**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, review of the clinical record, facility documentation, and facility policy, for the only sampled resident reviewed (Resident #43) for physical restraints, the facility failed to revise the Resident Care Plan (RCP) upon initiation of a resident's clip alarm. The findings include: Resident #43's diagnoses included vascular dementia, history of transient ischemic attack/cerebral infarction and primary open angle glaucoma. The Nurse Aide (NA) Assignment sheet, last updated on 4/8/24, failed to identify a bed/chair tab alarm under the area of Safety Devices. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #43 was moderately cognitively impaired and dependent with transfers, bed mobility and toileting. The MDS further indicated that a bed alarm and chair alarm were not used and that the resident had two or more falls since his/her last assessment. The Resident Care Plan (RCP) dated 6/30/24 identified Resident #43 had a history of falls with interventions that included a floor mat on the left side of the bed and a Dycem under the wheelchair cushion. The RCP failed to identify a clip alarm was utilized as an intervention. Observations on 7/9/24 at 1:50 PM and 7/11/24 at 10:40 AM identified Resident #43 seated in his/her bedside chair with a clip alarm in place. The alarm box was placed on the side of the top drawer of Resident #43's bedside table and the alarm clip was attached to Resident #43's sweatshirt. Interview, observation and review of facility documentation with NA #4 on 7/11/24 at 10:50 AM identified Resident #43 was a fall risk and the clip alarm was used on both his/her bed and chair. NA #4 demonstrated setting off the alarm and indicated that it was attached to Resident #43's sweatshirt. Additionally, NA #4 identified that she would refer to Resident #43's NA care card to determine if Resident #43 required a clip alarm. NA #4 then reviewed Resident #43's NA care card but could not find documentation for the clip alarm. NA #4 further indicated that the NA care card should have been updated by the nursing supervisor. Interview, observation and review of facility documentation with RN #1 on 7/11/24 at 11:00 AM identified that Resident #43 had a clip alarm in place and that the alarm clip was attached to Resident #43's sweatshirt. RN #1 indicated that nursing staff would know to place the alarm on Resident #43 by reviewing the NA care card and RCP. RN #1 then reviewed Resident #43's NA care card, however could not find documentation for the clip alarm. Additionally, RN #1 identified that it would have been the responsibility of the nursing supervisor to update the NA care card and would notify the nursing supervisor to update the NA care card updated. Interview and review of facility documentation and clinical record with the DNS on 7/15/24 at 10:50 AM identified Resident #43 required a clip alarm due to a history of falls, but she was unsure of the date the clip alarm was initiated. The DNS indicated that the resident's clip alarm had been put in place to alert staff when Resident #43 was possibly getting out of his/her bed or chair unassisted. Additionally, although the DNS identified that the need to use the clip alarm for Resident #43 should have been on his/her NA care card and in his/her RCP, review of facility documentation failed to alert staff to the need for a clip alarm. The DNS was unable to state the reason the use of the clip alarm was not added to Resident #43's NA care card and RCP, but that it was the responsibility of the nursing staff who had implemented the use of the clip alarm to update the documentation to ensure all staff knew Resident #43 required an alarm. Subsequent to surveyor inquiry, Resident #43's clip alarm was removed/discontinued by the facility. Review of the facility's Comprehensive Care Plan policy, dated 4/28/22, directs that qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, review of the clinical record, facility documentation, and facility policy for the only sampled resident (Resident #28) reviewed for activities of daily living, the facility failed to ensure Resident #28's fingernails were clean and trimmed. The findings include: Resident #28's diagnoses included unspecified dementia, cognitive communication deficit and weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #28 was moderately cognitively impaired and dependent with transfers, toileting and personal hygiene. The Resident Care Plan (RCP) dated 6/26/24 identified Resident #28 had deficits in activities of daily living (ADL's) and mobility related to weakness. Interventions included to set-up and assist resident as needed for morning/evening (am/pm) care. The RCP further identified that Resident #28 had a potential for impairment to skin integrity related to decreased mobility with interventions to avoid scratching and keep fingernails short. Observation and interview with Resident #28 on 7/9/24 at 12:48 PM identified that his/her fingernails on both hands were unclean, lengthy, and longer than he/she preferred. Resident #28 indicated that the Nurse Aides (NAs) had not cut his/her fingernails in the last few weeks and that he/she was going to ask them to cut them this week. Observation and interview with Licensed Practical Nurse (LPN) #1 on 7/10/24 at 11:30 AM identified that Resident #28's fingernails on both hands were lengthy and unclean. LPN #1 further indicated that Resident #28's fingernails should have been cleaned and trimmed on his/her last shower day and that she would make Resident #28's assigned NA aware to get them trimmed and cleaned. Additionally, LPN #1 identified that Resident #28's weekly shower day was Saturday on the 3:00 PM to 11:00 PM shift and that the assigned NA for the shower would have been responsible to trim and clean Resident #28's fingernails with his/her shower. Subsequent to surveyor inquiry, observation and interview of Resident #28 on 7/11/24 at 1:40 PM identified that his/her fingernails on both hands were clean and trimmed. Resident #28 further indicated that it was nice to finally have them cut. Interview and review of facility documentation with NA #7 on 7/11/24 at 1:49 PM identified that NA #8 was assigned to Resident #28 on Saturday 7/6/24 for the 3:00 PM to 11:00 PM shift. NA #7 further identified that NA #8 would have been responsible for Resident #28's shower and nail trimming on that shift. NA #7 further indicated she could not find documentation from NA #8 as to the reason Resident #28's fingernails were not cleaned and trimmed on the shower day of 7/6/24. Attempts to contact NA #8 were unsuccessful. Facility policy on Nail Care, dated 10/10/23, directed that routine cleaning and inspection of nails would be provided during ADL care and on an ongoing basis. In addition, the policy indicated that routine nail care, to include trimming and filing, would be provided on a regular schedule with weekly bath day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, facility policy, and review of the clinical record for 2 of 3 residents (Resident #6 and Resident #25) reviewed for skin conditions, the facility failed to follow physician orders regarding the application of compression stockings and heel offloading. Additionally, for 1 of 3 sampled residents (Resident #25) reviewed for pressure ulcers, the facility failed to complete weekly skin assessments 2 of 4 weeks. Also, for 1 of 3 residents (Resident #82), reviewed for nutrition, the facility failed to follow a physician's order for 1-to-1 assistance with eating for a dependent resident. The findings include: 1. Resident #6's diagnoses included cerebral infarction (stroke), hyperlipidemia, hypertension, and altered mental status. A Nurse Aide (NA) care card dated 4/19/24 directed TED (thrombo-embolic deterrent) hose to be applied on Resident #6 in the morning and to be removed in the evening. A significant change Minimum Data Set assessment dated [DATE] identified Resident #6 was severely cognitively impaired, was dependent with toileting hygiene and showering/bathing self, and required partial/moderate assistance with personal hygiene. A physician's order dated 5/7/24 directed compression stockings to be applied on Resident #6 in the morning and to be removed in the evening. The Resident Care Plan dated 5/23/24 identified Resident #6 was at risk for an altered cardiovascular status related to hypertension, hyperlipidemia, embolic stroke, and the presence of a cardiac monitor. Interventions included to administer medications per physician's orders and to wear compression stockings as ordered. Observations on 7/8/24 at 12:40 PM, 7/9/24 at 11:06 AM, 7/10/24 at 12:20 PM, and 7/11/24 at 10:59 AM identified that Resident #6 was not wearing compression stockings. The Electronic Medication Administration Record (EMAR) for the month of June 2024 identified that compression stockings were signed as being applied on all dates. Review of the EMAR for 7/1/24 through 7/11/24 identified that compression stockings were signed as being applied (despite on 7/8/24, 7/9/24, 7/10/24 and 7/11/24, Resident #6 was not wearing compression stockings). Interview, clinical record review, and observation with RN #4 on 7/11/24 at 11:07 AM identified that Resident #6 was not wearing compression stockings despite having a current order for compression stockings to be worn daily. Additionally, RN #4 had signed for the application of the compression stockings on 7/11/24 despite Resident #6 not wearing any compression stockings. RN #4 identified that the NA would apply the compression stockings on Resident #6. RN #4 further indicated she would change her documentation on the EMAR for 7/11/24 since the compression stockings were not observed on Resident #6. Subsequent to surveyor inquiry on 7/11/24, compression stockings were discontinued by the physician. Although requested, a facility policy for compression stockings was not provided. Interview with the Director of Nursing Services on 7/11/24 at 1:48 PM identified that in lieu of a policy, it would be expected that compression stockings be applied per the physician's order. 2. Resident #25's diagnosis included stroke, peripheral artery disease, and diabetes mellitus. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #25 had intact cognition, required partial/moderate assistance for bed mobility, and was at risk for developing pressure injuries. The Resident Care Plan (RCP) dated 4/17/24 identified Resident #25 as having the potential for impairment to skin integrity related to impaired mobility, history of pressure wound, and diabetes mellitus. A physician's order dated 5/14/24 directed facility staff to elevate and offload Resident #25's right heel while in bed, at all times and for facility staff to not place a pillow under the left limb to prevent contracture. a. Observation on 7/9/24 at 8:55 AM identified Resident #25 in bed asleep with his/her right heel flat on the mattress. The foot of the bed was noted to be elevated. Subsequent observations on 7/9/24 at 9:20 AM, 9:33 AM, 9:48 AM, 10:03 AM, 10:15 AM, 10:28 AM, 10:43 AM, 11:00 AM, 11:15 AM and 11:30 AM, identified Resident #25's position remained unchanged. Interview with NA #5 on 7/9/24 at 11:15 AM identified the NA care card included handwritten instructions including the symbol circle with a line through it, (signifying without) but she was unaware of the meaning of the symbol. NA #5 was unaware of what the initials AATs meant after the words foot of bed flat AAT's (at all times). Further, NA #5 identified the care card did not direct offloading of Resident #25's right heel. Interview and review of the clinical record with LPN #5 on 7/9/24 at 11:25 AM identified a physician's order directing offloading of the right heel and that the NA should know offloading instructions based on the NA care card. However, review of the Resident Care Plan (RCP) and NA care card failed to indicate that Resident #25's right heel was to be off-loaded according to physician orders. LPN #5 further identified the 11:00 PM to 7:00 AM shift was responsible for updating the NA care card and the care cards were frequently not updated. An interview with the DNS on 7/9/24 at 11:35 AM identified the NA care card should be updated by the licensed nurse who notes a new order and Resident #25's care card should have been updated with the right heel offloading order. The DNS stated it was facility policy for staff to follow physician's orders. b. Review of the facility's Weekly Bath Skin Observations identified 2 out of 4 assessments missing in June of 2024. Interview with the DNS on 7/9/24 at 10:40 AM, identified skin checks were to be completed weekly. The facility Pressure Injury Prevention and Management Policy included licensed nurses will conduct a full body assessment weekly. 3. Resident #82 was admitted to the facility with diagnoses that included dementia, dysphagia (swallowing difficulty), and osteoporosis. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #82 was severely cognitively impaired, required substantial/maximal assistance for bed mobility, was dependent for toileting, and was independent for eating. The Resident Care Plan dated 6/30/24 identified Resident #82 had an Activity of Daily Living (ADL)/mobility status deficit related to dementia and included an intervention to set up and assist as needed with eating. Review of the APRN's orders and progress note dated 7/4/24 directed that Resident #82 required 1-to-1 assistance with eating. During an observation on 7/9/24 at 9:10 AM, Resident #82 was sleeping in bed, with the head of bed elevated to approximately 45 degrees. Resident #82's breakfast tray was noted in front of him/her on the over bed table and was within Resident #82's reach. The meal was noted to be covered. No staff were observed in Resident #82's room or outside the door. Subsequent observations at 9:25 AM, 9:40 AM, 9:55 AM, 10:10 AM, and 10:25 AM were unchanged. At 10:40 AM Resident #82 was up in the wheelchair and the breakfast tray had been removed. During an observation on 7/9/24 at 12:45 PM Resident #82 was seated in his/her wheelchair in the main dining room at a table with 3 other residents. Resident #82 was noted to be independently eating a toasted piece of bread. There were no staff observed in the dining room. Review of the Nurse Aid (NA) care card dated 5/2/24 identified contradictory instruction to assist Resident #82. In one area staff were directed to provide Resident #82 with supervision but in another area, the resident was totally dependent on staff to eat. Review of the NA flow sheets titled Documentation Survey Report identified staff documented Resident #82 was independent for eating (no help or staff oversight at any time) for 87 out of 90 meals in June of 2024 and 27 out of 42 meals in July of 2024. An interview with RN #3 on 7/11/24 at 10:54 AM identified that residents who were dependent with 1-to-1 assistance meant that a staff member must always be present while the resident ate. RN #3 indicated that 1 NA was assigned and required to remain in the dining room while residents were eating due to the risk of choking. Additionally, RN #3 stated Resident #82's meal tray should not have been left within his/her reach on 7/9/24. An interview with NA #6 on 7/11/24 at 12:45 PM, indicated on 7/9/24 she placed Resident #28's breakfast tray in front of him/her and left because she had 3 other residents who required assistance. NA #6 identified she should not have left the meal within the resident's reach because Resident #82 required supervision with meals but had done so because she thought another NA was going to assist Resident #82 with breakfast. Further, NA #6 also indicated facility policy was to ensure a staff member was present, at all times, in the dining room, during meals to supervise residents while eating and that a staff member should have been present on 7/9/24 when Resident #28 was observed eating his/her bread. An interview with the DNS on 7/11/24 at 1:30 PM identified that a resident who is 1-to-1 dependent or 1-to-1 supervision with meals should not be left alone with a meal tray within reach and that physician orders should be followed for supervision directed during meals. Review of the facility's Assist Level with Feeding policy dated 1/25/24 defined, in part, dependent, as a resident who required total physical assistance to safely eat an entire meal and defined distant supervision as a resident requiring staff to be within eyesight to consume meals and may need intermittent verbal cues/encouragement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of the clinical record, and facility policy for 1 of 3 residents (Resident #80) reviewed for pressure ulcers, the facility failed to maintain infection control practices during a dressing change. The findings include: Resident #80's diagnoses included Parkinson's disease, generalized muscle weakness, abnormal posture, and age-related cognitive decline. An Interdisciplinary Transfer document from the hospital (W-10) dated 4/17/24 identified Resident #80 had a stage 2 pressure injury on the coccyx. The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #80 was moderately cognitively impaired and required partial/moderate assistance. Additionally, the MDS identified that Resident #80 had an unstageable pressure ulcer. The Resident Care Plan dated 6/28/24 identified Resident #80 had an unstageable pressure ulcer (coccyx) and potential for pressure ulcer development related to a decline in mobility and bowel incontinence. Interventions included to administer treatments as ordered and monitor for effectiveness, follow facility policies/protocols for the prevention/treatment of skin breakdown, inform the resident/family/caregivers of any new area of skin breakdown, monitor nutritional status, serve diet as ordered, monitor intake and record, monitor/document/report PRN any changes in skin status, weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. The physicians order dated 7/3/24 directed to cleanse the coccyx area with Normal Saline, pat dry, apply Triad to the peri wound, apply Silver Alginate to the wound bed, cover with foam dressing daily and as needed (prn) for excess drainage/dislodgement every evening shift for wound healing. Observations of the treatment to Resident #80's coccyx wound on 7/11/24 at 5:00 PM identified Licensed Practical Nurse (LPN) #4 appropriately donned personal protective equipment indicated for enhanced barrier precautions, removed the soiled dressing which contained a heavy amount of exudate, changed her gloves without the benefit of performing hand hygiene, applied the sterile gauze which already contained the normal saline and then cleaned the wound. LPN #4 then attempted to open the clean foam dressing with the gloved hands that she removed the soiled dressing with. The surveyor intervened to question clean dressing change technique (changing gloves and performing hand hygiene when going from dirty to clean). LPN #4 then applied the foam dressing per physician order. Facility policy for Clean Dressing Technique identified to remove the soiled dressing, remove gloves, wash your hands, and put on clean gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and facility policy for 1 of 5 sampled residents, (Resident #23) who were reviewed for unnecessary medications, the facility failed to include a stop date on an as needed (PRN) psychotropic physician order. The findings include: Resident #23's diagnoses included Alzheimer's disease, dementia and received hospice services. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #23 was severely cognitively impaired and required maximal assistance with eating and was totally dependent for toilet use, upper/lower body dressing and personal hygiene. The MDS further identified Resident #23 was on Antidepressant and Opiod medication. The Resident Care Plan identified Resident #23 used antidepressant medication related to depression, and poor appetite with interventions that include administering antidepressant medications as ordered by the physician monitoring/documenting side effects, and effectiveness every shift, educate the resident/family/caregivers about risks, benefits, and the side effects and or toxic symptoms. Additional interventions included to monitor/document/report as needed (PRN) adverse reactions to antidepressant therapy and change in behavior/mood/cognition. Physician orders dated 3/31/24 directed Trazodone (an antidepressant) 25 milligrams (mg) every 8 hours as needed for anxiety and agitation, but failed to identify a stop date. Medication Administration Records (MAR) for as needed (PRN) medications for April 2024 through 7/15/24 identified Trazodone 25 mg every 8 hours as needed for anxiety/restlessness was signed off as being administered on 4/1/24, 4/16/24, 4/18/24, 4/20/24, 4/21/24, 4/22/24, 4/23/24, 4/26/24, 4/29/24 and 4/30/24 (10 times in April 2024). The MAR further identified Resident #23 received PRN Trazodone 25 mg on 5/1/24, 5/4/24, 5/5/24, 5/6/24, 5/7/24, 5/8/24, 5/21/24, 5/23/24, and 5/27/24 (9 times in May 2024) and 6/21/24, 6/25/24 and 6/27/24 (3 times in June 2024). The MAR further identified Resident #23 received PRN Trazodone once (7/5/24) in July 2024. Pharmacy review dated 4/29/24 recommended including a stop date for the PRN psychotropic medication (Trazodone) due to The Centers for Medicare and Medicaid (CMS) guidelines not allowing open-ended orders for PRN psychotropics on medication profiles. Further review identified hospice patients were not excluded from this regulation. Physician orders failed to reflect a stop date, after the pharmacy recommendation dated 4/29/24. (Refer to F #756). A progress note dated 5/30/24 identified a medication review was completed by the pharmacy consultant; however, no recommendations for the prescriber were documented. An additional pharmacy recommendation dated 6/27/24 was identified with another recommendation for the prescriber to include a stop date for the PRN psychotropic medication (Trazodone) and that hospice patients were not excluded from this regulation. Review of the record from 7/3/24 identified the Advanced Practice Registered Nurse (APRN) responded to pharmacy recommendations from 6/27/24 and directed Trazodone 25 mg every 8 hours PRN anxiety/restlessness for 30 days. An interview with Pharmacist #1 on 7/15/24 at 1:15 PM, identified that the expectation for addressing pharmacy recommendations was within 14 days. The interview further identified the 4/29/24 MRR for Resident #23 was not addressed and they spoke verbally to the DNS on 5/30/24 to reiterate the April recommendation for adding a stop date to the PRN Trazodone. The interview further identified the prescriber had still not addressed the recommendation by the 6/27/24 MRR so a third recommendation was made. A review of facility policy and an Interview with the DNS on 7/15/24 at 12:15 PM did not identify a policy for including stop dates on psychotropic medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of the clinical record, and facility documentation for the only sampled resident (Resident #1) reviewed for dental, the facility failed to follow up regarding dental treatment. The findings include: Resident #1's diagnoses included dysphagia (swallowing difficulty), paraplegia, and osteoporosis. The annual Minimum Data Set assessment dated [DATE] identified Resident #1 was cognitively intact and was independent with eating, required setup or clean up assistance with oral hygiene, and required partial/moderate assistance with personal hygiene. The Resident Care Plan dated 2/6/24 identified Resident #1 had oral/dental health problems related to missing teeth and for denture placement. Interventions included to coordinate arrangements for dental care, transportation as needed/as ordered, and to consult with the dietitian to have the diet order changed if chewing/swallowing problems were noted. A facility agreement with a Dental service provider was effective as of 2/1/24. A Dental Consent and Problem form identified that Resident #1 indicated he/she wanted to discuss an upper denture on 2/14/24. A dental progress note dated 2/29/24 identified Resident #1 reported he/she was in the process of having his/her front teeth fixed and would like to continue treatment. The dentist referred Resident #1 to a community dentist for treatment of root tips #7 and #8. Interview with Resident #1 on 7/8/24 at 11:54 AM identified that he/she was supposed to get an upper denture at the beginning of 2024 and that he/she had scans completed, but the previous dental group left the facility. Resident #1 was seen by the facility's new dental group, (the Dental service provider from 2/1/24), however he/she was unsure what the status was of his/her upper denture. Interview with the Priority Care Supervisor at the Dental service provider on 7/15/24 at 9:45 AM identified that there was no documentation that Resident #1 wanted to receive an upper denture, however Resident #1 would need to have his/her root tips treated before he/she could receive an upper denture. The Priority Care Supervisor indicated that she would make a note of the request for an upper denture in Resident #1's chart. Interview with the Unit Secretary on 7/15/24 at 9:55 AM identified that Resident #1 was seen by a community dentist on 3/22/24, however Resident #1 preferred not to return to that specific dental provider. The Unit Secretary indicated that even though she was aware Resident #1 did not want to return to the community dental provider Resident #1 had been to on 3/22/24, she did not attempt to find an alternate dental provider, or discuss the issue with Social Services (SS) or the Director of Nursing Services (DNS). Additionally, the Unit Secretary identified that it was her responsibility to advise the facility contracted Dental service group of the residents' problems via email and was unable to confirm communication occurred via email regarding Resident #1 wanting to receive an upper denture. Interview with the DNS on 7/15/14 at 12:45 PM identified that she was not aware Resident #1 did not want to return to the community dental provider Resident #1 had been to on 3/22/24. Additionally, the DNS indicated that had she been aware, she would have discussed the issue with the interdisciplinary team and SS, and would have searched for a new dental provider after the 3/22/24 dental appointment. Subsequent to surveyor inquiry, the Unit Secretary emailed the facility contracted Dental service provider on 7/15/24 requesting information for additional dental providers. Additionally, the Unit Secretary contacted an alternative dental provider and indicated she would also discuss the need to find a different dental provider with SS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility policy, and interviews for 2 of 6 sampled residents (Resident #23 and Resident #48) who were reviewed for unnecessary medications, the facility failed to ensure timely responses to pharmacy recommendations for the use of psychotropic medications. The findings include: 1. Resident #23's diagnoses included Alzheimer's disease, dementia and received hospice services. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #23 was severely cognitively impaired and required maximal assistance with eating and was totally dependent for toilet use, upper/lower body dressing and personal hygiene. The MDS further identified Resident #23 was on Antidepressant and Opiod medication. The Resident Care Plan identified Resident #23 used antidepressant medication related to depression, and poor appetite with interventions that include administering antidepressant medications as ordered by the physician monitoring/documenting side effects, and effectiveness every shift, educate the resident/family/caregivers about risks, benefits, and the side effects and or toxic symptoms. Additional interventions included to monitor/document/report as needed (PRN) adverse reactions to antidepressant therapy and change in behavior/mood/cognition. Physician orders dated 3/31/24 directed Trazodone (an antidepressant) 25 milligrams (mg) every 8 hours as needed for anxiety and agitation, but failed to identify a stop date. Medication Administration Records (MAR) for as needed (PRN) medications for April 2024 through 7/15/24 identified Trazodone 25 mg every 8 hours as needed for anxiety/restlessness was signed off as being administered on 4/1/24, 4/16/24, 4/18/24, 4/20/24, 4/21/24, 4/22/24, 4/23/24, 4/26/24, 4/29/24 and 4/30/24 (10 times in April 2024). The MAR further identified Resident #23 received PRN Trazodone 25 mg on 5/1/24, 5/4/24, 5/5/24, 5/6/24, 5/7/24, 5/8/24, 5/21/24, 5/23/24, and 5/27/24 (9 times in May 2024) and 6/21/24, 6/25/24 and 6/27/24 (3 times in June 2024). The MAR further identified Resident #23 received PRN Trazodone once (7/5/24) in July 2024. Pharmacy review dated 4/29/24 recommended including a stop date for the PRN psychotropic medication (Trazodone) due to The Centers for Medicare and Medicaid (CMS) guidelines not allowing open-ended orders for PRN psychotropics on medication profiles. Further review identified hospice patients were not excluded from this regulation. Physician orders failed to reflect a stop date, after the pharmacy recommendation dated 4/29/24. A progress note dated 5/30/24 identified another medication review was completed by the pharmacy consultant, although no recommendations for the prescriber were documented on this visit, an interview with Pharmacist #1 on 7/15/24 at 1:15 PM identified that the pharmacist spoke to the DNS verbally on 5/30/24 about the Medication Review (MRR) for Resident #23 not being addressed from 4/29/24 regarding including a stop date for PRN Trazodone. An additional pharmacy recommendation dated 6/27/24 was identified with another recommendation for the prescriber to include a stop date for the PRN psychotropic medication (Trazodone) identifying that hospice patients were not excluded from this regulation. The further review identified on 7/3/24 the Advanced Practice Registered Nurse (APRN) responded to a pharmacy recommendation that was made on 6/27/24 and directed Trazodone 25 mg every 8 hours PRN anxiety/restlessness for 30 days. A progress note dated 6/28/24 identified that the APRN had an encounter with Resident #23 however did address the addition of the stop date for the PRN Trazodone in the note. Further review identified another progress note dated 7/4/24 of an encounter by MD #1 and ordered Trazodone 25 mg orally every eight hours as needed for anxiety with no stop date indicated. An interview with the Director of Nursing Services (DNS) on 7/15/24 at 12:25 PM identified that there was no specific time frame for addressing pharmacy recommendations on their facility policy, she did not have a copy of the pharmacy policy for MRRs, and that she did not remember if the pharmacy policy for MRR included an expected time frame for addressing their recommendations. An interview with Pharmacist #1 on 7/15/24 at 1:15 PM, identified that the expectation for addressing pharmacy recommendations was within 14 days. The interview further identified the 4/29/24 MRR for Resident #23 was not addressed and they spoke verbally to the DNS on 5/30/24 to reiterate the April 2024 recommendation for adding a stop date to the PRN Trazodone. The interview further identified the prescriber had still not addressed the recommendation by the 6/27/24 MRR so a third recommendation was made. The pharmacist was due to return for the July 2024 MRR at the end of the month. Facility policy for Medication Regimen Review (MRR) identified facility staff shall act upon all MRR recommendations according to procedures for addressing MRR irregularities; however, the policy is not specific to the facility staff's responsibility for ensuring the recommendations are brought to the prescriber's attention or the expected timeframe for addressing the pharmacy recommendations. 2. Resident #48's diagnoses included generalized anxiety disorder, depression, and insomnia. The admission baseline Resident Care Plan dated 1/24/24 identified Resident #48 received an anti-anxiety medication related to an anxiety disorder. Interventions included administering anti-anxiety medications as ordered by physician, monitor for side effects and effectiveness every shift, and to monitor the resident for safety. The admission Minimum Data Set assessment dated [DATE] identified Resident #48 was cognitively intact, required setup or clean-up assistance with eating, supervision or touching assistance with personal hygiene, and supervision or touching assistance with chair/bed-to-chair transfers. APRN's orders dated 1/22/24 directed to administer Hydroxyzine (Atarax) 25 milligrams (mg) by mouth every 8 hours as needed for anxiety/insomnia and to administer Trazodone 25 mg by mouth nightly as needed for insomnia/sleep. A pharmacy consultant note dated 1/23/24 at 11:40 AM identified recommendations were made for Resident #48's medication regimen for the prescriber to review. Review of the pharmacist recommendations dated 1/23/24 included to either provide a stop date for the as needed medications (Atarax and Trazodone) or consider discontinuing the medication(s) (Atarax and Trazodone) per Centers for Medicare and Medicaid Services guidance. The recommendation was not noted to be addressed. Further review of the clinical record identified a second request from the pharmacy consultant dated 3/29/24 (66 days following the initial request) for the prescriber to, again, either provide a stop date for the as needed medications (Atarax and Trazodone) or consider discontinuing the medication(s) (Atarax and Trazodone). Review of the psychiatric APRN orders dated 4/23/24 (91 days after the original request) directed to discontinue the as needed Trazodone and add a stop date to the Atarax medication for 90 days. Review of the Medication Regimen Review policy dated 3/12/2024 directed, in part, the pharmacist shall communicate any irregularities to the facility; written communication to the attending physician, the facility's Medical Director, and the Director of Nursing; and facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities.

Based on the tour of the Dietary Department, staff interviews, and facility documentation, the facility failed to ensure open food items were dated, failed to ensure food was served under sanitary conditions, and failed to ensure correct dishwasher temperatures. The findings included: Tour of the Dietary Department on 7/8/24 at 10:42 AM with the Assistant Dietary Manager identified the following: 1a. The windowsill, across from the walk-in freezer, was noted to have a heavy accumulation of dirt, dust, and a dead insect was present. b. The window tracking on the window outside of the walk-in refrigerator was noted to have a heavy accumulation of dirt, dust, and dead bugs. c. A brown substance was noted splattered on the door frame in between the kitchen and dish room and on the ceiling tiles in the dish room. d. The fan pointing over the 3 bay sink area was noted with a heavy accumulation of dust. e. The fan over a clean dish rack where clean items were stored (2 ladles, 1 hotel pan, 2 serving spoons, a scooper and a small pan) was noted with a heavy accumulation of dust. f. The inside of a Convection oven on the side of the tray line was noted to have an accumulation of crumbs and a dried splattered substance on the sides and bottom of the oven. g. A 10-gallon bin of flour was noted to have a heavy accumulation of a dried white substance on the lid. h. A 1-gallon jug of molasses stored on a tray with spices was noted to have a brown, sticky substance all over the outside of the container. i. The walk-in freezer was noted to contain an opened 3-pound bag of hash browns (that was 1/3 full), an opened 2-pound bag of french fries (that was ¾ full), an opened 2-pound bag of blueberries (that was ½ full), and an opened 10-pound bag of tilapia fish (that was ½ full) with no open date or expiration date identified. j. The walk- in refrigerator was noted to contain an opened 5-pound bag of mozzarella cheese (that was 2/3 full) with no open date or expiration date. k. On 7/11/24 at 12:39 PM observation of the dry storage room with the Assistant Dietary Manager identified an opened 10-pound bag of macaroni noodles (that was 1/8 full), an opened bag of nuts (that was ½ full) and an opened ½ bag of coconut flakes with no open date or expiration date. Interview with the Assistant Dietary Manager at that time identified that the staff member who opened the food items should have labeled the food item with a date when opened, as well as when items should have been discarded or expired. She also identified that it was her responsibility to do spot checks in the freezer, refrigerator, and dry storage room to ensure open items were dated and labeled correctly at least weekly but must have overlooked the non-dated items. Review of the Date Marking for Food Safety policy dated 10/1/23 directed, in part, that food should be clearly marked to indicate the date or day by which the food shall be consumed or discarded. The individual opening or preparing a food should be responsible for the date marking the food at the time the food is opened or prepared. The marking system should consist of a label, the day/date of opening, and the day/date the item must be consumed or discarded. The discard day or date may not exceed the manufacturer's use-by date, or four days, whichever is earliest. The date of opening or preparation counts as day 1. The Dietary Manager, or designee, should spot check refrigerators weekly for compliance, and document accordingly. Additionally, the Assistant Dietary Manager identified there was a cleaning schedule for cleaning equipment and areas of the Dietary department, she was responsible for ensuring areas were clean and did not identify the soiled areas. 2a. On 7/11/24 at 12:17 PM dishwasher temperature logs were reviewed with the Assistant Dietary Manager for 7/1/24, 7/2/24, 7/3/24 and 7/4/24, which identified the wash and rinse temperatures were low. On 7/1/24, 7/2/24, 7/3/24, and 7/4/24 the rinse temperatures were recorded at 160 degrees Fahrenheit, (should be 180 degrees Fahrenheit or above but not exceed 194 degrees Fahrenheit, per manufactures guidelines). On 7/2/24, 7/3/24, and 7/4/24 the wash temperatures were recorded at 140 degrees Fahrenheit, (should be 150 to 165 degrees Fahrenheit, per manufactures guidelines). The temperature logs failed to reflect any follow up regarding the low temperatures. Interview with the Assistant Dietary Manager at that time identified the temperatures were taken by Dietary Aide (DA) #1 for the dishwasher, which were inaccurate because he must have been reading the wrong dial on the dishwasher, however, DA #1 did not report obtaining low temperatures, so the reason for low temperatures could be identified. She identified that she noticed the incorrect temperature readings in the logs on 7/10/24 and notified the dishwasher company at that time to come out and assess the dishwasher. Additionally, she identified DA #1 should have reported obtaining low temperatures at the time he took them. Subsequent to surveyor inquiry of low dishwashing temperatures, Dietary staff were in-serviced on how to take dishwashing temperatures and the dials on the machine have been labeled according to the in-service instructions. On 7/11/24 at 1:06 PM interview with DA #1 identified that he documented the dishwashing temperatures on 7/1/24, 7/2/24, 7/3/24 and 7/4/24 and he was unsure of which gauge to look at to record the temperatures for the wash and rinse cycle. He stated that he was not aware of what the correct temperatures should be and that was the reason he did not notify the Assistant Dietary Manager of the low readings. 2b. On 7/15/24 at 9:55 AM observation with the Assistant Dietary Manager identified a plastic tray of metal cutlery being put through the dishwasher by DA #2. The wash temperature was 126 degrees Fahrenheit (normal temperature should be 150 to 165 degrees Fahrenheit) and the rinse temperature reading was 160 degrees Fahrenheit (normal temperature should be 180 to 194 degrees Fahrenheit) DA #2 did not note the low temperatures during or after the tray of utensils passed through the dishwasher and proceeded to load a plastic tray with lid covers through the machine even after a low wash cycle reading. Interview on 7/15/24 at 10:00 AM with the Assistant Dietary Manager identified that the wash and rinse temperatures were low and DA #2 should have checked the temperatures at the start of the dishwashing process and documented on the log. She identified that DA #2 should have been checking the temperatures throughout the process of running the machine and should have stopped the dishwashing and notified her of the low temperature, and she would have contacted the dishwasher company. She stated that they would put the cutlery through the sanitizing solution. Interview on 7/15/24 at 10:04 AM with DA #2 identified that he saw the temperatures were reading low and that he was going to tell the Assistant Dietary Manager later, but continued to pass items through the dishwasher. Review of the Dishwasher Temperature Policy identified the correct wash temperature should be 150-165 degrees Fahrenheit and the final rinse temperature should be 180 degrees Fahrenheit. Policy identified if the dishwasher is not working properly to notify the cook, supervisor, and the maintenance department. Corrective action for temperatures below the final rinse temperature (180 degree F) All dishes after being washed through the dishwasher will be submerged in premeasured sanitizer for greater than 30 seconds and racked to air dry. Corrective action taken for dishwasher being out of service would be All dishes would be scraped, washed, rinsed, and sanitized (submerged in premeasured sanitizer for greater than 30 seconds and racked to air dry) in a three-compartment sink. Another Corrective action for dishwasher being out of service would be to serve meals on all paper products until dishwasher is operational.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review and interviews for two of two residents (Resident #36 and Resident #75) reviewed for affectionate behaviors, the facility failed to ensure the Resident Care Plan was comprehensive to include the behaviors and interventions to address the occurrence of affectionate behaviors. The findings include: 1. Resident #36's diagnosis include Alzheimer's disease, anxiety disorder, dementia, cognitive communications deficit, and other recurrent depressive disorders. A quarterly MDS assessment dated [DATE] indicated Resident #36 was severely cognitively impaired and was independent with set up help only for bed mobility, transfers, walking in room/corridor and locomotion on/off the unit. The MDS further identified Resident #36 did not exhibit any physical/verbal behaviors. Nurse's notes dated 6/18/21 at 3:50 PM identified Social Worker #1 made the family aware of a male companion in the facility, SW #1 to remain involved as needed (PRN). 2. Resident #75's diagnoses included depression, anxiety, dementia with behavioral disturbances, depressive episodes, insomnia, and Type 2 diabetes. A quarterly MDS assessment dated [DATE] identified Resident #75 was severely cognitively impaired and was independent requiring no physical help with bed mobility, transfers, walking in room/corridor and locomotion on/off the unit. The MDS further identified Resident #75 exhibited verbal behaviors directed toward others (threatening/screaming/cursing at others) occurring 1 to 3 days in a 7 day period. On 3/28/22 at approximately 10:30 AM, Resident #36 was observed by the surveyor kissing Resident #75 on the lips in the corridor. Both Resident #36 and Resident #75 were subsequently observed at approximately 11:30 AM on 3/28/22 holding hands while walking on the second floor which was a secured dementia unit. Interview with NA #1 on 3/28/22 at 12:35 PM identified she observed Resident #36 and Resident #75 kiss earlier that morning. NA #1 further identified that it was not unusual for Resident #36 and Resident #75 to kiss, and staff attempt to separate and re-direct both residents when it occurs. An interview with the Director of Social Work, and SW #1 on 3/30/22 at 10:50 AM indicated that the situation was discussed with Resident #36's and Resident #75's Conservator, granting approval for kissing and hand holding in June 2021. When questioned about the parameters of the relationship should there be an escalation in the expression of affection, SW #1 indicated the behavior should be documented and if escalated, a Nursing Supervisor should be notified. Additionally, SW #1 and the Director of SW identified there was no care plan that directed parameters as to if the consensual activity escalated between Resident #36 and Resident #75. Additionally, both the Director of Social Work and SW #1 acknowledged the necessity of a care plan to provide parameters for staff and it was either their responsibility or the responsibility of the Care Plan Coordinator to include those parameters, but could did not know the reason that was not done. On 3/30/22 at 11:51 AM, review of the clinical record with the Care Plan Coordinator failed to identify a comprehensive plan of care to address the consensual activity between the Resident #36 and Resident #75 that was approved by their respective conservators. Subsequent to surveyor inquiry, the care plan was updated on 3/29/22 for Resident #36 and Resident #75 to include a problem with showing emotional support to another resident on the unit. The goal was that the resident would have no indications of psychosocial well being problem by/through review date and resident will verbalize feelings related to emotional state by review date. Interventions include to monitor/document residents feelings relative to his/her relationship with others on the unit, notify family and psych group if resident shows an increase in intimate behaviors, re-direct resident if the behaviors exceed more than hand holding and an occasional kiss, monitor resident's mood related to the relationship, if staff witness a decline, redirect the behavior and notify family/psych group and provide opportunities for the resident and family to participate in care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of medication administration, review of the clinical record, facility policy, and interviews for 1 of 3 residents observed for medication administration (Resident #98) , the facility failed to ensure medications were administered in a safe and or sanitary manner. The findings include: Resident # 98 was admitted to the facility on [DATE] with diagnoses that included atrioventricular block, type 2 diabetes mellitus without complications, and hypertension. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #98 had moderately impaired cognition, required extensive assistance with transfers, dressing and personal hygiene. The Resident Care Plan dated 9/4/19 identified Resident #98 required assistance with activities of daily living. Interventions included providing encouragement and verbal cues for safety with activities of daily living, assessing Resident #98 for pain level and medicating as needed to maintain optimal level of function. A physician's order dated 9/6/19 directed Cardizem CD capsule extended release 24 hour capsule 360 mg every morning, Eliquis tablet 2.5 mg by mouth every morning, Furosemide 20 mg by mouth every morning, Glimepiride tablet 1 mg by mouth every morning, Linagliptin tablet 5 mg by mouth every morning, Metformin Hcl tablet 500 mg by mouth every morning , and Metoprolol Tartrate tablet 25 mg by mouth every morning. On 9/17/19 at 9:18 AM an observation of Licensed Practical Nurse (LPN) #2 during medication pass identified LPN #2 removed 1 Cardizem CD extended release 24 hour capsule 360 mg from the medication cart and placed it into a medication cup. She then removed 1 Eliquis tablet 2.5 mg, 1 Furosemide 20 mg, 1 Glimepiride tablet 1 mg, 1 Linagliptin tablet 5 mg, 1 Metformin Hcl tablet 500 mg, and 1 Metoprolol Tartrate tablet 25 mg from the medication cart and placed them in another medication cup. At 9:23 AM, LPN #2 identified that a resident alarm was ringing necessitating her response. LPN #2 locked the 2 medication cups containing Resident #98's poured medications in the medication cart and responded to the ringing alarm at the other end of the hall. LPN #2 was observed going into another resident room and the alarm then stopped ringing. LPN #2 was heard telling a resident she would get them assistance to go to the bathroom. LPN # 2 was observed leaving the room headed toward the nursing desk and could be overheard asking for a Nurse Aide to assist a resident. LPN #2 returned to the medication cart, unlocked the top drawer without washing her hands or donning gloves, LPN # 2 opened the Cardizem CD capsule extended release 24 hour capsule 360 mg and sprinkled it onto the applesauce mixed with the other medications (that she had crushed in a plastic sleeve upon returning to the medication cart). LPN #2 entered Resident #98's room, identified the resident and administered the medications. LPN #2 washed her hands following administration of the medication to Resident #98. Interview with LPN #2 on 9/17/19 at 9:33 AM identified that as she poured medications for Resident #98, a resident's alarm rang. LPN #2 answered the ringing alarm in a resident room by touching the alarm to silence it with ungloved hands. LPN #2 identified after silencing a resident alarm, she did not wash her hands prior to her continuing to prepare Resident #98's medications. LPN #2 identified she opened Resident #98's Cardizem CD capsule with her hands and did not use gloves and/or sanitize her hands. LPN #2 identified she touched the ringing alarm with her hands and identified she never thought to wash her hands after touching the alarm as she was focused on ensuring the alarm was answered. LPN #2 identified that hand washing was important for infection prevention and that she should have washed her hands after touching an alarm and before preparation of a resident's medication. Furthermore, LPN #2 identified she should have utilized gloves to open the medication capsule so as to sprinkle the contents in applesauce for the resident. Interview with the DNS on 9/17/19 10:48 AM identified that handwashing was important for infection control. DNS identified that after silencing a resident alarm a nurse would be expected to wash his/ her hands. DNS identified prior to preparing medications, a nurse would be expected to wash his/her hands. Review of facility policy for administration of oral medications identified that staff was to wash hands at the beginning of a medication pass or when contact with a resident was expected or had occurred. Additionally, the policy identified that nursing was to take care to avoid touching the tablet or capsule unless wearing gloves.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the clinical record, facility documentation, facility policy, and interviews for one resident reviewed for bladder and bowel incontinence (Resident #56), the facility failed to provide evidence that scheduled toileting was completed per the physician's order. The findings include: Resident #56 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, anxiety disorder, diabetes, hypertension and urinary tract infection. The admission Minimum Data Set assessment dated [DATE] identified Resident #56 had moderately impaired cognition, was frequently incontinent of bowel and bladder and required extensive assistance with toilet use and personal hygiene. A bladder assessment dated [DATE] identified Resident #56 doesn't always void without having incontinence, was usually mentally aware of the need to toilet, and was a good candidate for routine scheduled toileting. A physician's order dated 7/26/19 directed routine scheduled toileting. Additionally, the physician's order directed to toilet upon waking, before and after meals, hour of sleep and every 4 hours while awake at night for incontinence management. The Resident Care Plan dated 7/30/19 identified a problem with bladder incontinence related to dementia. Interventions included to ensure a clean peri-area with each incontinence episode, monitor and document intake and output as per facility policy and to monitor for urinary tract infections. Interview with Resident #56 on 9/16/19 at 11:51 AM indicated that he/she was frequently incontinent of urine when he/she was not toileted in a timely manner. Furthermore, Resident #56 indicated that being incontinent was upsetting for him/her. Interview and review of the Nurse Aide (NA) care card on 9/18/19 at 9:50 AM with Registered Nurse (RN) #3 and RN #4 identified that the nurse who received the physician's order was responsible for updating the NA care card with that information. RN #3 was unable to provide the reason the NA care card was not updated to reflect the physician's order of routine toileting and/or provide evidence that Resident #56 was provided scheduled toileting. Interview with the DNS and ADNS on 9/18/19 at 1:35 PM identified that it was the expectation that the NA care cards are updated to indicate the physician's orders of scheduled toileting. Although requested, the facility did not provide a policy for bowel and bladder incontinence.