**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and record review the facility failed to ensure one resident (#27) out of 3 residents observed for insulin medication administration received care in accordance with professional standards of practice related to the time of administration of short acting insulin, in relation to the time the resident received her lunch meal. Findings included: Review of Resident #27's admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital with diagnoses to include type 2 diabetes mellitus with ketoacidosis without coma, morbid (severe) obesity due to excess calories, and lack of coordination. Review of Resident #27's physician's order revealed an order, with a start date of 2/23/23 and no end date, for Novolog Injection Solution 100unit/ml [Milliliters] inject per sliding scale: If 0-149= 0 Less than 60 call MD [Medical Doctor]; 150-200=2 [units] 201-250= 4; 251-300= 6; 301-350= 8; 351-400= 10 Greater that [sic] 401 given [sic] 12 units and call MD, subcutaneously before meals and at bedtime related to type 2 diabetes mellitus with ketoacidosis without coma. Review of Resident #27's December 2023 Medication Administration Record (MAR) revealed the Novolog sliding scale order with a start date of 2/23/23 was timed to be administered at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9:00 p.m. A medication administration observation was conducted on 12/13/23 at 11:07 a.m. with Staff C, Licensed Practical Nurse (LPN). Resident #27's blood sugar was 203. Staff C, LPN drew up 4 units of Novolog and she confirmed there was 4 units in the syringe. She administered the insulin using aseptic technique, discarded her supplies in the appropriate receptacles, washed her hands and signed off the insulin in the medical record. Review of the facility's MEALTIMES & SCHEDULE, undated, revealed the [NAME] Hall were scheduled to receive their breakfast at 8:00 a.m. The lunch meal is scheduled for 12:30 p.m. and the dinner meal is scheduled for 6:00 p.m. An interview was conducted with Resident #27 on 12/13/23 at 12:42 p.m. The resident said she feels the same as she did before she received insulin. An observation was conducted on 12/13/23 at 12:46 p.m. Resident #27 received her lunch tray. An interview was conducted on 12/13/23 at 12:27 p.m. with the Director of Nursing (DON) and he confirmed insulin is ordered to be given approximately one hour before meals are delivered. An interview was conducted with the facility's Medical Director on 12/13/23 at 4:49 p.m. He said, .The way short acting insulin works is it starts to work within 20-30 minutes and peaks within an hour, hour and a half. If the order reads before meals, I would want the resident to receive their meals within 30 minutes of receiving the medication. He said receiving insulin at 11:07 a.m. and her meal tray coming at 12:46 p.m., that's a little late, should be within a half hour. Review of the facility's policy titled, Medication Administration General Guidelines, dated 09/18, revealed the following: .Medication Administration: .14. Medications are administered within 60 minutes of scheduled time, except before and after meal orders, which are administered based on mealtimes .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure one resident (#35) out of four residents reviewed had a smoking evaluation completed to ensure safety during smoking. Findings included: During an interview on 12/11/23 at 7:44 a.m. Resident #35 stated the facility was supposed to let residents smoke at certain times but they make us wait and are about 15 to 20 late. Resident #35 stated, then once we get out there to smoke, we are then rushed to get done to come back in. An observation on 12/11/23 at 9:00 a.m. showed residents were exiting the door to the smoking designated area to smoke. Review of the facility's scheduled smoke times showed: 7:00 a.m. 9:00 a.m. 11:00 a.m. 1:30 p.m. 3:00 p.m. 5:00 p.m. 7:00 p.m. 9:00 p.m. An observation on 12/11/23 at 11:05 a.m. showed Resident #35 was outside smoking on the designated smoking area with supervision. Review of the admission Record showed Resident #35 was admitted to the facility with diagnoses including but not limited to chronic obstructive pulmonary disease, lack of coordination, muscle weakness (generalized) and other abnormalities gait and mobility. Review of the care plan showed Resident #35 was a current smoker with a goal resident will remain safe while smoking. The interventions included: inform of designated smoking areas and times, smoking materials are kept by facility staff and supervised smoking as indication. Review of the Resident, Family, Visitor Smoking Safety Education and Acknowledgement Form, showed Resident #35 signed and dated the form, acknowledging the smoking rules and protocols, on 10/31/23. Review of Resident #35's admission Minimal Data Set (MDS), dated [DATE], showed Resident had a brief interview for mental status (BIMS) of 15 (cognitively intact) and was marked as a current smoker in section A Identification Information. Review of Resident #35's medical record showed no smoking evaluation was completed or available. During an interview on 12/12/23 at 3:10 p.m. the Director of Nursing (DON) stated we do a smoking evaluation on residents the first time they go out to smoke. The DON stated we go out with the resident the first time to smoke to assess them for safety and complete the smoking evaluation. During an interview on 12/12/23 at 3:35 p.m. the DON stated, I do not see a smoking evaluation in the chart. The DON stated he would have expected a smoking evaluation to have been completed the first time Resident #35 went out to smoke. Review of the facility's policy titled, Smoking/Tobacco Use, dated October 2021, showed, Initiate and complete and admission Data Collection and Initial Plan of Care or a quarterly or prn [as needed] Data Collection form if the resident requests smoking privileges.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide intravenous (IV) care according to standards of practice for one resident (#40) out of one resident reviewed. Findings included: Review of Resident #40's admission Record revealed he was admitted to the facility on [DATE] from an acute care hospital with diagnoses not limited to Alzheimer's Disease, dementia, and pressure ulcer of unspecified site, unstageable. Review of Resident #40's physician orders revealed an order, with a start date of 12/11/23 and an end date of 12/16/23, for Cefepime intravenous solution 1gram/50ml [milliliters] .use 1 gram intravenously every 8 hours for wound infection for 5 days obtain midline for IV infusion. An intravenous medication administration observation with Staff A, Licensed Practical Nurse (LPN), Unit Manager (UM), was conducted on 12/13/23 at 2:26 p.m. for Resident #40. Staff A, LPN/UM primed the IV tubing with cefepime 1 gram for 5-6 seconds, removed the IV tubing cap, cleaned the IV cap, connected the IV tubing to the resident's midline and with her right gloved hand she pushed the button on the IV pump to begin running the medication and confirmed the IV pump was running. The surveyor asked Staff A, LPN/UM to stop the pump as she did not fully prime the tubing. An observation was then conducted with Staff A, LPN/UM and confirmed the IV filter, which was connected to the IV tubing, was not primed and the majority of the IV tubing below the IV pump was not primed. Staff A, LPN/UM, confirmed the tubing was not fully primed and began to prime the tubing holding the uncapped tip of the IV tubing with her right gloved hand until there was a drop coming out of the IV tubing tip. Staff A, LPN/UM clamped the IV tubing, and connected the IV tubing to the resident's midline IV. Staff A, LPN/UM said she should have cleaned the midline IV and the IV tubing before connecting the tubing to the midline IV since she touched the tip with her gloved hands. She cleaned the IV tubing tip with an alcohol wipe and the resident's midline IV cap with the same alcohol wipe and connected the tubing to the midline IV and ran the pump. She did not check the midline insertion site during the medication administration observation. Staff A, LPN/UM went to the computer and charted the cefepime medication administration and said she charted U meaning the insertion site was unremarkable. She went back into the resident's room, lifted up his shirt sleeve. Resident #40 was observed to have kerlex gauze wrapped completely around the resident's IV site and dressing. Staff A, LPN/UM said, I just put that dressing on because I don't want him to mess with his IV. She said she put the gauze dressing on 12/9/23 and confirmed there was no date on the gauze dressing. Staff A, LPN/UM lifted up the gauze dressing and there was a piece of gauze under the clear IV dressings covering the IV insertion site completely. (Photographic Evidence Obtained) What does priming the IV tubing mean? It means you will be allowing the solution in the bag to flow through the tubing to remove any air in the line. It is very important to remove any air or bubbles from the tubing before infusion so an air embolism can be avoided, According to an online learning resource https://www.merlot.org/merlot/viewMaterial.htm?id=773403234. On 12/13/23 at 2:45 p.m. the Director of Nursing (DON) observed Resident #40's IV dressing and confirmed the IV insertion site should be visible and should not have a piece of gauze over the insertion site. He also confirmed IV tubing should be fully primed before hooking the resident up to an IV. The DON was notified when the IV tubing was primed, staff held the tip of the IV tubing with her gloved hands and then connected the IV tubing to the IV without cleaning it first. Review of Resident #40's Medication Administration Record (MAR) revealed an order dated 12/9/23 for IV: Document IV site appearance every shift: U=unremarkable . Review of the documentation dated 12/13/23 for day shift revealed Staff A, LPN/UM documented U. Review of the facility's policy Administration of IV Fluids and Medications ., dated 08/16, revealed the following: Purpose To correctly and aseptically set up the primary IV bag and tubing. .Procedure: .5. Open clamp. Prime tubing. Close clamp. .7. If using pump, thread tubing into pump according to directions. Program pump. 8. Scrub needless connector on resident's catheter with antiseptic wipe. 9. Attach IV tubing to needless connector. 10. Open clamps on IV tubing and begin infusion. .13. Document according to facility procedure.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure respiratory care and services was consistent with professional standards of practice for one resident (#4) out of 33 sampled residents. Findings included: Review of Resident #4's admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital. Her medical diagnoses included chronic obstructive pulmonary disease, morbid obesity, need for assistance with personal care, nasal congestion, and obstructive sleep apnea. Review of Resident #4's physician orders revealed an order with a start date of 12/2/23 and no end date for Oxygen at 2LPM [liters per minute] Via NC [nasal cannula] PRN [as needed] for shortness of breath. An observation was conducted on 12/11/23 at 9:17a.m. of Resident #4 receiving 2.5LPM of oxygen via a nasal cannula. (Photographic Evidence Obtained) An observation and interview were conducted on 12/12/23 at 10:48 a.m. as Resident #4 was observed to be in bed with her nasal cannula on. The oxygen concentrator was observed to be between the resident's head of her bed and the wall. The oxygen concentrator dial flow was observed to be set to 2.5LPM. The resident said she wears her oxygen all the time because she has COPD (chronic obstructive pulmonary disease). She said her oxygen is supposed to be set on one to two LPM. She said the nurses look at the oxygen every day and they change the tubing. The nasal cannula was labeled 12/11/23. (Photographic Evidence Obtained) An observation was conducted on 12/13/23 at 9:10 a.m. of Resident #4 in bed, her head of the bed elevated with her nasal cannula on and connected to the oxygen concentrator. The oxygen concentrator was observed to be between the head of the bed and the wall with the oxygen dial flow display facing the wall. The resident's oxygen was set to 3LPM. (Photographic Evidence Obtained) An interview was conducted on 12/13/23 at 9:11 a.m. with Staff C, Licensed Practical Nurse (LPN). She said the resident is supposed to be on 2LPM oxygen. Staff C, LPN went into Resident #4's room to confirm her oxygen setting. Staff C, LPN said, It's hard. We have to tip it back to see what she is set on and I can't turn it, it's hard. Staff C, LPN was unable to view Resident #4's oxygen setting. Staff C, LPN walked out of the resident's room and reviewed Resident #4's oxygen orders and said the resident is supposed to be on 2 liters oxygen as needed. She said the order is as needed because the resident takes her oxygen on and off. An observation was conducted on 12/13/23 at 10:05 a.m. of Resident #4 in bed with her nasal cannula on and connected to her oxygen concentrator. The concentrator was observed to be in-between the head of the bed and the wall with the oxygen dial flow display facing the wall and not visible. The resident said, The nurse just came in and tried to move the oxygen, but she couldn't. I told her she was going to have to get maintenance to move the bed to get it out. (Photographic Evidence Obtained) Review of Resident #4's December 2023 Treatment Administration Order (TAR) revealed no documentation the resident was administered 2LPM of oxygen via nasal cannula as needed for shortness of breath, including no documentation oxygen was administered on 12/11/23, 12/12/23 and 12/13/23. Review of Resident #4's care plan, initiated on 11/9/21, revealed, The resident has Oxygen Therapy r/t [related to] Ineffective gas exchange. The goal included, Will experience minimal to no shortness of breath. Interventions included, Administer oxygen as ordered. (Refer to current POS/MAR [physician's order sheet/medication administration record] for current order). An interview was conducted with the Director of Nursing (DON) on 12/13/23 at 11:05 a.m. He observed Resident #4's oxygen concentrator between her headboard and the wall. The DON said, That should not be there. Review of the facility's policy titled, Oxygen Therapy, dated November 2023, revealed the following: Policy Oxygen is provided to residents based on physician's orders to supplement oxygen as needed per disease proceed .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. The bathroom shared between rooms [ROOM NUMBERS] was observed on 12/11/23 at 10:34 a.m. with a hole in the wall next to the toilet bowl. There are approximately 4 ½ tiles missing from the wall. A yellow and brown fuzzy substance inside of the wall was exposed. The baseboard to the bathroom was protruding away from the wall. An additional observation revealed the transition from the bathroom into room [ROOM NUMBER] had a space where the tile was coming apart from the transition and cement slab. (Photographic Evidence Obtained) The bathroom shared between rooms [ROOM NUMBERS] was observed on 12/11/23 at 10:45 a.m. with the cove base (baseboard) protruding from the wall. At the toilet base, that meets the floor had a dark brown substance surrounding the base. The transition from the bathroom floor into the shower had a gap between the floor and tile. In this gap was black bio growth and dirt. The doorframe of the bathroom had visible wood showing, which had cracks in it. Small pieces of wood could be seen. (Photographic Evidence Obtained) An interview was conducted with the Housekeeping and Laundry Supervisor (HLS) on 12/13/23 at 9:58 a.m. The HLS confirmed the bathroom between rooms [ROOM NUMBERS] was missing tile, and the cove base was protruding from the wall. The bathroom between rooms [ROOM NUMBERS] had protruding cove base, the toilet base had a dark brown substance, the gap between the shower and bathroom floor, and the door frame having splintered wood. The HLS stated the housekeepers have been letting maintenance know about both of these concerns for a while now. During an interview on 12/13/23 at 3:05 p.m. the Maintenance Director (MD) confirmed the findings above and said, I know. The MD stated he had an audit of the environment and has been in contact with a vendor. No audit or vendor contact had been given prior to the exit of the survey on 12/14/23. Review of the policy and procedure titled, Physical Environment, with an effective date of January 1, 2020 showed: Policy - A safe, clean, comfortable, and home-life environment is provided for each resident/patient, . Based on observations and interviews the facility failed to provide a clean and home-like environment for three resident shared bathrooms (Rooms 25/27, 12/13, and 14/15) out of 17 bathrooms sampled for environmental services. Findings included: 1. During an interview on 12/11/23 at 8:45 a.m. the resident in room [ROOM NUMBER] stated he had cleaned himself up today, so he washed his shorts out and hung them to dry in bathroom. An observation on 12/11/23 at 8:45 a.m. revealed a strong odor of feces. A pair of shorts soiled with a wet brown stain hung on the handrail in the shower of the bathroom shared between rooms [ROOM NUMBERS]. An additional observation showed a brown substance was smeared on the shower wall. (Photographic Evidence Obtained) During an interview on 12/11/23 at 9:00 a.m. Staff A, Licensed Practical Nurse (LPN)/Unit Manager (UM) stated those shorts should not be hanging there. Staff A, LPN/UM was observed holding her nose and stated, that is a strong smell. An observation on 12/12/23 at 1:45 p.m. of room [ROOM NUMBER] showed the smeared brown substance on the shower wall remained. (Photographic evidence obtained.) During an interview on 12/12/23 at 2:55 p.m. Staff D, Regional Nurse Consultant (RNC) stated the brown substance looked like feces and confirmed it was dried on the shower wall. Staff D, RNC stated she would have expected the feces to have been cleaned off the shower wall immediately upon identification. During an interview on 12/12/23 at 3:00 p.m. the Director of Nursing (DON) stated the feces should have been cleaned up yesterday when the shorts were removed from the bathroom. The DON stated the feces should not have remained there for a second day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. Review of the admission Record showed Resident #19's original admission on [DATE] and the last readmission was on 1/03/2023. Resident #19 had the following diagnoses: bipolar, traumatic brain injury, unspecified symptoms and signs involving cognitive function and awareness, major depressive disorder, anxiety, schizophrenia, and numerous other co-morbidities. Review of the medical record showed Resident #19 had a Level II PASARR completed prior to a readmission on [DATE]. The recommendations of the Level II PASARR were: resident should have psychiatric medical management with a prompt referral to psychiatry upon admission; supportive counseling: patient should be encouraged to participate in activities appropriate for her level of functioning; care staff should monitor for depressive symptoms as well as symptoms of psychosis; if a significant change in her mental status occurs it is recommended that an additional Level II review be conducted; Nursing Home placement is recommended. Resident #19 had a significant change of condition MDS completed on 2/08/2022 and received a new diagnosis of unspecified dementia with other behavioral disturbances on 10/01/2022. Resident #19 did not have a new PASARR Level II completed as recommended upon a change of condition. 9. Review of the admission Record showed Resident #40 was initially admitted to the facility on [DATE] with diagnoses to include anxiety disorder, major depressive disorder, recurrent, unspecified psychosis not due to a substance or known physiological condition, and unspecified dementia, unspecified severity, with other behavioral disturbances. Resident #40 was readmitted on [DATE] with the above diagnoses, and a new diagnosis of Alzheimer's Disease. Review of the Level I PASARR, dated 09/19/2022, showed Resident #40 had depressive disorder and a history of dementia, no other diagnoses were listed. The form stated no in the questions relating to a secondary diagnosis of dementia. There was no Level II PASARR available for review. 10. Review of the admission Record showed Resident #42 was initially admitted to the facility on [DATE] with the following diagnoses to include anxiety, intracerebral hemorrhage and bipolar II disorder. Resident #42 was readmitted on [DATE] with the above diagnoses and a new diagnosis of major depressive disorder, recurrent. Review of the Level I PASARR, dated 3/09/2023, did not show any diagnoses marked. There was no Level II PASARR available for review. During an interview on 12/14/23 at 12:05 p.m. the Director of Nursing (DON) stated, I make sure all PASARRs are accurate. The DON stated, PASARRs are reviewed on admission, when a resident was changed on medication, or when a resident gets a new diagnosis. The DON stated, I ensure they are accurate and complete. The DON stated, If a Level II is needed we will contact [oversight company] and if they qualify for a Level II those recommendations should be care planned and there would be coordination of care. The DON stated, We will review all new diagnoses on admission and during behavior meetings that occur weekly. Review of the facility's Policy and Procedure titled PASARR Requirements Level I and Level II - Florida, effective February 2021, from the Social Service Manual revealed: pre admission screening for mental illness and intellectual disabilities is required to be completed prior to admission to a nursing home. The screening is reviewed by admissions to ensure appropriate placement in the least restrictive environment and to identify any specialized services the applicant may need. Screening applies to all new admissions into a Medicaid certified nursing facility regardless of pay or source A resident review must be completed when there has been a significant change in a resident mental or physical condition resident review . PASARR Level I, Procedure . 2. Social services or registered nurse will review to determine if a serious mental illness (SMI) and intellectual disability (ID) or both exist while reviewing the PASARR form. The existence of either, or both, condition triggers the requirement for level II review and will be provided to the appropriate state agency by the social services director upon admission. The social services director/nursing administration will review for completion and accuracy during the clinical meeting process . PASARR Level II . 3. Level 2 PASARR must be completed if the below are listed but not limited to: * is there an indication the resident has or may have had a disorder resulting in functional limitations in major life activities that would otherwise be appropriate for the individuals developmental stage * the resident has a primary or secondary diagnosis of dementia or related neurocognitive disorder, and a suspicion, or diagnosis of, SMI, ID, or both and *are currently exhibiting interpersonal issues, *difficulty maintaining concentration, persistence and pace, *difficulty with adaptation to change *an indication that the resident has received treatment for mental illness with an indication that they have experienced at least one of the following: psychiatric treatment more intensive than outpatient care (partial hospitalization or inpatient hospitalization) *experienced an episode of significant disruption to the normal living situation, for which supportive services were required to maintain functioning at home, or in a residential treatment environment, or which resulted in intervention by housing or law enforcement official . 6. Review of the admission Record showed Resident #7 was initially admitted to the facility on [DATE] with diagnoses to include anxiety disorder, major depressive disorder, recurrent, mood disorder due to known physiological condition with mixed features and unspecified dementia, unspecified severity, with other behavioral disturbances. Review of Resident #7's care plan showed, Cognition: [Resident #7] has impaired cognition function/dementia or impaired thought process related to short term memory loss. The Goal showed, [Resident #7] will be able to communicate basic needs on a daily basis through the review. The Interventions included: Explain care before providing it, Ask yes/no questions in order to determine the resident's needs, Administer medication as ordered. A second focus showed, Psychotropic Medication: [Resident #7] uses antidepressant to manage: Depressive Disorder. The Goal showed, [Resident #7] will be at the lowest dose required to reduce symptoms while minimizing adverse effects to ensure maximum function ability both mentally and physically through the next review. The Interventions included: Administer medications as ordered, Psychiatric services per order, Consult with pharmacy and MD to consider dosage reduction, observe/document for potential side effects for Anti-Depressants. Review of the Annual Minimum Data Set (MDS), dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 11 (moderate cognitive impairment). Section I Active Diagnoses showed, Non Alzheimer's Dementia, Anxiety Disorder, Depression and Bipolar Disorder. Review of the Level I PASARR, dated 07/13/23, showed Resident #7 had anxiety disorder. The diagnoses bipolar disorder, depressive disorder and a secondary diagnosis of dementia were not marked. Review of the medical record revealed the resident was not assessed for a PASARR Level II. 7. Review of the admission Record showed Resident #44 was initially admitted to the facility on [DATE] with diagnoses to include anxiety disorder, major depressive disorder, recurrent, unspecified psychosis not due to a substance to known physiological condition and unspecified dementia, unspecified severity, with anxiety. Review of Resident #44's care plan showed, Cognition: The resident has impaired cognitive function/dementia or impaired through process related to Moderately impaired [brief interview for mental status] BIMS score of 8-12, Dementia. The goal showed, The resident will be able to communicate basic needs on a daily basis through the next review. The Interventions included: Explain care before providing, provide orientation and validation, administer medications as ordered, anticipate and meet needs per physical/non-verbal indications and use brief, simple consistent words, cues and statements. A second focus showed, Psychotropic Medication: [Resident #44] uses psychotropic mediation related to antidepressant to manage depression and Antianxiety to manager anxiety. The Goal showed, will have minimal side effects. The Interventions included: Psychotropic side effects monitoring, administer medications as ordered, psychological services per physician order and as needed, psychiatric services per physician order and as needed and psychotic medications will be reviewed at least quarterly. Review of the admission MDS, dated [DATE], showed a BIMS score of 12 (moderate cognitive impairment). Section I Active Diagnoses showed, Non Alzheimer's Dementia, Anxiety Disorder, Depression and Psychotic Disorder. Review of the Level I PASARR, dated 07/16/23, showed Resident #44 did not have Anxiety Disorder, Depressive Disorder, Psychotic Disorder or a secondary diagnosis of Dementia marked. Review of the medical record revealed the resident was not assessed for a PASARR Level II. Based on record review and staff interviews, the facility failed to complete the Preadmission Screening and Resident Review (PASARR) Level II upon a new qualifying mental health diagnosis for 10 residents (4, 7, 15, 19, 22, 28, 31, 40, 42, 44) of 33 sampled residents. Findings included: 1. Review of Resident #4's admission Record revealed she was initially admitted on [DATE] and re-admitted on [DATE] with diagnoses of generalized anxiety disorder, major depressive disorder, and psychosis. Review of Resident #4's PASARR, dated 8/7/23, revealed qualifying mental health diagnoses of anxiety disorder and depressive disorder, and no PASARR Level II was required. Review of Resident #4's admission Minimum Data Set (MDS), dated [DATE], Section I Active Diagnoses, revealed a diagnosis of anxiety disorder. Review of the Annual MDS, dated [DATE], and a Quarterly MDS, dated [DATE], Section I Active Diagnoses, revealed diagnoses of anxiety disorder, depression, and psychotic disorder. Review of the medical record revealed the resident was not assessed for a PASARR Level II. 2. Review of Resident #15's admission Record revealed she was admitted on [DATE] with diagnoses of psychosis, dementia and major depressive disorder. Review of Resident #15's PASARR, dated 7/29/23, revealed a qualifying mental health diagnosis of depressive disorder, and no PASARR Level II was required. Review of Resident #15's Medicare 5-day MDS, dated [DATE], Quarterly MDS, dated [DATE], and 7/21/23, Section I Active Diagnoses, revealed diagnoses of depression and psychotic disorder. Review of the medical record revealed the resident was not assessed for a PASARR Level II. 3. Review of Resident #22's admission Record revealed he was admitted on [DATE] with diagnoses of anxiety disorder, major depressive disorder, psychosis, and dementia. Review of Resident #22's PASARR, dated 8/7/23, revealed qualifying mental health diagnoses of anxiety and depressive disorder, and that no PASARR Level II was required. Review of Resident #22's admission MDS, dated [DATE], Section I Active Diagnoses, revealed a diagnosis of anxiety. Review of the Quarterly MDS, dated [DATE], 6/5/23, 3/14/23, revealed diagnoses of anxiety disorder, depression, and psychotic disorder. Review of the medical record revealed the resident was not assessed for a PASARR Level II. 4. Review of Resident #28's admission Record revealed she was admitted on [DATE] with diagnoses of anxiety disorder, major depressive disorder, and delusional disorders. Review of Resident #28's PASARR, dated 7/13/23, revealed there were no qualifying mental health diagnoses, and no PASARR Level II was required. Review of Resident #28's admission MDS, dated [DATE], and the Quarterly MDS, dated [DATE], and 5/26/23, Section I Active Diagnoses, revealed diagnoses of depression and psychotic disorder. Review of the Quarterly MDS, dated [DATE], and an Annual MDS, dated [DATE], Section I Active Diagnoses, revealed diagnoses of anxiety disorder, depression, and psychotic disorder. Review of the medical record revealed the resident was not assessed for a PASARR Level II. 5. Review of Resident #31's admission Record revealed he was re-admitted on [DATE] with diagnoses of dementia, bipolar disorder, anxiety disorder, and major depressive disorder. Review of Resident #31's PASARR, dated 7/13/23, revealed a qualifying mental health diagnosis of depressive disorder, and no PASARR Level II was required. Review of Resident #31's Annual MDS, dated [DATE], and Quarterly MDS, dated [DATE], and 11/28/23, Section I Active Diagnoses, revealed diagnoses of anxiety, depression and bipolar disorder. Review of the medical record revealed the resident was not assessed for a PASARR Level II.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to maintain accurate medical records related to insulin documentation for two residents (#28 and #27) out of four residents reviewed for medication administration. Findings included: 1. Review of Resident #28's admission Record revealed she was admitted to the facility on [DATE] with a diagnosis of type two diabetes mellitus and diabetes mellitus due to underlying condition with hyperglycemia. Review of Resident #28's December 2023 Medication Administration Record (MAR) revealed a physician's order, with an order date of 9/11/23 and no end date, for insulin glargine subcutaneous solution. Inject 32 units subcutaneously at bedtime for antidiabetics. Review of Resident #28's December MAR revealed on 12/1/23, 12/2/23, 12/3/23, 12/5/23, 12/7/23, and 12/11/23 the medication was documented as NS. Review of Resident #28's November 2023 MAR revealed the same medication was documented as NS on 11/1/23, 11/3/23, 11/7/23, 11/8/23, 11/9/23, 11/10/23, 11/13/23, 11/15/23, 11/16/23, 11/17/23, 11/21/23, 11/22/23, 11/24/23, 11/27/23 and 11/28/23. Review of the MAR Chart Codes revealed NS=Side Effects Present: No. Review of Resident #28's December 2023 MAR revealed a physician's order with an order date of 12/6/22 with no end date for Novolin R Injection Solution 100 unit/ML (Insulin Regular (Human)) Inject as per sliding scale: if 70 - 130 = 0; [units] 131-180=4; 181-240=8; 241-300=10; 301-350=12; 351-400=16 >400 give 20 units and call MD (medical doctor), subcutaneously two times a day for DM. On 12/1/23 the resident's blood sugar (BS) was documented as 277 at 5:00 p.m. The administration documentation revealed NS. On 12/2/23 the BS was documented as 130 at 5:00 p.m. The administration documentation revealed NS. On 12/3/23 the BS was documented as 130 at 5:00 p.m. The administration documentation revealed NS. On 12/5/23 the BS was documented as 138 at 9:00 a.m. The administration documentation revealed NS. On 12/7/23 the BS was documented as 130 at 9:00 a.m. The administration documentation revealed NS. On 12/7/23 the BS was documented as 138 at 5:00 p.m. The administration documentation revealed NS. On 12/11/23 the BS was documented as 188 at 9:00 a.m. The administration documentation revealed NS. On 12/11/23 the BS was documented as 143 at 5:00 p.m. The administration documentation revealed NS. Review of Resident #28's November 2023 MAR revealed her sliding scale insulin medication was documented as NS for the 5:00 p.m. doses 16 out of 30 opportunities. Review of Resident #28's diabetes mellitus care plan, initiated on 7/2/23, revealed, The resident has Diabetes Mellitus as evidence by: Hypertension, Type 2 diabetes. The goal revealed, Minimize effects of Hypoglycemia and Hyperglycemia. Interventions included, Routine insulin as ordered (refer to order for current order). Sliding scale coverage as ordered (Refer to Orders for current order) . An interview was conducted with the Director of Nursing (DON) on 12/12/23 at 6:10 p.m. He said, there is opportunity for education regarding the documentation of insulin. The DON stated one of the staff members that documented NS, I had him show me what he does, and he has been administering the medication but he's not clicking the add location button for the location where the insulin was administered. There is a drop-down box (on the electronic medical record) and he records it, but, because he doesn't click the add location button the system doesn't think he administered the medication, so it brings him to the code screen, and he chooses the code of no side effects therefore it was recording NS. The staff would never know it was a problem because they don't look at the MARs after everything is documented. 2. Review of Resident #27's admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital with diagnoses included but not limited to, type 2 diabetes mellitus with ketoacidosis without coma, morbid (severe) obesity due to excess calories, and lack of coordination. Review of Resident #27's physician's order revealed an order with a start date of 2/23/23 and no end date for Novolog Injection Solution 100unit/ml [Milliliters] inject per sliding scale: If 0-149= 0 Less than 60 call MD [Medical Doctor]; 150-200=2 [units] 201-250= 4; 251-300= 6; 301-350= 8; 351-400= 10 Greater that [sic] 401 given [sic] 12 units and call MD, subconsciously before meals and at bedtime related to type 2 diabetes mellitus with ketoacidosis without coma. Review of Resident #27's December 2023 MAR revealed the Novolog sliding scale order with a start date of 2/23/23 was timed to be administered at 6:30 a.m., 11:30 a.m., 4:30 p.m., and 9:00 p.m. A medication administration observation was conducted on 12/13/23 at 11:07 a.m. with Staff C, Licensed Practical Nurse (LPN). Resident #27's blood sugar was 203. Staff C,LPN drew up 4 units of Novolog and she confirmed there was 4 units in the syringe. She administered the insulin using aseptic technique, discarded her supplies in the appropriate receptacles, washed her hands and signed off the insulin in the medical record. Review of Resident #27's MAR was conducted on 12/13/23 at 11:14 a.m. and revealed an order for NovoLog injection solution. Inject 3 units subcutaneously before meals related to type 2 diabetes mellitus with ketoacidosis without coma. On 12/13/23 the medication was signed off as administered for the 11:00 a.m. dose by Staff C, LPN. Resident #27's NovoLog sliding scale order to be given before meals and at bedtime, with a start date of 2/23/23 and no end date, was documented as administered for the 11:30 dose for a blood sugar of 203. An interview was conducted with Resident #27 on 12/13/23 at 11:15 a.m. She said, I'm supposed to get 3 units on top of my sliding scale, but sometimes I don't get it just depending on what my blood sugar was. The nurses know my body better than I do. I didn't have diabetes before my coma. But I haven't gotten any more insulin since you were here. Review of Resident #27's Quarterly Minimum Data Set (MDS), Section C - Cognitive Patterns, dated 10/26/23, revealed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating Resident #27 is cognitively intact. An interview was conducted on 12/13/23 at 11:36 a.m. with Staff C, LPN. She said, I signed off her 3 units of insulin because I'm about to go do it right now. I just had to do some paperwork. I like to wait 30 minutes in between; even though it's the same medicine because I don't want to give her too much at one time. An interview was conducted on 12/13/23 at 12:42 p.m. with Resident #27. She said, the nurse came in and gave her the second insulin shot. The resident said she feels the same as she did before she received insulin. Review of the facility's policy titled, Medication Administration General Guidelines, dated 09/18, revealed the following: .Documentation: 1. The individual who administers the medication, dose, records the administration on the resident's MAR immediately following the medication being given .

On 12/13/2023 at 11:45 a.m. an ice chest on the [NAME] Hallway was observed to have brown and pink bio growth around the upper edge of the chest, the ice scoop was sitting in a tray with water and pink bio growth was observed in the corners. (Photographic Evidence Obtained) An interview was conducted with the Assistant Director of Nursing (ADON) on 12/13/2023 at 11:53 a.m. The ADON confirmed the ice chest had pink and brown bio growth around edges as well as in the ice scoop tray. The ADON stated, I thought they cleaned this yesterday with the ice machine, but I guess they did not. The ice chest and scoop should not be left like this. Review of the facility's policy titled, Cleaning and Sanitation, dated September 2021, showed, The facility promotes a clean and sanitary environment for its employees, residents and visitors. The entire Food and Nutrition Services team maintains clean and sanitary kitchen facilities and equipment. [sic] walls, floors, ceiling, equipment and utensils are clean, sanitized and in good working order. Based on observation and interviews the facility failed to ensure one of one ice machine for the facility and one ice chest on the [NAME] Hallway was clean and free from bio growth in the Ice Machine Room. Findings included: During an observation on 12/12/23 at 12:30 p.m. there was one ice machine in the facility located on the [NAME] Hall Ice Machine Room. The ice chute of the ice machine had a black and brown bio growth substance on the inside of the chute where the ice comes out. (Photographic Evidence Obtained) During an interview on 12/12/23 at 1:00 p.m. the Dietary Manager (DM) stated the ice machine located in the [NAME] Hall Ice Machine Room was the only ice machine for the entire facility. The DM stated the Maintenance Department was responsible for cleaning the ice machine. The DM was shown the black and brown bio growth substance and stated, How did that get there. During an interview on 12/12/23 at 1:17 p.m. Staff D, Regional Nurse Consultant (RNC) stated the facility did expect the ice machine to be cleaned and free from bio growth. During an interview on 12/12/23 at 1:20 p.m. the Director of Nursing (DON) stated the ice machine should be clean and not dirty like that. During an interview on 12/12/23 at 1:25 p.m. the Administrator stated, I will shut down the ice machine, so it does not get used, until it gets cleaned. During an interview on 12/14/23 at 11:38 a.m. the Maintenance Director (MD) stated there was a third-party company who comes into the facility to ensure the ice machine was well maintained and clean on the inside of the machine. The MD stated he was responsible for the cleaning of the outside of the ice machine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. A review of the admission Record revealed Resident # 24 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include dysphasia, cerebral infraction, atrial fibrillation, chronic respiratory failure, and type 2 diabetes mellitus. On 10/04/2021 at 10: 50 a.m. upon initial tour of facility, Resident #24 was observed laying in bed, no television or radio was observed on or playing in his room. During a follow up visit on 10/04/21 at 1:55 p.m., Resident #24 was observed lying in bed. Observations on 10/05/2021 at 2:00 p.m. and 10/06/21 at 12:18 p.m., did not reveal staffs' interaction with the resident or any form of stimulation (music/television) provided to Resident #24. A review of the most current quarterly Minimum Data Set (MDS) dated [DATE], Section C, Cognitive Patterns, documented a Brief Interview Mental Status (BIMS) 99 indicating that resident's cognitive function was severely impaired. Section D, Mood, D0100 documented 0 which indicated that resident was rarely/never understood. A reviewed of Resident #24's Care Plan, initiated on 06/04/2019, revealed a focus area for Activities: [Resident # 24] requires staff assistance with involvement of activities related to cognitive deficits, little interest in pleasure of doing things, prefers to stay in room. Requires physical assistance to and from activities. Interventions include: Encourage to participates in activities of choice, prefers/would benefit from large group, prefers/would benefit from small group, preferred activity times: Afternoon, referred activity times: Morning A reviewed of Resident #24's activity assessment dated [DATE], documented in section A2, preferred activity times: afternoon. Section B. Read: Resident would prefer or benefit from one to one, small groups, in room, and general activities program. Under the subheading Passive Activities, read: Watching TV (televisions), listening to music. On 10/06/21 at 3:23 p.m., an interview was conducted with Staff A, Certified Nursing Assistant (CNA). Staff A stated that she had been overseeing activities for the past six weeks. She stated that in addition for being temporary responsible for activities, she transported residents to doctor's appointment as needed. Staff A stated that Resident #24's CNAs usually got him out of bed in a [reclining] chair and transported him to the restorative room in the mornings. She stated that Resident #24 sat there and watched TV. She stated that, They usually never include the resident in a particular activity, or really do anything else with him. On 10/06/21 at 3:58 p.m., in an interview with Staff D, Certified Nursing Assistant, (CNA), she stated that Resident # 24 was taken to the TV room in a [reclining] chair in the mornings. She stated that there were only two [reclining] chairs available, and the chair that was usually utilized for Resident #24 was currently occupied by another resident. On 10/06/21 at 4:07 p.m., in an interview with the Nursing Home Administrator (NHA) with the Regional Nurse present, the Regional Nurse stated that she thought there were enough chairs in circulation for each resident. The NHA stated that he was not aware of the situation, no one had reported to him that there was a need for additional [reclining] chairs. He stated that he would put in an order/request for additional [reclining] chairs. A review of the policy entitled Activities Overview 1.1.1 effective October 2021 indicated the following: Policy: Activities Department employees will provide activities that include sensitivity and an understanding of each individual resident's needs and requirements including medical, emotional, spiritual, therapeutic, and recreational needs. The activity program will reflect individual needs and provide/promote the following: stimulation or solace physical, cognitive, and/or emotional health enhancement, to the extent practicable, of each resident's physical and mental status resident self-respect by providing activities that support self-expression, social and personal responsibility, and choice. The facility will sponsor activities that promote wellness in the 7 dimensions. This includes programs aimed at: Social wellness Emotional wellness Environmental wellness Spiritual wellness Physical wellness Life enrichment Intellectual wellness Programs will be designed to meet the resident at their level of functioning. Support activities-for residents who may be severely impaired or unable to tolerate the stimulation of a group Maintenance activities-schedule events that promote the highest level of physical, emotional, cognitive, psychosocial, and spiritual well-being. Empowerment activities-designed to provide self-expression, social and personal responsibility, and a sense of purpose in their daily lives. A qualified activities director who meets one of the following criteria will manage the activities department: 1-Must be a qualified therapeutic recreation specialist or an activities professional who is licensed, certified, or registered as required by State Regulation and is eligible for certification as a therapeutic recreation specialist or as an activity professional by a recognized accrediting body .OR 2-Two years' experience in a social or recreational program within the last five years, one of which was full-time in resident activities program in a health care setting .OR 3-Qualified occupational therapist or occupational therapy assistant .OR 4-Completed a training course approved by the state. Based on interviews, observations, and record reviews, the facility failed to implement an ongoing resident centered activities program that incorporated the residents' interests for two (Resident #16 and Resident #24) of two sampled residents investigated for activities. Findings included: 1. Resident #16 was admitted to the facility on [DATE] with diagnoses of acute kidney failure, dysphagia, urinary tract infection, adult failure to thrive, neuromuscular dysfunction of bladder, hypertension, hydrocephalus, neoplasm of bladder, convulsions, anxiety, and major depressive disorder. On 10/4/21 at 11:17 a.m., Resident #16 was observed seated in a wheelchair in his room. The resident indicated he had been at the facility for several months due to the unavailability in the Veterans Administration long term care facilities. He was watching a small television in his room. Resident #16 stated that there were not a lot of activities to get involved in at the facility. He stated he would like to get access to books and puzzles because he liked to read and do challenging puzzles. He indicated there were not a lot of books or puzzles in the facility of interest to him. A review of the quarterly Minimum Data Set (MDS) dated [DATE] for Resident #16, indicated a Brief Interview of Mental Status (BIMS) score of 13 indicating intact cognitive responses. A review of the activity assessment completed for Resident #16 on 9/20/21, revealed the resident required physical adaptations, preferred one to one and small group activities, enjoyed watching television, movies, word puzzles, and listening to music. On 10/5/21 at 11:27 a.m., Resident #16 was observed out in the hallways in a wheelchair moving around the facility. He had no signs of distress and was observed in a conversation with another resident. On 10/05/21 at 11:41 a.m., an interview was conducted with the Administrator. The Administrator stated the Activities Director went out with an injury in July and was not able to return. The Administrator stated since July, Staff A, Certified Nurse Aide (CNA) had been filling in. He stated Staff A was not currently at the facility because she was out providing resident transport for appointments. The Administrator stated he had developed the activity calendar and Staff A carried out what was on the calendar. On 10/05/21 at 1:56 p.m., an interview was conducted with the Administrator. The Administrator stated, I haven't done a good job with activities in her absence. The Administrator provided activities calendars for October and September 2021. The Administrator stated he could not access any calendars prior to September because the calendars were in the previous Activity Director's computer, and he did not have access to them. He stated he had hired a new Activity Director that would be starting on November 2nd, 2021. On 10/06/21 at 12:27 p.m., Resident #16 was observed in his room seated in a wheelchair. Resident #16 stated he had gone to look for any books or puzzles available in the facility a while ago, but felt the puzzles were for children and was only able to see five books that were of no interest to him. The resident was sitting by himself watching television. The resident stated no one ever came around to the rooms with any other activities. On 10/06/21 at 3:12 p.m., an interview was conducted with Staff A, Certified Nurse Aide (CNA), currently in charge of activities, and Staff B, Registered Nurse (RN) MDS. Staff A stated she had been in charge of activities for about six weeks. Staff A indicated she was not oriented to the position. She stated she was working on orientation with the Administrator, and it had begun today, 10/02/21. Staff A stated she worked Monday through Friday in the role. Staff A indicated the role was not a permanent position for her. Staff B, RN stated the facility had hired a new employee that would start in November for the role of activities director. Staff A indicated she also was responsible for transport of residents to and from appointments as needed. Staff A stated she was responsible to coordinate most of the activities on the activity board. Staff A stated the activities scheduled in the evening do not have anyone assigned to assure they occur. Staff A stated when a resident was unable to come to group activities she would sit in their room, turn the television on, and talk with the resident. She stated sometimes she read the newspaper to them. Staff A indicated she did not have anyone helping her with activities and she was not able to get to all the residents all of the time. Staff A stated she had not been doing any activity assessments for the residents to assess their needs and preferences. Staff B, RN stated an activity assessment was done on admission and yearly that would be included in the MDS assessment, and she was responsible for the assessment. She stated there was also an activity assessment that was done by activities, and no one had been doing that assessment since they lost their last activities director. Staff A stated Resident #16 liked to watch television and sometimes he had come to play bingo. She stated she was not aware of what other interests Resident #16 had. Staff A stated around the time of the onset of Covid all of the books and puzzles were removed because they could not be cleaned and there had been no effort to get new items. Staff A stated there were items to use to play games with residents like bowling, balls, and other activities but she was not aware of where those items were. Staff A and Staff B verified since the last activity director left the facility there had been no real activity program for the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that behavior and side effects monitoring was recorded for two (Residents # 50 and #28) of five sample residents who were reviewed for unnecessary medications. Findings included: 1. Resident #50 was originally admitted to the facility on [DATE] with the primary diagnosis of end stage renal disease. Other pertinent diagnoses included but were not limited to anxiety disorder, major depressive disorder, unspecified convulsions, and bipolar disorder. A review of the quarterly Minimum Data Set (MDS) dated [DATE], section C (Cognitive Patterns) reflected a Brief Interview for Mental Status (BIMS) of 15 indicating that Resident # 50's cognition was intact. A review of the active physician orders dated 10/04/21 for Resident # 50 included the psychotropic medications Risperidone tablet 1 mg (milligrams) by mouth one time a day for mood disorder. There was no physician order for the monitoring of behaviors or for the monitoring of side effects related to psychotropic medications. A review of the plan of care for Resident # 50 with a revision date of 7/15/2021, included a focus on behavioral, with interventions that stated: Document episodes of behavior and review to determine the effectiveness of interventions. The plan of care also revealed a focus on the uses of psychotropic medication. Goals for psychotropic drug use indicate that: Resident will have minimal side effects. Interventions included: Observe, document for side effects and effectiveness. A review of the medication administration record (MAR) for the period of 10/01/21 to 10/06/21, revealed that the psychotropic medications were administered as ordered and no documentation for the effectiveness, side effects, or behavior monitoring was provided. On 10/06/21 2:58 p.m. in a phone interview with the consultant pharmacist, she stated she would have expected nursing to have in place behavior and side effects monitoring for the use of psychotropic medication. On 10/06/21 3:06 p.m. in an interview with the DON, she stated that she developed a process to review medication orders in the morning meeting including psychotropic medications, to ensure orders were carried out appropriately and monitoring was in place. She stated that it was essentially the nurse's responsibility to input behavior and side effects monitoring in the resident's electronic medical record (EHR). She stated that the reason the monitoring got dropped, and not carried over, was because the resident went out to the hospital and was readmitted to the facility. The DON stated that it was her expectation that the nurses ensure that monitoring was in place for residents receiving psychotropic medications. 2. On 10/4/21 at 10:55 a.m., Resident #28 was observed seated on the bed in his room working on some paperwork. The resident appeared clean, dry and had no odors. He was fully dressed and able to be interviewed. Resident #28 was admitted to the facility on [DATE] with diagnoses of post laminectomy syndrome, gastroparesis, anxiety, chronic pain syndrome, angina, morbid obesity, Diabetes Mellitus, and hypertension. A review of the orders for Resident #28 revealed an order dated 9/27/21 for Buspirone Hydrochloride tablet give 7.5 milligrams by mouth every 12 hours for anxiety. A review of the Medication Administration Record (MAR) revealed Resident #28 had been receiving Buspirone Hydrochloride (a psychotropic medication) as ordered since 9/18/21. No evidence of behavioral or side effects monitoring for the medication was documented in the resident's record during the months of September or October 2021. A review of the comprehensive care plan for Resident #28 revealed the following: Focus Area: The resident uses psychotropic medications related to anxiety to manage anxiety, neuropathic pain management. (initiated 9/28/21) Goal: Will have minimal side effects Interventions: Administer medications as ordered. Observe/document for side effects and effectiveness; Observe for potential side effects may include dizziness, drowsiness, confusion, headache, anxiety, tremors, stimulation fatigue, depression, insomnia, hallucinations, weakness, unsteadiness, orthostatic hypotension, blurred vision, tinnitus, constipation, dry mouth, nausea, vomiting, anorexia, diarrhea, rash, dermatitis. On 10/5/21 at 10:11 a.m., Resident #28 was observed in the physical therapy department participating in therapy. He had no signs of pain or distress. He appeared cooperative with no behaviors noted. The resident completed all therapy without difficulties. On 10/6/21 at 2:57 p.m., an interview was conducted with the Consulting Pharmacist. The Pharmacist stated she had not done a review of Resident #28 for the month of October yet and was actually working on that currently. She indicated that when a resident was on psychotropic medications, the nursing staff entered an order into the system for the behavior and side effects monitoring. She stated this should be done when the order for a psychotropic medication was given. On 10/6/21 at 3:06 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated typically during the morning meeting, a review of all the residents was conducted and residents who were on psychotropic medications had the behavior and side effects monitoring order placed into the record at the time of the meeting. The DON stated, the nurses should also put the order in for the side effects and behavior monitoring when they received the order. She stated the monitoring was considered a nursing process order. She stated they review new orders in the morning meeting and that was when it was usually caught. The DON confirmed Resident #28 should have had the side effects and behavioral monitoring entered for the medication the entire time it was being administered. A review of the facility policy entitled Behavior Monitoring Record (effective October 2021) indicated the following: Policy: To qualitatively document the frequency of identified behavioral symptoms. To document the type of interventions used to reduce or eliminate the behavior and the effectiveness of the interventions. To document side effects of psychoactive medications on the MAR. The behavior monitoring record will be initiated on residents/taking psychoactive medications that require behavior monitoring. Procedure: 1. Enter the following information into the electronic medical record. 2. Describe the specific behavior to be monitored. 3. Code the interventions determined to address the specific behavior. 4. Enter the frequency of the behavior on each shift. 5. Enter the letter code of the interventions chosen to address the behavior. 6. Enter the outcome code of the intervention.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that resident council meetings were facilitated and failed to provide and train a designated staff person to assist with providing for the council meeting process for July 2021, August 2021, and September 2021. Due to this failure, there was no resident council activity for those months. Findings Included: The Nursing Home Administrator (NHA) was interviewed about the resident council during the survey entrance conference conducted on 10/04/21 at 9:32 a.m. He confirmed there was a council and identified the president as Resident # 35. On 10/04/21 at 4:46 p.m., the NHA was asked to provide the minutes from the past 3 months of resident council meetings (July 2021, August 2021, September 2021) after gaining permission from the council president. On 10/05/21 at 11:41 a.m., a follow up interview was conducted with the NHA to provide the requested minutes. He explained that there were no minutes for the months requested because there had been no resident council meetings for those months. He explained the former activities director had taken a leave due to injury and had not been able to return. He said that Staff A, Certified Nursing Assistant (CNA) had been filling in since July. He confirmed that he was the one responsible for creating the monthly calendar of activities and that Staff A carried out what was on the calendar. He said resident council meetings had not occurred in July, August, and September because he had not put meetings on the calendar. Minutes from the three most recent council meetings were requested, provided, and confirmed the NHA's report that the last meeting held was in June 2021. An interview was conducted with the NHA on 10/05/21 at 1:56 p.m. He provided copies as requested for the activities calendars for September 2021 and October 2021. He said he could not access August 2021 or July 2021 calendars because they were in the previous activity director's computer, and he did not have access. He said, I haven't done a good job with activities in her absence and re-confirmed that included not providing for resident council meetings since June 2021. He said the facility had an open door policy, which meant that residents could ask for a council meeting and nobody had but said, he should not have left it up to the residents to have to ask for the meetings. Review of the activities calendar for September 2021 revealed Resident Council on the calendar for 9/9/21 at 11:00 a.m. Review of the activities calendar for October 2021 revealed Resident Council on the calendar for 10/8/21 at 11:00 a.m. Members of the resident council were interviewed on 10/05/21 during a meeting with them at 2:00 p.m. Attendees were Resident #41, Resident #35 (council president), Resident #31, Resident #47, and Resident #43. The attendees confirmed they had not had a resident council meeting since the former activities director left. They confirmed the last council meeting the facility provided for was in June 2021 and there had been no alternate format in its place. Resident #35 said nobody in the facility said anything about it because they've been so busy. Medical records of the attendees were reviewed for their Brief Interview for Mental Status (BIMS) scores. Resident #41 had a score of 14, Resident #35 had a score of 15, Resident #31 had a score of 9, Resident #47 had a score of 11, and Resident #43 had a score of 12. A score range of 13-15 meant cognitively intact. A score range of 8-12 meant moderate impairment. An interview was conducted with Staff A on 10/6/21 at 3:18 p.m. She said she knew there was a resident council but was never told or assigned to do anything with the council or meetings. She said, I didn't know the process to get it started .I just got told about it today. [NAME] said, I'm just a CNA .I'm just helping out you know . going to the store for them (residents) and bingo and bringing coffee. An interview was conducted with the NHA on 10/06/21 at 3:24 regarding the facility quality assurance and process improvement activities. He reported he had started a process improvement plan related to activities because of concerns identified and brought to his attention during the survey which included the lack of resident council meetings. He said part of the improvement plan would be to ensure that resident council meetings were on the activities calendar and that he would be the designated staff member to assist with facilitating the meetings for the residents. He confirmed that he had never provided Staff A with any training specific to resident council meetings. He said, I told her to manage activities and that I would be posting the calendar .she received training mainly today. Review of facility standard titled Resident Council effective October 2021 revealed: Residents have the right to organize and participate in resident groups in the facility. The council will be provided with a private area to hold the meetings .The purpose of the meeting is to engage and empower the Residents to bring ideas and concerns to improve person centered care in the facility to increase resident satisfaction .The Activities Director or designee will be responsible to: host .organize .take minutes of the meeting . The NHA was interviewed about the standard on 10/05/21 at 4:03 p.m. He confirmed that the October 2021 effective date was probably a revised date. He said the standard had always been in place and confirmed it had not been followed. He said the last time he though it had been followed was July and said he had been spread too thin covering for the activities director in addition to other roles.

Based on observation, interview, and record review, the facility failed to ensure that resident food was stored under sanitary conditions in one of one refrigerator/freezer designated for resident food storage The facility failed to ensure that foods were labeled properly and discarded for food safety, failed to ensure no staff food was stored with resident food items, and failed to monitor the refrigerator/freezer for safe food storage temperatures. A tour of the facility resident nourishment pantry areas was conducted on 10/5/21 at 12:00 p.m. with Staff C, Registered Nurse (RN), Unit Manager (UM). She confirmed that there was only one refrigerator/freezer in the facility used for storage of resident's personal food, including food brought in by visitors and family. She revealed the refrigerator/freezer was located in the main dining room. Observation of the refrigerator/freezer revealed a typed sign posted on the freezer compartment that read STAFF ONLY. Staff C immediately removed the sign during the observation but replaced it upon request for photographic evidence to be obtained. There were no other signs posted and there were no temperature logs observed posted on the refrigerator/freezer or in the area. Upon opening the refrigerator compartment, an assortment of unlabeled food items was observed including partially consumed beverages in cups and bottles and what appeared to be personal lunch bags. There was an assortment of items contained in plastic grocery bags. Most of the items were without labels or dates. Staff C said it did not appear to her that all the food items in the refrigerator belonged to residents. She said she was not aware of any temperature log for the refrigerator or the freezer. Observation of the freezer compartment revealed unlabeled food items including an uncovered beverage with ice in it. Staff C said housekeeping and activities staff oversaw maintaining the refrigerator/freezer. Photographic evidence obtained. The facility Certified Dietary Manager (CDM) was interviewed on 10/05/21 at 12:10 p.m. and confirmed that the dietary staff/department did not have any responsibilities for maintaining the refrigerator/freezer in the dining room. Observation was conducted of the refrigerator/freezer in the dining room on 10/05/21 at 2:47 p.m. A new sign was observed posted on the refrigerator door that read, Resident food storage only. Only staff are permitted to open and close fridge. Items must be labeled and dated. A temperature log was observed posted on the freezer door and the date of 10/01/21 had been filled out with a refrigerator temperature of 33 and a freezer temperature of 0. During the observation the facility Regional Nurse Consultant (RNC) entered the room. She confirmed she had posted the temperature log and made the entry for 10/01. She said she had made an error and put her entry on the wrong date, clarified entry should have been made for that day (10/05) since this was the first date it was posted and completed. She replaced the log with one that had entry for 10/05. Photographic evidence obtained. An interview was conducted with the facility Administrator (NHA) and the facility Director of Nursing (DON) on 10/05/21 at 2:53 p.m. The DON confirmed that corrections had been made since the observation conducted that morning because Staff C had made them aware of the identified concern. The DON said that when they observed the contents of the refrigerator and freezer, they found a lot of the food wasn't labeled or dated and they had discarded those items. The NHA said that refrigerator/freezer had traditionally been for resident's personal food items. The DON said that she had interpreted the posted sign STAFF ONLY to mean it was a staff food refrigerator. Both parties said they had never provided instructions to the staff about what food items could be stored there. The NHA said the expectation had always been that nursing staff on the 11:00 p.m. - 7:00 a.m. shift was responsible to check and log the refrigerator/freezer temperatures, make sure all food items were labeled and dated, and discard any food items that were not labeled or dated properly. Previous temperature logs were requested for review and the NHA said there were none prior to the one started today (10/5/21) and confirmed they had not been done previously. The NHA reported the following process for food storage and labeling: resident name, food identifier, resident room number, and the date the item was first placed in the refrigerator. He said after an item was stored for 3 days it should be removed and discarded. He said that packaged food, unopened, could be stored until expiration date. The NHA confirmed that the sign posted on the refrigerator had been re-written to make it clear that the refrigerator/freezer was for resident food only and that only staff were allowed to access the refrigerator/freezer. He confirmed he did not want residents accessing for infection control measures. The NHA revealed he had begun in-servicing with facility staff that day (10/05/21) on the policy/procedure for resident food storage in that refrigerator/freezer and procedure for monitoring and logging the temperatures. Review of facility policy and procedure titled, Safe handling, storage, and reheating of food from visitors our outside source effective January 2021 revealed: When food items are intended for later consumption, the nursing staff will: 1. Ensure the food item(s) are in a sealed container, stored in the pantry refrigerator, and labeled with the current date and name of the resident. 2. Food will be stored for up to 3 days and then discarded. Refrigerators are equipped with thermometers and checked by staff daily to ensure maintaining a temperature at or less than 41 degrees F (Fahrenheit) and freezer at or less than 10 degrees F. 1. Temperatures will be logged. Storage of frozen items may be retained for 30 days .Shelf stable items may be retained up to the listed expiration date. Nursing staff will check the refrigerator daily for temperature, expired food, and is responsible for cleaning up spills on an as needed basis.

Based on record & policy review and interviews, the facility failed to provide timely and specific notification to include the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) Form CMS (Centers for Medicare and Medicaid Services) 10055 to one resident (Resident #31) of three sampled residents who no longer qualified for Medicare Part A skilled services and had Medicare benefit days remaining. Findings included: A review of the notifications for Resident #31 revealed the facility issued the NOMNC (Notice of Medicare Non-coverage)/CMS 10123 form to Resident #31 on 01/22/2020 for skilled nursing services end date of 01/24/2020. The facility did not issue the SNF ABN Form CMS 10055 as required due to the fact that the resident remained in the facility after being discharged from Medicare Part A. On 02/12/2020 at 8:57 a.m., the Social Services Director (SSD) reported that if a resident was being discharged from Medicare Part A and remained in the facility, she would only give the NOMNC form. The SSD stated that she would give the SNF ABN form if they were being discharged from the facility. On 02/12/2020 at 9:30 a.m., the Business Office Manager confirmed that she did not issue the SNF ABN form for Resident #31. A review of the policy and procedure provided by the facility titled Beneficiary Notice Initiative-NOMNC, DENC, and ABN with an effective date of July 2016 revealed the following: Both the NOMNC CMS 10123 and SNF ABN CMS 10055 should be issued when a resident was discharged from all skilled Medicare Part A services with days remaining.

Based on observation, interviews, and policy review, the facility failed to follow their policy to ensure proper storage for medications in one of two medication carts (East Wing). Findings included: 1. A review of the facility's policy Section 4.1 titled, Storage of Medications, effective 09/18, Page 01 of 02, included under Policy and subtitle Procedures reads: The provider pharmacy dispenses medications in containers that meet state federal labeling requirements, including requirements of good manufacturing practices established by the United States Pharmacopeia (USP). Medications are to remain in these containers and stored in a controlled environment. On 2/10/20 at 2:30 p.m., an observation of the medication cart located on the East Wing, included nine loose and or unsecured medications. The Director of Nursing (DON) was standing near the medication cart watching part of the observation made by the surveyor. In the second draw (from the top) it was observed to have four loose medications of two white and two pink tablets. Staff B, Registered Nurse (RN), confirmed the presence of the unsecured medications. The third drawer contained one loose medication in the back of the draw behind medication boxes. Staff B, (RN) confirmed the presence of the unsecured white tablet. The fourth drawer contained one loose white medication, and Staff B (RN) confirmed the presence of the unsecured medication. The fifth drawer contained one loose medication. Staff B (RN) confirmed the presence of the grey unsecured capsule. The sixth drawer contained two loose medications located in an empty medication box. Staff B (RN) confirmed the presence of the two unsecured white tablets. (Photographic Evidence Obtained.) On 02/10/20 at 3:20 p.m., an immediate interview with the DON was conducted. She revealed that she saw Staff B, (RN) confirm the presence of nine loose and unsecured medications in the East Wing medication cart. The DON stated, I am not happy with what I saw in regards to loose pills. On 02/12/20 at 11:06 a.m., a telephone interview was conducted with PharMerica facility Consultant. The pharmacist was informed observations that included nine loose pills found in the East Wing medication cart. She stated, I don't know if I have ever seen medication and supplies left out by the bedside by facility staff. Loose pills should never be in the medication cart.

Based on observations, record and policy reviews, and interview, the facility failed to maintain the facility in a sanitary manner related to dusty ceiling vents above clean dishes and food and peeling paint in the ceiling above the 3-compartment sink, failed to store personal items in an appropriate area, and failed to maintain equipment in a sanitary manner. Findings included: An initial tour of the kitchen was conducted on 02/09/2020 at 9:05 a.m. A dusty ceiling vent was observed above clean dishes and a box of tomatoes and onions that were stored on a drying rack (photographic evidence obtained). A dusty ceiling vent was observed above the four-door reach in cooler. The paint on the ceiling above the 3-compartment sink was peeling and cracked (photographic evidence obtained). Staff personal items (purses, keys, and jackets) were stored in the dry storage closet with food (photographic evidence obtained). On 02/12/2020 at 11:30 a.m., the CDM reported that staff had always stored their personal belongings in the dry storage closet with food. On 02/11/2020 at 11:56 p.m., the Certified Dietary Manager (CDM) reported that she had submitted a work order for the peeling paint and maintenance was aware of the issue. A work order for the ceiling above the 3-compartment sink was verified. The work order was created on 10/22. The CDM confirmed that there was a delay in getting the ceiling fixed. On 02/11/2020 at 12:10 p.m., the ice machine was observed with a white substance and peeling paint. The CDM was asked about the buildup and she stated that it looked like slime. The CDM reported that she was not sure who was responsible for cleaning the ice machine and that it was probably maintenance. A review of the Nutrition Services Cleaning Schedule revealed that the ice machine was not listed. The policy and procedure provided by the facility Ice Machine with an effective date of November 2013 revealed the following: Policy The ice machine, scoop and storage container will be maintained in a clean and sanitary condition. The ice machine will be cleaned once per month or more often as needed. The scoop and storage contained will be cleaned once per day. The policy and procedure provided by the facility Standards of Cleanliness with an effective date of July 2017 revealed the following: Ceilings- Clean; free of dust and spots; paint intact; vents clean and free of dust and lint Vents- Free of dust, fingerprints, marks, stains, and spider webs.