**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure accurate advance directive (legal documents that allow a person to identify decisions about end-of-life care ahead of time) information was in place for two residents (#7 and 33) of two residents reviewed for advance directives from a total sample of 9 residents. Resident #7 Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] revealed Resident #7 (R7) was admitted to the facility on [DATE] with diagnosis that included vascular dementia and hypertension. The MDS revealed R7 had long and short-term memory impairment and severely impaired decision-making skills. A statement of decision-making capacity, signed by the Physician on 7/30/25 and signed by a psychologist on 7/22/25 revealed R7 was unable to fully participate in medical treatment decisions due to vascular dementia. Further review of R7's medical record reflected R7's Durable Power of Attorney (DPOA) signed an advanced directive for Do Not resuscitate (DNR), meaning if the heart and breathing should stop, no attempts were to be made to resuscitate R7. R7's legal agent signed the Advance Directive form on May 15, 2025. R7's DPOA signature was no be witnessed by two persons. The form did have one witness signature and was dated May 15, 2025, the other witness signature was dated June 2, 2025. Resident 33 Review of the clinical record, including the Minimum Data Set (MDS) dated [DATE] revealed Resident #33 (R33) was admitted to the facility 01/11/22 with diagnoses that included dementia and diabetes. The MDS revealed R33 also had long and short-term memory impairment. The clinical record revealed R33 had an activated DPOA. R33's advanced directives form revealed the DPOA's signature was dated 01/06/2022 with one witness signature dated 01/06/22. The other witness signature was dated 1/10/2022. On 10/07/2025 8:28 AM during an Interview with Director of Nursing (DON) B she reported the facility Social Worker (SW) C handled the Advanced Directives, however the SW C had an emergency and was not at the facility and was unable to be interviewed. Review of R7 and R33's advanced directive documents were reviewed with DON B acknowledged the witness section of both R7's and R 33's advanced directive forms did not have the two required witnesses.

Based on observation, interview, and record review the facility failed to ensure that residents were free from significant medication errors for one resident (#28) of four residents reviewed during medication administration. Findings Included:Resident #28 (R38)Review of the medical record revealed R28 was admitted to the facility 09/23/2025 with diagnoses that included atrial fibrillation, hyperlipidemia, sleep apnea, congestive heart failure (CHF), hypertension, muscle wasting, ischemic cardiomyopathy (damage of heart muscle), gastro-esophageal reflux disease, anxiety, and cerebral infarction (CVA). The most recent Minimum Date Set (MDS), with an Assessment Reference Date (ARD) of 09/23/2025, revealed R28 had Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15. On 10/07/2025 at 08:56 a.m. Registered Nurse (RN) D was observed preparing medication to provide to R28. R28 was observed sitting at a dining room table. RN D provided six medications to R28 who then was observed to orally consume the six medications. One of the medications observed to be provided to R28 was Digoxin 125 mcg (micrograms). During medication reconciliation and record review it was revealed that R28's physician order for Digoxin 125mcg (micrograms), one orally once per day, was written 09/25/2025 and was discontinued on 10/03/2025. No further order for Digoxin 125mcg was observed in R28s' medical record.In an interview on 10/07/2025 at 09:22 a.m. Director of Nursing (DON) B was asked review R28's medication orders. She was asked why R28 was observed to have been provided Digoxin 125mcg (microgram) one tab orally during the morning medication administration. DON B confirmed that R28 should not have been provided Digoxin 125mcg because the order had been discontinued on 10/03/2025. DON B explained that medications are delivered to the facility once per month, for a thirty day supply, called ATP (around the clock pack). DON B explained that it is the nurses responsibility to verify the list of medication in the ATP against the computerized medication administration record (MAR) and if medications were provided in the ATP, the nurse would discard that medication and not provide it to the resident. DON B could not explain why Registered Nurse (RN) D had not followed the process and why R28 had received Digoxin 125mcg (micrograms) one tablet during morning medication administration.

Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food in the kitchen. Findings include: On 10/06/2025 at 09:00 a.m. during an initial tour of food services was conducted with Certified Dietary Manager (CDM) “E”, the following items were observed: Cooler was observed to have red substance on the back wall and on the floor-CDM “E” explained that it was possibly spilt Jello from the weekend. Freezer was observed to have two individual containers of ice cream on the floor. Dry storage was observed to have particles on the floor which CDM “E' explained that it was possibly spilt oatmeal. The top of the enclosed stove appeared to be soiled with food particles and dust. Inside of the same stove appeared soiled with multiple layers of burn on food. End of the dish counter appeared soiled with multiple layers of old food and the back of the splash wall was observed to have black substance in the caulk. The dishwasher appeared to have multiple layers of lime deposits on the sides and front door. On 10/06/2025 at 9:45-10:24 AM during the kitchen tour with the Kitchen Manager I, observed the can opener visibly soiled. The Kitchen Manager I, removed the can opener and put it in the dishwashing area. When interviewed, the Kitchen Manager I stated that the can opener is cleaned once a week. On 10/06/2025 at 9:45-10:24 AM observed the slicer visibly soiled with orange debris, located in the main kitchen. When interviewed, the Kitchen Manager I stated that the slicer is cleaned after every use. On 10/06/2025 at 9:45-10:24 AM observed the mixer visibly soiled, located in the main kitchen. When interviewed, the Kitchen Manager I said the mixer is cleaned after every use, but that it definitely needs to be deep cleaned now. On 10/06/2025 at 9:45-10:24 AM observed the drain line to the ice machine sitting directly inside the drain, located in the main kitchen. On 10/06/2025 at 9:45-10:24 AM observed black residue on the inside wall of the ice machine, located in the nursing kitchen. When interviewed, the Kitchen Manager I stated that the ice machine is cleaned once a month. On 10/06/2025 at 9:45-10:24 AM observed the drain line to the ice machine sitting directly inside the drain and multiple dirty plastic cups and lids on the floor behind the ice machine, located in the nursing kitchen. On 10/06/2025 at 9:45-10:24 AM observed the inside walls of the microwave visibly soiled, located in the nursing kitchen. When interviewed, the Kitchen Manager I said that the microwave should be cleaned once a week, but it doesn't look like it's been done. On 10/06/2025 at 11:45AM-12:34PM during the lunch observation with the Kitchen Manager I, reviewed the temperature logs for hot and cold holding. On 10/2, garden salad was temped at 45 degrees Fahrenheit at dinnertime. On 10/3, potato salad was temped at 60 degrees Fahrenheit during dinnertime. On 10/4, seafood salad was temped at 56 degrees Fahrenheit and broccoli salad was temped at 52 degrees Fahrenheit. On 10/06/2025 at 11:45AM-12:34PM during lunch observation, observed the Kitchen Manager I take the cold holding temperature for chicken salad, and the temperature was 50 degrees Fahrenheit. When interviewed, the Kitchen Manager I stated they try to keep the cold holding temperatures at 40 degrees Fahrenheit. According to the 2022 Food Code, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, Equipment food-contact surfaces and utensils shall be clean to sight and touch, the food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations, nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. According to the facility policy on Cleaning of food contact surfaces and nonfood contact surfaces, To prevent cross contamination, kitchenware and food contact surfaces of equipment shall be washed, rinsed, and sanitized after each use and following any interruption of operations during which time contamination may have occurred. According to the 2022 Food Code, 5-202.13 Backflow Prevention, Air Gap, An air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). According to the 2022 Food Code, 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding, Except during preparation, cooking, or cooling, or when time is used as the public health control, time/temperature control for safety food shall be maintained: .at 5°C (41°F) or less.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform ongoing re-evaluation of the need for a restraint for one (Resident #25) of one reviewed. Findings include: Review of the medical record revealed Resident #25 (R25) admitted to the facility on [DATE] with diagnoses that included major depressive disorder, epilepsy, Parkinson's Disease, and dementia. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/28/24 revealed R25 was severely cognitively impaired and had a restraint that was used daily. An observation on 10/23/24 at 10:37 AM revealed R25 was asleep, seated in a Broda chair (a wheelchair that provides supportive positioning through a combination of tilt, recline, adjustable leg rest angle, wings with shoulder bolsters and height adjustable arms) in their room. R25 had an air mattress on their bed. The right side of the bed was against the wall. Bolsters, approximately six inches high, were observed on both sides of the bed and ran the full length of the mattress. On 10/23/24 at 2:22 PM and 3:31 PM, R25 was observed asleep in bed. The bed was low to the floor and a fall mat was observed on the left side of the bed. The right side of the bed was against the wall and the bolsters were in place. R25 had their legs bent, leaning against the bolsters. R25 was not moving around in bed. Review of the Progress Note dated 3/15/24 revealed Post fall investigation summary note: [R25] was observed on the floor in front of his bed at 1900 [7:00 PM] on 3/14/2024. Nursing progress note states that [R25] was reaching for the drapes prior to the incident. Fall was unwitnessed .[R25] requires an air mattress to promote comfort and prevent skin breakdown. While [R25] is unable to roll left to right, he is able to make minor changes in position. He has been observed close to the edge of the bed, if the air mattress makes a pressure change when he is close to the edge, he could be at risk for rolling out of the bed. Bed was in lowest position and fall matt was next to the bed .completed a restraint screen, findings are as follows: Patient has a hx of falls, rolling out of bed. Pt [patient] would benefit from roll control bolsters due to lack of control for functional bed mobility, use of air mattress with uncontrolled movements resulting in increased fall risk. [Family member] was made aware of the new restraint being put in place and is in agreement with new intervention. Restraint consent obtained, restraint care plan in place. IDT [Interdisciplinary Team] to follow up as needed. Review of the Physician's Order dated 3/15/24 revealed R25 requires roll control bolsters to his bed at all time r/t hx [related to history] of falls, rolling out of the bed and use of air mattress with uncontrolled movements resulting in increased fall risk. Review of the Care Plans revealed R25 requires roll control bolsters to bed at all times d/t [due to] hx [history] of falls, rolling out of bed and use of air mattress with uncontrolled movements resulting in increased fall risk. Interventions included obtain signed consent before applying restraint (if restraint consent is included in the facility admission package and is signed at the time of admission, this does not qualify as before applying) and complete a restraint assessment before applying restraint and quarterly thereafter as long as restraint is used. Review of the medical record revealed R25 did not have a signed consent for the use of the bed bolsters prior to applying the bed bolsters. The only restraint consent was the admission restraint consent. Per R25's care plans, a new restraint assessment needed to be signed. Review of the medical record revealed R25 had one additional fall out of bed on 8/6/24. In an interview on 10/23/24 at 12:57 PM, Director of Nursing (DON) B reported R25's bed bolsters were a restraint and that therapy performed restraint assessments yearly. DON B reported the most recent restraint assessment was completed by therapy on 3/15/24. When asked about the quarterly assessments per the care plan, DON B was unable to provide any additional assessments. Review of the Rehab Services Screening Form dated 3/15/24 revealed Patient has hx of falls, rolling out of bed. Pt would benefit from roll control bolsters due [to] lack of control for functional bed mobility, use of air mattress [with] uncontrolled movements resulting increased fall risk. The form did not include any assessment of the bolsters being a restraint. Review of the Rehab Services Screening Form dated 8/9/24 revealed R25 was screened due to a fall. No PT or OT [physical therapy or occupational therapy] was needed at that time. There was no assessment of the bolsters being used as a restraint or a re-evaluation of the continued need of the restraint. Review of the facility's Restraint Free Environment policy dated 10/8/24 revealed 4. A physician's order alone is not sufficient to warrant the use of a physical restraint. The facility is responsible for the appropriateness of the determination to use a restraint. 5. Before a resident is restrained, the facility will determine the presence of a specific medical symptom that would require the use of restraints, and determine: a. How the use of restraints would treat the medical symptom. b. The length of time the restraint is anticipated to be used to treat the medical symptom, who may apply the restraint, and the time and frequency that the restraint will be released. c. The type of direct monitoring and supervision that will be provided during use of the restraint. d. How the resident will request staff assistance and how his/her needs will be met while the restraint is in place. e. How to assist the resident in attaining or maintaining his or her highest practicable level of physical and psychosocial well-being. Medical symptoms warranting the us of restraints should be documented in the resident's medical record. The resident's record needs to include documentation that less restrictive alternatives were attempted to treat the medical symptom but were ineffective, ongoing re-evaluation of the need for the restraint, and the effectiveness of the restraint in treating the medical symptom. According to the State Operations Manual, Falls generally do not constitute self-injurious behavior or a medical symptom that warrants the use of a physical restraint. Although restraints have been traditionally used as a falls prevention approach, they have major, serious drawbacks and can contribute to serious injuries. There is no evidence that the use of physical restraints, including, but not limited to, bed rails and position change alarms, will prevent or reduce falls. Additionally, falls that occur while a person is physically restrained often result in more severe injuries (e.g., strangulation, entrapment).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure their medication error rate was below 5% when four medication errors were observed from a total of 26 opportunities for three residents (Resident #2, Resident #3, and Resident #7) of six reviewed resulting in a medication error rate of 15.38%. Resident #3 (R3) Review of the medical record revealed R3 admitted to the facility on [DATE] with diagnoses that included dementia and seizures. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/7/24 revealed R3 was severely cognitively impaired. Review of the Physician's Order dated 5/7/18 revealed an order for topiramate 25 milligrams (mg) two tablets twice a day. The order did not specify that the medication could be crushed. Review of the Physician's Order dated 7/13/22 revealed an order for levetiracetam solution 100 milligrams/milliliters (mg/mL); administer 1250 mg/12.5 mL twice a day. On 10/22/24 at 10:18 AM, Licensed Practical Nurse (LPN) D was observed preparing and administering medications to R3. LPN D crushed two tablets of topiramate 25 mg and then measured levetiracetam oral solution 100 mg/mL by pouring the medication into a medication cup. LPN D filled the cup to between the 10 mL and 15 mL mark and reported it was 12.5 mL. The cup had lines/marks for 2.5 mL, 5 mL, 7.5 mL, 10 mL, 15 mL, 20 mL, 25 mL, and 30 mL. There was not a line/mark for 12.5 mL. LPN D administered the medications to R3. Resident #7 (R7) Review of the medical record revealed R7 admitted to the facility on [DATE]. The MDS with an ARD of 8/25/15 revealed R7 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 10/23/24 at 09:02 AM, LPN D was observed preparing and administering medications to R7. LPN D administered one tablet of gerikot (sennosides 8.6 mg) to R7. Review of the Physician's Order dated 4/18/24 revealed an order for Senna-S (sennosides-docusate sodium) tablet; 8.6-50 mg. R7 only received the sennosides and not the docusate sodium. Resident #2 (R2) Review of the medical record revealed R2 admitted to the facility on [DATE] with diagnoses that included depression and Parkinson's Disease. Review of the Physician's Order dated 1/17/24 revealed an order for paroxetine 30 mg one tablet once per day. The order did not specify that the medication could be crushed. On 10/23/24 at 09:14 AM, LPN D was observed preparing and administering medications for R2. LPN D crushed one tablet of paroxetine 30 mg. In a telephone interview on 10/23/24 at 10:58 AM, Pharmacist C reported topiramate 25 mg should not be crushed or split. Pharmacist C reported the dose was available in sprinkles which could be opened and placed in applesauce/yogurt. Pharmacist C reported paroxetine 30 mg also should not be cut or crushed. Pharmacist C reported there was a liquid form of the medication available. In an interview on 10/23/24 at 12:47 PM, Director of Nursing (DON) B reported nurses had access to a list of medications that should not be crushed. DON B reported they would have expected the levetiracetam oral solution to be measured to 12.5 mL by using one medication cup measured to 10 mL and a second medication cup measured to 2.5 mL. Review of the facility's Meds that Should Not Be Crushed dated February 2023 revealed topiramate and paroxetine were not on the list. The list revealed This table has some common meds that should not be crushed; many more may not be listed. Brand names are representative and may not be all-inclusive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to offer an updated pneumococcal vaccine for one (Resident #2) of five reviewed. Findings include: Review of the medical record revealed Resident #2 (R2) admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, depression, and hypertension. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/30/24 revealed R2 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was up to date on the pneumococcal vaccine. Review of R2's vaccine history revealed R2 received a PCV13 pneumococcal vaccine on 7/22/16. R2 did not have documentation of any further pneumococcal vaccines. According to the Centers for Disease Control and Prevention (CDC) PneumoRecs VaxAdviser application, the recommendation for R2 was give one dose of PCV20 or PPSV23 at least 1 year after PCV13. Regardless of which vaccine is used (PCV20 or PPSV23), their pneumococcal vaccinations are complete. However, if PPSV23 is administered, use shared clinical decision-making to decide whether to administer one dose of PCV20 at least 5 years after the last PPSV2 dose. In an interview on 10/24/24 at 8:54 AM, Director of Nursing (DON) B reported they did not have a consent or declination for any further pneumococcal vaccines for R2.

Based on observations, interviews, and record reviews, the facility failed to: (1) effectively clean food service equipment (toaster), (2) ensure proper sanitizer concentration within the 3-compartment sink, and (3) effectively date mark all potentially hazardous ready-to-eat food products effecting 30 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, improper three-compartment sink sanitization, and resident foodborne illness. Findings include: On 10/22/24 at 09:45 A.M., An initial tour of the food service was conducted with Dietary Manager E. The following items were noted: One gallon of Country Fresh 2% milk (3/4 full) was observed within the 2-door reach-in cooler, without an effective discard date. The manufacturer's best-by-date was also observed to read 10-26-24. Dietary Manager E stated: Staff should have placed a discard date on the container. The 2017 FDA Model Food Code section 3-501.17 states: (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. On 10/22/24 at 10:55 A.M., An initial tour of the Nursing Kitchenette was conducted with Dietary Manager E. The following items were noted: The commercial toaster was observed heavily soiled with accumulated and encrusted food residue. The interior and exterior surfaces were also observed soiled with accumulated and encrusted food residue. Dietary Manager E stated: I will have someone clean the toaster. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (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. One gallon of Country Fresh 2% milk (1/8 full) was observed within the General Electric refrigerator without an effective open date or discard date. The manufacturer's best-by-date was also observed to read 10-26-24. Dietary Manager E stated: Our date marking policy is day of plus 3 days for a total of 4 days on dairy products. The 2017 FDA Model Food Code section 3-501.17 states: (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under § 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5ºC (41ºF) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. The three-compartment-sink sanitizer concentration was observed to read greater than 500 parts-per-million, during a routine check. The quaternary sanitizer utilized was also observed to be Diversey J-512. The product concentration range provided by the manufacturer was additionally observed to read 200-400 parts-per-million. Dietary Manager E stated: I will call the Diversey technician for adjustments. The 2017 FDA Model Food Code section 4-501.114 states: A chemical SANITIZER used in a SANITIZING solution for a manual or mechanical operation at contact times specified under 4-703.11(C) shall meet the criteria specified under §7-204.11 Sanitizers, Criteria, shall be used in accordance with the EPA-registered label use instructions, and shall be used as follows: (A) A chlorine solution shall have a minimum temperature based on the concentration and PH of the solution as listed in the following chart; Concentration Range (MG/L) Minimum Temperature PH 10 or less °C (°F) Minimum Temperature PH 8 or less °C (°F) 25 - 49 49 (120) 49 (120) 50 - 99 38 (100) 24 (75) 100 13 (55) 13 (55) (B) An iodine solution shall have a: (1) Minimum temperature of 20°C (68°F), (2) PH of 5.0 or less or a PH no higher than the level for which the manufacturer specifies the solution is effective, and (3) Concentration between 12.5 MG/L and 25 MG/L; (C) A quaternary ammonium compound solution shall: (1) Have a minimum temperature of 24oC (75oF), (2) Have a concentration as specified under § 7-204.11 and as indicated by the manufacturer's use directions included in the labeling, and (3) Be used only in water with 500 MG/L hardness or less or in water having a hardness no greater than specified by the EPA-registered label use instructions; (D) If another solution of a chemical specified under (A) (C) of this section is used, the PERMIT HOLDER shall demonstrate to the REGULATORY AUTHORITY that the solution achieves SANITIZATION and the use of the solution shall be APPROVED; (E) If a chemical SANITIZER other than chlorine, iodine, or a quaternary ammonium compound is used, it shall be applied in accordance with the EPA-registered label use instructions; and (F) If a chemical SANITIZER is generated by a device located on-site at the FOOD ESTABLISHMENT it shall be used as specified in (A) - (D) of this section and shall be produced by a device that: (1) Complies with regulation as specified in §§ 2(q)(1) and 12 of the Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA), (2) Complies with 40 CFR 152.500 Requirement for Devices and 40 CFR 156.10 Labeling Requirements, (3) Displays the EPA device manufacturing facility registration number on the device, and (4) Is operated and maintained in accordance with manufacturer's instructions. On 10/24/24 at 09:00 A.M., Record review of the Policy/Procedure entitled: Sanitizing Food Contact Surfaces dated 1/24 revealed under Policies: Sanitizer solution must be at 200 ppm to 400 ppm for (Diversey) J-512 Sanitizer. Dispensing units are used to mix the sanitizing solutions. On 10/24/24 at 09:15 A.M., Record review of the Policy/Procedure entitled: Toaster Operation dated 11/10/2023 revealed under Before Use: (2) Check that the toaster is turned off at the power outlet, and the plug is removed from the power outlet. Ensure that the toaster is clean inside and out. Record review of the Policy/Procedure entitled: Toaster Operation dated 11/10/2023 further revealed under On Completion of Use: (6) Ensure toaster is not hot and wipe down with a clean damp cloth, and clean racks where applicable.

Based on observation, interview, and record review, the facility failed to ensure accurate completion of advance directive information for one (Resident #24) of one resident reviewed for advance directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time) resulting in the potential for a resident's preferences for medical care to not be followed by the facility. Findings include: Review of the medical record reflected that Resident #24 (R24) was admitted to facility 9/7/2023 with diagnoses including unspecified dementia. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/8/23 reflected that R24 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 00 (severe cognitive impairment). In an observation and interview on 9/25/23 at 3:36 PM, R24 was observed sitting in wheelchair, in front yard of building, with daughter sitting at side. R24 was noted to be alert, watching passing by traffic, nodded head yes when questioned if he was enjoying the day, but otherwise did not respond to questions. Review of R24's electronic medical record included a physician order dated 9/7/2023 which stated, Code Status: DNR (Do Not Resuscitate) must be signed by (R24's physician name). R24's profile within the electronic medical record listed R24's name, age, room location, date/time of facility admission, as well as DNR status. R24's paper chart, located in cabinet behind nurses' station, was noted with a red DNR sticker on the outer binder of the chart. Further review of both R24's electronic medical record and paper medical record failed to reveal identification of Durable Power of Attorney for Health Care (DPOA-HC) paperwork, Statement of Decision-Making Capacity form, or a Do-Not-Resuscitate Order form. In an interview on 9/27/23 at 3:28 PM, Social Worker (SW) G stated that she had only been employed at facility since August 2023, worked part time, was gradually familiarizing self with job duties, had not yet completed a code status form with a resident, and was not sure what her role was in the completion or review of these forms. SW G further stated that she believed the facility's admissions coordinator obtained advanced directive paperwork from the resident and/or responsible party at admission and reviewed and completed the code status form at that time as well. SW G confirmed familiarity with R24, stated that he was a newer facility admission, had cognitive impairments secondary to dementia process, was oriented to self only, and was indicated as a DNR in his electronic medical record. Upon review of paper chart, SW G confirmed that R24's record did not contain DPOA-HC paperwork, Statement of Decision-Making Capacity form, or a Do-Not-Resuscitate Order form. Per SW G, only financial Power of Attorney paperwork could be located within R24's paper chart. During the same interview, SW G stated that she had begun coordinating completion of decision-making capacity forms just that week, had Psychiatrist assess R24 on 9/26/23 and complete form, and that the form had since been faxed to R24's attending physician for a second signature. SW G obtained R24's Statement Of Decision-Making Capacity form from file cabinet within SW office with review of form reflecting that R24 Is unable to fully participate in medical treatment decision, secondary to: severe cognitive impairment. Dx (diagnosis) Alzheimer's Dementia. A physician signature was noted on the line labeled Consulting Physician or Licensed Psychologist with corresponding date of 9/26/23. Line labeled as Attending Physician was noted to be blank. Per SW G, as a second physician had not yet completed form, R24 was not yet deemed unable to make medical treatment decisions and therefore his DPOA paperwork would not yet be activated. In an interview on 9/27/23 at 3:43 PM, Nursing Home Administrator (NHA) A stated that the facility's admissions coordinator coordinated with the resident and/or responsible party upon admission to obtain advance directive and power of attorney paperwork and then reviewed and completed the facility's code status form with them, as well. NHA A stated that completion of the code status form was part of the admissions process and therefore completed by the admissions coordinator, but that SW G was expected to review code status forms annually with the resident and/or responsible party. Per NHA A, the facility's admissions coordinator was not available in person or via phone for interview regarding process for completion of code status form and deferred remainder of interview to Director of Nursing (DON) B as was more familiar with the clinical aspect of a resident's care. In an interview on 9/27/23 at 4:02 PM, DON B located R24's Do-Not-Resuscitate Order form on her desk as stated that she had faxed to attending physician for signature and was awaiting return of signed form. Per DON B, the facility's admissions coordinator had completed the form with R24's son at his 9/6/23 admission with review of form reflecting that the form was signed by R24's son and two witnesses all with corresponding dates of 9/6/2023. Line labeled as Physician's signature, within form, was noted to be blank. Upon review of R24's paper chart, DON B confirmed that only financial POA paperwork could be located and denied knowledge as to whether R24 had a DPOA-HC as paperwork was unable to be located within paper chart. Furthermore, DON B stated that until R24's statement of decision-making-capacity form was completed, and the DPOA-HC paperwork could be located for activation, R24 would have to be a full code. In a follow-up interview on 9/27/23 at 4:55 PM, DON B was observed to remove the red DNR sticker from the binder of R24's paper chart as stated that R24's code status had been changed to a full code. Upon review of R24's electronic medical record, an order dated 9/2723 at 4:37 PM stated, Code Status: Full Code. Review of the facility policy titled Communication of Code Status with a reviewed/revised date of 11/20/2022 stated, Policy: It is the policy of this facility to adhere to residents' rights to formulate advance directives. In accordance to these rights, this facility will implement procedures to communicate a resident's code status to those individuals who need to know this information .Policy Explanation and Compliance Guidelines .6. In the absence of an Advance Directive .the default direction will be Full Code .7. The presence of an Advance Directive or any physician directives related to the absence or presence of an Advance Directive shall be communicated to Social Services .8. The Social Services Director shall maintain a list of residents who have an Advance Directive on file . Review of the facility policy titled Residents' Rights Regarding Treatment and Advance Directives with a reviewed/revised date of 2/24/2023 stated, Policy: It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and formulate an advance directive .Policy Explanation and Compliance Guidelines .1. On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive .3. Upon admission, should the resident have an advance directive, copies will be made and placed on the chart .4. The facility will periodically assess the resident for decision-making abilities and approach the health care proxy or legal representative if the resident is determined not to have decision making capacities .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake number MI00134805. Based on interview and record review, the facility failed to immediately report to the State Agency an injury of unknown origin of one resident (Resident #30) of 1 reviewed for abuse, resulting in the potential of abuse to go unreported, undetected and the potential for further abuse to continue and go unrecognized. Findings include: Resident #30 (R30) During an interview on [DATE] at 08:05 AM, Licensed Practical Nurse (LPN) D stated that on [DATE] on the afternoon shift, R30 went to the shower room with 2 Certified Nursing Assistants (CNAs), CNA E and CNA F. LPN D said she noticed R30 had bruising on her arm later that evening. LPN D said that R30 was swatting at the CNA E and CNA F. LPN D was unsure of how the bruises occurred, but she noted them. Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE] revealed R30 admitted to the facility on [DATE] and had diagnoses of visual and auditory hallucinations, dementia, and depression. Brief Interview for Mental Status (BIMS) on [DATE] was not completed by the facility and the score was left blank. BIMS on [DATE] was a score of 1 which indicated severe cognitive impairment. R30 expired on [DATE] on Hospice. During an interview on [DATE] at 04:35 PM, Nursing Home Administrator (NHA) stated he didn't report the incident on [DATE] to the State Agency, but he had an investigation file on the incident. During an interview on [DATE] at 09:47 AM, Director of Nursing (DON) stated that on [DATE] it was R30's shower day and the girls took her back to the shower. When R30 got back in the shower room she was combative and stood up and CNA E and CNA F tried to keep her safe and finish washing her up. DON said R30 wasn't restrained in her wheelchair. The nurse (LPN D) noticed bruising on her left hand. DON said the CNAs were educated that it was okay if a resident refuses showers and the steps to take when this happens. DON mentioned R30's bruising was from hitting and flailing her arms in the shower room. DON stated an all-staff in-service was given on [DATE] on dementia training/approach, abuse and neglect, and resident rights. DON said that staff will ask for help when they are in difficult situations. During an interview on [DATE] at 10:10 AM, CNA E said CNA F was helping her with R30's shower since she was in training. CNA F was taking R30's clothes off in the shower room and R30 didn't want to take a shower and CNA F was acting like she was resident's (R30's) mother and was a little forceful making sure she took a shower. CNA E said that CNA F went to take her top off and maybe R30 swung and hit her arm because she had her arms up, but she couldn't see anything since they were on opposite sides of R30 washing her up. During an interview on [DATE] at 10:45 AM, CNA F stated that on [DATE], she was working with CNA E and R30 was very combative. R30 bit her, pinched her, and dug her nails into her. CNA F said that R30 must have received the bruises from swinging her arms in the shower room. Review of Progress note dated [DATE] at 12:26 PM written by Social Worker (SW) N revealed that R30 reported that there was an incident that happened when she was asked to shower. She reported she did not want to take a shower and she was attacked by two girls who made her take a shower. She reported she fought back with the girls and showed SW a bruise on her arm. When asked how the bruise happened, she reported she was grabbed. Review of progress note on [DATE] at 01:50 PM written by DON revealed that R30 said, I didn't feel I could take a shower. I haven't been feeling well. These two girls took me to the shower. I was fighting all the way. I was screaming. I fought it out with them. She revealed a large discoloration to her left forearm. When asked about the discoloration R30 said I got that in the process of fighting them off. They grabbed me. During another interview on [DATE] at 12:55 PM, NHA said that he was aware of R30's daughter calling the police since she had done that multiple times in the past, but the police did not talk to him when they came in. NHA stated he did not get a copy of the police report. He stated that he didn't report what happened since the previous Social Worker (SW) reviewed the surveillance video with Human Resources and noted no change in behavior before and after R30's shower. NHA stated he (they) knew right away that it must have occurred in the shower room, so it wasn't reported to the State Agency. Review of the Abuse, Neglect and Exploitation Policy with implementation date of [DATE] and a revised date of [DATE] under VII. Reporting/Response revealed, A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to complete a significant change Minimum Data Set (MDS) assessment for one (Resident #29) of 12 reviewed for MDS assessments, from a total sample of 12, resulting in the potential for inaccurate care plans and unmet care needs. Findings include: Resident #29 (R29) Review of the medical record revealed Resident #29 (R29) was admitted to the facility on [DATE] with diagnoses that included inflammation of the vagina and vulva, Multiple Sclerosis (a disease in which the immune system eats away the protective covering of the nerves), history of falls and wheelchair bound. R29 is dependent of repositioning in bed and all cares. According to Resident #29 (R29)'s Minimum Data Set (MDS) dated [DATE], revealed R29 scored 03 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. Record review revealed R29 was receiving hospice services through said hospice agency effective 07/25/23. Facilities care plan included terminal diagnosis of Multiple Sclerosis (MS), increased risk for skin breakdown on coccyx, needed repositioned every two hours, needed assistance with eating, had a pureed diet, required full assist with all activities of daily living, transfers and repositioning. During record review, there was no hospice care plan or hospice signed certification. During an interview on 09/26/23 at 3:16 PM, Director of Nursing (DON) stated she did not know where the hospice certification was at, she would contact the hospice agency to receive hospice certification and hospice care plan. DON also stated she was responsible for the Minimum data set (MDS) assessments. Record review of hospice binder revealed a calendar with scheduled upcoming visits from disciplines, past nursing notes, past CNA notes, past social workers notes and spiritual notes. There was not a hospice signed certification detailing the plan of care for R29 during a certain time frame, including the visits to be made, medications that were covered and the hospice care plan that their CNA's would follow. Record review revealed there was no change in condition completed when R29 was admitted to hospice. MDS Section O, Special Treatments, Procedures and Programs, Hospice was not selected. State Operators Manual (SOM) identifies A Significant Change in Status MDS is required when: o A resident enrolls in a hospice program; or o A resident changes hospice providers and remains in the facility; or o A resident receiving hospice services discontinues those services; or o A resident experience a consistent pattern of changes, with either two or more areas of decline or two or more areas of improvement, from baseline (as indicated by comparison of the resident's current status to the most recent CMS-required MDS).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement person center care plans for 2 residents (#1 and #16) of 12 residents reviewed for care plans, resulting in the potential for unmet needs. Findings include: According to the clinical record, Resident 1 (R1) was admitted to the facility in 2019 with diagnose that included heart failure and diabetes. Review of the Minimum Data Set (MDS) dated [DATE] reflected R1 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). Review of an occupational therapy evaluation dated 09/15/23 reflected R1 could benefit for a lap tray during meals in order to allow for self feeding and improved body mechanics. Review of R1's care plans did not include or identify the use of a full lap tray. On 09/26/23 at 02:34 PM, R1 was observed sitting in wheelchair in room has full lap tray attached to the wheelchair which R1 kept many personal items, (phone, tissue candies). On 09/27/23 at 08:53 AM, R1 was observed in dining room at breakfast, lap tray in place and tableware placed on the tray, R 1 was observed feeding herself independently. On 09/27/23 at 8:41 during an interview with the Director of Nursing (DON) B she reported R1 was very short in stature with short limbs and evaluated by the Occupational therapist whom recommended the lap tray for increased independence and to keep personal items within reach. On 09/27/23 at 10:25 AM, during an interview with Certified Nursing Assistant (CNA) M she reported R1 liked the tray and requested it on her chair not just for meals but all the time, as she had short arms and the lap tray helped significantly keep R1's personal items in reach. On 09/27/23 03:35, after a completed record review and during an interview with DON B whom reported lap tray was fairly new and acknowledge there was no care plan in place for its use. Resident #16 According to the medical record, including the Minimum Data Set (MDS) dated [DATE] reflected R16 was admitted to the facility with diagnosis that included bi-disorder, major depression, generalized anxiety and hypertension, R16 scored 15 out 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). On 09/25/23 02:14 PM, Resident # 16 (R16) observed resting in bed, stated staff are rude especially on midnight shift , R16 then reported she was mean and nasty to staff because I can be. R16 then began issuing personal insults and became verbally abusive toward surveyor. Review of R16's care plans reflected identified concerns related to psychotropic drug use , but there were no care plans that identified what R16's behaviors were or how to best address them. On 09/27/23 at 08:30 am, during an interview with Director of Nursing (DON) B she reported R16 was known to be belligerent and insulting with staff including, but not limited to her (DON), and would often use profanity. DON B reported she would reiterate to R16 that the behavior was not appropriate but to never argue back. On 09/27/23 at 11:23 AM, during an interview with Certified Nursing Assistant (CNA) M reported R16 was known to be difficult and have inappropriate behaviors. When queried how she handled R16 she stated she tried to re-direct R16 and change topic of conversations to things she liked, such as traveling to New Mexico. On 09/27/23 at 03:09 PM during an interview with Social Worker SW G she reported she had been employed at the facility for one month, SW G agreed t Resident # 16 had care plans in place to address psychotropic medication use but nothing to address R16 behaviors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that pressure wounds were assessed, monitored and treated according to acceptable professional standards for one resident (#26) out of two reviewed with pressure ulcers resulting in the potential for worsening of pressure ulcers and delayed healing. Findings include: Resident #26 (R26) Medical record revealed Resident #26 (R26) was admitted to the facility on [DATE] with diagnoses that included Pressure Ulcer on left buttock, right femur fracture, history of Falls, muscle weakness, dementia, right hip pain, trochanteric fracture of the right femur. According to R26's Minimum Data Set (MDS) dated [DATE], revealed R26 scored 99 out of 15 (unable to answer any questions) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R26 requires assistance with activities of daily living and ambulation. During an interview on 09/27/23 at 08:38 AM, DON stated the sacral pressure ulcer is now healed and left gluteal is now stable. During an interview and observation on 09/27/23 at 01:45 PM, Registered Nurse (RN) O prepared to complete wound care on the coccyx pressure ulcer. Observation of RN O cleaning the over the bed table and covered with a barrier. RN O explained what she was doing to R26 prior to providing care. R26 was repositioned up on right side, held in place by Certified Nursing Assistant (CNA) P. RN O removed soiled dressing and disposed of it in the trash can, gloves changed, hand sanitizer, new gloves on, wound cleaned with a wound wash and gauze dressing. RN O used hand sanitizer, new gloves put on, RN O packed the wound with calcium alginate with sterile Q-tip, hand sanitized, new gloves put on, large band-aid dated and initials, placed over site. Barrier cream applied over buttock area, disposed of gloves, hands washed in the bathroom, RN O stated the wound had decreased in size, no s/s of infection, no smell or drainage noted. Record review revealed R26 did not receive weekly ordered wound care by the wound care nurse. No wound care on 08/18, 07/21, 07/07, 06/26, 06/12, 06/05, 05/15, 05/08, 05/01, 04/24, 04/17 by the wound care nurse. Staff floor nurses completed the daily wound care. Wound care nurse Q completed the weekly wound care and completed measurements and characteristics of the wound. During an interview on 09/27/23 at 3:40 PM, DON stated she did not have the documentation for the dates requested, also stated she guessed they were not done. Record review revealed no documentation of care or measurements under the wound care management.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to properly transfer one Resident (#8) of 2 reviewed for falls, resulting in a fall, facial injuries, and need for emergency room transfer. Findings include: Review of the medical record reflected that Resident #8 (R8) was admitted to facility 9/10/2020 with diagnoses including unspecified dementia with behavioral disturbance, polyosteoarthritis, essential hypertension, and diabetes mellitus. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/11/23 reflected that R8 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 4 (severe cognitive impairment). Section G of the same MDS reflected that R8 required one-person extensive assist with bed mobility and transfers, one-person limited assist with toilet use, and was independent with eating after set-up. In an observation and interview on 9/25/23 at 3:10 PM, R8 was observed sitting in nursing day room in tan leather recliner chair sipping can of soda from a straw. Legs were noted to be bent at knees, feet were touching floor with blue nonskid socks and purple Velcro slippers noted to bilateral feet. A deep purple bruise with yellowing edges was observed just below R8's right eye. R8 nodded head when questioned regarding a recent fall, remained otherwise nonverbal, and did not offer any additional information regarding source of injury. Review of R8's electronic Nursing Progress Note dated 9/21/2023 at 6:57 AM stated, 0528 (5:28 AM) CNA (Certified Nurse Aide) reported, while transferring (R8's name) from the toilet to her w/c (wheelchair) via walker residents right leg slipped from under her and she fell to the bathroom floor and hit her right side of her face/cheek. Writer observed discoloration to the right side of her face w/ (with) 0.5cm (centimeter) x (by) 0.5cm laceration to the corner of the right eyelid. Resident c/o (complained of) pain 2/10 (numerical pain scale from 0 to 10 with 0 meaning no pain with pain level gradually increasing as numbers increase). Resident was assisted back to her bed via Hoyer lift x (times) 3 person. MD (Medical Doctor) made aware with an order to send to the Hospital .(name of ambulance service) arrived at 6:45 AM . Review of R8's electronic Nursing Progress Note dated 9/21/2023 at 2:17 PM stated, (R8's name) returned form hospital ER (Emergency Room) @ (at) 2:45 PM. She was seen in the emergency room and they performed a CT (Computed Tomography-a scan that uses a series of X-rays to detect injuries) of cervical spine .Head .Maxillofacial .and a Chest Xray .After evaluation it was determined that there was no evidence of fractures but there was evidence of facial bruising . Review of Incident/Accident Report, provided by NHA A, dated 9/21/23 at 5:28 AM indicated that R8 sustained a fall in the bathroom with narrative description on report mimicking documentation contained within Nursing Progress Note dated 9/21/2023 at 6:57 AM. Further review of report indicated that Certified Nurse Aide (CNA) L was a witness to the fall. Review of R8's electronic medical record revealed separate orders for transfer, ambulation, and toilet use all with a created dated of 7/18/2023 and all indicating need for 1 person assist. Review of R8's Comprehensive Care Plans included, Problem: (R8's name) is at risk for deterioration in bed mobility, transfer, walking in room, walking in corridor, locomotion on unit, locomotion off unit, dressing, eating, toilet use, personal hygiene . with associated approaches noted to include One person assist for transfer as needed depending on R8's participation in the activity and Provide 1 person assistance for ADLS (Activities of Daily Living). Review of all care plan approaches within the indicated problem was not noted to include an approach related to toilet use. Review of R8's [NAME] (tool used by the CNA to guide them as to the care needs of a specific resident) located on the back of R8's room entrance door outlined the following care needs: Ambulation: Assist of 1, Bed mobility: Assist of 1, Transfer: Assist of 1, Toilet Use: Assist of 1. The reverse side of R8's [NAME] contained CNA Standard of Care guidelines which included Follow your [NAME] for transfer directives. In a telephone interview on 9/27/23 at 8:35 AM, CNA L stated that she had been employed at facility for 2 years, routinely worked midnight shift, was familiar with R8, and confirmed that she had witnessed R8's fall on 9/21/23. Per CNA L, each resident had a form on the back of their room door that outlined information needed to provide care for the resident and included both transfer status and toilet assistance needs. CNA L stated that R8 required 1 person assist with transfer and that her ability to transfer varied depending on time of day, her willingness to participate in the transfer process, and her level of pain at the time of the transfer. Per CNA L, R8 generally had a harder time getting out of bed as did not have anything to grab onto and therefore she would apply gait belt to assist her to stand up to walker. CNA L then stated she would either walk R8 to the bathroom or sit her in the wheelchair and push her into the bathroom. CNA L stated that sometime after 5:00 AM on 9/21/23 she assisted R8 to get up out of bed and ready for the day. Per CNA L, on that date, she placed gait belt on R8, assisted her from a sitting position on bed to a standing position at walker, and then R8 proceeded to turn and sit in wheelchair parked at bedside. CNA L stated that she then pushed R8, in her wheelchair, up to the grab bar on the wall to the left of the toilet, R8 grabbed onto the bar, pulled herself to a standing position, pivoted so that her bottom was up against the toilet, and sat on toilet after brief was removed. CNA L stated that she then moved R8's wheelchair out of the bathroom so that she could provide R8's care, removed the gait belt at R8's waist, got her cleaned up, dressed, and replaced shoes. CNA L stated that upon completion of care, she moved behind wheelchair positioned in the doorway of the bathroom as R8 typically stood from the toilet without difficulty by pulling self to standing position with bar on wall at left of toilet and then used walker to ambulate from toilet to wheelchair, positioned in bathroom doorway, and turned and sat in wheelchair. CNA L stated that when transferring off the toilet on the morning of 9/21/23, R8 used the grab bar on the wall to the left of the toilet to pull self to standing position, per her normal routine, but that morning CNA L stated that R8 seemed to be in a rush as wanted to get to her wheelchair fast and after pulling herself to a standing position in front of the toilet, grabbed her walker that was positioned in front of her, began taking steps toward wheelchair, and began turning to position self in front of wheelchair at which time her right leg slipped, and she fell hitting her head on the sink. CNA L stated that she believed that R8's [NAME] reflected that she required 1 assist for transfer, ambulation, bathing, dressing, and toilet use but stated that R8 could generally pull herself to a standing position, from the toilet, without any help. CNA L stated that when a resident's [NAME] reflected the need for 1 assist with transfers, that she provided one assist which would include standing directly beside a resident during transfer but did not always include use of a gait belt. CNA L stated that she only used a gait belt for R8 when she was having a hard time moving, especially in the morning when getting out of bed, when she said she was in pain, or when she asked for help with the transfer. CNA L stated that R8 was vocal, would report pain, and would ask for help when needed and then she would use the gait belt to assist R8 with the transfer but reiterated that R8 typically did not need help transferring on and off the toilet or taking steps to move from the toilet to the wheelchair and therefore typically did not use a gait belt. In an interview on 9/27/23 at 9:52 AM, Licensed Practical Nurse (LPN) K stated that she was familiar with R8 and was her assigned nurse that date. Per LPN K, R8 required assist of 1 for all ADL tasks including bathing, dressing, and toilet use and since she was also a 1 assist with transfer and ambulation, a gait belt should be used in addition to her walker. In an interview on 9/27/23 at 10:04 AM, Contracted Occupational Therapist (OT) I confirmed familiarity with R8, stated that R8 had recurrent falls, impaired safety awareness due to cognitive impairments, was unpredictable and may sit without warning, and that a gait belt should routinely be used with all transfer and ambulation. Upon review of the OT Discharge summary dated [DATE], that she confirmed to have completed, Contracted OT I stated that the Toilet transfer discharge level of set up assistance with additional comments within same section reflecting SBA (stand by assist) required using 2ww and minimal cues required for safety and sequencing d/t (due to) patient with cognitive impairments pertained only to R8 completing a stand pivot transfer directly from toilet to wheelchair parked at toilet. Contracted OT I stated that if the wheelchair was parked at the bathroom doorway, CNA should have a gait belt in place at R8's waist and walk with R8 from toilet to wheelchair as several feet separated toilet and bathroom doorway. Additionally Contracted OT I stated that a therapy screen was generally completed after every resident fall, she was uncertain if one had yet been completed after R8's 9/21/23 fall but that would check with PT (Physical Therapy) to verify completion. In an interview on 9/27/23 at 11:36 AM, Contracted Physical Therapy Assistant (PTA) H stated that any order that indicated the need for an assist of one for transfer, a gait belt should automatically be used. Upon review of R8's PT Discharge summary dated [DATE], Contracted PTA H stated that R8 was discharged as an assist of 1 with sit to stand transfer as well as need for constant cueing for safety and follow through and stated that a gait belt should be used with all transfer. In an interview on 9/27/23 at 1:07 PM, Director of Nursing (DON) B stated that R8 would ambulate at times with staff but would refuse at other times. Per DON B, R8 used a front wheeled walked for transfer and ambulation and required 1 person assist with all ambulation and 1 to 2 people assist with transfers depending on her willingness to participate in the transfer process. DON B stated that with R8's transfers, her walker was placed in front of her, a boost was provided by staff, and that she could then generally use her walker to stand. DON B stated that use of a gait belt was not routinely used for transfer or ambulation for a resident that required a 1 person assist and that if a gait belt was required, the resident specific [NAME] would indicate the need. DON B proceeded to state that OT I had completed a therapy screen that date and that the current recommendation included use of a gait belt when transferring R8. During the same interview, DON B stated that upon review of R8's Incident and Accident Report post 9/21/23 fall, that it was her understanding that R8 was using her walker to transfer from the toilet, leg slipped, and she fell. DON B stated that she was uncertain as to where CNA L was at the time of R8's fall as the fall occurred on the midnight shift and therefore, she was not in the building and the report only indicated that CNA L witnessed the fall but did not include exactly where she was at the time of the fall. DON B stated that as R8 required an assist of one for transfer and ambulation, she would have expected CNA L to be directly beside R8 for transfer and beside or behind her for ambulation. Review of R8's Rehab Services Screening Form, signed and dated by Contracted OT I on 9/27/23, indicated within section titled Reason for Screen that R8 had a fall on 9/21/23. Problems indicated to have been identified by screen included R8's transfers, balance, and falls. Comments section of form stated, Educated nursing staff on using gait belt during all transfers to prevent falls during toileting. No therapy services indicated at this time.

Based on interview and record review, the facility failed to complete an annual performance review and provide education based on the review for one staff member, Certified Nursing Assistant (CNA) F of 1 reviewed for yearly performance evaluation. This could potentially put all residents at risk for poor quality of care. Finding include: Review of the Nurse Aide Training Program Policy with a Reviewed/Revised Date of 7/25/2023 under Policy Explanation and Compliance Guidelines step 2 revealed Each nurse aide shall be provided at least 12 hours of in-service training annually, based on his/her employment date, not calendar year. Under Step 5, Additional training will be provided to each nurse aide based on any areas of weakness as determined in the nurse aide's performance reviews. a. The Director of Nursing shall communicate the educational needs of the employee to the Staff Development Coordinator upon final review of the annual performance appraisal. b. Education that is needed based on the performance appraisal will be completed within 90 days of the appraisal, unless otherwise specified in the appraisal. Review of CNA F's human resource file revealed that CNA F's hire date was 06/27/2022 and there wasn't an annual competency in the file or in-service education since date of hire. An interview was conducted on 09/27/23 at 03:50 PM with the Director of Nursing (DON). DON stated that the annual competencies haven't been done this year and she wasn't sure where the in-service education for CNA 'F was. During an Interview with NHA on 09/28/23 at 08:18 AM, NHA stated he didn't have any competency or in-service information on CNA F.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to integrate hospice and facility services and care plans to coordinate hospice care for one Resident (#29) of two resident reviewed for hospice services. This deficient practice resulted in the potential for care not being provided and lack of continuity of care between hospice staff and the facility. Findings include: Resident #29 (R29) Review of the medical record revealed Resident #29 (R29) was admitted to the facility on [DATE] and admitted to hospice on 07/25/23 with diagnoses that included inflammation of the vagina and vulva, Multiple Sclerosis (a disease in which the immune system eats away the protective covering of the nerves), history of falls and wheelchair bound. R29 is dependent of repositioning in bed and all cares. According to Resident #29 (R29)'s Minimum Data Set (MDS) dated [DATE], revealed R29 scored 03 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. Record review revealed R29 was receiving hospice services through said hospice agency. Facilities care plan included terminal diagnosis of Multiple Sclerosis (MS), increased risk for skin breakdown on coccyx, needed repositioned every two hours, needed assistance with eating, had a pureed diet, required full assist with all activities of daily living, transfers and repositioning. During record review, there was no hospice care plan or hospice signed certification. During an interview on 09/26/23 at 3:16 PM, Director of Nursing (DON) stated she did not know where the hospice certification was at, she would contact the hospice agency to receive hospice certification and hospice care plan. Record review of hospice binder revealed a calendar with scheduled upcoming visits from disciplines, past nursing notes, past CNA notes, past social workers notes and spiritual notes. There was not a hospice signed certification detailing the plan of care for R29 during a certain time frame, including the visits to be made, medications that were covered and the hospice care plan that their CNA's would follow. During an interview on 09/27/23 at 03:29 PM, DON stated the hospice CNA had been giving R29 bed baths, facility CNA didn't give her the baths, clean her up as needed. DON also stated hospice staff documents on paper chart, and electronic medical record (EMR). DON stated the CNA's do not chart repositioning, no documentation to reflect that R29 was being repositioned every 2 hours. R29 had hand braces but now she is hospice, and it is as tolerated. DON then stated all the responsibilities of her role, then got upset and left the conference room. During a request 09/28/23 at 08:32 AM, Administrator stated he would have the DON collect the hospice care plan, hospice signed certification. Record review revealed that R29 had a [NAME] (part of the hospice care plan) located on the back of her room door. [NAME] did not have a date on it, still had foley catheter care and her foley came out on 08/10/23. [NAME]'s are to reflect the care that is needed from the care plan condensed to a task sheet. There was no mention of the resident being on hospice, or the care that the facility CNA would provide and what the hospice CNA would provide. Record review did not reflect collaboration between the facility and the hospice agency. There was no hospice care plan, no signed certification showing what the frequency was going to be for discipline visits, no statement of covered medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #8 Review of the medical record reflected that Resident #8 (R8) was admitted to facility 9/10/2020 with diagnoses including unspecified dementia with behavioral disturbance, polyosteoarthritis, essential hypertension, and diabetes mellitus. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/11/23 reflected that R8 had a Brief Interview for Mental Status (BIMS-a cognitive screening tool) score of 4 (severe cognitive impairment). Review of R8's paper medical record revealed a form titled Medication Regimen Review that reflected monthly reviews from 9/2022 through 4/2023 with no issues indicated for all months within that time frame except for 4/2023. Pharmacy Medication Regimen Review for 4/2023 was indicated to have been completed on 4/4/2023 and stated, See report for any noted irregularities and/or recommendations. Further review of R8's paper medical record included no additional reports that pertained to the 4/4/2023 recommendation. Additionally, no monthly reviews were noted to have been completed, per the same form, after 4/2023. In an interview on 9/26/23 at 4:52 PM, Director of Nursing (DON) B stated that the consultant pharmacist had completed the monthly medication regimen reviews at the facility through 4/2023 but since then had completed remotely and therefore the monthly reviews were no longer indicated on the medication regimen review form contained within each resident's paper chart. DON B stated that she facilitated completion of the monthly medication regimen reviews, that she received a summary report from the pharmacist of all recommendations completed for the month as well an individual form for each recommendation, and that she would either review the recommendation with the physician via phone or place the recommendation in the physician book located at the nurses' station for review at the next physician visit. Per DON B, the physician reviewed the recommendation, indicated any desired orders on the form and then either the assigned nurse would review and write indicated order, or the form would be returned directly to her for completion. Upon review of R8's paper medical record, DON B stated that the recommendation form dated 4/4/2023 could not be located within the physician order section, as anticipated, or any other section of the chart nor could she find any evidence within R8's electronic medical record of what the recommendation was or if it was followed up on. DON B stated that she would be contacting the pharmacy for the report. Upon review of a consultation summary report that DON B stated she received from the pharmacist, reported that the summary did not reflect any recommendations for R8 in 5/2023, 6/2023, or 7/2023 but that the report did indicate a recommendation from 8/2023. Per DON B, as the 8/2023 recommendation form was not located within R8's paper medical record with prior review, the physician likely had not yet completed and therefore would still be in the physician's binder where she had placed it after receipt from the pharmacist. Upon review of the physician's binder located at the nurses' station, DON B located R8's 8/2023 recommendation and confirmed that the recommendation had not yet been reviewed by the physician. Review of the recommendation dated 8/10/2023 stated, (R8's name) PRN (as needed) orders below have not been used within the previous 30+ (plus) days: Robitussion with Recommendation: Please consider discontinuing due to lack of use. The Physician's Response section within the same form was noted to be blank. On 9/27/23 at 10:33 AM, DON B provided R8's pharmacy recommendation from 4/2023. Review of report reflected a recommendation date of 4/4/2023 and stated, (R8's name) receives Losartan and Potassium .Most recent serum K+ (potassium) was elevated at 5.2 in [DATE] . with Recommendation: Please consider rechecking BMP (Basic Metabolic Panel-a blood test that included a potassium level) and discontinuing Potassium supplement if appropriate with remainder of form noted to be blank. Review of R8's electronic medical record reflected two physician orders for lab work (one dated 6/6/2023 and the other 6/7/2023) in which both included an order for a comprehensive metabolic panel (a blood test that included a potassium level as recommended in R8's pharmacy recommendation dated 4/4/2023). Review of R8's paper medical record revealed completion of the comprehensive metabolic panel lab draw on 6/14/2023 with a potassium level reflected. Further review of both R8's paper and electronic medical record included no indication that a potassium level was ordered until 6/6/2023 or drawn until 6/14/2023 (over 2 months after R8's 4/4/2023 pharmacy recommendation for a potassium level recheck). In a follow up interview on 9/27/23 at 1:04 PM, DON B acknowledged that R8's pharmacy recommendation dated 8/10/2023 had not yet been followed up on and that R8's recommendation dated 4/4/2023 was not completed until 6/2023 (a full 2 months after the recommendation was made). DON B stated that the goal was to complete the recommendations within the same month that they were made and would have expected that the 8/10/2023 recommendation would have been completed but stated that R8's physician had just started in 6/2023, was still familiarizing self with facility and was likely the reason the recommendation remained incomplete in the physician binder. DON B also confirmed that the potassium level recheck recommended by the pharmacist in 4/2023 was not completed until 6/2023, denied knowledge as to why there was a delay in follow-up unless R8 had refused prior lab draws but stated that there was no documentation to indicate that. Review of the facility policy titled Medication Regimen Review with a date reviewed/revised of 5/30/2023 stated, Policy: The drug regimen of each resident is reviewed at least once a month by a licensed pharmacist and includes a review of the resident's medical chart .Policy Explanation and Compliance Guidelines .3 .To facilitate the completion of the MRR (Medication Regimen Review), the facility shall provide the licensed pharmacist access to the following .g. Answers to the previous month's pharmacy recommendations .6 .Written communications from the pharmacist shall become a permanent part of the resident's medical record .7 . Timelines and responsibilities for Medication Regimen Review .f .Facility staff shall act upon all recommendations according to procedures for addressing medication regimen review irregularities . Resident #13 (R13) Review of the medical record revealed Resident #13 (R13) was admitted to the facility on [DATE] with diagnoses that included UTI, psychotic disorder with delusions due to physiological condition, depression, dementia and stroke. According to Resident #13 (R13)'s Minimum Data Set (MDS) dated [DATE], revealed R13 scored 99 out of 15 (unable to answer any questions) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R13 is bedbound and dependent of all activities of daily living. Record review reflected monthly medication regimen reviews were conducted monthly from 11/22/22 thru 04/4/23 with notations of see report for irregularities for 11/29/22, 2/22/23 and 03/02/23. There was no supporting documentation that R13 had any monthly medication reviews from 05/23 to 09/23. During an interview on 09/27/23 at 10:48 AM, Administrator and DON stated they would get a hold of pharmacy. DON stated she did not know where they were, she could have shredded them. documentation for monthly medication regimen reviews from 05/23 to 09/23, along with the pharmacy reports and recommendations for 11/29/22, 2/22/23, and 3/02/23. Record review of one monthly medication regimen review received dated 3/30/23 and reflected the pharmacist reported metoprolol and verapamil are known to cause and or exacerbate depression, please consider discontinuing metoprolol. The bottom of recommendation was left blank where there was a signature line for the Physician and the DON to address and sign. During an interview on 09/27/23 at 03:34 PM, DON she reported she had been the interim DON for 3 months and reported she had contacted the pharmacy to obtain requested documents/pharmacy reports as they were not in the facility, DON acknowledged none of the recommendations had a physician signature and she could not be sure the Physician was aware of pharmacy accommodations. Based on interview and record review, the facility failed to ensure the physician reviewed and acted upon identified medication regimen irregularities for four (Residents #'s 8, 13, 15 and 16) of five reviewed for unnecessary medications, resulting in the potential for unnecessary medications and adverse reactions. Findings include: Resident #15 According to the clinical record, including the Minimum Data Set (MDS) dated [DATE] resident 15 (R15) was admitted to the facility with diagnoses that included diabetes, heart failure , and depression. R15 scored 14 out of 15 (cognitively intact) on Brief Interview Mental Status (BIMS). Further review of both the facility's electronic medical record and hard copy medical record for R15 did not reflect any monthly reviews by a pharmacist. On 09/27/28 at 11:00 am evidence that R15 had a monthly medication management review was completed by a Pharmacist, along with any indication of irregularities and physician recommendation reports were requested. What was received was pharmacy recommendations dated 2/27/23 where the pharmacist recommended was to consider discontinuing Certizine, while continuing flonase and the recommendation to the physician to consider discontinuing docusate. The 8/10/23 pharmacy recommendation report reflected to consider increasing Lyrica for pain management and to considering monitoring A1c (lab to indicate glucose level) and to consider initiating Ozempic. None of the reports indicated if the physician agreed or declined with explanation nor did any of the reports have physician signature. There was no evidence provided by the end of the survey that R15 had any additional monthly medication reviews. Resident #16 According to the medical record, including the Minimum Data Set (MDS) dated [DATE] reflected R16 was admitted to the facility with diagnosis that included bi-disorder, major depression, generalized anxiety and hypertension, R16 scored 15 out 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). R16's medical record reflected pharmacy reviews were conducted monthly from 11/22/22 thru 04/4/23 with notations of see report for irregularities for 11/29/22, 2/22/23 and 03/02/23. There was no supporting documentation R16 had any monthly medication reviews from May to September 2023. On September 27 at 10:48, documentation for monthly medication reviews from May to September were requested along with the pharmacy reports/recommendations for 11/29/22, 2/22/23, and 3/02/23. Only was received at dated 3/30/23 and reflected the pharmacist reported metoprolol and verapamil are known to cause and or exacerbate depression, please consider discontinuing metoprol. The bottom of recommendation was left blank where there was a signature line for the Physician and the DON. On 09/27/23 at t 03:34 PM, during an interview with Director of Nursing (DON) B she reported she had been the interim DON for 3 months and reported she had contacted the pharmacy to obtain requested documents/pharmacy reports as they were not in the facility, DON B acknowledged none of the recommendations had a physician signature and she could not be sure the Physician was aware of pharmacy accommodations.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 29 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 09/25/23 at 02:30 P.M., An initial tour of the food service was conducted with Director of Food Services C. The following items were noted: The interior and exterior surfaces of the South Bend convection ovens were observed soiled with accumulated and encrusted food residue. The exterior surfaces of the South Bend stove/ovens were observed soiled with accumulated and encrusted food residue. The Proctor Silex commercial toaster was observed soiled with accumulated and encrusted food residue. The General Electric microwave oven interior and exterior surfaces were observed soiled with accumulated and encrusted food residue. The meat slicer was observed soiled with accumulated and encrusted food residue. The can opener assembly was observed soiled with accumulated and encrusted food residue. The spice rack shelves were observed (etched, scored, particulate), allowing soil residues to accumulate. The ice machine exterior surfaces were observed soiled with accumulated and encrusted food residue. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (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. The ice machine drawer lid was observed loose-to-mount with a faulty stop assembly. Director of Food Services C indicated he would contact maintenance for necessary repairs. The 2017 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened. The oscillating wall fan was observed heavily soiled with dust and dirt deposits, adjacent to the mechanical dish machine. The three-compartment sink drain funnel assembly was observed soiled with accumulated and encrusted food residue. The drain and drain trap assembly was also observed malodorous with a few visible drain flies. Director of Food Services C stated: We have a pest control contract with Orkin. The 2017 FDA Model Food Code section 6-501.12 states: (A) PHYSICAL FACILITIES shall be cleaned as often as necessary to keep them clean. (B) Except for cleaning that is necessary due to a spill or other accident, cleaning shall be done during periods when the least amount of FOOD is exposed such as after closing. On 09/25/23 at 03:10 P.M., An initial tour of the Nursing Lobby was conducted with Director of Food Services C. The following item was noted: The refrigerator interior appliance light bulb was observed missing from the socket assembly. The 2017 FDA Model Food Code section 6-303.11 states: The light intensity shall be: (A) At least 108 lux (10 foot candles) at a distance of 75 cm (30 inches) above the floor, in walk-in refrigeration units and dry FOOD storage areas and in other areas and rooms during periods of cleaning; (B) At least 215 lux (20 foot candles): (1) At a surface where FOOD is provided for CONSUMER self-service such as buffets and salad bars or where fresh produce or PACKAGED FOODS are sold or offered for consumption, (2) Inside EQUIPMENT such as reach-in and under-counter refrigerators; and (3) At a distance of 75 cm (30 inches) above the floor in areas used for handwashing, WAREWASHING, and EQUIPMENT and UTENSIL storage, and in toilet rooms; and (C) At least 540 lux (50 foot candles) at a surface where a FOOD EMPLOYEE is working with FOOD or working with UTENSILS or EQUIPMENT such as knives, slicers, grinders, or saws where EMPLOYEE safety is a factor. On 09/25/23 at 03:20 P.M., An initial tour of the Main Dining Room Kitchenette was conducted with Director of Food Services C. The following items were noted: The interior surface of the Magic Chef microwave oven was observed (etched, scored, particulate, corroded). Director of Food Services C stated: I will replace the unit as soon as possible. The 2017 FDA Model Food Code section 4-501.13 states: Microwave ovens shall meet the safety standards specified in 21 CFR 1030.10 Microwave ovens. The Proctor Silex commercial toaster was observed soiled with accumulated and encrusted food residue. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (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. The toe board was observed indented and loose-to-mount, adjacent to the ice machine. The 2017 FDA Model Food Code section 6-501.11 states: PHYSICAL FACILITIES shall be maintained in good repair. On 09/27/23 at 12:11 P.M., Record review of the Policy/Procedure entitled: Cleaning Procedures Library dated 2018 revealed under 007: Cleaning Procedures for Can Opener - Manual: Cleaning frequency: Daily: Can opener - after use, or minimum of every 4 hours. Weekly: Base/mounting bracket. On 09/27/23 at 12:34 P.M., Record review of the Policy/Procedure entitled: Cleaning Procedures Library dated 2018 revealed under 013: Cleaning Procedures for Convection Oven: Cleaning frequency: Daily: Exterior, handles, doors, knobs, top, and side. Weekly: Interior. On 09/27/23 at 12:39 P.M., Record review of the Policy/Procedure entitled: Cleaning Procedures Library dated 2018 revealed under 026: Cleaning Procedures for Ice Machine: Cleaning frequency: Daily: Exposed areas of ice bin/ice chute interior and exterior. Bi-annual: Ice machine cleaning/service. Complete ice bin cleaning and sanitizing. On 09/27/23 at 12:51 P.M., Record review of the Policy/Procedure entitled: Cleaning Procedures Library dated 2018 revealed under 031: Cleaning Procedures for Microwave: Cleaning frequency: Daily: Interior and exterior. On 09/27/23 at 12:54 P.M., Record review of the Policy/Procedure entitled: Cleaning Procedures Library dated 2018 revealed under 042: Cleaning Procedures for Range Oven: Cleaning frequency: Daily: Exterior, handles, doors, knobs, top, and side. Weekly: Interior.