**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure the resident assessments accurately reflected the resident's status. The facility failed to ensure staff accurately: 1. Coded the discharge status for 1(#39) of 2 (#27 and #39) residents reviewed for hospitalizations. 2. Coded a resident reviewed for PASRR for 1 (#13) of 2 (#13 and #18) residents reviewed for PASRR. Findings: 1. Review of Resident #39's clinical record revealed that she was admitted to the facility on [DATE] and discharged from the facility on 12/11/2024. Review of Resident #39's MDS Discharge Assessment, dated 12/11/2024, revealed the resident was discharged to an acute hospital. Review of Resident #39's Nurses Notes revealed the following: in part: 12/11/2024 Resident #39 scheduled for discharge today with home health services. On 02/04/2025 at 4:17 p.m., an interview was conducted with S2MDS. She reviewed Resident #39's MDS Discharge Assessment, dated 12/11/2024, and confirmed it indicated Resident #39 discharged to an acute hospital. She further reviewed Resident #39's medical record and confirmed the resident was discharged home. She confirmed Resident #39's MDS Discharge Assessment was not coded correctly and should have been coded discharge to home. On 02/04/2025 at 4:22 p.m., an interview was conducted with S1DON. She was made aware of the findings and confirmed the MDS Discharge Assessment should be accurate. 2. Review of Resident #13's clinical record revealed that she was admitted to the facility on [DATE] with a 142 Form Notification of Medical Certification with approval of admission by the state Level II authority dated 10/16/2023 through 10/14/2024. Review of Resident #13's annual MDS assessment dated [DATE] revealed section A1500 PASRR: Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition, was coded as 0. No. Section A1510 level II PASRR conditions was blank. Review of Resident #13's current care plan revealed the following: Focus: Level II PASRR On 02/05/2025 at 9:58 a.m., an interview was conducted with S2MDS. She reviewed Resident #13's Annual MDS Assessment, dated 09/24/2024, and confirmed section A1500 should have been coded as 1-Yes, and was not. On 02/05/2025 at 10:00 a.m., an interview was conducted with S1DON. She reviewed Resident #13's Annual MDS assessment dated [DATE]. S1DON further reviewed Resident #13's Form 142 which indicated Resident #13 was approved for nursing home admission and approved by level II authority effective 10/16/2023 through 10/14/2024. S1DON confirmed section A1500 should have been coded as 1-Yes, and was not.

Based on record review and interviews, the facility failed to complete quarterly assessments for 1 (#18) of 2 (#18 and #22) residents reviewed for resident assessment. Findings: Review of Resident #18's most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/08/2024 revealed no completion date. An interview was conducted on 02/28/2024 at 11:08 a.m. with S2MDS. She stated she was responsible for completing MDS assessments. She reviewed the quarterly MDS for Resident #18 dated 02/08/2024. She confirmed Resident #18's quarterly MDS assessment was not complete. She confirmed the quarterly MDS assessment was 6 days late. An interview was conducted on 02/28/2024 at 11:25 a.m. with S1DON. She reviewed the quarterly MDS for Resident #18 dated 02/08/2024. She confirmed Resident #18's quarterly MDS assessment was not complete. She confirmed the quarterly MDS assessment was 6 days late.

Based on record review, observations, and interviews, the facility failed to store food in accordance with professional standards for food service safety. This had the potential to effect 36 residents who were served meals from the kitchen. Findings: Review of the facility's policy titled Date Marking for Food Safety revealed the following: Policy: The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food. Policy Explanation and Compliance Guidelines for Staffing: 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 4. The discard day or date may not exceed the manufacturer's use-by date, or four days whichever is earliest. The date of opening or preparation counts as day one. On 02/26/2024 at 8:25 a.m., an observation was conducted of the kitchen's dry storage room and the following items were found to be labeled with the month and date but no year: Ground basil 12oz opened container labeled 3/15 Opened 25oz container garlic salt labeled 1/17 The following items were found with expired open dates: Opened 32oz container lemon juice labeled 3/9/22 Opened 18oz container chili powder labeled 2/23/22 The following items were found open with no open date label: Opened 8oz container kosher salt Opened 19oz container garden seasoning Opened 32oz container imitation almond extract Opened 32oz container kitchen bouquet Opened 3oz container chili powder Opened 24oz container seasoning blends On 02/26/2024 at 8:45 a.m., an observation was conducted of the walk in freezer, and the following items were found to be opened and unlabeled: Opened 48oz container vanilla ice cream Indivual wrapped 1.65oz ice pops-3 orange, 4 purple, 3 red were noted out of the original box in a plastic container On 02/26/2024 at 9:05 a.m., an observation was conducted of the cooking area, the following items were found to be opened and unlabeled: Opened 5lb bag grits On 02/26/2024 at 8:55 a.m., an interview was conducted with S3DM. She confirmed all 36 resident eat from the kitchen. She confirmed the above observations, and stated open food items were to be labeled with the open date including the month, date and year and were not. She also confirmed the above items with open dates of 2022 should have been discarded and were not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to make prompt efforts to resolve grievances for 1 (#10) of 2 (#10 and #26) residents reviewed for grievances. The facility failed to ensure a grievance was promptly investigated when Resident #10 reported a missing cell phone to staff. Review of the facility policy reveals, in part: Resident and Family Grievances Policy Explanation and Compliance Guidelines: 1. Administrator has been designated as the Grievance Official. 2. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations. Procedure: b. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form, or assist the resident or family member to complete the form. Findings: Review of the clinical record revealed Resident #10 was admitted to the facility on [DATE]. Resident #10 had diagnoses which included Metabolic Encephalopathy, Chronic Obstructive Pulmonary Disease, and Type 2 Diabetes. Review of Resident #10's Quarterly MDS with an ARD of 01/06/2023 revealed Resident #10 had a BIMS Summary score of 15, which indicated Resident #10 was cognitively intact. Review of the facility's Grievance Log dated August 2022 through January 2023 revealed no entries for Resident #10. On 01/23/2023 at 10:40 a.m., an interview was conducted with Resident #10. She said she had a missing cell phone. She said she reported it to S6CNA about a week ago. She said her cell phone remained missing. On 01/24/2023 at 08:22 a.m., an interview was conducted with S5CNA. She said Resident #10 reported her phone missing to her. She said she reported the missing phone to S3LCSW. She confirmed Resident #10's cell phone remained missing. On 01/24/2023 at 8:35 a.m., an interview was conducted with S3LCSW. She said she was made aware Resident #10's phone was missing since last week. She confirmed she did not file a grievance for the missing phone. On 01/24/2023 at 9:00 a.m., an interview was conducted with S1NFA. He verified a grievance report should have been started when Resident #10's phone was reported missing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents' drug regimens were free from unnecessary psychotropic medications for 1 (#6) of 5 (#6, #7, #11, #15, #20) residents reviewed for unnecessary medications. The facility failed to ensure: 1. A gradual dose reduction was attempted for a psychotropic medication for Resident #6; and 2. An antipsychotic medication was used only when there was an acceptable diagnosis for Resident #6. Findings: Review of the facility's policy titled Use of Psychotropic Medication revealed the following, in part: Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medications beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Policy Explanation and Compliance Guidelines: 5. Residents who use psychotropic drugs shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue these drugs. 12. (c.) New Admissions: ii. The physician in collaboration with the consultant pharmacist shall re-evaluate the use of the medication and consider whether or not the medication can be reduced or discontinued upon admission or soon after admission. Review of Resident #6's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, Anxiety Disorder, and Major Depressive Disorder, Recurrent. Review of the Quarterly MDS with an ARD of 11/02/2022 for Resident #6 revealed the following: BIMS =01(severe cognitive impairment) Section-N-Medications Medications received: days: antipsychotic-7 days a week Review of the current Physician Orders for Resident #6 revealed the following: Start Date 07/27/2022- Quetiapine Fumarate Tablet 100 mg Give 1 tablet by mouth two times a day related to Anxiety Disorder. Review of the MAR dated July 2022 - January 2023 for Resident #6 revealed she received Quetiapine twice daily at 8:00 a.m. and 6:00 p.m. starting on 07/27/2022. Review of The Gradual Dose Reduction dated 08/30/2022 for Resident #6 from the facility's pharmacist revealed the following: Please evaluate the routine use of the following psychoactive medications and consider a dose reduction. If a dose reduction is not desired, please indicate below a rationale for the continued use. 8. Seroquel 100mgBID 9. Please provided an appropriate diagnosis for the use of Seroquel as Anxiety is not appropriate according to the CMS guidelines. Review of Antipsychotic Diagnosis Verification sheet dated 01/20/2023 for Resident #6 from S2DON revealed the following: Quetiapine Fumarate Tablet 100 mg give 1 tab by mouth two times a day related to anxiety disorder, unspecified. The use of Seroquel for the treatment of anxiety is considered inappropriate according to the CMS guidelines. Please consider an alternate medication. Further review of the clinical record for Resident #6 revealed there was no documentation of an acceptable diagnosis for the use of an antipsychotic or an attempt of a gradual dose reduction. An interview was conducted on 01/25/2023 at 1:55 p.m. with S2DON. She reviewed Resident #6's Physician Orders and Progress Notes and verified there was no documented diagnosis to justify the administration of Quetiapine100mg po twice daily. She also reviewed the Psychoactive Gradual Dose Reduction for Resident #6 and verified there was no attempt of a gradual dose reduction for Quetiapine100mg po twice daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable disease and infection by failing to ensure staff were knowledgeable and cleaned residents' whirlpools according to manufacturer's guidelines. This deficient practice had the potential to affect 32 female residents who used the whirlpool in the facility as documented on the facility's Whirlpool Assignment Sheet. Findings: Review of facility's policy titled, Whirlpool Tub and Bathroom Cleaning revealed the following, in part: It is the policy of this facility to establish policies, procedures and guidelines to provide a clean and sanitary environment for residents, staff and visitors in order to prevent cross contamination and transmission of healthcare-associated infection (HAI) Procedure: 1. Working from clean areas to dirty areas: h. Clean tub faucets, walls and railing, scrubbing as required to remove soap scum. Inspect grout for mold, apply disinfectant to interior surfaces of shower/tub, including soap dish, faucets and shower head. Allow sufficient contact time for disinfectant according to manufacturer's recommendations. Rinse and wipe dry. Review of the Whirlpool System Cleaning instructions titled, RS8 Geneva (Fixed Height) Operating and Disinfecting Procedure revealed the following, in part: Pull the drain plug. Rinse and dry the resident while the tub is draining. Unlock and open the Disinfectant Cabinet door. Remove the disinfectant wand from its holder and point spray head into the tub. Turn the disinfectant valve to the disinfect position. Spray the interior surface of the tub. Use brush or sponge if needed. Turn the disinfectant wand to the off position. Allow disinfectant solution to remain on the interior surface of the tub for the period of time recommended by the manufacture. Turn the disinfectant valve to the rinse position. Thoroughly rinse the interior of the tub. Turn the disinfectant valve to the off position. Return the disinfectant wand to its holder and lock the disinfectant cabinet door. Review of [NAME] disinfectant solution's label instructions used to disinfect the whirlpool revealed: leave on the surface for 10 minutes and rinse off. On 01/24/2018 at 9:57 a.m., an observation was conducted of bathing room a. There was a large sign next to the whirlpool bath with instructions for disinfecting the whirlpool, which read, in part, the instructions from the Whirlpool System Cleaning Instructions titled, RS8 Geneva (Fixed Height) Operating and Disinfecting Procedure. On 01/24/2023 at 1:15 p.m., an interview was conducted with S4CNA. She said she had worked at the facility for one week and she was responsible for bathing residents in the whirlpool room. She said she was not sure what to use to disinfect the whirlpool. An observation was conducted of Whirlpool Room A at that time. She demonstrated what she does when she bathed residents. She said she used the liquid soap by the whirlpool and rinses it out. She said she was supposed to use a special cleaner but did not know where it was. On 01/24/2023 at 1:45 p.m., an interview was conducted with S5CNA. She said she worked in the bathing room and does whirlpool baths. She verified 32 female residents were bathed in the whirlpool in bathing room a. On 01/24/2023 at 2:01 p.m., an interview and observation was conducted with S6CNA. She said she had worked at the facility since October 2022. She said she cleaned the whirlpool with the disinfectant in the whirlpool and let it set for about 5 minutes while she got the resident out of the tub and then she rinsed it off. She said she did not realize the disinfectant was supposed to set for 10 minutes. On 01/24/2023 at 1:20 p.m., an interview was conducted with S2DON. She said she expected the staff to clean the whirlpool per policy and manufacture's guideline.