**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 36 residents. The 12 sampled residents included three dependent residents reviewed for activities of daily living (ADLs). Based on observation, interviews, and record review the facility failed to provide bathing opportunities and grooming of facial hair in accordance with the residents' preferred bathing schedule to ensure necessary services to maintain good personal hygiene for Resident (R)5 and R9. This placed the residents at risk for impaired dignity and poor hygiene. Findings included: - A review of R5's undated Physician Orders, (POS), included diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and major depressive disorder (major mood disorder which causes persistent feelings of sadness). The Annual Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of eight, indicating moderate cognitive impairment. He exhibited fluctuating behaviors of inattention and disorganized thinking and demonstrated other behavioral symptoms not directed toward others one to three days of the look-back period. The resident reported choosing his bath type was very important. He was dependent on staff for bathing and personal hygiene which included shaving. The Quarterly MDS dated 04/04/25, documented the resident did not complete the BIMS interview. The Functional Abilities [Self-Care and Mobility] Care Area Assessment (CAA), dated 10/25/25, documented R5 was dependent on staff assistance for bathing and grooming/personal hygiene due to his diagnosis of Alzheimer's dementia noted by primary care physician (PCP) on 09/26/24. The facility planned to proceed to care planning and staff would continue to assist R5 with ADL. R5's Care Plan (CP) dated 01/09/25, documented the resident was not able to perform his own ADL and was dependent on staff for bathing and grooming. The CP lacked the resident's preferences and schedule for bathing. Review of R5's Electronic Medical Record (EMR) for Tasks /ADL shower dated 03/17/25 through 04/14/25, revealed the resident received one shower on 03/21/25.ThR5'sEMR lacked documentation of bathing opportunities offered, or refusals by the resident. The documentation in the Task section of the EMR documented bathing was not applicable on 03/26/25, 3/28, 03/31/25, 04/04/25, 04/07/25, 04/09/25, and 04/11/25 . Review of R5's Bath Sheets, dated 03/17/25 through 04/17/25, documented the following: 1. On 04/01/25, R5 was combative and refused a shower. 2. On 04/04/25, R5 refused a shower. 3. On 04/14/25 R5 refused a shower. R5's entire clinical record reflected the staff offered four bathing opportunities, including shaves from 03/15/25 through 04/14/25, versus the required eight bathing opportunities as a minimum requirement, unless otherwise indicated as resident preference. On 04/15/25 at 01:41 PM, R5 spoke incoherently while he rocked his wheelchair back and forth with his feet. He had prominent beard stubble on his face with irregular borders. R5 did not respond to direct questioning but continued to speak incoherently and repeating ho. On 04/16/25 at 12:40 PM, Certified Medication Aide (CMA) F confirmed R5's beard stubble. She reported residents were shaved with their shower/bath, and as needed. CMA F said staff should document baths in the EMR and complete bath sheets when baths are offered and if the residents refused their bath/shower, the refusal should be documented and reported to the charge nurse for follow-up. CMA F stated R5 liked his bath very early in the morning. On 04/17/25 at 01:27 PM, Administrative Nurse B verified the above findings. She stated R5 was dependent on staff for bathing, grooming, and personal hygiene and he preferred to take a bath at 04:00 AM. Administrative Nurse B said R5 would refuse baths occasionally depending on his moods. She said if that happened, staff should go back and offer R5 other bathing opportunities. Administrative Nurse D said staff should offer to shave the resident with his bath/shower and document any offering and/or refusal. She stated staff should offer a minimum of two showers per week and/or in keeping with the resident's preferences and shaving assistance should be offered during baths/showers and as needed, as part of grooming and personal hygiene. The facility policy Activities of Daily Living, dated 04/27/2018, documentation included residents will be given the appropriate treatment and services to maintain or improve his/her ability to carry out the activities of daily living. The facility will provide care and services based on the comprehensive assessment of the resident and consistent with his/her needs or choice for following activities of daily living which include hygiene-bathing, and grooming. Residents who are unable to carry out activities of daily living and are dependent on staff will receive the necessary services to maintain grooming and personal hygiene. - R9's Electronic Health Record (EHR) revealed diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) and end-stage renal disease (ESRD-a terminal disease of the kidneys). The 03/28/25 Annual Minimum Data Set (MDS) did not have a Brief Interview for Mental Status (BIMS) score, or staff interview completed. The MDS documented that choosing his bath type was very important to R9. R9 required moderate assistance with personal hygiene which included shaving. The 04/04/25 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) did not trigger. The 01/03/25 Quarterly MDS documented the resident had a BIMS score of 10, which indicated moderately impaired cognition. R9's bathing and personal hygiene were not assessed. R9's Care Plan documented an intervention dated 05/12/23 which directed staff that R9 preferred his mustache, and he would let staff know when he required shaving/trimming facial hair. R9's Bathing Task in the EHR documented the staff offered six bathing opportunities, to include shaves from 03/25/25 through 04/15/25. R9 refused his showers on 04/01/25, 04/08/25 and 04/15/25. On 03/25/24 R9 was dependent on staff for bathing. On 03/27/25 and 04/03/25 staff documented bathing as non-applicable. R9's Personal Hygiene Task described as the ability to maintain personal hygiene, including combing hair, and shaving reviewed from 03/24/25 thru 04/15/25 documented seven times that R9 was dependent on staff for personal hygiene. Additionally, nine times R9 required moderate to maximal assistance from the staff. During an observation on 04/15/25 at 02:29 PM, R9 had prominent beard stubble on his face with irregular borders and a mustache. R9 reported that he required help to be shaved. R9 had visible involuntary movements of the right hand and arm. During an observation on 04/16/25 at 12:30 M, R9 sat in his room with his beanie cap on and lightweight coat. R9 had involuntary movements of the hands and arms. R9 reported he was not cold, but he had just come back from dialysis. When asked, R9 reported he would like a shave. During an interview on 04/16/25 at 12:40 PM, Certified Medication Aide (CMA) F reported residents were shaved with their shower/bath, and as needed. CMA F said staff should document baths in the EHR and complete bath sheets when baths are offered and if the residents refused their bath/shower, the refusal should be documented and reported to the charge nurse for follow-up. During an interview on 04/17/25 at 08:10 AM, CMA K reported that R9 required more assistance with holding items like his cup of fluids when she administered his medications. CMA K reported that R9's tremors had progressively gotten worse for the past several months and that R9 required more assistance from the staff for shaving and combing his hair. CMA K reported that R9 would refuse his showers at times. On 04/17/25 at 01:27 PM, Administrative Nurse B verified the above findings. She stated that R9 was dependent on staff for bathing, grooming, and personal hygiene. Administrative Nurse B reported that R9 would refuse baths occasionally dependent on his mood. She said if that happened, staff should go back and offer R9 other bathing opportunities. Administrative Nurse D said staff should offer to shave the resident with his bath/shower and document any offering and/or refusal. She stated staff should offer a minimum of two showers per week and/or in keeping with the resident's preferences and shaving assistance should be offered during baths/showers and as needed, as part of grooming and personal hygiene. The facility policy Activities of Daily Living, dated 04/27/2018, documentation included residents will be given the appropriate treatment and services to maintain or improve his/her ability to carry out the activities of daily living. The facility will provide care and services based on the comprehensive assessment of the resident and consistent with his/her needs or choice for following activities of daily living which include hygiene-bathing, and grooming. Residents who are unable to carry out activities of daily living and are dependent on staff will receive the necessary services to maintain grooming and personal hygiene.

The facility identified a census of 36 residents, with 12 residents sampled, including two residents reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, interview, and record review, the facility failed to identify and implement measures consistent with in accordance with professional standards of practice to prevent the development of and promote the healing of pressure ulcers for Resident (R) 34 when staff failed to ensure R34's heels were offloaded and failed to develop a consistent repositioning plan. The facility further failed to ensure R24 received the required interventions including a low air loss mattress to prevent pressure ulcers. This placed the residents at risk for the development of new pressure ulcers, delayed healing, and worsening of existing ulcers. Findings included: - R34's Electronic Health Record (EHR) revealed diagnoses of pneumococcal arthritis of the right and left knees (a condition where the knee joints are infected with Streptococcus pneumoniae [bacteria] leading to inflammation and pain), diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) and effusion (abnormal accumulation of fluid between tissues) of right and left knees. The 03/25/25 admission Minimum Data Set (MDS) documented the resident did not have a Brief Interview for Mental Status (BIMS) assessed and no staff interview was completed. R34 required total assistance with activities of daily living (ADL) including transfers, toileting hygiene, dressing, and applying footwear. R34 required maximal assistance for bed mobility, turning from side to side, and was frequently incontinent of urine. The MDS documented R34 had no turning and repositioning program. The 03/31/25 Pressure Ulcer/Injury Care Area Assessment (CAA) documented R34 had an open area on her left buttock when she admitted from the hospital that healed in one week; R34 had no other pressure injuries. The CAA noted risk was present due to decreased independent mobility. R34 was assisted with turning and positioning and pressure injury prevention will be care planned. R34's Care Plan documented R34 did not want to develop any pressure injuries and included interventions dated 03/31/25 that directed staff to provide R34 with turning from side to side; staff were instructed to reposition R34 from side to side in bed and to move R34 in her chair at least every two to three hours. The plan noted R34 could move herself but could not fully change position without help. R34's Tasks Roll Left and Right in EHR the staff documented 17 times from 03/25/25 through 04/17/25 that R34 required total dependent on staff to roll left to right side in bed. R34's Tasks in the EHR lacked a turn and repositioning program. R34's Physician's Orders documented the following: Low air loss mattress ordered 03/20/25. Wound care one time a day every other day for left heel pressure wound. Apply Medi-Honey (a medical-grade wound care dressing that incorporates manuka honey to promote wound healing) to the wound bed, cover with Opti foam dressing (a type of foam wound dressing designed to promote healing by absorbing wound fluid, protecting the wound bed, and providing a comfortable environment for healing) and as needed if the dressing is soiled, or missing, ordered 04/15/25. Review of the Braden Scale (a tool used to assess a patient's risk for developing a pressure injury) documented on 03/25/25 and 04/01/25 R34 was at risk with a score of 16 which indicated mild risk. The assessment performed on 04/08/25 R34 was at risk with a score of 17 which indicated mild risk. The 03/28/25 at 04:30 PM Weekly Wound Assessment documented a small pressure ulcer to the back of the left heel when the assessment was completed that measured 0.5 centimeters (cm) by 0.5 cm, stage two. This was the first observation of an open area. Interventions in place was a low loss air mattress, pressure relieving cushion in wheelchair and recliner. The 04/01/25 at 08:28 AM Progress Note documented R34's left heel was brown, red and discoloration noted. The 04/07/25 Weekly Wound Assessment documented R34's left heel was unchanged, with very little improvement. It measured 0.5 cm by 0.4 cm. The assessment directed staff to continue with the same treatment. The 04/14/25 Weekly Wound Assessment documented R34's left heal improved, measured 0.5 cm by 0.4 cm. The assessment noted a very slight improvement in size, and the color was better; the physician assessed the wound and a new order was received. Interventions in place was a low loss air mattress, pressure relieving cushion in wheelchair and recliner. During an interview on 04/15/25 at 01:52 PM, R34 reported the facility provided her with an air mattress a couple of days after she was admitted for her back pain. During an interview on 04/16/25 at 12:20 PM, R34 reported that she did have an open area on her left heel. R34 reported the facility had not provided an offloading bootie and revealed she was told the booties had been ordered. R34 reported she required staff to assist her with repositioning in the bed. R34 pulled her sheet back from off her legs; her right leg was elevated on a pillow, and her left leg was positioned directly on the air mattress. During an interview on 04/16/25 at 01:30 PM, Certified Nurse Aide (CNA) G reported that R34 had no open areas and did not have a turn and reposition schedule on her assigned tasks on the EHR that staff were to document the care provided. Additionally, CNA G reported R34 did not have offloading booties and staff would position heels off the bed with a pillow. CNA G reported R34 was able to reposition herself independently. During an interview on 04/17/25 at 09:00 AM Administrative Nurse C reported that R34's open area on her left heel was not observed until 03/31/25. Administrative Nurse C reported that the physician had requested a sheepskin bootie for R34's left heel and forgot to place an order for the bootie. Additionally, Administrative Nurse C reported that R34's left heel was healing slowly and was unaware if the CNAs were required to document a turn and position program in the EHR. During an interview on 04/17/25 at 10:00 AM Administrative Nurse B reported she expected staff to document a turn and position intervention in the EHR. She also expected the staff to order the medical interventions to help prevent or heal skin occurrences. The facility's policy Wound Assessment, Prevention, And Treatment dated 11/28/17 documented on admission, assessment of resident's skin will be documented on the admission assessment. The Braden Scale would be completed at the time of admission, the first four weeks after admission, quarterly, and with any significant change. The wound nurse would complete an initial wound assessment of any newly identified skin issue by the end of the next working day. A care plan would be developed for a resident with a skin issue with specific wound healing interventions and an individualized turning/repositioning scheduled as indicated. - R24's Electronic Health Record (EHR) revealed diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and depression. The 06/28/24 Annual Minimum Data Set (MDS) documented the resident had a Brief Interview for Mental Status (BIMS) score of zero, which indicated severely impaired cognition. R24 required maximal assistance with activities of daily living (ADL) including bed mobility, standing, and transfers. The MDS noted R24 had no skin issues and was at risk for development of pressure ulcer injuries. The 07/15/24 Pressure Ulcer/Injury Care Area Assessment (CAA) documented R24 had no skin issues at that time. R24 was incontinent and required briefs. R24 had a pressure relieving mattress and pressure relieving cushion in the recliner and wheelchair. The 03/07/25 Quarterly MDS documented R24 had a BIMS of zero,. R24 was totally dependent for all ADLs except required moderate assistance with ambulation of 10 feet required. The MDS noted R24 had no skin issues and was at risk for development of pressure ulcer injuries. R24's Care Plan documented an intervention dated 08/07/23 that directed staff to provide a low air loss mattress on R24's bed and pressure relieving cushion in her chair. R24's Tasks and Care Plan in the EHR lacked a turn and repositioning program. R24's Braden Scale (a tool used to assess a patient's risk for developing a pressure injury) documented on 08/03/23, R24 was at risk with a score of 17 which indicated mild risk for pressure injuries. Review of the Physician Orders lacked an order for treatment and/or monitoring for any skin conditions. The 03/09/25 at 04:34 AM Skin/Wound Note documented that staff notified the nurse of a wound on R24's right inner buttock; staff observed a broken blister, and the wound bed was pink. No measurements were documented. Staff applied a GentilFoam (a foam wound dressing designed to provide a moist wound healing environment) dressing to the area. The 03/09/25 at 04:37 AM Skin/Wound Note documented the wound care nurse was notified at that time. The 04/05/25 at 05:33 PM Skin/Wound Note documented a small open area was noted approximately one quarter inch on both the right and left gluteal (buttock) folds. The 04/17/25 at 11:14 AM Skin/Wound Note documented Administrative Nurse C was requested to assess R24's wound to the right lower shin and a small pressure ulcer to the right buttock. The note documented dressings were placed to both areas, and a wound assessment was opened. During an observation on 04/16/25 at 12:05 PM, R24 sat in a recliner in the lounge area. Further observation revealed R24's bed had a regular mattress instead of a low air loss mattress. A hydrocolloid dressing (a type of wound dressing that creates a moist healing environment) in a packet laid on her dresser. During an interview on 04/16/25 at 01:54 PM Certified Nurse Aide (CNA) H reported that R24 did not have any open areas on her skin when he completed incontinent care prior to lunch. He said that R24 did not have any wound dressing noted on her skin either. CNA H reported that R24 had never had an air mattress on her bed. During an interview on 04/16/25 at 02:05 PM, Licensed Nurse (LN) L reported that Administrative Nurse C would complete the weekly wound assessments in the EHR for residents who had a skin concern that required monitoring. LN L reported that if a resident would have a new open area noted, Administrative Nurse C would be notified to assess the area during the week and if an open area occurred when Administrative Nurse C was not at work, the nurse would use a standing order for a treatment and leave Administrative Nurse C a note to assess the area when she worked next. During an interview on 04/16/25 at 02:22 PM, CNA G reported that R24 did not have any open wounds, skin conditions, or dressings noted on her skin when she assisted with incontinent care that day. CNA G reported that if a resident did have a skin concern, she would notify the nurse. CNA G reported that if the resident's dressing came off they would notify the nurse. CNA G reported that the staff were required to reposition R24 every two to three hours. During an observation on 04/17/25 at 09:26 AM, R24 had an open area on her right buttock with approximate measurement of 0.8 centimeter (cm) by 1.0 cm. and an open area on the right lower shin, approximate measurement of 0.8 cm by 0.5 cm. During an interview on 04/17/25 at 10:00 AM, Administrative Nurse C reported that R24 had a chronic surgical wound on her lower back that would re-open and close from time to time and that area would never heal. Administrative Nurse C reported that the pressure ulcer she observed on R24's right buttock was the first time she had been notified of an open area. Administrative Nurse C reported she was unaware of the progress notes written on 03/09/25 and 04/05/25. Administrative Nurse C revealed the hydrocolloid dressing that was in R24's room was used on the chronic surgical area on R24's lower back when it would get red. Administrative Nurse C verified that R24 did not have an air mattress on her bed as documented on R24's Care Plan. Administrative Nurse C said R24 did not have a physician's order to have an air mattress and was unaware if the CNAs were required to document a turn and position program in her. Administrative Nurse C reported R24 was unable to reposition herself in her room. The facility's policy Wound Assessment, Prevention, And Treatment dated 11/28/17 documented on admission, assessment of resident's skin will be documented on the admission assessment. The Braden Scale would be completed at the time of admission, the first four weeks after admission, quarterly, and with any significant change. The wound nurse would complete an initial wound assessment of any newly identified skin issue by the end of the next working day. A care plan would be developed for a resident with a skin issue with specific wound healing interventions and an individualized turning/repositioning scheduled as indicated.

The facility reported a census of 36 residents with 12 residents in the sample and seven residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to provide an environment free from accident hazards for two residents. The facility failed to complete an investigation to determine causative factors and implement interventions to prevent further falls for Resident (R) 24. This failure placed the affected resident at risk for further falls, accidents, and related injuries. Findings included: - R24's Electronic Health Record (EHR) revealed diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and depression. The 06/28/24 Annual Minimum Data Set (MDS) documented the resident had a Brief Interview for Mental Status (BIMS) score of zero, which indicated severely impaired cognition. R24 required maximal assistance with activities of daily living (ADL) including bed mobility, standing, and transfers. R24 required supervision for ambulation for 10 feet. The MDS documented R24 had one fall which resulted in a major injury. The 07/15/24 Falls Care Area Assessment (CAA) documented R24 was at risk for falls and had a fall the past quarter. The care plan was updated to direct staff to assist R24 with toileting after meals and to offer her a recliner after meals. R24 had a diagnosis of dementia (a progressive mental disorder characterized by failing memory, and confusion) and was forgetful and will try to transfer and ambulate by herself. The 03/07/25 Quarterly MDS documented R24 had a BIMS of zero. R24 was totally dependent for all ADL except moderate assistance with ambulation of 10 feet required. The MDS noted R24 had no falls. R24's Care Plan documented an intervention dated 07/09/24 which directed staff to assist R24 to the recliner after mealtimes. An intervention dated 09/13/24 directed staff to provide a gait belt when transferring R24 to the bathroom. An intervention dated 11/20/24 directed staff to keep a close eye on R24 until the resident's behaviors were resolved. R24's Care Plan documented an intervention initiated on 05/22/24 and resolved on 10/03/24 that documented R24 had a fractured toe on her left foot and wore a boot for healing which allowed the resident to bear weight. R24's EHR documented a Fall Risk Assessments dated 01/12/24 which a documented R24 was at high fall risk and staff were to provide frequent checks and maintain R24's bed in the lowest position. The 05/11/24 at 07:22 AM Progress Note documented R24 was transferred to the hospital as R24 was found leaning in her wheelchair unresponsive with labored breathing. The 05/11/24 at 10:38 AM Emergency Department Encounter Note documented R24 reportedly had an unresponsive episode that occurred just prior to arrival. Her extremities were symmetrical, full passive range of motion. Final diagnosis documented: cystitis (inflammation of the bladder, often caused by a bacterial infection), alteration in mental status, chronic kidney disease (a condition where the kidneys are damaged and cannot filter blood effectively), and systemic inflammatory response syndrome (SIRS- a widespread, exaggerated inflammatory response to an insult, like infection, trauma, or surgery, that involves changes in body temperature, heart rate, respiratory rate, and white blood cell count. The 05/11/24 at 11:25 AM Progress Note documented R24 transferred back to the facility and received orders for Keflex (an antibiotic). R24's EHR did not have any progress notes for 05/12/24. The 05/13/24 at 03:53 AM Progress Note documented R24's left lower extremity was swollen, warm and painful to touch. R24 had groaned out in pain when the left foot was rotated. The 05/13/24 at 05:10 PM Progress Note documented X-ray results returned that noted a fracture of fifth metatarsal (bone of the foot on the outer edge of foot behind the small toe). The 05/13/24 X-ray Report documented a nondisplaced hairline fracture of the distal (situated away from the center of the body) aspect of the fifth metatarsal bone and a subtle fracture at the base of the proximal (nearer to the center of the body) fifth phalanx (toe). The 05/15/24 at 10:45 AM Orthopedic Consult Note documented R24 had a fracture related to an assisted fall on 05/11/24 per the resident's husband. A Physician's Order dated 05/16/24 noted an order for a bunion (painful swelling of the first joint of the big toe) shoe when ambulating, weight bearing as tolerated for a diagnosis of fifth metatarsal fracture. The order was discontinued on 07/31/24 due to the foot was well healed per the note. The Care Plan Review and Progress Note dated 07/11/24 documented R24 was doing very well and continued to wear her boot due to her toe fracture. The note recorded R24 saw her orthopedic doctor and he requested R24 wear her boot for another two weeks and then follow up on her progress. Upon request, the facility was unable to provide additional documentation including evidence an investigation was conducted and causative factors identified. During an observation on 04/16/25 at 12:05 PM, Certified Nurse Aide (CNA) G and CNA H assisted R24 up from the recliner to the wheelchair, staff used a gait belt though R24 appeared to have difficulty with straightening out her legs to bear weight when she stood up. During an interview on 04/16/25 at 03:45 PM Administrative Staff A said he looked for the report with all the facility reported incidents, but he could not locate the investigation regarding the fractures that R24 sustained in May 2024. During an interview on 04/16/25 at 03:50 PM Administrative Nurse B reported that she could not locate a fall investigation in the EHR for R24. Additionally, she reported that she could not locate any investigation for the regarding R24's left foot. During an interview on 04/17/25 at 08:54 AM Licensed Nurse (LN) I could not recall if R24 had ever had a fractured foot. During an interview on 04/17/25 at 09:41 AM, Certified Medication Aide (CMA) J reported that R24 had a fractured foot in May 2024, CMA J could not recall how R24 fractured her foot. During an interview on 04/17/25 at 10:30 AM Administrative Staff A reported that he expected staff to complete an investigation for all incidents and report them, if needed, to the state agency, The facility's policy Fall Management dated 10/19/20 documented all fall occurrences will be documented and thoroughly investigated using risk management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 36 residents, with 12 residents selected for review which included six residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure the residents remained free from unnecessary medications when the facility failed to follow physician orders related to blood pressure monitoring and related parameters for three residents, Resident (R)10, R25, and R9. This placed the resident at risk for adverse medication effects. Findings included: - R10's Electronic Health Records (EHR) recorded an undated Physician Orders (POS) that documented diagnoses which included Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure) and hypertension (high blood pressure). The admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of nine, indicating moderate cognitive impairment. The Functional Abilities (Self Care Mobility) Care Area Assessment (CAA) and Falls CAA dated 09/17/24 documented R10 recently admitted to the facility with a diagnosis of Alzheimer's disease. She lived on her own and was independent prior to a fall on 08/17/24, for which she was hospitalized . The reason for her fall was unknown. R10 was admitted to skilled services for physical therapy and occupational therapy (PT/OT) for strengthening and safety with activities of daily living (ADL), with plans to return home independently. R10's Care Plan (CP) dated 03/26/25 directed staff to administer medications as ordered by the physician and monitor for side effects and adverse reactions of medication. The CP heading included Special Instruction for parameters which included notifying the physician if the systolic blood pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) was less than 80 millimeters (mm) of Mercury (Hg) or greater than 200 mm/Hg. R10's Physician Orders documented the following cardiac and blood pressure medication orders: Cozaar (medication used to treat high blood pressure) tablet 50 milligrams (mg); give 50 mg by mouth daily for hypertension and hold for blood pressure (BP) of less than 130/80 mm/Hg, ordered 02/22/25. A review of R10's 02/22/25 through 04/15/25, Medication Administration Record (MAR), revealed the Cozaar was given outside of the prescribed physician order for 45 of 54 doses as follows: On 02/22/25 through 02/27/25, six doses, On 03/02/25 through 03/16/25, 16 doses, On 03/18/25 through 03/30/25, 12 doses, On 04/01/25 through 04/05/25, four doses On 04/09/25 and 04/10/25, two doses, On 04/12/25 through 04/16/25, five doses. On 04/17/25 at 09:09 AM R10 sat at the dining room table feeding herself. Certified Medication Aide (CMA) K checked R10's BP which was 159/90 mm/Hg then administered the resident her medications which included Cozaar. R10 took her medications without question or hesitation. CMA K verified the medication should be given in keeping with the physician-prescribed orders. CMA K stated if the resident's BP was less than 130/80 mm/Hg, she should hold the medication, notify the charge nurse, and await further instructions. 04/17/25 11:32 AM, Administrative Nurse B reviewed R10's MAR for 02/22/25 through 3/31/25 and confirmed the antihypertensive medications during that time frame (as noted above) were given outside of the physician's prescribed parameter. She stated the Cozaar should have been held by the CMA until such time the charge nurse and the physician were notified to provide further instructions. The facility policy Unnecessary Medications, dated 12/04/24, documentation included each resident's drug regimen must be free of unnecessary drugs. An unnecessary drug is any drug when used in excessive doses. - R25's Electronic Health Records (EHR) recorded an undated Physician Orders (POS) that documented diagnoses which included agoraphobia (anxiety disorder that causes fear of places and situations that might cause panic, helplessness, or embarrassment), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), and hypertension (high blood pressure) heart disease with heart failure. The Annual Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact. She received diuretics (a medication used to promote the formation excretion of urine) and anti-anxiety medication. The Quarterly MDS, dated 04/08/25 documented changes from above which included sR25 received anti-depressant (medication used to treat depression) medication, opioid (narcotic pain medication), and antibiotics (class of mediation used to treat bacterial infections) in addition to the above medications. The Psychotropic Drug Use Care Area Assessment (CAA) dated 09/10/24 documented R25 had diagnoses that included anxiety and agoraphobia. The CAA noted R25 received Xanax (anti-anxiety medication) daily and the dose was recently increased to manage symptoms. R25 scored a 15 on her BIMS during the lookback. Staff monitored for adverse side effects of medications and the pharmacist reviewed medications per regulatory requirements. R25s Care Plan (CP) dated 03/26/25, directed staff to administer medications as ordered by the physician and monitor for side effects and adverse reactions of medication. The CP heading included Special Instruction for parameters which included notifying the physician if the systolic blood pressure (SBP- top number, the force your heart exerts on the walls of your arteries each time it beats) was less than 80 millimeters (mm) of Mercury (Hg) or greater than 200 mm/Hg. R25's Physician Orders documented the following cardiac and blood pressure medication order: Norvasc tablet 2.5 milligrams (mg), by mouth, daily for hypertension. Hold if SBP was less than 120 mm/Hg, ordered 09/08/23. Review of R25's Medication Administration Record (MAR) and EHR for the time frame from 02/01/25 through 04/15/25, revealed the resident's BP was not obtained on 74 occasions prior to the administration of the prescribed antihypertensive medication as ordered (Norvasc) . On 04/17/25 at 08:44 AM, observation revealed Certified Medication Aide (CMA) K administered R25's morning medications which included the Norvasc. She stated R25's MAR did not include monitoring for R25's blood pressure. On 04/17/25 at 09:09 AM CMA K verified R25's medication should be given in keeping with the physician prescribed orders. CMA K stated if R25's orders indicated the medication should be monitored for specific values, then the blood pressure should be obtained prior to giving a resident the medication. CMA K said if the medication was held, the nurse should be notified and provide further instructions. On 04/17/25 at 11:32 AM, Administrative Nurse B reviewed R25's MAR for 02/01/25 through 04/16/25 and confirmed the blood pressure was not monitored prior to the administration of the antihypertensive medication as ordered by the physician. The facility policy Unnecessary Medications, dated 12/04/24, documentation included each resident's drug regimen must be free of unnecessary drugs. An unnecessary drug is any drug when used in excessive doses. - R9's Electronic Health Record (EHR) revealed diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin), end-stage renal disease (ESRD-a terminal disease of the kidneys) and hypertension (HTN-elevated blood pressure) The 03/28/25 Annual Minimum Data Set (MDS) did not have a Brief Interview for Mental Status (BIMS) score or staff interview completed. R9 required moderate assistance with personal hygiene which included shaving. The 04/04/25 Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) did not trigger. The 01/03/25 Quarterly MDS documented the resident had a BIMS score of 10, which indicated moderately impaired cognition. R9's bathing and personal hygiene were not assessed. R9's Care Plan documented an intervention dated 05/01/23 that directed staff to monitor for indicated reactions of medications and notify the physician right away if any were noted. A Physician's Order dated 09/19/24 noted an order for Procardia Extended Release (ER) (a medication used to treat hypertension) tablet 30 milligrams (mg), give one tablet by mouth, daily for hypertension. Contact the physician for a blood pressure (B/P) greater than 160/90 millimeters (mm) of Mercury (Hg). R9's Vital Signs tab and Medication Administration Record (MAR) in R9's EHR were reviewed for the dates 09/19/24 through 04/17/25. The records lacked evidence of a BP assessment prior admisnitration of the Procardia. During an observation on 04/17/25 at 08:02 AM, Certified Medication Aide (CMA) K administered R9's Procardia ER 30 mg tablet without checking R9's B/P. CMA K reported that R9 did not require a B/P check for any medications, only a pulse. During an interview on 04/17/25 at 08:40 AM, CMA K reported that if a B/P did not show up on the computer screen for her to complete a B/P, she would not check the B/P. CMA K reviewed the Procardia order on the electronic MAR and reported she was aware of the comment to notify the physician for the specified B/P but said she did not really pay attention to it as the B/P was not scheduled to be taken. During an interview on 04/17/25 at 08:47 AM, Licensed Nurse (LN) I reviewed the order for the Procardia on the MAR and orders in the EHR and reported that R9 should have had a B/P taken before the medication was administered. LN I reviewed the B/P in R9's EHR and confirmed that he did not have the B/P taken before the medication was given since it was ordered on 09/19/24. LN I reported that the nurse should place the supplemental documentation that the physician required on the MAR so that it would alert the staff to complete it. During an interview on 4/17/25 at 10:00 AM, Administrative Nurse B stated they expected the vital signs parameters that the physician ordered to be placed on the supplemental documentation of the order and the staff to obtain those vital signs. The facility policy Unnecessary Medications, dated 12/04/24, documentation included each resident's drug regimen must be free of unnecessary drugs. An unnecessary drug is any drug when used in excessive doses.

The facility reported a census of 36 residents with 12 residents selected for review which included six residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to complete an industry-accepted assessment for abnormal movements related to antipsychotic (class of medications used to treat major mental conditions that cause a break from reality) use for Resident (R) 24 who received Zyprexa (antipsychotic). This deficient practice placed the affected resident at risk for adverse effects associated with the use of psychotropic (alters mood or thoughts) medications. Findings include: - R24's Electronic Health Record (EHR) revealed diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and depression. The 06/28/24 Annual Minimum Data Set (MDS) documented the resident had a Brief Interview for Mental Status (BIMS) score of zero, which indicated severely impaired cognition. R24 required maximal assistance with activities of daily living (ADL) including bed mobility, standing, and transfers. R24 required supervision for ambulation for 10 feet. The MDS documented R24 received antipsychotics, antianxiety (a class of medications that calm and relax people), and antidepressants (a class of medications used to treat mood disorders) on a routine basis. The 07/15/24 Psychotropic Drug Use Care Area Assessment (CAA) documented R24 was prescribed multiple medications to manage her anxiety and behaviors due to her dementia (a progressive mental disorder characterized by failing memory, and confusion). The MDS noted R24 had been taking Ativan (an antianxiety medication), Zoloft (an antidepressant medication), and Zyprexa (an antipsychotic medication) and tolerated the medications well with no adverse reactions; interventions were in place and no other changes were noted at that time. The 03/07/25 Quarterly MDS documented R24 had a BIMS of zero. R24 was totally dependent on staff for all ADLs except with ambulation for which she required moderate assistance from staff. The MDS noted R24 received an antipsychotic, antianxiety, and antidepressants on a routine basis. R24's Care Plan documented interventions on 08/07/23 which directed staff to monitor side effects such as sedation, and tardive dyskinesia (an abnormal condition characterized by involuntary repetitive movements of the muscles of the face, limbs, and trunk) from Zyprexa and Zoloft. Staff were instructed to update the physician of any increased behaviors. R24's EHR lacked evidence of an assessment completed to identify abnormal movements related to medication use. R24's Physician's Orders documented an order for Zyprexa five milligram (mg) tablet, give five mg tablet by mouth, one time a day at bedtime for aggressive behaviors such as hitting related to Alzheimer's, date ordered 01/09/24. R24's Medication Regimen Review (MRR) dated 10/01/24 through 03/31/25 lacked evidence of a recommendation for an assessment for abnormal movements to be completed. During an observation on 04/16/25 at 12:05 PM, Certified Nurse Aide (CNA) G and CNA H assisted R24 up from the recliner to the wheelchair. Staff used a gait belt though R24 appeared to have difficulty with straightening out her legs to bear weight when she stood up. During an interview on 04/17/25 at 08:54 AM Licensed Nurse (LN) I reported that the administrative nurses would complete any required assessments in the EHR. LN I reported she had never been requested to complete an assessment to identify abnormal movements. During an interview on 04/17/25 at 01:17 PM Administrative Nurse B reported she expected had never received resident-specific reminders for abnormal movement assessments to be completed on the MRR. Administrative Nurse B reported she did not know what an Abnormal Involuntary Movement Scale (AIMS-a rating scale to measure involuntary movements associated with the use of some medications) assessment was until 04/16/25. The facility's policy Unnecessary Medications dated 12/04/24 documented each resident's drug regime must be free from unnecessary medications. An unnecessary medication is any drug when used without adequate monitoring, or without adequate indications for the use of the medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 45 residents. The sample included 15 residents reviewed for misappropriation and exploitation. Based on interview and record review, the facility failed to ensure Resident (R)1 remained free from misappropriation of funds, when housekeeping staff I exploited the resident of approximately $100.00. This deficient practice placed R1 at risk for a negative psychosocial impact in safety and security. Findings included: - R1's Electronic Health Record (EHR) revealed diagnoses that included hemiparesis (muscular weakness of one half of the body) and hemiplegia (paralysis of one side of the body) following cerebral infarction (stroke - sudden death of brain cells due to impaired blood flow to the brain by blockage or rupture of an artery), dementia (a progressive mental disorder characterized by failing memory, confusion), depression (an abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness), anxiety (a disorder characterized by chronic free-floating anxiety and such symptoms as tension or sweating or trembling or lightheadedness or irritability that has lasted for more than six months) and traumatic brain injury (TBI - a disruption of the normal function of the brain caused by blunt force trauma to the head). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. R1 required extensive assistance from one to two staff members for all cares with the exclusion of eating, which was independent. The Quarterly MDS dated 05/24/24, documented a BIMS score of 14, which indicated intact cognition. R1 required partial to moderate assistance for all cares except oral hygiene and eating which required supervision and setup. Review of facility investigation notes revealed the following information: On 04/24/24 at 03:30 PM, R1's family member alerted Administrative Staff A of an allegation of exploitation of funds from R1 by way of R1's spouse who does not reside in the facility. Review of R1's spouse's bank records by R1's family revealed a check in the amount of $100 written to housekeeping staff I's name on 01/04/24 with the comment line written for haircuts although the resident cuts his own hair. Law enforcement interviewed R1 and reported housekeeping staff I provided him with cash of approximately $50, and housekeeping staff I had told him about being short on money and had instructed housekeeping staff I to contact R1's family about a small loan. R1's family stated that R1's spouse had informed him that she had removed cash via an ATM and provided it to the housekeeping staff I, but the family was unable to determine the amount and/or dates. Facility staff interviewed housekeeping staff I and stated that she did not take money from R1 or his spouse for rent but had gone to R1's home to acquire money to purchase chocolate covered cashews. R1 interviewed related to the cashews and a receipt and change and R1 stated that he advised housekeeping staff I to keep the change/receipt as it was only a few dollars. The facility suspended housekeeping staff I and the facility staff terminated housekeeping staff I on 04/11/24. The investigation concluded housekeeping staff I obtained money from the resident in an amount of at least $100. Review of a witness statement from Housekeeper I with self-contradictory statements of unable to take money from R1 but confirmed that she had gone to R1's house and picked up money from the family. A witness statement from R1 documented housekeeping staff I requested $200 for rent. Housekeeping staff I received abuse, neglect and exploitation (ANE) training and signed the policy statement on 03/18/22. Housekeeping staff I completed Gifts From Residents training on 12/05/23. Housekeeping staff I completed Preventing Abuse, What is Abuse and Ethics for Healthcare training on 08/17/23. On 06/25/24 at 09/45 AM, R1 stated he loaned one of the staff members money, but that staff member did not work at the facility anymore. R1 further stated the staff member had requested a loan of $200 to pay her rent, so R1 directed her to contact his spouse (who does not reside at the facility). R1 stated he never got any of the money back. On 06/25/24 at 11:40 PM, Activity Director H stated following R1's family making the allegation against housekeeping staff I, the facility held a resident council meeting and the residents present reminded that any outside purchases needed to be made by asking Activity Director H. Furthermore, all staff had been educated that if a resident requested staff to make an outside purchase for the resident, staff were to notify their immediate supervisor who would then notify Activity Director H. On 06/25/24 at 11:50 AM, Certified Nurse Aide (CNA) F stated staff are not allowed to take money or any item of values from residents or family members of residents. On 06/25/24 at 12:01 PM, Certified Medication Aide (CMA) E stated that if a resident would ask staff to take money to purchase something, staff were to notify activity director H or Administrative Nurse B or Administrative Staff A. On 06/25/24 at 12:00 PM, Licensed Nurse (LN) C stated that staff members were not allowed to accept gifts or money from residents or family members. If a resident wanted a staff member to buy something for a resident, then Activity Director H would be notified and would address the request. On 06/25/24 at 12:06 PM, housekeeping staff G stated if a resident attempted to give her money to go buy something, she would tell her immediate supervisor, Social Services Designee (SSD) J or Administrative Staff A. On 06/25/24 at 01:40 PM, Administrative Nurse B stated the expectation was staff would not accept gifts or anything of monetary value from residents or their families per the facility policy and all staff should report requests for purchases to their immediate supervisor or Activity Director H. On 06/25/24 at 08:35, Administrative Staff A reported on 04/04/24 at approximately 03:30 PM, R1's family made an allegation that housekeeping staff I exploited money from R1. Additionally stated the facility suspended housekeeping staff I on 04/04/24 at approximately 04:00 PM, pending a full investigation. The facility notified local law enforcement on 04/04/24 at approximately 06:00 PM. Further, confirmed the above information and stated that the result of her investigation substantiated the claim that housekeeping staff I exploited at least $100 from R1 and his family. Administrative staff A reported housekeeping staff I did not follow the established procedures of notifying Activities Director H for outside purchases. The facility's Abuse, Neglect and Exploitation policy, dated 11/28/17, documented the resident has the right to be free from exploitation and misappropriation of resident property. Further defined exploitation as taking advantage of a resident for personal gain and misappropriation of resident property as the deliberate exploitation of a resident's belongings or money. The facility would provide an environment free of exploitation. The facility failed to ensure Resident (R)1 remained free from misappropriation of monies, when housekeeping staff I exploited the resident of approximately $100.00. This deficient practice placed R1 at risk for a negative psychosocial impact in safety and security. The facility implemented the following interventions prior to the surveyor entrance and were verified by the surveyor during an onsite visit on 06/25/24 at 11:40 AM: On 04/04/24 at approximately 04:00 PM, the facility suspended housekeeping staff I pending the results of a formal and complete investigation. On 04/04/24 at approximately 06:00 PM, law enforcement notified, and a report made. On 04/11/24 at an unknown time, the facility terminated housekeeping staff I's employment after the facility's investigation substantiated the claim made by R1's son that housekeeping staff I obtained money from R1 in an amount of at least $100. Due to the corrective actions the facility implemented and completed prior to the onsite visit, the deficient practice was deemed past non-compliance and existed at a D scope and severity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 50 residents with 13 residents sampled, including one resident sampled for hospitalization. Based on interview and record review, the facility failed to provide a copy of the facility bed hold policy to Resident (R)38 and/or their representative, with a written notice specifying the duration and cost of the bed hold policy, at the time of the resident's two transfers to the hospital. Findings included: - Review of Resident 38's Electronic Health Record (EHR) documented the resident had diagnoses that included atrial fibrillation (rapid, irregular heartbeat), hypertension (elevated blood pressure), and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure. Review of the Discharge Assessment- return anticipated Minimum Data Set (MDS), dated [DATE], revealed the resident had an unplanned discharge to an acute hospital. The Entry tracking record MDS, dated [DATE], revealed the resident returned to the facility on [DATE]. The Discharge assessment-return anticipated MDS, dated [DATE], revealed the resident had an unplanned discharge to an acute hospital. The Entry tracking record MDS, dated [DATE], revealed the resident returned to the facility on [DATE]. Review of the resident's EHR, lacked a signed bed hold with a written notice specifying the duration and cost of the bed hold policy, at the time of the resident's transfers to the hospital on [DATE] and 03/07/23. On 07/31/23 at 10:48 AM, Licensed Nurse (LN) G stated the charge nurse would send a face sheet and a medication list with the resident to the hospital. On 07/31/23 at 11:13 AM, Consultant GG reported the facility's social service designee (SSD) was responsible for the written notice of the bed holds, however, the SSD was unable to work, and the facility was unable to produce the written notices of the bed holds. The facility did not provide a bedhold policy. The facility failed to provide R38 and/or their representative, with a written notice specifying the duration and cost of the bed hold policy, at the time of the resident's two transfers to the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - Resident (R)12's Electronic Medical Record (EMR) revealed the resident had a diagnosis that included cardiomyopathy (heart disease). The Annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. The resident required limited assistance of one staff with care and was occasionally incontinent of urine. The resident had an unhealed stage two pressure ulcer. The resident had pressure relieving devices on bed and chair, and the resident received wound care. The Pressure Ulcer Care Area Assessment (CAA) dated 07/07/23, documented the resident had a pressure ulcer on her right buttock. It was initially staged as II when opened but since improved. The resident was under the care of a wound nurse that would make weekly wound assessments. The resident had occasional incontinent in she was unable to make it to the bathroom in time. The resident had a Low air loss mattress (LALM) and a cushion in her wheelchair when she is using her wheelchair for longer distances. The Quarterly MDS dated 04/07/23, revealed a BIMS score of 99 indicating severe cognitive impairment. She required limited assistance for locomotion, otherwise supervision/setup for all cares. The resident was continent of bowel/bladder. The resident was not a high risk for development of pressure ulcers. The resident had a low air loss mattress to her bed. The Care Plan dated 07/07/23 lacked guidance for skin/wound care. The Electronic Health Records (EHR) Physician Orders lacked active orders specific to wound care/management or wound prevention. The weekly wound/skin notes documented the following: 1. On 07/05/23, the resident had an open area on her right buttock that measured 0.4 centimeter (cm) by 0.5 cm. 2. On 07/10/23, the resident had an open area on her right buttock that measured 0.3 cm by 0.3 cm. 3. On 07/17/23, the resident had an open area on her right buttock that measured 0.3 cm x 0.3 cm. The EMR Progress Notes revealed the following: 1. On 07/04/23, the resident complained of pain to her bottom. The resident had a, 0.5 cm area noted. Staff notified the wound nurse, and R12's Durable Power of Attorney. 2. On 07/05/23, the resident had two small open areas on her buttocks, but the clinical records lacked documented measurements. 3. On 07/10/23, a wound care note revealed that the wound care nurse would perform dressing changes until 07/19/23. 4. On 07/19/23, the resident had open areas on both buttocks. The left much improved. The right unchanged. Sacral dressing in place. On 07/27/23 at 11:40 AM, Licensed Nurse (LN) V assisted R12 to pivot transfer to her wheelchair without the use of a gait belt, then assisted the resident into the bathroom for a skin check where the resident stood up, holding onto a grab bar in the bathroom. Observation at that time revealed R12 had redness to her sacrum (large triangular bone area between the two hip bones/coccyx (small triangular bone area at the base of the spine) with a small area that appeared to have sheared/peeling skin, redness to both buttocks with a small area that appeared to have sheared/ peeling skin on her left buttock and all red areas blanched (to press on a person's skin to push blood away and wait for return to determine blood circulation). LN V acknowledged that R12 lacked active orders for wound care and stated that she did not know if the facility had any standing orders or protocols for wound care that she could initiate without a provider/physician's order. LN V stated the reddened areas on her buttocks should have some sort of skin protectant, like a foam dressing. On 07/31/23 at 07:50 AM, LN O, announced herself after performing hand hygiene with alcohol-based hand rub (ABHR) and asked the resident if she could perform the dressing change and wound care. (There were no active physician orders for treatment of the wounds). The resident ambulated to the toilet by herself, and after the resident toileted, the resident stood up and held on to a walker while LN O performed cares. The resident lacked wound dressings to her buttocks area. LN O cleaned the wound to the left buttock with normal saline, then performed peri care for the resident with disposable wipes. LN O did not measure the wound but estimated to be about the size of a nickel. LN O placed hydrogel (wound gel) on the wound bed and covered with wound with mepilex (a type of foam wound dressing) dressing. On 07/31/23 at 10:25 AM, Administrative Nurse B reported that her expectation is that if someone had a pressure wound that it would be on the care plan. States that corporate staff were the ones updating the care plan up until a couple of weeks ago, then LN W took over that role. LN W had not caught up for all the care plans to be up to date. Review of the facility policy for Care Plans dated 11/28/17 revealed the Comprehensive Care plan should reflect individualized problems, goals, and interventions with input from the care planning team, the resident and the resident's family and re/or representative. The facility's Wound Assessment, Prevention and Treatment policy, dated 11/28/17 documented that residents would be evaluated and monitored to prevent the development of pressure ulcers/injury and to promote rapid healing of any pressure ulcers/injury that was present. A comprehensive, individualized care plan would be developed to address prevention of pressure ulcers/injuries including management of risk factors and treatment strategies for residents with pressure ulcers/injuries through a collaboration between the resident, the resident's representative, the physician/provider, the dietitian, and the clinical staff. The facility failed to include pressure ulcer care and prevention on the comprehensive care plan. - Resident (R)20's Electronic Health Record (EHR) documented the resident had diagnoses that included chronic kidney failure, stage three, frequency of micturition (frequency of bladder), and benign prostatic hyperplasia (non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections. The 06/23/23 Annual Minimum Data Set (MDS) documented a Brief interview for mental status (BIMS) score of 10, indicating moderately impaired cognition. The resident did not have a urinary catheter during the lookback period. The 06/23/23 Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) documented R20 wore an incontinence brief and was dependent on staff for transfers to the toilet as well as toilet hygiene. The 02/14/23 Care Plan lacked any mention of an indwelling catheter or staff guidance to care for the resident's urinary catheter. The physician's order included the resident had an indwelling Foley catheter, related to benign prostatic hyperplasia with lower urinary tract symptoms, dated 07/07/23. It further instructed to maintain the catheter until urology follow-up and as needed. Review of the progress Notes revealed on 07/07/23, the resident returned from the hospital with a urinary catheter. On 07/27/23 at 07:13 AM, observation revealed Certified nurse aide (CNA) L and CNA M dressed the resident. Staff placed the urinary catheter bag directly on the bathroom floor. Staff reported they should put the catheter collection bag on a paper towel as a barrier. On 07/31/23 at 07:08 AM, CNA D and CNA N entered the resident's room to provide morning cares. The urinary catheter had no covering/dignity bag, and once cares provided, CNA N placed the urinary catheter collection bag directly on the floor. On 07/27/23 at 12:40 PM Administrative Nurse B stated corporate staff updated the care plans in the past, and until a couple of weeks ago, the MDS coordinator was to keep the care plans up to date. The facility's policy for Care Plan, dated 11/28/17, revealed a care plan would be developed for each resident that included measurable objectives to meet a resident's medical, nursing, mental and psychosocial needs and were consistent with the resident's desires and preferences. The care plan must be individualized to address the resident specific needs. The facility failed to develop and implement a person-centered care plan for this resident that required an indwelling urinary catheter. The facility census totaled 50 residents with 13 included in the sample. Based on observation, interview, and record review, the facility failed to develop comprehensive care plans for two of 13 residents reviewed for care plans. Resident (R)3 and R20 regarding urinary catheter use and one resident, R12, related to pressure ulcers/wound care. Findings included: - Resident (R) 3's signed physician orders dated 06/04/23 revealed; CVA (any abnormal condition characterized by dysfunction of the heart and blood vessels), Hemiplegia (paralysis of one side of the body), vascular dementia (progressive mental disorder characterized by failing memory, confusion), neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), diabetes mellitus (when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin). The Annual Minimum Data Set (MDS) dated [DATE] revealed the resident was severely cognitively impaired. The resident had rejection of care on 4-6 days of the 7 day. The resident required extensive assistance of 2 staff. The resident received antipsychotic and antidepressant 7 days of the 7 day observation period. The Quarterly MDS dated [DATE] revealed the resident never/rarely understood. The resident equired extensive assistance of two staff for all daily cares. The resident had an indwelling urinaty catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). The Cognitive loss/Dementia Care Area Assessment (CAA) dated 09/30/22, revealed the resident only able to recognize the location of his room. His decision making skills were severely impaired. Diagnosis of Vascular dementia with behaviors. The Urinary Incontinence and Indwelling Catheter CAA dated 09/30/22, revealed the resident had a urinary catheter in place. Staff assist with cares for the catheter and emptying the catheter per orders. Review of the Care Plan dated 07/09/19, R3 was able to take himself to the bathroom and was continent of bowel and bladder. The resident was having more accidents with urinating so began wearing pullups and the family took his underwear home. The care plan lacked the presence of a suprapubic catheter (urinary bladder catheter inserted through the skin) or care for the catheter. The physician orders dated 10/17/22 revealed the resident with a large hernia of bladder with placement of indwelling urinary catheter for outlet obstruction. The physician progress notes dated 04/25/23 revealed a placement of suprapubic catheter. Review of the physician orders dated 06/04/23, revealed and order for suprapubic catheter care, two times a day. Observation on 07/26/23 at 8:00 AM, the resident propelled wheelchair in the hall towards the dining room. The urinary catheter tubing had yellow urine with sediment visible in the tubing. The drainage bag was in a dignity bag. On 07/27/23 at 11:00 AM, Licensed Nurse C reported the resident had a history of urinary problems and first had an indwelling urinary catheter placed but had a blockage of some sort so a suprapubic catheter was finally placed. LN C reported she did not make changes on the resident care plan. On 07/27/23 at 12:40 PM Administrative Nurse B stated the MDS coordinator was to keep the care plans up to date. Review of the facility policy for Care Plans, dated 11/28/17 revealed the Comprehensive Care plan should reflect individualized problems, goals and interventions with input from the care planning team, the resident and the residents family and re/or representative. The facility failed to develop comprehensive care plans for R3 regarding urinary catheter use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 50 residents with 13 selected for review including three residents reviewed for wounds. Based on observation, record review, and interview, the facility failed to perform an ongoing assessment and treatment of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) and implement interventions to prevent further development of pressure areas for one of the three Residents (R)12. Findings include: - Resident (R)12's Electronic Medical Record (EMR) revealed the resident had a diagnosis that included cardiomyopathy (heart disease). The Annual Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of six, indicating severe cognitive impairment. The resident required limited assistance of one staff with care and was occasionally incontinent of urine. The resident had an unhealed stage two pressure ulcer. The resident had pressure relieving devices on bed and chair, and the resident received wound care. The Pressure Ulcer Care Area Assessment (CAA) dated 07/07/23, documented the resident had a pressure ulcer on her right buttock. It was initially staged as II when opened but since improved. The resident was under the care of a wound nurse that would make weekly wound assessments. The resident had occasional incontinence in she was unable to make it to the bathroom in time. The resident had a low air loss mattress (LALM) and a cushion in her wheelchair when she is used her wheelchair for longer distances. The Quarterly MDS dated 04/07/23, revealed a BIMS score of 99 indicating severe cognitive impairment. She required limited assistance for locomotion, otherwise supervision/setup for all cares. The resident was continent of bowel/bladder. The resident was not a high risk for development of pressure ulcers. The resident had a low air loss mattress to her bed. The Care Plan dated 07/07/23 lacked guidance for skin/wound care. The Electronic Health Records (EHR) Physician Orders lacked active orders specific to wound care/management or wound prevention. The weekly wound/skin notes documented the following: 1. On 07/05/23, the resident had an open area on her right buttock that measured 0.4 centimeter (cm) by 0.5 cm. 2. On 07/10/23, the resident had an open area on her right buttock that measured 0.3 cm by 0.3 cm. 3. On 07/17/23, the resident had an open area on her right buttock that measured 0.3 cm x 0.3 cm. The Assessments documented on 01/05/23 and 07/10/23 that the resident had a Braden (an assessment tool utilized to determine the risk of skin breakdown/injury) score of 21 which indicated that the resident was not at risk for skin breakdown/injury. The EMR Progress Notes revealed the following: 1. On 07/04/23, the resident complained of pain to her bottom. The resident had a 0.5 cm open area noted. Staff notified the wound nurse, and R12's Durable Power of Attorney. 2. On 07/05/23, the resident had two small open areas on her buttocks, but the clinical records lacked documented measurements. 3. On 07/10/23, a wound care note revealed that the wound care nurse would perform dressing changes until 07/19/23. 4. On 07/19/23, the resident had open areas on both buttocks. The left much improved. The right unchanged. Sacral dressing in place. On 07/27/23 at 11:40 AM, Licensed Nurse (LN) V assisted R12 to pivot transfer to her wheelchair without the use of a gait belt, then assisted the resident into the bathroom for a skin check where resident stood holding onto a grab bar in the bathroom. Observation at that time revealed R12 had redness to her sacrum (large triangular bone area between the two hip bones)/coccyx (small triangular bone area at the base of the spine) with a small area that appeared to have sheared/peeling skin, redness to both buttocks with a small area that appeared to have sheared/ peeling skin on her left buttock and all red areas blanched (to press on a person's skin to push blood away and wait for return to determine blood circulation). LN V acknowledged that R12 lacked active orders for wound care and stated that she did not know if the facility had any standing orders or protocols for wound care that she could initiate without a provider/physician's order. LN V stated the reddened areas on her buttocks and areas of sheared/peeling skin appeared to be pressure ulcer/injury but declined to classify or stage the open areas. Further, LN V stated the wounds should have some sort of skin protectant, like a foam dressing. On 07/31/23 at 07:50 AM, LN O, announced herself after performing hand hygiene with alcohol-based hand rub (ABHR) and asked the resident if she could perform the dressing change and wound care. (There were no active physician orders for treatment of the wounds). The resident ambulated to the toilet by herself, and after the resident toileted, the resident stood up and held on to a walker while LN O performed cares. The resident lacked wound dressings to her buttocks area. LN O cleaned the wound to the left buttock with normal saline, then performed peri care for the resident with disposable wipes. LN O did not measure the wound but estimated to be about the size of a nickel. LN O placed hydrogel (wound gel) on the wound bed and covered with wound with mepilex (a type of foam wound dressing) dressing. The facility's Wound Assessment, Prevention and Treatment policy, dated 11/28/17 documented that residents would be evaluated and monitored to prevent the development of pressure ulcers/injury and to promote rapid healing of any pressure ulcers/injury that was present. A comprehensive, individualized care plan would be developed to address prevention of pressure ulcers/injuries including management of risk factors and treatment strategies for residents with pressure ulcers/injuries through a collaboration between the resident, the resident's representative, the physician/provider, the dietitian, and the clinical staff. The facility failed to perform ongoing weekly skin assessments and treatment of pressure ulcers on the resident's buttocks and sacrum/coccyx and failed to implement interventions to prevent further development of pressure areas for the resident.

The facility reported a census of 50 residents, with 13 residents in the sample that included six residents reviewed for unnecessary medications. Based on interview and record review, the facility failed to ensure Resident (R)12 was free from unnecessary medications, when on two occasions, the facility administered an antibiotic medication that she was resistant (the ability not to be affected by something) to. Findings include: - R12's diagnoses from the Electronic Health Record (EHR) included extended-spectrum beta-lactamases (ESBL - enzymes produced by certain microorganisms that allow them to be resistant to the actions of some antibiotics) resistance. The 07/07/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of six, which indicated severely impaired cognition. R12 received an antibiotic four of the seven days in the seven-day look-back period. The 04/07/23 quarterly MDS documented a BIMS of 99, indicating that the BIMS was not completed by the resident and documented a staff assessment of memory problems with moderately impaired cognition. R12 received an antibiotic three of the seven days in the seven-day look-back period. The Electronic Health Record (EHR) included a physician order for Sulfamethoxazole-Trimethoprim Tablet 800-160 milligrams (mg) (Bactrim DS - an antibiotic), 0.5 tablet to be given once daily on Monday, Wednesday, and Friday, for urinary tract infection (UTI) prophylaxis (procedure or treatment to prevent something from happening), dated 10/19/22. Review of laboratory results revealed the following: 1. On 09/21/22, a urinalysis (UA - a physical, chemical and microscopic laboratory examination of the urine that is used to detect and manage a wide range of disorders and diseases) with culture and sensitivity (c/s - a laboratory test to check for the presence of a bacterial infection and checks which antibiotics the bacteria are sensitive or resistant to so the correct medications may be prescribed) that revealed a UTI and c/s results documented resistance to Sulfamethoxazole-Trimethoprim. Review of the physician order, the physician ordered Fosfomycin (an antibiotic) 3grams (gm) to be given orally as a single dose. Review of the MAR from 09/18/22 to 09/30/22, R12 continued to receive the Sulfamethoxazole- Trimethoprim medication. On 07/05/23, a UA with c/s revealed a UTI and c/s results documented resistance to Sulfamethoxazole-Trimethoprim. Review of the physician order, the physician ordered Cefdinir (an antibiotic) 300 milligrams (mg) to be given orally twice daily for 10 days. Review of the MAR from 07/01/23 to 07/31/23, R12 continued to receive the Sulfamethoxazole- Trimethoprim medication. The Progress Notes lacked documentation related to physician notification from staff of the correlation between the prophylactic antibiotic use and the urine culture and sensitivity testing. On 07/31/23 at 01:42 PM, Licensed Nurse (LN) G was unable to give rationale why R12 was taking an antibiotic that laboratory tests indicated that she was resistant to. On 07/31/23 at 10:25 AM, Administrative Nurse B reported she was unable to provide rational why staff would administer an antibiotic that would have not been effective. The facility's Unnecessary Medications policy dated 11/28/17 documented that each resident's drug (medication) regimen must be free of unnecessary medications. The facility failed to ensure Resident (R)12 was free from unnecessary medications, when on two occasions, the facility administered an antibiotic medication that laboratory results indicated the bacteria was resistant to the prescribed antibiotic.

The facility identified a census of 50 residents. The sample included 13 residents with five reviewed for medications. Based on observation, interview, and record review, the facility failed to implement antibiotic use protocols to avoid unnecessary and/or inappropriate antibiotic use to reduce the risk of adverse events, including antibiotic resistance, when the facility failed to monitor effectiveness and identify inappropriate extended administration of antibiotic administration for Resident (R) 12. This placed the resident at risk for complications related to extended antibiotic use. Findings include: - Review of the facility infection control log from October 2022 thru June 2023 lacked documentation of R12's on-going usage of Sulfamethoxazole-Trimethoprim Tablet 800-160 milligrams (Bactrim DS - an antibiotic). R12's diagnoses from the Electronic Health Record (EHR) included extended-spectrum beta-lactamases (ESBL - enzymes produced by certain microorganisms that allow them to be resistant to the actions of some antibiotics) resistance. The 07/07/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of six, which indicated severely impaired cognition. R12 received an antibiotic four of the seven days in the seven-day look-back period. The 04/07/23 quarterly MDS documented a BIMS of 99, indicating that the BIMS was not completed by the resident and documented a staff assessment of memory problems with moderately impaired cognition. R12 received an antibiotic three of the seven days in the seven-day look-back period. The 07/07/23 Care Area Assessment (CAA) lacked documentation related to antibiotic use. The 07/27/23 Care Plan lacked documentation related to antibiotic use. The Electronic Health Record (EHR) included a physician order for Sulfamethoxazole-Trimethoprim Tablet 800-160 milligrams (mg) (Bactrim DS - an antibiotic), 0.5 tablet to be given once daily on Monday, Wednesday, and Friday, for urinary tract infection (UTI) prophylaxis (procedure or treatment to prevent something from happening), dated 10/19/22. Review of R12's laboratory results revealed the following: 1. On 09/21/23, a urinalysis (UA - a physical, chemical and microscopic laboratory examination of the urine that is used to detect and manage a wide range of disorders and diseases) with culture and sensitivity (c/s - a laboratory test to check for the presence of a bacterial infection and checks which antibiotics the bacteria are sensitive or resistant to so the correct medications may be prescribed) that revealed a UTI and c/s results documented resistance (the ability not to be affected by something) to Sulfamethoxazole-Trimethoprim (Bactrim DS). 2. On 07/05/23, a UA with c/s revealed a UTI and c/s results documented the infection was resistant to Sulfamethoxazole-Trimethoprim (Bactrim DS). The Progress Notes lacked documentation related to physician notification from staff the correlation between antibiotic use and urine culture and sensitivity testing. On 07/31/23 at 01:42 PM, Licensed Nurse (LN) G was unable to give rationale why R12 was taking an antibiotic that laboratory tests indicated that she was resistant to. On 07/31/23 at 02:31 PM, LN O reported she was responsible for the antibiotic stewardship program that included monitoring of antibiotic use for the residents. She was not aware R12 received an antibiotic for UTI prophylaxis. Upon review of R12's orders, LN O confirmed that R12 was on Sulfamethoxazole-Trimethoprim Tablet 800-160 mg (Bactrim DS), 0.5 tablet once daily on Monday, Wednesday, and Friday, for UTI prophylaxis since 10/19/22. The facility's policy, Antibiotic Stewardship, dated 04/27/19, documented that the use of antibiotics would be used for conditions that meet clinically approved indications for use. Further documented that antibiotic stewardship would be an integral part of the infection control program. The Director of Nursing Services (DNS or director of nursing [DON]) had primary responsibility along with the pharmacist consultant and medical director. Antibiotic prescriptions would be reviewed monthly to assess for appropriateness and included laboratory test results and compared to McGeer Criteria. The DON or infection control nurse would then report to the pharmacy consultant and medical director for review. The facility failed to monitor effectiveness and identify inappropriate extended administration of antibiotic administration for Resident (R) 12. This placed the resident at risk for complications related to extended antibiotic use.

The facility reported a census of 50 with 13 residents in the sample that included six residents reviewed for unnecessary medications. Based on observation, interview, and record review, the consultant pharmacist failed to identify an unnecessary medication for Resident (R)12, related to an antibiotic that the resident was resistant to. In addition, the facility failed to ensure a system to acknowledge and respond to the consultant pharmacist recommendations for R 21, R 38, R 42, and R 2. Findings include: - R12's diagnoses from the Electronic Health Record (EHR) included chronic obstructive pulmonary disease (COPD - a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), anemia (a condition without enough healthy red blood cells to carry adequate oxygen to body tissues) and extended-spectrum beta-lactamases (ESBL - enzymes produced by certain microorganisms that allow them to be resistant to the actions of some antibiotics) resistance. The 07/07/23 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of six, which indicated severely impaired cognition. R12 received an antibiotic four of the seven days in the seven-day look-back period. The 04/07/23 quarterly MDS documented a BIMS of 99, indicating that the BIMS was not completed by the resident and documented a staff assessment of memory problems with moderately impaired cognition. R12 received an antibiotic three of the seven days in the seven-day look-back period. The 07/07/23 Care Area Assessment (CAA) lacked documentation related to antibiotic use. The 07/27/23 Care Plan lacked documentation related to antibiotic use. The Electronic Health Record (EHR) included a physician order for Sulfamethoxazole-Trimethoprim Tablet 800-160 milligrams (mg) (Bactrim DS - an antibiotic), 0.5 tablet to be given once daily on Monday, Wednesday, and Friday, for urinary tract infection (UTI) prophylaxis (procedure or treatment to prevent something from happening), dated 10/19/22. Review of the facility's pharmacy consultant's medication regimen reviews (MRR) revealed that antibiotic use was not addressed by the pharmacist. Review of lab results revealed the following: 1. On 09/21/22, a urinalysis (UA - a physical, chemical and microscopic laboratory examination of the urine that is used to detect and manage a wide range of disorders and diseases) with culture and sensitivity (c/s - a laboratory test to check for the presence of a bacterial infection and checks which antibiotics the bacteria are sensitive or resistant to so the correct medications may be prescribed) that revealed a UTI and c/s results documented resistance to Sulfamethoxazole-Trimethoprim. 2. On 07/05/23, a UA with c/s revealed a UTI and c/s results documented resistance to Sulfamethoxazole-Trimethoprim. The Progress Notes lacked documentation related to physician notification from staff the correlation between antibiotic use and urine culture and sensitivity testing. On 07/31/23 at 01:42 PM, Licensed Nurse (LN) G was unable to give rationale why R12 was taking an antibiotic that laboratory tests indicated that she was resistant to. Further, LN G was unable to verbalize process used for MRR. On 07/31/23 at 10:25 AM, Administrative Nurse B reported she was not able to find the physician responses, or the pharmacist recommendations as requested on 07/27/23 and 07/31/23. The facility's Unnecessary Medications policy dated 11/28/17 documented that each resident's drug (medication) regimen must be free of unnecessary medications and defines that as any medication used without adequate monitoring or adequate indications. Further documents that the pharmacist would review the resident's regimen monthly to identify any unnecessary medications. The facility failed to provide a policy that outlined the process for MRR as requested on 07/27/23 and 07/31/23. The facility and the consultant pharmacist failed to identify an unnecessary medication for Resident (R)12. This caused the resident to receive an unnecessary medication on 120 occasions from 10/19/22 thru 07/31/23. - R2's diagnoses from the Electronic Health Record (EHR) included dementia (a progressive mental disorder characterized by failing memory, confusion) and Alzheimer's (progressive mental deterioration characterized by confusion and memory failure). The 11/04/22 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) of 13, which indicated intact cognition. R2 received an antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) and an antidepressant (class of medications used to treat mood disorders and relieve symptoms of depression) daily during the seven days in the seven-day look-back period. The 05/05/23 quarterly MDS documented a BIMS of 12, which indicated moderately impaired cognition. R2 received an antipsychotic and an antidepressant daily in the seven-day look-back period. The 11/04/22 Psychotropic Care Area Assessment (CAA) documented the resident had a dose reduction for Zoloft attempted on 06/06/22 without success, and a dose reduction for Zyprexa attempted on 05/09/22 without success. The 07/27/23 Care Plan documented the following: 1. Instructed staff to contact the physician every six months to try and reduce the amount of Zyprexa and Zoloft. 2. Instructed staff to give Zoloft and Zyprexa as the provider has ordered to control behaviors. 3. Instructed staff to monitor for side effects of antipsychotic medications and notify the provider if they became present. 4. Instructed staff to monitor for side effects of antidepressant medications and notify the provider if they became present. 5. Instructed the nurse to perform an abnormal involuntary movement scale (AIMS - an assessment of abnormal movements that may be side effects of antipsychotic medications) every quarter and with any significant change in resident's condition. The Electronic Health Record (EHR) included a physician order for: 1. Zyprexa (Olanzapine) 2.5 milligram (mg) to be given orally each morning, related to pseudobulbar affect (a type of emotional disturbance characterized by uncontrollable episodes of crying, laughing, anger or other emotional displays), order date on 06/01/22. 2. Zoloft (sertraline) 50 mg to be given orally each morning related to pseudobulbar affect, order date on 10/04/22. Review of the pharmacist medication regimen listing sheet, revealed the hard copy paper documented the pharmacist addressed Zyprexa administration on 11/14/22 and 05/15/23, however, the facility was unable to provide what those recommendations were or how the provider responded. The Progress Notes documented that on 05/19/23, staff spoke with family regarding decreasing the Zyprexa dose due to pharmacist recommendations, however; review of R2's clinical record lacked evidence the facility acknowledged and responded to the consultant pharmacist recommendations. On 07/31/23 at 10:25 AM, Administrative Nurse B reported she was not able to find the physician responses, or the pharmacist recommendations as requested on 07/27/23 and 07/31/23. On 07/31/23 at 01:42 PM, Licensed Nurse (LN) G was unable to verbalize the process used for the monthly medication review. The facility's Unnecessary Medications policy dated 11/28/17 documented the pharmacist would review the resident's regimen monthly to identify any unnecessary medications. However, the facility lacked a policy for following-up on the pharmacist recommendations. The facility failed to ensure a system to acknowledge and respond to the consultant pharmacist recommendations for R 2. This failure placed the resident at risk for unnecessary psychotropic medications and/or adverse side effects. - Resident (R) 21's Electronic Health Record (EHR) documented the resident had diagnoses that included Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) and allergies. The 09/02/22 Annual Minimum Data Set (MDS) documented a Brief interview for mental status (BIMS) score of 99 with severe impaired cognition. The resident received an antipsychotic (class of medications used to treat psychosis and other mental emotional conditions), antidepressant (class of medication used to treat mood disorders and relieve symptoms of depression), and antianxiety (class of medications that calm and relax people with excessive anxiety). The 09/02/22 Psychotropic Drug Use Care Area Assessment (CAA) documented R21 had physician orders for Seroquel (antipsychotic medication), 50 milligrams (mg) twice a day; Zoloft (antidepressant medication) 100 mg daily; and Ativan (antianxiety medication) 0.5 mg, at bedtime. The Behavioral Symptoms CAA revealed R21 had behaviors and rejection of care, and was on Seroquel, Ativan and Zoloft to assist with management of her moods. The physician orders included: Remeron, 15 mg, daily for decreased appetite, dated 12/20/22. Ativan, 0.5 mg, at bedtime, for dementia, dated 07/26/22. Seroquel, 50 mg, twice a day, for dementia, dated 05/17/22. Zoloft, 100 mg, daily, for anxiety, dated 03/10/23. Review of the pharmacist Medication review regimen listing sheet, from 11/2021 thru 07/2023 revealed the hard copy paper documented the date the pharmacist reviewed the resident's medication and had an area for a comment. The comments included the following: On 07/17/22, Seroquel, need signed. On 10/14/22, Zoloft, need signed. On 01/18/23, Seroquel, need signed. On 2/10/23, Ativan, need signed. On 06/17/23, Remeron, Need signed. Review of R21's clinical record lacked evidence the facility acknowledged and responded to the consultant pharmacist recommendations. Upon request, on 07/31/23 at 10:25 AM, Administrative Nurse B reported she was not able to find the physician responses or the pharmacist recommendations. On 07/31/23 at 11:48 AM, Consultant HH revealed he would make his recommendations and check if the facility replied to the recommendations. If the facility had not replied to the recommendations, he would revisit in six months. Consultant HH verified the facility had trouble with responses due to regular turnover staffing of the Director of Nursing. On 07/31/23 at 01:42 PM, Licensed Nurse (LN) G was not able to verbalize the process used for the monthly medication review. The facility's Unnecessary Medications policy dated 11/28/17 documented the pharmacist would review the resident's regimen monthly to identify any unnecessary medications. However, the facility lacked a policy for following-up on the pharmacist recommendations. The facility failed to ensure a system to acknowledge and respond to the consultant pharmacist repeated recommendations for R21. This failure placed the resident at risk for unnecessary psychotropic medications and/or adverse side effects. - Resident (R) 38's Electronic Health Record (EHR) documented the resident had diagnosis that included anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The 10/26/22 Significant change Minimum Data Set (MDS) documented a Brief interview for mental status (BIMS) score of 0, indicating severely impaired cognition. The resident received an antipsychotic (class of medications used to treat psychosis and other mental emotional conditions). The 06/09/23 Quarterly MDS documented the resident had severely impaired cognition and continued to receive an antipsychotic medication. The 10/26/22 Psychotropic Drug Use Care Area Assessment (CAA) documented R38 was seen for an inpatient psychiatric initial evaluation for increased behaviors including physical aggression. He returned to the facility with orders for Seroquel 25 milligrams (mg) which was discontinued on 10/28 [lacked year] after he was noted to have more difficulty communicating with others and becoming more frustrated with others along with other behaviors of defecating (feces) on the floor, and being very somnolent (drowsy, sleepy). He continued to receive Zoloft 50 mg daily for anxiety. The physician orders included: Seroquel, 25 mg, daily for anxiety and obsessive-compulsive disorder (OCD- anxiety disorder characterized by recurrent and persistent thoughts, ideas, and feelings of obsessions severe to cause marked distress, consume considerable time or significantly interfere with the resident's occupational, social, or interpersonal functioning), ordered 02/08/23. Review of the pharmacist Medication review regimen listing sheet, from 11/2021 thru 07/2023 revealed the hard copy paper documented the date the pharmacist reviewed the resident's medication and had an area for a comment. The comments included the following: On 03/16/23, Seroquel, need signed. Review of R38's clinical record lacked evidence the facility acknowledged and responded to the consultant pharmacist recommendations. Upon request, on 07/31/23 at 10:25 AM, Administrative Nurse B reported she was not able to find the physician responses or the pharmacist recommendations. On 07/31/23 at 11:48 AM, Consultant HH revealed he would make his recommendations and check if the facility replied to the recommendations. If the facility had not replied to the recommendations, he would revisit in six months. Consultant HH verified the facility had trouble with responses due to regular turnover staffing of the Director of Nursing. On 07/31/23 at 01:42 PM, Licensed Nurse (LN) G was not able to verbalize the process used for the monthly medication review. The facility's Unnecessary Medications policy dated 11/28/17 documented the pharmacist would review the resident's regimen monthly to identify any unnecessary medications. However, the facility lacked a policy for following-up on the pharmacist recommendations. The facility failed to ensure a system to acknowledge and respond to the consultant pharmacist recommendations for R38. This failure placed the resident at risk for unnecessary psychotropic medications and/or adverse side effects. - Resident (R)42's Electronic Health Record (EHR) documented the resident had diagnoses that included anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), insomnia (inability to sleep), and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, and emptiness. The 09/28/22 Annual Minimum Data Set (MDS) documented a Brief interview for mental status (BIMS) of not assessed. The resident received antipsychotic (class of medications used to treat psychosis and other mental emotional conditions), and antidepressant (class of medication used to treat mood disorders and relieve symptoms of depression). The 06/16/23 Quarterly MDS documented the resident had severely impaired cognition and received antipsychotic and antidepressant. The 09/28/22 Psychotropic Drug Use Care Area Assessment (CAA) documented R42 had psychotic symptoms and anxiety and received medications that included Ativan (medication used to treat anxiety) 0.5 milligrams (mg), every 12 hours, as needed for anxiety and Zoloft (medication used to treat depression), 25 mg, daily for depression. The resident continued to have behaviors of delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), cussing and threatening staff. The physician orders included: Seroquel, 50 mg, daily, for insomnia, dated 10/24/22. Zoloft, 25 mg, daily, for depression, dated 09/22/22. Review of the pharmacist Medication review regimen listing sheet, from 10/14/22 thru 07/16/2023 revealed the hard copy paper documented the date the pharmacist reviewed the resident's medication and had an area for a comment. The comments included the following: On 03/16/23, Zoloft, see signed. On 11/14/22, Seroquel, see signed. Review of R42's clinical record lacked evidence the facility acknowledged and responded to the consultant pharmacist recommendations. Upon request, on 07/31/23 at 10:25 AM, Administrative Nurse B reported she was not able to find the physician responses or the pharmacist recommendations. On 07/31/23 at 11:48 AM, Consultant HH revealed he would make his recommendations and check if the facility replied to the recommendations. If the facility had not replied to the recommendations, he would revisit in six months. Consultant HH verified the facility had trouble with responses due to regular turnover staffing of the Director of Nursing. On 07/31/23 at 01:42 PM, Licensed Nurse (LN) G was not able to verbalize the process used for the monthly medication review. The facility's Unnecessary Medications policy dated 11/28/17 documented the pharmacist would review the resident's regimen monthly to identify any unnecessary medications. However, the facility lacked a policy for following-up on the pharmacist recommendations. The facility failed to ensure a system to acknowledge and respond to the consultant pharmacist recommendations for R42. This failure placed the resident at risk for unnecessary psychotropic medications and/or adverse side effects.

The facility census totaled 50 residents with one central kitchen. Based on observation, interview, and record review the facility failed to store, prepare and serve foods safely and in a sanitary manner which included failure to date and reseal open food items in the refrigerator and freezer; failure to clean and disinfect the food thermometer while taking the temperature of food items; and failure to use gloves appropriately when handling/serving of food. This had the potential to affect all 50 residents receiving meals from the kitchen. Findings Included: - On 07/25/23 at 12:30 PM, initial tour of the kitchen revealed the following items: The walk-in refrigerator contained a raw meat patty in a baggie with no identification of what it was or a date; cooked hamburger patties in separate bags undated; an open package of cheese slices undated; a partially sliced onion in an open bag undated; and two separate packages of corn tortillas not dated and with visible mold growing on the tortillas. The freezer contained an open bag of French fries and an open bag of tater tots with no dates. An open to air bag of apple slices with no date. The freestanding refrigerator contained a lidded cup of brown fluid with no date and no identifying label. Dietary staff H reported she did not know what it was, but it had been in there for quite a while. On 07/26/23 at 12:00 PM, Dietary Staff J placed food on the steam table in a satellite kitchen in A and B. Staff J then put gloves on and took a bare thermometer not in a sheath with a bent end out of a drawer in the kitchen. He then took the thermometer and ran it under the water at the sink and dried with a paper towel. Dietary staff J proceeded to check the temperature of all food items with just wiping the thermometer with a paper towel between the food items. Further continued observation of food service with dietary staff J serving all food items revealed him touching and cupping the food on the plates to keep them from mingling together while serving. Dietary staff J wore the same gloves throughout the entire food service of the noon meal to the residents of the facility. On 07/27/23 at 08:00 AM, an interview with dietary staff I confirmed dietary staff J's actions were not appropriate. Review of the facility policy named Food Storage dated 04/06/20 revealed staff were to label all food items with the name of the food and date it was opened or prepared. Review of the facility policy named Monitoring Food Temperatures for Meal Service dated 04/06/20 revealed a properly functioning and calibrated thermometer will be used when taking temperatures of food items. Thermometers are to be washed, rinsed, and sanitized before and after each meal use. An alcohol swab may be used to sanitize between uses while taking temperatures during the same meal or if contamination of the thermometer occurs. Review of the facility policy Proper Hand Washing and Proper Use of Gloves dated 04/06/20 revealed staff should be reminded that gloves become contaminated just as hands do and should be changed often. When in doubt, remove gloves and wash hands again. The facility failed to store, prepare and serve foods safely to the residents of the facility.

The facility reported a census of 50 residents. Based on interview and record review, the facility failed to maintain a quality assessment and assurance committee that consisted at the minimum of the director of nursing services, the medical director or his/her designee, at least three other members of the facility's staff, at least one of who must be the administrator, owner, board member or other individual in a leadership role, and the infection preventionist, as required. Findings included: - Review of the facility's Quality Assurance Performance Improvement (QAPI) sign in sheets, revealed a lack of documentation of the Infection Preventionist in attendance from July 2022 until current. In addition, the February 2023 and April 2023 lacked the required members for the QAPI meeting when only the facility's medical director and the facility administrator were the only members in attendance. On 07/31/23 at 01:46 PM, Administrative staff A reported he did not know the Infection Preventionist was to attend the QAPI meetings. The facility's Quality Assurance and Performance improvement policy, dated 04/27/18, lacked guidance on the members required to attend the meetings. The facility failed to ensure the Infection Preventionist attended the required QAPI meetings. In addition, the facility failed to maintain a QAPI committee meeting that consisted of the required members.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - R2's Electronic Medical Record (EMR) dated 07/03/23 revealed the following diagnoses that included dementia (progressive mental disorder characterized by failing memory, confusion), neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system), and diabetes mellitus (when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin). The Quarterly Minimum data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. The resident required extensive assistance of two staff for all cares. The resident had an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) and was always incontinent of bowel. The resident was at risk for pressure ulcers and had a current stage four pressure ulcer and moisture associated skin damage (MASD). The (11/4/22) Annual MDS documented a BIMS of 13, indicating intact cognition. R2 required extensive assistance of two staff for all cares. The resident had an indwelling catheter and always incontinent of bowel. The Pressure Ulcer Care Area Assessment (CAA), dated 11/04/22, documented the resident had no pressure ulcers during lookback period however was at increased risk for skin breakdown. R2 developed skin breakdown to her left and right buttocks and had dressing changes for each of these. R2 was dependent on a wheelchair for mobility and the full body lift with two staff assistance for all transfers. The resident had a catheter in place for neurogenic bladder and was always incontinent of bowel. Observation on 07/31/23 at 08:00 AM revealed Licensed Nurse (LN) O, Certified Medication Aide (CMA) U and CMA T in the resident's room preparing to perform morning cares and LN O to perform wound care and dressing change. CMAs, using a draw sheet rolled the resident to her right side, then removed the resident's brief. The resident was incontinent of bowel. CMA T performed cares as much as possible using one wipe per swipe. LN O stepped in to remove the wound dressing and complete cleaning of the peri area. LN O removed and discarded the dressing to R2's left hip and coccyx, then proceeded to clean perineal area of BM using one wipe, folding then wiping area with clean area of wipe. LN O then cleaned the coccyx wound with normal saline (NS). LN O changed her gloves though no hand hygiene was done prior to donning clean gloves. She then cleaned the hip wound with NS and while wearing the same gloves, LN O packet the wound with with betadine-soaked packing gauze and she then changed gloves, however LN O failed to utilize hand hygiene prior to donning clean gloves. Interview on 07/31/23 at 01:36 PM, CNA D stated staff should always wash their hands when going from dirty phase to clean phase of providing cares. On 07/31/23 at 08:10 AM, LN O stated staff could fold a wipe to make a second pass with a clean portion of the wipe. On 07/31/23 at 10:25 AM Administrative Nurse B reported during cares, gloves should be changed, and hand hygiene performed between gloves when transitioning from the dirty phase to the clean phase. Hands should be sanitized and/or changed between resident contact. Review of the facility's policy for Proper Hand Washing and Proper Use of Gloves dated 04/06/20, revealed all employees would use proper hand washing procedures and glove usage in accordance with State and Federal Guidelines. When gloves must be changed, they are removed, hand washing procedure is followed, and a new pair of gloves applied. The facility failed to perform hand hygiene when changing gloves between dirty and clean dressing changes. The facility reported a census of 50 residents with 13 residents sampled. Based on observation, interview and record review, the facility failed to maintain an effective infection control program when they failed to provide safe and sanitary care for one Resident (R) 20, regarding his urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag), for R3, in regards to incontinent care, R2 in regards to failure to change gloves from dirty to clean during wound care, and failure to change gloves in the kitchen who served food to all of the residents of the facility. Findings included: - Resident (R)20's Electronic Health Record (EHR) documented the resident had diagnoses that included chronic kidney failure, stage three, frequency of micturition (frequency of bladder), and benign prostatic hyperplasia (non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections. The 06/23/23 Annual Minimum Data Set (MDS) documented a Brief interview for mental status (BIMS) score of 10, indicating moderately impaired cognition. The resident did not have a urinary catheter during the lookback period. The 06/23/23 Urinary Incontinence and Indwelling Catheter Care Area Assessment (CAA) documented R20 wore an incontinence brief and was dependent on staff for transfers to the toilet as well as toilet hygiene. The 02/14/23 Care Plan lacked any mention of an indwelling catheter or staff guidance to care for the resident's urinary catheter. The physician's order included the resident had an indwelling Foley catheter, related to benign prostatic hyperplasia with lower urinary tract symptoms, dated 07/07/23. It further instructed to maintain the catheter until urology follow-up and as needed. Review of the progress Notes revealed on 07/07/23, the resident returned from the hospital with a urinary catheter. On 07/27/23 at 07:13 AM, observation revealed Certified nurse aide (CNA) L and CNA M dressed the resident. Staff placed the urinary catheter bag directly on the bathroom floor. Staff reported they should put the catheter collection bag on a paper towel as a barrier. On 07/31/23 at 07:08 AM, CNA D and CNA N entered the resident's room to provide morning cares. The urinary catheter had no covering/dignity bag, and once cares provided, CNA N placed the urinary catheter collection bag directly on the floor. On 07/31/23 at 07:22 AM, CNA N verified staff should not have placed the catheter bag directly on the floor. On 07/31/23 at 07:32 AM, CNA D reported staff should always put a privacy cover over the resident's catheter bag. On 07/31/23 at 07:34 AM, Licensed Nurse (LN) O stated staff should place a cover over the resident's catheter collection bag, and verified staff should not place the urinary catheter directly on the floor. On 07/31/23 at 07:42 AM, Administrative nursing staff B stated she expected CNAs know and follow directions for catheter cares. The facility failed to provide a policy related to infection control with urinary catheters. The facility failed to maintain an effective infection control program when they failed to provide care for this resident that required a urinary catheter, to prevent further urinary tract infections. - R3's Electronic Medical Record dated 06/04/23 revealed the following diagnoses: CVA-cerebral vascular accident (stroke-any abnormal condition characterized by dysfunction of the heart and blood vessels), hemiplegia (paralysis of one side of the body), neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system) and diabetes mellitus (when the body cannot use glucose, not enough insulin is made or the body cannot respond to the insulin). The Annual Minimum Data Set (MDS) dated [DATE], revealed the resident was severely cognitively impaired. The resident required extensive assistance of two staff for all activities of daily care (ADL). The Quarterly MDS dated 06/30/23, revealed the resident never/rarely understood others. The resident required extensive assistance of two staff for ADL's. The resident had an indwelling urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). Review of the Care Plan dated 07/09/19, revealed the resident had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion) and did not always understand what was going and would often refuse cares. The resident could take himself to the toilet. The resident had more episodes of incontinence and wore pull up (disposable) briefs. Observation on 07/26/23 at 02:58 PM, revealed Certified Nursing Assistant (CNA) L and CNA M assisted R3 to his room. Staff placed a gait belt on the resident and staff transferred the resident's catheter bag to the side of the bed, and both staff assisted the resident to stand and pivoted him to his bed. The resident's pants and brief were pulled down to expose the front of the resident. CNA M gave peri care to the front of the resident, then he was turned to his right side, and staff cleaned the resident's buttocks. The resident had an incontinent bowel movement. Staff removed the resident's soiled clothing, and staff re-dressed the resident, however, staff failed to change their soiled gloves between the soiled process of cleansing the resident to the clean brief and outer clothing. Interview on 07/26/23 at 03:10 PM, CNA M reported they should have changed gloves between the dirty cleansing process and before they applied the clean clothing. Interview on 07/27/23 at 10:00 AM, Administrative Nurse B reported she expected the CNAs to know how to correctly care for a resident, including proper incontinent cares. Review of the Facility Policy named Proper Hand Washing and Proper Use of Gloves dated 04/06/20, revealed all employees would use proper hand washing procedures and glove usage in accordance with State and Federal Guidelines. When gloves must be changed, they are removed, hand washing procedure followed, and a new pair of gloves applied. The facility failed to change gloves between clean and dirty while performing incontinent care for R3.

The facility reported a census of 50 residents. Based on interview and record review, the facility failed to maintain an in-service training program for nurses' aides that was appropriate and effective to ensure the continuing competence of nurse aides. Four of five current certified nurse aide records reviewed for the required annual in-service trainings revealed the lack of dementia management training, resident abuse prevention training, and/or social media training, out of the 12 required in-service trainings, to ensure the continuing competence of nurse aides and appropriate care and services to all the residents of the facility. Findings included: - During the survey, review of five certified nurse aides' in-service records revealed four of the five, lacked all 12 required trainings as follows: 1. Certified Nurse's Aide (CNA) P lacked dementia management training, resident abuse prevention training, and/or social media training. 2. CNA Q lacked dementia management training, resident abuse prevention training, and/or social media training. 3. CNA R lacked dementia management training. 4. CNA N lacked dementia management training. On 07/31/23 at 01:18 PM, CNA D reported she completed the annual dementia training. On 08/02/23 at 01:40 PM, Administrative Nurse B reported when a staff member is first hired, the social media should be part of the orientation training. The facility just transitioned to an on line system on 07/01/23, and she would be responsible for assigning and auditing staff to make sure the required training completed. Administrative Nurse B reported she was aware that that staff lacked the required training. The facility's policy for Abuse, Neglect and Exploitation, dated 11/28/17, revealed the facility would conduct an orientation process and annual in-servicing which would review resident rights, grievances process and facility process for investigation of abuse neglect, involuntary seclusion and misappropriation of property, exploitation, and mistreatment . The facility failed to maintain an in-service training program that was appropriate and effective for these four certified nurse aides, who lacked all of the required 12 in-services within the prior year, to ensure the continuing competence of nurse aides and appropriate care and services to all of the residents of the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 42 residents with 12 sampled including one for hospitalization. Based on observation, interview, and record review the facility failed to provide a copy of the facility bed hold policy to Residents (R) 12 or her representative for her facility-initiated hospitalizations. Findings Include: - Review of R12's Minimum Data Set (MDS) tracking form dated May 2020 documented the resident discharged to the hospital on [DATE] and returned to the facility on [DATE]. Review of R12's Minimum Data Set (MDS) tracking form dated February 2021 documented the resident discharged to the hospital on [DATE] and returned to the facility on [DATE]. Review of R9's Electronic Health Record lacked evidence of written notification of the facility-initiated hospitalization transfers and bed holds to R12 or her representative. Observation on 10/27/21 at 10:27 AM revealed R12 sat in her wheelchair in her room watching television, and she had all needed items within her reach. On 10/28/21 at 08:20 AM Social Service Designee (SSD) E stated she would call the family following their allotted time away to check and see if they would like to keep their current bed at the current rate. She stated she did not believe there was any form the nurses sent with residents upon discharge to the hospital. SSD E stated she went over the bed-hold policy with the resident and their representative upon admission. On 10/28/21 at 08:29 AM Licensed Nurse (LN) F stated she did not send a bed-hold policy with the resident when they discharged to the hospital. On 10/28/21 at 08:35 AM Administrative Nurse A stated the SSD covered the bed-hold policy on admission, but she would not send a policy with a resident when they went to the hospital. She stated she did not know it was required. On 10/28/21 at 02:05 PM Administrative Nurse G confirmed the facility must provide a bed hold policy at time of discharge to the hospital. The Bed-Hold Policy Notice revised 11/28/17 documented a written notice which specifies the duration, or the bed-hold policy will be provided at the time of transfer of a resident for hospitalization. The facility failed to provide a copy of the bed hold policy for R12 or her representative for her 05/08/20 and 02/03/20 hospitalizations.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility census totaled 42 residents with 12 residents included in the sample. Based on observation, interview, and record review the facility failed to revise the care plan related to the use of psychotropic medications (Haldol/Haloperidol/Remeron) for Resident (R)40. Findings included: - R40's Order Summary Report signed by the physician on 10/04/21 revealed a diagnosis of vascular dementia with behavioral disturbance (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain.) The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating a BIMS score could not be determined, and noted R40 received an antipsychotic medication for three days and an anti-depressant medication two days during the seven-day lookback period. The Annual MDS dated 10/08/21 revealed a BIMS score of 00, indicating a BIMS score could not be determined and R40 received an antipsychotic medication daily and an anti-depressant three days during the seven-day lookback period. The Psychotropic Drug Use Care Area Assessment (CAA) dated 10/08/21 revealed R40 received Haldol both PRN and scheduled. The Care Plan dated 07/09/21 revealed R40 had a diagnosis of dementia and did not always understand what was going and would often refuse cares. R40 would often become frustrated and had behaviors such as raising his voice, raising his hand in a fist and shook it, or tried to hit or kick at staff. A review of the Physician Orders included the following: Order dated 07/13/21 for Haldol one milligram (mg), inject intramuscularly PRN for agitation, if the resident refused the Haldol by mouth (PO). Order dated 07/13/21 for Haloperidol one mg, give one tablet PO two times a daily with meals and did not include a diagnosis. Order dated 07/27/21 for Haldol 40 mg, inject intramuscularly in the evening every month for vascular dementia with behavioral disturbance. Order dated 10/17/21 for Remeron (antidepressant medication) 30 mg, one tablet by mouth in the evening related to vascular dementia with behavioral disturbance. Review of the August - October 2021 Electronic Medication Administration Record (EMAR) revealed the R40 received psychoactive medications (Haldol/Haloperidol/Remeron.) Observation on 10/28/21 at 08:34 AM revealed R40 stayed in his room and did not exhibit any negative verbal or physical behaviors. In an interview on 10/26/21 at 02:21 PM, Certified Nurse Aide (CNA) M stated R40 had his days, some days he was okay, other days he would be stubborn and could get physical towards staff at times depending on who worked with him. In an interview on 10/28/21 at 08:51 AM, Licensed Nurse (LN) F stated R40 refused his medications and would resist cares, swing at staff, and curse in Spanish if staff tried to change him or bathe him. In an interview on 10/28/21 at 10:53 AM, Administrative Nurse A stated psychotropic medications should be included in the care plan if the policy stated it should be. The Unnecessary Medications policy revised November 2017 revealed, .The care plan for psychotropic medication includes the name of the medication used, the indicated behaviors being treated, and the potential side effects of the medication. The facility failed to revise the care plan for R40 to include information concerning the use of the psychotropic medications (Haldol/Haloperidol/Remeron).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - The Physician Orders in the Electronic Health Record (EHR) documented R13 with a diagnosis of dementia (a progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of eight, which indicated moderately impaired cognition and the resident required extensive assistance with bed mobility, transfers, and locomotion on the unit. R13 had one fall without injury in the last month. The Quarterly MDS dated 08/13/21 revealed a BIMS score of four which indicated severe cognitive impairment and had two falls since the prior assessment, without injury. The Activities of Daily Living (ADL's) Functional/Rehabilitation Potential Care Area Assessment (CAA) dated 12/01/20 documented R13 required extensive assistance with all ADLs due to a decline of mobility since she fell at home. R13 had increased pain and required encouragement with ADLs. The Falls CAA dated 12/01/20 documented R13 had a potential for behaviors due to rejection of care. The Care Plan dated 12/01/20 documented multiple interventions including to provide a mat on the floor beside the bed to prevent injuries in case R13 fell. A Fall Risk Assessment completed on 04/27/21 documented R13 was at risk for falls. Review of 17 fall investigations documented multiple interventions were implemented and the care plan was updated after each fall. The Fall Investigation dated 07/21/21 documented an unwitnessed fall without injury in which staff last saw R13 in bed at 02:15 AM. R13 did not state what she was attempting to do, she just said, Help. The staff noted no injury at the time of the fall. The care plan was updated to include a bed mat at the bedside to break falls. Observation on 10/27/21 09:37 AM revealed R13 slept in a recliner in the commons area with the footrest up and legs on the footrest. R13 did not appear restless and did not try get up out of the recliner. Observation on 10/27/21 at 03:42 PM revealed no bed mat in R13's room. On 10/26/21 09:37 AM, an unidentified family member stated R13 fell about 10 times since her admission to the facility, with no injuries. R13 forgot she could not get up and tried to go to the bathroom or somewhere else. On 10/27/21 10:30 AM, Certified Nurse Aid (CNA) P stated R13 walked with assistance with a gait belt and walker. CNA P stated she did not know if a bedside mat was used for R13. On 10/27/21 at 11:52 AM, CNA Q stated she did not know of any mat placed by R13's bed to prevent injury from falls. On 10/27/21 at 03:44 PM, CMA R stated she could not find a bed mat in R13's room. On 10/26/21 at 04:33 PM, Licensed Nurse (LN) N stated a mat was used by the bed at night to prevent injury if R13 tried to get out of bed by herself. On 10/27/21 at 03:48 PM, Administrative Nurse A verified a bed mat was in R13's care plan and she got a bed mat and placed it in R13's room today. Administrative Nurse A stated she did not know how long R13 had not had a bed mat at her bedside at night. The Falls policy revised 04/27/18 documented, Individualized care plan interventions will be developed for residents identified thorough assessment as being at fall risk. Those interventions will be reviewed and updated on a regular basis and if/when a fall occurs. The facility failed to ensure staff implemented all care planned fall prevention interventions for R13 when staff did not provide a bedside mat per the care plan. The facility reported a census of 42 residents with 12 residents in the sample and two residents reviewed for accidents. Resident 13, and Resident 30. Based on observations, interview, and record review the facility failed to implement care planned fall prevention measures to include the use of a floor mat at night to prevent falls for Resident (R) 13 and failed to ensure staff monitoring the wander guard bracelet for R30 every shift to prevent a potential elopement. Findings include: - The Physician Orders dated 09/29/21 for R30 revealed the following diagnosis: schizoaffective disorder bipolar type (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought). The Annual Minimal Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 10, indicated moderate cognitive impairment. and noted R30 as independent with Activities of Daily Living (ADL), with no behaviors noted. The Quarterly Minimal Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of seven, indicating severely impaired cognition. The Care Plan dated 07/31/19, revised on 05/18/20, revealed staff were to ensure R30's wander guard bracelet was in place and working, every shift The Task reviewed from 09/27/21 to 10/27/21 revealed six days out of 30 days the Nurses did not monitor the wander guard every shift (shifts are 12 hours and run 6AM-6PM and 6PM to 6AM). The Task documentation revealed the following days lacked evidence of the wander guard checked as care planned: 10/3/21 wander guard checked on first shift, no documentation on second shift 10/7/21 wander guard checked on first shift, no documentation on second shift 10/11/21 wander guard checked on first shift, no documentation on second shift 10/13/21 wander guard checked on first shift, no documentation on second shift 10/15/21 wander guard checked on first shift, no documentation on second shift 10/16/21 wander guard checked on first shift, no documentation on second shift Observations of R30 on 10/25/21 at 04:39 PM revealed he wore a wander guard on his left ankle. R30 remained in his room during the day shift with no wandering observed. Interview with Certified Medication Aide (CMA) K on 10/27/21 at 08:34 AM revealed he/she saw R30 try to leave the facility by trying all the doors and say he was looking for his truck. CMA K said R30 work a a wander guard and the nurses checked the wander guard and the nurse aides did not. Interview with Certified Medication Aide (CMA) L on 10/27/21 08:55 AM revealed R30 did wander and had tried to leave the facility, but so far had not made it outside. CMA L said the nurses are the ones that check the wander guard. Interview with Licensed Nurse (LN) M on 10/27/21 at 10:23 AM revealed the wander guard was checked every shift and documented in the electronic charting system. LN M said the LN have two 12 hour shifts per day and R30 wanders at night looking for his truck or thinks he needs to go to work. Interview with Administration Nurse A on 10/28/21 at 11:18 AM revealed she expected the wander guard to be checked on all shifts and said the machine will check the battery and the LN staff checked the expiration date. The new staff received orientation on residents that wander and elopement risk. Administrative Nurse A said R30 would not make it out the door, with the way the doors are set up, but if the staff did not check his wander guard and it malfunctions that could be a problem. The facility policy Elopement dated November 28, 2017 revealed the facility would ensure each resident received adequate supervision and devices to deter elopement. The residents care plan would be updated to ensure wandering and potential for elopement interventions were included. The facility used an elopement monitoring bracelet if the resident was determined to be at risk for elopement, in facilities equipped with such a system. The facility failed to monitor R30's wander guard every shift, for six days out of 30 days reviewed to prevent potential elopement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility census totaled 42 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure the physician was notified when parameters for blood sugars were exceeded for Resident (R)3 and R40. Finding included: - R3's signed Order Summary Report dated 09/23/21 revealed a diagnosis of diabetes mellitus (when the body cannot use glucose, not enough insulin was made, or the body cannot respond to the insulin.) The Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition and received insulin daily. The Quarterly MDS dated 07/23/21 revealed a BIMS score of 15 indicating intact cognition and received insulin daily. The Care Plan dated 07/09/19 revealed staff were to check R40's blood sugar levels as the doctor ordered and let them know if the levels were outside the range the physician set. A review of the Physician Orders included the following: Order dated 06/16/20 for Blood Glucose Monitoring before meals and at bedtime related to diabetes mellitus. Notify physician if blood glucose was greater than 400 milligrams/deciliter (mg/dL) or less than 70 mg/dL. Review of the August 2021 Electronic Medication Administration Record (EMAR) revealed the physician was not notified on the following dates when blood sugars were out of parameters (mg/dL): 08/02/21 for a blood sugar of 471. 08/06/21 for a blood sugar of 405. 08/13/21 for a blood sugar of 435. 08/15/21 for a blood sugar of 523. Review of the October 2021 EMAR revealed the physician was not notified on the following dates when blood sugars were out of parameters (mg/dL): 10/22/21 for a blood sugar of 466. Review of the Progress Notes and documents scanned under the Miscellaneous tab of the Electronic Health Record did not reveal any notification to the physician about blood sugars that were greater than 400 mg/dl. Observation on 10/27/21 at 12:05 PM, revealed R3 sat in his chair in his room watching television. R3 did not show any signs or symptoms of hypoglycemia (less than normal amount of glucose in the blood) or hyperglycemia (greater than normal amount of glucose in the blood.) In an interview on 10/28/21 at 11:10 AM, Certified Medication Aide (CMA) O stated R3 was a diabetic and the nurses were the ones who obtained blood sugars and reported any blood sugars out of parameters to the physician. In an interview on 10/27/21 at 04:11 PM, Licensed Nurse (LN) N stated R3 was on insulin and nursing staff obtained the blood sugars. LN N stated there were parameters to call the physician if blood sugars were less than 70 mg/dL or greater than 400 mg/dL. LN N stated if blood sugars were out of parameter they would notify the physician either by fax or phone call and stated they would document in a progress note. In an interview on 10/28/21 at 10:50 AM, Administrative Nurse A stated she expected the nursing staff to notify the physician for any results outside of the specified parameters and to document this notification in a progress note. The Clinician Notification policy revised November 2017 revealed, It is the policy that notification of physicians and other clinicians will be done on a timely basis .based on physician orders and physician specific parameters. The facility failed to ensure the physician was notified as ordered for blood sugars greater than 400 mg/dL for R3. - R40's Order Summary Report signed by the physician on 10/04/21 revealed a diagnosis of diabetes mellitus (when the body cannot use glucose, not enough insulin was made, or the body cannot respond to the insulin.) The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating a BIMS score could not be determined, and noted R40 received insulin for three days during the seven-day lookback period. The Annual MDS dated 10/08/21 revealed a BIMS score of 00, indicating a BIMS score could not be determined and R40 received insulin daily. The Care Plan dated 07/09/19 revealed staff were to check R40's blood sugar levels as the doctor ordered and let them know if the levels were outside the range the physician set. A review of the Physician Orders included the following: Order dated 07/12/21 for blood glucose monitoring in the morning related to diabetes mellitus and to notify the physician if blood glucose is greater than 300 milligrams/deciliter (mg/dL) or less than 70 mg/dL. Review of the August 2021 Electronic Medication Administration Record (EMAR) revealed the physician was not notified on the following dates when blood sugars were out of parameters (mg/dL): 08/08/21 for a blood sugar of 404. 08/14/21 for a blood sugar of 384. 08/17/21 for a blood sugar of 440. 08/25/21 for a blood sugar of 345. 08/27/21 for a blood sugar of 302. Review of the September 2021 Electronic Medication Administration Record (EMAR) revealed the following blood sugar results (and lacked documentation of the physician notification) on the following dates when blood sugars were out of parameters (mg/dL): 09/09/21 for a blood sugar of 397. Review of the October August 2021 EMAR revealed the following blood sugar results (and lacked documentation of the physician notification) on the following dates when blood sugars were out of parameters (mg/dL): 10/22/21 for a blood sugar of 379. Observation on 10/28/21 at 08:34 AM revealed R40 did not show any signs or symptoms of hypoglycemia (less than normal amount of glucose in the blood) or hyperglycemia (greater than normal amount of glucose in the blood.) In an interview on 10/28/21 at 08:20 AM, Certified Medication Aide (CMA) S stated the nurses were the ones who took resident blood sugars. In an interview on 10/28/21 at 08:51 AM, Licensed Nurse (LN) F stated R40 was an insulin dependent diabetic. LN F stated if blood sugars were out of parameters the nurse should notify the physician by either a phone call or fax and stated any physician notifications should be documented in a progress note. In an interview on 10/28/21 at 10:50 AM, Administrative Nurse A stated she expected the nursing staff to notify the physician for any results outside of the specified parameters and to document this notification in a progress note. The Clinician Notification policy revised November 2017 revealed, It is the policy that notification of physicians and other clinicians will be done on a timely basis .based on physician orders and physician specific parameters. The facility failed to ensure the staff notified the physician as ordered for blood sugars greater than 300 mg/dL for R40.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility census totaled 42 residents with five residents reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure an appropriate diagnosis for the use of antipsychotic medications (Haldol/Haloperidol) for R40 and failed to ensure the staff did not administer as needed (PRN) longer than 14 days without a renewed physicians order or reason provided by the physician for the continued administration of Haldol on a PRN basis. Findings included: - R40's Order Summary Report signed by the physician on 10/04/21 revealed a diagnosis of vascular dementia with behavioral disturbance (a progressive mental disorder characterized by failing memory and confusion caused by a decreased blood flow to the brain.) The Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating a BIMS score could not be determined, and noted R40 received an antipsychotic medication for three days during the seven-day lookback period. The Annual MDS dated 10/08/21 revealed a BIMS score of 00, indicating a BIMS score could not be determined and R40 received an antipsychotic medication daily during the seven-day lookback period. The Psychotropic Drug Use Care Area Assessment (CAA) dated 10/08/21 revealed R40 received Haldol both PRN and scheduled. The Care Plan dated 07/09/21 revealed R40 had a diagnosis of dementia and did not always understand what was going and would often refuse cares. R40 would often become frustrated and had behaviors such as raising his voice, raising his hand in a fist and shook it, or tried to hit or kick at staff. A review of the Physician Orders included the following: Order dated 07/13/21 for Haldol one milligram (mg), inject intramuscularly PRN for agitation, if the resident refused the Haldol by mouth (PO). Order dated 07/13/21 for Haloperidol one mg, give one tablet PO two times a daily with meals and did not include a diagnosis. Order dated 07/27/21 for Haldol 40 mg, inject intramuscularly in the evening every month for vascular dementia with behavioral disturbance. Review of the September 2021 Electronic Medication Administration Record (EMAR) revealed the resident did receive PRN Haldol on 09/06/21 (beyond the 14 day time frame from the 07/13/21 order without a renewed order or reason provided by the physician for the continued use). Review of the Mayo Clinic website on 10/28/21 at 09:06 AM at: https://www.mayoclinic.org/drugs-supplements/haloperidol-oral-route/proper-use/drg-20064173?p=1 revealed, Haloperidol is used to treat nervous, emotional, and mental conditions (eg, schizophrenia a psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought). It is also used to control the symptoms of Tourette's disorder (a nervous system disorder involving repetitive movements or unwanted sounds.) This medicine should not be used to treat behavior problems in older adult patients who have dementia. Observation on 10/28/21 at 08:34 AM revealed R40 stayed in his room and did not exhibit any negative verbal or physical behaviors. In an interview on 10/26/21 at 02:21 PM, Certified Nurse Aide (CNA) M stated R40 had his days, some days he was okay, other days he would be stubborn and could get physical towards staff at times depending on who worked with him. In an interview on 10/28/21 at 08:51 AM, Licensed Nurse (LN) F stated R40 refused his medications and would resist cares, swing at staff, and curse in Spanish if staff tried to change him or bathe him. In an interview on 10/28/21 at 10:53 AM, Administrative Nurse A stated the use of an antipsychotic medication for dementia was not an acceptable diagnosis. In an interview on 10/28/21 at 12:38 PM, Administrative Nurse G stated the physician order system was set up to automatically place a 14 day stop on PRN psychotropic medications with an alert provided that the 14 days is up so the physician may be contacted for further guidance. The nurse entering the order does have the capability to remove the stop date, but they have all been educated regarding the regulatory requirements for PRN psychotropic med use. The Unnecessary Medications policy revised November 2017 revealed, Each resident's drug regimen must be free from unnecessary drugs .Antipsychotic medications are indicated for the treatment of schizophrenia, Tourette's, and Huntington's (rare abnormal hereditary condition characterized by progressive mental deterioration; a disabling central nervous system movement disorder.). The use of antipsychotic medications for any other diagnoses must include physician documentation of the rationale . The facility failed to ensure R40 did not receive unnecessary medications by the failure to ensure an appropriate diagnosis was provided for the use of Haldol and Haloperidol, and by the failure to ensure the prescribing physician provided a rationale to extend the use of the PRN Haldol beyond the 14-day limit for use of PRN psychotropic medications.

The facility reported a census of 42 residents. The facility had one main kitchen where food was stored and prepared serving two dining rooms. Based on observation, interview, and record review the facility failed to properly store food in the main kitchen refrigerator and two nourishment room refrigerators due to the lack of temperature monitoring; failed to discard expired food items; failed to ensure the dishes and cookware were washed under sanitary conditions due to the lack of chemical or temperature monitoring; failed to store clean pots and pans separate from used, soiled pots and pans; failed to use appropriate hand hygiene when handling food; failed to prepared potentially hazardous foods with the potential food-borne pathogens when staff utilized unpasteurized eggs for a residents request for soft or undercooked eggs as opposed to pasteurized eggs (eggs that have been treated in order to reduce the risk of food-borne illness when eaten uncooked or lightly cooked); and failed to serve food in accordance with professional standards for food service safety and ensuring the residents remain free from infections, when observations revealed dietary staff did not hold, deliver, and transport resident food/cups in a sanitary manner. Findings included: - Observation on 10/25/21 at 03:42 PM revealed two boxes of Easy Mix Simply Thick. The first box was labeled with best used by date of 03/24/21 and the second one with a best used date of 04/01/21. Liquid eggs were on the shelf next to the non-pasteurized eggs. No pasteurized eggs were present. On 10/25/21 at 05:19 PM Certified Nurse Aide (CNA) J observed passing out and refilling beverages for residents in the dining room. CNA J touched the tops/lips of the resident beverage glasses multiple times, and CNA J's finger observed on the eating surface of the plate nearly touching the resident's food. On 10/25/21 at 05:31 PM observed Licensed Nurse (LN) F touched her hair and other staff, touched her mask, pushed her gown sleeves up her arms, and put her hands on her hips under her gown onto her clothes. LN F did not perform hand hygiene after she touched other resident's, staff, and other items and she continued to pick up plates with food and carried them to the residents sitting at the tables. Observation revealed several hand sanitization stations on the walls around the room and LN F verified the hand sanitizing stations were available. On 10/27/21 at 11:49 AM, observed revealed DS H used his gloved hands to re-tie his gown at the neck in the back, then he reached down to remove the foil from a plate without removing gloves or performing hand hygiene. On 10/25/21 at 05:39 PM CNA I observed passing out three evening meal trays with no use of hand hygiene. On 10/25/21 at 05:50 PM CNA I stated she used hand sanitizer before she passed meal trays, and did not know she needed to use hand hygiene between each meal tray. On 10/25/21 at 05:55 PM CNA J confirmed she did not know how and was never trained on passing drinks, she stated the dietary staff generally do it. On 10/26/21 at 07:53 AM revealed raw whole eggs in the shell in a dish on the serving line with no pasteurization stamp. On 10/26/21 at 07:53 AM Dietary Staff (DS) B stated uncooked whole eggs in the shell were for frying for residents who did not want scrambled eggs. DS B said the eggs were not pasteurized and they were fine to serve them sunny-side up (eggs cooked until the whites are solid and the yolk is still runny). Some residents requested eggs sunny-side up or over easy (the egg is flipped while cooking but the yolk remains runny) and she cooked them per the resident's request. DB S stated she had not been told about any cooking guidelines to ensure non-pasteurized eggs were fully cooked before being served to residents. On 10/27/21 at 07:42 AM observed the nourishment room kitchen refrigerator temperature log for mornings and evenings was not filled out for the month of October except for the 8th and the 26th. The refrigerator contained one large applesauce container with an expiration date of 10/19/21. The freezer contained one opened unrecognizable item, a croissant sandwich dated 02/20/09, and an unlabeled, undated paper plate with what looked like leftover dessert. Another nourishment room kitchen refrigerator and freezer were both missing 11 temperatures in the morning and evening. The refrigerator contained a plastic clamshell with moldy strawberries, an unlabeled, undated squirt bottle which contained a white substance, a glass bottle of red liquid that had settled into different layers with a dark spot on the inside of the lid that resembled mold, a metal container with seven strawberry flavored, three chocolate flavored, and four vanilla flavored, thawed, undated, four-ounce containers of Imperial shakes with the label instructions to use within 14 days of thawing. On 10/27/21 at 09:01 AM observed approximately 11 Resource Thicken Up cans with an expiration date of 10/26/21 in the dry goods pantry. An unsealed bag of sharp yellow cheddar cheese in the refrigerator. There were four large baking sheets that had a dark brown/black baked on substance around the edges. There were three seven-inch frying pans with a dark brown/black hard substance inside and outside of the pans. Two of the pans had dried food particles inside. There was one eight-inch frying pan with a dark brown/black hard substance inside and out. There was one 10-inch and one 9.5-inch frying pans with a dark brown/black hard substance inside and outside of the pans. The surface appeared to have the non-stick coating flaking off. On 10/27/21 at 09:01 AM dietary manager (DM) C stated she did not know if they used unpasteurized eggs, she would have to ask the cook. She stated the liquid eggs were used for scrambling eggs for breakfast. She stated the cooks always used a liner to line the baking sheets. She expected any baked-on or cooked-on grease on baking sheets or frying pans to be removed before storing. DM C said it was unacceptable to place frying pans with food particles present, back on the storage shelf with clean pans. She expected all refrigerator and freezer temperatures to be monitored and logged on the provided log sheets twice daily. On 10/27/21 at 10:46 DS D stated whole, in-the-shell, unpasteurized eggs were used for frying sunny side up, over easy, or over hard however the resident prefers them. She knew the egg was ready to eat by looking at it and said there were no other guidelines in place to ensure unpasteurized eggs were cooked well enough for safe eating. On 10/27/21 at 10:48 AM, DS B stated it was the dietary department's responsibility to monitor and log the temperatures of refrigerators and freezers in the snack rooms. On 10/27/21 at 10:51 AM, DM C stated she expected staff to throw out any expired food items in the refrigerator, freezer, or dry storage. On 10/27/21 at 12:02 DM C stated that Imperial shakes should be dated at the time of removal from the freezer and used within 14 days. On 10/27/21 at 05:17 PM observed the chemical log for the kitchen dishwasher sanitization was missing 13 entries for the breakfast shift, 15 entries for the lunch shift, and 22 entries for the dinner shift. The Food Storage policy revised 04/06/21 documented: Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety . Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration. Leftover food items must be discarded after 7 days . Check refrigerator temperature regularly. Check freezer temperature regularly. The Refrigerator/Freezer Temperatures revised 04/27/20 documented: In order to ensure all perishable food stays fresh and palatable, temperatures will be recorded on all refrigerators and freezers in use, including unit refrigerators in nourishment rooms . Dining Services will be responsible for taking temperatures on all kitchen and nourishment room refrigerators and freezers, and recording temperatures on temperature logs daily, during each shift. The Employee Health Program and Infection Control policy revised 08/31/21 documented: At the time of hire and at least annually thereafter, employees will receive training regarding personal health standards and the spread of communicable disease .As part of the infection control program, all employees will be trained on proper hand washing, proper glove use, appropriate use of personal protective equipment (PPE), and universal infection control precautions. The Use of Shell Eggs and Pasteurized Eggs and Procedure for Undercooked Eggs policy documented: Pasteurized eggs or egg products shall be used when little or no cooking is required . Pasteurized eggs or egg products shall be used when eggs are served undercooked and for fried eggs. Waivers to allow undercooked unpasteurized eggs for resident preference are not acceptable since pasteurized eggs are available and allow for safe consumption. The facility failed to properly store food in the main kitchen refrigerator and two nourishment room refrigerators due to the lack of temperature monitoring; to discard expired food times before the expiration date; to ensure the dishes and cookware were washed under sanitary conditions due to the lack of chemical or temperature monitoring; to store clean pots and pans separate from used, soiled pots and pans; to use appropriate hand hygiene when handling food; to prepare potentially hazardous foods free from potential food-borne pathogens by providing pasteurized eggs for resident's requests for soft or undercooked eggs; and to serve food in accordance with professional standards for food service safety, ensuring the residents remain free from infections, when observations revealed dietary staff did not hold, deliver, and transport resident food/cups in a sanitary manner.