**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, review of the facility-provided document titled, PASRR (Preadmission Screening and Resident Review) Management Process, and review of the facility's policy titled, Collection of Pre-admission Information, facility failed to ensure a PASRR Level II referral was made to ensure that individualized care and services were offered to meet resident needs for three of 25 sampled residents (R) (R22, R46, and R13) that were reviewed for PASARR. This failure had the potential for residents with mental disorders not to receive identified specialized services. Findings include: Review of the facility-provided document titled PASRR (Preadmission Screening and Resident Review) Management Process dated July 17, 2015, in the section titled, Level II Screening revealed, Transition Nurse must verify a Level II screening has been completed prior to admission. In the section titled, Morning Meetings revealed, All expected admission should be discussed in the facility morning meeting. At this time, it must be confirmed that the pending admission does have a valid PASRR in the state system .Expected admission should be discussed including PASRR accuracy. Review of the facility's policy titled Collection of Pre-admission Information dated September 2009 under Policy revealed, Prior to admission, the admission Coordinator will obtain the following information and provide to the Financial Counselor: Copy of state specific PASSAR FORM (if applicable). 1. Review of R22's Face sheet revealed the resident admitted to the facility on [DATE] with diagnoses that include but are not limited unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, mood disorder due to known physiological condition, unspecified, bipolar disorder, current episode mixed, severe, with psychotic feature and major depressive disorder, single episode, unspecified. Review of R22's admission Minimum Data Set (MDS) dated [DATE] revealed: Section A- Identification Information: indicated no PASRR Level II; Section C-Cognition: a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition; Section D-Mood: Total Severity score of 0 (zero); Section E-Behavior: indicated no behaviors; Section I-Active Diagnoses: indicated Non Alzheimer's, seizure disorder, depression, and bipolar; Section N-Medications: indicated resident received antipsychotic, antidepressant, and antipsychotic medications. Review of R22's care plans included but not limited to: (Resident Name) receives anti-depressant, and anti-psychotic to manage dx of depression, mood disorder, bipolar, dementia. Risk for falls and adverse side effect with problem start date of 7/19/2024; (Resident Name) adjustment difficulty to new environment related to recent admission. HX (history) of bipolar, dementia, mood disorder, dementia, etc. with problem start date of 7/19/2024; (Resident Name) is inpatient with staff, becomes easily angered if they are not on time with tasks or late with problem start date of 8/14/2024. Review of R22's physician orders included but not limited to, duloxetine capsule, delayed release; 60 mg (milligram); one capsule by mouth once a day; risperidone 0.5 mg; one tablet by mouth once a day; and risperidone 1 mg; one tablet by mouth at bedtime; all with start date of 7/22/2024. Review of R22's medical record revealed an approved PASRR Level I dated 1/23/2015, however there was no primary diagnosis of serious mental illness, developmental disability, or related condition indicated. Review of the facility provided list of residents at the facility with a PASRR Level II titled PASRR LEVEL II [Facility Name] August 2024 revealed, R22 did not have a PASRR Level II. Review of R22's Social Services Progress Note dated 7/19/2024 revealed the resident did not have any discharge plans and would require LTC (Long Term Care) at the facility. Review of R22's medical record revealed that R22 was not receiving psychiatric services. 2. Review of R46's Face sheet revealed the resident admitted to the facility on [DATE] with diagnoses that include but are not limited mood disorder due to known physiological condition, unspecified, bipolar disorder, current episode mixed, severe, without psychotic major depressive disorder, recurrent, moderate, unspecified mood [affective] disorder, and generalized anxiety disorder. Review of R46's admission MDS dated [DATE] revealed: Section A- Identification Information: indicated no PASRR Level II; Section C-Cognition: a Brief Interview of Mental Status (BIMS) score of 14, indicating intact cognition; Section D-Mood: Total Severity score of 6 (six); Section E-Behavior: indicated no behaviors; Section I-Active Diagnoses: indicated anxiety disorder, depression (other than bipolar), bipolar disorder Section N-Medications: indicated resident received antipsychotic, antianxiety, antidepressant medications. Review of R46's care plans included but not limited to: (Resident Name) referred to Life Source for depressive symptoms with problem start date of 8/16/2024; (Resident Name) receives anti-anxiety, anti-depressant, and anti-psychotic medication. Also receives mood stabilizer medication. Risk for falls and adverse side effects. Has dx of Bipolar, MDD, Mood disorder, and alcohol dependence with unspecified alcohol induced disorder with problem start date of 8/15/2024. Review of R46's physician orders included but not limited to: buspirone 5 (five) mg, (two tablets) by mouth three times a day (TID) with start date of 8/20/2024; duloxetine 60 mg capsule, one capsule by mouth at bedtime with start date of 8/14/2024; divalproex 125 mg, one tablet by mouth TID with start date of 8/14/2024 and quetiapine 50 mg tablet extended release 24 hr, one tablet by mouth at bedtime with start date of 8/20/2024. Review of R46's medical record revealed an approved PASRR Level I dated 4/12/2023, however there was no primary diagnosis of serious mental illness, developmental disability, or related condition indicated. Review of the facility provided list of residents at the facility with a PASRR Level II titled PASRR LEVEL II [Facility Name] August 2024 revealed, R46 did not have a PASRR Level II. Review of R46's Social Services Progress Note dated 8/15/2024 revealed the resident was at the facility for LTC and was receiving psychiatric services for psychotherapy. Interview on 8/31/2024 at 12:17 pm with Social Service Director revealed she reviewed new admissions to ensure they have a PASRR Level I in place. She reported if a resident's stay were long-term, she would review their diagnoses to determine if they had qualifying diagnoses for a Level II PASARR and submit the screening application at that time. She revealed that both R22 and R46 was at the facility for long term care. She confirmed that a Level II screening application had not been submitted for R22 and R46 that included the residents' qualifying diagnoses. She stated they were in the process of auditing all residents with qualifying diagnoses to ensure Level II screenings had accurately submitted. Interview on 8/31/2024 at 12:40 pm with the Administrator revealed his expectations of staff were to review and ensure PASRR Level I screenings were completed accurately prior to residents' admission and to follow the facility's PASRR process. Interview on 9/1/2024 at 9:30 am with the admission Director, revealed she was responsible for obtaining PASRR Level I screenings on residents prior to admission. She reported that she would review the residents' medical records to determine if they had qualifying diagnoses and would submit a Level I screen. She stated that the R46 had a Level I screen completed at another facility and did not think she had to complete another one. She confirmed that both R22 and R46 had qualifying diagnoses on admission that would have triggered a Level II. She confirmed that a Level II screening should have been completed that included the qualifying diagnosis. She acknowledged that it had been overlooked. 3. Record review of R13 's medical record revealed an admission date to the facility on 7/28/2023 with the following diagnoses, but not limited to, major depressive disorder, recurrent severe with psychotic symptoms and anxiety disorder. Record review of R13's PASRR Level I revealed an official approval date of 7/28/2023. Continued review of the form revealed no indications that resident had any medical diagnosis or criteria which would prevent ineligibility for a PASRR Level II. Record review of R13's Annual MDS dated [DATE] Section C revealed a BIMS score of eight, a score of 8 of 12 indicated moderate cognitive impairment. In Section D for Mood, R13 was assessed for feeling down or depressed and having little energy or feeling tired for 12-14 days (almost every day). Review of R13's medical record revealed no PASRR Level 2 found in the record. Review of the list of residents at the facility with a PASRR Level II provided by the facility and titled PASRR LEVEL II [Facility Name] August 2024, revealed R46 did not have a PASRR Level II. Review of R13's Physician Order Form (POF) and Medication Administration Record (MAR) revealed an order for a psych medication, Cymbalta (duloxetine). The order dated 8/22/2024 read, Cymbalta (duloxetine) capsule, delayed release (DR/EC); 20 mg (milligram); amt (amount): 1 CAP (one capsule); oral Once A Day Every Other Day. Interview with the Social Service Director (SSD) on 8/31/2024 at 1:06 pm, the SSD confirmed that a PASRR was not submitted for R13. She stated the last time that the facility residents were screened for a PASRR Level II was March 20, 2024. Interview on 9/1/2024 at 9:34 am, the admission Coordinator confirmed that R13's PASRR Level II was not submitted. She reported that prior to any resident admission to this facility from a discharge facility, the process was to ensure that the resident had a PASRR Level II. Once the resident was admitted to a room, and on the facility census, the SSD would follow up with submitting the PASRR Level II.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review, and review of the facility policy titled, Care Plan the facility failed to ensure the care plan was implemented for one of five residents (R) (R48). The deficient practice had the potential to affect the care and services provided to R48. Findings include: Review of the facility policy titled, Care Plan revised date of 7/27/2023 revealed under policy statement: It is the policy of the health care center for each patient/resident to have a person-centered baseline care plan followed by a comprehensive care plan developed following completion of the Minimum Data set (MDS) and Care Area Assessment (CAA) portions of the comprehensive assessment according to the resident Assessment Instrument (RAI) Manual and the patient/resident choice. Under admission Comprehensive Plan of care 4. The goal is an expected outcome the patients/residents should achieve by implementing specific interventions. Record review for R48 revealed resident was admitted to the facility with diagnoses of but not limited to the following: Acute and chronic respiratory failure with hypercapnia, Chronic systolic (congestive) heart failure, Morbid (severe) obesity due to excess calories, and Chronic obstructive pulmonary disease (COPD). Review of the physician orders revealed an order dated 8/5/2024 that indicated oxygen at five LPM (liters per minute) via nasal cannula (NC) continuous. Review of the Annual Minimum Data Set (MDS) dated [DATE] Section O (Special Treatments, Procedures, and Programs) indicated resident was utilizing supplemental oxygen. Review of R48's care plan revealed under problem, R48 required oxygen related to disease process: CHF, A-Fib, morbid obesity, and chronic resp. failure with hypoxia, COPD. The approach was to administer oxygen as ordered at five LPM via NC. Observation on 8/30/2024 at 10:22 am revealed R48 was receiving 3 liters of oxygen via NC with no humidifier bottle noted. Observation on 8/31/2024 at 1:15 pm revealed oxygen was set at 4.5 LPM. Interview on 8/31/2024 at 2:46 pm with the Director of Health Services (DHS) revealed her expectation was that staff follow the care plan as written.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility's policy titled, Oxygen Administration the facility failed to ensure oxygen therapy was administered as ordered for two of eight Residents (R) (R48 and R19). Specifically, the facility failed to ensure oxygen was administered at five litters per minute (LPM) as ordered and a humidifier bottle was utilized during oxygen administration for R48; and failed to ensure R19's humidifier bottle was changed and contained the required humidifying solution. Findings include: Review of the facility policy titled, Oxygen Administration with revise date of 8/2/2023 revealed under Policy Statement: It is the policy of (Facility Name) Hospice and Healthcare Centers/Veteran Homes to provide oxygen safely and accurately to appropriate patients/residents. Under Procedure: Oxygen will be administered by licensed personnel only when ordered by the physician, PA or NP. The physician order may be written PRN for comfort/dyspnea or may specify the number of liters, method of administration and length of time the oxygen is to be administered. 4. Regulate liter flow to ordered/desired flow rate. Continued review under Infection Control Policy of 02 Humidifier Bottles: 1. 02 humidifier bottles should be used on all patients/residents receiving higher than 2 Liters/minute of oxygen flow. 1. Record review for R48 revealed resident was admitted to the facility with diagnoses of but not limited to the following: Acute and chronic respiratory failure with hypercapnia, Chronic systolic (congestive) heart failure, Morbid (severe) obesity due to excess calories, and chronic obstructive pulmonary disease (COPD). Review of the physician orders revealed an order dated 8/5/2024 that indicated oxygen at five LPM via nasal cannula (NC)continuous. Review of the Annual Minimum Data Set (MDS) dated [DATE] Section C (Cognitive Patterns) revealed Brief Interview for Mental Status (BIMS) score of 15 indicating resident had little to no cognitive impairment. Section O (Special Treatments, Procedures, and Programs) indicated resident was utilizing supplemental oxygen. Review of the care plan review under problem, R48 required oxygen related to disease process: CHF, A-Fib, morbid obesity, and chronic resp. failure with hypoxia, COPD. The approach was to administer oxygen as ordered at five LPM via NC. Observation on 8/30/2024 at 10:22 am revealed R48 was receiving oxygen at 3 liters per minute (LPM) via NC with no humidifier bottle noted. Observation on 8/31/2024 at 1:15 pm revealed oxygen was set at 4.5 LPM. Interview on 8/31/24 at 1:20 pm with Licensed Practical Nurse (LPN) AA revealed R48 is supposed to be on 5 liters of oxygen continuously but sometimes the settings get changed accidentally during care. Further interview revealed at the beginning of the shift the oxygen concentrators are checked against the physician's order. Sometimes there are water bottles put on the oxygen concentrators and sometimes they are not, depending on if the resident wants them on there or not. Interview on 8/31/2024 at 1:52 pm with the Director of Health Services (DHS) revealed residents must have a physician's order for oxygen and should be checked by the Charge Nurse before oxygen is administered. The Charge Nurses should also be checking to ensure that residents receiving oxygen are getting the correct amount as ordered by the physician throughout their shift. The DHS confirmed R48's oxygen was not set on the correct flow rate as ordered by the physician.2. Record review of R19's medical record revealed the following diagnoses but not limited to, chronic obstructive pulmonary disease and chronic kidney disease. Record review of R19's Quarterly MDS dated [DATE] Section C revealed a BIMS score of 15 (a score of 13 to 15 indicated little to no cognitive impairment). Section O, special treatments and therapy use assessed R19's for oxygen use. Observation on 8/30/2024 from 10:00 am until 10:30 am, revealed R19 was receiving oxygen by oxygen concentrator and nasal cannula with a setting of 4 LPM (liters per minute). Continued observation revealed the humidifier bottle (pre-filled humidifier bottle) attached to the oxygen concentrator was empty. Review of R19's Physician Order (POF) listed an order dated 10/17/2023 for Oxygen at 4 LPM via nasal cannula PRN SOB (as needed for shortness of breath). Special Instructions: SOB, < 90% every shift (shortness of breath, oxygen saturation less than 90 percent every shift). A second order dated 10/17/2023 stated oxygen: change respiratory circuit/supplies weekly prn once a day on Sunday nights. Review of R19's care plan created 8/23/2022 (last revised 8/30/2024) stated R19 requires supplemental Oxygen Use at times related to: COPD, CHF (congestive heart failure), morbid obesity, and chronic respiratory failure. Interventions included, my apply oxygen as needed at 4 LPM via NC for oxygen levels less than 90%. During an interview on 8/30/2024 at 11:39 am (at the time of observation) with Licensed Practical Nurse (LPN) II, she confirmed that the R19's humidifier bottle was empty. LPN II reported being aware that the humidifier bottle needed replacement earlier during her visit to R19's room, she stated that her plan was to replace the bottle. Interview on 8/31/2024 at 3:10 pm, the DON confirmed that humidifier bottle should be attached and filled to prevent the resident from intake of dry oxygen. She reported her expectation was for nursing staff to monitor oxygen supplies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff and resident interviews, and review of the facility policy titled, MDS Assessment Accuracy, the facility failed to ensure three of 31 residents (R) (#5, #29, and #18) were accurately assessed on the Minimum Data Set (MDS) for physical restraints. The deficient practice had the potential to affect the accurate assessment of the facility's residents' care needs. Findings include: Review of facility policy titled, MDS Assessment Accuracy with a revision date of 12/06/2022 revealed under Policy Statement: it is the policy of this healthcare facility that each Minimum Data Set (MDS)reflect the acuity and the medical status of each patient/resident in accordance with acceptable professional standards and practices. 1. Clinical record review for R#5 revealed resident was admitted to the facility with diagnoses that included but not limited to, Alzheimer's disease with early onset, dementia in other diseases classified elsewhere with behavioral disturbance, paranoid schizophrenia, muscle weakness (generalized), difficulty in walking, abnormal posture, weakness, and lack of coordination. Review of current physician orders for R#5 included but not limited to, 1/2 Siderails for turning and repositioning dated 9/26/2019. Review of the Quarterly MDS dated [DATE] revealed R#5 with a Brief Interview of Mental Status (BIMS) score of seven indicating severe impairment. Section P (Restraints) - documented bed rails restraint was used daily. Record review revealed a Restraint/Adaptative Use Observation Form dated 1/09/2023 which indicated R#5 did not have restraints or adaptative equipment in use. Observations on 1/20/2023 at 2:26 p.m., 1/21/2023 at 9:10 a.m., and 1/21/2023 at 1:45 p.m., revealed two quarter bedrails on his bed being utilized for bed mobility. 2. Clinical record review for R#29 revealed resident was admitted to the facility with diagnoses that included but not limited to, cerebrovascular disease, Type 2 diabetes mellitus without complications, chronic obstructive pulmonary disease, chronic pain syndrome, acquired absence of right leg above knee, peripheral vascular disease, low back pain, contracture of muscle, left lower leg. Review of current physician orders for R#29 included but not limited to, Bilateral assistive 1/4 side rails for bed mobility, positioning, and turning per resident request - start date 9/28/2020. Review of the Quarterly MDS dated [DATE] revealed R#29 with a BIMS score of 15 indicating resident is cognitively intact. Section P - documented bed rails restraint was used daily. Record review revealed a Restraint/Adaptative Use Observation Form dated 1/04/2023 which indicated R#29 did not have restraints or adaptative equipment in use. 3. Clinical record review for R#5 revealed resident was admitted to the facility with diagnoses that included but not limited to, muscle weakness (generalized), difficulty in walking, abnormal posture, unsteadiness on feet, history of falling. Review of current physician orders for R#18 included but not limited to, 1/4 Siderails for turning and repositioning - start date 9/29/2022. Review of the Quarterly MDS dated [DATE] revealed R#18 with a BIMS score of four indicating severe impairment. Section P - documented bed rails restraint was used daily. Record review revealed a Restraint/Adaptative Use Observation Form dated 12/24/2022 which indicated R#18 did not have restraints or adaptative equipment in use. Interview on 1/21/2023 at 9:48 a.m. with MDS/Care Plan Coordinator revealed that she is responsible for the MDS assessments and Care plans. She states that the facility does not have any real restraints in the facility. She further stated that she coded that bed rails as a restraint because she understood restraints as any device that is adjacent to the resident which restricts the resident from moving freely or independently that the resident cannot remove on their own. She further stated that she is aware that resident uses the bedrails for bed mobility, and she has learned now that she was not supposed to code the siderails as restraints. Further interview also revealed that the siderails were care planned as an enabling device but coded it on the MDS as a restraint. She stated that she had very little training for the position and stated that mistake with coding was due to a lack of knowledge. MDS Coordinator confirmed that the bed rails were coded incorrectly. Interview on 1/21/2023 at 1:20 p.m. with the Director of Nursing (DON) revealed that currently there are not any restraints in the facility. She further stated that the MDS coordinator is new to the position and need additional training in the MDS process. DON stated that the facility does not have any restraints in the facility and all resident with bedrails uses them to assist with bed mobility and repositioning and it should not be coded on the MDS as a restraint. Interview on 1/22/2023 at 8:33 a.m. with Certified Nursing Assistant (CNA) AA revealed that resident uses the bedrails for positioning while in the bed. She further stated that the facility does not have restraints. She stated that resident can assist during care with the use of the bedrails. Interview on 1/22/2023 at 8:40 a.m. with CNA BB revealed that resident uses the bedrails also to assist with helping him to stand and it is not a restraint. Interview on 1/22/2023 at 9:04 a.m. with Licensed Practical Nurse (LPN) CC revealed that the facility is a restraint free facility and does not utilize restraints. She stated that residents with the quarter bedrails uses them for positioning. She further stated that the nurses are responsible for completing and documenting the Restraint/Adaptative Equipment Observation on Admission, readmission, quarterly and additionally as changes occur with the resident in the electronic record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to submit an application for Level II PASRR (Preadmission Screening and Resident Review) for evaluation and determination of specialized services for one (1) resident (R) #26. This deficient practice has the potential to effect residents requiring Level II PASARR specialized services. The census was 63 residents. Findings include: Record review revealed R#26 was admitted to the facility on [DATE] with diagnosis of but not limited to: Unspecified psychosis not due to a substance or known physiological condition, adjustment disorder with mixed anxiety and depressed mood, and Generalized anxiety disorder. Medications listed but not limited to: Celexa 10mg daily, and Seroquel 50mg daily. Record review for R#26 revealed a DMA-6 (Physician's Recommendation Concerning Nursing Facility Care or Intermediate Care for Mentally Retarded) form signed and dated by physician on 1/20/2020 with diagnosis not checked however admission diagnosis of Unspecified psychosis not due to a substance or known physiological condition, adjustment disorder with mixed anxiety and depressed mood, and Generalized anxiety disorder. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed the PASARR Level II assessment was not selected. Review of section C- cognitive patterns reveal the resident has a Brief Interview for Mental Status (BIMS) score of seven indicating the resident has severe cognitive impairment. Section D- Mood assessed that R#26 had a total severity score of two indicating minimal depression. Section I- Active Diagnosis coded that the resident had Anxiety disorder, Depression, and Psychotic disorder. Section N- Medications coded that R#26 received an antipsychotic seven days of the assessment look back period, and an antidepressant medication six days of the assessment look back period. Review of R#26 care plan with revision date of 11/23/2022 revealed the following documented behavioral symptoms: Resident refuses medications, history of being non-compliant with medications at times, Refuses to go to dialysis at times, displays aggressive behaviors towards staff at times related to diagnosis of psychosis, displays exit seeking behaviors, makes sexual/inappropriate comments towards staff, refuses his baths at times, and refuses lab draws at times. Review of resident progress notes dated 12/12/2022 3:28 AM revealed Resident refused his 9 pm medication and BS check this shift. Writer made several attempts to get resident to take meds and check his bs, resident refused, covered his head with his covers and stated he wants to go home. Will continue to monitor and encourage resident to take his medication. On 12/06/2022 08:40 AM As soon as staff exits room resident stopped hollering out. Writer checked on resident who was sitting up on side of bed at this time. Asked resident why he was hollering, and he states, what, damn when are yall going to let me go home, shit I want to leave and go to [NAME] where my apartment is. Resident is non-complaint with medications at times, and refuses dialysis at times. Interview on 1/21/2023 at 3:15 p.m. with the Social Services Director (SSD) revealed she is responsible for making the referral to the appropriate state-designated authority when a resident is identified as having an evident or possible Mental Disorder (MD), Intellectual Disorder (ID) or related condition. SSD stated if a resident is identified as having a newly evident or possible MD, ID, or a related condition after admission the facility's process for referring the resident to the appropriate state-designated authority is in house psych through Life Source. SSD stated if residents have behaviors after admission, she refers them to psych. SSD also stated that she did not have a response as to why a level 2 was not completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility Policy review entitled (Infection Control- Housekeeping), and staff interviews the facility failed to ensure that it was maintained in a safe clean and comfortable environment. Specifically, the facility failed to ensure privacy curtains were clean and in good repair for three out of 36 occupied resident rooms. In addition, the facility failed to ensure in room three that the base boards were clean and free of debris and black markings on the walls. The facility census was 62. Findings: Review of facility policy entitled (infection control - Housekeeping Services) revealed in policy statement; it is the policy of this facility to ensure housekeeping services will be performed on a routine and consistent bases to ensure an orderly, sanitary, and comfortable environment. Further review of policy under procedure - Routine cleaning of Horizontal Surfaces: In patient/resident care area cleaning of non-carpeted floors and other horizontal surfaces will be performed daily and more frequently of spillage or visible soiling occurs. Observation on 7/12/21 11:14 a.m. revealed the privacy curtain between bed A and B in room [ROOM NUMBER] had noted brown stains on the outer edge of the curtain as well as a hole in the netting at the top of the curtain as well as a tear in the crease of the curtain. Observation on 7/12/21 11:29 a.m. of room [ROOM NUMBER] (R#211) revealed privacy curtain for A bed had noted rust-colored spots that are in the middle of the curtain as well as stains noted to the outer aspect of the curtain as well. Observation of curtain for B bed revealed privacy curtain had noted brown stains at the bottom of the curtain as well as noted brown stains in the middle of the curtain on both sides. Observation on 7/12/21 11:01 a.m. of room [ROOM NUMBER] revealed privacy curtain for bed B has large rust colored stain in the middle of the curtain, base boards have debris buildup along wall of the perimeter of the room, black marks noted on the wall leading into the resident's bathroom. Observation on 7/13/21 7:40 a.m. of room [ROOM NUMBER] revealed privacy curtain continues to be in disrepair and visibly stained. Observation on 7/13/21 7:46 a.m. of room [ROOM NUMBER] revealed privacy curtains continue to be visibly stained, base boards have visible debris noted, as well as black marks on the wall leading into the bathroom. Observations on 7/13/21 10:00 a.m. with Administrator and Housekeeping Supervisor confirmed room [ROOM NUMBER] base boards had build up and debris noted around the perimeter of the room, black marks on the wall leading into the bathroom as well as brown stains noted on privacy curtains for bed B. Continued observation rounds also confirmed in room [ROOM NUMBER] the hole in the privacy curtain noted at the top of the curtain netting and in the middle of the curtain as well. Observation rounds of room [ROOM NUMBER] revealed and confirmed privacy curtain was stained and or soiled with a brown substance in the middle of the curtain for resident in bed B. Interview on 7/13/21 10:22 a.m. with the Administrator revealed that some of the brown stain that was noted in room [ROOM NUMBER] was from the chain that holds the curtain in place had rust on it which rubbed off on the curtain. Continued interview also revealed that staff had recently removed curtains that were soiled and laundered them and that the curtains would be replaced, and that maintenance would be notified of the condition of the base boards that needed painting. Interview on 7/13/21 10:26 a.m. with the Housekeeping Supervisor revealed that deep cleanings are randomly chosen by facility system (building engines) and during the deep clean everything in the room is be cleaned including the privacy curtains and the walls.

Based on observation, interviews, and review of facility policy titled, 'Medication Storage in Healthcare Centers' the facility failed to ensure all medication carts were locked when out of view of the nurse for one of three medication carts and failed to ensure medications were properly secured inside of the medication cart when out of view of the nurse. Findings include: Review of facility policy 'Medication Storage in Healthcare Centers' states '2. Only licensed nurses and pharmacy personnel are allowed access to medications. Respiratory Therapist may access medications used in the provision of respiratory services. Medications rooms, carts, and medication supplies are locked or attended by persons with authorized access.' Observation on 7/13/21 at 3:32 p.m. the west hall medication cart was observed sitting in the nursing station unlocked and unattended. At 3:39 p.m. Licensed Practical Nurse (LPN) DD returned to the nurse's station and locked the cart. LPN DD stated she had been at the front of the building and did not realize the cart was unlocked. Observation on 7/14/21 at 8:12 a.m. during medication administration revealed that LPN DD walked away from the medication cart into a resident's room, out of site of the medication cart, leaving two bottles of vitamins sitting on top of the cart. Upon exiting the resident's room LPN DD stated she should not have left the vitamins sitting on the cart. LPN DD then gathered a box of eye drops from the cart and removed two doses the box. She then placed the remaining eye drops inside of the box on top of the medication cart. LPN DD then locked the medication cart and entered a resident room, closing the door behind her. The box of eye drops remained on top of the cart until after LPN DD finished administering medication to a resident at which time LPN DD stated, 'I just keep forgetting'.

Based on observation, resident interviews, family interviews, staff interviews and policy review of the facility policy titled, Menu Planning, Cycles and Alternates, the facility failed to ensure food preferences were honored. This deficient practice affected two of 20 sampled residents (R#49 and R#32). Findings include: Review of the facility policy titled Menu Planning, Cycles and Alternates effective 09/01/2001 and revised on 10/16/2017 states: It is the policy of PruittHealth to develop menus in order to provide patients/residents with three meals plus a bedtime snack each day. Procedural guideline number eight states: Menus may be individualized by the Registered Dietitian to meet the food preferences and holiday traditions of the patients/residents of the healthcare center. Record review for R#49 revealed a Quarterly Minimum Data Set (MDS) assessment dated which documented a Brief Interview for Mental Status (BIMS) summary score of fifteen, indicating no cognitive impairment. Per physician orders dated 4/22/21, R#49 is to receive a Liberalized Diabetic NAS (no added salt) diet with special instructions of a high protein diet. Interview with R#49 on 7/12/21 at 9:27a.m. revealed that she has advised staff that she does not eat eggs, string beans, creamed potatoes nor drink orange juice, which these items continue to be placed on her tray. Observation of the breakfast tray revealed scrambled eggs, which were untouched by the resident. Interview with R#49 on 7/13/21 at 9:38 a.m. revealed her breakfast tray consisted of scrambled eggs again. Resident now states that she does eat eggs, but just does not like the powdered eggs served at the facility. She stated she likes fried eggs. Interview with R#49 on 7/14/21 at 9:30a.m. Resident advised that she was served powdered eggs again this morning. R#49 continued to voice her dislike of these eggs and how she has expressed this issue on numerous occasions to the staff including the dietary manager. Interview and observation on 7/15/21 at 1:15, R#49 is in the dining room R#49 stated breakfast consisted of powdered eggs, bacon, grits, and milk. R#49 stated that she is ready to leave this facility and return to Virginia with her son. She also advised that she is frustrated. Family Interview via telephone on 7/15/21 at 2:00 p.m. Family member of R#49 contacted to inquire of any concerns of the facility. Resident's son stated that his mother has complained about the food and the choices lack flavor or variety. He advised that his mother spoke to him about her breakfast choices as well as other food items disliked, yet the staff continues to send these items. 2. Record review for R#32 revealed Quarterly Minimum Data Set (MDS) assessment dated which documented a Brief Interview for Mental Status (BIMS) summary score of fifteen, indicating no cognitive impairment. Per physician orders, R#32 is to receive a Liberalized Diabetic NAS (no added salt) diet with special instructions of a high protein diet. Interview with R#32 on 7/12/21 at 9:40. She stated she does not like the eggs poured from a carton. R#32 stated she spoke with dietary a month ago regarding regular fresh, pasteurized eggs, which this issue has not been resolved. Interview with R#32 on 7/13/21 at 9:54 a.m. She stated she had the liquid eggs again this morning. According to this resident, she has written notes on the back of the meal tickets in addition to conveying this to staff including the dietary manager. Interview with R#32 on 7/14/21 at 9:18 a.m. R#32 advised she received powdered eggs, bacon, grits and a pancake. She stated that she wrote on her tray ticket again her concerns and preferences. R#32 also advised that each time she makes a request, she takes a picture on her mobile phone as proof that she has advised staff of the concerns. Interview with R#32 on 7/15/21 at 8:45. She advised that she had powdered eggs again though breakfast was palatable except for the eggs. Family interview via telephone on 7/15/21 at 2:03 p.m. via phone. R#32's family member advised that the resident complained about the powdered eggs two weeks ago. Interview with the Dietary Manager, Staff KK on 7/13/21 at 1:35p.m. revealed that she is aware of the two residents that have concerns about the eggs and named them. She also advised that the eggs are poured from a carton and that residents are vocal about their likes and dislikes. In addition to this, she stated residents write on their meal tickets and the contents of the notes are typed up as well as noted in their files. She also advised that care plan meetings are every Thursday, which updated information is conveyed. Staff KK revealed that when she became an employee of the facility October 2020, there were no updated food preferences, and she has made an effort to update the likes and dislikes on the meal tickets.