**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide specialized rehabilitative services or obtain the required services from an outside resource that is a provider of specialized rehabilitative services for 1 of 2 residents reviewed for rehabilitative services. (#43) Findings: On 10/21/24 at 2:12 p.m. during an interview, Resident #43, stated that he/she was admitted to the facility on [DATE], and thought he/she was there for rehab but had not seen anyone from Physical Therapy (PT) or Occupational Therapy (OT). Review of the medical record contained a Physician order dated 10/7/24 for PT and OT evaluation. On 10/22/24 at approximately 11:30 a.m., in an interview with the PT/OT staff that were working on the unit, a surveyor asked if they had provided therapy for Resident #43. They stated that they could not because he/she is waiting for an evaluation prior to starting his/her therapy. On 10/22/24 at approximately 11:45 a.m., in an interview with the Admissions Coordinator, she stated the facility has been waiting on an available staff member to complete the Therapy Evaluation for Resident #43. On 10/22/24 approximately 12:00 p.m., during an interview, the Administrator stated they had lost their contract with the prior Therapy company and decided to bring the staff in house, and they have had difficulty staffing the Therapy Department. At this time, the Administrator confirmed Resident #43 had been waiting since 10/7/24 for a therapy evaluation.

Based on observations and interviews, the facility failed to ensure the resident environment remained as free of accident hazards, as is possible, related to a patient lift on 2 of 2 units (Periwinkle and Hummingbird) and for 1 of 3 days of survey. (10/21/24) Findings: 1. On 10/21/24 at 6:16 a.m., during a tour of the Periwinkle unit, two surveyors observed a Easy Way Smart patient lift, available for use, which was missing one of the safety clips on an arm. 2. On 10/21/24 at 6:23 a.m., during a tour of the Hummingbird unit, two surveyors observed a Easy Way Smart patient lift, available for use, which was missing one of the safety clips on the an arm. The surveyor reported the unsafe lifts to nursing at approx. 6:38 a.m. on 10/21/24. He/she stated that the Maintenance Director would be notified when he arrives. On 10/21/24 at 7:23 a.m., the above missing safety clips were discussed with the Senior Facilities Manager. On 10/21/24 at 7:26 a.m., observation of the Periwinkle easy lift to have both safety clips in place. On 10/21/24 at 7:33 a.m., during an interview, the Senior Facilities Manager stated both lifts have the safety clips in place.

Based on observation, facility policy, record review and interviews the facility failed to adequately ensure medications were monitored and stored at appropriate temperatures in 1 of 1 refrigerator observed. Finding: On 10/21/24 at 11:45 a.m., a surveyor observed the medication refrigerator temperature logs with Registered Nurse (RN). Review of these temperature logs from 7/2024 through 10/2024 showed temperatures were not being monitored properly, with the following information missing: > July 2024 temperatures are documented out of range for 30 out of the 30 days > August 2024 is missing temperature readings for 5 out of 31 days and temperatures are documented out of range for 31 out of 31 days > September 2024 is missing temperature readings for 3 out of 30 days and temperatures are documented out of range for 30 out of 30 days > October 2024 is missing temperature readings for 5 out of 21 days and temperatures are documented out of range for 21 out of 21 days reviewed. Facility policy and procedure for Storage of Medications dated 5/1/2018 states under procedure subsections J Medication storage conditions are monitored on a regular basis by the facility and corrective action taken if problems are identified. Subsection L states, All medications are maintained within temperature ranges noted in the United States Pharmacopeia . Refrigerated 36°F to 46°F. Subsection E states, The facility should maintain a temperature log in the storage area to record temperatures at least once a day. On 10/21/24 during an interview, the above information was confirmed with the Director of Nursing.

Based on observation, interview, and the facility's Food Receiving and Storage Policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for ceiling vents, the surrounding ceiling, and a food disposal unit. Additionally, the facility failed to ensure foods were dated and labeled in the walk-in refrigerator and the walk-in freezer for 1 of 1 tour. Findings: Review of the facility's Food Receiving and Storage Policy (last reviewed 4/4/23) noted: II. Scope: he Dietary Director, Dietary Supervisor, and Cooks are responsible for receiving and storing all food and non-food items. These tasks are delegated as needed. III. Policy/Procedure: 6) All opened foods and beverages, prepared foods and leftovers are dated. On 8/7/23 from 9:10 a.m. to 9:50 a.m., a surveyor conducted an initial kitchen tour with the Food Service Director in which the following findings were observed: > There were 4 ceiling vents, along with the surrounding ceiling areas, that were dirty/dusty throughout the kitchen. These ceiling vents were above clean dish storage areas, food preparation areas and food service areas. > The food disposal unit, attached the right side of the two bay vegetable sink, had dried food spatter, dried liquid residue and spots rust on it. > The walk-in refrigerator had one previously opened bag of broccoli florets that was not labeled and dated. > The walk-in freezer had one case of French Bread Pizzas that were open to the air and not sealed and dated, one package of cauliflower that was not dated and labeled and one package of cinnamon buns that was not dated and labeled. On 8/7/23 at 9:50 a.m., in an interview, the Food Service Director confirmed the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and sanitary condition, on 2 of 3 units(Hummingbird and Periwinkle) and the kitchen hallway, for 1 of 1 environmental tours. Findings: On 9/1/21 from 10:25 a.m. to 10:45 a.m., an Environmental Tour was conducted with the Maintenance Mechanic and the Administrator in which the following findings were observed. Hummingbird Lane Unit: > The hallway wall, outside of resident room [ROOM NUMBER] had chipped/missing paint creating an uncleanable surface. >Resident room [ROOM NUMBER]-1 - The foot board was gouged and had worn off sealer. The wall had chipped/missing paint on the left as you enter the room. The floor/caulking, around the base of the toilet was dirty. All creating uncleanable surfaces. > Resident room [ROOM NUMBER]-1 - The foot board was gouged and had worn off sealer. There was chipped/missing paint on all four walls. The bathroom door and door jamb had chipped/missing paint creating uncleanable surfaces. > Resident room [ROOM NUMBER]-1 - The room entrance door jamb had chipped/missing paint creating an uncleanable surface. > Resident room [ROOM NUMBER]-2 - The foot board was gouged and had worn off sealer. The wall behind the bed, had chipped/missing paint. Both created uncleanable surfaces. > Resident room [ROOM NUMBER]-1 - The room entrance door had chipped/missing paint. The wall across from the beds, had chipped/missing paint. The closet doors and drawers were gouged and had worn off sealer. The bathroom door and closet door had chipped/missing paint. All created uncleanable surfaces. > The exit door near room [ROOM NUMBER] had chipped/missing paint creating an uncleanable surface. Periwinkle Unit: > Resident room [ROOM NUMBER]-1 - The surface coating of the commode in the bathroom was peeling off creating an uncleanable surface. > Resident room [ROOM NUMBER]-2 - The floor/caulking around the base of the toilet was dirty creating an uncleanable surface. > Resident room [ROOM NUMBER]-2 - The floor/caulking around the base of the toilet was dirty creating an uncleanable surface. There were chunks of debris in the bathroom exhaust fan. Kitchen Hallway: > There were eight ceiling tiles in the hallway outside the kitchen that had brownish stains on them. On 9/1/21 at 10:45 a.m., in an interview, the Maintenance Mechanic and the Administrator confirmed the findings listed above.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop a comprehensive care plan for monitoring of antiepileptic medications for 2 of 2 residents reviewed for seizures/epilepsy. (#13, #34) Findings: 1. Resident #13's clinical record indicated that the resident was admitted to the facility on [DATE] with a diagnosis of Alzheimer's Disease, Chronic Diastolic (Congestive) Heart Failure, Epilepsy, Dementia Without Behavioral Disturbance, and a history of falling. Resident #13's's physicians orders dated 10/2/20 instructed staff to administer the following antiepileptic medications: divalproex sodium capsule, delayed release sprinkles,125 milligrams (mg.), give 125 mg. by mouth (p.o.) at bedtime for seizure disorder, and lamotrigine tablet, 100 mg., give 100 mg. p.o. two times a day for seizure disorder. The Quarterly Minimum Data Set (MDS) 3.0 dated 7/30/21, indicated in Section I-10020 Primary Medical Condition Category - Fractures and Other Multiple Trauma. Section I- I5400 indicates - Seizure disorder or Epilepsy. Resident #13's clinical record lacked evidence of a care plan that was developed for monitoring of antiepileptic medications. Resident #34's clinical record indicated that the resident was admitted to the facility on [DATE] with a diagnosis of Conversion Disorder with Seizures/Convulsions, Major Depressive Disorder, and Dementia with Behavioral Disturbances. Resident #34's physicians orders dated 8/20/21 instructed staff to administer the following antiepileptic medications: Depakote ER tablet (Extended Release) 24 hour, 500 mg. (Divalproex Sodium ER) give 1500 mg. two times a day for seizure disorder. The Significant Change Minimum Data Set (MDS) 3.0 dated 8/13/21, indicated in Section I-10020 Primary Medical Condition Category - Non-Traumatic Brain Disfunction. Section I- I5400 indicated - seizure disorder or Epilepsy. Resident #34's clinical record lacked evidence a care plan was developed for monitoring of seizures/epilepsy and antiepileptic medications. On 8/31/21 at 11:35 a.m., in an interview, the Clinical Nursing Supervisor confirmed that Resident #13's and Resident #34's care plans were not developed and did not reflect the current status of the residents to include specific interventions as related to seizure disorders or epilepsy and seizure disorders or epilepsy medication monitoring. The care plans were updated on 8/31/21 after surveyor intervention.

Based on record review, observations and interview the facility failed to provide appropriate treatment to prevent the risk of complications related to enteral feeding, for 1 of 1 resident review for enteral feeding (#42). Finding: The Facility's Enteral Medication Administration Policy and Procedure Effective 8/1997 instructions state to 8. Unclamp the tube, inject 10 cc (cubic centimeter) of air into the feeding tube while auscultating with your stethoscope approximately 3 below the sternum to hear for air bubbling. 9. Draw back on the piston of the syringe to see if there are gastric contents in the syringe, which will confirm that the tube is placed into the stomach. If no gastric contents appear or you meet resistance, the tube may be lying against the gastric mucous. Attempt to reposition the patient or withdraw the tube slightly. Review of Resident #42's care plan dated 2/14/19, instructs staff to Monitor/document/report PRN any signs and symptoms of: aspiration-fever, SOB, (shortness of breath) tube dislodged, infection at tube site, self-extubation, tube dysfunction or malfunction, abnormal breath/lung sounds, abnormal lab values, abdominal pain, distention, tenderness, constipation or fecal impaction, diarrhea, nausea/vomiting, dehydration. On 8/31/21 at approximately 12:00 p.m., during an observation of medication preparation and administration with Registered Nurse (RN) #12 for Resident #42, who requires medications through his/her Gastrostomy tube (G-Tube), the following was observed: The RN had the medications and prepared to administer the medications through the Gastrostomy (G-tube). Surveyor intervened and asked RN if he/she was going to check placement and residuals, RN stated she had not been trained to do that for Resident #42. The RN stated she knows they usually do that but had not been trained to do that for this resident. The RN then asked the resident if other employees do that and resident responded no. On 9/01/21 at approximately 1:30 p.m., in an interview with the Administrator, a surveyor confirmed the RN did not follow facility policy and procedure when adminstering medications via G-Tube to Resident #42.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure an as needed (PRN) psychotropic medication met the required 14-day limit for 1 of 5 residents reviewed for unnecessary medications (#44). Finding: A review of Resident #44's physician orders dated [DATE] instructs staff to administer Lorazepam (Ativan) 0.5 mg (milligrams) (an anxiolytic medication) - give 0.25 mg by mouth as needed for anxiety, agitation TID (three times daily). A review of Resident #44's clinical record revealed a pharmacist recommendation, printed [DATE], which stated the Resident has an order for Ativan PRN (as needed): Beginning [DATE], PRN orders for psychotropic medications (excluding antipsychotics) are limited to 14 days. Order may be extended beyond 14 days if the attending physician or prescribing practitioner believes it is appropriate to extend the order. Attending physician or prescribing practitioner should document the rationale for the extended time period in the medical record and indicate a specific duration. Provider may wish to review current order and document need for continued use and that order will be reviewed every 60 days. On [DATE], the provider indicated he/she agreed with the recommendation. The provider did not write a new order to continue the medication until [DATE], at which time the order was electronically renewed to continue the PRN dosing. Additionally, the provider ordered the medication to be given scheduled four times a day for anxiety and agitation. A review of the Resident #44's Medication Administration Record indicated Lorazepam was administered 13 times after the 14-day order had expired on the following days: [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE] at 1:15 p.m., the Clinical Nursing Supervisor confirmed that the provider did not renew the order until [DATE], 7 days after the PRN order had expired on [DATE], and that Resident #44 had received additional doses after the order had expired.

Based on observations and interviews, the facility failed to ensure expired medications were removed from the supply and available for use in 2 of 2 medication rooms. Findings: 1. On 9/01/21 at approximately 10:50 a.m., a surveyor observed (the refrigerator across the hall from the Nurse's station near Hummingbird Lane) an open, multidose vial of Tuberculin Purified Protein Derivative with an opened on date of 7/10/21; and 31 doses of Influenza vaccine that expired on 6/30/2021. This was confirmed by Registered Nurse #10 at that time of the finding. The Medication Storage in the Facility policy (Revised January 2018), Expiration Dating (Beyond -use dating) section states, D. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1. The facility staff shall place a date opened sticker on the medication and enter the date opened and the new expiration date. It goes on to state, The expiration date on the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating. Accordingly, the Tuberculin Purified Protein Derivative should have been discarded 30 days after opening. The Registered Nurse removed this vial from the refrigerator and stated it would be thrown away. 2. On 9/1/21, at approximately 12:15 p.m. a surveyor observed (the refrigerator in the skilled unit med room) 96 Bisacodyl Suppositories that had an expiration date of 7/31/21 and 10 doses of Influenza vaccine that expired on 6/30/21. This was confirmed by Registered Nurse #11 at that time of the finding. On 9/1/21 at 12:22 p.m. these findings were also confirmed with the Assistant Director of Nursing.

Based on observations, interviews, record review of the facility's refrigerator and freezer temperature logs, and the facility's kitchen policy and procedure, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for the walk-in refrigerator fans, ceiling vents, and an exhaust fan; failed to secure, label and/or date foods in the reach-in refrigerator and the walk-in freezer; and failed to document refrigerator and freezer temperatures for 2 of 2 kitchen tours on 2 of 3 days of survey. (8/30/21 and 8/31/21) Findings: On 8/30/21 from 9:10 a.m. to 9:45 a.m., a surveyor conducted a tour of the kitchen with the Kitchen Supervisor/Certified Dietary Manager in which the following were observed: 1. The ceiling vent over the walk-in refrigerator door, was dusty/dirty. > The ceiling vent and surrounding ceiling over the steam table were dusty/dirty. > The ceiling light over the steam table was dusty/dirty. > The ceiling vent over the cart storage area was dusty/dirty. > Two ceiling vents above a food preparation area were dusty/dirty. > The ceiling above the cook stove had soiled brownish areas. > The kitchen janitor closet had a yellowish stained exhaust fan. 2. The following was observed in the walk-in refrigerator : > air circulation fan that had dirty/dusty grill covers. > unlabeled and undated opened package of cheese. > A large bag of frozen blue berries, a large bag of mixed vegetables, and a large bag of vegetable burgers that were open to the air (not sealed) and not dated. Also, there was an undated, unlabeled half a pie. On 8/30/21 at 9:45 a.m., in an interview, the Kitchen Supervisor/Certified Dietary Manager confirmed the findings. 3. On 8/31/21, during a kitchen tour with the Kitchen Supervisor/Certified Dietary Manager and the Food Service Director, the following documentation was reviewed. The facility's Quality policy(05.6780.26) noted under Procedure: 3. Dietary Department refrigerator/freezer temperatures are recorded twice daily. The Food Service Department, Kitchen Refrigerator/freezer Temperature Record noted *Per the recommendation of Food and Drug Administration(FDA) + Federal/State Regulations Hazardous Analysis Critical Control Point(HACCP), temperatures should be taken twice daily(opening and closing procedure). The following dates and times were not completed on the stated refrigerators and freezers. *July 2021- Little Refrigerator- July 23 - p.m, July 24 -a.m., and July 28- p.m. *July 2021- Cook's Reach-in Refrigerator - July 21 - p.m., July 23 - p.m., July 24 - a.m., July 27 - p.m., and July 28- a.m. *July 2021- Walk-in Freezer - July 20 - p.m., July 23 - p.m., July 24 - p.m., July 27 - p.m., and July 28 - a.m. *July 2021 - Walk-in Refrigerator - July 23 - p.m. and July 24 - a.m. *July 2021 - Ice Cream Freezer - July 21 - p.m. July 23 - p.m., July 24 - a.m, July 27 - p.m., and July 28 - a.m. *July 2021 - Aide's Refrigerator- July 21 - p.m July 23 - p.m., July 24 - p.m., July 27 - p.m., and July 28 - p.m. *August 2021 - Freezer - July 31 - a.m. and p.m. *August 2021 - Walk-in Refrigerator - July 31 - a.m. and p.m *August 2021 - Cook's Reach-in Refrigerator - July 30 - a.m. and p.m., July 31- a.m. and p.m. *August 2021 - Ice Cream Freezer - July 30 - p.m. and July 31, 2021 - a.m. and p.m. *August 2021 - Aide's Refrigerator- July 30 - p.m. and July 31, 2021 - a.m. and p.m. On 8/31/21 at 9:00 a.m., in an interview, the Kitchen Supervisor/Certified Dietary Manager and the Food Service Director, confirmed that the refrigerator and freezer temperatures logs were not filled out on the above days and times, according to facility policy and procedure.