Based on record review and interview the facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) was completed in a timely manner for two residents (Resident #31 and Resident #46) out of 18 residents sampled as evidenced by Level I PASRR dated 2/13/15 for Resident#31 omitted diagnosis of Depression and Psychotic disorder with delusions due to known physiological condition and Level I PASRR dated 4/3/24 for Resident#46 omitted diagnosis of Major depressive disorder, and Psychotic disorder. There were 85 residents residing in the facility at the time of survey. The findings included: Resident #31 Record review of Level I PASRR for Resident #31 Screen and Determination Admitting diagnosis: Paralysis Agitation others: Altered Mental status: PASRR: Section I: Guide for Determining an indication of, or a Diagnosis of, a serious mental illness (MI), Mental Retardation (MR) or Related Condition: check those that apply: none checked. Section II: Part A: Mental Illness: No Part B- Mental Retardation: No. Signed by Social Worker from Hospice on 2/13/2015. Record review of demographic sheet for Resident #31 revealed an admission date of 2/13/15 and readmission date of 12/11/23 with diagnosis that included Depression and Psychotic disorder with delusions due to known physiological condition. Record review of an Annual admission Minimum Data Set (MDS) with a reference date of 7/8/24 Section A (Identification) revealed the resident is not currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section N (medications) revealed Resident #31 was taking antidepressant medication during the last seven (7) days. Section O (special treatments and therapy) revealed the total number of minutes Psychological Therapy (by any licensed mental health professional) administered to the resident in the last 7 days was Zero (0). Record review of Care Plan with Start Date 02/11/2022 and Reviewed/Revised date of 08/04/2024 revealed Resident #31 was at risk for alteration in thought process secondary to diagnosis that included depression, psychotic disorder with delusions. Interventions included: Psychiatry/neurology consult and follow up as needed and anticipate all possible needs and provide them to resident accordingly. Record review of physician orders dated 10/13/2023 revealed Seroquel 25 milligram(mg) tablet directions: one tablet by mouth twice a day for Delusions and Sertraline 25 mg tablet directions: take one tablet by mouth once a day for Depression. Record review of a physician progress note dated 10/19/17 revealed family requested Resident #31 be followed up by a Neurologist from psychiatric point of view. Record review of a Report of Consultation dated 7/7/23 revealed a consulting physician Neurologist Report with findings of a diagnosis that included: Depression. Record review of a Psychiatric Note dated 2/2015 with diagnosis that included: Anxiety. On 08/08/24 10:09 AM The Director of Nursing (DON) stated Resident #31's diagnosis of Depression and Psychotic disorder were secondary to Parkinson Disease, and therefore the PASRR did not need to be reviewed. There is no documentation specifying that this resident's diagnosis of Depression is secondary to Parkinson Disease. The Gradual Dose Reduction (GDR) from pharmacy indicated that the hallucinations were secondary to Parkinson. Review of Consultant Pharmacist Services Note to Attending Physician/Prescriber for Resident #31 dated 1/14/24 revealed a recommendation to review the following medications and consider for GDR: Zoloft 25mg QD (daily) and Seroquel 25 mg (milligrams) BID (twice daily). Physician response dated 2/27/24: cannot be reduced or discontinued (d/c) for treatment of Depression and Seroquel cannot be reduced of discontinue (d/c) for treatment of hallucinations secondary to Parkinson disease. Resident #46 Record review of demographic sheet for Resident #46 revealed an admission date of 4/4/24 with diagnosis that included Major depressive disorder and Psychotic disorder. Record review of Preadmission Screening and Resident Review (PASRR) for Resident #46 dated 2/19/24 PASRR: Section I: PASRR Screen Decision Making: no diagnosis checked Section IV: PASRR Completion: No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability Indicated. Level II PASRR evaluation not required. Electronically signed by Social Worker of local hospital on 4/3/24. Record review of a significant change MDS with reference date of 4/10/24 revealed Section A 1500: PASRR: The resident was not considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Further Record review of a quarterly MDS with reference date of 07/09/2024 Section I (Active diagnosis) revealed Depression. Section N revealed antidepressants and anticoagulants were taken in last 7 days and Section O the number of days psychological therapy (by any licensed mental health professional) was administered for at least 15 minutes a day in the last 7 days was 0. Record review of a Care Plan started on 3/20/24 and revised / reviewed on 7/29/24 revealed R#46 had the potential for changes in mood related to a diagnosis of Depression and history of Psychosis. Interventions included: Approach resident in a calm friendly manner, administer medications as ordered, and encourage interactions with others. Record review of physician orders revealed an order on 4/04/2024 for Trazodone 50 mg directions: take a half of tablet at bedtime for diagnosis of Depression. Record review of a Psychiatric Initial Evaluation/Consultation observation date 4/11/24 and recorded date of 4/27/24 revealed reason for initial psychiatric evaluation was for psychotropic use and a past medical history that included Depression. On 08/08/24 10:09 AM The DON and Director for Admissions revealed they both work together to ensure an accurate PASRR is completed for all residents. The process is to review the PASRR before admission by reviewing all the medications to determine if there is any psychiatric diagnosis and if the resident has a qualifying mental diagnosis, check the appropriate box and submit the PASRR to Atrezzo and they report if a Level II is required. The PASRR stays with the resident for the duration while residing in the facility unless there is a change in behavior or if the psychiatrist is involved or a mental illness history is discovered. Then a resident review of PASRR is performed after consent from the family is obtained. Then the clinicals are submitted to Atrezzo and they inform us if a Level II is required and if the needs for the resident can continued to be met in the facility. A review did not need to be submitted for [Resident #46] prior because her Depression and Psychosis are secondary to a medical diagnosis. Record review of the facility's policy titled Resident Assessment and PASAAR effective date: November 2016 Last revision date: January 7, 2017 last review date: January 7, 2017, April 11, 2017, January 11, 2024 revealed Policy: The facility must make a comprehensive assessment of each residents' needs, strengths, goals, life history and preferences, using the residents assessment instrument (RAI) specified by CMS. Procedure: 2. Preadmission Screening for Individuals with a Mental Disorder and Individuals with Intellectual Disability d. A nursing facility must notify the state mental health authority or a state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has a mental disorder or intellectual disability for resident review.

Based on observation, interviews, and record review the facility failed to prepare food under sanitary conditions by ensuring the gas burner stove was cleaned and maintained on a regular basis. The gas burner contained brown-like food stains and food particles on top and black like buildup on the side panel of the stove and grill. This has the potential to affect 84 out of 85 residents who eat orally residing in the facility at the time of survey. The findings include: Oberservation of the gas stove burners on 8/7/2024 at 11:24 AM with the Dietary Supervisor revealed brown-like food stains and food particles on top and black like buildup on the side panel of the stove and griddle. Photographic evidence submitted. On 8/7/2024 at 11:26 AM, interview with the Dietary Supervisor, she revealed the gas stove is cleaned everyday and the facility is purchasing a new stove. On 8/7/2024 at 1:38 PM, interview with the Registered Dietician (RD), she revealed the stove is cleaned daily and weekly with a deep clean monthly. On 8/7/2024 at 1:43 PM, interview with the Administrator, he revealed he could probably produce a kitchen cleaning task sheet for weekly and monthly cleaning staff has done but not for daily cleaning. He revealed the black like buildup was soot and accumulated from cooking on it at breakfast and lunch. Record review of the Kitchen Cleaning Task Weekly dated 7//5/2024, 7/12/2024, 7/19/2024, 7/26/2024, and 8/2/2024 and Kitchen Cleaning Task Monthly dated 1/1/2024, 2/1/2024, 3/1/2024, 4/1/2024, 5/1/2024, 6/1/2024/ 7/1/2024, and 8/1/2024 had no documentation the Kitchen Cleaning Task Daily was provided. Kitchen Cleaning Task Weekly and Kitchen Cleaning Task Monthly documented wash behind your ovens and fryers to eliminate grease and clean underneath any applicances and other surfaces. Second observation of the gas stove burners on 8/8/2024 at 7:31 AM during breakfast preparation with the Dietary Supervisor and Administrator revealed attempts were made to clean the black like buildup on the side panel of the stove. The grill still contained black like buildup on the side panel. Photographic evidence submitted. On 8/8/2024 at 7:32 AM interview with the Dietary Supervisor, she stated, At the end of the shift at 7:00 PM yesterday, I cleaned the stove. I spray with degreaser, scrubbed and wash it out. On 8/8/2024 at 7:33 AM interview with the Administrator, he stated, She cleans daily for particles and soot. She cleans weekly and scrubs every part of the stove. Once a month, we remove the burners and clean them with [ ] from Corporate and do a complete cleaning of the stove. Third observation of the gas stove burners on 8/8/2024 at 11:11 AM during lunch preparation revealed attempts were made to clean the black like buildup on the side panel of the stove. The grill still contained black like buildup on the side panel. Photographic evidence submitted.

Based on observations, interviews and record review the facility failed to prepare food under sanitary condition by ensuring the gas burner stove was cleaned and maintained on a regular basis. The gas burner contained brown-like food stains and food particles on top and black like buildup on the side panel of the stove and grill. This has the potential to affect 84 out of 85 residents who eat orally residing in the facility at the time of the survey. The findings included: Observation of the gas stove burners on 8/07/24 at 11:24 AM with the Dietary Supervisor revealed brown-like food stains and food particles on top and black like buildup on the side panel of the stove and griddle. Photographic evidence submitted. On 8/07/24 at 11:26 AM, interview with the Dietary Supervisor. She revealed the gas stove is cleaned everyday and that the facility is purchasing a new stove. On 8/07/24 at 1:38 PM, interview with the Registered Dietitian (RD). She revealed the stove is cleaned daily and weekly with a deep clean monthly. On 8/07/24 at 1:43 PM, interview with the Administrator. He revealed he could probably produce kitchen cleaning task sheet for weekly and monthly that the staff has done but not for daily cleaning. He revealed that the black like buildup was soot and was accumulated from cooking on it at breakfast and lunch. Record review of the Kitchen Cleaning Task Weekly dated 7/05/24, 7/12/24, 7/19/24, 7/26/24 and 8/02/24 and Kitchen Cleaning Task Monthly dated 1/01/24, 2/01/24, 3/01/24, 4/01/24, 5/01/24, 6/03/24, 7/01/24 and 8/01/24. No documentation of the Kitchen Cleaning Task Daily was provided. Kitchen Cleaning Task Weekly and Kitchen Cleaning Task Monthly documented wash behind your ovens and fryers to eliminate grease and clean underneath any appliances and other surfaces. Second observation of the gas stove burners on 8/08/24 at 7:31 AM during breakfast preparation with the Dietary Supervisor and the Administrator revealed attempts were made to clean the black like buildup on the side panel of the stove. The grill still contained black like buildup on the side panel. Photographic evidence submitted. On 8/08/24 at 7:32 AM, interview with the Dietary Supervisor. She stated, At the end of the shift at 7:00 PM yesterday, I cleaned the stove. I spray with degreaser, scrubbed and wash it out. On 8/08/24 at 7:33 AM, interview with the Administrator. He stated, She cleans daily for particles and soot. She cleans weekly and scrubs every part of the stove. Once a month, we remove the burners and clean them with [ ] from Corporate and do a complete cleaning of the stove. Third observation of the gas stove burners on 8/08/24 at 11:11 AM during lunch preparation revealed attempts were made to clean the black like buildup on the side panel of the stove. The grill still contained black like buildup on the side panel. Photographic evidence submitted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete a significant change assessment (MDS) for 1 (Resident#28) out of 18 sampled residents whose assessments were reviewed. The facility had 87 residents at the time of the survey. The findings included: On 12/14/2021 at 10:30 am, Resident # 28 was observed in bed. The resident did not respond when spoken to, but her eyes were open. It was observed that the resident had two small siderails up on the bed. The resident's left arm appeared to be flaccid, had decreased movement and to have limited range of motion as it laid on the bed. The resident was in a low bed and there were two mats next to the bed, one on the right side and one on the left side. It was observed that the resident had a tube feeding pump with Two Cal HN (High Nitrogen) tube feeding bottle and a water flush at the bedside. The tube feeding was not infusing during this observation. The resident was offsite selected for limited range of motion, and tube feeding with weight loss/dehydration. Observation of Resident #28 on 12/16/21 at 11:50 AM, revealed the resident was sitting up in a high back wheelchair, asleep, the television (TV) was on, and the resident was observed to move both arms. Record review revealed Resident #28 was admitted to the facility on [DATE]. Diagnoses included, but were not limited to Coronary Artery Disease, Hypertension, Alzheimer's Disease, Gastrostomy and was a Do Not Resuscitate (DNR). During the review of Resident #28's Annual Comprehensive Minimum Data Set (MDS) dated [DATE] and a comparison of the most recent MDS quarterly assessment dated [DATE], revealed there were declines in Section G, Functional Status, G0110 Activities of Daily Living (ADL) Assistance and Section K Swallowing/Nutritional Status. The following declines were documented: The 01/13/2021 Annual MDS documented for: Section G - Bed Mobility - 3-Extensive Assistance and 2-One person physical assistance, a 3/2. Transfers - 3-Extensive Assistance and 2-One person physical assistance, a 3/2. Locomotion on Unit - 2-Limited Assistance and 2-One person physical assistance, a 2/2. Personal Hygiene - 3-Extensive Assistance and 2-One person physical assistance, a 3/2. The most recent MDS quarterly assessment dated [DATE] documented: Section G - Bed Mobility - 3-Extensive Assistance and 3-Two+ persons physical assistance, a 3/3. Transfers - 7-Activity occurred only once or twice and 3-Two+ persons physical assistance, a 7/3. Locomotion on Unit - 7-Activity occurred only once or twice and 2-One person physical assist, a 7/2. Personal Hygiene - 4-Total Dependence and 2-One person physical assistance, a 4/2. The 01/13/2021 Annual MDS documented for: Section K - Swallowing/Nutritional Status. K100 - None. K200 - 66 IN (inches), 131 lbs.(pounds). K300 - Weight Loss - 0 - No or unknown. The most recent MDS quarterly assessment dated [DATE] documented: Section K - Swallowing/Nutritional Status. K100 - None. K200 66 IN, 110 lbs. K300 - Weight Loss - 2- Loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Yes, not on physician prescribed weight loss regimen. During an interview on 12/16/21 at 4:46 PM with the MDS Coordinator about the declines in Section G and Section K. The MDS Coordinator reported, they followed the guidelines in the MDS manual for the significant change. During an interview on 12/17/21 at 12:59 PM with the MDS Coordinator and Chief Nursing Officer about the declines documented in the MDS, it was revealed that they did not think a significant change assessment needed to be completed.