Based on observation, staff interview, record review, and facility policy review, the facility failed to ensure a resident's right to privacy and confidentiality by posting personal health information on the resident's wall for one (1) of twenty-three (23) sampled residents, Resident #82. Findings included: A review of the facility's policy titled, Promoting/Maintaining Resident Dignity, dated 2/10/25, revealed, .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity as well as care for each resident in a manner and in an environment, that maintains or enhances resident's quality of life by recognizing each resident's individuality . Compliance Guidelines .11 .No signage shall be posted in the room with personal information . On 6/23/25 at 8:48 AM, during an observation, signage was observed posted on the wall above the bed for Resident #82 which indicated 205 A- Nectar thick liquids with no straws. On 6/24/25 at 11:45 AM, during an observation and interview while Resident #82 was assisted with lunch, Certified Nurse Aide (CNA) #1 explained that Resident #82 was on nectar thickened liquids and was assisted with each meal. CNA #1 confirmed the signage on the wall above the bed, which read Nectar thick liquids no straws. She stated this information was already included in the resident's plan of care and meal ticket and expressed uncertainty as to why it was also posted on the wall. On 6/25/25 at 10:45 AM, during an observation and interview with the Director of Nursing (DON), she confirmed that signage in resident rooms disclosing personal care or health information was not permitted and constituted a violation of resident dignity. She verified the presence of the sign referencing nectar thick liquids and no straws in Resident #82's room. The DON stated she did not know who had posted the sign or how long it had been there but affirmed that she would have it removed and conduct a facility-wide audit to ensure compliance. On 6/26/25 at 12:21 PM, during an interview with the Administrator, she acknowledged being informed of the signage and affirmed that resident health information should not be posted in resident rooms. She stated that her expectation was for all staff to honor residents' dignity and privacy and to avoid posting any health-related care information on the walls. A record review of the admission Record revealed the facility admitted Resident #82 on 7/6/23 with diagnoses including Nontraumatic Intracranial Hemorrhage. A record review of the Order Listing Report with active orders revealed Resident #82 had a Physician's Dietary Order, dated 4/10/25, for Nectar/mildly thick consistency and no straws.

Based on observation, staff interview, record review, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) assessment related to a resident having a restraint, when no restraint had been ordered or used, for one (1) of twenty-three (23) residents reviewed. Resident #99. Findings included: A review of the facility's policy titled Conducting an Accurate Resident Assessment, dated 2/10/25, revealed, . The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment . A record review of the admission Record revealed the facility admitted Resident #99 on 6/14/24 with diagnoses including Unspecified Dementia. A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/21/25 revealed Resident #99 had a limb restraint. A record review of the medical record revealed there was no documentation indicating Resident #99 had a limb restraint. On 6/23/25 at 7:34 AM, during an observation and interview, Resident #99 was lying in bed on her left side. Certified Nurse Aide (CNA) #1 explained that Resident #99 did not have any restraints. On 6/24/25 at 12:20 PM, during an interview, Licensed Practical Nurse (LPN) #1 explained the facility does not use restraints, and Resident #99 has not had any restraints since being admitted . On 6/24/25 at 2:30 PM, during an interview, the Director of Nursing (DON) reported the facility is a restraint-free building. During a review of Resident #99's Annual MDS with an ARD of 5/21/25, Section P0100 indicated the use of a limb restraint less than daily. The DON explained this was coded in error and confirmed that Resident #99 does not have a restraint. She stated that all assessments are expected to be coded accurately to reflect the resident's status. On 6/24/25 at 3:10 PM, during an interview, LPN #2 explained that she had coded the restraint in error on the MDS and confirmed that Resident #99 did not and had never had a restraint. On 6/26/25 at 12:10 PM, during an interview, the Administrator explained that she expected all residents' MDS assessments to be coded accurately to reflect their current assessments.

Based on observation, interview, and policy review, the facility failed to acknowledge and honor the documented food preferences of one (1) of twenty-three (23) sampled residents, Resident #88. Findings included: A review of the facility's policy titled Resident Meal Service, revised 1/2025, revealed, .Residents will be offered menu choices for all meals, beverages, and snacks, and are based on their .food preferences . A record review of the Clinical record revealed the facility admitted Resident #88 on 7/5/23 with diagnoses that included Hemiplegia and Hemiparesis. A record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/22/25 revealed Resident #88 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated his cognition was intact. A record review of the meal ticket, dated 6/23/25, revealed Resident #88 had Food Dislikes listing of multiple vegetables including broccoli, carrots, and cauliflower. A record review of the facility's MenuWorks Weekly Menu revealed the meal for Monday (06/23/2025) included California Vegetables. On 6/23/25 at 11:58 AM, during an observation and interview in the main dining hall, Resident #88 was removing vegetables from his plate. The meal on his tray included a California blend of vegetables consisting of broccoli, cauliflower, and carrots. Resident #88 stated he disliked vegetables and explained that this issue occurred frequently, despite his documented food preferences excluding such items. On 6/24/25 at 12:05 PM, during an interview with the Dietary Manager, he stated that kitchen staff do not currently review or acknowledge the food preferences listed on the residents' meal tickets. He explained that he had been in his role for less than ninety (90) days and had not yet had adequate time to address staff training or resolve deficiencies related to honoring resident meal preferences. He confirmed that dietary staff do not consistently review or implement resident preferences during meal service. On 6/26/25 at 1:14 PM, during an interview with the Administrator, she stated her expectation was for kitchen staff to ensure meals are prepared properly and meet residents' expectations. She acknowledged that the dietary department was newly staffed and that the Dietary Manager was still learning his role and responsibilities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility policy review, the facility failed to follow safe food storage and handling practices on one (1) of four (4) survey days. Specifically, the facility failed to properly store, label, and date frozen food items that were opened, discard expired bakery rolls and refrigerate lemon juice in accordance with manufacturer instructions. Findings included: A record review of the facility's policy titled, Food and Supply Storage dated 01/2025, revealed, .All food .used in food preparation shall be stored in such a manner as to prevent contamination .Procedures .Foods past the use by, sell by, best-by or enjoy by date should be discarded. Cover, label and date unused portions and open packages .Frozen Storage .Label both the bind and the lid. Use food grade plastic bags for food storage .Wrap food tightly to prevent cross contamination . On 6/23/25 at 8:23 AM, during an observation and interview with the Dietary Manager, there was one (1) tray of [NAME] Artesano Bakery Sausage Rolls in the dry goods storage room with an expiration date of 6/20/25. The Dietary Manager stated he was unaware when the expired rolls had last been served. In the freezer, there was a package of breaded okra that was open, not repackaged, and not labeled. A bag of frozen biscuits was open without proper repackaging or dating. A bag of frozen chicken tenders was stored in a torn clear plastic bag that had been rolled down and was neither repackaged, labeled, nor dated. The Dietary Manager acknowledged that dietary aides routinely open large food packages, use a portion of the contents, and return the rest to storage without labeling or dating. There was a one-gallon container of opened ReaLemon juice stored on a shelf, despite manufacturer instructions requiring refrigeration after opening. The Dietary Manager confirmed the juice was not stored according to manufacturer guidelines. On 6/26/25 at 1:14 PM, during an interview with the Administrator, she stated that her expectation is for kitchen staff to ensure residents receive food that is properly prepared and tastes good. She acknowledged that the Dietary department was newly staffed, including the Dietary Manager, who was still learning the position and job responsibilities.

Based on record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of previously cited deficiencies, specifically, the facility was cited for failing to properly store, label, and date food items and discard expired food on an annual recertification survey on 2/29/24 and was cited again for the same deficiencies during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for one (1) of seven (7) deficiencies cited. F812. Findings Include: Record review of the facility's policy, Quality Assurance and Performance Improvement, dated 2/1/2025, revealed, .It is the policy of this facility to .maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care and quality of life .Policy Explanation and Compliance Guidelines .2. The QAA Committee shall .c. Develop and implement appropriate plans of action to correct identified quality deficiencies . Record review of the Provider History Profile revealed the facility received a citation for F812-Food Procurement, Store/Prepare/Serve Sanitary on the survey conducted on 2/29/24. Record review of the CMS-2567 (a record that identifies the federal regulation in violation and describes the findings of noncompliance and the facility's plan of correction), with a survey date of 2/29/2024, revealed the facility received a citation for F812, .Based on observation, staff interview, record review, and facility policy review, the facility failed to store food .in accordance with professional standards for food service safety related to food items not dated with a use-by-date, no identifying label, expired foods, improperly stored and exposed food for one (1) of three (3) kitchen observations . During the current recertification survey, the facility failed to follow safe food storage and handling practices on one (1) of four (4) survey days. Specifically, the facility failed to properly store, label, and date frozen food items that were opened. discard expired bakery rolls and refrigerate lemon juice in accordance with manufacturer instructions On 6/26/25 at 2:31 PM, during an interview with the Administrator, she confirmed that during the facility's last recertification survey, they were cited under F812 for failing to date and label food items, specifically applesauce, orange juice, and apple juice. She acknowledged that the same concern was identified again during the current survey. She explained that, following the previous citation, the facility's Quality Assurance and Performance Improvement (QAPI) Committee implemented a corrective plan, which included weekly audits conducted by the dietitian or kitchen manager for four (4) weeks, followed by monthly audits for three (3) months, beginning on 3/4/24. She confirmed that the QAPI Committee meets monthly, although the facility policy only requires quarterly meetings, and those meetings include the full interdisciplinary team and medical staff, including the Medical Director. The Administrator stated that additional in-service training could be provided to reinforce expectations, and that the Quality Assurance(QA) nurse could conduct follow-up with dietary staff. She also noted that the dietary team currently in place is new and many were not employed during the time of the last survey, emphasizing the need for education on proper procedures and regulatory requirements.

Based on observation, interview, facility policy review, and record review, the facility failed to follow appropriate infection control practices when a Certified Nurse Aide (CNA) placed soiled linens on the floor of a resident's room after incontinent care for one (1) of twenty-three (23) sampled residents, Resident #97. Findings included: A review of the facility's policy titled Infection Prevention and Control Program, dated 2/1/25, revealed, . This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections .Policy Explanation and Compliance Guidelines .12. A. Linens and direct care staff shall handle, store, process, and transport linens to prevent spread of infection . e. Soiled linen shall be collected at the bedside and placed in a linen bag . When the task is complete, the bag shall be closed securely and placed in the soiled utility room . A record review of Resident #97's admission Record revealed the facility admitted the resident on 7/31/24 with diagnoses including Cerebral Infarction. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/17/25 revealed Resident #97 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated she was cognitively intact. On 6/23/25 at 12:15 PM, during an observation and interview in Resident #97's room, CNA #2 was returning to complete perineal care. Soiled linens were observed resting directly on the floor without a barrier or a bag. When asked whether the soiled linens should be in direct contact with the floor, CNA #2 responded, No, and stated that infection could be spread and cross-contamination could occur. CNA #2 then placed the soiled linens in a soiled utility bag. On 6/26/25 at 10:31 AM, during an interview with the facility's Infection Preventionist (IP) Nurse, she stated that proper infection control guidelines require placing soiled linens directly into a linen bag to prevent contact with the floor. Allowing linens to touch the floor increases the risk of cross-contamination and infection for staff and residents. On 6/26/25 at 11:39 AM, during an interview with the Director of Nursing (DON), she stated that CNA #2 should have placed the soiled linens in a bag immediately and avoided letting them touch the floor to prevent contamination and the spread of infection throughout the building. She confirmed it was her expectation for staff to follow infection prevention guidelines when providing care.

Based on observation, interview, record review, and facility policy review, the facility failed to maintain an effective pest control program related to ants for one (1) of twenty-three (23) sampled residents, Resident #49. Findings included: A review of the facility's policy titled .Pest Control Program, dated 2/1/25, revealed: .It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. Definition: 'Effective pest control program' is defined as measures to eradicate and contain common household pests (e.g .ants .) . A record review of the Transfer/Discharge Report revealed the admitted Resident #49 on 8/5/21 and he had diagnoses including Acute Respiratory Failure with Hypoxia. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/25/25, revealed Resident #49 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated he was cognitively intact. On 6/24/25 at 10:44 AM, during an interview, Resident #49 stated that his room had ants and he had been bitten on his knees while lying in bed earlier that morning. He explained that this was not the first occurrence, stating it also happened on the prior Saturday (6/21/25). On 6/24/25 at 11:45 AM, during an interview with the Administrator, she explained that the open cookies above the resident's bed and the proximity of his bed to the window likely contributed to the presence of ants. She confirmed that pest control services were provided monthly and that records showed visits dating back to January 2025, with the last visit in May. She added that the resident declined an offer to move to another room. On 6/24/25 at 12:30 PM, an observation of Resident #49 revealed two older-appearing insect bites with individual pustules, one on each mid-thigh, and approximately five (5) newer red pustules located on the back of both knees. On 6/24/25 at 12:41 PM, during an interview with the Director of Nursing (DON), she confirmed that visible bites were present on both legs. The DON explained that an unopened container of cookies found on the resident's above-bed shelf likely attracted the ants. She stated an investigation was conducted on Saturday (6/21/25) following the initial report, but no ants or bites were observed during the body audit. She confirmed that ants were later seen by Certified Nurse Aide (CNA) #3, who attempted to remove them from the resident's legs, but the resident declined, requesting the DON view them. The DON verified that pest control last visited the facility on 5/9/25 and was scheduled to return that day (6/24/25). On 6/24/25 at 3:37 PM, during an interview with the Ombudsman, he stated that residents in the past year had complained to him about ants getting into their rooms at the facility. On 6/26/25 at 11:46 AM, during a follow-up interview with the DON, she confirmed that Resident #49 had five (5) ant bites on the backs of his knees and two (2) older bites on the mid-thighs. She explained that the initial complaint was reported on 6/21/25 and a body audit conducted at that time did not reveal any bites or ants. However, the room was cleaned and treated. The DON stated the resident reported new ant bites again on 6/24/25. She acknowledged the risk of anaphylaxis from insect bites and emphasized the importance of staff reporting pest activity promptly. She reiterated that a pest control vendor conducts monthly visits and is expected to survey for infestations during each visit. Her expectation was that residents remain free from insect bites while residing in the facility. On 6/26/25 at 2:20 PM, during an interview with the Maintenance Director, he stated that a pest control vendor provides monthly services and responds to any pest-related concerns as needed. He explained that staff typically report any sightings and he remains vigilant during his daily rounds to monitor for pests.

Based on interviews, record review, and facility policy review, the facility failed to protect residents from misappropriation of property for one (1) of 23 sampled residents. Resident #64 Findings include: Review of the facility's policy, Abuse, Neglect and Exploitation, dated and initialed 3/23/23, revealed, Policy: It is the policy of this facility to provide protections for health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent .misappropriation of resident property .Definitions: .Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent . Record review of the Facility Investigation, dated 2/09/24, revealed, that on 1/16/2024, Resident #64 reported fraudulent changes on his bank statement to the Social Worker and Director of Nurses (DON). Resident #64 still had the card present in his wallet. Social services contacted the bank and placed a hold on the bank card. The local police were also contacted, and a report was made. An investigation was initiated for Resident #64. The resident was asked to provide the facility with any further documents received from the bank to the DON. The week of January 31, 2024, Resident #64 received another bank statement. Upon review of the bank statement with Resident #64, there was a charge noted on the bank statement for CPR (Cardiopulmonary Resuscitation) certification on January 9, 2024. The charge was placed through CPR National Foundation. An e-mail was sent to the CPR National Foundation to identify the CPR certification for January 9, 2024, using Resident #64's card number. A response was received on February 6, 2024, at 2:08 PM identifying the individual that had used the bank card number with the last four numbers of the bank card belonging to Resident #64. The local police were contacted, and another report was made including the identity of the person's information. The suspect was identified as (proper name) of a Certified Nurse aide (CNA). The CNA was an employee of (proper name) contracting company. The CNA worked as needed scheduling at the facility through (proper name) contracting company. The CNA has not worked at the facility since December 28, 2023. The facility identified interventions in response to the incident, which, in addition to notification of the local police department, in-services were initiated on abuse, neglect, and misappropriation of funds, the resident's bank replaced the money back into the resident's account, the State Agency, as well as the Attorney General were contacted, the Social Worker conducted interviews with other residents that reside in the same area of the facility, and the contracting agency was notified. The conclusion of the investigation resulted in substantiation of misappropriation of resident funds. On 02/26/24 at 12:15 PM, an interview with Resident #64 revealed he discovered fraudulent charges on the January statement of his bank account. He stated that he reported the charges on his bank statement to the Social Worker who in turn reported the charges to the DON and the Administrator. The resident added that the charges went back as far as December 2023 all the way through February of 2024. Review of the bank documents depicting the fraudulent charges were reviewed and the charges were listed as the following: $82.05 on 12/30/23 (pizza restaurant), $61.59 on 12/30/23 (grocery store), $42.05 on 12/30/23 (chicken restaurant), $35.09 on 12/31/23 (department store), $35.56 on 12/31/23 (grocery store), $29.07 on 1/5/24 (chicken restaurant), $28.32 on 1/3/24 (pizza restaurant), $41.47 on 1/3/24 (fast food restaurant), $14.07 on 1/10/24 (fast food restaurant), $14.95 on 1/9/24 (national CPR certification), $11.73 on 1/9/24 (fast food restaurant), $8.71 on 1/9/24 (fast food restaurant), $17.10 on 1/6/24 (pizza restaurant), $24.32 on 1/6/24 (pizza restaurant), $4.69 on 1/6/24 (fast food restaurant), $9.28 on 1/5/24 (fast food restaurant), $12.23 on 1/4/24 (fast food restaurant), $13.57 on 1/4/24 (fast food restaurant), $17.87 on 1/2/24 (food delivery service), $62.96 on 1/2/24 (food delivery service), $171.20 on 1/5/24 (sporting good store), $2.56 on 1/5/24 (fast food restaurant), $44.49 on 1/9/24 (wireless telephone service), and $29.41 on/5/24 (fast food restaurant). On 02/27/23 at 12:00 PM, during an interview with the DON, she confirmed that Resident #64 had made the Social Worker aware of the fraudulent charges on his bank statement and revealed that he still had his bank card in his wallet. The DON revealed that it was at that time that the local police department was notified, and the facility began an investigation. The DON stated that she had asked the resident to bring any future bank documents that he received to her for review. The week of January 31, 2024, when Resident #64 received another bank statement, there was a charge made for CPR certification and that charge provided the information needed to identify the individual responsible for the charges. The suspect was identified as (proper name), CNA, as an as needed CNA contracted to work through (proper name) contracting company. The DON revealed that the contracting company was notified, and the employee had not worked at the facility since December 28, 2023. Record review of the Face Sheet for Resident #64 revealed the facility admitted the resident to the facility on 1/28/21, with diagnoses that included Essential Hypertension and Type 2 Diabetes Mellitus. Record review of the Annual Minimum Data Set (MDS), for Resident #64, with an Assessment Reference Date (ARD) 11/13/23, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12. which indicated the resident had moderate cognitive impairment.

Based on observation, interview, record review, and facility policy review, the facility failed to implement care plan approaches related to an indwelling catheter care for one (1) of 23 sampled residents. Resident #70 Findings include: A record review of the facility's policy Care Plans, Comprehensive Person-Centered, revised December 2022 revealed . A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation 1. The Interdisciplinary Team .implement a comprehensive, person-centered care plan for each resident . 7. The comprehensive, person-centered care plan will: . b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Record review of the Care Plan with a problem onset date of 9/15/2025 revealed Problem/Need .high risk for UTI (Urinary Tract Infection) r/t (related to) presence of indwelling foley (type of indwelling catheter) .Approaches .Wipe front to back when providing pericare .Secure catheter tubing using leg strap . During an observation and interview on 2/27/24 at 11:00 AM, Certified Nurse Aide (CNA) #3 and CNA #4 provided catheter care for Resident #70. There was no leg strap securing the catheter tubing to reduce the risk of tension or pulling on the catheter to prevent trauma. Both CNAs reported the resident does not wear a leg strap because the resident would pull it off. CNA #3 used a disposable wipe and wiped the perineal area from the from the back to the front. CNA #4 reminded CNA #3 that she should wipe from the front to the back. After discarding the wipe and repositioning the resident, CNA #3 used a disposable wipe to clean the catheter by wiping the tubing several times, using the same wipe, and not changing the position of the wipe. After completing the care, CNA #3 reported she was unsure how many times she wiped the catheter with the disposable wipe, but thought it was at least five (5) to six (6) times and explained she was nervous. During an interview with the Director of Nursing (DON) on 02/27/24 at 12:00 PM, she explained all residents with a catheter should have a leg strap to secure the catheter. She stated that CNAs should inform the nurse if a resident does not have a leg strap. She said she expected all CNAs to perform catheter care properly. The DON also stated that she expected the staff to follow the resident's care plan. On 02/29/24 at 4:40 PM, during an interview with Licensed Practical Nurse (LPN)#3/Care Plan Nurse she explained she expected the staff to review and follow resident's care plans because they are individualized and inform the staff how to care for the resident. Record review of the Face Sheet revealed the facility admitted Resident #70 on 7/27/23 with current diagnoses including Neuromuscular Dysfunction of Bladder. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/12/24 revealed Resident #70 required a Staff Assessment for Mental Status which indicated her cognition was severely impaired.

Based on interviews, record review and facility policy review the facility failed to provide showers for residents who require assistance for three (3) of (23) sampled residents. (Residents #74, #78 and #97) Findings Include: Review of the facility's policy, Activities of Daily Living (ADL's), revised 11/28/2023, revealed .The facility will, based on the residence comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADLs do not deteriorate .Care and services will be provided for the following activities of daily living .1. Bathing, dressing, grooming . Review of the facility policy, Resident Showers, revised 11/29/23, revealed, .It is the practice of this facility to assist residents with bathing to maintain proper hygiene .Policy Explanation and Compliance Guidelines .1. Residents will be provided showers are per request or as per facility schedule protocols . Resident #74 On 2/28/29 at 04:50 PM, in an interview with Resident #74, she stated that she does not receive a shower consistently. The resident explained that she received a shower on Tuesday, Thursday, and Saturday and she did not receive a shower the previous day, which was a Tuesday. The resident said that she hoped she would get a shower tomorrow because the staff give showers whenever they want to and not when it is scheduled. A record review of the facility's, Activities of Daily Living (ADL) Assistance and Support documentation revealed Resident #74 received four (4) showers for the month of February. A record review of the Face Sheet revealed the facility admitted Resident #74 on 2/22/20 and she had current diagnoses Muscle Weakness. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/26/23 revealed Resident #74 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated her cognition was moderately impaired. Resident #78 During an interview on 02/28/24 at 4:46 PM, with a Resident #78's family member, she explained that every time she visited her mother, she was dirty, and her hair was greasy. She stated that her family member was not getting bathed, and she had previously met with the Director of Nursing (DON) and other staff regarding this matter. During an interview on 02/28/24 at 04:50 PM, with Resident #78, she explained that she was incontinent and needed to have showers, but she had to have help. During an interview on 02/28/24 at 05:00 PM, with Licensed Practical Nurse (LPN) #2, she explained she was the cart nurse for the hall. She stated that she has not been told by a nurse aide that the resident refused her shower. During an interview on 2/28/24 at 05:10 PM, with Certified Nurse Aide (CNA) #5, she stated that Resident #78 often refused to take a shower. She acknowledged that the resident's family visited and wanted to know why the resident was dirty and she explained that the resident refused to take showers. CNA #5 confirmed Resident #5 had not received a shower at 4:30 PM because the resident had refused, but she did not notify the nurse or the DON that the resident had refused. A record review of the ADL Assistance and Support documentation for February 2024 revealed Resident #78 was dependent upon staff for bathing and received five (5) baths for the month of February. A record review of the Face Sheet revealed the facility admitted Resident # 78 on 7/31/23 and she had current diagnoses including Hypertension. A record review of the MDS with an ARD of 12/26/23 revealed Resident #78 had a BIMS score of 11, which indicated her cognition was moderately impaired. Resident #97 In a phone interview on 2/26/24 at 2:00 PM, with the social worker at the local hospital, she stated she received report from the emergency room medical doctor and nurses that Resident #97 was dirty, unkempt, and had an odor when he arrived from the facility. She confirmed the resident was currently admitted to the hospital. During an interview on 2/26/24 at 5:00 PM, with Resident #97's family member, she confirmed Resident #97 was sent to the hospital dirty and unkempt. The wife said she told the hospital staff that he was always dirty and had odors. A record review of the ADL Assistance and Support document for February 2024 revealed Resident #97 was dependent upon staff for bathing and received one (1) bath on 2/14/24 for the month of February. A record review of the Face Sheet revealed the facility admitted Resident #97 on 8/16/22 and he had current diagnoses including Alzheimer's Disease. A record review of the MDS with an ARD of 12/19/23 revealed Resident #97 had a BIMS score of 8, which indicated his cognition was severely impaired. During an interview 02/29/24 at 09:31 AM with the DON, she confirmed there was no documentation on the shower sheets to show Resident #78 had received showers three (3) times per week and confirmed she had recently met with the resident's family. The DON said she believed the CNAs were giving showers but were not documenting it on the computer. The DON explained that if a resident refused a shower, the CNAs are trained to document the refusal and notify the nurse, and the cart nurse should notify the charge nurse so the charge nurse can further encourage the resident. If a resident continues to refuse a bath, then the Assistant Director of Nurses (ADON) and DON should be notified. The DON explained the shower schedule is set up for residents who are on the A bed received showers on Monday, Wednesday, and Friday and the residents on the B bed received showers on Tuesday, Thursday, and Saturday. The DON said the charge nurse was responsible for monitoring the CNAs to ensure the showers and baths were given. The DON also said she was not aware that Resident #74 was not getting a shower. During an interview on 02/29/24 at 10:00 AM, with the Administrator, she revealed she was not aware residents were not getting their baths or showers. The Administrator said she was going to make changes to ensure the resident's needs and preferences were being met.

Based on observation, interviews, record review, and facility policy review, the facility failed to provide catheter care in a manner to prevent complications for one (1) of one of seven (7) residents with urinary catheters. Resident #70 Findings include: A record review of the facility's policy Catheter Care, dated 10/2022 revealed, . It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use . Policy Explanation: . Female .10. Wipe from front to back with a clean cloth . 11. Use a new part of the cloth or different cloth for each side. 12. With a new moistened cloth .wipe the catheter . At 11:00 AM on 02/27/24, during an observation and interview, Certified Nurse Aide (CNA) #3 and CNA #4 provided catheter care for Resident #70. There was not a leg strap securing the catheter tubing to reduce the risk of tension or pulling on the catheter to prevent trauma. Both CNAs reported the resident does not wear a leg strap because the resident would pull it off. CNA #3 used a disposable wipe and wiped the perineal area from the from the back to the front. CNA #4 reminded CNA #3 that she should wipe from the front to the back. After discarding the wipe and repositioning the resident, CNA #3 used a disposable wipe to clean the catheter by wiping the tubing several times, using the same wipe, and not changing the position of the wipe. After completing the care, CNA #3 reported she was unsure how many times she wiped the catheter with the disposable wipe, but thought it was at least five (5) to six (6) times and explained she was nervous. On 02/27/24 at 12:00 PM, during an interview with the Director of Nursing (DON), she explained all residents with a catheter should have a leg strap to secure the catheter. She stated that CNAs should inform the nurse if a resident does not have a leg strap. She said she expected all CNAs to perform catheter care properly and explained the facility completed competency check offs for CNAs yearly. Record review of the Face Sheet revealed the facility admitted Resident #70 on 7/27/23 with current diagnoses including Neuromuscular Dysfunction of Bladder. Record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/12/24 revealed Resident #70 required a Staff Assessment for Mental Status which indicated her cognition was severely impaired. Section H revealed Resident #70 had an indwelling catheter.

Based on observation, staff interview, record review, and facility policy review, the facility failed to store food and engage in sanitary practice in accordance with professional standards for food service safety related to food items not dated with a use-by-date, no identifying label, expired foods, improperly stored and exposed food for one (1) of three (3) kitchen observations. Findings include: A review of the facility's policy, Food Safety Requirements, revised 9/20/22, revealed, .Foods will also be stored, prepared, distributed and served in accordance with professional standards for service safety .Policy Explanation and Compliance Guidelines Policy .1. Food safety practices shall be followed .b. Storage of food in a manner that helps prevent .contamination of food .3. Facility shall inspect all food .C. Refrigerated storage .iv. Labeling, dating and monitoring refrigerated food .so it is used by its use-by date . On 02/26/24 at 10:10 AM, an observation with the Dietary Manager (DM) revealed the following: 1. Refrigerator #1 contained 24 (4)-ounce (oz) containers of apple juice with no use by date, one (1) 4 oz container of cranberry flavored juice cocktail with no use by date, one (1) opened 46 oz jar of apple sauce opened on 2/22/24 and was good though 2/25/25, one (1) opened 46 oz jar of apple sauce with no use by date, one (1) tray containing six (6) 4 oz containers of orange juice with no use by date, and eight (8) - 4 oz containers of apple juice with no use by date. 2. Refrigerator #2 contained two (2) unopened bags of coleslaw with a use by date of 2/23/24. One (1) unopened gallon of milk with the best by date of 02/16/24. One (1) opened gallon of milk with the best by date of 02/16/24, one (1) opened quart carton of heavy cream with no use by date, one (1) opened five (5) pound block of processed cheese with no use by date. 3. Freezer #2 contained one (1) opened and exposed plastic bag of hash browns with no identifying label or manufacturer date and 1 (one) opened bag of diced chicken with no identifying label and no manufacturers date. 4. An observation of the pantry revealed the sugar bin lid was not secured and left a large gap, leaving the sugar exposed. On 02/28/24 at 8:09 AM, in an interview with the DM, she acknowledged the outdated, improperly stored, and exposed foods. The DM reported it is her responsibility to label and check expiration dates for food items. She explained the kitchen staff receive monthly in-service training on food safety. On 02/29/24 at 12:07 PM, in an interview with the Administrator, she confirmed she had been made aware of the issues in the dietary department related to outdated, improperly stored, and exposed foods in the kitchen.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide a pest free living environment for one (1) of 23 sampled residents. Resident #262 Findings include: A record review of the facility investigation dated 11/13/23, revealed Resident #262 was admitted by the facility on 9/22/23, as a skilled resident, with diagnoses of Acute Embolism and Thrombus of the Right Popliteal Vein. The investigation stated that on November 11, 2023, at approximately 9:00 AM, the resident reported to a day shift nurse that she thought she had some insect bites. The day shift nurse visually noted several red raised areas on skin upon. However, the nurse inspected the resident's bed and found no insects in the resident's bed or on her body at the time the red raised areas were observed. The investigation noted that the resident's husband was at the bedside when the day nurse observed the red raised areas on the resident's skin, and he requested the resident be sent to the hospital. The facility honored his request, and the resident was sent a local hospital for evaluation. Upon further investigation by the facility, the resident had an incident on the previous shift, on November 11th at approximately 12:14 AM. At that time, insects were observed on the residence bed. The resident was given a bath and clothing was changed, her room was inspected and cleaned. All the bedding in the resident's room was removed and replaced with clean fresh bedding. A body audit was completed, and no insect bites were observed at that time and there were no complaints of pain and itching. An interview on 2/28/24 at 11:45 AM, with the Resident Representative (RR) of Resident #262 revealed that ants had been found in his wife's room during the night shift on 11/11/23. He commented that the resident had not wanted to be moved, so staff came in and sprayed and cleaned her room and made sure that ants were no longer there. The RR stated the following day or night, ants came in more this time than the first time and got in the bed with his wife and bit her around the groin area. He requested that his wife be taken to a hospital for the ant bites and to follow up on other issues. He confirmed his wife was moved the second time until the room was completely cleaned, and outside extermination had been completed. The RR commented that if more attention had been paid to his wife after the first incident, the second incident would not have happened. An interview on 02/28/24 at 1:01 PM, was conducted with the Maintenance Lead Tech (MLT). The MLT revealed that when was made aware of the incident, he did an initial walk through of the room and all the rooms on that side of the hall. The MLT stated that it had been raining and that had possibly led to the ants coming in from the outside of the building. The MLT revealed that all the patient's belongings were taken out of the room, the room was cleaned per their protocol and pest control was called in to further exterminate. He commented that he was told that the ants were seen on that Saturday, but the resident had refused to move. He stated that after the second incident, the resident was sent to the hospital and all belongings were removed from the room until further evaluation could be done. The MLT confirmed that the facility has an ongoing contract with a local pest control company. A record review of the facility's pest control contract revealed that the facility has an ongoing contract with a local pest control company. The contract was signed on 4/13/20. There were two recent visits made by the pest control company, as the company filled out a report of their inspection and activities related to the incident. There was a routine pest control visit made on 11/10/23, prior to the incident and a second visit made of 11/13/23, when the facility requested the company to come inspect the facility for insects and perform additional spraying. A record review of the progress note from the emergency room visit of Resident #262, dated 11/11/23, revealed, .Patient has a benign exam insect bites were confirmed on exam there is no acute emergent intervention required . there is no acute cellulitis of the skin. I find no criteria for admission to the hospital . A review of the physical examination section of the document revealed, .Well nourished, in no apparent distress . An interview on 2/29/24 at 10:07 AM, with the facility Administrator and Director of Nurses revealed that they were told about the incident by nursing staff. They confirmed that the incident as depicted in the investigation was an accurate account of the incident involving Resident #262. The Administrator revealed that since the resident refused to move after the first incident, due diligence had been done by the staff to make sure that there were no more pests in the room. However, after the second incident, they strongly encouraged the resident to take another room until pest control could come and complete a review of the environment. The DON confirmed that part of nursing assessment includes assessing the environment, and staff should look at the whole picture when checking on residents. An interview on 2/29/24 at 3:01 PM, with the facility Social Worker (SW), revealed, the resident was admitted [DATE]. The Social Worker stated that the incident of Resident #262 involving ants was reported to her on that following Monday. She confirmed she did a follow up with the husband and the resident. However, she revealed that the resident has since been discharged from the facility to a nursing home located closer her family. A review of the facility's Face Sheet revealed the facility admitted the resident on 9/22/23, with diagnoses that included Acute Embolism and Thrombosis of Right Popliteal Vein. The discharge date noted on the form was 1/22/24. A review of the Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 1/4/24, revealed Resident #262 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. Level II

Based on interviews, record review, and review of resident council monthly meeting minutes, the facility failed to resolve grievances regarding food complaints for five (5) of eight (8) months reviewed. Findings include: Review of the Resident Council minutes revealed the residents complained about the food during their meetings in October 2023, November 2023, December 2023, January 2024, and February 2024. A record review of a written letter, dated 2/5/24, from the Resident Council President revealed the resident council had concerns regarding the food. During an interview on 02/26/24 at 10:32 AM, with the Ombudsmen stated the residents invited him to their last resident council meeting. The Ombudsmen stated the residents complained about the food being cold and not tasting good. The Dietary Manager (DM) attended that meeting. During an interview on 2/29/24 at 1:00 PM, with the Activities Director (AD), she confirmed that she recorded the minutes at the Resident Council meetings and the residents complained every month for the last five (5) months about the food. The AD explained the residents complained about the taste and the temperature of the food and she had reported their complaints to the DM and the Administrator. During an interview on 2/29/24 at 1:30 PM, with the DM she confirmed the residents have been complaining about the food being cold and not palatable for several months. She explained the previous Administrator was going to buy new food warmers to help with the temperature of the food and she would discuss this issue with the current Administrator. During an interview on 2/29/24 at 02:00 PM, with the Administrator, she confirmed the residents had complained about the food being cold and not tasting good. She stated she would be talking with the resident to get these issues corrected.

Based on interviews, record review, and the facility policy review the facility failed to offer residents in the facility a bedtime snack for (3) of 23 sampled residents. (Resident #94, Resident #95, and Resident #107). Findings Include: A review of the facility's policy, Offering/Serving Bedtime Snacks, revised 4/20/23, revealed, .It is the practice of this facility to offer and serve residents with a nourishing snack in accordance with their needs, preferences and requests at bedtime on a daily basis .Policy Explanation and Compliance Guidelines .1. The nursing staff offers bedtime snacks to all residents . Resident #94 On 02/27/24 at 01:30 PM, in an interview with Resident #94, she explained she has not noticed the staff offering snacks to residents in the facility, or taking bedtime snacks to residents who are unable to leave their room. She said that if she asked for a snack, the staff would provide it. A record review of the Face Sheet revealed the facility admitted Resident #94 on 12/21/22 and she had current diagnoses including Type 2 Diabetes Mellitus. A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/01/24 revealed Resident #94 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. Resident #95 On 02/27/24 at 01:30 PM, an interview with Resident #95, he stated that he had never been offered a snack after dinner and did not know that bedtime snacks were available. A record review of the Face Sheet revealed the facility admitted Resident #95 on 11/10/22 and he had current diagnoses including Hypertension. A record review of the Quarterly MDS with an ARD of 12/27/23 revealed Resident #95 had a BIMS score of 14, which indicated he was cognitively intact. Resident #107 On 02/26/24 at 11:39 AM, an interview with Resident #107 revealed the activities staff offered snacks to the residents after breakfast and lunch, but there was no snack offered at bedtime. The resident reported mainly staying in her room and seldom ventures down the hall. The resident stated she has not been offered an after-dinner snack in the time she has been at the facility. A record review of the Face Sheet revealed the facility admitted Resident #107 on 01/31/24 with current diagnoses including Osteoarthritis. A record review of the admission MDS with an ARD of 2/07/24 revealed Resident #107 had a BIMS score of 14, which indicated he was cognitively intact. On 02/27/24 at 03:13 PM, an interview with the Assistant Director of Nursing (ADON) revealed snacks are brought from the kitchen at 10 AM and 2 PM and the Activities staff offered them to the residents. The ADON confirmed there was no bedtime snacks offered, but if a resident wanted a snack, they could ask a nurse. On 02/29/24 at 12:07 PM, in an interview with the Administrator, she confirmed that although snacks were available upon request, all residents were not offered a bedtime snack. She stated that going forward, the nursing staff would offer all residents a bedtime snack.

Based on interviews, record review, and facility policy review, the facility failed to protect a resident from misappropriation of property for one (1) of five (5) sampled residents. Resident #5 Findings include: Review of the facility's policy, Abuse, Neglect and Exploitation with a review/revision date 5/1/23, revealed Policy: It is the policy of this facility to provide protections for health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent .misappropriation of resident property .Definitions: .Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent . Record review of the Facility Investigation, dated 4/18/23, revealed, On April 13th, 2023, (Proper Name of Resident #5) reported to ADON (Assistant Director of Nursing) that her bank card was missing and she had noted some unauthorized charges on her account. The (Proper Name of Local police department) was contacted and a report was made .Upon Investigation: on April 6th, 2023 between 8:00am and 8:55am, (Proper Name of Resident #5) had requested that a staff member use her bank card to go get her and her roommate some donuts. (Proper Name of Resident #5) stated that the staff member returned her bank card, the donuts and her receipt. Later that evening the following unauthorized charges were made .April 6th @ (at) 1523 (3:23 PM) (Proper Name of Local Gas Station) April 6th @ 1742 (5:42 PM) (Proper Name of Local Daquari establishment), April 6th @ 2106 (9:06 PM) (Proper Name of Local Gas Station). The unauthorized charges continued over the next few days, these charges are as follows: April 7th @ 0532 (5:32 AM) (Proper Name of Local Gas Station) and April 11th @12:08 (PM) (Proper Name of Local Gas Station). (Proper Name of Resident #5) did not realize the bank card was missing until April 13th, 2023. At that time she requested her niece .go by the bank and get a print out of her recent transactions due to the changes on her statement .Conclusion: Substantiated: Misappropriation of funds . On 7/12/23 at 12:15 PM, an interview with Resident #5 revealed she discovered that her debit card was missing after her niece had contacted her on 4/13/23 and asked about questionable charges to the resident's checking account. Resident #5 stated she reported to the Assistant Director of Nursing (ADON) that the card was missing and there were questionable charges on her account. She said she obtained a copy of the ATM/Debit Card Details from her bank and identified four transactions which she had not made or authorized. She stated that she did not see anyone take the debit card from her room and she was told by the facility administration that Certified Nurse Aide (CNA) #1 had taken the debit card. She said that since the transactions were reported to her bank as fraudulent, her bank had reimbursed her account for the total amount. She stated that she did recall giving her card to CNA #1 on 4/06/23 to go get us some donuts and she recalled the CNA returned her card the same day, along with the donuts. She stated that she could not recall if CNA #1 observed her take her card out of her wallet or replace it upon return. On 7/12/23 at 12:35 PM, during an interview with the ADON, she said she had been notified by Resident #5 on 4/13/23 at approximately 4:40 PM that the resident's debit card was missing and that there had been unauthorized charges/purchases made using her debit card. The ADON stated that she had immediately reported the allegation to the Director of Nursing (DON) and the Administrator. She stated that she had participated in the investigation which had been initiated immediately. She stated that Resident #5 had told her that the last time she saw her debit card was when she put the card back into her wallet after she had given it to CNA #1 to purchase some donuts for her and her roommate. On 7/12/23 at 8:42 PM, during a telephone interview with CNA #1, he stated that on 4/06/23, Resident #5 had provided her debit card and requested donuts from the store. He went to the store on his break, used the card to purchase donuts, delivered them, and returned the card to Resident #5. He stated that he was interviewed by the ADON a week or two later regarding the whereabouts of the debit card and he was notified on 4/14/23 that he was suspended pending investigation of the allegation and should not return to the facility. He stated that on the afternoon of 4/17/23 he was notified by the DON that his employment at the facility was terminated. CNA #1 stated he had not taken or used the debit card. CNA #1 confirmed that the facility provided an in-service training regarding misappropriation of resident funds, abuse, and neglect on 4/13/23. On 7/12/23 at 12:00 PM, an interview with the DON revealed that she had been made aware of the allegation of misappropriation by the ADON at approximately 4:45 PM on 4/13/23 and an investigation was initiated immediately. She confirmed that all staff that had entered the room of Resident #5 on the last day the resident reported seeing her debit card were interviewed. She said she had also interviewed Resident #5. She stated the results of the investigation included the suspension of CNA #1 pending conclusion of the investigation. She said she had spoken with the police department investigator following his investigation and was told that charges were being processed against CNA #1 for credit card fraud based on the conclusion of the police investigation. On 7/13/23 at 9:19 AM, during a telephone interview with the investigator of the local sheriff's office, he confirmed that he had been assigned to investigate what he described as credit card fraud against a resident at the nursing home. He stated that after review of the unauthorized transactions conducted with Resident #5's debit card, he had visited one of the establishments involved and viewed security camera footage recorded at the time of the transaction. He stated the footage clearly showed CNA #1 conducting the transaction. He stated he had also interviewed the bartender and obtained a statement in which the bartender confirmed the identity of CNA #1. The investigator confirmed that the total amount of unauthorized purchases made on 4/06/23 using Resident #5's debit card totaled thirty-five dollars and fifty-nine cents ($35.59). The investigator said he had filed a felony warrant request with the county justice court clerk against CNA #1 on 4/18/23 and a felony arrest warrant had been issued. Record review of the Face Sheet revealed the facility admitted Resident #5 on 1/14/22 with diagnoses including of Chronic Obstructive Pulmonary disease and Osteoarthritis. Record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/19/23 revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated she was cognitively intact. The SA validated through record review of the In-Service Sign-In sheet dated 4/13/23 and staff interviews that the facility provided in-service training related to Misappropriation of Residents Funds, Abuse and Neglect on 4/13/23. The SA validated through record review of the Quality Assurance and Assessment QAPI) Sign-In Sheet dated 4/18/23 that the QAPI committee met on 4/18/23 and discussion included Abuse, Neglect and Misappropriation of Funds with review of current practices and new practices designed to prevent recurrence of misappropriation; In-Service training for employees; and incident investigation. The QAPI Sign-In Sheet confirmed attendance by the Administrator, DON, Medical Director and other attendees including department supervisors. The SA validated through record review of the personnel file for CNA #1 revealed his employment at the facility was officially terminated on 4/18/23. The SA validated that the facility had taken all necessary measures to be at past noncompliance by 4/18/23 with the deficient practice that occurred on 4/6/23.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) for a resident taking an antipsychotic medication for one (1) of 20 residents sampled for MDS accuracy. Resident #74. A record review of the signed statement by the Nursing Home Administrator revealed the facility used the Resident Assessment Instrument (RAI) for coding the MDS. A record review of the Face Sheet revealed the facility admitted Resident #74 on 06/16/21, with diagnoses including Personal History of Traumatic Brain Injury, and Personal History of Other Mental and Behavioral Disorders. A record review of Resident #74's Physician Orders List revealed a physician order with a start date of 06/16/21 for Zyprexa 5 milligram (mg) tablet one (1) tablet by mouth (PO) every hour sleep (QHS). A record review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/05/22 revealed N0410A was coded as zero (0) which indicated Resident #74 did not receive an antipsychotic medication during the seven (7) day look-back period. A review of the question for N0450A, Resident received antipsychotic medications was coded as No - Antipsychotics were not received. A record review of Resident #74's electronic-Medication Administration Record (e-MAR) for December 2021 and January 2022 revealed Resident #74 was administered Zyprexa, which is an antipsychoitc medication, on 12/30/2021, 12/31/2021, 01/01/2022, and 01/02/2022, totalling four (4) days of the seven (7) day MDS look-back period. On 01/28/22 at 11:30 AM, during an interview with the facility's MDS Coordinator, LIcensed Practical Nurse (LPN) #1, she confirmed the MDS submitted on 01/05/22 for Resident #74 was entered incorrectly and was inaccurate. She explained the facility uses the RAI manual as guidance for accurately coding the MDS. On 01/28/22 at 11:40 AM, during an interview with the Director of Nursing (DON) , she confirmed the facility uses the RAI manual for guidance in coding the MDS. She stated she expects the MDS to be coded accurately. On 01/28/22 at 11:45 AM, during an interview with MDS LPN #2, she confirmed the MDS submited by her on 01/05/22 for Resident #74 was a documentation error. After she reviewed Resident #74's e-MAR, she verified he had received Zyprexa, which is an antipsychotic medication, during the seven (7) day look-back period of the MDS.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review, and staff interviews, the facility failed to act upon a Consultant Pharmacy (CP) recommendation for one (1) resident of seven (7) residents reviewed for unnecessary medications. Resident #22 A record review of the facility's policy, Medication Regime Reviews with a revised date of April 2007 revealed, .7. The Consultant Pharmacist will document his/her findings and recommendations . A record review of the Note to Attending Physician/Prescriber revealed .Please consider if GDR (Gradual Dose Reduction) is appropriate for: Lexapro 10 mg (milligrams) po (by mouth) daily .RECOMMENDATION: If a gradual dose reduction is appropriate, please consider reducing dose to Lexapro 5 mg po daily .Physician/Prescriber Response .Agree. The recommendation was signed by the Nurse Practitioner (NP) and dated 10/13/21. A record review of the medical record for Resident #22 revealed there was no physician order to reduce the Lexapro from 10 mg to 5 mg as was recommended by the CP and agreed upon by the NP. A record review of the electronic-Medication Administration Records (e-MAR's) from October 2021 through December 2021 revealed Resident #22 continued to receive Lexapro 10 mg with an order date of 4/27/21, instead of the Lexapro 5 mg that was recommended on 10/13/21 by the CP and agreed upon by the NP. On 01/26/22 at 4:30 PM, during an interview with the Director of Nursing (DON), she confirmed a CP recommendation was written for Resident #22 on 10/13/21 to decrease Lexapro from 10 mg to 5 mg daily and that the NP did agree with the recommendation. The DON stated that staff missed carrying out the recommendation and no dose reduction was completed. On 01/26/22 at 4:45 PM, during a phone interview with the facility's Medical Director, he confirmed the CP recommendation was not acted upon and gave the facility a new order on 01/26/22 to decrease the Lexapro to 5 mg PO daily. A record review of Resident #22's Face Sheet revealed the the resident was originally admitted on [DATE], and was re-admitted by the facility on 09/22/2019 with diagnoses including End Stage Renal Disease, Anxiety Disorder, and Other Recurrent Depressive Disorders.