**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to provide food at an appropriate temperature per resident's request for Resident (#104) out of 37 sampled residents. There were 186 residents residing at the facility at the time of the survey.During the initial screening observation on 07/21/2025 at 9:26 AM Resident #104 was in the hallway in a wheelchair, no distress noted, stated the food here is not so good, the food is cold by the time I get around to eating it, When I asked the staff, particularly the Certified Nursing Assistants to heat my food up, they always say we are too busy to eat your food up and the microwave is too far away in the recreation room. Receiving cold food is a daily occurrence, especially breakfast, the eggs are always cold. I mentioned it months ago to the kitchen staff, but nothing has changed, I eat my food in the room, and I am of sound mind, I am fully aware of what I am talking about and am sure the staff will deny everything I am talking about. Observation and Interview on 07/22/2025 at 7:53 AM Resident #4 in the room eating breakfast, sitting on the side of his bed, stated carrots at lunch yesterday were cold and unappetizing and I like vegetables. Today's breakfast is lukewarm, I did not ask anyone to reheat my breakfast, they are not going to do it anyway. The food observed on the resident's breakfast tray include eggs, pancakes, bacon, cereal, juice and milk.Review of the medical records for Resident #104 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Other specified disorders of muscle, Type 2 diabetes mellitus without complications Record review of Resident # 104's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental status Score 15, on a 1-15 scale indicating the resident is cognitively intact. Section GG for Functional Status documented the resident is independent for eating.Interview on 07/22/2025 at 8:01 AM Staff A, Certified Nursing Assistant (CNA) revealed he was assigned to Resident #104 today and mostly worked on the second-floor unit and did not serve the resident's breakfast tray today. Staff A reported the resident did not ask to reheat his food this morning. If a resident requests to have their food reheated, the nurse would be notified and take the food to the pantry to be reheated in the microwave for at least a minute and return the food to the resident.Interview on 07/23/2025 at 11:10 AM, Staff B, CNA on the second-floor unit, stated: I have never been assigned to this resident, I may have helped him in the past if the call light is on because I work in the hallway where his room is. I do not recall the resident ever asking me to heat up his food for him.Interview on 07/23/2025 at 11:12 AM, Staff C,CNA on the second floor unit, stated: I am not assigned to this resident but have worked with him in the past, He has asked me to heat up his food in the past, usually it is his lunch, when he asks, I take his lunch tray to the dining room pantry and reheat the food for him. The times [Resident #104] asked me to reheat his lunch was when he was sleeping and lunch was served on the floor. After he wakes up from his nap and is ready to eat, he would ask me to reheat his lunch.Interview on 07/23/2025 at 11:20 AM, Staff Registered Nurse (RN), stated: today the resident is out on a medical appointment at the hospital, I have worked with this resident several times. As far as I can recall this resident has never asked me to reheat his food because it is cold or complained to me about his food being cold. The resident goes out frequently on medical appointments and may have requested staff reheat his lunch on his return to the facility, if lunch is served prior to him returning to the facility.Interview on 07/23/2025 at 11:24 AM Social Services Director stated: The resident has never complained to me about any issues with his food. He did request to see a dentist regarding his dentures, and an appointment has been set up for him.Review of the facility policy and procedure titled Food and Nutrition Services revision date 10/2017 states: Each resident is provided with a nourishing, palatable, well balanced et that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure privacy of delivered mail for one resident (Resident #1) out of three residents that receive personal mail. As evidenced by mail addressed to Resident #1 was opened without his consent. This has the potential to affect 176 residents residing in the facility at the time of this survey. The findings included: Record review of the Mail/Package Screening Policy and Procedure (reviewed dated January 2025); Policy Statement-To prevent contaminated mail/packages from circulating through the facility, mail, express shipping packages and messenger deliveries are subject to our established screening and handling precautions; Policy Interpretation and Implementation-1) To aid in preventing the spread of contaminated materials, the following delivery precautions have been established: a) Mail, express packages and messenger deliveries must be delivered to the administrative office; 5) To prevent the spread of contaminated mail to our resident population and upon written consent from the resident, the resident's incoming mail (e.g. letters) will be opened before delivery to the resident. Our facility will open only private mail addressed to the resident. Mail from federal or state agencies will not be opened and 6) Should a resident refuse to consent to having his/her private mail opened, the administrative office will forward such mail to the resident's representative of record. Review of the Resident Rights Policy and Procedure (revised January 2025); Policy Statement-Employees shall treat all residents with kindness, respect and dignity; Policy Interpretation and Implementation-1) Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: h. Privacy in sending and receiving mail. Review of the Demographic Face Sheet for Resident #1 documented the resident was admitted on [DATE] with diagnoses to include diabetes mellitus, morbid severe obesity, hypertension, insomnia, atrial fibrillation, mixed anxiety and depressed mood. Review of the Minimum Data Set (MDS) Annual Assessment for Resident #1 dated 5/09/25 revealed the resident had no cognitive impairment, he was able to make his own decisions and make his needs known and required independent assistance for ADLs (Activities of Daily Living). On 6/03/25 at 9:04 AM observation and interview with Resident #1, revealed the resident sitting up in bed on his cellular telephone. He stated, I received a [state agency] letter and it was opened when given to me. I told them to respect my privacy and not to do it again. On 6/03/25 at 11:54 AM, interview with the Director of Social Services. She stated, He told us we are not allowed to open his package. We deliver the package to the residents and encourage them to open it, so that we can see if there is something harmful in it. On 6/03/25 at 12:04 PM, interview with the Recreation Therapy Director. He stated, My department oversees setting up the resident council meetings. The meetings are held every Thursday of the month. We always address the mail. We remind the residents of the mail and package delivery schedule from Monday to Friday by activity staff and the Social Service Department delivers the packages. I get the mail every day from the receptionist, and she gives it to me. Then I give it to my staff, and they do a daily delivery of mail to the residents. We do not open the residents' mail. He addressed me one time about his mail being opened. I'm not sure how the mail was opened. I asked [] the receptionist to ask why the mail was opened with the resident. I left and he spoke to [] the receptionist. On 6/03/25 at 12:18 PM, interview with the Administrator. He stated, Anything that comes in for the resident, first it goes to the receptionist and if it is for residents, we put it in the Admissions office including packages. We keep it safe there and activities will come and deliver them. The mail is put in the Admissions office and not opened. If they need help with opening the mail, we try to get consent to open it for them. He had an incident that happened a few months ago. [] the receptionist opened the letter because it had [state agency name] on it and bought it to my attention. I apologized to him and gave the letter to him. I told [] the receptionist to be careful when opening the mail. Sometimes she opens the mail when she sees [] state agency name on it. On 6/03/25 at 12:28 PM, interview with Receptionist. She stated, I get all the mail. If there is mail for the Administrator, I put it on his desk. I do not open the mail. I did not open any mail for a resident.

Based on observations, interviews and record reviews facility failed to keep residents' information confidential on the second floor, as evidenced by observations of open unattended computer screens with residents' information on the facility's back medication cart and Station II nursing station desk. There were 79 residents residing on the second floor at the time of the survey. The findings included: Observation on 06/3/25 at 10:09 AM of a blood glucose check conducted by Staff A, Licensed Practical Nurse (LPN), noted that at 10:15 AM Staff A, LPN returned to the medication cart, verified the physician's order and prepared the insulin for administration, locked the medication cart and entered the resident's room leaving a medication bag labeled with the resident's name and physician order visible on top of the medication cart. Further observation revealed Staff A, LPN, had also left the computer screen open with residents' information visible. During an interview on 6/3/25 at approximately 10:25 AM, Staff A, LPN was asked about the protocol for protecting resident information, Staff A, LPN stated: I usually close the computer screen, but I was nervous. There is a lock key on the screen that I am supposed to press to close the screen immediately. On 6/3/25 at 12:15 PM, the Director of Nursing (DON) walked away leaving the computer screen at the south nursing station open with residents' information visible; after stating she would print information requested by the surveyor. The DON returned at 12:25 PM with the requested information. The DON was informed of the privacy concerns related to the computer screen being left open. The DON acknowledged the concern and stated, it was a mistake. Record review of a policy titled Protected Health Information (PHI), Safeguarding Electronic revised January 2024, reviewed January 2025 revealed Policy Statement: Electronic protected health information (e-PHI) is safeguarded by administrative, technical and physical means to prevent unauthorized access to protected health information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to implement a nutritional care plan for one (Resident #4) out of three sampled residents who receive enteral feedings, as evidenced by an observation revealed Resident #4 receiving Glucerna 1.2 calorie feeding despite a Nutritional Care Plan with an intervention to provide tube feeding and water flushes as ordered: Jevity 1.5 calorie. There were 18 residents receiving enteral feedings in the facility at the time of survey. The findings included: On 6/3/25 at 8:45 AM Resident #4 was observed in bed with eyes closed a tube feeding bottle labeled Glucerna 1.2 was hanging and in progress at 45 milliliters per hour (ml/hr.) and a water flush at 45 ml, amount infused: 328 ml (photographic evidence). The bottle, syringe bag and water flush bag were dated 6/3/25, with Resident #4's name, and rate 50 ml, no time was written. Record review of Resident #4's physician orders revealed an order dated 5/30/25 directions: Jevity 1.5 or equivalent Isosource 1.5 at 50 ml/hr. for 20 hours on at 2:00 PM off at 10:00 AM one time a day. On 6/3/25 at approximately 9:30 AM, Staff A, Licensed Practical Nurse (LPN) was asked about Resident #4's current physician order for enteral feedings. Staff A, LPN stated: Jevity 1.5. The surveyor then notified Staff A, LPN that Glucerna was in progress. During an interview on 6/3/25 at 10:35 AM; The Registered Dietitian (RD) revealed: Upon first admission [Resident #4] was eating by mouth and losing weight. After a hospitalization, [Resident #4] returned with a feeding tube and gained some weight; but went to the hospital again. [Resident #4] is diabetic, but she was not recommended for Glucerna because of compromised kidney function evidenced by abnormal labs, therefore Jevity was recommended to help protect the kidneys. Record review of Resident#4's demographic sheet revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnosis that included: Gastrostomy, Acute Kidney Failure, and Dysphagia following Cerebral Infarction. Record review of a Significant Change/Medicare/ 5 Day Minimum Data Set (MDS) reference dated 4/20/25 revealed Resident #4 had a Brief Interview of Mental Status score 00, indicating severe cognitive impairment, had a feeding tube and dependent for all Activities of Daily Living, Record review of a care plan initiated on 1/03/25 and revised on 4/29/25 revealed Resident # 4 was at risk for altered nutrition/hydration related to: diagnoses that included: Dysphagia, acute kidney failure, enteral feeding with a goal to not show signs and symptoms of dehydration through next review date. Interventions included: provide tube feeding and water flushes as ordered: Jevity 1.5 at 50 ml/hr. for 20 hours. Record review of a Nutrition Assessment for readmission dated 6/2/25 revealed; Enteral Feeding Formula: Jevity 1.5 at 50 ml/hr. for 20 hours. Record review of a basic metabolic panel dated 6/2/25 revealed Resident#4 had a blood urea nitrogen (BUN) level of 63, (the normal range is 7 - 25) which indicated the level was high which further indicated compromised kidney function. Interview on 6/3/25 at 11:50 AM Staff A, Licensed Practical Nurse (LPN) stated, I am the nurse for [Resident#4.] The current order for this resident feeding is Jevity 1.5 at a rate of 45 ml/hr. and water flush at a rate of 45 ml/hr. The Glucerna feeding was in progress at 45 ml/hr. but was hung on the previous shift. My mistake was I did not check the feeding to ensure accuracy when I rounded this morning. Interview on 6/3/25 at 12:00 PM, the Director of Nursing (DON) stated: Every morning the department heads check all the enteral tube to make sure the feedings are correct. The floor nurse is supposed to check and verify that it is according to the physician's order. I also do random rounds and check the feeding. On 5/2/25 at 12:15 PM Staff B, RN Unit Manger stated, This morning I inserted the IV and visualized the feeding was in place and in progress, but I didn't verify if it was according to the order. Record review of a policy titled Care Plans, Comprehensive Person-Centered revised January 2025 revealed Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review the facility failed to ensure six out of thirty-four sampled residents were treated with dignity; as evidenced by staff did not knock on doors and failed to request permission before entering the residents' rooms (Residents #475, #476, #477 and #478) and staff were observed standing over residents while assisting them to eat (Resident #54 and Resident #98). There were 172 residents residing in the facility at the time of the survey. The findings included: On 03/04/2024 at 7:42 AM housekeeping staff (Staff J) walked into Resident #475's room did not knock or ask permission to enter the resident's room. Staff J was asked about not knocking before entering the resident's room. Staff J revealed staff are supposed to knock and ask for permission before entering residents' rooms. Staff J stated: I always knock and ask for permission, but I have no answer for why didn't knock this time. Moving forward I will knock and request permission before entering a resident's room. Record review of Resident # 475's demographic face sheet revealed the resident was admitted to the facility on [DATE] with diagnosis that include Cerebral Infarction and Chronic Obstructive Pulmonary Disease. Review of the admission Minimum Data Set (MDS) dated [DATE], Section C for cognitive patterns revealed a Brief Interview Mental Status (BIMS) score of 12 out of 15, that suggested moderate cognitive impairment. Section K for swallowing/nutrition status revealed Resident #475 required substantial/maximal assistance for eating and hygiene and dependent for transfer. Observation on 03/04/2024 at 1:52 PM, Staff K Registered Nurse (RN) walked into Resident # 476's room without asking permission or knocking before entering. Record review of demographic face sheet revealed Resident # 476 was admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnosis included major depressive disorder and blindness in one eye. Review of the admission MDS dated [DATE] Section C for cognitive patterns revealed a BIMS score of 13 out of a scale of 0-15, that indicated no cognitive impairment. Section GG for Functional Abilities and Goals revealed Resident #476 required setup or clean up assistance for eating, supervision or touching assistance for personal hygiene, substantial/maximal assistance for toileting, and dependent for putting on/taking off footwear. Review of ADL Care Plan initiated on 5/9/2019 and revised on 2/16/2024 revealed Resident #476 required assistance with ADL functions. Interventions included Maintain privacy and dignity. On 03/04/2024 at 7:58 AM, Staff K stated she is aware she should knock and ask permission before entering. Staff K stated: I did not knock or ask permission because my coworker was already in the room with the resident. I will knock ask permission moving forward. On 03/04/2024 at 7:33 AM Nurse Staff E, RN walked into the room shared by Resident # 447's and Resident # 478 room without knocking or asking permission before entering. Record review of Resident # 447's demographic face sheet revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included Osteomyelitis and Diabetes Mellitus. Review of Discharge Return Anticipated MDS dated [DATE] Section C for cognitive patterns revealed a Brief Interview Mental Status (BIMS) score of undetermined out of a scale of 0-15, that indicated severe cognitive impairment. Section GG for Functional Abilities and Goals revealed Resident #477 documented that the resident requires partial/moderate assistance for transferring and hygiene and set up clean up assistance for eating. Review of the ADL Care Plan dated 2/10/2024 revealed Resident #477 needed assistance with ADL care. Interventions include maintaining privacy and dignity. Record review of Resident #478's demographic face sheet revealed the resident was admitted on [DATE] with diagnosis that include Diabetes Mellitus. Review of admission MDS dated [DATE] Section C for cognitive patterns revealed a BIMS score of 2 out of a scale of 0-15, that indicated severe cognitive impairment. Section GG for Functional Abilities and Goals revealed Resident #478 required setup or clean up assistance for eating, partial/moderate assistance for hygiene and transfer. Review of the ADL care plan initiated on 2/9/2024 revealed Resident #478 had a self-care deficit. Interventions included encourage resident to do as many ADL tasks for themselves as possible. During an interview on 03/04/2024 at 7:35 AM, Staff E, RN revealed staff are to knock and ask for permission before entering residents' rooms, and he did not knock or ask permission before entering the room because the residents are like family here. Staff E further stated that he will make sure he knocks moving forward. On 03/05/2024 at 11:25 AM the Director of Nurses (DON) stated: Staff are to knock on door and introduce themselves before entering a resident's room. This is to provide the resident with a homelike environment. I have done in-services in the past regarding knocking on the door and asking permission to enter. On 03/07/2024 at 3:34 PM, Staff F, Certified Nursing Assistant (CNA) stated the protocol for entering a resident's room is to knock on door and ask for permission before entering. On 03/07/2024 at 3:37 PM, Staff G, CNA stated the facility's protocol for entering a resident's room is to knock on door and ask for permission before entering. On 03/07/2024 at 3:38 PM, Staff H, CNA stated when staff enters a resident's room they are to knock first and ask for permission before they enter. Review of the facility's Policy and Procedure titled, Dignity. Revised February 2021, Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation: 7. Staff are expected to knock and request permission before entering residents' rooms. Observation on 03/04/2024 at 12:14 PM, Staff I, RN was observed standing while assisting to feed Resident #54 lunch. Record review of demographic face sheet revealed Resident #54 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included Diabetes Mellitus. Review of Medicare 5-day MDS dated [DATE], Section C for cognitive patterns revealed a BIMS score of 4 out of a scale of 0-15, that indicated severe cognitive impairment. Section GG for Functional Abilities and Goals revealed partial/moderate assistance for eating, substantial/ maximal assistance for hygiene and dependent for toileting. Review of the ADL Care Plan initiated on 8/2/19 and revised on date 12/21/2023 revealed Resident #54 needed assistance with ADL care. Interventions included maintaining privacy and dignity. On 03/04/2024 at 12:14 PM, Staff I, RN stated: Staff are to be seated next to resident when assisting to feed meals to maintain the dignity of the residents. I was standing while assisting to feed [Resident#54] lunch because [Resident #54] normally eats alone but today needed help. Moving forward I will take a seat next any resident she assists to feed a meal. On 03/05/2024 at 11:19 AM DON stated: It is protocol for staff to be seated when assisting residents with meals. This is to ensure the dignity of the residents. I have done in-services in the past regarding the proper way to assist with feeding residents. On 03/04/2024 at 07:26 AM observed Resident #98 in bed, head of bed elevated, Medical Records Personnel (Staff A) feeding the resident breakfast standing up. Review of the medical records for Resident #98 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Gastro-esophageal reflux disease without esophagitis and Dysphagia, oropharyngeal phase. Review of the Physician's Orders Sheet for March 2024 revealed Resident #98 had orders that included but not limited to: Diet-CCHO (Consistent Carbohydrates) diet, Pureed texture, thin consistency. Record review of Resident # 98's Quarterly Minimum Data Set (MDS) dated [DATE] revealed in Section C Section for Cognitive Patterns documented Brief interview for Mental Status score 3, on a 0-15 scale indicating the resident is cognitively impaired. Section GG for function Abilities and Goals documented the resident is dependent for eating. Review of Resident #98's Care plans Reference Date 12/30/2023 revealed resident with self-care deficit and requires supervision with eating and extensive assistance with dressing, hygiene, and total assistance with the rest of Activities of Daily Living (ADL's). ADLS may fluctuate throughout the course of the day. Interventions include- Set up care items and supplies at bedside a needed. Interview on 03/06/2024 at 10:01 AM Staff A stated that she knows that she needs to be sitting when feeding the resident, she started feeding the resident and then realized that she did not have a chair and went out of the room to get a chair. Interview on 03/06/2024 at 11:51 AM, the Director of Nursing (DON) stated regarding facility staff standing up feeding residents: We are going to re-educate staff about residents' dignity, especially feeding residents, you must sit down, you cannot stand over the resident. Review of the facility policy titled, Assistance with Meals revision date July 2017 states: Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, for example: a. Not standing over residents while assisting them with meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessment for four (Resident #75, Resident #83, Resident #138, Resident #150) out of four residents reviewed for resident assessments were accurately coded. There were 171 residents residing in the facility at the time of the survey. The findings included: Record review of the facility's policy titled, MDS (Minimum Data Service) revised September 2021, reviewed January 2024 documented: Policy Statement: The Assessment Coordinator and/or the Interdisciplinary Assessment Team will follow the established processes for completing, submitting and making corrections to the MDS; Policy Interpretation and Implementation: Completion of MDS-1) Interdisciplinary Team will complete sections of MDS for a resident in the facility; Correction of Error-5) If an error is discovered after the encoding period determine if the error is major or minor. MDS Coordinator may modify assessment within 2 years of ARD (assessment reference date) and modification can be completed 14 days after is discovered. 1) Record review of the Demographic Face Sheet for Resident #75 documented the resident was admitted on [DATE] with a diagnosis of metabolic encephalopathy, anoxic brain damage, diabetes mellitus, epilepsy, major depressive disorder, insomnia, and anxiety disorder. Review of the Physician's Order Sheet (POS) and Medication Administration Records (MAR) for December 2023, January 2024, February 2024, and March 2024 documented the resident was receiving the following medications: Clonazepam 0.5 mg (milligrams) 1 tab (tablet) PO (by mouth) BID (twice a day) for anxiety, Escitalopram Oxalate 10mg tab 1 tab PO one time a day for major depressive disorder and Trazodone HCL (hydrochloric acid) 100 mg tab 1 tab PO HS (at night) for major depressive disorder. Review of the Minimum Data Service (MDS) Annual assessment dated [DATE] for Resident #75 documented the resident's Mental Status (BIMS) Summary Score was 05, indicating severe cognitive impairment and section A question Preadmission Screening and Resident Review (PASRR): Resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, was coded as No and Level II Preadmission Screening and Resident Review (PASRR) Conditions were not coded for A) Serious mental illness; B) Intellectual Disability or C) Other related conditions. Review of the Psychotropic Drug Use Care Plan for Resident #75, written 4/07/2022 documented the resident was currently receiving antianxiety and antidepressants medications. Review of the PASRR Level I Screen for Resident #75 dated 4/06/2022 documented: Section I: PASRR Screen Decision-Making: Depressive disorder; Section II: Other Indications for PASRR Screen Decision-Making: All questions in this section were coded No. Review of the PASRR Level I Screen dated on 1/21/2024 documented: Section I: PASRR Screen Decision-Making: Anxiety Disorder, Depressive Disorder and Other-Intellectual Development Disorder, Moderate, Current diagnosis of an ID (intellectual disability) and Section II: Other Indications for PASRR Screen Decision-Making: 1) Is there an indication the individual has or may have had a disorder resulting in functional limitations in major life activities that would otherwise be appropriate for the individual's developmental stage was coded Yes, 2) Does the individual typically have or may have had at least one of the following characteristics on a continuing or intermittent basis was coded Yes and 3) Is there an indication that the individual has received recent treatment for a mental illness with an indication that the individual has experienced at least one of the following? A. Psychiatric treatment more intensive than outpatient care was coded Yes. Review of the PASRR Level II Determination Summary Report for Resident #75 dated 2/15/2024 documented the resident met the state definition of serious mental illness and specialized services were not recommended. Interview and record review with the Assistant Director of Nursing (ADON) on 3/07/2024 at 11:04 AM. He confirmed the resident did receive a PASRR Level II on 2/15/2024. He stated, A [local state agency] came in February 2024 to evaluate her to make sure she qualified. She was interviewed because of the traumatic brain injury, and she qualified for a Level II. MDS should have made the change to reflect a Level II was done. Interview and record review with Staff L, Registered Nurse (RN), MDS Coordinator on 3/07/2024 at 1:10 PM. He confirmed the resident did receive a PASRR Level II on 2/15/24. He stated: Her annual is due 3/10/2024 and the Level II will be captured on it. Subsequent interview on 3/07/2024 at 1:48 PM he confirmed that he would be opening a new comprehensive assessment today for the resident to reflect the Level II. On 3/07/2024 at 1:28 PM interview via telephone with RN, Corporate MDS Consultant stated: I will have them open up an early comprehensive MDS to reflect the PASRR Level II. 2) Record review of the Demographic Face Sheet for Resident #83 documented the resident was admitted on [DATE] with a diagnosis of polyneuropathy, chronic respiratory failure, peripheral vascular disease, anxiety, hypertension, post-traumatic stress disorder (PTSD), bipolar disorder and gastrostomy status. Review of the Physician's Order Sheet (POS) and Medication Administration Records (MAR) for December 2023, January 2024, February 2024, and March 2024 documented the resident was receiving the following medications: Olanzapine 15 mg (milligrams) tab (tablet) 1 tab via PEG tube HS (at night) for bipolar disorder, Valproic Acid 250 mg/5 ml (milliliters) Solution 5 ml via PEG tube TID (three times a day) for bipolar disorder and Buspirone HCL 5 mg tab 1 tab via PEG tube BID (twice a day) for anxiety. Review of the Minimum Data Service (MDS) admission assessment dated [DATE] for Resident #83 documented the resident's Mental Status (BIMS) Summary Score was 12, indicating minimum cognitive impairment and section A question Preadmission Screening and Resident Review (PASRR): Resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, was coded as No and Level II Preadmission Screening and Resident Review (PASRR) Conditions were not coded for A) Serious mental illness; B) Intellectual Disability or C) Other related conditions. Review of the Psychotropic Drug Use Care Plan for Resident #83, written 12/01/2023 documented the resident was currently receiving antianxiety and bipolar medications. Review of the PASRR Level I Screen for Resident #83 dated on 11/30/2023 documented: Section I: PASRR Screen Decision-Making: Antianxiety Disorder, Bipolar Disorder, Depressive Disorder and Other-PTSD; Section II: Other Indications for PASRR Screen Decision-Making: All questions in this section were coded No. Review of the PASRR Level II Determination Summary Report for Resident #83 dated 1/21/2024 documented the resident was not considered to have met the state definition of serious mental illness. Interview and record review with the Assistant Director of Nursing (ADON) on 3/07/24 at 11:22 AM. He confirmed the resident did receive a PASRR Level II on 1/21/2024. He stated, A Level I was done, and a Level II was done and the MDS should reflect it. Interview and record review with Staff L, Registered Nurse (RN), MDS Coordinator on 3/07/2024 at 1:05 PM. He confirmed the resident did receive a PASRR Level II on 1/21/2024. He stated, The MDS is not incorrect and won't be done until the next comprehensive one. On 3/07/2024 at 1:28 PM interview via telephone with RN, Corporate MDS Consultant stated: I will have them open up an early comprehensive MDS to reflect the PASSR Level II. 3) Record review of the Demographic Face Sheet for Resident #138 documented the resident was admitted on [DATE] with a diagnosis of encephalopathy, anxiety disorder, peripheral vascular disease, psychotic disorder, and dementia. Review of the Physician's Order Sheet (POS) and Medication Administration Records (MAR) for December 2023, January 2024, February 2024, and March 2024 documented the resident was receiving the following medications: Depakote 250 mg (milligrams) DR (delayed release) tab (tablet) 1 tab PO (by mouth) one time a day for anxiety disorder, Citalopram Hydrobromide 10mg tab 1 tab PO one time a day for depression and Risperidone 1 mg tab 1 tab PO HS (at night) for psychosis. Review of the Minimum Data Service (MDS) admission assessment dated [DATE] for Resident #138 documented the resident's Mental Status (BIMS) Summary Score was 13, indicating minimum cognitive impairment and section A question Preadmission Screening and Resident Review (PASRR): Resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, was coded as No and Level II Preadmission Screening and Resident Review (PASRR) Conditions were not coded for A) Serious mental illness; B) Intellectual Disability or C) Other related conditions. The MDS Annual assessment dated [DATE] documented the resident's BIMS Summary Score was 04, indicating severe cognitive impairment and section A question Preadmission Screening and Resident Review (PASRR): Resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, was coded as No and Level II Preadmission Screening and Resident Review (PASRR) Conditions were not coded for A) Serious mental illness; B) Intellectual Disability or C) Other related conditions. Review of the Psychotropic Drug Use Care Plan for Resident #138, written 1/13/2023 documented the resident was currently receiving antianxiety, antidepressants and antipsychotic medications. Review of the PASRR Level I Screen for Resident #138 dated 1/13/2023 documented: Section I: PASRR Screen Decision-Making: Psychotic Disorder; Section II: Other Indications for PASRR Screen Decision-Making: All questions in this section were coded No. Review of the PASRR Level II Determination Summary Report for Resident #138 dated 5/11/2023 documented the resident was not considered to have met the state definition of serious mental illness. Interview and record review with the Assistant Director of Nursing (ADON) on 3/07/2024 at 11:10 AM. He confirmed the resident did receive a PASRR Level II on 5/11/2023. He stated, A Level I was done, and a Level II was done and the MDS should reflect it. Interview and record review with Staff L, Registered Nurse (RN), MDS Coordinator on 3/07/2024 at 1:08 PM. He confirmed the resident did receive a PASRR Level II on 5/11/2023. He stated, She is not considered to have a serious mental illness. On 3/07/2024 at 1:28 PM interview via telephone with RN, Corporate Consultant MDS stated: I will have them open up an early comprehensive MDS to reflect the PASRR Level II. 4) Record review of the Demographic Face Sheet for Resident #150 documented the resident was admitted on [DATE] with a diagnosis of degenerative disease of nervous system, encounter for palliative care, anxiety disorder, Schizoaffective disorder, hypertension, dementia, and major depressive disorder. Review of the Physician's Order Sheet (POS) and Medication Administration Records (MAR) for January 2024, February 2024 and March 2024 documented the resident was receiving the following medications: Seroquel 300 mg (milligrams) tab (tablet) 0.5 tab via PEG tube HS (at night) for Schizoaffective disorder, Seroquel 50mg tab 1 tab via PEG-tube BID (twice a day) for Schizoaffective disorder and Remeron 15 mg tab 1 tab via PEG tube HS for depression. Review of the Minimum Data Service (MDS) admission assessment dated [DATE] for Resident #150 documented the resident's Mental Status (BIMS) Summary Score was 03, indicating severe cognitive impairment and section A question Preadmission Screening and Resident Review (PASRR): Resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, was coded as No and Level II Preadmission Screening and Resident Review (PASRR) Conditions were not coded for A) Serious mental illness; B) Intellectual Disability or C) Other related conditions. Review of the Psychotropic Drug Use Care Plan for Resident #150, written 1/03/2024 documented the resident was currently receiving antidepressants and antipsychotic medications. Review of the PASRR Level I Screen for Resident #150 dated on 1/09/2024 documented: Section I: PASRR Screen Decision-Making: Depressive Disorder, Schizoaffective Disorder, IQ of 70 or less; Section II: Other Indications for PASRR Screen Decision-Making: 1) Is there an indication the individual has or may have had a disorder resulting in functional limitations in major life activities that would otherwise be appropriate for the individual's developmental stage was coded Yes, 2) Does the individual typically have or may have had at least one of the following characteristics on a continuing or intermittent basis was coded Yes and 3) Is there an indication that the individual has received recent treatment for a mental illness with an indication that the individual has experienced at least one of the following? A. Psychiatric treatment more intensive than outpatient care was coded Yes. Review of the PASRR Level II Determination Summary Report for Resident #150 dated 2/16/2024 documented the resident met the state definition of serious mental illness and specialized services were not recommended. Review of the PASRR Level II Care Plan for Resident #150, written 2/22/2024 documented the resident was admitted with a Mental Illness/Intellectual Disability/Developmental Disability Retardation condition and does not require specialized services. Interview and record review with the Assistant Director of Nursing (ADON) on 3/07/2024 at 11:20 AM. He confirmed the resident did receive a PASSR Level II on 2/16/2024. He stated, A Level I was done, and a Level II was done and the MDS should reflect it. The Level II care plan was done and is not coded on the MDS. Interview and record review with Staff L, Registered Nurse (RN), MDS Coordinator on 3/07/2024 at 1:01 PM. He confirmed the resident did receive a PASRR Level II on 2/16/2024. He stated, We don't do a modification of the MDS unless there is a correction. It will reflect on the next comprehensive assessment that will be done next year. Subsequent interview on 3/07/2024 at 1:48 PM he confirmed that he would be opening a new comprehensive assessment today for the resident to reflect the Level II. On 3/07/2024 at 1:28 PM interview via telephone with RN, Corporate MDS Consultant stated: I will have them open up an early comprehensive MDS to reflect the PASRR Level II. Interview and record review with Staff L, Registered Nurse (RN), MDS Coordinator on 3/07/2024 at 3:19 PM of the Education Sign-In Sheet dated 3/07/2024. He revealed the MDS Coordinators received education on the accuracy of PASRR MDS. The education summary documented the PASRR Level II and opening early comprehensive assessment to capture changes in PASRR audits.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure residents assessments were coordinated with the pre-admission screening and resident review (PASRR) program for four (Resident #75, Resident #83, Resident #138, Resident #150) out of seven residents reviewed. There were 171 residents residing in the facility at the time of the survey. The findings included: 1) Record review of the Demographic Face Sheet for Resident #75 documented the resident was admitted on [DATE] with a diagnosis of metabolic encephalopathy, anoxic brain damage, diabetes mellitus, epilepsy, major depressive disorder, insomnia and anxiety disorder. Review of the Physician's Order Sheet (POS) and Medication Administration Records (MAR) for December 2023, January 2024, February 2024 and March 2024 documented the resident was receiving the following medications: Clonazepam 0.5 mg (milligrams) 1 tab (tablet) PO (by mouth) BID (twice a day) for anxiety, Escitalopram Oxalate 10mg tab 1 tab PO one time a day for major depressive disorder and Trazodone HCL (hydrochloric acid) 100 mg tab 1 tab PO HS (at night) for major depressive disorder. Review of the Minimum Data Service (MDS) Annual assessment dated [DATE] for Resident #75 documented the resident's Mental Status (BIMS) Summary Score was 05, indicating severe cognitive impairment and section A question Preadmission Screening and Resident Review (PASRR): Resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, was coded as No and Level II Preadmission Screening and Resident Review (PASRR) Conditions were not coded for A) Serious mental illness; B) Intellectual Disability or C) Other related conditions. Review of the Psychotropic Drug Use Care Plan for Resident #75, written 4/07/2022 documented the resident was currently receiving antianxiety and antidepressants medications. Review of the PASRR Level I Screen for Resident #75 dated on 4/06/2022 documented: Section I: PASRR Screen Decision-Making: Depressive disorder; Section II: Other Indications for PASRR Screen Decision-Making: All questions in this section were coded No. Review of the PASRR Level I Screen dated on 1/21/2024 documented: Section I: PASRR Screen Decision-Making: Anxiety Disorder, Depressive Disorder and Other-Intellectual Development Disorder, Moderate, Current diagnosis of an ID (intellectual disability) and Section II: Other Indications for PASRR Screen Decision-Making: 1) Is there an indication the individual has or may have had a disorder resulting in functional limitations in major life activities that would otherwise be appropriate for the individual's developmental stage was coded Yes, 2) Does the individual typically have or may have had at least one of the following characteristics on a continuing or intermittent basis was coded Yes and 3) Is there an indication that the individual has received recent treatment for a mental illness with an indication that the individual has experienced at least one of the following? A. Psychiatric treatment more intensive than outpatient care was coded Yes. Review of the PASRR Level II Determination Summary Report for Resident #75 dated 2/15/2024 documented the resident met the state definition of serious mental illness and specialized services were not recommended. Interview and record review with the Assistant Director of Nursing (ADON) on 3/07/2024 at 11:04 AM. He confirmed the resident did receive a PASSR Level II on 2/15/2024. He stated, A [local state agency] came in February 2024 to evaluate her to make sure she qualified. She was interviewed because of the traumatic brain injury and she qualified for a Level II. MDS should have made the change to reflect a Level II was done. Interview and record review with Staff L, Registered Nurse (RN), MDS Coordinator on 3/07/2024 at 1:10 PM. He confirmed the resident did receive a PASRR Level II on 2/15/2024. He stated, Her annual is due 3/10/2024 and the Level II will be captured on it. Subsequent interview on 3/07/2024 at 1:48 PM he confirmed that he would be opening a new comprehensive assessment today for the resident to reflect the Level II. On 3/07/2024 at 1:28 PM interview via telephone with RN, Corporate Consultant MDS. She stated, I will have them open up an early comprehensive MDS to reflect the PASRR Level II. 2) Record review of the Demographic Face Sheet for Resident #83 documented the resident was admitted on [DATE] with a diagnosis of polyneuropathy, chronic respiratory failure, peripheral vascular disease, anxiety, hypertension, post-traumatic stress disorder (PTSD), bipolar disorder and gastrostomy status. Review of the Physician's Order Sheet (POS) and Medication Administration Records (MAR) for December 2023, January 2024, February 2024 and March 2024 documented the resident was receiving the following medications: Olanzapine 15 mg (milligrams) tab (tablet) 1 tab via PEG tube HS (at night) for bipolar disorder, Valproic Acid 250 mg/5 ml (milliliters) Solution 5 ml via PEG tube TID (three times a day) for bipolar disorder and Buspirone HCL 5 mg tab 1 tab via PEG tube BID (twice a day) for anxiety. Review of the Minimum Data Service (MDS) admission assessment dated [DATE] for Resident #83 documented the resident's Mental Status (BIMS) Summary Score was 12, indicating minimum cognitive impairment and section A question Preadmission Screening and Resident Review (PASRR): Resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, was coded as No and Level II Preadmission Screening and Resident Review (PASRR) Conditions were not coded for A) Serious mental illness; B) Intellectual Disability or C) Other related conditions. Review of the Psychotropic Drug Use Care Plan for Resident #83, written 12/01/2023 documented the resident was currently receiving antianxiety and bipolar medications. Review of the PASRR Level I Screen for Resident #83 dated on 11/30/2023 documented: Section I: PASRR Screen Decision-Making: Antianxiety Disorder, Bipolar Disorder, Depressive Disorder and Other-PTSD; Section II: Other Indications for PASRR Screen Decision-Making: All questions in this section were coded No. Review of the PASRR Level II Determination Summary Report for Resident #83 dated 1/21/2024 documented the resident was not considered to have met the state definition of serious mental illness. Interview and record review with the Assistant Director of Nursing (ADON) on 3/07/2024 at 11:22 AM. He confirmed the resident did receive a PASRR Level II on 1/21/2024. He stated, A Level I was done and a Level II was done and the MDS should reflect it. Interview and record review with Staff L, Registered Nurse (RN), MDS Coordinator on 3/07/2024 at 1:05 PM. He confirmed the resident did receive a PASRR Level II on 1/21/2024. He stated, The MDS is not incorrect and won't be done until the next comprehensive one. On 3/07/2024 at 1:28 PM interview via telephone with RN, Corporate MDS Consultant. She stated, I will have them open up an early comprehensive MDS to reflect the PASRR Level II. 3) Record review of the Demographic Face Sheet for Resident #138 documented the resident was admitted on [DATE] with a diagnosis of encephalopathy, anxiety disorder, peripheral vascular disease, psychotic disorder and dementia. Review of the Physician's Order Sheet (POS) and Medication Administration Records (MAR) for December 2023, January 2024, February 2024 and March 2024 documented the resident was receiving the following medications: Depakote 250 mg (milligrams) DR (delayed release) tab (tablet) 1 tab PO (by mouth) one time a day for anxiety disorder, Citalopram Hydrobromide 10mg tab 1 tab PO one time a day for depression and Risperidone 1 mg tab 1 tab PO HS (at night) for psychosis. Review of the Minimum Data Service (MDS) admission assessment dated [DATE] for Resident #138 documented the resident's Mental Status (BIMS) Summary Score was 13, indicating minimum cognitive impairment and section A question Preadmission Screening and Resident Review (PASRR): Resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, was coded as No and Level II Preadmission Screening and Resident Review (PASRR) Conditions were not coded for A) Serious mental illness; B) Intellectual Disability or C) Other related conditions. The MDS Annual assessment dated [DATE] documented the resident's BIMS Summary Score was 04, indicating severe cognitive impairment and section A question Preadmission Screening and Resident Review (PASRR): Resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, was coded as No and Level II Preadmission Screening and Resident Review (PASRR) Conditions were not coded for A) Serious mental illness; B) Intellectual Disability or C) Other related conditions. Review of the Psychotropic Drug Use Care Plan for Resident #138, written 1/13/2023 documented the resident was currently receiving antianxiety, antidepressants and antipsychotic medications. Review of the PASRR Level I Screen for Resident #138 dated on 1/13/2023 documented: Section I: PASRR Screen Decision-Making: Psychotic Disorder; Section II: Other Indications for PASRR Screen Decision-Making: All questions in this section were coded No. Review of the PASRR Level II Determination Summary Report for Resident #138 dated 5/11/2023 documented the resident was not considered to have met the state definition of serious mental illness. Interview and record review with the Assistant Director of Nursing (ADON) on 3/07/2024 at 11:10 AM. He confirmed the resident did receive a PASRR Level II on 5/11/2023. He stated, A Level I was done and a Level II was done and the MDS should reflect it. Interview and record review with Staff L, Registered Nurse (RN), MDS Coordinator on 3/07/2024 at 1:08 PM. He confirmed the resident did receive a PASRR Level II on 5/11/2023. He stated, She is not considered to have a serious mental illness. On 3/07/2024 at 1:28 PM interview via telephone with RN, Corporate MDS Consultant. She stated, I will have them open up an early comprehensive MDS to reflect the PASRR Level II. 4) Record review of the Demographic Face Sheet for Resident #150 documented the resident was admitted on [DATE] with a diagnosis of degenerative disease of nervous system, encounter for palliative care, anxiety disorder, Schizoaffective disorder, hypertension, dementia and major depressive disorder. Review of the Physician's Order Sheet (POS) and Medication Administration Records (MAR) for January 2024, February 2024 and March 2024 documented the resident was receiving the following medications: Seroquel 300 mg (milligrams) tab (tablet) 0.5 tab via PEG tube HS (at night) for Schizoaffective disorder, Seroquel 50mg tab 1 tab via PEG-tube BID (twice a day) for Schizoaffective disorder and Remeron 15 mg tab 1 tab via PEG tube HS for depression. Review of the Minimum Data Service (MDS) admission assessment dated [DATE] for Resident #150 documented the resident's Mental Status (BIMS) Summary Score was 03, indicating severe cognitive impairment and section A question Preadmission Screening and Resident Review (PASRR): Resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, was coded as No and Level II Preadmission Screening and Resident Review (PASRR) Conditions were not coded for A) Serious mental illness; B) Intellectual Disability or C) Other related conditions. Review of the Psychotropic Drug Use Care Plan for Resident #150, written 1/03/2024 documented the resident was currently receiving antidepressants and antipsychotic medications. Review of the PASRR Level I Screen for Resident #150 dated on 1/09/2024 documented: Section I: PASRR Screen Decision-Making: Depressive Disorder, Schizoaffective Disorder, IQ of 70 or less; Section II: Other Indications for PASRR Screen Decision-Making: 1) Is there an indication the individual has or may have had a disorder resulting in functional limitations in major life activities that would otherwise be appropriate for the individual's developmental stage was coded Yes, 2) Does the individual typically have or may have had at least one of the following characteristics on a continuing or intermittent basis was coded Yes and 3) Is there an indication that the individual has received recent treatment for a mental illness with an indication that the individual has experienced at least one of the following? A. Psychiatric treatment more intensive than outpatient care was coded Yes. Review of the PASRR Level II Determination Summary Report for Resident #150 dated 2/16/2024 documented the resident met the state definition of serious mental illness and specialized services were not recommended. Review of the PASRR Level II Care Plan for Resident #150, written 2/22/2024 documented the resident was admitted with a Mental Illness/Intellectual Disability/Developmental Disability Retardation condition and does not require specialized services. Interview and record review with the Assistant Director of Nursing (ADON) on 3/07/2024 at 11:20 AM. He confirmed the resident did receive a PASRR Level II on 2/16/2024. He stated, A Level I was done and a Level II was done and the MDS should reflect it. The Level II care plan was done and is not coded on the MDS. Interview and record review with Staff L, Registered Nurse (RN), MDS Coordinator on 3/07/2024 at 1:01 PM. He confirmed the resident did receive a PASRR Level II on 2/16/2024. He stated, We don't do a modification of the MDS unless there is a correction. It will reflect on the next comprehensive assessment that will be done next year. Subsequent interview on 3/07/2024 at 1:48 PM he confirmed that he would be opening a new comprehensive assessment today for the resident to reflect the Level II. On 3/07/2024 at 1:28 PM interview via telephone with RN, Corporate MDS Consultant. She stated, I will have them open up an early comprehensive MDS to reflect the PASRR Level II. Interview and record review with Staff L, Registered Nurse (RN), MDS Coordinator on 3/07/2024 at 3:19 PM of the Education Sign-In Sheet dated 3/07/2024. He revealed the MDS Coordinators received education on the accuracy on PASRR MDS. The education summary documented the PASRR Level II and opening early comprehensive assessment to capture changes in PASRR audits.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to ensure a resident received an accurate Preadmission Screening and Resident Review (PASRR) Level I screening for one (Resident #13) of seven residents reviewed. There were 171 residents residing in the facility at the time of the survey. The findings included: Record review of the Demographic Face Sheet for Resident #13 documented the resident was admitted on [DATE] with a diagnosis of diabetes mellitus, dementia, hypertension, insomnia, peripheral vascular disease, atherosclerotic heart disease, major depressive disorder and anxiety disorder. Review of the Physician's Order Sheet (POS) and Medication Administration Records (MAR) for December 2023, January 2024, February 2024 and March 2024 documented the resident was receiving the following medications: Valproic Acid 250 mg (milligrams)/5 ml (milliliters) 2.5 ml PO (by mouth) BID (twice a day) for anxiety disorder and Mirtazapine 7.5 mg tab (tablet) 1 tab PO HS (at night) for major depressive disorder. Review of the Minimum Data Service (MDS) admission assessment dated [DATE] for Resident #13 documented the resident's Mental Status (BIMS) Summary Score was 06, indicating severe cognitive impairment and section A question Preadmission Screening and Resident Review (PASRR): Resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, was coded as No and Level II Preadmission Screening and Resident Review (PASRR) Conditions were not coded for A) Serious mental illness; B) Intellectual Disability or C) Other related conditions. Review of the Psychotropic Drug Use Care Plan for Resident #13, written 9/08/2023 documented the resident was currently receiving antidepressant medications. Review of the PASRR Level I Screen for Resident #75 dated on 4/06/2022 documented: Section I: PASRR Screen Decision-Making: Depressive disorder; Section II: Other Indications for PASRR Screen Decision-Making: All questions in this section were coded No. Review of the PASRR Level I Screen dated on 9/04/2023 documented: Section I: PASRR Screen Decision-Making, diagnoses for anxiety disorder and depressive disorder were not checked. Level II was not conducted. Interview and record review with the Assistant Director of Nursing (ADON) on 3/07/2024 at 11:13 AM. He confirmed the diagnoses should have been checked on the PASRR Level I Screen dated on 9/04/2023 and that the PASRR Level I is incorrect. Interview and record review with Staff L, Registered Nurse (RN), MDS Coordinator on 3/07/2024 at 12:57 PM. He confirmed that the PASRR Level I was corrected today to include the diagnoses. He stated, The MDS did not reflect the diagnoses. Subsequent interview and record review with Staff L, Registered Nurse (RN), MDS Coordinator on 3/07/2024 at 1:21 PM of the PASRR Level I dated 3/07/2024 revealed a new PASRR Level I was done to include the diagnoses of anxiety disorder, depressive disorder and other (insomnia).

Based on observations, interviews and record review, the facility failed to ensure controlled medications (narcotics) reconciliation was accurate for two narcotic medications (Lorazepam and Clonazepam) as evidenced by the number of total pills in bingo cards were less than the amount recorded on Medication Monitoring/ Control Record. There were 172 residents residing in the facility at the time of survey. The findings included: On 03/06/2024 at 9:18 AM, the surveyor approached nursing station 4 where Staff C Registered Nurse (RN) was seated behind the desk and asked Staff C if morning medication administration was completed and requested to review the medication cart, Staff C agreed. A narcotic count was done with Staff C, RN. Review of Medication Monitoring/ Control Record revealed Lorazepam 0.5 milligrams (mg) totaling 10 signed off by Staff C on 3/5/2024 at 7:11 PM. Observation of the bingo card revealed physical total of Lorazepam 0.5 mg pills was 9. (see photo evidence). The surveyor reviewed the Electronic Medication Record and verified that the narcotic was given on 3/6/2024 by Staff C. On 03/06/2024 at 9:19 AM when Staff C, RN was asked about the discrepancy. Staff C stated: I have been working at facility for 1 year. nurses are to sign out narcotics when they are removed from package. I did not sign this narcotic out because I forgot. Next time I will sign at the moment I administer the narcotic. It is important to sign so I can know what time the resident can receive the next dose. On 03/06/2024 at 10:21 AM the surveyor approached nursing station 3 (back) cart and verified Staff D, RN completed morning medication administration and requested to check medication cart. Staff D agreed. A narcotic count was done with Staff D, RN. Review of the Medication Monitoring/ Control Record revealed Clonazepam 1 mg totaling 3 signed out by Staff D on 3/5/2024 at 2:30 PM and observation of bingo card revealed physical total of Clonazepam 1 mg pills was 9. (see photo evidence). The Electronic Medication Record indicated that the narcotic was given on 3/6/2024 by Staff D. On 03/06/2024 at 10:22 AM Staff D, RN stated nurses are supposed to sign out narcotic once it is removed from the bingo card. I did not sign because someone called me to help with another resident. Moving forward I will sign out narcotic at the time I remove from bingo card. The importance is to ensure documentation is accurate and in a timely manner. On 03/06/2024 at 10:25 AM, the Nurse Consultant stated: The procedure for signing out narcotics includes pop out the narcotic pill then sign out the pill at the time it is popped. On 03/06/2024 at 10:30 AM, Staff B, RN Supervisor stated: Nurses are to pop out narcotic pill and sign removal of pill on narcotic count sheet at that time. Review of Policy and Procedure entitled, Preparation and General Guidelines. Revised January 2018. IIA7: Controlled Substances: Policy: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility, in accordance with federal and state laws and regulations. Procedures: E. Accurate accountability of the inventory of all controlled drugs is maintained at all times. When a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the medication administration record (MAR): 1) Date and time of administration (MAR, Accountability Record). 2) Amount administered (accountability Record) 3) Remaining quantity (Accountability Record) 4) Initial of the nurse administering the dose, completed after the medication is actually administered (MAR, Accountability Record).

Based on record review and interview the facility failed to ensure the arbitration agreements presented to three residents (Resident number 83, Resident number 54 and Resident number 150) out of three residents reviewed informed residents or their representatives of the nature and implications of any proposed binding arbitration agreement, to inform their decision on whether or not to enter into such agreements. There were 171 residents residing in the facility at the time of the survey. The findings included: Record review of the Binding Arbitration Agreements Policy and Procedure (implemented 3/2020, revised 3/2023) documented: Policy-This facility asks all residents to enter into an agreement for binding arbitration. Policy Explanation and Compliance Guidelines: 3) The agreement must not contain any language that prohibits or discourages the resident or anyone else from communication with federal, state or local officials, including but not limited to, federal and state surveyors, other federal or state health department employees and representatives of the Office of the State Long-Term Care Ombudsman. Review for Voluntary Arbitration agreements on facility letterhead documented the following: 1) The facility offers arbitration agreements; 2) The facility asks residents to enter into an arbitration agreement and provides new admissions with the arbitration agreement during the admission process and 3) The Admissions Director is responsible for the binding arbitration agreements. Review of the facility Voluntary Arbitration Agreements documented the following: Resident number 83's representative signed and dated on 12/12/2023, Resident number 54's representative signed and dated on 12/20/2023 and Resident number 150's representative signed and dated on 1/07/2024 did not document that the binding arbitration agreement allow the resident or anyone else to communicate with federal, state or local officials such as federal and state surveyors, other federal or state health department employees and representative of the Office of the State Long Term Care Ombudsman. On 3/07/2024 at 9:16 AM, interview with the Director of Admissions. She stated, Some of the residents have signed a voluntary arbitration agreement. Interview and record review with the Director of Admissions on 3/07/2024 at 9:19 AM confirmed that the Voluntary Arbitration Agreement did not document that the binding arbitration agreement allow the resident or anyone else to communicate with federal, state or local officials such as federal and state surveyors, other federal or state health department employees and representative of the Office of the State Long Term Care Ombudsman.

Based on observations, interview and record review, the facility failed to demonstrate the implementation of effective plan of actions to correct identified deficiencies in problem areas, resulting in repeated deficient practices for F550 Residents Right/Exercise of Rights, as evidenced by the facility's failure to ensure six residents out of thirty-four sampled residents were treated in a dignified manner. There were 171 residents residing in the facility at the time of survey. The finding included: Record review of the facility's survey history revealed, during a recertification survey with exit dated 12/01/2022, F550 Residents Rights/Exercise of Rights was cited due to the facility's failure to provide services in a manner that maintained dignity for 3 of 3 sampled residents. During this recertification survey that was conducted from 03/04/2024 through 03/072024, the facility was cited F550 for Residents Rights/Exercises of Rights related to staff failure to knock on doors and failed to request permission before entering the residents' rooms (Residents #475, #476, #477 and #478) and staff were observed standing over Resident #54 and Resident #98 while feeding the residents. During an interview with the Nursing Home Administrator and Director of Nursing on 03/07/2024 at 2:55 PM. The Administrator stated that The Quality Assurance and Performing Improvement (QAPI) committee had a meeting every month on the Third Thursday. The Administrator stated the QAPI committee members are Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, Infection Prevention, Maintenance Director, Registered Dietitian, Activities Director, Social Services Director, and Departments Heads. The identified concerns related to repeat deficient practices were discussed. The Director of Nursing stated the QAPI committee is working closely with staff providing in-services education related to dignity. Record review of the Policy and Procedures for Quality Assurance and Performance Improvement implemented on 11/28/2017, revised on 01/03/2024 revised by Administrator and Interdisciplinary Team revealed Policy: It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life. Goal: Our goal is to create an exceptional person-centered care environment where the residents are involved in their own care and their needs are addressed individually. We want to cultivate an ongoing performance improvement process to support and improve our residents' quality of care and quality of life. QAPI goals: Using the goal, purpose, and guiding principles we developed or goals by stating what we want to accomplish, how we will measure our progress, how we will determine an achievable goal, how the goals determined to be relevant to the care we deliver, and how we will choose a timeline to attain the goal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to maintain appropriate infection control standards related to biohazard disposal of wound dressing. As evidenced by soiled wound dressing observed on the floor in resident's room. There were 171 residents residing at the facility at the time of the survey. The findings included: On 03/06/2024 at 06:35 AM an observation of [room #] was conducted, a soiled wound dressing, approximately 4x4 in size was observed on the floor close to Bed A (Photo Available), several facility staff were observed going in and out of Room. On 03/06/2024 at 07:51 AM, housekeeping staff was observed cleaning rooms on the 300 hallways where the room was located. The housekeeping cart was in the hallway, no biohazard disposal supplies were seen on the cart. The surveyor checked room [] and the soiled wound dressing was no longer on the floor. During an interview on 03/06/2024 at 11:56 AM, the Director of Nursing (DON) stated: I will educate the wound care nurse and all nursing staff about infection control. Maybe one of the residents in the room was moving around and turning in the bed, and the dressing slipped off onto the floor, to be honest maybe it was an accident. The wound dressings are disposed of in the red biohazard bag and placed in the red bins in the soiled utility room. On 3/7/2023 at 01:43PM, when the Assistant Director of Nursing (ADON) was told about the wound care dressing found on the floor in room [] the ADON stated he will educate staff about picking up items from the floor, and discarding them in the correct disposal manner . He further stated: Maybe the wound dressing belonged to Resident #55 who resides in the room that has a colostomy bag. Review of the facility's policy titled Infection Control revision date October 2018 states: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmissions of diseases and infection.

Based on observation, record review and interviews, the facility failed to provide a safe environment for residents as evidenced by four employee bathrooms not specifically labeled and locked when not occupied. There were 172 residents residing in the facility at the time of the survey. The findings included: On 03/05/2024 at 9:26 AM, during facility tour with Staff B, Registered Nurse (RN) Supervisor observation revealed the bathrooms at each nursing were unlocked. (see photo evidence) Residents were observed walking throughout the facility. The bathrooms did not have a sign that specified employee bathroom. The bathroom on nursing station two was not labeled. No call devices were observed inside the bathrooms near the nursing stations. On 03/05/2024 at 10:29 AM, The bathrooms in the lobby were observed to be locked. The key for lobby bathrooms kept in drawer at front desk. No call devices were observed inside the bathrooms in lobby. On 03/05/2024 at 09:30 AM, Staff B RN supervisor reported that the bathrooms near the nursing stations are for employees and visitors. There should be a sign on bathrooms to ensure everyone knows who the bathroom is for. All bathrooms are unlocked. There is no sign on the bathroom at station 2. There are signs indicating bathroom in nursing stations 1, 3 and 4. The bathroom on Station 4 (locked unit) should be locked due to the residents' mental incapacities and wandering behaviors. The residents are not allowed to use restrooms at nursing stations for privacy and dignity. On 03/05/2024 at 09:58 AM; The administrator stated, bathrooms should be labeled bathroom. Residents can use all the bathrooms in facility upon request and staff are available to assist. Bathrooms do not need to be locked because there are no hazardous chemicals inside. We allow the freedom of the residents to use bathroom of their choice. Staff should always be with residents when using a restroom that is not in their room to ensure safety. No other safety precautions need to be inside bathrooms that are used by residents. On 03/05/2024 at 11:19 AM, the Director of Nursing (DON) stated: Bathrooms located near the nursing stations are for employees only. When a staff member is hired, I orient staff to the facility, so they know which bathrooms to use. Residents never enter employee bathrooms. I will label the bathrooms near the nursing stations to emphasize to any visitors that this is an employee bathroom. The bathrooms can remain unopened when not in use. I have not witnessed or received any report of residents entering the employee bathroom. The DON did not provide an answer when asked if there is a potential for residents to enter the unlocked bathrooms near nursing stations. On 03/07/2024 at 9:05 AM, the Director of Environmental Services stated: The employee bathrooms are located by nursing stations. The employee bathrooms were only able to be locked once someone is inside, but I changed all four locks so that each bathroom door requires a key to enter and automatically locks once inside. I have worked here for six years, and we have had the same locks without any issue. Review of Policy and Procedure entitled, Safety and Supervision of Residents (revised January 2024) Policy Statement: Our facility strives to make the environment as free from accidents hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities. Policy Interpretation and Implementation: Facility - Oriented Approach to Safety: 1. Our facility - oriented approach to safety address risks for groups of residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide services in a manner to maintain dignity for 3 of 3 sampled residents. The facility failed to ensure Residents #146 and #233 had clothing other than a hospital gown. Facility staff failed to speak to Resident #152 in a dignified manner. The findings included: 1) Multiple daily observations during the survey from 11/28/22 through 12/01/22 revealed Resident #146 in bed wearing a hospital gown. The resident's room was near the nurse's station and her bed was the one next to the door, thus she was easily seen throughout the survey. During an interview on 12/01/22 at 10:18 AM, Resident #146 explained she had been admitted to the facility with only the clothes she had on at the time, to include one dress, a sweater, a pair of shoes, and underclothing. The resident stated she was trying to get those clothes back. The resident further explained that she was admitted to a room on the second floor, moved up to the third floor, and was now back on the second floor in a different room. Resident #146 stated she was also trying to obtain some additional clothing. Resident #146 was again dressed in a hospital gown. With the resident's permission, the surveyor looked in the resident's closet and dresser, and there were no clothes. The surveyor went to the resident's previous room on the third floor, having moved from there on 11/27/22, and noted that half of the room was empty and lacked any clothing. Review of the resident's clinical records revealed Resident #146 was admitted to the facility on [DATE], moved to the third floor on 10/11/22, and back to the second floor on 11/27/22. The records lacked any type of inventory list of her belongings. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #146 had a Brief Interview for Mental Status (BIMS) score of 12, on a 0 to 15 scale, indicating the resident was alert and oriented with minimal confusion. During an interview on 12/01/22 at 11:27 AM, the Social Services Director (SSD) was asked the process should a resident come to the facility with little or no clothing. The SSD explained she should be notified by nursing, and they have clothing that had been donated to the facility and could be given to those in need. The SSD also stated if the resident would like to buy some clothing, the activity department could help with that. During an interview on 12/01/22 at 12:06 PM, Staff J, a Registered Nurse (RN) and the resident's primary nurse at the time, was asked about the lack of clothing for Resident #146. The RN stated she believes she only came with a very few clothes. When asked the process for residents who were admitted with little or no clothing, and the RN stated the Certified Nursing Assistants (CNAs) should let nursing know of the need for clothes. Staff J then stated she was unaware of the lack of clothing, stating the resident had only been on that unit a few days. During an interview on 12/01/22 at 12:25 PM, Staff U, an RN/Unit Manager for the third floor, was asked about clothing for Resident #146. The Unit Manager stated that most of the time she saw the resident wearing a hospital gown. The Unit Manager further explained they document all the resident's personal belongings on an inventory sheet in the electronic medical record, but was unable to locate one for this resident. The Unit Manager further stated they should inform the SSD of any clothing needs. During an interview on 12/01/22 at 1:41 PM, the Activity Director was asked if he was aware of any clothing needs for Resident #146, and he stated he was not. 2) An observation and interview were made with Resident #152 on 11/29/22 at 9:09 AM. The resident had some hair on the sides of his head and a scruffy mustache and beard. When asked if he likes to have the facial hair or prefers to be clean shaven, the resident stated he prefers a bald head and cleaner shave. When asked if he had asked for assistance with the shave, Resident #152 stated he was reluctant to ask for help because of the length of time it takes and their (referring to the CNAs) attitude. Resident #146 stated when he calls for assistance, especially for a [adult disposable uderwear] change, they scold me and say I just changed you a couple of hours ago. Resident further reported that the CNAs come in his room and talk on their personal phones. The resident voiced concerns about saying anything as he knew he had to stay at the facility for some time and did not want any trouble. Review of the clinical records revealed Resident #152 was originally admitted to the facility on [DATE], with the most current re-admission on [DATE]. The resident's photograph in the electronic record showed him with a bald head and a neatly shaven goatee. Review of the current MDS assessment dated [DATE] documented Resident #152 had a BIMS score of 15, indicating the resident was cognitively intact. This MDS documented the resident needed the extensive assistance of one person for personal hygiene, to include shaving. Review of the current care plan initiated on 07/09/22 documented the resident needed limited to extensive assistance for all Activities of Daily Living. 3) During the observation and screening of Resident #233 on 11/28/22 it was noted the resident to state he had been admitted approximately 1 week ago. When asked by the surveyor where he was residing prior to admission the resident replied that he has been homeless for some time. During the observation of the resident it was noted that his clothing was stained and soiled. When asked if he had additional clothing in the room the resident stated he only owns the clothes that he is currently wearing. Resident # 233 further stated no staff has asked about obtaining additional clothing. An observation of the resident's room closet and dresser noted no clothing (pants,, shirts, socks, jackets, foot ware, underclothing. The resident stated to the surveyor that he would appreciate obtaining some clothing and to able to [NAME] the clothing he was wearing. Interview with the Social Service Director on 11/30/22 revealed that she had not seen the resident for assessment since he was admitted and additionally stated that nursing staff had not informed her that the resident was admitted with no clothing inventory. The surveyor requested the Social Service Director to interview the resident concerning the clothing issues and homelessness issue. On 11/30/22 the Social Service Director approached the surveyor to state that she confirmed that the resident has been in the facility for approximately 7 days and had no inventory of additional clothing to wear. The Social Service Director further stated that she had already obtained a facility check/monies to send activity staff out to stores to purchase new clothing for the resident. On 11/30/22 the resident was again observed and interviewed by the surveyor and it was noted the resident was wearing new clothes and appreciated the facility's effort to purchase new clothing. During the review of the clinical record of Resident #233 on 12/01/22 it was noted an admission date of 11/23/22 and [AGE] years of age. The diagnoses included: Major Depressive Disorder, Suicidal Ideation's, and Symptoms and Signs Involving Cognitive Functions. Further review of the record failed to locate a documented list of personal belongings inventory upon admission for Resodent #233.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide a means of communication via a working telephone for residents throughout the third floor, including Residents #93 and 50. The facility failed to provide side rails per resident request for 1 of 1 resident reviewed for choices, #152 The findings included: 1) Resident #93, was admitted on [DATE]. According to a Quarterly Minimum Data Set (MDS) Resident #93 had a Brief Interview for Mental Status (BIMS) score of. 11, indicating 'moderately impaired'. Resident #93's diagnoses at the time of the assessment included but not limited to Hypertension, Renal insufficiency, Diabetes Mellitus (DM), Hyponatremia, Hyperlipidemia, Depression, Alcohol abuse, disorders of muscle and dysphagia. During an interview with Resident #93, on 11/29/22 at 8:36 AM, the Resident stated that the telephone in the room did not work, I need it to call my family. It hasn't worked for about a month. I have to use the one at the nurse's station. This surveyor attempted to make a phone call to state issued cellular device, and there was no dial tone or any indication that the phone was in working order. Resident #50 was admitted on [DATE]. According to an Annual MDS, dated [DATE], Resident #50 had a BIMS score of 14, indicating 'cognitively intact. Resident #50's diagnoses at the time of the MDS included: Anemia, Hypertension, DM, Depression, Schizophrenia, chronic lung disease and mental disorder. During an interview with Resident #50, on 11/28/22 at 3:03 PM, Resident #50 stated that the telephone did not work in the room. Resident #50 stated that the phones did not work for the entire floor for the last month and that he needed the phone to get in touch with family. This surveyor attempted to make a phone call to sate issued cellular device, and there was no dial tone or any indication that the phone was in working order. Review of the facility's brochure, on the corporation's web site, documented that the facility provides Cable, telephone and Internet. During an interview, on 12/01/22 at 8:52 AM, with the Maintenance Director and the Central Supply Clerk, when asked about the phones not working on the third floor, the Maintenance Director replied, when the CNAs lift the beds, they yank the cords right out of the walls. Sometimes it is fixed by replacing the ports or replacing the whole line and then I have to call [company name], other times, when the patient uses the phone, they drop the phones. The biggest problem is the walls and they pull the lines right out of the walls. Sometimes I can fix them, other times I have to call IT and if they can't fix it, I call [ phone company]. The Maintenance Director stated that the facility uses TELs system for maintenance requests. When asked how he is informed of any concerns voiced by the residents, the Maintenance Director replied, Usually they will just call me or text me when something needs to be fixed and we fix it. I go into the rooms and check them. We check for lights monthly, water temperatures monthly, randomly from room to room for water temperatures. I send my guys to check the air condition (a/c) filters on a monthly basis. I have logs of the a/c filters. We check almost everything, the walls and we spot paint, we check for water leaks and we go through phones like crazy here. IT's not just the third floor, it's the building. We have the same problem with the remote controls for the televisions. I have a person that's in charge of the third floor that is not here anymore and I replaced him about a week ago. When this surveyor requested documentation of repairs that had been made and maintenance requests, the Maintenance Director was unable to provide any such documentation. When asked about equipment being ordered and received, the Central Supply staff replied, They go to maintenance when I receive them. Each department has a requisition and I send them for approval and when It's approved, I order the items. The last time ordered was $1008 for telephones for the residents' rooms was 09/11/22 and it never came. Every week I have to follow up with them. I have to email the purchasing Director form Direct Supply to find out about the order. The Central Supply described the process as receiving the request from staff and or department and then sending the request to the Administrator for approval. Once the Administrator approves the request, the Central Supply forwards the request to a corporate office for approval. Once the Corporate office approves the request, a purchase order is sent to a company in [NAME] and they fill the order with a third party vendor. During an interview, on 12/01/22 at 9:35 AM, with Staff U, RN/Unit Manager, when asked how issues are reported to the Maintenance Department, Staff U replied, Whenever we have a complaint, we fill out a form on a clipboard and then we call Maintenance. When asked about the concerns with the phones in the residents' rooms, Staff U replied, At this time, we don't have phones, they have been waiting for the phones to be installed by the people that are installing them. when the family calls, I go get the resident and bring them here to talk on the phone. We explain to the family that we are in the process of installing the phones and for many of them, the family will provide a phone. When asked for any documentation of reporting to maintenance, Staff U was unable to provide any documentation of requests related to the phones not working. On 12/01/22 at 10:34 AM, the Maintenance Director reported. I have phones in my office, 4-5 phones, the order that we are waiting on is for future repairs. It's the phone lines, the line is dead. I just went and put a brand new phone and opened the box and the phone and the box were good so it has to be the lines. Review of the policy Quality of Life - Accommodation of Needs dated January 2022 documented, Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity and well-being. 3) During an interview on 11/29/22 at 9:23 AM, Resident #152 stated he had a side rail on his right side of the bed that became really loose, and the maintenance man took it off and did not replace it. The resident stated that one of the staff told him, You are only allowed one anyway. Resident #152 explained he would like both upper side rails on the bed to assist him with turning and to prop his pillows against so they don't fall on the floor. The resident stated he had asked several staff about the missing side rail. During an environmental tour on 11/30/22 at 1:23 PM with the Admissions Director and Housekeeping/Maintenance Director, Resident #152 again asked for the missing side rail, stating it had been missing about two weeks. The Housekeeping/Maintenance Director stated he could get one without a problem, and that it was removed the Monday before last (11/21/22). The Housekeeping/Maintenance Director was unsure why it had not been replaced. Review of the resident's clinical records revealed a current care plan initiated on 06/30/22 that documented Resident #152 was using quarter side rails. The record also contained four Side Rail Consent Forms, the most current dated 11/08/22, indicating the resident consented to quarter side rails as an enabler for bed mobility. 4) During the initial pool process on 11/28/22 and 11/29/22, it was noted that multiple rooms on the second floor had been remodeled. Each room had a new panel on the wall behind the bed, with a new light fixture (photographic evidence obtained). The new lights were turned on and off by a light switch on the wall about halfway between the top of the headboard and the call light reset button. A resident would not be able to reach the switch from the bed or a chair. During an interview on 11/29/22 at 9:23 AM, Resident #152 stated there was no way for him to turn the over bed light on or off. The resident stated in the evening or night his only light comes from the hall or the outside lights shining into the window. The resident stated he would not be able to read anything if he needed or wanted to do so. During an environmental tour on 11/30/22 at 1:23 PM with the Admissions Director and Housekeeping/Maintenance Director, the managerial staff agreed with the resident's inability to turn the over the bed lights on or off in the newly renovated rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide documentation to validate using resident's funds for services and supplies for 1 of 1 resident reviewed for Personal Funds (Resident #56). The findings included: Review of the facility's provided policy titled Management of Residents' Personal Funds revised in April 2017 documented .a copy of all financial transactions will be filed in the resident's permanent records Review of Resident #56's clinical record documented an initial admission to the facility on [DATE] with no readmissions. The resident diagnoses included Alzheimer's, Chronic Obstructive Pulmonary Disease (COPD) and Muscle Wasting and Atrophy. Review of Resident #56's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 0 of 15 indicating that the resident had severe cognition impairment. The assessment documented under Functional Status that the resident was totally dependent on staff for the activities of daily living. On 12/01/22 at 1:03 PM, an interview was conducted with the facility's Business Office Manager (BOM). The BOM stated that she had 40 residents that had a personal funds account. The BOM stated that the facility gets the residents social security or SSI- (Supplemental Security Income) check around the first or the third of the month and the facility deposit it in the bank. The BOM stated that the residents will get $130 dollars every month and added that some residents will ask not to get the whole 130 dollars. The BOM stated that a resident can have up to $2,000 in the account and added that some residents have an irrevocable funds account, meaning that if the accounts show more than $2,000 dollars, the money will either be sent to the resident's Power of Attorney (POA) for funeral arrangements or the facility will do the irrevocable funds account. The BOM stated she did not have any residents with an irrevocable funds account at the time of the survey. The BOM was asked who determines on how to spend the resident funds, the BOM stated that she will get in touch with the facility's Social Worker (SW) who will contact the family member/POA. The BOM added that if the resident does not have a POA, the SW will see what the resident's needs are and added that they will either to do funeral home arrangements, buy clothing or any other items that the resident may need utilizing the residents' personal funds monies. The BOM stated that Resident #56 was on hospice care and had a balance of $525.07 in her personal funds account at the time of the survey review. The BOM stated that the resident's daughter did not have POA paperwork but was getting the account quarterly statements. She added that the daughter was asking for the funds but because she did not have the POA, the facility could not give her any money. The BOM stated that she asked the resident's daughter for the funeral home arrangements contract before dispersing money to the daughter. A side by side of Resident #56's personal funds account statement from 01/02/20 to 12/01/22 was conducted with the facility's BOM. The review revealed the following debited amounts: 02/25/20- For MOM's personal use amount $509.94 (receipt were not available at the time of the review) 06/04/20- COVID 19/DIFF for F/A (Funeral Arrangements) amount $1042 (receipt were not available at the time of the review) 12/30/21- (12/20-12/26/21-Serv) amount $1200 12/30/21- (12/6-12/12/21-Serv) amount $450.00 01/20/22- Wheelchair (w/chair) amount $691.81 On 12/01/22 at 1:45 PM, during the review, the BOM was asked to submit the receipts for the amounts debited from February 2020 thru July 2022. The BOM stated that the receipts from January 2020 thru December 2020 are in storage outside the facility and will take 2-3 days to get them. The BOM was informed to fax them to the area office as soon as they receive them. Review of a receipt from [company name] documented service period starting 12/13/21 ending 12/19/21 for a total charge of $375 dollars and previous week's ending balance of $450 dollars for a total of $825 dollars. The receipt for the previous week was not submitted. The receipt did not include the type of service provided. Review of a receipt from [company name] documented service period starting 12/20/21 ending 12/26/21 for a total charge of $375 dollars and previous week's ending balance of $825 dollars for a total of $1200 dollars. The receipt did not include the type of service provided. During the review, the BOM was asked about the type of service provided by Value Care and stated that Resident #56 was provided a companion during those dates. The BOM was asked who authorized the companion and if the daughter was contacted regarding the expense. The BOM asked to speak with the Social Worker regarding the expense. Review of receipt dated 01/20/22 for a Reclining Wheelchair for the amount of $691.81 was conducted. On 12/01/22 at 1:39 PM, a joint interview was conducted with Staff B, a Social Worker (SW) and the BOM. Staff B stated that previous Director of Social Services (DSS) note dated 01/04/21 documented that resident's daughter was contacted regarding need for clothes and the daughter gave permission to buy items from Residential Essential. Staff B was asked about the reclining wheelchair expense and if that wheelchair was covered by Medicaid or Medicare. Staff B stated she did not know. The DSS note lack documentation related to the need for a reclining wheelchair and permission from the daughter. A side-by-side review with Staff B, SW of Resident #56's SW note dated 03/29/22 was conducted. The note documented .Social worker also educated daughter that if the resident was over the allowable amount for Medicaid benefits, funds would need to be spend down on services or items that would benefit resident, daughter verbalized understanding and stated excess funds to be forwarded for funeral expenses . During the review, Staff B was asked to submit written evidence/documentation to support the need for [company name] home service and the resident's daughter consent/approval for the facility to spend Resident #56's personal funds on services provided by [company name] from 12/20/21 to 12/26/21 service for the amount of $1200 and from 12/06/21 to 12/12/21 service for the amount of $450.00. Staff B stated that she was not able to find any written documentation and added that the service would have to be approved by the daughter. During the review, Staff B and the BOM were asked why Resident #56's over $2,000 limit amount of money was not spent on the funeral arrangements rather than [company name] companion services. The BOM stated that the resident's daughter took a long time to submit the funeral home contract. The BOM added that the daughter was doing the resident's funeral home arrangements and did not want the facility to do it. Review of the resident's funds account statement documented that on 06/04/20 $1042 were debited for funeral arrangement. The BOM stated that the receipt was in storage outside of the facility. Review of the Social Services notes dated from 08/31/19 to 11/15/22 lacked documentation of Resident #56's need for a companion that was paid with the resident's personal funds during the month of December 2021. The clinical record lacked evidence that the resident's daughter was communicated with or involved in the decision of that expense. At the end of the survey the facility staff was not able to produce documentation to support the expense to [company name] that was debited in December 2021.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to provide appropriate treatment and services to maintain or improve the ability to continue self-feeding for 1 (Resident #57) of 6 sampled residents. The findings included: During the screening and observation of Resident #57 during the lunch meal of 11/28/22, it was noted that the resident suffered from severe shaking, however, was attempting to self-feed without staff assistance or supervision. The resident was noted to be spilling beverages when attempting to drink independently. The resident appeared underweight and to be frustrated with the spillage of food and drink during the meal. During observation of the breakfast meal of 11/30/22 at 8 AM, it was noted that the tray was served to the room of Resident #57. Further observation noted that the resident was served a Mechanical Soft/Easy to Chew Diet. During the observation it was noted that the resident had severe trembling and shaking of the hands. Eating the plated foods was noted to be difficult and the resident was noted to be spilling liquids when attempting to drink. The resident stated to the surveyor that she does not drink much liquid beverages especially coffee due to spillage. Following the observation, an interview was conducted with the Director of Skilled Therapy to discuss the potential assessment of adaptive eating equipment and assistance with meals for Resident #57. The director stated that the resident will be evaluated for adaptive equipment. On 11/30/22 the director submitted an Occupational Therapy (OT) Evaluation dated 11/30/22 for Resident #57 the documented indicated the resident required an Adult Double Handle Sippy Cup during meals to reduce incident of spilling or dropping cup in order to decrease caregiver burden and maximize eating independence. It was also noted that the resident will receive OT treatment that includes therapeutic exercises and neuromuscular reeducation 3-5 times per week for a duration of the next 30 days. It was discussed that the nursing staff failed to contact skilled therapy to inform of the resident's issues with drinking independently and spilling liquids when attempting to drink fluids during meals. Review of clinical record of Resident #57 noted the resident was readmitted to the facility on [DATE]. Clinical diagnose include but not limited to Parkinson's, Lack of Coordination, and Dysphagia. Review of the current Physician Orders revealed dietary order dated 3/30/22 for Mechanical Soft-Easy To Chew Texture and Pureed Vegetable/Fruits. Review of the Minimum Data Set (MDS) dated [DATE] Quarterly indicate in section B for Hearing, Speech and Vision Section that the resident : Usually Understood. Section C for cognitive pattern documented a Brief Interview of Mental Status score of 3 out of 15 indicating the resident has severe cognitive impact. Section D for mood and behavior indicated no. Section G for functional status indicated that the resident required extensive assistance. Review of the Current Care Plan dated 9/19/22 indicated that the resident is at Risk For Alteration in Hydration - encourage fluids. Risk For Alteration Nutrition: Assist with meals. Requires assist by 1 staff 1 eating.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure range of motion and mobility services was being provided for 3 of 3 sampled residents. The facility failed to ensure that splint devices were put in place as ordered/recommended by therapy for Residents #26 and #139. The facility failed to assist with recommended ambulation for Resident #146. The findings included: Review of the facility's policy titled Restorative Nursing Services revised in January 2022 documented residents will receive restorative nursing care as needed to help promote optimal safety and independence . Review of the facility's website brochure accessed on 12/01/22 read .The Interdisciplinary Rehabilitation Team at The [NAME] at South Beach Care Center by [ company name] provides personalized restorative nursing care 1) Review of Resident #26's clinical record documented an initial admission to the facility on [DATE] and no readmissions. The resident diagnoses included Unspecified Lack of Coordination, Epilepsy, Sequelae following Cerebrovascular Disease, Aphasia following Cerebrovascular Disease, Dysphagia following Unspecified Cerebrovascular Disease, Heart Diseases, Major Depressive Disorder, Anxiety Disorder, Traumatic Arthropathy (a joint disease), Speech and Language Deficits following Cerebrovascular Disease, Unspecified Intellectual Disabilities, Dementia, Peripheral Vascular Disease, Specified Disorders of Bone Density and Structure, Functional Quadriplegia, and Contracture of Muscle, Multiple Sites. Review of Resident #26's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 0 of 15 indicating that the resident had severe cognition impairment. The assessment documented under Functional Status that the resident was total dependent on the staff for her activities of daily living (ADLs). The assessment documented that the resident had functional limitation in range of motion of upper and lower extremities and had not received Restorative Nursing Program services during the assessment period. Review of Resident #26's MDS quarterly assessment dated [DATE] documented a BIMS score of 0 of 15 indicating that the resident had severe cognition impairment. The assessment documented under Functional Status that the resident was total dependent on the staff for her ADL's. The assessment documented that the resident had functional limitation in range of motion of upper and lower extremities and had no received Restorative Nursing Program services during the assessment period. Further review revealed that Resident #26's last Physical Therapy treatment was on 12/19/18. Review of Resident #26's care plan titled Self-care deficit, resident needs staff interventions to complete ADLs related to severely impaired, impaired mobility, non-ambulatory .initiated on 01/25/19 and revised on 11/29/21 documented an intervention that read hip abduction splint as ordered . Review of Resident #26's care plan titled RESOLVED: Need for RNP due to decrease in ROM (range of motion), decreased mobility, presence of contractures initiated on 04/04/2019, revision on 11/28/22 and a resolved date on 11/28/22. The resolved care plan goal included Resident will maintain strength and joint integrity and to facilitate correct performance of passive and active movements to enhance flexibility of the joints, Resident will maintain current level of function and mobility. The resolved care plan interventions included: Apply Hip abduction splint apply after am care and prom (passive range of motion), remove for restorative, ROM, ADLs and at bedtime . Review of Resident #26's physician order dated 12/26/19 documented Restorative nursing as needed or tolerated. Review of Resident #26's Rehab Referral/Screening dated 08/31/22 documented Rehab not warranted, no significant decline in function .continue hip abduction splint to prevent contractures . On 11/28/22 at 10:49 AM, a side-by-side review of Resident #26's upper extremities and lower extremities was conducted with Staff E, Certified Nursing Assistant (CNA). Observation revealed the resident was not able to open her right hand and was not wearing a splint. Further observation revealed that the resident did not have the hip abduction splint in place as ordered. On 11/29/22 at 10:38 AM, an interview was conducted with Staff B, Certified Nursing Assistant (CNA) who stated that she had a regular CNA assignment. Staff B stated that she had not been able to do resident's restorative nursing care for a long time because she was getting a regular CNA assignment doing resident care. During the interview, Staff B stated that she had not applied any splints to Resident #26. Observation revealed no splint in the resident's room. On 11/29/22 at 10:40 AM, an interview was conducted with Staff L, CNA who stated that she was helping with resident care and may or may not be able to do restorative care in the afternoon. Staff L stated she had not been doing restorative care because she was getting a resident regular assignment meaning doing resident care. On 11/29/22 at 2:36 PM, observation revealed Resident #26 in bed and awake. During the observation the resident had her right hand closed tight and no splint noted. The resident was able to open her right hand with great difficulty. Observation revealed her left-hand finger contracted. Further observation revealed the resident was not wearing the hip abduction splint as ordered. On 11/30/22 at 8:10 AM, an interview was conducted with Staff P, CNA who stated that Resident #26 was total care and that she was not putting any splints on the resident. Staff P stated that she did not know if Resident #26 was getting Restorative Nursing care. On 12/01/22 at 7:19 AM, an interview was conducted with the facility's Director of Rehabilitation (DOR). The DOR stated that Resident #26 was screened on 08/31/22 and the resident was dependent on staff and recommendations were to continue with hip abduction splint, apply either by RNP (Restorative Nursing Program) or floor staff. The DOR stated there was a RNP however after COVID it has been difficult and added that the RNP was partially functioning. The DOR stated that on 08/31/22 OT screen documented recommendations as to bilateral extension splints for elbow, left hand upward extended and bilateral comfy hand to be placed after morning care as tolerated. The DOR stated that the splint application documentation should be under the CNA's task. The DOR was apprised that there was not documentation related to Resident 26's splints application. The DOR stated that the OT did not address the resident right hand during the 08/31/22 screen. During the interview, the DOR stated there was no recommendations for PT/OT evaluation on 08/31/22, only the screen and added that she believes the resident was on the RNP. The DOR stated Resident #26 was screened on 11/22/22 and that she asked for an Occupational (OT) and Physical Therapy (PT) evaluation to further assess the resident for orthotic management. The DOR was asked why it took 8 days to evaluate the resident and stated that she had to wait for referral from the insurance company. The DOR stated she received an approval from the insurance for the evaluation on 11/28/22 and the resident was evaluated on 11/30/22, two days later. The DOR stated that the PT recommendations was for the resident to use an abductor wedge between the legs, and it was reordered. The DOR stated that the previous wedge was misplaced, and the staff were using regular pillows which it was not the best. The DOR stated she did not know for how long Resident #26's abduction splint was misplaced. The DOR stated that on 11/30/22 the OT evaluation revealed bilateral impairment of upper extremities, right side shoulder, elbow, forearm, wrist, and forearm. The DOR stated that the resident had left upper side shoulder, elbow, forearm, wrist hand and digits impaired and bilateral elbow extensions splints and bilateral comfy hands splints were recommended to be put on after care as tolerated. The DOR was apprised that Resident #26 was observed not wearing any upper or lower extremities splints. The DOR replied that the splint was misplaced, and she did not know for how long. On 12/01/22 at 9:09 AM, an interview was conducted with Staff F, Registered Nurse (RN) who stated that she did not see the need to refer Resident #26 to therapy. Staff F stated that the resident had her left hand closed/tight for a longtime and now they noticed that she was having pain when the CNA was cleaning her. Staff F was apprised that Resident #26 was having pain on 11/28/22 while the CNA tried to open her hand. Staff F stated that the resident was not receiving RNP and did not have any splints. On 12/01/22 at 9:19 AM, an interview was conducted with Staff J, Restorative Nursing Program-RN (RNP-RN). Staff J stated that she was always working as a floor, passing medications, and also doing the RNP. Staff J stated last week she did the restorative care to the residents in station three, and for Resident #26. Staff J stated that she tried to put a hand roll on her hand, but that the resident did not need it. Staff J stated it had been very hard to be pulled to do two jobs at the same time. Staff J was asked how many times she had been able to do the restorative care in the last 30 days and replied about 10 days out of 30 days. Staff J added she was pulled to do the floor nursing many times. Staff J was asked to submit the RNP documentation. On 12/01/22 at 9:50 AM, during an interview Staff J stated she was just told that she was not in charge of the RNP. Staff J stated that she was off for two weeks and could not find the restorative program records. On 12/01/22 at 9:51 AM, an interview was conducted with the facility's Director of Nursing (DON) who stated that the facility did not have an active RNP. The nurses and CNA were doing the residents range of motion (ROM) and ambulating the residents. The DON was apprised that during the survey, no resident was observed been ambulated by the staff on the second floor. The DON stated that they had hired Staff J to do RNP and that she did when the facility had nurses available to do the floor. The DON was apprised that it was noted throughout the four days survey that the facility's Restorative CNAs had been working on the second floor and having a regular resident care assignment. The DON called Staff L, CNA and asked for the last time she did restorative care and the CNA replied that she did not remember and that she had been getting a regular resident assignment. On 12/01/22 at 10:07 AM, during the interview, the DON was asked to submit the resident's Restorative RNP documentation. At the end of the survey, Staff J nor the facility's DON had not submitted the RNP documentation requested. 2). Review of Resident #139's clinical record documented an initial admission to the facility on [DATE] with no readmissions. The resident diagnoses included Nontraumatic Subarachnoid Hemorrhage (bleeding in the space that surrounds the brain), Speech and Language Deficits following a Cerebral Infarction, Hemiplegia and Hemiparesis following a Cerebral Infarction affecting left non-dominant side, Peripheral Vascular Disease, Hydrocephalus (fluid accumulation in the brain) and Encephalopathy (functioning of the brain is affected by some agent or condition (such as viral infection or toxins in the blood). Review of Resident #139's MDS quarterly assessment dated [DATE] documented a BIMS score of 0 of 15 indicating that the resident had severe cognition impairment. The assessment documented under Functional Status that the resident was total dependent on the staff for her activities of the daily living (ADLs). The assessment documented that the resident had functional limitation in range of motion of one lower extremity and had no received Restorative Nursing Program services during the assessment period. Review of Resident #139's care plan titled Self-care deficit and is at risk for deterioration in ADL function .initiated on 03/21/22 documented an intervention that read .monitor/document/report to MD (doctor) as needed any changes, any potential improvement reasons for self-care deficit .declines in function . Review of Resident #139's physician order dated 11/17/22 documented Nursing rehab: apply left hand roll after AM care. Remove for ADL's, rest as needed and at bedtime . On 11/28/22 at 10:45 AM, a side-by-side observation of Resident #139's extremities was conducted with Staff E, CNA. The review revealed the resident had a left-hand contracture and had hand roll noted. Staff E confirmed that the resident did not have a hand roll. On 11/29/22 at 2:38 PM, observation revealed the resident in bed, awake, left hand closed tight no splint noted. During an interview, the resident stated that the staff do not place a hand roll on her hand. The resident added that she had to do her part when therapy comes. Observation revealed that resident was able move three finger of her left hand with difficulty and the heart finger was contracted. Observation revealed no splint/hand roll noted. Further observation revealed no splints or hand roll noted on the resident's nightstand. On 11/30/22 at 7:33 AM, a side-by-side review of resident #139's extremities was conducted with Staff P, CNA. Staff P stated that she does the resident care and that she was not applying any hand roll to the resident's left hand. Staff P stated that the resident complained of pain to her left hand when she opened it to do care. On 12/01/22 at 8:08 AM, an interview was conducted with the DOR who stated Resident #139 had a rehabilitation screen on 11/16/22 and an evaluation was completed 11/19/22 for PT and OT. The DOR stated that the OT recommended a hand roll to the left hand. The DOR stated that the resident had left hand impairment, including the ring, middle and little finger. The DOR stated that the resident was on therapy caseload and the rehabilitation staff was responsible to applying the hand roll and remove it. The DOR stated that the therapist was not leaving the hand roll in the room and that the therapist was putting the hand roll during therapy. The DOR was asked if the resident will benefit from the hand roll in place longer than only during therapy and replied that they can do that. The DOR was apprised that throughout the survey at different times of the day, Resident #139 was observed without a hand roll. 3) Review of the clinical records for Resident #146 revealed the resident was admitted to the facility on [DATE], moved to the third floor on 10/11/22, and was transferred back to a second-floor room on 11/27/22. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #146 had a Brief Interview for Mental Status (BIMS) score of 12, on a 0 to 15 scale, indicating the resident was alert and oriented with minimal cognitive deficits. Review of the Physical Therapy Discharge summary dated [DATE] documented, Discharge Recommendations: D/C (discharge) to floor staff for ambulation with RW (rolling walker) as indicated. RNP (Restorative Nursing Program): N/A (not applicable). This discharge summary also documented the patient (Resident #146), and primary caregivers were instructed on the use of assistive devices, safety precautions and safe transfer techniques in order to preserve current level of function. Review of the current care plans documented as of 09/23/22, Resident #146 had functional limitations and to refer to physical therapy treatment as ordered. A care plan initiated on 09/23/22 documented Resident #146 required assistance with ADL (Activities of Daily Living), and included interventions for transfers, dressing, grooming, and eating, but failed to include ambulation. During an interview on 11/28/22 at 11:07 AM, Resident #146 explained she had been admitted to the facility and received therapy for walking, and now that the therapy was completed, she has not walked. Resident #146 stated she wanted more therapy and wanted to walk more. Resident #146 finished by stating she doesn't want to just stay in the bed and get weaker. Multiple daily observations during the survey from 11/28/22 through 12/01/22 revealed Resident #146 in bed. The resident's room was near the nurse's station and her bed was the one next to the door, thus she was easily seen throughout the survey. At no time during the survey was Resident #146 seen ambulating. During a subsequent interview on 12/01/22 at 10:18 AM Resident #146 was again in bed and stated she wanted to walk. The Physical Therapy Discharge Summary was reviewed with the Director of Rehabilitation (DOR) services on 12/01/22 at 10:36 AM. The DOR confirmed Resident #146 was safe to ambulate with the rolling walker and staff assistance. When asked about a Restorative Program, the DOR stated the facility did not have that program, and confirmed it was currently the responsibility of the nursing staff to assist a resident with ambulation, after discharged from therapy services. During an interview on 12/01/22 at 10:54 AM, Staff R, the resident's direct care Certified Nursing Assistant (CNA) for the day, was asked if she had ever assisted Resident #146 to walk with the walker. Staff R stated, No she has therapy to do that. When told Resident #146 was no longer on therapy, the CNA stated for safety she just transfers her to the chair. The CNA further stated she did not know that the resident could walk. When asked how she would know if a resident was safe to walk, the CNA stated therapy would tell her. When asked if she had been told by therapy or anyone that Resident #146 could ambulate with a walker and the assistance of staff, the CNA again stated she did not know the resident could walk. During a subsequent interview on 12/01/22 at 10:59 AM, the DOR was asked who are the primary caregivers that were instructed upon discharge from therapy. The DOR said the CNA who was on the floor that day. During an interview on 12/01/22 at 12:06 PM, Staff J, Registered Nurse (RN), whose name tag documented Restorative Nurse was asked about Resident #146's ability to ambulate. The RN explained she saw the resident walking with therapy in the past but had not seen any CNA assisting Resident #146 with ambulation since her admission to the second floor. During an interview on 12/01/22 at 12:25 PM, Staff U, RN and third floor Unit Manager, was asked about the walking ability of Resident #146, when she resided on the third floor. The Unit Manager stated she had only seen Resident #146 in bed or sitting in her wheelchair. The Unit Manager stated she was on therapy services while residing on the third floor. The Unit Manager was made aware that Resident #146 was discharged from therapy on 11/17/22 and remained on the third floor until 11/27/22. When asked again if her CNA staff assisted Resident #146 to ambulate with her rolling walker, the Unit Manager stated she believed it should only be the licensed therapist to walk with the resident. The Unit Manager then stated she was not aware Resident #146 could walk and did not know she had finished therapy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined that the facility failed to provide 1 (Resident #149) of 6 sampled residents reviewed for nutrition adequate supervision and assistance during meals and prevent potential environment accidents 32 resident residing on Unit 2 which included sampled Resident's #132, #146, #152, #172, and #233. The findings included: During the observation of the breakfast meal of 11/30/22 at 8:15 AM, it was noted that Resident #149 was being fed by a young man (visitor) in street clothes. Further investigation noted the resident to be laying horizontal in the bed and being fed by the visitor. Observation of the meal ticket and meal tray noted puree, consistent carbohydrate diet. It was also noted that the visitor was feeding the resident [fast food chain company] which included tater tots and sausage. Interview with the visitor revealed that he comes every day to feed the family friend and was unaware that the resident requires pureed carbohydrate-controlled foods. It was also revealed that he was unaware that the resident could possibly choke or aspirate while feeding the resident non-pureed foods and feeding the resident while laying horizontally in bed. The visitor stated the resident can feed himself, but staff will not put him in a chair prior to feeding. The visitor stated he has never been made aware or trained by staff on how to feed the resident safely. Following the observation, the surveyor spoke with the Director of Therapy concerning the safety issue with Resident #149 and requested to speak with the visitor. The Director of Therapy stated she had spoken with the visitor who stated that he does feed the resident daily and has never been trained by staff on the specifics to feeding Resident #149. The surveyor requested the Director of Therapy to screen or evaluate the resident to eliminate the potential for choking/aspiration. On 12/01/22 the Director of Therapy submitted a progress Note dated 12/01/22. The note documented that their director spoke to the visitor prior to leaving the facility during the morning of 12/01/22 and was educated about the resident's diet and that any food from the outside should be brought directly to the nurse to ensure that it meets the resident's diet requirements and proper positioning of the resident. The note further documented that the interdisciplinary team was made aware of the issue. Review of clinical record of Resident #149 noted the resident was admitted to the facility on [DATE]. Diagnoses include but not limited to Cognitive Deficit, Dysphagia, Chronic Kidney Disease, Type 2 Diabetes and Dementia. Review of the Current Physician Orders dated 9/2/22 indicated dietary order for Pureed, Carbohydrate Consistent Diet. Order dated 9/9/22 - Mighty Shake 2 times per day (BID). Order dated 9/9/22 to give Glucerna three times per day (TID). Review of the quarter Minimum Data Set (MDS) dated [DATE] indicated the resident Sometimes Understands and Understood. Section C for Cognitive Pattern indicated for the Brief Interview of Mental Status (BIMS) No BIMS Score (Unable to participate) indicating the resident has cognitive impairment. Section D for Mood and Behaviors indicated no mood. Section G for Functional Status indicated the resident required extensive assistance. Review of the Current Care Plans indicated the resident has Alteration in Nutrition/Hydration and intervention included assist with all meals. 2) During a routine observation of the Unit 2 (Rooms #226 through #250) on 11/29/22 revealed an unlocked storage room located off the main hallway next to the community shower room. Further observation of the unlocked room noted it contained approximately fifteen (15) 5-gallon containers of wall paint and assorted containers (5) of cleaning chemicals. It was noted that there were ambulatory cognitively impaired residents in the facility's main hallway and within the proximity of the room's entrance area. Following the observation, the surveyor requested the Director of Maintenance and Director of Nursing to view the storage room with the surveyor. The directors stated to the surveyor that the room is required to be locked at all times due to the hazardous chemicals contained within the room. It was also discussed by the surveyor that the room door is not self-locking and that there are numerous cognitively impaired residents residing in the area that could potentially gain access to the room without staff knowledge. A review of the resident census for 11/29/22 noted that there were 32 residents residing in Unit 2 (Rooms #226 - #250). Of the 32 residents residing in Unit 2 it was noted to include Resident's #132, #146, #152, #172, #233, and #233.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews the facility failed to assess for the removal of an indwelling urinary catheter and failed to follow up with hospital discharge recommendations to see a Urologist for alternative means of the use of the indwelling urinary catheter for 1 of 1 resident reviewed for perineal and urinary catheter care (Resident #151). The findings included: Review of Resident #151's clinical record documented an initial admission to the facility on [DATE] with a readmission on [DATE]. The resident diagnoses as per the record demographic information (face sheet) included: Dementia, Retention Of Urine, Encounter For Fitting And Adjustment Of Urinary Device, Displaced Intertrochanteric Fracture Of Left Femur, Subsequent Encounter For Closed Fracture and Cognitive Communication Deficit. Review of Resident #151's physician order dated 09/29/22 documented [indwelling urinary catheter] and for [] catheter care every shift. Review of Resident #151's Minimum Data Set (MDS) quarterly assessment dated [DATE] documented a Brief Interview of the Mental Status (BIMS) score of 3 of 15 indicating that the resident had severe cognition impairment. The assessment documented under Functional Status that the resident needed extensive assistance from the nursing staff to do her activities of daily living. Review of Resident #151's care plan titled Resident requires [indwelling urinary catheter] . at risk for UTI (Urinary Tract Infection). The care plan was initiated on 07/27/2022, revision date documented 07/27/2022. The care plan interventions included assess continued need of catheter . On 11/28/22 at 10:01 AM, observation revealed Resident #151 in bed, awake. Attempted to interview the resident but the resident was not responding to questions asked. Continued observation revealed a urinary drainage bag hanging down on the right side of the resident's bed. The bag was connected to a cloudy tubing and into the resident. On 11/28/22 at 10:05 AM, an interview was conducted with Staff E, a Certified Nursing Assistant (CNA) who stated that Resident #151 had an indwelling urinary catheter. On 11/28/22 at 12:45 PM, an interview was conducted with Resident #151's son who stated that the resident had not seen a specialist regarding the urinary catheter. The resident's son stated that he did not know how long the resident had the catheter in place and did not know the reason for it. On 12/01/22 at 11:15 AM, an interview was conducted with Staff G, a Registered Nurse (RN) who stated that Resident #151's came into the facility from the hospital with an indwelling urinary catheter. Staff G stated that the resident had not had a voiding trial to see if the indwelling catheter can be removed. Staff G was asked if the resident had seen a Urologist for the justification of the catheter and Staff G stated No. Staff G, RN stated that she called the resident's primary physician last week and was told to keep the catheter in because the resident had urinary retention after the surgery. Staff G was asked to submit written evidence and Staff G stated that she did not document the call with the physician anywhere. Consequently, a side-by-side review of Resident #151's hospital discharge record dated 09/29/22 was conducted with Staff G, RN. The record documented discharge diagnosis of Septic Shock secondary to complicated UTI. The discharge paperwork documented culture with ESBL . (extended spectrum beta-lactamase- enzyme found in bacteria in the urine) discharge on antibiotic for seven (7) days given complex UTI in the setting of patient with Chronic [indwelling urinary catheter]. Should see urology to consider alternative means . During the review, Staff G, RN stated that she searched for a Urologist consult and did not see one in the resident clinical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 11/27/22 at approximately 2:30 PM a tour was conducted with the Housekeeping Director and the Admissions Coordinator. As part of the tour a stop was made in the Central Supply store room. In Central Supply there were cardboard boxes stacked on wooden pallets. [NAME] is an absorbent material that is prone to rot, to harbor mold, mildew, water borne pathogens and attract insects; these hazards have the potential to contaminate the contents of the boxes. The pallets do not provide enough clearance to properly clean the floors. Other areas of the floor were blackened and had rust coloring in places where shelving had been moved. The metal shelving used in the supply room did not provide clearance for proper cleaning. The laundry room was observed during the tour. In the dirty laundry holding area there was a fixed position laundry bin constructed of plywood. As stated above, wood is an absorbent materiel prone to many negative conditions. Additionally, dirty laundry has the potential to harbor harmful bacterium and virus. Workers could be injured by splinters in the wood with the potential of causing serious illness. Based on observation and interview, it was determined that the facility failed to provide housekeeping and maintenance service necessary to maintain a sanitary, orderly, and comfortable interior in 2 of 2 (first & second Floors) living area and 1 of 2 dining areas (second floor) The findings included: . 1) During resident screenings conducted on 11/128/22 and the environment tour conducted on 11/30/22 at 1:00 PM accompanied with the Director of Housekeeping and Admissions Director the following were noted: Second Floor: room [ROOM NUMBER] - The ceiling area above the room windows was noted have large areas of peeling paint. room [ROOM NUMBER] - The window blinds were broken and inoperable. room [ROOM NUMBER] - The room mirror noted to have large areas of desilverization. room [ROOM NUMBER] - The room mirror noted to have large areas of desilverization. room [ROOM NUMBER] - Bathroom floor noted to have large areas of yellow stains, and bathroom call light cord was wrapped around the handrail. room [ROOM NUMBER] - The over commode chair was rust laden, and noted 4 holes in the room walls. room [ROOM NUMBER] - Bathroom floor noted to be heavily stained, room wall had numerous large black scuff marks, and the resident's privacy curtain was soiled and stained. room [ROOM NUMBER] - Room sink bowl was heavily stained, and resident's privacy curtain was soiled and stained. room [ROOM NUMBER] - Room windows were soiled and residents unable to see through. room [ROOM NUMBER] - Room windows were soiled and residents unable to see through. Community Shower room [ROOM NUMBER] - Call light wrapped around handrail, and light bulb not working. Community Shower #2 - The shower staff was missing the emergency pull cord, and the floor drain in the shower stall was missing cover. Community Shower #3 - Emergency call light was inoperable, room wall damage, and shower stall drain cover was missing. Third Floor: room [ROOM NUMBER] - The pull cord for the overhead lights were missing, resident's privacy curtains were soiled and stained, dresser exteriors were heavily worn, room closet door knob missing, and 4 of 4 over-bed tables exterior were worn and damaged. room [ROOM NUMBER] - Two of two overbed table exterior were heavily worn and damaged, room window blinds were damaged and not operable. room [ROOM NUMBER] - Bathroom light was inoperable, Overbed light not working, and numerous holes in room walls. room [ROOM NUMBER] - Two of two overbed table exterior were heavily worn and damaged. room [ROOM NUMBER] - Bathroom floor was in disrepair, over commode chair was rust laden, and room mirror had large areas of desilverization. room [ROOM NUMBER] - Bathroom baseboard coming off the wall. room [ROOM NUMBER] - Bathroom walls noted to have large areas of peeling paint, large cracks in room walls, and overbed table exterior was worn and in disrepair. Community Shower room [ROOM NUMBER] : Shower chair soiled and stained, privacy curtain missing, emergency call light was inoperable, and room wall damage. Following the tour an interview was conducted was conducted with the Director of Housekeeping to confirm the tour findings. During the interview it was noted that there was no policy developed or system developed for staff to document and inform housekeeping and maintenance issues. The director stated the only phone calls are made to housekeeping and maintenance to report issues. 2) During the observation of the lunch meal on 11/28/22 in the second floor dining room it was noted that the central air condition produced a high loud continuous screech when on. The noise was so loud the residents required the television to be turned up to be able to hear. Interviews with conducted with residents at the time of the observation were noted to state the the noise issue has been ongoing. Interview with the Maintenance Director following the meal observation noted to state the the issues has been going on for approximately one week but not not been able to have a air-conditioning vendor repair the issue.

Based on interviews and record review the facility failed to maintain the combined Nursing, Certified Nursing Assistant (CNA), PCA (Personal Care Attendant) and Direct Care Staff minimum requirement of 3.6 hours weekly hours. The findings included: Review of the facility's Daily Schedule for 11/28/22, 11/29/22, 11/30/22 and 12/01/22 documented Staff N, Personal Care Attendant (PCA) scheduled to work 16 hours shift (3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shift) a total of 4 consecutive days- 64 hours. Review of the facility's Daily Schedule for 11/29/22 and 12/01/22 documented Staff M, PCA scheduled to work 16 hours shift (3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shift). On 11/28/22 at 9:47 AM, an interview was conducted with the facility's Staff Coordinator (SC) who stated that she had a hard time finding staff to work. The SC stated that the facility was using agencies for all shift during the week and on the weekends. On 11/28/22 at 9:55 AM, an interview was conducted with Staff E, a Restorative Nursing Care CNA. Staff E stated that she had not been able to do the resident restorative care due to been doing resident care because of short staff. Staff E stated she had been asked to work overtime a lot. On 11/29/22 at 9:48 AM, an interview was conducted with Staff H, CNA who state that she works on Saturday and they are short of staff on the weekends. On 11/29/22 at 9:50 AM, an interview was conducted with Staff I, Registered Nurse (RN) working in the locked down unit. Staff I stated that this past weekend on Sunday (11/27/22) a CNA called off and they were not able to pull a CNA from another unit because the other unit had a CNA that called off too. Staff I stated the facility Activities Aide came and helped with resident's bath. On 11/29/22 at 10:03 AM, an interview was conducted with the Unit Secretary who stated that that the facility had Personal Care Attendant (PCA's) scheduled in the afternoons. On 11/29/22 at 3:01 PM, a joint interview was conducted with the facility's Administrator and the SC. A side by side review of the facility's staffing schedule from April 2022 to June 2022 was conducted with the SC and the Administrator. The SC and the administrator were asked for a copy of the Calculating State Minimum Nursing Staffing for Long Term Care Facilities from April 2022 to June 2022. During an interview, the administrator stated that the facility started to use the new Calculating State Minimum Nursing Staffing for Long Term Care Facilities on 04/10/22. The administrator stated that the weekly average of the combined Direct Care staff hours required was 3.6. The SC stated she did not do the Calculating State Minimum Nursing Staffing for Long Term Care Facilities form prior to 04/24/22. The administrator and the SC were not able to retrieve and submit the Calculating State Minimum Nursing Staffing for Long Term Care Facilities prior to 04/24/22. A side by side review of the Calculating State Minimum Nursing Staffing for Long Term Care Facilities from 04/24/22 to 06/30/22 was conducted with the administrator and the SC. The review revealed the following: week 05/01/22 to 05/07/22 documented 3.00 hrs combined nursing, CNA and PCA direct care staff hours. week 05/15/22 to 05/21/22 documented 2.95 hrs combined nursing, CNA and PCA direct care staff hours. week 05/29/22 to 06/04/22 documented 2.96 hrs combined nursing, CNA and PCA direct care staff hours. week 06/12/22 to 06/18/22 documented 2.90 hrs combined nursing, CNA and PCA direct care staff hours. week 06/26/22 to 07/02/22 documented 2.96 hrs combined nursing, CNA and PCA direct care staff hours. During the review, the administrator was informed that the facility's Payroll Based Journal (PBJ) Staffing Data Report for the third quarter in 2022 (April 1- June 30) showed excessive low weekend staffing. The administrator was appointed that it is reflected on the Calculating State Minimum Nursing Staffing for Long Term Care Facilities. The administrator was apprised that the facility did not meet the combined direct care staff hours of 3.6 for the quarter. On 11/30/22 at 12:35 PM, during an interview, the administrator submitted another copy of the reviewed Calculating State Minimum Nursing Staffing for Long Term Care Facilities. The administrator stated that the form was corrupted and it was redone. The administrator was asked why it was not identified before the surveyor review. The administrator stated that the hours submitted to the PPBJ was done by the corporate office. On 12/01/22 at 12:47 PM, an interview was conducted with the facility's administrator and was apprised that the Calculating State Minimum Nursing Staffing for Long Term Care Facilities form given during the review with her and the SC on 11/29/22 showed less than 3.6 hours of combined direct care staff required and that the updated forms given the next day showed that the combined hours were above 3.6 hours. The administrator stated that the next day they identified that the form was corrupted. The administrator was apprised that deficiency practice was identified on 11/29/22 and the updated forms will be submitted to the area supervisor for review.

Based on record review, observations and interviews, the facility failed to perform Personal Care Attendant (PCA) competencies and failed to provide documentation of required training prior to have direct contact with the residents for 4 of 4 PCAs (Staff M, Staff N, Staff O and Staff W). The findings included: Excerpt from the Florida Statutes 59A-4.1081 Personal Care Attendant Program (PCA) Requirements. This program permits a nursing home .to employ a trained Personal Care Attendant .The program must consist of a minimum of sixteen (16) hours of education. The 16 hours of required education and eight (8) hours of simulation must be completed before the PCA has any direct contact with a resident . Training must consist of a minimum of sixteen (16) hours of classroom teaching and eight (8) hours of supervised simulation in which the PCA is required to demonstrate competency in all areas of training. The PCA program is established under section 400.211 (2) (a) Florida Statutes. On 11/29/22 at 3:31 PM, during a joint interview with the facility's Staff Coordinator (SC) and the administrator, the SC stated the facility had four (4) PCAs. The SC stated that the PCA were working the 3:00 PM to 11:00 PM or 11:00 PM to 7:00 AM shift and added that sometimes the PCAs worked 16 hours shift. During the interview, the SC and the administrator were asked who did the PCA's competencies. The Administrator stated that she believed the DON and the ADON were doing the staff education and the staff competencies. 1) Review of the facility's Daily Schedule for 11/29/22 and 12/01/22 documented Staff M, PCA scheduled to work 16 hours shift (3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shift). On 11/29/22 at 4:25 PM, an interview was conducted with Staff M, PCA who stated that her start date to work in the facility was on 09/18/22. Staff M was asked to show her the facility's ID badge and stated that she did not have an ID, the facility had not given her one. Staff M was asked if she had any PCA competencies, or any training or shown by a nurse how to do her duties and replied No. The surveyor mentioned the facility's Director of Nursing (DON) and the Assistant Director of Nursing (ADON) names and Staff M stated she did not remember doing training with any of them. Staff M was asked if she had an assignment and replied she Yes and added that her assigned residents were 207, 208, 209, 210 and 211. Staff M stated she had 12 residents on her own. Staff M was asked what she would be doing for them and stated that she will clean them, change their brief and that one CNA (Certified Nursing Assistant) will be with her. Staff M stated that she will get resident out of bed by herself, she will feed them, if they need to be fed. Staff M stated that she was working 16 hours today because the facility asked her if she could do 16 hours and she was available. Staff M was asked if she had taken the CNA test and stated she was scheduled to take it in December 2022. Staff M stated that she worked at a local skilled nursing home as a PCA prior to come to the facility. On 11/30/22 at 12:53 PM, an interview was conducted with the facility's Regional Human Resources Manager (RHRM). The RHRM stated she is not sure if any of the PCA were scheduled to do the CNA test. A side-by-side review of Staff M, PCA personnel file was conducted with the RHRM. The RHRM stated that the PCAs do certain things and added that an HHA (Home Health Aide) will be similar as PCA. The review revealed Staff M was hired as a PCA on 09/13/22. Staff M employment application dated 09/07/22 under employment history documented former employer a local skilled nursing facility in Hialeah, position title-PCA. Review of Staff M job description signed on 09/13/22 documented under qualifications training must consist of five (5) hours of classroom teaching and three (3) hours of supervised simulation in which the PCA candidate exhibits competency in all areas of training . During the review, the RHRM was asked to submit Staff M PCA training record and competencies. The RHRM submitted 29 sheets titled competency check-off. Review of the sheets revealed that the competencies sheets were (blank) not checked off. The sheets did not indicate if Staff M passed or not the competency (no check off noted). All 29 pages were signed by Staff M but were incomplete. The RHRM stated that was all she had for Staff M and asked to check with the DON regarding the competencies. The RHRM was asked if she would hire someone who was a PCA prior to applying to the facility and the RHRM stated that she will not. The RHRM was apprised that Staff M application documented that she worked as a PCA at her previous employment. The RHRM was apprised that during an interview on 11/29/22, Staff M confirmed that she worked at a skilled nursing facility as a PCA prior to coming to this facility. 2) Review of the facility's Daily Schedule for 11/28/22, 11/29/22, 11/30/22 and 12/01/22 documented Staff N, Personal Care Assistant (PCA) scheduled to work 16 hours shift (3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shift). On 11/29/22 at 4:36 PM, an interview was conducted with Staff N, PCA who stated that she was a Home Health Aide (HHA) and was hired as a PCA. Staff N stated that she passed the practical test for to her to become a CNA. Staff N stated that she needs to make an appointment to take the CNA test. Staff N stated she went to a school in Miramar and did the PCA hands on practice there. Staff N was asked if the facility DON or ADON when over duties or watch her doing her duties and stated she did not. Staff N added that she helps the CNA reposition the resident, change the brief, and did do the resident care by herself. Staff N stated that fed residents by herself. Staff N stated she entered as a helper and added that she had not had a nurse do competencies with her. Staff N stated she did not have an assignment. Staff N stated she requested to work 16 hours because she need the money. Staff N confirmed she was scheduled to work 16 hours shift on Monday, Tuesday, Wednesday, and Thursday. Staff N stated she started to work as PCA at the facility on 10/2022 and was a PCA at a local skilled nursing home. On 11/30/22 at 1:03 PM, a side-by-side review of the Staff N, PCA's personnel file was conducted with the RHRM. The RHRM stated that Staff N was hired as a PCA on 10/12/22. Staff N employment application dated 10/14/22 under employment history documented former employer a local skilled nursing facility in Hialeah, position title-PCA, dates of employment 03/08/22. Review of Staff N job description signed on 10/12/22 documented under qualifications training must consist of five (5) hours of classroom teaching and three (3) hours of supervised simulation in which the PCA candidate exhibits competency in all areas of training . During the review, the RHRM was asked to submit Staff N's PCA training record and competencies. The RHRM submitted 29 sheets titled competency check-off. Review of the sheets revealed that the competencies sheets were (blank) not checked off. The sheets did not indicate if Staff N passed or not the competency (no check off noted). All 29 pages were signed by Staff N but were inaccurately completed. The RHRM was apprised that Staff N application documented that she worked as a PCA at her previous employment facility. The RHRM was apprised that during an interview on 11/29/22, Staff N confirmed that she worked at a skilled nursing facility as a PCA prior to come to the facility. 3) Review of the facility's Daily Schedule for 11/29/22 and 12/01/22 documented Staff O, PCA scheduled to work 16 hours shift (3:00 PM to 11:00 PM and 11:00 PM to 7:00 AM shift). On 11/29/22 at 4:44 PM, an interview was conducted with Staff O, PCA who stated she had been working in the facility as PCA since 11/04/22. Staff O stated that she did 75 hours of HHA (Home Health Aide) school and worked as PCA at a local facility for 7 months. Staff O stated that she needed to ask for an appointment to take the CNA test and added that she had not done the practice test. Staff O stated that she was going to school and had to stop due to surgery and had not continue to take the classes. Staff O stated that she got training on how to help the CNA, listening to the residents, feed the residents and changes their brief. On 11/30/22 at 1:15 PM, A side by side review of Staff O, PCA's personnel file was conducted with the RHRM. The review revealed Staff O was hired as a PCA on 10/18/22. Staff O employment application was dated 10/17/22. Review of Staff O's unsigned job description documented under qualifications training must consist of five (5) hours of classroom teaching and three (3) hours of supervised simulation in which the PCA candidate exhibits competency in all areas of training . During the review, the RHRM was asked why Staff O job application was not signed and stated that she had not get around to do it. The RHRM was asked to submit Staff O's PCA training record and competencies. The RHRM submitted 29 sheets titled competency check-off. Review of the sheets revealed that half of the competencies sheets were left (blank) not checked off. The sheets that had a check-off were not signed by the DON or designee. All 29 pages were signed by Staff O but were inaccurately completed. 4) Review of the facility's Daily Schedule for 11/28/22, 11/29/22, 11/30/22 and 12/01/22 documented Staff W, PCA scheduled to work 8 hours shift (3:00 PM to 11:00 PM shift). On 11/29/22 at 5:02 PM, an interview was conducted with Staff W, PCA. Staff W stated that he was hired in 06/2022. Staff W stated that he helps the CNA, watching and feeding the residents. Staff W stated that he received the PCA via watching videos and added that he did almost 8 hours on training. Staff W stated that a floor nurse watched him feeding the resident. Staff W stated that he had not taken the CNA test as of yet. Staff W stated he was scheduled to work 8-hour shift today, tomorrow and may come back Thursday (11/29/22 and 11/30/22). On 11/30/22 at 1:35 PM, A side by side review of Staff W, PCA's personnel file was conducted with the RHRM. The RHRM stated that Staff W was hired on 07/30/22. The RHRM was asked to submit his CNA certificate and stated that Staff W was off the schedule because of 120 days from training and had no taken the CNA test. Review of Staff W's job description signed on 07/30/22 documented under qualifications training must consist of five (5) hours of classroom teaching and three (3) hours of supervised simulation in which the PCA candidate exhibits competency in all areas of training . During the review, the RHRM was asked to submit Staff W PCA training record and competencies. The RHRM submitted 29 sheets titled competency check-off. Review of the sheets revealed that some competencies sheets were left (blank) not checked off. The sheets that had a check-off were not signed by the DON or designee. All 29 pages were signed by Staff W but were inaccurately completed. On 11/30/22 at 1:45 PM, an interview was conducted with the facility's ADON who stated that he had been working in the facility for 8 months and that the DON was doing the PCA's competencies. On 11/30/22 at 2:49 PM, an interview was conducted with the facility's DON. The DON stated that the staff in-services are been done by the ADON. The DON stated that she had currently PCA working in the building. The DON stated that after 120 days if the PCA did not become a CNA, they know they can't work in the facility. The DON stated that she had like a three day; 16 hours classroom, play a TV, what means to be a PCA, will go over the job description. The DON added that on the third, they gave 8 hours of supervised simulation that takes them on the floor, let them observe the CNA, then the PCA demonstrate how to do handwashing, how the make an occupied bed, how pass fresh water, how to pass a tray. The DON stated that the PCA had to demonstrate before they get in contact with the resident. The DON added once they do that, and passed, once they demonstrate competency, that it is when they get contact with the resident. The DON stated that all PCA are interested on becoming a CNA. A side-by-side review of the PCA inaccurately completed competencies was conducted with the DON. The DON stated that she will check with Human Resources (HR) regarding the incomplete competencies. The DON was apprised that all PCA competencies were provided by HR. The DON was asked who was arranging or tracking the PCA and that need to take the CNA test before the 120 days. The DON stated that the HR person communicates with the Staff Coordinator when the time was approaching. The DON stated the employee select the school to go to become a CNA and then they will bring the certificate. The DON added it is their responsibility to schedule the test. The DON stated the PCA can't take assignments, they can only go into each resident's room, pass fresh water, passing tray, assist CNA with care, they can make an occupied bed. The DON acknowledged that the competencies sheets were supposed to be checked off and were not.

Based on observation and record review, the facility failed to ensure a medication error rate of less than 5%, during medication administration of 25 medications opportunities with two errors that were made during one observation, which gave an error rate of 8%. The findings included: A medication administration observation was conducted on 11/30/22 at 10:55 AM with Staff A, Licensed Practical Nurse for Resident #34. Staff A stated Resident #34's vital signs had been obtained prior to the observation by a Certified Nursing Assistant. Staff A stated Resident #34 blood pressure was 128/68 and heart rate was 76. Staff A prepared the following medications: 1) Cranberry 450 milligram (mg) 1 tablet poured-for supplement 2) Ferrous Sulfate 325mg 1 tablet poured-for supplement 3) Folic Acid 400 microgram (mcg) 2 tablets poured-for supplement 4) Multiple Vitamin 1 tablet poured-for supplement 5) Mirtazapine 7.5mg 1 tablet poured-for depression The nurse and surveyor counted 6 tablets to be given to Resident #34. Resident #34 took all the tablets with water without difficulty. During a review conducted of Resident #34's physician orders and Medication Administration Record (MAR), it was noted by the surveyor that Resident #34 was due for Nebivolol 10mg (for high blood pressure) at 9:00 AM and not Mirtazapine, but rather that the Mirtazapine was due for Resident #34 at 9:00 PM. Further review of the MAR revealed Staff A signed off that she had given Resident #34 Nebivolol and not Mirtazapine. However, during the medication administration observation, the surveyor had confirmed via the medication card that the medication given by Staff A was Mirtazapine. This accounts for two medication errors-that one medication was given that was not due and that a wrong medication was signed off in Resident #34's chart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On [DATE] at approximately 2:30 PM a tour was conducted with the Housekeeping Director and the Admissions Coordinator. During this tour a stop was made in the Central Supply store room. In the store room, in a random bin, there was a bottle of multivitamins that had been hand labeled with a date on the top, [DATE]. Upon further inspection, the bottle had been opened with the inner seal removed. In the storage cabinet used for Over the Counter medications, a sign was also noted that indicated opened bottles should not to be placed back onto the shelves. Open medications no longer in use need to be returned to the pharmacy or disposed of properly. Based on observation, interview, and policy review, the facility failed to follow their policy of documenting the expiration date on 5 of 8 open eye drop vials, affecting Residents #43, #87, and #159; and failed to properly store and dispose of open medications in central supply. The findings included: Review of the policy Medication Storage in the Facility revised [DATE] documented, Procedures: . B. Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access. Expiration Dating (Beyond-use dating): C. Certain medications or package types, such as . ophthalmics, . once opened, require an expiration date shorter than the manufacturer's expiration date to insure [sig] medication purity and potency. c. Drugs dispensed in the manufacturer's original container will carry the manufacturer's expiration date. Once opened, these will be good to use until the manufacturer's expiration date is reached unless the medication is: . 2. an ophthalmic medication . D. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1) The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. The expiration date of the vial or container will be (30) days unless the manufacturer recommends another date or regulation/guidelines require different dating. 1) A medication storage observation was made on [DATE] at 12:37 PM, with Staff S, Registered Nurse (RN), for the second floor Unit 2 medication cart. The following was noted: a) Cosopt (a glaucoma medication) eye drops for Resident #87 with no documented expiration date. b) Dorzolamide (a glaucoma medication) eye drops for Resident #87 with no documented expiration date. c) Xalatan (a glaucoma medication) eye drops for Resident #159 with no documented expiration date. d) Timoptic (a glaucoma medication) eye drops for Resident #159 with no documented expiration date. e) Brimonidine (a glaucoma medication) eye drops for Resident #43 with no documented expiration date. All of these eye drops had dated open dates, but lacked expiration dates. During the observation, Staff S was asked if he had access to a medication expiration after opening list. The RN provided two documents that revealed the Cosopt eye drop was good until the manufacturer's expiration date or one year (as it was not preservative free), whichever was sooner; the Xalatan expired 42 days from opening; and the other three eye drops expired 28 days after opening. Staff S agreed there should have been documented expiration dates on each of the eye drop bottles.

Based on observation, record review and interview, it was determined that the approved menu was not followed potentially for 172 facility residents with physician ordered Therapeutic and Mechanically Altered diets. The menu was also not followed for 19 residents with Thickened Liquids that included Resident's #32, #51, and #64. The findings included: 1) During the review of the approved breakfast menu for 11/29/22 the following were noted to be served; (a) 8 ounces milk for Regular, Mechanical Soft, Pureed, and Renal Dialysis diets. (b) Bite Sized Blueberry Muffin for Chopped/Soft Soft Bite Sized diets. (c) #10 scoop Pureed Blubbery Muffin for Pureed, Mechanical Soft-Easy to Chew diets. (d) 6 ounces Pureed grits for Pureed diets. (e) 1 English Muffin for Renal Dialysis diets. During the observation of the breakfast meal tray-line in the Main Kitchen on 11/29/22 at 7:30 AM, the following were noted: (a) All Regular, Mechanical Soft, Chopped Pureed, and Renal diets were served 8 ounces of 2% milk. Interview with the Food Service Director (FSD) revealed that the dietary department had been out of whole milk for the last 3 days due to non-delivery. The FSD stated no attempt was made to purchase whole milk from an alternate source. Review of the diet census for 11/29/22 noted that the were currently 172 residents who were required to be served whole milk with current physician orders for Regular, Chopped, Mechanical Soft, Pureed, and Renal Dialysis diets. (b) Bite Sized Blueberry Muffins failed to be prepared and served to Chopped /Soft & Bite Sized diets. Regular toast was noted to be served. Interview with the FSD at the time of the observation noted to state that the cook was unaware that the approved menu included the Bite Sized Blubbery Muffin portion . Review of the facility diet census for 11/29/22 noted that there was currently 17 residents with physician ordered Chopped/Soft & Bite Sized diet. (c) Pureed Blubbery Muffin failed to prepared and served to Mechanical Soft and Pureed diets. Pureed bread was noted not be served. Interview with the FSD at the time of the observation noted that the cook was unaware that pureed Blubbery Muffin was included on the approved menu. Review of the diet census for 11/29/22 noted that there was currently 54 resident's with physician ordered Mechanical Soft (Easy To Chew) diets and 42 residents with physician ordered Pureed diets. (d) Pureed Grits were not prepared and served to Pureed diets. Regular Grits were noted to be served. Interview with the FSD at the time of the observation stated that the cook was unaware the the menu included Purred Grits. A review of the diet census for 11/29/22 noted that the was currently 42 resident with physician ordered Pureed diets. (e) English Muffin was not prepared and served to Renal Dialysis diets. Blubbery Muffin was noted to be served . Interview with the FSD at the time of the observation noted to state that the cook was unaware that the menu included English Muffin for Renal Dialysis Diets. A review of the diet census for 11/29/22 noted that there were currently 3 residents with physician order Renal diet. (f) Only a 4 ounce portion of Thickened Milk was noted to be served to resident with physician ordered Nectar and Honey Thick Consistency diets, Interview with the FSD at the time of the observation noted that staff were unaware that an 8 ounce portion of thickened milk was to be served. A review of the diet census for 11/29/22 noted that there was currently 14 residents with physician ordered Nectar Thick Liquids (included Resident's #51 and #64) and 5 resident with physician ordered Honey Thick Liquids (included Resident #32) .

4) While standing at the second floor Unit 2 nurse's station on 11/29/22 at 3:18 PM, the surveyor heard ice being scooped or being moved. Upon looking at the alcove beside the nurse's station, Resident #63 was observed standing over the open ice cooler. The resident was there for a few moments, more ice was heard moving about, when Staff S, Registered Nurse (RN), redirected the resident away form the cooler. During an interview at this time, when asked if the resident had obtained ice with his personal water cup, Staff S confirmed he had. An observation at this time revealed the ice chest was about a third full of both ice and water. The surveyor remained at the nurse's station to observe until 4:27 PM, and no staff changed out the ice from the now contaminated cooler. During an interview on 11/29/22 at 5:15 PM, while standing back near the nurse's station, Staff T, an evening shift Certified Nursing Assistant (CNA), explained that the day shift (7 AM to 3 PM) fills up the ice cooler, and then later during the evening shift, one of the CNAs would be assigned to get fresh ice before they leave at 11 PM. Staff T confirmed she had not refilled the ice cooler. During an interview on 11/29/22 at 5:17 PM, The second floor Unit Manager was made aware of the earlier observation, and agreed the ice cooler needed to be cleaned and new ice provided. Based on observation and interview, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety that include; maintenance of air-conditioning vents to prevent food contamination, holding of hot and cold foods at regulatory requirement, proper use of the 3-compartment sink, replacement of worn food production equipment, handling of silverware in sanitary manner, maintenance of refrigeration equipment, handling of clean ice to prevent contamination, and ensure sanitary conditions in food storage and serving areas. The findings included: 1) During the initial sanitation tour conducted in the main kitchen conducted on 11/28/22 at 9:00 AM and accompanied with the facility's Registered Dietitian, the following were noted: a) Three air-conditioning ceiling vents located near the walk-in refrigerator were noted to be soiled and full of condensation on the exterior of the vents. Further observation noted that the condensation was heavy and was dripping off of the vents on racks of resident's prepared food trays, food preparation surfaces, and staff walking under the vents. The surveyor informed the Dietitian that the condensation may potential cause food borne illness and need to be corrected following the tour. The Dietitian was also informed that the resident trays must be moved from under the vents and the food preparation surfaces not be used until the issue was corrected. (b) Observation of the 3-compartment sink noted that only the wash and sanitizing sinks were full. The rinse sink was noted to be empty. Staff were also noted to be utilizing the sinks to wash food preparation equipment. The surveyor informed the Dietitian that food preparation equipment should be re-washed utilizing all 3 sinks. (c) Observation of Walk-in refrigerator #1 noted that the internal thermometer read at 50 degrees F. The surveyor requested the daily temperature log however they could not be located. The Dietitian was informed by the surveyor that the unit must always maintain a regulatory minimum temperature of 41 degrees F or below. Also informed that the contents of the refrigerator should be moved or discarded if the regulatory temperature is not obtained. (d) Three large commercial cooking skillets/pans were noted to have a thick build-up of carbon. Further observation noted that the interior [] nonstick surface has be scrapped away form continued use. The surveyor informed the Dietitian that the pans need to be replaced. (e) During the tour it was noted that 4 carts full of soiled resident dishware were located with the main food preparation area and were uncovered. The surveyor informed the Dietitian that the soiled trays and dishware need to be always covered. (f) During the tour it was noted that Staff C (dietary aide) was rolling silverware in paper napkins. Further observation noted the following: - The silverware was scattered in an open dish rack and Staff C was handling the silverware by the eating stem. - Staff C noted to be dipping her fingers in a cup of soiled water to be able to grasp a paper napkin prior to rolling the contaminated silverware. It was discussed with the Dietitian that Staff C was contaminating the resident silverware on multiple occasions. The survey requested the Dietitian to review proper policy for washing and handling clean silverware. (g) The 2 commercial ovens noted to have a thick carbon build-up and rust build-up on the inside exterior. The surveyor informed the Dietitian that the ovens require to be cleaned and sanitized before continued use. (h) Observation of walk-in refrigerator #2 noted that the 8 eight food storage racks were heavily soiled and that the plastic exterior fining was falling off. The surveyor informed the Dietitian that the rack required to be replaced. (i) Observation of the cooks preparation table noted a pitcher of a liquid that was uncovered and not dated. Further investigation noted the cook (Staff D) to state that the uncovered liquid was vegetable oil. The surveyor informed the Dietitian that all food must be properly covered and dated. The surveyor requested that the oil be discarded. (j) During the observation of reach-in refrigerator #1 it was noted that the 8 food storage shelves located within the unit were soiled and rust laden. The surveyor requested that the food storage be replaced. (k) The commercial bench mounted can open was noted to be heavy rusted and the opener blade was mold laden. The surveyor informed the Dietitian that the opener not be used unit properly cleaned and sanitized. 2) During the observation of the lunch meal of 11/28/22 at 12 PM in the second-floor dining room it was noted that there was a small food serving pantry. Further observation noted that the pantry included a food storage refrigerator, micro-wave oven, food storage cabinets, and food preparation counter and sink. Continued observation noted that stacks of uncovered soiled dishes, soiled thermal food lids, and soiled food trays were stored on the food counters. The surveyor informed the Dietitian that the food serving pantry was to be maintained clean at all times and that soiled resident dishware, lids, and trays are not to be stored in the room at any time. 3) During the second follow-up visit to the main kitchen on 11/29/22 at 7:30 AM accompanied with the Administrator, the following were noted; (l) The administrator informed the surveyor that the condensation dripping on the 3 ceiling air-conditioning vents had been resolved by an air conditioning contractor on 11/28/22. During the tour of the main kitchen it was noted that all or above. The vents were still full of condensation and dripping the contaminated condensation onto resident food trays, and food preparation surfaces. (m) During the observation of the breakfast tray line prepared foods located on the steam tables had the temperatures taken with the facility's calibrated thermometer. The findings noted that foods were not being held at regulatory requirements that included cold foods at 41 degrees or less and hot foods at 135 degrees F (Fahrenheit) temperatures were documented as follows: - Boiled Eggs = 130 degrees F - Corned Beef Hash = 131 degrees F - Individual Milk Portions = 47 degrees F - Individual Yogurt Portions = 45 degrees F