she did not mind getting a bed bath but would like to have a shower every now and then. A shower/bath policy was requested on 06/24/21, however, a policy was not provided as of the facility exit on this date.

Based on record review, document review and interview, the facility failed to provide an ongoing program to support residents in their choice of activities designed to meet the interests of and support the well-being of each resident for three of 34 residents, Resident Identifier (RI) #'s 85, 39 and 53, reviewed for activities. Findings include: During an interview on 06/21/21 at 10:30 AM, RI#85 stated that there have not been any activities offered since the majority of the Coronavirus Disease 2019 (COVID-19) restrictions have been lifted. RI #85 stated he/she missed the church services that used to occur on site and being taken on outings. During an interview on 06/21/21 at 10:45 AM, RI #39 stated that he/she would like the opportunity to participate in activities since COVID-19 was not such an issue at this time. During an interview on 06/21/21 2:00 PM, RI #53 stated that he/she missed the morning social (10:00 AM-11:00 AM) that would occur in the main dining room. RI# 53 stated that residents could get together, drink coffee and have a snack. RI #53 stated that the residents have missed playing BINGO and winning prizes. RI #53 stated that during COVID-19 staff would come by with a cart and offered residents various activities they could do in their rooms, but even that activity has not been occurring. During an interview on 06/23/21 at 9:35 AM with Employee Identifier (EI) #4, the Activities Director (AD) explained that prior to COVID-19 and more recently, the facility did provide holiday celebrations for the residents. During an interview on 06/23/21 at 10:00 AM with EI#2, the Director of Nursing (DON) stated that throughout COVID-19 nursing staff did conduct some activities for the residents. EI#1, Administrator provided a document titled, Diversicare of Bessemer Activities Program March 2020 through May 2021 which indicated, Activities for the Center have been composed of those activities that could be accomplished with social distancing, frequent hand hygiene and appropriate personal protective equipment in place .Activity books and games were placed in rooms for personal use. Music and entertainment that could be conducted from the hallway for all to enjoy were implemented at varied intervals .Nurses and Certified Nursing Assistants worked to present special moments to the residents on all floors. Theme party or a Seasonal celebration provided additional time for residents to enjoy laughter, songs . EI #1 provided a written statement from EI#25, Social Services Director, dated 06/23/21 which indicated, .Checking in with residents to ensure that they were coping as well as could be expected. Assisting the residents with telephones calls to family using social worker's cell phone and/or facility's cordless phones to talk and/or face time. If requested (although always suggested) arrange weekly zoom calls .Social worker would also offer and provide residents with the MP3s to listen to music of their choice. Social worker also had a supply of activity booklets related to resident rights .which was passed out .Staff would make religious service available to residents through their TVs, radios, or the facility's .Family would call facility to set a time that they could come and see their loved ones (through window visits) . EI #1 provided a written statement by EI#26, Director of Care Coordination, dated 06/23/21 which indicated, Zoom calls were held weekly on Thursdays and as requested any other day during the week by residents or their family members . I oversaw the Zoom calls schedule and assigned them to be set up for the residents and conducted by the speech therapists .There would be approximately 10-12 Zoom calls on the scheduled Thursday.

Based on interview and document review, the facility failed to support the residents' right to participate in a resident group by not restarting the resident council meetings post Coronavirus Disease 2019 (COVID-19). This deficient practice affected four residents in the sample of 34 (Resident Identifier (RI) #'s 85, 2, 39 and 53). Findings include: During an interview on 06/21/21 at 10:30 AM, Resident Identifier (RI) #85 stated he/she did attend Resident Council (RC) meetings prior to the COVID-19 pandemic, but there have not been any meetings held since they were discontinued due to the pandemic restrictions. During an interview on 06/21/21 at 10:40 AM, RI #2 stated he/she did attend RC meetings prior to the COVID-19 pandemic, but there have not been any meetings held since they were discontinued due to the pandemic. During an interview on 06/21/21 at 11:00 AM, RI #39 stated he/she did attend RC meetings prior to the COVID-19 pandemic, but the RC meetings have not been restarted post pandemic. During an interview on 06/21/21 at 2:30 PM, RI #53 stated he/she did attend RC meetings prior to the COVID-19 pandemic, but there have not been any meetings held since they were discontinued during the pandemic. RI #53 revealed he/she was the RC President. During an interview on 06/23/21 at 9:25 AM, Employee Identifier (EI) #4, the Activities Director stated that RC meetings have not been occurring to my knowledge. During an interview on 06/23/21 at 10:00 AM, EI #2, Director of Nursing (DON), E stated RC meetings were being held prior to COVID-19. Review of the RC Binder revealed the last recorded RC meeting was held March of 2020 with 10 residents in attendance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, document review, facility assessment, policy review and review of Centers for Medicare and Medicaid memo, the facility failed to ensure pharmacy services thoroughly reviewed the resident medication regimens to identify irregularities related to the use of psychotropic medications, and residents who were prescribed psychotropic medications received gradual dose reductions (GDR) or had a physician documented clinical rationale for the continued use of the psychotropic medication for four (Resident Identifier (RI) #32, RI#76, RI#75 and RI#18) of five residents reviewed for unnecessary psychotropic medication. Findings include: 1. Review of RI #32's electronic medical record (EMR) undated Face Sheet under the face sheet tab revealed RI #32 was admitted to the facility on [DATE]. Review of RI #32's EMR annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/20/20 under the MDS tab revealed RI #32's Brief Interview for Mental Status (BIMS) score was a 14 which indicated he/she was cognitively intact. RI #32 received an antipsychotic, antidepressant, and antianxiety medication routinely for seven-days during the assessment period and was indicated to have depression listed under psychiatric/mood disorder. It was documented RI #32 had no behaviors or psychosis. Review of RI #32's EMR quarterly MDS with an ARD of 03/19/21 under the MDS tab revealed RI #32's BIMS score was 15 which indicated that he/she was cognitively intact with a psychiatric/mood diagnosis of depression. It was documented RI #32 received an antidepressant and antianxiety medication routinely for seven-days during the assessment period and was indicated to have depression under psychiatric/mood disorder. There were no behaviors or psychosis documented. There was no documentation RI #32 received an antipsychotic medication. Review of RI #32's EMR Medication Administration Record (MAR) dated for the month of March 2021 under the orders tab verified RI #32 had received the antipsychotic medication Abilify daily during the MDS ARD of 03/19/21 and for the entire month of March 2021. Review of RI #32's EMR Clinical Physician Orders dated from 04/20/12 through June 2021 under the orders tab revealed RI #32 was prescribed Abilify (an antipsychotic medication) routine daily starting 10/01/19 and continued to the current active medication orders (June 2021). Review of RI #32's EMR Care Plan under the care plan tab with various dates revealed RI #32 had a care plan for the use of an antidepressant, antianxiety, and antipsychotic medication. The care plan problem and goal were as follows; .02/03/20 Potential for drug related complications associated with the use of psychotropic medications .the goal RI #32 will be free of psychotropic drug related complications and the target date was for 01/15/21. The care plan interventions were as follows: .08/02/19 Monthly pharmacy review of medication regimen, 09/13/19 Psychotropic medication risk/benefit and reduction plan as recommended by physician and pharmacist . Review of RI #32's handwritten Physician's Orders located in the hard copy chart dated 06/03/21 revealed there was a physician order to discontinue Abilify 2 milligrams (mg) and start Abilify 5 mg every day (QD). There was no specification to which 2 mg Abilify order was to be discontinued. RI #32 had been prescribed Abilify 2 mg by mouth (PO) every night at hour of sleep (QHS) on 02/17/21 in addition to a prior order of Abilify 2 mg PO QD ordered on 12/04/20. Only one of the Abilify 2 mg orders was discontinued on 06/03/21 leaving one Abilify 2 mg order and the new Abilify 5 mg order for a total of 7 mgs of Abilify prescribed daily. This irregularity was not identified through pharmacy review or by the facility. Review of the facility's monthly Gradual Dose Reduction Tracking Report provided by the facility and completed by the pharmacy dated from January 2021 through May 2021 revealed there was no tracking report provided for the month of March 2021. The report detailed the following information: In January 2021 RI #32 was prescribed a routine antipsychotic medication for mood disorder starting on 10/01/19 with the next review for a GDR on 04/01/21. There was no pharmacy GDR consultation report provided for this medication review. In February 2021 RI #32 was prescribed a routine antipsychotic medication for mood disorder starting on 10/01/19 with the next review for a GDR on 04/01/21. There was no pharmacy GDR consultation report provided for this medication review. In April 2021 RI #32 was prescribed a routine antipsychotic medication for mood disorder starting on 10/01/19 with the next review for a GDR on 04/23/21. There was no pharmacy GDR consultation report provided for this medication review. In May 2021 RI #32 was prescribed a routine antidepressant medication for depression on 10/01/19, antipsychotic medication for mood disorder on 10/01/19, and an anxiolytic medication for anxiety on 12/04/20. The antidepressant next review for GDR was on 03/31/22, the antipsychotic next review for GDR was on 10/29/21, and the antianxiety next review for GDR was on 01/28/22. There were no pharmacy consultation reports provided for these medication reviews. Review of RI #32's pharmacy Consultation Report for GDR recommendations dated October 22, 2020, through October 25, 2020, revealed documentation that the pharmacy reviewed the following psychotropic medications: Abilify 1 mg QD, Elavil 25 mg QHS, Cymbalta 30 mg twice daily (BID), and Ambien 5 mg QHS. It was documented the physician declined the GDR without an appropriate clinical rationale to continue the prescribed medications. There were no GDR pharmacy consultation report recommendations for the dates of January 2021 through May 2021 to correlate with the dates of the monthly Gradual Dose Reduction Tracking Report. Review of RI #32's physician visit progress note with no title dated 01/13/21, located in the MISC section of the EMR revealed RI #32 was seen by the physician for a readmission from the hospital and annual review. The physician documented reviewing the antianxiety, antidepressant and antipsychotic medications and the plan stated the medication to be continued, consider taper or adjustment if patient tolerates and psych consult as needed. The goal documented was the .member's depression will improve by goal target date 01/13/22 . There was no documentation of an attempted gradual dose reduction, no clinical rationale for continuing the psychotropic medications and no assessment of the resident's identified target behaviors related to the prescribed medications. Review of RI #32's physician visit progress notes with no title dated 02/15/21, 03/12/21, 03/23/21, 04/26/21, 05/20/21, 05/24/21, and 06/07/21, revealed there was no documentation of attempted gradual dose reduction for the prescribed psychotropic medications, no clinical rationale for continuing the psychotropic medications and no assessment of the resident's identified target behaviors related to the prescribed medications. During an interview on 06/24/21 at 2:47 PM, the Medical Director (MD) confirmed RI #32's Abilify medication was generally used for specific type of diagnoses such as schizophrenia and bipolar disorder and stated RI #32 did not have those diagnoses. The MD stated due to the COVID pandemic the main concern was making sure the residents were doing well emotionally and he/she had not wanted to make any unnecessary medication changes and the goal was to not be too aggressive. In regard to RI #32's prescribed medication Abilify and the discrepancy with the written Abilify order in June 2021, the MD stated the 4 mg dose had to be ordered for once a day and did not come in a 4 mg tablet, so he/she had to order the 5 mg tablet daily. The MD stated he/she was not aware the facility had not discontinued both of the prior 2 mg daily orders. The MD confirmed the intention was not for the resident to be prescribed a total of 7 mg daily and stated that was facility and pharmacy error and confirmed the order should have been clarified. The MD stated RI #32 was originally placed on psychotropic medications by another physician and that physician was a psychiatrist from the community prior to RI #32's admission to the facility. The MD stated the community physician knew RI #32 well and had treated him/her for psychiatric depression. The MD stated it was his/her opinion that was why RI #32 was placed on the Abilify antipsychotic medication in the first place. 2. Review of RI #76's undated Face Sheet in the EMR revealed the resident was admitted on [DATE] with diagnoses including: cellulitis of right below the knee amputation/stump, muscle weakness, unsteady gait and falls. Review of a scanned physicians progress note found in the MISC tab of the EMR and dated 04/05/21 revealed the MD was RI#76's attending physician. Review of RI#76's gero-psychiatric evaluation dated 02/20/21 indicated RI#76 reported no history of mental health treatment prior to this assessment. The psychiatrist added Trazadone (an antidepressant/sedative medication) to aid in sleep and recommended supportive treatment .follow up 1-2 months . There were no other psychiatric notes located in the medical record review. Review of RI#76's Physician Orders under the Orders tab, in the EMR for the months of January 2021 through June 2021 revealed the resident was prescribed the following psychotropic medications: Prozac (anti-anxiety medication) 20mg daily for depression (not included in diagnoses list); Seroquel (anti-psychotic medication) 150mg daily for behavioral disturbances and acute agitation. There was no appropriate psychiatric diagnosis for RI#76's use of an antipsychotic medications: Trazadone (antidepressant medication) 150mg at bedtime for depression/sleep; -Trileptal (anti-seizure medication) 600mg twice daily for mood. There was no indication in the medical record review that RI #76 had seizures; and Zyprexa (antipsychotic medication) 10mg twice daily for agitation. There was no psychiatric diagnosis for RI#76's use of an antipsychotic medication. Review of the consultant pharmacy monthly reviews for RI#76 titled, Gradual Dose Reduction Tracking Report from the resident's admission in January 2021 through the current survey in June 2021 revealed the following: February 26, 21 - revealed the pharmacy requested a diagnosis (required for antipsychotics) to support the use of the Seroquel. March 30, 21 - again, the pharmacy requested a supporting psychiatric diagnosis. April 26, 21 - the request for a supporting diagnosis had not been answered. May 27, 21 - the physician added an additional antipsychotic (Zyprexa). There continued to be no supporting psychiatric diagnosis to support the use of antipsychotics. Additionally, on this report the pharmacist noted the MD had also added Prozac on 05/20/21. Prozac is a Selective Serotonin Reuptake Inhibitor/SSRI a psychoactive medication used to treat depression, obsessive-compulsive disorder, bulimia, and panic disorder. RI#76 did not have a diagnosis to support the use of Prozac. The MD also added Trileptal on 05/20/21 for mood. Trileptal is an anticonvulsant medication but has been used off label to modify mood/behaviors. RI#76 had no diagnoses of mood disorders or of seizures/convulsions. A phone interview on 06/24/21 at 12:00 PM, with the Consultant Pharmacist revealed she did not believe there were specific pharmacy policies for performing GDRs. The Consultant Pharmacist stated, .we try to go slow and stay low with respect to psychoactive medications. When asked if she followed up with the physician when the pharmacy recommendations went unanswered, the Consultant Pharmacist stated, No. 3. Review of RI# 75's admission Record located in the EMR indicated the resident was admitted to facility on 01/10/14 with a diagnosis that included but not limited to Alzheimer, dementia without behavioral disturbance, and anxiety disorder. Review of RI#75's Physician Orders located under the Orders Tab of the EMR for May 2021 and June 2021 revealed the resident was prescribed Seroquel. Further review of the Physician Order, found under the Orders Tab of the EMR, dated 11/18/20, documented, Seroquel tablet 100 mg. Give one tablet at bedtime related to unspecified dementia without behavioral disturbance. On 04/13/21, RI#75 was ordered Seroquel tablet 100mg. Give one 50 mg every morning and at bedtime related to unspecified Dementia without behavioral disturbance. During an interview with the Consultant Pharmacist on 06/24/21 at 12:09 PM, the Pharmacist stated that on April 26, 2021, she completed a recommendation to clarify the diagnosis of dementia without behavioral disturbance and to change the diagnosis to dementia with behavioral disturbances if he/she was having behaviors. When asked if he/she thought the diagnosis was appropriate indication for use [for the antipsychotic], EI#24 stated, I think so if the resident is on an antipsychotic for dementia with behavioral disturbance. Review of the Gradual Dose Reduction Tracking Report, provided by the facility revealed RI#75 was reviewed for use of antipsychotic medication on 12/17/21, 01/26/21 and 02/26/21. Further review of the Consultation Report completed by the Consultant Pharmacist and provided by the facility, indicated there was a recommendation to discontinue the as needed order for the medication Seroquel due to antipsychotic medications can only be limited to 14 days. This was the only Consultation Report the facility was able to provide. 4. Review of RI #18's undated Face Sheet in the EMR revealed RI #18 was admitted on [DATE] with diagnoses of adjustment disorder with depressed mood, unspecified dementia with behavioral disturbance, anxiety disorder due to known physiological condition, traumatic brain injury. Review of RI #18's admission MDS with an ARD dated 03/09/21 revealed RI #18 was moderately cognitively impaired with no behaviors. RI #18 was independent with activities of daily living. RI #18 received an anti-psychotic medication during the assessment period. Review of RI #18's EMR annual MDS with an ARD of 03/09/21 under the MDS tab revealed RI #18's BIMS score was a 11 which indicated he/she was moderately cognitively impaired. RI #18 received an antipsychotic, antidepressant, and antianxiety medication routinely for seven-days during the assessment period. It was documented RI #18 had no behaviors or psychosis. Review of RI #18's EMR Order Summary Report dated 06/24/21 under the orders tab revealed RI #18 was prescribed Seroquel routine daily starting 03/19/20 and continued to the current active medication orders (June 2021). Review of RI #18's EMR Care Plan under the care plan tab with the target date of 06/22/21 revealed RI #18 had a care plan for the use of an antidepressant, antianxiety, and antipsychotic medication. The care plan problem and goal were as follows; .revision date 04/26/21 Potential for drug related complications associated with the use of psychotropic medications .the goal RI #18 will be free of psychotropic drug related complications and the target date was for 09/20/21. The care plan interventions were as follows: .05/07/17 Monthly pharmacy review of medication regimen, 05/07/17 Medication risk/benefit and reduction plan as recommended by physician and pharmacist . During an interview on 06/24/21 at 12:05 PM, the Consultant Pharmacist stated that EI#2, Director of Nursing (DON) should have the paper copies of the gradual dose reduction request she made for RI #18 for the dates of 08/11/20, 12/16/20 and 04/26/21. During an interview on 06/24/21 at 3:55 PM, EI #2 stated she could not locate the GDR requests made by the Consultant Pharmacist for RI #18 for the dates of 08/11/20, 12/16/20 and 04/26/21. Review of RI #18's physician's visit progress notes with no title dated 02/22/21 and 03/22/21 revealed there was no documentation of attempted gradual dose reduction for the prescribed psychotropic medications, no clinical rationale for continuing the psychotropic medications and no assessment of the resident's identified target behaviors related to the prescribed medications. Review of the Facility Assessment Tool dated/reviewed on 06/04/21 revealed under the Mental Health and Behavior section, Manage the medical condition and medication-related issues causing psychiatric symptoms and behaviors, identify and implement interventions to help support individuals with these issues . Under the Medications section of the assessment indicated, .Assessment/management of polypharmacy is important. Gradual dose reduction is done on antipsychotic medications, antianxiety medications, antidepressant medications, anxiolytics/antianxiety and hypnotics. Review of Centers for Medicare and Medicaid S&Q Memo Ref 13-35-NH dated May 24, 2013 revealed: . When antipsychotic medications are used without an adequate rationale, or for the purpose of limiting or controlling behavior of an unidentified cause, there is little chance that they will be effective. In addition, they commonly cause complications such as movement disorders, falls, hip fractures, cerebrovascular adverse events (cerebrovascular accidents and transient ischemic events) and increased risk of death . Review of the undated facility's policy titled, Antipsychotic Reduction Guide indicated that the facility would establish a quality committee to monitor all antipsychotic medications at least monthly and consider tapering or discontinuing the use of antipsychotic medication in the residents that do not exhibit behaviors. The facility provided a letter dated 06/23/21 which indicated the facility did not have a psychotropic medication policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, review of the facility's assessment, review of the manufacturer's guidelines for medication use, review of Centers for Medicare and Medicaid Services memo and review of the facility's policies and procedures, the facility failed to ensure that four of five residents (Resident Identifier (RI) #18, RI#32, RI#75, and RI#76) were free from unnecessary psychotropic medications. Specifically, an antipsychotic and psychoactive medications were used by the facility without an attempted gradual dose reduction (GDR), proper medical rationale, proper indication for use, and the lack of /or behavior and side effect monitoring. Additionally, residents received PRN (as needed) anti-anxiety medication for more than 14 days without proper medical rationale and/or indication for use. Findings include: Review of Centers for Medicare and Medicaid S&Q Memo Ref 13-35-NH dated May 24, 2013 revealed: . The problematic use of medications, such as antipsychotics, is part of a larger, growing concern. This concern is that nursing homes and other settings (i.e., hospitals, ambulatory care) may use medications as a quick fix for behavioral symptoms or as a substitute for a holistic approach that involves a thorough assessment of underlying causes of behaviors and individualized, person-centered interventions . When antipsychotic medications are used without an adequate rationale, or for the purpose of limiting or controlling behavior of an unidentified cause, there is little chance that they will be effective. In addition, they commonly cause complications such as movement disorders, falls, hip fractures, cerebrovascular adverse events (cerebrovascular accidents and transient ischemic events) and increased risk of death . Review of the facility's Facility Assessment Tool dated/reviewed on 06/04/21 revealed under the Mental Health and Behavior section, Manage the medical condition and medication-related issues causing psychiatric symptoms and behaviors, identify and implement interventions to help support individuals with these issues .Under the Medications section of the assessment indicated, .Assessment/management of polypharmacy is important. Gradual dose reduction is done on antipsychotic medications, antianxiety medications, antidepressant medications, anxiolytics/antianxiety and hypnotics . 1. Review of RI #32's electronic medical record (EMR) undated Face Sheet under the face sheet tab revealed RI #32 was admitted to the facility on [DATE]. Review of RI #32's EMR annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/20/20 under the MDS tab revealed RI #32's Brief Interview for Mental Status (BIMS) score was a 14 which indicated he/she was cognitively intact. RI #32 received an antipsychotic, antidepressant, and antianxiety medication routinely for seven-days during the assessment period and was indicated to have depression listed under psychiatric/mood disorder. It was documented RI #32 had no behaviors or psychosis. Review of RI #32's EMR quarterly MDS with an ARD of 03/19/21 under the MDS tab revealed RI #32's BIMS score was 15 which indicated he/she was cognitively intact with a psychiatric/mood diagnosis of depression. It was documented RI #32 received an antidepressant and antianxiety medication routinely for seven-days during the assessment period and was indicated to have depression under psychiatric/mood disorder. There were no behaviors or psychosis documented. There was no documentation RI #32 received an antipsychotic medication. Review of RI #32's EMR Medication Administration Record (MAR) dated for the month of March 2021 under the orders tab verified RI #32 had received the antipsychotic medication Abilify daily during the MDS ARD of 03/19/21 and for the entire month of March 2021. Review of RI #32's EMR Clinical Physician Orders dated from 04/20/12 through June 2021 under the orders tab revealed RI #32 was prescribed Abilify (an antipsychotic medication) routine daily starting 10/01/19 and continued to the current active medication orders (June 2021). Review of RI #32's handwritten Physician's Orders located in the hard copy chart dated 06/03/21 revealed there was a physician order to discontinue Abilify 2 milligrams (mg) and start Abilify 5 mg every day (QD). There was no specification to which 2 mg Abilify order was to be discontinued. RI #32 had been prescribed Abilify 2 mg by mouth (PO) every night at hour of sleep (QHS) on 02/17/21 in addition to a prior order of Abilify 2 mg PO QD ordered on 12/04/20. Only one of the Abilify 2 mg orders was discontinued on 06/03/21 leaving one Abilify 2 mg order and the new Abilify 5 mg order for a total of 7 mgs of Abilify prescribed daily. This irregularity was not identified through pharmacy review or by the facility until the re-certification survey from 06/21/21 through 06/24/21. Review of the facility's monthly Gradual Dose Reduction Tracking Report provided by the facility and completed by the pharmacy dated from January 2021 through May 2021 revealed there was no tracking report provided for the month of March 2021. The report detailed the following information: In January 2021, RI #32 was prescribed a routine antipsychotic medication for mood disorder starting on 10/01/19 with the next review for a GDR on 04/01/21. There was no pharmacy GDR consultation report provided for this medication review. In February 2021, RI #32 was prescribed a routine antipsychotic medication for mood disorder starting on 10/01/19 with the next review for a GDR on 04/01/21. There was no pharmacy GDR consultation report provided for this medication review. In April 2021, RI #32 was prescribed a routine antipsychotic medication for mood disorder starting on 10/01/19 with the next review for a GDR on 04/23/21. There was no pharmacy GDR consultation report provided for this medication review. In May 2021, RI #32 was prescribed a routine antidepressant medication for depression on 10/01/19, antipsychotic medication for mood disorder on 10/01/19, and an anxiolytic medication for anxiety on 12/04/20. The antidepressant next review for GDR was on 03/31/22, the antipsychotic next review for GDR was on 10/29/21, and the antianxiety next review for GDR was on 01/28/22. There were no pharmacy consultation reports provided for these medication reviews. Review of RI #32's pharmacy Consultation Report for GDR recommendations dated October 22, 2020, through October 25, 2020, revealed documentation that the pharmacy reviewed the following psychotropic medications: Abilify 1 mg QD, Elavil 25 mg QHS, Cymbalta 30 mg twice daily (BID), and Ambien 5 mg QHS. It was documented the physician declined the GDR without an appropriate clinical rationale to continue the prescribed medications. There were no GDR pharmacy consultation report recommendations for the dates of January 2021 through May 2021 to correlate with the dates of the monthly Gradual Dose Reduction Tracking Report. Review of RI #32's EMR General and Weekly Nurses Notes located under the Progress Notes tab dated from 01/04/21 through 06/04/21 revealed there was no documentation of RI #32's behaviors related to the routine use of multiple psychotropic medications. Review of RI #32's physician visit progress note with no title dated 01/13/21, located in the MISC (miscellaneous) tab of the EMR revealed RI #32 was seen by the physician for a readmission from the hospital and annual review. The physician documented he was reviewing the antianxiety, antidepressant and antipsychotic medications and the plan stated the medication to be continued, consider taper or adjustment if patient tolerates and psych consult as needed. The goal documented was the .member's depression will improve by goal target date 01/13/22 . There was no documentation of an attempted gradual dose reduction, no clinical rationale for continuing the psychotropic medications and no assessment of the resident's identified target behaviors related to the prescribed medications. Review of RI #32's physician visit progress notes with no title dated 02/15/21, 03/12/21, 03/23/21, 04/26/21, 05/20/21, 05/24/21, and 06/07/21, revealed there was no documentation of attempted gradual dose reduction for the prescribed psychotropic medications, no clinical rationale for continuing the psychotropic medications and no assessment of the resident's identified target behaviors related to the prescribed medications. During an interview on 06/23/21 at 12:10 PM, EI #20, Registered Nurse (RN) revealed RI #32 was alert and oriented times three and was up daily to the wheelchair out of his/her room socializing with other residents and staff. EI #20 stated in regard to behaviors, RI #32 had no behaviors such as yelling out, or anything negative towards others or harm to self. EI #20 stated when RI #32 had gone out to the hospital a while back he/she was having hallucinations and was more depressed, but not recently. EI #20 stated the reason the resident was prescribed an antipsychotic was for psychotic behaviors which RI #32 did not have any longer. EI #20 stated RI #32's depression goes up and down and RI #32 would cry a lot at times. EI #20 stated resident behaviors should be monitored daily and documented on the behavioral monitoring sheets kept in the narcotic binder on the medication cart. EI #20 stated sometimes the nurses would chart a behavior in the progress notes under the general note. EI #20 stated she wasn't aware of any recent GDRs related to RI #32's psychotropic medications. During an interview on 06/23/21 at 1:24 PM, RI #32 revealed he/she was alert and oriented and answered questions accurately and when asked how he/she was doing, RI #32 stated, I'm fine and feel pretty good. RI #32 stated he/she had no concerns related to medications. RI #32 stated the MD had explained the medications that were prescribed, and he/she had understanding of the potential side effects. RI #32 stated he/she had received visits from psych services and had a visit last week with no new recommendations. During an interview on 06/24/21 at 3:30 PM, EI#2, Director of Nursing (DON) stated in regard to the RI #32's incorrect antipsychotic medication order, EI #2 stated the expectation would be for any physician order that was in conflict with another order should be clarified for accuracy. EI #2 stated it would be the responsibility of the nurses to check physician orders for accuracy. 2. Review of RI#76's undated Face Sheet in the EMR revealed resident was admitted on [DATE] with diagnoses including cellulitis of right below the knee amputation/stump site, muscle weakness, unsteady gait and falls. Review of R76's quarterly MDS with an ARD of 04/28/21 revealed the BIMS score of 13 which indicated RI#76 had mild cognitive impairments but was capable of making decisions regarding in his/her care. The MDS further documented that RI#76 had no behaviors, no hallucinations, or delusions, and had no active neurological or psychiatric diagnoses. The MDS indicated that RI#76 received antipsychotic medications on five of seven days, an antianxiety medication on six of seven days and an antidepressant medication on seven or seven days., In an interview on 06/22/21 at 4:25 PM, EI#12, Licensed Practical Nurse (LPN) stated, [name of resident] settled down since he/she got here .can still be manipulative but used to be out right mean. EI#12 stated RI #76 was aggressive and frequently attempted to hit staff during cares when he/she was admitted . Review of a physicians progress note found in the MISC. tab of the EMR and dated 02/20/21 revealed that since RI#76's admission to the facility he/she had a gero-psychiatric evaluation on 02/20/21. The psychiatric note revealed RI#76 reported no history of mental health treatment prior to this assessment. Per the 02/20/21 psychiatric progress note the psychiatrist added Trazadone 100mg at bedtime (an antidepressant/sedative medication) to aid in sleep and recommended supportive treatment .follow up 1-2 months . There were no added psychiatric diagnoses; nor were there any follow up psychiatric notes located in RI#76's medical record review . On 06/23/21 at 4:15 PM. EI#2 was asked if there were additional psychiatric notes. She stated, only this one, but I will check again. EI#2 concurred that RI#76 did not have psychiatric diagnosis from either the Medical Director/attending physician or by the psychiatrist. Review of RI#76's Physician Orders under the Orders tab in the EMR for the months of January 2021 through June 2021 revealed the resident was prescribed the following psychotropic medications by the attending physician/Medical Director (MD): Prozac (anti-anxiety medication) 20mg daily for depression (not included in diagnoses list) Seroquel (anti-psychotic medication) 150mg daily for behavioral disturbances and acute agitation. There was no appropriate psychiatric diagnosis for the use of antipsychotics. Trazadone (antidepressant medication) 150mg at bedtime for depression/sleep Trileptal (anti-seizure medication) 600mg twice daily for mood. There was no indication in the medical record review that RI#76 had seizures. Zyprexa (antipsychotic medication) 10mg twice daily for agitation. There was no psychiatric diagnosis for the use of antipsychotic medication. There were no orders to monitor medication specific adverse effects or to monitor for resident specific target behaviors related to the use of these psychotropic medications. On 06/23/21 at 4:20 PM, EI#2 was asked about behavior monitoring and stated the was no flow sheet, some of the nurse's notes should include behaviors if exhibited, and there was an area on the back of the MAR the nurses could use to document behaviors. Review of RI#76's nursing progress notes under the Progress Notes tab in the EMR revealed the following: Describe Behavior/Mood, what the resident is doing, interventions attempted and effectiveness. 01/23/21 at 10:51 PM - very hostile behavior .verbally abusive staff .curses frequently . no interventions were included. 02/05/21 at 5:55 PM - resident very hostile .continuous outbursts .much profanity and derogatory and racial remarks to staff. Interventions included a call to the physician and a psychiatric consult was ordered. [Psychiatrist name] contacted and orders received: Seroquel 50mg TID [three times a day]) and Buspar15 mg with meals . -02/12/21 at 7:00 PM, RI#76 threatened to throw a urinal full of urine at another resident as he/she passed RI#76's room in wheelchair because RI#76 asked for a cigarette from the other resident. No interventions were included. -03/21/21 - called to lobby by staff - resident was in lobby cussing at staff about food .cussed another resident about cigarettes. Resident redirected was the intervention. -04/18/21 - the resident was yelling and cussing .CNA [Certified Nurse Aid] found cigarettes and a lighter in resident room and turned into the nurses station. Resident threatening to throw things .and cussing .resident doubled up fist .stated I am going to have your job and say you stole my money and my watch .you should have given those cigarettes to me not the nurse . Intervention was MD notified of behaviors. -05/09/21 at 4:30 PM .resident came to 4th floor using profanity and yelling at staff .became loud using racial slurs to both black and wite [sic] staff .making sexually inappropriate comments .swung and attempted to hit a female resident confined to a wheelchair. Stated he was going to punch her in the face. MD [name] Administrator and DON notified of behaviors. Review of the consultant pharmacist's monthly reviews titled, Gradual Dose Reduction Tracking Report from RI#76's admission in January 2021 through the current survey in June 2021 revealed the following: February 26, 2021 - revealed the pharmacy requested a diagnosis (required for antipsychotics) to support the use of the Seroquel. March 30, 2021 - again, the pharmacy requested a supporting psychiatric diagnosis. April 26, 2021 - the request for a supporting diagnosis had still been unanswered. May 27, 2021 - the physician added an additional antipsychotic (Zyprexa). There continued to be no supporting psychiatric diagnosis to support the use of antipsychotics. Additionally, on this report the pharmacist noted that the MD had also added Prozac on 05/20/21. Prozac is a Selective Serotonin Reuptake Inhibitor/SSRI a psychoactive medication used to treat depression, obsessive-compulsive disorder, bulimia, and panic disorder. There was no documentation in RI#76' medical record of these diagnoses. The MD also added Trileptal on 05/20/21 for mood. Trileptal is an anticonvulsant medication but has been used off label to modify mood/behaviors. Review of RI#76 medical record revealed no diagnoses of mood disorders or of seizures/convulsions. No GDR attempts had been made for R76's psychoactive medications. During an interview on 06/24/21 at 2:30 PM, RI#76's MD stated he/she reviews the nurse's notes and talks to staff and the residents to make resident care decisions. The MD stated, I manage those medications [psychotropics] unless [psychiatrist name] has decided to make recommendations. The MD further stated that he/she was not sure if he/she had included a written indication for use of each specific psychotropic medication and that he/she was unaware the pharmacy had made multiple requests for an appropriate diagnosis for the use of the antipsychotic medications Seroquel and Zyprexa. The MD stated that he/she was unaware that the facility had no specific behavioral monitoring program and/or policy to assure that residents on psychotropic medications were monitored for specific behaviors (delusions and hallucinations) and/or side effects of psychotropic medications. 3. Review of RI# 75's admission Record located in the EMR indicated the resident was admitted to facility on 01/10/14 with a diagnosis that included but not limited to Alzheimers, dementia without behavioral disturbance, and anxiety disorder. Review of RI#75's significant change MDS with an ARD of 03/04/21 indicated the resident was moderately impaired with no hallucinations, delusions or any type of behaviors. The resident was not coded as having any psychotic disorders including schizophrenia. Review of RI#75's Physician Orders located under the Orders Tab of the EMR for May 2021 and June 2021 revealed the resident was prescribed Seroquel, an antipsychotic medication. Further review of the Physician Order, found under the Orders Tab of the EMR, dated 11/18/20, documented, Seroquel tablet 100 mg. Give one tablet at bedtime related to unspecified Dementia without behavioral disturbance. On 04/13/21 RI#75 was ordered Seroquel tablet 100 mg. Give one 50 mg every morning and at bedtime related to unspecified Dementia without behavioral disturbance. Review of RI#75's care plan for Potential drug related complication associated with use of psychotic medication, revised on 11/13/20, did not list any non-pharmacological interventions for the resident as well as list any specific behaviors to monitor. During an interview with EI #15, an LPN, on 06/23/21 at 10:55 AM regarding RI#75's behaviors stated she had not observed any behaviors with RI#75. No hallucination/disorganized speech. Stated the resident had been on Seroquel for a while. EI#15 reviewed the Physician Order stated the resident was just ordered the Seroquel on 05/12/21. EI#15 stated she has been up and down with his/her meds. When asked about what behaviors RI#75 exhibits she stated RI#75 talks to himself/herself but knows he/she is talking to himself/herself so that is the behavior we monitor. Interview with EI #15 on 06/23/21 at 2:04 PM, stated Social Services has not put the Behavioral Monitoring Flowsheets out for this month. She stated the old flowsheet can be found in the paper chart. EI#15 also stated behaviors are documented on the MAR. When asked how you know which behaviors to observe, she indicated the Behavior Monthly Flowsheet. Review of the paper chart revealed the only Behavior Monthly Flowsheet was last dated February 2021. The behavior code for monitoring indicated, 12. Depression/Withdrawn and 17. Hallucinations paranoia/ delusions There was no Behavior Monthly Flowsheet for the months March, April, May and June 2021. Review of RI#75's, Progress Notes, found under the Notes Tab of the EMR, from January 2021 until June 2021 revealed the following: Weekly note, dated 03/25/21- . Have conversation with self at intervals. Frequently yelling out ghost busters . 04/13/21- Behavior Charting revealed - Resident has noted change in behaviors all throughout the day, increased agitation with attempting to redirect him/her, becomes more aggressive with the staff and other residents, excessive eating throughout the day, yelling out, medications not effective and attempted to get on the elevator to leave the facility, looking for his/her sister, MD has been notified of increased behaviors. Further review of RI#75's Progress Notes located in the EMR, indicated from 04/15/21 to 06/23/21, the question Was a behavior observed? Answered Yes. There was no additional documentation indicating what behavior was observed. Review of the most recent Psych Note found in the paper medical record, dated 02/19/21, indicated no symptoms of suicidal idealities, auditory/visual hallucinations, or delusions. During an interview with the Consultant Pharmacist, on 06/24/21 at 12:09 PM, she stated on April 26, 2021, she completed a recommendation to clarify the diagnosis of dementia without behavioral disturbance and to change the diagnosis to dementia with behavioral disturbances if RI #75 was having behaviors. When asked if she thought the diagnosis was appropriate indication for use [for the antipsychotic], the Consultant Pharmacist said she thought so if the resident is on an antipsychotic for dementia with behavioral disturbance. During an interview with EI#2 on 06/24/21 at 2:18 PM, in regard to the resident being on an antipsychotic without appropriate indication. EI#2 stated, in our population we have residents with dementia on antipsychotic medication that if they were not, they could potentially be a threat to themselves and others. RI#75 falls into that category when he/she is off his/her medication. Our Behavior Monitoring is in our nursing notes or our point of care document. We do have Behavior Monitoring Flowsheets for residents on psych meds and they are put in the chart by our Social Worker and nursing document on them. The form should be put out for nursing at the beginning of the month, and it is collected at the end of the month and returned to the Social Worker for review. The form should never go back into the medical chart. EI#2 was informed there was no Behavior Monitoring Flowsheet for the Month of June currently for nursing to document on. EI#2 confirmed there were no additional flowsheets for RI#75. Interview with the MD on 06/24/21 at 3:03 PM, in regard to the indication for use for the Seroquel, the MD stated, no dementia is not an indication for use. 4. Review of RI #18's undated Face Sheet in the EMR revealed RI #18 was admitted on [DATE] with diagnoses of adjustment disorder with depressed mood, unspecified dementia with behavioral disturbance, anxiety disorder due to known physiological condition, traumatic brain injury. Review of RI #18's admission MDS with an ARD dated 03/09/21 revealed RI #18 has a BIMS score of 11 which indicates resident was moderately cognitively impaired with no behaviors. RI #18 received anti-psychotic medication during the assessment period. Review of RI #18's Physician Orders included the following: 03/19/20- Seroquel 100 mg tablet give 1 tablet by mouth three time a day related to anxiety disorder due to known physiological condition. There was no indication for use listed for this antipsychotic medication. 03/19/20 - Seroquel 150 mg tablet take one tablet by mouth at bedtime related to unspecified dementia with behavioral disturbance. There was no indication for use listed. Review of the manufacturer's guidelines for the Seroquel revealed that they were to treat specific conditions, which did not include dementia, anxiety, and agitation. In addition, use of these medications for residents with dementia placed the resident at increased risk of death. These guidelines included: Review of the manufacturer's guidelines for the use of the medication Seroquel last updated 10/20 revealed, .Approved Uses Seroquel is a once-daily tablet approved in adults for major depressive disorder (MDD) who did not have an adequate response to antidepressant therapy; bipolar disorder; acute manic or mixed episodes in bipolar disorder alone or with lithium or divalproex; long-term treatment of bipolar disorder with lithium or divalproex; and schizophrenia .Elderly patients with dementia-related psychosis (having lost touch with reality due to confusion and memory loss) treated with this type of medicine are at an increased risk of death, compared to placebo (sugar pill). Seroquel is not approved for treating these patients . During an interview on 06/24/21 at 3:55 PM, EI #2, stated he/she could not locate the GDR request documentation made by the pharmacist (dated 08/11/20, 12/16/20 and 04/26/21) for RI #18. Review of the manufacturer's guidelines for the use of the medication Seroquel last updated 10/20 revealed, .Approved Uses Seroquel is a once-daily tablet approved in adults for major depressive disorder (MDD) who did not have an adequate response to antidepressant therapy; bipolar disorder; acute manic or mixed episodes in bipolar disorder alone or with lithium or divalproex; long-term treatment of bipolar disorder with lithium or divalproex; and schizophrenia .Elderly patients with dementia-related psychosis (having lost touch with reality due to confusion and memory loss) treated with this type of medicine are at an increased risk of death, compared to placebo (sugar pill). Seroquel is not approved for treating these patients . Review of the undated facility's policy titled, Antipsychotic Reduction Guide revealed the facility would establish a quality committee to monitor all antipsychotic medications at least monthly and consider tapering or discontinuing the use of antipsychotic medication in the residents that do not exhibit behaviors. The facility provided a letter dated 06/23/21 stating they have no psychotropic medication policy.

Based on observation, interview, record review and facility policy review, the facility failed to ensure the kitchen staff adhered to safe practices to prevent the potential spread of food-borne illness to all residents who received their meals from the kitchen. Concerns were noted with dish-washing procedures, sanitizing solution concentrations, cleaning contact surfaces after exposure to raw meat, failure to remove significantly dented cans from the general canned food supply, and cleanliness in the dry food store room. Findings include: 1. On 06/21/21 from 10:40 AM - 11:05 AM, the three-sink pot washing sinks were in use, each filled with a separate solution (wash, rinse, sanitize). There were multiple pots on counter drying next to the third sink. Employee Identifier (EI)#9, Diet Tech (kitchen manager) used a quaternary ammonia test strip to check the level of the sanitizing solution in the third sink. The test strip did not register any parts per million (PPM) of the sanitizer. EI#9, asked EI#11,Cook, who was in the vicinity to drain the sink and refill it. EI#9 asked EI#11 why there was no sanitizer present in the third sink. EI#11 stated he did not know. 2. On 06/23/21 at 10:05 AM, EI#10, Cook, prepared the pureed pork chops for the noon meal. EI #10 first took a steam table pan full of boneless pork chops and watery fluid and drained the fluid off the meat, pouring it down the left side of the food preparation sink. There were two food prep sinks right next to each other. EI#10 then placed the pork chops into the Robot Coupe commercial food processor and took the steam table pan to the three-sink pot washing area. After blenderizing the pork chops, he/she washed the pan that held the pork chops in the food preparation sink, dunked it in the rinse solution in the second sink, and then dunked it in the sanitizer solution in the third sink. He/she then brought the pan back to where he/she prepared the pureed pork chops. He/she did not immerse the pan in the third sink for more than a second when he/she dunked it. EI#10 then poured the pureed pork chops into this steamtable pan and reheated the mixture to bring it up to temperature for serving. EI#9 was notified of the observation at this time and stated that the pots should be immersed in the third sink sanitizer solution but would have to check on how much time the pots should be immersed. 3. On 06/23/21 at approximately 10:12 AM, EI#11 took a batch of raw pork chops and placed them in the food preparation sink and kneaded the pork chops with a spice mixture. After the pork chops were removed, he/she wiped out the sink with a wiping rag from the sanitizer bucket without washing the sink first with soap/detergent. EI#11 was interviewed at the time and stated he/she used the rag that was in the sanitizing solution to wipe out the sink and had not washed the sink first with soap or detergent. Review of the facility's policy titled, Dietary Food Handling with an effective date of 01/01/17, from the DMS Policy & Procedure Food Service Manual, revealed, It is the policy of this center to provide guidelines for the safe preparation, handling and storage of perishable foods and proper environmental cleaning .Each time there is a change in processing from raw to ready to-eat foods, each new operation should begin with clean and sanitized food contact surfaces and utensils . Review of the facility's policy titled, Pots and Pans with an effective date of 08/01/12, from the DMS Policy & Procedure Food Service Manual, revealed it was the policy of the facility to, clean and sanitize pots and pans to maintain sanitary food preparation, service and delivery environment .The three-sink system is preferred if the dishwashing machine is not used. For three-sink system: In Sink No [number] 1 [wash sink] prepare a hot solution of facility approved cleaner. Sink No. 11 [Rinse Sink] should be a clear, hot water rinse. In Sink No. III [Sanitizing Sink], prepare a solution of the facility approved sanitizer and hot water. After pre-soak/wash, excess soil was to be scraped, all surfaces were to e scrubbed, the item was to be immersed in the rinse sink and then immersed in the sanitizing sink following manufacturer instructions for sanitizer. Review of the Manufacturer's Instructions titled, Auto Chlor System, Dishwashing Three Sink Method instructions, revealed the system included wash [clean water and detergent], rinse [clean water], and sanitizing [clean water and sanitizer] solutions be used in that order. Food contact surfaces sanitizing called for a solution between 200 - 400 PPM of the sanitizer [quaternary ammonia]. The product label was to be consulted for the required contact time [of the sanitizer]. Review of the product label revealed thorough washing was to occur prior to sanitizing. The treated surfaces must remain wet for 60 seconds [with the sanitizer solution]. 4. During the initial kitchen inspection with EI#9 on 06/21/21, from 10:40 AM - 11:05 AM, the dry store room was observed. There was a #10 can in the general can rack with a dent of approximately one - two inches along the bottom seal of the can. In addition, there was a window sill that had dirt, debris and contained approximately five dead bugs. There were also multiple spider webs in the window sill area. There was canned food on a shelf in the window near the window sill. 5. During a second observation with EI#9 on 06/23/21 at 9:24 AM, in the dry store room there was a dented #10 can noted on 06/21/21 (apple pie filling) and there were three significantly dented #10 cans of peaches with large dents along the bottom seal. The cans were disfigured from the large dents. EI#9 stated the staff member who put away the last order should not have put the peaches on shelf with canned goods that were to be used. He/she stated the dented cans were supposed to be placed on a separate shelf and it was supposed to be labeled (although it was not) with a sign for dented cans. The window sill was in the same condition noted on 06/21/21 with approximately five dead bugs, multiple spider webs, and cans of soup and olives stored on shelf near the window sill. EI#9 stated the area needed to be cleaned. Review of the facility's policy titled, Dry Storage with an effective date of 01/01/17, from the DMS Policy & Procedure Food Service Manual, revealed, It is the policy of this center to store, prepare and serve food that is stored in accordance with federal, state, and local sanitary codes . The floors, walls, shelves, and equipment in the storeroom will be kept clean and in good repair . The storeroom will be kept free from insects and rodents . Leaking cans and spoiled food will be removed promptly. Damaged cans will be identified for removal . Damaged canned food containers will be stored together in the storeroom in a separate and distinct area away from other food items. This area should be labeled. The damaged food containers will be returned to the vendor .Damaged containers are defined as: a. all dented containers (other than those with a slight to moderate dent that does not involve the seam and does not rock on a flat surface) . Review of the facility's policy titled, Equipment Cleaning Schedules with an effective date of 08/01/12, from the DMS Policy & Procedure Food Service Manual, revealed, It is the policy of this facility to assign cleaning schedules on a daily, weekly and monthly basis. The policy indicated the dry store room was scheduled for weekly cleaning. 6. On 06/23/21 at approximately 10:24 AM, a dietary aide was observed removing clean dishes from the commercial dish machine. He/she wiped out a small, clean bowl with a dry rag and stacked it with the clean dishes. Review of the Food Code U.S. Public Health Service, Food and Drug Administration, College Park MD, 2017 indicates, Drying 4-901.11 Equipment and Utensils, Air-Drying Required. Items must be allowed to drain and to air-dry before being stacked or stored. Stacking wet items such as pans prevents them from drying and may allow an environment where microorganisms can begin to grow. Cloth drying of equipment and utensils is prohibited to prevent the possible transfer of microorganisms to equipment or utensils. During an interview on 06/24/21 at 4:47 PM, EI#8, Registered Dietitian (RD), stated dented cans should be placed in a separate area (distinct from the general can storage area). EI#8 stated the sanitizer level for quaternary ammonia sanitizer should be between 200-400 PPM. Regarding immersion of pots/pans in the sanitizer solution in the third sink for pot washing, he/she stated items should be immersed, but the manufacturer's information did not document an exact time and instead it indicated the items should be immersed or remain wet for 60 seconds. EI#8 stated he/she had gone by 30 - 60 seconds timeframe for how long pots should be immersed in the third sink sanitizer solution. When notified of the food preparation sink with raw meat and wiping it with a wiping rag that was in the sanitizing solution prior to washing the sink first, she/he stated the sink should be washed first and then staff should sanitize it. EI#8 stated dishes should be air dried when they were removed from the dish machine and should not be dried with towels.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and review of Potter and [NAME], Fundamentals of Nursing, Ninth Edition, page 465, Chapter 29, Infection Prevention and Control, the facility failed to ensure a licensed nurse did not assist with repositioning and adjusting Resident Identifier (RI) #11's bed linens while still wearing gloves worn during wound care for RI #11. This deficient practice affected RI #11, one of one residents observed during wound care. Findings Included: A review of Potter and [NAME] Fundamentals of Nursing, Ninth Edition, page 465, Chapter 29, Infection Prevention and Control, revealed the following under the heading, Gloves: . Change gloves and perform hand hygiene between tasks and procedures on the same patient after contact with material that contains a high concentration of microorganisms. RI #11 was readmitted to the facility on [DATE]. A current diagnosis included pressure ulcer of sacral region, stage 3. On 02/20/20 at 11:15 a.m., the following was observed by the surveyor during wound care observation for RI #11. Employee Identifier (EI) #4, Licensed Practical Nurse (LPN)/Treatment (TX) Nurse, was observed cleaning RI #11's wound. After cleaning the wound EI #4 washed her hands and put on clean gloves. She then applied Santyl to the wound bed and then covered the area with dry 4x4 and adhesive dressing. With the same gloves on, EI #4 was then observed removing an incontinence pad from under RI #11 and assisting another staff member with repositioning RI #11 and adjusting his/her bed linens. On 02/20/20 at 1:22 p.m., an interview was conducted with EI #4. EI #4 was asked when should she wash her hands when wearing gloves. EI #4 said before she put them on and after she took them off, after removing the dressing, after cleaning the wound and after she discarded her dirty stuff. EI #4 was asked did she remove her gloves and wash her hands after cleaning RI #11's wound before she helped reposition and adjust his/her covers. EI #4 replied no, she did not. EI #4 was asked should she have. EI #4 stated yes. EI #4 was asked what was the concern with not removing her gloves and washing her hands after cleaning a wound. EI #4 answered cross contamination. On 02/20/20 at 2:04 p.m., an interview was conducted with EI #3, Registered Nurse (RN)/Infection Preventionist. EI #3 was asked when should a nurse wash her hands when using gloves. EI #3 said before she applies them, anytime they get contaminated and when they take them off. EI #3 was asked should a nurse remove her gloves and wash her hands after providing wound care before assisting a resident to reposition and touching the resident's covers. EI #3 replied yes, when they complete the wound care, they are considered dirty. EI #3 was asked what was the concern with not removing gloves and washing hands after wound care. EI #3 stated they are contaminating the other areas whether they see anything on them or not. EI #3 further stated they should remove their gloves, wash their hands and put on clean gloves to perform whatever other task they did. EI #3 was asked what was the concern with these things. EI #3 answered cross contamination and infection control.