Based on observation and staff interview the facility failed to ensure a qualified dietary professional served as a Dietary Manager for 43 of 43 residents. The facility reported a census of 43 residents. Findings include: During an interview and observation of the kitchen on 1/2/24 at 9:36 AM with the Dietary Manager revealed she is not certified, when asked to provide a list of diets and adaptive equipment she informed she did not have access to that information and has been here only a week, however an observation of a white board in the kitchen showed a list of resident diets and adaptive equipment. During an interview on 1/2/24 at 2:43 PM the Administrator revealed they currently do not have a Certified Dietary Manager, she informed however the Dietary Manager in place is new to her role and other facilities Certified Dietary Managers are helping out but they are not employed by this facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and policy review the facility failed to maintain a clean environment with 1 out of 4 bathrooms observed with brown substance on walls, floor and baseboard. The facility reported a census of 44 residents. Findings include: During an observation on 11/29/22 at 09:08 AM in room [ROOM NUMBER] bathroom noted a build up of a brown substance on the floor around the base of the toilet. The wall has a smeared brown substance behind the handrail next to the toilet and on the baseboard behind the toilet. During an interview on 11/29/22 09:41 AM with Staff B, housekeeper stated no housekeeper or supervisor at this facility. I am the only housekeeper in the building today so after cleaning the general areas I will have to clean all the bathrooms and rooms. The toilets should be cleaned every day and I would say they are not getting done every day but maybe every other day. I cleaned them yesterday and they definitely were not very clean and you could tell they needed more attention. During an observation on 11/30/22 at 8:01 AM the brown substance remains on the wall, baseboard and at the base of the toilet in the bathroom of room [ROOM NUMBER]. During an interview on 12/01/22 at 8:14 AM the Administrator stated I would expect the bathrooms to be cleaned daily. During an observation on 12/01/22 at 8:26 AM the surveyor showed the administrator the bathroom she confirmed the bathroom was dirty and had an odor. Review of the undated Housekeeping Schedule - 1 housekeeper provided by the facility the document directed staff When cleaning the room you want to: 1. Clean the bathroom - mirror, sink, grab bar, towel bars, paper towel dispenser, toilet , wood shelf, step-on can/flower pot 2. Empty garbage's in the room and bathroom 3. Sweep and mop room floor and bathroom floors- move all small furniture, get under the bed and behind furniture and doors. 4. Must remain in the area while floors are wet from mopping 5. Check bathroom supplies- paper towels, cups, soap, 2 spare toilet paper, garbage bags, gloves. The Housekeeping Daily Cleaning Schedule Task to Do Form undated provided by the facility directed staff in resident bathroom to spot clean walls beside toilets, sinks, and sides of cabinets and dispensers.

Based on clinical record review, staff interviews and facility policy review the facility failed to address a diuretic medication in 1 out of 5 resident reviewed for unnecessary medication (Resident # 9). The facility reported a census of 44 resident. Findings included; The Minimum Data Set (MDS) Assessment for Resident # 9 dated 11/9/22, included diagnoses of anemia and cancer. The MDS listed the Resident's Brief Interview for Mental Status (BIMS) as 15 (intact cognition). The MDS showed Resident # 9 took a medications in the drug classification of diuretic for 7 days in the reference period. The Medication Administration Record (MAR) dated 11/2022, directed bumetanide (diuretic) 1 milligram (mg) daily for edema. The Care Plan for Resident # 9 dated 10/25/22, failed to address the use of the diuretic and failed to address what the staff are expected to monitor for the medications effectiveness. On 12/01/22 at 10:58 AM the Director of Nursing (DON) stated she expected diuretics addressed on the Care Plan. The facility provided a policy titled Goals and Objectives, Care Plan dated 4/2009, directed at point #1; Care plan goals and objectives are defined as the desired outcome for a specific resident problem.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to complete accurate minimum data set assessments for 4 out of 14 residents reviewed (Resident #9, 17, 25 and #36). The facility reported a census of 44 residents. Findings include: 1. The Minimum Data Set (MDS) for Resident #25 dated 11/2/22 stated the resident received an antipsychotic medication 7 day. Review of the medication administration record revealed resident did not receive antipsychotic medication. During an interview on 11/30/22 at 3:19 PM with the MDS Coordinator stated Resident # 25 is not receiving an antipsychotic and she has not been on the medication. The MDS was coded wrong. We follow the Resident Assessment Instrumnet (RAI) manual for policy when filling out the MDS. 2. The MDS dated [DATE] indicated Resident #36 had a fall with major injury. During an interview on 11/30/22 at 2:33 PM the Director of Nursing (DON) states she can not recall any injuries from a fall for Resident # 36. During an interview on 11/30/22 at 2:35 PM the MDS Coordinator stated Resident # 36 MDS is coded incorrectly. I checked and she should not have a major injury checked. The medications are probably coded wrong also I think I was looking at that as if they are taking psychotropic medications. 3. The Minimum Data Set (MDS) Assessment for Resident # 9 dated 11/9/22, included diagnoses of anxiety and depression. The MDS listed the Resident's Brief Interview for Mental Status (BIMS) as 15 (intact cognition). The MDS showed Resident # 9 took a medications in the drug classification of antipsychotic for 7 days in the reference period. The Medication Administration Record (MAR) dated 11/2022, failed to direct the use of an antipsychotic medication. During an interview on 11/30/22 at 11:51 AM, Staff Registered Nurse (RN) reported, Resident # 9 never received an antipsychotic medication. Interview 11/30/22 at 3:19 PM, the MDS Coordinator, reported she coded Resident # 9 for an antipsychotic medication. The MDS Coordinator, confirmed the resident took an antidepressant 4. The MDS for Resident # 17 dated 10/19/22, included diagnoses of non-Alzheimer's dementia and psychotic disorder. The MDS showed Resident # 9 took a medications in the drug classification of antianxiety medication for the 7 days in the reference period. The MAR dated 11/17/22, failed to include a medication in the drug classification of antianxiety medication. Interview 11/30/22 at 3:19 PM, the MDS Coordinator, reported Resident # 17 is on antipsychotic medication and she coded it incorrectly on the MDS dated [DATE]. During an interview on 12/01/22 10:54 AM the DON states the expectation is the MDS will be completed timely and accurately.