**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, review of the facility's investigation titled Verification of Investigation, and review of facility policy Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, the facility failed to ensure Licensed Practical Nurse (LPN) #6, did not misappropriate Resident Identifier (RI) #43's Percocet and Lyrica after signing the medication as administered. This was cited as a result of investigation of complaint/report number AL00045405, and affected one of one residents reviewed for misappropriation of resident property. Findings Include: Review of a facility policy Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, with an effective date of 05/01/2023 documented PURPOSE: . All of our resident/guest(s) have a right to be free from . misappropriation of resident/guest property. The Policy also prohibits the misappropriation of resident/guest property. D. Misappropriation of Resident/Guest Property. Misappropriation of resident/guest property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident/guest(s) belongings or money without the resident/guest(s) consent. The facility's investigation of the incident titled Verification of Incident documented . On the morning of Monday 08/28/2023 (RI #43) reported to the charge nurse not receiving medication on the 3 p - 11p shift. He/she was interviewed by the Director of Nursing and repeated the same allegation . Stated had pain medication due at 10:00 PM realizing had not received it around 11:30 PM asked the nurse on duty she stated could not give it as the 3 - 11 shift nurse had signed it out. OUTCOME OF INVESTIGATION: . As a part of the investigation, a review of the Electronic Medical Record (EMR) and a printed narcotic log stated all medications scheduled during the 3 - 11 pm shift were signed out as given by Nurse (LPN #6). Nurse was contacted by phone and stated . passed all medication scheduled . The administrator reviewed the camera system . While counting . medication cart, LPN #6 is seen punching seven pills from the narcotic box into one cup and signing the medication log. LPN #6 is witnessed placing the medication in her right hand and transferring it to a personal pill bottle, and then to her purse. RI #43 was admitted to the facility on [DATE] with diagnoses of Pain and Neuropathy. Review of RI #43's August 2023 Physician Orders documented . Lyrica Capsule Three Times a Day DX (Diagnosis) Neuropathy .Percocet 10-325 Milligram 1 Tablet every 8 hours DX Pain . Review of RI #43's Controlled Drug Record for Oxycodone (Percocet) indicated the medication signed out on 08/27/2023 at 9:00 PM by LPN #6. Pregabalin (Lyrica) indicated it was signed out by LPN #6 on 08/27/2023 at 8:00 PM. On 04/14/2024 at 1:40 PM during an interview with RI #43 when asked if any nurses did not give medications as scheduled, RI #43 said one did. When asked how long he/she went without pain medication, RI #43 said a few hours. RI #43 denied increased pain when the pain medication was not administered. On 04/15/24 at 10:37 AM during an interview with (Registered Nurse) RN #4, she said she came on shift at 11:00 PM, counted with LPN #6 and all counts were correct. She said it was around midnight when she went into RI #43's room, he/she said he/she did not get pain medications, RN #4 said she would check on it. She said she looked in the record it was signed out as administered. On 04/15/2024 at 11:23 AM during an interview with the oncoming nurse LPN #5, she recalled RI #43 telling her he/she did not get pain medication the evening before. She said she told the Director of Nursing (DON) because it was unusual. She said RI #43 was alert, oriented and aware of medications administered. LPN #5 said RI #43 said he/she did not receive the Lyrica or the Percocet. On 04/16/2024 at 8:34 AM during an interview with the DON, she said RN #4 told the morning nurse, LPN #5, RI #43, said he/she did not get medication for pain at 10:00 PM, she checked the books found it signed as administered. The next morning RI #43 told LPN #5 the nurse on 3 to 11 did not give his/her pain medication. The DON said LPN #5 said RI #43 was alert, and oriented. The DON said she told the Administrator, and they started an investigation. The DON said the Administrator watched the camera footage. The DON said RI #43 said did not get Lyrica and Percocet, those medications were signed out as administered. The DON said they called LPN #6 to come to the facility, she said she could not, she said she gave it to RI #43, she said she gave all the medications. The Administrator said he watched the video and wrote down her actions. The Administrator said he could not tell which resident's medications she was pulling while she was in the cart and could only tell she was in the narcotic drawer. LPN #6 was observed taking the medication cup around the nurses' station and poured the medication into her personal prescription bottle. On 04/16/2024 around 2:00 PM during a phone interview with the previous Administrator, he said he was made aware of RI #43 not receiving medication on the evening before shift after the morning nurse told the DON, what RI #43 told that morning. He said the medication was signed out as administered. He said because RI #43 was alert, and the nurses knew him/her he thought to look on camera. He said he documented a timeline according to the camera footage. He said he saw LPN #6 was pushing medications in a cup and hid it under the binder. He said they did a review of the medications that were signed out by LPN #6 and recalling by memory not sure, he thought he saw her punching out seven, that may not have been exact. The Administrator said they could be sure of RI #43's by him/her saying he/she did not get his/hers. They could only validate RI #43 not receiving his/her pain medications as he/she told two nurses. The Administrator said after watching the video they saw some concerns, and called her back with no answer, she was terminated although she never returned calls or returned to the facility. The Administrator said it was abuse by misappropriation when the nurse did not give scheduled pain medication, however signed them out as given, and the timeline from watching the video indicated she punched pills and did not give to a resident. The Administrator said the concern with LPN #6 misappropriating RI #43's medication was abuse, and the nurse being untrustworthy. He said during her orientation she was presented with the policy on abuse and went through a week of orientation; he said the event was her first shift out of orientation. On 04/16/2024 at 4:09 PM during a follow-up interview with the DON, she said it was misappropriation of resident property when a nurse signed out a resident's medication, but did not administer it to the resident. The DON said they could only determine RI #43 had medication misappropriated as LPN #6 took medication from the narcotic box, signed it out as administered and never administered it to the resident. The DON said the facility determined the misappropriation when RI #43 told the nurses he/she had not received pain medication on the evening shift, although it was signed out as given. On 04/17/2024 at 9:26 AM during an interview with the Regional Nurse she it was misappropriation of property when a nurse signed out a resident medication, but did not administer the medication. She said the only medication determined misappropriated was RI #43's as RI #43 told two nurses he/she did not receive it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of a facility policy Pre-admission Screening Resident Review, and review of Resident Identifier (RI) #103's PASRR (Preadmission Screening and Resident Review), the facility failed to ensure RI #103's PASRR was accurately marked with an admission diagnosis of Bipolar Disorder, which indicated a Level II was indicated. This affected one of two residents sampled for PASRR. Findings Include: A review of a facility policy titled Pre-admission Screening Resident Review, with a revised date of 06/2009 documented . 4. The nursing facility is responsible for ensuring that a level I screening is completed, submitted and has a Level I Determination on or before nursing home admission . Process for PASRR . 3. Nurse Consultants and Case Managers will review Level I and/or Level II Determination during medical records audits for newly admitted or re-admitted residents. 4. QA Nurses will review Level I and/or Level II Determinations as part of their audit of the admissions process. On 04/15/2024 at 2:15 PM a review of RI #103's PASRR which was signed on 09/15/2023 did not indicate resident had a Major Mental Illness of Bipolar Disorder. Based on the results there was no need for a Level II. The PASRR review revealed only a Level I and no diagnoses were selected or marked on the screening form. RI #103 was admitted to the facility on [DATE] with a diagnosis of Bipolar Disorder. A review of RI #103's diagnoses sheet included Bipolar Disorder with onset date of 10/27/2023. On 04/15/2024 at 3:00 PM during an interview with Social Services staff, when she was asked what was the facility's process to identify residents needing a Level I or Level II. She said they looked at the diagnoses and medications, marked diagnoses and medications on the screening form, then submitted it to the screening office. When asked what the date of onset for RI #103's Bipolar Disorder, she said 10/27/2023 which was the date RI #103 admitted to that facility. She was asked if Bipolar Disorder should be marked on the PASRR, she said yes she would have marked it. She said Social Service was responsible for ensuring the PASRR was accurate if a resident was admitted from another facility. She said the PASRR not having Bipolar Disorder marked or selected resulted in an inaccurate PASRR. She said the concern in the PASRR not updated to include Bipolar Disorder was not having accurate diagnosis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of the facility policy titled Medication Administration Documentation for Medication Administration, facility failed to ensure Resident Identifier (RI) #43's Medication Administration Record (MAR) was accurate. On 08/27/2023 Licensed Practical Nurse (LPN) #6 documented the administration of Lyrica and Percocet in RI #43's medical record and did not administer the medications to RI #43. This affected RI #43, and was cited as a result of investigation of complaint/ report number AL00045405. Findings Include: Review of a facility policy Documentation for Medication Administration with an effective date of 04/2020 documented . Procedures 1. The individual who administers the medication dose records the administration on the resident's MAR directly after the medication is given. RI #43 was admitted to the facility on [DATE] with diagnoses of Pain and Neuropathy. Review of RI #43's August 2023 Physician Orders documented . Lyrica Capsule Three Times a Day DX (Diagnosis) Neuropathy . Percocet 10-325 Milligram 1 Tablet every 8 hours DX Pain . Review of RI #43's August 2023 Medication Administration Record (MAR) indicated Percocet and Lyrica was documented as administered by LPN #6 on 08/27/2023. An interview was conducted with RI #43 on 04/14/2024 at 1:40 PM. RI #43 stated one nurse did not give him/her medication as scheduled around 10:00 PM on 08/27/2023. An interview was conducted with Registered Nurse (RN) #4 on 04/15/2024 at 10:37 AM. RN #4 stated she went into RI #43's room around midnight, and he/she stated he/she did not get his/her pain medication. RN #4 stated she reviewed the record and confirmed that it was signed out as administered. An interview was conducted with LPN #5 on 04/14/2024 at 11:23 AM. She stated she became aware of RI #43 not getting pain medication on second shift on 08/27/2023 when RI #43 told her. She stated she told the DON because RI #43 was alert and oriented and it was unusual. A telephone interview was conducted with the Former Administrator on 04/16/2024 at 2:00 PM. He stated LPN #6 did not administer RI #43 his/her scheduled pain medication on 08/27/2023, however signed them out as given. He stated it was inaccurate documentation. An interview was conducted with The Director of Nursing (DON) on 04/16/2024 at 4:09 PM. The DON stated RI #43's medication was signed out by LPN #6 on the Medication Administration Record (MAR) and it was not given to him/her on 08/27/2023. The DON stated it was falsifying the records when LPN #6 signed out medication and she did not administer the medications. An interview was conducted with the Regional Nurse on 04/17/2024 at 9:26 AM. She stated RI #43's medications was signed out on both the narcotic sheet and MAR on 08/27/2023 as given. The Regional Nurse stated it was falsifying the records when LPN #6 signed out medication and she did not administer the medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and review of facilities Resident Handbook and the facility's document titled Resident - These are YOUR Rights, the facility failed to ensure residents had reasonable access to personal funds/petty cash after business hours and on the weekends. This affected Resident Identifier (RI) #64. Further affected RI #43, RI #55, RI #6, RI #81, RI #28, RI #69, RI #34, RI #85, RI #26, and RI #76 who attended Resident Council Group meeting on 04/16/2024 and reported they were unable to access funds on the weekends. This had the potential to affect all residents who have a Resident Trust Account established with the facility. Findings include: A review of the Resident Handbook revealed the following: . Personal Funds . no personal account withdrawals may can be made after the close of business hours or on weekends. You should anticipate your cash needs for weekend and withdraw funds accordingly on Friday before the business office closed . A review of undated facility document titled Resident- These are YOUR Rights documented . You have the right to your money. RI #43 was admitted to the facility on [DATE]. RI #43's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/12/2024 noted a Brief Interview for Mental Status (BIMS) of 15/15 which indicated no cognitive impairment. RI #64 was admitted to the facility on [DATE]. RI #64's Quarterly MDS with an ARD of 03/18/2024 noted a BIMS score of 15/15 which indicated no cognitive impairment. RI #55 was admitted to the facility on [DATE]. RI #55's Annual MDS with an ARD of 03/18/2024 noted a BIMS score of 15/15 which indicated no cognitive impairment. RI #6 was admitted to the facility on [DATE]. RI #6's Quarterly MDS with an ARD of 03/18/2024 noted a BIMS score of 6/15 which indicated cognitive impairment. RI #81 was admitted to the facility on [DATE]. RI #81's Quarterly MDS with an ARD of 01/08/2024 noted a BIMS score of 15/15 which indicated no cognitive impairment. RI #28 was admitted to the facility on [DATE] and re-admitted on [DATE]. RI #28's Quarterly MDS with an ARD of 03/04/2024 noted a BIMS score of 6/15 which indicated cognitive impairment. RI #69 was admitted to the facility on [DATE]. RI #69's Quarterly MDS with an ARD of 03/11/2024 noted a BIMS score of 15/15 which indicated no cognitive impairment. RI #34 was admitted to the facility on [DATE]. RI #34's Quarterly MDS with an ARD of 03/04/2024 noted a BIMS score of 15/15 which indicated no cognitive impairment. RI #85 was admitted to the facility on [DATE]. RI #85's Annual MDS with an ARD of 01/15/2024 noted a BIMS score of 15/15 which indicated no cognitive impairment. RI #26 was admitted to the facility on [DATE]. RI #26's Quarterly MDS with an ARD of 02/05/2024 noted a BIMS score of 6/15 which indicates cognitive impairment. RI #76 was admitted to the facility on [DATE]. RI #76's Quarterly MDS with an ARD of 03/18/2024 noted a BIMS score of 15/15 which indicated no cognitive impairment. On 04/14/2024 at 1:58 PM during initial tour RI #64 stated personal money withdrawals were not available on the weekends due to the business office not being open. On 04/16/2023 at 3:00 PM Resident Council meeting was held with RI #43, RI #55, RI #6, RI #81, RI #28, RI #69, RI #34, RI #85, RI #26 and RI #76 were in attendance. When the group was asked how personal funds were accessed on the weekends and after hours, residents stated personal funds were not accessible on the weekends due to the business office not being open. On 04/16/2023 at 3:29 PM during further interview, RI #64 stated the business office was only open Monday through Friday. RI #64 said even when money was in his/her account he/she could not get it when the business office was closed and they made the business hours very clear. On 04/16/2024 at 3:55 PM an interview was conducted with RI #43. RI #43 reported he/she was unable to access funds on the weekend. RI #43 said he/she used his/her funds for snacks from vending and if he/she did not get cash on Friday he/she was unable to access funds on the weekend to purchase snacks. On 04/16/2024 at 4:16 PM an interview was conducted with the Financial Specialist Assistant (FSA) and when asked about how residents are made aware of how to access personal money on the weekend, the FSA stated it was on the nurses' station and that they were made aware of this by word of mouth. Other than word of mouth, the FSA was uncertain how this was communicated to residents. The FSA reported it was difficult to keep up with the checks and balances when residents withdraw funds outside of business hours. When asked why it was important for residents to have reasonable access to personal funds outside of business hours, the FSA stated it was very important; therefore, residents were given more money on Fridays before the close of business hours. The FSA stated this was why she tried to get them to get personal money on Fridays. On 04/16/2024 at 4:36 PM the Financial Specialist (FS) was interviewed and asked how residents accessed personal funds after hours. The FS stated according to policy petty cash funds were locked up on nurses' cart. The FS further stated that when residents funds initially started coming to the facility, they (residents) were made aware that they could obtain personal funds through business office during the week. When asked why it was important that residents have reasonable access to personal funds after hours, FS stated it was their money to do as they desired, and residents should have access to funds at all times.

Based on observations, interviews and the facility's Residents Rights, the facility failed to ensure rooms on three of five halls were not found in need of repair. This deficient practice affected seven residents' rooms on three halls. Findings Include: The facility's undated Residents Rights, documented, These are YOUR Rights: YOU have the right .to live in a safe, clean, comfortable and homelike environment. On 04/14/2024 at 1:18 PM, surveyor observed Resident Identifier (RI) #56's closet was missing a door. On 04/14/2024 at 4:09 PM, surveyor observed RI #100's wall behind bed with scraped paint. On 04/14/2024 at 4:25 PM, surveyor observed RI #67's wall behind bed with scraped paint. On 04/15/2024 at 8:28 AM, surveyor observed RI #18's wall behind bed with scraped paint and chipped paint and hole in the wall on the side of bed. On 04/15/2024 at 10:56 AM, surveyor observed dark stain and no caulking at base of RI #9's toilet. On 04/15/2024 at 9:00 AM, surveyor observed stained ceiling tile and wall at foot of RI #103's bed scuffed and peeling. On 04/14/2024 at 8:45 AM, surveyor observed a hole in RI #35's wall under the sink. On 04/17/2024 at 11:29 AM surveyor and Maintenance Director (MTD) made observations of the noted concerns in residents' rooms. Observed RI #100's wall behind bed. The MTD stated the wall had scraped paint. An observation was made of RI #67's wall behind bed, maintenance stated had scraped paint behind his/her bed. An observation was made of a hole under the sink in RI #35's room. An observation was made of a brown stained on ceiling tile, the wall scuffed and peeling in RI #103's room. An observation was made of RI #56's room which had a missing closet door. An observation was made of scraped paint and wall with hole in the wall behind the bed in RI #18's room. An observation was made of the toilet in RI #'9's bathroom. The MTD stated the toilet had a red-brownish stain around the base and missing caulking. An interview was conducted with the MTD on 04/17/2024 at 11:50 AM. The MTD stated the walls behind the bed that had scraped paint, the hole under the sink, the missing closet door, the holes in the walls, the stained ceiling and the red/brownish base of the toilet that needed caulking did not look good and needed to be repaired.

On 04/14/2024 at 5:17 PM CNA #18 obtained trays and proceeded to assist two residents, RI #47 and RI #1 with their meal at the same time and without performing hand hygiene. At 5:18 PM CNA #18 was observed as she got up, picked up a soiled tray from another resident, and continued to assist RI #47 and RI #1 without performing hand hygiene. Next, CNA #18 washed her hands, escorted a resident out of dining room, and resumed assisting RI #1 and RI #47 with their dinner meals without performing hand hygiene. An interview was conducted with CNA #18 on 04/16/2024 at 10:19 AM. CNA #18 said that she did not perform hand hygiene between trays and assisted RI #1 and RI #47 with their dinner meal on 04/14/2024 simultaneously. CNA #18 stated it was not possible to perform hand hygiene while assisting two residents with their meals at the same time. CNA #18 stated the concern of not performing hand hygiene while passing trays and assisting with feeding two residents at the same time is cross-contamination. An interview was conducted with the Director of Nursing (DON) on 04/17/2024 at 12:11 PM. The DON stated staff should perform hand hygiene after passing each tray. The DON stated the concern of not performing hand hygiene between each tray was possible cross-contamination. The DON also stated staff should never feed two residents at the same time. She stated the concern of feeding two residents at the same time was cross-contamination. 2) On 04/15/2024 at 3:47 PM, surveyor observed MAC #12, obtain a blood glucose level for RI #73. Afterwards, MAC #12 left RI #73's room and placed the used barrier tray which contained the glucometer on the med cart. MAC #12 cleaned the glucometer with tissue paper and hand sanitizer. The glucometer was then placed on the med cart. An interview was conducted with MAC #12 on 04/15/2024 at 4:00 PM. MAC #12 said she should have thrown the used barrier away instead of bringing it out of RI #73's room. She also said that she cleaned the glucometer with hand sanitizer. MAC #12 stated there were Clorox wipes on the cart, but stated she usually just wiped off the glucometer with hand sanitizer. MAC #12 stated the concern of bringing a used barrier from resident's room and placing on medication cart was cross-contamination. An interview was conducted with The DON on 04/17/2024 at 12:15 PM. The DON stated it was never acceptable to take a used barrier from a resident's room and place it on the medication cart. She stated glucometers were to be cleaned with Clorox wipes, never hand sanitizer. She stated the concern was cross-contamination and infection control. Based on observations, interviews and a facility policy titled, Hand Hygiene, the facility failed to ensure: 1) staff sanitized their hands on 04/14/2024 while passing meal trays on Station 4. The facility further failed to ensure staff performed hand hygeine while assisting Resident Identifer (RI) #1 and RI #47 with their meal. This deficient practice affected residents residing on two of five halls, including RI #1 and RI #47. 2) staff followed Standard Precautions and properly disinfected the glucometer after routine testing of blood glucose. This affected RI #73, one of two residents observed for blood glucose testing. Findings Include: A facility policy titled, Hand Hygiene, with an effective date of 06/11/2020, documented, PURPOSE: To provide guidelines to employees for proper and approriate hand washing techniques that will aide in the prevention of the transmission of infections. III. Hand Hygiene . The following is a list of some situations that require hand hygiene. Before and after . handling food . Before and after assisting a resident/guest with meals . On 04/14/2024 at 5:12 PM, surveyor observed the dinner meal cart on hall. Certified Nursing Assistant (CNA) #13 was observed as she sanitized her hands, took dinner tray off meal cart and took into room came back to the meal cart, retrieved another tray. CNA #13 passed three meal trays before she sanitized her hands again. CNA #12 walked up to the meal cart and began to pass trays. She passed four trays then sanitized her hands. An interview was conducted with CNA #12 on 04/14/2024 at 5:18 PM. CNA #12 stated she washed her hands before she began passing trays. CNA #12 admitted she did not perform hand hygiene between passing each tray and stated she should have. CNA #12 stated the concern of not performing hand hygiene between each tray was passing bacteria. An interview was conducted with CNA #13 on 04/14/2024 at 5:24 PM. CNA #13 admitted she only sanitized her hands after passing the third tray. CNA #13 stated the concern of not performing hand hygiene after passing each tray was the possibilty of contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, medical record review, and a review of [NAME] AND PERRY's, FUNDAMENTALS OF NURSING, the facility failed to ensure a licensed nurse: 1) did not lay the insulin pen, needles, Fentanyl pain patch, and alcohol swabs on Resident Identifier (RI) #90's bedside table without first laying a barrier down; Further, while administering medications to RI #90, the licensed nurse stored medications and supplies in her pocket, and used scissors from her pocket to cut up a used Fentanyl patch, then returned them to the pocket without cleaning or disinfecting them; and 2) did not stack medication cups, each containing medication, on top of each other, after the cups had been placed on the medication cart, prior to administering medication to RI #63. These failures affected two of six residents and two of three nurses observed during medication pass observations. Findings Include: A review of [NAME] AND PERRY's, FUNDAMENTALS OF NURSING, NINTH EDITION, CHAPTER 29, page 443 revealed: Infection Prevention and Control . Reservoir, a reservoir is a place where microorganisms survive, multiply, and await transfer to a susceptible host. Humans can transmit microorganisms . inanimate objects can also be reservoirs for infectious organisms. 1) RI #90 was admitted to the facility on [DATE] with diagnoses of Type 1 Diabetes Mellitus and Chronic Pain. On 5/23/19 at 8:01 a.m., the surveyor observed Employee Identifier (EI) #1, a Licensed Practical Nurse, do the following while administering medications to RI #90: 1. store medications and injections supplies in her pocket prior to drug administration; 2. lay RI #90's insulin pen, needles, alcohol swabs, and Fentanyl patch on RI #90's bedside table without first laying a protective barrier. She then returned the insulin pen to the medication cart; and 3. cut up RI #90's Fentanyl patch, that had been removed from his/her body, and return the scissors to her pocket without first cleaning or disinfecting them. An interview was conducted on 5/23/19 at 9:00 a.m. with EI #1. EI #1 was asked, what should be done before laying the insulin pen, diabetic supplies, and Fentanyl pain patch on the resident's over bed table EI #1 stated, Clean area, paper towel. EI #1 was asked, what should be done after cutting up RI #90's Fentanyl pain patch before placing the scissors back in her pocket. EI #1 stated, Clean them. EI #1 further stated she was not supposed to store medications and supplies in her pockets. EI #1 was asked what the potential for harm was with these concerns. EI #1 stated, Infection control. 2) RI #63 was readmitted to the facility on [DATE] with a diagnoses to include Dementia and Gastro-esophageal Reflux Disease. On 5/22/19 at 4:20 p.m., the surveyor observed EI #2, Licensed Practical Nurse,stack medication cups on top of each other, each containing RI #63's medication, after the cups had been placed on the medication cart, prior to administration. An interview was conducted on 5/23/19 at 3:23 p.m. with EI #3, a Registered Nurse/Director of Nursing/ Infection Control Officer. EI #3 stated medication cups with medicines in them should not be stacked on top of each other after placing them on the medication cart. EI #3 was asked, what was the potential for harm. EI #3 stated, Infection Control.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure Resident Identifier (RI) #24's admission Minimum Data Set (MDS) assessment, dated 04/02/18, reflected RI #24 had a colostomy. This affected RI #24, one of 42 sampled residents whose MDS assessments were reviewed. Findings Include: RI #24 was admitted to the facility on [DATE], with a diagnosis of Colostomy Status. A review of RI #24's admission MDS assessment, with an Assessment Reference Date (ARD) of 04/02/18, revealed RI #24 was not coded as having a colostomy. 06/06/18 04:29 PM Resident # 24 raised gown & said Someone needs to see about this. Colostomy bag VERY full of gas & stool. Staff LPN notified. On 06/07/18 at 11:28 a.m., the surveyor conducted an interview with Employee Identifier (EI) # 4, the RN (Registered Nurse), MDS Coordinator. The surveyor asked EI # 4 did RI #24 have a colostomy. EI # 4 said RI #24 did. The surveyor asked EI # 4 how long had RI #24 had the colostomy. EI # 4 said RI #24 had the colostomy on admission to the facility. The surveyor asked EI # 4 was the colostomy coded on RI #24's 04/02/18 admission MDS assessment. EI # 4 said, no it was miscoded. The surveyor asked EI # 4 should it have been. EI # 4 said yes. The surveyor asked EI # 4 was this an accurate MDS assessment. EI # 4 said, it was an omission as far as the colostomy and section H was not accurate. On 06/07/18 at 2:51 p.m., the surveyor conducted an interview with EI # 5, the Restorative LPN (Licensed Practical Nurse). The surveyor asked EI # 5 did she code under the Bowel & (and) Bladder section on RI #24's 04/02/18 admission MDS assessment. EI # 5 said yes. The surveyor asked EI # 5 did RI #24 have a colostomy. EI # 5 said yes. The surveyor asked EI # 5 how long had RI #24 had the colostomy. EI # 5 said since admission. The surveyor asked EI # 5 was the colostomy coded on RI # 24's 04/02/18 admission MDS assessment. EI # 5 said no. The surveyor asked EI # 5 should it have been. EI # 5 said yes. The surveyor asked EI # 5 was this an accurate MDS assessment. EI # 5 said no.

Based on interview, the facility's policy for Master Meal Schedule, and the facility's Schedule of Meals, the facility failed to ensure the period between the facility's scheduled meal times for supper and breakfast did not exceed fourteen hours. The facility also failed to request or receive approval from the Resident Council for the period between the facility's scheduled meal times for supper and breakfast to exceed fourteen hours. This had the potential to affect all residents receiving meals from the facility, 91 of 93 residents. The facility's policy for Master Meal Schedule, dated April 23, 2012, included the following: . Standard: According to federal regulations, three meals should be served at regularly scheduled times. No more than a 14-hour span between supper and breakfast should occur. Residents are encouraged to express preferences for self-directed mealtimes including options to normal/regular mealtimes. On 06/05/18, Employee Identifier (EI) #1, the Administrator, provided a copy of the facility's Schedule of Meals for residents, dated November 2012, to the surveyors. This document was reviewed on 06/06/18 at 09:25 AM and the following was revealed: a.) The schedule documented supper for Station 2 was started at 4:00 PM and that breakfast for Station 2 was started at 7:00 AM, which was a 15 hour overnight time span between the two meal services. (Note: On the original document, the start time for supper had been altered with a black pen to create a zero over the first number for minutes, changing the time from 4:30 PM to 4:00 PM.) b.) The schedule documented supper for North. Hts (Northern Heights, the dementia unit) was started at 4:40 PM and that breakfast for North. Hts was started at 7:10 AM, which was a 14 hour 30 minute overnight time span between the two meal services. c.) The schedule documented supper for Dining Room was started at 4:50 PM and that breakfast for Dining Room was started at 7:20 AM, which was a 14 hour 30 minute overnight time span between the two meal services. d.) The schedule documented supper for Station 4 was started at 5:00 PM and that breakfast for Station 4 was started at 7:30 AM, which was a 14 hour 30 minute overnight time span between the two meal services. e.) The schedule documented supper for Station 1 was started at 5:10 PM and that breakfast for Station 1 was started at 7:40 AM, which was a 14 hour 30 minute overnight time span between the two meal services. f.) The schedule documented supper for Station 3 was started at 5:20 PM and that breakfast for Station 3 was started at 7:50 AM, which was a 14 hour 30 minute overnight time span between the two meal services. On 06/06/18 at 9:51 AM, EI #2, the Dietary Manager, provided a current copy of the Schedule of Meals, dated May 2018. The start times for meals on this document were the same as the one dated November 2012, except the start time for supper for Station 2 was 4:30 PM. This schedule revealed the period of time between the evening meal and breakfast for each resident area was 14 hours and 30 minutes. On 06/06/18 at 9:51 AM, EI #2 was asked if the Resident Council or any resident group had given approval for the time period between supper and breakfast to be more than 14 hours. EI #2 said she was not aware of any approval being given by the residents. EI #3, the Registered Dietitian was present during this conversation. EI #3 also said she was not aware of any approval being given by the residents. On 06/06/18 at 9:51 AM, EI #1 was asked if he had any knowledge or documentation of the residents giving approval for a time period greater than 14 hours between supper and breakfast. EI #1 said no. A Resident Council meeting was held on 06/06/18 at 3:30 PM with a surveyor and four residents. When asked about the issue, these residents said no approval had been asked for or given to allow a time period greater than 14 hours between supper and breakfast for the regular schedule. On 06/07/18 at 4:03 PM, EI #2 was asked, how could a resident be negatively affected if the period of time between supper and breakfast was more than 14 hours. EI #2 said, They could be a little hungry. On 06/07/18 at 4:06 PM, EI #3 was asked, how could a resident be negatively affected if the period of time between supper and breakfast was more than 14 hours. EI #3 said, They could possibly get hungry.

Based on observation, interview, the facility's policy for Insect and Rodent Control, and the 2017 Food Code, the facility failed to ensure the tile coving along the juncture of the floor/floor sink and the wall in the chemical/mop closet was not cracked and did not have holes, which allowed the potential for pests to enter the kitchen and for moisture to seep behind the walls. This had the potential to affect all residents receiving meals from the facility, 91 of 93 residents. The facility's policy for Insect and Rodent Control, dated February 1, 2002, included the following: . Purpose: To prevent the spread of bacteria that may cause food borne illnesses. Process: . f. Cracks in walls, floors, along baseboards or ceilings should be reported to maintenance for repair. The 2017 Food Code by the United States Public Health Service and the Food and Drug Administration, included the following: . 6-201.13 Floor and Wall Junctures, Coved, and Enclosed or Sealed. (B) The floors in FOOD ESTABLISHMENTS in which water flush . methods are used shall be provided with drains and be graded to drain, and the floor and wall junctures shall be coved and SEALED. 6-202.15 Outer Openings, Protected. (A) . a FOOD ESTABLISHMENT shall be protected against the entry of insects and rodents by: (1) Filling or closing holes and other gaps along floors, walls, and ceilings; . 6-501.11 Repairing. PHYSICAL FACILITIES shall be maintained in good repair. During the initial tour of the kitchen on 06/05/18 at 6:52 PM, the ceramic tile coving in chemical/mop closet at the right-hand corner of the floor/floor sink was observed to have a hole at the base, which was approximately one inch to one and one-half inches high and three inches across. On 06/06/18 at 3:17 PM, the chemical/mop closet was viewed with Employee Identifier (EI) #2, the Dietary Manager. In addition to the hole seen on 06/06/18, a second, smaller hole in the tile coving along the back wall was observed. Also, numerous cracks in the tile coving were observed. EI #2 verified this area was also the service sink (a floor sink style with a short ledge about one-third way into the closet to create a sink depression and the floor gradually graded down to a drain that was flush to the floor). It was also determined with EI #2 that the back wall of the chemical/mop closet adjoined an interior stairwell. When asked the problem with having large holes in the wall/tile coving of the floor sink in the chemical/mop closet, EI #2 said, Potential for pests. When asked if a request had been made to repair this area, EI #2 said, No. On 06/06/18 at 3:20 PM, the chemical/mop closet was viewed with EI #3, the Registered Dietitian. EI #3 agreed there was a potential for pests due to the holes in the tile coving. When asked if there could be a potential for water seepage behind the walls due to the holes and cracks in the tile coving surrounding the floor drain/sink, the RD said the potential was there. On 06/06/18 at 5:09 PM, EI #3 said the Maintenance Director had measured the two openings in the tile coving of the chemical/mop closet today as requested. EI #3 said the first hole was four inches wide and the second hole was two inches wide.