The facility reported a census of 47 residents. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the residents of the facility to prevent possible food-borne illnesses. Findings included: - On 02/13/24 at 08:36 AM, a kitchen tour with Dietary Staff BB identified the following concerns: 1. An uncovered trash can/ barrel uncovered, at the handwashing station. 2. A gallon bottle of opened Worchester sauces with a sticky brown hardened rim around the exterior of the gallon jug. 3. The floor soiled with a black substance and debris throughout the kitchen and dish room. 4. A pot rack had rusted legs. 5. A commercial can opener, with a pointed spike that enters the sealed container of food, had black debris hardened on the spike and metal within the bracket used for storage. 6. Eleven flat baking sheets had a brown substance on the cooking surface of the pan, which was reported to be in direct contact with the food. On 02/13/24 at 08:36 AM, kitchen tour with Dietary Staff BB confirmed the above findings. He stated the identified areas of concern should be corrected to provide safe sanitary food preparation for the residents. On 02/14/24 at 11:45 AM, the commercial vent hood over the stove in the food preparation area had a bubbled appearance and missing paint on the exterior of the hood. Dietary Staff CC confirmed and stated the hood had been like that and should be fixed to prevent flaking paint in the food during food prep. The facility lacked a policy to address the repair and maintenance of the kitchen to provide a safe and sanitary operation during food preparation. The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the residents of the facility.

The facility reported a census of 47 residents. Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary environment for residents and staff in the facility kitchen for the residents of the facility to help prevent the development and transmission of infections. Findings included: - On 02/13/24 at 08:36 AM, during the kitchen tour with Dietary Staff BB identified the following concerns: 1. The dish room hand washing sink with an uncovered trash barrel/can which lacked a foot operated lid closure to prevent the staff from having to touch the lid to dispose of paper towels. 2. The food prep area with a barrel trash at the handwashing sink, with an uncovered trash barrel/can which lacked a foot operated lid closure to prevent the staff from having to touch the lid to dispose of paper towels 3. The kitchen and dish room floor with black substance and debris throughout. 4. The dish room had approximately 30 four-inch tiles missing with black substance build up on floor, which could not be sanitized. 5. A metal shelving unit with soiled vinyl/linoleum covered the bottom shelf which contained eight dish racks. The legs of the shelving unit had rust which could not be sanitized. 6. A food preparation area had a hanging rack for pots and pans with rusty poles, which were unable to be sanitized. 7. The commercial spike can opener had black debris hardened on the spike and inside the metal bracket mounted on the food prep counter which stored the can opener. On 02/13/24 at 08:46 AM, Dietary Staff BB confirmed the above findings and stated the identified concerns prevented the areas from being sanitized. The facility lacked a policy to address to appropriate trash/garbage disposal in the kitchen to prevent cross contamination. Additionally, the facility lacked a policy to address the repair and maintenance of the kitchen equipment to prevent cross contamination and the spread of infection The facility failed to provide a safe, functional, sanitary environment for residents and staff in the facility kitchen to prevent possible contamination.

The facility reported a census of 47 residents. Based on observation, interview, and record review, the facility failed to maintain all mechanical and electrical equipment in safe operating condition in the kitchen. Findings included: - On 02/13/24 at 08:36 AM, kitchen tour with Dietary Staff BB revealed the following identified concerns: 1. Eight dish racks stacked on a metal stand that had soiled vinyl linoleum which covered the shelf. The shelf had rust on the legs. 2. A commercial spike can opener had a build-up of hardened black debris on the spike which enters the sealed can of food, and metal black dried hard substance within the bracket which housed the can opener. 3. The upright poles attached to the pot rack were rusted. On 02/13/24 at 08:45 AM, Dietary Staff BB confirmed the above findings and stated the equipment needed to be cleaned and maintained for safe operation. On 02/14/24 at 11:45 AM, the commercial stove hood had bubbled peeled paint. Dietary Staff CC confirmed the above finding and stated the stove hood had been like that for a while. Dietary Staff BB confirmed the above finding and stated the equipment needed to be cleaned and maintained for safe operation. The facility lacked a policy to address repair and maintenance of equipment in the kitchen in safe operation condition. The facility failed to maintain all mechanical and electrical equipment in safe operating condition in the kitchen.

The facility reported a census of 47 residents. Based on observation, interview, and record review the facility failed to ensure a safe and sanitary environment for residents and staff in the facility kitchen. Findings included: - On 02/13/24 at 08:36 AM, kitchen tour with Dietary Staff BB, revealed the dish room floor with approximately 30, four-inch tiles missing with black substance build up on the bare concrete where the floor tiles were missing. On 02/13/24 at 08:55 AM, Maintenance Staff U, joined the kitchen tour and confirmed the above finding. He stated the tile had been missing for a while. The facility usually placed a rubber mat over the missing tile. Maintenance Staff U confirmed the area was a trip hazard and was unsanitizable. On 02/14/24 at 10:42 AM, during additional tour of the kitchen, two wall tiles laid on the windowsill in food prep area. On 02/14/24 at 10:54 AM, Dietary Staff BB and dietary staff CC confirmed the above finding, and reported they did not know why or how long the tiles had been lying in the windowsill. The facility lacked a policy to address maintenance and repair related to the kitchens safe and sanitary environment. The facility failed to ensure a safe and sanitary environment for residents and staff in the facility kitchen.

The facility had a census of 43 residents with 13 included in the sample. Based on observation, interview and record review the facility failed to ensure the resident's dignity by the failure to place the catheter drainage bag in a dignity bag and away from public view for Resident (R) 29. Findings include: - R29's 02/02/22 signed Physician Orders revealed diagnoses of neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system) and dementia (progressive mental disorder characterized by failing memory, confusion). The 10/25/22 Significant Change in Status Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident required extensive assistance from one staff for daily care, had a urinary catheter, and received hospice care. The 01/25/22 Quarterly MDS revealed no significant changes in status since the 10/25/22 MDS assessment. The 10/25/22 Urinary Incontinence Care Area Assessment (CAA) revealed the resident continued to require an indwelling urinary catheter and the staff change the catheter monthly and as needed (PRN) per physician orders. The 09/30/22 Care Plan revealed the resident had an indwelling urinary catheter and staff were to position the catheter bag and tubing below the level of the bladder and away from entrance room door. Observation on 03/21/22 at 11:29 AM revealed the resident's catheter bag hung on the side of bed, not in a dignity bag and urine visible in the bag. The bag was visible from the hallway outside the resident's room to anyone who passed by. Observation on 03/21/22 at 02:58 PM revealed the resident remained in bed, with the catheter bag hung on the side of the bed without a dignity bag. On 03/22/22 at 07:55 AM, the resident sat in a wheelchair in the dining room for breakfast. The resident's urinary catheter tubing resting on the floor, with the drainage bag hung mostly out of the dignity bag, not fully covering the bag and urine visible in the bag. On 03/22/22 at 08:00 AM the resident moved to a different table in the dining room propelled by Certified Nursing Assistant (CNA) K. The catheter tubing drug on the floor as they moved to the other table and the bag was almost completely out of the dignity bag as it hung under chair. On 03/23/22 at 10:25 AM Licensed Nurse (LN) L entered the resident's room to look at the resident's catheter bag. The bag hung on the bed frame with urine visible in the bag. No dignity bag or privacy flap noted on the drainage bag. On 03/22/22 at 0:800 AM CNA K reported he would get a dignity bag for the resident's catheter. He was from an agency, but knew the catheter needed to be in a dignity bag. On 03/22/22 at 01:20 PM CNA M reported the catheter should be in a dignity bag. She reported she did not know the tubing drug on the floor that morning, but knew the dignity bag was torn and not covering the urine collection bag. On 03/23/22 at 10:15 AM LN L reported the catheter bags the facility used had a privacy flap over the bag, so there was no need for a dignity bag. LN L reported the hospice staff must have changed R29's urinary collection bag, but acknowledged the bag should have been covered either by the facility bag with the privacy flap or with the dignity bag and verified neither were in place. The facility did not have a policy regarding dignity bags for urinary catheter drainage bags. The facility failed to protect the dignity of R29 when staff did not ensure the use of a dignity bag to cover the urinary catheter bag that was visible to the public.

The facility had a census of 43 residents with three reviewed for Beneficiary Protection Notification. The facility failed to provide notification (CMS form 10055) prior to ending Medicare Part A coverage for Resident (R) 99, which did not provide the resident the opportunity to dispute the decision to discontinue therapy services. Findings included: - On the Beneficiary Notice Discharge List R99 discharged from Part A skilled therapy on 02/09/22. Review of R99's record revealed the facility failed to have prior notification of the discharge date of therapy. The record lacked completion of CMS form 10055 signed by the resident or representative prior to the resident's discharge. On 03/23/22 at 08:36 AM Administrative Nurse I reported she was responsible for the beneficiary notices when residents discharged from therapy services. She stated she met with the director of therapy services every morning to discuss resident progress and therapy progress. When discharge was coming up for a resident, she then talked to Social Services Designee (SSD) C who then worked with the resident and family to make discharge plans whether staying in the facility or going home. He set up services such as home health visits if the resident was going home. She reported when R99 discharged she just returned from vacation and missed getting it done. No discharge notice was given to the resident with the information about an appeal listed on the discharge. The resident then discharged to an Assisted Living facility. The facility failed to provide notification (CMS form 10055) prior to ending Medicare Part A coverage for Resident (R) 99, which did not provide the resident the opportunity to dispute the decision to discontinue therapy services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 43 residents with 13 sampled, including one for hospitalization. Based on observation, interview, and record review the facility failed to send a copy of the facility-initiated hospitalization transfer/discharge notice to the representative of the Office of the State Long-Term Care Ombudsman for Resident (R) 28. Findings Included: - Review of R28's Minimum Data Set (MDS) tracking form documented the resident discharged to the hospital on [DATE] and returned to the facility on [DATE]. Review of R28's Medical Record lacked evidence of written notification of the facility-initiated hospitalization transfer/discharge to R28's Office of the State Long-Term Care Ombudsman. On 03/21/22 at 02:14 PM R28 sat in her wheelchair outside of her room and used her legs to move her wheelchair toward the dining room. Several staff through the area stop and spoke to R28, offered her assistance, snacks, and drinks. On 03/22/22 at 02:09 PM Social Service Designee (SSD) C confirmed he did not send a notice to the Office of the State Long-Term Care Ombudsman when a resident discharged to the hospital. On 03/22/22 at 03:09 PM Administrative Nurse B confirmed no notice was sent to the Office of the State Long-Term Care Ombudsman when the resident transferred to the hospital. She stated she did not know that a notice was needed. On 03/23/22 at 10:15 AM Administrative Nurse B stated if no policy was provided, the facility used the Regulation for their policy. The facility failed to send a copy of the notice of facility-initiated hospitalization transfer/discharge to a representative of the Office of the State Long-Term Care Ombudsman when R28 transferred to the hospital.

The facility reported a census of 43 resident with 13 residents included in the sample and two residents reviewed for respiratory care. Based on observation, interview, and record review the facility failed to ensure Resident (R)148's plan of care included changing of nebulizer tubing, and cleaning of respiratory equipment in a timely manner. Findings included: - The 12/22/21 signed Physician Orders for R148 included a diagnosis of chronic pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The 12/29/21 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The Plan of Care dated 12/22/21 indicated R148 had potential for respiratory distress related to a diagnosis of chronic obstructive pulmonary disease, staff would administer breathing treatments as ordered, and staff would monitor for effectiveness. The care plan lacked any further direction to staff regarding changing nebulizer tubing and/or cleaning of respiratory equipment. Review of the Medication Administration Record (MAR) revealed R148 received a nebulizer treatment of Ipratropium-Albuterol solution 0.5 - 2.5 milligrams (mg) three milliliters (ml) inhale orally two times a day for shortness of air. Review of the MAR and Treatment Administration Record (TAR) from 12/22/21 to 03/17/22 lacked documentation for staff to clean the nebulizer after each use, and/or when to change the resident's nebulizer mask and or tubing. Observation on 03/22/22 at 08:04 AM revealed the resident's nebulizer had leftover fluid in the base still connected to the mask and crusty material observed inside the mask. The date on the tubing was noted as 01/17/22. Interview on 03/23/22 at 12:35 PM Administrative Nurse B stated she would expect the information related to changing tubing and cleaning the nebulizer to be placed on the care plan. The facility failed to provide a policy regarding respiratory care as requested on 03/23/22. The facility failed to ensure the plan of care included to change R148's nebulizer tubing, and or direction to staff on cleaning of respiratory equipment.

The facility reported a census of 43 with 13 residents included in the sample. Based on observations, interviews, and record review the facility failed to ensure Resident (R) 148 received appropriate assessments and foot care. Findings include: - The 12/22/21 signed Physician Orders included a diagnosis of type two diabetes (a disease in which the body's ability to produce or respond to the hormone insulin is impaired, resulting in abnormal metabolism of carbohydrates and elevated levels of glucose in the blood and urine). The 12/29/21 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The Activities of Daily Living (ADL) Care Area Assessment (CAA) dated 12/29/21 stated the resident was independent with ADLs except required some assistance for balance with mobility. The 12/22/21 Care Plan indicated R148 needed assistance of one staff member with dressing and personal cares. The care plan lacked information to provide diabetic foot care. Review of the Medical Record from 12/22/21 to 03/17/22 lacked an admission skin assessment and weekly skin assessments. Observation on 03/21/22 at 09:23 AM, R148 removed a sock from her left foot revealing long toenails which curved towards the her little toe. Observation on 03/22/21 at 08:02 AM revealed R148 ambulating in the hallway with gripper socks on both feet with no complaints of pain. Interview on 03/22/22 at 07:11 AM with Certified Nurse Aide (CNA) G revealed she informed the nurse about R148's nails about two and half weeks ago, but had not seen her toenails since then. Interview on 03/23/22 at 07:33 AM with Licensed Nurse (LN) E indicated the skin assessment should be completed on admission and weekly. LN E did not hear R148 complain about her toenails. Interview on 03/22/22 at 02:50 PM with Social Services Designee (SSD) C revealed SSD C set up the appointments with the podiatrist, but due to COVID, he has not came to the facility for about eight months. On 03/23/22 at 12:35 PM Administrative Nurse B stated she expected the nurses to complete a skin assessment upon admission and then weekly. The facility's Wound Prevention and Management policy revised on 12/2018 stated the facility's Licensed Nurse was responsible for weekly assessments of skin for all residents and should document findings in the Skin Condition Note in the electronic medical record. The facility failed to complete an admission skin assessment including the feet of diabetic R148, complete weekly skin assessments, and to provide appropriate foot care.

The facility census totaled 43 residents with 13 included in the sample, and one reviewed for urinary catheter. Based on observation, interview, and record review the facility failed to provide necessary services to decrease the risk of a urinary tract infection when staff failed to ensure Resident (R) 29 urinary catheter tubing did not come in contact with the floor. Findings included: - R29's signed Physician Orders dated 02/02/22 revealed the following diagnoses: neurogenic bladder (dysfunction of the urinary bladder caused by a lesion of the nervous system) and dementia (progressive mental disorder characterized by failing memory, confusion). The 10/25/21 Significant Change in Status Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The resident required extensive assistance of one staff for daily care. The resident had a urinary catheter and received hospice care. The 01/25/22 Quarterly MDS revealed no significant changes in status since assessment on 10/25/21. The 10/25/21 Urinary Incontinence Care Area Assessment (CAA) revealed the resident continued to require an indwelling urinary catheter for neuropathic bladder. Staff change the catheter monthly and as needed (PRN) per physician orders. The 09/30/21 Care Plan revealed the resident had an indwelling urinary catheter related to neurogenic bladder. Staff were to position the catheter bag and tubing below the level of the bladder and away from entrance room door. Monitor/record/report to nurse signs of a urinary tract infection (UTI): pain, burning, blood tinged urine, cloudiness, no output, deepening or urine color, increased pulse, increasing temp, urinary frequency. Staff to provide catheter care every shift. The Physician Order dated 01/15/22 ordered staff to change the urinary catheter monthly and as needed (PRN). Observation on 03/22/22 at 07:55 AM revealed the resident sat in a wheelchair in the dining room for breakfast. The resident's urinary catheter tubing drug on the floor. Observation on 03/22/22 at 08:00 AM revealed the resident moved to different table in the dining room by Certified Nurse Aide (CNA) K. The catheter tubing drug on the floor as they went by, with the urinary catheter bag hung under the chair. On 03/22/22 at 08:00 AM CNA K reported he knew the catheter tubing needed to be off of the floor. On 03/22/22 at 01:20 PM CNA M reported she did not know the tubing drug on the floor early that morning. On 03/23/22 at 10:15 AM Licensed Nurse (LN) L reported the catheter tubing should always remain off the floor. LN L reported Hospice staff must have changed the resident's urinary collection bag but acknowledged the bag should have been off the floor. The facility did not provide a policy regarding catheter care, as requested on 03/23/22 at 08:00 AM. The facility failed to provide necessary services to decrease the risk of a urinary tract infection when staff failed to ensure Resident (R) 29 urinary catheter tubing did not come in contact with the floor.

The facility reported a census of 43 resident, with 13 residents included in the sample, and two residents reviewed for respiratory care. Based on observation, interview, and record review the facility failed to ensure they had a system in place to change oxygen tubing, nebulizer tubing, and cleaning of respiratory equipment in a timely manner for Residents (R) 148 and R25. Findings included: - The 12/22/21 signed Physician Orders for R148 included a diagnosis of chronic pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). Them12/29/21 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The Plan of Care dated 12/22/21 indicated R148 had a potential for respiratory distress related to a diagnosis of chronic obstructive pulmonary disease, staff would administer breathing treatments as ordered, and staff would monitor for effectiveness. The care plan lacked any further direction to staff regarding changing oxygen and nebulizer tubing and/or cleaning of respiratory equipment. Review of the Medication Administration Record (MAR) revealed R148 received a nebulizer treatment of Ipratropium-Albuterol solution 0.5 - 2.5 milligrams (mg) three milliliters (ml) inhale orally, two times a day for shortness of air. Review of the (MAR) and Treatment Administration Record (TAR) from 12/22/21 to 03/17/22 indicated a lack of documentation for staff to clean the nebulizer after each use, and/or when to change the resident's nebulizer mask and or tubing. Observation on 03/22/22 at 08:04 AM revealed the resident's nebulizer had leftover fluid in the base and was still connected to the mask. The mask had crusty material observed to the inside the mask. The date on the tubing was noted as 01/17/22 (over two months prior). Observation on 03/23/22 at 09:25 AM revealed R148 received a breathing treatment per mask and after completing the treatment R148 laid the mask and tubing on her nightstand. Observation on 03/23/22 at 10:10 AM the resident's nebulizer remained laid on the bedside table in the same position and no signs the staff had disconnected and rinsed the equipment. Interview on 03/22/22 at 09:35 AM with R148 revealed she removed the nebulizer mask after the treatment was complete. R148 stated the staff did not come into her room and rinse the equipment out. Interview on 03/22/22 at 01:06 PM with Certified Medication Aide (CMA) J revealed the nurse provided the nebulizer treatment and cleaned the equipment after each use. CMA J stated they changed the tubing weekly and marked the tubing with a piece of tape or on the tubing itself. Interview on 03/23/22 at 07:33 with Licensed Nurse (LN) E revealed the nebulizer should be cleaned after each use and the tubing and mask should be changed on a weekly basis. Interview on 03/23/22 at 12:35 PM Administrative Nurse B stated she expected the licensed nurse to rinse the nebulizer out after each use, place it on a paper towel in the resident's room, and expected the staff to change out the tubing and mask weekly. She further expected the information be placed on the care plan and MAR/TAR. The facility failed to provide a policy regarding respiratory care as requested on 03/23/22. The facility failed to ensure a system to change R148 oxygen tubing, nebulizer tubing, and cleaning of respiratory equipment. - Review of R25's signed Physician Orders dated 02/24/22 included a diagnosis of chronic obstructive pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). The 01/20/22 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The resident had shortness of breath with exertion, sitting, and at rest. The Baseline Care Plan dated 03/21/22 revealed the resident had a potential for respiratory distress related to a diagnosis of chronic obstructive disorder, staff would monitor for signs and symptoms of respiratory distress, and the resident used oxygen use to assist with their breathing. Review of the Medical Record dated 03/10/22 revealed an order for oxygen at four liters per nasal cannula continuously, every shift. Observation 03/22/22 at 08:07 AM revealed oxygen tubing in the resident's room with no markings to indicate the last time staff changed out the tubing. Interview on 03/22/22 at 01:12 PM with Certified Nurse Aide (CNA) J revealed they changed the oxygen tubing out weekly and did not mark the tubing. Interview on 03/23/22 at 07:46 AM with Licensed Nurse (LN) E revealed the oxygen tubing changes should be documented on either the MAR/TAR when staff competed the task. Interview on 03/23/22 at 12:40 PM with Administrative Nurse B revealed she expected the tubing to be changed weekly and documented on the (MAR/TAR) and plan of care. The facility failed to provide a policy regarding respiratory care as requested on 03/23/22. The facility failed to ensure a system in place to change oxygen tubing, nebulizer tubing, and cleaning of respiratory equipment in an timely manner.

The facility census totaled 43 residents with 13 sampled including five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to initiate a physician's order for a dose reduction for an antipsychotic medication, as recommended by consulting pharmacist, for six months for Resident (R) 33. The facility further failed to limit the time frame of an as needed (PRN) psychotropic medication, as recommended by the consulting pharmacist, for R28. Findings Included: - R28's Physician's Orders Sheet dated 03/21/22 documented a diagnosis of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The 01/18/22 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident was unable to complete the interview. R28 received an antianxiety medication on one day in the seven-day look back period. The 03/21/22 Care Plan for R28 instructed staff to administer medications and monitor for side effects as ordered by the physician. The Physicians Orders in the electronic health record (EHR) documented the following orders for lorazepam 0.5 milligrams (mg) as needed (PRN): Order dated 01/10/22 and discontinued on 02/01/22 for a total of 22 days Order dated 02/01/22 and discontinued on 03/21/22 for a total of 48 days Review of the monthly pharmacy Medication Record Review (MRR) for 01/21/22 with the recommendation PRN psychotropic orders cannot exceed 14 days with the exception that the prescriber documents their rationale in the residents medical record and indicate the duration for the prn order. Please address the noncompliant PRN lorazepam order. Review of R28's EHR lacked documentation from the provider for a rationale to continue use of PRN for longer than the 14 days. On 03/21/22 at 02:14 PM R28 sat in her wheelchair outside of her room and used her legs to move her wheelchair toward the dining room. Several staff through the area stopped and spoke to R28, offered her assistance, snacks, and drinks. On 03/22/22 at 01:43 PM Certified Medication Aid (CMA) J stated R28 took her medications crushed and that she would usually take her medications. She stated when R28 was upset or anxious, she would move through the facility in her wheelchair and try to stand up without assistance. On 03/22/22 at 03:09 PM Administrative Nurse B stated the consultant pharmacist would email the recommendations to her and her Assistant Director of Nursing. Administrative Nurse B would print them off, the medical records staff would complete the nursing portion, and the nurse practitioner for the provider would sign and complete physician portion. She stated she expected the nursing staff to be mindful of the PRN orders for the residents and assist with keeping them at the 14-day limit. Unable to interview pharmacist with attempts made to contact the Consulting Pharmacist on 03/23/22 and 03/24/22 at 12:34 PM. The facility's Medication Regimen Review and Reporting policy revised 09/18 documented that the nursing center would follow up on recommendations to verify that appropriate action was taken. Recommendations would be acted upon within 30 calendar days. The facility failed to adequately monitor the use of psychotropic medications for R28 by the failure to limit the PRN antianxiety medication to 14 days, as recommended by the consulting pharmacist, to ensure the lowest effective dose received and ensure minimal side effects. - Resident (R)33's signed Physician Orders dated 02/02/22 revealed the following diagnoses: major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and vascular dementia (progressive mental disorder characterized by failing memory, confusion). The 05/13/21 admission Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The resident had no behaviors, had rejection of care one to three days of the observation period, and did not recieve psychotropic medications in the seven day review period. The Quarterly MDS dated 02/02/22 revealed verbal behaviors one to three days of the observation period. The resident received an antipsychotic medication seven days of the observation period. The Care Plan dated 02/17/22 revealed the resident received therapeutic psychotropic medications. The resident received Seroquel (antipsychotic) for agitation, verbal aggression mood/behavior and psychosocial problems and could be manipulative, passive/aggressive and attention seeking. The Physician Orders dated 06/15/21 revealed Seroquel Tablet 25 milligrams (MG) give one tablet by mouth at bedtime related to major depressive disorder. The Consulting Pharmacist Monthly Medication Regimen Report revealed a pharmacist request for a gradual dose reduction (GDR) of Seroquel 25 mg to 12.5 mg on 10/13/21. Physician reported the resident's condition was stable and agreed to decrease with a signed order to decrease the medication to 12.5 mg. The Consulting Pharmacist Medication Regimen Reviews dated 11/11/21, 12/21/21, 01/21/22 and 02/20/22 made no mention of the Seroquel dose not being decreased as ordered on 10/13/21. The Medication Administration Record dated 10/21, 11/21, 12/21, 01/22, 02/22 and 03/22 revealed the Seroquel dose remained unchanged at 25 mg. The resident received Seroquel 25 mg every day since the order was to be decreased to 12.5 mg. Observation on 03/21/22 at 01:20 PM revealed the resident walked down the hall and came across a dietary staff standing with a cart by the elevator. The resident made very rude comments to the staff before the staff got on the elevator. The resident walked off as if nothing happened. The resident declined an interview on 03/21/22 at 09:30 AM. On 03/22/22 at 10:24 AM Certified Medication Aide (CMA) J stated she would report to the nurse if the resident had behaviors. She would also report if she saw the resident with increased sleepiness or not acting herself. On 03/22/22 at 01:40 PM Licensed Nurse (LN) E reported the resident would have behaviors like yelling and cursing if you told her she could not do something or have something. When she has behaviors the nurse charts them in the nurse's notes. The Certified Nursing Assistants (CNA) will chart it and then tell us and we will assess the resident. On 03/22/22 at 04:00 PM, Administrative Nurse L reviewed the physician order and agreed the medication should have been decreased. On 03/23/22 at 11:30 AM Administrative Nurse B reported she was made aware of the medication error and contacted the physician. Administrative Nurse B reported she obtained a new order to decrease the medication and to monitor for resident behaviors. She received the pharmacy consults monthly but missed the order for the medication. Attempted to interview the pharmacist on 03/23/22 at 12:17 PM and on 03/24/22 with no contact made. The facility policy Medication Regimen Review and Reporting dated 09/2018 revealed the consultant pharmacist reviewed the medication regimen and medical chart of each resident at least monthly to appropriately monitor the medication and ensure the medications each resident received were clinically indicated. The facility failed ensure the Consultant Pharmacist identified continued use of an antipsychotic medication without a GDR and the facility failed to implement the physician order for a GDR in response to the pharmacist's recommendation.

The facility census totaled 43 residents, with 13 sampled, including five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to initiate a physician's order for a dose reduction for an antipsychotic medication for six months for Resident (R) 33. The facility further failed to limit the time frame of an as needed (PRN) psychotropic medication for R28. Findings Included: - R28's Physician's Orders Sheet dated 03/21/22 documented a diagnosis of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear). The 01/18/22 Significant Change Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 99, which indicated the resident was unable to complete the interview. R28 received an antianxiety medication on one day in the seven-day look back period. The 03/21/22 Care Plan for R28 instructed staff to administer medications and monitor for side effects as ordered by the physician. The Physicians Orders in the electronic health record (EHR) documented the following orders for lorazepam 0.5 milligrams (mg) as needed (PRN): Order dated 01/10/22 and discontinued on 02/01/22, for a total of 22 days. Order dated 02/01/22 and discontinued on 03/21/22, for a total of 48 days. On 03/21/22 at 02:14 PM R28 sat in her wheelchair outside of her room and used her legs to move her wheelchair toward the dining room. Several staff through the area stopped and spoke to R28, offered her assistance, snacks, and drinks. On 03/22/22 at 01:43 PM Certified Medication Aid (CMA) J stated R28 took her medications crushed and usually take her medications. She stated when R28 was upset or anxious she would move through the facility in her wheelchair and try to stand up without assistance. On 03/22/22 at 03:09 PM Administrative Staff B stated she expected the nursing staff to be mindful of the PRN orders for the residents and assist with keeping them at the 14-day limit. Telephone attempts to interview the consulting pharmacist on 03/23/22 and 03/24/22 at 12:34 PM with no contact made. The facility's Medication Regimen Review and Reporting policy revised 09/2018 documented the nursing center would follow up on recommendations to verify that appropriate action was taken. Recommendations would be acted upon within 30 calendar days. The facility failed to adequately monitor the use of psychotropic medications for R28 by the failure to limit the PRN antianxiety medication to 14 days to ensure the lowest effective dose received and ensure minimal side effects. - R33's signed Physician Orders dated 02/02/22 revealed the following diagnoses: major depressive disorder (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness, emptiness and hopelessness), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), and vascular dementia (progressive mental disorder characterized by failing memory, confusion). The 05/13/21 admission Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The resident had no behaviors and had rejection of care one to three days of the observation period and did not receive psychotropic medications in the seven-day review period. The 02/02/22 Quarterly MDS revealed R33 had verbal behaviors one to three days of the observation period. The resident received psychotic medication daily in the seven-day review period. The Care Area Assessment (CAA) dated 05/13/21 had all appropriate triggers. The Care Plan dated 02/17/22 revealed the resident received therapeutic psychotropic medications. The resident received Seroquel (antipsychotic) for agitation verbal aggression mood/behavior and psychosocial problems and could be manipulative, passive/aggressive and attention seeking. The resident needed to develop a trusting, therapeutic relationship with others. Staff to allow the resident to express her emotions without judgement or criticism. Staff to encourage the resident to participate in activities of her choice. Assist the resident to develop more appropriate methods of coping and interacting with staff. Staff to intervene as necessary to protect the rights and safety of others. Speak to the resident in a calm voice, divert attention. Remove from the situation and take to alternate location as needed. Refer the resident to have psychological referral. The 06/15/21 Physician Orders revealed Seroquel Tablet 25 milligrams (MG) give one tablet by mouth at bedtime related to major depressive disorder. The Consulting Pharmacist Monthly Medication Regimen Report revealed a pharmacist request for a gradual dose reduction (GDR) of Seroquel 25 mg to 12.5 mg on 10/13/21. Physician reported the resident's condition was stable and agreed to decrease with a signed order to decrease the medication. The Medication Administration Record for the months of 10/21, 11/21, 12/21, 01/22, 02/22 and 03/22 revealed the Seroquel dose remained unchanged at 25 mg. The resident received Seroquel 25 mg every day since the order was to be decreased to 12.5 mg. Observation on 03/21/22 at 01:20 PM revealed the resident walked down the hall and came across a dietary staff standing with a cart by the elevator. The resident made very rude comments to the staff before the staff got on the elevator. The resident walked off as if nothing happened. The resident declined an interview on 03/21/22 at 09:30 AM. On 03/22/22 at 10:24 AM Certified Medication Aide (CMA) J stated she would report to the nurse if the resident had behaviors. She would also report if she saw the resident with increased sleepiness or not acting herself. On 03/22/22 at 01:40 PM Licensed Nurse (LN) E reported the resident would have behaviors like yelling and cursing if you told her she could not do something or have something. When she has behaviors the nurse charts them in the nurse's notes. The Certified Nursing Assistants (CNA) will chart it and then tell us and we will assess the resident. On 03/22/22 at 04:00 PM the pharmacy consult and the physician order was given to Administrative Nurse L and Administrative Staff A and told Administrative Nurse L about the medication error. On 03/23/22 at 11:30 AM Administrative Nurse B reported she was made aware of the medication error and contacted the physician. Administrative Nurse B reported she obtained a new order to decrease the medication and to monitor for resident behaviors. Attempted to interview the pharmacist on 03/23/22 at 12:17 PM and on 03/24/22 with no contact made. The facility policy Medication Regimen Review and Reporting dated 09/18 revealed the nursing care center followed up on the recommendations to verify appropriate action was taken. Recommendations shall be acted upon within 30 calendar days. The facility failed to initiate a doctor's orders for a dose reduction of an antipsychotic medication for six months for R33.

The facility reported a census of 43 residents. Based on observation, interview, and record review the facility failed to ensure nursing staff used Personal Protective Equipment (PPE) appropriately, by the failure to change gloves between dirty and clean tasks when providing care for Residents (R) 23 and R9. The facility further failed to clean a glucometer (instrument used to calculate blood glucose) after use to reduce the risk of spread of infectious diseases. Findings Included: - On 03/21/22 at 08:50 AM, observation revealed Certified Medication Aid (CMA) J and Administrative Nurse I entered R23's room and informed R23 of care to be provided. Both staff performed hand hygiene and donned gloves, positioned R23 with shorts down and brief open lying on his side. While Administrative Nurse I held R23 on his side, CMA J cleaned the bowel movement (BM) off of R23 with gloved hands and wipes, then cleaned R23's front side, CMA J continued with the same gloved hands to close R23's brief, pull up his shorts, and cover him with a blanket. CMA J then continued, with dirty/same gloved hands, to adjust her mask. CMA J then moved the lift sling to R23's wheelchair and moved the wheelchair to a position in front of R23's nightstand. CMA J then removed the gloves and performed hand hygiene. On 03/21/22 at 09:20 AM, observation revealed CMA J and Administrative Nurse I performed hand hygiene and entered R9's room. Informed R9 of care to be provided and positioned R9 on his side with his brief open. Administrative Nurse I cleaned R9's BM with gloved hands and wipes, retrieved a tube of barrier cream, and applied it to R9. With the same gloved hands, she then scratched her head, adjusted R9 in bed, adjusted the resident's hospital gown, adjusted R9's feeding tube, and placed the bed control within R9's reach. Administrative Nurse I then placed the wipes and barrier cream tube in the resident's nightstand drawer and then removed her gloves and performed hand hygiene. On 03/21/22 at 08:50 AM CMA J confirmed she was educated on infection control procedures and donning and doffing of PPE. She confirmed she should have changed her gloves between dirty and clean fields. On 03/21/22 at 09:20 AM Administrative Nurse I confirmed she should have changed her gloves between clean and dirty fields. She stated she was educated on infection control procedures of donning and doffing PPE. On 03/22/22 at 07:38 AM Administrative Nurse H confirmed all staff were trained in donning and doffing PPE and she completed competency audits with several staff. She would expect all staff to perform hand hygiene between glove use as well as change gloves from dirty to clean fields. On 03/23/22 at 08:26 AM Administrative Nurse B stated her expectation would be that all staff use PPE appropriately with changing gloves to be at the top of the list. The facility Infection Management Process policy revised December 2019 documented the staff were educated on proper hand hygiene. The facility failed to ensure staff changed gloves between dirty and clean tasks when providing cares for R23 and R9. - Observation on 03/22/22 at 07:52 AM revealed Licensed Nurse (LN) O checked the blood sugar for R10 using a glucometer (instrument used to calculate blood glucose). The nurse donned gloves and cleaned the resident's finger with alcohol. LN O then used a lancet (sharp object to pierce the skin to obtain a blood sample) to draw blood and placed a small drop of blood onto the glucometer strip. LN O then cleaned the resident's finger and LN O took gloves off and took the glucometer out of the resident's room. LN O then put the glucometer in the box filled with cotton balls and lancets before cleaning the machine. On 03/22/22 at 8:00 AM LN O reported staff used the glucometer for all residents receiving blood sugar checks and she probably should have cleaned it before she put it away. Observation on 03/22/22 at 08:02 AM Administrative Nurse B walked up to the medication cart and gave the nurse a towelette to clean the glucometer. Nurse O then cleaned the machine. On 03/22/22 at 08:02 AM Administrative Nurse B reported the glucometer should be cleaned between each use. The facility policy for Infection Management Process dated 12/2019 revealed glucometers will be properly sanitized between each use. The device will be wiped with products that kill c-diff spores and blood borne pathogens. Staff will be educated on appropriate dry time before using. The facility failed to clean a glucometer after use to reduce the risk of spread of infectious diseases.

The facility reported a census of 43 residents one main kitchen that served all residents that received meals. Two residents received nutrition via feeding tubes. The facility failed to store food in a sanitary manner in the main kitchen. Findings Included: - Tour of the kitchen on 03/21/22 at 08:10 AM in the dry storage area revealed a large bag of Cheetos laid open on the shelf. Observation in the freezer revealed a bag of hamburger patties open with no closure, a bag with five fish fillets with no date, and a box of pizza dough left open to air. Interview on 03/23/22 at 01:10 PM with Certified Dietary Manager N verified she expected the staff to date all items when opened and all opened items should have proper closures. The facility policy Food Storage revised in 2011 stated food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. Wrap food properly and never leave food items uncovered and not labeled. The facility failed to store food in a sanitary manner in the main kitchen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 45 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to complete a comprehensive assessment after a significant change in status after Resident (R)19 admitted to hospice services on 07/24/20. Findings included: - Review of the signed Physician Order Sheet dated 08/11/20 documented diagnoses of Parkinson's disease (slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity and weakness) and adult failure to thrive (included not doing well, feeling poorly, weight loss, poor self-care that could be seen in elderly individuals). Review of the Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognitive function. The MDS documented R19 required supervision with the assistance of one staff member for most Activities of Daily Living (ADLs) and had an unsteady gait (manner or style of walking). Review of R19's MDS information lacked a comprehensive assessment after the significant change occurred on 07/24/20, when R19 admitted to hospice services. Review of the Physician's Order dated 07/24/20 instructed to refer R19 to hospice of choice for a diagnosis of adult failure to thrive. Review of the signed hospice document titled, Election of Hospice Medicare Benefit and Patient Authorization dated 07/24/2020 revealed consent from a legal representative for R19 to receive services hospice. An observation on 09/03/20 at 11:20 AM revealed R19 in her room seated on the side of her bed as the resident watched television. An interview on 09/02/20 at 01:08 PM with Administrative Nurse C stated the facility did not have a current in-house MDS coordinator and explained the nurses did the clinical review assessments and a corporate nurse completed the MDS offsite. An interview on 09/02/20 at 01:48 PM with Administrative Nurse B stated she communicated with the clinical reimbursement consultant regarding assessments and charting. When asked how the offsite consultant knew about non-scheduled comprehensive assessments such as when a significant change occurred, Administrative Nurse B stated she notified the offsite consultant. Administrative Nurse B stated she did not notify the offsite consultant regarding a significant change when R19 admitted to hospice care. An interview on 09/02/20 at 01:48 PM with Administrative Staff A stated the offsite clinical reimbursement consultant completed comprehensive assessments and confirmed R19 should have had a comprehensive assessment for a significant change when she signed on to receive hospice services. An email on 09/03/20 at 12:53 PM from Administrative Staff A stated the facility utilized the Resident Assessment Instrument RAI (comprehensive, standardized tool to assess residents in long-term care settings) manual for MDS comprehensive assessments regarding significant changes. The RAI indicated resident placement on hospice services did qualify as a significant change in status. The facility failed to complete a comprehensive assessment for a significant change after R19 admitted to hospice services.

The facility census totaled 45 residents with two medications rooms toured. Based on observation, interview, and record review the facility failed to remove three opened and expired medications to include, two vials of influenza vaccine (marked as opened on 01/23/20 and expired on 06/26/20) and one vial of tuberculosis serum (marked as opened on 04/22/20) the vial of tuberculosis serum still remained in the refrigerator 30 days after opening, in one medication room. Findings included: - Observation of one facility medication storage room refrigerator on 09/02/20 at 01:02 PM revealed it contained two vials of influenza vaccine, with an open date of 01/23/20 and an expiration date of 06/26/20. Continued observation of the medication storage room refrigerator revealed one package of tuberculosis serum with an open date 04/22/20 (over 30 days after opening). An interview on 09/03/20 at 01:51 PM with Administrative Nurse B revealed she expected the night nurse on duty to check the medication room and refrigerator nightly for expired medications and place any expired medications in a box for the pharmacy to destroy. Review of the Medication Storage policy dated 09/2016 revealed refrigerated medications kept in closed and labeled containers should be immediately removed from stock and disposed of for all outdated, contaminated, or deteriorated medications and those in containers that were cracked, soiled, or without secure closures. The facility failed to remove three expired vials of injectable medications from the one medication storage room refrigerator.