Based on clinical record review and staff interview, the facility failed to notify the State Ombudsman when a resident transferred and admitted to the hospital for 1 of 1 residents reviewed for hospitalization (Resident #7). The facility reported a census of 18 residents. Findings include: The discharge Minimum Data Set (MDS) for Resident #7 dated 2/11/23 documented the resident discharged to the hospital 2/11/23. The clinical record census documented Resident #7 went on hospital leave 2/11/23 and returned to the facility 2/14/23. Review of facility form titled, Notice of Transfer Form to Long Term Care Ombudsman emailed 3/24/23 revealed Resident #7's name was not on the list of residents that transferred from the facility in February 2023. During an interview on 7/26/23 at 3:40 PM the Director of Nursing acknowledged Resident # 7's name had not been added to the list to notify the Ombudsman of the residents transfer to the hospital in February 2023 as expected.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review and staff interview, the facility failed to refer a resident to the appropriate state-designated authority for a Level II Pre-admission Screening and Resident Review (PASRR) after the resident was identified to have a mental health diagnosis for 1 of 1 residents reviewed for PASRR evaluation (Resident #10). The facility reported a census of 18 residents. Findings include: The Minimum Data Set, dated [DATE] documented Resident #10 had a Brief Interview for Mental Status (BIMS) of 3 indicating severely impaired cognition and diagnoses including anxiety, depression and Post Traumatic Stress Disorder (PTSD). The MDS further documented the resident received an antidepressant medication for 7 out of the past 7 days. The Care Plan for Resident #10 with a target date 10/3/23, revealed the resident had the potential for behavior disturbance. The Care Plan directed staff to intervene as necessary to protect the rights and safety of others. During an observation 7/24/23 at 11:10 AM, Resident #10 requested staff not leave her during an introduction by the writer. Clinical record review revealed Resident #10 had a diagnosis of Post Traumatic Stress Disorder (PTSD) dated 10/26/21. Review of the Level 1 PASRR completed by Ascend for Resident #10 dated 11/4/21 documented the resident had mental health diagnoses including major depressive disorder, anxiety and depression/depressive disorder and there were no indicators identified that would signify the need for further evaluation at the time. The Level 1 evaluation further documented that if there was a discrepancy in the reported information a status change should be submitted to Ascend for further evaluation. The Level 1 PASRR lacked the diagnoses of PTSD. During an interviewon 7/26/23 at 7:52 AM, the Director of Nursing (DON) acknowledged a Level II PASRR had not been completed for Resident #10 regarding her Post Traumatic Stress Disorder diagnosis. The DON further revealed the facility does not have a policy or protocol in place regarding completion of PASSR's.

Based on observations, policy review, and staff interviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. The facility reported a census of 18 residents. Findings include: During the initial kitchen visit on 7/24/23 at 9:43 AM, the following observations were made: Bowls and plates were stored on a cart face up and not covered. Three rubber spatulas were noted to be chipped. A bag of what appeared to be sausage patties unlabeled and undated in the refrigerator. Opened and undated gallon of milk, and jugs of orange, prune, grape, cranberry, and tomato juice in the refrigerator. Review of an undated facility document titled Food Storage revealed that all foods that have been opened and partially used shall be dated and sealed before returning to a storage area. Interview with Staff A Dietary Manager (DM) on 7/27/23 at 10:15 AM, revealed that her expectation was that all food and drink would be dated when opened. She stated that she had not thought about the dishes not being covered or face down and acknowledged that spatulas were chipped.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, interviews, and record review, the facility failed to ensure appropriate monitoring for one of five residents reviewed for unnecessary use of psychotropic medication, ( Resident #17). Behaviors were not monitored related to medications administered for sleep. The findings include: Review of the facility's policy titled, Psychotropic Medication Policy dated 05/2013 read, in pertinent part, When a psychotropic medication is ordered interventions and behaviors will be documented. Record review revealed Resident #17 was admitted to the facility on [DATE], according to the admission Record located in the Electronic Medical Record (EMR) under the Profile Tab, with diagnoses including cerebrovascular disease, anxiety, chronic pain, and insomnia. Review of the Minimum Data Set (MDS) located in the MDS tab in the EMR with an Assessment Reference Date (ARD) of 08/16/22, indicated a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating the resident was moderately cognitively impaired. The assessment indicated the resident exhibited behaviors including trouble falling or staying asleep or sleeping too much on half or more of the days of the assessment reference period and indicated Resident #17 received hypnotic medications (for sleep) on seven of seven days during the assessment period. Review of Resident #17's undated Psychotropic Medication Care Plan, found in the EMR under the Care Plan Tab, indicated the resident was receiving psychotropic medications. Approaches included: Administer psychotropic medications as ordered and monitor and document for behaviors on behavior flowsheets. Review of the resident's Medication Review Report found in the EMR under the Orders Tab and dated 09/23/22, indicated orders for Zaleplon (a hypnotic medication used to induce sleep) 5 MG (milligrams) at bedtime for insomnia. Review of Resident #17's Medication Administration Records (MARs) and Treatment Administration Records (TARs) for 09/01/22 through 09/23/22 revealed nothing to indicate hours of sleep/quality of sleep for his use of Zaleplon was being monitored. Review of Resident #17's Behavior Intervention Monitoring documentation 09/01/22 through 09/23/22 revealed nothing to indicate hours of sleep/quality of sleep for his use of Zaleplon was being monitored. During an interview with the MDS (Minimum Data Set)/Care Plan Nurse/Infection Preventionist (MDS/CP1/IP) on 09/23/22 at 3:44 PM, she indicated proper monitoring was not being done for the resident's use of Zaleplon for sleep. She stated Resident #17 should be monitored for sleep. During an interview with the Director of Nursing (DON) on 09/23/22 at 4:22 PM, she stated staff should be monitoring Resident #17 for quality of sleep. She stated, We will have to develop a plan for that.