**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to enusre non pharmacologic interventions were utilized prior to giving anti-anxiety medication to 1 of 6 residents reviewed. (Resident 4) Findings include: In an interview, on 11/21/24 at 10:02AM, the Registered Nurse (RN 3) indicated Resident 4 frequently had behaviors related to anxiety. RN 3 indicated Resident 4 was difficult to redirect but if caught early or at the right time you could attempt playing music or walk with her. RN 3 indicated giving her the prn (as needed) Ativan ( anti anxiety medication) was the easiest and best way to deal with the behaviors. Resident 4's record review began on 11/22/24 at 12:22PM. Resident 4's diagnoses included Alzheimer's disease, chronic pain, and anxiety. Resident 4's physician orders included Buspar 20mg three times a day. Ativan tablet 0.5mg give 1 tablet by mouth every 4 hours as needed for distress start date 10/29/24 end date 11/12/24. Ativan 1mg tablet give 1 tablet by mouth every 4 hours as needed for anxiety for 14 days start date 11/13/24 and end date 11/21/24. Ativan tablet 1mg, give 1 tablet by mouth every 4 hours as needed for anxiety for 3 Months dated 11/21/24. Resident 4's current comprehensive Minimum Data Set (MDS), dated [DATE], Section D, for mood indicated no issues. Section E for Behaviors indicated no issues. Resident 4's Medication Administration Record (MAR), dated November 2024 was reviewed. On 11/1/24, Ativan 0.5 mg was administered at 3:02 PM. On 11/7/24, Ativan 0.5mg was administered at 12:34PM On 11/8/24, Ativan 0.5mg was administered at 8:57PM. On 11/9/24, Ativan 0.5mg was administered at 9:00AM. On 11/9/24, Ativan 0.5mg was administered at 4:40PM. On 11/12/24, Ativan 0.5mg was administered at 2:05PM. On 11/13/24, Ativan 0.5mg was administered at 2:00PM. On 11/15/24, Ativan 0.5mg was administered at 7:04PM. On 11/21/24, Ativan 0.5mg was administered at 7:20PM A progress note, dated 11/1/24 at 3:16 PM, indicated the resident refused medications all day. She had a garbage bag packed of random things, and said she was going home. She had been paranoid, hallucinating, and interfereing with other residents. RN3 was finally able to convince the resident to take prn Ativan at around 3PM. The note indicated the staff would continue to monitor behaviors. No deescalating techniques were documented in the note. A progress note, dated 11/7/24 at 6:14PM, indicated Resident 4 was VERY anxious throughout the shift. Very argumentative with staff and refused to come back from hair salon. Resident 4 refused to take her medications after several attempts, until RN 3 indicated they were from her daughter. PRN Ativan was given at this time. Resident 4 was tearing apart an entire box of tissues and pulling apart the layers and trying to sew them back together. Resident 4 refused to use her walker. Resident 4 attempted to enter the restroom with other residents. PRN Ativan was given. The note did not indicate any deescalating techniques were attempted. A progress note, dated 11/8/24 at 10:39PM, indicated Resident 4 was anxious, was getting dressed for the day after bedtime shower. The resident stated she had to go pick up her kids several times asking where her car was and when the family was coming. PRN Ativan given and effective. No deescalating techniques were documented as attempted. There were no progress notes, dated 11/9/24, regarding Resident 4's behaviors, anxiety, or any interventions attempted prior to antianxiety medication administration . A progress note, on 11/12/24 at 3:55PM, indicated Resident 4 very anxious. PRN Ativan given. Resident 4 asked the same questions repeatedly, the residents packed the entire closet onto her walker and took them to nursing station to inform them she was moving out. Resident 4 was attempting to rouse other residents into leaving with her. PRN Ativan was given but was ineffective. The staff would continue to monitor. No deescalating techniques were documented. A progress note, dated 11/13/24 at 5:52PM, indicated Resident 4 was very anxious after lunch and packing clothes again. Received new orders from the physician to increase Ativan from 0.5mg to 1mg every 4 hours as needed (PRN). It was given. Resident 4 calmed down and was able to enjoy visiting with daughter and friend. There was no documentation deescalating techniques had been attempted. No progress notes were available, dated 11/15/24, to address the use of PRN Ativan. A progress note, dated 11/21/24 at 6:07 PM, indicated Resident 4 refused medications, refused to get dressed and stayed in a house coat throughout the day. Resident 4 was hitting the utility room door. Resident 4 was very difficult to redirect and became very argumentative with staff. Resident 4 was packing belongings. Resident 4's daughter was at supper and indicated she could not convince her mother to get dressed either. There was no documentation of PRN Ativan administration or the medications effectiveness. Behavior monitoring, dated November 2024, indicated the facility was monitoring frequent crying, repeated movements, yelling, kicking/hitting, pushing, grabbing, pinching, biting, wandering, abusive language, threatening behavior, sexually inappropriate, rejection of care, none of the above, and not applicable. The only behavior symptom marked was on 11/1/24 at 11:23 PM for refusal of care. There was no other documentation regarding Resident 4's behaviors. Resident 4 was care planned for resistive to care related to dementia, behavioral problems increased anxiety and repetitive questioning, the resident has anxiety, and resident used psychotropic medications. The increased anxiety, refusing medications, attempting to get peers to elope, and repetitive questioning were not on CNA behavior monitoring tasks. Resident 4's Behavior Summary, dated November 2024, indicated Resident 4 had an increase in anxiety 11/20, 11/17, 11/16, and 11/13. The interventions were listed as one-on-one and calls to family. Behavior committee recommendations were; Resident 4 had an increase in anxiety, Ativan 1mg was effective, continue to observe. In an interview, on 11/26/24 at 9:32 AM, the Administrator indicated all staff should be using deescalating techniques and documented behaviors. The Administrator indicated they recently switched their computerized charting, yet the staff were required to document deescalating techniques used and their effectiveness. A policy titled, Behavioral Health Services [NAME] Heritage/[NAME] Woodcrest dated 2/2017, provided by the Administrator on 11/26/24 at 9:24AM indicated .11.Facility will implement person-centered care approached designed to meet the goals and needs of each resident, which includes non-pharmacological interventions. Examples of individualized non pharmacological interventions to help meet behavioral health needs of all ages may include but are not limited to .focusing the resident on activities that decrease stress and increase awareness of actual surroundings, such as familiar activities, offering verbal reassurance, n. utilizing techniques such as music, art, massage, reminiscing, Providing support with skills related to verbal reescalation, coping skills, and stress management. A policy titled, Psychotropic Medication Policy and Procedure dated 2/1/1994 provided by the Administrator on 11/26/24 at 9:24AM, focused on the duration of the order and each member of the team responsibility to ensure monitoring was in place. There were no noted specified nonpharmacological interventions noted throughout the policy. 3.1-48(b)

Based on observation, interview, and record review the facility failed to ensure sanitation of an ice machine; labeling, dating and removal of expired food items in the kitchen and unit pantries. 110 of 110 residents received food prepared in the facility kitchen. Findings include: During a kitchen observation beginning 11/21/24 at 9:11 AM, a bottle of lemon juice was observed in a reach in cooler with an open date of 9/14/24. No printed manufacturers expiration date was found on the bottle. Ziploc baggies filled with light brown material were observed in a container directly beneath the evaporator and fan unit in the walk-in freezer. The bags were frozen together and covered in an irregular pyramid shaped clump of ice about 4 inches above the container and spread across the width of the container, covering about 2/3 of the contents of the container. An additional container of Ziploc bagged bananas contained bananas dated 3/19/24 and 1/5/24 with visible white frosty debris on top of the bananas. A bag of tater tots tied closed with a twist-tie was observed on a shelf. No open date was recorded on the bag of tater tots. During an interview, on 11/21/24 at 9:14 AM, the Nutrition Services Manager (NSM) indicated lemon juice was fine for a long time and did not need discarded. The NSM did not provide a date on which the juice should be discarded. During an interview, on 11/21/24 at 9:15 AM, the Dietary Manager (DM) indicated the lemon juice should be discarded within 7 days. The DM indicated the bags covered in ice contained bananas and should be discarded. She indicated frozen bananas were good for one year. The DM indicated the tater tots should have been dated upon opening. During an observation, on 11/21/24 at 10:13 AM, two cups of yogurt were observed in the refrigerator in the A-wing pantry. The expiration date on each container was 10/21/24. Two containers of lime sherbet were observed in the freezer with no expiration date. During an interview, on 11/21/24 at 10:14 AM, Qualified Medicine Aide (QMA) 5 indicated the yogurt cups should have been discarded upon expiration and should not have been in the refrigerator. QMA 5 indicated she was not able to determine when the lime sherbet should be discarded because the container did not have an expiration date. During an observation, on 11/21/24 at 10:38 AM, a round container of ice cream with a loosely applied lid was observed in the freezer in the dementia unit. No open date or manufacturer's expiration date was observed on the container. A rectangular container of black raspberry ice cream was observed in the same compartment of the freezer with no open date on the container. The expiration date on the container contained an ink smear, obscuring the date. Certified Nurse Aide (CNA) 7 opened each lid, revealing a ½ inch coating of frost covering the top of each product. During an interview, on 11/21/24 at 10:39 AM, CNA 7 indicated the ice cream containers should have been dated when opened and should be discarded. During an observation, on 11/21/24 at 11:20 AM, black debris was observed in the upper interior portion of the ice machine in the A- wing pantry. In the refrigerator, a foil wrapped container was observed with no date visible. Containers of lime sherbet with no expiration date, and a container of chocolate ice cream with an expiration date on 8/24 were observed in the freezer. During an interview, on 11/21/24 at 11:21 AM, Licensed Practical Nurse 6 indicated the black debris should not be present in the ice machine and the machine should be taken out of service and cleaned prior to any further use. She indicated items in the refrigerator and freezer should be dated when opened and discarded upon the expiration date. She indicated any undated items should be discarded. A current policy, titled Resident Pantry, dated 7/2023, provided by the Administrator on 11/21/24 at 5:12 PM indicated the nursing staff was responsible for cleaning and maintaining the residents' pantries. The policy indicated all food and drink items should be marked with the date opened at the time of opening and discarded 7 days after opening. The policy indicated the nursing department was responsible for checking for and discarding expired items daily. A current policy, titled Labeling, Dating, and Discarding Foods, provided by the Administrator on 11/21/24 at 5:12 PM indicated all foods, once opened or manufactured, should be labeled, dated, and discarded to food code regulations. The policy indicated frozen items should be discarded within 180 days. A current policy, titled Ice Machines and Portable Ice Carts, provided by the Administrator on 11/21/24 at 5:12 PM indicated ice machines should be cleaned quarterly and as needed when contaminated or visibly soiled. 3.1-21(i)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure physician orders were followed for 2 of 8 Residents reviewed. (Resident 20, and Resident 31) Findings include: 1) During an observation, on 2/1/23 at 8:47AM, QMA 3 (Qualified Medication Aide) took Resident 20's blood pressure prior to medication administration. Resident 20's blood pressure was 122/63. QMA 3 indicated to Resident 20, the medication propranolol would be held due to the blood pressure result. Resident 20 received all other medications due at 8AM. QMA 3 documented medication as held. Resident 20's record was reviewed, on 2/1/23 at 02:08 PM, indicated an order for propranolol 80mg daily related to hypertension to be held if SBP (Systolic Blood Pressure) was below 110. Resident 20's blood pressure medication was documented as follows: On [DATE], propranolol was given, blood pressure result was documented as 105/71 On [DATE], propranolol was held, blood pressure result was documented as 125/81 On [DATE], propranolol was held, blood pressure result was documented as 118/76 On [DATE], propranolol was given; blood pressure result was documented as 104/76 On [DATE], propranolol was held, blood pressure result was documented as 113/71 On [DATE], propranolol was given; blood pressure result was documented as 104/62 Resident 20's diagnosis included weakness, history of fractures, heart disease, and personal history of pulmonary embolism. 2) Resident 31's record was reviewed on 01/31/23 2:24 PM. The record indicated she had a pharmacy recommendation dated 8/8/22 for Metoprolol tartrate 50mg twice a day to be reduced to 25mg twce per day. The Physician/Prescriber response indicated they agreed with a note to take daily blood pressure for a week and call reults to the presciber. The review was signed by nurse practioner (prescribing provider) on 8/11/22. Resident 31's diagnosis included dementia, heart disease, and edema. Resident 31's medication orders indicated metoprolol was prescribed in May 2022, 50mg twice a day for hypertension and to hold if pulse was below 60. The medication was not changed according to the pharmacy recommendation. In the month of August 2022, Metoprolol was documented as held on: 8/3 am dose 8/4 am dose 8/5 am dose 8/6 am dose 8/7 am dose 8/8 pm dose 8/9 am dose 8/10 am and pm dose 8/11 pm dose 8/12 pm dose 8/13 am dose given with pulse of 49, pm dose held 8/17 am dose 8/18 am dose 8/19 am and pm dose 8/22 am dose 8/23 pm dose 8/26 am dose 8/28 am dose 8/29 am dose The month of September 2022, Metoprolol was documented as held on: 9/2 pm dose 9/7 am dose 9/10 am dose 9/11 am dose 9/14 am and pm dose 9/16 am dose 9/17 am dose 9/19 am dose 9/21 am dose 9/22 am dose 9/24 pm dose 9/26 pm dose 9/27 am dose 9/29 am dose 9/30 am dose The month of October 2022, Metoprolol was documented as held on: 10/3 am dose 10/4 am dose 10/5 am dose 10/6 am dose 10/8 pm dose 10/25 pm dose 10/30 am dose 10/31 am dose documented as given with pulse of 56 In the month of November 2022, Metoprolol was documented as held on the following: 11/2 am dose 11/3 am dose 11/6 am dose 11/8 am dose 11/9 am dose 11/10 am dose 11/11 am dose 11/12 am dose 11/13 am dose was documented as given with pulse of 52 11/14 pm dose 11/16 am and pm doses 11/18 am dose 11/19 am dose 11/20 am dose 11/21 am dose 11/23 am dose 11/25 am dose 11/26 am dose 11/27 am dose 11/28 pm dose 11/29 pm dose 11/30 pm dose In the month of December 2022, Metoprolol was documented as held on the following: 12/1 both am and pm doses 12/5 pm dose 12/6 am dose held; pm dose given with pulse of 52 12/7 pm dose 12/8 pm dose 12/9 am dose 12/13 am dose 12/15 am dose 12/16 am dose 12/17 am dose 12/18 pm dose 12/20 am dose 12/21 am dose held; pm dose documented as given with pulse 51 12/22 am dose 12/23 am dose 12/27 pm dose 12/29 am dose 12/30 am dose 12/31 am and pm doses In the month of January 2023, Metoprolol was documented as held on the following: 1/4/23 am dose 1/5 am dose 1/7 pm dose 1/8 pm dose 1/9 am dose 1/10 am dose documented as given with pulse 58 1/11 am dose 1/12 am dose documented as given with pulse 53 1/13 am dose 1/16 am dose 1/19 am and pm doses 1/20 am dose 1/24 pm dose 1/25 am and pm doses 1/29 pm dose 1/30 am dose 1/31 am dose In an interview on 2/1/23 at 10:04 AM, the ED (Executive Director] indicated the nurse putting the order in did not properly read the pharmacist recommendations and only put in an alert to send the prescriber blood pressures for one week. The ED indicated the prescriber generally writes out the order in the note section of pharmacy reviews and the directions were unclear. The ED indicated she asked the provider who agreed with the pharmacy recommendations to clarify her order from August of 2022. The provider indicated she agreed with the pharmacy recommendations and the medication was reduced as intended. No current policy was provided by time of exit conference. 3.1-37

Based on observation, interview, and record review, the facility failed to ensure hand hygiene was observed during food delivery. 16 of 23 residents were present in the dining room. On 2/1/23 beginning at 11:21 AM, meal service in the A-wing dining room was observed. Server 2 was observed removing her pen from her shirt pocket, then going from table to table taking orders for residents seated at the tables. Server 2 went back and forth to the kitchen window, passing order slips to the kitchen staff through the window. She was observed reaching into the service window placing dishes of food on trays for delivery. Server 2 was observed touching dishes, glassware, tables, silverware, occupied wheelchairs, and residents. She used hand sanitizer one time during meal service to 16 residents. In an interview on 2/1/23 at 11:53 AM, Server 2 indicated she did not know how frequently hand hygiene should be performed. She indicated she normally uses hand sanitizer between every few trays and after touching a resident or their belongings, but she did not during the lunch meal that day. During an interview on 2/2/23 at 11:10 AM, the Dietary Manager indicated hand hygiene should be performed between tasks and after touching residents. A current facility policy titled Hand Hygiene dated 4/27/1987 was reviewed. The policy indicated antiseptic hand rub should not be used during the assembly of meal trays. The policy also indicated servers should ensure their hands were always clean when holding plates or cutlery and hand hygiene should be performed after contact with residents' skin and medical equipment. 3.1-21(a)(3)