Based on observations, staff interviews, and review of the facility's policy titled, Heating, Ventilation, and Air Conditioning (HVAC), (Packaged Terminal Air Conditioner (PTAC)): Clean Air Filters, the facility failed to maintain a clean, homelike environment by not ensuring that the PTAC unit filters were free of debris in 2 of 48 rooms (A9, A8 located in A Hall) and failed to ensure PTAC unit grills were free of debris in 1 of 48 rooms (A8 located in A Hall) . The deficient practice had the potential to affect resident comfort, air quality, and infection control.Findings include: Review of the facility policy titled, Heating, Ventilation, and Air Conditioning (HVAC), (Packaged Terminal Air Conditioner (PTAC)): Clean Air Filters”, documented under section titled, Steps, 1. Remove or open access cover. 2. Remove air filter and inspect for cleanliness. If filter is dirty, either wash or replace depending on type of filter. If clean, reinstall filter. 3. Re-install access cover. 4. Clean grill on cover. 5. Close and make sure it is secure. 6. At a minimum, air filters are to be replaced or thoroughly cleaned depending on type of filter every three months. Observation on 8/4/2025 at 11:36 am and 8/25/2025 at 2:03 pm in Room A9 revealed gray, fuzzy debris on the PTAC filters. Observation on 8/4/2025 at 11:23 am and 8/5/2025 at 2:02 pm in Room A8 revealed gray, fuzzy debris on the PTAC filters and additional debris on the unit’s grill. Interview and observation on 8/7/2025 at 10:30 a.m. with the Maintenance Director (MD) revealed he is solely responsible for the inspection, cleaning, and upkeep of all PTAC units throughout the facility. He confirmed that the PTAC filters in Room A9 contained gray, fuzzy debris and that the PTAC filters and grill in Room A8 also contained debris. He emphasized that proper PTAC maintenance was critical for resident comfort, air quality, and infection control. He stated his expectation is that all PTAC units remain clean, fully functional, and resident-ready at all times, with routine cleaning and inspections conducted on a schedule. Interview on 8/7/2025 at 11:41 am with the Administrator revealed PTAC filters were to be cleaned monthly and whenever a resident was admitted or discharged . She stated that a possible negative outcome of unclean filters was compromised air quality, which could affect residents with respiratory issues in a healthcare setting. During an interview and observation on 8/7/2025 at 12:55 pm with the MD, he outlined the current efforts and plans in place to address ongoing facility repair needs and environmental improvements. Any unit reported to be malfunctioning or excessively dirty was addressed immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility policy titled, Infection Prevention and Control Program, the facility failed to maintain appropriate infection control practices by not using sterile procedure during tracheostomy care for one of 60 sampled residents (R) (R120), not storing respiratory equipment in an approved container for two of 60 sampled R's (R2 and R5), not protecting shared medical supplies from contamination during wound care for one of 60 sampled R's (R10), by storing personal items on clean linen carts, and by staff not adhering to contact precautions by entering a room with a sign for contact precautions without proper PPE (personal protective equipment). The deficient practices had the potential to contribute to the transmission of infectious organisms among residents, staff, and visitors.Findings include: A review of the facility's policy titled Infection Prevention and Control Program, dated June 2025 revealed under Policy Statement: Facility’s infection prevention and control policies/practices are intended to facilitate in maintaining a safe, sanitary, and comfortable environment and to prevent and manage transmissions of disease and infections. Under Standards of Practice: 1. The objectives of our infection control policies and practices are to: Prevent, detect, investigate, and control infections in the facility. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public. Establish guidelines for the availability and accessibility of supplies and equipment necessary for standard precautions. Maintain records of incidents and corrective actions related to infections. Provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment. Under PRECAUTION GUIDELINES…Use disposable or dedicated patient-care equipment (e.g., blood pressure cuffs). If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient. Review of the facility’s policy titled “Tracheostomy Care” revised 4/5/2024 revealed under Policy Statement: revealed under Purpose: Residents who have a tracheostomy will have trach care done as ordered by a physician or as needed to keep the airway clean and unobstructed. Under Procedure Guidelines: Clean The Removable Inner Cannula: … 2. Put on sterile gloves. 3. Set up supplies on a sterile field. … 9. Keep one hand sterile and one hand dirty. 1. Review of the electronic medical record (EMR) revealed resident R120 was admitted to the facility with pertinent diagnoses including but not limited to chronic respiratory failure with hypoxia (low oxygen levels in the blood), and hemiplegia and hemiparalysis following cerebral vascular accident. Review of R120’s five-day Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00, which indicated R120 was identified having severe cognitive impairment. Section GG, Functional Status, revealed R120 required extensive assistance for activities of daily living (ADLs) with one/two or more-person assistance. Section O, Special Treatments, Procedures, and Programs, revealed R120 receives continuous oxygen via tracheostomy. Review of R120 care plan dated 6/24/2025 indicated a problem of has a tracheostomy. Goals included but not limited to no signs and symptoms of infection through the review date. Interventions included but not limited to give humidified oxygen as prescribed, suction as necessary, use universal precautions. assist with coughing as needed. Review of the “Physician’s Orders” for R120 included but was not limited to: Order dated 7/9/2025 for Tracheostomy care every shift and prn using aseptic technique. Remove the inner cannula, clean with half strength H2O2 (peroxide) and sterile H20 (water), dry with sterile gauze and cotton swab. Re-insert the inner cannula, turn to lock. Clean outer cannula/stoma with sterile H20, rinse with sterile H20, pat dry with sterile gauze. May use split sterile gauze PRN (as needed). Observation on 8/6/2025 at 8:19 am Respiratory Therapist (RT) SS donned (put on) non-sterile exam gloves, opened sterile suction catheter and proceeded to suction R120’s tracheostomy. Interview on 8/6/2025 at 8:21 am with RT SS confirmed suctioning was a sterile procedure and sterile gloves should have been worn. RT SS also shared that the suction valve was only held while removing the suction catheter and R120 was suctioned about every three hours. An interview with the Director of Nurses on 8/7/2025 at 2:00 pm revealed using non-sterile exam gloves during suctioning of a trach was an unacceptable practice. 2. Review of R10’s quarterly MDS assessment dated [DATE] revealed a BIMS score of 10, indicating moderate cognitive decline, Section I, Active Diagnoses, revealed pertinent diagnoses including but not limited hypertension, renal insufficiency, and depression. Immediately after wound care observation on 8/6/2025 at 10:16 am on R10, RN GG placed the hand sanitizer back into the plastic bag without sanitizing the outside of the bottle or the clear plastic bag, transported the clear plastic bag into the hallway and placed the clear plastic bag onto the wound care dressing cart located in the hallway outside of the resident's room door. RN GG verbalized that her plan was to bring it out of the room and clean it with bleach wipe. 3. Review of R2’s quarterly MDS assessment dated [DATE] revealed a BIMS score of 0, indicating R2 was not able to complete, Section I, Active Diagnoses, revealed pertinent diagnoses including but not limited to heart failure, hypertension, non-Alzheimer’s dementia, and respiratory failure. Review of R5’s quarterly MDS assessment dated [DATE] revealed a BIMS score of 5, indicating severe cognitive decline, Section I, Active Diagnoses, revealed pertinent diagnoses including but not limited to hypertension, diabetes mellitus, and cerebral vascular accident (CVA). Observation on 8/4/2025 and 8/5/2025 revealed R2’s CPAP (continuous positive airway pressure) mask stored inside a cluttered nightstand drawer with miscellaneous personal items, including papers, coins, and loose debris. The mask was not in a clean, dry, dust-free container as per manufacturer guidelines and facility policy. Observation on 8/4/2025 and 8/5/2025 revealed R5’s CPAP mask placed on the seat of a bedside chair without protective covering. The surface contained visible dust and lint. Interview on 8/6/2025 at 3:45 pm with DON confirmed that CPAP masks should be stored in a clean, dry, dust-free container or designated storage bag to prevent contamination. The DON acknowledged the observed storage methods did not meet facility expectations. 4. Observation on 8/5/2025 at 12:43 pm revealed a linen cart containing a personal staff cell phone. Interview with laundry aide MM on 8/5/2025 at 12:43 pm confirmed that only linens should be stored inside the linen cart. However, she acknowledged storing her personal cell phone inside the cart, stating it was so her supervisor could reach her if needed. Interview with Certified Nursing Assistant (CNA) EE on 8/5/2025 at 12:48 pm revealed that she was not aware of any policy restricting items other than linen inside the linen carts and had not received any training specific to linen cart contents. Interview with LPN KK on 8/5/2025 at 12:56 pm revealed that she was unsure about any linen policy and stated that when deciding what items could be stored in the linen cart, “it depends on where it came from.” 5. Observation on 8/6/25 at 12:26 pm revealed Licensed Practical Nurse (LPN) BB enter room C6-P, which had signage for Contact Precautions related to Pneumonia- Methicillin-Resistant Staphylococcus aureus (MRSA), wearing only gloves and no gown, in violation of the facility's infection control expectations and signage instructions. Interview with LPN BB on 8/6/2025 at 12:30 pm confirmed she entered the isolation room without donning (putting on) a gown and acknowledged failure to follow Contact Precautions and further recognized the importance of PPE use and acknowledged the potential for spreading infection. Interview with Staff Development Coordinator (SDC) on 8/5/2025 at 2:46 pm and on 8/6/2025 at 5:20 pm revealed that she had not provided any training to staff on proper linen cart use and contents. Additionally, confirmed that for isolation precautions, staff should wear gowns, gloves, and goggles. Interview with Director of Nursing (DON) on 8/5/2025 at 3:20 pm and on 8/6/2025 at 5:05 pm confirmed that staff were expected to wear gown and gloves when entering Contact Precaution rooms and stated that the SDC is responsible for training clinical staff while the Director of Environmental Services trained laundry aides on clean linen carts. Additionally, they do not have a clean linen cart policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interview, and review of the policies titled Care Plan Policy and Smoking Policy for Residents, the facility failed to develop a care plan for three of 44 sampled residents (R) R108 for Post-Traumatic Stress Disorder (PTSD), R116 for dementia, and R126 for smoking. Findings include: Review of the facility's Care Plan Policy, reviewed 10/25/2022, revealed the policy is that each resident would have a plan of care to identify problems, needs, and strengths that would identify how the facility staff would provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Standards of Practice: Number 2. A care plan to identify past trauma would be developed through input of the resident and/or resident representative to prevent re-traumatization to the resident. Number 10. Areas of concern or potential concern and residents' strengths would be addressed with measurable goals and specific person-centered approaches to promote attainment or maintenance of the goal(s). 1. Review of the clinical record revealed R108 was admitted to the facility on [DATE] with diagnoses including anxiety disorder, schizoaffective disorder, and post-traumatic stress disorder (PTSD). Review of a Mental Health Note dated 6/8/2023 documented the resident was displaying symptoms indicative of PTSD, including agitation, irritability, hostility, hypervigilance, emotional detachment, and intrusive thoughts. Further review revealed R108 reported two men raped the resident on two occasions. Additionally, the resident reported a history of domestic violence, physical abuse, emotional abuse, kidnapping, and being forced to play Russian Roulette. The clinician diagnosed the resident with acute PTSD. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed R108 had a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment. Section revealed no moods exhibited; Section E behaviors revealed resident displayed rejection of care four - six days during look back period; Section I revealed a diagnosis of PTSD. Review of the current care plan revealed there was no comprehensive plan of care developed to address R108's diagnosis of PTSD. 2. Review of clinical record revealed R116 was admitted to the facility on [DATE] with a diagnosis of dementia with other behavioral disturbances and adjustment anxiety disorder. Review of the Significant Change MDS assessment, dated 12/15/2023, revealed R116 had a documented BIMS score of 10, indicating moderate cognitive impairment. Section D revealed the resident reported feeling down and depressed for two - six days of the look back period. Section I revealed a diagnosis of dementia. Review of R108's MD orders revealed an initial order for psych services on 6/6/2023, Seroquel (a medication used to treat mental health conditions) 23 milligrams (mg) by mouth daily at bedtime and Aricept (a medication used to treat symptoms of Alzheimer's disease) 10 mg by mouth daily at bedtime. Review of the current care plan for R116 revealed there was no comprehensive plan of care developed to address R116's diagnosis of dementia. Interview on 3/23/2024 at 8:32 am, Assistant MDS Coordinator (AMDS) revealed that she developed resident care plans by reviewing the resident's diagnoses and MDS assessments. She explained that staff discuss additional resident information during clinical meetings, and any changes to the care plans were added based on that information. During further interview, she stated that any behavioral or psych components of the care plan, including interventions, were handled by the Social Worker (SW). The AMDS did not know why there was no comprehensive care plan developed for R108 for PTSD. The AMDS acknowledged that R116 had no care plan for dementia and stated he did not know why one had not been developed. Interview on 3/23/2024 at 8:41 am, Social Worker (SW) stated based the residents' psych notes and recommendations and other clinical information, she tailored the residents' care plan to reflect any interventions or special needs the residents might have based on their diagnoses and symptoms. She stated she did not know the reason why R108 had PTSD and stated she had not reviewed the 6/8/2023 mental health notes. She indicated that if she had reviewed the notes, she would have personalized R108's care plan to reflect her symptoms and interventions. During further interview she acknowledged that R116 had a diagnosis of dementia, and verified there was no care plan developed. She stated R116 should have had a care plan for dementia developed but could not answer why one was not developed and added that it may have been overlooked. 3. Review of the facility policy titled Smoking Policy for Residents dated 9/1/2018, revealed the policy of the facility is to establish and maintain safe resident smoking policies in accordance with resident rights and preferences. Standards of Practice: Number 2. Residents who smoke will have a plan of care related to this activity. Review of the clinical record revealed R126 was admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, anxiety disorder, and convulsions. Further review revealed a smoking assessment was completed on 12/28/2023 indicating resident was safe to smoke and he signed a smoking contract on 12/29/2023 indicating that he understood the smoking policy and the rules. Review of the current care plan revealed there was no care plan developed to address R126 smoking. Interview on 3/23/2024 at 10:50 am, MDS Coordinator revealed that she is not responsible for developing and entering resident care plan for smoking. The MDS Coordinator stated that the activities department is responsible for developing resident care plans for smoking. The MDS coordinator confirmed that no smoking care plan had been developed for R126. The MDS Coordinator revealed that each department that is responsible for a certain section of the MDS assessment and there is no oversight to ensure all aspects of the residents care plan have been addressed. Interview on 3/23/2024 at 10:55 am, Activities Director (AD) revealed that the activities department is responsible for the development of care plans for residents who smoke. The AD confirmed that there was no care plan for R126 smoking, and stated it should have been, it was an oversite. Interview on 3/23/2024 at 12:35 pm, DON stated that she expects a care plan for smoking to have been developed for R126. The DON revealed that she expects each department to develop care plans for their assigned sections. During further interview, she indicated there is not a specific staff member to ensure all necessary areas are addressed in a resident care plan,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and review of the facility's Holiday Newsletter, policy titled Cleaning and Disinfecting Residents' Rooms, and the Material Safety Data Sheet (MSDS) for Rapid Multi Surface Disinfectant Cleaner, the facility failed to ensure the environment was free from potential accident hazards. Specifically, R2 had an electrical power strip lying in the bed with her, providing electrical to multiple devices. In addition, the facility failed to ensure a chemical spray bottle with cleaning solution was properly stored while not in use placing R82 at risk for exposure to the chemical. The sample size was 44. Findings include: Review of the facility's Holiday Newsletter Volume 5 Edition 12 dated December 2022, indicated extension cords are NEVER allowed in the facility. Extension cords are prohibited, except when used on a portable appliance, such as a vacuum cleaner. NFPA 70 440.8; IFC 605.4. Review of the policy titled Cleaning and Disinfecting Residents' Rooms reviewed November 2020 revealed General Guidelines: Number 3. Manufacturer's instructions will be followed for proper use of disinfecting products. c. Storage. Number 8. Use heavy-duty gloves (and other PPE as indicated) for housekeeping tasks. a. Gloves, protective eyewear and masks may be indicated to reduce exposure levels to disinfectant chemicals. Review of the MSDS for Rapid Multi Surface Disinfectant Cleaner revealed in Section 7. Handling and Storage - Advice on safe handling: Do not ingest. Do not get in eyes, on skin, or on clothing. Do not breathe dust/fume/gas/mist/vapors/spray. Use only with adequate ventilation. Wash hands thoroughly after handling. Conditions for safe storage: Keep away from strong bases. Keep out of reach of children. Store in suitable labeled containers. 1. Review of the clinical record revealed R2 was admitted to the facility on [DATE] with diagnoses of multiple sclerosis (MS), hypertension, muscle weakness, pulmonary embolism (PE) without acute cor pulmonale, and chronic pain. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status Score (BIMS) of 14 indicating little or no cognitive impairment. Section GG indicated R2 was dependent on staff for transfers and mobility with functional limitations in range of motion with impairments on both sides of lower extremities. Observation on 3/22/2024 at 9:41 am and at 11:19 am, revealed an electrical power strip lying in the bed with R2. The power strip was plugged into a wall outlet and the red light was illuminated indicating the power strip had power. The power strip had 3 cords plugged into it. Observation on 3/23/2024 at 9:48 am, revealed R2 was lying in bed. An electrical power strip was lying in the bed and positioned at the top left side of the bed, with the red indicator light illuminated, indicating the power was on. Interview on 3/23/2024 at 9:38 am, R2 informed surveyor that the power strip was placed on her bed approximately two weeks ago, and stated when it is on the floor, the cords plugged into the power strip come out and she was unable to use them. Interview on 3/23/2024 at 9:52 am, Certified Nursing Assistant (CNA) NN revealed she provided care for R2 on 3/22/2024 and today and was aware the electric power strip was on the bed. During further interview, CNA NN stated that she was aware the power stirp should not be on the bed due to the potential risk for fire. She stated she had entered a work order into the electronic system on 3/18/2024 but had not reported the issue to a supervisor. Review of the facility's electronic work order record dated 3/17/2024 through 3/22/2024 revealed no evidence of a work order for the maintenance department related to the power strip in use by R2. Interview on 3/23/2024 at 9:57 am, Assistant Director of Nursing (ADON) revealed during compliance rounds this morning, she assisted R2 her with her breakfast. She stated she did not notice the power strip in her bed at the time. During further interview, the ADON confirmed that the power strip should not be placed on R2's bed, and stated whoever knew it was there, should have removed it immediately. Interview on 3/23/2024 at 10:10 am, Director of Nursing (DON) revealed a resident should never have a power strip in the bed. She further stated the power strip should have been removed immediately and the supervisor informed. Interview on 3/23/2024 at 11:17 am, Assistant Maintenance Director MM revealed he checks the electronic maintenance system several times a day for repair issues needed in the facility. He stated he had not seen anything in the electronic system related to a power strip being used in a resident's room, until today. The Maintenance Assistant reviewed all work orders entered into the electronic system from 3/17/2024 through 3/22/2024 and verified a work order had not been previously entered into the system. 2. Review of clinical record revealed R82 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, chronic systolic congestive heart failure, chronic obstructive pulmonary disease (COPD), dementia with behavioral disturbances, and generalized anxiety disorder. Review of the admission MDS assessment dated [DATE] revealed a BIMS of 12 indicating moderate cognitive impairment. Section GG revealed the resident is independent with ambulation. Observation on 3/23/2023 at 8:48 am in room C12, R82 was ambulating from the bathroom using a rolling walker. The surveyor observed an unlabeled spray bottle of cleaning solution sitting in front of the television. Certified Nursing Assistant (CNA) KK was observed to pick up the bottle of cleaning solution and place it behind the television. This action was verified by Licensed Practical Nurse (LPN) Unit Manager (UM) BB, who removed the cleaning solution from the room and stated it should not be there. Interview on 3/23/2024 at 8:59 am, CNA KK stated she should have removed the cleaning solution from the room. During continued interview, she stated she was aware that it was not supposed to be there, which was why she placed it behind the television when she saw a surveyor standing in the room. Interview on 3/23/2024 at 10:22 am, Housekeeper LL stated she was asked to clean the sticky floor in room C12. She revealed she was rushing to clean the floor because the breakfast trays were on the unit to be delivered, and she knew she was not allowed to clean during meal service. She stated she was aware that cleaning solutions/chemicals should never be left in residents' room, and stated it was left there by mistake. During further interview, she identified the contents of the spray bottle cleaning solution as Rapid Multi-Surface Disinfectant Cleaner. Interview on 3/23/2024 at 10:43 am, Director of Environmental Services revealed the bottle of cleaning solution left in R82's room contained Rapid Multi-Surface Disinfectant Cleaner and verified it should not have been left in the room. She stated the housekeeping staff are trained to not put chemicals/cleaning solutions down in resident's rooms, but to return it to the cleaning cart immediately after each use. Interview on 3/23/2024 at 11:21 am, Administrator revealed that cleaning chemicals should never be left in a resident's room unattended. She stated the CNA was aware that the cleaning chemical should have been removed, and stated she became nervous when she saw a surveyor in the room. During further interview, the Administrator revealed residents should not have a power strip lying in the bed at any time. She stated the facility did not have a policy related to electrical power strips or a policy that addressed accidents and hazards. She provided a newsletter addressing extension cords, which was given to residents and their families.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the facility policy titled, Notification of Resident's Change in Condition, the facility failed to ensure the physician was immediately notified when resident (R) R#32, complained of pain following a fall for one of three residents reviewed for falls. Findings include: Review of the facility policy titled, Notification of Resident's Change in Condition, revised September 1, 2019, indicated, Standards: This facility will promptly notify the resident, his or her attending physician, and Responsible Party of changes in the patient's medical/mental condition and/or status. Action: 1. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician when there has been: a. An accident or incident involving the patient. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed that R#32's Brief Interview for Mental Status (BIMS) score was nine, indicating moderate cognitive impairment. Resident required supervision with one-person assistance for transfers and set-up only for walking in the room. R#32 had one fall with major injury and one fall with no major injury since admission or prior assessment. Review of care plan, revised on 1/18/22, revealed the resident had a pubis fracture related to a fall. Interventions included monitoring/documenting the resident's pain on a scale of 0 to 10 before and after implementing measures to reduce pain. Review of the Nurses' Notes dated 1/4/22 at 6:30 p.m., revealed the nurse observed the resident lying on her back on the floor. The resident reported she was getting ready to sit on the commode and lost her balance. The nurse assessed the resident, then assisted her back to bed. During further review, the Nurse's Notes indicated R#32 sustained a hematoma to the back of the head and a cold compress was applied. The resident denied pain and was able to move upper and lower extremities. The note indicated the physician, and a family member were informed. Review of the Nurses' Notes, dated 1/5/22 at 2:00 a.m. and signed by Licensed Practical Nurse (LPN) II, revealed R#32 was alert and able to make her needs known. The note indicated the resident complained of pain to the buttocks and left anterior thigh but was able to move the leg with little discomfort. Tylenol was administered. The note also indicated the nurse would continue to monitor. There was no documentation to indicate the physician was consulted regarding the resident's complaint of post-fall buttock and thigh pain. Review of the Nurses' Notes, dated 1/9/22 at 11:22 p.m. and signed by Registered Nurse (RN) KK, revealed that upon assessment, resident was unable to walk like used to be. The nurse notified the physician and received an order for bilateral hip x-rays. Review of Nurses' Notes, dated 1/9/22 at 4:04 p.m., revealed R#32 was observed in bed and reported pain to the left hip related to the recent fall. The note indicated an order was received for bilateral hip x-rays. Review of the Radiology Report, dated 1/9/22 at 9:01 p.m. revealed there was an acute fracture of the resident's left pubic rami with mild displacement and modest osteoarthritis, but no left hip fracture. Review of a Communication note dated 1/11/22 at 10:41 a.m. revealed a call was placed to R#32's family member to discuss the x-ray results and transfer to the hospital. The note indicated the x-ray showed a pelvic bone fracture, degenerative disease, osteopenia, and osteoarthritis. The note also indicated the resident was not a candidate for surgical intervention and would return to the facility from the hospital once her blood pressure was stabilized. During an interview on 3/30/22 at 10:15 a.m. with LPN II stated when a resident was found on the floor, she would assess them for injuries and pain. She would then notify the family and physician, as well as follow any orders that were given. LPN II stated R#32 used the toilet independently but was a high fall risk. During further interview, she stated R#32 had a fall on 1/4/22, complained of pain, and an x-ray was ordered a few days later. LPN II was asked why the x-ray was not ordered until 1/9/22, when resident complained of pain to the left anterior thigh and buttocks on 1/5/22? LPN II stated they did not correlate R#32's complaints of thigh and buttock pain to the fall that occurred the previous day. She stated she administered pain medication to the resident but did not notify the physician about her complaints of pain. During an interview on 3/30/22 at 10:30 a.m. with RN KK revealed resident was independent with toileting. She stated that LPN JJ notified her on 1/4/22 that R#32 was found on the floor of the bathroom. During further interview, she stated LPN JJ assessed R#32 and she was able to move all extremities with no complaints of pain and R#32 was able to ambulate back to bed with assistance. She revealed when R#32 complained of pain on 1/9/22, she notified the physician, who then ordered an x-ray. During an interview on 3/30/22 at 10:40 a.m. with LPN JJ stated she found R#32 on the floor on 1/4/22 and R#32 did not complain of pain at that time. She stated R#32 could move all extremities and was able to ambulate back to bed with assistance immediately following the fall. LPN JJ further stated it was normal practice to wait a few days after a fall to get an x-ray if a resident complained of pain. She stated that if R#32 had complained of pain the day after a fall, she would have notified the physician to get an x-ray. During further interview, LPN JJ stated did not know why the facility waited five days to get an x-ray for R#32. During an interview on 3/30/22 at 12:55 p.m. with the Medical Director (MD) HH stated if the facility notified him when a resident had a fall and there were complaints of pain, he would order an x-ray. MD HH then stated he did not remember if the facility notified him when R#32 complained of pain on 1/5/22 following the fall on 1/4/22. During an interview on 3/31/22 at 11:42 a.m. with the Director of Nursing (DON) stated when a resident had a fall, the nurse would do a fall, pain, and skin assessment, then notify the responsible party, and physician for any follow-up orders. The DON further stated she expected the nurses to notify the MD if a resident complained of pain following a fall to get an order for an x-ray if needed. During an interview on 4/1/22 at 10:55 a.m. with the Administrator, stated she expected the nursing staff to notify the MD if a resident was complaining of pain following a fall. LPN II administered Tylenol to the resident for pain and should have notified the physician of R#32's complaints of pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to ensure showers were regularly provided as scheduled and facial hair was removed when needed for one resident (R) #58 of three sampled residents reviewed for activities of daily living (ADLs). Findings include: Review of the admission Record revealed R#58 was admitted to the facility on [DATE] with diagnoses which included chronic kidney disease and essential hypertension. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed that R#58 was moderately impaired in cognitive skills for daily decision-making per staff assessment for mental status. R#58 was dependent on two-plus person physical assistance for bathing and required extensive assistance of one person for personal hygiene, including shaving. Review of the care plan, revised 8/17/21, revealed a goal to have R#58's ADL needs met. The interventions indicated the resident was totally dependent on one staff member to provide a bath/shower and was totally dependent on one staff for personal hygiene and oral care. A review of Hospice Aide Visit Notes revealed for the month on January 2022, R#58 was provided a complete bed bath two times, 1/3/22 and 1/10/22. For the month of February, R#58 was provided a complete bed bath seven times in February 2022, on 2/2/22, 2/9/22, 2/11/22, 2/16/22, 2/18/22, 2/23/22, and 2/25/22. For the month March 2022, R#58 was provided a complete bed bath six times in March 2022, on 3/2/22, 3/9/22, 3/11/22, 3/16/22, 3/18/22, 3/30/22. A review of the Visual/Bedside [NAME] Report, used by the certified nurse aides (CNAs) as a quick reference on the type of care a resident required, indicated R#58 received hospice services and was totally dependent on one staff member to provide the bath/shower, personal hygiene, and oral care. Observations on 3/28/22 at 1:21 p.m. and 3:54 p.m., R#58 was lying in bed in her room, wearing a blue gown. The resident's hair was greasy and uncombed. There was long facial hair on her chin and upper lip. Review of the Shower/Bath Sheet, dated 3/29/22, indicated R#58 received a shower on the 6:00 a.m. to 2:00 p.m. shift. The sheet indicated the resident's linens were changed, her hair was washed, and she was shaved. However, observations on 3/30/22 revealed R #58 still had facial hair and her hair was still greasy. Observation on 3/30/22 at 8:40 a.m., 3/31/22 at 9:27 a.m. and 4/1/22 at 9:28 a.m., R#58 was lying in bed in her room. The resident's hair was greasy and uncombed, and the resident had long hairs on her chin and upper lip On 4/1/22 at 10:18 a.m., surveyor attempted to call CNA JJJ, who documented on the shower sheet that the resident received a shower on 3/29/22. Message was left for the CNA to return call but had not received a return call as of the end of the survey. On 4/1/22 at 10:47 a.m., an interview was attempted with R#58's hospice provider. There was no response by the end of the survey. Interview on 3/31/22 at 11:24 a.m., the Director of Nursing (DON) stated the CNA's gave showers at least twice a week. The DON stated it was brought to her attention that the baths were being documented every shift, every day, instead of when they were provided. The DON stated if the resident was on hospice, the hospice CNA would usually give the bath/shower, but if they were not able to provide it, then the facility staff would. She stated the resident's hair should be shampooed once a week or per the resident's preference, and the resident should be shaved as needed, regardless of whether they were male or female. The DON stated she was not aware R#58 was not getting routine baths. Interview on 4/1/22 at 8:44 a.m., with Licensed Practical Nurse (LPN) CCC, revealed hospice came to see the resident two to three times a week and that hospice provided the showers for R#58. Interview on 4/1/22 at 9:28 a.m., with LPN FFF, revealed hospice provided bed baths for R#58 two to three times a week. She stated the resident required a bed bath and was unable to have showers, because the resident's legs were too contracted to get on a shower gurney. LPN FFF stated the hospice CNA should be washing the resident's hair at least once a week and shaving them as needed. LPN FFF agreed R #58 had long facial hair and needed to be shaved. She stated she was going to have a facility CNA shave the resident since it had not been done. LPN FFF stated if hospice was unable to give the resident a bed bath, then the facility staff would do it. Interview on 4/1/22 at 9:52 a.m., with CNA GGG, revealed showers were given two to three times a week depending on the resident, and their hair should be washed once a week or as needed. CNA GGG stated both male and female residents should be shaved if needed, on their shower days. CNA GGG stated she did not know if hospice documented the showers they gave. She stated she did not document showers for R#58 since they were given by hospice. She stated the hospice CNA should also be shaving the resident. Interview on 4/1/22 at 10:07 a.m., with Registered Nurse (RN) HHH, revealed showers were done two to three times a week, depending on the resident's preference. She stated hospice provided showers to their residents, and the facility would only do the shower if hospice was unable to. Interview on 4/1/22 at 10:52 a.m., the Administrator stated the facility staff had identified a problem with the documentation of showers when they were monitoring resident grievances. She stated she expected the staff to offer showers and not just bed baths. She stated if hospice did not show up to provide care for one of their residents, then the facility staff should provide the care instead. The Administrator stated shaving should also be offered with showers for men and women.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and review of facility policies, the facility failed to ensure causative factors for falls were investigated and documented, interventions were developed and implemented to address the causative factors, and care planned interventions to prevent falls were consistently implemented for one resident (R) R#46, of three sampled residents reviewed for falls. Findings include: Review of the facility policy titled, Fall Prevention Protocol Policy, dated 9/1/18, revealed 4. After an incident of a fall: a. Complete the Post Fall Risk Assessment; b. Notify MD [medical doctor] and Resident Representative; c. Start neuro [neurological] check if there is a suspected head injury or for an unwitnessed fall as per facility protocol; d. Complete pain assessment after the fall; e. Fall placed on the 24-hour report; f. Refer to therapy or restorative nursing as deemed appropriate; g. Referrals, interventions, care plan updated completed in the clinical meeting; and h. Review fall incident during the clinical meeting with a root-cause analysis. Review of the facility policy titled, Incident Report - Documentation, Investigation, and Reporting, revised 9/20/2021, revealed 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident and then notify of the Director of Nursing (DON) and Administrator. 2. The Charge Nurse at the time of the incident is responsible for documenting the incident in the resident's medical record. The nurse notes should contain the following documentation: a. Clear, objective facts of what occurred; b. A thorough assessment of the resident's condition at the time of the accident/incident. (This assessment should include a description of the resident, vital signs, and any other physical characteristics apparent as a result of the accident/incident), c. Any quotes by the resident and/or witness involved or present at the time of the accident/incident; d. Any treatment provided; e. Any contacts made or attempted with the resident's physician, family, legal representative or any other health care professional or person involved with the resident's care; f. The resident's outcome and any information concerning the incident; and g. The nurse's signature, date and time of the charting. The policy indicated the following information should also be included on the incident report, if applicable, 5. The supervisor designee is to document the investigation of the event and the interventions put into place. They will ensure that the care plan is updated, that the medical record contains documentation of the event, and that the resident has been added to the 24-hour report. 6. Indicate the follow up intervention put into place to prevent reoccurrences. Review of the clinical record for R#46 revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to left femur fracture, right patella (knee) fracture, muscle weakness, lack of coordination, osteoarthritis, disorder of bone density, and a history of falls. The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. Section G revealed resident required extensive assistance of two-plus people for activities of daily living (ADLs). The resident used a wheelchair as a mobility device and the resident had no falls since the prior assessment. Review of the care plan revised 12/21/2021, revealed resident was at risk for falls and had a history of falls related to poor balance, poor communication/comprehension, and unsteady gait. Interventions included Physical therapy (PT) to evaluate and treat as needed (PRN), provide clutter free environment with unobstructed pathways for wheelchair mobility, place resident at nursing station for observation, maintain in high traffic areas when out of bed to wheelchair, encourage/remind resident to use call light and call for assistance. Keep call light in reach, encourage resident to call for assistance with transfers/mobility, frequent rounds while in wheelchair, provide extensive assist of one to two with transfers/mobility, place essential items in reach. Review of an Incident Report, dated 6/21/2021 at 5:30 p.m., revealed R#46 was observed lying on the floor on her stomach with her legs stretched out under a wheelchair. The report indicated the resident stated she fell on her knees picking up paper from the floor. A complete body assessment was done, and the right knee was noted to be red, slightly swollen, warm, and tender to the touch. The report indicated nurse practitioner (NP) was notified, who then ordered an x-ray. The report indicated there were no predisposing environmental, physiological, or situational factors that contributed to the fall and no witnesses to the fall. Per the report, no immediate interventions were initiated to prevent the resident from falling again. Review of the Fall Risk Assessment dated 6/21/2021 at 6:41 p.m. revealed a score of 12. According to the Instructions a score of 10 or greater indicated the resident should be considered at high risk for falls and a prevention protocol should be immediately initiated and documented on the care plan. Review of care plan revised 6/21/2021 revealed R#46 was to be sent to emergency room for evaluation and an orthopedic referral for a knee injury. No interventions were documented to prevent the resident from falling again per the care plan. Continued review of the care plan documented resident had four additional falls in four months. Review of the Nurse's Note, dated 6/22/2021 at 8:30 a.m., revealed the resident was transferred to emergency room due to an abnormal x-ray result. Review of the Nurse's Note, dated 6/22/2021 at 3:30 p.m., indicated the resident returned to the facility with an immobilizer to the right leg. Review of the Physical Therapy Treatment Encounter Note, dated 6/23/2021 revealed R#46 was diagnosed with a patellar fracture, was fitted with a knee immobilizer, and was to be non-weight-bearing (NWB) with the knee immobilizer on at all times. The note indicated the resident was waiting for a follow-up appointment with an orthopedic doctor. Review of an Incident Report, dated 7/24/2021 at 9:46 p.m., revealed Certified Nursing Assistant (CNA) was doing rounds and observed R#46 on the floor beside the bed. Per the report, the CNA notified the nurse. The report indicated the nurse performed a range of motion (ROM) assessment on the resident, which was within normal limits (WNL), with the knee immobilizer to the right knee intact. The report indicated the resident was confused, there were no predisposing environmental factors, and the bed was in the lowest position. During further review, the report indicated there were no witnesses and that notifications were made to the family and physician. Per the report, no immediate interventions were initiated to prevent the resident from falling again. Review of the care plan updated on 7/24/2021, following a recent fall, denoted an intervention for a medication review was to be conducted; however, there was no documentation that the medication review was completed. Review of Physical Therapy Treatment Encounter Notes dated 7/26/21 revealed no documentation that R#46 had a fall the previous day or of new interventions implemented for the resident's safety; however, the note indicated the resident received bed mobility training, standing pivot transfer training, and postural training during the therapy session. Review of an Incident Report dated 10/3/21 at 8:04 a.m. revealed resident was observed lying on her back on the floor with complaints of pain to the right knee. The report indicated the resident stated she was reaching for the wheelchair and slid off the bed to the floor onto her knees. Further review indicated both knees were red, and the resident was medicated for pain. Per the report, neurological checks were initiated, and an x-ray was ordered of the bilateral knees. The note indicated the resident had a dislocation of the left knee. The report noted there were no predisposing environmental, physiological, or situational factors related to the fall. The report indicated there were no witnesses to the event and that notifications were made to the family and physician. No immediate interventions were initiated to prevent the resident from falling again according to the report. Review of an eInteract Change of Condition Evaluation dated 10/3/2021 indicated R#46 had a fall at 8:24 a.m. and resident's bilateral knees had redness with no swelling, though the resident complained of pain. The evaluation indicated the resident was medicated for pain, the physician was notified, and orders were received for an x-ray of the bilateral knees. Review of Physical Therapy Treatment Encounter Note dated 10/4/2021 indicated the resident was being trained on techniques to improve the ability to self-support on the edge of the bed for increased safety and techniques to improve postural stability. The note did not reference the resident's fall from the previous day. Review of care plan updated 10/3/2021 following residents recent fall, to include encouraging the resident to call for assistance and obtaining a right knee x-ray. However, encouraging the resident to call for assistance was a not a new intervention, and the order to obtain an x-ray was not a fall prevention intervention. Review of the Incident Report, dated 10/14/2021 at 7:28 a.m. indicated R#46's roommate called out for help and a CNA entered the room and found R#46 lying on the floor with her head toward the end of the bed. Per the report, the resident stated she was trying to get in her wheelchair. The report indicated a head-to-toe assessment was done with no injuries noted, and the resident was able to move all extremities. The report indicated the resident was assisted back to bed and was provided with incontinence care and fluids. The report revealed the resident then began to complain of pain to the right foot and right knee, rated at a severity of four (on a scale of one to ten, with ten being the worst possible pain). The report indicated the resident was administered pain medication, which decreased the pain level to a three. The report indicated there were no predisposing environmental and physiological factors but did list ambulating without assistance as a predisposing situational factor. The report indicated there were no witnesses, and notifications were made. The report revealed the resident was encouraged to always use the call light to call for help, and the bed was placed in the lowest position. Review of an eInteract Change in Condition Evaluation dated 10/14/2021 at 1:26 p.m. indicated R#46 had a fall that morning while trying to transfer without assistance from the bed to the chair. The evaluation indicated the resident had no injury though there was discoloration to the right foot. Per the evaluation, the resident was medicated for complaints of pain to the foot and right knee. Review of the Fall Risk Assessment dated 10/14/2021 indicated a score of 14, which indicated the resident remained at high risk for falls. Review of Physical Therapy Treatment Encounter Notes, dated 10/15/2021, revealed no documentation of the resident's fall the previous day nor any new interventions implemented for the resident's safety; however, the note indicated the resident participated in gait training, therapeutic activities to increase functional skills, and bed mobility and transfer skills. Review of the care plan updated on 10/14/20/21 revealed an intervention of placing residents' bed in the lowest position. Review of the Incident Report dated 10/23/2021 at 6:40 p.m. revealed a nurse heard R#46 screaming and entered the room to find R#46 lying on her left side on the floor between the bed and the window. The report indicated the resident stated she was trying to put some books in her bag when she fell. The report indicated the resident was unable to move her left leg without screaming in pain and stated, I can't move my left leg. It hurts real bad. The report noted the resident was rolled onto a sheet and lifted to the bed by four staff members. Per the report, the NP was notified and ordered the resident to be sent to a hospital. The report indicated there were no predisposing environmental factors, that impulsiveness was a predisposing physiological factor, and that predisposing situational factors included the call light being within reach and the bed being in the lowest position. The report indicated there were no witnesses, and that notifications were made to the resident representative. Review of an eInteract Change in Condition Evaluation dated 10/23/2021 indicated R#46 was heard screaming and was found lying on her left side on the floor complaining of severe pain to the left hip area, rated at a severity of ten (on a scale from one to ten, with ten being the worst possible pain). The evaluation indicated the primary care clinician was notified with recommendations to send the resident to the hospital for evaluation. No other interventions were documented. Review of the Fall Risk Assessment dated 10/23/2021 revealed a score of 15 for R#46, which indicated the resident remained at high risk for falls. Review of an admission Note, dated 10/28/2021 at 4:30 p.m. revealed the resident returned to the facility via stretcher and was able to move her arms and right leg independently but was unable to move the left leg. The note indicated the resident had an elastic bandage to the left upper thigh from a surgical procedure done on the left femur, and staples were present to the surgical site. Review of a Nurse's Note, dated 10/29/2021 at 7:15 p.m. revealed the resident complained of pain and discomfort to the left hip related to fracture. Interview on 3/30/2022 at 3:55 p.m. with Licensed Practical Nurse (LPN) LL, stated when a resident fell, they were assessed by an LPN or supervisor, the family and physician were notified, and if required, the resident was sent to the hospital for x-rays or received in-house x-rays, if possible. During further interview, she stated when implementing new interventions, they look at the care plan to see what is already in place and call the manager or Director of Nursing (DON) and discuss with them what interventions to put into place to prevent another fall. She revealed that the facility did not update the care plan every fall, only falls with injury, and the care plan was updated by the MDS staff. She stated they did tell the resident to use her call light. Interview on 3/31/2022 at 9:32 a.m. with LPN FFF, stated after a resident fell, they were assessed for injury and, moved back into the bed or wheelchair to do a full body assessment. She stated the incident report asked what interventions were put into place at the time of the fall, and then at the morning meeting, the interventions were discussed with the nursing team, and they care planned it. She stated she was the nurse working when R#46 fell and broke her femur in October of 2021. After reviewing the incident report from that fall, LPN FFF stated the resident was sitting up in her wheelchair and was trying to put books away and fell. She stated the resident was able to go where she wanted, and the LPN was not aware of an intervention to keep the resident in a high traffic area. Observation on 3/31/2022 at 9:50 a.m. revealed R#46 was lying in bed, and the bed was not in a low position. Interview on 3/31/2022 at 9:50 a.m. with CNA GGG stated she was assigned to float and not assigned to any hall. She stated she was unsure if R#46 was a high fall risk and was not aware of any fall precautions for her. She stated she did not know if the resident was supposed to be in a low bed. CNA GGG observed the resident in bed at this time and confirmed the bed was not in a low position. Interview on 3/31/2022 at 9:57 a.m. with LPN CCC stated R#46 had been doing well with therapy and had no falls since fracturing her leg in October of 2021. She stated fall interventions for R#46 included a low bed but checked and confirmed R#46's bed was not in a low position at that time. Interview on 3/31/2022 at 11:24 a.m. with the DON, stated after a fall, the nurse performed an assessment of the resident and completed a fall, pain, and skin assessments. She stated the physician and responsible party should be notified of a fall and the nurse may put in a progress note. Per the DON, nursing administration reviews falls to determine whether the fall was documented and whether the skin and pain were assessed. The DON stated they did not do a formal investigation of the falls, but they were discussed in the morning clinical meetings, and they look at the documentation and the circumstances to know what type of interventions to put into place. She stated the MDS staff update the care plan with the interventions. She stated they were not documenting the root cause of falls, even though they were having a meeting and discussing it. The DON stated after R#46's fall in June of 2021, according to the care plan, the resident was sent to the emergency room for an orthopedic evaluation and no interventions were put into place after the resident returned to the facility. She also stated after the 10/23/2021 fall, according to the care plan, the resident was sent to the emergency room for evaluation and when the resident returned to the facility, no new interventions were initiated. She stated new interventions should have been initiated after each of these falls. Interview on 4/1/2022 at 10:52 a.m. with the Administrator, stated after a resident fell, a nurse should assess the resident for pain, fall risk, and injuries, and then, during the clinical meetings, the fall would be discussed to determine interventions and make referrals to therapy. She stated the facility had a performance improvement plan (PIP) for falls to include that an investigation should be done at the point of the event and statements should be collected from the staff. She said this information should be reviewed by the clinical nurse manager and therapy for proper documentation, noting they were expected to look at the environment for causes and any needs the resident had, such as bathing or toileting, and a review of behaviors. The Administrator stated she expected the fall with interventions to be documented on the incident report. She stated the incident report was an internal record and not part of the medical record, so a narrative note should be documented in the medical record to reflect what was on the incident report.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the facility policies titled, Physician Order Review Process and Medication and Treatment Orders, the facility failed to ensure a psychiatric consultation was provided in accordance with the physician's order for one resident (R) R#7, of five residents reviewed for unnecessary medications. Findings include: Review of the facility policies titled, Physician Order Review Process dated 9/1/2018, and Medication and Treatment Orders dated 11/28/2017, revealed the policies did not specifically address the facility's process for following physician orders for psychiatric consults. Review of the admission Record revealed R#7 was admitted to the facility on [DATE] with diagnoses which included hemiplegia (paralysis) and hemiparesis (weakness) following unspecified cerebrovascular disease affecting left dominant side, diabetes, hypertension (HTN), dementia, and anxiety. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that R#7 had a Brief Interview of Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. The resident had trouble falling or staying asleep almost every day. R#7 exhibited behavioral symptoms not directed toward others daily. The resident received antipsychotic medication seven days out of the seven-day assessment period and antianxiety medication one day out of the seven-day assessment period. R#7 did not receive any psychological therapy by any licensed mental health professional in the last seven days. Review of the care plan revised 2/22/2022 revealed resident has impaired cognitive function/dementia or impaired thought process related to dementia. He has episodes of yelling out at times. Interventions to care include administering medications as ordered, providing behavioral health consults as needed, and assisting the resident with a meaningful program of activities. Review the Order Summary Report revealed R#7 had a physician's order dated 2/17/2022 for a psychiatric (psych) consult. Review of the Nurses' Notes dated 2/17/2022 at 1:44 p.m. revealed the physician ordered a psychiatric (psych) consult for R#7, and to increase the resident's lorazepam to one milligram (mg) every six hours as needed (PRN). The note was signed by Licensed Practical Nurse (LPN) PP. Interview on 3/31/2022 at 12:20 p.m. with LPN CCC, stated when the physician writes or gives a verbal order for a resident to receive a psychiatric consult, the nurse should give the order to the social worker, who would then add the resident to the list for the psychiatric nurse practitioner to see. Interview on 3/31/2022 at 12:23 p.m. LPN PP stated she would give all orders for psychiatric consults to the secretary to set up an appointment. Interview on 3/31/2022 at 12:28 p.m. with the Director of Nursing (DON), stated the nurses should give any orders for a psychiatric consult to the social worker, who would then contact the psychiatric nurse practitioner. Interview on 3/31/2022 at 2:47 p.m. with the Social Worker LLL, stated if a resident had a psychiatric consult, she would add them to the list of residents for the psychiatric nurse practitioner to see on her next visit in the building. Social Worker LLL further stated she was not aware that R#7 had a written physician's order for a psychiatric consult. Interview on 3/31/2022 at 2:58 p.m. with the DON, stated she expected all physician's order to be followed, including referrals for psychiatric services. During further interview, she stated the nurse who received the order should have given it to the SW, who keeps a list for the psychiatric nurse practitioner to see on her next visit. Interview on 3/31/2022 at 3:31 p.m. with the psychiatric nurse practitioner, stated she had not seen R#7 for a psychiatric consultation. She further stated the SW would notify her of all referrals and confirmed she had not received a referral for R#7. Interview on 4/1/2022 at 9:00 a.m. with the Secretary XX, stated she sets up appointments for residents, but if a resident had an order for a psychiatric consult, the nurse would give the order to the SW to set up the referral. Secretary XX stated she had not received any physician orders for psych consults. Interview on 4/1/2022 at 10:55 a.m. with the Administrator, stated she expected the nurse to give an order for a psychiatric consultation to the SW, who then notified the psychiatric nurse practitioner to see the resident on the next visit. The Administrator stated there was no documentation that R#7's psychiatric consultation was given to the psychiatric nurse practitioner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews, and review of a facility policy titled, Controlled Substances, the facility failed to ensure controlled substances were accurately documented on a destruction form for 4 of 59 controlled substances reviewed. Findings include: A review of the facility's policy titled, Controlled Substances, revised [DATE], indicated Standards: The facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled medications. Number 14. Controlled medications remaining in the facility after the order has been discontinued or expired are retained in the facility in a securely locked area with restricted access until destroyed by two licensed clinicians or as otherwise directed by state regulation. Interview on [DATE] at 3:08 p.m. with the Director of Nursing (DON), stated Schedule II controlled medications were double locked in the DON's office. Per the DON, the pharmacist came to the facility approximately once a month to complete medication destruction. She stated the procedure for destruction is to place the medications in cat litter or coffee, with water added and placed in a sharp's container. During further interview, she stated a biohazard company picks up the biohazard containers and removes them from the facility. The DON stated the facility's records of receipt and disposition of controlled medications were documented on a carbon copy form, which was signed by three staff members (the DON, the pharmacist, and another nurse) when the medications are destroyed. The DON provided a Certificate of Inventory and Destruction form that was dated [DATE]. Review of the Certificate of Inventory and Destruction form dated [DATE] revealed there were three signatures at the bottom: the DON, Licensed Practical Nurse (LPN) YY, and Licensed Pharmacist (LP) EE. The DON stated that she filled out the form and verified it was her handwriting. There were three liquid medications that did not indicate an amount destroyed. All other oral medications had an amount listed as destroyed. The DON stated she did not know why she did not include the liquid amount but stated they were destroyed. She stated that all wasted medication should have an amount listed on the form. Further review of the Certificate of Inventory and Destruction, dated [DATE], indicated resident (R) R#9 had Vimpat (an anticonvulsant), with no strength or amount destroyed documented. R#160 had morphine (an opioid pain reliever) with a strength of 100 milligrams (mg) per 5 milliliters (ml), with no amount destroyed documented. R#158 and R#159 had morphine 100 mg per 20 ml, with no amount destroyed documented. A review of Controlled Drug Record - Liquids, Multidose for R#9 revealed the amount of Vimpat that should have been documented on the Certificate of Inventory and Destruction form was 20 ml. A review of Controlled Drug Record - Liquids, Multidose for R#160 revealed the amount of morphine that should have been documented on the Certificate of Inventory and Destruction form was 15 ml. A review of Controlled Drug Record - Liquids, Multidose for R#159 revealed the amount of morphine that should have been documented on the Certificate of Inventory and Destruction form was 13.75 ml. A review of Controlled Drug Record - Liquids, Multidose for Resident #160 revealed the amount of morphine that should have been documented on the Certificate of Inventory and Destruction form was 28.5 ml. Interview on [DATE] at 3:53 p.m. with Licensed Pharmacist (LP) EE, stated the DON should complete the Certificate of Inventory and Destruction before the Pharmacist arrived at the facility. The LP clarified that the numbers listed on the morphine medications were the strength in milligrams per milliliters. LP EE stated that he must have looked at the Controlled Drug Record - Liquids, Multidose form, along with the medication, and verified the amount that was wasted. Phone interview on [DATE] at 5:05 p.m., LP EE stated he had reviewed his carbon copy of the Certificate of Inventory and Destruction form and confirmed that he signed off that all medications that were wasted and did not know why the form did not include the amount wasted. LP EE again stated he had compared the Controlled Drug Record - Liquids, Multidose form with the medication that was wasted. Interview on [DATE] at 10:49 a.m. with the Administrator stated the Pharmacist and the DON destroyed the medications together. The Certificate of Inventory and Destruction form was provided to the Administrator, who stated that the form did not show how much medication was destroyed and that it should have been filled out completely. The Administrator stated they had never had an issue before with medication destruction. Interview on [DATE] at 11:02 a.m. with LPN YY verified that her signature was on the Certificate of Inventory and Destruction form and stated she had witnessed the destruction of the medications. LPN YY stated that she did sign off that all the medications were disposed of but did not know why the amount was not documented. LPN YY stated she remembered disposing of the liquid medication with LP EE and the DON.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy titled, Pharmacy Services Overview, the facility failed to follow the consultant pharmacist's recommendations related to an as-needed (PRN) antianxiety medication order for one of five resident's (R) R#7, reviewed for unnecessary medications. Findings include: Review of the facility policy titled, Pharmacy Services Overview, dated 9/1/2018 revealed, The facility shall contract with a licensed pharmacist to help obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements. This includes, but is not limited to, collaborating with the facility and Medical Director: a. reviews each resident's medical chart during each monthly drug regimen review. b. The pharmacist consultant must report any irregularities to the attending physician and the facility's Medical Director and Director of Nursing, and these reports must be acted upon within thirty (30) days of receipt of notification of irregularities unless the pharmacy consultant notifies the Director of Nursing that the irregularity must be addressed as soon as possible. In the event of this circumstance, the attending physician will be notified and provide a response to the identified irregularity within twenty-four (24) hours of initial notification by the pharmacist consultant. c. Irregularities include, but are not limited to, any drug that meets the criteria set forth for an unnecessary drug. d. Any irregularities noted by the pharmacist during the monthly review must be documented on a separate, written report that is sent to the attending physician and the facility's Medical Director and the Director of Nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. The attending physician must provide documentation to be placed in the resident's medical record to support that the irregularity has been reviewed and what, if any action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. A review of the clinical record for R #7 revealed resident was admitted to the facility on [DATE] with diagnoses of but not limited to hemiplegia (paralysis) and hemiplegia (weakness) following unspecified cerebrovascular disease (disease affecting blood flow through the brain), dementia without behavioral disturbance, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed R#7 had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. The resident received an antianxiety medication one day out of the seven-day assessment period. Review of the care plan dated 12/22/2021 revealed R#7 used the antianxiety medication lorazepam (Ativan) related to a diagnosis of anxiety disorder. The interventions included to give the antianxiety medications as ordered by the physician and to monitor/record the occurrence of side effects and target behavior symptoms. Review of the pharmacist consultant's, Recommendations Summary for Director of Nursing (DON) & (and) Medical Director, dated 1/14/2022, revealed the resident was receiving Ativan on an as-needed (PRN) basis. The summary indicated this order must have a duration and that PRN psychotropic orders could not exceed 14 days unless the prescriber documented their rationale in the resident's medical record and indicated the duration for the PRN order. The form did not include any documentation to indicate the Director of Nursing (DON) or physician acted upon the recommendations. Review of R#7's February 2022 Medication Administration Record (MAR) revealed the order for lorazepam tablet 0.5 milligrams (mg). The directions were to give one mg by mouth every six hours as needed for anxiety. The start date on the order was 12/21/2021, and the discontinued date was 2/17/2022, over one month after the pharmacist consultant's recommendations were documented. Review of the pharmacist consultant's, Note to Attending Physician/Prescriber, dated 3/10/2022, revealed that the pharmacist consultant again recommended evaluating the current diagnosis, behaviors and usage patterns related to the PRN Ativan order. The note again indicated that PRN psychotropic orders were not to exceed 14 days unless the prescriber documented the rationale in the resident's medical record and indicated the duration for the PRN order. The form was signed by the psychiatric nurse practitioner on 3/29/2022, and the option to discontinue the PRN Ativan was selected. Review of R#7's March 2022 MAR revealed an order for lorazepam (Ativan) tablet 0.5 mg. The directions were to give one mg by mouth every six hours as needed for anxiety. The start date on the order was 2/20/2022 (three days after the previous discontinued date), and the discontinued date was 3/29/2022. Interview on 3/30/2022 at 12:40 p.m. with Licensed Practical Nurse (LPN) EE confirmed R#7 received lorazepam as needed for anxiety. LPN EE stated the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) assessed the residents for the effectiveness and appropriateness of ordered medications. Interview on 3/31/2022 at 10:30 a.m. with Licensed Pharmacist QQ, stated he expected PRN psychotropic medications to have an order duration of only 14 days. Licensed Pharmacist QQ further stated if he continued to see a resident with an order for a prn psychotropic, he would continue to write a recommendation to have a stop date or to get the physician's rationale for continued use. If there were no changes to a medication order, the physician's documentation should be on the pharmacy recommendations and in the resident's medical record. Interview on 4/1/2022 at 10:55 a.m. with the Administrator, stated they had a pharmacist who reviewed resident medications monthly and made recommendations. The Administrator indicated he expected the DON and nurse managers to follow up on pharmacy recommendations, so residents would not have any adverse effects due to medications. Interview on 4/1/2022 at 1:00 p.m. with the DON stated she gave pharmacy recommendations regarding psychiatric medications to the psychiatric nurse practitioner for follow-up. The DON stated it was important to follow up on any pharmacy recommendations because the pharmacist could identify things that nursing did not catch.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of facility policies, the facility failed to ensure psychotropic medications including antipsychotic and antianxiety medications were not ordered as needed (PRN) beyond 14 days, failed to document the rationale in the resident's medical record and indicate the duration for the PRN order for two of five sampled residents (R) R#102 and R#7; and failed to provide consistent documentation of target behaviors and potential side effects of psychotropic medications for two of five sampled residents (R) R#102 and R#7, reviewed for unnecessary medications. Findings include: Review of the facility policy titled, Antipsychotic Medication Use, revised December 2020, revealed Antipsychotic medications shall generally be used only for the following conditions/diagnoses as documented in the record: a. schizophrenia; b. schizo-affective disorder; c. schizophreniform disorder; d. delusional disorder; e. mood disorders (e.g. [for example], bipolar disorder, depression with psychotic features and treatment refractory major depression); f. psychosis in the absence of dementia; g. medical illnesses with psychotic symptoms and/or treatment-related psychosis or mania (e.g., high-dose steroids); h. Tourette's disorder; i. Huntington disease; j. hiccups (not induced by other medications); or k. Nausea and vomiting associated with cancer or chemotherapy. 7. Diagnoses alone do not warrant the use of antipsychotic medication. In addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met: a. The behavioral symptoms present a danger to the resident or others; AND: (1) The symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations; delusions, paranoia or grandiosity); or (2) Behavioral interventions have been attempted and included in the plan of care, except in an emergency. The policy also documented, 11. All antipsychotic medications will be used within the dosage guidelines listed in F758, or clinical justification will be documented for dosages that exceed the listed guidelines for more than 48 hours. 12. If antipsychotic medications are administered as PRN dosages repeatedly over several days, the Physician should discuss the situation with staff and evaluate the resident as needed to determine whether the use is appropriate, and the symptoms are responding to the medication. 13. The staff will observe, document, and report to the Attending Physician information regarding the effectiveness of any interventions, including antipsychotic medications. 14. Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medication to the attending physician: a. General/anticholinergic: constipation, blurred vision, dry mouth, urinary retention, sedation; b. Cardiovascular: orthostatic hypotension, arrhythmia; c. Metabolic: increase in total cholesterol/triglycerides, unstable or poorly controlled blood sugar, weight gain; or d. Neurologic: akathisia, dystonia, extrapyramidal effects, akinesia; or tardive dyskinesia, stroke or TIA [transient ischemic attack]. 15. The physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences. Review of the facility policy titled, Pharmacy Services Overview, dated 9/1/2018, revealed c. Irregularities include, but are not limited to, any drug that meets the criteria set forth for an unnecessary drug. d. Any irregularities noted by the pharmacist during the monthly review must be documented on a separate, written report that is sent to the attending physician and the facility's Medical Director and the Director of Nursing and lists, at a minimum, the resident's name, the relevant drug, and the irregularity the pharmacist identified. The attending physician must provide documentation to be placed in the resident's medical record to support that the irregularity has been reviewed and what, if any action has been taken to address it. If there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record. 1. Review of the clinical record for R#102 revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to end stage renal disease, dementia without behaviors, major depressive disorder, and insomnia. The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as two, indicating severe cognitive impairment. R#102 had no potential indicators of psychosis and did not exhibit any behavioral symptoms. She was totally dependent on one to two staff for all activities of daily living (ADLs). The resident received an antipsychotic medication on one out of the past seven days, an antianxiety medication on two out of the past seven days, and an antidepressant on seven out of the past seven days. The resident received antipsychotic's on a routine basis and had not had a gradual dose reduction (GDR) attempted. Review of the care plan dated 4/2/2021 revealed R#102 had a history of yelling or screaming out at times, exhibited inappropriate sexual behaviors toward others, displayed hallucinations or acute confusion related to chronic kidney disease, and used psychotropic medications including antidepressants. Interventions to care include distract resident, if possible, psychiatric referral as needed/ordered, remove resident from public area when behavior is disruptive/unacceptable. Talk with resident in a low pitch, calm voice to decrease/eliminate undesired behavior and provide a diversional activity, give antidepressant medication as ordered, monitor/document side effects and effectiveness, monitor/document/report to the physician as needed any ongoing signs and symptoms of depression unaltered by antidepressant medications and engage resident in simple, structured activities that avoid overly demanding tasks. Review of the Social Service Assessment, dated 1/2/2022, indicated resident had diagnoses of major depressive disorder and dementia without behavioral disturbance. The assessment indicated the resident's behaviors included periods of yelling out profanity and using derogatory language. Review of the Clinical admission Evaluation, dated 2/2/2022, indicated residents' mood was pleasant with no unwanted behaviors witnessed. Review of the Order Summary Report revealed the following orders: Lorazepam (an anti-anxiety medication) 0.5 milligrams (mg), one tablet daily on Tuesday, Thursday, and Saturday for anxiety, dated 2/2/2022; Melatonin (a supplement used for sleep) 3 mg two tablets at bedtime for insomnia, dated 2/2/2022; Sertraline (an antidepressant) 50 mg one tablet once daily for dementia, dated 2/3/2022; Seroquel (an antipsychotic) 25 mg one tablet one time every Tuesday, Thursday, and Saturday for agitation at dialysis, administer 30 minutes prior to pick-up for dialysis dated 2/18/2022; Lorazepam 0.5 mg every 12 hours as needed (PRN) for anxiety and agitation, dated 2/21/2022. Trazodone (an antidepressant) 100 mg at bedtime for insomnia, dated 2/2/2022; however, an order dated 3/30/2022 indicated the Trazodone was to be decreased to 50 mg and the directions were to give 1.5 tablets (75 mg) at bedtime related to insomnia. Review of the Nurse's Note, dated 2/21/2022 written by the Nurse Practitioner (NP), indicated R#102 had periods of anxiety and agitation, and Ativan 0.5 milligrams (mg) was ordered as needed (PRN) for anxiety. Review of a Psychosocial/Social Service Note, dated 2/22/2022, revealed R#102 exhibited no behavioral symptoms at that time. Review of the Long Term Care Evaluation, dated 2/25/2022, revealed R#102 was anxious but was currently not experiencing unwanted behaviors. The evaluation indicated the resident slept through the night. Review of a Part B Therapy, note dated 2/25/2022, indicated R#102 was alert, responsive and communicated with staff. The note indicated the resident occasionally yelled out curse words but was not agitated. Review of the Recommendations Summary for DON [Director of Nursing] and Medical Director Medication Regimen Review, dated 3/10/2022, revealed that resident had been taking Trazodone 100 mg at bedtime since 10/2021 and the pharmacist was recommending a dose reduction; resident was currently receiving PRN Ativan (lorazepam). The form indicated PRN psychotropic medication orders required a duration, so the pharmacist recommended evaluating the continued need for the medication and documenting the rationale in the medical record, as well as adding a duration for the PRN order; resident was receiving the antipsychotic Seroquel, and the pharmacist requested an appropriate indication for the use of the antipsychotic medication for this resident. Review of the Note to Attending Physician/Prescriber, dated 3/29/2022, indicated the physician's response to the consultant pharmacist's recommendations was the Seroquel was used for agitation during dialysis three times a week, the PRN Ativan was to be discontinued, and the Trazodone was to be decreased to 75 mg every night. Review of R#102's record revealed no documentation of behavior monitoring to warrant the use of psychotropic medications and no documentation of non-pharmacological interventions being attempted prior to administering psychotropic medications. Further review of the record revealed that the resident's hours of sleep were not being documented to determine the continued need for medications to induce sleep. There was no documentation that the risks versus benefits of taking a psychotropic medication were reviewed with the resident or responsible party. Review of Pre/Post Dialysis Evaluation forms, dated 3/17/2022 and 3/19/2022, indicated R#102 was noted with agitation. No further description was documented. Review of the Medication Administration Record (MAR) for R#102 revealed she received lorazepam 0.5 mg on 2/27/2022 at 10:56 p.m., 3/15/2022 at 11:30 a.m., and 3/17/2022 at 8:54 a.m. There was no documentation to indicate the reason the medication was given or that any non-pharmacological interventions were attempted prior to administering the medication. Interview on 3/31/2022 at 10:33 a.m. with the pharmacy consultant, stated he came to the facility once a month to do medication regimen reviews (MRRs). He stated PRN psychotropic medications should only be ordered for 14 days unless another specific duration was ordered. He stated if there was no response from the physician regarding a stop date for a PRN psychotropic medication, he would continue making the recommendation for the physician. Interview on 3/31/2022 at 11:24 a.m. with the DON, stated if a resident came to the facility from the hospital with an order for a psychotropic medication, they would try and wean them off the medication. She stated the pharmacist reviewed psychotropic medication use monthly. She stated staff should try other interventions and attempt a gradual dose reduction (GDR) to attempt to discontinue the medication. She stated it should be documented if a GDR was not possible. During further interview, she stated behaviors should be documented under the behavior monitoring section in the electronic charting system, and monitoring of behaviors and side effects should be documented on the MARs. She confirmed there was no rationale documented for the psychotropic medications use for R#102. Interview on 4/1/2022 at 10:52 a.m. with the Administrator, stated non-pharmacological interventions should be attempted before staff use a psychotropic medication. The Administrator stated the nurse manager should follow up on the recommendations from the pharmacy consultant to decrease the medications if possible. The Administrator stated the facility had a behavior management meeting on Wednesday and started a Performance Improvement Plan (PIP) because they had identified that GDRs needed to be discussed at the behavior management meetings. She stated the PIP included the nurse managers having a meeting with the psychiatric nurse practitioner (NP) to discuss notification and requirements for the implementation of psychotropic medications 2. Review of the clinical record for R#7 revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to hemiplegia following cerebrovascular accident (CVA) dementia, and anxiety disorder The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 12, indicating moderate cognitive impairment. The resident received an antianxiety medication on one day out of the seven-day assessment period; antipsychotic medication seven of seven days; and antidepressant medication seven of seven days. Review of the care plan, dated 12/22/2021, indicated R#7 used the antianxiety medication related to anxiety disorder. The interventions included to give the antianxiety medications as ordered by the physician and to monitor/record the occurrence of side effects and target behavior symptoms. Review of the Recommendations Summary for Director of Nursing (DON) & (and) Medical Director Medication Regimen Review, dated 1/14/2022, revealed the resident was receiving Ativan (lorazepam) on an as-needed (PRN) basis. The summary indicated this order must have a duration and that PRN psychotropic orders could not exceed 14 days unless the prescriber documented their rationale in the resident's medical record and indicated the duration for the PRN order. The form did not include any documentation to indicate the Director of Nursing (DON) or physician acted upon the recommendations. Review of R#7's February 2022 MAR revealed an order for lorazepam tablets 0.5 mg. The directions were to give one mg by mouth every six hours as needed for anxiety. The start date on the order was 12/21/2021, and the discontinued date was 2/17/2022, over one month after the pharmacist consultant documented the recommendations regarding the lorazepam. Review of the pharmacist consultant's Note to Attending Physician/Prescriber dated 3/10/2022, revealed that the pharmacist consultant again recommended evaluating the current diagnosis, behaviors and usage patterns related to the PRN Ativan order. The note again indicated that PRN psychotropic orders were not to exceed 14 days unless the prescriber documented the rationale in the resident's medical record and indicated the duration for the PRN order. The form was signed by the psychiatric nurse practitioner on 3/29/2022, and the option to discontinue the PRN Ativan was selected. Review of R#7's March 2022 MAR revealed the order for lorazepam (Ativan) tablet 0.5 mg. The directions were to give one mg by mouth every six hours as needed for anxiety. The start date on the order was 2/20/2022 (three days after the medication was previously discontinued), and the discontinued date was 03/29/2022. Interview on 3/30/2022 at 12:40 p.m. with Licensed Practical Nurse (LPN) EE revealed R#7 received lorazepam as needed for anxiety. LPN EE stated the Assistant Director of Nursing (ADON), and the DON assessed the residents for the effectiveness and appropriateness of ordered medications. Interview on 3/31/2022 at 10:30 a.m. with Licensed Pharmacist QQ, stated he expected PRN psychotropic medications to have an order duration of only 14 days. Licensed Pharmacist QQ further stated if he continued to see a resident with an order for a prn psychotropic, he would continue to write a recommendation to have a stop date and/or get the physician's rationale for continued use. If there were no changes to a medication order, the physician's documentation should be on the pharmacy recommendation and in the resident's medical record. Interview on 4/1/2022 at 10:55 a.m. with the Administrator, stated the facility always tried to use non-pharmacological interventions in place of medications when possible, and that the facility had psychiatric services who saw the residents routinely. The Administrator stated they had a pharmacist who reviewed resident medications monthly and made recommendations. The Administrator indicated he expected the DON and nurse managers to follow up on pharmacy recommendations, so residents would not have any adverse effects due to medications. During an interview on 4/1/2022 at 1:00 p.m. with the DON, stated she gave pharmacy consultant recommendations regarding psychiatric medications to the psychiatric nurse practitioner for follow-up. The DON stated it was important to follow up on any pharmacy recommendations because the pharmacist could identify things that nursing may not catch.

Based on observations, staff interviews, and review of a facility policy, the facility failed to ensure medication carts were locked when not attended for one of six medication carts. The census was 153. Findings include: Review of the facility's policy titled, Storage of Medications and Biologicals, dated September 1, 2018, indicated, Standards: The facility shall ensure that the medications and biologicals are stored appropriately and securely at any given time. 5. Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. All Medication, Treatment carts must be secured/locked when not attended by licensed staff. Observations on 3/29/2022 from 12:22 p.m. to 12:25 p.m. revealed an unlocked medication cart directly across from Room A1. The medication cart was unattended at this time. At 12:23 p.m., two maintenance employees walked by the cart at the same time, in opposite directions. At 12:24 p.m., a cognitively impaired resident in a wheelchair self-propelled past the unlocked cart. At 12:25 p.m., Licensed Practical Nurse (LPN) ZZ walked by the cart, looked down at the cart, and then kept walking down the hall. After LPN ZZ walked down the hall, LPN PP walked up to the cart. Interview on 3/29/2022 at 12:25 p.m. with LPN PP, stated she was responsible for the cart. During this interview, LPN PP was able to open the drawers without using the keys to unlock the cart. She stated she had to go to the back room to get something and did not realize she had left the cart unlocked. LPN PP stated the cart should always, always, always be locked when unattended. Interview on 3/29/2022 at 1:29 p.m. with LPN ZZ, stated she did not remember walking past the medication cart. She stated medication carts should always be locked when not in use. Interview on 3/31/2022 at 11:27 a.m. with the Director of Nursing (DON), stated staff should ensure medication carts were locked when not in use. Interview on 33/31/2022 at 12:03 p.m. with the Administrator, stated staff should ensure medication carts were locked when not in use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observations on 3/30/2022 at 9:23 a.m. with Housekeeper DDD, who was working on the B Hall, began cleaning room eight. The housekeeper emptied the trash, got a cloth out of a white bucket on the housekeeping cart, and wiped down all the surfaces in the room, including the door handles and the bathroom. Housekeeper DDD stated the solution was peroxide disinfectant solution that was premixed in the janitor's closet. After completing the cleaning for room eight, Housekeeper DDD took the cart and moved down to room [ROOM NUMBER] on the B Hall. She removed her gloves and donned a new pair of gloves. At 9:30 a.m., Housekeeper DDD replaced the paper towels in the room, emptied the trash out of the room and the bathroom, then took a cloth out of the white bucket on the top of the housekeeping cart and wiped down the door handles, the countertop by the television, and the handles on the bathroom. She then wiped down the bathroom sink, came out of the room and put the cloth in a plastic bag, then changed her gloves without doing hand hygiene. The housekeeper walked down the hall with the gloves on and returned at 9:39 AM, removed her gloves, and put a new pair of gloves on without performing hand hygiene. The housekeeper then started cleaning room [ROOM NUMBER] on the B Hall. Interview on 4/1/2022 at 10:09 a.m. with the Housekeeping Supervisor, stated glove changes should occur between every room upon entering, and hand hygiene should occur between glove changes. 3. Review of the clinical record for resident (R) #90 revealed he was admitted to the facility on [DATE] with diagnoses including but not limited to hemiplegia affecting the right dominant side and contractures of the right lower leg, left lower leg, right hand, and right elbow. The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as eight, indicating moderate cognitive impairment. Section G revealed that resident required extensive physical assistance of two people for toilet use. Section H revealed R#90 was always incontinent of bladder and bowel. Review of the care plan dated 3/11/2022 revealed resident was incontinent of bowel. Interventions included checking the resident as required for incontinence and to wash, rinse, and dry the perineum. Observation on 3/28/2022 at 11:07 a.m. with CNA GG providing incontinent care for R#90. There was feces noted on the left hip and right heel. CNA GG was in the process of providing incontinent care and was wearing gloves. There were no clean gloves visible or within reach of CNA GG during the provision of incontinent care for R#90. CNA GG removed wet wipes from a wipe container and cleaned the feces from the resident's hip and foot. CNA GG then used wipes to clean the resident's anal region. CNA GG did not change or remove gloves before applying a clean incontinent pad underneath the resident and putting a new brief on the resident. CNA GG then removed the soiled top sheet and blanket and replaced them with clean linens. Still wearing the same gloves, CNA GG put a clean gown on the resident. After covering the resident up, CNA GG removed the gloves, placed them in the trash, and asked the resident if they wanted their facial hair shaved. The resident stated they would like to be shaved. CNA GG walked to the supply cart, located outside the resident's room, but at the door entry, and without washing or sanitizing their hands, grabbed a handful of gloves from the supply cart. Interview on 3/29/2022 at 1:20 p.m. with CNA GG, stated that when providing incontinent care, he applied two pairs of gloves because sometimes they bust open. CNA GG stated that during the surveyor's observation on 3/28/2022, the CNA was wearing two sets of gloves and removed the first set after providing incontinent care and you just didn't see me. I put them in the trash. Review of the CNA Competency/Skills Checklist dated 8/16/2021 for CNA GG revealed the CNA was very competent with perineal care. Interview on 3/30/2022 at 1:49 p.m. with CNA SS, stated she did not apply two sets of gloves when providing care. Interview on 3/30/2022 at 1:54 p.m. with CNA TT, stated he did not wear two sets of gloves when providing care. Interview on 3/31/2022 at 11:24 a.m. with the DON, stated that when providing incontinent care, gloves should be changed during the care being provided if the resident was soiled. She stated if staff wiped feces from a resident, they should change their gloves before touching anything else. The DON stated that staff were allowed to apply two sets of gloves if the staff member thought they may soil the gloves. The DON stated CNA GG should have changed gloves and washed his hands prior to placing a clean brief on the resident. Interview on 3/31/2022 at 12:00 p.m. with the Administrator, stated when staff were providing incontinent care, they should change gloves in between touching surfaces and the resident. The Administrator stated CNA GG should have changed gloves after providing incontinent care, and before putting a clean brief on the resident. The Administrator confirmed staff were allowed to wear two sets of gloves; however, it was not the norm. Interview on 3/31/2022 at 4:22 p.m. with CNA VV, stated she did not wear two sets of gloves when providing care and stated staff were not allowed to do that. Interview on 3/31/2022 at 4:34 p.m. with Licensed Practical Nurse (LPN) WW indicated she did not wear two sets of gloves while providing care. During an interview on 04/01/2022 at 8:37 a.m. with Licensed Practical Nurse (LPN) BB indicated she did not wear two sets of gloves while providing care. Based on observations, record review, interviews, review of the Centers for Disease Control and Prevention (CDC) guidelines and facility policies titled, Hand Washing/Hand Hygiene Policy and, Perineal (Skin) Care for Incontinent Resident, the facility failed to implement an effective Infection Control Program to prevent the development and transmission of communicable diseases and infection. Specifically, the nursing staff failed to offer and/or encourage hand hygiene for residents during meal delivery by four of four staff members observed delivering meals; housekeeping staff failed to perform hand hygiene between resident rooms and between glove changes on one of five halls (A Hall); and nursing staff failed to change gloves and perform hand hygiene when going from dirty to clean during incontinent care for one of two sampled residents (R#90) reviewed for incontinent care. The census was 153. Findings include: Review of the Centers for Disease Control and Prevention (CDC) Hand Hygiene Guidance, updated 1/30/2020, retrieved from https://www.cdc.gov/handhygiene/providers/guidelin.html, indicated, Multiple opportunities for hand hygiene may occur during a single care episode. Following are the clinical indications for hand hygiene: Use an alcohol-based hand sanitizer immediately before touching a patient, before performing an aseptic task (e.g. [for example], placing an indwelling device) or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. Wash with soap and water when hands are visibly soiled, after caring for a person with known or suspected infectious diarrhea, and after known or suspected exposure to spores. Review of the facility's Hand Washing/Hand Hygiene Policy, reviewed 11/20/2020, revealed Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infection. 5. Residents, family members and/or visitors will be encouraged to practice hand hygiene through the use of fact sheets, pamphlets and/or other written materials provided at the time of admission and/or posted throughout the facility. Review of the facility policy titled Perineal (Skin) Care for Incontinent Resident, reviewed October 2018, revealed that after providing perineal care, staff were to 10. Remove gloves and discard. Wash hands. 11. Place dry brief on the resident. 12. Replace any other articles of clothing that may have been removed . Upon completion of the procedure, staff were to, 16. Wash hands. 1. Observations on 3/29/2022 from 1:20 p.m. to 1:56 p.m. on A Hall, Certified Nursing Assistant (CNA) AAA was observed delivering meal trays to residents in rooms A7 and A13; CNA GG was observed delivering meal trays to residents in rooms A13, A16 and A14; CNA SS was observed delivering meal trays to residents in rooms A10, A15 and A14; CNA BBB was observed delivering meal trays to residents in rooms A9, A12, A11 and A14. The identified rooms were shared rooms with double and triple occupancy. Although the observed CNAs performed hand hygiene on their own hands prior to delivering the meal trays to the different residents, they did not encourage or offer hand hygiene to the residents when they delivered their noon meal. Interview on 3/29/2022 at 2:11 p.m. with R#104 stated she was not encouraged or offered hand hygiene before she ate her meal. The resident stated that it would be a good idea to have something to clean her hands with before she ate. Interview on 3/29/2022 at 3:07 p.m. with the Administrator, stated her expectation was that staff performed hand hygiene on themselves and encourage/offer hand hygiene to the residents as well. She stated hand hygiene was important to ensure residents' hands were clean when they ate their meals. Interview on 3/29/2022 at 3:27 p.m. with the Director of Nursing (DON), stated nursing staff should not only perform hand hygiene on themselves but should provide the same to the residents. The DON stated hand hygiene was important for infection control and prevention. Per the DON, nursing staff should perform and/or encourage hand hygiene for the residents to ensure the residents ate their meals under clean conditions. Interview on 3/30/2022 at 8:24 a.m. with CNA GG, stated the residents were given bed baths during morning care and the residents' hands were cleaned during the morning care as well. CNA GG stated he relied on the hand cleaning conducted during the morning care as sufficient. The CNA stated he had been trained on indications for hand hygiene, to include but not limited to after using the bathroom, between resident contacts, before donning and after doffing gloves. The CNA indicated he thought the residents should be doing hand hygiene on themselves. Interview on 3/30/2022 at 11:55 a.m. with CNA SS, stated she had been trained on the need to perform hand hygiene prior to serving meals to residents and the importance of performing or offering hand hygiene to residents during meal delivery. During further interview, she stated she was supposed to carry a portable container of hand sanitizer with her; however, she did not. The CNA verified that she failed to perform hand hygiene and failed to offer the same to the residents because she forgot to do it.

Based on observation, interview, record review and policy review, the facility failed to ensure six out of 37 sampled residents (R) (R#6, R#14, R#16, R#57, R#133, R#134), residents attending resident council meetings, and residents attending the group interview were served palatable food. Specifically, food was not satisfactory in taste or temperature and condiments were not consistently served creating the potential for dissatisfaction and weight loss. Findings include: 1.Background information Review of the Parkside Post-Acute & Rehabilitation Census dated 12/10/18 revealed there were 94 residents prescribed regular texture diets, 62 prescribed mechanical soft texture diets, and 23 prescribed pureed texture diets. Interview with the Dietary Manager on 12/10/18 at 9:30 a.m. was conducted in the kitchen during the initial kitchen inspection. The Dietary Manager indicated meal times were between 7:00 a.m. and 8:30 a.m. for breakfast, 12:00 p.m. and 1:20 p.m. for lunch, and 5:00 p.m. and 6:30 p.m. for dinner. The Dietary Manager stated meals were also served to residents residing in the personal care part of the building; they were served prior to the nursing home residents. The food was dished up in the kitchen from the steamtable and the individual meal trays were sent to residents eating off the hall carts and dining rooms on the units. Food was dished up from a steamtable in the main dining room for residents eating in the main dining room. The main dining room was served first for the nursing home residents. The Dietary Manager stated there was a main dining room and small dining rooms in the A and B units. The Dietary Manager stated residents could eat in their rooms if they wanted to or could eat in the dining rooms. The Dietary Manager stated there were six meal carts that were sent to A, B, C and E halls; A and B halls had two carts whereas C and E halls had one cart each. The facility Food Delivery Log undated, revealed for the lunch meal the main dining room meal service began at 12:00 noon, E hall meal service was from 12:10 p.m. - 12:30 p.m., B hall meal service was from 12:30 p.m. - 12:50 p.m., A hall meal service was from 12:50 p.m. - 1:10 p.m. and C hall meal service was from 1:10 p.m. - 1:20 p.m. 2. Resident council minutes a. September 2018 Resident Council Minutes dated 9/13/18 under New Business, indicated food was not being prepared to residents' satisfaction. Residents wanted more variety of food. Desserts did not look like desserts and were missing a lot of ingredients. b. October 2018 Resident Council Minutes dated 10/11/18 under New Business, indicated food was not prepared properly and was missing a lot of condiments. The food was not tasty. c. November 2018 Resident Council Minutes dated 11/8/18 under New Business, indicated the food was often overcooked or undercooked. Residents stated they were tired receiving fruit for dessert. 3. The Resident group interview was held on 12/11/18 at 11:00 a.m. in the A hall restorative dining room. Nine residents were in attendance, three residents each from A and B halls, two residents from C hall and one resident from E hall. A resident from A hall said the meals were served cold at times. When asked to clarify if the cold meals were served at a specific time, the resident said it could be anytime. The remaining residents in group concurred they were served cold meals at times. 4. Resident interviews revealed concerns with the food: a. In an interview on 12/12/18 at 10:10 a.m. in the resident's room, R#57 stated she did not like the food, especially mushy food. b. In an interview on 12/11/18 at 2:06 p.m. in the resident's room, R#16 stated, The food is not so great. The food does not taste good. c. In an interview on 12/10/18 at 12:26 p.m. in the resident's room, R#133 stated, I don't like the food. d. In an interview on 12/10/18 at 2:53 p.m. in the resident's room, R#14 stated she did not like the food. e. In an interview on 12/10/18 at 10:12 a.m. in the resident's room, R#134 stated the food was terrible in appearance and taste. 5. In an interview on 12/12/18 at 10:24 a.m. in the surveyor conference room the Ombudsman stated there had been a lot of food issues. The Ombudsman stated she attended the November 2018 resident council meeting and there were numerous complaints voiced by the residents about the food, including complaints of overcooked food, a lack of condiments, and cold food. 6. Meal Observations a. Lunch 12/10/18 The menu Week at-a-Glance, Week 4 revealed lunch on 12/10/18 consisted of an open-faced turkey sandwich, mashed potatoes, whole kernel corn, roll/bread, and fruit salad for dessert. The alternate was lemon pepper fish fillet, parsley rice, and seasoned zucchini. Meal observations were made in the main dining room and on all the units (A, B, C, and E) from 12:00 p.m. to 1:05 p.m. Residents eating in the main dining room were served starting at 12:13 p.m. There were approximately 30 residents eating in the dining room. Residents were first served beverages, then foods from the salad bar (fruit, salad, cottage cheese) per request, then homemade pea soup was poured into bowls and the bowls were placed on a cart which was wheeled around the dining room and offered to residents. A staff member offered soup to most of the residents. Crackers were not served at the time soup was served, which started at 12:18 p.m. Approximately 10 minutes after the soup was served a staff member offered crackers to most of the residents who were served soup. However, R#6 asked for crackers when she was served her soup at 12:21 p.m. The resident asked two staff members for crackers; neither brought the resident crackers. R#6 did not eat any of her soup until she received crackers after asking in a loud exasperated manner, We don't get any crackers? at 12:34 p.m. at which time an activity staff member passing through the dining room notified staff R#6 requested crackers and they were then served to her. The resident waited 13 minutes to be served crackers. The alternate vegetable was zucchini which was served to residents in a small bowl. The zucchini was a faded green color, was mushy and overcooked in a watery solution. The residents did not have salt and pepper served with the meal (either on the table or salt and pepper packets). One resident asked for salt and staff went and obtained a salt packet. Residents were not served margarine with their rolls. Staff were not observed to ask residents if they wanted margarine; it was not observed to be served. At 12:34 p.m. the first plate was served (entrée, vegetable and starch). There was one dietary staff member dishing up the plates from the steamtable. There were four staff members delivering the plates, one at a time, to residents seated in the dining room. The dietary staff member was not able to keep up with the nursing staff serving the plates. There were usually three to four nursing staff members standing at the steamtable waiting for plates to be dished up. The plates were not covered after they were dished up. They were served directly from the shelf above the steamtable to residents in the dining room. The last resident was served their plate at 12:55 p.m. b. Lunch 12/12/18 The menu Week at-a-Glance, Week 4 revealed lunch on 12/12/18 consisted of garlic herb pork loin, ranch style potato wedge, succotash, dinner roll/bread, and peach crisp for dessert. The alternate was breaded chicken on a bun, buttered noodles, and roasted brussel sprouts. French fries were served instead of ranch style potato wedges. The homemade soup was cabbage/tomato. The hot foods on three (main dining room, A unit, and B unit) of four test trays (main dining room, A unit, B unit and E unit) were cool or lukewarm; these menu items were not palatable. Test Tray A Unit On 12/12/18, the sheet pan rack with residents' trays arrived on the unit at 12:35 p.m. The test tray was evaluated at 12:50 p.m. after the last resident was served their meal; the test tray was a regular diet main meal selection. Temperatures of the foods were measured; the entrée and starch were not hot. Temperatures were 110 degrees F for the pork and 110 degrees F for the french fries. Test Tray B Unit On 12/12/18, the sheet pan rack with residents' trays arrived on the unit at 12:35 p.m. There were ten resident trays located on the rack. The staff began distributing the trays to residents seated in the B Unit dining room. When there were three trays remaining on the cart, the B Unit Manager came walking down the hall and placed an additional tray on the cart and stated it was the test tray. When the remaining three trays were served, the test tray was obtained from the cart. The test tray was a regular diet with pork loin, french fries, and corn with lima beans. Temperature was 110.8 for the pork loin, 110 for the french fries. The food tasted as though it was room temperature and not hot. Test Tray Main Dining Room On 12/12/18 at 12:40 p.m., there were approximately 30 residents in the main dining room for lunch. Residents had already been served beverages, salad bar items per preference and soup. Tray line meal service began at 12:40 p.m. All the lids were removed from the steamtable pans. The steamtable pans of food remained completely uncovered for the duration of the tray line meal service. There was one dietary staff member dishing up the plates from the steamtable. There were four to five staff members delivering the plates, one at a time, to residents seated in the dining room. The dietary staff member was not able to keep up with the nursing staff serving the plates. Four to five staff were waiting at the steamtable for the dietary staff to dish up the plates. The plates were not covered after they were dished up. They were served directly from the shelf above the steamtable to residents in the dining room. The last resident was served his/her plate at 1:00 p.m. No ketchup was served with the french fries and no margarine was served with the dinner rolls. Residents were served salt and pepper if they requested it. Residents who were served the alternate meal of a dry chicken breast on a bun with a tomato slice and piece of lettuce were served the sandwich without mayonnaise or any other sauce/dressing. If residents asked, staff obtained mayonnaise packets for them. A test tray of the alternate meal consisting of the chicken sandwich on a bun with lettuce and tomato, egg noodles, brussel sprouts and cabbage tomato soup was evaluated right after the last resident was served his/her tray at 1:00 p.m. The chicken was 102 degrees F and was cool to the palate. The egg noodles were cool at 89 degrees F. The brussel sprouts were lukewarm at 115 degrees F. The cabbage tomato soup was 123 degrees F. The cabbage chunks in the soup were hard and undercooked. 7. Staff interviews In an interview on 12/13/18 at 2:31 p.m. in the personal care day room, the Dietary Manager stated she attended resident council meetings and had been working to address residents' concerns related to food palatability/food temperatures. The Dietary Manager stated she occasionally tested the temperatures of meals; however, she did not provide documentation of checking the temperatures. The Dietary Manager stated meal temperatures had been a problem and the facility recently purchased three insulated food carts. The Dietary Manager stated there were a total of six carts used for transporting residents' meals to the A, B, C and E halls. The Dietary Manager stated the other three carts used to transport residents' meals were sheet pan racks that were not enclosed or insulated in any way. The trays with residents' meals were placed on the shelving of the sheet pan racks. There were no sides, no bottom, and no top to the sheet pan racks. The Dietary Manager stated the temperature of the hot food should be 135 degrees Fahrenheit (F) when residents received their meals. The Dietary Manager stated the plates were placed into a plate warmer to heat prior to meal service. Plates of dished food were placed onto plastic bases and lids were placed on top of the plates for delivery to the halls. In an interview on 12/13/18 at 9:13 a.m. in the surveyor conference room, the Registered Dietitian stated she causally checked things out in the kitchen; however, did not complete any kitchen audits per se. The Registered Dietitian stated she did not check tray line food temperatures or check the temperatures of meals that had been plated. The Registered Dietitian stated she had been working with the Dietary Manager to address the residents' food concerns raised in resident council meetings. 8. Policies a. The Food Quality and Palatability Policy dated May 2014 revealed the policy was for food to be, prepared by methods that conserve nutritive value, flavor and appearance. The policy indicated food was to be palatable, attractive and served at the proper temperature. Under Action Steps, the Food Service Director and Cooks were noted as being responsible for food preparation. Menu items were to be prepared according to the menu, production guidelines and standardized recipes. The cook was to season food appropriately in accordance with recipes, regional and/or ethnic preferences, and use cooking techniques to ensure color and flavor retention. b. The Food Preparation Policy dated May 2014 revealed the Food Service Director and [NAME] were responsible for food preparation techniques, which minimized the amount of time, that food items were exposed to temperatures greater than 41 degrees Fahrenheit and/or less than 135 degrees Fahrenheit, or per state regulation.