**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, review of the electronic medical record (EMR), and review of the facilities policies and procedures for individual activities, the facility failed to provide recreational activities designed to meet the interests of and support the physical, mental, and psychosocial well-being for one of one resident sampled for activities. (Resident #4) The findings include: Observations: On 08/26/24 at approximately 01:23 PM, Resident #4 was seen sitting in a wheelchair at the nurses' station not engaged with any activities and with her eyes closed. On 08/27/24 at approximately 10:41 AM, Resident #4 was seen lying in bed with eyes closed. The resident does not have a TV but a radio/CD player is observed on the nightstand, but it is not on. On 08/27/24 at approximately 04:01 PM, Resident #4 was observed lying in bed with eyes closed, but the music was not on. On 08/28/24 at approximately 08:38 AM, Resident #4 was observed sitting in a reclining broda chair at the nurses station. Both hands are clenched and drawn in toward her torso. The residents' eyes are closed. Staff interviews: On 08/28/24 at approximately 12:10 PM, Staff A, a certified nursing assistant (CNA), stated that the resident does not participate in activities and does not have a TV in her room. She acknowledged that there is a radio/CD player in the resident's room, however the CNA states the resident does not have any CD's, and they do not play music for the resident. On 08/28/24 at approximately 03:16 PM, the Activities Director stated in an interview, the resident is care planned for 1 on 1 visits, the 1 on 1 visits are done several times per week if not daily. Charting on the activity provided is to be done daily by the activity's aides. The Activities Director was asked for documentation concerning Resident #4's activities. On 08/28/24 at approximately 04:01 PM the Activities Director stated, there was missed documentation for the department, we do not have any documentation for [Resident #4]'s participation in activities. Record review: A review of Resident #4's care plan revealed that she is dependent on staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits, disease process, blindness, immobility and physical limitations. Goals include: the resident will participate in activities of choice 2/3 times weekly by next review date. Interventions include bedside /in-room visits and activities if unable to participate in out of room events, the resident needs assistance to activities functions, the resident prefers activities which do not involve overly demanding cognitive tasks. Engage in simple, structured, activities such as: talking to resident, playing music, massaging lotion on hands and legs. The resident prefers the following radio station: gospel music. (photographic evidence obtained). A review of the quarterly minimum data set (MDS) dated [DATE], revealed that, in response to, How important is it to you to listen to music you like?, it was noted as very important. During a review of the EMR, it was discovered that no documentation was present for Resident #4's participation in activities for the last 30 days. (photographic evidence obtained). A review of the facilities policy and procedure named, Individual Activities, CL-540, dated 11/01/2021, indicates: Preferred activities and activity times of the resident can be found on the Psychosocial Evaluation, Activity Plan of Care, and MDS. Duration and visits according to need/tolerance, with a minimum of three times per week for fifteen-minute periods.

Based on record review, staff interview, and policy review, the facility failed to ensure the provider documented a resident specific rationale for declination of a pharmacist's request for a gradual dose reduction for a psychotropic medication for 1 of 5 sampled residents reviewed for unnecessary medications. (Resident #25) The findings include: A review of Resident #25's medical record revealed a Consultant Pharmacist Medication Regimen Review dated 7/10/24. The physician recommendation stated the resident had been receiving Paxil (an anti-depressant) 40 mg, 1 tablet by mouth one time a day, starting in January 2024. This review states, If an anti-depressant is used for sleep or to manage behavior, stabilize mood, or treat a psychiatric disorder, it must be reviewed for a possible gradual dose reduction in an effort to find the lowest effective dose. If a dose reduction is deemed clinically contraindicated at this time, please state the rationale below and the risk versus benefit of continuing the drug at the current dose. The physician's response stated to continue the medication and did not include a specific rationale for continuing the medication. An interview was conducted with the Director of Nursing (DON) on 8/28/24 at 9:38 AM. The DON stated a new psychiatric group was going to be taking over the review of any gradual dose reduction requests for psychotropic medications and the facility refers to the notes from the psychiatric provider stating to continue the current medications. She was not able to provide a documented, specific rationale from the provider for continuing the Paxil. Review of the facility policy for Medication Management- Psychotropic Medications (document N-1255 revised 10/24/22) revealed on page 2, gradual dose reductions to be attempted per accepted standards of practice unless clinically contraindicated. Documentation by the prescriber includes specific risk versus benefit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, the facility failed to provide housekeeping and maintenance services to maintain a clean and orderly environment for 7 of 26 sampled resident rooms. (Rooms 701, 703, 705, 706, 707, 708, and 710) The findings include: A tour of the 700 hall was conducted with the Director of Nursing (DON) on 8/28/24 at 3:12 PM. The following items were observed: Resident #42's wheelchair frame was heavily soiled with dust. room [ROOM NUMBER] had 5 wash basins under the sink on the floor in the bathroom stacked on top of each other. The basins were not labeled or bagged. Resident #20's left wheelchair arm was in disrepair with exposed inner foam. room [ROOM NUMBER]B's overbed table border was missing and the table had rough edges. room [ROOM NUMBER]'s bathroom had 2 wash basins not bagged or labeled and stacked on top of each other on a shelf. room [ROOM NUMBER]'s bathroom had a bedpan sitting in a wash basin on the floor that was not labeled or bagged. room [ROOM NUMBER] had basins on the floor that were not labeled or bagged. room [ROOM NUMBER] had 2 wash basins on the floor under the bathroom sink. room [ROOM NUMBER]A had an overbed table that was missing the border. room [ROOM NUMBER] bathroom also had 3 wash basins not labeled or bagged on top of the trash can. (Photographic evidence was obtained.) An interview was conducted with the DON on 8/28/24 at 3:25 PM. The DON stated the facility completed mock survey rounds in the mornings. The DON stated they have been replacing some of the overbed tables. She acknowledged that bedpans and wash basins should be labeled and bagged. She stated that night shift cleans the wheelchairs once a week and they are also pressure washed every month.

Resident #76: A record review was completed for Resident #76 which revealed a progress note entered on 01/25/2023 at 3:19 PM by RN A, stating, Resident in wheelchair sitting in dining room in pleasant mood. Another resident slapped resident on right cheek. Resident able to voice concerns, no complaints of pain. No noted bruising to right cheek, just red. Notified family and MD. Both residents, #76 (victim) and #45 (perpetrator) reside in the locked Memory Care Unit. A review of submitted abuse reports failed to reveal a submitted report for this incident. On 05/16/2023 at 2:11 PM, an interview was conducted with RN A regarding this incident. RN A was asked about the policy for reporting abuse when one resident assaults another resident. RN A indicated administration is contacted immediately and the facility has two hours to report the incident. The nurses are responsible for gathering the witness statements and submitting statements to administration and the director of the particular unit. RN A did recall the event that occurred on 01/25/2023. She indicated the resident to resident abuse took place in the small dining area. She stated both residents involved were placed on change of condition (COC) for 72 hours and kept apart. RN A was asked if there have been any other incidents involving resident to resident abuse for resident #45 (perpetrator), and she stated there were none not that she could recall. On 05/16/2023 at 1:15 PM, an interview was conducted with the Social Worker regarding the incident. The Social Worker was asked if resident to resident abuse is reportable. She indicated a resident placing hands on another resident is reportable. On 05/16/2023 at 1:55 PM, an interview was conducted with Certified Nursing Assistant (CNA) C regarding the appropriate staff response to resident to resident abuse. The CNA was asked what steps are taken when abuse occurs or is alleged to have occurred between two residents. The CNA indicated the residents are separated immediately, the nurse is notified for further investigation, and witness statements are gathered for investigation. On 05/16/2023 at 3:30 PM, an interview was conducted with the Administrator. The Administrator was asked about the abuse incident occurring on 01/25/2023. He stated the abuse was not reported to administration, therefore, there was no report made. He stated he was told by nursing staff that the nurses and CNAs were unsure whether the abuse even occurred. The Administrator stated he will do a delayed report by tomorrow morning. On 05/17/2023 at 11:30 AM, a second interview was conducted with RN A. The nurse was asked about her documentation regarding the incident on 01/25/2023. RN A indicated that she did not mean to word the progress note as if she saw the abuse. She indicated she meant to communicate in the progress note that she was only reporting what the victim resident (Resident #76) told her. RN A indicated at that point she could not remember much about the incident since it was so long ago. Based on staff interviews, clinical record reviews, and review of facility investigations, the facility failed to submit federal immediate reports for 2 of 2 residents sampled for abuse reporting (Residents #46 and #76). The facility failed to report an allegation of neglect for Resident #46 in May 2023, and an allegation of resident to resident abuse for Resident #76 in January 2023. The findings include: Resident #46: On 05/18/2023 at approximately 12:36 PM, an interview was conducted with the Director of Nursing (DON) who stated that, on 05/06/2023, Resident #46 was in the independent dining room eating lunch and talking and chewing at the same time, that is kind of her normal behavior. One of the bites she took she started talking and got a piece of food stuck. The nurse in the dining room responded and performed the Heimlich and was able to get the food dislodged. The DON further stated that, during their investigation of the event, they identified that the resident was served a hamburger patty. The DON confirmed that Resident #46's diet at the time of the incident was Dysphagia Advanced Diet, a diet that includes of chopped/pureed meat, and the resident was not served the correct texture of meat and choked. When asked if that would be considered harm, the DON responded yes. A review of Resident #46's medical records revealed a nursing progress note written by Registered Nurse D (RN D) dated 05/06/2023 at 12:30 PM labeled Late Entry. This nursing progress note states, This RN is supervising the independent dining room and towards the end of lunch time, patient exhibited the universal choking sign and trying to reach for a drink to relieve choking. Subsequently, this RN cleared all the drink/food away from patient and yelled for help from nearby/adjacent assisted dining room, where other staff are present feeding other residents. While performing abdominal thrust, Nurse 2 came in and was able to provide assistance and after 4 abdominal thrusts, food is cleared from airway. Airways patent, patient was able to breathe and say a word. Patient stabilized and able to resume eating her food. Patient is awake, alert, and coherent after incident. Diet order verified and patient on Advanced Dysphagia Texture. Family member informed on 05/08/2023 20:19 (8:19 PM). On 05/19/2023 at approximately 3:15 PM, an interview was conducted with the DON concerning any federal neglect reports submitted in connection with Resident #46's choking incident. The DON responded that none had been filed.

Based on observations, resident interviews, staff interviews, and record reviews, the facility failed to provide appropriate wound care and treatment for 1 of 1 residents sampled for non-pressure related skin conditions. (Resident #34) The findings include: On 05/15/2023 at approximately 11:00 AM, an observation was made of a dressing to Resident #34's left forearm. The dressing was not dated, timed, or initialed. When the resident was asked what the dressing was for, she stated, this wound has been there for 5 days and has only been changed once, I bumped my arm on the wall. On 05/16/2023 at approximately 1:49 PM, a second observation was made of a dressing to Resident #34's left forearm with no date, time, or initials. The dressing appeared to be the same dressing noted on the prior observation and was stained and lifted on one side. The resident confirmed that it was the same dressing and it had not been changed. When asked if staff assessed the area or offered to change it, the resident stated, no. A review of resident #34's electronic medical record (EMR) revealed no current order for any wound treatment to the left forearm. There was an active order dated 04/19/2023 for weekly skin sweeps to be done on day-shift every Wednesday and Saturday. A review of Resident #34's TAR (Treatment Administration Record) for May 2023 showed that skin sweeps were documented as completed on 05/03/2023, 05/06/2023, 05/10/2023, 05/13/2023, and 05/17/2023. A review of the skin assessment conducted on 05/17/2023 at 12:44 PM per Registered Nurse A (RN A), revealed a documented skin tear to the left forearm and treatment in place. A review of the skin assessment on 05/13/2023 at 12:45 PM revealed a skin tear to the left forearm with treatment in place and that the skin was not intact. A review of resident #34's TAR showed that the resident did receive care for a wound to the left forearm that was started on 05/03/2023 and discontinued on 05/08/2023. No additional documentation was found in the MAR (Medication Administration Record) or elsewhere in the medical record regarding wound treatment after 05/08/2023. A review of resident #34's care plans revealed: Skin Inspections: The resident requires SKIN inspection as directed, Observe for redness, open areas, scratches, bruises, and report changes to the Nurse-04/21/2021. Potential/Actual impairment to skin r/t (related to) impaired mobility and incontinence: Encourage good nutrition and hydration in order to promote healthier skin, follow facility protocols for treatment of any injury. and Resident has a skin tear/potential for: Encourage good nutrition and hydration in order to promote healthier skin, if skin tear occurs treat per facility protocol and notify MD (medical doctor), family, keep skin clean and dry, monitor/document location, size and treatment of skin tear-report abnormalities- 03/29/2023. On 05/17/2023 at approximately 10:10 AM, Resident #34 was observed in her wheelchair in the hallway with the wound to her left forearm uncovered and open to air at this time. The wound was observed as a nickel sized skin tear to the left outer forearm, with a partial flap absent, and dark red in color. Resident #34 stated, I just got out of the shower, and I am going to get a dressing for my arm. On 05/18/2023 at approximately 10:22 AM, an interview was conducted with RN A who was Resident #34's assigned nurse. When asked to explain the current treatment Resident #34 was receiving for the wound to her left forearm, she checked the TAR and the MAR (Medication Administration Record) and stated, I don't see an order, but there should be because she has a wound on her left forearm, but I did change it yesterday after she got out of the shower, I cleansed it with wound cleanser, I think it was because she had a shower and she came up to me and asked for a new bandage, applied hydrogel and a border gauze. I dated it, initialed it and timed it, matter of fact I've already done it again today because it fell off. RN A explained the process for discovery of a skin tear is to notify the doctor after the skin assessment, see what treatment needs to be ordered, and put the recommended orders into the computer and it will show on the MAR/TAR so that every nurse knows what needs to be done. RN A stated, I don't see that with Resident #34, we usually change the dressing every other day with skin tears, or more often, PRN (as needed) if they become loose, wet, or dirty. RN A agreed there was no current order for skin tear wound care or documentation of care provided. On 05/18/2023 at approximately 10:39 AM, an observation was made of Resident #34 with a dressing in place to left forearm, dated 05/17/2023, and initialed. Resident #34 stated, the nurse put a new dressing on it yesterday after I requested her to because it fell off while I was in the shower.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #36 A review of Resident #36 medical record revealed documented diagnoses on admission on [DATE] of Bipolar Disorder, Schizophrenia, Obsessive Compulsive Disorder, Major Depressive Disorder and Adjustment Disorder with Anxiety. The Level I PASARR for resident #36 only included the diagnosis of Depressive Disorder. On 5/18/2023, a review of the PASARR Policy was completed. Preadmission Screening and Resident Review, document name SS-402, dated 11/8/2021 and revised 11/8/2021. Under the procedure section, item #4 states, If it is learned after admission that a PASARR Level II screening is indicated, it will be the responsibility of Social Services to coordinate and/or inform the appropriate agency to conduct the screening and obtain the results. Resident #4 A review was conducted of Resident #4's list of medical diagnoses. This list included Psychotic Disorder with Delusions due to known Physiological Condition (present on admission 9/08/2004), and Unspecified Dementia (present on admission 9/08/2004). A review of Resident #4's PASARR dated 03/03/2015 revealed under Section II A of the form there is no diagnosis listed. On 5/17/23 at approximately 4:10 PM, an interview was conducted with the Director of Nursing (DON) concerning resident #4's PASARR. The DON agreed that the PASARR was not completed correctly and would redo the PASARR along with reviewing all PASARR's facility wide. Based on staff interview and record review, the facility failed to accurately complete the Level I Preadmission Screening and Resident Review (PASARR) forms, which resulted in the facility failing to complete appropriate Level II PASARR forms for residents with mental disorders and/or Intellectual Disabilities for 4 of 5 residents reviewed. (Residents #29, #2, #36, and #4) The findings include: Resident #29 A review was conducted of Resident #29's list of medical diagnoses. This list included Schizoaffective disorder (documented in the chart on 10/10/2022), Generalized Anxiety Disorder (documented in the chart on 10/10/2022), Major Depressive Disorder (documented in the chart on 10/10/2022) and Schizophrenia (documented in the chart on 1/18/2023). A review was conducted of the Psychiatrist's progress note for Resident #29's, dated 8/11/2022. The progress note listed Schizophrenia and Major Depressive Disorder as diagnoses at the time of the assessment. A review was conducted of Resident #29's level I PASARR, dated 10/7/2023. Under section one of the form, only Anxiety was checked as an applicable diagnosis. On 5/17/23 at 11:04 AM, the Director of Nursing (DON) was shown the above information and asked for clarification for the reason Schizophrenia and Depression were not included in section one of the PASARR form. The DON stated that she would look into it. On 5/17/23 at 11:09 AM, the DON returned and stated, It was an honest mistake. I am going to go put in a new one right now. Resident #2 On 5/15/23, a record review was conducted for Resident #2. The resident, admitted on [DATE], had diagnoses of major depressive disorder, general anxiety disorder and vascular dementia. The PASARR dated 9/18/20, did not list these diagnosis. The facility did not correct the PASARR upon admission and had not updated the form at the time of this survey. On 5/17/23 at approximately 3:49 PM, an interview was conducted with the DON who stated she does the PASARR if the resident comes from home or a hospice. If they come from the hospitals, they usually come in with a PASARR already completed. The DON stated that they always review to make sure the PASARRs are appropriate and completed and signed. The DON stated she doesn't know who was in charge of it back in 2020, so she can't say who missed it or why it was missed and verbally agreed the PASARR was not accurate and was missing the relevant diagnoses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record review, and policy review, the facility failed to provide 6 of 7 residents sampled with palatable meals and snacks that took resident preferences into consideration (Residents #49, #8, #63, #278, #26, and #34). The findings include: Resident #49: On 05/15/2023 at approximately 11:20 AM, an interview with conducted with Resident #49 who talked about concerns regarding poor food quality and preparation. Resident #49 stated, the milk has been served curdled, there aren't enough snacks for the residents, we have several diabetics without any juice on the hall, they don't keep the nutrition room stocked, if I ask one of the Certified Nursing Assistants (CNA) for it, they try to bring it if they have them, but they usually don't have any. The food is ill prepared, the meat is too tough to cut much less chew. Residents are receiving the wrong diets, one (identified Resident #46) even choked on her food because they gave her regular food instead of pureed, that happened just this last week. Staff had to do the Heimlich, this has happened before. They get orders mixed up, broccoli is mush and English peas are served with ice crystals. People are losing weight because they don't like the food, so they just won't eat at all. I am the food committee president and the vice president of resident council, so the residents tell me everything. I've made several grievances about this, and nothing is being done. On 05/16/2023 at approximately 2:00 PM, a follow-up interview was conducted with Resident #49 who stated, yesterday for supper I received a cheeseburger instead of the fish sandwich that I ordered. She reported that she told the District Dietary Manager (District DM F) today, he just shook his head and said that he will try to get this problem fixed. She went on to describe the food committee meeting from this morning stating that multiple managers were in attendance such as District DM F, the Dietary Cook, the Social Worker, the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the Activities Director. She is hopeful that things will improve and states, some of the solutions they proposed were to increase meetings to twice a month instead of once a month. Me as well as other residents expressed the good and the bad, we are supposed to be getting more fresh fruits, we told them that we are tired of always receiving the same old canned fruits. Also multiple residents requested salsa for taco day, this is something the previous Dietary Manager never let us have, even though we asked multiple times. A review of Resident #49's medical record showed a current order dated 03/24/2022 for Regular diet, Regular texture, Regular/Thin liquids consistency with instructions to give double portions with all meals. Resident #49 had a care plan with a target date of 06/02/2023 stating, Resident is independent with all self-directed activities with an intervention for food, snacks available. On 05/16/2023 at approximately 2:40 PM, an interview was conducted with the Social Worker (SW). The SW confirmed that she was aware of Resident #49's concerns with the food and Resident #49 has made many grievances in the past. The SW stated that she did attend the food committee meeting this morning. When asked if she received any concerns or complaints regarding food quality, preferences, lack of variety, the SW stated, oh yeah, I have a whole page over here that I have to type up from Resident #49. When asked if any other residents shared concerns during this meeting, the SW answered, yes, well, they more or less agreed with Resident #49, but did reiterate some of the same concerns . The SW confirmed Resident #49 was the food committee president. During an interview on 05/17/2023, District DM F stated that he is aware that Resident #49 did not receive the correct meal for dinner yesterday and confirmed that he spoke with Resident #49 earlier. Resident #8 and #63 On 05/16/2023 at approximately 1:20 PM, while observing the lunch meal in the assisted dining room, it was noted that Resident #8's lunch plate did not include all items listed on the tray ticket. The meal ticket listed pureed bread and peas, neither of which were on the resident's plate. Resident #8 was served mashed potatoes, but this item was not on the meal ticket. At this time an interview was conducted with the Certified Nursing Assistant, Employee P (CNA P), who was assisting Resident #8 with lunch and she confirmed items were missing from the tray and stated, I didn't realize it until now. A record review of Resident #8 revealed that she has a current diet order dated 07/28/2020 for Dysphagia Puree texture, Regular/Thin Liquids consistency and a nosey cup with all meals. Resident #8's Quarterly MDS dated [DATE] showed the resident had total dependence when eating which required one person assist and was receiving a mechanically altered diet. On 05/16/2023 at approximately 1:15 PM, an observation was made of Resident #63 in the assisted dining room during lunch. Resident #63's lunch plate did not include all of the food items listed on the meal ticket. An interview was conducted during the observation with CNA Q, who was assisting Resident #63 with lunch. CNA Q confirmed that Resident #63 did not receive sweet potatoes or a peanut butter and jelly sandwich. CNA Q was asked who checks the meal to ensure that residents receive the correct diet including all items listed on the meal ticket. CNA Q replied, we usually do the final check. CNA Q was asked to describe what she does when something is incorrect on the resident's tray or if items were missing, and she responded, I mean I can go get it or let the nurse know but I usually don't worry about it because she (Resident #63) never eats all of her food anyway. CNA Q was then asked if she notified the nurse today of the missing items, and she replied, no, but I can. A record review for Resident #63 revealed she had a current diet order dated 05/10/2023 for Fortified Foods, Dysphagia Puree Texture, regular/thin liquid consistency. On 05/17/2023 at approximately 12:35 PM, an interview was conducted with Licensed Practical Nurse R (LPN R), who confirmed that she was present in the assisted dining room yesterday (05/16/2023) during lunch. LPN R explained that she was not present when the trays were initially served but other employees were in the room at that time. LPN R confirmed that the nurse is supposed to do a second check for tray accuracy prior to serving it to the resident. LPN R was asked if any reports were made to her yesterday of trays being inaccurate or items missing from the residents' trays and she stated, No, I was never notified by any CNA or other staff that diets were wrong or missing things. Resident #278: On 05/17/2023 at approximately 6:35 PM, an observation was made of the tray cart being delivered from the kitchen to the assisted dining area. During this observation, Staff K, a Unit Manager, was observed removing resident trays from the cart and lifting plate covers while looking at the meal ticket on the tray. An observation of Resident #278's tray was made and compared to the resident's meal ticket. Resident #278's meal ticket revealed a diet order for Dysphagia Mechanically Altered and the items on the plate did not match the items listed on the ticket. The ticket listed ground smothered turkey patty with poultry gravy, pureed oven browned potatoes, pureed dinner roll/bread with margarine, pureed Vanilla glazed angel food cake, milk, tea, food in bowls. The plate was observed to include chopped dry fish (no sauce) served on a regular hamburger bun, (the bread was not pureed), and all food was on the plate, no bowls were present. Resident #278 received apple sauce instead of pureed cake. (Photographic Evidence was obtained) On 05/17/2023 at 6:38 PM, an interview was conducted with Unit Manager K, in which she confirmed she looked at the tray items and ticket and agreed that the resident did not receive the correct items as on the ticket and that he should have received ground turkey and it should have been served in bowls. When asked if it was safe for him to consume the meal he was served based on his diet ordered, Unit Manager K stated, I would say no because it's not listed on the ticket but I'm not sure, I could've sworn I looked at his ticket, I'm not supposed to be in here right now, the other nurse was still in the independent dining room so I came in here so there would at least be one nurse in here. A review of Resident #278's medical record revealed a current diet order dated 05/10/2023 for Dysphagia Mechanically Altered texture and regular/thin liquids consistency with directions to serve food in bowls. A review of the MDS (Minimum Data Set Assessment) 5-day PPS (prospective payment system) dated 05/14/2023 found in section G (Functional status) eating requires supervision with physical assistance by 1 person. Section K (Swallowing/Nutritional status) indicated that Resident #278 required both a mechanically altered diet and a therapeutic diet. Resident #26: On 05/15/2023 at approximately 11:45 AM, an interview was conducted with Resident #26. When asked about any concerns, Resident #26 stated, the food is not good, it's not seasoned and not cooked well, would like more fried foods, would also like more snacks, would like different types of snacks and more fruits like melon, they always give us the same thing old fruit out of a can. When asked if she has discussed her concerns to any facility staff, Resident #26 states yes, I tell the staff immediately if something is wrong on my tray and also tell the food committee president and they discuss it at every meeting. On 05/18/2023 at approximately 10:10 AM, an interview was conducted with Resident #26 who stated, breakfast was okay I guess but the eggs were horrible, so I only ate the grits, yogurt, and toast. I ordered a grilled cheese sandwich for lunch and the BBQ for dinner, the BBQ is always good. On 05/19/2023 at approximately 11:25 AM, an interview was conducted with Resident #26 who confirmed she got the grilled cheese sandwich she ordered yesterday for lunch, but the cheese tasted bad. She stated, supper was not what I ordered, I got some unknown kind of meat, broccoli and white rice, but ordered BBQ. I told my CNA and asked what kind of meat was on my tray? The CNA said, it's food, in which I replied, well I know it's food but it's not the BBQ that I ordered. The CNA tried to fix it, but she was told by the kitchen they were out of BBQ. A review of Resident #26's medical record showed an active diet order on 09/12/2022 for Consistent Carbohydrates (CCD) diet, Regular texture, and regular/thin liquids consistency. Resident #34: On 05/15/2023 at approximately 11:00 AM, an interview was conducted with Resident #34, who stated, I wish that we had more choices to choose for meals, they do have a standing list of items that can be requested all the time or you can choose the alternate meal if you don't like the main meal being served but staff don't ask you these preferences unless you are in the dining room, but either way the food is no good, half the time it comes out cold or late, also wish we had better snacks, we are supposed to have pudding on the hall but every time I ask for it, the CNA's go check but say they don't have any. On 05/15/2023 at approximately 12:45 PM, while observing the independent dining room, Resident #34 was noted sitting in a wheelchair at the dining room table, not eating. The resident's plate contained a hamburger and French fries. When Resident #34 was asked about her food, she responded, it's cold, my fries are cold as ice, I can't eat this like that, I don't even have mayonnaise for my burger. When asked if she notified staff, she responds, what's the use, they don't care. A staff member observing dining and standing nearby was notified that Resident #34 had concerns with her meal, and the staff member responded, yeah, they are getting her some mayonnaise right now. It was reported to the same staff member that the resident stated her food is cold, staff member responds, I will get it fixed. On 05/16/2023 at approximately 1:49 PM, a follow up interview was conducted with Resident #34 who stated, I did get the mayonnaise that I requested yesterday for my hamburger, but they never brought me warmer fries or offered to heat them. She explained that she attended the food committee meeting this morning and, they said that we are supposed to be getting more food options, several residents complained about the food being bad, not getting what they order, and that we need more snacks. A review of resident #34's medical record showed a current diet order on 04/13/2023 for a Regular Diet, Regular Texture, with Regular/Thin Liquids consistency. Tray line observations: On 05/17/2023 at 1:00 PM, an interview was conducted with District DM F, who is currently the on-site Director of Food and Nutrition Services, who stated that there is no policy regarding the tray assembly line but the process of the tray assembly line starts with a starter who puts the ticket on the tray and calls out to the cook a specific diet, request, and such. The cook then plates the food and the tray is passed by the starter, down to the drink person who places the drink on the tray, checks the tray for accuracy, covers it and places it on the cart and takes it to the dining room or hall. After the trays are delivered to the appropriate area, the duties are assigned to nursing at that point. An observation of the kitchen dinner tray line was conducted on 05/17/2023 beginning at 5:15 PM. The observation of the tray line revealed there was no quality assurance checks for diet accuracy by Food and Nutrition Services staff prior to the tray being placed on the meal cart for distribution to residents. The cook plated the food. The tray line starter was observed to correct some inaccurate food items plated by the cook. The drink aide placed drinks on the tray but did not compare the tray accuracy against the ticket. No other Food and Nutrition Services staff member was observed to check the accuracy of food items. The tray line was disorganized with multiple distractions from outside the kitchen, which required the drink aide to leave her position on the tray line, exit the kitchen, then return to finish putting drinks on the tray. On 05/19/2023 at approximately 12:55 PM, an observation of the lunch tray line was conducted. There were 4 Food and Nutrition Services staff working the tray line. Employee O, dietary aide, initiated each tray and called out the diet to the cook. Then Employee L (the cook during this meal) plated the food and placed the plate on the tray where Employee G, a dietary aide, would cover the plate and pass the tray to Employee H, dietary aide, who would add the drink and then check the completed tray for accuracy. An interview was conducted with Employee H, dietary aide, during the observation. Employee H stated that she was here from a different nursing home helping and her assignment at this time is the last check for tray accuracy and to supply the drinks. When asked how she verifies tray accuracy, Employee H stated that she is aware that a blue ticket is allergies. She was not sure what the yellow ticket (the ticket that signifies altered fluid consistency is required) meant because they do not use those in her facility but she always reads the ticket to check the correct fluid consistency. During this interview, Employee H was asked to review the tray just received from Employee G, dietary aide. Employee H reviewed the tray and ticket for resident #278 who was on a Dysphagia Mechanically Altered Diet. Employee H was asked what should not be included on a tray for residents ordered a Dysphagia Mechanically Altered Diet. Employee H stated that items listed on the ticket would be on the tray. When Employee H was asked again about this diet, Employee H responded, nothing regular, chopped meat. Employee H was asked if bread could be included in a Dysphagia Mechanically Altered diet (diet for resident #278), Employee H said that she did not know. Employee G and Employee O, both dietary aides, confirmed that they did not know if bread was allowed on the Dysphagia Mechanically Altered diet. Employee L, the cook, stated, bread is allowed but has to be pureed on that diet. Nutrition Room observations: On 05/15/2023 at approximately 12:15 pm, an observation was made of the B-Wing Nourishment Room with Certified Nursing Assistant W (CNA W). There was no pudding or Jell-O observed in the refrigerator or in the storage cabinet. When asked if there was supposed to be snacks in this room for resident consumption, Employee W, states yes, but I don't see any pudding or Jell-O. Two bowls of applesauce were noted in the refrigerator and 5 packets of crackers were in the cabinet. A review of the Nutrition Room Par Levels document revealed the following items with the amount required to be regularly stocked: Pudding - 8 cups Applesauce - 8 cups Jell-O - 8 cups On 05/15/2023 at approximately 12:50 PM, an observation was made of the A-Wing nourishment room. No pudding, applesauce, or jello was noted in the refrigerator or cabinet. An interview with CNA X was conducted at this time. When asked about the delegated responsibility of restocking snacks, CNA X stated, I think the cafeteria restocks it at night, but we can go ask for extra if we need it or it's out. I'm not sure who checks the temperature logs, maybe nursing, or dietary, maintenance might do it. On 05/16/2023 at approximately 10:05 AM, an observation was made of Employee Y (a dietary aide) entering the B-Wing Nourishment room with a cart. Employee Y explained that she is about to stock. When asked how often it is restocked, she explains that it is supposed to be done twice a day, at 10:00 AM and at 2:00 PM by the dietary staff and stocked with supplies to match the par levels on the Nutrition Room Refrigerator Par Levels sheet. Employee Y confirmed there is no pudding or Jell-O present and multiple other items are low. An interview with District DM F was conducted on 05/17/2023 at approximately 1:00 PM. District DM F was asked about refrigerator stocking and temperature checks/blank logs. District DM F stated it is dietary's responsibility to stock the nourishment rooms with snacks and this is supposed to be done twice a day at 10:00 AM and at 2:00 PM. On 05/17/2023 at approximately 10:45 AM, an interview was conducted with the Administrator who stated, I am aware I've got a problem in the kitchen, and I've got a Performance Improvement Plan (PIP) for it. We just had a resident satisfaction survey on 03/25/2023. He stated the PIP was started on 05/08/2023. Policy reviews: A review of the facility policy titled Menus (HCSG [Health Care Service Group] Policy 004, revised 09/2017) found: Menus will be planned in advance to meet the nutritional needs of the residents/patients in accordance with established national guidelines. Menus will be developed to meet the criteria through the use of an approved menu planning guide. Procedures 1. Menu cycles will be developed and tailored to the needs and requirements of the facility. 2. Menus will be periodically presented for resident review, including the resident council, menu review meetings, or other review board as indicated by the center. The menu will identify the primary meal, the alternate meal, and any always offered food and beverage items. 3. Menu cycles will include standardized recipes. 4. Menu cycles will include nutrient analysis to ensure that all client (adolescent, adult, geriatric) nutritional needs are met in accordance with the most recent edition of the Food and Nutrition Board, Institute of Medicine, National Academies, and the Dietary Guidelines for Americans, 2015-2020 edition. 5. A Registered Dietitian/Nutritionist (RDN) or other clinically qualified nutrition professional reviews and approves the menus. The RDN or other clinically qualified nutrition professional will adjust the individual meal plan to meet the individual requests, including cultural, religious, or ethnic preferences, as appropriate. 6. Menus will be served as written, unless a substitution is provided in response to preference, unavailability of an item, or a special meal. 7. A menu substitution log will be maintained on file. 8. Menus will be posted in the Dining Services department, dining rooms and resident/patient care areas. 9. Menus are kept on file per state regulations. A review of the facility policy titled Dining and Food Preferences (HCSG Policy 005, revised 09/2017) found: Individual dining, food, and beverage preferences are identified for all residents/patients. Procedures: 1. The Diet Requisition form will notify the Dining Services department of food allergies upon admission and prior to any meals served. 2. The Dining Services Director, or designee, will interview the resident or resident representative to complete a Food Preference Interview within 48 hours of admission. The purpose of identifying individual preferences for dining location, meal times, including times outside of the routine schedule, food, and beverage preferences. 3. The Food Preference Interview will be entered into the medical record. 4. Food allergies, food intolerance, food dislikes, and food and fluid preferences will be entered into the resident profile in the menu management software system. 5. The Registered Dietitian/Nutritionist (RDN) or other clinically qualified nutrition professional will review, and after consultation with the resident, adjust the individual meal plan to ensure adequate fluid volume and appropriate nutritional content for residents that do not consume certain foods or food groups. 6. The Dining Services Director, RDN or other clinically qualified nutrition professional, or designee, will enter information pertinent to the individual meal plan into the plan of care. 7. The individual tray assembly ticket will identify all food items appropriate for the resident/patient based on diet order, allergies and intolerances, and preferences. 8. Upon meal service, any resident/patient with expressed or observed refusal of food and/or beverage will be offered an alternate selection of comparable nutrition value. 9. The alternate meal and/or beverage selection will be provided in a timely manner. A review of the facility policy titled Food: Quality and Palatability (HCSG Policy 006, revised 09/2017) found: Food will be prepared by methods that conserve nutritive value, flavor and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. Food and liquids are prepared and served in a manner, form, and texture to meet resident's Needs. Definitions: Food attractiveness refers to the appearance of the food when served to the residents. Food palatability refers to the taste and/or flavor of the food. Proper (safe and appetizing) temperature Food should be at the appropriate temperature as determined by the type of food to ensure resident's satisfaction and minimizes the risk for scalding and burns. Procedures 1. The Dining Services Director and Cook(s) are responsible for food preparation. Menu items are prepared according to the menu, production guidelines, and standardized recipes. 2. The Cooks) prepare food in a sanitary manner utilizing the principles of Hazard Analysis and Critical Control Point (HACCP) and time and temperature guidelines as outlined in the Federal Food Code. 3. Food and liquids/beverages are prepared in a manner, form and texture that meets each resident's needs. 4. The Cook(s) prepare food in accordance with the recipes, and season for region and/or ethnic preferences, as appropriate. Cook(s) use proper cooking techniques to ensure color and flavor retention. 5. Hot liquid foods or beverages will be served in containers (mugs, cups, and bowls) that will minimize the potential for spillage. A review of the facility policy titled Meal Distribution (HCSG Policy 013, revised 09/2017) found: Meals are transported to the dining locations in a manner that ensures proper temperature maintenance, protects against contamination, and are delivered in a timely and accurate manner. Procedures 1. All meals will be assembled in accordance with the individualized diet order, plan of care, and preferences. 2. All food items will be transported promptly for appropriate temperature maintenance. 3. All foods that are transported to dining areas that are not adjacent to the kitchen will be covered. 4. The nursing staff will be responsible for verifying meal accuracy and the timely delivery of meals to residents/patients. 5. For point-of-service dining, the Dining Services department staff, under the supervision of the licensed nurse, will assemble the meal in accordance with the individual meal card and present it to the resident/patient or care staff for delivery to the resident/patient. 6. Proper food handling techniques to prevent contamination and temperature maintenance controls will be used for point-of-service dining. A review of the facility's policy titled Snacks (HCSG Policy 011, revised 09/2017) found: Snacks and beverages will be provided as identified in the individual plans of care. Bedtime also known as HS) snacks will be provided for all residents. Additional snacks and beverages will be available upon request for all residents who want to eat at non-traditional times. Procedures 1. The Dining Services department will collaborate with the residents/patients, nursing and management team to identify necessary beverage and snack items to be provided to each resident/patient. 2. The Dining Services department assembles on a daily basis snack items (food and beverages) for delivery to each resident/patient care area. 3. Snacks will be assembled, labeled, and dated in accordance with the individual plan of care for each resident and those items will be delivered to patient care areas in a timely manner. 4. The Dining Services department will assemble and deliver to each unit the individually planned snack items and bulk snack items to be offered at bedtime. 5. The Dining Services department provides a listing of the current diet orders and snacks for each resident to each care area. 6. Nursing Services is responsible for delivering the individual snacks to the identified residents and for offering evening snacks to all other residents. 7. All snacks will be properly stored for time and temperature control, as appropriate.

Based on observations, interviews, record reviews of temperature logs, maintenance logs, and policy review, the facility failed to maintain 1 of 2 ice machines and 2 of 2 nourishment room refrigerators located on A and B wing, in a sanitary and safe operating condition. The unsanitary condition of the ice machine represented a potential source of pathogen exposure to all residents served ice. Inadequate temperature control of residents' food during refrigeration indicates an unsafe food storage practice that can promote bacterial growth thereby increasing the nursing home residents' risk of food borne illness. The findings include: On 05/15/2023 at approximately 10:50 AM, an observation of the kitchen ice machine with District Dietary Manager F (District DM F) revealed an external surface that was unclean with unknown dark colored residue build-up and calcification present. The storage bin on the interior of the ice machine had the same type of residue as on the exterior surface. This residue appeared to be from an external leak, and, based on the amount of build-up, appeared to have been leaking for an extended period of time. The dark colored residue resembled biological growth (such as mold or mildew) and extended downward into the ice. District DM F agreed that the ice did not appear to be safe for use and stated, it needs to be cleaned. District DM F was asked when the last time the ice machine was cleaned, and he responded, I don't know, I will have to get with maintenance for the logs. District DM F stated that he will shut down the ice machine, discard the ice and have maintenance come clean it. (Photographic evidence obtained) On 05/15/2023 at approximately 12:15 PM, an observation was made of the B-Wing Nourishment Room with Certified Nursing Assistant W (CNA W). The temperature check logs were posted on the side of the nourishment refrigerator. A review of these logs showed multiple dates with empty or blank entries, indicating the temperature was not checked. An interview was conducted with CNA W during the observation regarding who was responsible for checking the refrigerator temperature. When asked who checks the temperature of this refrigerator daily and logs it on the sheet attached to the refrigerator, CNA W responded, I'm not really sure, I think nursing, maybe maintenance or dietary, I know it is stocked by dietary, think at night but not sure. On 05/15/2023 at approximately 12:50 PM, an observation was made of the A-Wing nourishment room with CNA X. Temperature check logs were posted on the wall adjacent to the refrigerator. A review of this log showed multiple dates with empty or blank entries. An interview with CNA X was conducted at this time. When asked about the delegated responsibility of checking the refrigerator temperatures and restocking snacks, CNA X stated, I think the cafeteria restocks it at night, but we can go ask for extra if we need it or it's out. I'm not sure who checks the temperature logs, maybe nursing, or dietary, maintenance might do it. She explained that when she restocks the portable ice cooler with ice for passing, she gets the ice from the B-wing ice maker or from the kitchen ice maker. When asked if she retrieved the ice currently in the portable cooler from the kitchen, CNA X stated, I don't remember, I think this was already stocked when I came in. When asked if she was aware not to use the ice from the kitchen, CNA X stated, no one has told me not to use the ice from the kitchen. On 05/15/2023 at approximately 4:00 PM, the Administrator stated, District DM F showed me the ice machine and I see your concerns with it. I just want to let you know, it has been taken completely out of service, and I've ordered a new one. I can provide you with a copy of the receipt if you want. On 05/16/2023 at approximately 10:05 AM, an observation was made of employee Y (dietary aide) entering the B-Wing Nourishment room with a cart. Employee Y explained that she was about to stock. When asked to describe the blank entries on the refrigerator temperature check log, she explained it should have entries every day and that this is also dietary's responsibility to check it twice a day. During an interview with District DM F on 05/17/2023 at approximately 1:00 PM, he was asked about temperature checks/blank logs. He stated The refrigerator temperature checks are dietary's responsibility and should be done twice a day. He explained that he was made aware of the empty logs by other staff prior to this interview and was instructed by the administrator to put up new logs and start over from the day it was brought to his attention. He agreed that blank entries on the log would indicate that the temperature checks were not done. On 05/17/2023 at approximately 3:45 PM, an interview was conducted with the Maintenance Director, who stated, I'm trying to get together the logs for any service of kitchen equipment and policies, just having a little trouble finding everything. He explained that he will get it as soon as possible. He also stated, I cleaned the inside and outside of the ice machine. A review of the Maintenance Logs for the kitchen ice machine reveal it was last serviced on 03/31/2023. Policy review: A review of the facility policy titled ICE (HCSG [Health Care Services Group] Policy 021, revised 09/2017) included: Ice will be prepared and distributed in a safe and sanitary manner. Procedures 1. The Dining Services Director and/or Maintenance Director will ensure that all ice machines are plumbed from a potable water source and that air gap drains are appropriately maintained. 2. The Dining Services Director will coordinate with the Maintenance Director to ensure that the ice machine will be disconnected, cleaned and sanitized quarterly and as needed, or according to manufacturer guidelines. 3. The exterior of the ice machine will be cleaned weekly. 4. Ice bins will be cleaned monthly and as needed. 5. Ice scoops will be cleaned and stored in a separate container that limits exposure to dust and moisture retention. 6. Staff will adhere to proper utensil usage or clean gloved hands for handling. 7. In the event of a mechanical malfunction, ice will be purchased from an approved vendor and stored in manner that maintains proper temperature and prevents cross contamination. A review of the facility policy titled Equipment (HCSG policy 027, revised 09/2017) included: All food service equipment will be clean, sanitary, and in proper working order. Procedures 1. All equipment will be routinely cleaned and maintained in accordance with the manufacturer's directions and training materials. 2. All staff members will be properly trained in the cleaning and maintenance of all equipment. 3. All food contact equipment will be cleaned and sanitized after every use. 4. All non-food contact equipment will be clean and free of debris. 5. The Dining Services Director will submit requests for maintenance or repair to the Administrator and/or Maintenance Director as needed. 6. The Dining Services Director will notify the Administrator when repairs are completed. 7. Copies of service repairs and preventative maintenance reports will be submitted monthly. A review of the facility policy titled Snacks (HCSG Policy 011, revised 09/2017) included: 7. All snacks will be properly stored for time and temperature control, as appropriate. A review of the facility policy titled Food: Safe Handling for Foods from Visitors (HCSG Policy 031, revised 09/2017) included: 5. Refrigerator/freezers for storage of foods brought in by visitors will be properly maintained and: Equipped with thermometers. Have temperature monitored daily for refrigeration < 41° F (Fahrenheit) and freezer < 0° F. o Daily monitoring for refrigerated storage duration and discard of any food items that have been stored for > 7 days. (Storage of frozen foods and shelf stable items may be retained for 30 days.) o Cleaned weekly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #70 A review was conducted of MDS date for Resident # 70. The Quarterly Review Assessment, dated 01/20/2022 under section N0410E stated that the resident received 7 days of antipsychotic, antianxiety, and antidepressant medications. A review was conducted of medication orders for resident # 70 which revealed no antipsychotic, antianxiety, or antidepressant during the 7 day lookback period of the assessment. On 02/24/2022 at approximately 11:36 AM, an interview was conducted with the MDS coordinator, who pulled up the most recent MDS assessment dated [DATE] and verified that an antipsychotic, an antidepressant, and an antipsychotic were documented as used for 7 days. MDS coordinator sated that there were no antipsychotic, antianxiety, or antidepressants administered during the look back period and the assessment was incorrect. Based on interview with the Minimum Dataset (MDS) coordinator and review of physician orders and MDS Assessments the facility failed to accurately code assessment data for 2 of 27 (#39 and #70) resident Minimum Datasets reviewed. The findings include: A review was conducted of the MDS data for Resident #39. The Quarterly Review Assessment, dated 12/23/2021 under section N0410E stated that the resident received 7 days of Anticoagulant (blood thinner). A review was conducted of medication orders for Resident #39 which revealed no anticoagulants during the time of the 7 day lookback period of the assessment. On 2/24/22 at 10:20 AM, an interview was conducted with the MDS coordinator. She pulled up the 12/23/21 MDS assessment and verified that an anticoagulant was documented as used during the 7 day lookback. She then pulled up the medication administration records which revealed no anticoagulants were administered. She stated that there were no anticoagulants administered during the look back period and the assessment was incorrect. She stated that she would submit an update.

Based on interview, record review and facility policy review the facility failed to implement the plan of care regarding the administration of antibiotic medications for 1 of 5 (#66) residents sampled for unnecessary medications. The findings include: A review was conducted of Resident #66's care plan, which revealed the resident had a care plan with a Focus: The resident has infection of the surgical wound to left hip, initiated 02/01/2022, and an Intervention: Administer antibiotic as per Medical Doctor orders, initiated 02/01/2022. A review was conducted of the physician orders for Resident #66, which revealed the following: Vancomycin Solution (an antibiotic) 1000 milligrams (mg) in 200 milliliters (ml) intravenously (Also called IV, which is a way to give medication directly into the blood stream) one time a day for surgical site infection for 30 Days, ordered on 2/10/2022 Rifampin (an antibiotic) 600mg by mouth one time a day for bacterial infection for 30 Days, ordered on 2/11/2022 Ceftriaxone Sodium Solution (an antibiotic) 2 gram (GM) intravenously one time a day for hip infection for 30 Days, ordered on 2/11/2022. A review was conducted of Resident #66's Medication Administration record (MAR). During review it was noted that the following medication administrations were documented as, 9 - see nurses notes. vancomycin 1GM IV every 18 hours for left hip wound on 2/10/22 at 9:19 pm. vancomycin 1GM IV every 18 hours for left hip wound on 2/11/22 at 11:08 am. ceftriaxone 2GM IV once per day for hip infection on 2/11/22 at 9:00 am. levofloxacin 750mg IV every evening for surgical site infection on 2/9/22 at 5:00 pm. rifampin 600mg by mouth once per day for infection for 30 days on 2/11/22 at 9:00 am. rifampin 600mg by mouth once per day for infection for 30 days on 2/12/22 at 9:00 am. A review was conducted of the nurse's progress notes for the dates and times listed above which revealed the following notes: 2/10/2022 21:19 - Medication Administration Note - Note Text: Vancomycin .Solution Reconstituted 1 GM - Use 1 gram intravenously every 18 hours for Left hip wound - Draw trough after 3rd dose. order in progress. will extend. 2/11/2022 at 11:08 AM - Medication Administration Note - Note Text: med has not arrived. 2/11/2022 8:54 AM - Medication Administration Note - Note Text: On order. 2/11/2022 8:53 AM - Medication Administration Note - Note Text: On order. On 2/23/22 at 12:37 PM, an interview was conducted with Licensed Practical Nurse (LPN) A. When asked how to proceed when a new antibiotic order is prescribed, she stated that it would be pulled from the Omnicell (a proprietary medication machine that stores, tracks and dispenses medication). When asked how to proceed if the medication were not in the Omnicell she stated that, we would notify the pharmacy and start it as soon as it comes. We would reach out to the Medical Doctor. She was asked where this information would be documented and she responded that it would be documented in the progress notes or on the Change in Condition Assessment Form. On 2/24/22 at 10:10 AM, an interview was conducted with the Regional Nurse. When asked about how nursing staff should address a missing medication she stated, We would call the doctor and the pharmacy to ensure that it its coming on the next delivery. If it is not on the next delivery we would call the pharmacy about getting it quicker or call the physician to see if there is another medication or form of the missing medication that could be used. It is ultimately up to the doctor. A review was conducted of the facility policy, 7.0 Medication Shortages/Unavailable Medications, effective 12/01/2007 and last revised 1/1/22. Under the procedure section the policy stated: 1. Upon discovery that Facility has an inadequate supply of a medication to administer to a resident, Facility staff should immediately initiate action to obtain the medication from Pharmacy. If the medication shortage is discovered at the tie of medication administration, Facility staff should immediately take action to notify the Pharmacy. 2. If a medication is unavailable during normal Pharmacy hours: 2.1 A Facility nurse should call Pharmacy to determine the status of the order, which may be found on Omniview under the Pharmacy Connection menu. If the medication has not been ordered, the licensed Facility nurse should place the order or reorder for the next scheduled delivery. 2.2 IF the next available delivery causes delay or a missed dose in the resident's medication schedule, Facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose. 2.3 If the medication is not available in the Emergency Medication Supply, Facility staff should notify Pharmacy and arrange for an emergency delivery, if medically necessary. 3. If a medication is unavailable is discovered after normal Pharmacy hours: 3.1 A Facility nurse should obtain the ordered medication from the Emergency Medication Supply. 3.2 If the ordered medication is not available in the Emergency Medication Supply, the licensed Facility nurse should call Pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. Action may include: 3.2.1 Emergency delivery; or 3.2.2 Use of an emergency (back-up) Third party Pharmacy. 4. If an emergency delivery is unavailable, Facility nurse should contact the attending physician to obtain orders or direction. 5. If the medication is unavailable from Pharmacy or a Third Party Pharmacy, and cannot be supplied from the manufacturer, Facility should obtain alternate Physician/Prescriber orders, as necessary. 6. If the medication is unavailable from Pharmacy due to formulary coverage, contraindication, drug-interaction, drug-disease interaction, allergy or other clinical reason, Facility should collaborate with Pharmacy and Physician/Prescriber to determine a suitable therapeutic alternative. 7. If Facility nurse is unable to obtain a response from the attending physician/prescriber in a timely manner, Facility nurse should notify the nursing supervisor and contact Facility's Medical Director for orders/direction, making sure to explain the circumstances of the medication shortage. 8. When the pharmacy notified the facility that a medication is unavailable due to a recall or manufacturer issues, facility staff should notify the physician/prescriber for a new order. 9. When a missed dose is unavoidable, Facility nurse should document the missed dose and the explanation for such missed dose in the MAR or TAR and in the nurse's noted per Facility policy. Such documentation should include the following information: 9.1 A description of the circumstances of the medication shortage; 9.2 A description of Pharmacy's response upon notification; and 9.3 Action(s) taken.

Based on observation, interview, and record review, the facility failed to provide an ongoing program to support residents in their choice of activities for 1 of 2 residents sampled for activities. (Resident #95) The findings include: On 2/21/22, at approximately 2:09 PM, an interview was conducted with resident #95, who reported a reduced activities service, including: in-house activities and shopping trips. On 2/21/22, at approximately 3:13 PM, an observation was made of the A wing activity board which advertised 4 in-house facility activities per day in February 2022. However, observations of the activity room revealed that activities were being canceled to include a Jazzercise class scheduled at 2/23/22 and a balloon toss on 2/24/22. On 2/23/22, at approximately 9:09 AM, an interview was conducted with the Assistant Activities Aide (AAA) during which it was revealed that due to the staffing shortage the activities department had been cut. The AAA reported that they perform activities duties on Tuesday and Thursday and that the Activities Director (AD) was covering night shifts. When asked about the activities posted on the Activity Boards, the AAA explained, if nurses are not able to organize, activities are canceled. The AAA further stated that activities are canceled more often than they occur. On 2/24/22, at approximately 9:47 AM, an interview was conducted with the Administrator who confirmed the AD was responsible for organizing outings to local shops but had been covering night shifts. On 2/24/22, at approximately 11:30 AM, a review was conducted of resident #95's care plan which revealed a care plan for Activities: dependent on staff for cognitive stimulation, requires social interaction, Resident participates with Activity of choice as tolerate.

Based on interview and record review, the facility failed to ensure appropriate certification for Personal Care Attendants (PCA) within 4 months of the date of hire for 6 of 16 PCAs reviewed (Staff members D, E, F, G H and I). The findings include: On 02/24/22 at approximately 2:30 PM, the Administrator brought documentation of the Patient Care Attendant's (PCA) hired by the facility. A review of the documentation revealed that 6 PCAs had been on working at the facility for over 4 months without obtaining certified nursing assistant certification: -Staff D, Patient Care Attendant was hired on 8/10/2021 -Staff E, Patient Care Attendant was hired on 9/14/2021 -Staff F, Patient Care Attendant was hired on 4/23/2020 -Staff G, Patient Care Attendant was hired on 7/28/2021 -Staff H, Patient Care Attendant was hired on 9/14/2021 -Staff I, Patient Care Attendant was hired on 6/15/2021 On 02/24/2022 at approximately 2:30 PM, an interview was conducted with the Administrator who stated, they have had challenges getting the PCA's scheduled for testing and in some cases the PCA has not wanted to travel to take the exam. He stated other facilities have had problem scheduling the certification also. The plan was to create a testing site in a long term care facility in Pensacola. The Executive Director at that facility abruptly left and then they closed the facility, so that has not been pursued. The other option is to travel to central or southern Florida and the PCAs don't wish to travel that far. Since then some testing has opened up and they are going to work on scheduling them.