**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 1) was free from abuse when Resident 2 struck her on the left cheek.This failure had the potential to result in serious physical harm to Resident 1.Findings:A review of Resident 1's admission record indicated she was admitted in 5/19 with the diagnosis of cognitive impairment (persistent function deficits that can impact a person's ability to think, learn and remember).A review of Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 8/16/25, indicated she had severe cognitive impairment.A review of Resident 1's nursing note, dated 8/13/25 and written by Licensed Nurse 1 (LN 1), indicated a staff person had reported to him she had witnessed Resident 1 being struck in the left cheek by Resident 2.A review of Resident 2's admission record indicated he was admitted in 8/20 with the diagnosis of dementia (a progressive state of decline in mental abilities).A review of Resident 2's MDS, dated [DATE], indicated he had severe cognitive impairment.A review of Resident 2's nursing note, dated 8/13/25 and written by LN 1, indicated a staff person had reported to him she had witnessed Resident 2 strike Resident 1 in the left cheek.During an interview on 9/8/25 at 11:56 a.m. with Activities Assistant 1 (AA 1), AA 1 stated she had been in the dining room on 8/13/25 and witnessed Resident 2 strike Resident 1 in her left cheek as he wheeled himself past her in his wheelchair. AA 1 stated Resident 1's cheek was a little red but she had not cried out in pain.During an interview on 9/8/25 at 12:39 p.m. with the Social Services Director (SSD), the SSD stated she was aware of the incident that had occurred between Resident 1 and Resident 2 on 8/13/25. The SSD agreed Resident 1 had suffered abuse by Resident 2 and confirmed it was the facility's responsibility to keep all residents safe.During an interview on 9/8/25 at 1:24 p.m. with LN 1, LN 1 stated he assessed Resident 1 on 8/13/25 after she had been struck by Resident 2 and her left cheek was slightly reddened after the incident but there were no complaints of pain.During an interview on 9/8/25 at 1:42 p.m. with the Administrator (ADM), the ADM agreed Resident 2 striking Resident 1 in the cheek was abuse.During a review of the facility's policy titled, Abuse Prevention Program, undated, the policy stipulated, Our residents have the right to be free from abuse.This includes physical abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to immediately notify the responsible party (RP, a person who is designated in making decisions about health care and financial matters) for one out of two residents (Resident 1), when Resident 1's RP was not notified until 4/20/25 that Resident 1 fell on 4/18/25 and 4/19/25.This failure was a violation of residents' rights. Findings:A review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the residents) indicated Resident 1 was admitted to the facility in April of 2025 with a RP listed and a note that indicated, .[phone] number corrected to [xxx-xxx-1966] from [xxx-xxx-9518] on 4/20/25.A review of Resident 1's Nursing Progress note, dated 4/18/25 at 4:26 a.m., indicated, .[Resident 1] is found sitting on the floor next to his bed. [Resident 1] stated, ‘.I just fell on my butt.'.Called RP.no answer.A review of Resident 1's Nursing Progress, dated 4/19/24 at 4:40 p.m., indicated, . [Resident 1] was sitting in his w/c [wheelchair] . resident was trying to turn his w/c around when he slid down from his w/c, landed [on] his bottom [buttocks].RP.left 3x [three times] voice mail, no return call noted.A review of Resident 1's Nursing Progress note, dated 4/20/25 at 11:15 a.m., indicated, .spoke with [Resident 1's RP] .during course of conversation, brought up to [RP] .writer called her at [phone number xxx-xxx-9518] and left a voicemail to call facility back; per [RP] she did not receive the voicemail. We then checked the face sheet. The contact number that is in the face sheet [xxx-xxx-9518], according to [RP] is not the number that she is using but it's [xxx-xxx-1966]. This may be the reason why she did not receive the call.During an interview on 8/4/25 at 3:44 p.m., Licensed Nurse (LN) B stated a fall was considered a change of condition (COC, a noticeable alteration in a patient's health status, either positive or negative) and should be reported to the resident's RP and the resident's physician. LN B stated fall incidents should be reported to RP immediately or at least before the end of shift. LN B stated the facility was responsible to ensure the correct contact information is listed on the resident's face sheet to be able to notify the RP for a fall. LN B stated not notifying the RP of a COC was a violation of residents' rights.During a concurrent interview and record review on 8/4/25 at 4:34 p.m. with LN A, Resident 1's face sheet was reviewed. LN A verified there was a note on Resident 1's face sheet indicating on 4/20/25, the day of Resident 1's discharge, the RP's contact number was changed to the correct contact number [xxx-xxx-1966]. LN A stated the facility was responsible for ensuring the RP's contact number on residents' files were accurate. LN A verified that due to the wrong contact number on the face sheet, the RP was not made aware of Resident 1's fall incidents on 4/18/25 or 4/19/25 timely. LN A stated it was important that RPs were aware of COC such as falls.During a telephone interview on 8/5/27 at 1:57 p.m., the Director of Nursing (DON) verified Resident 1's RP contact number listed on Resident 1's face sheet was incorrect and that was the reason why Resident 1's RP was not notified of the fall incidents on 4/18/25 and 4/19/25. The DON confirmed Resident 1's RP was only made aware of the falls on 4/20/25 when the RP was picking Resident 1 for discharge. The DON stated it was the facility's responsibility to ensure the contact information on the face sheet was correct.A review of the facility's policy and procedure (P&P) titled, Changes in Resident's Condition, undated, indicated, . the resident and/or resident representative [RP] (if resident has no capacity to make health care decisions or resident may have requested the Licensed Nurse to contact a family member during a change of condition),.[RP] and physician are notified by [LN]/Company Designee when there is. an accident involving resident.and has the potential for requiring physician intervention.

Based on interviews and record reviews, the facility failed to ensure a summary of the baseline care plan (BCP, a document created within 48 hours of a resident's admission to a nursing home, outlining the initial care needed to ensure residents' safety and well-being, focusing on basic needs and resident-specific information) was provided for one resident out of two sampled residents (Resident 1), when there was no documentation indicating Resident 1's responsible party (RP, a person who is designated in making decisions about health care and financial matters) was provided the BCP summary. This failure has the potential to decrease the RP's ability to be informed about Resident 1's care and services.Findings:A review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the residents) indicated Resident 1 was admitted to the facility in April of 2025 with a RP listed.A review of Resident 1's BCP, dated 4/14/25, did not indicate a copy of the summary of the BCP was provided to Resident 1's RP.During a concurrent interview and record review on 8/4/25 at 4:34 p.m. with Licensed Nurse (LN) A, Resident 1's BCP, dated 4/14/25, was reviewed. LN A stated a BCP was important because it provided a map for the residents' safe care. LN A stated it was important to provide a resident's RP with a summary of the BCP so they can ensure the facility will provide quality care the resident requires. LN A stated there was no indication a summary of Resident 1's BCP was provided to Resident 1's RP.During a telephone interview on 8/5/25 at 1:57 p.m., the Director of Nursing (DON) verified she had looked into Resident 1's BCP dated 4/14/25 and acknowledged there was no indication a copy of the BCP summary, dated 4/14/25, was provided to the RP. The DON stated, if it was not documented, then it did not happen.A review of the facility's policy and procedure (P&P) titled Baseline Care Planning, undated, the P&P indicated, .a baseline plan of care to meet the resident's immediate needs shall be developed for each residents within 48 hours of admission. the resident and their [RP] will be provided a summary of the [BCP].Documentation In Electronic Health Record (EHR) .may use the paper form and will be uploaded in EHR.

Based on interviews and record reviews, the facility failed to ensure one out of two sampled residents (Resident 1) was provided an environment free of accident hazards and received adequate supervision to prevent accidents, when Resident 1 fell from a wheelchair (WC) provided by the facility. This failure could result in the increased risk of accidents.Findings:A review of Resident 1s face sheet (front page of the chart that contains a summary of basic information about the residents) indicated an admission date of 4/2025 with a diagnosis of Alzheimer's Disease (AD, a disease characterized by a progressive decline in mental abilities) and Anxiety (fear, worry).A review of the Fall care plan (CP, a detailed, written document that outlines a resident's individual needs, goals, and how their care will be managed), dated 4/14/25 , did not indicate Resident 1 used a WC.A review of Resident 1's Nursing Progress Note, dated 4/14/25 at 11:00 a.m., indicated, .[Resident 1] ambulatory [walking] with cane, fall risk.Hx [history] of falls (1 fall per month) .prone to wandering behavior, 1:1 [a situation where a single healthcare professional provides care or observation to a single patient] redirection advised.A review of Physical Therapy (PT, a healthcare profession that focuses on improving and restoring physical function and mobility) evaluation and plan of treatment, dated 4/15/25, indicated Resident 1 did not use a wheelchair and there was no recommendation from the PT that Resident 1 was safe to use the WC.A review of Resident 1's Nursing Progress Note, dated 4/19/24 at 4:40 p.m., indicated, . [Resident 1] was sitting in his w/c [wheelchair] . resident was trying to turn his w/c around when he slid down from his w/c, landed [on] his bottom [buttocks].A review of Resident 1's electronic health records produced no documentation that Resident 1 had a WC assessment (an evaluation to determine a person's specific needs for a wheelchair and related equipment).During a concurrent interview and record review, on 8/4/25 at 4:34 p.m., with Licensed Nurse (LN) A, Resident 1's electronic health records were reviewed. LN A verified the progress note dated 4/14/25 at 11:00 a.m. indicated Resident 1 walked with cane. LN A verified Resident 1's Nursing Progress Note, dated 4/19/25 at 4:40 p.m., indicated Resident 1 fell while he was on a WC. LN A stated Resident 1 should not be placed on a wheelchair since there was no evaluation done that Resident 1 needed or was safe to use a WC.During a telephone interview on 8/8/25 at 10:07 a.m., the Director of Nursing (DON) verified on 4/19/25 Resident 1 slid from a WC and landed on his buttocks. The DON verified there was no care plan to indicate Resident 1 should be using a WC. The DON verified Resident 1 was seen by PT with no note or assessment to indicate Resident 1 was safe to use the WC.A review of the facility's policy and procedure (P&P) titled Fall Management, undated, the P&P indicated, .based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to reduce the risk of the resident falling .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report to the Department an injury of unknown source (an injury which was not observed, cannot be explained by the resident, and is suspicious because of the extent or location) for one of four sampled residents (Resident 1) when Resident 1 sustained a broken left arm. The facility was aware of Resident 1's injury on 7/6/25, but did not report it to the Department until 7/8/25.This failure resulted in a delay in the Department's investigation into Resident 1' s injury and its cause, putting Resident 1 at risk for additional harm. A review of Resident 1's Resident Face Sheet, printed 7/16/25, indicated Resident 1 was initially admitted to the facility on [DATE], with diagnoses including Alzheimer's disease (a progressive brain disorder that gradually impairs memory, thinking, and language skills, eventually affecting a person's ability to carry out daily tasks), epilepsy (defined by recurrent seizures, which are sudden, temporary disruptions of normal brain activity), and hemiparesis (a condition characterized by weakness on one side of the body) following cerebral infarction (a condition where brain tissue dies due to a lack of blood supply) affecting the left side of the body.During a review of Resident 1's Minimum Data Set (MDS-an assessment and care planning tool), Section B (describing hearing, speech and vision ability), dated 6/13/25, it indicated Resident 1 could not speak or communicate in any way that could be understood by others. During a review of Resident 1's MDS Section C (describing abilities relating to the mental process involved in knowing, learning, and understanding things), dated 6/13/25, it indicated Resident 1's ability to make decisions was severely impaired, and Resident 1 had short and long-term memory deficits.During a review of Resident 1's Resident Progress Notes, dated 7/5/25 at 9:54 p.m., it indicated resident was noted with facial grimace, moaning and almost crying upon repositioning left arm.resident with behavior of grabbing and pulling with right hand. N.O. (new order) from [MD]-Xray of LT (left) wrist 3 view; LT hand 3 view; LT forearm; noted and carried out.During a review of Resident 1's Radiology Report, dated 7/6/25, it indicated Resident 1 had the following , Forearm.Left, Results: Severely comminuted fracture (where the bone is broken into three or more pieces) of the distal radial (near the wrist joint) and ulnar metaphysis (the ulna is one of the two bones in your forearm, located on the pinky side. The metaphysis is the area between the diaphysis (shaft) and the epiphysis (end) of the bone). Radial fracture shows complete lack of apposition and alignment (apposition refers to the degree of contact between bone fragments at the fracture site, while alignment describes the overall position and orientation of the bone fragments). Ulnar fracture shows angulation (describes the degree to which the broken bone fragments are misaligned, forming an angle with each other).During a review of Resident 1's Resident Progress Notes, dated 7/6/25 at 1:30 p.m., it shows the time/date the facility became aware of Resident 1's left forearm fracture.A review of CDPH (California Department of Public Health) Incident/Intake Report for intake number CA00971772 (for incident date 7/6/25) indicated the facility reported this incident to CDPH on 7/8/25 at 5:40 p.m., via telephone voicemail message.During a concurrent interview and record review on 7/16/25 at 2:00 p.m. with Resident 1's primary care provider (PCP) and the Director of Nursing (DON), Resident 1's radiology results and recent skin assessments were reviewed. The DON agreed on multiple occasions Resident 1 was noted to have unexplained skin discoloration, redness, or other abnormal marks on her arms, face, trunk, thighs, and hands. The PCP stated it would be hard to determine exactly where or how Resident 1's broken arm occurred. The PCP further stated although Resident 1's medical conditions and medications may contribute to brittle bones and spontaneous fractures, he agreed a comminuted fracture is usually connected to falls, car accidents or other high-impact blows.During an interview with the facility's Administrator (ADM) on 7/16/25 at 3:30 p.m., the ADM stated he did not believe that this incident was required to be reported within two hours because abuse was not suspected. The ADM did not give any indication of how abuse could be ruled out for such a serious unexplained injury before a preliminary investigation was conducted. A review of facility policy and procedure titled Abuse Investigation and Reporting (undated), indicated: Reporting:1. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of an unknown source and misappropriation of property will be reported to the Company Administrator, or his/her designee, to the following persons or agencies: a) The State licensing certification agency responsible for surveying/licensing the facility; b) The local/state Ombudsman (works independently as an intermediary to provide individuals with a confidential avenue to address complaints and resolve issues); c) The Resident's Representative (Sponsor) of Record; d) Adult Protective Services (where state law provides jurisdiction in long-term care); e) Law enforcement officials; f) The Resident's Attending Physician; and g) The Company Medical Director. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown sources and misappropriation of resident property) will be reported immediately but not later than: a) Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b) Twenty-four (24) hour if the alleged violation does not involve abuse AND has not resulted in bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to meet professional standards of nursing care for one resident (Resident 1) of three sampled residents when laboratory tests were not completed per physican orders. This failure had the potential to delay treatment for Resident 1. Findings: A review of Resident 1 ' s admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of multiple fractures (broken bones), diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypokalemia (a low level of potassium (an important mineral) in the blood), hypertension (HTN-high blood pressure), and atherosclerotic heart disease (a narrowing of the vessels in the heart, causing obstruction of blood flow). A review of Resident 1 ' s progress note, dated 3/12/25 at 11:49 a.m., indicated Licensed Nurse K (LN K) documented a telephone order from the Medical Director (MD, a physician) to Test norovirus [a virus that affects the digestive tract], C. diff. [inflammation of the digestive tract caused by the bacteria Clostridium difficile], COVID [Coronavirus Disease- an infectious disease caused by a virus], KUB [an x-ray of body structures responsible for processing urine]. LN K documented in the progress note the order was noted (the doctor ' s instructions were recorded in the patient ' s medical record) and carried out. A review of Resident 1 ' s Care Plan (CP) indicated Resident 1 had a plan for loose stools, initiated on 3/12/25. The interventions included, Test norovirus, c. diff. covid, KUB. A record review of a document titled, Lab Administration History indicated Resident 1 had an order for Other Tests: C. diff panel, norovirus, and covid. Special instructions indicated discontinue the order once results available, and MD notified. The start date for the order was 3/12/25 and the end date was 3/14/25. During a concurrent interview and record review of Resident 1 ' s CP on 4/17/25 at 12 p.m., LN L confirmed an order for norovirus lab was noted but the norovirus test was not completed, and the MD was aware. During a concurrent interview and record review of Resident 1 ' s progress note on 4/17/25 at 12:45 p.m., LN K confirmed the progress note indicated orders for lab tests for c. diff., covid, norovirus, and KUB were noted and carried out. LN K also stated she recalled a discussion with the MD and norovirus lab was not completed. A record review of all laboratory reports for Resident 1 indicated a test for C. Diff. was collected on 3/12/25 and reported to the facility on 3/14/25 as negative (the C. Diff. bacteria was not present). The facility did not have a laboratory report for norovirus. During a concurrent interview and record review of Resident 1 ' s Lab Administration History on 4/17/25 at 3:42 p.m., LN M confirmed Resident 1 had an order for tests for c diff, norovirus, covid, and KUB. LN M stated the order was for four tests and all four of the tests should have been completed. A review of Resident 1 ' s progress note, dated 3/13/25 at 8:05 p.m., indicated LN G received a phone call from the facility laboratory services which indicated Resident 1 had a critical low value (a laboratory test result that was significantly lower than the normal range and indicates a potential life-threatening condition) for potassium (a crucial mineral for the body). LN G notified the MD and received a telephone order for administration of potassium and magnesium. The order also indicated check Resident 1 ' s magnesium (a crucial mineral for the body) and CMP (a blood test that measures 14 different substances in your body) in 2 days. LN G documented the order was noted and carried out. A review of Resident 1 ' s CP indicated Resident 1 had a plan for dehydration/fluid maintenance/low potassium levels, initiated on 3/14/25. The interventions included, lab test as ordered: magnesium CMP in 2 days. During an interview on 4/17/25 at 3:30 p.m., the MD stated if he had written an order for labs, he would have expected all the labs were completed. The MD stated if he ordered a norovirus lab it should have been done and he didn ' t know why it wasn ' t. The MD also stated when he ordered a lab to be rechecked in two days it should have been rechecked in two days. During a concurrent interview and record review of Resident 1 ' s CP on 4/17/25 at 3:42 p.m., LN M confirmed CP indicated, lab tests as ordered: magnesium, CMP in 2 days with approach start date of 3/14/25. LN M stated 2 days would be 3/16/25. During a concurrent interview and record review of Resident 1 ' s Progress Notes on 4/17/25 at 4:05 p.m., LN B stated the MD order on 3/13/25 indicated repeat labs for magnesium and CMP in two days. LN B stated the order was due on 3/15/25. A record review of a document titled, Lab Administration History indicated Resident 1 had an order for CMP and Magnesium with instructions to inform MD once resulted, upload to Matrix (EHR- electronic health record) and may discontinue. The order start date was 3/17/25 and the end date was 3/17/25. A chart note was entered in the EHR on 3/17/25 at 3:58 p.m. with comments indicating the order administration was late and LN D received instructions from the lab to rebook. Review of a facility policy titled, Physician Orders indicated, Physician orders are obtained to provide a clear direction in the care of the resident. The policy further indicated, A physician ' s order is required prior to the discontinuation of any current order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to: 1. Ensure nursing staff were able to correctly state the facility ' s policy on how and when to perform Cardiopulmonary Resuscitation (CPR – an emergency procedure that combines chest compressions (the action of pushing hard and fast on the chest while performing CPR) and rescue breathing to restart a person ' s heartbeat and breathing) and Basic Life Support (BLS- a set of life-saving procedures performed on someone if/when their heart stops beating or the person has difficulty breathing until advanced medical help arrive) when four nursing staff (Certified Nursing Assistant A (CNA A), Licensed Nurse C (LN C), LN D, and LN G) of six nursing staff incorrectly stated the facility ' s policy; 2. Immediately perform CPR on one resident (Resident 1) of three sampled residents on [DATE] when she was found in bed not breathing and without a heartbeat; 3. Ensure an Automated External Defibrillator (AED- a portable medical device used to deliver an electric shock to a person experiencing an abnormal heart rhythm) was present for LNs to use as part of the CPR/BLS) procedure; and, 4. Ensure one LN of four LNs were currently certified to perform CPR/BLS for one resident (Resident 1) of three sampled residents when Resident 1 was found unresponsive, without a heartbeat and not breathing in her room. This failure decreased the facility ' s potential to provide successful resuscitation (to revive from unconsciousness or apparent death) efforts to Resident 1 and other residents who were identified as a Full Code (the resident ' s choice to receive all emergency treatment including CPR to resuscitate and maintain life). Findings: 1. A review of Resident 1 ' s Face Sheet (a summary of basic information about the resident) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of multiple fractures (broken bones), diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypokalemia (a low level of potassium (an important mineral) in the blood), hypertension (HTN-high blood pressure), and atherosclerotic heart disease (a narrowing of the vessels in the heart, causing obstruction of blood flow). A review of Resident 1 ' s Physician Orders for Life-Sustaining Treatment (POLST – a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) signed by Resident 1 ' s Representative and dated [DATE], indicated Resident 1 selected, Attempt Resuscitation/CPR. During an interview on [DATE] at 10:20 a.m., CNA A stated the facility trained CNAs on CPR. During an interview on [DATE] at 10:50 a.m., LN C stated if a resident was found unresponsive by a CNA, the CNA is expected to go to one of the nurses ' stations to alert an LN. An LN then would assess the resident. If the resident was unresponsive, the LN would call another LN to stay with the resident while the other LN checked the resident ' s POLST in the paper chart or in the EHR. If the resident was Full Code, an LN was expected to call 911 (a phone number used to call emergency services) and make an overhead announcement on the paging system to activate the Rapid Response Team (RRT- a designated group of nurses who respond to assist residents whose condition requires an immediate response). LN C stated the rapid response would be activated after the POLST was checked. LN C also stated the time CPR was provided mattered because if oxygen (a gas essential for human life) did not get to the brain quickly brain cells died. During an interview on [DATE] at 11:12 a.m., LN D stated if a CNA reported an unresponsive resident, the LN was expected to assess the resident and instruct the CNA to call for help. LN D stated help was summoned by using a call light in the resident ' s room so someone at the nurses ' station would respond. LN D stated she was unsure if the facility had a paging system and did not really know how to call for help. LN D stated she printed a daily census (a list of residents residing in the facility each calendar day) and wrote the code status of the residents she was assigned to. LN D confirmed she did not have the census on her person and kept it at the nurses ' station. LN D stated the time CPR was started was important because brain cells were affected by a lack of oxygen. During an interview on [DATE] at 2:12 p.m., the Director of Staff Development (DSD) stated CNAs were instructed to report to an LN when a resident was found unresponsive. The DSD stated CNAs did not provide CPR in the facility; only licensed staff (nurses who have the legal authority to practice nursing within a specific scope of practice as granted by a state or regulatory department) provided CPR. During an interview and record review on [DATE] at 10:47 a.m., the Director of Nursing (DON) stated she expected LNs to have residents ' code statuses easily accessible. The DON confirmed the RRT was made up of four people which included the Unit Manager (a nurse who supervises and manages staff in a specific unit) and the charge nurses from each of the three nurse ' s stations. The DON also stated there were phones in the hallways for staff to use to make an overhead Rapid Response announcement so everyone could hear it. During an interview on [DATE] at 4:28 p.m., LN G stated CNAs were CPR certified and could assist with CPR. A review of an undated facility policy titled, Emergency Procedure – Cardiopulmonary Resuscitation indicated, .General Guidelines .The chances of surviving SCA [Sudden Cardiac Arrest – when a person ' s heart stops] may be increased if CPR is initiated immediately upon collapse . If an individual .is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR .Instruct a staff member to activate the .[Rapid Response] code and call 911 .Verify or instruct a staff member to verify the DNR or code status .Initiate the .BLS sequence of events . When the AED arrives, assess for need and follow AED protocol as indicated. 2. A review of Resident 1 ' s progress note documented by Resident 1 ' s assigned LN (LN E) dated [DATE] at 9:40 p.m. indicated, During med [medication] pass; the [Resident 1] was observed eye closed with no chest rise and fall. Attempts to call the resident by her name three times yielded no response. Upon checking the resident ' s pulse, found it to be pulseless. The resident ' s skin was noted to be warm to touch; This writer promptly informed other LN ' s to verify the resident code status. Once the complete code status was confirmed, I commenced [started] CPR. Another nurse promptly dispatched 911. Subsequently, another nurse retrieved the crash cart [a wheeled container which stored equipment used in emergency resuscitations]. A review of Resident 1 ' s progress note documented by the UM of Resident 1 ' s nurse ' s station dated [DATE] at 9:43 p.m. indicated, This writer informed to help asses [Resident 1]. Resident is warm to touch. No chest rise and fall noted. Pupillary reflex [the automatic change in the size of a person ' s pupils, which are the openings in the center of the eye, in response to light] checked and bilaterally [both eyes] unreactive to light and accommodation. A review of Resident 1 ' s progress note dated [DATE] at 10:57 p.m. indicated, Paramedics terminated CPR. Death pronounced at 10:55 p.m. During an interview on [DATE] at 3:55 p.m., LN F stated on the evening of [DATE] she heard shouting and went to Resident 1 ' s room. LN F called 911. LN F stated she did not know why LN H had not called 911 or why LN H had left Resident 1 ' s room and later returned. During a concurrent interview and record review on [DATE] at 10:42 a.m., the DON confirmed a document titled, .County EMS [Emergency Medical Services] Field Determination of Death indicated emergency personnel from the local Fire Department arrived on the scene at 10:25 p.m. on [DATE]. During a concurrent interview and review of Resident 1 ' s progress note on [DATE] at 10:47 a.m., the DON stated she expected CPR should be done immediately and LNs should have code statuses easily accessible. The DON confirmed Resident 1 ' s nurse progress notes dated [DATE], indicated at 9:40 p.m. LN E found Resident 1 unresponsive, not breathing, without a pulse and other LNs were asked to verify Resident 1 ' s code status prior to starting CPR. The DON also confirmed Resident ' s progress note dated [DATE] indicated at 9:43 p.m. LN G went to Resident 1 ' s room and checked Resident 1 ' s skin temperature, apical pulse (a pulse point on a chest at the bottom tip of the heart), respiratory status, and pupillary response. After LN G confirmed Resident 1 did not have a pulse, was not breathing, and Resident 1 ' s code status was confirmed, LN E then started CPR. The DON stated LNs had residents ' code status written on the daily census and was in the EHR system on the medication cart. The DON stated she was unaware if the RRT used the paging system when Resident 1 required CPR on [DATE]. During an interview on [DATE] at 2:08 p.m., LN H stated on the evening of [DATE] he was documenting on resident charts at the nurse ' s station when LN E walked to the nurse ' s station and said he needed help. LN H did not recall who checked Resident 1 ' s code status. LN H stated he finished typing his documentation and went to Resident 1 ' s room. LN H stated he saw LN E was performing chest compressions on Resident 1. LN H stated LN F called 911. LN H took over chest compressions on Resident 1 while the EMS dispatcher coached the team over the phone. During an interview on [DATE] at 4:28 p.m., LN G confirmed she was the UM on the evening of [DATE]. LN G stated LN E came to the nurse ' s station and requested an assessment of Resident 1. LN G got her stethoscope (a medical instrument used for listening to a person ' s heart and/or breathing) and pen light (a small flashlight). LN G stated Resident 1 was in her bed and warm to the touch. LN G stated she listened to Resident 1 ' s apical pulse and four quadrants of her lungs and heard no heartbeat or breath sounds. LN G also stated Resident 1 ' s pupils were fixed (not reacting/moving) to light and dilated (enlarged). LN G told LN E to make sure Resident 1 was a full code and then LN G ran out of the room to get the crash cart. LN G then paged all nurses to go to Resident 1 ' s room. LN G stated LN E started chest compressions and she used the Ambu bag. LN H entered the room and then left. LN F came to the room and was told to call 911. LN H later returned to Resident 1 ' s room and assisted with chest compressions. LN G confirmed there was a paging system at the nurse ' s station. LN G stated the paging system was used for emergencies after 9 p.m. LN G stated the RRT team members were expected to respond to the RRT overhead announcement. A review of an email and records received from the facility Administrator (ADM) on [DATE] at 12:18 p.m. indicated: - A Medication Administration Record dated [DATE] at 9:54 p.m., LN E had passed medication to a resident in another room which did not align with the LN E ' s progress note documented on [DATE] at 9:40 p.m. which indicated LN E discovered Resident 1 unresponsive and promptly initiated CPR. - According to a screen shot of a phone log, LN H called the DON at 10:10 p.m. on [DATE]. - According to a screen shot of a phone log, a call was placed to 911 was placed at 10:11 p.m. on [DATE]. - According to a screen shot of a phone log, a call was made to the DON a second time to notify her Resident 1 was found unresponsive, CPR was initiated, and 911 had been called at 10:11 p.m. A review of an undated facility policy titled, Emergency Procedure – Cardiopulmonary Resuscitation indicated, .If an individual .is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR . If the resident ' s DNR [DNR- a medical order instructing healthcare providers not to perform CPR or other life-saving measures if a person ' s heart or breathing stop] status is unclear, CPR to be initiated until it is determined that there is a DNR or a physician ' s order not to administer CPR . Instruct a staff member to activate the .[Rapid Response] code and call 911 . A review of the 2020 American Heart Association ' s Adult Basic Life Support [BLS] Algorithm for Healthcare Providers indicated, .Look for no breathing .and check pulse (simultaneously). Is pulse definitely felt within 10 seconds? .[If] No breathing .pulse not felt .By this time in all scenarios, emergency response system or backup is activated, and AED [automatic external defibrillator] and emergency equipment are retrieved or someone is retrieving them .Start CPR .Use AED as soon as it is available .AED arrives. Check rhythm. Shockable rhythm [the pattern or timing of the heart beats]? Yes, shockable .Give 1 shock [an electric shock to a person experiencing an abnormal heart rhythm]. Resume CPR immediately . 3. During a concurrent interview and policy review on [DATE] at 10:47 a.m., the DON confirmed the facility policy, Emergency Procedure – Cardiopulmonary Resuscitation indicated, .Instruct a staff member to retrieve the automatic external defibrillator [AED]. The DON stated the facility did not have an AED to be used to provide BLS to a resident who needed it. During an interview on [DATE] at 3:30 p.m., the Medical Director (MD) stated he expected nursing staff to follow the CPR policy. The MD also stated the use of an AED was expected as part of the BLS process. A review of an undated facility policy titled, Emergency Procedure – Cardiopulmonary Resuscitation indicated, Purpose .Personnel have completed training on the initiation of .CPR and .BLS, including defibrillation for victims of .SCA. Early delivery of a shock with a defibrillator plus CPR within 3-5 minutes of collapse can further increase chances of survival . Maintain equipment and supplies necessary for CPR/BLS in the facility at all times .Initiate the .BLS sequence of events . When the AED arrives, assess for need and follow AED protocol as indicated. 4. A review of an email received from the DON on [DATE] at 12:31 p.m. indicated, .Hereto attached are the CPR certs [certification] for [LN H], [LN G], and [LN E]. [LN F ' s] is expired. But she [LN F] did not perform CPR that day [[DATE] on Resident 1]. A review of an undated facility policy titled, Emergency Procedure – Cardiopulmonary Resuscitation indicated, Purpose .Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation for victims of sudden cardiac arrest. CPR/BLS certifications are required for the Registered Nurses, Licensed Vocational Nurses .Preparation for [CPR] .Obtain and/or maintain American Red Cross or American Heart Association .certification in .BLS/CPR for key clinical staff members who will direct resuscitative efforts, including non-licensed personnel .

Based on record review, interview, and document review, the facility failed to complete the quarterly Minimum Data Set (MDS) for 2 (Resident #5 and Resident #22) of 18 sampled residents. The facility further failed to timely complete a quarterly MDS for 2 (Resident #1 and Resident #48) of 18 sampled residents. Findings included: The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated 10/2024, indicated, The Quarterly assessment is an OBRA [Omnibus Budget Reconciliation Act] non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored. Per the User's Manual, The MDS completion date must be no later than 14 days after the ARD. 1. A Resident Face Sheet indicated the facility readmitted Resident #5 on 08/22/2024. Resident #5's medical record revealed evidence to indicate a quarterly MDS, with an Assessment Reference Date (ARD) of 09/06/2024. There was no further evidence to indicate another MDS had been completed. 2. A Resident Face Sheet indicated the facility admitted Resident #22 on 08/19/2024. Resident #22's medical record reviewed evidence to indicate an admission MDS, with an Assessment Reference Date (ARD) of 08/23/2024. There was no further evidence to indicate another MDS had been completed. During an interview on 12/11/2024 at 2:47 PM, the MDS Coordinator stated he was not aware of Resident #5's need for an MDS in 12/2024. Per the MDS Coordinator, he was aware of Resident #22's MDS for 11/2024 had not been completed. During an interview on 12/11/2024 at 3:00 PM, the Director of Nursing (DON) stated the MDS Coordinator was responsible for MDS completion. The DON stated she was notified on 12/10/2024 of the late MDS assessments. Per the DON, she expected the MDS to be completed timely. During an interview on 12/11/2024 at 3:36 PM, the Administrator stated he was aware of late MDS assessments, and his expectation was for MDS assessments to be timely submitted. 3. A Resident Face Sheet revealed the facility admitted Resident #1 on 12/06/1997. Resident #1's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/08/2024, revealed the MDS was signed as being completed on 12/02/2024. During an interview on 12/11/2024 at 1:31 PM, the MDS Coordinator stated he had 14 days from the ARD to sign the MDS as being completed. The MDS Coordinator acknowledged he was late with completing some MDS assessments. During an interview on 12/11/2024 at 3:07 PM, the Director of Nursing stated she did not know the MDS Coordinator was behind with the completion of MDS assessment and expected the MDS assessments to be completed timely. During an interview on 12/12/2024 at 1:02 PM, the Administrator stated there had not been any issues with MDS assessments in the past and did not know there was an issue with the MDS assessments being late. The Administrator stated the MDS Coordinator was new and had not let anyone know there was a problem with the MDS assessments. Per the Administrator, he expected the MDS assessments to be completed in a timely manner. 4. A Resident Face Sheet revealed the facility admitted Resident #48 on 04/15/2021. Resident #48's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/16/2024, revealed the MDS was signed as being completed on 12/02/2024. During an interview on 12/11/2024 at 1:29 PM, the MDS Coordinator stated he had been the MDS Coordinator since 07/2024 and struggled to complete MDS assessment timely. The MDS Coordinator acknowledged the MDS assessment for Resident $38 was late During an interview on 12/11/2024 at 3:07 PM, the Director of Nursing stated she did not know the MDS Coordinator was behind with the completion of MDS assessment and expected the MDS assessments to be completed timely. During an interview on 12/12/2024 at 1:02 PM, the Administrator stated there had not been any issues with MDS assessments in the past and did not know there was an issue with the MDS assessments being late. The Administrator stated the MDS Coordinator was new and had not let anyone know there was a problem with the MDS assessments. Per the Administrator, he expected the MDS assessments to be completed in a timely manner.

Based on observation, interview, record review, document review, and facility policy review, the facility failed to ensure staff provided a communication board and a pointer to 1 (Resident #189) of 2 sampled residents reviewed for communication. Findings included: An undated facility policy titled Alternative Communication Device revealed, The purpose of developing and training use of an alternative communication device is to provide the non-verbal resident with a means of functionally communicating his or her wants and needs. Background An alternative communication device is any system of communication used in place of or as a supplement to normal speech and language to facilitate functional communication. The system may be manual or electronic and may include the use of gestures, pictures, words, symbols, voice output, or writing A Resident Face sheet revealed the facility admitted Resident #189 on 02/22/2021. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of cerebral infarction due to embolism of the right middle cerebral artery and need for assistance with personal care. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/29/2024, revealed Resident #189 had a Staff Assessment for Mental Status (SAMS) that indicated the resident had modified independence in cognitive skills for daily decision making. Per the MDS, the resident had no speech - absence of spoken words. Resident #189's Care Plan included a problem statement initiated 06/10/2021, that indicated the resident was unable to verbally communicate in a dominant language. Interventions directed staff to provide the resident a commination board and communication cards for basic needs. During an observation on 12/09/2024 at 11:13 AM, the surveyor noted a sign posted in Resident #189's room that indicated the resident was unable to speak, used a letter board for basic communication, and to provide the resident with a pointer, that was kept in the drawer. The surveyor noted the resident was not able to use their communication board as the communication board was not within the resident's reach and there was no pointer present. During an interview on 12/10/2024 at 9:26 AM, Resident #189 informed the surveyor that staff did not always ensure they had access to their pointer. During an interview on 12/10/2024 at 11:49 AM, Resident informed the surveyor they did not have a pointer to use. During an observation on 12/10/2024 at 1:15 PM, the surveyor noted there was no pointer in Resident #189's drawer. During an observation on 12/11/2024 at 8:49 AM, the surveyor noted Resident #189 in bed and there was no pointer within the resident's reach or in the drawer. During an interview on 12/11/2024 at 9:39 AM, Certified Nurse Aide (CNA) #11 stated Resident #189 did not speak, used signed to communicate, and pointed to things they needed. CNA #11 acknowledged the resident did not have a pointer and he had never seen a pointer in the resident's room During a concurrent observation and interview on 12/11/2024 at 9:54 AM, Registered Nurse (RN) #8 entered Resident #189's room and could not locate the pointer. RN #8 stated she did not know how long the resident's pointer had been missing During an interview on 12/11/2024 at 9:58 AM, the Director of Nursing (DON) stated she did not notice Resident 189's pointer was missing. The DON asked Resident #189 if they wanted a pointer and the resident gave a thumbs up, which indicated yes. The DON stated the pointer will be replaced. During an interview on 12/12/2024 at 1:24 PM, the Administrator stated all resident should be able to make their needs known.

Based on interview, record review, and facility policy review, the facility failed to ensure the environment of a resident did not provide a means to exit the facility without staff knowledge for 1 (Resident #13) of 3 sampled residents reviewed for accidents. Findings included: An undated facility policy titled, Resident Elopement, indicated, Purpose The facility will provide a safe environment and preventive measures for elopement with the aim to monitor and document patients at risk for elopement. A Resident Face Sheet revealed the facility admitted Resident #13 on 11/14/2023. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of chronic pain, acute systolic heart failure, and epilepsy. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/11/2024, revealed Resident #13 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS indicated the resident did not display wandering behavior. Resident #13's Elopement Risk Assessment dated 07/19/2024, revealed the resident was not at risk for elopement. Resident #13's Resident Progress Notes dated 09/05/2024 at 11:48 AM revealed the resident was noted to head out of the facility and two licensed nurses immediately followed the resident and intervened. Per the Resident Progress Notes, the resident stated they needed to go to the bank and get some money. The Resident Progress notes indicated the resident was informed that was not safe for them to go out of the facility unsupervised. Resident #13's Resident Progress Notes dated 09/10/2024 at 6:30 PM, revealed the facility received a telephone call from the local police department which indicated the resident was found strolling on the sidewalk of a street by themselves. Resident #13's Care Plan included a problem statement initiated 09/05/2024, that indicated the resident was noted to have exit-seeking behavior and left the facility without assistance on 09/11/2024. Interventions directed staff to transfer the resident to a room with no sliding door and no fence (initiated 09/11/2024 During an interview on 12/10/2024 at 3:22 PM, Licensed Vocational Nurse #3 stated at the time Resident #13 eloped from the facility on 09/10/2024, the resident resided in a room that had a sliding door, which exited to outside the facility. During an interview on 12/11/2024 at 3:32 PM, Registered Nurse (RN) #7 stated she received a telephone call from the police department that indicated Resident #13 had been found near the facility. RN #7 stated when Resident #13 arrived back in the facility, the resident stated they jumped over the fence. RN #7 stated the resident had not had any issue with exit seeking, except the few days prior that they were found outside by staff. According to RN #7, since the elopement incident on 09/10/2024, the resident had not had any other incidents of elopement. During an interview on 12/12/2024 at 8:19 AM, the interim Social Services Director stated Resident #13 was moved to a different room after the resident left of the facility without staff knowledge by way of the sliding door that was in their room During an interview on 12/12/2024 at 10:54 AM, the Director of Nursing (DON) stated 09/05/2024 was the first time the resident eloped from the facility. The DON stated prior to 09/05/2024, the facility had no knowledge the resident had exit-seeking behavior or attempted to leave out of the sliding door in their room. According to the DON, after the resident eloped again on 09/10/2024, the resident was moved to a room without a sliding door. During an interview on 12/12/2024 at 11:57 AM, the Administrator stated Resident #13 had been in the same room for a long time and had never tried to go out the sliding door and there were no indicators that the room could pose an issue to the resident. The Administrator acknowledged the facility did not consider moving the resident to a different room once the resident started to display exit-seeking behaviors. The Administrator stated he expected residents to remain in the facility so that staff could monitor them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure residents' rooms measured at least 80 square (sq) feet (ft) per resident in 7 (Rooms 26 through 29, room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) of 45 resident rooms in the facility. Findings included: On 12/11/2024 at 3:13 PM, the Environmental Services staff person measured the following rooms and confirmed the following dimensions: - In room [ROOM NUMBER], there was 74.96 sq ft for each resident. - In room [ROOM NUMBER], there was 74.96 sq ft for each resident. - In room [ROOM NUMBER], there was 73.92 sq ft for each resident. - In room [ROOM NUMBER], there was 74.29 sq ft for each resident. - In room [ROOM NUMBER], there was 71.31 sq ft for each resident. - In room [ROOM NUMBER], there was 73.92 sq ft for each resident. - In room [ROOM NUMBER], there was 70.19 sq ft for each resident. During an interview on 12/11/2024 at 3:43 PM, the Administrator stated was aware of the rooms that did not meet the regulatory guidance for the required square footage During an interview on 12/12/2024 at 8:35 AM, the Director of Nursing stated she was not aware of the square footage requirement for resident rooms. the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, interview and record review, the facility failed to ensure the safety of one sampled resident (Resident 1), when he was allowed to leave out on pass (physician approval to leave for a few hours at a time) without a physician ' s order and against facility policy. This failure resulted in Resident 1 purchasing alcohol, consuming three fifths of vodka and attempting to leave the facility against medical advice (without the doctors orders or a discharge plan) while intoxicated. Findings: During an interview on 5/23/24, at 3:11 a.m., Complainant D stated she was a response team member for Specialized Assist for Everyone,(SAFE) (A mobile crisis team through the city that attempted to work with marginalized people to prevent homelessness.). She stated she had responded to a police call on 5/19/24 at 7:20 p.m. for a resident who was intoxicated, uncooperative, verbally aggressive and had attempted to leave the facility against medical advice. She stated she observed Resident 1 in the parking lot, holding onto his walker and facility staff had attempted to de-escalate the situation and persuade Resident 1 to return inside the facility. She stated she observed an almost empty bottle of clear liquid in a vodka bottle in his pocket. Complainant D stated a male nurse had stated that Resident 1 was observed to have already consumed two other bottles of vodka in his bedroom. The male nurse stated he had attempted to confiscate the remaining bottle of vodka and Resident 1 refused and stated he could do what he wanted and attempted to leave the facility. Complainant D stated the police had arrived and she attempted to de-escalate the situation with Resident 1. She stated Resident 1 had informed her that earlier in the day, he was accompanied to the corner convenience store by a facility staff who had purchased the three bottles of vodka with Resident 1 ' s personal money. She stated Resident 1 was blind, used a walker and was safety risk. She stated eventually Resident 1 agreed to return to the facility. A review of a document titled Resident Face Sheet, indicated Resident 1 was admitted [DATE], with diagnoses that included Alcoholic hepatitis(Inflammation of the liver caused by drinking excessive amounts of alcohol) without ascites (Abnormal build up of fluid in the abdomen). Visual Loss-Legally Blind: Slight vision, Glaucoma, Alcohol abuse, Alcohol dependence with withdrawal, Alcoholic cirrhosis of liver with ascites (Scar tissue in the liver caused by alcohol.), Falls with injuries, Difficulty in walking. During an interview with facility Administrator, on 5/28/24 at 9:45 a.m., he stated he was aware of the incident that involved Resident 1 drinking alcohol. He stated he did not investigate it or had any documentation of the events that resulted in the incident. He stated residents requested to go the corner convenience store all the time. He stated staff accompanied residents for safety and did not know if the staff had reported that Resident 1 had purchased three bottles of vodka. He stated the nurse at the facility at the time of the incident, had assumed Resident 1 had a pass to go out. Administrator stated he had been informed by the nurse that Resident 1 had been observed drinking vodka in his room by unlicensed staff who told the nurse. Administrator stated the nurse observed Resident 1 was extremely intoxicated, had two of three bottles of vodka empty in Resident 1 ' s room, and observed the third bottle had an inch or so of vodka left. Administrator stated the nurse attempted to confiscate the bottles and Resident 1 became agitated and informed the nurse he wanted to leave against medical advice (AMA). Administrator stated the nurse accompanied Resident 1 outside, called the police and administrator and had resident 1 sign AMA documents. Administrator stated eventually the situation was de-escalated and Resident 1 returned inside the facility. He stated he did not investigate it. Administrator stated the nurse had assumed Resident 1 had a pass to go out but did not check for a physician ' s order. He stated Resident 1 did not have an order and it was wrong for him to go out. He stated the facility policy and procedure for a day pass was to have a physician order, sign the resident out and then sign them back into the facility. He stated it was important for resident to know the location of the resident while under the care of the facility. He stated it was resident safety issue. During an interview on 5/28/24, at 10:05 a.m., Unlicensed Staff B stated if a resident wanted to go out on pass, the nurse would document and sign the resident out of the facility. He stated a resident could buy anything he wanted and if he observed a resident to have purchased alcohol, he would have informed the nurse. During an interview on 5/28/24, at 10:15 a.m., Licensed Nurse C stated if a resident made a request to go out on pass, she would check for a physician ' s order, fill out documents and then sign them out. He stated resident had to have a physician ' s order to leave the facility on a day pass. She stated staff could accompany them if they had enough staff. She stated if a resident wanted to leave the facility, she would accompany the resident to keep the resident safe. She stated it was staff responsibility to always observe the resident to make sure they would not fall or get hurt. She stated if a resident wanted to leave AMA and they were assessed to have dementia or under the influence of alcohol they could not sign the AMA forms. She stated she would have called the physician, police and administrator. During an interview on 5/28/24, at 10:25 a.m., with Unlicensed Staff A, he stated residents needed a physician ' s order to go out on pass. He stated he would inform the nurse. He stated if he walked with the resident to the store, he would be sure the resident was safe, would not fall, and would not take his eyes off the resident. He stated alcohol is not allowed at the facility. During a record review and interview with Administrator on 5/28/24 at 10:35 a.m., a document titled Resident on Pass, not dated, indicated All residents leaving the facility must be signed out and have an appropriate ' out-on-pass physician order written. Residents must be signed in upon return to the facility. Record in the Progress Notes any information pertinent to the resident ' s absence from the facility. Administrator reviewed the facility Day Pass Binder for documentation on 5/19/24 and stated there was no documentation that Resident 1 went out of the facility, or was signed back into the facility. Administrator stated the staff did not follow the facility policy and procedure for Resident on Pass from the facility. He stated it was a safety issue. Administrator did not answer what the responsibilities were for staff who accompanied residents shopping outside the facility. Administrator stated the facility could not do anything about a Resident who wanted to purchase alcohol and bring it back to the facility. A review of a document titled Resident Progress Notes, dated 5/19/24, did not indicate any documentation that Resident 1 had left the facility, accompanied by staff, to walk to the convenience store. Administrator stated staff did not follow facility policy and procedure. A request was made to interview the nurse who did not check the order and the unlicensed staff who accompanied Resident 1 to the convenience store and was not provided an opportunity to interview them. A review of Resident 1 ' s Brief Inventory of Mental Status (BIMS)(An assessment of cognitive function), dated 4/26/24, indicated BIMS Summary Score 14 ( No impairment of mental status). A review of a document titled Care Plan History, did not indicate a care plan had been initiated for alcohol intoxication, history of alcohol dependency, or the incident that occurred on 5/19/24 that included purchase of alcohol while out on pass, and intoxicated behaviors that included attempted AMA while intoxicated.

Based on interview and record review the facility failed to report an allegation of abuse within the required timeframes when allegation was not reported to authorities within the required two hours timeframe after the facility was notified of the allegation. This failure to report allegations of abuse within the federally mandated requirement of two hours, had the potential to contribute to ongoing resident physical abuse, as well as the potential for mental and emotional harm. It also delayed the timely investigation by authorities. Findings: During review of a document titled SOC 341 (a state of California form for reporting allegations of abuse), dated 3/15/24, revealed Resident 1 reported that before lunch the CNA (Certified Nursing Assistant) that was working with her put his hand on her face and around her mouth area. The report indicated the time and date of the alleged event was 3/14/24 at approximately 11:00 a.m. During a further review of SOC 341 it indicated telephone report made to law enforcement on 3/15/24 at 11:00 a.m. The form was faxed to CDPH on 3/15/24 at 1:07 p.m. During an interview and concurrent record review with the Administrator on 3/20/24 at 11:43 a.m., when discussing reporting abuse within 2 hours, the Administrator stated I didn't realize when reviewing the required reporting timeframes in the facility's abuse policy. Review of the facility's Policy and Procedure titled Abuse Investigation and Reporting, not dated, indicated: Reporting 2. An alleged violation of abuse, neglect, exploitation, or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than: a.) Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b.) Twenty-four hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three residents (Resident 1) received care in accordance with professional standards of practice when Resident 1 had a physician's order for monthly body weights and the facility did not weight Resident 1 monthly. This failure had the potential for Resident 1 to have undetected weight loss or gain and not receive respective medical interventions. Findings: A review of Resident 1 ' s Facesheet indicated he was originally admitted to the facility on [DATE] with an admitting diagnosis of cerebrovascular disease (a disease that affects blood flow and blood vessels in the brain). A review of Resident 1 ' s physician orders indicated order dated 8/14/22 as follows: Monthly weights (start after weekly weights x [times] 4 is completed) A review of Resident 1 ' s weights for the period 8/15/22 to 7/2/23 indicated no weights on the months of December 2022 and February and March 2023. During an interview and record review on 7/21/23, at 10:15 a.m., the Nursing Supervisor confirmed Resident 1 had a physician's order dated 8/14/22 for monthly weights and staff did not take Resident 1's weights during the months of December 2022 and February and March 2023. A review of facility policy and procedure titled Weight Measurements indicated: Body weight is a value used to monitor the nutritional status of the resident. Residents are weighed weekly, monthly, or according to physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure medically related social services were available and provided to all residents in the facility when, there was no social service director (SSD) or qualified staff at the facility to meet the medical needs of residents. This failure resulted in the residents not receiving timely medical appointments to meet their needs, potentially causing a decline in their physical and psychosocial health. Findings: During an observation and concurrent interview on 7/22/22 at 12:53 p.m., Resident 1 was sitting up in bed awake and alert, she was wearing a hospital gown and appeared clean with clean bed linens. Resident 1 ' s skin was pink in color, with no visible signs of the resident itching or scratching. The Resident was aphasic and responded to questions by shaking her head. She attempted to speak but her words were garbled. When asking Resident 1 if she had seen a physician, her granddaughter stated that her grandmother had not seen or spoken with a physician while in the facility, and the facility finally made another dermatology appointment with a Dr. in Novato for 8/1/22. During an interview on 7/22/22 at 1:00 p.m., Resident 2 was asked how her care was in the facility. Resident 2 stated she does not get the care or treatment she needed. When asked what treatments she needed, she stated she needed an orthopedic Dr. appointment (a physician who specializes in care of musculoskeletal problems) and had to wait four months before she went to the appointment and the staff did not follow-up, so you don ' t know what is going on. During an interview on 7/22/22 at 1:15 p.m., the DON was asked who was responsible for arranging IDT (interdisciplinary team) meetings and medical appointments for the residents. The DON stated she and a designated nursing staff member assist with scheduling the IDT meetings and medical appointments. When asked if an SSD was available to schedule medical appointments for the resident ' s, she stated No, we do not have an SSD at this time. During an interview on 7/25/22 at 1:15 p.m., Resident 1 ' s daughter stated the facility was not meeting her mother ' s needs. Resident 1 ' s daughter stated the medical care was substandard, and the communication was poor. Resident 1 ' s daughter was asked if Social Services was able to assist with the medical appointments for her mother and she stated there was no Social Worker at the facility. The DON and staff helped arrange the medical appointments and IDT meetings. When asked if there had been any IDT team meetings for her mother or if she had spoken to the DON regarding her mother ' s care, she stated she had spoken to the DON several times requesting an IDT meeting, but nothing had been scheduled. During an interview on 8/16/22 at 1:20 p.m., the DON and asked who when the IDT meeting were scheduled. The DON stated IDT meetings are scheduled quarterly or as needed, or if the family requests one. Social Services or the SSD and MDS (minimum data set-an assessment instrument used for each resident) coordinator arranged the IDT meetings. When asked who attended the meetings the DON stated SSD, nursing, activities, dietary, and the MD attends only if there are issues. The staff will ask the MD to come to the meeting on a conference call. Changes on a resident ' s condition are documented in the [resident's] progress notes. When asked the responsibilities of the SSD, the DON stated the SSD arranged the IDT care conferences, discharge planning and Dr. appointments and transportation to the appointments. When asked the DON if the SSD was in the facility, she stated No, we do not have an SSD at this time. When asked who is taking over the responsibilities of this role, the DON stated she would arrange some meetings and designate nursing staff to conduct initial assessments for new admissions and arrange meetings until an SSD was hired. The DON was asked if the resident's needs were being met and she stated the system she had put in place was working until they could hire an SSD. During an interview on 1/6/23 at 12:08 p.m., the SS designee was asked if she worked full-time and the SS designee stated she recently retired as the activity ' s director in October and was helping the facility with SS responsibilities 1-3 days a week until they hired a full-time staff. When asked what her responsibilities were as the SS designee stated she called families and provided facility updates (e.g., when the facility had a scabies outbreak), she helped with admissions and discharges and ordered durable medical equipment as needed for resident discharges. When asked if the SS designee arranged medical appointments for residents, she stated she does not arrange doctor appointments for the residents. The SS designee stated she assisted the nurses and arranged doctor appointments for follow-up care for discharged residents. The SS designee stated she was not formally trained as an SSD, but over the years she had assisted and filled-in for the SSD and learned a lot on her own. When asked who completed her responsibilities when she was not at the facility, the SS designee stated the designated nursing staff and the DON. The facility job description titled Social Services Manager dated 10/1/2003, indicated, the essential duties and responsibilities of the social services manager as: Implements social service interventions that achieve treatment goals, address resident needs, link social supports, physical care and physical environment to enhance quality of life; Coordinates family council; Coordinates grievance and complaint process . Review of the facility assessment dated [DATE], indicated Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident population Every Day and During Emergencies: Social Services, and Therapy Services (e.g., social worker, and mental health social worker) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was treated with dignity and respect, when the resident received a letter by facility staff threatening to call law enforcement on him and evict him from the facility without Administrator's knowledge or involvement. This failure resulted in fear and intimidation to Resident 1, and had the potential to result in serious psychosocial (Relating to the interrelation of social factors and individual thought and behavior) trauma. Findings: Record review indicated Resident 1 was admitted to the facility on [DATE] with medical diagnoses including Pedestrian on Foot Injured in Collision with Car, Intracranial Injury (Damage to the brain caused by sudden trauma), and Schizophrenia (A serious mental disorder in which people interpret reality abnormally), according to the facility Face Sheet (Facility demographic). Record review of Resident 1's MDS (Minimum Data Set-An assessment tool) dated 7/11/22 indicated his BIMS (Brief Interview of Mental Status-A cognition assessment) score was 15, which indicated his cognition was intact. During an interview on 10/03/22 at 11:00 a.m., Resident 1 stated about 15 days prior, he was given a threatening letter by Unlicensed Staff A. Resident 1 provided the note, which was written in Spanish. The letter did not indicate what resident it was intended to, a date or the signature of the person who wrote it, but did have the facility logo on the top right hand corner, and was typed. The letter stated: Al Residente (To the resident), Nos han llamado a la atencion que no esta siguiendo las reglas y la etiqueta de las instalaciones (It has come up to our attention that you are not following the rules and etiquette of this facility) .Les daremos un aviso de desalojo de esto continuara sucediendo (We will give you an eviction notice if this continues to occur). Puedes irte si no estas satisfecho con nuestro servicio (You can leave if you are not satisfied with our service) .Si segues molestando a nuestros empleados y residents, llamaremos a la policia (If you continue to bother our employees and residents, we will call the police). La gestion [NAME] PRCC (PRCC [Pine Ridge Care Center] management). During the interview on 10/03/22 at 11:00 a.m., Resident 1 stated he felt very upset about the eviction letter. He also stated in addition to the note above, he was recently given a form to leave the facility against medical advice (AMA form) by Licensed Staff B, and was asked to sign it. Resident 1 stated Licensed Staff B told him if he did not sign it he would go to jail. Resident 1 stated he did not sign it, and provided the form, which was indeed, the form used by the facility for residents to sign if they wished to leave the facility against medical advice. This AMA form presented by Resident 1 had not been signed or filled out. Resident 1 stated he refused to sign the form. During an interview with Resident 1 on 10/03/22 at 11:15 a.m., he stated he felt discriminated against by staff. He stated he was just wanted to be treated with respect and dignity. Resident 1 also stated he did not have a place to go as he had no family, therefore, he wanted to stay at the facility. During an interview with Licensed Staff B on 10/03/22 at 11:49 a.m., he confirmed he provided Resident 1 with the AMA form because Resident 1 told him he wanted to leave as the food was not acceptable. Licensed Staff B stated he must have forgotten the form in Resident 1's room, but did not ask him to sign the form, or threaten Resident 1 with jail if he did not sign the form. During an interview on 10/03/22 at 1:51 p.m., Unlicensed Staff A confirmed he gave the eviction letter to Resident 1 about a month prior, as he thought this letter was a memo for all the Spanish speaking residents. Initially Unlicensed Staff A stated Licensed Staff B gave him the letter to give it to Resident 1, but then he changed his story and stated he did not remember if he made the decision himself or was told to give this letter to Spanish speaking residents, including Resident 1. Unlicensed Staff A stated he found the letter in the nursing station, made copies, and gave the copies to all the Spanish speaking residents. Unlicensed Staff A stated he did not create the form himself. Unlicensed Staff A confirmed he spoke Spanish and knew what the letter said. During an interview with the Administrator on 10/03/22 at 1:30 p.m., he stated not being aware of the eviction letter given to Resident 1 before the investigation, which started today. The Administrator stated this letter should not have been given to Resident 1 without his authorization. The Administrator stated he found out this letter had been given to Resident 1 by Unlicensed Staff A. During an interview with the DON on 10/03/22 at 3:00 p.m., the DON stated she was not aware of the eviction letter given to Resident 1 prior to today. The DON stated there was no English version of this letter, and staff were not authorized to give these types of letters to residents, much less without management authorization. The DON stated Resident 1 had anger against staff, and would confabulate against them, but had no history of physical aggression other than throwing spoons at staff during his anger outbursts. She also stated Resident 1 sometimes yelled at staff, but had no history of being aggressive toward other residents. During an interview with Resident 1 on 11/01/22 at 9:45 a.m., stated he had been verbally threatened several times by staff telling him they would call the police on him if he screamed at them, in addition to the eviction letter provided to him by Unlicensed Staff A. Resident 1 stated when staff threatened him with calling the police he felt frightened, disrespected, and treated with lack of dignity. According to Resident 1, when he received the eviction letter he felt, super bad. He confirmed he yelled at staff when he was upset but stated he had never touched anybody. During an interview with Resident 2 on 10/03/22 at 3:30 a.m., who spoke only Spanish, he denied having the received the eviction letter provided to Resident 1 by Unlicensed Staff A. During an interview with Resident 3 on 10/03/22 at 3:40, who spoke only Spanish, he also denied having received the eviction letter provided to Resident 1 by Unlicensed Staff A, demonstrating this letter was not given all Spanish speaking residents as indicated by Unlicensed Staff A. Record review of the facility policy titled, Resident's Rights, last revised in April of 2020, indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity .h. be supported by the facility in exercising his or her rights, exercise his or her rights without interference, coercion, discrimination or reprisal from the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow its own policy on resident discharges when one of three sampled residents (Resident 1) was threatened to be evicted from the facility in writing, and asked to sign a document to leave against medical advice against his wishes, not following the proper discharge protocols or involving the Administrator in the process. This failure had the potential to result in improper facility initiated discharge of Resident 1, which could have resulted in physical and psychosocial (Relating to the interrelation of social factors and individual thought and behavior) harm. Findings: Record review indicated Resident 1 was admitted to the facility on [DATE] with medical diagnoses including Pedestrian on Foot Injured in Collision with Car, Intracranial Injury (Damage to the brain caused by sudden trauma), and Schizophrenia (A serious mental disorder in which people interpret reality abnormally), according to the facility Face Sheet (Facility demographic). Record review of Resident 1's MDS (Minimum Data Set-An assessment tool) dated 7/11/22 indicated his BIMS (Brief Interview of Mental Status-A cognition assessment) score was 15, which indicated his cognition was intact. During an interview on 10/03/22 at 11:00 a.m., Resident 1 stated about 15 days prior, he was given a threatening letter by Unlicensed Staff A. Resident 1 provided the note, which was written in Spanish. The letter did not indicate what resident it was intended to, a date or the signature of the person who wrote it, but did have the facility logo on the top right hand corner, and was typed. The letter stated: Al Residente (To the resident), Nos han llamado a la atencion que no esta siguiendo las reglas y la etiqueta de las instalaciones (It has come up to our attention that you are not following the rules and etiquette of this facility) .Les daremos un aviso de desalojo de esto continuara sucediendo (We will give you an eviction notice if this continues to occur). Puedes irte si no estas satisfecho con nuestro servicio (You can leave if you are not satisfied with our service) .Si segues molestando a nuestros empleados y residents, llamaremos a la policia (If you continue to bother our employees and residents, we will call the police). La gestion [NAME] PRCC (PRCC [Pine Ridge Care Center] management). During the interview on 10/03/22 at 11:00 a.m., Resident 1 stated he felt very upset about it. He also stated in addition to the note above, he was recently given a form to leave the facility against medical advice (AMA form) by Licensed Staff B, and was asked to sign it. Resident 1 stated Licensed Staff B told him if he did not sign it he would go to jail. Resident 1 stated he did not sign it, and provided the form, which was indeed, the form used by the facility for residents to sign if they wished to leave the facility against medical advice. This AMA form presented by Resident 1 had not been signed or filled out. Resident 1 stated he refused to sign the form. During a phone interview with Ombudsman AA (assigned to the facility) on 10/19/22 at 11:20 a.m., she stated she received a call from Resident 1 on 9/26/22 asking her to visit him. During an onsite visit on 9/27/22, Resident 1 provided her with a letter (the eviction letter above) that was given to him threatening to evict him from the facility. Resident 1 also told her he was given a form to leave the facility against medical advice and was asked to sign it. Ombudsman AA stated she had not receiving any notification of pending discharge directly from the facility regarding Resident 1. During an interview with Resident 1 on 10/03/22 at 11:15 a.m., he stated he felt discriminated against by staff. He stated he was just wanted to be treated with respect and dignity. Resident 1 also stated he did not have a place to go as he had no family, therefore, he wanted to stay at the facility. During an interview with Licensed Staff B on 10/03/22 at 11:49 a.m., he confirmed he provided Resident 1 with the AMA form because Resident 1 told him he wanted to leave as the food was not acceptable. Licensed Staff B stated he must have forgotten the form in Resident 1's room, but did not ask him to sign the form, or threaten Resident 1 with jail if he did not sign the form. During an interview on 10/03/22 at 1:51 p.m., Unlicensed Staff A confirmed he gave the eviction letter to Resident 1 about a month prior, as he thought this letter was a memo for all the Spanish speaking residents. Initially Unlicensed Staff A stated Licensed Staff B gave him the letter to give it to Resident 1, but then he changed his story and stated he did not remember if he made the decision himself or was told to give this letter to Spanish speaking residents, including Resident 1. Unlicensed Staff A stated he found the letter in the nursing station, made copies, and gave the copies to all the Spanish speaking residents. Unlicensed Staff A stated he did not create the form himself. Unlicensed Staff A confirmed he spoke Spanish and knew what the letter said. During an interview with the Administrator on 10/03/22 at 1:30 p.m., he stated not being aware of the eviction letter given to Resident 1 before the investigation, which started today. The Administrator stated this letter should not have been given to Resident 1 without his authorization. The Administrator stated he found out this letter had been given to Resident 1 by Unlicensed Staff A. During an interview with the DON on 10/03/22 at 3:00 p.m., the DON stated she was not aware of the eviction letter given to Resident 1 prior to today. The DON stated there was no English version of this letter, and staff were not authorized to give these types of letters to residents, much less without management authorization. The DON stated Resident 1 had anger against staff, and would confabulate against them, but had no history of physical aggression other than throwing spoons at staff during his anger outbursts. She also stated Resident 1 sometimes yelled at staff, but had no history of being aggressive toward other residents. During an interview with Resident 1 on 11/01/22 at 9:45 a.m., stated he had been verbally threatened several times by staff telling him they would call the police on him if he screamed at them, in addition to the eviction letter provided to him by Unlicensed Staff A. Resident 1 stated when staff threatened him with calling the police he felt frightened, disrespected, and treated with lack of dignity. According to Resident 1, when he received the eviction letter he felt, super bad. He confirmed he yelled at staff when he was upset but stated he had never touched anybody. During an interview with Resident 2 on 10/03/22 at 3:30 a.m., who spoke only Spanish, he denied having the received the eviction letter provided to Resident 1 by Unlicensed Staff A. During an interview with Resident 3 on 10/03/22 at 3:40, who spoke only Spanish, he also denied having received the eviction letter provided to Resident 1 by Unlicensed Staff A, demonstrating this letter was not given all Spanish speaking residents as indicated by Unlicensed Staff A. Record review of the facility policy titled, Transfer/Discharge Notice, revised in August of 2022, indicated, Each resident will be permitted to remain in the facility, and not be transferred or discharged unless: The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in this facility .The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident .The notices of transfer/discharge shall contain the following information: a. The reason for the transfer/discharge; b. The effective date of the transfer/discharge; c. The location to which the resident is being transferred or discharged ; d. A statement of the resident's rights to appeal the transfer/discharge .The name, address, email and telephone number of the agency responsible for the protection and advocacy of residents with a metal disorder or related disabilities.

Based on observation and interview, the facility failed to post the results of recent Federal or State surveys, including plans of correction, in an area accessible to all residents. This failure did not ensure residents' rights to access survey results for review Findings: During an observation of the three bulletin boards on 8/3/21, at 3:00 p.m., a document indicated Facility Survey Binder is available for your review and is located on the side wall of the front lobby entryway. An observation of the side wall of the front lobby entryway did not locate a binder titled Facility Survey Binder. During an interview with Staff K, on 8/3/21, at 3:10 p.m., she stated she did not know what a survey facility binder was or where it would be located. During an interview with Administrator on 8/5/21, at 2:30 p.m., in his office, he stated he keeps the survey binder in his office. The Administrator stated if residents wanted to see survey results they had to ask.

Based on observation, interview, and record review, the facility failed to post grievance and complaint notices in a manner accessible to all residents, when it posted grievance and complaint notices in areas that were difficult for residents using wheelchairs to view. This failure did not ensure resident rights, and had the potential to delay the facility's identification and response to resident needs or complaints. Findings: During an interview with Resident #40 on 8/3/21 at 11:07 a.m., he stated: CDPH information is posted on board so high, you can't see it and there is always equipment parked there. During an observation in the main dining room, on 8/3/21 at 2 p.m., an upright piano was observed against the south wall, to the left of a bulletin board. On top of the piano was a tall flower arrangement and a black plastic basket, with arts and craft supplies and two puzzle boxes. Attached to the wall, behind the black plastic basket and flowers, was a frame holding a document titled Grievance & Complaints. On the front of the document holder was a document titled Facility Grievance Policy. Inside the document holder were paper forms title Grievance/Complaint Report. An observation of the location of the grievance information and forms indicated a resident in a wheelchair would not be able to read or access the information and forms. During observations of the facility communication bulletin board, on 8/3/21, at 3:00 p.m., a push-cart that contained a blue ice chest was positioned in front of the board. The position of the cart was observed to potentially prevent a resident confined to a wheelchair from viewing the information on the bulletin board. The middle communication board was blocked by the push-cart. The board contained a document titled CONCERN/COMPLAINT RESOLUTION PROCEDURE. During an interview and observation, in front of the facility communication bulletin board, with Administrator L, on 8/5/21, at 2:30 p.m., she stated the notice for residents and families indicating how to file a grievance was posted too high for residents in wheelchairs to see. She stated notices for resident needed to be large enough and low enough so that everyone could review the information. During an interview and document review, on 8/5/21, at 1:00 p.m., License Staff L stated residents could file a grievance and sign their own form. She stated she didn't know where residents would find the forms or information on how to complete the grievance. She stated most resident find a staff member and tell them what their complaints were. During an interview with Administrator on 8/5/21, at 2:30 p.m., in his office, he stated all residents know how to file grievances. He stated he did not know if information on how to file a grievance was provided upon admission or reviewed during Resident Council. A review of the facility P&P titled Grievance & Complaints OP2 0306.00 Chapter: Resident Rights, dated April 2005, indicated The Administrator is responsible for: Resolving all grievances and/or complaints. If a resident, a resident's representative, or another interested family member of a resident has a complaint, a staff member should encourage and assist the resident, or person acting on the resident's behalf, to file a written grievance with the facility using the Grievance/Complaint Report.Grievances and complaints may be submitted orally or in writing. The resident, or the person filing the grievance or complaint on behalf of the resident, should be encouraged to sign written complaints or grievances If a grievance is submitted orally the facility employee taking the grievance must write it up on the report form.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and modify comprehensive care plans for five sampled residents (Residents 42, 45, 51, and 87) that were person-centered. These failures had the potential result in care and services that did not meet residents' needs, as well as cause a decline in residents' physical health and emotional well-being. Findings: Resident 42 During an observation and attempted interview with Resident 42, on 8/2/21, at 9:30 a.m., Resident 42 was observed laying on his back in bed in a dark room with the curtains closed and no lights on. When introduced, Resident 42 slowly lifted his head, moved his mouth but did not speak or respond. During observations on 8/2/21, at 10:00 a.m. and 11:15 a.m., and on 8/3/21 at 9:30 a.m., Resident 42 was observed laying on his back, in bed, in a dark room with the curtains closed and no lights on. Resident 42 opened his eyes and stared when asked if he would like to talk. During an observation on 8/5/21, at 8:45 a.m. and 9:45 a.m., Resident 42 was observed in his bed, laying on his back, with his eye open. During an interview on 8/5/21, at 9:40 a.m., CAN S stated Resident 42 never gets out of bed. During observations between 8/2/21 and 8/12/21, Resident 42 was not observed in any group activities, was not observed out of his bed, no activity calendar was observed by the resident's living area, and no activity staff were observed entering the room or engaging with him. Review of a document titled Interdisciplinary Team Care Conference Notes, dated 5/28/21, indicated: . Care plan - review and updated. Additional Comments . Resident enjoys activities of choice but is very passive. Will continue to monitor and update care plan as needed. During a review of Resident 42's medical record, a document titled Face Sheet, indicated he was admitted [DATE] with diagnoses that included Dementia, Major Depressive disorder Mild Cognitive Impairment. The resident's BIMS (Brief Interview for Mental Status, a short quiz used to determine cognitive ability) indicated Resident 42 did not receive a scored quiz because the resident was rarely/never understood. During a review of the clinical record for Resident 42, the care plan did not indicate an updated, person-centered plan with effective interventions for Activities since 10/14/2019. Review of a care plan titled Activities, dated 10/14/19, indicated Resident needs motivation to join and participate in group activities. When in group refuses to do anything at times will look a magazine can be verbally aggressive to leave him alone and if music group seems to listen have give him in room activities to do but does not want to do them will visit says he is fine but refuses to do anything and does not like to be up. Approach, dated 10/14/19, indicated Encourage resident to socialize with other residents. Identify resident's activity of interest does not have much interest but introduce some group actives or 1.1 in group. Invite to activities daily and assist to and from activity room if needed and encourage to attend at least 3 x a week for socialization.provide activity calendar in resident's room. Resident 45 During an observation on 8/3/21 at 10:00 a.m., Resident 45 was observed walking (shuffling) in the facility with her walker, and going into the activity room. Resident 45 was diagnosed as having Alzheimer's/Dementia and Unspecified Psychosis with a BIMS of 9, indicating a moderately impaired cognitive ability. During an interview on 8/5/21 at 2:45 p.m., Licensed Nurse B stated she cared for Resident 45. Licensed Nurse B stated the resident wandered through the facility and has tried to elope. Licensed Nurse B stated Resident 45 does wear a wanderguard (e.g., an electronic device that alarms when a resident tries to leave the facility). Licensed Nurse B further stated the resident would wander in-and-out of resident rooms and try to take resident belongings. Resident 45 currently received visual checks every-15-minutes. Licensed Nurse B stated facility staff had implemented distraction techniques to minimize Resident 45's wandering and attempted elopements. Licensed Staff B stated the resident wore a wanderguard, the facility took her to activities and also offered her food, ice cream to manage behaviors. During a review of the clinical record for Resident 45, the care plan did not show a person-centered care plan with goals or timeframes for specific non-medication interventions for dementia and behavior care, such as use of foods like ice cream to minimize behaviors. Resident 51 During observations from initial tour on 8/2/21, at 10:55 a.m., Resident 51 was in bed on an air-mattress. During an interview on 8/2/21 at 11:15 a.m., Licensed Nurse Q stated facility staff get residents out of bed when residents ask, for therapy, and sometimes for meals if the residents did not want to go to the dining room. Resident 51 complained they get him out of bed 1-2 times per week when he goes to therapy, no one offers to get me out of bed. I do go to physical therapy, but they don't come to help me move. The Resident also stated he rings the call bell, and no one comes, and he is left for long periods of time in his diaper. During a review of the clinical record on 8/4/21, Resident 51 was admitted for rehabilitation related to a stroke (e.g., when a blood vessel carrying oxygen and nutrients to the brain is either blocked by a clot or ruptures) that caused left-sided weakness. Resident 51 had a BIMS score of 11, indicating moderately impaired cognitive ability. During an interview on 8/9/21 at 9:30 a.m., the Physical Therapist (PT) and Occupational Therapist (OT) stated Resident 51 has reached his highest potential for physical therapy. The PT stated the facility's therapy service recommended maintenance care, which involved having the resident continue getting out-of-bed for sitting and standing from the chair, one-to-two times each day. During a review of the clinical record for Resident 51, the care plan did not indicate a person-centered care plan that included goals or timelines for implementing effective interventions for maintenance care, such as sitting and standing movements. Resident 87 During an observation and interview on 8/5/21 at 11:00 a.m., Resident 87 was lying in bed with head of bed elevated. Resident 87 stated she sometimes got out of bed, and she also got out of bed for therapy. When asked if staff comes when she rang the call bell, she stated, Yes. Resident 87 was diagnosed with a stroke, alcoholic cirrhosis of the liver, Diabetes type 2, and a BIMS of 12, indicating moderately impaired cognition. During an interview on 8/9/21 at 9:30 a.m., the Physical Therapist (PT) and Occupational Therapist (OT) stated Resident 87 had a large stroke and is making slow progress with her therapy. During a review of the clinical record for Resident 87, the care plan did not show person-centered care planning for physical therapy, including goals and timelines for activities Resident 87 may undertake while in her room, or behavior care. Review of the facility Policy and Procedure titled, Comprehensive Care Planning dated 11/15/2001, indicated, The Comprehensive Care Plan must: Include interventions to prevent avoidable decline in function or functional level; Be developed by an interdisciplinary team that includes the attending physician, a registered nurse, and other appropriate staff as determined by the resident's needs; Be periodically reviewed and revised by the interdisciplinary team as changes in the resident's care and treatment occur; and reflect participation of the resident, the resident's family, or the resident's legal representative. Review of the facility Policy and Procedure titled, Comprehensive Care Planning dated 11/15/2001, indicated, The Comprehensive Care Plan must: Include interventions to prevent avoidable decline in function or functional level; Be developed by an interdisciplinary team that includes the attending physician, a registered nurse, and other appropriate staff as determined by the resident's needs; Be periodically reviewed and revised by the interdisciplinary team as changes in the resident's care and treatment occur; and reflect participation of the resident, the resident's family, or the resident's legal representative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the safety of residents when: 1. Two residents (Residents 19 and Resident 79) left the facility without supervision; and 2. The facility disposed unused medications using sharps containers (a sturdy, puncture-resistant plastic container for sharp items) and placed sharps containers in an unlocked storage room. These failures had the potential to result in accidents and/or injuries to Residents 19 and 79 while alone and unsupervised, and had the potential to result in diversion of medication or resident injury arising from access to harmful medication. Findings: 1. During review of records, Nurse's Notes dated 4/20/21 at 1:00 PM indicated Licensed Nurse R was informed Resident 19 was not in his room. A search in and around the facility was conducted but the resident could not be found. Further review of Nurses' Notes dated 4/20/21 at 3:13 PM indicated the Resident went out for a walk to get fresh air and had destroyed the wander guard bracelet on his right wrist. During interview on 8/9/21 at 2:35 PM at the resident's room, Resident 19 stated he just wanted to go out to get fresh air or smoke. Resident 19 stated he did not go too far and was just coming back to the facility when a staff saw him. Resident 19 stated he was bored at the facility. During review of records, the face sheet of Resident 19 indicated he was admitted to the facility on [DATE], for alcohol use, lack of coordination, muscular weakness, repeated falls, anemia, and unspecified dementia. A review of the resident's MDS (Minimum Data Set (a federally mandated standardized assessment of each resident's functional capabilities and health needs), dated 4/9/21, indicated the resident was not steady, but able to stabilize without staff assistance when walking and had a fall and fracture in the last month prior to his admission. During review of the clinical record for Resident 19, the care plan for at risk for elopement and wandering out of facility, dated 4/3/21, indicated for staff to provide activities that will divert resident's attention from wandering, check resident's whereabouts, wanderguard bracelet, check alarm for functioning and placement every shift, place wanderguard to remind resident of unassisted going out of the facility. Special instructions included Licensed Nurse to check function and placement every shift. During an observation on 8/9/21 at 2:40 p.m., Resident 19 and his care assistant heard knocking on the glass window outside the resident's room. When Resident 19 pushed the drapes back, Resident 79 was seen standing outside between the building and the driveway. During an observation and interview on 8/9/21 at 2:55 PM, Resident 79 was observed walking in through the front door. When asked who was with him outside, Resident 79 stated: No one. When asked if anyone knew he was outside, Resident 79 stated, he did not ask anyone, and nobody knew he went out. Resident 79 added this was the first time he went out and was just checking if the facility would know. During an observation and interview on 8/9/21 at 3:12 p.m., Staff K saw Resident 79 as he was walking in through the front door. Staff K stated she did not see Resident 79 go out but saw him entering the facility. During interview on 8/9/21 at 3:20 p.m., when asked what should be done when a resident leaves the facility without the facility staffs' knowledge, Licensed Nurse A stated the patient should be assessed. Licensed Nurse A stated that if alert and oriented, the resident should be informed to notify staff to obtain out-on-pass approval. Licensed Nurse A stated that if a resident was not alert or oriented, the resident should still be brought in and assessed. Licensed Nurse A stated that if a resident is missing and is not found in the facility, staff should notify the physician and begin identifing the resident an elopement risk and apply a wander guard on them. During a review of the Elopement Binder at the front desk Nurses station on 8/9/21 at 3:27 p.m., Resident 79 was not indicated at risk for elopement and was not included in the list of at Risk for Elopement residents. During review of records, Resident 79's MDS dated [DATE] indicated he was admitted for sepsis (a life-threatening complication of an infection), anemia, congestive heart failure and high blood pressure. Resident 79's functional assessment indicated he needed limited assistance (one-person physical assist) when walking around the facility. Resident 79's balance during walking was assessed as not steady, but able to stabilize without assistance. During interview on 8/9/21 at 2:18 PM, Staff J was asked to provide the maintenance log that documented the functionality of the exit door alarms and wander guards. Staff J provided a one-page document titled Signaling Device/Alarm Testing Checklist - Daily Monitor for the month of August 2021. The document indicated an entry was for 8/9/21, only, specific to the front door, back door, Station 1 door, Station 2 door, short hallway, and Station 3 door. Staff J was asked why the facility had only one page of information, and why the document provided did not indicate testing on other dates. Staff J stated he started in March, but was not told about documenting whatever he did. The facility policy and procedure titled Wander/Elopement Alarm System Testing, updated 5/19, indicated: Regular testing of door monitors and signaling devices in the alarm system verifies the integrity of the system . Regular testing is essential. This is the function of the preventive maintenance program and regular testing is essential to resident safety. The policy's procedure indicated to 1.) Perform regular and frequent checks to verify the operation of each signaling device(s). Procedure on Signaling Device Testing: 1.) Test signaling devices at least daily. Use a signaling device tester. 2.) Test the tester. 3.) Test the signaling device. 4.) If applicable, check the wristbands for tears or other damage. Replace damaged bands immediately. 5.) Record the test results in the Medication Administration Record (MAR) for the Licensed Nurses and the Signaling Device Form for Maintenance Staff/Designee. Procedure on Door Monitor test indicated the following: 1.) Inspect and test each door monitor daily. 2.) Any door alarm that is not tested at least once per shift should be intentionally activated at least once a day as a test. Procedure on Door Monitor range test indicated: 1.) Test the range of the door monitors at least monthly. 2.) Record test results on the Preventive Maintenance Monthly Checklist. The facility policy and procedure titled Elopement, effective 12/1/2005, indicated the purpose was to monitor and document patients at Risk for Elopement. The procedure indicated: . 2.) Patients showing to be at Risk for Elopement will have a wander guard band placed if applicable for facility. 3.) Patients showing to be at Risk for Elopement will have completed the Elopement Identification Form with attached photo. 4.) Elopement Risk Identification Forms will be in an Elopement Binder and maintained at the Reception Desk. 5.) Patients at Risk for Elopement will have the appropriate box checked on the patient [NAME]. 2. During observation on 8/5/21 at 11:02 AM, whole pills and unopened ampules were found in a sharps container located within a large, plastic, red-hazard waste bin, located inside an unlocked storage room along Hall 3. (See photos). During interview on 8/5/21 at 10:58 AM, the Director of Nursing Services (DON) stated two Licensed Nurses tasked to destroy unused medication placed medications in a sharps container and disposed the container in a biohazard bin for collection every Monday. The DON stated the pills were left whole and the ampules unopened. The DON further stated that once the sharps container is closed, it is locked. A review of the facility policy and procedure titled Medication Destruction, revised 2/09/15, indicated the following procedure: . Disposal on Non-Controlled medications . 4. Facility will dispose of discontinued medications, outdated medications, or medications left in the facility after the resident has been discharged within 90 days of the date the medication was discontinued by physician/prescriber.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain the usual body weight of one resident (Resident 42) as evidenced by repeated delayed assessment and follow-up by the registered dietitian and repeated delayed implementation of registered dietician's recommendations. This failure could lead to the potential for further decline for Resident 42 who was considered at nutritional risk and experiencing impaired nutrition status. Weight loss is also associated with other negative outcomes such as impaired wound healing or increased risk of death. Findings: Review of resident records indicated Resident 42 was admitted on [DATE] with unspecified dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), major depression, mild cognitive impairment, dysphagia (difficulty swallowing) and history of alcoholism. Review of Registered Dietician's (RD) initial nutritional assessment dated [DATE] indicated Resident 42's admission weight was 170.3 pounds. The RD's notes indicated Resident 42's ideal body weight was 142 pounds for a height of 66 inches. The RD also indicated that Resident 42's current meal intake met his nutritional needs. The RD recommended snacks twice a day, multivitamins once daily, regular/puree diet, weekly monitoring of weight for 4 weeks, and monitoring of oral intake. Resident 42 was taken to the hospital on 5/14/21 and readmitted on [DATE]. Review of Resident 42's plan of care dated 5/22/19 included weight monitoring and to notify the physician for any undesirable weight changes, monitor food and fluid intake, honor resident's reasonable food preferences, offer substitutes if needed, encourage family/friends to bring food within dietary guidelines, discuss with resident and responsible party acceptable weight, and follow diet as ordered. Review of RD's annual nutritional assessment dated [DATE] indicated Resident 42's weight was 128 pounds, was underweight and attributed the gradual weight loss over 12 months to the resident's advancing dementia and other clinical conditions requiring 1:1 assistance with all meals/snacks. The RD recommended to encourage and provide high-calorie supplements. The RD estimated Resident 42 required 1512 calories per day to promote weight gain. Review of RD's progress notes on monthly weight assessment dated [DATE] and 9/6/20 indicated Resident 42 had significant weight losses over a 6-month period (180 days) and over 7 days, respectively. The RD attributed the weight loss to resident's clinical condition and need for 1:1 feeding. RD recommended to continue with plan of care, to continue monthly weight monitoring and oral intake. A review of an SBAR (tool following the format Subject, Background, Assessment and Recommendation nurses use to report changes in a resident's status) dated 11/29/20 indicated that the patient had a significant weight loss from 129 to 123 pounds. A review of the RD Weekly Weight Note indicated a 6-pound weight loss in seven days that could be unavoidable due to the resident's advanced clinical condition. RD recommended to continue current plan of care. No new nutritional interventions were recommended or attempted. Review of Resident 42's weight record beginning 5/18/21 revealed consistent weight loss. Weights were recorded as follows: 5/18/21-129 pounds; 5/25/17-117 pounds, a loss of 9 percent in 1 week, which is considered severe. Weight was recorded as 114 pounds on 5/31/21, a total of 15 pounds in 2 weeks. Additional weights taken on 6/19 and 7/18/21 revealed weights of 114 and 112 pounds respectively resulting in weight loss of 13 percent. It was also noted during this period, except for dinner, the amount of meal intake decreased, with the resident refusing greater than 10 breakfasts and lunches during the month. Review of the Dietary Manager's Quarterly Nutritional assessment dated [DATE], indicated Resident 42 likes all meats, vegetables, and fruits. The Dietary Manager added supplemental health shakes twice a day to address weight loss and referred resident to the Occupational Therapy to assess for adaptive eating utensils and two-handled cup. The Dietary Manager does not have the ability to assess the nutritional status or needs of residents, rather is limited to providing guidance and oversight to dietetic services staff. Nutritional assessments are within the Scope of Practice of the Registered Dietitian, Registered Nurse, mid-level Practitioner or Physician. During concurrent observation and interview on 8/5/21 at 7:45 AM, CNA G was feeding Resident 42 his breakfast consisting of pureed sausage, scrambled eggs, cream of wheat, orange juice and milk shake. CNA G stated that he adds sauce to the sausage and to make the food tastier. Resident 42 was alternatingly looking at the CNA and his food opening his mouth on cue until he finished eating. CNA G had patiently cued and fed Resident 42 his breakfast until 8:11AM when he finished 100% of the meal. During subsequent interview on 8/5/21 at 12:52 PM, CNA G stated Resident 42 did not fully consume his lunch meal. CNA G also indicated he did not consume his mid-morning snack on 8/4/21 despite documentation of 100% (percent) consumption. During interview on 8/4/21 at 11:34 AM, Licensed Nurse H stated that Restorative Nursing Assistants (RNAs) take turns obtaining the residents' weight on a weekly and monthly monitoring schedule. The weights are recorded in the Stop and Watch binder and a copy sent to the DON. If weight variances were noted, an SBAR is sent to the physician and RD for orders. Licensed Nurse H further stated RD comes in twice a week and make resident rounds. Licensed Nurse H stated weights are discussed during daily stand-up meetings. There was no indication an SBAR was completed for the weight decline beginning 5/17/21 and as a result there was no notification to the physician or RD. During interview on 8/4/21 at 1:11 PM, the RD stated that she had been working in the facility for 5 years. RD stated that her notes are in the Nutritional Assessments reports. The RD stated the facility has no weight committee, but the facility held Multidisciplinary meetings where she can be called as needed. When asked about Resident 42, RD stated the resident has advanced dementia, is on 1:1 and had a steady decline for almost a year. The RD admitted she does not know what else to do. She stated she is surprised Resident 42 had not passed by now. During review of records, RD weekly weight notes four months after the Dietary Manager's and dated 7/20/21 and 7/29/21 indicated Resident 42 had lower oral intake and significant weight loss, but there was no change in orders to address the weight loss. The RD's recommendation only reiterated the recommendation of the Dietary Manager for Healthshakes twice a day and reduced the MedPlus to twice a day in the 7/20/21 recommendation. The RD's notes on 7/29/21 reverted the MedPlus frequency to three times a day. The RD recommendation was not acted upon until 8/4/21, during the survey, when the physician ordered Healthshakes, MedPlus, and Ensure. During review of the Policy and Procedure on Weight and Vital Signs, RD Recommendations dated 12/1/2005 and revised 5/09 indicated under Procedures: #6. All patients with significant weight variances should have a timely intervention initiated by the dietary manager/RD. #7. All significant weight variances will be reviewed at the weekly Risk Meeting to assure that the appropriate interventions are in place and that the desired outcome is attained. # 9. Registered Dietician's recommendations will be discussed with a Licensed Nurse and acted upon within 72 hours. The Physician will need to be notified for any RD recommendations that may need a Physician's order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure attending physicians responded to the Consultant Pharmacists recommendations for Antipsychotic Medications (e.g., medication that alters brain chemistry to reduce psychotic symptoms such as harmful behaviors, hallucinations, delusions, and disordered thinking) for 10 residents (Residents 86, 62, 45, 55, 76, 59, 75, 66, 71 and 37). This failure had the potential for resident harm, including death, due to the increased risk of adverse side effects related to Antipsychotic Medication use. Findings: (Reference F758) During an observation and interview, on 8/2/21, at 9:30 a.m., Resident 62's bed was observed in the low position with a mat on the floor next to the bed. Licensed Staff Q stated the mat beside his bed was there to prevent injury if he fell out of bed. She stated Resident 62, sometimes would not call for help when he tried to get out of bed. During an observation on 8/2/21, at 12:30 p.m., Resident 45 was observed seated in the main dining room waiting for lunch. She responded to questions and comments with 2-3 word sentences. Her facial expression indicated a flat affect. No behaviors resembling signs or symtpoms of Antipsychotic side effects were observed. During a concurrent interview and record review on 8/4/21, at 3:00 p.m., DON stated the facility pharmacist conducted monthly medication reviews for residents, and recommended GDRs for resident's on Antipsychotic Medications. She stated the purpose of the GDR was to monitor and reduce medication dosages to prevent side effects. She stated she did not know how many GDRs were conducted for Residents on Antipsychotic Medications. She stated the facility did not have an Antipsychotic Medication Committee. She stated monitoring Antipsychotic Medication use occurred during Inter Disciplinary Team (IDT) meetings for each resident. She stated the documentation of those meetings were found in the resident medical record. DON stated the Pharmacist Medication Review notes and recommendations were reviewed by the physicians. DON then reviewed the binder and the electronic medical records for Residents 42, 59, 37 and 71, to locate information on the GDRs of each resident. On review of each resident's medical record, the DON could not locate data indicating that each resident's GDR had been initiated, or data indicating that each resident's physician had documented the clinical contraindications for not initiating a GDR. During an interview on 8/5/21, at 3:30 p.m., Resident 62 was observed in the lobby of the facility in a wheelchair. He was observed to slowly mobilize himself using his feet, and his arms were immobile and flexed in front of his torso. He was observed to not be able to respond to questions. Resident 62 was observed to have the ability focus his gaze upon people but not gesture or vocalize responses. No behavior resmbling signs or symptoms of Antipsychotic medication side effects were observed. During an interview with Physician U, on 8/6/21, at 11:00 a.m., he stated for residents on Antipsychotic medications he evaluated the risk versus the benefit of GDR and either accepted or declined the recommendation from the pharmacist. He was unable to state if he had recently approved any GDRs for his residents. Review of a document titled Executive Summary of Consultant Pharmacist's Medication Regimen Review, dated 2/23/21 to 7/22/21, indicated the medical records of residents who received antipsychotic medication, contained inadquate reasons for antipsychotic medication use. According to the document, the facility had more residents on antipsychotic medication 'for physical aggression' than expected, and the document further indicated the facility cared for some residents using multiple antipsychotic medications with high doses. The document indicated the facility was on notice that its prescribing practice was highly unusual, and a flag to surveyors, even with prescriber documentation to continue the orders. During a concurrent interview and record review on 8/10/21, at 12:49 p.m., with Administrator, he stated resident safety issues were discussed in the Quality Assurance Performance Improvement (QAPI) meeting. Administrator stated the facility's Director of Nursing Services (DON) and Consultant Pharmacist (Pharmacist O) met monthly to discuss GDR monitoring. He stated data from that meeting was submitted and reviewed during QAPI. He stated DON had a verbal confirmation of who had a GDR and the issue was discussed during QAPI. He could not find in the QAPI minutes, what residents received a GDR for antipsychotic medication last quarter. Administrator stated the Pharmacy report was reviewed by DON and Medical Director at the last meeting, and the Pharmacist expressed concern how the facility's attending physicians ordered antipsychotic medication. Administrator reviewed the last QAPI meeting binder, specifically a documented pharmacist report titled PharMerica RX Quality Assurance Report, dated Quarter 1, 2021 (January, February, March, and Quarter 2, 2021 (April, May, June), which indicated the Pharmacist O's recommendations for Antipsychotic Therapy, Dose Scheduling. Administrator stated the discussion indicated Concerns: Antipsychotic listed as verbal aggression? No pattern physical aggression Why justifying for verbal aggression, too many residents behavior targeted specific behaviors. Administrator stated the Pharmacist expressed concern about the facility order/use of antipsychotic medication without adequate indication or individualization for the resident. Administrator stated the DON was supposed to review all Antipsychotic medication orders but Administrator could not find any documentation in the QAPI minutes that indicatde the DON reviewed the orders. During an interview on 8/10/21, at 11:46 a.m., Physician V stated as the Medical Director of the facility, he provided oversight and discussed resident GDR recommendations from the pharmacist. He stated issues that concerned him were related to the GDR process and recommendations from the pharmacy. Physician V stated GDR recommendations should be assessed by the provider and should be initiated if past GDR's were successful or not. He stated if a resident was at the facility for a long time, and the pharmacy recommended a GDR because resident behaviors were no longer present, then a GDR should definitely be attempted. Physician V stated if GDR recommendations were attempted they should be reconsidered and reviewed every three to six months. He stated side effects of Antipsychotic's were somnolence (The condition of drowsiness, lethargy and sleepiness preceding falling asleep), that may contribute to falls, or decline in activities of daily living (ADL). During the interview with Physician V, he stated at the last QAPI meeting, the pharmacist indicated he had concerns about the documented reasons for Antipsychotic medication orders. Physician V stated he agreed with the pharmacist, that verbal abuse or verbal aggression was not an appropriate reason for prolonged Antipsychotic medication. He stated each Antipsychotic medication needed to be assessed on a case by case basis. He stated GDR's should attempted and attending physicians should follow pharmacy recommendations. He stated he is a peer of the other physicians and would not tell them what to do. He stated inappropriate Antipsychotic medication prescription was considered to be a chemical restraint and was not appropriate. He stated he did not recall a review during the last QAPI meeting of residents who were on Antipsychotic medications, how many GDRs were recommended, conducted or declined. Physician V stated I told the facility I was willing to be really involved in review of GDR. So far hasn't happened. During an interview on 8/12/21, at 2:15 p.m., Pharmacist O stated he conducted Monthly Medication Regime Reviews (MMRR) for every resident, and he notified DON of his recommendations and the need for follow up. He stated he reviewed each resident's medical record to determine if his recommendations from the previous month were accepted, initiated or declined. He stated for residents on Antipsychotic medications he monitored and recommended new medications and lab studies, as well as use of the Abnormal Involuntary Movement Scale (AIM, a scale to assess severity of dyskinesias, specifically orofacial movements and extremity and truncal movements) for patients receiving antipsychotic medications. Pharmacist O stated when he was finished with his MMRR, he sent summary notifications titled Executive Summary of Consultant Pharmacist's Medication Regimen Review, to the attending physician, DON, and the Administrator. He stated each provider should evaluate the behavior monitoring for every resident on Antipsychotic medication and determine the justification for continuation of the Antipsychotic Medication. He stated a copy of his notes should be placed in the resident's medical record Pharmacist O stated the side effects of prolonged use of Antipsychotic medications included, but not limited to, akesthesia (a state of agitation and distress, that causes a feeling of restlessness and an urgent need to move) as well as extra pyramidal movements (involuntary or uncontrollable movements, such as tremors, muscle contractions, and other undesired body movements). He stated the facility's Policy and Procedure (P&P) for Residents' GDR indicated GDRs should be performed every six months. Pharmacist O stated he had documented his concerns regarding the Antipsychotic Medication monitoring among residents. During an interview, on 8/5/21, at 1:30 p.m., Licensed Staff M stated the IDT met quarterly, annually or as needed to discuss each resident's plan of care and Antipsychotic Medication use. She stated notification of the IDT meeting is provided to residents or their family members so they can attend and participate. She stated copies of those notifications should be in the resident's medical record. Licensed Staff M stated the IDT reviewed the resident's medical record and discussed diagnoses, medications, issues regarding care including behaviors and care plans. During an interview and record review with Unit Manager, on 8/11/21 starting at 9:30 a.m., a request for documentation of GDR or clinical contraindication of a GDR for Resident 66 was requested. At 11:30 a.m., Unit Manager stated she would need more time to locate the documentation. For Residents 86, 62, 45, 55, 76, 59, 75, 66, 71, and 37, a request was made for documentation of any progress notes that indicated a GDR, documentation of benefit versus risk of GDR, Pharmacist Monthly Recommendations for Antipsychotic medications, behavior monitoring, and psychiatric and psychology consults. Documents were received at 5:30 p.m and reviewed. During a review of requested medical records, the records indicated no clinical contraindications for initiating GDRs for Antipsychotic Medication with Residents 86, 62, 45, 55, 76, 59, 75, 66, 71, and 37. During a record review of Resident 66's medical record it indicated she was admitted [DATE], with diagnoses that included Schizophrenia and Anxiety, manifested by Uncontrollable yelling and Verbalization of feeling anxious. Review of a document titled Behavioral Monitoring Administration History: 7/29/21 - 8/12/21, indicated no observations by staff of Uncontrollable yelling .Verbalization of feeling sad. Review of a document titled Care Plan, dated 3/21/18, indicated Resident with mental illness/psychosis [diagnosis of] Schizophrenia, manifested by: Uncontrollable yelling; Verbal Outburst 9/17/18 pharmacy GDR recommendation declined by MD 4/23/19 verbal aggression towards staff. Resident 66's Progress Notes from 1/16/19, 5/15/19 and 6/20/19 indicated: Monthly MRR completed - recommendation made. 6/27/19 Received pharmacy recommendation referred to MD. Noted MD declined GDR. During the review, a Note to Attending Physician/Prescriber, dated 6/25/21, indicated: This resident is receiving valproic acid, identified by the Center for Medicaid and Medicare Services (CMS) as potentially able to cause clinically significant adverse consequences if use of this medication is necessary, CMS requires an assessment of risk vs. benefits. The facility did not provide documentation indicating Resident 66's attending physician had performed a risk-versus-benefit analysis. A pharmacist consultant report titled CONSULTATION REPORT, dated 6/18/19 - 6/21/19, indicated: Please attempt a gradual dosage reduction (GDR). The document indicated no response from Physician U. The MONTHLY IDT PAIN/PSYCHOTROPIC REVIEW, dated 7/19/21, indicated the following concern regarding GDRs: Fluoxetine for depression, Miritazapine for Depression, Olanzapine for Schizophrenia, Ativan for anxiety and Diazepam for anxiety, no behaviors observed for verbalization of feeling sad, uncontrollable yelling, verbalization of feeling anxious. No plan for any GDR or most recent GDR was documented. The document further indicated PLAN: Next GDR due: Monthly. GDR as needed. Review of Resident 66's INTERDISCIPLINARY TEAM CARE CONFERENCE NOTES, dated 3/2019 - 6/8/21, indicated a list of medication and behaviors but did not mention a GDR, or the success of non-pharmaceutical interventions for managing behaviors. During a review of Resident 62's medical record it indicated he was admitted [DATE], with diagnoses that included Unspecified Psychosis, manifested by behaviors that included Uncontrollable Yelling and verbalization of feeling anxious and sad. Review of a document titled Consultant Pharmacist's Medication Regimen Review Recommendations Pending a Final Response, dated 4/1/21 - 5/26/21, indicated Recommendation: Re: TWO concurrent antipsychotic meds. Is this person experiencing akatheasia from olanzapine which is manifested by thrashing about in bed? If so, the added haldol will just make this worse until the resident is obtunded. In many cases, the combined use of two or more antipsychotic medications has not been demonstrated to be more effective than a single agent and has the potential for increased side effects. Please review the duplicate antipsychotic therapy and choose from the following: Consider discontinuation of Haldol and reduction in dose of olanzapine. Recommendation Status Pending. Review of the record titled Note to Attending Physician/Prescriber, dated 2/21, 4/9/21, and 7/2/21, indicated Physician U disagreed with the Pharmacist recommendation regarding two concurrent antipsychotic meds documented New Admit . no adjustment, Patient with Depression . benefit [outweighs] risk, benefit [outweighs] risks continue current treatment, still active behaviors. During a review of Resident 45's medical record it indicated she was admitted [DATE], with diagnoses that included Unspecified psychosis not due to a substance or known physiological conditions and major depressive disorder. Review of a document titled Consultant Pharmacist's Medication Regimen Review, dated 2/25/21 and 4/19/21, indicated Re: PRN lorazepam, PRN psychotropic orders cannot exceed 14 days with the exception that the prescriber documents their rationale in the residents medical record and indicate the duration for the PRN order. Notation by the physician indicated: New Admit continue current orders, continue to monitor. The Medication Regimen Review also indicated Re: TWO concurrent antipsychotic meds[,] in many cases the combined use of two or more antipsychotic medications has not been demonstrated to be more effective than a single agent and has the potential for increased side effects[.] Please review the duplicate antipsychotic therapy and choose from the following: New order or order to discontinue therapy written below, Both medications are to be continued as they improve the quality of this residents life[,] The benefits outweigh the risks . Review of the document indicated the physician did not agree or disagree and the physician indicated new admit, no new orders. During a review of a document titled Note to Attending Physician / prescriber, dated 4/19/21, indicated This resident is most likely experiencing significant exacerbation of preexisting behavior issues due to overmedication with multiple psychotropic medications. The excessive dose of Seroquel alone is likely causing an akathisia adverse reaction which is being incorrectly assessed as increased behavioral issues and consequently treated with multiple other psychotropic meds. Current psych meds include: Haldol decanoate 100 mg[,] Seroquel 800 mg / day[,] Valproic acid 250 mg/day[,] Trazodone 100 mg/day. During an observation on 8/3/21, 8/5/21 and 8/9/21, Resident 45 was seen sitting on the side of her bed reaching for an item on her bedside table. No signs of potential adverse medication effects such as shaking, loss of balance, repetative or uncoordinated movements were observed. On 8/5/21, Resident 45 was seen walking in the hallway with her walker, shuffling along. On 8/9/21, Resident 45 was seen sitting in a chair next to her bed, no specific actions were observed. During a concurrent observation and interview on 8/6/21, at 12:57 p.m., Resident 45 was asked where her wanderguard was located, she sated why, do you wat it for yourself? Resident 45 did notexhibit any uncoordinated movements and was responding jokingly/normal. On 8/10/21 and 8/12/21, interviews were attempted with Resident 45's attending physician to discuss the resident's psychotropic medications. Physician X scheduled a telephone conference for 8/12/21, but never presented for interview during the period of the survey. A review of Resident 55's medical record indicated he was admitted [DATE], with diagnoses that included Schizophrenia with behaviors manifested by Verbal aggression towards staff and verbalization of feeling sad. A review of Resident 86's medical record indicated he was admitted [DATE], with diagnoses that included Schizoaffective disorder and Bipolar disorder. Review of Physician Orders indicated he was prescribed two Antipsychotic medication for behaviors of Verbal aggression towards staff. Review of a document titled Behavioral Monitoring Administration History, did not indicate the presence of any behaviors from 5/1/21 - 8/9/21. IDT Antipsychotropic Review documents, from 5/2021 - 7/2021, did not describe the frequency of the resident's behaviors, and indicated the consultant pharmacist recommended monthly GDRs. A review of Resident 59's medical record indicated he was admitted [DATE], with diagnoses that included Undifferentiated schizophrenia with behaviors manifested as Physical aggression towards staff. Review of a document titled Behavioral Monitoring Administration History, indicated the resident exhibited no behaviors from 5/1/21 - 8/9/21. A review of Resident 75's medical record indicated she was admitted [DATE], with diagnoses that included Schizophrenia and Bipolar disorder, with behaviors manifested by Sad Facial Expression, Verbal Aggression Towards Staff, Physical Aggression by hitting inanimate objects and Verbal outburst. Review of a document titled Behavioral Monitoring Administration History, indicated the resident exhibited no behaviors from 5/1/21 - 8/9/21. Review of Resident 71's medical record indicated he was admitted [DATE], with diagnoses that included Bipolar disorder and d by Schizoaffective Disorder, with behaviors manifested by Aggression toward staff, Verbal Aggression Towards Staff, and Verbalization of feeling anxious. Review of a document titled Behavioral Monitoring Administration History, indicated the resident exhibited no behaviors from 5/1/21 - 8/9/21. IDT Antipsychotropic Review dated 7/19/2021 indicated no behaviors noted, and recommended a GDR as needed. Review of Resident 76's medical record indicated he was admitted [DATE], with diagnoses that included Restlessness and agitation, Unspecified psychosis . paranoid, and Unspecified dementia with behavioral disturbance, with behaviors as manifested by Constant refusal of care, verbal aggression, throwing inanimate objects. Behavioral monitoring indicated one iteration of a moinitored behavior (refusing clinical care). An IDT Antipsychotropic Review, dated 7/30/2021, indicated no behaviors, and recommended a GDR. A review of Resident 37's medical record indicated he was admitted [DATE], with diagnoses of Schizophrenia and depression, with behaviors as manifested by verbal and physical aggression towards staff. Behavioral monitoring, dated 4/1/21- 8/12/21, indicated one interation of a monitored behavior. IDT Antipsychotropic Review, dated 7/19/2021, indicated no behaviors noted, and a GDR performed Monthly. During a review of a facility document titled Monthly Director of Nursing Report, last revised 6/19, indicated The Monthly Director of Nursing (DON) Report is a vital component of the facility's Quality Assessment and Assurance (QA&A)/Quality Assurance Performance Improvement (QAPI program. The ultimate purpose is to make certain that proper care and treatment are being provided to the residents/patients of the facility. The Director of Nursing will gather the data needed for completion of the Monthly DON report as outline in the form. Psychoactive Medications-total number of residents for the month on anti-psychotic, anti-anxiety, anti-depressant, hypnotic. The Monthly DON Report is submitted by the DON to the facility's Administrator and reported to during the monthly QA&A/QAPI meeting at the facility. During a review of a facility policy titled Medication Monitoring Medication Regimen Review and Reporting Section 8.1, dated 2007, it indicated Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, . The findings are communicated to the director of nursing or designee and the medical director. These findings are documented and filed . in the resident's chart. Resident-specific MRR recommendations and findings are documented and acted upon by . nursing . and/or physician. For those issues that require physician intervention, the attending physician either accepts and acts upon the report and recommendations or rejects all or some of the report and should document his or rationale of why the recommendation is rejected in the resident's medical record. Review of a facility policy titled Psychotropic Medication Assessment & Monitoring RC3 0401.00, dated 3/00 DRAFT, indicated Psychotropic drugs are used only when necessary, and then at the lowest effective dose. Monitoring for drug side effects leads to early identification and reporting. Criteria for Psychotropic Medication Use . Behavioral interventions have been attempted first without adequate resolution. The behavior presents a danger to the resident or to others . Dosage reduction or re-evaluations are provided: Antipsychotic drugs: every 6 months of continuous use . Reductions or re-evaluations are not necessary if, within the last reduction time frame, the resident has had a gradual dose reduction and the dose has been reduced to the lowest possible dose to control the symptoms, and the physician document this information. The Interdisciplinary Team assesses and monitors the appropriateness, effectiveness, and side effects associated with psychotropic medications for each resident. Gradual dose reductions will be attempted at least one time every six months after antipsychotic therapy has begun.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to initiate Gradual Dose Reductions (GDR), for 10 residents (Residents 86, 62, 45, 55, 76, 59, 75, 66, 71, and 37) on Antipsychotic Medication (e.g., medication that alters brain chemistry to reduce psychotic symptoms such as harmful behaviors, hallucinations, delusions, and disordered thinking), when the facility did not implement a GDR as recommended by the facility's pharmaceutical consultant, or document specific clinical contraindications for a GDR when a GDR was not performed. These failures had the potential to cause harmful side effects for residents receiving due to prolonged use of antipsychotic medications, including death. Findings: During an interview with Physician U, an attending physician, on 8/6/21, at 11:00 a.m., he stated he evaluated the risk-versus-benefit of GDR for residents on Antipsychotic medications and either accepted or declined the recommendation for GDR made by the consultant pharmacist. When asked, Physician U could not state if he had recently approved any GDRs for his residents. During a concurrent interview and record review on 8/10/21, at 12:49 p.m., Administrator stated the Pharmacist has expressed concern for the way physicians ordered residents' antipsychotic medication. Administrator stated this concern was discussed in the Quality Assurance Performance Improvement (QAPI) meeting. During a review of facility's QAPI binder, the binder contained a report titled PharMerica RX Quality Assurance Report, dated Quarter 1, 2021 (January, February, March), and Quarter 2, 2021 (April, May, June), indicated recommendations by the Pharmacy Consultant that included: Antipsychotic Therapy, Dose Scheduling. Administrator stated discussion at QAPI included: Concerns: Antipsychotic listed as verbal aggression? No pattern [of] physical aggression . Why justifying for verbal aggression, too many residents [without] targeted specific behaviors. Administrator stated the Pharmacist expressed concern that physician orders did not indicate an individualized need for antipsychotic medication specific for each resident receiving the medication. Administrator stated the DON was supposed to review all antipsychotic medication orders for appropriateness, but Administrator could not find any documentation in the QAPI minutes that indicated the DON completed a review. When asked to provide documentation that facility was conducting GDRs according to the P&P, the Administrator did not respond. During an interview on 8/10/21, at 11:46 a.m., Physician V stated he was the Medical Director of the facility. Physician V stated in that role he provided oversight of attending physicians and discussed residents' GDR recommendations from the pharmacist. Physician V stated at the facility's last QAPI meeting, the consultant pharmacist indicated concerns how the facility physicians documented reasons for ordering antipsychotic medication. Physician V stated how the facility responded to GDR recommendations from the pharmacy concerned him. Physician V stated GDR recommendations should be addressed by the provider and a GDR should be initiated whether past GDRs were successful or not. He stated if a resident was at the facility for a long time and the pharmacy recommended a GDR because resident behaviors were no longer present, then a GDR should definitely be attempted. Physician V stated if GDR recommendations were attempted they should be reviewed every three to six months. Physician V stated residents can exhibit side effects of using antipsychotic medication, including somnolence (The condition of drowsiness, lethargy and sleepiness preceding falling asleep), as well as increased risk of falls, or a decline in activities of daily living (ADL). Physician V stated he did not recall a review during the last QAPI meeting of residents who were on antipsychotic medications, or a review of how many GDRs were recommended, conducted, or declined. Physician V stated I told the facility I was willing to be really involved in review of GDR. So far, hasn't happened. When asked if the facility was following the P&P for GDRs Physician V did not respond. During an interview on 8/12/21, at 2:15 p.m., Pharmacist O stated he conducted Monthly Medication Regime Reviews (MMRR) for every resident, and he notified DON of his recommendations and the need for follow up. He stated he reviewed every resident's medical record to determine if his recommendations from the previous month were accepted, initiated or declined. Pharmacist O stated for resident's on Antipsychotic medications he monitored their use and recommended new medications, as well as lab studies and Abnormal Involuntary Movement Scale (AIM, a scale to assess severity of dyskinesias (specifically, mouth and facial movements as well as extremity and truncal movements)). Pharmacist O stated when he was finished with his MMRR, he sent summary notifications titled Executive Summary of Consultant Pharmacist's Medication Regimen Review, to the attending physician, DON, and the Administrator. He stated each provider should evaluate the behavior monitoring for every resident on antipsychotic medication and determine the justification for continuation of the Antipsychotic medication. He stated a copy of his notes should be placed in the resident's medical record. Pharmacist O stated the side effects of prolonged use of antipsychotic medications included, but not limited to, akesthesia (a state of agitation and distress, that causes a feeling of restlessness and an urgent need to move) and extrapyramidal movements (involuntary or uncontrollable movements, such as tremors, tics, or muscle contractions). He stated the facility Policy and Procedure (P&P) for GDRs indicated a GDR should occur every 6 months. When asked if the facility were performing GDRs for residents on Antipsychotics, Pharmacist O stated he had documented his concerns regarding the facility's monitoring of Antipsychotic medication use for residents in the facility. During an observation on 8/2/21, at 9:45 a.m., Resident 71 was observed laying in bed, sleeping. During an observation on 8/2/21, at 10:00 a.m. and 11:15 a.m., and on 8/3/21 at 9:30 a.m., Residents 59, 42, and 37 were observed awake and lying on their backs, in a room with no lights on and with privacy curtains pulled. No television was turned on. The residents did not respond to an introduction or a request for permission to speak with them. During an observation on 8/2/21, at 9:30 a.m. and 11:15 a.m., Resident 71 was observed in bed, watching television with headphones on. During a concurrent interview and record review, on 8/3/21, at 3:34 p.m., Resident 71's family member, stated she had never been called by the facility to discuss the resident's care. She stated this morning her daughter arrived to take Resident 71 out of the facility on a day pass to go to the movies, but was informed by the licensed staff that he could not go because he was sleeping. She stated he was always sleeping and thought he was getting too much medication. The family member stated she had not received communication about reducing the resident's medications. Record review of Resident 71's medical record did not indicate the facility attempted to contact the family member to discuss his plan of care or use of Antipsychotic medication therapy. During an interview and record review on 8/4/21, at 3:00 p.m., the DON stated the facility pharmacist conducted monthly medication reviews for residents and recommended GDRs for resident's on Antipsychotic Medications. The DON stated the purpose of the GDR was to monitor and reduce medication dosages to prevent side effects. The DON stated she did not know how many GDRs were conducted for residents on Antipsychotic medications. She stated the facility did not have an Antipsychotic Medication Committee and monitoring Antipsychotic Medication use occurred during Interdisciplinary Team (IDT) meetings for each resident. She stated the documentation of those meetings would be found in the resident medical record. The DON stated the Pharmacist Medication Review notes and recommendations were reviewed by residents' physicians. The DON reviewed the binder and the electronic medical records for Residents 42, 59, 37 and 71, and stated she could not locate documentation indicating any GDRs had been initiated, or any physician documentation indicating how GDRs were clinically contraindicated. During an interview, on 8/5/21, at 1:30 p.m., Licensed Staff M stated the IDT met quarterly, annually or as needed to discuss each resident's plan of care and Antipsychotic Medication use. She stated the facility notified residents or their family members about IDT meetings so they can attend and participate. She stated copies of those notifications should be in the resident's medical record. Licensed Staff M stated the IDT reviewed the resident's medical record and discussed diagnoses, medications, issues regarding care including behaviors and care plans. During an interview and record review with Unit Manager, on 8/11/21 starting at 9:30 a.m., a request for documentation of GDR or clinical contraindication of a GDR for Resident 66 was requested. At 11:30 a.m., Unit Manager stated she would need more time to locate the documentation. For Residents 86, 62, 45, 55, 76, 59, 75, 66, 71, and 37, a request was made for documentation of any progress notes that indicated a GDR, documentation of benefit versus risk of GDR, Pharmacist Monthly Recommendations for Antipsychotic medications, behavior monitoring, and psychiatric and psychology consults. Documents were received at 5:30 p.m. and reviewed. During a review of requested medical records, the records indicated no clinical contraindications for initiating GDRs for Antipsychotic Medication with Residents 86, 62, 45, 55, 76, 59, 75, 66, 71, and 37. During a record review of Resident 66's medical record it indicated she was admitted [DATE], with diagnoses that included Schizophrenia and Anxiety, manifested by Uncontrollable yelling and Verbalization of feeling anxious. Review of a document titled Behavioral Monitoring Administration History: 7/29/21 - 8/12/21, indicated no observations by staff of Uncontrollable yelling .Verbalization of feeling sad. Review of a document titled Care Plan, dated 3/21/18, indicated Resident with mental illness/psychosis [diagnosis of] Schizophrenia, manifested by: Uncontrollable yelling; Verbal Outburst 9/17/18 pharmacy GDR recommendation declined by MD 4/23/19 verbal aggression towards staff. Resident 66's Progress Notes from 1/16/19, 5/15/19 and 6/20/19 indicated: Monthly MRR completed - recommendation made. 6/27/19 Received pharmacy recommendation referred to MD. Noted MD declined GDR. During the review, a Note to Attending Physician/Prescriber, dated 6/25/21, indicated: This resident is receiving valproic acid, identified by the Center for Medicaid and Medicare Services (CMS) as potentially able to cause clinically significant adverse consequences if use of this medication is necessary, CMS requires an assessment of risk vs. benefits. The facility did not provide documentation indicating Resident 66's attending physician had performed a risk-versus-benefit analysis. A pharmacist consultant report titled CONSULTATION REPORT, dated 6/18/19 - 6/21/19, indicated: Please attempt a gradual dosage reduction (GDR). The document indicated no response from Physician U. The MONTHLY IDT PAIN/PSYCHOTROPIC REVIEW, dated 7/19/21, indicated the following concern regarding GDRs: Fluoxetine for depression, Miritazapine for Depression, Olanzapine for Schizophrenia, Ativan for anxiety and Diazepam for anxiety, no behaviors observed for verbalization of feeling sad, uncontrollable yelling, verbalization of feeling anxious. No plan for any GDR or most recent GDR was documented. The document further indicated PLAN: Next GDR due: Monthly. GDR as needed. Review of Resident 66's INTERDISCIPLINARY TEAM CARE CONFERENCE NOTES, dated 3/2019 - 6/8/21, indicated a list of medication and behaviors but did not mention a GDR, or the success of non-pharmaceutical interventions for managing behaviors. During a review of Resident 62's medical record it indicated he was admitted [DATE], with diagnoses that included Unspecified Psychosis, manifested by behaviors that included Uncontrollable Yelling and verbalization of feeling anxious and sad. Review of a document titled Consultant Pharmacist's Medication Regimen Review Recommendations Pending a Final Response, dated 4/1/21 - 5/26/21, indicated Recommendation: Re: TWO concurrent Antipsychotic meds. Is this person experiencing akatheasia from olanzapine which is manifested by thrashing about in bed? If so, the added haldol will just make this worse until the resident is obtunded. In many cases, the combined use of two or more Antipsychotic medications has not been demonstrated to be more effective than a single agent and has the potential for increased side effects. Please review the duplicate Antipsychotic therapy and choose from the following: Consider discontinuation of Haldol and reduction in dose of olanzapine. Recommendation Status Pending. Review of the record titled Note to Attending Physician/Prescriber, dated 2/21, 4/9/21, and 7/2/21, indicated Physician U disagreed with the Pharmacist recommendation regarding two concurrent Antipsychotic meds documented New Admit . no adjustment, Patient with Depression . benefit [outweighs] risk, benefit [outweighs] risks continue current treatment, still active behaviors. During a review of Resident 45's medical record it indicated she was admitted [DATE], with diagnoses that included Unspecified psychosis not due to a substance or known physiological conditions and major depressive disorder. Review of a document titled Consultant Pharmacist's Medication Regimen Review, dated 2/25/21 and 4/19/21, indicated Re: PRN lorazepam, PRN psychotropic orders cannot exceed 14 days with the exception that the prescriber documents their rationale in the residents medical record and indicate the duration for the PRN order. Notation by the physician indicated: New Admit continue current orders, continue to monitor. The Medication Regimen Review also indicated Re: TWO concurrent Antipsychotic meds[,] in many cases the combined use of two or more Antipsychotic medications has not been demonstrated to be more effective than a single agent and has the potential for increased side effects[.] Please review the duplicate Antipsychotic therapy and choose from the following: New order or order to discontinue therapy written below, Both medications are to be continued as they improve the quality of this residents life[,] The benefits outweigh the risks . Review of the document indicated the physician did not agree or disagree and the physician indicated new admit, no new orders. During a review of a document titled Note to Attending Physician / prescriber, dated 4/19/21, indicated This resident is most likely experiencing significant exacerbation of preexisting behavior issues due to overmedication with multiple psychotropic medications. The excessive dose of Seroquel alone is likely causing an akathisia adverse reaction which is being incorrectly assessed as increased behavioral issues and consequently treated with multiple other psychotropic meds. Current psych meds include: Haldol decanoate 100 mg[,] Seroquel 800 mg / day[,] Valproic acid 250 mg/day[,] Trazodone 100 mg/day. During an observation on 8/2/21, at 12:30 p.m., Resident 45 was observed seated in the main dining room waiting for lunch. She responded to questions and comments with 2-3 word sentences. Her facial expression indicated a flat affect. No behaviors resembling signs or symptoms of Antipsychotic side effects were observed. During an observation on 8/3/21, 8/5/21 and 8/9/21, Resident 45 was seen sitting on the side of her bed reaching for an item on her bedside table. No signs of potential adverse medication effects such as shaking, loss of balance, repetitive or uncoordinated movements were observed. On 8/5/21, Resident 45 was seen walking in the hallway with her walker, shuffling along. On 8/9/21, Resident 45 was seen sitting in a chair next to her bed, no specific actions were observed. During an observation and concurrent interview on 8/6/21 at 12:57 p.m., Resident 45 was asked where her wanderguard was located, she sated why, do you want it for yourself? Resident 45 did not exhibit any uncoordinated movements and was responding jokingly/normal. An interview with Resident 45's Physician to discuss her Psychotropic medications was attempted on 8/10/21 and scheduled on 8/12/21 with an expected call from the Physician. Physician X did not return the phone calls. A review of Resident 55's medical record indicated he was admitted [DATE], with diagnoses that included Schizophrenia with behaviors manifested by Verbal aggression towards staff and verbalization of feeling sad. A review of Resident 86's medical record indicated he was admitted [DATE], with diagnoses that included Schizoaffective disorder and Bipolar disorder. Review of Physician Orders indicated he was prescribed two Antipsychotic medication for behaviors of Verbal aggression towards staff. Review of a document titled Behavioral Monitoring Administration History, did not indicate the presence of any behaviors from 5/1/21 - 8/9/21. IDT Antipsychotropic Review documents, from 5/2021 - 7/2021, did not describe the frequency of the resident's behaviors, and indicated the consultant pharmacist recommended monthly GDRs. A review of Resident 59's medical record indicated he was admitted [DATE], with diagnoses that included Undifferentiated schizophrenia with behaviors manifested as Physical aggression towards staff. Review of a document titled Behavioral Monitoring Administration History, indicated the resident exhibited no behaviors from 5/1/21 - 8/9/21. A review of Resident 75's medical record indicated she was admitted [DATE], with diagnoses that included Schizophrenia and Bipolar disorder, with behaviors manifested by Sad Facial Expression, Verbal Aggression Towards Staff, Physical Aggression by hitting inanimate objects and Verbal outburst. Review of a document titled Behavioral Monitoring Administration History, indicated the resident exhibited no behaviors from 5/1/21 - 8/9/21. Review of Resident 71's medical record indicated he was admitted [DATE], with diagnoses that included Bipolar disorder and by Schizoaffective Disorder, with behaviors manifested by Aggression toward staff, Verbal Aggression Towards Staff, and Verbalization of feeling anxious. Review of a document titled Behavioral Monitoring Administration History, indicated the resident exhibited no behaviors from 5/1/21 - 8/9/21. IDT Antipsychotropic Review dated 7/19/2021 indicated no behaviors noted, and recommended a GDR as needed. Review of Resident 76's medical record indicated he was admitted [DATE], with diagnoses that included Restlessness and agitation, Unspecified psychosis . paranoid, and Unspecified dementia with behavioral disturbance, with behaviors as manifested by Constant refusal of care, verbal aggression, throwing inanimate objects. Behavioral monitoring indicated one iteration of a monitored behavior (refusing clinical care). An IDT Antipsychotropic Review, dated 7/30/2021, indicated no behaviors, and recommended a GDR. A review of Resident 37's medical record indicated he was admitted [DATE], with diagnoses of Schizophrenia and depression, with behaviors as manifested by verbal and physical aggression towards staff. Behavioral monitoring, dated 4/1/21- 8/12/21, indicated one iteration of a monitored behavior. IDT Antipsychotropic Review, dated 7/19/2021, indicated no behaviors noted, and a GDR performed Monthly. During a review of a facility document titled Monthly Director of Nursing Report, last revised 6/19, indicated The Monthly Director of Nursing (DON) Report is a vital component of the facility's Quality Assessment and Assurance (QA&A)/Quality Assurance Performance Improvement (QAPI program. The ultimate purpose is to make certain that proper care and treatment are being provided to the residents/patients of the facility. The Director of Nursing will gather the data needed for completion of the Monthly DON report as outline in the form. Psychoactive Medications-total number of residents for the month on anti-psychotic, anti-anxiety, anti-depressant, hypnotic. The Monthly DON Report is submitted by the DON to the facility's Administrator and reported to during the monthly QA&A/QAPI meeting at the facility. During a review of a facility policy titled Medication Monitoring Medication Regimen Review and Reporting Section 8.1, dated 2007, it indicated Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, . The findings are communicated to the director of nursing or designee and the medical director. These findings are documented and filed . in the resident's chart. Resident-specific MRR recommendations and findings are documented and acted upon by . nursing . and/or physician. For those issues that require physician intervention, the attending physician either accepts and acts upon the report and recommendations or rejects all or some of the report and should document his or rationale of why the recommendation is rejected in the resident's medical record. Review of a facility policy titled Psychotropic Medication Assessment & Monitoring RC3 0401.00, dated 3/00 DRAFT, indicated Psychotropic drugs are used only when necessary, and then at the lowest effective dose. Monitoring for drug side effects leads to early identification and reporting. Criteria for Psychotropic Medication Use . Behavioral interventions have been attempted first without adequate resolution. The behavior presents a danger to the resident or to others . Dosage reduction or re-evaluations are provided: Antipsychotic rugs: every 6 months of continuous use . Reductions or re-evaluations are not necessary if, within the last reduction time frame, the resident has had a gradual dose reduction and the dose has been reduced to the lowest possible dose to control the symptoms, and the physician document this information. The Interdisciplinary Team assesses and monitors the appropriateness, effectiveness, and side effects associated with psychotropic medications for each resident. Gradual dose reductions will be attempted at least one time every six months after antipsychotic therapy has begun.

Based on observation, interview, and record review the facility failed to ensure there was enough dietary and food nutrition staff in the kitchen to carry out the functions of the food and nutrition service safely and effectively. This failure resulted to the Dietary Manager cooking dinner and breakfast for two days in the absence of a cook. Findings: During the initial tour on 8/2/21, a review of the dietary staff schedule for the day did not indicate the facility had assigned a cook to work the afternoon shift. During interview on 8/2/21 at 4:00 PM, the Dietary Manager stated the facility had been advertising for an additional cook. The Dietary Manager also stated she was cooking dinner that evening. During interview on 8/3/21 at 9:30 AM, the Dietary Manager stated the cook scheduled to prepare breakfast called off, so she prepared breakfast that morning. The Dietary Manager stated she appreciated having the cook scheduled for the afternoon shift coming in early to help with food preparation. During review of the Facility Assessment, developed 11/29/2017 and revised 3/15/21, the staffing plan for the facility's Food and Nutrition Services (RD, Food Services Manager, Dietary staff including cook) did not specify the number of staff required, or specificy whether the facility a problem with not having enough cooks.

Based on observation and record review, the facility failed to follow the approved menu and physician diet orders for 1 of 15 residents on puree diet (Resident 24), 1 of 2 residents on low fat low cholesterol renal diet (Resident 43), 1 of 7 residents on small portion regular diet (Resident 9), and 1 of 13 residents on low fat low cholesterol diet (Resident 93). This failure can result in undesirable changes of nutritional status, impaired healing, or poor well-being of residents in the facility. Findings: During review of the facility's menu for 8/2/21, a regular portion lunch would consist of 4 ounces of meatloaf, ½ cup garlic mashed potatoes, ½ cup spinach, and one wheat roll. During continuous tray line observation on 8/2/21 at 12:00 PM, [NAME] F prepared the following food items for the following resident plates: Resident 9 - whose tray ticket read small portions, regular should have received ¼ cup mashed potatoes and ½ wheat roll; however, the resident received a regular portion of mashed potatoes and 1 wheat roll. Resident 24 - whose tray ticket read regular pureed should have received ½ cup meatloaf, ½ cup mashed potatoes, ½ cup spinach and one wheat roll; however the resident received 1/3 cup mashed potato, 1/3 cup spinach and ¼ cup wheat roll. Resident 43 - whose tray ticket read renal low fat, low cholesterol should have received ½ cup whole wheat spiral pasta, ½ cup cauliflower, ½ dessert portion and ½ cup skim milk; however, the resident received ½ cup white rice, 2 cookies (full dessert portion) whole milk and no cauliflower. The substituted white rice would not offer the same amount of fiber for Resident 43 as the whole wheat pasta. Resident 93 who had a low-fat, low-cholesterol diet received whole milk; however, the resident should have received ½ cup skim milk or the preferred 2% milk.

Based on observation, interview and record review, the facility failed to ensure: 1. Kitchen staff practiced safe food handling habits to prevent contamination of food; and 2. Expired food items were disposed by expiration date. These failures could potentially result to food safety hazards, food contamination and outbreak of foodborne illness among residents of the facility. Findings: 1. During observation of the kitchen and staff on 8/2/21 at 12:20 PM, [NAME] F was observed wearing a bracelet and two rings on his right ring finger. [NAME] F washed his hands but did not remove his bracelet and rings. He proceeded to don gloves and work at tray line wearing his rings and bracelet. During observation on 8/2/21 at 12:20 PM, Dietary Aide E, was noted not to be wearing her apron while assisting the cook at tray line. During observation on 8/3/21 at 9:30 AM, Dietary Aide E was observed wearing a plastic apron while working at the washing section of the kitchen. She was removing food items from used residents' trays. During continued observation on 8/3/21 at 12:42 PM, Dietary Aide E was observed not wearing an apron while assisting the cook at tray line. During interview on 8/5/21 at 10:41 AM, Dietary Manager stated that staff in the kitchen should use cloth or plastic apron. The Dietary Manager stated that kitchen staff should change apron when moving from washing section to tray line. A review of the Centers for Disease Control and Prevention article on Healthcare Providers Introduction to Hand Hygiene, last reviewed on 1/8/21, the section under Fingernail Care and Jewelry on page 3 indicated: Some studies have shown that skin underneath rings contain more germs than comparable areas of skin on fingers without rings. Further studies are needed to determine if wearing rings results in an increased spread of potentially deadly germs. Review of the Food Code of 2017 indicated: Except for a plain ring such as a wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands. 2. During initial tour on 8/2/21 at 10:27 AM, a plastic container of sour cream labeled Opened 7/4/21; Use by: 7/12/21; and best by 7/31/21was located inside the second refrigerator from the kitchen door. During tour of the dry goods section of the kitchen on 8/2/21 at 10:43 AM, a bin held an original, opened paper bag containing powdered milk, with a scoop still inside. During interview with Dietary Manager on 8/2/21 at 10:52 AM, the Dietary Manager stated that there should be no scoop inside, that the powdered milk should be transferred to a container, and that stated the opened powdered milk should be removed from storage. During review of the facility's Food Receiving and Storage of Cold Foods Policy and Procedure taken from the Food Service Policy and Procedures Manual, dated 2018, the policy and procedure recommended using the sour cream's expiration date to identify the maximum storage period for sour cream. During review of the Sanitation and Infection Control section of the Food Service Policy and Procedure Manual, dated 2018, on Canned and Dry Goods Storage, procedures #9 on page 81 indicated: Metal, plastic containers with tight fitting lids, or resealable plastic bags will be used for staples and opened packages of items such as pastas, rice, dry cereals, etc . Scoops are to be stored in a separate area, not inside food containers, and need to be cleaned each time they are used.

Based on interview and record review, the facility failed to ensure its Medical Director coordinated physician services for residents, when the Medical Director did not ensure attending physicians followed policy for Gradual Dose Reductions (GDR) and monitoring of residents on antipsychotic medications. This failure did not demonstrate appropriate physician leadership and had the potential to cause resident harm related to side effects of prolonged use of antipsychotic medications. Findings: (Refer to F756 and F758) During an interview on 8/6/21, at 11:00 a.m., Physician U stated for residents on Antipsychotic medications he evaluated the risk-versus-benefit of GDR for the antipsychotic medication prescribed, and either accepted or declined the recommendation from the pharmacist. Physician U was unable to state if he had recently approved any GDRs for his residents. Physician U stated ultimately he would be the one to decide how to treat his residents. Physician U was unable to generally describe the facility Policy and Procedure for Antipsychotic Medication Monitoring. During an interview on 8/10/21, at 11:46 a.m., Physician V stated GDR's should attempted and attending physicians should follow pharmacy recommendations for GDRs. Physician V stated he is a peer of the other physicians and could not tell them what to do. He stated he has not met with attending physicians, but has forwarded emails to them regarding Monthly Medication Regimen Reviews and GDR recommendations by the facility's Consultant Pharmacist. Physician V stated stated he did not recall the facility reviewing residents who were on antipsychotic medications during the last QAPI meeting, or reviewing how many GDR's were recommended, conducted or declined by attending physicians in the facility. Physician V stated I told the facility I was willing to be really involved in review of GDR. So far hasn't happened. During an interview and record review on 8/10/21, at 12:49 p.m., with Administrator, he stated the Medical Director attending the Quality Assurance Performance Improvement (QAPI) meeting. Administrator stated the Pharmacy Consultant's report was reviewed by the DON and Medical Director at the last meeting, and the Pharmacist expressed concern how antipsychotic medication orders were written. Review of the last QAPI meeting binder indicated a Pharmacist report titled PharMerica RX Quality Assurance Report, dated Quarter 1, 2021 (January, February, March, and Quarter 2, 2021 (April, May, June), indicated top recommendations by the pharmacist included Antipsychotic Therapy, Dose Scheduling. Administrator stated there were no recommendations from the Medical Director on GDR or Antipsychotic Medication monitoring in the minutes from the QAPI meeting. During an interview on 8/12/21, at 2:15 p.m., Pharmacist O stated each ordering physician should evaluate the behavior monitoring data for every resident on antipsychotic medication and determine the continuation of the antipsychotic medication at the current dose is justified. Pharmacist O stated the facility Policy and Procedure (P&P) for Resident GDR indicated a resident receiving antipsychotic medication should have a GDR every 6 months. Pharmacist O stated he had documented his concerns regarding Resident Antipsychotic Medication monitoring and had reported to the QAPI his concerns about the high rate of Antipsychotic Medication use at the facility. During a review of a facility policy titled Medication Monitoring Medication Regimen Review and Reporting Section 8.1, dated 2007, it indicated Medication Regimen Review (MRR) or Drug Regimen Review is a thorough evaluation of the medication regimen of a resident, . The findings are communicated to the director of nursing or designee and the medical director. These findings are documented and filed . in the resident's chart. Resident-specific MRR recommendations and findings are documented and acted upon by . nursing . and/or physician. For those issues that require physician intervention, the attending physician either accepts and acts upon the report and recommendations or rejects all or some of the report and should document his or rationale of why the recommendation is rejected in the resident's medical record. Review of a facility policy titled Psychotropic Medication Assessment & Monitoring RC3 0401.00, dated 3/00 DRAFT, indicated Psychotropic drugs are used only when necessary, and then at the lowest effective dose. Monitoring for drug side effects leads to early identification and reporting. Criteria for Psychotropic Medication Use . Behavioral interventions have been attempted first without adequate resolution. The behavior presents a danger to the resident or to others . Dosage reduction or re-evaluations are provided: Antipsychotic rugs: every 6 months of continuous use . Reductions or re-evaluations are not necessary if, within the last reduction time frame, the resident has had a gradual dose reduction and the dose has been reduced to the lowest possible dose to control the symptoms, and the physician document this information. The Interdisciplinary Team assesses and monitors the appropriateness, effectiveness, and side effects associated with psychotropic medications for each resident. Gradual dose reductions will be attempted at least one time every six months after antipsychotic therapy has begun. Review of a document titled Medical Director Services Agreement, dated 6/1/20, indicated DUTIES AND OBLIGATIONS OF MEDICAL DIRECTOR 1.1 Services. Medical Director shall be responsible for implementation of resident care policies, coordination of medical care in the Facility. Review of a document titled EXHIBIT A DUTIES & RESPONSIBILITIES OF MEDICAL DIRECTOR, not dated, indicated The following are examples of the types of duties to be performed by the Medical Director from time to time .B. Coordinate medical care in the Facility to insure the adequacy and appropriateness of the medical services provided . C. Act as liaison between Facility administration and attending physicians .Assist the Facility in communicating resident care policies to physicians who attend residents at the facility.

Based on interview and record review, the facility's Quality Assessment and Performance Improvement (QAPI) committee failed to identify and address quality deficiencies, when the facility's QAPI committee: 1. Had knowledge of a concern raised by its pharmaceutical consultant but the committee did not develop an action plan to correct the concern; 2. Did not prioritize known deficiencies, or establish goals for monitoring, tracking, and correcting deficiencies for Resident Care. These failures did not ensure the facility implemented QAPI system, and had the potential to negatively impact residents' quality of care and quality of life through the facility not addressing resident care issues or ensuring its provision of care was performed at the highest level and in the safest environment. Findings: (Refer to F756 and F758) Review of the QAPI meeting minutes for the months of January, February, and March of 2021 indicated a report from the facility's pharmaceutical consultant, which recommended the facility initiate Gradual Dose Reductions (GDR's) for residents on antipsychotic medications. During an interview on 8/10/21 at 12:45 p.m., the Administrator (QAPI Director) was asked what the facility's QAPI committee was currently working on. The Administrator stated he was working on recruitment of a full time Minimal Data Set (MDS) Coordinator, and Director of Staff Development (DSD) staff. The Administrator stated he hired a part time DSD Coordinator who can work only on Thursday and Fridays. He stated he has also been working on an emergency plan with a Dialysis Clinic. The Administrator stated he lead the facility's QAPI meetings. The Administrator stated the following people were members of the QAPI committee: Medical Director, Pharmacist (on phone to review his report), Social Services, Infection Preventionist (IP), Facilities management, Dietary, and the Director of Nursing Services (DON). The Administrator stated he compiled the meeting minutes, and reviewed the agendas and made notes for follow-up during subsequent meetings. The Administrator stated he identified and prioritized issues from these meetings by writing notes on all the records and it goes into the QAPI binder. The Administrator was asked to provide documentation for any corrective action plans, including the monitoring and evaluation of the effectiveness of the plans, but the Administrator did not respond or provide any documentation. The Administrator stated the QAPI committee discussed agenda items during each meeting, and the Administrator submitted a copy of the QAPI minutes he compiled to the Governing Body on conclusion of the meeting. The Administrator stated the Governing Body provided no feedback to the facility's QAPI committee after receipt. The Administrator stated the facility's pharmacy consultant has recommended the facility implement GDRs for residents receiving antipsychotic medications, but stated the facility's QAPI committee had no plan to identify the affected residents on antipsychotic medications, ensure the pharmacy recommendations were implemented, improve care planning around behavior monitoring, or address the pharmacist concerns around the facility's unusual prescribing processes that resulted in multiple prescribed antipsychotics, high doses, and questionable indications for antipsychotic use. During an interview on 8/10/21 at 1:00 p.m., the Medical Director stated he had been informed of recommendations from the facility's Pharmaceutical Consultant for residents receiving antipsychotic medications. When asked if there was a plan to monitor or review the recommendations, or do anything about the care planning for behaviors he stated, he was not involved in monitoring issues or ensuring facility initiated QAPI projects to improve resident care issues for antipsychotic monitoring. Review of the facility Policy and Procedure titled, Quality Assurance and Performance Improvement (QAPI) Plan, dated 11/2017, indicates the QAPI is to: Establish and implement plans to correct deficiencies and to monitor the effects of these action plans on resident outcome. The facility shall evaluate the effectiveness of its QAPI Program at least annually and shall present their conclusions to the owner/governing board for review. The Policy and Procedure did not indicate a process for gathering information that would and should be followed-up by the committee. During a review of a facility document titled Monthly Director of Nursing Report, last revised 6/19, indicated The Monthly Director of Nursing (DON) Report is a vital component of the facility's Quality Assessment and Assurance (QA&A)/Quality Assurance Performance Improvement (QAPI) program. The ultimate purpose is to make certain that proper care and treatment are being provided to the residents/patients of the facility. The Director of Nursing will gather the data needed for completion of the Monthly DON report as outline in the form. Psychoactive Medications-total number of residents for the month on anti-psychotic, anti-anxiety, anti-depressant, hypnotic. The Monthly DON Report is submitted by the DON to the facility's Administrator and reported to during the monthly QA&A/QAPI meeting at the facility.

Based on interview and record review, the facility's Quality Assessment and Performance Improvement (QAPI) committee failed to develop and implement a plan of action to correct an identified quality deficiency, when the facility's QAPI committee did not develop or implement a plan of action to correct a quality deficiency concerning antipsychotic prescribing and gradual dose reductions (GDR). This failure did not comply with facility policy or ensure care to maintain the highest level of resident functioning. Findings: (Refer to F865) During an interview on 8/10/21 at 12:45 p.m., the Administrator spoke about the facility's QAPI committee. The administrator stated he wrote notes on all the reports submitted from the departments for the meeting, and placed those notes into the QAPI binder. The Administrator was asked to provide documentation for any corrective action plans on any topic, including the monitoring and evaluation of the effectiveness of the plans, but the Administrator did not respond or provide any documentation. The Administrator stated the facility's pharmacy consultant has recommended the facility implement GDRs for residents receiving antipsychotic medications, but stated the facility's QAPI committee had no plan to identify the affected residents on antipsychotic medications, ensure the pharmacy recommendations were implemented, improve care planning around behavior monitoring, or address the pharmacist concerns around the facility's unusual prescribing processes that resulted in multiple prescribed antipsychotics, high doses, and questionable indications for antipsychotic use.The Administrator was unable to provide satisfactory evidence that the facility identified its own high risk, high volume, and problem-prone quality deficiencies, or provide evidence the facility made any good faith attempt to correct them. Review of the facility Policy and Procedure titled, Quality Assurance and Performance Improvement (QAPI) Plan, dated 11/2017, indicated the QAPI committee would establish and implement plans to correct deficiencies and to monitor the effects of these action plans on resident outcome. The Plan indicated individual departments or services shall develop quality indicators for programs and services in which they are involved and which affect their function. The Plan indicated the facility shall evaluate the effectiveness of its QAPI Program at least annually and shall present their conclusions to the owner/governing board for review. The Plan indicated no formal process for gathering information deemed important for the QAPI committee to review and follow-up on.

Based on observation, interview and record review, the facility failed to maintain a safe and sanitary environment in the kitchen as evidence by cracked tiles on several areas in the kitchen floor. This failure could cause trips and falls among the kitchen staff and cause dirt to build up on the floor attracting cockroaches and rodents. Findings: During an observation in the kitchen on 8/3/21, at 11:07 AM, cracked tiles were noted on several areas of the kitchen floor. During interview on 8/5/21, at 10:41 AM, the Dietary Manager stated that she had spoken to maintenance the previous week the need to replace the cracked tiles in the kitchen. The Dietary Manager stated there is no time frame, but she plans to follow-up with maintenance to address the problem as soon as possible. Review of the Food Code 2017 indicated: It is the standard of practice to ensure materials for indoor floor, wall, and ceiling surfaces under conditions of normal use shall be: smooth, durable, and easily cleanable for areas where food establishment operations are conducted.

Based on interviews and a record review, the facility failed to ensure residents' privacy as well as residents' timely receipt of mail items when two residents (Resident 40 and Resident 19) had received opened mail, and all residents did not receive mail promptly on weekends. This failure had the potential to cause residents to feel isolated from society and disrespected by the facility. Findings: During an interview with Resident #40 on 8/2/21 at 11:22 a.m., he stated: All our mail is open, two state letters opened. Resident deliveries are left outside front door and the Administrator has to go through it. Resident 40 stated this was a violation of privacy. During an interview with Resident #40 on 8/3/21 at 11:07 a.m., he stated: I had a letter from CDPH that was opened. Last three months, I received CDPH, SS and Federal government and they were opened. Couldn't talk to the Administrator, not available. Mail is delayed if Administrator has not gone through it. I don't know why Administrator stole it. I know on July 12 packages for another Resident stored by front door. No log. We find out about it from another Resident. During an interview and observation with Resident 19, on 8/4/21, at 2:00 p.m., in front of Nursing Station One, he stated a package was delivered to him and it was opened. Observation of the package indicated a brown package five inches by five inches, addressed to Resident 19, and the tape on the package appeared to be opened. Resident 19 stated the Receptionist handed it to him opened. He stated his mail was delivered opened and packages were lost frequently. During an interview with Resident 19, on 8/5/21, at 8:45 a.m., in the main dining room, he stated his mail has been delivered to him late and opened. He stated it is Dehumanizing. During an interview with Administrator, on 8/5/21, at 2:30 p.m., he stated resident mail and packages are never opened before they are delivered to the residents. He stated he was unaware of any resident complaints that mail was opened, delayed or missing. He stated mail is delivered to the facility and Monday through Friday he goes through the mail to separate facility mail from resident's personal mail. He stated the mail is then distributed to the residents. The Administrator also stated if a resident sees mail on the receptionist desk, then the receptionist will give it to them. The Administrator stated resident mail is not delivered on Saturday and Sunday. The Administrator stated he goes through the mail on Monday and then it is distributed to residents. He stated he remembered one instance when he mistakenly opened a resident's envelope because he thought a was something for the facility. During an interview with the Administrator on 8/5/21 at 3:32 p.m. he stated: Residents' packages come to the front desk. They bring it to me. I like to see whose it is. It is sorted. I either take it directly or give it to Activities. When asked if he opens the mail? He stated: No. When asked if he opens the packages? He stated: No. I have accidently opened letters addressed to Pine Ridge, then I tell the Resident and apologize. Review of a facility Policy and Procedure (P&P), titled Resident Mail OP2 0312.00 Chapter: Resident Rights, dated 4/15/2001, indicated: Residents have the right to privacy in written communications, including the right to send and promptly receive mail that is unopened. Promptly means delivery of mail or other materials to the resident within 24 hours or delivery by the postal service.

Based on observation and record reviews, the facility failed to ensure the nurse checked gastric residual (Gastric residual refers to the volume of fluid remaining in the stomach at a point in time during enteral nutrition feeding. Nurses withdraw this fluid via the feeding tube by pulling back on the plunger of a large (usually 60 mL) syringe at intervals typically ranging from four to eight hours. Ideally, most or all of the measured residual fluid should be replaced into the patient's stomach to prevent fluid, electrolyte, and nutrient loss.) prior to medication administration for one resident who had a gastric tube (A tube is inserted through the abdomen that deliver the nutrition or medication directly to the stomach). This failure had the potential to cause the resident to aspirate medications and/or feedings. Findings: During an observation on 5/22/19 at 10:00 a.m., Licensed Nurse A did not check residual before administering medications for Resident 92. During a record review of facility policy titled Resident Care 1: Basic Resident Care: Enteral Feeding: Residual Check, effective date 3/00, indicated Residual checks are performed to monitor gastric emptying and to prevent complications.

Based on observation, interview, and record review, the facility failed to provide at least 80 square feet per resident in one of 19 sampled resident rooms (Resident 16). This failure resulted in Resident 16 complaining of insufficient space to move about, maneuver equipment, and diminished initiative to get out of bed. This failure also had the potential to cause a decline in Resident 16's physical functioning. Findings: During an observation on 05/21/19, at 4:25 p.m., Resident 16 shared a room with two other residents, divided by privacy curtains. Resident 16 laid in a hospital bed on his right side, facing a flat television screen with a program on. The television was on a bedside table pressed up between a wall and the bed. Resident 16 laid on his right side watching television. Resident 16 left leg had been amputated above the knee, and did not have a prosthesis on. Resident 16 repositioned himself using the bed's quarter bed rails. A concurrent review of Resident 16's cognitive status, indicated he had a BIMS score (Brief Interview for Mental Status) 15 out of 15. The BIMS interview is a tool to assess the resident's attention, orientation, and ability to recall information. The BIMS is scored 0-15. A score of 13-15 indicates the resident's cognition is intact. On 5/22/19, at 9:35 a.m., Resident 16 slept on his right side with a current event channel on his television. A Certified Nursing Assistant attending another resident in the room, stated Resident 16 liked to stay in bed during the morning. During an interview on 5/23/19, at 12:03 p.m., Resident 16 and a visiting family member were in Resident 16's room. Resident 16 had a prosthetic on and had transferred to his bed from a wheelchair with limited space for maneuvering. When asked about whether he had the space necessary to maneuver, Resident 16 stated he tried to be as independent as possible and not ask for help, but the prosthesis was heavy, and he needed staff to assist with moving furniture out of the way in order to have access to his equipment and get out of bed, and staff were not always readily available to help. Resident 16 stated too much effort to get up and around dissuaded him from making an effort and getting out of bed. Resident 16's family member stated he visited almost daily and the cramped room space prevented Resident 16 from doing activities of daily living (ADLs) independently. Resident 16's family member stated concern that Resident 16's inability to do ADLs independently would be detrimental to Resident 16's health. Resident 16's family member stated the facility had placed Resident 16 on a waiting list for a room with only two residents. On 5/23/19, at 3:57 p.m., Maintenance measured Resident 16's room, which indicated each client had 74.71 square feet (less than 80 square feet). Administrator stated the facility had no room waiver for Resident 16's room.

Based on interview and record review, the facility failed to ensure that call lights were answered in a timely manner. Not answering call lights in a timely manner had the potential to result in an injury to the resident who tried to move or get out of bed without assistance or emotional distress to the resident who needed to use the bathroom or who was left wet in an incontinent brief. Findings: During interviews with concurrent observation on 5/19/19 between 10:00 a.m. and 12 noon during the initial tour of the facility, the following residents stated the following regarding response to call lights. During record review of the following residents on 5/19/19, The Minimum Data Set (MDS) of all the following residents indicated they were understood and could understand. The MDS is an assessment designed to assess the functional status, mood, and medical conditions of Nursing Home Residents. The following residents Brief Interview for Mental Status (BIMS) indicated they were alert and oriented. The BIMS interview is a tool to assess the resident's attention, orientation, and ability to recall information. The BIMS is scored 0-15. A score of 0-7 indicates the resident's cognition is severely impaired; 8-12 indicates the resident's cognition is moderately impaired; and 13-15 indicates the resident's cognition is intact. Resident 94, BIMS 8/15, stated that response time was more than an hour anytime of day. Resident 82, BIMS 15/15, stated that during the day the response time was 20 minutes to one-half hour. During the night it was an hour. Resident 148, BIMS 15/15, stated the response time was 15 minutes to one hour. Resident 51, BIMS 15/15, stated that usually the response time was 15 minutes but occasionally no one ever came and on weekends no one responded. Resident 52, BIMS 15/15, stated that the usual wait time was one hour. Resident 4, BIMS 13/15, stated through an ASL (American Sign Language) interpreter that the wait time was 15 minutes to one-half hour. Resident 76, BIMS, 15/15 stated that she sometimes had waited up to an hour for a response to the call light. During an interview on 5/20/19, at 4:43 p.m., alert and oriented Resident 97 laid in bed, with a bandage on his head, after a fall on 5/18/19, in which he suffered a compression fracture on his lower back. The facility had assigned one-to-one staff with Resident 97 after the fall. Resident 97 stated he had a lot of pain when staff repositioned him. When asked whether staff had been prompt at answering call bells, Resident 97 stated they took more time at night, when he felt he needed a pain pill. Resident 97 stated it may take a long time to show up and then a long time to return with the pain pill, up to several hours. Review of Resident 97's MDS indicated no BIMS score. During an interview on 5/23/19, at 12:03 p.m., Resident 16, BIMS 15/15, stated he had waited up to two hours for staff's response to his call light. Resident 16 had left above knee amputation, with a prosthetic that could be attached. Resident 16 stated he tried to do as much as possible for himself, but needed assistance with getting a blanket, picking up his leg, or assistance changing his briefs. Resident 16 stated 50% of the time staff responded promptly within five minutes, 25% of the time within 20 minutes, and about 25% of the time it took longer. Resident 16 stated a lot of the time, staff would turn off the call light, without asking what he needed and say they would return. Resident 16 stated sometimes they did, sometimes they did not come back. During an interview on 5/23/19 at 9:30 a.m., the Director of Staff Development stated that the expectation was that call lights be answered within 5 minutes.

Based on observation, interview, and record review, the facility failed to consistently accommodate resident's preferences, deliver meals timely, and ensure all residents had access to information about the daily menu, substitutions, and alternate meal choices. This failure resulted in residents feeling their preferences were not consistently observed, meals were often late, and one resident (Resident 16) and their family were unaware of alternate choices. Not honoring the food preferences had the potential to result in reduced intake. Reduced intake had the potential to result in less than optimum physical well-being for the resident. Findings: During an initial tour observation, on 5/19/19, between 9:35 a.m. and noon, a bulletin board in Hallway 3 had posted list of alternatives residents could order. Hallway 3 had no resident rooms, but had entrances to a therapy room and kitchen. Review of requested meal times, provided by the kitchen, indicated early trays (for diabetics) were served at: Breakfast at 7:20 a.m. Lunch at 12:05 p.m. Dinner at 5:20 p.m. Meals at the Fireside dining, were served at: Breakfast at 7:30 a.m. Lunch at 12:25 p.m. Dinner at 5:40 p.m. The document indicated Hallway 2 residents, eating in their rooms, were served last: Breakfast 8 a.m. Lunch 1:05 p.m. Dinner 6:10 p.m. During an interview on 5/19/19 at 11 a.m., alert and oriented Resident 51 stated that she was allergic to papaya but got papaya on her tray which she did not eat. A review of Resident 51's cognitive score, indicated a BIMS (Brief Interview for Mental Status) of 15 out of 15, which indicated Resident 51 was cognitively intact. A review on 5/21/19, of resident 51's allergies, indicated an allergy to papaya. During an interview on 5/19/19 at 12:30 p.m., alert and oriented Resident 76 stated that she did not want eggs on her tray or any pork product but was getting both. A concurrent review of the white diet paper on Resident 76's tray indicated that Resident 76 disliked pork and eggs. A review of Resident 76's cognitive score, indicated Resident 76 had a 15 out of a possible 15. During a dining observation, on 5/19/19 at 12:35 p.m., staff had not served lunch yet at the Fireside dining room. Residents 67, 91, and 86 sat together at a table and stated meals were typically late, Dinner worse. Residents 67, 91, and 86 stated dinner was supposed to be at 5 p.m., but came at 6 p.m. At 12:40 p.m., the first trays were delivered to the Fireside dining room. During dining observations and interviews, on 5/19/19, between noon and 1:15 p.m., when asked whether residents knew where alternatives were listed and whether their preferences were honored, Sampled Resident 91 stated residents could ask the receptionist if they did not know what the daily menu and alternatives were, but that orders for alternatives had to be made 2-3 hours prior to the meal. Resident 91 complained that the facility sometimes ran out of items needed for alternatives, saying he had recently ordered a cheese burger, but had been told by staff at mealtime, the kitchen had no cheese for the burger. Resident 5 stated she thought the facility did not order in advance for continuity, but rather waited until food items were out before re-ordering, so they did not have them available when they should. Resident 94's family member, stated she visited daily. Sampled Resident 94's family member stated Resident 94 did not eat pork, but had been served ham or bacon. Resident 94's family member stated she thought kitchen staff did not always recognize pork in all its incarnations, like bacon and ham, or that sausage may also be pork. Residents 67, 86, and 91 stated white meat, like pork and chicken, tended to be dry, some meats were very salty, and they tried to avoid salty foods because of medical conditions. During an interview on 5/20/19, at 04:02 p.m., Resident 86 stated chicken had not always been dry, prior to 12/2018, chicken had not been so tough. Resident 86 stated scrambled eggs were bad, and that she needed to fill out a new preference list. Resident 86 stated she thought the facility needed to substitute some real fruit in with canned fruit cocktail, and complained the kitchen put too much mayonnaise on some sandwiches. Resident 86 stated she now asked for items without mayonnaise, so she could apply herself. During an interview on 05/20/19, at 02:57 PM, Dietician stated she had heard about kitchen staff serving residents sausage, who had 'no pork' preferences. A review of the Dieticians monthly quality reports, indicated increased complaints of preferences not consistently honored, and meals served late to residents, since November 2018. The previous Dietary Manager had provided monthly in-services to staff. During an interview on 5/20/19, at 5:04 p.m., Sampled Resident 97 stated he did not like the food because it had no flavor, and his oatmeal was served cold in the mornings. When asked if he had complained, Resident 97 stated he had, but there had been no change. During dinner dining observation on 5/20/19, at 5:25 p.m., 21 residents and four staff waited in the Fireside dining room for dinner to appear. The first tray arrived to the Fireside dining room, with french dip sandwich, tater tots, tossed salad, dressing of choice, ketchup, and ice cream sundae, per menu. The french dip sandwiches had a slice of processed meat between dry soft buns. There was no dipping sauce, and residents received only one package of ketchup. Resident 81 asked staff for something else, saying he couldn't chew the sandwich. Sampled Resident 78 stated food was good tonight, but the other day it was not okay. At 6:07 p.m., staff served Sampled Resident 50, in Hallway 2, and his roommate their dinner. Resident 50 stated the meal was late, usually arriving at 5:30 p.m. At 6:22 p.m., Resident 5 ate all but her salad, and stated they didn't bring extra dressing as requested. During an interview on 5/21/19 at 10:30 a.m., alert and oriented Resident 23 stated she was allergic to bananas but got one every morning on her breakfast tray. A review of Resident 23's cognitive score, indicated a BIMS (Brief Interview for Mental Status) of 15 out of 15, and a review, on 5/21/19, of resident 23's allergies indicated an allergy to bananas. During a tray line observation on 5/21/19, between noon and 1:28, the earliest cart and one low trolley cart left the kitchen at 12:40 p.m. The last cart to Hallway 4 left the kitchen at 1:08 p.m., and staff served the last tray in Hallway 3 (Station 2) at 1:28 p.m. Trays were 15 minutes late. During a test tray testing at 1:28 p.m., the turkey tasted salty. During a confidential resident meeting on 5/21/19, at 03:38 PM, 3 of 10 alert and oriented residents stated food preferences were not being met, meals were late, food was salty, and the menu was inaccurate. During an interview on 5/23/19 at 11:00 a.m., the Dietary Manager stated that the facility staff should pay attention to resident allergies and honor resident preferences. During an interview on 5/23/19 at 12:11 p.m., when asked about food, Sampled Resident 16 stated food was pretty abominable. Resident 16's family member stated he visited daily, and it took him two weeks to get Resident 16 on the right diet (Regular diet, regular texture), after Resident 16's re-admission to long-term care on 4/8/19. Resident 16's family member stated staff served Resident 16 someone else's pureed meal, despite Resident 16's family member complaining directly to kitchen staff. Neither Resident 16 or his family member knew where menus were posted, or that alternatives could be ordered. At 12:45 p.m. staff served lunch to Resident 16 at his bedside. The meal was breaded pork chop, cauliflower, and rice with carrots. The pork chop looked hard and dry. When Resident 16 cut into it and tried a bite, he had difficulty eating and swallowing it. Resident 16 had his family member try a bite. Resident 16's family member came out into the hall and stated the pork was pretty dry, and went in search of water. A resident walked by and stated she tended to avoid pork every time it was on the menu, and ordered an alternative, because it was so dry. Concurrent review of Resident 16's diet, indicated he had been admitted with a regular diet, not pureed. Resident 16 and his family member denied receiving a tour in which posted meal times and alternates were pointed out. Review of the facility's admission Packet did not indicate meal times, or alternatives.

Based on observation, interview and record review, the facility failed to sanitize multi-use glucometer (A device is used for testing the blood sugar) between uses for two of four sampled Residents. This failure had the potential to spread blood-borne infection between residents. Findings: During an observation on 05/21/19 at 7:19 a.m., in Room XA, Licensed Nurse C washed her hands and donned gloves, but did not clean the glucometer prior to performing a blood sugar test on the resident. During an observation on 05/21/19 at 7:22 a.m., in Room YB, Licensed Nurse C did not clean the glucometer prior to performing a blood sugar test on the resident. During an observation on 05/21/19 at 7:27 a.m., Licensed Nurse C wiped the glucometer with a Clorox bleach germicidal wipe. During an interview with Licensed Nurse C on 5/22/19 at 10:55 a.m., when asked what the expectation would be after using the glucometer with each resident, she stated the protocol would be, We clean with bleach, let it dry 3-5 minutes. During review of the facility policy titled, Blood Glucose Sampling-Capillary Blood Sampling Devices, dated 1/2014, indicated, General Guidelines: Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses. During review of the package insert for [manufacturer name] Caring for the Meter, dated 5/23/19, Item 4. Indicated, To disinfect your meter, clean the meter surface with one of the following disinfecting wipes: Clorox Healthcare Bleach Germicidal and Disinfectant Wipes (EPA Registration Number 67619-12).

Based on interview and record review, the facility failed to provide the local Ombudsman with notices of patient discharges prior to the discharge, and provide residents with information for appeal and support upon discharge. This failure potentially resulted in lack of adequate resident advocacy upon discharge. Findings: During an interview on 5/23/19, at 10:29 a.m., Social Services Director, (SSD), stated the facility had recently hired her, after the previous SSD had retired. When asked what the facility's policy was regarding notifying the Ombudsman of discharges, SSD stated she did not know what the facility policy was and did not know where to access facility policies. SSD stated she created a report on the first of each month, listing the previous months discharges, and provided the Ombudsman office with a copy. During a phone interview on 5/23/19, at 10:57 a.m., the Ombudsman stated she did not know if discharged residents were getting notified of outside resources, including appeal contacts, and the ombudsman contact number. Ombudsman stated she had not been receiving any forms from the facility, in advance of discharges, I consider them out of compliance. Review of Skilled Nursing Facility (SNF): Transfer/Discharge/Eviction Regulation, dated 12/2017, distributed from the county's Ombudsman program, indicated that if a resident is notified of a facility-initiated transfer or discharge, AB 940 required the facility to send a copy of the notice to the local Ombudsman at the same time notice was provided to the resident or their representative. The document defined a facility-initiated transfer as a transfer of discharge initiated by the facility and not the resident, whether or not the resident agreed to the facility's decision. (Health and Safety Code 1439.6(d)). The facility's policy, Transfer and Discharge Notice,10/2017, indicated the facility provided a resident, or their representative, with a 30-day written notice of an impending transfer or discharge, and that a copy of the notice would be sent to the Office of the State Long-Term Care Ombudsman. The document did not specify resident transfers or discharge as facility-initiated.

Based on observation, interview and record review, the facility failed to schedule p.m. (afternoon) cooks on Friday, 5/10/19, and Sunday 5/12/19. This failure resulted in insufficient staff to accommodate residents needs, and fulfill menu requirements. Findings: During an initial kitchen observation on Sunday, 5/19/19 at 9:35 a.m., there were one cook, and two dietary aides. When questioned, [NAME] F stated he had been recently hired, and no managers were scheduled on weekends. During an interview on 5/20/19 at 2:48 p.m., alert and oriented Resident 52 stated that on Friday, (5/10/19), and Mother's Day (5/12/19), the facility served cold white pieces of bread and two slices super salty ham, packet mayo, and no vegetables, for dinner. Resident 52 stated he later learned the facility had not scheduled cooks during those times. An interview with the Dietary Manager, on 5/20/19 at 2:57 p.m., confirmed his first day to work was Mother's Day, 5/12/19, and no cook had been scheduled, so a dietary aide made sandwiches. A concurrent interview with the Registered Dietician stated the kitchen had recently lost a longtime cook, hired a new Dietary Manager, and gone through some upheaval. Registered Dietician stated her duties included more oversight during times when the facility had no Dietary Manager. During a dinner observation, and concurrent interviews, on 5/20/19 at 4:02 p.m., alert and oriented Resident 86 verified that staff served residents ham sandwiches and some mixed (packaged) tropical fruit for a couple of meals. Resident 86 stated she had heard cooks had not been scheduled (for the afternoon shift). Alert and oriented Resident 67 and Sampled Resident 91 also confirmed being served salty ham sandwiches on Mother's Day, and another evening as well. During a kitchen observation and concurrent interview on 5/21/19 at 10:35 a.m., [NAME] E stated he worked afternoon shifts, but had not worked the Mother's Day weekend, and [NAME] F had been recently hired for mornings. [NAME] E stated the facility had two cook positions, one recently filled by [NAME] F, and another in process. Review of a job description for Food Service Aide, indicated the aide could assist the Dietary Manager and [NAME] in preparation and service of food, but could not cook items. The facility's job description, Dietary Services Manager, indicated the Dietary Manager ensured staffing were sufficient and qualified. The job description also indicated when a qualified Dietary Manager was unavailable, a qualified Registered Dietician filled the role.

Based on interview and record review, the facility failed to: 1. Substitute two dinners with nutritionally equivalent substitutions, and document the substitution, resulting in insufficient information necessary for the Dietician to accurately assess each resident's dietary intakes, and potential weight loss due to palatability. 2. Consistently follow it's posted menu, resulting in confusion about what meals to expect, or whether they had been served in accordance with resident's preferences and nutritional needs. Findings: 1. During an interview on 5/20/19 at 2:48 p.m., alert and oriented Resident 52 stated that on Mother's Day (5/12), the facility served cold white pieces of bread and two slices super salty ham, packet mayo, and no vegetables, for dinner. Resident 52 stated it happened twice, Friday (5/10) and Sunday night (5/12), and residents found out later there had been no cook. An interview with the Dietary Manager, on 5/20/19 at 2:57 p.m, confirmed his first day to work was Mother's Day, 5/12/19, and no cook had been scheduled, so a dietary aide made sandwiches. Dietary Manager did not know whether there had been no cook on Friday, 5/10/19. The dietary aide was unavailable for interview, so it was uncertain what residents on a pureed diet had received. A review of the kitchen's Meal Substitution Log, dated 1/11/19 to 5/19/19, initialed by the Dietician, indicated no substitutions had been documented for May, prior to 5/19/19, indicating the log was inaccurate. Review of the menu posted for Mother's Day weekend, Week 2, indicated the kitchen should have prepared crab cakes, remoulade sauce, baked potato wedges, club spinach, wheat bread, margarine, and tropical fruit for dinner, on 5/12/19. The menu indicated the kitchen should have prepared grilled fish, tartar sauce, rosemary red potatoes, buttered beets, wheat roll, margarine, and pear slices on Friday, 5/10/19. 2. During an initial observation, on 5/19/19, between noon and 1:45 p.m., 24 residents sat at tables of four, awaiting dinner in the independent dining room, called the Fireside room. A menu posted in the facility's Fireside dining room was above reach of wheelchair-bound residents (approximately six feet off floor), printed in small print that was not readily legible from a distance of one foot, and had been posted in a far corner of the room, away from main residential traffic. The posted menu, Spring/Summer 2019: Week 2, dated Monday, 8, to Sunday, 14, indicated Sunday's menu was fried chicken, onion roasted potatoes, parslied cauliflower, wheat roll, margarine, and frosted cake. A posted menu in Hallway 3, next to the therapy room, also in small print and not readily legible to wheelchair-bound residents, Spring/Summer 2019: Week 3, dated Monday 15 through Sunday 21, indicated Sunday's menu was sugar glazed ham, baked beans, broccoli, wheat roll, margarine, and German chocolate cake. A whiteboard, posted by the Assisted Dining Room, indicated Glazed Ham, baked beans, and broccoli were for dinner. Neither of the printed, posted menus had the month printed on them, or dates that correlated with the month of May. At 12:40 p.m., staff served lunch to residents in the Fireside dining room. Lunch was Corned beef, baked beans, broccoli, and chocolate cake with white frosting. During concurrent interviews on 5/19/19, between noon and 1:45 p.m., when asked whether they knew in advance what the daily scheduled meal was, 13 of 16 residents denied knowing what the daily menu was. Three alert and oriented residents (Resident 67, 91, & 86) sat next to the posted menu, and stated, I don't think anyone can read it. They then stated they could ask the facility's receptionist what the menu was, but it was frequently inaccurate. Sampled Resident 91 stated alternatives had to be requested 2-3 hours prior to lunch, but if a resident expected the menu choice to be what was posted, and then the kitchen delivered something else at mealtime, it was too late to order an alternative of choice. Resident 91 stated that even when he had requested an alternative, he would not be told they were out of that item, until lunch had been served. Resident 86 stated food often tasted salty. Resident 67 and Resident 91 both stated they were on No-Added-Salt diets, and although the facility did not serve extra salt, food tasted salty. Resident 91 stated the facility served a gravy that tasted especially salty. Four alert and oriented residents sitting together at a table, (Resident 95, 75, 29, & 14) denied ever knowing what lunch was until it arrived. Resident 75 stated, They don't post a menu. I don't know how we're supposed to know. At 12:40 p.m. staff served lunch to the table, Resident 75 turned to Resident 25 and said beans again. When asked whether the facility had been serving alot of beans, Resident 75 stated this was the third or fourth day that beans had been served, and that the facility served beans and broccoli alot. A concurrent review of the posted menus did not indicate either beans or broccoli had been listed previous days. Resident 55, sitting in at an adjacent table, stated the facility did serve baked beans frequently, and that he never knew what the meal was going to be, until staff served it. Resident 16 and Resident 89 stated the facility served beans alot. Resident 50 stated food was alright, alot of broccoli and beans, and always a surprise what staff would serve. Resident 20 stated the facility served baked beans alot, and the vegetable of choice seemed frequently to be broccoli. Resident 5 stated the facility did serve alot of broccoli, and she ordered alternatives because she did not like alot of pork and beans. At 12:50 p.m., Resident 94's family member, stated she visited daily. Resident 94's family member stated Resident 94 did not eat pork, and she thought the menu indicated glazed ham. When Resident 94's plate arrived, her family member asked staff to return it to the kitchen, thinking ham had been served. Facility staff returned to tell Resident 94's family member the meat was corned beef, not ham. A review of the kitchen's Meal Substitution Log, dated 1/11/19 to 5/19/19, initialed by the Dietician, did not indicate beans and broccoli had been substituted for other named items on the menu. The menu, Week 2, listed seasoned beans on Saturday, (5/18/19), with red cabbage, and pinto beans were listed for Tuesday, (12/14/19). The menu did not indicate broccoli as a vegetable of choice during the week.