**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure the code status of a resident was accurate for the physician order, careplan, and POST (physician's order for scope of treatment) form for 1 of 17 records reviewed. (Resident 24) Findings include: On [DATE] at 11:21 a.m., the medical record of Resident 24 was reviewed. The resident was admitted to the facility on [DATE]. Admitting diagnosis included but not limited to Huntington's Disease (a progressive inherited brain disorder that causes uncontrolled movements, cognitive decline, and psychiatric symptoms), anxiety (a feeling of fear, dread, and uneasiness. It might cause you to sweat, feel restless and tense, and have a rapid heartbeat. It can be a normal reaction to stress) and dysphagia (difficulty swallowing). A physician order, dated [DATE], indicated that the resident chose to be a full code (to provide full resuscitation in the event of the need for life saving measures). A POST form (Physician Orders for Scope of Treatment form is a standardized document that allows patients with advanced chronic or terminal illnesses to document their specific treatment preferences for end-of-life care), dated [DATE], indicated that the resident chose to be a DNR (Do Not Resuscitate). The form had been updated from full code on the previous POST form to administer CPR. A quarterly Minimum Data Set (MDS) assessment, dated [DATE], indicated that the resident was cognitively impaired. A care plan, dated [DATE], indicated per the Power of Attorney (POA) for healthcare and per resident, the resident signed a valid DNR which indicated Do Not resuscitate should I stop breathing, display no pulse as a result of failure of the heart to contract effectively or at all. On [DATE] at 1:00 p.m., during interview the Administrator indicated the resident was to be a DNR and the POST form currently in the medical record was correct and the physician order was incorrect. On [DATE] at 9:47 a.m., during interview Licensed Practical Nurse (LPN) 6 indicated she would look for the most recent POST form to verify code status. She indicated the resident's status changes often and updates were recorded in the medical record. On [DATE] at 12:54 p.m., the Administrator provided a document, titled, Advanced Directives, dated [DATE], and indicated it was the policy currently being used by the facility. The policy indicated, . 8. If a resident or healthcare representative indicates an Advanced Directive regarding CPR or scope of treatment (POLST or POST) the appropriate forms will be completed. 9. A written physician's order is required in response to the resident's Advanced Directive(s). Physician's orders shall be specific and address each advanced Directive(s) 3.1-4(d)

Based on interview and record review, the facility failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for 1 of 11 residents MDS assessments reviewed (Resident 32). Findings include: During an interview, on 4/30/25 at 9:57 a.m., Resident 32 denied that she had a feeding tube for nutritional intake. She indicated that she had never had one. Resident 32's record was reviewed on 5/2/25 at 9:02 a.m. The profile indicated the resident's diagnoses included, but were not limited to, Huntington's disease (an inherited condition in which nerve cells in the brain break down over time), dysphagia, unspecified (refers to medical term for difficulty swallowing), and nutritional deficiency (lack of sufficient nutrients in the body). A quarterly MDS assessment, dated 4/25/25, indicated the resident had a feeding tube (a medical device used to deliver nutrition and fluids directly into the digestive system, bypassing the mouth and esophagus). A physician order, dated 10/7/24, indicated a regular diet, mechanical soft (foods that have been altered in texture to make them easier to chew and swallow) thick liquids consistency. A care plan, dated 10/11/24, indicated the resident had alteration in nutrition related to Huntington's disease. Interventions included, but were not limited to, honor food preferences, encourage good intake, and notify medical doctor of significant weight changes. During an interview, on 5/5/25 at 9:50 a.m., the MDS Coordinator indicated there was a coding error on Resident 32's quarterly MDS assessment and she would need to go in and modify it. She indicated the resident never had a feeding tube. During an interview, on 5/5/25 at 9:52 a.m., the Administrator indicated it was a possibility the Dietary Manager marked the wrong box on the MDS assessment. The MDS assessment had been coded wrong and needed to be modified. Section K of the CMS (Centers for Medicaid and Medicare Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, dated October 2024, indicated.N0520: Nutritional Approaches: Check all of the following nutritional approaches that apply: .3. while a resident .B. Feeding tube .Steps for Assessment: Review the medical record to determine if any of the listed nutritional approaches were performed during the look-back period .check all that apply .K0520B, feeding tube .Coding tip for K0502B: only feeding tubes that are used to deliver nutritive substances and or hydration during the assessment period are coded in K0502B 3.1-31(c)(5)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure quarterly care plan meetings, which addressed the specific needs of the Resident were completed for 1 of 16 residents reviewed (Resident 29). Findings include: On 5/1/25 at 9:32 a.m., during an initial interview, Resident 29 did not recall attending care plan meetings which addressed his specific needs. On 5/1/25 at 1:00 p.m., the medical record of Resident 29 was reviewed. The resident was admitted to the facility on [DATE]. Diagnosis included but not limited to Huntington's Disease (a progressive inherited brain disorder that causes uncontrolled movements, cognitive decline, and psychiatric symptoms), and epilepsy (a disorder of the brain characterized by repeated seizures). An annual Minimum Data Set (MDS) assessment, dated 3/15/25, indicated the resident was cognitively impaired. A comprehensive care plan addressing the resident's needs, initiated on 3/27/24, was reviewed and updated accordingly. The medical record lacked documentation of a quarterly care plan meeting or of the resident being notified and offered to attend. On 5/1/25 at 10:00 a.m., during an interview the Social Services Director indicated the facility had regular care plan meetings with the resident and the resident's responsible party were invited to attend. On 5/2/25 at 10:30 a.m., during interview the Administrator indicated the resident had several care plan meetings with the Social Services Director and the resident did attend. She acknowledged the documentation did not reflect a specific care plan meeting addressing all needs. She indicated the meetings they had with the resident had been regarding his desire for more freedom and ability to pursue intimacy. On 5/2/2025 at 10:38 a.m., the Administrator provided a document, titled, Comprehensive Care Plan, dated 11/28/12, and indicated it was the policy currently being used by the facility. The policy indicated, .A comprehensive care plan must be .To the extent practicable, the participation of the resident and the resident's representative (s). An explanation should be included in a resident's medical record .Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments .The resident and or resident representative shall be invited to review the plan of care with the interdisciplinary team either in person , via telephone or video conference (if available) at least quarterly 3.1-35(c)(1)

Based on observation and interview, the facility failed to ensure water temperatures in the dining room wash station and common restrooms were within safe parameters for 3 of 3 random observations. Findings include: On 4/30/25 at 11:51 a.m., while observing the staff washing their hands during meal service, noted the water was very hot and staff had to continually adjust the water. The water temperature was 143 degrees in the main dining room kitchen sink. During two observations one at 10:00 a.m. and again at 2:05 p.m., the door to the common restroom on the south hall was unlocked. The water temperature was 135.5 degrees. During observation of the south hall resident room and shower room indicated, the water temperature in the south hall shower and sink was 119 degrees. Resident rooms on both halls observed water temperatures were within acceptable parameters. On 4/30/25 at 2:39 p.m., during interview the Administrator indicated the water in the employee restroom was connected to the main kitchen. She was not aware the door was unlocked and indicated a visitor must have left it unlocked. She indicated the small dining kitchen serving area had a latch on the half door preventing residents from entering into the area. She indicated the water was set to the current temperature so they could prepare hot drinks and did not think it was too hot for the employees. She indicated she was advising the Maintenance Director to turn the temperature down. The Administrator provided water temperature logs indicating water temperatures in the resident rooms was within acceptable parameters. On 5/1/2025 at 12:54 p.m., the provided an undated document, titled, Domestic Water Temperature, and indicated it was the policy currently being used by the facility. The policy indicated, .Temperatures of water coming out of sink faucets and showers should be between 100-120 degrees F to prevent 3.1-45(a)

Based on observation, interview, and record review, the facility failed to ensure proper handwashing for 1 of 2 dining observations. Findings include: 1. During a dining observation, on 4/30/25 at 11:55 a.m., Dietary Aide 5 turned on the water faucet and obtained soap onto her hands, she proceeded to adjust the water temperature by touching the faucet handles with her bare hands, she washed her hands for 10 seconds and turned off the water faucet with her bare hands, obtained a paper towel and dried her hands. She proceeded to a table and adjusted a resident in their wheelchair, so she was closer to the table. 2. During a dining observation, on 4/30/25 at 11:56 a.m., Dietary Aide 5 turned on the water faucet and obtained soap onto her hands, she proceeded to adjust the water temperature by touching the faucet handles with her bare hands, she washed her hands for 10 seconds and turned off the water faucet with her bare hands, obtained a paper towel and dried her hands. She proceeded to wait at the counter for the lunch trays to be ready to be served, pulled on the back of her t-shirt and placed her hands behind her back. 3. During a dining observation, on 4/20/25 at 12:20 p.m., Dietary Aide 4 washed her hands for 5 seconds and turned off the water faucet with her bare hands, obtained a paper towel and dried her hands. She proceeded to the serving counter and served 3 bowls of cereal to residents. 4. During a dining observation, on 4/30/24 at 12:21, Dietary Aide 5 turned on the water faucet and obtained soap onto her hands, she proceeded to adjust the water temperature by touching the faucet handles with her bare hands, she washed her hands for 10 seconds and turned off the water faucet with her bare hands, obtained a paper towel and dried her hands. She proceeded to the serving counter and obtained a lunch tray to serve to a female resident. During an interview, on 4/30/25 at 2:58 p.m., the Assistant Director of Nursing (ADON) indicated she had noted there were some concerns identified during meal service today related to handwashing. She indicated the staff was observed to not be washing hands for the appropriate amount of time and not the correct technique. During an interview, on 4/20/25 at 3:05 p.m., the Administrator indicated they had provided a hand hygiene in-servicing to staff today after improper technique was noted during the lunch meal service. During an interview, on 5/5/25 at 10:34 a.m., Housekeeping Aide 7 indicated staff should wash their hands for approximately 1 minute, obtain a paper towel to turn off the faucet and then obtain a second paper towel to dry your hands. She further indicated staff should not touch the water faucet with bare hands. On 4/30/25 at 3:05 p.m., the Administrator provided an undated document, titled, Hand Washing, and indicated it was the policy currently being used by the facility. The policy indicated, .2. Apply soap, using friction rub hands together, cleaning under nails and between fingers thoroughly and up to wrist for 20 seconds. 3. Rinse hands well without touching the inside of sink or faucet. 4. Dry hands well with paper towel. Use clean paper towel to turn off faucet. Discard paper towel in trash receptacle 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure a call light was kept within the resident's reach for 1 of 16 residents reviewed for call lights (Resident 39). Finding includes: On 4/25/24 at 9:22 a.m., Resident 39 was observed sitting on his bed watching television. The resident's call light was observed on the floor underneath two plastic storage containers, out of the resident's reach. On 4/26/24 at 8:55 a.m., Resident 39 was observed sitting on his bed watching television. The resident's call light was observed on the floor underneath two plastic storage containers, out of the resident's reach. On 4/29/24 at 9:02 a.m., Resident 39 was observed sitting on his bed watching television. The resident's call light was observed on the floor underneath two plastic storage containers, out of the resident's reach. On 4/29/24 at 3:15 p.m., the Director of Nursing (DON) observed the call light under the two storage containers and indicated, Resident 39's call light should be within reach and not on the floor under the two storage containers. Resident 39's record was reviewed on 4/30/24 at 9:48 a.m. Resident 39 was admitted to the facility, on 2/26/24, with diagnoses included, but were not limited to, Huntington's disease (A condition that damages nerve cells in the brain causing them to stop working properly. The damage to the brain gets worse over time. It can affect movement, cognition, and mental health), unspecified lack of coordination, unsteadiness of feet, reduced mobility, and repeated falls. An admission Minimum Data Set (MDS) assessment, dated 3/4/24, indicated the resident had a severe cognitive impairment and required supervision or assistance from staff for activities of daily living (ADL) (daily tasks related to resident care and hygiene). A care plan, goal target, dated 5/26/24, indicated the resident was at risk for falls due to Huntington's disease. Interventions included, but were not limited to, keep all light within reach. On 4/30/24 at 8:45 a.m., the Administrator (ADM) indicated the residents' call lights should be within their reach. The ADM provided and identified a document as a current facility policy titled, Call Light, revision dated 2/2/18. The policy indicated, .Purpose: To respond to residents' requests and needs in a timely and courteous manner .1. All residents that have the ability to use a call light shall have the nurse call light system available at all times and within easy accessibility to the resident at the bedside or other reasonable accessible location 3.1-3(v)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff wore a hairnet restraint when in the kitchen, hand hygiene was completed appropriately, food items were labeled and dated, expired foods were discarded, dented cans were not stocked for usage for the residents' meals, and food was not stored directly onto the storeroom floor for 1 of 2 kitchen observations. This deficiency had the potential to affect 40 of 40 residents who received food from the kitchen. Findings include: During an initial tour of the kitchen with the Dietary Manager (DM), on 4/24/24 at 9:50 a.m., the following was observed: a. While in the kitchen, the DM had her hair in a ponytail without a hairnet and failed to wash her hands prior to beginning the kitchen tour and handling food items. b. The kitchen freezers contained an undated bag of biscuits, 2 undated bags of frozen French fries, 3 undated lemon pies, 2 undated bulk sausage tubes, 6 undated packages of waffles, 2 packages of puree peas labeled with a use by date of 11/9/23, 6 undated bags of tator tots, a large bag of frozen hamburger patties undated, an undated package of fish [NAME], 6 undated apple pies, 3 undated hamburger rolls, undated package of pizza crusts, 8 undated rolls of ground pork shoulder, undated package of chicken and dumplings seasoning, undated package of donuts, undated bag of chicken tenders, 2 undated packages of hashbrown, 2 undated bags of diced chicken, and 2 undated packages of chicken tender. c. The dry storage area contained 3 dented cans of 106-ounce (oz) tomato sauce and a large cardboard box of ice cream cones stored directly on the stockroom floor without a barrier. On 4/24/24 at 10:30 a.m., the DM wiped her brawl with her bare hand and tucked her hair behind her ear, then touched more food items. She indicated no food items should be stored directly on the floor, all dented cans including the dented cans of tomato sauce should be discarded. All food items should be dated when received and stocked in the kitchen, but it was not getting done. On 4/24/24 at 10:37 a.m., the DM washed her hands, turned off the water faucet with her bare hand, indicated there were no paper towels in the dispenser, shook out her wet hands onto the floor, wiped her wet hands onto her pants, and then continued the tour of the kitchen and dry storage area. On 4/25/24 at 11:00 a.m., the Administrator (ADM) indicated staff were required to wear hairnet restraints when in the kitchen. Staff were required to wash their hands and turn off the water faucet with a paper towel when entering the kitchen and before and after touching food items. All food items should be labeled and dated when received, food items should not be stored directly on the floor, and canned goods with a compromised seal (dented) should be returned to the vendor. The ADM provided and identified a document as a current facility policy titled, Hand Washing, dated 06/2018. The policy indicated, .Policy: It is the policy of the Dietary Department to prevent the spread of infection through proper handwashing .Procedure: .1. Hands are washed: .a When entering and before starting work in the Dietary Department .d. Before and after handling foods .e. After using the bathroom, sneezing, coughing, touching face or hair, scratching and using a handkerchief .2. Handwashing Procedure: .e. Hands must be washed for a minimum of 20 seconds .f. Rinse thoroughly .g. Wipe dry with disposable paper towels .h. Turn off water faucet with paper towels The ADM, on 4/25/24 at 11:00 a.m., provided and identified a document as a current facility policy titled, Food Storage (Dry, Refrigerated, and Frozen), dated 2020. The policy indicated, .Procedure: .General storage guidelines to be followed: .a. All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded .f. Dented cans are set aside in a separate labeled area of the storeroom to avoid using them and discarded according to vendor procedure The ADM, on 4/25/24 at 11:00 a.m., provided and identified a document as a current facility policy titled, Storage of Dry Foods, dated 06/2018. The policy indicated, .7. Food should not be exposed to splash, dust or other contamination and at least six inches above the floor 3.1-21(i)(1) 3.1-21(i)(3)

Based on interview and record review, the facility failed to provide Registered Nurse (RN) coverage 8 hours per day 7 days per week for 7 of 28 days reviewed for staffing. This had the potential to affect 40 of 40 residents who resided in the facility. Findings include: On 4/30/24 at 11:00 a.m., review of RN staffing schedules for 4/1/24 to 4/27/24 indicated the Director of Nursing was scheduled as the RN Monday through Friday. An RN was not scheduled for the weekends of 4/6/24, 4/7/24, 4/12/24, 4/13/24, 4/19/24, 4/20/24, or 4/28/24. The Administrator indicated the Director of Nursing was available for calls during the weekends. On 4/30/24 at 11:45 a.m., the Administrator provided a document titled, Staffing, dated 2001, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Statement .Our facility provides adequate staffing to meet needed care and services for our resident population .1. Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. Licensed registered nursing and licensed staff are available to provide and monitor the delivery of resident care services 3.1-17(b)(3)

Based on record review and interview, the facility failed to ensure medications had been documented as administered for 3 of 5 residents reviewed for unnecessary medications (Residents 30, 9, and 35). Findings include: 1. Resident 30's record was reviewed on 2/7/23 at 1:15 p.m. The profile indicated the resident's diagnoses included, but were not limited to, Huntington's disease (an inherited disease that causes the progressive breakdown [degeneration] of nerve cells in the brain and has a wide impact on a person's functional abilities and usually results in movement, thinking and psychiatric disorders), and unspecified leg pain. An annual Minimum Data Set (MDS) assessment, dated 8/25/22, indicated the resident had moderate cognitive deficit and received routine pain medications. A care plan, dated 12/30/22, indicated the resident has alterations in comfort related to leg pain. Interventions included, but were not limited to administer medications as ordered. A review of the resident's December 2022, January 2023, and February 2023, medication administration records (MAR) indicated the following: A physician's order, dated 8/18/22, indicated gabapentin (medication used to treat neuropathic pain) capsule 300 milligrams (mg), by mouth, one time daily at 5:00 p.m. The December 2022 MAR lacked documentation that the medication had been administered on 12/21/22 and 12/30/22. The January 2023 MAR lacked documentation that the medication had been administered on 1/2/23, 1/3/23, and 1/30/23. The February 2023 MAR lacked documentation that the medication had been administered on 2/1/23, 2/4/23, and 2/5/23. A physician's order, dated 9/30/22, indicated meloxicam (medications called nonsteroidal anti-inflammatory drugs [NSAIDs] and works by stopping the body's production of a substance that causes pain, fever, and inflammation) tablet 7.5 mg, by mouth two times daily at 8:00 a.m., and 5:00 p.m. The December 2022 MAR lacked documentation that the 5:00 p.m., dose of the medication had been administered on 12/21/22 and 12/30/22. The January 2023 MAR lacked documentation that the 5:00 p.m., dose of the medication had been administered on 1/2/23, 1/3/23, and 1/30/23. The February 2023 MAR lacked documentation that the 5:00 p.m., dose of the medication had been administered on 2/1/23, 2/4/23, and 2/5/23. 2. Resident 9's record was reviewed on 2/9/23 at 2:20 p.m. The profile indicated the resident's diagnoses included, but were not limited to, Huntington's disease (an inherited disease that causes the progressive breakdown [degeneration] of nerve cells in the brain and has a wide impact on a person's functional abilities and usually results in movement, thinking and psychiatric disorders), and vascular dementia (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). An annual Minimum Data Set (MDS) assessment, dated 9/8/22, indicated the resident had no cognitive deficit. A care plan, dated 6/10/21, indicated the resident has impaired cognitive function related to dementia. A care plan, dated 8/25/20, indicated the resident has a potential for alteration in nutrition related to unplanned weight loss due to diagnosis of Huntington's disease and disease process. A review of the resident's December 2022, and January 2023, medication administration records (MAR) indicated the following: A physician's order, dated 8/30/22, indicated Namenda (drug used to treat dementia) 10 milligrams (mg), by mouth two times daily at 8:00 a.m., and 5:00 p.m. The December 2022 MAR lacked documentation that the resident's scheduled 5:00 p.m., dose had been administered on 12/21/22. The January 2023 MAR lacked documentation that the resident's scheduled 5:00 p.m., dose had been administered on 1/2/23, 1/3/23, and 1/5/23. A physician's order dated 12/21/20, indicated Magic Cup (frozen dessert used as a great option for adding calories and protein for those experiencing involuntary weight loss) with meals, three times daily as a supplement at 8:00 a.m., 12:00 p.m., and 5:00 p.m. The December 2022 MAR lacked documentation that the resident's scheduled 5:00 p.m., dose had been administered on 12/21/22 and 12/30/22. The January 2023 MAR lacked documentation that the resident's scheduled 5:00 p.m., dose had been administered on 1/2/23, 1/3/23, and 1/5/23. 3. Resident 35's record was reviewed on 02/07/23 at 1:19 p.m. Diagnoses on the profile included, but were not limited to, Huntington's disease (a hereditary disease marked by degeneration of the brain cells and causing chorea [jerky involuntary movements affecting especially the shoulders, hips, and face] and progressive dementia) and dysphagia (difficulty swallowing), and gastro-esophageal reflux disease (GERD-when stomach acid repeatedly flows back into the tube connecting your mouth and stomach [esophagus]). A quarterly Minimum Data Set Assessment, dated 12/10/22, indicated the resident had a severe cognitive impairment and required supervision with one person assistance for eating. A care plan, initiated on 6/2/22 and revised on 9/27/22, indicated the resident received psychotropic medications (used to treat mental health disorders) with interventions included, but were not limited to, administer medications as ordered and monitor/document for side effects and effectiveness A care plan, initiated on 5/26/22 and revised on 9/27/22, indicated the resident received a regular, mechanical soft texture, thin liquids diet due to Huntington's disease and progression of such and was at risk for aspiration (choking or breathing in a foreign object [sucking food into the airway]). A physician's order, start dated 7/19/22, indicated to give the resident Magic Cup (nutritional supplement) two times a day with lunch and supper. The December 2022 medication administration record (MAR) lacked documentation the Magic Cup was administered at supper on 12/21/22 and 12/30/22. The January 2023 MAR lacked documentation the Magic Cup was administered at supper on 1/2/23, 1/3/23, 1/5/23, and 1/30/23. The February 2023 MAR lacked documentation the Magic Cup was administered at supper on 2/1/23, 2/4/23, 2/5/23. The record lacked documentation the resident had refused the Magic Cup. A Social Services' care conference progress note, dated 1/31/23 at 1:57 p.m., indicated the Administrator (ADM), Social Services Director (SSD), and Director of Nursing (DON) had a care plan meeting with Resident 35's husband, regarding the resident not feeling well. The husband was educated on possible aspiration, a chest x-ray was ordered, and the physician was notified. A physician's order, start dated 1/31/23, indicated to administer Augmentin oral tablet 875-125 milligrams (mg) (antibiotic medication) by mouth two times a day for possible aspiration for 10 days. The February 2023 MAR lacked documentation the medication was administered on the evening shifts of 2/1/23, 2/4/23, 2/5/23. The record lacked documentation the resident refused the medication. During an interview, on 2/7/23 at 2:45 p.m., the Administrator (ADM) indicated she was pretty sure the medication and Magic Cup supplement had been given, but just not signed off on the MAR. It was the nurse's responsibility to document on the MAR when a medication or the Magic Cup had been administered to the resident. On 2/7/23 at 2:49 p.m., the Administrator (ADM) provided an undated document, titled, Medication Administration General Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy .Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have properly oriented to the facility's medication distribution system (procurement, storage, handling and administration) .7. The medication administration record (MAR) is always employed during medication administration .4. The resident's MAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration 3.1-48(a)(3)

Based on observation, interview, and record review, the facility failed to ensure the laminate flooring (a multi-layer synthetic flooring product) in the facility was safe in good repair, for 5 of 5 days the facility environment was observed. Findings include: During a random observation, on 2/6/23 at 2:28 p.m., a mat on top of the laminate flooring at the entrance to the television (TV) lounge next to the nurse's station, appeared to move when stepped on. Upon request, the Administrator (ADM) lifted the rug and exposed a large area where the laminate flooring was broken and no longer stable on the subfloor (a rough floor laid as a base for a finished floor) and was sliding back and forth in place. The entire piece of a single laminate floor plank was loose and broken. Each surrounding plank of the flooring, around the initial broken area, were also beginning to become loose. Areas of exposed subfloor were visible around the broken area of the planks. Along the area of the hallway leading to mat was observed to have gaps between the laminate floor planks. A single large, gapped area appeared to be large enough that a walker (a wheeled device used to assist with ambulation) wheel could get stuck in the gap area. Several smaller gapped areas were also observed. During environment rounds with the Maintenance Director, on 2/7/23 at 9:16 a.m., measurements of the gapped and broken laminate flooring areas were completed by the Maintenance Director. The area at the beginning of the hallway leading to TV lounge measured 3/4 (three-quarters) inches by 5 and 1/2 (one-half) inches (the width of a laminate plank). At the same time, the Maintenance Director indicated the gap was large enough that a walker wheel could get caught up in it or a resident could trip over the gapped area. Further measurements, completed by the Maintenance Director, were as follows: a. The area with the broken laminate plank, covered by the mat, measured 36 inches in length (the entire length of a single laminate floor plank) had become totally loose from the subfloor. An area of exposed subfloor (on the left side of the broken plank, facing south), measured 18 inches in length, with the widest area of exposed subfloor measured 1 and 1/8 (one-eighth) inches and tapered down to 1/2 inch. A second area of exposed subfloor (central of the broken plank, facing south) measured 3/4 inch by 1 and 1/2 inches. A third area of exposed subfloor (right side of the broken plank, north facing), measured 1 inch by 5 and 1/4 (One-quarter) inches (the width of the plank) and tapered down to 1/4 inch. All of the surrounding floor planks were observed beginning to loosen from the subfloor. b. An area of exposed subfloor, approximately 12 inches from the large broken laminate floor plank was observed to have an area of exposed subfloor, which measured 1 and 1/4 inches by 5 and 1/2 inches and tapered to 1/4 inch. c. An area to left (facing north from the above area b) had exposed subfloor which measured 1 and 1/2 inches by 5 and 1/2 inches. d. A plank in front of nurse's station, had an area of exposed subfloor which measured 3/4 inch. The plank was coming loose from the floor at a length of 14 inches. e. Another area of exposed subfloor (south facing from area d) measured 1 inch by 1 inch. f. In the hallway, leading to the south end of the facility, multiple gaps of exposed subfloor were observed. The areas were small and were not measured. During an interview, on 2/7/23 at 9:26 a.m., the Maintenance Director indicated he had been taking bids for the replacement of the laminate flooring throughout the facility. He had yet to receive a final bid. The broken areas and the significant gapped areas were of significant concern to him, due to the increased fall risks potentials for the Huntington's disease (a rare, inherited disease that causes the progressive breakdown [degeneration] of nerve cells in the brain and has a wide impact on a person's functional abilities) resident who reside at the facility. On 2/8/23 at 11:48 a.m., the Maintenance Director provided a document, dated December 2004, titled, Maintenance Service, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy Interpretation and Implementation .2. The following functions are performed by maintenance, but are not limited to, a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. b. Maintaining the building in good repair and free from hazards 3.1-19(a)(4)

3. Observation made during the tour on 02/06/2023 at 10:15 a.m., noted that Resident 40 was in the North hallway sitting in wheelchair and was tearful and placed her head down towards the floor. On 02/07/2023 at 1:33 p.m., Resident 40 was observed in the common TV room sitting in her wheelchair, tearful and difficult to understand her speech. On 02/08/2023 at 8:45 a.m., Resident 40 was observed in the North hallway propelling self in a wheelchair down the hallway and was noted to be tearful and her head was down towards the floor. During an interview with LPN 12 (licensed practical nurse) on 02/07/2023 at 1:40 p.m., she indicated the psych physician (a medical doctor who specializes in mental health) believed Resident 40's tearfulness was from pseudobulbar affect (inappropriate involuntary laughing and crying due to a nervous system disorder). She further indicated the resident was good one minute and not the next. During an interview with the Administrator on 02/07/2023 at 09:45 a.m., she indicated Resident 40 had been tearful since arriving to the facility and tearfulness was not a new behavior. The facility was working with the psych physician on medication adjustments and psych services for the resident. Resident 40's record was reviewed on 02/7/2023 at 1:19 p.m. The profile indicated the resident's diagnoses included, but were not limited to, Huntington's disease (a hereditary disease marked by degeneration of the brain cells and causing chorea [jerky involuntary movements affecting especially the shoulders, hips, and face] and progressive dementia), anxiety disorder (characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), major depressive disorder (characterized by persistently depressed mood and long-term loss of pleasure or interest in life), dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking), and pseudobulbar affect (inappropriate involuntary laughing and crying due to a nervous system disorder). An admission Minimum Data Set (MDS) assessment, dated 12/6/22, indicated the resident had severe cognitive deficit, exhibited mood symptoms of feeling down, depressed, and hopeless and had been administered medications which included, but were not limited to antipsychotics (a class of psychotropic medication primarily used to manage psychosis, principally in schizophrenia but also in a range of other psychotic disorders), antianxiety medication (medications used to assist in the management of anxiety symptoms), and antidepressants (used to treat major depressive disorder and some anxiety disorders). A care plan, dated 12/08/2022, indicated the resident received antidepressant medication related to her diagnoses of depression. Interventions included, but were not limited to, administer medications as ordered by physician, monitor and document side effects and effectiveness. A care plan, dated 12/08/2022, indicated the resident received psychotropic medication related to her diagnoses of Huntington's disease and dementia. Interventions included, but were not limited to, administer medication as ordered by physician, monitor for signs and symptoms of adverse effects from psychotropic medication usage. an A care plan, dated 12/08/2022, indicated the resident received antianxiety medications related to her diagnoses of anxiety disorder. Interventions included, but were not limited to, administer medication as ordered by physician, monitor for signs and symptoms of adverse effects from psychotropic medication usage. Review of Social Service note, dated 11/30/2022 at 2:03 p.m., indicated Resident 40 was extremely tearful. Review of Social Service note, dated 12/06/2022, indicted Resident 40 was very tearful and would yell out and cry. Review of Social Service note, dated 01/18/2023 at 07:47 a.m., indicated Resident 40 was in the hallway crying and grabbing staff. Resident was not understood when crying. Review of the resident's December 2022, January 2023, and February 2023 medication administration records (MARs) indicated the following: A physician's order, dated 12/13/2022, indicated Risperdal (antipsychotic medication) 1milligram (mg), by mouth two times daily. The December 2022 MAR lacked documentation of the medication having been administered at 5:00 p.m. on 12/21/2022. The record lacked documentation of resident refusal. A physician's order, dated 12/13/2022, indicated Haloperidol (antipsychotic medication) 10mg, by mouth three times daily. The December 2022 MAR lacked documentation of the medication having been administered at 5:00 p.m. on 12/21/2022. The January 2023 MAR lacked documentation of the medication having been administered at 5:00 p.m. on 01/30/2023. The February MAR lacked documentation of the medication having been administered at 5:00 p.m. on 02/01/2023, 02/04/2023, and 02/05/2023. The record lacked documentation of resident refusal. A physician's order, dated 12/16/2022, indicated Lorazepam (antianxiety medication) 1mg, by mouth four times daily. The December 2022 MAR lacked documentation of the medication being administered at 5:00 p.m. on 12/21/2022. The January 2023 MAR lacked documentation of the medication being administered at 5:00 p.m. on 01/02/2023 and 01/03/2023. The record lacked documentation of resident refusal. A physician's order, dated 02/02/2023, indicated Mirtazapine (antidepressant medication) 7.5mg, by mouth one time daily. The February 2023 MAR lacked documentation of the medication being administered at 4:00 p.m. on 02/04/2023 and 02/05/2023. The record lacked documentation of resident refusal. A physician's order, dated 01/10/2023, indicated Sertraline HCl (antidepressant medication) 100mg, by mouth in the evening. The January 2023 MAR lacked documentation of the medication being administered at 5:00 p.m. on 01/30/2023. The February 2023 MAR lacked documentation of the medication being administered at 5:00 p.m. on 02/01/2023, 02/02/2023, and 02/05/2023. The record lacked documentation of resident refusal. A physician's order, dated 01/20/2023, indicated Diazepam (antianxiety medication) 5mg, by mouth three times daily. The January 2023 MAR lacked documentation of the medication being administered at 4:00 p.m. on 01/30/2023. The February 2023 MAR lacked documentation of the medication being administered at 4:00 p.m. on 02/01/2023, 02/04/2023, and 02/05/2023. The record lacked documentation of resident refusal. Based on observation, record review and interview, the facility failed to ensure psychotropic medications (drugs that affects how the brain works and causes changes in mood, awareness, thoughts, feelings, or behavior) had been documented as administered for 4 of 11 residents medications reviewed (Residents 30, 9, 40, and 35). Findings include: 1. Resident 30's record was reviewed on 2/7/23 at 1:15 p.m. The profile indicated the resident's diagnoses included, but were not limited to, Huntington's disease (an inherited disease that causes the progressive breakdown [degeneration] of nerve cells in the brain and has a wide impact on a person's functional abilities and usually results in movement, thinking and psychiatric disorders), mood affective disorder (mental disorders that primarily affect a person's emotional state), unspecified psychosis (inadequate information to make the diagnosis of a specific psychotic disorder), generalized anxiety disorder (a condition of excessive worry about everyday issues and situations), and depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities). An annual Minimum Data Set (MDS) assessment, dated 8/25/22, indicated the resident had moderate cognitive deficit and received antipsychotic medications (used to treat symptoms of psychosis), antianxiety medications (used to treat symptoms of anxiety), and antidepressant medications (used to treat symptoms of depression). A care plan, dated 10/13/21, indicated the resident used psychotropic medications. Interventions included, but were not limited to, administer medications as ordered. A review of the resident's December 2022, January 2023, and February 2023, medication administration records (MAR) indicated the following: A physician's order, dated 12/9/22, indicated Depakote sprinkles (medication used to treat mental and mood disorders) 125 milligrams (mg), 2 capsules, by mouth, two times daily, at 7:00 a.m., and 4:00 p.m. The December 2022 MAR lacked documentation that the 4:00 p.m., dose had been administered on 12/21/22 and 12/30/22. The January 2023 MAR lacked documentation that the 4:00 p.m., dose had been administered on 1/2/23, 1/3/23, and 1/30/23. The February 2023 MAR lacked documentation that the 4:00 p.m., dose had been administered on 2/1/23, 2/4/23, and 2/5/23. A physician's order, dated 11/22/22, indicated Haloperidol (used to treat certain mental and neurological disorders) tablet, 10 milligrams (mg), by mouth, three times daily at 8:00 a.m., 12:00 p.m., and 5:00 p.m. Give with 20 mg to equal 30 mg. The December 2022 MAR lacked documentation that the 5:00 p.m., dose had been administered on 12/21/22 and 12/30/22. The January 2023 MAR lacked documentation that the 5:00 p.m., dose had been administered on 1/2/23, 1/3/23, and 1/30/23. The February 2023 MAR lacked documentation that the 5:00 p.m., dose had been administered on 2/1/23, 2/4/23, and 2/5/23. A physician's order, dated 11/22/22, indicated Haloperidol (used to treat certain mental and neurological disorders) tablet, 20 milligrams (mg), by mouth, three times daily at 8:00 a.m., 12:00 p.m., and 5:00 p.m. Give with 10 mg to equal 30 mg. The December 2022 MAR lacked documentation that the 5:00 p.m., dose had been administered on 12/21/22 and 12/30/22. The January 2023 MAR lacked documentation that the 5:00 p.m., dose had been administered on 1/2/23, 1/3/23, and 1/30/23. The February 2023 MAR lacked documentation that the 5:00 p.m., dose had been administered on 2/1/23, 2/4/23, and 2/5/23. A physician's order, dated 9/22/22, indicated lorazepam (used to treat anxiety) tablet, 2 milligrams (mg), by mouth, three times daily at 7:00 a.m., 11:00 a.m., and 4:00 p.m. The December 2022 MAR lacked documentation that the 4:00 p.m., dose had been administered on 12/21/22 and 12/30/22. The January 2023 MAR lacked documentation that the 4:00 p.m., dose had been administered on 1/2/23, 1/3/23, and 1/30/23. The February 2023 MAR lacked documentation that the 4:00 p.m., dose had been administered on 2/1/23, 2/4/23, and 2/5/23. A physician's order, dated 1/11/22, indicated Seroquel (used to treat depression) tablet 300 milligrams (mg), by mouth, three time daily at 8:00 a.m., 12:00 p.m., and 5:00 p.m. The December 2022 MAR lacked documentation that the 5:00 p.m., dose had been administered on 12/21/22 and 12/30/22. The January 2023 MAR lacked documentation that the 5:00 p.m., dose had been administered on 1/2/23, 1/3/23, and 1/30/23. The February 2023 MAR lacked documentation that the 5:00 p.m., dose had been administered on 2/1/23, 2/4/23, and 2/5/23. 2. Resident 9's record was reviewed on 2/9/23 at 2:20 p.m. The profile indicated the resident's diagnoses included, but were not limited to, Huntington's disease (an inherited disease that causes the progressive breakdown [degeneration] of nerve cells in the brain and has a wide impact on a person's functional abilities and usually results in movement, thinking and psychiatric disorders), and depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities). A quarterly Minimum Data Set (MDS) assessment, dated 12/12/22, indicated the resident had moderate cognitive deficit and had a mood severity score of zero. A care plan, dated 1/3/23, indicated the resident uses antidepressant medication related to diagnosis of depression. Intervention included, but were not limited to, administer antidepressant medications as ordered. A review of the resident's January 2023, medication administration record (MAR) indicated the following: A physician's order, dated 12/20/22, indicated sertraline hydrochloride (HCl) (used to treat depression), 25 milligrams (mg), by mouth, one time daily at 5:00 p.m. Give with 50 mg to equal 75 mg. The January 2023 MAR lacked documentation that the 5:00 p.m., dose had been administered on 1/2/23, 1/3/23, and 1/5/23. A physician's order, dated 12/20/22, indicated sertraline hydrochloride (HCl) (used to treat depression), 50 milligrams (mg), by mouth, one time daily at 5:00 p.m. Give with 25 mg to equal 75 mg. The January 2023 MAR lacked documentation that the 5:00 p.m., dose had been administered on 1/2/23, 1/3/23, and 1/5/23. 4. Resident 35's record was reviewed on 02/07/23 at 1:19 p.m. Diagnoses on the profile included, but were not limited to, Huntington's disease (a hereditary disease marked by degeneration of the brain cells and causing chorea [jerky involuntary movements affecting especially the shoulders, hips, and face] and progressive dementia), anxiety disorder (characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and depression (characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). A quarterly Minimum Data Set Assessment, dated 12/10/22, indicated the resident had a severe cognitive impairment and routinely received medications which included, but were not limited to, antipsychotics (medications used to treat symptoms of psychosis, such as delusions), antianxiety medications (medication to treat anxiety symptoms), and antidepressants (used to treat depressive symptoms). A care plan, initiated on 6/2/22 and revised on 9/27/22, indicated the resident received psychotropic medications (used to treat mental health disorders) with interventions included, but were not limited to, administer medications as ordered and monitor/document for side effects and effectiveness. Review of Resident 35's December 2022, January 2023, and February 2023 medication administration records indicated the following: A physician's order, start dated 6/6/22, indicated to administer Zoloft tablet (antidepressant medication) 200 milligrams (mg) by mouth in the evening at 5:00 p.m. for depression. The December 2022 MAR lacked documentation the medication was administered on the evening shifts of 12/21/22 and 12/30/22. The January 2023 MAR lacked documentation the medication was administered on the evening shifts of 1/2/23, 1/3/23, 1/5/23, and 1/30/23. The February 2023 MAR lacked documentation the medication was administered on the evening shifts of 2/1/23, 2/4/23, 2/5/23. The record lacked documentation the resident refused the medication. A physician's order, start dated 10/4/22, indicated to administer Haloperidol tablet (antipsychotic medication) 5 mg by mouth two times a day, at 8:00 a.m. and 5:00 p.m., for psychosis. The December 2022 MAR lacked documentation the medication was administered on the evening shifts of 12/21/22 and 12/30/22. The January 2023 MAR lacked documentation the medication was administered on the evening shifts of 1/2/23, 1/3/23, and 1/5/23. The record lacked documentation the resident refused the medication. A physician's order, start dated 5/25/22, indicated to administer Risperdal tablet (antipsychotic medication) 2 mg by mouth two times a day, at 7:00 a.m. and 5:00 p.m., for psychosis. The December 2022 MAR lacked documentation the medication was administered on the evening shifts of 12/21/22 and 12/30/22. The January 2023 MAR lacked documentation the medication was administered on the evening shifts of 1/2/23, 1/3/23, 1/5/23, and 1/30/23. The February 2023 MAR lacked documentation the medication was administered on the evening shifts of 2/1/23, 2/4/23, 2/5/23. The record lacked documentation the resident refused the medication. A physician's order, start dated 8/9/22, indicated to administer clonazepam tablet (medication used to prevent and treat seizures, panic disorder, and anxiety disorders) 2 mg by mouth three times a day, at 8:00 a.m., 12:00 p.m., and 5:00 p.m., for anxiety. The December 2022 MAR lacked documentation the medication was administered on the evening shifts of 12/21/22 and 12/30/22. The January 2023 MAR lacked documentation the medication was administered on the evening shifts of 1/2/23, 1/3/23, 1/5/23, and 1/30/23. The February 2023 MAR lacked documentation the medication was administered on the evening shifts of 2/1/23, 2/4/23, 2/5/23. The record lacked documentation the resident refused the medication. During an interview, on 2/7/23 at 2:45 p.m., the Administrator (ADM) indicated she was pretty sure the medications had been given, but just not signed off on the MAR. It was the nurse's responsibility to document in the MAR when a medication had been administered. On 2/7/23 at 2:49 p.m., the Administrator (ADM) provided an undated document, titled, Medication Administration General Guidelines, and indicated it was the policy currently being used by the facility. The policy indicated, .Policy .Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have properly oriented to the facility's medication distribution system (procurement, storage, handling and administration) .7. The medication administration record (MAR) is always employed during medication administration .4. The resident's MAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration 3.1-48(b)(1)

Based on observation, interview, and record review, the facility failed to ensure safe food temperatures as evidenced by inadequate external and internal temperatures for 1 of 4 reach in refrigerators and the facility failed to dispose of expired food for 2 of 2 kitchen observations. This had the potential to effect 40 of 40 residents who received food from the kitchen. Findings Include: During an initial tour observation of the kitchen with Dietary Supervisor (DS), on 02/06/2023 at 09:50 a.m., the inside thermometer temperature was reading 48 degrees Fahrenheit (F) on reach in refrigerator # 3. No internal temperature of food was taken at that time. The reach in refrigerator contained 2 containers of heavy whipping cream, bags of shredded cheese, boxes of stick butter, and containers of sour cream. Inside freezer # 2 there were 3 frozen concentrated grape juice containers. They were dated April 15, 2020, May 15, 2020, and May 23, 2020. During an interview with DS on 02/06/2023 at 09:50 a.m., she indicated the reach in refrigerator had too much food in it and that was the reason it was reading warm. She would have to move stuff around. She also indicated she had a new staff member doing the stocking of the food as well. During a food storage observation with DS on 02/09/2023 at 10:50 a.m., inside freezer # 2 there were 3 frozen concentrated grape juice containers. They were dated April 15, 2020, May 15, 2020, and May 23, 2020. The reach in refrigerator # 3 had an inside thermometer temperature reading of 45 degrees F. An internal food temperature was obtained by DS using an infrared thermometer. The bottom shelf of food items was reading 47-48 degrees F. The bottom shelf contained stick butter, sour cream, and bags of shredded cheese. During an interview with DS on 02/09/2023 at 10:50 a.m., she indicated the frozen grape juice containers were expired but they were activities and weren't a part of kitchen's stock. She further indicated she should have noticed the expiration dates and disposed of the frozen juice concentrate but was missed. During an interview with DS on 02/09/2023 at 10:54 a.m., she indicated the thermometer was reading 45 degrees F, she would need to get the infrared thermometer to see what the foods internal temperature was. The internal temperature of the food on the bottom shelf was reading 47-48 degrees F. She again indicated that the refrigerator was too full, and items needed to be moved around. She indicated she would need to contact maintenance to see if there is an issue with the refrigerator unit. During an interview with Administrator on 02/09/2023 at 1:44 p.m., she indicated when a refrigerator temperature is reading over 41 degrees F than an internal temperature needs to be obtained by dietary staff of the food. She further indicated if the internal temperature is over 41 degrees F then the food needs to be discarded. If the food has an internal temperature lower than 41 degrees F, then they need to be moved to a properly working refrigerator unit. She indicated she was not made aware of recent elevated refrigerator temperatures from the kitchen staff. A document titled, Refrigerator/Freezer temperature log was obtained by Administrator on 02/09/2023 at 1:44 p.m., the log indicated on 02/08/2023 at 7:30 p.m., the inside of refrigerator # 3 thermometer was reading 45 degrees F. The log lacked documentation of an internal temperature being obtained. On 02/09/2023 at 1:30 p.m., the Administrator provided and identified a document as a current facility policy, titled Storage of Frozen Foods, dated 06/2018. The policy indicated, .Policy: A proper handling procedure for frozen food safety lessens the risks of acquiring foodborne disease .Procedure: .8. Food should be used within one year of receipt On 02/09/23 at 1:44 p.m., the Administrator provided and identified a document as a current facility policy, titled Cleaning and Maintenance of the Reach-In Refrigerator and Freezer, dated 06/2018. The policy indicated, .Policy: It is necessary to ensure that reach-in units are kept clean, organized, and operating safely. Procedure: Daily .9. Immediately check the internal temperature of food; should be < or = 41 degrees F in the refrigerator .10. If food items are within the safety zone in the refrigerator, move them to a properly working unit .11. Discard all food items with an internal food temperature > 41 degrees F .13. Notify your supervisor, administrator, and maintenance director that unit is not working 3.1-21(i)(1)(3)