**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews , the facility failed to provide a safe, clean, comfortable and homelike environment for the residents on two out of three hallways and one out of two dining rooms. Specifically, the facility failed to: -Ensure there were enough clean linens; and, -Maintain clean floors in the residents' rooms, hallways and main dining room. Findings include: I. Failure to ensure there were enough clean linens A. Facility policy and procedure The Laundry policy, dated October 2025 was provided by the nursing home administrator (NHA) on 6/3/25 at 2:30 p.m. It read in pertinent part, The facility launders linens and clothing in accordance with current CDC (Center for Disease Control and Prevention) guidelines to prevent transmission of pathogens. Laundry will be removed from washers promptly and will not be left in the machines overnight. B. Resident interviews Resident #5 was interviewed on 6/2/25 at 11:49 a.m. She said she did not get a shower last week, because the facility did not have any clean linens. Resident #7 was interviewed on 6/2/25 at 3:17 p.m. She said it seemed like the facility did not have enough linens. She said there had been times when she did not get her bed bath due to not having any linens. Resident #2 was interviewed on 6/3/25 at 9:58 a.m. She said the facility never had enough linens or towels and it has been an ongoing issue. C. Record review The facility census was provided by the NHA on 6/2/25 at 10:41 a.m. The census documented that the facility had a total census of 52 residents. D. Observations On 6/3/25 at 10:32 a.m. the linen storage closet was stocked with three flat sheets, two large washable chucks pads, four hand towels, four pillow cases, twelve wash cloths, a small shelf of regular towels, five blankets and zero fitted sheets. On 6/3/25 at 10:46 a.m. the washer and dryers in the laundry room were running. There were no clean linens being folded or stored anywhere in the room. C. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 6/3/25 at 10:32 a.m. She said the facility did not have enough linens. She said she noticed the lack of linens when the facility was purchased by a new company. She said there were never any linens after Friday. She said that staff always tried to give the residents their showers even when there were not any towels. She said they would have to get creative and would use the hospital blankets and regular blankets. Laundry aide (LA) #1 was interviewed on 6/3/25 at 10:46 a.m. She said she was not sure if the facility was low on linens. She said the facility had ordered blankets and fitted sheets a few months ago. The maintenance supervisor (MS) was interviewed on 6/3/25 at 11:15 a.m. He said he began working at the facility two months ago. He said he recently discovered that there had been stains on the linens and the staff had been throwing the linens away. He said he had not been taught to order linens and was not sure if he would be taking over that duty. He said the NHA was the person who was in charge of ordering the linens. He said the NHA was aware of the situation. He said the NHA had not ordered any more linens, since they discovered the staff was disposing of the stained linens. The director of nursing (DON) was interviewed on 6/3/25 at 12:02 p.m. She said she was not aware that the residents had not been receiving their showers due to the shortage of linens. She said the lack of linens had been an ongoing issue. She said there had been times when she had to go to the laundry room and grab linens so that the floor staff would have enough for their shift. She said the laundry staff needed more education regarding cleaning the linens. She said the laundry staff needed education regarding washing the sheets to see if the stains could be removed prior to disposing of them. The NHA was interviewed on 6/3/25 at 12:15 p.m. She said the facility did not have a shortage of linens. She said there was a lack of awareness of where linens were being held. She said the laundry staff was supposed to stock the linen closets but sometimes they did not stock it enough. She said the floor staff did not go downstairs to get more linens. She said that the laundry room was locked on the weekends and there was a disconnect between the laundry staff and the floor staff. She said the facility had an upcoming meeting with the linen supplier to go over par levels. She said she did not know the current par levels for linens. II. Failure to maintain clean floors in the residents' rooms, hallways and main dining room. A. Observations On 6/2/25 at 11:00 a.m., during the initial walk-through of the facility, the main hallway floors on all the units had wrappers from snacks, wheelchair tracks on the floors, spots where liquids were dropped and then dried and dust in the corners. In room [ROOM NUMBER] there were wheelchair tracks and dried liquid spots were on the floor. In room [ROOM NUMBER] there was black debris that outlined the resident's personal belongings that were placed on the floor. In room [ROOM NUMBER] the floor had dust in the corners and spills that had dried. The dining room had food and beverage spills on the floor and visible wheelchair tracks. B. Staff interviews Housekeeper (HK) #1 was interviewed on 6/3/25 at 11:06 a.m. She said she began working at the facility two months ago. She said there were two housekeepers during the week and one on the weekends. She said the facility hired a new housekeeper that was starting sometime that week. She said there were paper schedules that documented which rooms they were supposed to clean. She said the schedules were where they were supposed to document what they cleaned and if there were any needed repairs. She said they cleaned the dining room, shower rooms, employee and guest bathrooms every day. She said they cleaned the long hall and short hall every other day. The MS was interviewed on 6/3/25 at 11:15 a.m. He said that the residents' rooms and dining room were cleaned every day. He said everything was tracked on paper schedules. He said he was unsure how often the residents' rooms should be deep cleaned. He said he was not sure when the housekeepers cleaned the dining room, but he often saw them there in the mornings. He said he did not know if the housekeepers swept and mopped the dining room after each meal. He said he had three full-time employees. He said Sunday through Tuesday there were two housekeepers. He said on Wednesday there were three housekeepers and Thursday through Saturday there was one employee. He said he did not think that one employee would be able to clean all the residents' rooms, bathrooms, shower rooms and dining room by themselves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to incorporate the recommendations from the preadmission screening and resident review (PASRR) level II determination and evaluation report into the assessment, care planning and transition of care for one (#14) of one resident reviewed for PASRR out of 19 sample residents. Specifically, the facility failed to -Take steps to ensure services were provided as recommend in Resident #14's PASRR level II report; and, -Develop and implement a care plan to identify the PASRR level II recommendations for Resident #14. Findings include: I. Facility policy and procedure The Resident Assessment: Coordination with PASRR Program policy, revised 8/2024, was provided by the nursing home administrator (NHA) on 9/19/24 at 3:15 p.m. It read in pertinent part, Recommendations, such as any specialized services, from a PASRR level II determination will be incorporated into the resident's assessment, care planning, and transitions of care. II. Resident #14 A. Resident status Resident #14, age [AGE], was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), diagnoses included, bipolar disorder (mental illness that causes unusual shifts in behavior), post-traumatic stress disorder (PTSD), alcohol abuse, nicotine dependence, stimulant use, cerebral infarction due to occlusion or stenosis of small artery (stroke), dementia, stage three kidney disease and intervertebral disc disorders with myelopathy (spinal cord injury when the spinal cord was compressed). The 8/5/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 12 out of 15. He required partial assistance with toileting and dressing. He required complete assistance for showering and set up assistance for eating, oral hygiene and personal hygiene. B. Record review Resident #14 PASRR level II, dated 7/24/24, revealed the resident had a PASRR condition and required specialized services. The specialized services required were case management, psychiatric case consultation and individual therapy. -A review of the comprehensive care plan, dated 9/19/24, revealed there was no documentation regarding the resident's PASRR level II screening and specialized service recommendations for mental illness. A social services assessment was completed on 7/25/24. -The psychological and psychiatric section of the assessment revealed there was no documentation of a psychiatric diagnosis. However, the resident had a diagnosis of bipolar disorder and PTSD. -A review of the electronic medical record (EMR) from 7/25/24 to 9/19/24 did not reveal documentation that indicated the resident was receiving case management, psychiatric case consultation or individual therapy as recommended on the 7/24/24 PASRR level II determination. C. Staff interview The regional clinical resource (RCR) and the NHA were interviewed together on 9/19/24 at 12:12 p.m. The RCR said a care assessment was completed within 21 days from the residents admission date. The RCR said if the resident was already determined to have a level II assessment based on the level I assessment, the facility would follow the plan. The RCR said the facility identified residents with newly evident or possible mental disorder, intellectual disease or related disease during the monthly psych pharm meeting. The RCR said the DON and the social services director (SSD) collaborated together during the psych pharmacological meeting. The RCR said the SSD was responsible for making the referral to the appropriate authority based on the level II determination. The NHA said the SSD was unavailable during the survey period. The RCR said the facility followed the recommendations from the PASRR level II determination. She said the SSD documented the recommendations in the social services assessment and in the resident's comprehensive care plan. The RCR said the recommendations from Resident #14's level II PASRR were not included in the social services assessment that was completed on 7/25/24. The RCR said the level II PASRR recommendations were not included on the resident's care plan until 9/19/24 (during the survey). The NHA said the facility worked with an independent psychiatrist to provide the recommendations in the PASRR level II determination. The NHA said she was unsure why Resident #14's level II PASRR recommendations were not implemented. The RCR said the appointment was scheduled on 7/30/24. The RCR said there was no documentation indicating the resident attended the appointment on 7/30/24. The RCR said a new appointment was scheduled and the earliest available appointment was for 10/3/24. The RCR said it was important to ensure the PASRR level II recommendations were included in the resident's comprehensive care plan because it helped manage the resident's behavior and assist the resident in the best way possible.

Based on observations and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure the laundry room was free from environmental concerns. Findings include: I. Observations On 9/18/24 at 4:48 p.m. the laundry area was observed. There were multiple clean resident hoyer slings hanging in the dirty laundry room with their straps touching the ground. The hoyer slings were also hanging next to a mop bucket with the outermost sling touching the bucket. The ceiling above the washing machines had been damaged with peeling paint above where clean laundry would be removed from the machines. On the floor next to the slings were clean, folded blankets that had been partially bagged in black trash bags. The door between the clean and dirty laundry rooms was unable to be closed due to a shift in the door frame. II. Staff interviews The regional clinical resource (RCR) was interviewed on 9/19/24 at 11:31 a.m. The RCR said there had been a recent leak in the laundry room and there should be repairs made to the ceiling. The director of housekeeping (DH) was interviewed on 9/19/24 at 12:40 p.m. The DH said the staff members retrieved clean slings from the soiled utility room where they were hung during observation. The DH said he did not know that the placement of the clean slings in the laundry room would cause them to become dirty. The DH said the cleaned, folded blankets would be moved to a clean location. The DH said the facility needed to order a fire door to replace the door between the clean and dirty. The DH said that he was new to the role, as was the maintenance director and they had been playing catch up with needs in the facility.

Based on record review and interviews, the facility failed to provide a response, action and rationale to residents involved in group grievances. Specifically, the facility failed to: -Allow the resident council to meet without a staff member present; -Provide a private space for resident council; and, -Provide a response, action and rationale for food concerns. Findings include: I. Facility policy and procedure The Resident Council Meetings policy, revised June 2024, was provided by the nursing home administrator (NHA) on 9/19/24 at 3:15 p.m. It read in pertinent part, The facility shall act upon concerns and recommendations of the council, make attempts to accommodate recommendations to the extent practicable, and communicate its decision to the council. II. Resident group interview A group interview was conducted on 9/18/24 at 10:07 a.m. with five residents (#11, #14, #17, #31 and #35), who were identified as alert and oriented through facility and assessment. Resident #31 and Resident #11 said the resident council meeting was held in the large dining room. Resident #11 said the door was left open. Resident #11 said staff, visitors and residents came in and out of the room during the meeting. Resident #31 said the facility staff attended the meeting and they were not given an opportunity to talk without staff present at resident council meetings. Resident #31 said the staff listened to their concerns but did not provide an action to resolve their concern. Resident #31 said she was a vegetarian. She said the facility did not provide a lot of vegetarian protein choices for her meals. Resident #31 said she was served a lot of grilled cheeses as her meals. Resident #11 and Resident #17 said there were not a lot of desserts that were appropriate for a diabetic diet. Resident #17 said she had a lot of jello and pudding. Resident #11 said she wanted sugar free pies, cakes and cookies. Resident #17 and Resident #35 agreed with Resident #11. Resident #11, Resident #17, Resident #31 and Resident #35 said the food was overcooked and watery. The residents said they did not feel the facility provided prompt resolutions to their concerns. III. Resident council notes The July 2024 resident council meeting notes were requested. A resident council concern form was provided. It revealed residents wanted more food varieties and consistency. The staff response section revealed the dietary manager (DM) would attend the resident council meetings. -The recommendation and solution section was left blank. The resident council approval date section was left blank. -There was no documentation indicating the residents were offered the opportunity to meet without staff present. The 8/7/24 resident council meeting notes revealed the residents said the food was awful, there was too much seasoning and the soup was watery. It also documented the residents requested more diabetic dessert options and would like sugar free hot chocolate. The response for more diabetic desserts indicated the (DM) would look into adding more diabetic desserts to the menu. The DM said there was sugar free hot chocolate, but the residents had to ask for the sugar free hot chocolate. The DM said they would speak to the cooks and come up with suggestions on how to improve the food. The dietary response for the watery soup was the residents would tell the DM when they received watery soup so she could see who was cooking and educate the cook. -However, there was no documentation indicating the residents approved the food concerns brought up in the 8/7/24 resident council meeting. - There was no documentation the residents were offered the opportunity to meet without staff present. Resident council notes from 9/4/24 revealed residents said there was too much pepper in the food, soup was water, roasts too tough, wanted more fresh fruit and sugar free ice cream. The recommendation section said the dietary manager was notified. The staff response section said the DM would talk to staff about less pepper. The DM said the soup was not too watery because it was soup and not a stew. The DM said she would see if fresh fruit could fit in the budget, would look into sugar free ice cream and residents could buy their own food and keep the food at the nurse's station refrigerator and freezer. -However, there was no documentation residents approved the 8/7/24 food concern. -There was no documentation residents were offered the opportunity to meet without staff present. V. Staff interviews The activities director (AD) was interviewed on 9/19/24 at 11:29 a.m. The AD said she had been in her position for approximately three months. She said the NHA and the clinical resource consultant (CRC) helped her coordinate the resident council meeting. The AD said the resident council agenda started with the residents talking about dietary comments, concerns or suggestions. She said the meeting continued with a topic such as what was resident council, then she asked for general comments, concerns or suggestions. She said the topic was provided by the NHA and the last resident council topic was the purpose of resident council. The AD said the resident council meeting was held in the dining room and the dining room doors are left open. The AD said she did not ask if the residents wanted to meet without staff present. She said when a resident brought a concern up during resident council meeting she told the department head and asked what the timeline was to resolve the concern. The AD said she went over the department's response in the next resident council meeting. The AD said she did not ask the resident council if they approved the response. The AD said the food concerns were not resolved. The AD said there was no documentation indicating the resident council approved the food concern responses. The DM was interviewed on 9/18/24 at 12:14 p.m. The DM said she e was aware of the concerns residents brought up at the recent resident council meeting. The DM said the resident council did not approve the responses she provided to their concerns. The DM said she would follow up with the residents to come up with a solution. The NHA was interviewed on 9/19/24 at 11:57 a.m. The NHA said the AD was responsible to coordinate the resident council meeting. He said the agenda consisted of covering a topic, such as what was resident council. He said the residents were given an opportunity to voice their concerns. He said resident council were offered to meet without staff present and the dining room door should be closed. The NHA did not know the AD did not provide the residents the opportunity to meet without staff present and the door was not closed. He said the resident council concerns were reviewed in the morning meeting the day after resident council was held. He said the department head had five days to resolve the concern. The NHA said the AD went to the resident council's president to ensure the resolution was approved. The NHA said he did not know the AD did not go over the concerns with the president. The NHA said he reviewed the 7/3/24 resident council concern form. The NHA said the form should have been completed to ensure the resident council approved the residents concerns. The NHA said he reviewed the 8/7/24 resident council minutes. The NHA said there was no documentation the residents were offered to meet without staff present and the resident council approved the staff response to the residents concerns. The NHA said he reviewed the 9/4/24 resident council minutes. The NHA said there was no documentation the residents were offered to meet without staff present and the resident council approved the staff response to the residents' concerns. The NHA said he would work with the AD to ensure the residents were offered the opportunity to meet without staff present and to ensure the dining room door is closed during the resident council. The NHA said he would work with the AD to ensure the resident council approved the staff response to the residents' concerns.

Based on record review and interviews, the facility failed to provide ongoing communication to residents about their rights; and failed to inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. Specifically, the facility failed to provide ongoing communication and discussion to the resident's about their rights and responsibilities. Findings include: I. Facility policy and procedure The Resident Rights policy, revised August 2024, was provided by the nursing home administrator (NHA) on 9/19/24 at 3:15 p.m. It read in pertinent part, Information about resident rights and responsibilities will be given to the resident both orally and in writing. II. Resident group interview A group interview was conducted on 9/18/24 at 10:07 a.m. with five residents (#11, #14, #17, #31, and #35), who were identified as alert and oriented through facility and assessment. Resident #11, Resident #17, Resident #31 and Resident #35 said the facility did not provide ongoing discussion to review and explain their resident rights and responsibilities. The residents who attended the group meeting said they did know their rights as residents. The residents said they did not know the resident rights were posted on a wall in the facility. The rights were posted on the wall on the left side of the doors to the dining room. The residents said they wanted to know what their rights were so they could ensure the facility honored their rights. III. Record review The resident council monthly minutes from July 2024 through September 2024 were provided by the activities director (AD) on 9/18/24. The minutes revealed there was no documentation indicated the rights of residents were discussed and reviewed. IV. Staff interviews The AD was interviewed on 9/19/24 at 11:29 a.m The AD said she did know when resident rights were reviewed with residents. The AD said she assisted in running the resident council meetings monthly. She said the resident rights were not reviewed during resident council. The NHA was interviewed on 9/19/24 at 11:57 a.m. The NHA said the resident rights were reviewed verbally and in writing with the resident and the family at admission. He said there was a big poster on the wall next to the dining room. He said resident rights were not discussed at the resident council. The NHA said he would work with the AD to ensure rights were reviewed on an ongoing basis and documented in the resident council minutes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews the facility failed to provide a prompt effort to resolve grievances for one (#28) and the resident group out of 19 sample residents. Specifically, the facility failed to: -Follow through on grievances for lost/stolen items for and #28; and, -Ensure the residents had information on how to file a grievance. Findings include: I. Facility policy and procedure The Resident and Family Grievances policy and procedure, dated January 2023, was provided by the regional clinical resource (RCR) on 9/19/24 at 4:00 p.m. It read in pertinent part, It is the policy of this facility to support each resident's and family member's right to voice grievances with prompt effort to resolve. Information on how to file a grievance or complaint will be available to the resident. The Resident Personal Belongings policy and procedure, dated April 2022, was provided by the regional clinical resource (RCR) on 9/19/24 at 4:00 p.m. It read in pertinent part, It is the policy of this facility to protect the resident's right to possess personal belongings. All resident personal items will be inventoried at the time of admission. Additional possessions brought into the facility shall be added to the existing personal belongings inventory listing. The facility will exercise reasonable care for the protection of the resident's property from loss or theft. II. Failure to address Resident #28's grievances A. Resident #28 1. Resident status Resident #28, age greater than 65, was admitted on [DATE]. According to the September 2024 computerized physician orders (CPO), diagnoses included epileptic seizures and major depressive disorder. The 6/6/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. 2. Resident interview Resident #28 interviewed on 9/16/24 at 11:00 a.m. Resident #28 said he had a local sports team sweatshirt stolen out of his closet. Resident #28 said he also had a cotton towel stolen from off of his bed. Resident #28 said he had cash stolen from his room twice totaling $100.00. Resident #28 said many of his shirts go out to the laundry and do not come back. Resident #28 said he had filed many grievances without resolution. 3. Record Review The resident personal belongings inventory, dated May 2024, was provided by the nursing home administrator (NHA) on 9/18/24 at 9:00 a.m. It indicated the resident had eyeglasses, upper and lower dentures, chase debit card, one pair of gloves, one hat, five sweatpants, seven shirts, one pair white sneakers, eight pairs of socks, seven jackets/flannels, three shorts, one suitcase, one wooden box, one blanket, one dodge caravan, one fossil kit, one broken laptop and one model car. The September 2024 resident council meeting notes dated 9/4/24 provided by regional clinical resource (RCR) on 9/18/24 at 9:00 a.m. The notes revealed Resident #28 had reported on 9/4/24 during the resident council meeting that he had some clothing that had been stolen from his room. The notes documented social services notified. Grievances related to missing/stolen items for Resident #28 were requested on 9/17/24 for Resident #28. The facility did not provide documentation indicating they had attempted to resolve the resident's concern regarding missing clothing (see interview below). B. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 9/18/24 at 3:33 p.m. CNA #1 said if a resident reported missing items she would look in the trash can, dirty laundry and linen. CNA #1 said she would fill out a grievance form for social services. CNA #2 was interviewed on 9/18/24 at 3:35 p.m. CNA #2 said if property was reported missing or stolen she would notify the nurse and administration. The RCR interviewed on 9/19/24 at 12:54 p.m. The RCR was covering for the DON who was on vacation at the time of the survey. The RCR said she did not believe that any items had been missing or stolen from Resident #28. The RCR said we could not show he ever had the items. The RCR said the facility could not show the items went missing either. The RCR said Resident #28 had a current increase in external stressors and had become fixated on items. III. Failure to ensure residents had information on how to file a grievance A. Resident group interview A group interview was conducted on 9/18/24 at 10:07 a.m. with five residents (#11, #14, #17, #31 and #35), who were identified as alert and oriented through facility and assessment. Resident #11, Resident #17, Resident #31 and Resident #35 said they did not know how to file a grievance. After the group interview, Resident #17 and Resident #31 saw where the grievance form and grievance policy were located. Both residents said they did not know the grievance forms were in front of the social services office. Resident #31 said the grievance policy's font was too small to read. B. Observations On 9/16/24 at 8:30 a.m. an observation was conducted throughout the facility. There was a grievance policy located on the wall between the NHA's office and the social services office. The policy was in four frames sized eight and a half by 11 inches. The font size was approximately 10 to 12. The policy was displayed vertically from the ceiling to the middle of the wall, approximately at eye level for someone in a wheelchair. There was a wire mesh wall file on the left side wall of the social services office. There were grievance forms in the wall file. There were no signs around the wall file to say what the papers in the wall file were for. On 9/19/24 at 11:00 a.m. a sign was posted above the grievance forms to the left of the social services office on how to file a grievance form. C. Staff interviews The NHA was interviewed on 9/18/24 at 9:54 a.m. The NHA said there was not a sign next to the grievance forms (see observations above). The NHA was interviewed again on 9/19/24 at 11:57 a.m. The NHA said the social services director (SSD) was for managing grievances. The NHA said the SSD was unavailable to interview due to illness during the survey period. He said there should have been a sign next to the grievance form to indicate the mesh file held grievance forms. He was not aware the residents said the policy posted was too small to read. The NHA said he would fix it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews the facility failed to assist residents in obtaining routine or emergency dental services, as needed for three (#10, #11 and #17) of five residents reviewed for dental services out of 19 sample residents reviewed. Specifically, the facility failed to replace Resident #10, Resident #11 and Resident #17's dentures in a timely manner. Findings include: I. Facility policy and procedure The Dental Services policy and procedure, dated August 2024, was provided by regional clinical resource (RCR) on 9/19/24 at 4:00 p.m. It read in pertinent part, For residents with lost or damaged dentures, the facility will refer the resident for dental services within three days. The resident and/or representative shall be kept informed of all arrangements. II. Resident #10 A. Resident status Resident #10, age greater than 65, was admitted on [DATE]. According to the September 2024 computerized physicians order (CPO), diagnoses included dementia and dysphagia (difficulty swallowing). The 7/5/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The MDS assessment indicated the resident had no dental issues or concerns. -However, the resident had missing lower dentures. B. Resident interview Resident #10 was interviewed on 9/16/24 at 11:47 a.m. Resident #10 said her lower set of dentures went missing in February 2024. Resident #10 said she filed a grievance form. Resident #10 said she has not seen a dentist and her dentures had not been replaced. C. Record review A review of Resident #10's comprehensive care plan did not reveal the resident's dental concerns were addressed. A grievance form, dated 2/14/24, was provided by the RCR on 9/18/24 at 9:00 a.m. The grievance form indicated Resident #10 reported her lower dentures were missing on 2/14/24. The grievance said the resident reported the dentures had been missing for one week. The form documented the resident had increased confusion and this may not have been accurate. It indicated the resident was on the list to be seen by a dentist. A request was made for dental visit notes for Resident #10 on 9/17/24. The RCR said the resident had not been seen by the dentist since she submitted a grievance form on 2/14/24 reporting her dentures were missing (see interview below). III. Resident #11 A. Resident status Resident #11, age greater than 65, was admitted on [DATE]. According to the September 2024 CPO, diagnoses included unspecified dementia. The 7/19/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. The MDS assessment indicated the resident had no dental issues or concerns. -However, the resident was missing her lower dentures. B. Resident interview Resident #11 was interviewed on 9/17/24 at 9:42 a.m. Resident #11 said she had upper and lower dentures upon admission. Resident #11 said she no longer had her bottom set of dentures. Resident #11 said she had not seen a dentist and had not had the lower set replaced. Resident #11 said it changed which foods she chose to eat. C. Record review The nutritional care plan, revised 9/11/23, revealed the resident had missing lower dentures and often chose food she could easily chew with only upper dentures. Pertinent interventions included providing the resident with a dental consult. -However, there was no documentation indicating the resident was seen by the dentist to address her missing dentures. A request was made for dental visit notes for Resident #11 on 9/17/24. The facility did not provide documentation indicating the resident had been seen by the dentist. IV. Resident #17 A. Resident status Resident #17, age greater than 65, was admitted on [DATE]. According to the September 2024 CPO, diagnoses included dysphagia. The 8/29/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The MDS assessment indicated the resident had no dental issues or concerns. B. Resident interview Resident #17 was interviewed on 9/17/24 at 10:25 a.m. Resident #17 said that her lower dentures were not fitted correctly. Resident #17 said even after she had glued the dentures in, they popped out during meals. Resident #17 said she had been told by the facility that a dentist would be back to look at the fit. Resident #17 said she had not seen a dentist since October 2023. C. Record review A review of the resident's comprehensive care plan did not reveal information regarding the resident's dental status. A dental note, dated 10/5/23, documented an impression was taken with a custom tray. A request was made for dental follow up notes for Resident #17 on 9/17/24. The facility did not provide documentation indicated the resident had been seen by the dentist for follow up. V. Staff interviews Registered nurse (RN) #2 was interviewed on 9/18/24 at 11:49 a.m. RN #2 said if a resident had missing dentures she reported the missing dentures to the social services department. She said the social services director (SSD) would work with the family and the resident to get the dentures replaced. Certified nurse aide (CNA) #1 was interviewed on 9/18/24 at 3:33 p.m. CNA #1 said she was not aware of any residents that had missing dentures. CNA #1 said if a resident reported missing dentures she would look in the trash can and the linen for the dentures. CNA #1 said she would fill out a grievance form and give it to the social services department if the dentures were not found. CNA #2 was interviewed on 9/18/24 at 3:35 p.m. CNA #2 said some residents refused to wear their dentures, but she was not aware of any missing dentures. CNA #2 said if dentures were reported missing she would notify the nurse and the administration. The RCR was interviewed on 9/18/24 at 4:05 p.m. The RCR said if dentures were reported missing, a search should be conducted through the trash and laundry. The RCR said a report should be made by the staff to the social services department. The RCR said the SSD should have followed up with the residents in a timely manner and scheduled dental appointments as needed. The RCR said a resident should have an appointment set within 30 days. The RCR said the grievance for Resident #10 was overdue for a resolution. The RCR said there should be documented interventions while the dentures were missing to include diet accommodations. The RCR said if dentures had become ill-fitting the nursing staff should inspect the mouth for sores, swelling, a cause for the ill-fit. The RCR said the facility should have followed up timely when the residents reported their dentures were missing. The RCR said the SSD should have followed up with an appointment to get the dentures corrected and documentation indicating the steps that were taken. The RCR was interviewed again on 9/19/24 at 9:53 a.m. The RCR said Resident #10 had received a dental appointment on 7/9/24. -However there was no documentation that indicated the resident had a dental appointment on 7/9/24 (see record review above). The RCR said Resident #10 had a new appointment scheduled for 10/7/24. The RCR said she spoke to Resident #17's daughter regarding the ill-fitting dentures. The RCR said Resident #17 had been taken to multiple dentists and there was not anything further to be done about the lower dentures. The RCR said there should have been documentation with interventions, provider assessment, speech assessment and diet evaluation in the resident's electronic medical record.

Based on interviews, observations, and record review, the facility failed to consistently serve food that was palatable, attractive, and at the appropriate temperature. Specifically, the facility failed to ensure resident food was palatable in taste, texture and appearance. Findings include: I. Facility policy and procedure The Food Preparation Guidelines policy, revised 4/2024, was provided by the nursing home administrator (NHA) on 9/19/24 at 3:15 p.m. It read in pertinent part, Food should be palatable, attractive, and at a safe and appetizing temperatures. II. Resident group interview A group interview was conducted on 9/18/24 at 10:07 a.m. with five (#11, #17, #31, #35 and #14) residents, who were identified as alert and oriented through facility and assessment. Resident #11, #17, #31 and #35 said the food was not palatable. The residents said the food was overcooked and watery. II. Individual resident interviews Resident #5 interviewed on 9/16/24 at 9:40 a.m. Resident #5 said sometimes the food was overcooked causing her to order take-out. Resident #17 was interviewed on 9/17/24 at 10:25 a.m. Resident #17 said the food was not very good. Resident #17 said the food was served overcooked, dry, or very bland. Resident # 17 was interviewed on 9/18/24 at 10:03 a.m. Resident #17 said the facility needed to serve more fresh fruit. He said he did not like the canned fruit, because it was all the same texture. III. Record review The July 2024 resident council meeting notes were requested. A resident council concern form was provided. It revealed residents wanted more food varieties and consistency. The staff response section revealed the dietary manager (DM) would attend the resident council meetings. The 8/7/24 resident council meeting notes revealed the residents said the food was awful, there was too much seasoning and the soup was watery. It also documented the residents requested more diabetic dessert options and would like sugar free hot chocolate. The response for more diabetic desserts indicated the DM would look into adding more diabetic desserts to the menu. The DM said there was sugar free hot chocolate, but the residents had to ask for the sugar free hot chocolate. The DM said they would speak to the cooks and come up with suggestions on how to improve the food. The dietary response for the watery soup was the residents would tell the DM when they received watery soup so she could see who was cooking and educate the cook. Resident council notes from 9/4/24 revealed the residents said there was too much pepper in the food, soup was water, roasts too tough, wanted more fresh fruit and sugar free ice cream. The recommendation section said the DMwas notified. The staff response section said the DM would talk to staff about less pepper. The DM said the soup was not too watery because it was soup and not a stew. The DM said she would see if fresh fruit could fit in the budget, would look into sugar free ice cream and residents could buy their own food and keep the food at the nurse's station refrigerator and freezer. IV. Observations During a continuous observation during the lunch meal on 9/18/24, starting at 12:14 p.m. and ending at 1:32 p.m., the following was observed: The bread rolls were in a medium metal container in the food steamer. The rolls in the bottom of the container were sticking together and were smashed. The rolls did not maintain the shape. The lemon and thyme chicken was in a large metal container in the food steamer. The liquid surrounding the chicken was watery. The almond rice pilaf was in a large metal container. The rice on the edges were dark brown. A test tray for a carbohydrate-controlled diet was evaluated by three surveyors immediately after the last resident had been served their meal for lunch on 9/18/24 at 1:40 p.m The menu was grilled chicken breast with lemon and thyme, almond rice pilaf, sugar snap peas, bread or roll and butter, and spiced peaches. The test tray consisted of grilled chicken breast with lemon and thyme, almond rice pilaf, sugar snap peas, roll and spiced peaches. -The chicken was dry and did not taste like there was lemon or thyme; -The almond rice pilaf was bland and did not taste almondy; -Sweet green peas were served instead of the sugar snap peas; -The roll was squished; and, -The spiced peaches tasted like canned peaches with cinnamon. V. Staff interviews The dietary manager (DM) and the NHA were interviewed together on 8/19/24 at 1:50 p.m. The DM said the grilled chicken breast with lemon and thyme should have tasted like there was lemon thyme. She said the chicken should not have been dry. The DM said the almond rice pilaf should have tasted like there was almond in the rice pilaf. The DM said they did not put almonds in the rice pilaf. She said the rolls should not be squished. She said the peas should have been sugar snap peas like the menu indicated. She said it was important for the food to be palatable to reduce complaints and for the residents to have a well-rounded nutrition. The NHA said d he would work the DM to ensure the food was palatable for the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #17 A. Resident status Resident #17, age greater than 65, was admitted on [DATE]. According to the September 2024 CPO, diagnoses included diabetes mellitus and dysphagia (difficulty swallowing). The 8/29/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. B. Resident interview Resident #17 was interviewed on 9/17/24 at 10:25 a.m. Resident #17 said the facility needed more diabetic desserts than just jello. Resident # 17 was interviewed again on 9/18/24 at 10:03 a.m. Resident #17 said she would prefer to have more fresh fruit options. She said the facility only served canned fruit. IV. Resident #6 A. Resident status Resident #6, age less than 65, was admitted on [DATE]. According to the September 2024 CPO, diagnosis included diabetes mellitus. The 8/29/24 MDS assessment revealed the resident had moderately impaired cognition with a BIMS score of 10 out of 15. B. Resident interview Resident # 6 was interviewed on 9/18/24 at 5:20 p.m. Resident #6 said the facility had not been diabetic friendly. Resident #6 said the majority of the menu was carbohydrate heavy such as pancakes, waffles, potatoes, and corn. Resident # 6 said she had been struggling with her blood glucose levels being in the 500-600 range. Resident # 6 said she believed it was from the hidden additives and sugars in the food, for example canned fruit in syrup. Resident #6 said, even though the can of fruit may have said no added sugar, it is canned fruit, it is still full of sugar. Resident #6 said the only dessert and snack options available for diabetic residents were sugar-free jello, and sugar-free vanilla pudding. C. Record review The August 2024 resident council meeting notes were provided on 9/18/24 at 9:00 a.m. Resident Council Meeting notes dated August 2024 were provided by the regional clinical nurse resource (RCR). The council meeting notes documentedResident #6 requested more diabetic dessert options. The current diabetic dessert options are sugar-free jello and pudding. D. Staff interviews Registered nurse (RN) #2 was interviewed on 9/18/24 at 11:49 a.m. RN #2 said the dietary staff were responsible for stocking the refrigerator at the nurses station with sandwiches, pudding, crackers and cheese and string cheese. RN #2 said the facility had sugar-free jello and sugar-free pudding available for the diabetic residents. Certified nurse aide (CNA) #2 was interviewed on 9/18/24 at 3:35 p.m. CNA #2 said snacks were available in the nurse's station. CNA #2 said the diabetic residents could have sugar-free pudding. The DM was interviewed on 9/19/24 at 1:25 p.m. The DM said the facility would be working towards getting additional diabetic dessert/snack choices other than sugar-free jello and pudding. The DM said the only options the facility currently had to offer the diabetic residents were sugar-free jello and pudding. Based on observations, record review and interviews, the facility failed to provide food that accommodated resident preferences for three (#31, #6, #17) of five residents out of 19 sample residents. Specifically, the facility failed to offer food choices according to resident preferences for Resident #31, #Resident #6 and Resident #17. Findings include: I. Facility policy and procedure The Food Preparation Guidelines policy, revised April 2024, was provided by the nursing home administrator (NHA) on 9/19/24 at 3:15 p.m. It read in pertinent part, Staff shall accommodate resident allergies, intolerances, and preferences, providing appropriate alternatives when needed. Alternatives shall be appealing and of similar nutritive value to the food that is being substituted. Alternatives shall be consistent with the usual and or ordinary food items provided by the facility. Resident preferences and allergies shall be obtained during the resident assessment process and added to the resident dietary tray card. II. Resident #31 A. Resident status Resident #31, age [AGE] , was admitted on [DATE]. According to the computerized physician orders (CPO) diagnoses included dementia, psychotic disturbance (a collection of symptoms that causes a loss of reality), mood disturbance and anxiety. The 8/1/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. The MDS assessment indicated the resident was on a therapeutic diet. B. Resident interview Resident #31 was interviewed on 9/18/24 at 10:07 a.m. She said she was a vegetarian. She said there were not enough vegetarian choices for her lunch and dinner meals. She said she ate a lot of grilled cheese sandwiches. Resident #31 said since there were not enough choices she bought her own meal substitutions. She said it really upset her because no one else had to pay for their own meals. She said being a vegetarian was like being a diabetic and the facility should provide her vegetarian options. C. Observations On 9/18/24 at 1:03 p.m. cook (CK) #1 preparedResident #31's meal. CK #1 served Resident #31 one serving of peas, one serving of mixed vegetables, one serving of mashed potatoes and one roll. CK #1 said he did not have a vegetarian protein option for the resident. Resident #31's meal ticket indicated she was on a vegetarian diet. D. Record review The nutrition care plan, revised 3/20/24, revealed the resident followed a lacto-ovo vegetarian diet (vegetarian diet that includes dairy and eggs) and complained about the limited food choices. Interventions included providing the resident her diet as ordered, honoring food preferences and educating the resident on the variety of menu options available for preferences. The 9/4/24 quarterly dietary assessments revealed the resident was prescribed a vegetarian diet. E. Staff interview The dietary manager (DM) and the NHA were interviewed together on 9/19/24 at 1:50 p.m. The DM said she was responsible for obtaining the resident's preference. She said she reviewed the resident's food preferences at admission, quarterly and as needed. She said she documented the preferences on a paper form kept in her office. The DM said preferences were added to the meal tickets. She said the cooks were aware of the resident's food preferences, because they were documented on the meal ticket. The DM said Resident #31 was vegetarian. She said the facility provided vegetarian protein options such as tofu and meatless chicken patties. The DM said the cook did not provide a vegetarian protein because it was an oversight. She said the facility changed how to order food from their supplier and she was limited in choices for vegetarian proteins. The NHA said he would work with the DM to have more choice for vegetarian proteins.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** IV. Failure to ensure staff performed appropriate hand hygiene and glove usage in the dining room A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part, Single-use gloves shall be used for only one task, such as working with ready-to-eat food, or with raw animal food. Single-use gloves shall be used for no other purpose, and discarded when damaged, when interruptions occur in the operation, or when the task is completed. The Centers for Disease Control and Prevention (CDC) (2024), Clinical Safety: Hand Hygiene for Healthcare Workers, was retrieved on 9/9/24 from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html. It read in pertinent part, Perform hand hygiene before touching a patient, after touching a patient or their surroundings, immediately after glove removal. According to Treas, L.S., [NAME], K.L., & [NAME], M.H. (2022.) Basic Nursing: Thinking, Doing and Caring, (Third edition), pages 1601, 1604-1605, Use standard precautions to prevent the transmission of infection. Implement measures to prevent healthcare-associated infections (HAIs). HAIs are the leading complication of healthcare and one of the ten leading causes of death in the United States. Hand hygiene can remove transient flora (microbes acquired by touching objects or people). B. Observations During a continuous observation on 9/16/24, beginning at 7:50 a.m. and ending at 8:45 a.m., the following was observed in the main dining room: At 8:00 a.m., prior to the meal being served, the floor of the dining room was observed to have food crumbs and various debris on the floor such as straw and food wrappers. At 8:11 a.m. dietary aide (DA) #1 donned (put on) a pair of gloves and assembled resident meal trays as items were passed to him through the kitchen pass. At 8:14 a.m. DA #1 delivered a meal tray to a resident, with the same gloved hands he readjusted her wheelchair touching the handles, then returned to get the next tray. DA #1 delivered the remaining resident meal trays without changing gloves or performing hand hygiene. At 8:23 a.m. with the same gloved hands, DA #1 provided coffee refills to residents without changing gloves or performing hand hygiene. At 8:26 a.m. with the same gloves hands, DA #1 delivered a cart of meal trays to the main hallway without changing gloves or performing hand hygiene. Each resident tray was delivered, then each bowl, dish or cup was removed from the tray and placed in front of the resident with the lids or covers being removed. During a continuous observation on 9/16/24, beginning at 12:25 p.m. and ending at 1:45 p.m., the following was observed in the main dining room. At 12:28 p.m. DA #1 delivered a cart of meal trays to the main hallway wearing the same pair of gloves. At 12:30 p.m. DA #1 returned to the dining room and began to assemble resident meal trays as items were handed to him through the kitchen pass without changing gloves or performing hand hygiene. At 12:33 p.m. Resident #21 came into the dining room requesting ice to be refilled in her personal cup. Without removing his gloves, DA #1 opened the cup touching the mouthpiece, refilled it with ice, secured the lid and handed it back to Resident #21. DA #1 returned to the kitchen pass and resumed assembling meal trays without changing gloves or performing hand hygiene. At 12:36 p.m. DA #1 delivered a cart of resident meal trays to the main hallway with the same gloved hands . At 12:38 p.m. DA #1 returned to the dining room and proceeded to deliver the dining room meals trays with the same gloved hands. At 12:48 p.m. an unidentified CNA providing feeding assistance to a resident got up and walked across the room to provide assistance to another resident with their utensils without performing hand hygiene, then returned to the previous resident and continued feeding assistance without performing hand hygiene. At 1:00 p.m. the same staff member, walked to another resident, provided assistance by changing the position of food dishes and handing the resident a utensil that had been dropped on the table trying to eat from a dish that had been out of reach without performing hand hygiene, then returned to provide feeding assistance to the first resident without performing hand hygiene. During a continuous observation on 9/17/24, beginning at 12:00 p.m. and ending at 1:30 p.m., the following was observed in the main dining roo:. At 12:23 p.m. DA #2 picked up a soiled napkin from the floor, without performing hand hygiene, DA #2 then continued to serve resident's their meals until 12:31 p.m., when DA #2 assisted a resident to refill their personal cup with ice. With the same gloves hands DA #2 opened the cup, touching the mouth piece, filled the cup with ice, then secured the lid without performing hand hygiene. DA #2 then continued to serve residents lunch trays, opened and adjusted their food placement on the table without performing hand hygiene in between residents. C. Staff interviews The regional clinical resource (RCR) was interviewed on 9/19/24 at 11:31 a.m. The RCR said she was covering for the infection preventionist (IP) who was on vacation at the time of the survey. The RCR said that the DAs should be touching only the outer edges of trays, plates and performing hand hygiene in between providing assistance for residents. The RCR said staff should be washing hands in between, residents and touching surfaces. The RCR said if a staff member ws wearing gloves, the gloves should be changed before a residents meal tray for set up and in between tasks that would be considered clean or dirty. Based on observations and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to: -Ensure food was labeled and dated appropriately; -Ensure food stored at least six inches above the floor; -Ensure to ensure the kitchen equipment was clean; and, -Ensure staff completed hand hygiene appropriately in the dining room. Findings include: I. Failed to ensure food was labeled and dated A. Professional reference The Colorado Department of Public Health and Environment (2024) The Colorado Retail Food Establishment Rules and Regulations, was retrieved on 10/1/24 from https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view It read in pertinent part, A date marking system that meets the criteria may include: Using a method approved by the Department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded; marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded or using calendar dates, days of the week, color-coded marks, or other effective marking methods, provided that the marking system is disclosed to the department upon request. B. Observations On 9/16/24 at 8:42 a.m. during the initial kitchen tour, there were three plastic dispensing containers in the main dining room. The containers held three different types of breakfast cereal. The first container was labeled Cheerios and the label indicated the Cheerios were prepared 4/1, and to use by 5/1. The second container contained Raisin Bran, the container did not have a label or a date. The third container was labeled [NAME] Krispies and was labeled 6/7. The [NAME] Krispies label did not indicate if the date was the open date or the use by date. C. Staff interview The dietary manager (DM) was interviewed on 9/16/24 at 8:47 a.m. The DM said the cereal container without a label should have been labeled with what the cereal was, when it was prepared and when it should be discarded. She said the Cheerios and the [NAME] Krispies cereal should have been discarded by the use by date. The DM said when food was removed from the original packaging the food should be labeled with the food name, when the food was opened and when the food should be discarded. II. Failed to ensure food was stored at least six inches above the floor A. Professional reference The Colorado Department of Public Health and Environment (2024) The Colorado Retail Food Establishment Rules and Regulations, was retrieved on 10/1/24 from https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view read in pertinent part, Food shall be protected from contamination by storing the food in a clean, dry location; where it is not exposed to splash, dust, or other contamination and at least 15 centimeters (six inches) above the floor. B. Observations On 9/16/24 at 8:42 a.m. during the initial kitchen tour, there was a large box of individual bags of chips on the middle of the ground in the dry storage. There was a box that contained two large bottles of vinegar on thee ground in the dry storage. There were two boxes of soda on the ground in the dry storage. C. Staff interview The DM was interviewed on 9/16/24 at 8:47 a.m. The DM said the staff knew to keep food six inches off the ground in the panty. She said she would talk to her staff to remove the items from the floor. The DM said the kitchen was small and made it difficult to store food. III. Failed to ensure kitchen equipment was clean A. Professional reference The Colorado Department of Public Health and Environment (2024) The Colorado Retail Food Establishment Rules and Regulations, was retrieved on 10/1/24 from https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view read in pertinent part, Equipment food contact surfaces and utensils shall be clean to sight and touch. B. Observations and interviews On 9/16/24 at 8:42 a.m. during the initial kitchen tour, the commercial mixer was in the corner of a counter in the kitchen and not in use. The mixing device and the mixer attachment was covered with dry, dark brown food. The DM said the mixer was last used to make chocolate cake more than a week ago and the mixer should have been cleaned after use. On 9/18/24 at 1:04 p.m. during lunch meal service, the commercial mixer was in the corner of a counter in the kitchen. The mixer and the mixer attachement was covered with dry, dark brown food. C. Staff interview The DM was interviewed on 9/19/24 at 1:50 p.m. The DM said she did not know the mixer was not cleaned after use. The DM said the mixer should have been cleaned after she identified it was dirty on 9/16/24. She said the mixer should be free from food debris after use and prior to storage.

Based on observation and interviews, the facility failed to provide a clean, safe, homelike environment for the residents in one of four units. Specifically, the facility failed to store medical equipment in a specified area away from the resident's rooms and high traffic areas. Findings include: I. Facility policy and procedures The Homelike Environment policy, revised August 2019, was received from the nursing home administrator (NHA) on 411/23. It read in pertinent part: Residents should be provided with a safe, clean and homelike environment and encouraged to use their personal property to the extent possible. Staff shall provide person centered care emphasizing the residents comfort, independence and personal needs. A homelike environment is clean,sanitary and orderly. Clean bed and bath linens that are in good condition are supplied for the residents. Comfortable and adequate lighting makes maximum use of daylight and night lighting helps to promote safety and independence. II. Observations on unit two On 4/11/23 at 9:59 a.m. there were six hoyer (mechanical) lifts lined up right behind each other down the hall. These lifts were close to the entrance of the residents' rooms which made it cluttered and often difficult for the residents to leave their room and travel up and down the hall. At 10:13 a.m. each of the lifts had a dark brown substance on the wheels. The handles contained a light dusty looking substance. III. Interviews Certified nurse aide (CNA) #2 was interviewed on 4/11/23 at 10:30 a.m. She said the lifts were sometimes stored in the hall outside the therapy room. She said there were no specific areas designated to store medical equipment. She said there was not enough room to put the lifts in the shower rooms. She said the CNA who used the lifts should be the ones to clean them right after use. CNA #2 said they used disinfectant wipes to clean any of the medical equipment. The director of nursing (DON) was interviewed on 4/11/23 at 3:05 p.m. She said the CNAs should clean all medical equipment right after use including the hoyer lifts and sit to stand lifts. She said she would work with the maintenance department to find an appropriate storage place for the lifts. The DON included she would incorporate more training for the staff about cleaning and storage of medical equipment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide necessary assistance with activities of daily living (ADLs) for one (#12) out of 28 sample residents to maintain personal hygiene. Specifically, the facility failed to provide assistance with showers as scheduled to maintain personal hygiene and grooming for Resident #12, who was dependent for care. Findings include: I. Resident #12 A. Resident status Resident #12, under age [AGE], was admitted on [DATE]. According to the April 2023 computerized physician orders (CPO), diagnoses included multiple sclerosis (MS), attention and concentration deficit, muscle weakness, dysphagia (swallowing difficulty), anxiety, lack of coordination and polyneuropathy (malfunction of nerves in the body). The 3/8/23 minimum data set (MDS) assessment revealed Resident #12 was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She needed set up assistance for eating and oral hygiene and was totally dependent on two person assistance for toileting and showering/bathing. She needed substantial/maximum assistance for dressing, and putting on and taking off footwear. She also needed substantial/maximum assistance to move from sitting to lying and lying to sitting, and was totally depending for a chair/bed to chair transfer. II. Resident interview and observation Resident #12 was interviewed on 4/5/23 at 10:55 a.m. She said she sometimes received a shower as scheduled. She said there were times she did not get her shower and was not offered to shower on an alternate day; the alternate day was already filled and the staff were unable to fit her in the schedule. The white board in the Resident #12's room had shower written next to the days Tuesday and Friday. III. Record review Resident #12's care plan for ADLs (activities of daily living), revealed the resident was at risk for decreased ability to perform ADL(s) in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: Decreased mobility related to her diagnosis of MS. Pertinent intervention included to provide opportunity for bathing preference: preferred: shower, based on residents/patient's tolerance; initiated 3/11/21. Resident #12's care plan for refusal of care revealed she refused showers and weights frequently. A pertinent intervention included that staff would encourage resident to be compliant with care and provide education to risk (s) of refusing care; initiated 1/12/23. A shower task in the Resident #12's electronic record was reviewed with a lookback period of thirty days, retrieved on 4/11/23. A shower was marked as provided on 3/28/23 and 4/4/23. On 3/15/23 and 3/22/23 the response was marked NA (meaning not applicable) and on 3/25/23 the response was marked resident not available. There were no refusals marked in the record. -The responses in the record revealed a shower was offered twice to the resident in the lookback period. -The facility failed to document further attempts to offer showers, if and when the resident refused. -The facility failed to document resident refusals and attempts to offer the resident showers in resident's progress notes, and the facility failed to document any follow up to offer shower or hygiene activities or education to the resident regarding compliance of cares. IV. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 4/10/23 at 12:30 p.m. He said said Resident #12 frequently refused showers and sometimes did not want to get up from bed to shower. Certified nurse aide (CNA) #2 was interviewed on 4/10/23 at 1:19 p.m. She said she has provided showers for Resident #12, the resident normally chose a shower, and her showers were scheduled on Tuesday and Friday. She said the resident occasionally did refuse a shower which was once a month or once every three weeks. CNA #2 said Resident #12 would say she did not want the shower for a health reason or that she (the resident) was not feeling up to it. CNA #2 said Resident #12 sometimes requested a shower on a day she was not scheduled, and the staff tried to get her a shower on the requested day. CNA #2 said this information was recorded in the resident's electronic record and it was in tasks under bathing. The director of nursing (DON) was interviewed on 4/11/23 at 11:30 a.m. The DON said Resident #12 had showers scheduled Tuesday and Friday. She said Resident #12 did refuse showers quite a bit and her refusals depended on who the CNA was scheduled for her shower, and the resident's overall affect for the day. The DON said if Resident #12 did refuse a shower the CNA should have notified a nurse. The DON said the facility offered a make-up shower day on Saturday. The DON said while Resident #12's care plan was written for showers, Resident #12's refusal was usually to bathing in general. She said Resident #12 needed prompting multiple times to get her prepared for the shower, and then often the resident said she thought about it so much she was tired. She said Resident #12 had anxiety regarding things outside of her room and she was offered bed baths as an alternative, and bed baths were something the facility offered as an alternative.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview and staff interviews, the facility failed to ensure proper treatment and assistive devices to maintain vision abilities for one (#7) of three residents reviewed for visual problems out of 28 sample residents. Specifically, the facility failed to provide assistance with hearing aids to Resident #7 and ensure hearing aids were stored safely. Findings include: I. Resident #7 A. Resident status Resident #7, age under 88, was admitted on [DATE] and readmitted on [DATE]. According to the April 2023 computerized physician orders (CPO), diagnoses included cerebral infarction (stroke), dysphagia (swallowing difficulty), anxiety and history of falling. The 1/28/23 minimum data set (MDS) assessment revealed the resident's cognition was intact, with a brief interview for mental status (BIMS) score of 14 out of 15. The hearing assessment indicated the resident had no hearing aids and had adequate hearing. The resident did not have any behaviors and did not reject the care. B. Resident interview Resident #7 was interviewed on 4/11/23 at 10:02 a.m. She said she had a box in her room that had only one hearing aid. She said the other one was lost a while ago. She said she did not know how to use her hearing aids and no staff came to help her with them. She said she would use them if she could because she could not hear the television and had to increase the sound too much. The resident picked up a box with hearing aids, she was not able to open it, and asked for help to open it. Upon opening the box, only one hearing aid was observed inside. The resident stated the second one was lost. C. Record review Review of the resident's comprehensive care plan revealed no care plan for resident's hearing or her hearing aids. The resident's [NAME] (abbreviated staff directive) review revealed no mention of hearing aids. The [NAME] assessment report completed on 2/14/23 by audiologist read: (Resident) remembers receiving hearing aids in March 2022, but has not worn them because she does not feel comfortable operating them. Hearing aid case was found in the patient's room without a charging cord. Only one hearing aid was located in the case. Asked resident to look for missing hearing aid. Recommendations included: Schedule appointment at next visit for hearing aid check after resident locates missing hearing aid. Annual audiological evaluations are recommended to monitor for any changes in hearing health. II. Staff interview Licensed practical nurse (LPN) #2 was interviewed on 4/10/23 at 2:09 p.m. He said Resident #7 was hard of hearing, but did not have hearing aids. He said the resident was able to hear him well and did not want any hearing aids. Certified nurse aide (CNA) #2 was interviewed on 4/11/23 at 10:20 a.m. She said the resident had moderate hearing problems, but she was not using any hearing aid devices and to her knowledge never used one. She said speaking loud to the resident usually helped with communication. She said the resident had her television very loud, which led to complaints from her roommate. The social services director (SSD) was interviewed on 4/11/23 at 10:24 a.m She said the resident's hearing was poor. She said the resident had an audiology consult, and she did not report tinnitus (ringing or buzzing in ears). There was a concern from the roommate that the resident had the television too loud and the resident was offered the headset and declined. Regarding the audiology report, she said she submitted it to a primary care physician. She said she did not read the report and did not know what was in it. She said to her knowledge the resident never had or used hearing aids. The SSD was interviewed a second time on 4/11/23 at 11:14 a.m. She said she spoke with a resident and the resident said she wanted to use hearing aids. She said she would reach out to audiology to re-order the hearing ads.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure assessment, inspection and maintenance of a bed cane (fixed bed rail assistive device) was completed for one (#12) resident using bed cane (type of bed rail) for positioning out of 28 sample residents. Specifically, for Resident #12, the facility failed to: -Assess the resident for risk of entrapment prior to installing or using a bed cane/bed rail; and, -Check bed rail/bed cane regularly according to manufacturer's instructions for ongoing maintenance to make sure device was still installed correctly as rails may shift or loosen over time. Findings include: I. Professional standard The U.S. Food and Drug Administration (FDA) Clinical Guidance For the Assessment and Implementation of Bed Rails In Hospitals, Long Term Care Facilities, last updated 2/27/23 and retrieved on 4/13/23 from https://www.fda.gov/medical-devices/adult-portable-bed-rail-safety/recommendations-health-care-providers-using-adult-portable-bed-rails included bed rail safety guidelines read in pertinent part: -Any decision regarding bed rail use or removal from use should be made within the framework of an individual patient assessment. -Bed rail use for patient's mobility and/or transferring, for example turning and positioning within the bed and providing a hand-hold for getting into or out of bed, should be accompanied by a care plan. -The equipment (beds/mattresses/bed rails) should be inspected, evaluated, maintained, and upgraded to identify and remove potential fall and entrapment hazards and appropriately match the equipment to patient needs, considering all relevant risk factors. -The patient's needs should be re-assessed and the equipment re-evaluated if an episode of entrapment or near-entrapment occurred, with or without serious injury; this was done immediately because fatal 'repeat' events can occur within minutes of the first episode. -The bed, mattress and any accessories should be monitored and maintained on an ongoing basis. II. Facility policy and procedure The Proper Use of Side Rails policy, dated April 2019, was provided by the nursing home administrator (NHA) on 4/11/23 at 11:18 a.m. It read in pertinent part, Side rails/bed rails are adjustable metal or rigid plastic bars that attach to the bed. They (side rails/bed rails) are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eighth lengths. Also, some bed rails are not designed as part of the bed by the manufacturer and may be installed on or used along the side of a bed. Examples of bed rails include, but are not limited to side rails, bed side rails, safety rails, grab bars and assist bars. As part of the resident's comprehensive assessment, the following components will be considered when determining the resident's needs, and whether or not the use of side/bed rails meets those needs: medical diagnosis, conditions, symptoms, and/or behavioral symptoms; size and weight; sleep habits; medication; acute medical or surgical interventions; underlying medical conditions; existence of delirium; ability to toilet self safely; cognition; communication; mobility (in and out of bed); and risk of falling. The facility will assure the correct installation and maintenance of bed rails prior to use. This includes: Inspecting and regularly checking the mattress and bed rails for gaps and areas of possible entrapment; checking rails regularly to make sure they (side rails/bed rails) are still installed correctly, and have not shifted or loosened over time. Side rails that were permanently installed on the bed frame shall not be used, even incidentally, without proper assessment, informed consent, and physician orders. The facility will provide ongoing monitoring and supervision of side rail/bed rail use for effectiveness, assessment of need and determination when the side rail/bed rail will be discontinued. The maintenance director, or designee, is responsible for adhering to a routine maintenance and inspection schedule for all bed frames, mattresses, and rails. III. Assistive device manual The assistive device manual for the Joerns deluxe assist handle model F028 was provided by the NHA on 4/12/23 (after survey) at 11:33 a.m. The manual read in pertinent part, Do not use this assist device until you have verified that it is locked in place. Injury to resident or caregiver may result if this procedure is not followed. An optimal bed system assessment should be conducted on each resident by a qualified clinician or medical provider to ensure maximum safety of the resident. Do not use the device as an assist if the hand grip was wet. A wet surface may lead to the resident's hand slipping on the assist device and result in injury or death. Maintenance/inspection information: Visually inspect the assist handle and mounting bracket, and check for loose hardware on a monthly basis. Tighten loose hardware as stated in the installation instructions. IV. Resident #12 A. Resident status Resident #12, under age [AGE], was admitted on [DATE]. According to the April 2023 computerized physician orders (CPO), diagnoses included multiple sclerosis (MS), attention and concentration deficit, muscle weakness, dysphagia (swallowing difficulty), anxiety, lack of coordination and polyneuropathy. The 3/8/23 minimum data set (MDS) assessment revealed Resident #12 was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She needed set up assistance for eating and oral hygiene and was dependent on assistance for toileting and showering/bathing. She needed substantial/maximum assistance for dressing, and putting on and taking off footwear. She also needed substantial/maximum assistance to move from sitting to lying and lying to sitting, and was totally depending for a chair/bed to chair transfer. The MDS assessment was not marked to indicate a bed cane/bed rail was in use. B. Resident interview Resident #12 was interviewed on 4/6/23 at 1:50 p.m. She said she did not think her bed/bed rail fit the bed correctly, and she used it to reposition herself in bed. C. Record review A review of the Resident #12's March 2023 CPO showed an order on 11/28/22 for a bed cane added to the resident's bed for mobility and positioning. Resident #12's care plan was reviewed. The care plan for pressure ulcers was with the resident actual or at risk due to: Assistance required in bed mobility, and the resident insistent on multiple cushions, wedges, blankets in bed with her at all times; staff education ineffective, was initiated on 11/14/22. The intervention for the left bed cane/bed rail for bed mobility and positioning was initiated on 11/28/22. Resident #12's care plan for decreased ability to perform activities of daily living (ADL(s) in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to: Decreased mobility due to diagnosis of MS, revised on 3/25/21. The intervention for the left bed cane for mobility and positioning was initiated on 10/16/22. A review of Resident #12's quarterly comprehensive assessments showed the assessment included a section for a side rail/patient positioning device. The quarterly assessments for Resident #12 were signed on 12/7/22 and 3/4/23. The safety measures reviewed in the section that were checked included: Side rails attached to the frame are easily raised and lowered; the gap between the rail/bed frame and mattress edges was less than 2.5 inches; and did the side rail fit appropriately to prevent potential entrapment. -There was no documentation in the quarterly assessment that the staff visually inspected the assisted device (bed cane/bed rail) handle and mounting bracket, and checked for loose hardware on a monthly basis per the device's manufacturers instructions. The initial assessment for Resident #12's bed cane/bed rail was completed on 4/11/23 (during the survey). V. Staff interviews The director of nursing (DON) was interviewed on 4/11/23 at 11:30 a.m. She said Resident #12's bed cane/bed rail was for bed mobility and that the therapy department oversaw quarterly assessments to see if the bed cane/bed rail was appropriate. The director of therapy service (DTS) on 4/11/2 at 1:00 p.m. She said she completed the initial assessment for Resident #12's bed cane/bed rail today. She said she used a checklist to ensure all the necessary steps were completed and the initial assessment was checked as completed but the initial assessment was not done. She said the initial bed cane/bed rail assessment was a digital form and was found in the resident's electronic medical record. She said she did not obtain written consent from the resident but obtained verbal consent instead because she did not think a bed cane was a bed rail. She said any resident who had an order for a bed cane should have an assessment, a physician's order and have it on their care plan. She said the maintenance department installed the bed canes/bed rails. She said staff should check the bed cane/bed rails daily for safety, but staff had not checked daily as it was not documented. The DON was interviewed on 4/11/23 at 1:10 p.m. She said the quarterly nursing assessments included a check of the bed cane for Resident #12 and these could be found in the resident's electronic medical record. She said she did not know if the assessment was based on the bed cane/bed rail's manufacturing instructions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure that residents were free of unnecessary psychotropic medications for one (#247) of one resident reviewed for psychotropic medications out of 16 sample residents. Specifically, the facility failed to: -Ensure the staff monitored Resident #247 for side effects of eight psychotropic medications including sedation and hypotension; -Ensure staff accurately monitored and tracked Resident #247 for target behaviors and hours of sleep for four antidepressant medications, with one being used for insomnia, one for depression, one for anxiety and one for hallucinations; two antipsychotic medications for dementia with behavioral disturbance; and, two anti anxiety medications for generalized anxiety; -Ensure consents were signed by Resident #247's representative prior to psychotropic medication administration; -Have the Resident #247's physician document the rationale for extending the use and indicate the duration of a PRN (as needed) psychotropic medication beyond 14 days; and, -Document non-pharmacological interventions attempted for Resident #247's expressions and indications of distress before the use of as needed (PRN) psychotropic medications. Findings include: I. Facility policy and procedure The Use of Psychotropic Medication policy, revised December 2022, was received from the nursing home administrator (NHA) on 6/8/23 at 12:47 p.m. It documented in pertinent part, Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). The attending physician will assume leadership in medication management by developing, monitoring, and modifying the medication regimen in collaboration with residents, their families and/or representatives, other professionals, and the interdisciplinary team. PRN (as needed) orders for all psychotropic drugs shall be used only when the medication is necessary to treat a diagnosed specific condition that is documented in the clinical record, and for a limited duration (14 days). If the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she shall document their rationale in the resident's medical record and indicate the duration for the PRN order. II. Resident status Resident #247, age [AGE], was admitted on [DATE]. According to the June 2023 computerized physician orders (CPO) diagnoses included dementia with behavioral disturbance, anxiety, depressive episodes, insomnia, legal blindness, [NAME] Bonnet syndrome (visual hallucinations caused by the brain's adjustment to significant vision loss) and osteoarthritis. Resident #247 was admitted to the facility's secure unit. The 5/31/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) with a score of seven out of 15. She was independent with bed mobility, transfers, dressing, personal hygiene and toileting. She ambulated without an assistive device. The 5/31/23 MDS assessment documented Resident #247 received antipsychotic, antianxiety, and antidepressant medications daily. She did not reject care and had one day of physical and verbal aggression. She wandered daily. Resident #247 had one day of feeling down and one day of trouble sleeping. III. Record review The May and June 2023 medication administration record (MAR) and treatment administration record (TAR) were reviewed on 6/7/23. Since her admission on [DATE] she was unfamiliar with the care providers, environment and her daily routine had changed. She was on multiple psychotropic medications and additional psychotropic medications were added after her admission to the facility due to her behaviors. The May and June MAR and TAR revealed the resident was administered the following psychotropic medications: Risperdal (antipsychotic) Oral Tablet 0.5 MG (Risperidone) Give one tablet by mouth in the morning for dementia w/behavioral disturbances, ordered 5/4/23, discontinued 5/9/23; Escitalopram Oxalate (antidepressant) Oral Tablet 10 MG (Lexapro) Give 1 tablet by mouth in the morning for Anxiety, ordered 5/4/23 Mirtazapine (antidepressant) Oral Tablet 15 mg, Give 0.5 tablet by mouth in the evening for depression, ordered 5/4/23; Trazodone HCl Oral Tablet 50 MG (antidepressant) Give 50 mg by mouth in the afternoon for Insomnia, ordered 5/16/23; Venlafaxine HCl Oral Tablet 75 MG (Effexor) Give 1 tablet by mouth in the evening for hallucinations, ordered 5/4/23. The medication was given in the evening despite known stimulant effects and residents history of insomnia, the medication was changed to 8:00 a.m. on 6/3/23. Buspirone HCl Oral Tablet 10 MG (Buspar) Give 10 mg by mouth two times a day related to generalized anxiety order, Started 5/24/23, discontinued 6/6/23 (during the survey); Quetiapine Fumarate Oral Tablet 100 MG (Seroquel) Give 1 tablet by mouth two times a day for behaviors/hallucinations started 5/4/23, increased to three times per day on 5/9/23; Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by every 8 hours PRN for anxiety, agitation, ordered 5/9/23, discontinued 5/13/23; the resident received three doses; Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 8 hours PRN for anxiety, agitation, ordered 5/14/23, discontinued 5/16/23; the resident received three doses; Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth three times a day for Anxiety, agitation, and aggression -started 5/16/23, orders to hold and not give the medication due to lethargy 5/19/23 to 5/20/23. However, the medication was given anyway on 5/19/23 at 7:00 a.m. and 1:00 p.m; Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 24 hours PRN (as needed) for anxiety and agitation started 5/20/23, discontinued 5/21/23; The resident received one dose; Lorazepam Oral Tablet 0.5 MG (Lorazepam) Give 1 tablet by mouth every 24 hours PRN for anxiety and agitation, ordered 5/21/23. The resident received one to two doses daily as needed from 5/22/23 through 6/8/23. The resident had received 23 doses in less than 16 days. Additionally, the resident received melatonin Oral Tablet 10 MG (Melatonin) Give 1 tablet by mouth in the evening for insomnia. -There were no hours of sleep documented for the use of the Trazodone or melatonin on the MAR, TAR or behavior monitoring for May or June 2023. -There was no monitoring for side effects of the antipsychotic, antianxiety, or antidepressant medications. The behavior monitoring, nursing and physician progress notes were reviewed on 6/7/23: The behavior log was a 30 day look back period to 5/10/23. -There was no monitoring for hallucinations, sleep or symptoms of anxiety. The behavior tracking log did document that the resident wandered almost daily and she was admitted to the secure unit for that reason. The 5/11/23 the behavior log documented she had no behaviors except wandering, there were no behaviors in the progress notes. The SNF (skilled nursing facility) charting documented at 2:36 p.m. the resident was combative and unsteady on her feet. The resident received lorazepam at 5:45 a.m. At 11:45 a.m. the nurse documented the lorazepam was effective. It was unclear when the resident was combative and unsteady on her feet. There was no further ativan documented as given around the time the nurse wrote the note. The physician progress note on 5/11/23 documented the resident was combative, yelling and throwing things. The note documented the resident was doing better on the Seroquel three times per day and he ordered to continue the lorazepam as needed for 14 days. -However, there was no documentation to indicate what strategies were used for her behaviors besides administering psychotropic medications. The 5/16/23 at 9:41 a.m. nursing progress note documented the nurse called the physician and lorazepam was ordered three times per day. The resident received lorazepam three times a day through 5/19/23. -However, the lack of consistent documentation of the resident's behavior, made it difficult to determine what medications were effective. The 5/18/23 at 8:39 p.m. nursing progress note documented the resident fell in her bathroom, the nurse documented she was lethargic. She had lorazepam at 5:36 p.m., even though it was scheduled for 7:00 p.m. Trazodone had been started on 5/16/23. The on call physician gave orders to hold the lorazepam until the resident's physician reviewed it due to lethargy. -However, the resident was given lorazepam twice on 5/19/23 (see below). The 5/19/23 at 12:10 p.m. interdisciplinary (IDT) note documented the resident had fallen due to medication changes; the nursing progress notes documented the resident had all three doses of lorazepam because the nurse did not see the order to hold it (cross-reference F689 accident prevention). The 5/20/23 at 5:44 p.m. nursing notes documented the resident had been given lorazepam and fallen at 4:30 p.m. The MAR indicated the lorazepam was given at 3:24 p.m. The 5/21/23 at 9:21 a.m. nursing note documented the on call physician was contacted for an order for Lorazepam for symptoms of worry and anxious to wander even after toileting and food, drink and pain medication. The physician gave orders for lorazepam 0.5mg every eight hours PRN, the resident received a dose at 9:11 a.m. Beginning 5/22/23, the resident continued to get lorazepam one to two times PRN through 6/6/23. The 5/23/23 provider note documented she had discussed starting Buspar for anxiety with the director of nursing (DON) but did not want to change the medication yet, because the resident needed time to adjust before too many changes and to monitor her for now. -However, according to the resident's MAR the Buspar medication was started on 5/24/23. The 5/28/23 at 7:53 p.m. nursing note documented the resident fell again, her blood pressure was 74/50 (her blood pressure was low with normal range 120/80), she had lorazepam at 9:21 a.m. and had recently started on Buspar 5/24/23. The 6/2/23 at 4:54 p.m. nursing notes documented the resident was given lorazepam for exit seeking and stating she is getting out of here to go home, albeit pleasantly, but increasingly anxious. The 6/2/23 pharmacist documented a medication regimen review due to falls and hypotension. The recommendation was to schedule regular blood pressure medications. Additionally, the pharmacist documented the lorazepam, quetiapine, venlafaxine, buspirone, and trazodone (all psychotic medications) could all cause falls. On 6/6/23, during the survey, the provider responded that the falls were due to the residents impulsive, aggressive and violent behavior. The provider declined to reduce or change the medications. The 6/6/23 provider visit note documented a plan to discontinue lorazepam and Buspar, add Clonazepam (benzodiazepine used for seizures, panic disorders, anxiety) daily and PRN and titrate off escitalopram. -However, according to the resident's MAR the buspar was discontinued, but the PRN Lorazepam continued and there were no orders for Clonazepam. On 6/8/23 according to the resident's MAR the PRN lorazepam was still being given as needed and there were no orders for the clonazepam. There was no order or documented rationale by the MD to continue the medication due to it being administered PRN. The behavior care plan, initiated 5/9/23 documented I sometimes have behaviors which include bumping into other people, kicking, shouting, pacing, exit seeking, hitting other residents when agitated, ramming the exit doors, throwing items at the exit doors, banging on the exit doors, yelling at the exit doors, entering other resident's rooms. Encourage me to verbalize my anxious feelings, offer food fluids, encourage activity before behavior begins, encourage me to take medications, do not sit me by people who disturb me, help me maintain my favorite place to sit, help me avoid people or situations that disturb me, let my physician know if my behavior interferes with daily living, observe for pain, offer 1:1 activity, occupational therapy to access for outside safety. Place a colorful sign on the resident's room door to identify her room. Place me in a room with a roommate on the memory unit that get along better if needed. Please refer me to my psychologist/psychiatrist as needed. Please tell me what you are going to do before you begin. Request medication review. Speak to me unhurriedly and in a calm voice. Take blood pressures after morning and evening medications to monitor for adverse effects. -However, the behavior monitoring form did not document any non-pharmacological interventions attempted by staff per the resident's care plan. -The nursing progress notes frequently did not document non-pharmacological interventions attempted for anxiety or agitation before the resident was administered lorazepam. The resident was administered lorazepam for her behavior, without any documented attempts to redirect on: 5/11/23 at 5:57 p.m., 5/12/23 at 6:25 am, 5/13/23 at 5:15 a.m., 5/15/23 at 8:20 a.m. and 4:22 p.m., 5/18/23 at 5:36 p.m., 5/20/23 at 5:44 p.m., 5/22/23 at 7:16 a.m., 5/23/23 at 10:45 a.m. and 10:06 p.m., 5/24/23 at 8:08 a.m, 5/25/23 at 9:24 a.m., 5/27/23 at 7:26 and 4:09 p.m, 5/29/23 at 4:30 p.m., and 5/30/23 at 9:30 a.m. and 4:30 p.m. The antidepressant care plan, initiated 5/5/23 documented The resident uses antidepressant medication Lexapro (escitalopram) due to depression. Administer medications as ordered, monitor for adverse effects and effectiveness every shift. -However, the facility did not monitor the resident for any side effects of the multiple psychotropic medications.The care plan did not address any of the other multiple psychotropic medications. The resident's electronic medical record was reviewed for consent for use of psychotropic medications that included the risks and side effects associated with use. -There were no consents for the trazodone or buspar. IV. Interviews The DON was interviewed on 6/7/23 at 8:27 a.m. She said when Resident #247 had her falls, the IDT looked at the time of her medications. The DON said she was unsure if the IDT looked at the new psychotropic medications added buspar and trazodone. She said there was no consent from the representative for the trazodone or buspar that had been ordered. She said the hours of sleep should have been documented on the MAR for the trazodone and melatonin. The DON said she did not know why it was not. The DON said she was not sure why the PRN lorazepam did not have a stop date. She said when a physician or provider gave a verbal order, the nurse would write the order; but when the provider came to visit, the provider wrote the orders in the resident's record. The resident's medical doctor (MD) was interviewed on 6/8/23 at 2:15 p.m. The MD was contacted for clarification of medications. The 6/6/23 provider note documented a plan for lorazepam was to be discontinued and clonazepam would be started. The facility had still administered the lorazepam as needed. Additionally, there had been multiple lorazepam orders from various providers. -However, the MD did not clarify any of the orders during the interview. The MD said it was not uncommon in long term care to have multiple providers. He said polypharmacy (multiple medications) was not uncommon for residents with behaviors. The MD said long term care was short staffed and if a nurse called with a behavior concern, the provider gave them what they needed. -The MD did not clarify the multiple orders for psychotropic medications or what behaviors were presented for the administration of multiple psychotropic medications often being used for the same diagnosis. The MD ended the interview before the orders for psychotropic medications could be clarified. The DON, NHA and regional director of operations (RDO) were interviewed on 6/8/23 at 3:45 p.m. The DON said the facility had a psychotropic committee meeting weekly. The DON, social worker, pharmacist, medical director and some of the providers attended. She said the social worker kept track of what residents needed to be reviewed, who was due for a gradual dose reduction and consents were obtained for psychotropic medications. The DON said Resident #247 had not been reviewed by the psychotropic commitee.The DON said the committee did not discuss target behaviors for the psychotropic medications and should have. She said the facility had not been tracking side effects of psychotropic medications. She said she was not sure how it had been missed. The DON looked at her computer and said Resident #247 had received the quetiapine for dementia with behaviors, the citalopram for anxiety, risperdal for dementia with behavior, venlafaxine for hallucinations, trazodone and melatonin for sleep, lorazepam for agitation. She did not read the rest of the medications. She said she did not see any tracking for sleep. The DON said the pharmacist had sent her multiple recommendations regarding Resident #247. -However, only the pharmacist recommendations from 6/2/23 (see above) were provided. Registered nurse (RN) #1 was interviewed on 6/8/23 at 1:45 p.m. She said she administered lorazepam twice per day to the resident when she worked to avoid the agitation. She said she crushed the medications and masked them in the resident's supplement shake. -However, there were no physician orders to crush the medications and place them in a medium.

Based on record observations, record review and interviews, the facility failed to residents received food and fluids prepared in a form designed to meet the residents' needs. Specifically, the facility failed to ensure residents had food prepared according to their diet orders of mechanical dysphagia level 2 as indicated on their meal tray cards. Findings include: I. Facility policy The Therapeutic Diet policy, revised January 2023, was provided by the nursing home administrator (NHA) on 4/11/23 at 11:29 a.m. The policy read in pertinent part, The facility provided all residents with foods in the appropriate form and/or the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences. A mechanically altered diet was one in which the texture or consistency of food was altered to facilitate oral intake. Examples included soft solids, pureed foods, ground meat, and thickened liquids. Dietary and nursing staff were responsible for providing therapeutic diets in the appropriate form and/or the appropriate nutritive content as prescribed. II. Observations Lunch service was observed on 4/6/23. A baking pan of whole, intact dinner rolls was placed on a rack next to the hot food serving station. -At 12:05 p.m. cook (CK) #1 prepared a plate for a resident whose meal tray card indicated dysphagia mechanical level 2, ground ham and a slurry roll. CK #1 then grabbed a whole dinner roll from the pan, placed the roll on the plate and the dietary manager told CK #1 to use white cream gravy and ladle it over the top of the roll. The dietary manager then sent the resident's meal tray out for service. -At 12:09 p.m. CK #1 prepared a plate for a resident whose meal tray card indicated dysphagia mechanical level 2, ground ham and slurry roll. CK #1 grabbed a whole dinner roll from the baking pan, placed the roll on the plate and the dinner roll was topped with white cream gravy. The dietary manager then sent the resident's meal tray out for service. -At 12:15 p.m. CK #1 prepared a plate for a resident whose meal tray card indicated dysphagia mechanical level 2, ground ham and a slurry roll, with food served in individual bowls. CK #1 then grabbed a whole dinner roll from the baking pan, placed the roll on the plate and the dinner roll was topped with white cream gravy. The dietary manager then sent the resident's meal tray out for service. -At 12:22 p.m. CK #1 prepared a plate for a resident whose meal tray card indicated dysphagia mechanical level 2, ground ham and a slurry roll. The dietary manager then sent the resident's meal tray out for service. III. Record review Menu extensions (food modifications for diet and texture) and recipes for slurried bread products were provided by the NHA on 4/6/23 at 3:46 p.m. The menu extension for the dysphagia mechanical level 2 revealed the roll was to either be pureed or slurried. The slurry recipe instructions read: Ingredients for the slurry were milk, water or juice and food thickener; remove the crust from the bread; blend the liquid and thickener to form a slurry and pour half of the slurry mixture on the sheet pan. Place the soft bread items on top of the slurry and pour remaining slurry over the bread product, and pierce the bread with a fork. Allow the bread to sit a minimum of 15 minutes or until the bread was thoroughly softened and gelled through the entire thickness of the product. Drain any liquid that had been separated from the bread or bread products. IV. Interviews A representative for the company that provided the facility food menus, recipes and menu extensions was interviewed by phone on 4/11/23 at 9:30 a.m. She stated the diet manual used by the facility was found in their menu program and could be printed by the facility staff. She said in the description for the dysphagia mechanically altered level 2 diet read '(company name) menus serve ground meat' on pages 42-43 of the diet manual. CK #1 was interviewed on 4/11/23 at 11:35 a.m. She said any resident with a dysphagia mechanical level 2 order should have ground ham. For the slurry roll, she said she was not given a recipe but she knew if it was a slice of bread she could brush the gravy or the slurry mix the facility could buy over the top of the bread. She said the facility did not have any of the slurry mix you could purchase at that time and that was why the gravy was used and put on top of the roll. The DM was interviewed on 4/11/23 at 1:00 p.m. He said CK #1 did not use a recipe for slurried bread. The DM said he would check to make sure that the slurry will go through the inside of the roll. He said CK#1 was not using the recipe and was doing what she was told. He said he was unsure if the information was in the diet manual and he was unsure where the diet manual was, but he did have the diet manual. -The diet manual was requested for review but not provided by the end of the survey on 4/11/23 . The director of nursing (DON) was interviewed on 4/11/23 at 11:30 a.m. She said care staff were trained to read meal tray cards and look for accuracy to see if what was served matched what was on the meal tray card. She said a little bit of training had taken place during the staff's initial orientation to look at the meal tray before it was provided to the resident.

Based on observations, record review and interviews, the facility failed to implement their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption for three residents out of 28 sample residents. Specifically, the facility failed to: -Ensure resident refrigerators maintained appropriate temperatures for refrigerated food storage; and, -Ensure sanitary food storage for Resident #12's refrigerator in her room. Findings include: I. Professional reference The Food and Drug Administration (FDA) Food Code 2022, last reviewed 1/18/23 and retrieved on 4/12/23 from https://www.fda.gov/food/retail-food-protection/fda-food-code, read in pertinent part, Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature 'danger zone' of 41 degrees Fahrenheit to 135 degrees Fahrenheit too long. II. Facility policy The Resident Refrigerators policy, revised January 2023, was provided by the nursing home administrator (NHA) on 4/11/23 at 9:07 a.m. It read in pertinent part, Dormitory-size refrigerators were allowed in a resident's room under the following conditions: The refrigerator maintained proper temperatures; the resident complied with the facility's policy for use of the refrigerator. Dietary staff shall record refrigerator temperatures weekly on a temperature log attached to the refrigerator. Temperatures will be at or below 41 F, and freezers will be cold enough to keep foods frozen solid to the touch (or in accordance with state regulations). If temperatures were out of range, dietary staff shall discard any foods that required refrigeration, and take measures to remedy the problem. If problems persist with maintaining proper temperatures, the refrigerator shall be removed from use and the resident/family notified. Nursing and or housekeeping staff shall clean the refrigerator weekly and discard any foods that are out of compliance. Nursing staff shall clean up spills as needed, or refer to housekeeping staff. Leftovers shall be dated upon receipt and discarded within three days. Foods with use-by dates shall be discarded accordingly. The resident and/or family shall be educated on safe food storage and use of the refrigerator prior to its use, and as needed. Noncompliance with safety and sanitation requirements of this policy will result in the removal of the refrigerator from the resident's room. IV. Resident interview and observation Resident #12's room refrigerator log was reviewed on 4/5/23 at 11:00 a.m. A refrigerator temperature monitoring log posted on Resident #12's refrigerator had columns titled temperature, cleaning and food dated. The log was missing recorded refrigerator temperatures, and verification of cleaning and verification food dates for 26 days in March 2023 , and there were no recordings of any kind for April 2023. The last recorded temperature and verification of cleaning and dated food on the refrigerator log was 3/14/23. Two yogurts were observed in Resident #12's refrigerator with expiration dates of 3/19/23. Resident #12 was interviewed on 4/5/23 at 11:00 a.m. She said that she ordered food from Walmart, and it was delivered and put in her refrigerator. She did not recall anyone talking with her about proper food storage in her room. Resident #12's refrigerator was checked on 4/6/23 at 10:13 a.m. A new log was posted on the resident's refrigerator. The expired yogurts had been removed from the resident's refrigerator. Resident #12's refrigerator was checked on 4/11/23 at 11:55 a.m. A half eaten piece of store bought carrot cake was in the refrigerator with no expiration date on the container. III. Record review The night shift binder was reviewed on 4/11/23 at 10:35 a.m. and revealed a temperature log where refrigerator temperatures were recorded for refrigerators stored in resident rooms. Each resident who had a refrigerator to be monitored was listed on the temperature log. The refrigerator log listed the range the refrigerator temperatures should be as between 36-46 degrees Fahrenheit. The log also had recorded refrigerator temperatures for the unit snack refrigerators, and refrigerators in the soiled utility room (that were not food storage). The refrigerator log also had a column for corrective actions if a refrigerator was out of range. There were no corrective action notes written on the logs for February, March or April 2023. Temperatures for refrigerators in resident rooms were recorded once a day on the log. The temperature log had temperatures of 42 degrees Fahrenheit recorded in February 2023, March 2023 and April 2023 from 4/1/23 to 4/10/23 for one resident's room refrigerator. The temperature log had recorded temperatures on 4/1/23, 4/2/23, 4/5/23 and 4/6/23 as 42 degrees Fahrenheit for another resident's room refrigerator. -The NHA was notified on 4/11/23 at 11:30 a.m. that the resident refrigerator temperatures were recorded as out of range and the NHA saw the temperature logs in the night shift binder. She said she was not aware there was a binder that the nurses were recording refrigerator temperatures in. IV. Staff interviews The NHA, dietary manager (DM) and director of therapy services (DTS) were interviewed on 4/6/23 at 2:30 p.m. The DTS said she discarded the expired yogurts in Resident #12's refrigerator; it was a group effort and that all staff including nurses and certified nurse aides (CNAs) were to check the refrigerator temperatures and ensure expired products were removed from resident refrigerators. Licensed practical nurse (LPN) #1 was interviewed on 4/11/23 at 10:35 a.m. She said the night nurse checked the temperatures for the resident refrigerators between 10:00 p.m. and 6:00 a.m. and recorded them on the temperature logs in the night shift binder kept at the nurses station. LPN #2 was interviewed on 4/11/23 at 12:00 p.m. He said the night nurse went through and checked resident refrigerator temperatures. He said the night nurse and all nursing staff could check the refrigerators for food from outside sources. The DM was interviewed with the NHA, DTS, director of nursing (DON) and social services director (SSD) on 4/11/23 at 1:00 p.m. The SSD said she did talk to families who brought in food and the family had to write on the containers the date the food when it was brought in, but a policy was not handed to the family. She said if the food was homemade the facility staff liked to know the date the food came in because the staff could not verify the date the food was made, only when it was brought to the facility. The DM said the temperature range listed on the log of 36 degrees Fahrenheit to 46 degrees Fahrenheit was incorrect and the temperature range should not go above 40 degrees, or really 41 degrees. -The NHA, DTS, DON and SSD were informed a half eaten piece of carrot cake was observed in Resident #12's refrigerator earlier in the morning on 4/11/23. The DTS said she had checked Resident #12's refrigerator earlier that morning and did not see an opened carrot cake. The DON said the night nurses were recording refrigerator temperatures in the night shift log, and that none of the refrigerators in the soiled utility held anything that had a range of 36-36 degrees Fahrenheit. CNA #1 was interviewed on 4/12/23 at 2:30 p.m. She said she did check refrigerators in resident rooms as she did resident showers, but that it was a group effort between nurses and she had seen the therapy department staff clean expired products out of the refrigerators.

Based on observations, record review, and interviews, the facility failed to ensure residents received their meals in a timely manner and to offer substantial nourishing snacks. Specifically, the facility failed to ensure: -There were not more than 14 hours between a substantial evening meal and breakfast the following day; and, -Nourishing snacks were offered to residents at bedtime. Findings include: I. Facility policy The Frequency of Meals policy, dated January 2023, was provided by the nursing home administrator (NHA) on 4/10/23 at 4:57 p.m. It read in pertinent part, The facility has scheduled three regular meal times, comparable to normal meal times in the community, per day and offers snacks at all times. There will be no more than 14 hours between an evening meal and breakfast the following day, unless a nourishing snack is served at bedtime; then, up to 16 hours may elapse between an evening meal and breakfast the following day if the resident council agrees to this meal time span. Nutritious snacks and convenience foods (canned soups, peanut butter, crackers, cereal, and fruit) shall be available on the nursing units for those residents who request food outside scheduled meal and snack times. II. Meals served greater than 14 hours Meal times were posted at the entrance of the main dining room and were listed as follows: Breakfast 8:00 a.m. Lunch 12:00 p.m. Dinner 5:00 p.m. Based on the meal times, the breakfast meal was served 15 hours after the dinner meal with the absence of a nourishing snack at bedtime (see below). III. Resident observations and interviews Resident #12 was interviewed on 4/5/23 at 10:50 a.m. She had a shelf of multiple dry food snacks in her room in addition to a personal refrigerator with snacks. She said the facility did not offer snacks. Resident #6 was interviewed on 4/6/23 at 10:05 a.m. She said, 'they (the facility) don't have snacks and I don't think they (the facility) would have any if I asked. Resident #7 was interviewed on 4/6/23 at 10:07 a.m. She said, I don't ask for snacks and they (the staff) don't offer any. IV. Resident group The resident group, who were identified by facility and assessment as interviewable, were interviewed on 4/14/23 at 12:49 p.m. Resident #11 said they only get snacks when they ask for them. Resident #31 said he has never been offered a snack. He said he was told the residents did not get snacks after 7:00 p.m. Resident #31 said if it was not for his children bringing him snacks, he would not have any. Resident #11 said the snacks consist of fruits, yogurts and applesauce. She tried to get ice cream for a snack and the staff would not give it to her. She said she never got what she wanted for a snack. V. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 4/10/23 at 10:35 a.m. She said some snacks were in the medication administration record (MAR) to offer the resident if the resident had weight loss. She said both nurses and certified nurse aides (CNAs) asked if residents wanted snacks but not at a specific time. The dietary manager interviewed on 4/10/23 at 1:00 p.m. He said snacks both were offered and available on request and there were snacks stocked on the units. The director of nursing (DON) was interviewed on 4/11/23 at 11:30 a.m. She said in terms of snacks in general, if the facility identified any resident at risk and had snack offerings it would be recorded in the treatment administration record (TAR). She said snacks were always available such as yogurts, pudding and crackers; and the resident can ask for snacks at any time of day. She said the registered dietitian and risk management team were good at identifying residents who were not cognitively able to ask for a snack. In the memory care, snack offerings were part of their redirection all day long. The bedtime (HS) snack time frame was about 8:00 p.m., a long enough time that the residents were not full anymore.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food in a sanitary manner. Specifically, the facility failed to: -Ensure staff washed hands and changed single use gloves appropriately; and, -Ensure only food was stored in two out of two unit snack refrigerators, and food was sealed appropriately and discarded by the use by date. Findings include: I. Ensure staff washed hands and changed single use gloves appropriately A. Professional reference The Food and Drug Administration (FDA) Food Code 2022, last reviewed 1/18/23 and retrieved on 4/12/23 from https://www.fda.gov/food/retail-food-protection/fda-food-code, read in pertinent part, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: -After handling soiled equipment or utensils; -During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; when switching between working with raw food and working with ready-to-eat food; before donning (to put on) gloves to initiate a task that involved working with food; and after engaging in other activities that contaminated the hands. Food employees shall clean their hands in a handwashing sink or approved automatic handwashing facility and may not clean their hands in a sink used for food preparation or warewashing. B. Facility policy The Food Safety Requirements policy, revised January 2023, was provided by the nursing home administrator (NHA) on 4/10/23 at 4:14p.m. The policy read in pertinent part, Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. Food safety practices shall be followed throughout the facility ' s entire food handling process that included employee hygienic practices such as washing hands properly before distributing trays. Foods and beverages shall be distributed and served to residents in a manner to prevent contamination. Strategies included but were not limited to: Wash hands between contact with residents and after collecting soiled plates and food waste and the use of gloves when touching and assisting with ready-to-eat foods. Staff shall: -Wash hands prior to handling clean dishes, and shall handle them by outside surfaces or touch only the handles of utensils. -Adhere to safe hygienic practices to prevent contamination of foods from hands or physical objects and wash hands according to facility procedures. -Not touch food with bare hands, exhibiting appropriate use of gloves, tongs, deli paper, and spatulas. The Handwashing Guidelines for Dietary Employees policy, revised January 2023, was provided by the NHA on 4/10/23 at 3:24 p.m. It read in pertinent part, Handwashing was necessary to prevent the spread of bacteria that may cause foodborne illnesses. Dietary employees shall clean their hands in a handwashing sink or approved automatic handwashing facility and may not clean hands in a sink used for food preparation, warewashing, or in a service sink used for the disposal of mop water or similar waste. Compliance Guidelines: -Dietary employees shall keep their hands and exposed portions of their arms clean. -Dietary employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single use articles and also in the following situations: -Every time an employee enters the kitchen; at the beginning of the shift; after returning from break; after using the toilet. -After hands have touched anything unsanitary i.e., garbage, soiled utensils/equipment, dirty dishes, etc. -After hands have touched bare human body parts other than clean hands (such as face, nose, hair). -While preparing food, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. -Before donning gloves for working with food. -After engaging in any activity that may contaminate the hands. C. Observations Lunch service was observed on 4/6/23. -At 11:12 a.m. cook (CK) #2 wiped his gloved hands on a towel twice then grabbed a box containing frozen pie, did not remove his glove or wash his hands and then touched the ready to eat pie while placing a slice on a plate. -At 11:17 a.m. CK #2 rinsed his gloves in the two compartment sink and did not remove the gloves or wash his hands. -At 12:01 p.m. CK #1 touched her surgical face mask while wearing gloves, and then touched utensils on the hot food serving station without washing her hands and changing her gloves. -At 12:03 p.m. CK #1 touched the meal tray cards and then put her hands in the center of two dinner plates on the hot food serving station, and then used the plates for residents ' food. -At 12:04 p.m. CK #1, while still wearing the same pair of gloves, grabbed a ready to eat dinner roll and placed the roll on the plate. -At 12:06 p.m. CK #1, while still wearing the same pair of gloves, touched the center of three dinner plates on the hot food serving station and then used the plates for residents ' food. -At 12:09 p.m. CK #1, while still wearing the same pair of gloves, grabbed a ready to eat dinner roll with her hand and placed it on a dinner plate. -At 12:11 p.m. CK #1 while wearing the same pair of gloves, touched her eye glasses, and then her surgical face mask. She then rinsed her hands in the sink but did not wash them with soap, and donned new gloves. She stated she used a lot of gloves. -At 12:14 p.m. CK #1 touched her surgical face mask, then picked up three soup bowls with her fingers inside the bowls, and then used the bowls for residents ' food. -At 12:15 p.m. CK #1, while still wearing the same pair of gloves, grabbed a ready to eat dinner roll with her hand and placed it on a dinner plate. -At 12:19 p.m. CK #1 touched her gloved hands on her pants, and then grabbed a ready to eat dinner roll with her hand and placed it on a dinner plate. -At 12:49 p.m. CK #1 touched her ear, then touched her hair and removed her gloves and did not wash her hands before donning a new pair of gloves. D. Staff interviews DA #1 was interviewed on 4/11/23 11:31 a.m. He changed his gloves between the clean and dirty side of the dish area when washing dishes, and did not wear a pair of gloves for more than 15 minutes at a time before washing his hands and changing his gloves. CK #1 was interviewed on 4/11/23 at 11:35 a.m. She said she preferred to use tongs for ready to eat foods like the dinner roll, but she said she was told she did not have to use utensils for the rolls. She said because she was touching the scoop handles on the hot food serving station she liked to use tongs to serve the dinner rolls instead of her hands. The dietary manager (DM) was interviewed on 4/11/23 at 1:00 p.m. He said he did not notice CK#1 ' s improper hand hygiene during 4/6/23 lunch service, and she should have used a pair of tongs to serve the dinner rolls. He said the staff could not rinse their gloves off in between tasks and instead the gloves should be changed and hands washed. II. Ensure only food was stored and food was labeled and discarded by the use by date. A. Facility policy The Food Safety Requirements policy, revised January 2023, was provided by the nursing home administrator (NHA) on 4/10/23 at 4:14 p.m. The policy read in pertinent part, Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage. Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it was used by its use-by date, or discarded. B. Observations On 4/5/23 at 1:00 p.m. the following items were observed in the unit snack refrigerator and freezer (non-secure unit): -Opened jar of [NAME] ' s grape jelly in the refrigerator, with no expiration date. -Opened, half full, clear plastic container of store bought mini boston chocolate donuts in the refrigerator, and a production sticker date of 3/25/23, and no expiration date. -A four ounce container of unidentified food in the refrigerator with a person ' s first name, dated 3/12/23. -Container of apricots placed in a clear ziploc bag in the refrigerator, dated 3/4/23. -Two gel cooling packs were in the freezer (that touched resident skin) with food items, one was labeled a body gel pack and the other had a resident ' s last name on it. On 4/5/23 at 1:10 p.m. in the cupboard labeled resident snacks next to the (non-secure) unit snack refrigerator, were two opened bags of potato chips, with no expiration date and not sealed. On 4/5/23 at 1:15 p.m. the following items were observed in the secure unit ' s refrigerator and freezer: -One body gel cooling pack in the freezer. -A frozen drink in a clear plastic cup from a local coffee shop, less than half full, with no name or expiration date. -One opened and partially eaten four ounce container of ice cream in the freezer, with no name or expiration date. -A honey dijon dressing bottle in the refrigerator, less than half full, with name or expiration date. -Opened jar of [NAME] ' s grape jelly in the refrigerator, with no expiration date. -One dozen Noosa yogurts in the refrigerator with an expiration date of 3/26/23. On 4/5/23 at 1:49 the dietary manager (DM) was notified there were a dozen expired yogurt containers in the secure unit refrigerator. The DM stated that the staff on the units were supposed to check the unit refrigerators for expired products. The (non secured) unit snack refrigerator was checked on 4/6/23 at 10:27 a.m. The two body gel packs were still in the freezer. A container of meadow gold dairy milk, less than half full with an expiration date of 4/5/23 was in the refrigerator. The mini boston chocolate donuts had been removed. The two open bags of potato chips in the resident snack cupboard were still opened and unsealed. The secure unit snack refrigerator was checked on 4/6/23 at 10:33 a.m. The expired Noosa yogurt containers and local coffee house frozen drink had been removed. An open container of Yoplait yogurt was in the refrigerator unsealed with no name. The body gel cooling pack was still in the freezer. C. Staff interviews The DM, nursing home administrator (NHA) and the director of therapy services (DTS) were interviewed on 4/6/23 at 2:30 p.m. The DTS stated she removed the expired product from the unit refrigerators, but did not check the snack cupboard with the open bags of chips. She said the dietary staff used to maintain the unit refrigerators and their logs. Licensed practical nurse (LPN) #1 was interviewed on 4/10/23 at 10:35 a.m. She said she was a charge nurse; the night nurse on the 10:00 p.m. to 6:00 a.m. shift checked the temperatures for the snack refrigerators and recorded them in the night shift binder and that the kitchen staff were responsible for cleaning the expired food out of the unit refrigerators. The DM was interviewed on 4/11/23 at 1:00 p.m. in the presence of the NHA, DTS and the director of nursing (DON). He said that the dietary staff monitored the unit snack refrigerators but currently that he was the only one checking them. He said he did ask the care staff to check the unit refrigerators but he should be looking at temperatures and product dates. He said different products had different expiration dates, for example dairy could be a three day expiration and fruit could be seven days from when the product was open. The DON said that upon hire for nursing staff, the care staff shadowed another employee during training, and were trained to check dates on items in the refrigerators and the temperature logs. The NHA said the expiration date on an opened product was three days in both unit refrigerators.

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to develop and implement effective action plans to address repeat deficiencies and ensure systemic and lasting improvement for quality of care issues. Findings include: I. Facility policy The Quality Assurance and Performance Improvement (QAPI) Plan, revised October 2022, was received from the nursing home administrator (NHA) on 6/8/23 at 12:47 p.m. The plan read in pertinent part, It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides.The QAPI plan will address the following elements: Tracking and measuring performance.Establishing goals and thresholds for performance improvements. Identifying and prioritizing quality deficiencies.Systematically analyzing underlying causes of systemic quality deficiencies. Developing and implementing corrective action or performance improvement activities.Monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. II. Cross-referenced citations Cross-reference F689: The facility failed to implement interventions to prevent resident falls. Cross-reference F692: The facility failed to identify and implement interventions to prevent significant weight loss. Cross reference F697: The facility failed to ensure an effective pain management program. Cross reference F805: The facility failed to ensure foods were prepared according to their diet orders. Cross reference F809: The facility failed to ensure a substantial snack was offered when meal times were greater than 14 hours. Cross reference F812: The facility failed to ensure foods were stored in a sanitary manner. III. Review of the facility's regulatory record revealed it failed to operate a QAPI program in a manner to prevent repeat deficiencies and initiate a plan to correct. F689 Accident prevention During the recertification survey on 4/11/23, F689 was cited at a G scope and severity. During the revisit survey on 6/8/23, the facility was cited at a E scope and severity. F692 Weight loss During the recertification survey on 4/11/23, F692 was cited at a G scope and severity. During the revisit survey on 6/8/23, the facility was cited at a G scope and severity. F697 Pain management During the recertification survey on 4/11/23, F697 was cited at a D scope and severity. During the revisit survey on 6/8/23, the facility was cited at a G (actual harm) which was an increased scope and severity. F805 During the recertification survey on 4/11/23 was cited at a D scope and severity. During the revisit survey on 6/8/23, the facility was cited at an increased scope and severity at an E. F809 During the recertification survey on 4/11/23was cited at an E scope and severity. During the revisit survey on 6/8/23, the facility was cited at an E scope and severity. F812 During the recertification survey on 4/11/23, F812 was cited at a F scope and severity. During the revisit survey on 6/8/23, , the facility was cited at a D scope and severity. IV. Interviews The NHA, director of nursing (DON) and regional director of operations (RDO) were interviewed on 6/8/23 at 5:22 p.m. The DON said the QAPI committee met monthly on the second Tuesday of the month with all department heads, the medical director and the pharmacist. She said no direct care floor staff attended the meetings. The DON said areas of concern were identified from concerns discussed in the daily morning meeting, grievance forms, clinical data gathered such as resident falls during the month and audits. The DON said the QAPI committee looked for trends and then root causes and then put a performance improvement plan in place. The DON said the committee reviewed the citations from the 4/11/23 recertification survey in the May 2023 QAPI. She said the committee had started to develop action plans at that time, but had not met to review progress since then. She said the department leaders met weekly to discuss the action plans from their recertification survey. The DON said falls were discussed at the QAPI meeting, however the committee had not identified that residents at risk for falls did not have fall care plans and interventions were not consistently implemented. The DON said significant weight loss was reviewed at QAPI when a resident triggered a significant loss. They DON said the registered dietitian (RD) reviewed weights weekly for changes. She said she was not sure why the RD had not addressed the significant weight loss. The DON said pain was reviewed at the QAPI committee if there was a concern. She said she did not know why there were residents without routine pain monitoring, pain goals, pain care plans or non-pharmacological interventions for pain. She said those were not things that had been identified by the committee. The NHA said the dietary manager (DM) had educated the staff and audited food textures. She said she was not aware of the continued deficiency in food texture. She said this had not been identified and she had not observed or audited the textures. The NHA said the facility had changed the time of meals and were offering a substantial snack at bedtime. She said the facility's weekly meeting to review their plans of correction had not identified any concern. She said they had not identified that the sign by the dining room still had meal time hours with a 14 hour gap between dinner and breakfast the following morning. She said the weekly facility meetings had not identified that residents were still not aware of the time change. She said the nursing staff were educated to offer a snack at bedtime. She said the DM was the only person auditing meal times and snacks offered. The NHA said food storage concerns were not identified by the QAPI process. She said the DM was monitoring refrigerators for labeled foods and foods beyond their use by date. She said she thought he had just missed it and the weekly meetings had not identified a concern.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to maintain an infection control and prevention program designed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to: -Assess where Legionella and other opportunistic waterborne pathogens could grow and spread; and, -Implement measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems according to nationally accepted standards. Findings include: I. Water management A. Professional reference According to the Centers for Disease Control (CDC), Legionella (Legionnaires Disease and Pontiac fever), last reviewed 3/25/21, retrieved from on 4/17/23: https://www.cdc.gov/legionella/wmp/toolkit/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Flegionella%2Fmaintenance%2Fwmp-toolkit.html and https://www.cdc.gov/legionella/wmp/overview.html. It read in pertinent part, Many buildings need a water management program to reduce the risk for Legionella growing and spreading within their water system and devices. Legionella bacteria are typically found naturally in [NAME] environments, but can become a health concern when they grow and spread in human-made water systems. Legionella can cause a serious type of pneumonia (lung infection) known as Legionnaires disease. Some water systems in buildings have a higher risk for Legionella growth and spread than others. Legionella water management programs are now an industry standard for many buildings in the United States. Legionella bacteria can cause a serious type of pneumonia (lung infection) called Legionnaires disease. Legionella bacteria can also cause a less serious illness called Pontiac fever. The key to preventing Legionnaires disease is to reduce the risk of Legionella growth and spread. Building owners and managers can do this by maintaining building water systems and implementing controls for Legionella. Water management programs identify hazardous conditions and take steps to minimize the growth and transmission of Legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program is a multi-step process that requires continuous review. Seven key elements of a Legionella water management program are to: -Establish a water management program team -Describe the building water systems using text and flow diagrams -Identify areas where Legionella could grow and spread -Decide where control measures should be applied and how to monitor them -Establish ways to intervene when control limits are not met -Make sure the program is running as designed (verification) and is effective (validation) -Document and communicate all the activities. Principles: In general, the principles of effective water management include: -Maintaining water temperatures outside the ideal range for Legionella growth - Preventing water stagnation -Ensuring adequate disinfection -Maintaining devices to prevent sediment, scale, corrosion, and biofilm, all of which provide a habitat and nutrients for Legionella. Once established, water management programs require regular monitoring of key areas for potentially hazardous conditions and the use of predetermined responses to respond when control measures are not met. A consultant with Legionella-specific environmental expertise may sometimes be helpful in implementing and operating water management programs. B. Facility policy and procedure The Water Management program revised on 1/1/23 read in pertinent part: It is the policy of this facility to establish water management plans for reducing the risk of legionellosis and other opportunistic pathogens in the facility's water systems based on nationally accepted standards. The maintenance director maintains documentation that describes the facility's water system evaluation potential environmental exposures performing an environmental assessment performing environmental sampling, as indicated by the environmental assessment In the event event of an update to the water management program, the water management team shall: Update the water system schematic/description, associated control limits, and predetermined corrective actions Train those responsible for implementing and monitoring the updated program. C. Interviews The director of maintenance was interviewed on 4/11/23 at 2:00 p.m. He said that he started the position three months ago and since then the facility did not initiate a water management plan. He said that the nursing home administrator (NHA) and himself were working to update the water management program which included using the Legionella Environmental Assessment Form from the CDC. He said before he became the director the facility did not have a plan in place. The NHA was interviewed on 4/11/23 at 2:15 p.m. She said that the facility had not implemented a water management plan as of the date of the survey but the facility had intentions to initiate the plan in the near future. She said that the current director of maintenance was only in the position for three months and the previous director had not completed a water management plan to her knowledge. She said that before the date of the survey she was under the impression that the facility only needed a policy but said moving forward the facility would implement a water management plan.

Based on record review and interviews, the facility failed to implement a training system to ensure certified nurse aides (CNAs) had no less than 12 hours of education in the required areas each year. Specifically, the facility failed to: -Ensure five of five CNAs (#1, #2, #5, #6, and #7) were provided the required 12 hours of annual training based on their start date; and, -Ensure abuse prevention training was provided to CNAs #1 and #5. Findings include: I. Facility policy The Nurse Aide Training Program policy, dated April 2019, was provided by the nursing home administrator (NHA) on 4/11/23 at 11:18 a.m. It read in pertinent part, Each nurse aide shall be provided at least 12 hours of in-service training annually, based on his/her employment date, not calendar year. The Staff Development Coordinator shall maintain documentation of training in his/her office during the current training year, and shall forward to the HR (human resources) Director at the completion of the training year to be maintained in the employee's personnel file. In-service training will be provided by qualified personnel and will be based on the special needs of the residents in the facility. Minimum training will include: Effective communication; dementia management and care of the cognitively impaired; abuse, neglect, and exploitation prevention; elements and goals of the facility's QAPI (quality assurance performance improvement) program; resident rights and facility responsibilities; written standards, policies, and procedures for the facility's infection prevention and control program; requirements under the facility's compliance and ethics program; safety and emergency procedure; and behavioral health. II. Record review A record of CNA in-services was provided by the NHA on 4/10/23 at 2:00 p.m. Start dates for the CNAs were requested on 4/10/23 at 2:45 p.m. but not provided. The NHA said only two CNAs had worked there for at least a year. The documented in-services provided were held monthly beginning on 8/18/22 and ending on 3/21/23 (eight months). Two additional in-services were held on 8/19/22 and 9/15/22 for one hour each. All documented in-services provided were one hour in length with the exception of the inservice on 12/20/22 and 1/17/23 which were 1.5 hours. The total hours of documented in-services provided was 11 hours. -However, multiple topics were covered during the in-services and topics were not broken down by time covered. Specifically: -CNA #1 had recorded five hours of inservice training that did not include abuse training. -CNA #2 had recorded 11 hours of inservice training. -CNA #5 had recorded six hours of inservice training that did not include abuse training. -CNA #6 had recorded three hours of inservice training. CNA #6 had a start date listed on a competency sheet as 5/15/18. -CNA #7 had recorded five hours of inservice training hours that did not include abuse training. III. Staff interviews The NHA was interviewed on 4/11/23 at 11:00 a.m. She said the facility started a new training binder for 2023 after the facility discovered in November 2022 competency and in-services were not kept track of. -However, according to the training information provided by the facility, the sample CNAs still did not have required training and hours. The director of nursing was interviewed on 4/11/23 at 11:30 a.m. She said the old inservice topics were too broad so the facility switched in November 2022 to the current format that had the inservice times listed on it. She said she did not think the training duration was listed on the sign in sheets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews the facility failed to develop and implement a comprehensive centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for one (#30) of five out of 25 sample residents. Specifically, the facility did not ensure care plans and interventions were developed for the resident's use of anticoagulant, antidiabetic and hypertensive medications for Resident #30. Findings include: I. Facility policy The Person Centered Care Plan policy, revised on 7/1/2019, was provided by the nursing home administrator on 1/18/22 at 1:43 p.m. The policy revealed the facility must develop and implement a baseline person-centered care plan within 48 hours for each resident that included the instructions needed to provide effective and person centered care that meet professional standards of quality care. The policy also revealed a comprehensive, individualized care plan would be developed within seven days after completion of the comprehensive assessment for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, nutrition, mental and psychosocial needs that were identified in the comprehensive assessments. The interdisciplinary team, in conjunction with the resident and/or resident representative (as appropriate) would establish the expected goals/outcomes of care, the type/amount/frequency/duration of care and any other factors related to the effectiveness of the plan of care. The care plan would be communicated to the appropriate staff, the resident, resident's representative and/or family. The care plan would be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and/or as needed to reflect the response to care and changing needs and goals. II. Resident #30 A. Resident status Resident #30, age [AGE], was admitted on [DATE]. According to the January 2022 computerized physician orders (CPO), diagnoses included diabetes mellitus with hyperglycemia, essential hypertension, and atrial fibrillation. The 12/17/21 minimum data set (MDS) assessment revealed the resident was modified independence in cognitive skills for daily decision making with no behaviors. The resident required extensive staff assistance for bed mobility, transfers, dressing, and toileting. The resident required limited staff assistance for personal hygiene. During the seven-day assessment period, the resident received an anticoagulant for seven days, and insulin for three days. B. Record review A physician order dated 12/10/21 at 1:21 p.m., revealed to administer Spironolactone tablet 25 milligrams (mg) orally in the morning for hypertension. A physician order dated 12/10/21 at 1:21 p.m., revealed to administer Pioglitazone HCl tablet 30 mg orally in the morning for Diabetes. A physician order dated 12/10/21 at 1:12 p.m., revealed to administer Xarelto Tablet 15 mg (Rivaroxaban) orally in the evening for A-fib. A physician order dated 12/10/21 at 1:21 p.m., revealed to administer Olmesartan Medoxomil tablet 20 mg orally in the morning for High BP Hold for SBP <110. A physician order dated 12/20/21 at 1:21 p.m., revealed to administer (inject) Humalog Solution 100 units/milliliter per the following sliding scale: if 0 - 150 = 0 units Call MD if blood glucose is less than 70; 151 - 200 = 2 units; 201 - 250 = 4 units; 251 - 300 = 6 units; 301 - 350 = 8 units; 351+ = 10 units call MD immediately for further instruction if blood glucose is greater than 400, subcutaneously before meals and at bedtime for Type 2 Diabetes. The medication administration record (MAR) for December 2021 revealed the resident was administering: Spironolactone 21 times, Pioglitazone 21 times, Xarelto 22 times, Olmesartan Medoxomil 17 times and sliding scale insulin nine times. The medication administration record (MAR) for January 2022 revealed the resident was administering: Spironolactone 14 times, Pioglitazone 14 times, Xarelto 13 times, Olmesartan Medoxomil 14 times and sliding scale insulin two times. The resident's clinical record was reviewed on 1/17/22 at 11:30 p.m. The record did not contain plans of care with interventions for the use of anticoagulant, antidiabetic and hypertensive medications. IV. Staff interviews The director of nursing (DON) was interviewed on 1/17/22 at 12:43 p.m. She said there were no care plans for diabetes, hypertension and anticoagulant medications for Resident #30. She said care plans should have been developed with interventions for each of the medications. She said she was responsible for the development of the care plans. She said care plans alerted the staff on the resident's preferences and how to care for the resident. She said interventions for the care plans further told the staff on how to care for the resident. The nursing home administrator (NHA) #2 was interviewed on 1/17/22 at 12:52 p.m. She said care plans were developed to meet the resident's needs, specific interests, interests, behaviors, likes/dislikes, preferences and things that they enjoy. It should contain information on anything that makes the resident unique.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility failed to ensure residents had the right to a safe, clean and comfortable homelike environment for six out of 16 resident rooms. Specifically, the facility did not facilitate the necessary housekeeping and maintenance services to maintain the resident rooms to include room [ROOM NUMBER], #117, #118, #120, #128, and #130 in a sanitary and comfortable manner. Findings include: 1. Facility policies The Preventive Maintenance Policy, revised on 6/1/2007, was provided by the nursing home administrator (NHA) #2 on 1/18/22 at 1:43 p.m. The policy revealed the facility was to facilitate a program in place that scheduled preventive maintenance on equipment and the physical plant (facility). The request for routine maintenance on the physical plant, fixtures and equipment would require a work order. An inspection of the physical plant would be performed quarterly that included resident rooms for paint/paper in good condition. The Cleaning: Resident/Patient Areas policy, effective on 11/1/2007, was provided by NHA #2 on 1/17/22 at 12:17 p.m. The policy revealed the resident rooms were cleaned daily. The resident ' s room was cleaned using a seven step cleaning procedure that included high dusting, spot cleaning, surface sanitization, bathroom cleaning, waste collection, floor dust mopping, floor wet mopping and a visual inspection after these procedures and correcting any issues before leaving the room. II. Room observations An environment tour of the facility was conducted on 1/13/22 at 9:00 a.m. The following concerns were identified: One resident resided in room [ROOM NUMBER]. Observations revealed there were two broken horizontal window blinds, chipped paint on the room metal heater cover, four screws heads protruding from one room wall, chipped paint on one room wall, chipped paint on one room wall corner edge, chipped paint on the bathroom door frame, one non-functional light in the bathroom, sheet rock damage adjacent to the bathroom hand soap dispenser, three unfinished sheetrock patches on one bathroom wall, two broken floor tiles, loud bathroom exhaust fan and sheet rock damage on one room corner by the closet. Two residents resided in room [ROOM NUMBER]. Observations revealed there was one missing bathroom light cover, one wood shelf lying on the bathroom floor, chipped paint on the bathroom door frame, dirty bathroom transition strip with a piece of tape attached to the strip, two missing room floor tiles, one missing handle on dresser by the bathroom, torn cove base on at room corner near the bathroom, dirty (marked with an unclean substance) room floor, dirty room corners, and three plastic soufflé cups on the floor. Two residents resided in room [ROOM NUMBER]. Observations revealed there was torn wallpaper on one room wall, one hole in the closet door, dirty room corners, scraped sheetrock on one wall at the room entrance, and chipped paint on the bathroom door frame. Two residents resided in room [ROOM NUMBER]. Observations revealed there was chipped paint on the bathroom door frame, multiple black marks on one bathroom wall, one piece of missing room cove base, dirty room corners and two missing floor tiles. One resident resided in room [ROOM NUMBER]. Observations revealed there was chipped paint on the entrance door frame, two dirty room privacy curtains, chipped paint on one room wall, four metal wall anchors on one bathroom wall, cracked caulk where the sink contacts the bathroom wall, cracked bathroom linoleum floor, chipped paint on the bathroom door frame, one missing bathroom transition strip, dirty caulk around toilet base, and dirty room corners. Three residents resided in room [ROOM NUMBER]. Observations revealed there was chipped paint on the bathroom door frame, chipped pain on the bathroom metal heater cover, three small holes in one bathroom wall, chipped paint adjacent to the sink, cracked caulk where the sink contacts the bathroom wall, cracked bathroom linoleum floor, dirty caulk around the toilet base, three black marks on one bathroom wall, unfinished ceiling sheetrock patch at the room closet, missing closet cove base, two broken floor tiles, loose room wallpaper, non-matched room wallpaper, dirty room ceiling light plastic cover, torn wall paper behind one headboard, chipped paint on one room wall, chipped paint on the metal room heater cover, room heater pulled away from the wall, one broken window blind and chipped paint on entrance door frame. III. Staff interviews The NHA and the maintenance director (MD) accompanied the surveyor on a second environmental tour on 1/17/22 at 8:45 a.m. The above mentioned concerns were observed by the MD and the NHA. The MD said the facility used the TELS (facility management computerized program) and staff could access the system to generate work orders. He said he reviewed the TELS system daily. The MD said he did not have any work orders for the above concerns. He said when a resident room became vacant, he did an audit of the room and repaired any concerns found in the room. The environmental services manager (ESM) was interviewed on 1/17/22 at 9:18 a.m. She said each resident room was swept and mopped daily. She said each resident room was also thoroughly (deep) cleaned once a month. She observed resident room [ROOM NUMBER] and agreed it needed to be swept/mopped and cleaner than it was at this time. She said the service contractor she worked for usually assigned one housekeeper and one manager in training to this facility. She said the service contractor had been short on staff since November 2021.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide assistance with activities of daily living (ADLs) to ensure the highest practicable quality of life and care, for five (#11, #23, #32, #3, and #10) of six residents reviewed out of 25 sample residents. Specifically, the facility failed to: -Provide regular and consistent showers according to preferences and plan of care for Residents #11, #23, #32, #3, and #10 who needed assistance with ADLs. Findings include: I. Facility policy The Activities of Daily Living policy, revised on 6/1/2021, was provided by the nursing home administrator (NHA) #2 on 1/17/22 at 1:43 p.m. The policy revealed, based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure a resident's ADLs (bathing) were maintained or improved and did not diminish unless circumstances of the individual's clinical condition demonstrate a change was unavoidable. The purpose of the policy was to ensure ADLs were provided with accepted standards of practice, the care plan and the resident's choices and preferences. II. Resident #11 A. Resident status Resident #11, age [AGE], was admitted on [DATE]. According to the January 2022 computerized physician orders (CPO), diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side and aphasia. The 11/5/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required supervision with bed mobility and limited assistance with transfers. Bathing assistance needs were not specified. It documented bathing activity did not occur. No rejection of care documented. B. Resident interview and observation Resident #11 was interviewed on 1/12/22 at 11:36 a.m. She was seated in her wheelchair in her room. She said she is supposed to receive showers two times a week but only received one shower or sometimes did not receive any showers during the week. She said the staff said there was not enough staff to provide her showers. She said she had not had a shower for the past week and she feels dirty. She said she would like to have a shower. C. Record review The comprehensive care plan, revised on 5/18/21, identified Resident #11 required assistance for ADLs care in bathing, grooming, personal hygiene, dressing, bed mobility, transfer, locomotion, toileting related to chronic disease/condition and had an activity of daily living (ADL) self-care. Intervention included: Stand on weaker side of resident right side when assisting with ADLs or other activities, provide resident with extensive assistance of one person for bed mobility, encourage the use of left side and bed cane to assist and provide resident with extensive assistance of one person for bathing. Resident #11 likes shower two times a week. The shower schedule was reviewed. It documented, Resident #11 shower days were Mondays and Thursdays. -The facility was unable to provide showers documentation for December 2021 indicating the resident did not receive any showers in December 2021. The January 2021 shower record was reviewed. It documented the Resident #11 received two showers and missed three. There was no documentation that the resident refused showers. III. Resident #23 A. Resident status Resident #23, age [AGE], was initially admitted on [DATE] and was readmitted on [DATE]. According to the January 2021 CPO, diagnoses included muscle weakness and difficulty in walking. The 12/8/21 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. She required extensive assistance with bed mobility, total dependence with transfer and bathing. No rejection of care documented. B. Resident interview and observation Resident #23 was interviewed on 1/12/22 at 12:07 p.m. She was observed lying in her bed. She said her hair was greasy and she needed it washed. Resident's hair was observed to be greasy. She said she had not received showers for two weeks. She said she was supposed to receive two showers a week. She said her shower days were Mondays and Thursdays. She said she would ask the certified nurse aide (CNA) to give her a shower but the CNA would tell her there was not enough staff to assist with showers. C. Record review The comprehensive care plan failed to include the resident's preference for showers, how often she would like shower/bath and what assistance was required. The shower schedule was reviewed. It documented, Resident #23 shower day was Wednesday. (once a week). -However, during the resident's interview, she said she would like to receive showers twice a week. Review of the bath/shower record for December 2021, there were no showers documented indicating the resident did not receive any showers. Review of the bath/shower record for January 2022, revealed the resident had one shower on 1/5/21 out of five opportunities. -No refusals were documented. IV. Resident #32 A. Resident status Resident #32, age [AGE], was initially admitted on [DATE] and readmitted on [DATE].According to the January 2022 CPO, diagnoses included muscle weakness and pain in right knee. The 12/23/21 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required supervision with bed mobility, transfers and personal hygiene. There was no rejection of care documented. B. Resident interview and observation Resident #32 was interviewed on 1/12/22 at 1:00 p.m. She said she had not had a shower for a week. She said she was supposed to receive two showers a week. Her hair was greasy and sticky in appearance. She said her hair needed to be washed. She said a CNA said there was not enough staff to provide showers. She said today was her shower day and was looking forward to receiving a shower but the CNA said there was not enough staff to provide showers. Resident #32 was interviewed again on 1/13/22 at 10:00 a.m. She said she did not receive a shower again this morning. She said she asked a CNA but she said the shower aide did not come to work. She said they did not have enough staff. She said she was disappointed because she wanted to wash her hair. C. Record review The care plan, revised on 8/6/21, identified Resident #32 was at risk for decreased ability to perform ADLs in specify: bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer, locomotion, toileting related to acute respiratory distress and congestive heart failure (CHF). Interventions included: To provide resident with extensive assistance with bathing and dressing. -The care plan failed to include the resident's preference for showers and how often she would like showers/baths. The shower schedule was reviewed. It documented, Resident #32 shower day was Wednesday. (once a week). -However, during the resident's interview, she said she would like to receive showers twice a week. Review of the bath/shower record for December 2021, revealed the resident did not receive any showers missing eight opportunities. Review of the bath/shower record for January 2021, revealed the resident had one shower on 1/13/21 out of five opportunities. V. Resident #3 A. Resident status Resident #3, age [AGE], was admitted on [DATE]. According to the January 2022 computerized physician orders (CPO), diagnoses included schizophrenia, vascular dementia, muscle weakness, and difficulty walking. The 10/6/21 minimum data set (MDS) assessment revealed the resident was moderately impaired in cognition with a brief interview for mental status (BIMS) score of 11 out of 15. The resident required extensive staff assistance for dressing and toileting. The resident required limited staff assistance for bed mobility, transfers and personal hygiene. The MDS revealed the bathing activity did not occur during the seven-day assessment period. B. Resident interview The resident was interviewed on 1/12/22 at 1:15 p.m. She said she usually received one shower on Tuesdays and she would like at least two showers per week. She said she was not sure why she was not getting two showers per week. She said she was really ready for her next shower. C. Record review A care plan, revised on 4/1/2020, revealed the resident required assistance with ADLs that included bathing related to vascular dementia, low back pain and a history of schizophrenia. One of the interventions was to provide the resident with the opportunity for her bathing preference: a tub bath twice a week in the morning, add bubble bath to the water, and pull the privacy curtain during the bath. After she washed herself, the resident liked to have the tub jets on for a while to relax. The weekly bathing schedule revealed the resident received showers on Tuesdays and Fridays. The weekly skin/bath reports and the point click care (PCC) computerized clinical record for the resident revealed that for the month of November 2021, the resident refused a shower on the 9th and received three showers on the 12th, 26th and 30th out of eight opportunities. For the month of December 2021, the resident refused a shower on the 7th out of eight opportunities. For the month of January 2022, the resident refused a shower on the 11th out of four opportunities. VI. Resident #10 A. Resident status Resident #10, age [AGE], was admitted on [DATE]. According to the January 2022 computerized physician orders (CPO), diagnoses included Parkinson's disease, bipolar disorder, seizures, muscle weakness, and lack of coordination. The 11/9/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required supervision for bed mobility, transfers, dressing, eating, toileting and personal hygiene. The resident required the assistance of one staff member for bathing. B. Resident interview The resident was interviewed on 1/13/22 at 3:04 p.m. She said sometimes she did not receive a shower because the facility only had CNA in the hall and with only one CNA, some showers could not be given. She said she would like at least two showers per week. She said not getting a shower made her feel unclean. C. Record review The care plan, revised on 5/6/2021, revealed the resident required assistance with ADLs that included bathing related to fatigue, activity intolerance, limited mobility and recent illness with a hospitalization. One of the interventions was to monitor for ADL decline in function. The care plan did not specifically have interventions related to bathing. The weekly bathing schedule revealed the resident received showers on Mondays and Thursday. The weekly skin/bath reports and the PCC documentation for the resident revealed that for the month of December 2021, the resident received four showers on the 7th, 18th, 28th and 29th out of eight opportunities. VII. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 1/17/22 at 8:00 a.m. She said staffing had been a challenge. She said usually there were three CNAs scheduled, one was the shower aide. She said they had been working with two CNAs which made it difficult to provide showers to the residents on their scheduled days. She said sometimes residents complain to her that they have not received showers as scheduled. She said they tried to accommodate the residents by providing showers the next day but it was not always possible due to not enough staff. The director of nursing (DON) was interviewed on 1/17/22 at 10:00 a.m. She said staffing had been a challenge. She said there had not been enough staff to meet the resident's needs such as showers. She said some residents do not receive showers as scheduled due to not enough staff. She said the staff do the best they can to meet the basic needs of the residents such as meals assistance and toileting. She said Residents #11, #23 and #32 had missed several showers as scheduled. She said the facility is hiring more staff now. She said moving forward she would ensure showers are being provided as scheduled. The director of nursing (DON) was interviewed again on 1/17/22 at 12:26 p.m., and again at 2:04 p.m. She acknowledged that the Resident #3 and Resident #10 received her showers on Tuesdays and Fridays according to the bath schedule. She said to her knowledge the residents did not refuse showers. She said each resident should get two or more showers per week if they want them. She said the certified nurse aides (CNAs) provided showers to residents. She said if a resident refused a shower, it would be documented in point-click care (PCC) , the facility's computerized resident clinical record and on the weekly skin/bath reports. She said the staff member that was with a resident should document as soon as the shower was completed. She said the reason some showers were not provided to residents was because a scheduled CNA would call off from work and the facility was unable to find a replacement for that CNA. She said at times the facility had a lack of staff to provide showers to residents according to their preferences. She said sometimes a nurse would provide a shower to a resident. Certified nurse aide (CNA) #4 was interviewed on 1/17/22 at 1:11 p.m. He said usually there should be three CNAs scheduled which one was responsible to provide showers. He said they had been working with two CNAs which made it difficult to provide showers as scheduled. He said they tried to accommodate the residents by providing showers the next day but it does not usually happen. He said due to not enough staff showers do not get done. The NHA #2 was interviewed on 1/17/22 at 1:13 p.m. She said a resident should receive two or more showers per week if they want them. She said CNAs that assisted residents with care also provided showers. The CNA #1 was interviewed on 1/18/22 at 10:31 a.m. She said she did provide showers to residents when the facility was able to staff three CNAs to the skilled side of the facility. She said the resident's days to receive a shower was documented on the weekly bathing schedule. She said she documented when a shower was provided in PCC and on the weekly skin/bath reports at the end of her shift. She said at times she had to stay past her shift to complete her shower documentation. She said she could chart in PCC and on the weekly skin/bath reports that a resident refused a showers. She said if a resident refused a shower she would tell a nurse of the refusal and also chart the refusal. She said residents rarely refuse a shower. She said sometimes showers were not provided because the facility was understaffed. She said she did not have sufficient time to shower all of the residents according to the daily bathing schedule. She said some residents have expressed to her there was not enough staff to provide showers. She said she had apologized to residents at times because she could not provide the resident with a shower as scheduled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide an ongoing program to support residents in their choice activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the memory care unit for four (#1, #27, # 31and #38) of six out of 25 sample residents. Specifically, the facility failed to invite and offer activities of choice to Residents #1, #27,# 31 and #38 in the memory care unit. Findings include: I. Facility policy The Recreation Services policy and procedures, revised 4/1/18, was provided by the activity director (AD) on 1/17/22. It read in pertinent part, residents/patients have the right to participate or not participate in leisure of their choosing. The purpose is to provide opportunities for leisure, recreation, and social involvement. Residents will be invited to attend activities and will be provided the opportunity to participate in structured and individual programs. Preferences for individuals who have dementia will be determined through communication with the resident, family, friends or caregivers. Assistance will be provided for the residents who wish to participate but are not able to get activities on their own. II. Activity schedule 1/12/22-Household chores, News update, Reminiscing, snack and Reminiscing. 1/13/22- Morning reminisce, Friendly visits, Household chores, Music time and walk about. 1/17/22- Morning reminisce, Friendly visits, Household chores, Music time and walk about. 1/18/22- Household chores, moving to music, Balloon Toss, reminiscing and television (TV) classics. -The above scheduled activities did not include scheduled times when activities would be held. III. Resident #1 A. Resident status Resident #1, age [AGE], was admitted on [DATE]. According to the January 2022 computerized physician orders (CPO), diagnosis included vascular dementia without behavioral disturbance. The 10/4/21 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of four out of 15. She was usually understood and sometimes understood by others. She had no rejection of care documented, but she wandered daily. She required limited assistance with bed mobility and transfers. Activities preferences were not assessed. B. Observations On 1/12/22 at 11:05 a.m. the resident was sitting in the common area. There were two staff members Present(unidentified) The television (TV) was on but the resident was not watching it. She was sitting at the table and was looking towards the floor. There was no activity observed on the unit. On 1/13/22 from 10:00 a.m. to 11:45 a.m., Resident #1 was sitting in the common area. The TV was on but she was not watching it. She was looking towards the door. There was no music on (western music) she liked as documented in her plan of care. At 10:20 a.m., she was observed to walk up and down the hall. She went back to her seat and continued to look towards the door. There was no activity observed on the unit. Two staff members were present and did not offer any activity to the residents. On 1/18/22 at 10:00 a.m., Resident #1 was observed sitting in a chair at the table. There was no activity observed on the unit. Resident #1 appeared to be bored and was sitting with her hands folded. Two staff members were present and did not offer activity to the resident. C. Record review The comprehensive care plan, revised on 1/11/22, identified that the resident enjoyed walking up and down the hallways and going outside. It further identified, the resident liked country western music and calming relaxing sounds. Interventions included: Staff will invite, remind, and encourage resident to activities of her interest, will provide resident with a monthly room activity calendar. Staff will respect resident's wishes to decline in activity of her interest. The recreation quarterly progress note and care plan evaluation, dated 1/4/22, was reviewed. It documented that the resident preferred to participate in activity in the mornings and afternoons one to three times a week and would participate in group activities. It documented the most frequently group programs the resident participated in was to watch live music and sometimes sit for activity The January 2022 activity participation log was requested during the survey from 1/12-1/19/22. The facility was unable to provide Resident's #1 participation log. III. Resident #27 A. Resident status Resident #27, age [AGE], was initially admitted on [DATE] and readmitted on [DATE]. According to the January 2022 CPO, diagnoses include Alzheimer's disease and cognitive communication deficit. The 12/14/21 MDS assessments revealed the resident had severe cognitive impairments with a BIMS score of zero out of 15. She had a clear speech. She sometimes makes self-understood and sometimes understands others. She required extensive assistance with bed mobility and transfers. Rejection of care happened one to three days. It documented activities preferences could not be completed by resident or family. B. Observations On 1/12/22 at 11:10 a.m. Resident #27 was sitting in the common area. There were two staff members Present(unidentified). She was sitting at the table with her head bent over. There was no activity observed on the unit and no activity was offered to the resident. On 1/13/22 from 10:00 a.m. to 11:45 a.m., Resident #27 was sitting in the common area. The TV was on but she was not watching it. There was no music on for the resident to listen to as documented in her plan of care. She was doing nothing and looking around. There were two staff members present and no one offered any activities to the resident. On 1/18/22 at 10:00 a.m., Resident #27 was observed sitting in a chair at the table. There was no activity observed on the unit. Resident #27 was looking around. There were two staff members on the unit and no one offered activities to the resident. C. Record review The comprehensive care plan, revised on 3/16/21, identified the resident enjoyed spending time in the common area visiting with her peers and staff, walking around outside and in the facility, assisting with cleaning and organizing, watching tv, listening to music, dancing and ladies tea time. Interventions: staff will invite, remind and encourage the resident to activities of her interest and provide the resident with a monthly calendar. The January 2022 activity participation log was requested during the survey from 1/12-1/19/22. The facility was unable to provide Resident's #27 participation log. -The resident was not offered any of the activities she enjoyed doing as documented in her care plan (see above). IV. Resident #31 A. Resident status Resident #31, age [AGE], was initially admitted on [DATE] and readmitted on [DATE]. According to the January 2022 CPO, diagnoses included Alzheimer's disease and generalized anxiety disorder. The 12/23/21 MDS assessments revealed the resident had a severe cognitive impairment with a BIMs score of zero out of 15. She required extensive assistance with bed mobility and transfer. She had no behaviors documented. B. Observations On 1/12/22 at 11:05 a.m. Resident #31 was lying in her recliner in the common area. There were two staff members Present(unidentified). The TV was on but the resident was not watching it. She was lying down with her eyes closed At 11:10 a.m., she sat up in the recliner. She was looking around the room. No activity was observed on the unit.The staff did not offerre activity to the resident. On 1/13/22 from 10:00 a.m. to 11:45 a.m., Resident #31 was lying in her recliner in the common area. The TV was on but she was not watching it. She was looking towards the door. There was no music on for the resident to listen to as documented in her care plan. She was observed to walk up and down the hall and the certified nurse aide(CNA)(unidentified) redirected the resident to sit down. There was no activity going on. There were two staff members who did not offer any activity to the resident. On 1/18/22 at 10:05 a.m., Resident #31 was observed lying in her recliner. There was no activity staff on the unit. The resident was staring across the room. She appeared to be bored. C. Record review The comprehensive care plan, revised on 7/19/21, identified the resident enjoyed walking outside on a daily basis and showed little interest in scheduled group activities, looking at pictures, helping other people, looking at picture books of animals and flowers, watching tv, taking naps and going outside. Interventions include: staff will provide resident with a monthly room activity calendar, provide materials for self-directed activities as needed and respect resident's decision to pursue self-directed activities. The 4/8/21, activities preferences, revealed it was very important to Resident #31 to have books/newspapers to read, listen to music she liked and have animals around such as pets. The January 2022 activity participation log was requested during the survey from 1/12-1/19/22. The facility was unable to provide Resident #31's participation log. -The resident was not offered any of the activities she enjoyed doing as documented in her care plan (see above). IV. Resident #38 A. Resident status Resident #38, age [AGE], was initially admitted on [DATE] and readmitted on [DATE]. According to the January 2022 CPO, diagnoses included dementia without behavioral disturbances and cognitive communication deficits. The 12/31/21 MDS assessments revealed the resident had a severe cognitive impairment with a BIMs score of three out of 15. She required limited assistance with bed mobility and transfers. She had verbal behaviors one to three days a week. The activity preference section documented that it was very important to listen to music and participate in religious services. B. Resident observation and interview On 1/12/22 at 11:14 a.m., Resident #38 was lying in bed in her room. There was a TV in her room but it was not turned on. She said no one offered her anything to do. She said she was bored just being in her room doing nothing. On 1/13/22 at 11:45 a.m., the resident was lying on her bed without any stimulation. The TV was not turned on. She was looking at the ceiling. On 1/17/22 at 3:16 p.m., the resident was observed lying on her bed in her room. She said she stayed in her room most of the time because there was nothing to do in the common area. She said there was no activity staff to offer activity and she was bored. C. Record review The comprehensive care plan, revised on 10/22/21, identified the resident enjoyed watching musical tv, puzzle books, singing songs, resting, loved drinking coke, getting her nails painted, but when asked she will say there is nothing to paint. She expressed interest in all activities, however, she often refuses when she is tired or doesn't feel well. She is Methodist and expressed interest in any spiritual services. Interventions include: staff will invite, remind, and encourage the resident to scheduled group activities, provide the resident with a monthly room activity calendar and will respect the resident's wishes to decline in activity of her interest. The January 2022 activity participation log was requested during the survey from 1/12-1/19/22. The facility was unable to provide Resident #38's participation log. -The resident was not offered any of the activities she enjoyed doing as documented in her care plan (see above). V. Staff interviews The certified nurse aide (CNA) #4 was interviewed on 1/17/22 at 1:15 p.m. She said she was from the agency but had not observed activity this week on the unit. She said there were activity materials in the drawer and sometimes she would offer puzzles or play music for the residents. She said there was a staff member who sometimes came to the memory care unit to sing and play guitar for the residents. She said she had not seen the staff for a while. She said there was another activity staff member who provided activities on the open unit but was not sure if she worked on the memory care unit. She said she had not seen any activities being offered to the residents this week. The activity assistant (AA) was interviewed on 1/17/22 at 1:25 p.m. She said she was assigned to the open unit. She said she did not work on the memory care unit. She said there was another activity staff member who worked on the memory care unit. She said she believed the staff was part-time. She said she had not seen her this week. The activity director (AD), who was also the social service director, was interviewed on 1/17/22 at 1:30 p.m. She said she had two activity assistants. She said one staff member worked full time and was assigned to the open unit and the other staff worked part-time and was assigned to the memory care unit. She said the part-time staff member worked every Tuesday and alternate every other Thursday and the weekend. She acknowledged that the memory care unit residents were not offered activities. She said she provided education to the nursing staff to assist in offering activities to the residents when the activity assistants were not available. She said she expected the nursing staff to offer activities to the residents and encourage participation. She said she would check in again with the nursing staff and re-educate them about offering activities to the residents in the absence of the activity assistant. She said the activity staff were not documenting participation in activities. She said she would provide education to the nursing staff to document any activity provided to the residents on the report sheet and she would then document it in the electronic record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** IV. Resident #15 A. Resident status Resident #15, age [AGE], was initially admitted [DATE] and readmitted on [DATE]. According to the January 2022 (CPO), diagnoses included vascular dementia with behavioral disturbances and generalized anxiety disorder. The 11/8/21 MDS assessment revealed the resident had a severe cognitive impairment and was unable to complete the BIMS score due to resident rarely or never understood. He had no behaviors documented. It documented the resident receive antipsychotic, antidepressants and antianxiety medications daily. B. Record review The care plan, revised on 8/25/21, identified the resident was at risk for distressed/fluctuating mood symptoms related to sadness/depression caused by major depression, anxiety(specify. Recent changes affecting daily routine. He is taking antianxiety, antidepressants and antipsychotic medication for this. He has behaviors such as making loud noises when care is needed. Interventions included: Non-pharmaceutical interventions: 1:1 (one-to-one) attention, offer food or drink, offer activity of choice, remove stressor, redirect resident, monitor lab test results and report abnormal results to physician/mid-level practitioner, monitor for signs of delusions/hallucinations, notify physician. -The care plan failed to identify that the target behaviors should be tracked and monitored for the use of Ativan, Zyprexa and Zoloft. The October 2021 pharmacy recommendation read: Resident #15 has not had an assessment of renal function within the past six months. Please monitor a basic metabolic panel(BMP) with serum creative on the next convenient lab day and at least every six months thereafter. Assessment of renal function is beneficial for drug dosing, medication monitoring and assessment or identification of renal disease. -The facility failed to address the pharmacy recommendation above.(was not addressed three months after the recommendation was made). The January 2022 CPO documented: Ativan tablet 0.5 milligram(mg) dated 8/15/2020, give one tablet by mouth two times daily for dementia with behavioral disturbance, Zyprexa tablet 2.5mg dated 11/14/2021,give one tablet one time a day for dementia with behaviors and Zoloft 50mg dated 11/14/2021, give one tablet by mouth in the morning. The January 2022 medication administration records (MAR) read, Ativan tablet 0.5 mg, give one tablet by mouth two times daily for dementia with behavioral disturbance, Zyprexa tablet 2.5mg, give one tablet one time a day for dementia with behaviors and Zoloft 50mg, give one tablet by mouth in the morning. -There was no evidence in the medical record that behaviors were tracked and monitored for the use of medications listed above. V. Resident #31 A. Resident status Resident #31, age [AGE], was initially admitted on [DATE], readmitted on [DATE]. According to the January 2022 CPO, diagnoses included Alzheimer's disease and generalized anxiety disorder. The 12/23/21 MDS assessments revealed the resident had a severe cognitive impairment with a BIMs score of zero out of 15. She required extensive assistance with bed mobility and transfer. She had no behaviors documented. It documented the resident received anti-anxiety and antipsychotic medications daily. B. Record review The care plan, revised 9/14/18, identified the resident exhibits or had the potential to exhibit physical behaviors related to cognitive loss/dementia, depression diagnosis. Resident take an antipsychotic for dementia with behavioral disturbance and antidepressant for depression. Interventions included: If resident becomes combative or resistive, postpone care/activity and allow time for her to regain composure, observe for nonverbal signs of physical aggression, provide a calm, quiet lit environment and encourage resident to seek staff support for distressed mood. -The care plan failed to identify the target behaviors that were being treated with the use of antianxiety and antipsychotic medications. It also failed to include tracking and monitoring behaviors for the continued use of the medications. The January 2022 CPO documented: Ativan tablet 0.5 mg dated 10/30/2021, give one tablet by mouth in the afternoon for anxiety and Seroquel 50mg dated 5/31/2021, give two times a day every Tuesdays, Thursdays, Fridays, Saturdays and Sundays for agitation. The January 2022 MAR read, Ativan tablet 0.5 mg, give one tablet by mouth in the afternoon for anxiety and Seroquel 50mg two times a day every Tuesdays, Thursdays, Fridays, Saturdays and Sundays for agitation. -The medical record failed to include behaviors tracking and monitoring for the use of antianxiety and antipsychotic medications. VI. Staff interviews The social service director (SSD) was interviewed on 1/17/22 at 4:05 p.m. She said she was new in her role and she was a part of the psychotropic medication review. She said Residents #15 and #31's behaviors should be tracked and monitored to determine if the medication was effective or not. She said the staff were not tracking and monitoring behaviors. She said the corporate office was implementing a system of point click care (PCC) that would alert the staff of specific behaviors to track and monitor. She said she did not know exactly when it would be implemented but it would happen soon. She said staff would be educated immediately on tracking and monitoring specific behaviors. The director of nursing was interviewed on 1/17/22 at 4:15 p.m. She said she had been in her position for about four months and she was a travel DON. She said the staff should document and monitor specific behaviors for the use of psychotropic medications. She said Resident #15 and #31's behaviors were not tracked and monitored. She said she was not aware that Resident #15's pharmacy recommendation since October 2021 had not been addressed. She said Resident #15 BMP was scheduled to be done today after the facility was made aware (three months later). She said education would be provided to staff on behavior tracking and monitoring. Based on observations, record review and interviews, the facility failed to ensure consents were obtained, behaviors were tracked/monitored and pharmacist recommendations were followed for the use of psychotropic medications for four (#2, #3, #15 and #31) of five out of 25 sample residents. Specifically, the facility failed to ensure: -Resident #2: the resident or their representative gave consent for the use of Sertraline (antidepressant) prior to its administration. The facility also did not initiate a methodology of tracking/monitoring the resident's behaviors for the use of this medication. The facility failed to have a specific care plan for the Sertraline medication. -Resident #3: the facility did not initiate a methodology of tracking/monitoring the resident's behaviors for the use of Risperidone (antipsychotic), Duloxetine (antidepressant) and Lorazepam (antianxiety) -Resident #15: the facility did not follow the pharmacist's recommendations and did not initiate a methodology of tracking/monitoring the resident's behaviors for the use of Lorazepam, Sertraline, and Olanzapine (antipsychotic) medications. -Resident #31: the facility did not initiate a methodology of tracking/monitoring the resident's behaviors for the use of Lorazepam, Seroquel (antipsychotic) and Sertraline medications. Findings include: I. Facility policy The Behaviors Management of Symptoms policy, revised on 6/1/21, was provided by the nursing home administrator (NHA) #2 on 1/17/22 at 1:43 p.m. The policy revealed for staff to observe for the early signs of withdrawal/decreased social interactions, frustration, agitation, and anger such as physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, and other behavioral symptoms not directed toward others. The policy revealed in the state of California, a medication cannot be administered without written or verbal consent. The policy did not elaborate on the state of Colorado. The policy also revealed if a resident could be managed in the facility, initiate the Behavior Monitoring and Interventions Flow Record. This record was used for residents receiving psychotropic medications including antipsychotics. The record would be used as long as the resident was administered the medications. The record was used to identify patterns, possible causes, results of non-pharmacological interventions and side effects of the medications if any were present. If non-pharmacological approaches were not successful, consult with the resident's physician for alternative treatments. The policy further revealed that if challenging behavioral symptoms persist, notify the resident physician to report the onset, frequency, duration, severity, causes and consequences of the problem behavior, as documented in the Behavior Monitoring and Interventions Flow Record and the Psychotropic/therapeutic Medication Use Evaluation. If indicated, consider a possible referral to the consultant pharmacist and/or behavioral health services, if indicated. The policy did reveal the frequency that a pharmacist would review each resident's medications and did not elaborate that the facility had to follow pharmacist recommendations. II. Resident #2 A. Resident status Resident #2, age [AGE], was admitted on [DATE]. According to the January 2022 computerized physician orders (CPO), pertinent diagnoses included dementia without behaviors, encephalopathy, attention/concentration deficits and encounters with palliative care. The minimum data set (MDS) dated [DATE] noted the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of five out of 15 with no behaviors. The resident had difficulty focusing her attention as evidenced by being easily distractible or having difficulty keeping track of what was said (behavior present, fluctuates that comes and goes, changes in severity). The resident had disorganized or incoherent thinking as evidenced by rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject (behavior present, fluctuations that come and goes, changes in severity). The resident felt down, depressed, or hopeless. The resident required extensive staff assistance for bed mobility, transfers, dressing, and toileting. The resident received hospice services and was administered an antidepressant medication for seven days during the assessment period. B. Record review A physician's order dated 4/10/21 at 7:00 a.m., revealed to administer Sertraline 75 HCL milligrams (mg) by mouth once a day for depression and to discontinue this medication on 1/12/22. A physician's order dated 1/12/22 at 1:58 p.m., revealed to administer Sertraline HCL 75 mg by mouth once a day in the morning for depression. The care plan, revised on 4/30/2021, revealed the resident was at risk for complications related to the use of an antidepressant psychotropic medication. Some of the interventions were to monitor for changes in mental status and/or functional level and report to her physician as indicated. Monitor for the continued need of the medications as related to mood and behavior. Staff were to complete the behavior monitoring flow sheet. -There were no specific interventions or non-pharmacological interventions for the use of an anti-depressant medication. The care plan, revised on 10/27/2021 revealed the resident was resistant to care related to mood/psychiatric disorders of encephalopathy, cognitive loss/dementia. Some of the interventions were that if the resident became combative or resistant, staff were to postpone the care/activity and allow time for the resident to regain their composure. Provide the resident with a calm, quiet and well-lit environment. Staff were to observe the resident for non-verbal signs of resistance such as rigid body position, clenched fists, etc. The medication administration record (MAR) for the month of December 2021 revealed the resident was administered Sertraline HCL 75 mg as physician ordered for 31 consecutive days. The MAR for the month of January 2022 revealed the resident was administered Sertraline HCL 75 mg as physician ordered for 14 out of 14 consecutive days. -Review of the resident's electronic medical record revealed no consent for use of Seroquel medication. In addition, there was no tracking for the resident's behaviors with the use of this antidepressant psychotropic medication. C. Staff interviews The director of nursing (DON) was interviewed on 1/17/22 at 11:15 a.m., 11:33 a.m., and again at 12:41 p.m. She said a consent for the use of the antidepressant medication Sertraline had not been obtained prior to its administration. She said consent should have been obtained before it was administered. She said it was the director of social services responsibility to obtain psychotropic medication consents. She said resident behaviors should be listed in their care plans. She said nursing staff documented resident behaviors in point click care (PCC), the computerized clinical record under the task section. She said behaviors were documented when they occurred (by example). She said nursing staff could also document resident behaviors in progress notes. She said resident behaviors should be monitored to see if there was an increase or decrease in their behaviors. She said monitoring of behaviors was also related to the possibility of a dose reduction in medications. She reviewed Resident #2's clinical record and said no behaviors were documented in the last 30-days. NHA #2 was interviewed on 1/17/22 at 12:52 p.m., and at 1:04 p.m. She said consent for psychotropic medication should have been obtained prior to the use She said the facility should have some type of behavior tracking/monitor for psychotropic medications. She said the monitoring of behaviors helped the facility determine if a medication was unnecessary. She said the goal was to decrease the use of medication as much as possible. III. Resident #3 A. Resident status Resident #3, age [AGE], was admitted on [DATE]. According to the January 2022 computerized physician orders (CPO), pertinent diagnoses included schizophrenia, vascular dementia, muscle weakness, and difficulty walking. The 10/6/21 minimum data set (MDS) assessment revealed the resident was moderately impaired in cognition with a brief interview for mental status (BIMS) score of 11 out of 15 with no behaviors. The resident had little interest or pleasure in doing things, felt down, depressed or hopeless. The resident had trouble falling/staying asleep or slept too much, felt tired and/or had little energy. The resident had a poor appetite or overate. The resident felt bad about herself or she was a failure and/or had let herself or her family down. The resident required extensive staff assistance for dressing and toileting. The resident required limited staff assistance for bed mobility, transfers and personal hygiene. During the seven day assessment period the resident was administered antipsychotic and antidepressant medications daily. B. Record review A physician order dated 10/6/21 at 3:21 p.m., revealed to administer Risperidone tablet 0.5 mg orally in the evening for behaviors. A physician's order dated 11/13/21 at 1:33 p.m., revealed to administer Duloxetine HCL capsule delayed-release 60 mg orally once a day for depression. A physician order dated 11/13/21 at 2:01 p.m., revealed to administer Risperidone tablet 0.25 mg orally in the morning for behaviors. A physician's order dated 11/16/21 at 11:30 a.m., revealed to administer Lorazepam tablet 0.5 mg orally twice a day for anxiety and administer 0.5 mg orally every 24-hours as needed for anxiety. The care plan, initiated on 4/1/2020, revealed the resident was at risk for complications related to the use of antipsychotic, antianxiety and antidepressant medications. Some of the interventions were to monitor the resident for changes in mental status and functional level and report to her physician as indicated. Monitor the resident for continued need of medications as related to behavior or mood and to complete the behavior montier flow sheet. -There were no specific interventions or non-pharmacological interventions for the use of antipsychotic, antianxiety and antidepressant medications. The MAR for November 2021 revealed the resident was administered Risperidone in the evening 30 times, Risperidone in the morning 30 times, Duloxetine HCL 30 times and Lorazepam 30 times. The MAR for December 2021 revealed the resident was administered Risperidone in the evening 31 times, Risperidone in the morning 31 times, Duloxetine HCL 31 times and Lorazepam 31 times. The MAR for January 2022 revealed the resident was administered Risperidone in the evening 15 times, Risperidone in the morning 14 times, Duloxetine HCL 15 times and Lorazepam 15 times. -Review of the resident's medical record did not reveal any behavior tracking for the use of the administered antipsychotic, antianxiety and antidepressant medications. C. Staff interview The DON was interviewed on 1/17/22 at 2:01 p.m. She said there was no behavior tracking or monitoring for Resident #3's use of Risperidone, Duloxetine and Lorazepam. She said the facility should have been monitoring the resident's behaviors for the use of these medications.