**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition were referred for a Level II evaluation and examination for two (Residents #67 and #60) of 37 residents sampled for Preadmission Screening and Resident Review (PASARR). The findings include: 1. Review of Resident #67's PASARR dated 5/10/22 documented a negative Level 1 with no mental illness or intellectual disability listed. Review of the admission record for Resident #67 revealed an initial admission date of 4/13/22 and a re-admission date of 5/10/22. Diagnosis listed on the admission record included other specified anxiety disorders dated 5/5/23. Review of the psychiatry note for Resident #67 dated 7/10/23 read, This is a [AGE] year-old patient with past history of anxiety and insomnia. On 5/5/23 patient was anxious. Patient was presented with compulsive behaviors of touching and playing with stomach. Patient reported itching around the site. Presented increased or worsening depression. Started Sertraline at 50 mg QD (milligrams every day) for anxiety and Hydroxyzine at 10 mg Q12H PRN (milligrams every 12 hours as needed) for anxiety and itching. DX (diagnosis): Other specified anxiety disorders. Review of the minimum data set quarterly assessment dated [DATE] documented Resident #67 active diagnosis included anxiety disorder and psychotic disorder. Review of Resident #67's clinical record failed to show documentation that the resident had been referred for a Level II PASARR evaluation following the diagnosis of other specified anxiety disorders on 5/5/23. During an interview on 9/24/24 at 1:17 PM, the Director of Nursing confirmed the facility should have done a new screening when the resident received the new diagnosis. 2. Review of Resident #60's Level I PASARR screening, dated 12/20/2022, showed anxiety disorder and depressive disorder documented in Section I: PASRR Screen Decision-Making A. MI [Mental Illness] (check all that apply). Review of Resident #60's admission record, initial date of admission [DATE], revealed Resident #60 had diagnoses that included other bipolar disorder, onset date 12/13/2022 and brief psychotic disorder, on set date 3/6/2023. Review of Resident #60's clinical records failed to show documentation Resident #60 had been referred for a Level II PASARR evaluation following the diagnoses of other bipolar disorder, onset date 12/13/2022 and brief psychotic disorder, on set date 3/6/2023. During an interview on 9/24/2024 at 2:10 PM, the Director of Nursing confirmed Resident #60 had not been referred for a Level II PASARR after he was identified with a newly evident or possible serious mental disorder. Review of the policy titled, Resident Assessment - Coordination with PASARR Program, date reviewed, 9/18/2023, read, Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidelines: 9. Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or related condition will be referred promptly to the state mental health and intellectual disability authority for level 2 resident review. Examples include: a. A resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting the presence of a mental disorder (where dementia is not the primary diagnosis) b. A resident whose intellectual disability or related condition was not previously identified and evaluated through PASARR. .

Based on interview and record review, the facility failed to ensure each resident was screened for a mental disorder or intellectual disability prior to admission to ensure those individual identified with mental disorders or intellectual disabilities are evaluated and receive care and services in the most appropriate setting for one (Resident #4) out of 37 residents sampled for Preadmission Screening and Resident Review (PASARR). The findings include: Review of the admission record for Resident #4 documented an initial admission date of 1/2/2018 with readmission dates following hospital stays on 12/28/23 and 3/29/24. Diagnoses included cerebral palsy unspecified (onset date 1/2/2018), generalized anxiety disorder (onset date 10/26/2020), bipolar disorder unspecified (onset date 1/2/2018), and major depressive disorder (onset date 5/20/2022). Review of the PASARR Level 1 screening for Resident #4 dated 12/28/2023 did not document anxiety disorder, bipolar disorder, depressive disorder or a related condition of cerebral palsy. The Level I screening for Resident #4 documented on page 5: No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASARR evaluation not required. Review of the Minimum Data Set Annual Assessment for Resident #4 dated 6/17/2023, Section I documented the resident has cerebral palsy, anxiety disorder, depression and bipolar disorder. It further documented the resident is taking antipsychotic and antidepressant medication, the antipsychotic is received on a routine basis, and a gradual dose reduction (GDR) has not been attempted. During an interview on 9/24/2024 at 3:10 PM, the Director of Nursing stated that the Level 1 Preadmission Screening and Resident Review (PASARR) for [Resident #4's Name] was not accurate. Review of the policy titled Resident Assessment - Coordination with PASARR Program, date reviewed, 9/18/2023, read, Policy: This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to provide central venous catheter dressing changes as ordered in accordance with professional standards of practice for one (Resident # 237) out of one resident reviewed with a peripherally inserted central catheter, out of a total sample of 37 residents. The findings include: During an observation on 9/23/2024 at 10:25 AM, Resident #237 was sitting in bed with a right arm single lumen peripherally inserted central catheter (PICC) line. The transparent dressing was lifting up at the edges, exposing the insertion site. The date on the dressing was 9/10/2024. During an interview on 9/23/2024 at 10:30 AM, Resident #237 stated, They have not changed this (the PICC line dressing) since I was admitted , I get antibiotics for a blood infection. I have not been offered a dressing change. During an observation on 9/23/2024 at 2:30 PM, Resident # 237 was observed sitting up in bed with a right upper arm single lumen PICC line with date of 9/10/2024 on the transparent dressing, with the edges of dressing lifting up exposing the insertion site. Review of the admission record documented that Resident #237 was admitted to the facility on [DATE] with the following diagnoses: Sepsis due to enterococcus (a life-threatening condition that occurs when the body's immune system has an extreme response to an infection or injury), Type 2 diabetes mellitus with hyperglycemia (high blood glucose), and essential (primary) hypertension. Review of Resident #237's physician orders dated 9/20/2024 reads, Change central line catheter site dressing every week with only transparent dressing. Change needleless access device every day shift every fri (Friday). Review of Resident #237's physician orders from 9/12/2024 through 9/24/2024 revealed there were no orders for central line catheter site dressings changes prior to 9/20/2024. During an observation of medication administration for Resident #237 on 9/24/2024 at 1:27 PM, Staff E, Licensed Practical Nurse (LPN) flushed the right upper arm PICC Line with 5 milliliters of normal saline. Staff E, LPN did not verify PICC line placement by aspirating to check for blood return prior to administering the normal saline and did not use a push-pause motion when administering the normal saline flush. During an interview on 9/24/2024 at 1:38 PM with Staff E, LPN, she stated, I did take care of him (Resident #237) after the 17th, I did not change his dressing or check it, I should have, all PICC lines get changed every 7 days, so his dressing should have been changed on September 17th. He has not refused to have his dressing changed, because I didn't ask to change it when I took care of him. I should have checked for placement by verifying whether it had a blood return. I did not use a push pause when I flushed his line. We should check whether a dressing is current every day when we flush the line or give the antibiotic. During an interview on 9/24/2024 at 2:04 PM, the Director of Nursing (DON) stated, All midline or PICC line dressings get changed every week. We should have changed his (Resident #237) dressing on the 17th. I 'm not sure why it was not completed. We don't need an order to change the dressing, it would be a standard of care to change it every 7 days at least, more often if it needs it. Review of the policy and procedure titled Central Venous Catheter Dressing Changes last review date of 1/25/2024 reads, Policy: Central venous catheter dressings will be changed at specific intervals, or when needed, to prevent catheter-related infections that are associated with contaminated, loosened, soiled, or wet dressings, Preparation: 2. A physicians order is not needed for the procedure, General guidelines: 1. Apply and maintain sterile dressing on intravenous access devices. Dressings must stay clean, dry, and intact. 5. Change transparent semi-permeable membrane (TSM) dressings every 5 to 7 days and PRN (when wet, soiled, or not intact). Review of the policy and procedure titled Flushing Midline and Central line IV catheters last review date of 1/25/2024 reads, Policy: Midline and central line IV catheters (CVAD's) will be flushed to maintain patency; to prevent mixing of incompatible medications and solutions; and to ensure entire dose of medication is administered into the venous system. Flushing Technique: 2. Use a push-pause motion or pulsing motion for flushing technique. 3. Aspirate the CVAD catheter for blood return to confirm patency prior to administration of medication and solutions. Procedure: Flushing to maintain patency of catheter: 4. Aspirate slowly for blood return to ensure patency of catheter. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to ensure that oxygen was administered consistent with professional standards of practice for two (Residents #80 and #187) out of four residents reviewed for respiratory care, from a total of 37 residents sampled. The findings include: 1. Review of Resident #80's admission record revealed the following diagnoses: cerebral infarction, unspecified (a stroke), acute respiratory failure with hypoxia (low levels of oxygen in the blood), acute pulmonary edema (fluid in the lungs), essential (primary) hypertension (high blood pressure), major depressive disorder, hypothyroidism, unspecified, and hemiplegia (paralysis of one side of the body), unspecified affecting right dominant side. Review of Resident #80's physician orders dated 4/8/24 reads, Oxygen at 2 liters/ min (minute) via nasal cannula with Humidification PRN (pro re nata) [as needed]-to keep O2 (oxygen) sat (saturation) above 90% as needed for SOB (shortness of breath). Review of Resident #80's nursing progress notes from 9/16/2024 through 9/24/24 revealed there was no documentation related to change of condition or need to increase oxygen. During an observation on 9/23/24 at 11:34 AM, Resident #80 was observed sitting at bedside in a wheelchair with oxygen being administered via nasal cannula. The oxygen concentrator was administering oxygen at 3.5 liters with no humidification. The oxygen concentrator was across the room from the resident and out of the reach of the resident. During an observation on 9/24/24 at 7:23 AM, Resident #80 was observed in bed, with the oxygen concentrator at the head of the bed outside of the reach of the resident. The oxygen concentrator was administering oxygen at 3 liters nasal cannula with no humidification. During an interview on 9/24/24 at 7:25 AM, Resident #80 stated, I cannot reach that (the oxygen concentrator), I don't try to change the oxygen, the nurses do that. During an interview on 9/24/24 at 8:00 AM, Staff A, LPN stated, The oxygen should be at 2 liters, I'm not sure how it's at 3 liters. I will need to change that. No, there is no humidification, I have to see the order to see if she needs that. We should be checking what the rate of oxygen at least once a shift. We do walking rounds; I did not check the oxygen when I did them today. During an interview on 9/24/24 at 12:19 PM, the Director of Nursing (DON) stated, I expect staff to assess residents on oxygen at a minimum daily and make sure that we are following the orders for correct oxygen administration. 2. During an observation on 9/23/24 at 12:31 PM, Resident #187 was receiving oxygen from a concentrator via a nasal cannula. The concentrator was set at 4 liters and the humidification bottle was wrapped in plastic, empty, and was not hooked up to the concentrator. During an interview on 9/23/24 at 12:41 PM, Resident #187 confirmed that 4 liters of oxygen was correct. Review of the admission record for Resident #187 revealed the resident was admitted on [DATE] with diagnosis that included: Chronic Obstructive Pulmonary Disease With (Acute) Exacerbation, Acute Respiratory Failure With Hypoxia and Acute Respiratory Failure With Hypercapnia (elevated level of carbon dioxide in the blood). Review of the physician orders for Resident #187 dated 9/3/24 read Oxygen at 2 liters/min (minute) via nasal cannula, humidification: Yes. During an observation on 9/24/24 at 8:38 AM, Resident #187 was receiving oxygen from a concentrator via a nasal cannula. The concentrator was set at 2.5 liters and the humidification bottle was wrapped in plastic, empty, and was not hooked up to the concentrator. During an interview on 9/24/24 at 3:14 PM, with Staff D, Registered Nurse regarding his observation of Resident #4's concentrator, he stated, The humidification is not connected. The liters are currently slightly above 2 liters. [Resident #187's name] had previously told the therapist that his oxygen was to be set on 4 but she stated that she corrected him. When asked what the physician orders were for Resident #187, he stated, The order is for 2 liters with humidification. Review of the policy and procedure titled Oxygen Administration last date revised 5/4/2022, last approval date of 1/25/2024 reads, Policy: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. Policy explanations and compliance guidelines: 1. Oxygen is administered under orders of a physician. Except in the case of an emergency. In such case, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. .

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in a secured manner to limit unauthorized access to medications for three (Residents #78, #74, and #6) out of six residents reviewed for medication storage. The findings include: 1. During an observation on 9/23/2024 at 12:24 PM of Resident #78's room, one bottle of Tylenol PM (acetaminophen 500 milligrams (mg)) and diphenhydramine HCL 25 mg was sitting on dressing table unsecured. During an interview on 9/23/2024 at 12:24 PM Resident #78 stated I take one tablet every night and they know that I have it and take it. During an observation on 9/23/2024 at 2:50 PM of Resident #78's room, one bottle of Tylenol PM (acetaminophen 500 milligrams (mg)) and diphenhydramine HCL 25 mg was sitting on dressing table unsecured. During an observation on 9/24/2024 at 07:55 AM of Resident #78's room one bottle of Tylenol PM (acetaminophen 500 milligrams (mg)) and diphenhydramine HCL 25 mg was sitting on dressing table unsecured. During an observation in Resident #78's room on 9/24/2024 at 1:38 PM with Staff A, License Practical Nurse (LPN), one bottle of Tylenol PM (acetaminophen 500 milligrams (mg)) and diphenhydramine HCL 25 mg was sitting on dressing table unsecured. During an observation in Resident #78's room on 9/24/2024 at 1:42 PM with Staff C, LPN, one bottle of Tylenol PM (acetaminophen 500 milligrams (mg)) and diphenhydramine HCL 25 mg was sitting on dressing table unsecured. 2. During an observation on 9/23/2024 at 12:41 PM of Resident #74's room, one tube of Zinc ointment 20% was lying on the dresser. During an interview on 9/23/2024 at 12:41 PM with Resident #74, the resident stated, I don't know what that is or what it's for. During an observation on 9/24/2024 at 8:58 AM of Resident #74's room, one tube of Zinc ointment 20% was lying on the dresser unsecured. During an observation on 9/24/2024 at 1:38 PM of Resident #74's room, one tube of Zinc ointment 20% was lying on the dresser unsecured. During an observation in Resident #74's room on 9/24/20924 at 01:38 PM with Staff A, LPN, one tube of Zinc ointment 20% was lying on the dresser unsecured. During an observation on 9/24/2024 at 01:42 PM with Staff C, LPN of Resident #74's room, one tube of Zinc ointment 20% lying on the dresser unsecured 3. During an observation on 9/23/2024 at 12:58 PM of Resident #6's room, one tube of Muscle rub menthol 2% ointment was on the bedside table unsecured. During an interview on 9/23/2024 at 12:58 PM with Resident #6, the resident stated, My friend comes in and will rub the cream anywhere that I hurt. During an observation on 9/24/2024 at 8:58 PM of Resident #6's room, one tube of Muscle rub menthol 2% was lying on the dresser unsecured. During an observation in Resident # 6's room on 9/24/20924 at 1:38 PM with Staff A, LPN, one tube of Muscle rub menthol 2% was on bedside table unsecured. During an observation in Resident # 6's room on 9/24/2024 at 1:42 PM with Staff C, LPN, one tube of Muscle rub menthol 2% on bedside table unsecured. During an interview on 9/24/2024 at 1:38 PM with Staff A, LPN, she stated, Medication cannot be at the bedside or the residents rooms. All medications has to be locked in the medication cart and a physician must write an order for self-administration. During an interview on 9/24/2024 at 1:45 PM with Staff C, LPN, she stated, Medication cannot be in the room unsecured. All medication must be secured in the medication cart. During an interview on 9/24/2024 at 1:58 PM with the Director of Nursing (DON), the DON stated, Medications are to be secured. No medications are to be in the residents rooms unsecured. All medications are to be locked in the medication cart. Review of facilities policy and procedure titled Medication Storage dated 01/25/2024 read It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and or medications=rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security .a. All drugs and biologicals will be stored in locked compartments (i.e. medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls . c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart. (Photographic evidence obtained) .

Based on observation, interview, and record review, the facility failed to ensure proper sanitation and food storage practices were adhered to in order to prevent the outbreak of foodborne illnesses. The findings include: During an initial tour of the kitchen with the Certified Dietary Manager on 9/23/2024, beginning at 11:00 AM, the following was observed: Three (3) salads prepared on individual plates with no date or label in reach in refrigerator #1. Two (2) undated cut halves of honey dew melon, 2 undated cut quarter slices of honey dew melon and 1 undated cut half of a watermelon without dates stored in the produce refrigerator. One (1) undated and unlabeled bag of diced vegetables stored in the produce refrigerator. Five (5) undated and unlabeled 5-ounce containers of pureed fruit in the pastry freezer. One (1) uncovered, undated and unlabeled picture of a red drink. Two (2) undated and unlabeled pitchers of beverages stored underneath raw meat products in the meat freezer. During an interview on 9/23/2024 beginning at 11:00 AM, the Certified Dietary Manager acknowledged not all food items stored in the kitchen were labeled and dated. She confirmed all food items should be labeled, dated and covered. She confirmed beverages should not be stored underneath raw meat products. Documentation provided by the facility related to facility practices of storage for Temperature Control for Safety (TCS) Foods, undated, read, Labeling and storing of TCS food correctly ensures our ingredients are safe to use in food served to our customers. All TCS food we prepare and keep for over 24 hours must be labeled and used within 7 days. The document continued Transfer or rewrite labels with the original Use By date from the first container if you move labeled items to different containers. Put Ready-to-Eat food on top, raw meat and fish below and raw poultry on bottom. .

Based on observation, interview, and policy and procedure review, the facility failed to maintain an infection prevention and control program designed to help prevent the transmission of communicable diseases and infection, by 1) failing to perform appropriate hand hygiene during medication administration for four (Residents #51, #80, #238, and #71) of eight residents observed for medication administration, and 2) failed to follow acceptable standards of care for enhanced barrier precautions for a central venous catheter for one (Resident #237) resident during medication administration from a total survey sample of 37 residents. Failure to follow proper infection control standards increases the risk of adverse health outcomes for facility residents, staff, and other facility occupants. The findings include: 1. During an observation of medication administration on 9/23/2024 at 12:03 PM, Staff B, Registered Nurse (RN), returned to the medication cart from the nurses station, removed medication cart keys from their pocket, unlocked the medication cart, activated the computer and typed on the computer. Then Staff B, RN removed insulin from the medication cart, and went to Resident #51's room, entered the room without performing hand hygiene, did not don gloves and administered insulin to Resident #51. Exited the residents room and returned to the medication cart without performing hand hygiene. During an interview on 9/23/2024 at 12:08 PM, Staff B, RN stated, I don't know why I didn't wash my hands or put gloves on. I guess you just make me nervous. I should have done that, I should have washed my hands and put on gloves before I gave him (Resident #51) the insulin. During an observation of medication administration on 9/24/2024 at 8:05 AM, Staff A, Licensed Practical Nurse (LPN) returned to the medication cart from a residents room, reached into pocket for keys unlocked the medication cart and began to prepare medications for Resident #80 without performing hand hygiene. Staff A entered Resident #80's room without performing hand hygiene and administered medications to the resident. Staff A exited the room without performing hand hygiene and returned to the medication cart. During an observation of medication administration on 9/24/2024 at 8:23 AM, Staff A, LPN returned to the medication cart, reached into pocket removed keys and unlocked the medication cart, Staff A prepared medications for Resident #238 without performing hand hygiene, entered Resident #238's room without performing hand hygiene, administered medications to the resident and exited the room returning to the medication cart and began preparing another residents medications without performing hand hygiene. During an interview on 9/24/2024 at 8:28 AM, Staff A, LPN stated, I should have washed my hands, I'm not sure why I didn't, I guess I was just nervous. During an observation of medication administration on 9/24/2024 at 9:00 AM, Staff A, LPN returned to the medication cart from the nurses station, reached in her pocket, removed keys, unlocked the medication cart, activated the computer and typed on the computer keyboard. Staff A prepared medications for Resident #71 without performing hand hygiene, entered Resident #71's room without performing hand hygiene and administered Resident #71's medications. Staff A exited the residents room and returned to the medication cart without performing hand hygiene. 2. During an observation of medication administration on 9/24/2024 at 1:27 PM there was enhanced barrier precautions signage on Resident #237's doorway, but there was no personal protective equipment of gowns available either inside or outside of the room. Staff E, LPN assembled all supplies to administer an Intravenous (IV) antibiotic and prepared the IV antibiotic to infuse. Staff did not perform hand hygiene and donned gloves; staff did not don a gown. Staff E went to cleanse the needleless connector and there was no needleless connector on the Peripherally inserted central catheter. Staff E, LPN reached into pocket with gloved hand and got a needleless connector attached it to the peripherally inserted catheter and administered 5 milliliters of normal saline without cleansing the needleless connector with alcohol and attached the intravenous tubing and began to infuse the antibiotic. During an interview on 9/24/2024 at 1:38 PM, Staff E, LPN stated, I should have washed my hands before I put my gloves on. He is on enhanced barrier precautions so I should have also had on a gown. I'm not sure why I didn't do these things. During an interview on 9/24/2024 at 2:05 PM, the Director of Nursing stated,I expect all staff will follow our infection control policies for hand washing and enhanced barrier precautions. Review of the policy and procedure titled, Medication Administration last approval date of 1/25/2024 reads, Policy: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Policy explanation and compliance guidelines: 4. Wash hands prior to administering medication per facility policy. Review of the policy and procedure titled, Hand Hygiene last approval date of 1/25/2024 reads, Policy: Staff will perform hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Policy explanation and compliance guidelines: 1. Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice. 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. Hand hygiene table documents: Between resident contacts; Before applying and after removing personal protective equipment (PPE) including gloves; and before preparing or handling medications. Review of the policy and procedure titled Flushing midline and central line IV catheters last approval date of 1/25/2024 reads, Procedure: 1. Perform hand antisepsis. [NAME] non-sterile gloves. 2. Disinfect needleless connection device with antiseptic solution. .

Based on observation and interview, the facility failed to provide a safe, functional, and comfortable environment for residents, by not ensuring proper repair of hand rails in the north and south wings of the facility. The findings include: During an observation on 9/23/2024 at 11:59 AM of railings on South [NAME] wing, four caps were observed missing off of the end of the railing in the hall. The opened area of the rail was observed to have jagged metal exposed. During an observation on 9/24/2024 at 11:10 AM of railings on North [NAME] wing, three caps were observed missing off of the end of the railing in the hall. The opened area of the rail was observed to have jagged metal exposed. During an observation on 9/24/2024 at 11:40 AM with the Director of Maintenance, he confirmed the railings in South [NAME] and North [NAME] wing had missing caps with jagged metal exposed. During an interview with the Administrator on 9/24/2024 at 1:17 PM, the administrator stated, I know all of these need to be fixed. Review of the facilities policy and procedure titled Safe and Homelike Environment dated 1/25/2024 read In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment . This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk .3. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment. .

Based on record review and interview, the facility failed to issue proper notices to inform each resident of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate. This affected one of three residents reviewed. (Resident #22) The findings include: On 4/14/2021 at 3:03pm, the Business Office Manager provided the survey team with three incomplete Beneficiary Notice forms. She inquired about possible changes in the Skilled Nursing Care Advanced Beneficiary Notice (ABN), Centers for Medicare and Medicaid (CMS) form 10055. She was advised to provide the documentation that was given to the residents selected for the beneficiary notice task. On 4/14/2021 at 3:21 pm, the Social Services Director provided the survey team with incomplete beneficiary notice forms. The ABNs, CMS forms 10055, were incomplete and not signed by the residents, and there were no Notice of Medicare Non-Coverage (NOMNC), CMS forms 10123 found for the residents. The form for Resident #22 indicated the last day of coverage was 1/20/21 with days not exhausted and a facility initiated discharge,. On 4/15/2021 at 4:53 pm, the Business Office Manager confirmed that the NOMNC's were not given to any of the residents. She confirmed this with the Social Services Director. On 4/16/2021 at 12:53 pm, the Social Services Director confirmed that she is responsible for issuing the cut letters. She stated that she inherited the duty when the building was purchased by the current owners and the previous Business Office Manager retired. She had not received any training, but knew they needed to be done and so she began doing them to the best of her knowledge. She was not familiar with the NOMNC. .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure an allowable diagnosis for the use of antipsychotic medication and to obtain new physician orders to extend duration beyond 14 days for an as needed psychotropic medication for 1 of 5 residents sampled for unnecessary medications from a total sample of 38. (Resident #23) The findings include: Record review for Resident #23 revealed a [AGE] year old male admitted on [DATE] and readmitted from the hospital on 3/30/21. His diagnoses included acute and chronic respiratory failure with hypercapnia, diabetes, osteomyelitis, major depressive disorder and anxiety. He was alert and oriented and required extensive assistance with activities of daily living. Upon admission he was ordered the medication Seroquel (antipsychotic) 25 mg at bedtime for anxiety and Xanax (antianxiety) 0.5 mg every eight hours, as needed for anxiety. Review of the Medication Administration Record (MAR) revealed Xanax 0.5 mg was ordered 3/30/21 and had not been used as of 4/15/21. There was no 14 day stop date for Xanax or no new order written to extend duration beyond the 14 days. Review of the consultant pharmacy report from April 2021 indicated that the diagnosis of anxiety for use of Seroquel was not an allowable diagnosis. The recommendation from the pharmacist had not been followed up. During an interview with the unit manager on 4/16/21 at 10:20 am she confirmed that there was no order no extend the use of Xanax and she said she would notify the physician of the need for appropriate diagnosis for Seroquel. .

Based on observation and staff interview, the facility failed to ensure oral medications and external biological and topical treatments were kept in separate areas of the medication room for 1 of 2 medication rooms, medications were stored under proper temperature control, and expired medications were removed from one of four medication carts. The findings include: During an observation of the medication room on the the south wing on 4/16/21 at 12:15pm, the following was found: over the counter oral medications (milk of magnesia, Prostat, Promod) were commingled on the shelves with wound cleaners, Betadine (antiseptic external solution), and Hibiclens (solution for cleaning wounds). An interview with the unit manager at 12:20pm confirmed the oral medications were not separated from external solutions. Observation of the medication refrigerator on the north wing at 12:30pm with the unit manager (UM) found the temperature was at 38 degrees and the freezer section was totally engulfed with ice and the bottom shelf was very soiled. The UM confirmed the temperature and the refrigerator needed to be defrosted and cleaned. An observation was made of the medication cart on the north wing with Licensed Practical Nurse (Emp A) on 4/16/21 at 1:40pm. There were two insulin pens that were found to be expired. Flex-touch Levemir Insulin pen for Resident #77 was opened on 3/19/21 and was dated to expire on 4/15/21. Lantus Solostar insulin pen for Resident #23 was dated to expire on 4/5/21. Employee A verified the insulin pens were expired and removed them from the cart. .

Based on observation, and interviews, the facility failed to ensure a safe, functional, sanitary environment for 41 of 72 residents by not replacing missing tiles, and not repairing an area on the wall which was covered with gray substance on one of two nursing units. The findings include: Observation of the shower room on South wing on 4/13/21 at 11:00 AM revealed green tiles missing around the sink area with a large gray area on the wall near venting unit with multiple white tiles missing. (photographic evidence obtained) Additional observations of the shower room on South wing were conducted on 4/14/21, 4/15/21 and 4/16/21. The shower room continued to have missing tiles with a large gray area on the wall. An interview was conducted with Employee B, Maintenance Assistant, at 9:10 AM on 4/16/21 concerning the observations in the shower room on South wing. He reported the sink was replaced in the shower room at least 6 months ago due to a leak and the tile was not replaced. He reported there was a leak and the tiles were taken down in order to reach the pipes and the leak. Employee B was asked about the gray area on the wall with the tiles missing near the venting unit. He stated the gray area was a concrete spreader that must have been used to patch a hole. He confirmed the gray area on the wall with tiles missing and stated, I will have to replace the tiles and fix the area. An interview was conducted with the Unit Manager, Licensed Practical Nurse (LPN,) on 4/16/21 at 9:18 AM. The LPN reported a work order is located on both units in a maintenance book that is checked by Maintenance staff daily. She reported she was not aware of a previous work order for the areas of concern. .

Based on observations and interviews, the facility failed to keep the kitchen safe from potential food contamination due to a ceiling area under which food was being prepared and distributed, having gaps and hanging tape on it. The findings include: On 4/13/21 at 1:40 pm, the kitchen's ceiling was observed with open areas and gaps. Some piping was visible. There was tape hanging from an area between ceiling tiles. One ceiling tile had a plastic, sheet-like covering that was hanging loose and had opening on one side where it had been taped up. On 4/15/21 at 11:30 am, the same observations were made of the kitchen's ceiling with no changes. Staff were observed working under open areas of the ceiling while preparing food. The areas of ceiling where gaps were observed have the potential to contaminate foods with dust/debris. On 4/16/21 at 11:50 am, the same observations were made of the kitchen's ceiling with no changes made. The residents' food was being prepared under open areas of ceiling that had gaps in it where dirt/dust or debris could fall into resident's food or food tray. The hanging tape had the potential to break off and fall into food. (photographic evidence obtained) The District Kitchen Manager was interviewed on 4/16/21 at 11:50 am about the condition of ceiling. He stated it was in terrible condition, it had been like that for a while, and the Administrator was aware. On 4/16/21 at 12:00 pm, the Administrator was asked about the condition of the kitchen ceiling. He reported it was like this when he came on board and he was working on it. The administrator has been at this facility for nine months. .