. Based on observation, interview and record review, the facility failed to regularly assess the nutritional needs and follow the physician's diet order for two Residents (#11 & #18) of three residents reviewed for nutritional needs. This deficient practice resulted in the potential for nutritional compromise, undetected physical decline, and weight loss. Findings include: Resident #11 (R11) The medical record for R11 revealed an admission date of 11/25/21. Current diagnoses for R11 included: dementia, anxiety, depression, history of stroke, and history of traumatic brain injury. During meal rounds on 1/21/25 at 1:35 PM, R11 was observed in the dining room eating a pureed consistency lunch. She consumed 100% of her meal. The tray card read Regular Diet, Regular Texture although she was served a puree consistency diet. The tray card also included: Dislikes: .Split Pea Soup . R11 received pureed split pea soup. The medical chart for R11 revealed an active care plan which included, (R11) is at risk for nutritional deficits r/t (related to) many diagnoses that may affect nutrition unspecified dementia without behavioral disturbances, HTN (hypertension), major depressive disorder, GERD (gastroesophageal reflux disease) .traumatic brain injury . anxiety disorder, weakness . Date initiated: 01/31/2023. Interventions for this care plan focus included: .Provide and serve diet as ordered. (R11) has pureed diet, regular fluids, uses covered cup. Revision on 1/7/2025. While the care plan revealed a puree diet was planned, the physician diet order read: REGULAR CONSISTENCY, REGULAR DIET, THIN LIQUIDS dated 12/01/2021. This order was reviewed and signed as approved by Medical Director (MD) G on 1/8/25. (Handwritten telephone orders were present in the medical record from 12/1/24 which read pureed diet and were signed by Medical Director (MD) G on 12/1/24 but had not been carried forward to the January 2025 orders.) The medical chart for R11 also included quarterly and annual nutritional assessments dated 12/13/23, 3/4/24, and 12/31/24. The 12/13/23 annual nutritional assessment concluded R11 had a normal nutritional status with a score of 13. The 3/4/24 quarterly nutritional assessment concluded R11 had a normal nutritional status with a score of 14. The 12/31/24 quarterly nutritional assessment had changed and concluded R11 was At risk of malnutrition with a score of 8.0. There were no quarterly nutritional assessments between the 3/4/24 and 12/31/24 assessments. The nutritional status had the potential to be identified earlier if the missing assessments were completed. During an interview on 1/23/25 at 2:15 PM, Certified Dietary Manager (CDM) A was asked what actions were taken with this decline in nutritional status. With the missing nutritional assessments, she was not certain when the decline occurred and said, I must have missed a few (assessments). CDM A said with a decline in condition she would contact the consulting Registered Dietitian (RD) H. There was no documentation of RD H being alerted following the 12/31/24 assessment which identified R11 was At risk of malnutrition. Resident #18 (R18) The medical record for R18 revealed an admission date of 6/28/22. Current diagnoses for R18 included: kidney disease, depression, diabetes, dementia, and anxiety. During meal rounds on 1/21/25 at 1:00 PM, R18 was observed being fed lunch by Certified Nurse Aide (CNA) F. CNA F reported R18 usually accepted most of her pureed food but did not always take the fluids as well. R18's tray card read Regular Diet, Regular Texture although she was served a puree consistency diet. The medical chart of R18 was reviewed. The care plan for R18 included, Care plan: (R18) is at risk for nutritional deficits r/t many diagnoses that may affect nutrition (elevated blood pressure . chronic kidney disease [CKD] with stage 1 through stage 4 CKD, major depressive disorder, palpitations, DMII w/o (Diabetes type 2 without) complications . Interventions for this care plan focus included: .Provide and serve diet as ordered. Regular diet, regular texture, regular fluids, thin consistency . While the meal served was a puree diet, the physician diet order read: REGULAR dated 1/4/2023. This order was reviewed and signed as approved by Medical Director (MD) G on 1/9/25. (Handwritten telephone orders were present in the medical record from 12/1/24 which read pureed diet carnation instant breakfast drink (CIB) 4 oz [ounces] and were signed by Medical Director (MD) G on 12/1/24 but had not been carried forward to the January 2025 orders and had not been included in the care plan.) The medical chart for R18 included quarterly and annual nutritional assessments dated 1/7/24, 4/8/24, and 7/7/24. The 1/7/24 nutritional assessment concluded R18 was At risk of malnutrition with a score of 11. The 4/8/24 nutritional assessment concluded R18 was At risk of malnutrition with a score of 11. The 7/7/24 nutritional assessment concluded was At risk of malnutrition with a score of 10. There were no further quarterly or annual nutrition assessments after 7/7/24. This 7/7/24 last nutritional assessment completed by the CDM recorded a weight of 90.2 pounds. R18's most current weight was 86.1 pounds recorded in January 2025. During an interview on 1/23/25 at 2:33 PM, CDM A was asked about the missing assessments for R18 and replied, I am behind on that. I guess I missed two assessments. She (R18) has always been nutrition at risk. The consultant RD H progress note dated 12/13/2024 read in part: Note Text: Resident currently receives a regular diet, regular texture, regular fluids, thin consistency. It should be noted the handwritten telephone order of 12/1/24 had changed the diet to puree consistency. The consultant RD H progress note dated 12/17/2024 read: Note Text: Per discussion with CDM at facility visit CIB was added TID (three times daily) and diet cahnged (sic) to pureed in attempt to increase intake and weight. Will review as needed. .

Resident #6 (R6) Review of R6's medical record revealed an admission date of 7/1/23 with diagnoses including depression, anxiety and diabetes. The current physician's orders dated 1/8/25 read: BLOOD SUGAR VIA FINGERSTICK (a short needle used to draw blood) VIA METER THREE TIMES DAILY ., GLIMEPIRIDE 4 MG (milligram) tablet Give 1 tablet by mouth twice daily with food A review of R6's pharmacy consultant report recommendations dated 10/22/24, read in part, - Comment: (R6) receives a sulfonylurea Glimepiride. Recommendation: Please discontinue Glimepiride. If appropriate, adjust the diabetes regimen by increasing Levemir. - Rationale for Recommendation: Sulfonylurea's should be avoided in older adults due to the risk of cardiovascular events and prolonged hypoglycemia . - Physician Response: I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below. Rationale: The Medical Director (MD) G did not provide a rationale and signed the consultation report on 11/6/24. A review of R6's pharmacy consultant report recommendations dated 12/18/24, read in part, - Comment: (R6) receives insulin and a sulfonylurea, Glimepiride concomitantly, increasing the risk of hypoglycemia. - Recommendation: Please discontinue Glimepiride. - Physician Response: I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below. Rationale: The Medical Director (MD) G did not provide a rationale and signed the consultation report on 1/8/25. A review of R6's pharmacy consultant report recommendations dated 12/18/24, read in part, - Comment: (R6) frequently requires insulin per sliding scale . - Recommendation: Please decrease sliding scale insulin to BID (twice per day) with the end goal of discontinuing sliding scale while adjusting the diabetes regime by increasing Levemir to 67 u (units) BID. Close monitoring (e.g. glucose) should accompany any change in diabetic therapy and guide further adjustments. - Rationale for Recommendation: Prolonged use of sliding scale insulin is not recommended as it often results in wide variations in blood glucose, including prolonged periods of hyperglycemia or hypoglycemia. - Physician's Response: I decline the recommendation(s) above and do not wish to implement any changes due to the reasons below. Rationale: The Medical Director (MD) G did not provide a rationale and signed the consultation report on 1/8/25. During an interview on 1/23/25 at 12:26 PM, the DON stated, I have addressed this issue with this physician in the past and will have to do it again. Review of the Quality Assurance (QA) Committee policy, undated, read in part, .The QA committee shall include the following components for quarterly review .Pharmaceutical Services: Safe and effective drug therapy. Medication records will be reviewed monthly by the Registered Pharmacist for safety and effectiveness of the prescribed regimen. Problems will be referred to the attending physician. The DON will also review PO (oral) and medication records for UN necessary (sic) drugs, appropriate diagnosis for drug use, appropriate administration and side effects . Review of policy titled Antipsychotic Medication Use, revised April 2007, read in part, Policy Statement: Antipsychotic medication therapy shall be used only when it is necessary to treat a specific condition. The Physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences. Based on interview and record review, the facility failed to provide rationale on pharmacy medication regimen review (MRR) recommendations being declined by the physician for two Residents (#6 and #11) of five residents reviewed for MRR's. Findings include: Resident #11 (R11) Review of R11's medical record revealed an admission date of 11/25/21 with diagnoses including dementia, depression, and anxiety. A review of the 12/31/24 Minimum Data Set (MDS) assessment revealed a score of 3 on the Brief Interview for Mental Status (BIMS) assessment indicative of severely impaired cognition. Review of R11's pharmacy recommendation, dated 11/26/24, read in part, Comment: [R11] has a PRN (as needed) order for an anxiolytic, which has been in place for greater than 14 days without a stop date: Lorazepam 0.5 mg (milligrams), give 1 tablet by mouth twice daily as needed. Recommendation: Please discontinue PRN Lorazepam .If the medication cannot be discontinued at this time, please document the indication for use, the intended duration of therapy, and the rationale for the extended time period . R11's MRR dated 11/26/24 was signed by Medical Director (MD) G on 12/4/24 and marked decline to discontinue the medication without providing a rationale for continuation of use.

Resident #6 (R6) Review of R6's medical record revealed an admission date of 7/1/23 with diagnoses including depression, and anxiety. The current physician's orders dated as approved by the attending physician on 1/8/25 included: Duloxetine HCL (hydrochloride) 60 MG capsule Give on capsule by mouth once daily (a medication used to treat depression). The care plan for R6 included a focus of: (R6) uses antidepressant medication Cymbalta r/t (related to) Depression. Date Initiated: 07/01/2023 Revision on: 08/20/2023 The only intervention for this focus was listed as, Administer ANTIDEPRESSANT medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT. Date Initiated: 07/01/23. No behavioral interventions were included. The care plan for R6 included a focus of: (R6) has a mood problem r/t Use/side effects of medication. Date Initiated: 07/01/2023 Revision on: 08/20/2023. The only intervention for this focus was listed as, Administer medications as ordered. Monitor/document side effects and effectiveness. Date Initiated: 07/01/23. No behavioral interventions were included. During an interview on 1/23/25 at 2:00 PM, the DON reviewed the care plan for R6 and indicated she could not find non-pharmacological interventions. The medical chart also included a daily BEHAVIOR/MOOD SYMPTOM TRACKING TOOL. It was noted for the January 2025 tracking, the tool included a column to document interventions for behaviors. For all days in January no behavioral interventions were listed. Review of the Quality Assurance (QA) Committee policy, undated, read in part, .The QA committee shall include the following components for quarterly review .Pharmaceutical Services: Safe and effective drug therapy. Medication records will be reviewed monthly by the Registered Pharmacist for safety and effectiveness of the prescribed regimen. Problems will be referred to the attending physician. The DON will also review PO (oral) and medication records for UN necessary (sic) drugs, appropriate diagnosis for drug use, appropriate administration and side effects . Review of policy titled Antipsychotic Medication Use, revised April 2007, read in part, Policy Statement: Antipsychotic medication therapy shall be used only when it is necessary to treat a specific condition. Policy Interpretation and Implementation .9. For acute psychiatric situations, antipsychotic medication use shall meet the following criteria: a. The acute treatment period is limited to seven days or less; and b. A clinician in conjunction with the interdisciplinary team must evaluate and document the situation within 7 days, to identify and address any contributing and underlying causes of the acute psychiatric condition and verify the continuing need for antipsychotic medication; and c. Pertinent non-pharmacological interventions must be attempted .15. The Physician shall respond appropriately by changing or stopping problematic doses or medications, or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences Facility requirements for antipsychotic use: 1. All physicians review and make note on effectiveness at each rounds visit .6. Annual gradual dose reduction or risk vs benefit statement for continued use. Based on interview and record review, the facility failed to indicate a specific duration (end date) for PRN (as needed) psychotropic (drug that affects brain activity) medication, provide gradual dose reductions for psychotropic medications and include non-pharmacological interventions when psychotropic medications were prescribed for three Residents (#6, #11, and #12) of five residents reviewed for unnecessary medications. Findings include: Resident #11 (R11) Review of R11's medical record revealed an admission date of 11/25/21 with diagnoses including dementia, depression, and anxiety. A review of the 12/31/24 Minimum Data Set (MDS) assessment revealed a score of 3 on the Brief Interview for Mental Status (BIMS) assessment indicating severely impaired cognition. Review of R11's, physician orders, dated January 2025, revealed a signature from the physician on 1/8/25 and an order dated 11/4/24 for Lorazepam 0.5 mg tablet, give 1 tablet by mouth twice daily as needed. No indication for use or end date for PRN Lorazepam was present on the physician orders. Review of R11's care plan, date revised 1/7/25, read in part, .Focus: [R11] has a behavior problem anxiety r/t (related to) dementia. Goal: [R11] will have fewer episodes of anxiety by review date .Interventions: Administer medications as ordered. Monitor/document side effects and effectiveness . R11's care plan lacked any non-pharmacological interventions for their anxiety. Review of R11's pharmacy recommendation, dated 11/26/24, read in part, Comment: [R11] has a PRN (as needed) order for an anxiolytic, which has been in place for greater than 14 days without a stop date: Lorazepam 0.5 mg (milligrams), give 1 tablet by mouth twice daily as needed. Recommendation: Please discontinue PRN Lorazepam .If the medication cannot be discontinued at this time, please document the indication for use, the intended duration of therapy, and the rationale for the extended time period . R11's MRR dated 11/26/24 was signed by the Medical Director (MD) G on 12/4/24 and it was marked decline recommendation without providing a rationale for continuation of this as needed medication. On 1/23/25 at 12:15 PM, a review of R11's medical record and physician progress notes, dated September 2024 through January 2025, revealed the lack of monitoring for the effectiveness and continued use of the PRN Lorazepam. On 1/24/25 at 11:00 AM, an interview was conducted with the Director of Nursing (DON), who was asked why R11 was prescribed the as needed Lorazepam and replied, (R11) was going through an adjustment period. The DON was asked why there was not an end date to the medication and replied, I am not sure, but there should have been an end date. The DON was asked if there was any follow-up from the physician on the use of the Lorazepam. The DON then reviewed R11's medical record and replied, I do not see any follow-up. Resident #12 (R12) Review of R12's medical record revealed an admission date of 3/8/22 with diagnoses including depression and Parkinson's disease (a disorder of the central nervous system that affects movement). A review of the 12/20/24 MDS assessment revealed they scored 11 on the BIMS assessment indicating moderately impaired cognition. Review of R12's, physician orders, dated January 2025, revealed an order for citalopram 10 mg, give one tab daily. Review of R12's, MRR's dated July through December 2024, revealed R12 last had a gradual dose reduction (GDR) attempt on 9/6/23 and was due for another GDR on 9/17/24, but was not attempted. Review of R12's physician progress notes, dated September 2024 through January 2025, lacked any documentation regarding R12's citalopram depression medication. There was no evidence of a GDR attempt or rationale for clinical contraindication for not performing a GDR. On 1/24/25 at 11:00 AM, an interview was conducted with the DON, who was asked if R12 had any documentation of an attempt or clinical rationale for not performing a GDR in September 2024. The DON replied, I am not sure about a GDR or an explanation. I do not have any documentation that a GDR was attempted in September. Review of R12's care plan, date revised 1/7/25, read in part, .Focus: [R12] uses antidepressant medication r/t (related to) depression. Goal: [R12] will be free from discomfort or adverse reactions related to antidepressant therapy through the review date .Interventions: Administer antidepressant medication as ordered by physician. Monitor/document side effect and effectiveness Q (every) shift . R12's care plan lacked any non-pharmacological interventions for their depression.

. Based on observation, interview, and record review the facility failed to serve the correct portions as planned on the menu. This deficient practice had the potential to negatively affect the nutritional status of all 18 residents residing in the facility. Findings include: During an observation in the dietary department on 1/21/25 at 12:48 PM, Certified Dietary Manager (CDM) A was serving lunch of split pea soup, ham salad sandwich, mixed fruited jello and beverage of choice. The following portion sizes were served: - Regular diet: 4 oz (ounces) split pea soup, ½ ham salad sandwich, - Puree diet: 2 oz split pea soup, 2 oz pureed ham salad bread mixture The planned menu was reviewed and revealed: - Regular diet: 8 oz split pea soup, ½ ham salad sandwich, - Puree diet: 4 oz (#8 scoop) split pea soup, 2 oz (#16 scoop) pureed ham salad bread mixture During an observation of lunch service on 1/22/25 at 12:30 PM in the dietary department, the following portion sizes of hot pork sandwich (pork over a slice of bread with gravy) mashed potatoes, mixed vegetables, and pears were served: - Regular diet: 2 oz pork on one slice of bread, 4 oz (1/2 cup) mashed potatoes/gravy, 4 oz (1/2 c) mixed vegetables - Puree diet: 2 oz. pork (pureed with bread), 2 oz mixed vegetables, 2.67 oz (#12 scoop) mashed potatoes The planned menu was reviewed and revealed: - Regular diet: 2 oz pork on slice of bread, 4 oz mashed potatoes/gravy, 4 oz mixed veg. (vegetables) - Puree diet: 4 oz (#8 scoop) pureed pork blended with bread, 4 oz pureed mixed vegetables, 4 oz mashed potatoes. The puree consistency diet received only half of the food that was planned on the menu. The menus were discussed at 2:05 PM on 1/22/25. CDM A stated a #8 scoop (or 4 oz) portions for each item on the puree diet would be too much. The evening meal was reviewed for 1/22/25, it planned the regular diet receive 8 oz of goulash, while the puree diets receive a #16 scoop (2 oz). The diet plan was not the same portion for each consistency. During a telephone interview on 1/22/25 at 1:46 PM, the Registered Dietitian (RD) H stated those residents receiving a pureed diet should receive the same portions as those with a regular consistency. The recipes were requested for the ham salad sandwich and the split pea soup. Neither recipe gave portion sizes or nutritional break downs. The ham salad sandwich recipe did not indicate the steps, ingredients, or amounts needed to produce a puree portion. .

. Based on observation, interview and record review the facility failed to train non-licensed employees with the State-approved training course for feeding assistance to residents. This deficient practice put vulnerable residents at risk of complications associated with being fed for all residents needing feeding assistance (approximately six residents). Findings include: During the breakfast observation in the dining room on 1/22/25 at 8:34 AM, Certified Dietary Manager (CDM) A was observed feeding Resident #4 (R4) a pureed diet. When asked why she was feeding R4, CDM A said assistance was needed as other staff were not available. When asked about the risk involved, CDM replied that all residents on a pureed diet were at risk for choking. CDM A stated, Occasionally they ask me to help out and feed . When asked if she had taken the State-approved training program for feeding assistants, CDM A said the DON (Director of Nursing) gave me a refresher when I started 3 maybe 4 years ago. During an interview on 1/22/25 at 10:35 AM, the DON stated, I taught (CDM A), not a class - just common-sense stuff . (CDM A) used to be a CNA (Certified Nurse Aide) and is a CDM now. I don't know if she has kept up her license . We were short staffed this morning. The DON did not have record of CDM A taking the State-approved training course for paid feeding assistants including, at a minimum, 8 hours of training in: feeding techniques, assistance with feeding and hydration, communication and interpersonal skills, appropriate responses to resident behavior, safety and emergency procedures, including the Heimlich maneuver, infection control, resident rights, and recognizing changes in residents that are inconsistent with their normal behavior and the importance of reporting those changes to the supervisory nurse. The DON stated she was not familiar with the State-approved training course. The facility provided a paper that read in its entirety: Procedure for feeding resident a pureed diet: Sit the resident up straight, give them time to swallow between bites, and offer liquids between every few bites. The page was signed by the Nursing Home Administrator (NHA) and was undated as to initiation date or review date. The facility also provided a paper that read in its entirety: Kitchen Staff Feeding Policy: DON can train kitchen staff to feed puree residents. If Kitchen staff is needed to help feed residents the DON should instruct them on the proper procedures in feeding Residents both puree and regular diets. The page was signed by the NHA and was undated as to initiation date or review date.

. Based on observation, interview, and record review, the facility failed to monitor operation of the dish machine to assure dishes, utensils, and other food preparation equipment were properly sanitized. This deficient practice had the potential to promote food borne illness amongst any or all of the facility population of 18 Residents. Findings include: On 1/22/25 at 1:00 PM, the kitchen staff were observed operating the chlorine based cold temperature dish machine. (This was a chemical sanitizing dish machine which used chlorine rather than hot water plus chemicals in the ware washing process.) Certified Dietary Manager (CDM) A was asked to measure the chemical sanitizer dispensing in the machine. A quaternary strip was used (which cannot measure chlorine present to sanitize the dishes or food preparation equipment being washed in the dish machine). When the strips were examined and determined to be unable to measure the sanitizer, the kitchen staff found one roll of chlorine strips in a bag labeled expires 2/14/24. The dish machine was retested and while the strip turned dark, there was not a comparison color chart to accurately compare and determine the level of chlorine the dish machine had dispensed. The amount of sanitizer could not be accurately determined. CDM A noted the kitchen staff had been recording the sanitizer level on the dish machine logs, but stated they had been using the wrong strips since the interim CDM had left last April. The FDA Food Code 2017 states: 4-703.11 Hot Water and Chemical. After being cleaned, EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be SANITIZED in: . (C) Chemical manual or mechanical operations, including the application of SANITIZING chemicals by immersion, manual swabbing, brushing, or pressure spraying methods, using a solution as specified under § 4-501.114. Contact times shall be consistent with those on EPA-registered label use instructions by providing: (1) Except as specified under Subparagraph (C)(2) of this section, a contact time of at least 10 seconds for a chlorine solution specified under 4-501.114(A), P (2) A contact time of at least 7 seconds for a chlorine solution of 50 MG/L (liter) that has a PH of 10 or less and a temperature of at least 38oC (100oF) or a PH of 8 or less and a temperature of at least 24oC (75oF) . .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement and develop an enhanced barrier precautions (EBP) policy, and update infection control policies annually based on standards of practice. This deficient practice has the potential to affect all residents regarding infection control practices. Findings include: On 1/21/25 at 11:00 AM, during the entrance conference, the Nursing Home Administrator (NHA) and the Director of Nursing (DON) were asked to provide the infection control program policies for the facility. Resident 14 (R14) Review of R14's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) assessment of 15, indicative of intact cognition. Review of R14's care plan, date revised 12/28/24, read in part, .Focus: [R14] has a catheter: Neurogenic bladder. Goal: [R14] will remain free from catheter-related trauma .Interventions: Check tubing for kinks 1 x and prn (as needed) each shift. Monitor and document intake and output as per facility policy. Cath (catheter) will be changed monthly . R14's care plan lacked any initiation for EBP as indicated by the Centers for Disease Control (CDC) while performing catheter care, which is listed as a high contact care activity involving a medical device. On 1/21/25 at 12:30 PM, an observation was made of R14's room which lacked any Personal Protective Equipment (PPE) cart or EBP sign on the door indicating precautions were necessary to perform high contact direct care activities, such as catheter care. During an interview on 1/22/25 at 2:10 PM, R14 declined the opportunity for this Surveyor to observe catheter care. R14 was asked if facility staff wear any kinds of PPE and replied, They wear gloves. R14 was asked if facility staff wear a gown when performing catheter care and replied, No, just gloves. On 1/22/25 at 2:20 PM, an interview was conducted with Certified Nurse Aide (CNA) F, who was asked what PPE was used to perform catheter care for R14 and replied, I wear gloves and put a barrier down on the floor. I use alcohol swabs and a hat to collect the urine. CNA F confirmed no other PPE was used when providing catheter care. On 1/22/25 at 3:00 PM, a review of all the infection control policies was completed. The following infection control policies had not been updated annually per standards of practice: a. Covid-19 Vaccination policy last updated on 12/1/20; b. Influenza Vaccination policy undated and no revision; c. Pneumococcal Vaccination policy undated and no revision; d. Isolation - Initiating Transmission-Based Precautions last updated on 12/2007; and e. Surveillance/Antibiotic Stewardship policy undated and no revision. On 1/23/25 at 10:35 AM, an interview was conducted with the NHA, who was asked if she knew how often infection control policies were reviewed and updated and replied, I don't know, you would have to go ask the DON. On 1/23/25 at 10:45 AM, an interview was conducted with the DON, who was asked if she knew how often infection control policies were reviewed and updated and replied, Well yearly. We look at them in quality assurance (QA) and I have a sign off sheet in the infection control book that they were reviewed. The DON was asked to provide the sign off sheet that all the infection control policies were reviewed annually. The DON was also asked if the facility had a policy for EBP and if they had implemented EBP per CDC guidance. The DON replied, No, we do not have a policy for EBP. I did not know that a new implementation with infection control was out for EBP. The DON was unable to provide the sign off sheet by the time of exiting the survey. Review of the Quality Assurance policy, undated, read in part, Policy Statement: It is the policy of this facility to develop, implement, and maintain an ongoing program designated to monitoring and evaluate the quality of resident care, pursue methods to improve quality care, and to resolve identified problems .2. To establish and provide a system whereby a specific process, and the documentation relative to it, is maintained to support evidence of an ongoing Quality Assessment and Assurance Program, encompassing all aspects of resident care including safety, infection control .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure appropriate monitoring and assessment for a change in condition for one Resident (#4) of one residents reviewed for hospitalization. This deficient practice resulted in the potential for worsening in condition and delay in treatment. Findings Include: Resident #4 (R4) Review of R4's medical record revealed initial admission to the facility on 8/28/21 with diagnoses including cerebral infarction (stroke), hypertension (high blood pressure), and frontotemporal neurocognitive disorder (a type of dementia) . Review of R4's most recent Minimum Data Set (MDS) assessment, dated 10/19/23, revealed a Brief Interview for Mental Status (BIMS) score of 1, indicative of severe cognitive impairment. Review of Resident Transfer Form revealed R4 was transferred from the facility to the local hospital on [DATE]. The reason for transfer was listed as a decrease in hemoglobin (the protein contained in red blood cells that is responsible for delivery of oxygen to the tissues). Review of hospital admission records dated 10/12/23 read, in part: .CHIEF COMPLAINT: Dark and tarry stools and anemia. HISTORY OF PRESENT ILLNESS: This patient is a [AGE] year-old white female who was sent here [hospital] from [facility] nursing home. She had been having dark stools for the past 2 weeks. Laboratory studies were done that showed her hemoglobin was 4.3 [reference range 12.0-16.0 g(grams)/dL(deciliter)] when she arrived here [hospital] but her hemoglobin was actually 3.3 [g/dL] . .IMPRESSION: .GI (gastrointestinal) bleed with acute blood loss anemia .transfused 4 units of packed red blood cells in the emergency room . On 2/7/24 at approximately 9:50 AM, an interview was conducted with Registered Nurse (RN) D regarding the events leading up to R4's hospitalization. RN D stated R4 had a gradual decrease in appetite and reported abdominal pain which prompted the physician to order lab work. RN D denied reports of abnormal stools or abnormal vital signs. Review of a Nursing Note dated 10/10/23 at 1800 (6:00 PM) read, in part: .skin paleness + [and] hypotensive (low) B/P's (blood pressures) in the last few wks (weeks). Dark stools, poor appetite at times. Belching . Review of R4's Bowel Movement Record in the 14 days leading up to her hospitalization did not reveal documentation of color nor consistency of the stools. Review of the physician notes in the prior two weeks did not indicate dark stools or alteration of appetite. Review of the R4's Vital Sign and Weight Flow Sheet revealed the following blood pressure measurements in the two weeks which lead up to R4's transfer to the hospital: 9/28/23: 104/61 (millimeters of mercury [mmHg]) 9/29/23: 96/54 9/30/23: 96/53 10/1/23: 113/43 10/2/23: 109/56 10/3/23: 98/49 10/4/23: 124/70 10/7/23: 93/48 10/8/23: 121/90 10/9/23: 111/63 10/10/23: 97/49, 99/58 10/11/23: 109/54 Review of R4's blood pressure measurements from 9/1/23 to 9/27/23 (the month leading up to R4's hospitalization on 10/11/23), revealed an average blood pressure of 126/72. On 2/7/24 at 10:04 AM, an interview with conducted with the Director of Nursing (DON). The DON was asked the protocol that is expected if a vital sign was determined to be out of normal parameters. The DON stated, It would be expected to retake it [the vital sign]. If it was still too low or too high, the physician would be notified. The DON reviewed R4's blood pressure readings leading up to her hospitalization and acknowledged an overall reduction in blood pressure readings and several measurements that were considered out of normal parameters. The DON stated that the physician was noted via text message or call on the instances R4's blood pressures fell outside the normal range. No physician documentation prior to the day of the hospital transfer was produced to support this statement. On 2/7/24, at approximately 11:39 AM, a follow-up interview was conducted with RN D. RN D acknowledged that R4's blood pressures were trending down and not within her normal range in the days leading up to her hospitalization. RN D verified that communication with the physician is expected in these circumstances. No physician documentation prior to the day of the hospital transfer was produced to support this statement. Review of an undated facility policy titled, Nursing Policy and Procedure: Vital Signs Notification read, in part: .if warranted, nurses will contact doctor of any abnormal vital signs. Review of an undated facility policy titled, Change in Condition Policy read, in part: Detecting and promptly reporting changes in a nursing home resident's condition are critical for ensuring the resident's well-being and safety . .1. Summarize Baseline Condition: Nursing staff should summarize a resident's normal (baseline) condition 2. Identify Important Changes: It's essential to identify whether changes in a resident's condition are important or not . .Remember that timely reporting of changes can lead to better outcomes for residents, while unreported changes may result in serious complications or even hospitalization. Communication and vigilance play a crucial role in maintaining resident safe and well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure requirements for Preadmission Screening/Annual Resident Review (PASARR) were reviewed and revised annually for five Residents (R1, R11, R13, R14, and R16) of seven residents reviewed for PASSAR requirements, resulting in the potential for unmet mental health and/or intellectual/developmental disability care needs. Findings include: Resident #1 (R1) Review of R1's medical records, revealed a PASARR form (Form DCH-3877 [State Agency] used to determine mental health needs) dated 8/5/22 and indicated a Level II evaluation. There was no Mental Illness/Intellectual/Developmental Disability/Related condition exemption Criteria Certification. The PASARR dated 8/5/22 revealed an original admission to the facility on 2/19/19. No annual review documentation could be found. The 'medical diagnoses' indicated R1 had resided at the facility since 2019 with diagnoses that included dementia and major depressive disorder. According to the Minimum Data Set (MDS) dated [DATE], R1 had moderate cognition impairment with a Brief Interview for Mental Status (BIMS) score of 11/15. R1 received an antidepressant medication seven days a week. Resident #11 (R11) Review of R11's medical records, revealed a PASARR form dated 8/1/22 and lacked any further PASARR form as required. The PASARR dated 8/1/22 revealed an original admission to the facility on 6/2/17. According to the MDS dated [DATE], R11 had medical diagnoses of dementia and depression. Resident #13 (R13) Review of R13's medical records, revealed a PASARR form dated 8/5/22 and a Level II evaluation dated 8/5/22. The PASARR dated 8/5/22 revealed an original admission to the facility on 1/19/20. No annual updated PASARR could be located in the medical record. According to the MDS dated [DATE], R11 had a medical diagnosis of depression. Resident #14 (R14) Review of R14's medical records, revealed a PASARR form dated 12/14/21 and lacked any further PASARR as required. The PASARR dated 12/14/21 revealed an original admission to the facility on [DATE]. According to the MDS dated [DATE], R1 had moderate cognition impairment with a BIMS score of 8/15. R14 received an antidepressant medication seven days a week and had medical diagnoses of depression and dementia. Resident #16 (R16) Review of R13's medical records, revealed a PASARR form dated 8/5/22 and a Level II evaluation dated 8/5/22. No updated PASARR could be found in the medical record. The PASARR dated 8/5/22 revealed an original admission to the facility on 3/29/21. According to the MDS dated [DATE], R16 had severe cognitive impairment with a BIMS score of 1/15. R16 received an antipsychotic and antianxiety medications seven days a week and had medical diagnoses of anxiety, depression, and dementia. On 2/5/24 at 4:00 PM, a request was made to the Director of Nursing (DON) for an updated PASARR for R1, R11, R13, R14, and R16. On 2/6/24 at 1:30 PM, an interview was conducted with the DON and a second requested was made for the missing PASARR forms as stated above. The DON replied, I looked for them in the charts and I noticed they were not completed. I called Community Mental Health (CMH), and they are overdue. I just did them and now they are in the charts. On 2/7/24 at 10:00 AM, an interview was conducted with the DON who confirmed that the PASARR forms were to be completed annually. Review of the facility document titled, Pre-admission Level II Evaluation and Annual Resident Review (PASARR), undated, read in part, .[name of nursing home] will review assessments annually. Review of the facility document provided agreement with the local CMH, dated 6/12/18, read in part, .Preadmission Level II Evaluation and Annual Resident Review (PASARR) .B. The Nursing Facility shall initiate the referral by annual completion and transmittal of (State Agency) Form 3877 to the Board or by forwarding admission 3877/3878 Hospital Exemption Discharge ([NAME]) forms prior to the expiration of the [NAME] .Documentation .B. The Nursing Facility will be responsible for the following documentation: .1. admission (State Agency) 3877/3878 Hospital Exempted Discharge forms .2. Annual completion and transfer to the Board of (State Agency) Forms 3877 and 3878 (as appropriate) at least 30 days, but preferably 2 weeks, prior to the previous review date or (State Agency) Determination .

Based on observation and interview, the facility failed to maintain smooth floors, secure free-standing wardrobes, and secure riser lids for the septic system, resulting in the potential for falls and entrapment, affecting residents, staff, and the public. Findings include: On 2/5/24 at 11:50 AM, the adhesive tile floor at the end of the hall, near rooms 101/102, was observed to have multiple tile squares peeling up, creating a tripping hazard. The peeling tiles were easily catching the Surveyors foot, while walking over them. An emergency exit was observed at the end of the hall, next to the damaged tiles. On 2/5/24 at 2:50 PM, the free-standing wardrobes in resident room #'s 122- 128 and 163-170 were observed to not be fastened to the wall. Multiple wardrobes were observed to not be level on the floor. The wardrobes have the potential to tip over when the door was opened, and weight was applied to the door. On 2/6/24 at 9:10 AM the septic tank riser at the south west drain system was observed to be damaged and duct taped together. Additionally, all four septic tank risers were not observed to be fastened shut to prevent accidental entrapment. During an interview on 2/6/24 at 9:30 AM, Maintenance Director F stated that the riser at the southwest drain system was run over by a car and they haven't found a replacement to match. During an interview on 2/6/24 at 10:55, the NHA was queried on the damaged floor and stated it was as a result of a carpet being placed in front of the emergency exit that would get wet from snow melt. The consistent wet floor warped the adhesive tiles. The NHA was queried further regarding the free-standing wardrobes potential for tipping over and stated that they haven't thought of securing the wardrobes to the wall.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the medication storage room was free of expired medications and failed to securely store medications, for one of one medication rooms and one of one medication carts reviewed for medication storage. This deficient practice resulted in the potential for administration of medications with reduced intended effect. Findings include: On 2/5/24 at 2:40 PM, an observation was made of the medication storage room with the Director of Nursing (DON). In the medication room the following items were found to be expired: a.) name brand needle 22-gauge with lot number 365608 and expiration date of 1/31/23 count seven; b.) name brand needle 21-gauge with lot number 365607 and expiration date of 3/31/23 count six; c.) name brand syringe with attached needle size 3 milliliters and 21-gauge inch and one half with lot number 7031546 and expiration date of 1/31/22 count twelve; d.) hydrocortisone cream, 2 ounces, with lot number 0110387 and expiration date of 10/22; e.) diclofenac sodium cream 1 % gel 100 grams with lot number SBBH and expiration date of 01/24; f.) name brand needle 23-gauge with lot number 6238534 and expiration date of 7/31/21 count two; g.) name brand needle 23-gauge with lot number CKDH12-01 and expiration date of 11/1/23 count half box 50 of 100 and; h.) name brand over the counter pain relief patches (lidocaine) with lot number 30L43 and expiration date of 12/23 count half box 10 of 20. On 2/5/24 at 3:00 PM, an interview was conducted with the DON. The DON was asked if the facility provides their own blood draws to residents and replied, Yes. We draw blood on the residents. The DON was asked if expired medication supplies should be kept in the active medication supply room and replied, No. I will throw them out now. The DON was asked how often the medication supply room is reviewed for expired medications and biologicals and replied, The medication room is reviewed by nursing staff and me twice a month on the 1st and the 15th of the month. On 2/6/24 at 10:42 AM, an observation was made of medication pass with Registered Nurse (RN) D who was in room [ROOM NUMBER] passing medications with this Surveyor. This Surveyor was observing medication pass and looked down at the floor and observed a round small pink pill on the floor under the base of the bedside table. RN D was asked if she had seen the pill and replied, Yes. I see it. RN D picked up the pill and later it was identified as Resident #20's lisinopril 20 milligrams that is administered at 9:30 PM every evening. Review of the Resident residing in room [ROOM NUMBER]'s medication administration record revealed that she received this medication at 9:30 PM and RN D verified and confirmed that the room had been cleaned the prior day by housekeeping. RN D was asked if the medication should have been loose on the floor of room [ROOM NUMBER] and replied, No. It should have been thrown away and re-dispensed. On 2/6/24 at 11:10 AM, an interview was conducted with the DON, who confirmed that no loose pills should be found or left in any residents' room. Review of facility policy titled, Medication Storage, dated 2015, read in part, Medication is stored and kept under lock and key in medication cart, and med room only .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain exhaust ventilation in resident bathrooms, resulting in the potential for odors, affecting room #'s 167, 168, 169, and 170. Findings include: On 2/5/24 at 2:50 PM, the exhaust ventilation for the bathroom of room [ROOM NUMBER] was tested using a paper towel to test the suction of the vent. The paper towel showed no pull from the exhaust ventilation. During an interview on 2/6/24 at 9:05 AM, Maintenance Director F was queried on the ventilation system and stated that the two roof top air units were iced over. Maintenance Director F continued to state that a staff member turned on the air conditioning (AC) unit two days ago, causing the roof top units to build up ice. Maintenance Director F confirmed that the residents bathroom exhaust vents are not working properly for this reason. On 2/6/24 at 10:45 AM, resident bathroom exhaust fans for room #'s 167, 169, and 170 were observed to not be functioning using the paper towel test.

Based on observation, interview, and record review, the facility failed to properly store potentially hazardous food and maintain a kitchen environment free of harborage conditions for pests, resulting in an increased risk of foodborne illness and potential for pests on the premise, affecting all residents that consume food from the kitchen. Findings include: On 2/5/24 at 11:28 AM, during an inspection of the kitchen, [NAME] C stated that the 1st section of the walk-in cooler was currently not working and they are working on getting it repaired. A bottle of opened ranch dressing was observed to be stored in the warm 1st section and the manufacturer's label states Keep Refrigerated. Additionally, an opened jar of sweet pickle relish was observed to be stored in the warm 1st section and the manufacturer's label states Refrigerate after opening. According to the facility's policy, Cold Food Storage Protocol, dated 10/28/2008, it notes, Policy: All perishable food will be stored according to HACCP guidelines. These food items will be maintained at 41*F or colder. According to the 2017 FDA Food Code Section 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under §3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57oC (135oF) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; P or (2) At 5ºC (41ºF) or less. P (B) EGGS that have not been treated to destroy all viable Salmonellae shall be stored in refrigerated EQUIPMENT that maintains an ambient air temperature of 7°C (45°F) or less. P (C) TIME/TEMPERATURE CONTROL FOR SAFETY FOOD in a homogenous liquid form may be maintained outside of the temperature control requirements, as specified under (A) of this section, while contained within specially designed EQUIPMENT that complies with the design and construction requirements as specified under 4 204.13(E). On 2/5/24 at 11:35 AM, mouse droppings were observed among trays and pot lids in the cupboard next to the oven. At this time, [NAME] 'C' was queried on pest problems in the facility and stated that they have caught one or two mice, but they hardly ever go in the cupboard where the mice droppings were observed. The kitchen was observed to have multiple rodent traps that were empty. No other areas in the kitchen were observed to have mouse droppings. According to the 2017 FDA Food Code Section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. Pf (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. During an interview on 2/5/24 at 4:05 PM, the Administrator stated that they do their own pest control program. The Administrator continued to state that they have caught a few mice but don't have an issue with pests currently.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to prevent and ensure appropriate assessment and tracking of wounds according to professional standards of practice for one Resident (#19) of two residents reviewed for pressure injuries. This deficient practice resulted in the potential for delayed healing and unidentified worsening of wounds. Findings include: Resident #19 was admitted to the facility on [DATE] and had diagnoses including a traumatic spinal cord injury with paraplegia (paralysis of lower body), neurogenic bladder and placement of a suprapubic catheter (catheter inserted into the bladder through the abdominal wall to drain urine). A review of Resident #19's Minimum Data Set (MDS) assessment, dated 9/17/2022, revealed Resident #19 required extensive, two-person physical assistance with bed mobility and transfers. Further review revealed Resident #19 scored 15 out of 15 (15/15) on the Brief Interview for Mental Status (BIMS), indicating the Resident was cognitively intact. A review of the MDS Section M - Skin Conditions, revealed Resident #19 was assessed as being at risk for the development of pressure ulcers. An observation on 12/19/2022 at 10:51 a.m., revealed Resident #19 sitting in a motorized wheelchair in her room. A blue, mechanical lift sling was observed to be underneath the Resident seated in the wheelchair with portions of the sling extending laterally from under each of the Resident's upper thighs. Resident #19 stated having the sling under her in the chair bothers her. The Resident stated she was unable to bear weight on her lower extremities and required the use of a total, mechanical lift for transfers. When asked if she was uncomfortable sitting on the sling, Resident #19 stated she had decreased sensation in her lower body and did not feel anything. Resident #19 reported she had an open wound on her left buttock. Resident #19 reported she often opted to stay up in her chair during daylight hours. When asked if staff approached her for repositioning throughout the day, the Resident stated, no. An observation with Registered Nurse (RN) F, on 12/20/2022 at 4:05 p.m., revealed an open, partial-thickness pressure wound located at Resident #19's gluteal fold (where the thigh meets the buttock). The wound was linear in shape and approximately six centimeters long by 2 centimeters wide. The lateral portion of the wound was open, with a red wound bed. The skin surrounding the wound was dusky gray and dry. RN F was unsure what caused the wound. RN F stated the only conclusion was the wound was caused by the lift sling being left under the Resident while she was seated in her wheelchair. A review of Resident #19's medical records, including all nursing notes, assessments from 6/01/2022 through 12/20/2022, as presented by the Director of Nursing (DON), revealed no documentation related to the wound located on the Resident's left buttock. A review of Resident #19's Treatment Administration Record(s) from 9/01/2022 through 12/20/2022 revealed no wound assessments, including no measurements or descriptions of the wound and peri-wound area, documented. On 12/20/2022 at 12:30 p.m., Registered Nurse (RN) G was asked about the progression of Resident #19's left buttock wound. RN G stated she would have to ask the DON. When asked if she provides wound care to Resident #19, RN G reported yes, but she would have to ask the DON prior to providing information. On 12/20/2022 at 12:45 p.m., the DON and RN G were approached in the Medical Record/Medication Storage Room, located inside the nurses' station. An inquiry was made of the DON and RN G of the facility's process for documenting assessments of wounds. The DON presented a white binder and proceeded to show this surveyor several forms titled Skin Audit Tool. A review of Resident #19's Skin Audit Tool, dated 6/30/2022 through 12/15/2022 revealed the following documentation: 8/4/2022: Spot L (left) buttocks. 9/1/2022: Healing . L buttock. 9/18/2022: Small open area R (right) buttock. 9/22/2022: Improving R buttock. 9/27/2022: R buttock open, cleaned, calmoseptine (barrier ointment used to protect skin from moisture) applied. 10/27/2022: Left buttock, inside buttock fold, calmoseptine. 10/30/2022: L buttock . calmoseptine applied . 11/3/2022: L buttock pink - dry, calmoseptine ointment. 11/13/2022: L buttock/leg, improving, calmoseptine . 11/17/2022: Under L buttock fold, red, dry, calmoseptine. 11/24/2022: Under L buttock fold . blister open . 11/27/2022: Left buttock open area cleaned, drsg (dressing) applied, left under buttock area open, cleaned (and) dsg applied. 12/1/2022: Under left buttock open area, no drainage, cleaned, dsg applied, left buttock . cleaned. 12/8/2022: Open area under L buttock . small . left buttock . calmoseptine ointment applied. 12/11/2022: L buttock improving, under L buttock open, calmoseptine ointment applied. 12/15/2022: L buttock . under L buttock red, shallow . dsg It was noted there were no wound measurements or descriptions of the wound bed and peri-wound area included in the documentation on Resident #19's Skin Audit Tool(s). On 12/20/2022 at 12:45 p.m., the DON stated wound care is provided by the Charge Nurse, per Standing Orders. The DON reported the facility does not document wound measurements or detailed descriptions of wounds in the medical record. The DON stated all wound documentation is completed on the Skin Audit Tool. A review of the Wound Care Standing Orders, revised 11/2015, revealed the following, in part: All wounds are measured weekly - no more than 7 days between measurements and preferably done by the same nurse. This is a state guideline . A review of the undated, facility policy titled Skin Tears/Injuries/Decubitus Ulcers, provided by the DON as the facility policy related to pressure ulcers, revealed no guidance related to assessment of wounds or documentation of wound assessments. Further review of the policy revealed the following, in part: When charting on a pressure ulcer, it can never be down graded. For instance, once you have a stage IV pressure ulcer, when it improves it must be charted as a healing stage IV not a stage III. No other language or guidance related to pressure ulcers was included in the policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure appropriate indications for the administration of antipsychotic medication through documentation of target behaviors and the use of non-pharmacologic interventions for one Resident (#4) of five residents reviewed for unnecessary medications. This deficient practice resulted in the potential for unnecessary use of mind-altering medications, negative side-effects of administered medications and decreased quality of life. Findings include: A review of Resident #4's Minimum Data Set (MDS) assessment, dated 10/18/2022, revealed the Resident was admitted to the facility on [DATE] and had diagnoses including dementia, stroke and right-side hemiplegia (one-side muscles weakness or paralysis). Further review of Resident #4's MDS assessment revealed the Resident scored six out of 15 (6/15) on the Brief Interview for Mental Status (BIMS), indicating Resident #4 had severe cognitive impairment. A review of Resident #4's medical record, as presented by the Director of Nursing (DON), revealed Resident #4 was administered risperidone (an anti-psychotic medication used to treat mental/mood disorders) 0.5 milligrams daily. Further review revealed the medication was discontinued on 3/8/2022 as a trial dose-reduction and restarted per physician order on 5/9/2022. A review of Resident #4's undated, Pre-Psychoactive Medication Assessment, revealed the following: This form as been developed to adequately assess all aspects of the resident's well-being prior to the use of medication interventions in order to identify the least restrictive intervention. Primary medical reason(s) or behavior(s) exhibited by resident to indicate a need to complete a Pre-Psychoactive Medication Assessment: resident admitted from home, alert to person (and) place only. The following non-medication approaches or interventions have proven to be ineffective: (blank, no answer provided). Further review revealed the following questions answered with a yes response: Disoriented x 2. Short Attention Span. Independent with or without cane, walker. Experiencing feelings of anger, fear, abandonment. A review of Resident #4's Psychoactive Medication Quarterly Evaluation, dated 6/2/2022 and signed by the DON, revealed the following: Drug: Risperidone. Dosage: 0.5 mg (milligram). Frequency: Daily. Diagnosis: Anxiety. Behavior warranting use of medication: upset at HS (bedtime) due to sundowners. Ineffective interventions: 1 on 1 (supervision), doing activities, offer TV and snacks. A review of Resident #4's Informed Consent for Antipsychotic Medication, dated 5/9/2022 revealed the reason for use of psychotropic medications as unable to provide care. The form listed possible consequences of not receiving the risperidone as: inability of staff to deliver necessary care (and) decreased ability to safely participate in activities. A review of Resident #4 medical record with the DON on 12/20/2022 at 11:53 a.m. revealed no documentation of staff inability to deliver care from the date the risperidone was discontinued on 3/8/2022 through 5/9/2022, the date the medication was restarted. Further review revealed no documentation of the Resident's inability to safely participate in activities from the time the risperidone was discontinued on 3/8/2022 though the date the medication was restarted on 5/9/2022. A review of Resident #4's Behavior/Mood Symptom Tracking Tool(s), with the DON on 12/20/2022 at 10:53 a.m., revealed the following: March 2022: 78 separate entries all documented Resident #4's behavior as Pleasant/Friendly/Cooperative. April 2022: 70 separate entries all documented Resident #4's behavior as Pleasant/Friendly/Cooperative. May 2022: 80 separate entries all documented Resident #4's behavior as Pleasant/Friendly/Cooperative. It was noted the documentation covered various time periods and shifts. The DON stated staff documented behavior for their entire shift and if behaviors occurred at all during the referenced time period and shift, staff should document the behavior on the tracking tool. The DON confirmed no negative behavior was documented on the tracking logs for the reviewed period of March 2022 through May 2022. A review of Resident #4's nursing notes and assessment from 3/8/2022 through 5/9/2022, revealed the following: 4/8/2022 at 6:00 a.m. - Resident was up over 6 times to go to the bathroom during the night. Sometimes she would go and other times she wouldn't. Resident not able to remember when she got up. She thinks she can get up herself. Tries to get out of bed, feet over and yelling to go to the bathroom. 4/8/2022 (no time documented) - Resident keeps trying to get up and out of (wheelchair), states she can get up and walk, close supervision needed all shift, resident gets angry with staff for not letting her walk. 4/8/2022 at 7:30 p.m. - Resident keeps trying to get out of (wheelchair). Wants to stand up and get up. Denies having a stroke and thinks that she can walk on her own. Repositioned many times, take to bathroom. Needs close supervision. 4/9/2022 at 7:00 a.m. - Resident was up to (bathroom) x 3 during the night. Sleeping well after (5:00 a.m.). 4/9/2022 at 6:00 p.m. - Resident alert (and) verbally oriented to self, appetite good, drinking fluids well. Raspy voice, clear, runny nose, (temperature) 100 (degrees Fahrenheit) - 99.4 (degrees Fahrenheit) . dry cough. Covid-19 rapid test performed, negative result. Voiding on bedside commode (assist) x 2. (Assisted) to propel in wheelchair to and from meals (and) group activities. Reading newspaper. Napping on (and) off, monitoring. Agitated in afternoon (through) evening . DON notified (physician), new order to restart risperidone .5mg, one (by mouth) in evening . No other documentation was present from 4/9/2022 until 5/16/2022. A review of Resident #4's physician progress notes revealed the following: 6/10/2022 at 3:29 p.m. - Provider Plan . bipolar disorder (mental disorder characterized by periods of depression and periods of abnormally elevated mood) - to continue with risperidone .5 mg po qd (by mouth daily). 10/5/2022 at 5:51 p.m. - Provider Plan . bipolar disorder - stable on risperidone .5 mg po qd. It was noted the physician progress notes reviewed for 6/10/2022 and 10/5/2022 did not include documentation of psychosocial assessment or any mention of Resident #4's mood or behavior. A review of Resident #4's Preadmission Screening Annual Resident Review (PASARR), dated 9/6/2022, revealed Resident #4 was not diagnosed with a mental illness/disorder. During an interview on 12/21/2022 at 10:15 a.m., the DON confirmed the physician order to restart the risperidone 0.5 mg daily was written on 5/9/2022. When asked why the medication was not restarted as documented in the nurses' notes on 4/9/2022, the DON stated antipsychotic medication was not restarted on 4/9/2022 because we were trying other things first. The DON was asked to provide documentation of the resident's behavior and any non-pharmacologic interventions attempted and failed from 4/9/2022 through 5/9/2022. The DON was queried regarding the physician documentation of bipolar disorder as the indication for Resident #4's administration of risperidone. The DON stated she was unsure why the physician documented Resident #4 had a diagnosis of bipolar disorder. The DON reported Resident #4 was never referred to behavioral health for evaluation since the Resident's admission on [DATE] and the Resident did not have bipolar disorder. By the end of the survey on 12/21/2022 at 2:00 p.m., no additional documentation was provided related to Resident #4's behavior and the use of non-pharmacological interventions attempted in response to any negative behavior exhibited by Resident #4 from 4/9/2022 at 6:00 p.m. through 5/9/2022. A review of the facility policy titled Behavior Assessment and Monitoring, provided by the DON and last revised 4/2007, revealed the following, in part: Problematic behavior will be identified and managed appropriately . The facility will comply with regulatory requirements related to the use of medications to manage problematic behavior . The nursing staff will identify, and inform the physician about an individual's mental status behavior and cognition, including: Onset, duration and frequency of problematic behaviors or changes in behavior, cognition or mood . The staff will identify and discuss with the practitioner situations where nonpharmacologic approaches are indicated and will institute such measure to the extent possible . The staff will document (either in progress notes, behavior assessment forms or other comparable approaches) the following information about specific problem behaviors: number and frequency of episodes; preceding or precipitating factors; interventions attempted; and outcome associated with interventions. A review of the facility policy titled Medication Utilization and Prescribing - Clinical Protocol, provided by the DON and last revised 4/2007, revealed the following, in part: When a medication is prescribed in response to an identified problem, condition or risk, the physician and staff will identify the indications (condition or problem for which it is being given, or what the medication is supposed to do or prevent) . symptoms should be characterized in sufficient detail to help identify whether a problem exists or whether a symptoms is just a variation of normal. A symptom may have diverse causes, so it is usually relevant to try to identify likely causes and pertinent non-pharmacologic interventions. A diagnosis by itself may net be sufficient justification for prescribing a medication. The existence of a condition or risk does not necessarily require a treatment and the treatment may be something besides, or in addition to, medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement comprehensive, person-centered care plans in accordance with resident assessments for five Residents (#4, #19, #18, #8 and #22) of ten residents reviewed for care plan development and implementation. This deficient practice resulted in the potential for unmet physical and psychosocial care needs. Findings include: Resident #4 A review of Resident #4's Minimum Data Set (MDS) assessment, dated 10/18/2022, revealed the Resident scored six out of 15 (6/15) on the Brief Interview for Mental Status (BIMS), indicating Resident #14 had severe cognitive impairment. A review of the MDS Section E - Behavior, revealed Resident #14 was assessed as having delusions (misconceptions or beliefs that are firmly held, contrary to reality) and rejected care on one to three days of the assessment look-back period. A review of Resident #4's medical record revealed the following physician order: A review of Resident #4's Medication Administration Record(s) (MAR) for 6/2022 through 12/21/2022 revealed the Resident was administered risperidone (anti-psychotic medication used to treat mental/mood disorders) 0.5 milligram (mg), daily. A review of the Psychoactive Medication Quarterly Evaluation, dated 6/2/2022, revealed the following, in part: Risperidone. Dosage: 0.5mg . daily. Behavior warranting use of medication: upset at HS (bedtime) due to sundowners (increased confusion and restlessness) . A review of the Psychoactive Medication Quarterly Evaluation, dated 9/2/2022, revealed the following, in part: Risperidone. Dosage: 0.5mg . daily. Behavior warranting use of medication: unable to provide care . A review of Resident #4's care plan revealed the following, in part: Focus: The resident uses anti-anxiety medications (related to) adjustment issues, anxiety disorder. Date Initiated: 6/7/2022 . Interventions: Administer medications as ordered. Monitor/document for side effects and/or toxic symptoms of medications. Date Initiated: 6/7/2022. Focus: The resident has a mood problem (related to) disease process, anxiety and sundowners. Date Initiated: 6/7/2022. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 6/7/2022. It was noted, Resident #4's care plan did not include resident-specific behavior targeted using anti-psychotic or anxiolytic medications. Resident #4's care plan did not include resident-specific, non-pharmacological interventions targeting behavior related to mood, anxiety or rejection of care. During an interview on 12/21/2022 at 10:15 a.m., the Director of Nursing (DON) confirmed Resident #4's care plan did not target resident specific behaviors. The DON confirmed staff utilized resident care plans to determine the appropriate care to provide to each resident. The DON was queried as to how staff would know what triggered the Resident's behavior and what non-pharmacological interventions to use to target the Resident's behavior and mood. The DON stated the staff just know. Resident #19 A review of Resident #19's MDS assessment, dated 9/17/2022, revealed Resident #19 required extensive, two-person physical assistance with bed mobility and transfers. Further review revealed Resident #19 scored 15 out of 15 (15/15) on the BIMS, indicating the Resident was cognitively intact. A review of the MDS Section M - Skin Conditions, revealed Resident #19 was assessed as being at risk for the development of pressure ulcers. An observation on 12/19/2022 at 10:51 a.m., revealed Resident #19 sitting in a motorized wheelchair in her room. A blue, mechanical lift sling was observed to be underneath the Resident seated in the wheelchair with portions of the sling extending laterally from under each of the Resident's upper thighs. Resident #19 stated having the sling under her in the chair bothers her. The Resident stated she was unable to bear weight on her lower extremities and required the use of a total, mechanical lift for transfers. When asked if she was uncomfortable sitting on the sling, Resident #19 stated she had decreased sensation in her lower body. Resident #19 reported she had an open wound on her left buttock. Resident #19 reported she often opted to stay up in her chair during daylight hours. When asked if staff approached her for repositioning throughout the day, the Resident stated no. An observation with Registered Nurse (RN) F, on 12/20/2022 at 4:05 p.m., revealed an open, linear wound, approximately six centimeters long by 2 centimeters wide, located at Resident #19's gluteal fold (where the thigh meets the buttock). RN F was unsure what caused the wound. RN F stated the only conclusion was the wound was caused by the lift sling being left under the Resident while she was seated in her wheelchair. When asked what interventions were in place to promote wound healing, RN F reported Resident #19 received daily wound care and staff were reminding the resident to be careful when shifting weight while up in her wheelchair. A review of Resident #19's care plan revealed the following, in part: Focus: The resident has limited physical mobility (related to) weakness. Date Initiated: 6/5/2021. Interventions: The resident is non-weight bearing. Locomotion: The resident uses powered wheelchair for locomotion. Clean daily and (as needed). Date Initiated: 6/5/2021. It was noted Resident #19's care plan included no interventions related to Resident #19 required two-person, physical assistance and the use of a total, mechanical lift for transfers. Further review of Resident #19's care plan revealed focus areas related to the potential for pressure ulcer development and the potential impairment to skin integrity . (related to) fragile skin. Both focus areas were revised on 6/22/2021. It was noted the interventions related to the potential for pressure ulcer development and impairment to skin integrity included no interventions related frequent repositioning, offloading or assessment of the sling placement while transferring the Resident or when Resident #19 was seated in the wheelchair. During an interview on 12/21/2022 at 10:15 a.m., the DON reported care plans should include a resident's risk for pressure ulcers and skin impairment along with resident specific interventions targeted at decreasing the likelihood of such. A review of the facility policy titled Care Planning Policy, provided by the DON and dated 2016, revealed the following: Care plans will be initiated upon admit, by charge nurse and reviewed by DON. It will be done withing 24 hours of resident's arrival. Care conferences will be done quarterly and annually. Interdisciplinary staff are present, and resident and families are notified and encourage(d) to attend. It was noted the care planning policy did not include information related to inclusion of resident specific focus areas, goals and interventions. Resident #18 A review of Resident #18's MDS assessment, dated 9/9/2022, revealed the Resident required one-person, physical assistance with transferring and bed mobility. Further review revealed Resident #18 scored two out of 15 (2/15) on the BIMS, indicating the Resident had severe cognitive impairment. A review of the MDS Section M - Skin Conditions, revealed the resident was assessed as being at risk for developing pressure ulcers. An observation on 12/19/2022 at 10:51 a.m., revealed Resident #18 seated in a recliner in her room. Resident #18's feet were observed to be resting on the raised footrest of the recliner and the Resident was wearing a green, heel protection boot on her right foot. An observation on 12/20/2022 at 2:15 p.m., revealed Resident #18 sitting in her recliner with both heels resting directly on the raised footrest. It was noted there were no heel protection devices in place at the time of the observation. An observation on 12/20/2022 at 2:38 p.m., revealed Resident #18 sitting in her recliner. Resident #18 was wearing socks on both feet and both of the Resident's heels were observed to be resting directly on the raised footrest. Certified Nurse Aide (CNA) G, present at the time of the observation, reported Resident #18 previously had a pressure injury on her right heel that was black and hard. An observation of Resident #18's right heel revealed the skin on the Resident's entire right heel was epithelialized (covered with new skin) and surrounded by a border of white, dry skin. CNA G was observed replacing the Resident's right sock. CNA G exited Resident #19's room without floating the Resident's heels or placing a heel protection device on the Resident's right foot. A review of Resident #18's Skin Audit Tool, provided by the DON and dated 7/29/2022 through 12/19/2022, revealed the following, in part: 12/2/2022. Findings: right heel scab off - healed. During an interview on 12/20/2022 at 12:45 p.m., the DON confirmed Resident #18 had a healed pressure injury on her right heel. The DON stated Resident #18 should have a heel protector on her right foot while seated in the recliner as part of the facility standard protocol. The DON stated resident with healed pressure injuries were at high risk of developing future wounds. A review of Resident #18's care plan revealed no focus area, goals or interventions related to skin integrity or the presence of or risk for pressure injuries. Resident #18's current doctor's orders had no diet ordered. The most recent Nutritional Assessment dated 7/20/21 revealed a weight of 107 pounds and a score of 11 indicating Resident #18 was At risk of malnutrition. On 12/19/22 at 1:11 PM and on 12/20/22 at 8:15 AM, Resident #18 was observed being fed by a staff member in the dining room. Resident #18 had a tray card at both meals indicating the diet as Reg. Mechanical. The other areas of the tray card including Special Requests:, Dislikes:, Beverage, Allergies: and Notes: were all blank. The food Resident #18 received was not a mechanically altered constancy but was pureed. On 12/20/22 at 8:17 AM, the Dietary Manager (Staff I) confirmed Resident #18 received a pureed diet, not a mechanical soft diet and stated the tray card was old. The care plan for Resident #18 was reviewed on 12/19/22 and revealed no nutritional care plan was included. There was an oral/dental problem listed related to poor oral hygiene, but the only intervention for this concern was to provide mouth care. There were no interventions or goals specific to the specialized diet consistency or the provision of assistance at meals for Resident #18. Resident #8 Resident #8 was admitted [DATE] with diagnoses which included dementia, diabetes, and long-term use of insulin. Resident #8's current doctor's orders included two types of insulin, to check the blood sugar with a fingerstick three times daily and a diet of Regular - CC (Consistent Carbohydrate) On 12/20/22 at 1:21 PM, the medical record for Resident #8 was reviewed with the Director of Nursing. The care plan for Resident #8 did not include the special diet of Regular Consistent Carbohydrate or any other resident centered nutritional plan or goals required. Resident #22 Resident #22 was admitted [DATE] with diagnoses which included major depressive disorder, high blood pressure and chronic kidney disease. The current care plan also included an additional diagnosis of diabetes. Resident #22's current doctor's orders had no diet ordered. The most recent Nutritional Assessment dated 6/29/22 revealed a weight of 80 pounds and a score of 10 indicating Resident #22 was At risk of malnutrition. During an interview on 12/19/22 at 12:01 PM, Resident #22 stated she ate in the dining room and had to watch what she ate as she sometimes had difficulty swallowing due to a dry throat. The current care plan for Resident #22 had a focused concern of The resident has nutritional problem or potential nutritional problem. The goal listed on the care plan was as follows: The resident will comply with recommended diet for weight gain daily through review date. The only intervention listed for this concern and goal was: Administer medication as ordered. Monitor/Document for side effects and effectiveness. During an interview on 12/20/22 at 1:20 PM, the DON confirmed there should have been a diet ordered by the doctor and care plan should have included interventions to support the dietary focused concern for Resident #22.

Based on interview and record review, the facility failed to implement their policy and have a process to track and document the COVID-19 vaccination status for three staff members (Therapist C, Physician D, and Pharmacist E). This deficient practice had the potential increase the spread of Covid-19 and effect all 22 residents in the facility. Findings include: During an interview with the Director of Nursing (DON) on 12/20/22 at 10:14 a.m., the DON provided the staff Covid-19 vaccination log. There was a total of 22 staff members. Five staff members were unvaccinated. Exemptions for these staff members were reviewed. When asked about staff who provided services in the facility, but were not directly employed, the DON said she had not obtained proof of vaccination for these individuals as they had not been tracked. The NHSN (National Healthcare Safety Network) data spreadsheet dated 12/4/22, indicated the facility had a Covid-19 staff vaccination/exemption percentage of 80.952% (81%). The staff Covid-19 vaccination log had indicated the staff vaccination/exemption percentage was 100%. This information indicated an 19% discrepancy between the two sources of information. On 12/21/22 at 12:00 p.m., the DON was asked about the 19% discrepancy between the NHSN data and the facility's staff Covid-19 vaccination log. The DON confirmed she had not been tracking the people who were not directly employed but had provided services such as Therapist C, Physician D, and Pharmacist E. The DON said the facility's staff Covid-19 staff vaccination rate was up to date until September 2022, but then there was an outbreak and the new booster had come out. Between these two factors, the DON thought the staff Covid-19 vaccination tracking may have gotten off course. The DON was unable to provide any further explanation regarding the discrepancy between the NHSN data and the facility's staff Covid-19 vaccination log. A copy of the facility's undated Covid-19 vaccination policies and procedures contained the following information, in part, Purpose Maximizing Covid-19 vaccination rates in the facility will help reduce the risk residents and staff have of contracting and spreading Covid-19. The purpose of this policy and procedure (P&P) is to outline the facility approaches to encourage both staff and residents to receive a Covid-19 vaccine .Staff: for the purpose of this policy, staff refers to any individuals that work or volunteer in the facility at least once a week. This includes individuals who may not be physically in the LTC [long Term Care] facility for a period (e.g., illness, disability, or scheduled time), but are expected to return to work, individuals under contract or arrangement (e.g., medical directors, hospice and dialysis staff, therapist, mental health professionals, or volunteers). Documenting Covid-19 Vaccine the facility will maintain documentation for all residents and staff on Covid-19 vaccination. For staff, the information will be documented in paper method and for residents, the information will be documented in their medical record. The information to be documented includes .if yes, which vaccine was administered. which dose was administered, date of vaccination . Reporting Covid-19 vaccine facility will report on a weekly basis via NHSN by Sunday at 11:59 p.m. ET, the Covid-19 vaccination status of residents and staff, total numbers and staff vaccinated, each dose of the vaccine received, Covid-19 vaccination adverse events, and therapeutics administered to residents for treatment of Covid-19.

Based on observation, interview and record review, the facility failed to post required staffing information on a daily basis to identify the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift. This deficient practice resulted in the potential for residents and their representatives being unaware of the nursing staff available to provide care each shift and the potential for unmet care needs. Findings include: During an interview on 12/19/2022 at 11:30 a.m., the Nursing Home Administrator (NHA) was asked where the required daily staff posting was located. The NHA stated the Director of Nursing (DON) used the whiteboard in the nurses' stations to post the nursing staff working each day. The NHA stated the DON filled out a staffing sheet at the end of each day to include the total hours worked by the schedule nursing staff for that given day. The NHA reported she filed the staffing information and did not post the information anywhere in the facility. The NHA presented a Daily Census Report, dated 12/18/2022, and reported the form as the daily staff posting. When asked to present the Daily Census Report, for the present day, 12/19/2022, the NHA stated the form would not be completed until the end of day. An observation on 12/19/2022 at 11:45 p.m., revealed a white board located on the wall in the nurses' stations. Further review revealed the following written on the board with erasable marker: (First name only) 7a-7p (First name only) 7p-7a (First name only) 6a-6p (First name only) 1-8:30 (First name only) 5a-1p (First name only) 10p-4a (First name only) 6p-10p Census 22, Hours (blank) The staffing information written on the white board only included first names of staff and did not include credentials to allow residents and resident representatives to determine whether the listed staff were licensed or unlicensed nursing personnel. The information did not break down the staffing per shift or list the required number of licensed and unlicensed staff needed to care for the resident population per shift. A review of the Daily Census Report, dated 12/18/2022, revealed the following: Nursing Assignments: Charge Nurse 7A - 7P: (DON) 12 (hours) 35 (minutes). Charge Nurse 7P- 7A: (LPN L), 12 (hours) 27 (minutes). CNA (Certified Nurse Aide): (CNA M), 12 (hours) 5 (minutes) (CNA N), 8 (hours) 39 (minutes) (CNA O), 7 (hours) 10 (minutes) (CNA P), 12 (hours) 8 (minutes) (CNA Q), 6 (hours) 13 (minutes. Actual Census: 22. It was noted the form did not include a breakdown of how many of each type of staff, licensed and unlicensed, were required each shift. Further review revealed the CNAs listed were not broken down by shifts therefore it could not be determined how many CNAs worked each shift. A review of the Daily Census Report(s), for April 2022, June 2022 and December 2022 revealed all reports did not include a list the daily staffing required by licensed and unlicensed nursing staff, but rather the acutal hours worked for each member of the nursing staff. Each report did not break down how many of each type of personnel were needed each day and per shift, to care for the resident population. During an interview on 12/20/2022 at 10:30 a.m., the DON confirmed the daily staff requirements were being completed by her at the end of each day for the previous day. The DON stated she filled out the Daily Census Report(s), based on who worked each day based on actual hours worked and did not use the reports to determine staffing needs. The DON reported after completion the Daily Census Report(s), were presented to the NHA for filing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to employ a qualified staff with the appropriate competencies, skill sets, and credentials to supervise and carry out the functions of the food and nutrition service including Resident nutritional assessments, service of individual diets with proper consistency and therapeutic needs, and follow up on residents at nutritional risk. This deficient practice resulted in the lack of oversight and leadership in the operation of the dietary department with the potential to result in clinical dietary needs of all 22 residents being compromised and unmet. Findings include: During an interview on 12/20/22 at 8:02 AM, the Dietary Manager (DM) I stated she was a cook and had agreed to try out the manager position. She stated she had been in the Certified Dietary Manager (CDM) correspondence class for over a year and it's not going so well. She stated she had been working 12-hour shifts until a new cook was hired about a month ago. DM I said it was hard to work long hours and complete class work. During an interview on 12/20/22 at 9:00 AM, the Nursing Home Administrator (NHA) stated she was unsure when DM I began the CDM course and did not have records. The NHA said the consulting Registered Dietitian (RD) J would know about that. On 12/20/22 at 9:43 AM, DM I presented an email revealing she had been enrolled in the CDM class since 11/2021. During an interview on 12/20/22 at 12:58 PM, the NHA said DM I was training for the dietary manager job, but the Director of Nursing (DON) was doing the nutritional assessments. During an interview on 12/20/22 at 1:15 PM the DON was asked about the nutritional assessments and said, I've never done them. The DON said she put the weights in the chart and notified RD J. The charts were reviewed together, and it was determined: - Resident #8 had no nutritional assessment. - Resident #18's most recent nutritional assessment was completed on 7/20/21. - Resident #6's most recent nutritional assessment was completed on 7/6/21. - Resident #22's most recent nutritional assessment was completed on 6/29/22. - Resident #2's most recent nutritional assessment was completed on 6/8/22. During a telephone interview on 12/21/21 at 8:52 AM, RD J stated they consulted for the facility and worked part time, approximately 4 hours every two or three months and precepted DM I for the CDM course completing six or seven lessons out of 16 or 18 lessons in the course. RD J said DM I had been at it for more than a year. RD J said the facility monitored the weights in the chart and if there were nutritional problems the facility let them know. RD J stated, I do not do quarterly nutritional assessments and they thought the DON was doing all of that. On 12/19/22 at 12:45 PM, the posted menu was reviewed. This menu was signed by RD J, but the attached copies of the therapeutic extension plan written for specialized diets were not signed or dated by RD J. Upon review, the planned posted menu did not match the therapeutic diet menu. On 12/19/22 at 1:00 PM, lunch was being served in the dining room. The menu listed Grilled Turkey and Cheese, Potato Salad, Potato chips, Ice Cream. The therapeutic diet menu listed coleslaw and no potato salad. No coleslaw had been produced for the therapeutic diets. The therapeutic diet menu indicated the Con CHO (Consistent Carbohydrate) diet was to include sliced peaches in place of the ice cream. The therapeutic diet menu also listed the 1500 calories diet was also to include sliced peaches in place of the ice cream. - Resident #8 had a tray card with a diet of Carb Control and had the Special Request of 4 starch, 1 fruit, 1 vegetable, 3 oz meat/equivalent, 1 fat. These listed exchanges would indicate a calorie controlled diet such as 1500 calories. Resident #8 received a meal of one-half turkey and Swiss cheese sandwich, potato salad, potato chips, ice cream and chocolate syrup and did not include any fruit (which should have been substituted for the ice cream per the therapeutic menu) and did not include a vegetable (which should have been coleslaw). The ice cream and sweet chocolate syrup had not been planned for that diet. - Resident #6 also had a tray card which indicated a Carb Control diet was to be served with the same notations of 4 starch, 1 fruit, 1 vegetable, 3 oz meat/equivalent, 1 fat listed. Resident #6 was also observed to receive one-half turkey and Swiss sandwich, potato salad, potato chips, and ice cream with strawberry syrup. (The same substitutions should have been made fore Resident #6 as was listed above for Resident #8.) The ice cream and sweet strawberry syrup had not been planned for that diet. - Resident #18 had a tray card indicating a diet of Reg. Mechanical. The other areas of the tray card including Special Requests:, Dislikes:, Beverage, Allergies: and Notes: were all blank. The food Resident #18 received was not a mechanically altered consistency but was pureed. The cook (Staff) A was asked about the diets printed on the tray cards and said the tray cards were not followed. On 12/20/22 at 8:17 AM, breakfast was served. - Resident #8 had a tray card specifying Carb Control but the Special Request area indicated 3 starch, 1 fruit, 1 milk, 1 oz meat/equivalent, 1 fat. Resident #8 received 4 oz apple juice (1 fruit), 2 pieces of buttered toast (2 starch and 2 fats), hash browns (1 starch) and eggs (1 meat), ~ 1 tablespoon jelly, and tea. No milk was received. Resident #8 stated she would like milk but I can't get everything I want. I am diabetic and they watch what I get. Resident #8 asked Registered Nurse (RN) F for more toast. RN F brought 2 more pieces of buttered toast (2 more starches and 2 additional fats) and another scoop of jelly (~2 tablespoons). In total, Resident #8 was served 5 starches, 4 fats, 1 fruit, 1 meat, no milk and 3 tablespoons of regular jelly. - Resident #6 also had a tray card specifying Carb Control and also listed 3 starch, 1 fruit, 1 milk, 1 oz meat/equivalent, 1 fat. Resident #6 was served: 4 oz orange juice (1 fruit) 1 tablespoon of peanut butter (1 meat), eggs (1 meat), 1 tablespoon scoop of jelly, and 2 slices of buttered toast. (2 starches 2 fats). Resident #6 reported she was not a milk drinker. The tray card also read oatmeal, sugar and banana on side, toast. No cereal or bananas were served to Resident #6. Resident #6 received 2 starch, 1 fruit, no milk, 2 meat, 2 fat and 1 tablespoon of regular jelly. - Resident #18's tray card read: Reg. Mechanical. Resident #18 received a pureed meal including pureed bread/toast and not a mechanically altered consistency. At 8:35 AM, DM I stated, Those are old cards. (Resident #6) does not ask for oatmeal and we are out of bananas today. When asked if there was special diet jelly as the therapeutic diet menu indicated, DM I said, We have regular jelly for the whole house. We use this jar. At 8:40 AM, RN F was asked about special diets and she replied, If the residents request something extra we try to stay within the parameters of the diet. During a chart review 12/20/22 at 10:15 AM the following was revealed: - Resident #8 was admitted [DATE] with diagnoses which included dementia, diabetes, and long-term use of insulin. Resident #8's current physician's orders included two types of insulin, check the blood sugar with a fingerstick three times daily, and a diet of Regular - CC (Consistent Carbohydrate). (The tray card with exchanges such as 3 starch, 1 fruit, 1 milk, 1 oz meat/equivalent, 1 fat observed at the breakfast meal had not been ordered by a physician.) - Resident #6 was admitted [DATE] with diagnoses which included diabetes, and gastroesophageal reflux disease (GERD). Resident #6's current physician's diet order was Regular. The most recent Nutritional Assessment dated over a year ago on 7/6/21 revealed a weight of 106 pounds, but the current weight was recorded on 12/4/22 as 129 pounds. (The tray card with exchanges such as 3 starch, 1 fruit, 1 milk, 1 oz meat/equivalent, 1 fat, which was observed at the breakfast meal had not been ordered by a physician.) - Resident #18's current physician's orders had no diet ordered. The most recent Nutritional Assessment dated over a year ago on 7/20/21 revealed a weight of 107 pounds and a score of 11 indicating Resident #18 was At risk of malnutrition. (The tray card printed with mechanical soft had not been ordered by a physician, and the diet received of puree had also not been ordered by a physician.) On 12/20/22 at 10:36 AM, DM I stated she had been in the CDM class but I have been working on the managerial part. The clinical part comes next. DM I said the RD and the Director of Nursing (DON) did the nutritional assessments in the medical charts as she has not really learned that part. When asked about special diets, DM I said, We have one with 1500 controlled calorie and a couple of pureed diets. When asked about Resident #6 (whose tray card read Carb Control and whose physician ordered diet was regular), DM I said, She would get peaches or fruit in place of ice cream. Potato salad would be the vegetable . We limit mostly her sugar intake . on days we have pudding or anything super sweet we give her fruit. She is our only one. When asked about Resident #8 (whose tray card also read Carb Control), DM I said she might be on a diet with restricted sugar maybe limited sugars. The therapeutic diet plan was discussed. This part of the menu was to direct the dietary staff on what to produce for residents on special diets. DM I said the RD only signed the top copy (not the therapeutic part). The menus were reviewed, and differences pointed out such as on Week 4 Wednesday the signed menu indicated beef stroganoff with noodles peas and ice cream was to be served, but the same day the therapeutic menu listed hot dogs, potato salad baked beans and pears. DM I said the therapeutic menus were wrong. DM I suggested we look at a different week. Week 3 Monday had a planned evening meal of meatloaf, mashed potatoes/gravy, green and yellow beans, bread/margarine, and apple crisp, while the same day the therapeutic menu listed taco casserole topped with taco chips, corn, and strawberry shortcake. During an interview 12/20/22 at 3:04 PM, the only member of the dietary staff in the facility, Staff K was asked for a policy or a manual on serving correct diets. Staff K said, I am new and the only one in the kitchen. I don't know about a diet manual. Staff K reported there were no diabetic diets that needed to be made. She said, there were two puree diets and one I think we are trying to beef up . I just go by the cards. When asked about the one diet she was referring to, Staff K looked up the tray card and found Resident #6 and said, It must be her. Look at the tray card. (Resident #6 whose tray card read Carb Control and also listed 3 starch, 1 fruit, 1 milk, 1 oz meat/equivalent, 1 fat) . She needs starch and fruit. During an interview on 12/20/22 at 1:31 PM, the chart discrepancies were reviewed with the DON who confirmed Residents (#18 and #22) had no diet ordered from the facility physician. The DON stated, They are not there . Why they never got put on the orders, I do not know. For Resident #18 (without a diet order, but with a tray card directing the staff to serve a mechanical soft diet, with ground meat and then observed to receive all formed items pureed) the DON did not see a care plan for nutritional concerns. The DON stated she would expect the diet consistency in the physician's orders and on the care plan. During the interview with the DON on 12/20/22 at 1:31 PM, Resident #6 was noted to have large weight increases for the past four months: - 12/4/2022 = 129.0 pounds - 11/6/2022 = 119.0 pounds - 10/5/2022 = 114.0 pounds - 9/5/2022 = 108.2 pounds No reweights had been taken. The DON stated, We get a reweight if the doctor orders it. We have not with her. The facility policy titled Weights and dated 11/24/2008, read in part: Re-weight: 1. Will be obtained immediately upon identification of weight gain or loss of 3 pounds or more . Charge Nurse: 2. ii. If the weight has a 3 pound variance immediately re-weigh. iii. Notify dietary of variance. During the interview with the DON on 12/20/22 at 1:31 PM, Resident #8 was noted to have a physician order for a Regular -CC (consistent carbohydrate) diet and was on insulin. The DON stated her expectation was the diet should have been on the care plan, but it was not included in the care plan. The DON stated Resident #8 did not get a lot of sugar and labs were good. Resident #8's A1C lab values (the primary test used for diabetes management) were reviewed with the DON and noted to be as follows: 7/12/21 9.8% 1/11/22 8.7% 8/24/22 9.8% The lab normal values for A1C were listed as 4.3% - 6.0%. The facility Diet Manual included a section on Diabetes and read in part: In order to prevent the serious complication of diabetes mellitus, individuals with diabetes and their caregivers are encouraged to: 1. Control Blood Glucose: According to the CDC (Centers for Disease Control and Prevention), 'In general, every percentage point drop in A1C blood test results (e.g. from 8.0% to 7.0%), reduces the risk of microvascular complications (eye, kidney and nerve disease) by 40%. An A1C indicates the average control of blood glucose level over a period of the past three months.' During the telephone interview on 12/21/22 at 08:52 AM, RD J stated the residents who were diabetic should receive a liberalized diet. When the observation of tray cards printed with 1500 calorie diet with exchanges was discussed, RD J stated That was a possibility as she was not in the building often. RD J stated she had not reviewed or signed the therapeutic diets. When the observation of the regular planned menus not matching the therapeutic menus was discussed, RD J stated, she was not surprised as she had not reviewed the therapeutic menus. During an interview on 12/21/22 at 10:51 AM, the NHA stated there was another staff member (Staff B) who was on the organizational chart over the dietary department. Staff B had taken the CDM course and had a certificate dated 3/12/1986. However, the NHA said Staff B had never taken or passed the CDM test after the course and had never become a CDM.

Based on observation, interview, and record review the facility failed to maintain sanitary conditions and confirm safe food handling practices in the kitchen resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting 22 residents who receive meal services out of the facility's total census of 22. Findings include: On 12/19/2022 at 10:31 AM, the kitchen's air conditioning unit above the entry door to the walk-in cooler was observed with an accumulation of dust and debris on its filters. Upon observation the surveyor inquired with the Cook, staff A, on how often the filters are cleaned or replaced on this unit to which they stated, maintenance cleans the filters, but I'm not sure when it was done last. On 12/19/2022 at 11:43 AM, an accumulation of dust and debris was observed on the fan grates, the ceiling, the walls, and on refrigeration lines in the walk-in cooler. At this time the surveyor inquired with staff A on the frequency in which the fan grates are expected to be cleaned to which they stated, I have no idea, that would be a maintenance question. On 12/19/22 at 12:07 PM, upon interview with the Maintenance Director, staff B, on the frequency in which the fan grates and surrounding areas are cleaned they stated, we take them apart once a year to clean them inside and out and paint the fan grates before reinstalling. Maybe we could start doing it twice a year. Review of U.S. Public Health Service 2017 Food Code, Chapter 4-602.13 Nonfood-Contact Surfaces directs that: NonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues. 2. On 12/19/22 at 11:21 AM, upon interview with the Cook, staff A, on if the facility prepares food products in advance and then cools them down for later use, they replied, Sometimes. We have a log posted on our freezer. At this time the surveyor reviewed the posted log on the reach in freezer mentioned by staff A. This document was titled, cool down tracking sheet and dated, December 2022. Review of the log by the surveyor revealed only one item dated, 12/6 stating, Tuna from can to freezer. Upon observation the surveyor asked staff A if they were the [NAME] who documented this on the log to which they stated, no, they are not here today. I really don't save things for later. I try to just cook what we need or make new when we run out. On 12/19/22 at 11:25 AM, containers labeled as sloppy joe dated, 17-21, macaroni and cheese dated, 16-20, potato salad dated, 18-19, cream of vegetables dated, 18-22 and scrambled eggs dated, 18-19 were observed in the walk-in cooler. On 12/19/22 at 11:27 AM, these items were confirmed by staff A via an interview as being prepared in advance and cooled for later use. At this time the surveyor asked staff A if they were responsible for cooling any of the food products identified as being prepared in advance in the walk-in cooler to which they replied, No. The surveyor then followed up by asking staff A how the facility would normally handle food items such as these if they could not verify the foods were properly cooled to ensure the foods safety to which they replied, I see your point, I guess we will need to start keeping better track on our cooling log and throw things out if we don't. Review of U.S. Public Health Service 2017 Food Code, Chapter 3-501.15 Cooling Methods, directs that: (A) Cooling shall be accomplished in accordance with the time and temperature criteria specified under § 3-501.14 by using one or more of the following methods based on the type of FOOD being cooled: (1) Placing the FOOD in shallow pans; Pf (2) Separating the FOOD into smaller or thinner portions; Pf (3) Using rapid cooling EQUIPMENT; Pf (4) Stirring the FOOD in a container placed in an ice water bath; Pf (5) Using containers that facilitate heat transfer; Pf (6) Adding ice as an ingredient; Pf or (7) Other effective methods. 3. On 12/19/2022 at 11:33 PM, Cook, staff A, was observed taking food temperatures of thin cuts of turkey lunch meat and grilled cheese sandwiches with a bimetal thermometer. At this time the surveyor inquired with staff A if that was the only type of thermometer they had available to use to which they stated, yes, we have several like this. Review of the U.S. Public Health Service 2017 Food Code, Chapter 4-302.12 Food Temperature Measuring Devices directs that: (B) A TEMPERATURE MEASURING DEVICE with a suitable small-diameter probe that is designed to measure the temperature of thin masses shall be provided and readily accessible to accurately measure the temperature in thin FOODS such as MEAT patties and FISH filets. Pf Further review of the 2013 Food Code Annex 3 states: The presence and accessibility of food temperature measuring devices is critical to the effective monitoring of food temperatures. Proper use of such devices provides the operator or person in charge with important information with which to determine if temperatures should be adjusted or if foods should be discarded. When determining the temperature of thin foods, those having a thickness less than 13 mm (1/2 inch), it is particularly important to use a temperature sensing probe designed for that purpose. Bimetal, bayonet style thermometers are not suitable for accurately measuring the temperature of thin foods such as hamburger patties because of the large diameter of the probe and the inability to accurately sense the temperature at the tip of the probe. However, temperature measurements in thin foods can be accurately determined using a small-diameter probe 1.5 mm (0.059 inch), or less, connected to a device such as thermocouple thermometer.

Based on observation, interview, and record review the facility failed to maintain an effective pest control program so that the facility is free of pests potentially affecting 22 residents who receive meal services out of the facility's total census of 22 and its staff. Findings include: 1. On 12/19/22 at 11:08 AM, a live mouse was observed by both the Cook, staff A, and the surveyor inside the waste receptacle located at the kitchens designated handwashing sink. Upon observation staff A promptly closed the lid to the waste receptacle and took the waste receptacle outside. On 12/19/22 at 11:10 AM, upon interview with staff A, the surveyor inquired if the facility used the services of a pest control company to which they stated, I don't think so, but maintenance would know more about the specifics on it. On 12/19/22 at 11:16 AM, upon interview with the Maintenance Director, staff B, regarding pest control responsibilities in the facility they stated, we lay glue traps down and monitor, we mostly leave them out in the kitchen and on the north side of the building. The surveyor then inquired who is responsible for monitoring of pests throughout the facility to which staff B replied, we all are. At this time the surveyor requested the most recent pest control related records to review. On 12/19/22 at 1:10 PM, record review of the last two months of hardware store receipt records revealed that the targeted pests being treated at the facility were mice via glue traps purchased on, 10/10/22 and, 11/10/22. On 12/19/22 at 1:19 PM, upon interview with staff B regarding the effectiveness of the glue traps they stated, they usually work pretty good, but when it gets colder outside, they always want to come in where it's warm. Review of 2017 U.S. Public Health Service Food Code, Chapter 6-501.111 Controlling Pests directs that: The PREMISES shall be maintained free of insects, rodents, and other pests. The presence of insects, rodents, and other pests shall be controlled to eliminate their presence on the PREMISES by: (B) Routinely inspecting the PREMISES for evidence of pests;