**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident's medication was available for 1 of 3 residents (R2) reviewed for medication administration in the sample of 3.The findings include:R2 September Treatment Administration Record (TAR) shows he was admitted to the facility on [DATE] with multiple diagnoses including type 2 diabetes mellitus without complications, non-pressure chronic ulcer of other part of right lower leg limited to breakdown of skin, and cellulitis.The TAR shows an order for triamcinolone Acetonide external cream 0.1%, apply to RLE (right lower extremity) open area topically every day shift for wound care.On 9/19/25 at 11:00 AM, V9 Registered Nurse was asked to provide the triamcinolone cream applied to R2's legs. She began searching the medication cart, and the treatment cart and said there was none in stock. She said she applied the antifungal cream instead. She could not recall when she had used the triamcinolone. V9 said it should be in the medication cart and applied every day to his right leg for cellulitis. V9 looked in the pharmacy orders and said the last time the cream was ordered was May 2025. She said the triamcinolone cream was being used to prevent infection and the derma fungal cream she was using was not the same thing. On 9/19/25 at 11:10 AM, V9 presented a tube of cream labeled Derma Fungal, Miconazole Nitrate 2%, and was used to treat athletes' foot, jock itch and ring worm. On 9/19/25 at 11:23 AM, V3 Director of Nursing (DON) said the triamcinolone cream comes from the pharmacy and is a steroid cream. The nurses should be re-ordering though the computer. She said the anti-fungal cream would not be effective for R2's wound care. The nurses should not have been documenting the cream as applied if it was not available. The antifungal cream is not an appropriate substitution for triamcinolone cream. They should have contacted pharmacy and if they could not get it, they should have let us know. and not just use something random.The order summary for R2s triamcinolone cream shows the last re-order date was 6/17/25.The facility's undated policy for medication administration policy documents: medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice. 10. Ensure that the six rights of medication administration are followed: b. Right drug. 11. Review medication administration record (MAR) to identify medication to be administered. 12. Compare medication source with MAR to verify resident name, medication name, form, dose, rout, and time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure blood pressure monitoring was performed after a change in condition for 1 of 3 residents (R1) reviewed for change in condition in the sample of 3. The findings include: R1's face sheet printed on 7/31/25 showed diagnoses including but not limited to left side hemiplegia and hemiparesis, psychophysiologic insomnia, epileptic syndrome, and cognitive social or emotional deficit following cerebrovascular disease. R1's facility assessment dated [DATE] showed no severe cognitive impairment. The same assessment showed R1 is capable of self-propelling her wheelchair with only supervision or touch assistance from staff. On 7/31/25 at 10:25 AM, R1 was seated in a wheelchair and easily wheeling herself down the hallway using the handrail. R1 was talkative and stated she did recall an incident about a week ago (7/24/25) when she was sitting outside. R1 said the exact details are fuzzy but she remembered staff taking her blood pressure when she was outside. R1 could not recall the temperature or weather that day. R1 said the aide was supervising her and other residents. R1 stated the aide told R1 her blood pressure was low. That was when the activity started. Staff pushed R1 back inside and laid her down in bed. Staff gave R1 fluids and checked her blood pressure again. R1 could not recall who the aide was, any other residents seated outside, or the time of day the incident occurred. On 7/31/25 at 11:20 AM, V3 RN (Registered Nurse) stated she was working on 7/24 on the afternoon shift. V3 said a CNA (Certified Nurse Aide) reported to her sometime around 6:30 PM, that R1 was acting different and seemed altered mentally. V3 said she ran vital signs, and the blood pressure was around 66/40. V3 said R1 was restless, slurred speech, and not herself. V3 stated she called the physician and R1's son. V3 stated R1's son wanted her to stay at the facility. The physician was notified and stated to continue monitoring the resident and to send out if any further declines were noted. V3 said she took R1's blood pressure 4 or 5 more times because it was so low. V3 said she did not know if R1 had been sitting outside in the hot sun earlier or what was going on. V3 said the blood pressure came up a little after laying her down and pushing fluids. V3 said she relayed the situation to the oncoming nurse and left around 11:00 PM. V3 said the oncoming nurse should have continued blood pressure checks and monitoring. V3 said considering R1's history of stroke, vital signs and offering fluids should be done every 30 minutes. That would be a safe and appropriate timeline for monitoring R1. The 7/24/25 oncoming night shift nurse (V5) was attempted to be reached during the survey but did not return any phone call messages. On 7/31/25 at 1:33 PM, V8 LPN (Licensed Practical Nurse) stated residents with a change in condition should be assessed right away, including a full set of vital signs. The physician is notified, and new orders should be carried out. Monitoring a resident includes checking and charting all vital signs and outward physical changes. Residents with a low blood pressure should be offered fluids, repositioned and have the blood pressure rechecked every 30 minutes to one hour. Nurses should be documenting under the vital sign tab or in progress notes of the medical record. No documentation means it was not done. On 7/31/25 at 1:40 PM, V2 (Director of Nurses) stated any resident with a change in condition should be monitored at least every four hours until stable. V2 said R1 did have a low blood pressure on 7/24 which was documented in a progress note at 66/40. The same progress note charted a second blood pressure at 87/46. V2 stated vital signs should have been taken and documented until R1 was stable. V2 said the time and vital sign levels should be recorded. There is no way of knowing if a resident is getting better or declining if it is not done. R1's progress note dated 7/24/25 at 6:51 PM, stated R1 was having altered mental status and speech was slurred. The note showed vital signs were taken and the blood pressure was 66/40. The note showed a second blood pressure was taken of 87/46 (no time documented). The same note showed report given to oncoming nurse to monitor pressure and contact physician of any further changes in condition. The note was authored by V3 (RN). R1's progress note dated 7/24/25 at 7:17 PM, stated resident remained in house and to monitor blood pressure. There was no blood pressure levels or times recorded. The note was authored by V3 (RN). R1's progress note dated 7/25/25 at 4:58 AM, stated will continue to monitor R1. There was no blood pressure levels or times recorded. The note was authored by V5 (LPN). R1's vital signs were reviewed under the electronic charting tab. The most recent blood pressure reading was from May of 2025. On 7/31/25 at 1:14 PM, V1 (Vice President of Operations) stated the only vital signs and blood pressure monitoring for R1 over the last 30 days are those that are in the progress notes. There are none other than those. The facility's Change in a Resident's Condition or Status policy revision dated May 2020 states: 6. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide resident's medical records when requested for 1 of 4 residents (R1) reviewed for medical records in the sample of 4. The findings include: R1's face sheet accessed on 6/13/25 show that R1 was admitted to the facility on [DATE] and discharged on 9/19/24 with diagnosis of Parkinson's. R1's facility assessment dated [DATE] show R1 has no cognitive impairment. (BIMS-15) On 6/13/25 at 9:35 AM, via telephone conversation with R1 and V6 (R1's sister). R1 said she wanted to get a copy of her medical records but has not gotten them yet. R1 also wanted this surveyor to speak to V6. V6 said my sister (R1) and I made a call to the Nursing Home a couple of weeks ago and spoke to V7 (Medical Record staff) requesting a copy of R1's medical record. V7 spoke to R1 to get her verbal consent. V7 said she was not sure if R1 was allowed to get a copy of her medical records so she had to ask permission from corporate first then she will call us back. V6 stated the medical record staff (V7) had not called us back. R1, my sister has the right to have copy of her records, we have important things to review in those records. On 6/13/25 at 10:34 AM, V7 said she had been the medical records for approximately a year now. Last week, R1 and her sister requested over the phone a copy of R1's medical records. V7 said she was not sure if residents themselves and their families can get a copy of their records. V7 said she thought only Insurance Companies can get copies of medical records. V7 said she used to just do supplies and was put in this Medical Record job and had not gotten much training. I do not know the process, so I emailed corporate and the DON. [V9] (Vice President of Operations) responded last week and said, yes they could. I have to have them fill out the request form. I have not called R1 and her sister back, I have been busy, I will do that today. On 6/13/25 at 2:30 PM, V1 (acting Administrator) said V7 had training to do the Medical Records job. V1 said V7 had been informed that residents and their families have the right to access their medical records. The facility policy entitled Release of Medical Records (undated) documents, Medical records will be released with a valid request and in accordance with state and federal laws. Access Rights to medical Information: 1. The resident's records is accessible to him/her within 24 hours (excluding weekends and holidays) notice, following an oral or written request .The resident may have designated a legal representative who can exercise the same rights as the resident. The resident or his/her legal representative may receive a copy within 2 working days after the request have been made.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify a physician of a high blood sugar for 1 of 4 residents (R2) reviewed for notification in the sample of 4. The findings include: R2's Physician Order Sheet dated 6/2025 show R2 was admitted to the facility on [DATE] and discharged on 6/1/25 with diagnoses that includes diabetes mellitus and diabetic neuropathy. On 6/13/25 at 9:47 AM, V4 (R2's son) said the time R2 was in the Nursing Home, R2 had been in the Hospital due to his blood sugar either being too high or too low. The family has a Dexcom system that's connected at home and sends triggers when R2's blood sugar is high or low. On 6/1/25 at around 2-3 in the morning, we had a trigger that showed my dad's bloods sugar was high at 400. My stepmom (V10) called the nursing home and requested the Nurse to please notify the doctor due to R1's high blood sugar but the nurse said no and refused to call my dad's physician. On 6/13/25 at 1:08 PM, V3 (Registered Nurse) said she was one of the Nurses working night shift on 5/31/25 and the morning of 6/1/25. V3 said she received a call from R2's wife (V10) on 6/1/25. V3 was not sure of the time but thought it close was to 6AM. R2's wife said she received a trigger that R2's blood sugar was 400. V3 said she went to check R2's blood sugar. R2 was asleep in bed, R2's blood sugar was 323 and V3 told the wife. The wife (V10) requested V3 notify R2's physician to ask if R2 needed insulin since blood sugar was high. V3 said she told V10 she was not calling R2's doctor, the blood sugar was below 350, V3's shift ends at 7AM. R2 was due to receive his insulin with morning med pass around 8AM by day shift staff. On 6/13/25 at 2PM, V5 (Nurse Practitioner-NP) said a blood sugar of above 300 was considered high and the night Nurse should have called R2's physician as per family's request and have the physician decide if R2 needed an insulin coverage at that time. V5 (NP) said on 6/1/25 at 9AM, she was informed that by the time the day shift checked R2's blood sugar around 8AM, it was already 426 and needed an extra 10 units of regular insulin coverage. R2's electronic medication record (EMAR) show R2's blood sugar on 6/1/25 at 8AM was 426. On 6/13/25 at 2:35 PM, V2 (Director of Nursing-DON) said R2's blood sugars were erratic and R2 had been back and forth at the hospital because of the issues of blood sugars. R2's family has a Sugar/pixel cube system that communicates with them R2's blood sugar, it read outs to them and alarms if R2's blood sugar was high or low. R2's wife (V10) must have gotten the alert that R2's blood sugar was high that was why she called on 6/1/25. V2 (DON) said she had counseled V3 (RN) that she should have called R2's physician per family's request. The Facility Policy entitled of Notification of Changes (undated) documents, the purpose of this policy is to ensure the facility promptly inform the resident, consults the resident's physician and notifies consistent with his or her authority when there is a change requiring notification.

Based on observation, interview, and record review the facility failed to prevent the theft of controlled medications for one resident (R2) of three residents reviewed for misappropriation of property in the sample of 15. Findings include: Facility Policy/Abuse, Neglect and Exploitation dated 2025 documents: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without resident consent. Facility Policy/Controlled Substance Administration and Accountability dated 2025 documents: It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility shall have safeguards in place in order to prevent loss, diversion, or accidental exposure. Physician Orders indicate R2 had an order dated 1/4/25 for Hydrocodone-Acetaminophen (opioid) 10-325mg (milligrams) Give 1 tablet by mouth every 6 hours as needed for Pain. On 4/28/25 at 11am the above order was changed to Hydrocodone-Acetaminophen Oral Tablet 10-325mg. Give 1 tablet by mouth every 6 hours as needed for Pain to include Do Not exceed 4000mg acetaminophen from all sources per day. Final Investigation Report dated 5/5/25 indicates the allegation of R2's missing narcotics (Hydrocodone) was substantiated. Investigation indicates local Police were notified of R2's missing medications and report filed. All medication carts were searched, and missing narcotics were not found; all other controlled medication counts were correct. Investigation indicates on 4/25/25 V17, RN (Registered Nurse) approached V8, LPN (Licensed Practical Nurse) who was working on the same hall but a different cart and asked V8 for excess medications from her narcotic box on V8's cart to go waste the medications with V2, DON (Director of Nursing). During an investigation interview V17 acknowledged asking V8 for R2's medications from the narcotic box and states she took the medications to V2, DON. Investigation interview with V2 indicates V2 acknowledged that V17 only brought her two bottles of liquid (controlled) medications that belonged to R6 and nothing else. Investigation indicates based on video footage, V17 was seen entering V2's office with a few bottles of medications and an indeterminate number of pill cards and when V17 leaves a few minutes later, V17 is still carrying the pill cards. During the investigation, V17 was asked what she did with the medications/cards and responded that she was unsure what she did with them. Investigation indicates V17 was the last person seen with R2's Hydrocodone and then was unable to account for what happened to the medications. Investigation indicates V17 was terminated from employment. Investigation indicates R2 did not at anytime go without the ordered medication as it was an as needed medication and R2 had not requested the medication. On 5/14/25 at 10:35am video footage dated 4/25/25 between 9am and 11am was reviewed with V3, Regional Nurse and V19, Human Resources Manager and corroborated details of the investigation. On 5/14/25 at 1pm V8, LPN stated that on 4/25/25 sometime between 9am and 11am V17 told V8 she was gathering medications to waste with V2, DON. V8 stated V17 told her - by name - which medications she wanted. V8 stated she was fairly new, wasn't really sure of the facility procedures and gave V17 R2's Hydrocodone medication/cards. V8 stated V17 then proceeded down the hall toward V2's office. V8 stated it was a couple days later and it bothered her about giving the medications to V17, so she called V2 to confirm that V17 had brought the medications to her to waste. V8 stated it was at that time she found out that V17 and V2 had only wasted two bottles of liquid medications and that V17 did not give R2's medications/cards to V2. On 5/15/25 at 11:20am V2, DON stated that on 4/28/25 at 10:47am, she added special instructions to R2's Hydrocodone medication order per pharmacy recommendation. V2 stated that at that time she was unaware that R2's medications were missing. V2 stated on 4/28/25 at 9:20pm she received a call from V18, RN reporting three of R2's Hydrocodone medication cards missing 2 cards with 28 tablets and 1 card with 8 tablets - totaling 64 tablets. V2 stated the search for R2's medications continued but were never found. V2 stated it was determined that V17, RN misappropriated R2's medications based on all of the evidence including video footage of 4/25/25.

Based on interview and record review the facility failed to obtain a urine specimen according to physician orders for one resident (R1) of three residents reviewed for implementing physician orders in the sample of 15. Findings include: NP (Nurse Practitioner) Note dated 4/28/25 at 10:22am indicates R1 Complaining of occasional burning pains with urination for a few days. Note indicates R1 has chronic urinary incontinence, chronic overactive bladder and history of UTI's (Urinary Tract Infections). Note Assessment and Plan indicates (obtain) UA (urinalysis) with C&S (Culture and Sensitivity) if indicted. R1's Physician Order dated 4/28/25 indicates Obtain urine sample for UA, C&S. May straight cath(eter) every shift for 2 Days. Progress Note dated 4/30/25 at 12:32am indicates Obtain urine sample for UA, C&S. May straight cath(eter) every shift for 2 Days sample contaminated. Progress Note dated 5/4/25 at 3:50pm indicates UA obtained per straight cath(eter) using sterile procedure, 100ml (milliliters) of turbid, viscous, foul smelling urine returned. (R1's) daughter at bedside and is aware. Laboratory Results Report indicates R1's urine specimen was collected on 5/4/25 at 2:30pm, received by the lab on 5/5/25 at 4:22pm and results reported back to the facility on 5/8/25 at 2:28pm. Results indicate R1 was positive for a urinary tract infection and also included antibiotics sensitive to the organism identified. On 5/14/25 at 9:15am V9, NP (Nurse Practitioner) stated there was a delay in obtaining the UA for R1. V9 stated the order was to obtain within two days. V9 stated there was only one documented attempt to obtain the UA on 4/29/25, but the specimen was not sent.

Based on interview and record review the facility failed to ensure accurate shift-to-shift controlled medication counts for all residents that had controlled medications stored on the Station C/Front Hall medication cart in the month of April 2025. This failure has the potential to affect 27 residents (R2, R6-R41). Findings include: Facility Policy/Controlled Substance Administration and Accountability dated 2025 documents: It is the policy of this facility to promote safe, high quality patient care, compliant with state and federal regulations regarding monitoring the use of controlled substances. The facility shall have safeguards in place in order to prevent loss, diversion or accidental exposure. Inventory Verification: For areas without automated dispensing systems, two licensed nurses account for all controlled substances and access keys at the end of each shift. Medication Dispense History Report dated 4/1/25 to 4/30/25 indicates R2 and R6 - R41 had controlled medications stored in the Station C/Front medication cart. Narcotic and Controlled Substance Shift-To-Shift Count Sheet for Station C/Front cart dated April 2025 indicates: All resident supply and emergency supply controlled substances must be counted at the end of every shift change. The following Count Sheet dates are missing all or less than the required shift to shift signatures for controlled medication counts: April 1, 2, 3, 4, 7, 10,11,15,16 and 18th. The April Narcotic Count Sheet is blank (no signatures) for the 19th through 30th. On 5/16/25 V2, DON (Director of Nursing) indicated they were unable to find a shift-to-shift count sheet for the C/Front medication cart for April 19th - 30th. V2 stated both of the ADON's (Assisted Director of Nursing) should be monitoring compliance with the controlled substances shift counts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to utilize two staff members when transferring residents with a mechanical lift for two (R1 and R2) of four residents reviewed for mechanical lift transfers in the sample of eight. Findings include: The facility's policy titled Safe Resident Handling/Transfers, not dated, documents, It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risks for injury and provide and promote a safe, secure and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Policy Explanation: All residents require safe handling when transferred to prevent or minimize the risk for injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical lifts are a safer alternative and should be used. Compliance Guidelines: 10. Two staff members must be utilized when transferring residents with a mechanical lift., 13. Staff members are expected to maintain compliance with safe handling/transfer practices. Failure to maintain compliance may lead to disciplinary action up to and including termination of employment. 14. Resident lifting and transferring will be performed according to the resident's individual plan of care. R1's admission Record documents that R1 admitted to the facility on [DATE] and R1's diagnoses include Arthritis of Multiple Sites, Malignant Neoplasm of Endometrium, Chronic Kidney Disease Stage 4, Insomnia, Peripheral Vascular Disease, Hypertension, Diabetes, Generalized Anxiety Disorder, Transient Ischemic Attacks, Cerebral Infarction, and Hyperlipidemia. R1's Minimum Data Set (MDS) Assessment, dated 12/16/24, documents R1 has a Brief Interview for Mental Status (BIMS) score of 14, indicating cognition intact and documents R1 is dependent with sit to stand and chair to bed transfers. R1's current care plan documents that R1's weight bearing status is no weight bearing (NWB) to bilateral lower extremities (BLE) and transfers with a two assist with a mechanical lift. On 2/25/25 at 1:30pm, R1 stated, I have to use the lift to get out of bed and usually one staff member uses it (mechanical lift) to get me up. R2's admission Record documents that R2 admitted to the facility on [DATE] and R2's diagnoses include Radiculopathy of Lumbar Region, Pyoderma Gangrenosum, Protein-Calorie Malnutrition, Hyperlipidemia, Chronic Pain Syndrome, and Low Back Pain. R2's Minimum Data Set (MDS) assessment, dated 12/23/24, documents R2 has a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. R2's current care plan documents R2's transfer status with a mechanical lift. On 2/25/25 at 1:40pm, R2 stated, I (R2) use a mechanical lift to get out of bed. One staff member comes in to get me up with it (mechanical lift). On 2/25/25 at 10:30am V7/Certified Nursing Assistant (CNA) stated, I know I should not tell you this but, I have been doing mechanical lift transfers by myself because there are only two of us (CNAs) working in the (Memory Care/Dementia Unit) and it's too busy to wait for the other one to assist with the transfers. If I did not do this my residents would not get laid down or changed like they should. On 2/25/25 at 11:00am V8 and V9, both CNAs stated they are doing mechanical lifts by themselves most of the time because it gets too busy to wait for someone to assist.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents electronic medical records and care plans matched the Physician's Order for Life-Sustaining Treatment (POLST) for Cardio-Pulmonary Resuscitation (CPR) code status for three of five residents (R25, R69, R74) reviewed for Advanced Directives in a total sample of 39 residents. Findings include: The facility's Residents' Rights Regarding Treatment and Advance Directives policy, undated, documented It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. 9. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident. The Uniform Practitioner Order for Life-Sustaining Treatment (POLST) Form's section A has two options to choose from if the patient has NO pulse: attempt CPR (Cardiopulmonary Resuscitation) or to do not attempt CPR. Section B has three options to choose from if the patient has a pulse: 1) Full Treatment in which the goal is to prevent cardiac arrest by using all indicated treatments including but not limited to mechanical intubation/ventilation and cardioversion. 2) Selective Treatment in which the goal is to treat medical conditions with selected medical measures such as IV (Intravenous) fluids and IV medications (may include antibiotics and vasopressors), as medically appropriate and consistent with patient preferences do not intubate and to consider less invasive airway support (CPAP (continuous positive airway pressure) or BIPAP (bilevel positive airway pressure), transfer to hospital although generally avoid the Intensive Care Unit. 3) Comfort-Focused Treatment in which the goal is to relieve pain and suffering but do not use treatments as indicated in Full or Selective Treatment options. 1. R25's physician order, dated [DATE], documented R25 was a Do Not Resuscitate. R25's current care plan, dated [DATE], documented Code Status: DNR, DO NOT RESUSCITATE. The POLST, dated and signed by R25 on [DATE], documented R25 chose Selective Treatment. 2. R69's physician order, dated [DATE], documented R69 was a Do Not Resuscitate. R69's current dare plan, dated [DATE], documented Advanced Directives: DNR (R69) will not be resuscitated. The POLST, dated and signed by R69 on [DATE], documented R69 chose Selective Treatment. 3. R74's physician order, dated [DATE], documented R74 was a Do Not Resuscitate. R74's current care plan, dated [DATE], documented DNR: Resident has chosen Advanced Directives: Resident has signed Do Not Resuscitate. The POLST, dated and signed by R74's Power of Attorney on [DATE], documented R74 chose Selective Treatment. On [DATE] at 1:30 PM, V11 (Corporate Nurse-Nurse Consultant) reviewed R25, R69, R74's physician orders, care plans, and POLST and confirmed the resident's electronic medical records and care plans did not match the resident's medical intervention preference as indicated on the POLST. V11 confirmed the Selective Treatment option should have been entered into the electronic medical record as a physician's order and on the care plan.

Based on interview and record review the facility failed to revise an antipsychotic medication care plan and a dialysis care plan for two residents (R12, R23) of 19 residents reviewed for care plans in the sample of 39. Findings include: Facility Policy/Comprehensive Care Plans dated 2024 document, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS (Minimum Data Set) assessment. Current Physician Order Summary Report indicates R12 receives: Clozapine (atypical Antipsychotic) 25mg (milligrams) Give 1 tablet by mouth every 2 hours as needed for Neuromuscular with Lewy Body Dementia (as needed can take 2 hours up to 3 Tabs in 24 hours) (re-order date 11/15/24); Clozapine Give 225 mg by mouth three times a day for Anxiety related to Unspecified Anxiety Disorder; Unspecified Bipolar Disorder (order date 12/13/22); and, Benztropine Mesylate Give 0.5 mg by mouth as needed for EPS (Extrapyramidal Symptoms) administer one time daily (as needed) when as needed Clozaril given (order date 1/10/24). R12's current Care Plan indicates R12 is at risk for adverse effects related to: use of antianxiety/anxiolytic and antipsychotic medications. R12 admits with diagnosis of Lewy Body Dementia, Bi-polar disorder with manic and Psychotic Features, Insomnia, Agitation, and Anxiety. R12 exhibits Agitation, Crying, Pacing, Insomnia, restlessness, difficulty sitting still with history of Hallucinations, Delusions, Paranoia, Panic attacks, and combative behavior. R12 often needs reassurance that he has not done anything wrong during his crying episodes. R12's Care Plan does not indicate which of the above target behaviors are associated with what specific medications. R12's Care Plan does not specify Clozapine, an atypical antipsychotic which requires monthly blood tests and physician ordered administration of Benztropine to be given in conjunction with as needed Clozapine. Care Plan also does not include the 14-day required direct physician examination and assessment to reorder as needed Clozapine. On 11/15/24 at 9:15am V13/Registered Nurse stated that all diagnosis for R12's Clozapine should be Neuromuscular Disease with Lewy Body Dementia. V13 acknowledged that Clozapine does require special monitoring with monthly blood draws as well as close physician monitoring and should be included in R12's care plan. V13 stated that R12's spouse is R12's Legal Guardian and needs to be present each time R12's Clozapine is re-ordered (every 14 days) and should also be addressed in R12's care plan. On 11/13/24 at 9:40am V14/R12's Spouse stated It's a whole process every 14 days to renew (R12's) Clozapine, but he still needs an occasional (as needed) dose. Since I am R12's legal guardian I am the only one that can access the psychiatrist to renew the medication. 2. R23's Current Physician Order Summary Report indicates Monitor Bruit/Thrill right arm fistula every shift. Current R23's Care Plan indicates R23 receives Dialysis on Monday-Wednesday-Friday at an outside provider. R23's current Care Plan does not include type of dialysis access device, specific monitoring, or care of fistula. On 11/14/24 at 3:15pm V13/Registered Nurse stated the dialysis access site and monitoring should also be included on a resident's care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R23's Current Physician Order Summary Report indicates Monitor Bruit/Thrill right arm fistula every shift and 1500cc (cubic centimeter) fluid restriction. R23's dialysis physician orders do not include: Dialysis schedule; Nephrologist name and phone number; Dialysis facility name and phone number; Transportation arrangements to and from; or dialysis site. On 11/14/24 at 3:15pm V13, RN (Registered Nurse) stated the policy should be followed. Based on record review and interview the facility failed to ensure physician orders for dialysis were written and communication sheets were completed for two of two residents reviewed for dialysis (R23, R87) in a sample of 39. Findings include: A facility policy titled Hemodialysis, 2023 documents, This facility will provide the necessary care and treatment, consistent with professional standards of practice, physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences, to meet the special medical, nursing, mental, and psychosocial needs of residents receiving hemodialysis. A section titled Purpose documents: The facility will assure that each resident receives care and services for the provision of hemodialysis consistent with professional standards of practice. This will include: The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments received at a certified dialysis facility. Ongoing assessment and oversight of the resident before, during and after dialysis treatments, including monitoring of the resident's condition during treatments, monitoring for complications, implementation of appropriate interventions, and using appropriate infection control practices; and ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. Section 5 of this policy documents, The licensed nurse will communicate to the dialysis facility via telephonic communication or written format, such as a dialysis communication form or other form, that will include, but not limit itself to: a. Timely medication administration (initiated, held or discontinued) by the nursing home and/or dialysis facility; b. Physician/treatment orders, laboratory values, and vital signs; c. Advance Directives and code status; specific directives about treatment choices; and any changes or need for further discussion with the resident/representative, and practitioners; d. Nutritional/fluid management including documentation of weights, resident compliance with food/fluid restrictions or the provision of meals before, during and/or after dialysis and monitoring intake and output measurements as ordered; 3. Dialysis treatment provided and resident's response, including declines in functional status, falls, and the identification of symptoms that may interfere with treatments; f. Dialysis adverse reactions/complications and/or recommendations for follow up observations and monitoring, and/or concerns related to the vascular access site; g. Changes and/or declines in condition unrelated to dialysis; h. The occurrence or risk of falls and any concerns related to transportation to and from the dialysis facility. This policy documents that the facility will ensure that the physician's orders for dialysis include the following: type of access for dialysis, the dialysis schedule, the nephrologist's name and phone number, the dialysis facility name and phone number, transportation arrangements to and from the dialysis facility, any medications administration or withholding of specific medications prior to dialysis treatments, any fluid restriction if ordered by the physician. 1. R87's November Order Summary Report documents R87 has a dependence on renal dialysis. R87's physician orders only document the name and phone number of R87's nephrologist and R87's port access type. On 11/14/24 at 11:56 AM V9/Licensed Practical Nurse confirmed she is assigned to care for R87. V9 stated she does not know what facility R87 uses for dialysis. V9 stated she has never sent or received a communication form regarding R87's dialysis. On 11/14/24 at 11:59 AM V2/Director of Nursing stated nurses are to complete a dialysis communication form to send with R87 each dialysis day. V2 stated R87 was admitted on [DATE] and she could not provide any completed dialysis communication forms. V2 also confirmed R87's physician orders did not include orders for R87's dialysis facility name or phone number, transportation arrangements to and from the dialysis facility, R87's dialysis schedule, if any medications are to be withheld or any fluid restrictions if ordered by the physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to administer a medication to prevent EPS (Extrapyramidal Symptoms) in conjunction with an antipsychotic medication according to physician orders for one resident (R12) of five residents reviewed for psychotropic medications in the sample of 39. Findings include: Facility Policy/Medication Errors dated 2024 document, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. The facility shall ensure medications will be administered as follows: According to physician orders. In accordance with accepted standards and principles which apply to professionals providing services. Medication errors once identified will be evaluated to determine if considered significant or not by utilizing the following three general guidelines: Resident Condition Drug Category Frequency of Error - If an error is occurring repeatedly such as an omission of a resident's medication several times. Medication administered not in accordance with the prescriber's order. Examples include: Medication omission. Current Physician Order Summary (POS) Report indicates R12 was admitted to the facility on [DATE] with diagnoses that include Anxiety Disorder, Neurocognitive Disorder with Lewy Bodies, Bipolar Disorder, Dementia with Agitation, Unspecified Mood Disorder, Conduct Disorder, and a history of Malignant Neuroleptic Syndrome. POS indicates R12 receives the following medications based on the following orders: --Clozaril (atypical antipsychotic) 225mg (milligrams) three times per day for Neuromuscular Disorder with Lewy Bodies (date initiated 12/13/22) --Clozaril 25mg one tablet every two hours as needed for EPS - maximum three tablets in 24 hours (re-ordered 11/15/24) --Benztropine (anticholinergic) 0.5mg as needed to be given when as needed Clozaril is given - one time per day only (date initiated 1/10/24) Medication Administration Records (MARs) indicate: October MAR - R12 received as needed Clozaril 25mg on 10/1/24 and 10/2/24; Benztropine was not administered on either date. September MAR - R12 received as needed Clozaril 25mg on 9/4/24, 9/13/24 and 9/20/24; Benztropine was not given on those dates. August MAR - R12 received as needed Clozaril 25mg on 8/14/24; Benztropine was not given on that date. July MAR - R12 received as needed Clozaril 25mg on 7/14/24 and 7/28/24; Benztropine was not given on either date. June MAR - R12 received as needed Clozaril 25mg on 6/3/24, 6/5/24, 6/11/24, 6/13/24 and 6/23/24; Benztropine was not given on any of those dates. On 11/13/24 at 9:30am V14, (R12's) Spouse stated she is R12's Legal Guardian and R12 was diagnosed at [AGE] years of age with Early Onset Dementia, and it has taken years to find medication to help stabilize R12. V14 stated that R12 was in the ICU (Intensive Care Unit) twice due to Malignant Neuroleptic Syndrome due to the high dosages of other antipsychotics that had been prescribed including Haldol. V14 stated R12 had to be inpatient for 10 weeks to clear his system of all the medications physicians and psychiatrists were adding and then chose Clozaril to try and it's the only medication that has worked. V14 stated R12 is on other psychotropics, and his current medication regimen is what has worked well for years now. V14 stated R12 does have occasional exacerbations of behaviors and still requires the as needed Clozaril. V14 stated staff need to strictly follow the physician orders as it has taken a long time to get to this point. On 11/14/24 at 9:30am V12, RN (Registered Nurse) stated that Benztropine is supposed to be given once per day if R12 receives an as needed dose of Clozaril. V12 stated R12 can receive up to three doses of Clozaril per day but should only receive one dose of Benztropine per day. On 11/14/24 at 3:15pm V13, Psychotropic RN (Registered Nurse) stated that nurses should be following the orders as they are written. V13 stated I just recently noticed the nurses have not been giving the Benztropine with the Clozaril. V13 stated R12 needs the Benztropine to reduce the risk of EPS and the as needed Clozaril with the Benztropine was recently recommended to be continued on 11/13/24 by the psychiatry service that follows R12.

Based on observation, record review and interview the facility failed to ensure enhanced barrier precautions were followed for one resident (R78) of two residents reviewed for infection control in a total sample of 39. Findings include: An undated policy, entitled Enhanced Barrier Precautions (EBP) document, It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: Enhanced barrier precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. The policy further documents, 4. High-contact resident care activities include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, peripherally inserted central catheters, midline catheters and wound care. R78's November 2024 physician order sheet documents an order for enhanced barrier precautions for a tracheostomy and g-tube/gastrostomy tube. On 11/13/24, 11:30 AM, V6/Licensed Practical Nurse entered R78's room, washed her hands and donned gloves. V6 approached R78 who was sitting in a chair and proceeded to administer R78's medications through a gastrostomy tube. V6 did not wear a protective gown. V2/Director of Nurses and V7/Registered Nurse were present in the room and did not wear gowns. There was no EBP sign on R78's door. On 11/13/24, at 11:46 AM, V7 laid a towel across R78's abdomen prior to providing g-tube site care. V7 wore gloves but did not wear a protective gown during R78's cares. On 11/13/24, at 11:59 AM, V8/Registered Nurse and V2 entered R78's room, washed their hands and donned gloves. V8 also wore a face shield. V2 and V8 provided tracheostomy suctioning and care/cleaning to R78's tracheotomy site. V2 and V8 did not wear gowns to protect R78 from transmission of multidrug-resistant organisms while providing direct care. On 11/13/24, at 1:18 PM, V3/Assistant Director of Nurses/Infection Preventionist confirmed that it is the expectation of the facility that gowns should have been worn during R78's cares due to him having indwelling devices.

Based on record review and interview the facility failed to ensure quality assurance meetings were held quarterly and that the facility medical director attended quality assurance meetings. This failure has the potential to affect all 94 residents residing in the facility. Findings Include: A facility policy, entitled Quality Assurance and Performance Improvement (QAPI), undated, document, It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides; and 1. The QAPI program includes the establishment of a Quality Assessment and Assurance (QAA) committee and a written QAPI plan. 2 The QAA committee shall be interdisciplinary and shall: a, Consist at a minimum of: i. The director of nursing services, ii. the medical director or his/her/designee; iii. At least three other members of the facility's staff, at least one of which must be the Administrator, owner, a board member, or other individual in a leadership role; and the infection preventionist. b. Meet at least quarterly and as needed to coordinate and evaluate activities under the QAPI program, such as identifying issues with respect to which quality assessment and assurance activities, including performance improvement projects under the QAPI program, are necessary. Review of the facility QAPI meeting notes, provided by the facility, document the most recent QAPI meeting was June 26, 2024. The medical director or designee did not attend this meeting. On 11/14/24, at 1:30 PM, V10/Regional Director of Operations confirmed the facility has not had a quarterly meeting since June 2024 and the Medical Director or his designee did not attend. The facility's Long-Term Care Application for Medicare and Medicaid dated 11/12/24 document 94 residents reside in the facility.

Based on interview and record review the facility failed to ensure one resident (R1) was free of mistreatment of three residents reviewed for abuse. Findings include: Facility Policy/Abuse, Neglect and Exploitation dated 2023 documents: The facility will develop and implement written policies that: Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse. Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Mistreatment means inappropriate treatment or exploitation of a resident. Verbal Abuse means the use of oral, written, or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend or disability. On 6/11/24 at 9:45am R1 stated that V5, CNA (Certified Nurse Assistant) was rough and fast when handling her and disregarded the pain she was in. R1 stated she told her daughter and V1, Administrator and V5 was walked out the next day. R1 stated she did not want V5 to care for her anymore. Final Investigation Report dated 4/29/24 indicates: R1 reported that V6, CNA was assisting her with the bedpan when V5, CNA came in to assist. Report indicates V5 rolled R1 onto her side and R1 felt as though she was hanging off the bed and was scared. Report indicates R1 reported that V5 is not as gentle with her as other staff and doesn't allow R1 to move at her own pace. R1 reported not wanting V5 to care for her anymore. R1 reported that V5 makes her feel like she is bothering her when she needs help and reported feeling scared when V5 comes into the room because she doesn't know how V5 is going to be. Final Investigation conclusion indicates V5 was terminated due to allegations of abuse. On 6/11/24 at 2:40pm V1, Administrator stated that she also interviewed other residents that V5 was assigned to and found a pattern of discourteous behavior by V5 and a reluctance to provide cares.

Based on observation, interview and record review the facility failed to initiate and implement Enhanced Barrier Precautions for 24 residents (R1, R2, R3, R6, R8 - R27) reviewed for Infection Control practices of 26 residents reviewed. This failure has the potential to affect all 95 residents who reside in the facility. Findings include: Facility Policy/Enhanced Barrier Precautions dated 3/2024 documents: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves during high contact resident care activities. Prompt recognition of need: All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions. Initiation of Enhanced Barrier precautions: An order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds (chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers) and/or indwelling medical devices (central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with MDRO (Multidrug-resistant Organism). Infection or colonization with a CDC (Centers for Disease Control)-targeted MDRO when Contact Precautions do not otherwise apply. Implementation of Enhanced Barrier Precautions: Make gowns and gloves available immediately near or outside of the resident's room. High-Contact resident care activities include: Dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, any device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes and wound care. Enhanced Barrier Precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. Resident Room Roster (dated 4/16/24) indicated 95 residents resided in the facility on that date. On 4/17/24 at 9:20am V1, Administrator stated that the resident census was the same for 4/17/24. On 4/17/24 and 4/18/24 during tour of the facility at multiple times on those days, there were no posted signs indicating Enhanced Barrier Precautions (EBP) were in place on any of the 95 resident rooms or PPE (Personal Protective Equipment) outside of resident rooms or nearby. On 4/17/24 and 4/18/24 only R7 was observed to have a posted Contact Precaution sign on R7's door and PPE setup outside of R7's room. On 4/18/24 at 10:00am V8, Agency RN (Registered Nurse) stated she had no idea which residents were on Enhanced Barrier Precautions and stated she had not received any training from the facility on EBP. On 4/18/24 at 10:10am V9, Regional Nurse stated that she thought all the Enhanced Barrier Precautions were already in place and confirmed after discussion with V2, DON (Director of Nursing) that EBP's had not yet been implemented. At that time, V9 presented a list of 24 residents the facility had previously identified as requiring Enhanced Barrier Precautions and the indicator(s) requiring EBP: R1 - indwelling urinary catheter and chronic wounds. R9 - tracheostomy and gastric feeding tube R17 - wounds and gastric feeding tube R22 - straight (intermittent) urinary catheterization R26 - nephrostomy R6, R8, R9, R10, R11, R12, R16, R20, R21, R24, R25, R27 - chronic wound(s) R2, R3, R13, R14, R15, R18, R23 - indwelling urinary catheters.

Based on record review and interview the facility failed to prevent an occurrence of staff-to-resident verbal abuse from occurring for one of three residents (R1), reviewed for abuse in the sample of 6. Findings Include: The undated facility policy, Abuse, Neglect and Exploitation documents, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident altercations. It also includes verbal abuse. Verbal abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend or disability. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property and exploitation that achieves: Identifying, correcting and intervening in situations in which abuse, neglect, exploitation and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified registered, licensed and certified staff on each shift in sufficient numbers to meet the needs of the residents and assure that the staff assigned have knowledge the individual residents' care needs and behavioral symptoms. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors. The undated facility policy, Conduct and Behavior documents, All employees must adhere to professional standards. This includes displaying business conduct and behavior and exhibiting a high degree of integrity at all times. Conduct that interferes with the safe operation of the facility, brings discredit to the company, residents of staff or that is offensive to a resident, family member or employer will not be tolerated and can be grounds for disciplinary action. Examples of conduct and behavior that are considered inappropriate and are prohibited by this company include but are not limited to the following: Violation of the resident abuse policy; Failure to treat all residents with kindness, respect and dignity; Argumentative behavior. R1's current Physician Order Sheet, dated January 2024, documents R1's diagnoses as: Dementia and Anxiety and Alzheimer's Disease with Insomnia. R1's current Minimum Data Set Assessment, dated 11/11/2023 documents Section C: Cognitive Status C0500 Brief Interview for Mental Status Score as 10 (Moderately Impaired). R1's current Care Plan, dated 12/22/23 includes the following Focus areas: At low risk for abuse/neglect/trauma. He has history of Dementia and does not always understand or may misinterpret the actions of others. Goal: Will remain free of signs, symptoms of abuse, neglect, and/or trauma. Interventions: Always approach patient (R1) from the front, gain their attention first, introduce yourself to patient (R1) to avoid startling him. Physician will be notified of any signs or symptoms of abuse, neglect, trauma. Refer to psych if needed. Also: Focus Area: Cognitive loss as evidenced by confusion related to diagnosis of Dementia and Alzheimer's. Cognition fluctuates. Goals: Display appropriate response to situation. Will be able to make decision about ADL (Activities of Daily Living)/activity choices or preferences. Interventions: Allow adequate time to respond. Do not rush or supply words. Approach/speak in a calm, positive/reassuring manner. Explain each activity/care procedure prior to beginning it. Identify self when speaking with patient. Provide cueing and prompting for such things as activities, personal care, or room location. Remind patient (R1) of the day of the week during cares as needed to help reorient patient. Allow adequate time to respond. Do not rush or supply words. Approach/speak in a calm, positive/reassuring manner. Explain each activity/ care procedure prior to beginning it. Identify self when speaking with patient. Provide cueing and prompting for such things as activities, personal care, or room location. Remind patient (R1) of the day of the week during cares as needed to help reorient patient (R1). The facility Incident Initial Report dated 12/22/23 and completed by V1/Administrator documents, At 8:15 AM, (R1) reported that a CNA (Certified Nursing Assistant) named '(V8/Certified Nursing Assistant/CNA)' refused to give him coffee when he requested after supper meal. When (R1) went to pour it himself, (V8/CNA) smacked his hand and told him no. Resident assessed for injury, none noted, and he denies pain at this time. 'I can't even feel it today.' CNA identified as (V8) and suspended immediately, pending investigation. POA (Power of Attorney) and Physician notified. Investigation initiated. On 1/24/2024 at 2:43 P.M., V10/Certified Nursing Assistant/CNA stated, I remember that night (12/21/23). It was during suppertime. I heard loud yelling between (R1) and (V8/CNA). (R1) was yelling, 'Give it to me.' (V8/CNA) was yelling, 'If you hit me, I'm going to call the Police.' I was clear down the hall, and I heard all the yelling. I ran to diffuse the situation and kept telling (V8/CNA) to walk away, that she was only agitating (R1) more. (R1) kept saying, 'Get her away from me.' Finally, (V8/CNA) left the area, and I was able to calm (R1) down, and I gave (R1) another cup of coffee and (R1) was fine the rest if the night. The nurse (V12/Registered Nurse/RN) heard all the yelling and came to see what was going on. I didn't report this situation to anyone. I didn't think it was potential abuse. I don't know if the nurse (V12) called and reported it to (V1/Administrator) or (V2/Director of Nurses). On 1/24/2024 at 3:08 P.M., V9/Certified Nursing Assistant/CNA) stated, I was working the evening of 12/21/23. I became aware of the situation, around suppertime when I was in another resident's room feeding a resident and heard loud yelling between (R1) and (V8/Certified Nursing Assistant/CNA). I left the room (where I was feeding) and went to where (R1) and (V8/CNA) were arguing over coffee. (R1) was very agitated and upset. I finally convinced (V8/CNA) to walk away and stop arguing with (R1). I gave (R1) another cup of coffee, and he was quiet the rest of the night. I did not report the incident (potential verbal abuse) to anyone. I went back to feeding the other resident. On 1/24/2023 at 3:45 P.M., V12/Registered Nurse/RN) stated, I was down the hall passing medications when I heard a loud argument in the A- wing hallway. I could hear (V8/CNA) yelling and arguing with (R1), over coffee. When I got there, (V9/Certified Nursing Assistant) and (V10/Certified Nursing Assistant) were trying to calm (R1) down. (R1) kept saying, 'Get her (V8/Certified Nursing Assistant) away from me.' (R1) was pointing at (V8/CNA). Finally, we convinced (V8/CNA) to leave the area. We gave (R1) another cup of coffee and (R1) was calm the rest of the night. (V8/CNA) finished her shift on the A- Hall and left around 10:00 PM. I didn't report the situation to anyone. (V2/Director of Nursing) asked me about it the next day. (V1/Administrator) didn't interview me or ask me to write a statement.

Based on interview and record review, the facility failed to implement its abuse policy of immediately reporting potential abuse, protecting a resident from further potential abuse, and investigating an allegation of potential abuse for one of three residents (R1) reviewed for abuse in the sample of 6. FINDINGS INCLUDE: The undated facility policy, Abuse, Neglect and Exploitation, directs staff, The facility will develop and implement written policies and procedures that: Prohibit and prevent abuse, neglect and exploitation of residents and misappropriation of resident property; and Establish policies and procedures to investigate any such allegation. On 01/25/24 at 8:26 A.M., V1/Administrator, Abuse Coordinator stated, I became aware of a situation (potential verbal abuse 12/21/23 at 6:15 P.M.) between (R1) and (V8/Certified Nursing Assistant) on 12/22/23 at around 8:15 AM. I didn't report the incident to the (state agency), suspend the (CNA V8/Certified Nursing Assistant) or begin an investigation until 12/22/23 at 9:15 A.M. The (facility) Investigation Report, dated 12/22/23 at 9:15 A.M., between resident and CNA (V8/Certified Nursing Assistant) documents, At 8:15 AM, (R1) reported that a CNA, (V8/Certified Nursing Assistant) refused to give (R1) coffee when (R1) requested after supper meal (on 12/21/23). When (R1) went to pour it himself, (V8/CNA) smacked (R1's) hand and told (R1) no. (R1) assessed for injury, none noted, and (R1) denies pain at this time. CNA identified as (V8/Certified Nursing Assistant) and suspended immediately, pending investigation. POA (Power of Attorney) and Physician notified. Investigation initiated. V8/Certified Nursing Assistant's (facility) Timecard report, dated 12/20/23 to 12/31/23 documents that V8/Certified Nursing Assistant worked on 12/21/23 from 1:59 P.M. until 10:05 P.M.

Based on interview and record review, the facility failed to failed to ensure one allegation of abuse was immediately reported to the Administrator for one of three residents (R1) reviewed for abuse, in the sample of 6. FINDINGS INCLUDE: The facility Incident Initial Report, dated 12/22/23 and completed by V1/Administrator documents, At 8:15 AM, (R1) reported that a CNA (Certified Nursing Assistant) named '(V8/Certified Nursing Assistant/CNA)' refused to give (R1) coffee when (R1) requested it after the supper meal. When (R1) went to pour it himself, (V8/CNA) smacked (R1's) hand and told (R1) no. (R1) assessed for injury, none noted, and (R1) denies pain at this time. CNA identified as (V8) and suspended immediately, pending investigation. POA (Power of Attorney) and Physician notified. Investigation initiated. On 01/25/24 at 8:26 A.M., V1/Administrator, Abuse Coordinator stated, I became aware of a situation (potential verbal and/or physical abuse 12/21/23 at 6:15 P.M.) between (R1) and (V8/Certified Nursing Assistant) on 12/22/23 at around 8:15 AM. I didn't report the incident to the (state agency), suspend the (CNA V8/Certified Nursing Assistant) or begin an investigation until 12/22/23 at 9:15 A.M. At that time, V1/Administrator confirmed that V9/Certified Nursing Assistant, V10/Certified Nursing Assistant nor V12/Registered Nurse had reported the allegation of abuse to her on 12/21/2023.

Based on observation, interview and record review, the facility failed to provide range of motion exercises for one of one resident (R25) with a known history of limited range of motion, in a sample of 48. Findings include: The (undated) facility policy, Prevention of Decline in Range of Motion, directs staff, residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable. Staff will be educated on basic, restorative nursing care. This training may include: Assisting residents with range of motion exercises, performing passive range of motion for residents unable to participate. General Guidelines for Range of Motion: Explain the procedure to the resident then ask permission to proceed. Move each joint through its range of motion three times unless otherwise instructed. Move each joint gently, smoothly, and slowly through its range of motion. Stop an exercise before the point of pain. Report pain to the nurse. R25's admission Assessment, dated 12/15/2021 documents, Fall Risk Assessment: Left leg contracture. R25's Physician Progress Note, dated 3/7/22 documents, Extremity: Chronic contracture of the left lower extremity. Chronic right hand weakness. On 12/04/23 at 2:45 P.M., R25 was sitting up in bed watching television. R25's left leg was visible, and a contracture of R25's left leg was observed. At that time R25 stated, I don't get any range of motion exercises. On 12/04/23 at 3:11 P.M., V2/Director of Nurses confirmed the presence of contractures of R25's left leg. At that time, V2/DON stated, We don't currently have any ROM (Range of Motion) programs. I don't have a Restorative Nurse.

Based on observation, interview and record review, the facility failed to check placement of a gastrostomy feeding tube prior to the administration of fluids and medications; and failed to flush a gastrostomy feeding tube with the prescribed water flushes between medications for one of one resident (R70), reviewed for feeding tubes, in a sample of 48. Findings include: The (undated) facility policy, Medication Administration via Enteral Tube directs staff, It is the facility policy to ensure the safe and effective administration of medications via enteral feeding tubes by utilizing best practice guidelines. Enteral tube placement must be verified prior to administering any fluids or medication. Flush enteral tube with at least 15 ML (milliliters) of water prior to administering medications unless otherwise ordered by prescriber. Dilute the solid or liquid medication as appropriate and administer using a clean oral syringe. Flush tube again with at least 15 ML of water taking into account resident's volume status. Repeat with next medication. Flush the tube with a final flush of at least 15 ML of water to ensure drug delivery and clear the tube. On 12/5/2023 at 8:14 A.M., V7/Licensed Practical Nurse (LPN) prepared to administer medications for R70. V7/LPN crushed Atorvastatin 10 MG (milligrams) in an individual plastic pouch, Aspirin 81 MG, Metoprolol 50 MG (Milligrams) and Sertraline 50 MG, each in an individual pouch and then entered R70's room. V7/LPN applied gloves, exposed R70's feeding tube and without verifying placement of the tube, administered 30 ML (milliliters) of tap water. V7/LPN then mixed one of the medication pouches with 20 ML of tap water and administered the medication, then without flushing the tube between, mixed the second medication pouch with 20 ML of tap water and administered that medication, then repeated the administration by adding 20 ML of tap water to the third and fourth medication and administering each, without flushing the feeding tube between medication administrations. After V7/LPN administered the fourth medication, V7/LPN administered two 30 ML water boluses, clamped R70's feeding tube and exited the room. At that time, V7/LPN confirmed she had not checked placement of R70's feeding tube prior to the administration of medication and had not flushed R70's feeding tube with the required 15 ML of water between each medication administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure pain medication was available upon admission for a resident with reports of pain for one of one resident (R145) reviewed for pain in the sample of 48. Findings include: On 12/06/23, V2 (Director of Nursing) provided a copy of (contracted pharmacy's) undated policy titled 'New admission Policy & Procedure' and stated this policy is utilized by the facility in collaboration with (contracted pharmacy). This same policy documents the following: Process to provide medications prior to the next scheduled delivery: Review contents of the aforementioned boxes (E box or C box) that are on-site at the facility and with the nurse, confirm needed medications are available. If not, medications will either be: sent STAT (immediately) from the pharmacy or called into a local pharmacy and a courier scheduled by pharmacy will pick up the medication and deliver to the facility. If there is a control necessary and we do not have the medication or we cannot for legal reasons transfer the control medication, the pharmacist will contact the facility nurse to ask the prescriber to change the order to a medication or strength of medication that is available. Facility staff is notified to contact pharmacy if/when sending an admission after the facility 'cut-off' time to assure the medications will be sent in a timely manner. R145's current electronic medical record documents that R145 was admitted to the facility on the evening of 12/01/23 with the following diagnoses: Fracture of Sacrum; Anxiety Disorder; Arthritis; Sciatica; Age-related Osteoporosis; Spinal Stenosis. R145's Physician's Order Sheet (dated 12/01/23 - 12/31/23) documents the following medication order (date of order 12/01/23): Codeine Sulfate Oral Tablet 30 milligrams give 0.5 tablet by mouth every 6 hours as needed for moderate to severe pain. R145's Progress Note (dated 12/02/23 and timed 10:31 AM) documents the following: Per pharmacy 15 milligram codeine tablets are not in stock and will not be until Monday 12/04/23. The pharmacy does have 30 milligram tablets in stock. Communication with (V10, R145's Physician) resulted in new order for codeine sulfate 30 mg tablets, 1/2 tablet by mouth every 6 hours PRN (as needed) for moderate to severe pain (5-10). Script faxed to (V10) for completion and signature. Communicated new order with pharmacy and expected delivery of signed prescription from (V10) later today which will be forwarded to them upon receipt. R145's Progress Note (dated 12/02/23 and timed 11:07 AM) documents the following: Received signed script from (V10, R145's Physician) and faxed to (contracted pharmacy). R145's Progress Note (dated 12/02/23 and timed 01:32 PM) documents the following: Contacted (contracted pharmacy) to verify their receipt of resident's prescription. Representative verified receipt and stated that medication would be dispensed from the pharmacy and delivered with tonight shipment. Undated statement written by V11 (contracted pharmacy Chief Operating Officer) documents the following regarding R1's admission, The medication prescribed on 12/01/23 was OOS (out of stock), we called and informed nurse that we needed a new order for either a different pain med or to change to 30 milligram (take 1/2 tab), which came in on 12/02/23 late morning, and the med went out on the evening run (12/02/23). On 12/06/23 at 11:00 AM, V1 (Administrator in training) confirmed that R145 was admitted on [DATE], and the Codeine she had ordered was not available at the facility when R145 arrived. V1 stated, This medication was not delivered to the facility until the evening of 12/02/23. We do not keep Codeine in the emergency backup medication box, so V10 (R145's Physician) should have been notified as soon as (R145) arrived to see if we could utilize something that is stocked in the emergency backup box until we received R145's Codeine from (contracted pharmacy.)

Based on interview and record review, the facility failed to document a rational for the continued use of an antibiotic for one of one resident (R25) reviewed for unnecessary medications in a sample of 48. Findings Include: The (undated) facility policy, Antibiotic Stewardship Program directs staff, The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. All prescriptions for antibiotics shall specify the dose, duration and indication for use. R25's Physician Order Sheet, dated 12/5/2023 includes the following medication: Cefdinir Capsule 300 MG Give 1 capsule by mouth one time a day for maintenance. No stop date is included for the antibiotic usage. On 12/4/23 at 3:09 P.M., V2/Director of Nurses stated, (R25) is on continuous antibiotics due to recurrent knee wound infections. I didn't realize the antibiotic was started that long ago. There is no stop date for the medication. On 12/5/2023 at 8:10 A.M., V8/Wound Doctor stated, I have no idea why (R25) is on a maintenance dose of antibiotic. (R25) doesn't need that (antibiotic). On 12/07/23 at 11:04 AM, V2 stated, I didn't know that (R25) was on a prophylactic antibiotic. I don't have it on any of my infection control tracking. What are we supposed to do if a doctor orders a prophylactic antibiotic, we can't just tell them they can't prescribe it.

Based on interview and record review, the facility failed to ensure antibiotics were prescribed appropriately for one of one resident (R25) reviewed for antibiotic use in the sample of 48. Findings include: The facility's Antibiotic/Antimicrobial Stewardship Program policy (dated 11/28/17) documents the following: This facility is dedicated to implementing an Antibiotic/Antimicrobial Stewardship program to reduce the use of antibiotics. This program helps ensure that our residents get the right antibiotics at the right time for the right duration, and can improve individual patient outcomes, prevent deaths from resistant infections, slow antibiotic resistance, decrease Clostridium difficile infections, and healthcare costs. This policy also documents, Review the clinical record for new antibiotic starts to determine whether the clinical assessment, prescription documentation and antibiotic selection were in accordance with the antibiotic stewardship practices. When conducted over time, monitoring process measures can assess whether antibiotic prescribing policies are being followed by staff and clinicians. Track the amount of antibiotics used to identify patterns of use and determine the impact of new stewardship interventions. R25's Physician Order Sheet, dated 12/5/2023 includes the following medication: Cefdinir (antibiotic) Capsule 300 MG (milligrams). Give one capsule by mouth one time a day for maintenance. No stop date is included for the antibiotic usage. The facility's monthly Infection Control Log dated January 2023 - November 2023 does not document any tracking of R25's Cefdinir use. On 12/6/23 at 1:30 P.M., V2 Director of Nurses verified that R25's use of Cefdinir began on 4/11/2022 has not been tracked on the facility's monthly Infection Control Log for January through November 2023. On 12/07/23 at 11:04 AM, V2 stated, Anyone who is on antibiotic should have a stop date. With my infection control tracking, I track the antibiotics to ensure there is a stop date. That is the point of our antibiotic stewardship program. I didn't know that (R25) was on a prophylactic antibiotic. I don't have it on any of my infection control tracking. What are we supposed to do if a doctor orders a prophylactic antibiotic, we can't just tell them they can't prescribe it.

Based on observation, interview, and record review, the facility failed to treat residents with dignity by serving their meal fluids in disposable cups. This has the potential to affect all 29 residents (R2, R4, R5, R7, R11, R13, R17, R19, R22, R28, R30, R32, R33, R40, R42, R45, R54, R56, R60, R63, R65, R66, R68, R69, R71, R77, R80, R87, R295) residing on the Arcadia unit in the sample of 48. Findings include: The facility's Promoting/Maintaining Resident Dignity policy, dated 2/23, documents, It is the practices of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality. On 12/05/23 at 12:00 PM, the Arcadia meal tray cart was outside of the dining room. Staff were serving the residents their meal trays. Residents were served their milk, water, and juice in disposable clear cups and disposable Styrofoam cups. On 12/05/23 at 12:16 PM, V23 (CNA-Certified Nursing Assistant) stated, Since the company changed, this hallway does not get regular cups we get these plastic (disposable) cups. On 12/8/23 at 11:45 a.m., residents in the Arcadia dining room were served their juice, water, and milk in plastic disposable cups. V14 (Registered Nurse) stated, The residents are served their fluids in disposable cups all the time. We've been told it's because we don't have enough regular cups. On 12/8/23 at 11:50 a.m., V1 (Administrator in Training) stated, I was aware that we were needing to order more cups, but I didn't realize we didn't have enough that residents weren't using them. On 12/8/23 at 2:30 p.m., V4 (Dietary Manager) stated, The Arcadia unit residents are getting served disposable cups because we don't have enough cups in the facility for all of the residents. The facility's Room Roster, dated 12/3/23, documents that the following 29 residents reside on the Arcadia Unit: R2, R4, R5, R7, R11, R13, R17, R19, R22, R28, R30, R32, R33, R40, R42, R45, R54, R56, R60, R63, R65, R66, R68, R69, R71, R77, R80, R87, and R295.

Based on interview and record review, the facility failed to provide the resident council with responses, actions, and rationales taken regarding their concerns. This has the potential to affect all 96 residents residing within the facility. Findings include: The facility's Resident and Family Grievances policy, dated 2023, documents, Grievances may be voiced in the following forums: Verbal complaint to a staff member or Grievance Official; Written complaint to a staff member or Grievance Official; Written complaint to an outside party; Verbal complaint during resident or family council meetings; Via the company toll free Customer Service line. The Grievance Official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form: Steps to resolve the grievance may involve forwarding the grievance to the appropriate department manager for follow up; All staff involved in the grievance investigation or resolution should make prompt efforts to resolve the grievance and return the grievance form to the Grievance Official. 'Prompt efforts' include acknowledgment of complaint/grievances and activity working toward a resolution of that complaint/grievance. In accordance with the resident's right to obtain a written decision regarding his or her grievance, the Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. The written decision will include at a minimum: The date the grievance was received; The steps taken to investigate the grievance; A summary of the pertinent findings or conclusions regarding the resident's concerns; A statement as to whether the grievance was confirmed or not confirmed; Any corrective action taken or to be taken by the facility as a result of the grievance; The date the written decision was issued. The facility will make prompt effort to resolve grievances. The facility's Council Concern/Recommendation forms, dated 7/25/23, documents that concerns were given to: Laundry department regarding missing clothes and receiving clothes that do not belong to them; Housekeeping department regarding garbage cans not being emptied; Maintenance department regarding a leak in a bathroom and the threshold of a doorway. The forms also document for the concern response be returned to the Council by 7/31/23. However, there is no staff response documented as to how the facility is going to take action to resolve these concerns. The facility's Council Concern/Recommendation forms, dated 9/26/23, documents that concerns were given to: Maintenance regarding a call light and a clock not working; Administration regarding the front doors not being answered; Nursing regarding call lights not being answered timely and residents not receiving showers; Dietary regarding food being overcooked and cold, wanting more substitutions options and fresh foods. The forms also document for the concern response be returned to the Council by 10/3/23. However, there is no staff response documented as to how the facility is going to take action to resolve these concerns. The facility's Council Concern/Recommendation forms, dated 11/28/23, documents that concerns were given to: Laundry department regarding missing clothes; Nursing department regarding long call light response time and taking time to assist a resident with eating; Administration regarding the front door not being answered. The forms also document for the concern response be returned to the Council by 12/4/23. However, there is no staff response documented as to how the facility is going to take action to resolve these concerns. On 12/06/23 at 11:03 AM, during the survey resident meeting, R55 stated, How is this meeting going to help us? We have monthly meetings that we tell them our concerns, but they never get back to us. It's the same thing every month. On 12/06/23 at 11:04 AM, R43 stated, Every month we complain about call lights, clothes missing, and the food. However, no one ever comes to us to let us know how they're going to fix it, and things don't change. On 12/06/23 11:05 AM, R21 stated, Our resident council meetings are pointless because they don't listen. They don't tell us how they are going to fix our concerns, and the problems keep happening. On 12/8/23 at 9:50 AM, V6 (Activities Director) stated, We don't have a laundry supervisor. They do complain about missing clothes in the resident council meetings repeatedly. I don't fill out an individual grievance for each person. I feel bad after the resident council because I will fill out the concern forms, but the departments don't respond to the concerns. So, I don't have a response to give the residents the following month. The night before a resident council meeting, I can't hardly sleep worrying about what the resident concerns are going to be. The residents frequently express their concerns about call lights and missing clothing. They have complained about the cold food in the resident council meeting. On 12/8/23 at 11:50 AM, V1 (Administrator in training) stated, This (missing laundry) has been an ongoing issue. I'm aware that she (V6) is having issues with getting resident council concern responses. I've been trying to work with (V6) to continue to follow up with the department heads that she gives the resident council concerns to. I've told her she could ask for them during our morning meetings as well. The facility's room roster, dated 12/3/23, documents that 96 residents reside in the facility.

Based on interview and record review, the facility failed to provide a sufficient number of staff to provide assistance to dependent residents. This failure has the potential to affect all 96 residents residing within the facility. Findings include: The facility's Nursing Services and Sufficient Staff policy, dated 2/23, documents, It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility's census, acuity, and diagnoses of the resident population will be considered based on the facility assessment. The facility's Call lights: Accessibility and Timely Response policy, dated 2/23, documents, All staff who see or hear an activated call light are responsible for responding. If the staff member cannot provide what the resident desires, the appropriate personnel should be notified. On 12/06/23 at 11:09 a.m., during the survey resident council meeting the following resident statements were made: R43 stated, If they have enough staff, we can get the help we need. I've got stuck on the toilet waiting. We are short of staff, and we don't get showers because of it sometimes. R55 stated, When there isn't enough it falls on the residents. We are the ones who don't get cares or have to wait for long periods of time. R84 stated, I don't know how to tell time, and the staff will just keep telling me I'll be here in a minute. I wait and wait, then I end up having an accident, and it's so upsetting. They work short, and when they do, I don't always get my showers. They will tell me they don't have enough people. So, I just get a spit bath. On 12/8/23 at 11:10 a.m., V13 (CNA-Certified Nursing Assistant) stated, Staffing is an issue. On a regular day when we are fully staffed, we have 9-10 CNAs on the floor, but there are times we have 6-7. If we work short, it's hard on the staff and the residents. We get so stressed out because we can't do everything for the residents that we need to or in a timely manner. The call light times are longer, and the residents are waiting longer to be toileted. Sometimes we can't give showers either, and we have to offer the resident a bed bath. On 12/8/23 at 11:30 a.m., V18 (CNA) stated, We work short frequently. We aren't able to get things done in a timely manner when we aren't staffed with enough people. On 12/8/23 at 11:45 a.m., V14 (Registered Nurse) stated, The meals frequently are brought back to us in the cart, but not on hot plates. We try to act as quickly as possible to get the meals served, because we know that they will get cold quickly. However, it's hard to act quickly with not enough staff. There isn't enough staff frequently. It's hard for the CNAs to get everything done when they don't have enough staff. The facility's Grievance Form, dated 8/24/23, documents a grievance for R296 regarding R296 having to wait long periods of time for her call light to be answered. The facility's Resident Council Minutes, dated 9/26/23, document that the council had concerns with it taking too long to answer call lights and showers are not being received. The facility's Resident Council Minutes, dated 11/28/23, document that the council had concerns with it taking too long to answer call lights with waiting up to 45 minutes for their call light to be answered. The facility's Nursing Assignment sheet, dated 11/24/23, documents that on 1st shift four nurses and eight CNAs worked, and on 2nd shift five nurses and nine CNAs worked. The facility's Nursing Assignment sheet, dated 11/26/23, documents that on 2nd shift five nurses and nine CNAs worked. The facility's Nursing Assignment sheet, dated 11/24/23, documents that on 3rd shift three nurses and five CNAs worked. On 12/8/23 at 12:35 p.m., V19 (Nursing Scheduler) stated, The minimum number I am told to schedule is first and second shift 10 CNAs and 5 nurses, and third shift is three nurses and six CNAs. Staff have complained about working short, but with our call offs it's hard to be fully staffed. I wish we could have more staff on the floor. V19 confirmed that on 11/24/23, 11/26/23, and 12/2/23 there was less than minimum staff working. On 12/8/23 at 9:50 a.m., V6 (Activities Director) stated, (During resident council meetings) The residents frequently express their concerns about call lights and staffing. On 12/8/23 at 11:50 a.m., V1 (Administrator in Training) stated, We have a lot of new staff and agency staff. We are trying to develop the expectations with the staff for call lights. The facility's room roster, dated 12/3/23, documents that 96 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to serve food at a palatable temperature. This has the potential to affect all 96 residents residing in the facility. Findings include: The facility's Resident Council Minutes, dated 9/26/23, document that the residents have concerns with the food being cold. On 12/05/23 at 11:30 AM, upon entering the kitchen two insulated meal cart's doors were open. and contained trays of meals. One cart contained meals that were not on a hot plate. On 12/05/23 from 11:30 to 11:45 AM, throughout this observation, V4 (Dietary Manager) was present. The two meal cart doors remained open, and the one cart of meals were not on hot plates. V4 stated, All of our meals are sent out on carts and taken to the halls. All of the plates should be on top of a hot plate and covered with an insulated cover. The meal cart that is open and has no hot plates is the Arcadia Hall trays. The meal cart doors should always be closed to keep the heat in. V4 yelled to her staff, Why aren't Arcadia plates on hot plates? V21 replied, We don't have enough hot plates for everyone to get one. On 12/05/23 at 11:53 AM, the Arcadia Hall meal cart entered the Arcadia Hall. On 12/5/23 at 11:55 AM, the thermometer was calibrated using an ice water bath. On 12/05/23 at 12:00 PM, the Arcadia meal tray cart was outside of the dining room with both doors open. Staff were serving the residents their meal trays. On 12/05/23 at 12:16 PM, V23 (CNA-Certified Nursing Assistant) pulled the last tray from the meal tray cart. The plate contained pork loin, mixed vegetables, and sweet potatoes. The pork loin temperature was 90 degrees. The mixed vegetables temperature was 92 degrees. The sweet potatoes temperature was 94 degrees. V23 was present and confirmed all three temperatures. V23 stated, We don't have bottom hot plates today for some reason. On 12/5/23 at 10:15 AM, R43 stated The food is the only thing we complain about. It (food) is cold and gross. On 12/06/23 at 11:33 AM, during the survey resident meeting the following statements were made: R55 stated, It's (food) terrible and it's cold when we get to it. We complain but nothing happens. R43 stated, The food is cold. That happens a lot. R21 stated, The food is not edible. It's cold and it's awful. We complain, but it doesn't do any good. R84 stated, The food is lukewarm when it is served. On 12/4/23 at 10:00 AM, R12 stated The food is cold and bland and sometimes unrecognizable. On 12/05/23 at 12:10 PM, R20 was sitting in a wheelchair in his room conversing with his daughter. R20 stated his only concern is The food is always cold. On 12/06/23 at 12:20 PM, R20 was sitting in a wheelchair with a bedside table positioned in front of him. A lunch tray with less than 10% of the meal consumed was sitting in front of R20 on his bedside table. R20 stated, I didn't eat much. It was really cold today. It just doesn't taste very good when it is cold. On 12/8/23 at 11:45 AM, V14 (Registered Nurse) stated, the meals frequently are brought back to us in the cart, but not on hot plates. We try to act as quickly as possible to get the meals served, because we know that they will get cold quickly. However, it's hard to act quickly with not enough staff. There isn't enough staff frequently. It's hard for the CNAs to get everything done when they don't have enough staff. On 12/6/23 at 11:55 AM, V4 (Dietary Manager) stated, I'm aware that the residents keep complaining about the cold food. We serve them on the hot plates. So, what else am I supposed to do? When asked about the cold meal on 12/5/23, V4 stated, I'm done. This conversation is over. V4 turned and left the room refusing to further speak with the surveyor. On 12/6/23 at 11:50 AM, V1 (Administrator in training) stated, We had issues with them not liking the menus, but not that the food is cold. All the meals should be going out on hot plates in the meal carts. The facility's room roster, dated 12/3/23, documents that 96 residents reside in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to recognize signs and symptoms of illness of facility staff and residents as a possible contagious illness (RSV, COVID-19, Influenza), failed to perform the required COVID-19 testing on staff and residents actively demonstrating signs and symptoms of a possible infectious respiratory illness, failed to test for other infectious respiratory illnesses (RSV and influenza) when a COVID-19 test was negative, failed to implement isolation precautions with symptomatic residents, and failed to ensure a surgical mask covered the staffs' mouth and nose while serving food. These failures had the potential to affect all 96 residents residing within the facility. Findings include: The CDC (Centers for Disease Control and Prevention) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 5/8/23, documents, Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible. People with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to sever illness. Symptoms may appear 2-14 days after exposure to the virus. Anyone can have mild to severe symptoms. Possible symptoms. Include: Fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, diarrhea. This list does not include all possible symptoms. Place a patient with suspected or confirmed SARS-SoV-2 infection in a single-person room, the door should be kept closed (if safe to do so). The facility's Infection Control Policy and Procedure for COVID-19 Facility Response Strategy, dated 5/25/23, documents, The facility shall instruct HCP (Healthcare Professionals) to report a positive viral test, symptoms of COVID-19, or close contact with someone with SARS-CoV-2 infection or a higher-risk healthcare exposure to SARS-CoV-2 to the Infection Preventionist or another point of contact designated by the facility so these HCP can be properly managed. Source control is recommended for individuals in the facility who: Have suspected or confirmed SARS-CoV-2 infection or other respiratory infection (e.g., those with runny nose, cough, sneeze); Had close contact (residents or visitors) or a higher-risk exposure (HCP) with someone with SARS-CoV-2 infection for 10 days after their exposure. Reside or work on a unit or area of the facility experiencing a SARS-CoV-2 outbreak. If the facility is experiencing an outbreak of COVID-19 or other respiratory illnesses, at a minimum, HCP must wear a well-fitted mask while on the unit or floor experiencing an outbreak. COVID-19 testing is required for any of the following: Symptomatic residents or HCP, even those with mild symptoms of COVID-19 regardless of vaccination status, should receive a viral test for SARS-CoV-2 as soon as possible. Duration of Empiric Transmission-Based Precautions for symptomatic residents being evaluated for SARS-CoV-2 infection: The decision to discontinue empiric Transmission-based precautions by excluding the diagnosis of current SARS-CoV-2 infection for a resident with symptoms of COVID-19 can be made based upon having negative results from at least one NAAT (e.g. PCR) viral test; If a higher level of clinical suspicion for SARS-CoV-2 infection exists, consider maintaining Transmission-Based Precautions and confirming with a second negative NAAT or second negative antigen test taken 48 hours after the first negative test. The facility shall consult with residents' health care provider to rule out other respiratory infections before discontinuing Empiric Transmission-Based Precautions. On 12/05/23 at 10:15 AM, V2 (Director of Nursing) stated, Our outbreak started on 11/10/23 when a staff member tested positive. I'm the Infection Preventionist, but I haven't completed the Infection Preventionist training yet. During this outbreak, we've had 24 residents and 24 staff test positive for COVID. On 12/05/23 at 11:30 AM, upon entering the kitchen, V22 (Cook) was wearing a surgical mask below her nose dishing food onto plates. V22 would then pass the plate to V20 (Dietary Aide) to put it onto a hot plate and tray. V20 was wearing a surgical mask below his chin, leaving his nose and mouth uncovered. Then, V21 (Dietary aide) added uncovered dessert and drinks to the tray and placed it on the hall cart. V21 was wearing a surgical mask below her chin, leaving her nose and mouth uncovered. On 12/05/23 from 11:30 to 11:45 AM, V20, V21, and V22's masks were down while serving meals. Throughout this observation, V4 (Dietary Manager) was present. V4 (Dietary Manager) stated, I had one staff member test positive for COVID today. The staff are supposed to be wearing a surgical mask at all times. The masks should not be below their nose or chin. V4 confirmed the three staff members were not wearing their masks correctly. V4 yelled, (V20) put your mask up! V20 lifted his mask above his mouth but below his nose and continued with arranging the meals on the trays. V4 stated that is not correct placement of the mask, and yelled, (V20) get you mask all the way up! V15's (CNA-Certified Nursing Assistant) Employee Time Off Request form, dated 10/29/23, documents that V15 called off for diarrhea, headache, and cramps. V15's Timecard Report, dated 11/2-12/1/23, documents that V15 returned to work on 11/4/23. On 12/8/23 at 11:10 a.m., V15 stated, I called off on 10/29/23 with diarrhea and a headache. The facility never COVID tested me. Staffing is an issue. On a regular day when we are fully staffed, we have 9-10 CNAs on the floor, but there are times we have 6-7. If we work short, it's hard on the staff and the residents. We get so stressed out because we can't do everything for the residents that we need to or in a timely manner. The call light times are longer, and the residents are waiting longer to be toileted. Sometimes we can't give showers either, and we have to offer the resident a bed bath. V13's (CNA) Employee Time off Request Form, dated 10/29/23, documents that V13 called off for a sore throat and a headache. V13's Timecard Report, dated 10/28-11/2/23, documents that V13 returned to work on 10/30/23. V14's (Registered Nurse) Employee Time Off Request form, dated 10/29/23, documents that V14 called off for her 10/30/23 shift for having a cough. V14's Timecard Report, dated 10/28-11/2/23, documents that V14 returned to work on 10/31/23. On 12/8/23 at 11:45 a.m., V14 (Registered Nurse) stated, I called off on 10/30/23 with a really bad headache and sinus pressure. The facility did not test me for COVID before I came back to work. V18's (CNA) Employee Time off Request Form, dated 11/2/23, documents that V18 called off for having Strep throat. V18's Timecard Report, dated 10/31-11/4/23, documents that V18 returned to work on 11/4/23. V18's Timecard Report, dated 11/26-12/8/23, documents that V18 worked from on 11/26/23 from 10:03 p.m. to 10:00 a.m. on 11/27/23. The report also documents that V18 called in on 11/28/23 reporting she had COVID-19. On 12/8/23 at 11:30 a.m., V18 stated, On 10/31/23 at work I started getting a bad headache. I called in for my 11/2/23 shift. I felt like I had been hit by a truck. I was having chills, a bad headache, and a sore throat. I went to the doctor, and he tested me for COVID and Strep. I tested positive for Strep throat. I came back to work on 11/4/23, but I was still feeling sick I had not gotten any better. The facility never tested me for COVID during that time. I wasn't tested for Influenza or RSV either. On 11/26/23 I worked 10:00 p.m. to 10:00 a.m. I had a really bad headache, and I was getting cold symptoms like a head cold. I told the nurse working, and she gave me Tylenol. I never was tested that day by the facility. It was that afternoon at my other job that I was tested and tested positive for COVID. V17's (CNA) Employee Time Off Request Forms, dated 11/14/23 & 11/15/23, document that V17 called off for not feeling well. V17's Timecard Report, dated 11/13-11/17/23, documents that V17 called in sick on 11/13, 11/14, and 11/15/23. V17's Timecard Report, dated 11/17-12/1/23, documents that V17 returned to work on 11/18/23. R14's Nurses' note, dated 11/14/23 at 4:45 p.m., document, COVID test negative. Resident congested with cough. New orders received: Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3 ML (milligrams/milliliters) one vial inhale orally four times a day for upper respiratory infection, Prednisone Oral Tablet 20 MG give 20 mg by mouth in the morning for upper respiratory infection for 7 Days. Doxycycline (antibiotic) Oral Tablet 100 mg. Give 100 mg by mouth two times a day for Upper respiratory infection for 10 days. R14's EMAR (Electronic Medication Record), dated 11/15/23 at 5:51 p.m. and 10:29 p.m., document that R14 was administered Ipratropium-Albuterol Solution 0.5-2.5 (3) MG/3 ML one vial to inhale orally for an upper respiratory infection. R14's Nurse Practitioner Encounter note, dated 11/16/23, documents, Chief Complaint: Cough/Congestion. R14 seen and examined today per nurse request for patient recently seen and treated by doctor for acute URI (Upper Respiratory Infection) who was started on Doxycycline 100 mg (milligrams) by mouth twice a day for 10 days, Prednisone 20 mg by mouth every day for seven days, and DuoNebs four times a day PRN (as needed) for SOB/DOE/wheezing (Shortness of Breath/Dyspnea on Exertion/wheezing) on 11/14/23. Patient complains of wet congested cough for two days with occasional SOB/DOE. Patient complains of chills on and off yesterday. R14's Hospital History & Physical, dated 11/19/23, documents, Chief Complaint: Acute hypoxic respiratory failure. Came into the emergency room with complaints of shortness of breath. Patient was recently tested for COVID-19 infection. Was diagnosed with COVID-19 pneumonia. Patient oxygen saturation was in low 90's as per the ER (Emergency Room) physician there is concern for hypoxia secondary to COVID-19 pneumonia and patient was admitted for acute hypoxic respiratory failure. Patient complains of chest pain and shortness of breath for the past few days. Complains her chest hurts when she swallows. Complains of ongoing cough. On and off productive sputum. The facility's line listing, provided on 12/5/23 by V2 (Director of Nursing), documents that R14 tested positive for COVID-19 on 11/19/23 with the symptoms of dyspnea and chest pain. R14's medical record has no documentation of isolation precautions being implemented for R14 with the development of her symptoms on 11/14/23 until she tested positive on 11/19/23. R58's EMAR Administration note, dated 11/14/23 at 6:30 a.m., documents that R58 received Acetaminophen Oral Tablet 500 MG (milligrams) PRN (as needed) for a headache. R58's Nurses' notes, dated 11/15/23 at 12:48 a.m., document, Nurse alerted to room [ROOM NUMBER]:50 a.m., by CNA with concerns about R58 due to R58 being extremely shaky and pale. Nurse responded to room and noted Resident on toilet. Resident unable to hold self up without holding onto toilet bars. Due to facility COVID outbreak status, Nurse completed a rapid (COVID-19) test on Resident, which immediately read through as positive for COVID. Nurse left room to notify (V2), leaving Resident with CNAs. (V2) notified at 12:07 a.m. that Resident is COVID +. When Resident assisted 2:1 off of toilet, CNAs noted large blood clots coming from Resident's coccyx. Again, resident unable to stand per norm. Nurse notified by CNAs of increase in bleeding/clots noted. Nurse spoke with Resident, who at 12:10 a.m. requested to be sent to the ED (Emergency Department) for evaluation/treatment. Nurse called 911 at 12:11 a.m. for transport. R58's Nurses' notes, dated 11/15/23 at 4:58 a.m., document, Nurse called hospital and was notified that Resident is being admitted for COVID Pneumonia and Rectal Bleeding. The facility's line listing, provided on 12/5/23 by V2 (Director of Nursing), documents that R58 tested positive for COVID-19 on 11/15/23. V16's (CNA)'s Employee Time off Request Form, dated 11/19/23, documents that V16 called off for a headache and not feeling well. V16's Timecard Report, dated 11/21-12/1/23, documents that V16 returned to work on 11/23/23. On 12/8/23 at 9:50 a.m., V6 (Activities Director) stated, On Sunday 11/26/23 I was feeling like I was getting sick with a cold, and I was really tired. I didn't work 11/27/23 because I had a prescheduled vacation day. I came back to work on 11/28/23, and I didn't feel good I was losing my voice and coughing. I was like that all week. I was tested for COVID on 11/28/23 and 12/1/23 with the regular scheduled COVID testing. When I got up 12/4/23 I was really sick with upper respiratory stuff and couldn't talk. So, I called off and went to the doctor. The doctor tested me that day for COVID, Strep, and Influenza B. I ended up testing positive for Influenza B. I was off on 12/5/23 as well. Then, I came back on 12/6/23. I just tested for COVID today. On 12/06/23 at 01:34 PM, V2 stated, When (V4) tested positive we initiated contact tracing. Later that day, we had a therapist who said she wasn't feeling so well so she tested, and it was positive. So, then we added to the contact tracing list. When we had the additional positives, we went to facility wide testing. As the additional cases came up, we initiated masking for everyone, and testing facility wide twice a week. The staff in the kitchen should always have their masks up, especially while serving food. I can't believe they had them down even with (V4) in there. They have had multiple staff that are COVID positive in the kitchen. V2 confirmed that the following staff called off from work sick and were not COVID-19 tested prior to returning to work: V13-V18. V2 stated, Symptoms of COVID are cough, congestion, fever, respiratory type symptoms, and headaches. If a staff member or resident is displaying symptoms, they should be tested for COVID. If the COVID test is negative the staff can continue to work, and residents aren't placed in isolation until they test positive for COVID. So, if their test was negative, we don't do anything unless the doctor orders for us to put them in isolation. A headache by itself really isn't a symptom of COVID. They have to have other symptoms as well to consider it being COVID. We haven't ever considered any other respiratory illnesses when the residents are symptomatic. No residents have been tested for Influenza or RSV. R58 only had a headache so we didn't consider COVID even though we were in an outbreak. We didn't test her that day, we just treated the symptom. R14 wasn't put in isolation precautions because she tested negative when her symptoms started. She wasn't put into isolation until she tested positive on 11/17/23. The facility's Room Roster, dated 12/3/23, documents that 96 residents reside within the facility.

Based on observation, interview, and record review, the facility failed to designate an onsite staff member as Infection Preventionist. This has the potential to affect all 96 residents residing in the facility. Findings include: The facility's QAPI (Quality Assurance and Performance Improvement) Committee Meeting Attendance Records, dated 3/7/23, 6/6/23, and 9/5/23, document that V12 (Regional Nurse) is the Infection Preventionist. On 12/04/23 at 02:53 PM, V1 (Administrator in Training) stated, (V2/ Director of Nursing) is currently being trained to become our Infection Preventionist. V12 is an Infection Preventionist, but she doesn't work in our building on a full time basis. She is training (V2). On 12/05/23 at 10:15 AM, V2 stated, Our outbreak started on 11/10/23 when a staff member tested positive. I'm the Infection Preventionist, but I haven't completed the Infection Preventionist training yet. During this outbreak, we've had 24 residents and 24 staff test positive for COVID. On 12/07/23 at 11:01 AM, V12 stated, I have been filling in as the Infection Preventionist since March of this year. V12 confirmed that she worked in other buildings throughout her region, and she was not dedicated to this facility alone. The facility's room roster, dated 12/3/23, documents that 96 residents reside in the facility.

Based on observation, interview, and record review, the facility failed to ensure a smoke detector was not covered causing it to be inoperable and not providing smoke protection. This failure has the potential to affect all 96 residents residing in the facility. Findings include: According to the National Safety Council, dated 2023, about three out of five fire deaths happen in homes without working smoke alarms. Smoke alarms are a key part of a home fire escape plan providing early warning to reduce your risk of dying in a fire. On 12/04/23 at 10:45 AM, a fire alarm was installed on the ceiling of the kitchen located near the exhaust hood (approximately five feet). The fire alarm was covered with clear plastic, and the plastic was secured around the alarm's perimeter with painter's tape. V4 (Dietary Manager) stated, We have the fire alarm covered with the plastic, because if we do not keep it covered, it will alarm every time we open the steamer, and then the fire department has to come to the building. On 12/4/23 at 2:25 p.m., V4 stated, We removed the plastic from the smoke detector this afternoon. It was covered for about two weeks because any time we would open the oven the steam would set the smoke detector off. We had the fire department here all the time. So, to stop that from happening we covered the smoke detector with plastic. With this we discovered our exhaust hood was not working right, and that's why we had the excessive steam in the kitchen. The exhaust hood is fixed now. On 12/4/23 at 2:35 p.m., V24 (Maintenance Director), stated, The kitchen has two heat detectors and two smoke detectors. The one that was covered was a smoke detector. One of our fire drills was on 8/2/23. We had it because the steam from the oven activated the smoke detector. That's when the issues started. The exhaust hood was not working correctly we figured out, because the oven was constantly setting off the smoke detector. We covered the smoke detector to stop that from happening until the hood was fixed. I can't tell you how long we had it covered. The hood is fixed now so it shouldn't have been covered anymore. A facility Fire Drill, dated 8/2/23, documents, Actual smoke detector activation in Dietary due to steam. On 12/5/23 at 3:05 p.m., V25 (Fire Service Manager), stated, Our last inspection at the facility was in September (2023). All of the smoke detectors were fully functional and operating properly. The facility never alerted us to any issues they were having at that time, and we haven't gotten any calls from them since then. We inspect the facility's fire system bi-annually. They should never cover a smoke detector. With it being covered, it would take more fire and smoke accumulation to trigger another detector. It would cause a longer duration until it reaches the next detector, prolonging the facility response time. The active fire/smoke detector devices should be uncovered and fully operational at all times. On 12/8/23 at 11:50 a.m., V1 (Administrator in Training) stated, I was not aware that the smoke detector was covered by plastic. I knew we had some issues with the exhaust hood, and I should have checked back to make sure it was all taken care of, and I didn't. The facility's room roster, dated 12/3/23, documents that 96 residents reside in the facility.

Based on observation, interview and record review the facility failed to return telephone calls/messages placed to Administration for one Resident (R1) of three reviewed for communication response in a sample of three. Findings include: Facility Resident Rights undated, documents: you have the right to complete information and the Facility must allow you to see your medical records within 24 hours of your request. Facility Administrator Job Description, undated, documents: the Position Purpose as leads, guides and directs the operations of the healthcare facility in accordance with Local, State and Federal regulations, standards and establish Facility policies and procedures to provide appropriate care and services to Residents. The Facility message (photocopy of an adhesive note pad) documents a message for a return call regarding R1's insurance and billing statement. The message does not document a date or time received, but it is noted that the message was received between 3/29/23 and 4/5/23 and unsure of specific date. Intake Information Sheet, dated 4/4/23, documents that V1 (Administrator) is not available and did not follow-up with (V9/R1's Spouse) after messages were left with (V3/Secretary). On 4/6/23 at 1:34 pm, V3 (Receptionist/Secretary) stated, I am the Receptionist and I have taken a few messages over the last couple weeks from (R1) and (V9/R1's Spouse), but I have always given the messages to Management. What they do with them after that is out of my control. On 4/6/23 at 2:30 pm, V2 (Director of Nursing/DON) stated, We have an Interim Administrator (V1) and have not had a Business Office Manager for over two weeks. Our Dietary Manager just started this past week, we did not have a Dietary Manager for over a month. We no longer have an Assistant Director of Nursing and had to re-assign an employee as the Infection Preventionist. All of the Management has been restructured and we have not had consistent people in those management positions, so people are getting pulled in all different directions. On 4/6/23 at 1:50 pm, V1 (Corporate Interim Administrator and Interim Business Office Manager) stated, Our Business Office Manager quit about two weeks ago and I have a stack of messages that I am trying to get caught up on. I have one from (R1) that still needs to be returned. V1 provided an unorganized pile of sticky notes/message sheets, spread across the desk, that had not been returned. V1 stated, Can you see all of these messages, I am trying to get to all of them.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the Facility failed to follow the Diet Menu and serve palatable food. This failure has the potential to affect all 91 Residents residing in the Facility. Findings include: Facility Resident Census Roster, dated 4/6/23, documents 91 Residents residing in the Facility. Facility Dietary Menu, dated 4/6/23, was reviewed. The Menu documents the Breakfast Meal (Hot or Cold Cereal, French Toast/Syrup and Breakfast Sausage) and the Lunch Meal (Sloppy [NAME] on a Bun, Onion Rings, [NAME] Peas and Peach Crisp). Facility Nutritional Management Policy, dated 2/1/23, documents: the Facility provides care and services to each resident to ensure the Resident maintains acceptable parameters of nutritional status in the context of his or her overall health; the Dietary Manager or designee shall obtain the Resident's food and beverage preferences; the Dietician shall gather data from nutritional assessment to estimate the resident's calorie and nutrient needs; and follow the current standards of practice/formulas are used in calculating these estimates. Facility Concern Form, dated 1/16/23, documents, running out of food, still cold and meat tough, burnt food, chili was dry and nasty not edible. Facility Grievance Log, dated 2/27/23, documents issues with running out of food, the menu is not followed and need for ordering larger amounts of food. Facility Grievance Log, dated 3/20/23, documents diets are wrong. On 4/6/23, 11:30 am through 12:30 pm, the Lunch Meal was observed, with Resident's eating in the Main Dining Room and Assistive Dining Room. The 'Sloppy [NAME]' was served on bread and not a bun, black beans instead of peas and blueberry bread instead of peach crisp was served. On 4/6/23, at 11:02 am, R5 stated, I did not get any french toast with my breakfast this morning. Half the time we do not get what we are supposed to. On 4/6/23, at 11:03 am, R4 stated, I did not get any french toast for breakfast and I was looking forward to the french toast. I got scrambled eggs instead, I was bummed. A lot of times, we do not get the same food as the Menu, and they run out of food a lot too. On 4/6/23, at 11:24 am, R6 stated, Sometimes we do not get what they say we are supposed to get, we just eat what they have, and it is not the best tasting either. We cannot stop that, if something does not come, we just get something different, we do not have a choice. On 4/6/23, at 11:28 am, R7 stated, I do not even know what this is, I am not even hungry for this, pointing at the 'Sloppy [NAME]'. R7 refused to eat the lunch. On 4/6/23, at 11:31 am, R8 stated. We did not get french toast this morning, we got regular toast and scrambled eggs. Look at this (pointing at Sloppy [NAME] on bread), I do not even know what this is, it is supposed to be on a bun. And these are black beans, I did not get peas. Also, I have rang the bell a couple times to try and get their attention, and still have not gotten my coffee. No staff were present in the dining room. On 4/6/23, at 11:42 am, R9 stated, I do not have any peas or black beans with my sandwich. On 4/6/23 at 11:10 am, V10 (Dietary Aide) stated, We are trying to do the best we can hopefully our delivery comes today. The Residents did not get the right food on the breakfast menu. They did not get french toast this morning and there is no bun on their 'Sloppy [NAME]' sandwich, they got black beans instead of peas and there is no peach crisp today either. We have a brand new Dietary Manager, so I hope we can stick to the menu and things change. On 4/6/23, V11 (Dietary Aide) stated, We did not have french toast for breakfast today, they got scrambled eggs, because we did not have any french toast. They are eating black beans, a sloppy joe on bread and we did not have any peach crisp, so they are eating a blueberry bread and no buns on the sandwich. Our shipment and orders have been messed up. We went without a Dietary Manager, and one just started so hopefully it will get better. On 4/6/23, at 12:59 pm, V2 (Director of Nursing) stated, We have one feeding tube in house, but that person also eats food by mouth, so all of our Residents actually eat by mouth. On 4/6/23 at 2:30 pm, V2 (Director of Nursing/DON) stated, Our Dietary Manager just started this past week, we did not have a Dietary Manager for over a month. The new company that bought us, were sending a Dietary Manager from another facility to help out. I can confirm that the diet menu is not followed, and the Residents do not get the right food. All of the Management has been restructured and we have not had consistent people in those management positions. On 4/6/23 at 12:40 pm, V6 (Registered Dietician) stated, This Facility has been without a permanent Dietary Manager for over a month. Substitutions have definitely been getting used because they do not have the correct food stocked to accommodate the menu.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to identify specific target behaviors; and monitor and track behaviors for three residents (R2, R55, R69) of four residents reviewed for psychotropic medications in the sample of 21 residents. Findings include: The Facility's Psychotropic drug use policy dated 5/20/2022 documents Long-term care residents with dementia commonly display behavioral and psychological symptoms of dementia, such as agitation, wandering, aggression, and sleep disturbances, resulting in treatment with psychotropic drugs. A psychotropic drug is defined as any drug that affects brain activities associated with mental processes and behaviors. - Identify the date, time, and location of the resident's specific behavior that's causing concern as well as any identified triggers. Gather information from staff members who have witnessed the behavior. - Use a behavior monitoring tool to identify the frequency, intensity, duration, and impact of the resident's behavior. - Explain the resident's behavior and ask the staff members to document on your facility's behavior monitoring tool when they witness that behavior. - Review the documentation to analyze the frequency and severity of the resident's behavior as well as the circumstances surrounding it to help develop an appropriate care plan. - Review the resident's medical record to ensure that documentation reflects that the resident's behavior interferes with necessary care, causes persistent or inconsolable distress, or poses a danger to the resident or others. 1) R2's January 2023 Physician Order Sheet Documents Quetiapine Fumarate (antipsychotic) 2.5 mg (milligrams) every bedtime (night) for behaviors. R2's Medical Record does not include any target behaviors or diagnosis regarding the use of Quetiapine Fumarate 2.5 mg. On 1/26/23 at 9 A.M. V2 (Director of Nursing) stated, (R2) came back from the hospital on that (Quetiapine Fumarate) and no one knows why. 2) Current Physician Order Summary Report indicates R55 is [AGE] years old and was admitted to the facility 5/23/22 with diagnoses that include Anxiety Disorder, Delusional Disorder, (Unspecified) Hallucinations. Order Report indicates R55 receives Seroquel (antipsychotic) 25mg (milligrams) twice daily related to hallucinations (unspecified) that was initiated on 5/24/22. Psychotropic Medication Consent dated 8/4/21 indicates a consent for Seroquel for Delusions was signed on that date. On 1/25/23 and 1/26/23 R55 was observed at different times of the day. Surveyor was able to have brief appropriate conversations and R55 did not display delusional or agitated behavior and did not report auditory or visual hallucinations. Current Care Plan (revised on 1/18/23) indicates R55 has delusions related to delusional disorder and dementia with behavioral disturbances with delusions often involving worrying about family and pets. Care Plan indicates R55 has anxiety, hallucinations and depression - exhibiting agitation, hallucinations and decreasing socialization. No specific target behaviors were identified documented and no behaviors were documented as having occurred in R55's medical record. 3) Physician Order Summary Report indicates R69 was admitted to the facility 10/25/22. Order Report indicates R69 receives Seroquel (antipsychotic) 250mg (milligrams) at bedtime related to Bipolar Disorder (unspecified) that was initiated on 10/25/22. Current Care Plan indicates R69 is at risk for behavior symptoms related to other specified depressive episodes presented by feeling down and crying as well as bipolar disorder presented by rapid mood swings and impulsiveness - also exhibiting medication seeking and agitation toward staff. Psychotropic Consent (undated) indicates R69 signed a consent to receive Seroquel 250mg for agitation, crying, cursing and verbal aggression related to Bipolar Disorder. On 1/24/23 and 1/25/23, R69 was seen at random times throughout the day without evidence of any agitation, crying or impulsiveness. R69 spent much of the day out of her room, at activities and meals. R69's medical record did not include any type of behavior monitoring or tracking for identified behaviors. On 1/26/23 V1, Interim Administrator stated there doesn't seem to be anywhere staff are documenting and/or monitoring/tracking behaviors for R55 and R69.