**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and the facility policy review, the facility failed to honor residents' rights and dignity by not honoring requests for a second bed rail as an enabler and by posting signs at the head of the bed related to resident care for three (3) of 16 sampled residents: Resident #5, Resident #39, and Resident #54. Findings include: A review of the facility's Resident Rights Policy revised in 09/2022 revealed, . Facility will ensure the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Facility will treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance and enhancement of their quality of life, recognizing each resident's individuality. The facility will protect and promote the rights of each resident . Resident #5 On 01/28/25 at 10:51 AM, Resident #5 requested to speak with the State Agency (SA). During the interview and observation, the resident explained that she had only one bed rail on the right side but had requested another on the left. She was told that the state removed bed rails. Resident #5 stated she needed both rails to assist with turning and to feel safer at night following an elective hip replacement. The SA observed one half-bed rail on the right side of the bed. The resident explained that she used a recliner on the left side to assist with turning, which was unsafe, and she feared rolling out of bed. On 01/28/25 at 01:25 PM, during an interview, Certified Nurse Aide (CNA) #2 stated that Resident #5 had repeatedly requested an additional bed rail, as had other residents. The management was notified, but residents and staff were informed that only one bed rail was allowed. CNA #2 confirmed that Resident #5 used the existing bed rail for turning and getting out of bed. After her hip surgery, Resident #5 required a stand-up lift and had difficulty moving in bed with only one bed rail. On 01/28/25 at 03:40 PM, Licensed Practical Nurse (LPN) #1 confirmed that Resident #5 had only one bed rail, similar to most residents. According to LPN #1, upper management instructed staff that no resident could have two bed rails due to SA regulations. Resident #5 struggled to get out of bed post-hip replacement and continued to request two bed rails but was denied. On 01/29/25 at 04:10 PM, during an observation of Resident #5's transfer from a wheelchair to bed with the Therapy Director and CNA #3, staff used a stand-up lift. The resident demonstrated upper body strength while using the lift. Positioned on the left side of the bed, Resident #5 stated that an additional bed rail would assist with transfers. The Therapy Director confirmed that Resident #5 had requested another bed rail but was denied. A review of Resident #5's admission Record indicated admission on [DATE] with diagnoses including Other Chronic Pain and Presence of Neurostimulator. A review of Resident #5's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/15/24 indicated a Brief Interview for Mental Status (BIMS) score of 12, signifying intact cognition. Section GG showed no upper extremity impairment, and the resident required supervision or touch assistance with transfers. A review of Resident #5's Bedrails Consent signed by her daughter on 08/01/24 did not specify the use of only one bedrail. The consent form had Yes checked under the question, Do you choose to use bedrails on your bed while in the facility? Resident #54 On 01/27/25 at 01:41 PM, during an observation and interview, the SA observed Resident #54 in bed with one bed rail up. The resident asked why he did not have four bed rails like he had in the hospital. On 01/28/25 at 02:50 PM, Registered Nurse (RN) #5 explained that the facility only allowed one bed rail unless deemed necessary. Resident #54 had only had one side rail since admission, and no residents were allowed four bed rails. On 01/28/25 at 03:00 PM, during an interview, Resident #54 stated he had been at the facility for nearly a year and had requested another bed rail to assist with turning. He was informed that only one was allowed. The resident denied upper arm weakness and continued to request a second bed rail for assistance. On 01/29/25 at 03:30 PM, during an interview, the Director of Nursing (DON) stated that the facility limited bed rails to one per resident for safety reasons but lacked documentation supporting this decision. She was unaware of requests from Resident #5 or Resident #54 and confirmed that alternative positioning aids had not been considered. A review of Resident #54's admission Record indicated admission on [DATE] with diagnoses including Osteomyelitis of the Vertebra and Rheumatoid Arthritis. A review of Resident #54's Quarterly MDS with an ARD of 11/28/24 revealed a BIMS score of 14, indicating intact cognition. Section GG indicated no extremity impairments and the resident required supervision or touch assistance with transfers. A review of Resident #54's Bedrails Consent dated 02/21/24 did not specify the use of only one bedrail. The form had Yes checked under the question, Do you choose to use bedrails on your bed while in the facility? Resident #39 On 01/27/25 at 11:30 AM, the SA observed Resident #39 in bed with signage posted at the head of the bed, including: Enhanced barrier, Oral care, Turning schedule - keep heels floated, and Keep head of bed up at all times. A proper name was included on the signs. On 01/28/25 at 03:00 PM, CNA #5 confirmed that the signage had been in place for an extended period and contained resident care instructions. On 01/29/25 at 02:20 PM, the Administrator and DON confirmed that signage related to personal care should not be displayed on walls, as it violated Resident #39's dignity. The DON stated she was unaware of the postings and confirmed the signs would be removed. Both the Administrator and DON stated they expected all staff to honor residents' rights and avoid posting personal care instructions publicly. On 01/29/25 at 03:20 PM, RN #2 confirmed that one of the names on the signage belonged to a former staff member and acknowledged that resident care instructions should not be posted on the wall. She identified the postings as a dignity issue.

Based on observations, interviews, record review and facility policy review the facility failed to maintain a record log of bed rail maintenance for two (2) of 16 sampled residents (Resident #5 and Resident #54). Findings Include: A record review of the facility's policy, Side Rail Policy, dated 06/25/18, revealed, It is the policy of this facility to attempt to use appropriate alternatives prior to installing a side or bed rail. If a side or bed rail is used, the facility will ensure correct installation, use, and maintenance of bed rails . Follow the manufacturer's recommendations and specifications for installing and maintaining rails . A record review of the Zenith Series manual revealed . Recommended Maintenance . Regular maintenance of the Long Term Bed is necessary to ensure continuing proper and safe operations . Inspect all fasteners for wear or looseness every six (6) months . On 01/28/25 at 10:51 AM, during an interview and observation, Resident #5 requested to see the State Agency (SA). The resident explained she only had one bed rail on the right side but had asked for another on the left. She was told the state removed the bed rails. She stated she had at least six (6) falls from rolling out of bed and expressed a desire for another bed rail to assist with turning and to feel safer at night. She recently elected to undergo a hip replacement and stated she needed both rails to assist with turning in bed. The SA observed a half-bed rail on the right side of the bed. The resident explained that she had a recliner on the left side, which she used to assist with turning if she could reach it. However, she stated that this method was unsafe and that she was afraid of rolling out of bed. She also reported shaking the bed rail daily to ensure it was not too loose. The bed rail was observed to be loose but intact. On 01/28/25 at 3:00 PM, during an interview and observation, Resident #54 explained that he had been at the facility for almost a year. He stated that, while on therapy load, he asked why he could not have another bedrail on the left side of his bed to assist with turning and repositioning. The resident denied any upper arm weakness and stated he had asked staff for another bed rail but was told he could only have one. He clarified that he did not want or need four (4) bed rails but would like a second to assist with turning. On 01/29/25 at 2:20 PM, during an interview, Maintenance #1 explained that upon admission, if a resident needed a bed rail, the therapy director or nursing department notified him to install one. He stated that this was usually done upon admission and that he did not perform any maintenance on the bed rail or bed afterward unless staff submitted a complaint in the maintenance logbook at the nurse's station. He stated he had never checked bed rails for security or looseness unless staff reported an issue and submitted a maintenance request work order. He further stated that he did not maintain a log for bed rail maintenance. On 01/27/25 at 1:41 PM, during an observation, Resident #54 was observed upright in bed with one (1) bed rail up. The resident questioned why he did not have all four (4) rails up as he did in the hospital. He stated that he had requested another bed rail to help with positioning but was told he could only have one. On 01/29/25 at 2:45 PM, during an interview, the Administrator stated that he was not aware of any log for bed or bed rail maintenance. He confirmed that the facility had a maintenance book at the nurse's station and that staff were expected to document maintenance needs in the book. On 01/30/25 at 11:00 AM, during an interview, the Maintenance Director stated that he could not find any maintenance guidelines related to bed rails. He explained that he installed the bed rails by sliding the pins into the slots and did not check them again unless a maintenance request was submitted. On 01/30/25 at 2:30 PM, during an interview, the Administrator reported that he was not aware that maintaining a log of bed rail maintenance was a requirement but stated that the facility would make changes to comply with regulations. A record review of Resident #5's admission Record revealed the facility admitted her initially on 12/05/22 with diagnoses of Other Chronic Pain and Presence of Neurostimulator. A record review of Resident #5's Bedrails Consent revealed that her daughter signed the consent on 08/01/24. The consent did not specify the use of only one bed rail. The question Do you choose to use bedrails on your bed while in the facility? was checked Yes. A record review of Resident #54's admission Record revealed the facility admitted him on 02/21/24 with diagnoses of Osteomyelitis of the Vertebra, Sacral, and Sacrococcygeal Region and Rheumatoid Arthritis, Unspecified. A record review of Resident #54's Bedrails Consent dated 02/21/24 revealed an X in place of a signature. The consent did not specify the use of only one bed rail. The question Do you choose to use bedrails on your bed while in the facility? was checked Yes.

Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident received received necessary behavioral health services to address psychiatric needs and psychotropic medication management. Specifically, the resident was prescribed Rexulti and Trileptal for behavioral health needs in April 2024 but had not been reassessed by a psychiatric provider for ten (10) months which resulted in Resident #45 exhibiting excessive drowsiness, missing multiple meals, and experiencing a significant weight loss of over (10) percent (%) in six months for one (1) of (16) sampled residents. (Resident #45) Findings included: During an observation and interview on 01/27/2025 at 1:01 PM, Resident #45 was in the dining room being assisted by Certified Nursing Assistant (CNA) #1 with eating. The resident's family member was also present. The resident mostly slept throughout the meal, awakening briefly when the family member prompted him to eat. The family member stated that she was concerned because the resident had lost approximately 20 pounds since being discharged from a behavioral health hospital in March 2024. She explained the resident had been increasingly drowsy and sleeping throughout the day. During an observation on 01/28/2025 at 12:10 PM, Resident #45 was in the dining hall but remained asleep throughout the entire lunch period and did not wake up despite multiple attempts by CNA #1. During an interview on 01/29/2025 at 11:23 AM, Registered Nurse (RN) #2 stated that psychiatric services were being ordered for Resident #45 because his son requested a psychiatric consultation on 01/24/2025. RN #2 confirmed that the resident had not received a psychiatric follow-up since returning from the behavioral health hospital ten (10) months ago. During an observation on 01/29/2025 at 1:59 PM, Resident #45 was asleep in his wheelchair in the common area near the nurses' station. During an interview on 01/29/2025 at 3:12 PM, the Director of Nursing (DON) confirmed that a psychiatric consultation for medication management had not been in progress until the resident's son requested the consultation on 01/24/2025. The DON stated that it was standard practice for the facility's Medical Doctor of Behavioral Health to follow up with residents discharged from behavioral health units but acknowledged that this did not occur in this case. During an observation on 01/30/2025 at 9:35 AM, Resident #45 was asleep in his wheelchair in his room. On 01/30/2025 at 11:45 AM, during an interview, the Medical Director stated that typically, the facility's psychiatric Nurse Practitioner evaluates residents returning from psychiatric hospitalizations. He confirmed that Resident #45 should not have gone (10) months without a psychiatric follow-up and stated that a psychiatric consultation should have been completed within 90 days of admission to a behavioral health unit. On 01/30/2025 at 1:41 PM, during an interview, RN #3 stated that Resident #45 had exhibited altered sleep patterns prior to his psychiatric hospitalization but that his drowsiness had worsened in the past few months, causing him to miss meals. A record review of Resident #45's admission Record revealed the facility admitted the resident on 03/04/2024 with a diagnosis of Alzheimer's Disease, with an onset date of 04/04/2024. A record review of Resident #45's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/27/2024 revealed that the resident was currently prescribed an antipsychotic medication. The MDS also revealed the resident had lost five (5) percent or more of his weight in the last month or ten (10) % in the last six months. Section I indicated the resident had current diagnoses of Alzheimer's Disease and Dementia. Section C revealed a Brief Interview for Mental Status (BIMS) score of (5), which indicated the resident's cognition was severely impaired. A record review of the Order Summary Report with active orders as of 1/29/25 revealed Resident #45 had a physician's order dated 3/4/24 for a Low concentrated sweets diet with regular texture related to Type 2 Diabetes Mellitus with hyperglycemia, an order dated 4/2/24 for Trileptal 150 milligrams (mg) to be given twice daily for Dementia with Agitation and Depression and an order dated 4/2/24 for Rexulti 1 mg to be given daily for Dementia with Agitation. A record review of the facility's psychiatric consultation/referral criteria revealed that symptoms warranting a psychiatric consultation/referral included being prescribed an antipsychotic medication and experiencing changes in mood, withdrawing,or apathy (marked indifference to environment).

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 a previously cited deficiency. Specifically, the facility was cited for failing to label and date food stored in the refrigerator and freezer during an annual recertification survey on 8/3/23 and was cited again for the same deficiency during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for one (1) of nine (9) deficiencies cited. F812 Findings Include: Record Review of the facility's policy Quality Assessment and Performance Improvement (QAPI) Program revised September 2022, revealed, .The facility will .5. To establish that the facility's Quality Assurance and Assessment (QAA) committee has made a good faith attempt to correct an identified quality deficiency, a facility will do more than just subjectively assert it has made a good faith attempt; rather, the facility's actions, taken as a whole, will evidence a good faith attempt to identify and correct quality deficiencies . The Governing Body and/or executive leadership (or organized group of an individual who assumes full legal authority and responsibility for operation of the facility), must ensure the QAPI Program: is defined, implemented, and ongoing; . is sustained through transitions in leadership and staffing . Record review of the Provider History Profile on the Certification and Survey Provider Enhanced Reporting (CASPER) report revealed the facility received a citation for F812 - Food Procurement, Store/Prepare/Serve Sanitary on the previous annual survey conducted 8/3/2023. Record review of the Centers for Medicare and Medicaid Services (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 8/3/2023, revealed the facility received a citation for F812, .Based on observation, staff interviews, and facility policy review, the facility failed to ensure items in the kitchen refrigerator/freezer were dated and labeled and food items were discarded by the expiration date . During the current annual recertification survey, the facility failed to label and date food stored and dispose of expired foods in the refrigerator and freezer in one (1) of four (4) days in kitchen observations. On 01/30/2025 at 12:20 PM, during an interview, Registered Nurse (RN) # 3 who was previously responsible for QAPI stated that she was still overseeing QAPI despite the facility hiring someone else for the role. She explained that the new hire had not yet taken over the responsibilities, and the facility had scheduled a meeting to address the transition. RN #3 stated she was unaware that food storage issues were still occurring in the kitchen. She explained that at the time of the last survey, the facility's kitchen was associated with the hospital, but since April 2024, the facility had transitioned to its own independent kitchen. Since that transition, the kitchen staff has undergone several turnovers, and the facility was now on its third kitchen director. RN #3 reported that after the last survey on 8/3/2023, concerns related to food storage were discussed in QAPI meetings every month for the first four (4) months. She stated that audits were completed and submitted to the Director of Nursing (DON) until December 2023. However, she acknowledged that no further kitchen audits had been conducted since then, nor had kitchen issues been discussed, as the facility believed the concerns had been addressed with the new kitchen. She confirmed that although the facility had implemented the initial plan of correction, it failed to sustain those corrective actions following kitchen staff turnover and operational changes. RN #3 stated she would present these concerns to the QAPI committee again to develop new action plans and resume audits of the kitchen. On 01/30/2025 at 2:30 PM, during an interview, the Administrator and the DON confirmed that the facility had completed the plan of correction for the previous kitchen-related deficiency from 8/3/2023. The Administrator stated that the kitchen had been in operation since April 2024 and had undergone multiple staff turnovers. He further stated that he had spoken with the new kitchen manager, who was currently in training, and that they planned to continue addressing the kitchen-related concerns.

Based on observations, interviews, and facility policy review, the facility failed to label and date food stored in the refrigerator and freezer and failed to dispose of expired food for one (1) of four (4) days of kitchen observations. Findings include: A review of the facility ' s Food Storage Labeling policy, revised on 10/23, revealed: .8.a.i. Identify the food item's use-by date or expiration date . iv. Food in storage units will be surveyed routinely to identify and discard foods that have passed their manufacturer use-by or expiration date . 2. Refrigerator storage weekly On 01/27/25 at 11:14 AM, during an initial tour with the Dietary Manager (DM), the following observations were made: In Refrigerator #1, one (1) package of sliced ham was opened and unlabeled, and a spill of orange juice was observed on the bottom of the refrigerator. In Refrigerator #3, one (1) bag of bacon bits was opened and unlabeled, and (1) package of sliced roast beef with a use-by date of 09/12/24, received on 10/06/24, was opened. Additionally, three (3) unopened packs of sliced roast beef had a use-by or freeze-by date of 11/10/24. A five (5)-lb bag of shredded cheddar cheese was opened and unlabeled. Also, a thawed, unopened fire-braised pork loin with a use-by or freeze-by date of 08/23/24, received on 12/12/24, was observed. The DM confirmed these items were expired and collected them for disposal. In Freezer #1, one (1) bag of frozen biscuits was open and unlabeled. In Freezer #2, one (1) bag of frozen chicken patties and (1) package of hamburger patties was open and unlabeled. A 10-inch pecan pie with an expiration date of 01/24/25 was also observed. In the dry storage room, (1) 48-oz container of Real Lemon Juice was observed opened on 01/05/24 but not stored in the refrigerator, despite manufacturer instructions to refrigerate after opening. On 01/27/25 at 11:20 AM, the DM confirmed the presence of expired and improperly stored food items and collected them for disposal. On 01/30/25 at 11:10 AM, during an interview, the Certified Dietary Manager (CDM) and Registered Dietitian (RD) stated that their expectations for kitchen staff include completing education and training for their positions, following federal guidelines, and adhering to food labeling and handling policies to prevent foodborne illness among residents. On 01/30/25 at 02:00 PM, during an interview, the Administrator revealed that he was aware that some items had been out of date but had since been discarded. He explained that the facility added a kitchen in April 2024 because the previous contract with the local hospital's kitchen to service residents ended in May 2024. The Administrator stated there is now a completely different kitchen staff and that he believes the staff is competent. He also noted that the facility changed food providers in November 2024, which may have contributed to expired foods being delivered to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interview, staff interview, record review and facility policy review the facility failed to develop and/or implement the comprehensive care plan related to side effects and behavior monitoring for psychotropic medications and the use of an anticoagulant medication for four (4) of (20) residents care plans reviewed. Resident #19, Resident #33, Resident #35, and Resident #160 Findings Include: Record review of the facility's policy, Develop/Implement Comprehensive Care Plan, undated, revealed, The facility will develop and implement a comprehensive person-centered care plan for each resident .that includes measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment . Resident #19 During an observation on 7/31/23 at 1:00 PM, Resident #19 was sitting up in bed with her lunch meal in front of her and was served a whole chicken patty on a bun. Her husband stated that he comes to the facility and assists with feeding her lunch and explained that Resident #19 could not eat the chicken patty. He explained that it was in her record that her food was supposed to be chopped. Record review of the Facesheet revealed the facility admitted Resident #19 on 1/24/23 with diagnoses including Heart Failure and Chronic Obstructive Pulmonary Disease. Record Review of the Physician Orders for the month of July 2023 revealed Resident #19 had an order dated 1/24/23 for NAS (No Added Salt) Mechanical Soft with Chopped Meats with Gravy No Grits. Record review of the comprehensive care plan revealed a Care Plan Description for Alteration in Nutrition . The care plan included an Intervention with a start date of 1/24/23 for NAS Mechanical Soft with Chopped Meats with Gravy NO GRITS, and the Role(s) included Dietary, Nursing, and Nursing Assistant. On 8/01/23 03:15 PM, in an interview with the Director of Nursing (DON), she confirmed the resident's diet care plan was not being followed because she is supposed to be on a NAS Mechanical soft with chopped meats with gravy and no grits. Resident #33 Record review of the Facesheet revealed the facility admitted Resident #33 on 5/13/23 with diagnoses including Dementia with Behavioral Disturbance, Alzheimer's Disease, and Mood Disorder. Record review of Physician Orders for July 2023, revealed Resident #33 had an order dated 9/27/22 for Trazadone 50 mg(milligram) PO (by mouth) Q (every) HS (bedtime) R/T (related to) depression and an order dated 5/13/23 for Olanzapine 5 mg tablet give 1 tablet PO Q HS R/T Dementia. Both medications are classified as psychotropic medications. Record review of the comprehensive care plan for Resident #33 revealed there was no care plan for the monitoring of resident specific behaviors related to the use of the psychotropic medications. Record review of the of the Care Plan Description of Potential side effects due to multiple medications, with a start date 5/13/23, revealed an Intervention for Assess for side effects of meds (medications) and report to physician as needed. During an interview with the Director of Nursing (DON) on 8/01/23 at 1:15 PM, she reviewed the comprehensive care plan for Resident #33 and confirmed there was no care plan that addressed monitoring for target behaviors with the use of psychotropic medications. The DON explained the purpose of the comprehensive care plan was to provide resident specific care and confirmed there should be a care plan that addressed resident behaviors and that the monitoring for side effects of medications was not being followed. Resident #35 Record review of the Facesheet revealed the facility admitted Resident #35 on 11/30/18 and she had diagnoses including Major Depressive Disorder, Anxiety, Alzheimer's Disease, and Vascular Dementia with Behavioral Disturbance. Record review of Physician's Orders for July 2023, revealed Resident #35 had an order dated 9/6/22 for Sertraline 25 mg give one and a half tabs (tablets) to equal 37.5 mg po Q Day R/T Depression, an order dated 10/25/22 for Seroquel 25 mg tablet 1 PO BID (twice daily) R/T Dementia W/ (with) Behavioral Disturbance, and an order dated 11/1/22 for Buspirone 5 mg tablet Give one tab PO @ (at) 1700 (5:00 PM) R/T Anxiety. These medications are classified as psychotropic medications. Record review of the of the Care Plan Description of Potential for s/e (side effects) due to multiple medications, with a start date 7/7/22, revealed an Intervention for Assess for side effects of meds (medications) and report to physician as needed . An interview with the DON on 8/01/23 at 1:25 PM, she reviewed the comprehensive care plans for Resident #35 and confirmed there was no care plan that addressed monitoring for target behaviors with the use of psychotropic medications and confirmed the care plan for monitoring for side effects of medications was not being followed. Resident #160 A review of the Facesheet for Resident #160 revealed that she admitted to the facility on [DATE] with diagnoses of Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, Diabetes Type Two (2), Hypertension and Hypothyroidism. A record review of the Telephone Order Sign-Off document, dated 7/24/23, revealed Resident #160 had a Physician's Order for Eliquis 2.5 MG tablet give 1 PO BID . A review of the comprehensive care plans revealed there was no care plan developed related to the use of an anticoagulant medication. An interview on 08/02/23 at 09:45 AM, with the DON, confirmed that Resident #160 received an anticoagulant medication and did not have a comprehensive care plan that addressed the use and monitoring of the anticoagulant medication. The DON stated that there should have been a care plan developed for the anticoagulant medication.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents were free from unnecessary medications by failing to monitor resident behaviors and side effects for psychotropic and anticoagulant medication for three (3) of (11) residents reviewed for medications. Resident #33, Resident #35, and Resident #160 Findings Include: A review of the facility's policy, Use of Psychotropic Drugs, (undated), revealed, Policy: Residents are not to be given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medications .Policy Explanation and Compliance Guidelines .9. The effects of the psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis, such as: .d. In accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice. 10. The resident's response to the medications, including progress toward goals and presence/absence of adverse consequences, shall be documented in the resident's medical record . A review of the facility's policy, Medication Monitoring,, (undated), revealed, Policy: The facility takes a collaborative, systematic approach to medication management, including the monitoring for efficacy . Resident #33 Record review of the Facesheet revealed the facility admitted Resident #33 on 5/13/23 with diagnoses including Dementia with Behavioral Disturbance, Alzheimer's Disease, and Mood Disorder. Record review of Physician Orders for July 2023, revealed Resident #33 had an order dated 9/27/22 for Trazadone 50 mg(milligram) PO (by mouth) Q (every) HS (bedtime) R/T (related to) depression and an order dated 5/13/23 for Olanzapine 5 mg tablet give 1 tablet PO Q HS R/T Dementia. Both medications are classified as psychotropic medications. Record review of the electronic Medication Administration Record (eMAR) for the month of July 2023 revealed Resident #33 was administered Trazadone 50 mg and Olanzapine 5 mg. There was no documentation on the eMAR regarding monitoring the side effects of the psychotropic medications or documenting the behaviors exhibited by the resident. Record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/15/23, revealed Resident # 3 had a Brief Interview of Mental Status (BIMS) score of 14, which indicated he was cognitively intact. Further review of the MDS revealed Resident #33 received antipsychotic and antidepressant medications (psychotropic medications) for seven (7) days during the look back period. During an interview with the Director of Nursing (DON) on 8/01/23 at 1:15 PM, she reviewed the Physician's Orders and the eMAR for Resident #33 and confirmed there was no documentation regarding monitoring for side effects of psychotropic medications and no documentation regarding behaviors exhibited by the resident. She stated that staff should have been monitoring for side effects and the resident's targeted behaviors. Resident #35 Record review of the Facesheet revealed the facility admitted Resident #35 on 11/30/18 and she had diagnoses including Major Depressive Disorder, Anxiety, Alzheimer's Disease, and Vascular Dementia with Behavioral Disturbance. Record review of Physician's Orders for July 2023, revealed Resident #35 had an order dated 9/6/22 for Sertraline 25mg give one and a half tabs (tablets) to equal 37.5 mg po Q Day R/T Depression and an order dated 10/25/22 for Seroquel 25 mg tablet 1 PO BID (twice daily) R/T (related to) Dementia W (with) Behavioral Disturbance and an order dated 11/1/22 for Buspirone 5 mg tablet Give one tab PO @ (at) 1700 (5:00 PM) R/T Anxiety. These medications are classified as psychotropic medications. Record review of the eMAR for the month of July 2023 revealed Resident #35 was administered Sertraline 37.5 mg, Seroquel 25 mg, and Buspirone 5 mg. There was no documentation on the eMAR regarding monitoring the side effects of the psychotropic medications or documenting the behaviors exhibited by the resident. Record review of the Quarterly MDS, with an ARD on 7/03/23, revealed Resident # 35 had a BIMS score of which indicated she had severe cognitive impairment. Further review of the MDS revealed Resident #35 received antipsychotic, antianxiety and antidepressant (psychotropic) medications for seven (7) days during the look back period. An interview with the DON on 8/01/23 at 1:25 PM, revealed after review of Resident #35's physician's orders and medication record she was unable to find any monitoring for side effects for psychotropic medications and no monitoring for resident specific behavior monitoring for the use of the antipsychotic medication. She reviewed the Physician's Orders and the eMAR for Resident #35 and confirmed there was no documentation regarding monitoring for side effects of psychotropic medications and no documentation regarding behaviors exhibited by the resident. She stated that there should have been a special requirement added to the Physician's Order to trigger the nurse to document for monitoring the side effects and behaviors, but it had been missed. The DON then revealed that possible concerns from there being no monitoring is that staff may miss a side effect of the psychotropic medication. Also a resident's behaviors could improve or worsen and the resident could miss a dose reduction or need for a medication review. Resident #160 A record review of the Facesheet revealed the facility admitted Resident #160 on 7/12/2023 with a diagnosis of Atrial Fibrillation. A record review of the Telephone Order Sign-Off , dated 7/24/23, revealed Resident #160 had a Physician's Order for Eliquis 2.5 MG tablet give 1 PO BID . Record review of the eMAR for the month of July 2023 revealed Resident #160 was administered Eliquis 2.5 mg (order date 7/12/23). There was no documentation on the eMAR regarding monitoring the side effects of the anticoagulant medication. A record review of the admission MDS with an ARD of 7/19/23 revealed Resident #160 had a BIMS score of 15, which indicated she was cognitively intact. Further review revealed Resident #160 received an anticoagulant medication for 7 days during the look back period. An interview on 08/02/23 at 09:45 AM, with the DON, confirmed that Resident #160 received an anticoagulant medication Eliquis, and there was no monitoring in place for side effects or adverse reactions.

Based on observation, staff interview, and facility policy review, the facility failed to ensure a medication was securely stored for one (1) of 17 sampled residents. Resident # 10. Findings include: Record review of the facility's policy, Label/Store Drugs and Biologicals, (undated), revealed, .The facility will store all drugs and biologicals in locked compartments .and permit only authorized personnel to have access to keys . During an observation on 7/31/23 at 2:30 PM, a container of Dermoplast first aid spray was observed on the back of the commode in Resident #10's bathroom. During an observation and interview with Licensed Practical Nurse #1 (LPN), on 7/31/23 at 2:32 PM, she verified that the can of Dermoplast spray sitting on the back of the commode in Resident #10's bathroom. She explained that she had not been in the resident's bathroom and was not aware that the Dermoplast spray was there. LPN #1 stated that the item should not be stored in the room because another resident could get into the spray and have a negative reaction to it. She verified that Resident #10 did not self-administer the Dermoplast spray. During an interview with the Director of Nursing (DON), on 7/31/23 at 3:15 PM, she stated that the can of Dermoplast spray should not have been left in Resident #10's bathroom. She verified that a resident could have taken it which could lead to negative effects such as allergic reactions. Record review of the Facesheet revealed the facility admitted Resident #10 on 8/16/2006 with diagnoses that included Hemiplegia and Hemiparesis following unspecified Cerebrovascular Disease. A record review of the Physician Orders for the month of August 2023 revealed Resident #10 had an order dated 9/6/22 for Dermoplast First Aid Spray to hemorrhoids BID (twice daily) PRN (as needed) R/T (Related to) Hemorrhoids. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/4/23 revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact.

Based on observation, staff and resident representative interview, record review and facility policy review, the facility failed to ensure a mechanical soft, chopped meat diet was provided for one (1) of five (5) residents observed for dining. Resident #19 Findings Include: Review of the facility's policy, Dental Soft Diet (Mechanical), undated, revealed, . Principle:To use regular foods of a consistency which may be easily chewed and swallowed .Food Groups .Meat, Fish, Fowl .Foods Excluded .Any whole meat . On 7/31/23 at 1:00 PM, during an observation and interview, Resident #19 was sitting up in bed with her lunch meal in front of her on an overbed table. She had a whole chicken patty on a bun on her meal tray and her husband stated that he comes to the facility and assists with feeding her lunch. He explained that Resident #19 had eaten some French fries and a little of the Sherbert but could not eat the chicken patty. He explained that it was in her record that her food was supposed to be chopped. In an interview on 08/01/23 at 01:55 PM, with Certified Nurse Aide (CNA) #2 revealed she was assigned to Resident #19 on 7/31/23 when the resident received a whole chicken patty on a bun on her meal tray. CNA #2 explained that she compared the meal ticket with the food on the tray to ensure the meal was correct. She stated that Resident #19 had to be assisted with meals and her husband came to the facility every day to feed her lunch. CNA #2 said that Resident #19 should have chopped meats and confirmed that by getting a whole chicken sandwich yesterday, it was not the correct order because the chicken was supposed to be chopped. In an interview on 08/01/23 at 02:15 PM, with the Food Service Director, she confirmed the meal tray ticket for Resident #19 indicated the resident was to have Sodium Restriction, Chopped meats, and preferences gravy to all meat. She confirmed that Resident #19 was not supposed to get a whole chicken patty on a bun and that the meat should have had gravy on it. She explained that the kitchen had a new cook and she may have made a mistake, but it should have been caught before it ever went out on the floor. During an interview on 08/01/23 at 03:15 PM, the Director of Nurses (DON) revealed Resident #19 was supposed to be on a NAS (No Added Salt) mechanical soft, chopped meats diet and confirmed that a whole chicken patty was not mechanical soft, chopped meats and was not the correct diet order. She stated that if the CNAs were looking at the meal tickets like they were supposed to, then this would have been caught. An interview on 08/02/23 at 3:00 PM with the facility's Certified Dietary Manager confirmed that the diet order for mechanical soft, chopped meats for Resident #19 had not been followed regarding the lunch meal for Monday, 7/31/23. Record review of the Facesheet revealed the facility admitted Resident #19 on 1/24/23 with diagnoses including Failure to thrive and Gastro-esophageal reflux disease without esophagitis. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/27/23 revealed Resident #19 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated she had moderate cognitive impairment. Record Review of the Physician Orders for the month of July 2023 revealed Resident #19 had an order dated 1/24/23 for NAS Mechanical Soft with Chopped Meats with Gravy No Grits

Based on observation, staff interviews, and facility policy review the facility failed to ensure items in the kitchen refrigerator/freezer were dated and labeled and food items were discarded by the expiration date for one (1) of three (3) dietary observations. Findings Include: Review of the facility's policy, Storing: Food and Equipment, undated, revealed, Policy:Team members must store food in a manner that ensures quality, freshness and safeguards against foodborne illness .Procedure Label .Ensure all food items are labeled . Label information. Each label must contain the following information: Product name .Use-by date.Date the product was prepared or opened . Observation and interview on 7/31/23 at 11:10 AM, during a brief initial tour of the kitchen with the Food Service Director (FSD) revealed the following: 1. Observation of Kitchen refrigerator #1: During an observation and interview, there was a plastic container of a liquid which the FSD identified as tomato juice. It had a discard date of 7/28/23 and the FSD explained that it should have been discarded. There were two (2) plates of salad that was not labeled or dated. The FSD stated that she did not know how long the salads had been in the refrigerator. There were three (3) metal containers without identifying labels. The FSD identified one container as cream of chicken soup with an open date of 7/20/23 and an expiration date of 7/23/23 written on the plastic covering. Container #2 was identified by the FSD as apple sauce with no opened date and had an expiration date of 7/23/23 on the label, Container #3 was identified by the FSD as apples with a date of 7/23/23 and no expiration date. There were two (2) zip-lock bags of biscuits and cornbread with no identifying label and no opened or use-by date. The FSD revealed the prep cooks and cooks are responsible for keeping the refrigerators cleaned out. She stated that she tried to check the refrigerator at least every two weeks. She confirmed that because the foods did not have identifying labels or dates, the foods could be spoiled and cause food-borne illnesses. 2. Observation of Kitchen Freezer #1: During an observation and interview, there was three (3) opened bags with no identifying label or use by date. The FSD identified the bags as pancakes, French toast, and biscuits and stated that off the food items were supposed to be labeled and dated. 3. Observation of Kitchen Freezer #2: During an observation and interview, the FSD revealed that leftovers were stored in Freezer #2. There was a metal pan that the FSD identified as tuna fish with a made date of 7/27/23 and no use by date. The FSD stated that since it was a fish product, it should have been discarded within three (3) days. There was a white container with a manufactured label of Pimento Cheese with no use by date or expiration date. There was also a white container with a manufactured label of Potato salad with an opened date of 7/25/23 and no use by or expiration date. The FSD revealed this should have been discarded in three (3) days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility policy review, and record review, the facility failed to complete and submit a discharge Minimum Data Set (MDS) for one (1) of 19 resident MDS's reviewed, Resident #1. Findings include: Review of facility's Assessment Frequency/Timeliness policy, dated [DATE], revealed: The purpose of this policy is to provide a system to complete standardized assessments in a timely manner, according to the current Resident Assessment Instrument (RAI) Manual. The policy also revealed, a discharge assessment will be completed within 14 days of the discharge date . An interview with the MDS Coordinator on [DATE], at 10:02 AM, revealed Resident #1 was sent to the emergency room on [DATE] and passed away approximately three (3) hours later. The MDS Coordinator stated she wrote the resident's information in a notebook to prepare to enter it into the computer. She stated she tested positive for COVID-19 the next day and was off work for 15 days. Stated she was working from home, but this resident's assessment fell through the cracks and was not entered into the computer or submitted. Stated she failed to communicate the need for the assessment to the MDS Nurse, so therefore, the assessment was not completed. An interview with the MDS Nurse on [DATE], at 03:20 PM, revealed she completes the Medicaid assessments, except for the discharge Medicaid assessments. She stated the discharge assessments are completed by the MDS Coordinator. She stated she does not do the discharge assessments, but if needed, she could probably complete one. An interview with the Director of Nursing (DON) on [DATE], at 3:30 PM, revealed both the MDS Coordinator and the MDS Nurse should be able to complete the required MDS assessments. She stated the MDS should be completed as required. The DON confirmed the facility failed to complete and submit the discharge MDS assessment in a timely manner. Record review revealed Resident #1 was admitted to the facility on [DATE], with diagnoses which included Chronic Diastolic (Congestive) Heart Failure, Parkinson's Disease, Muscle Weakness, Dementia, and Cardiomegaly. Review of facility notes revealed Resident #1 was transferred to the emergency room on [DATE] by ambulance. Review of facility notes revealed the emergency room notified the facility the resident had expired. Review of physician's order revealed on [DATE], Resident #1 was sent to the emergency room due to Tachycardia and a change in the level of consciousness. Review of resident's most recent MDS was a quarterly assessment dated [DATE].

Based on staff and resident interviews, record review and facility policy review the facility failed to promptly resolve resident council grievances for eight (8) of eight (8) residents who attended the resident council meeting out of a census of 50 residents. Findings include: Review of the facility's Grievance Policy, dated November 2016, revealed: It is the policy of this facility that the resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. The resident has the right to, and this facility will make prompt efforts to resolve grievances the resident may have. This facility grievance policy ensures the prompt resolution of all grievances regarding the residents' rights. Interview on 03/10/2021, at 10:00 PM with eight (8) of eight (8) residents in attendance of the resident council meeting revealed that eight (8) of eight (8) residents stated that they all have unresolved food issues. They have constantly on a regular basis complained about the food to no avail. The residents stated they never go hungry, they have more than plenty of snacks and their families bring food. They stated that what comes to them from the kitchen is terrible tasting and the food's texture is hard as a rock. Review of Section C of the most recent Minimum Data Set (MDS) revealed that all eight (8) residents in the resident council meeting had scored 11-15 on the Brief Interview for Mental Status (BIMS) which indicated all eight (8) residents in attendance at the resident council group meeting were cognitively intact. Review of the resident council minutes for the past six (6) months (September 2020 through February 2021) were obtained and reviewed. Each month the resident council issued food concerns and complaints of poor tasting and poor textured foods. The resident council minutes did not contain any written documentation of resolutions from the complaints issued by the residents. During the resident council meeting the eight (8) residents in attendance all confirmed that their food concerns were continuing to go on without resolution. Record review revealed that there was no documentation of residents being informed of the action taken to resolve their grievances. Interview on 3/9/2021, at 2:00 PM, with the Activities Director (AD) revealed that the residents issue complaints about the taste and texture of the food at each resident council meeting. The AD stated that after the food complaints are issued at the monthly meetings, she copies the minutes and faxes them to Dietary Manager (DM) in the kitchen. The AD stated that she has no knowledge of any responses from the DM. The AD states that she has Bingo money that the residents win playing bingo and that she shops for the residents with their Bingo winnings, and that the residents request snacks and food items more than any item. The AD stated that the facility has ample snacks in abundance for the residents and that the residents were never hungry. The AD confirmed that the residents never issue any complaints much outside of poor tasting and poor quality food. The AD stated that the DM does not come to the facility and talk to the residents about their food issues. The nursing home facility sends a list to the kitchen about the issues and requests of the residents. The residents are allowed to request whatever they want to eat and the kitchen attempts to honor their requests. The AD stated that the poor taste of the food was a monthly concern issued at resident council meetings. Interview on 3/10/2021 at 3:20 P.M. with the Dietary Manager (DM) revealed that he had not been faxed copies of the Resident Council minutes since August 2020. He had not been notified of food concerns or complaints from the residents. He stated that if he were asked to attend resident council he would gladly attend, but he had not been requested to attend the meetings. The DM did confirm that he had not sent written responses or called to give verbal response. The DM did confirm he had not sent documentation of his food resolutions to the facility or to the residents. The DM stated that he just made the changes and honored the requests. The DM stated he has only received one (1) copy of resident council minutes in August 2020 for all the 2020 year. He stated that the owners of the nursing home facility would not allow him inside of the facility because of COVID-19. The DM had not visited with the residents since prior to March 2020. Interview with the Director of Nursing (DON) on 3/10/2021, at 3:30 PM, revealed that she would make sure that the DM was allowed inside the building to visit with the residents and to attend resident council meeting if invited. The DON did not have copies of communications from the DM concerning food complaints and she did not have any facility responses to the resident's grievances from resident council meetings. Interview on 3/10/2021, at 4:00 PM, with the Resident council members for a follow up from the meeting of 3/10/2021 at 10:00 AM revealed that the DM stated that he would meet with them in person, if invited, and try to resolve their dietary issues. The residents stated that they would be even more happy when their food issues were resolved. The residents stated, we just want to be heard. Our issues with the food requests have been an on-going thing, it did not just occur during the pandemic of COVID-19.