**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure residents have a right to make choices about aspects of their life in the facility which are significant to the resident for 1 of 26 sampled residents (Resident 89) and 3 unsampled residents (Residents 29, 32, and 61). The failure to accommodate the residents' preferences and choices had the potential risk to cause psychosocial distress to the residents. Findings include: The facility is located off a major street close to the downtown areas and the parking lot is combined with the neighboring hospital. The facility had a secured covered patio in the back of the facility off the Activity Room. This patio area had a covered area which is complete with misters, lights, plants, and numerous park benches to sit and enjoy the quiet peaceful outdoor air. Resident 89 (R89) was admitted to the facility on [DATE] with diagnosis of paraplegia, cellulitis, and a puncture wound with a foreign body. R89 had a Brief Interview for Mental Status (BIMS) score of 15 indicating no cognitive impairment. On 06/10/2025 in the afternoon, R89 stated would like one thing to be changed so residents would be allowed to go out and sit in the back patio area of the building. R89 asserted residents must be back in the facility by 6:00 PM or 7:00 PM. R89 affirmed during the summertime, this was when the sun was just starting to go down and the temperatures were also going down to where it was nice enough to be outside. However, the facility would not let residents stay outside past 7 PM because there was no one available after this time to chaperone the residents. During the Resident Council Meeting on 06/11/2025 in the afternoon, unsampled Resident 29 (R29) stated residents were not permitted to stay outside on the back patio of the building past 7:30 PM. Resident 32 and Resident 61 both confirmed this was in fact correct. R29 expressed the council was told residents had to go back inside the building at 7:30 PM due to a few residents using the back patio to smoke, and since smoking was not allowed in the facility, the patio was locked by 7:30 PM when Activity Staff went home. R23 asserted because of a few residents not following the rules, the rest of the residents were punished. On 06/12/2025 at 12:59 PM, the Administrator stated given the facility's location, the facility recommended the residents come back in around 7:30 PM in the summer. For safety, when it gets dark, the facility staff had the residents come inside. There were no current outdoor places for the residents to go. The outdoor patio was closed at night because there were some residents who were trying to smoke on the patio at night. The Administrator stated was not aware the resident council was inquiring about the use of the patio after the curfew times. To the Administrator's knowledge, there was one resident who wanted to try to smoke in the patio area, so the facility decided to close the patio. The Administrator was unaware if the facility had tried alternatives to closing the patio. The Administrator asserted it was important the facility did not have smoking inside the building. The Administrator acknowledged was aware a resident had complained could not access outside fresh air which did not smell of cigarette smoke. On 06/12/2025 at 2:32 PM, the Activity Director (AD) stated the time the patio closed was at 8pm. The AD acknowledged had heard from the Resident Council, residents were upset because could not utilize the patio after 8pm. After 8pm was when the sun goes down and when it gets cooler so the residents can go out to enjoy the patio. The AD was not sure who the one person was, but there were a few residents who were caught smoking on the patio before the facility closed it. The AD also acknowledged no alternatives to locking the door to the patio were tried. The AD expressed it was not fair for the non-smokers who wanted to be able to get some fresh air when it starts to get cooler later in the day in the summer. On 06/12/2025 at 2:56 PM the Director of Nursing (DON) stated the patios are closed around 8 pm. The DON clarified the facility closed the patios at 8 PM because the facility did not have anyone to supervise the patios after 8pm. The DON further clarified the patios need to be monitored for safety. The DON also acknowledged the patio gates to the outside were always locked making it a secured patio. The DON stated there were a few residents caught smoking, and the facility had to close the patio. The DON acknowledged the non-smokers had let the facility know the residents wanted to use the outdoor spaces. The DON agreed the residents who did not smoke should not be penalized for those smokers who broke the rules. The DON also acknowledged the residents did not have the ability make their own life choices at this time regarding the patio availability. On 06/12/2025 a policy restricting the residents from going out to sit in the secured patio area after 8 PM was requested. The Administrator affirmed the facility did not have a policy relating to the patio restrictions. The facility's Resident Rights document (regarding self-determination and Participation), documented the resident had a right to and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to the resident's choice of activities, schedules, healthcare and providers of healthcare services consistent with his/her interests, and assessments and plans of care. The resident had the right to make choices about aspects of his or her life in the facility that are significant to the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, document review and interview, the facility failed to ensure a resident was provided information about the right to formulate an advanced directive for 1 of 26 sampled residents (Resident #67). The deficient practice has the potential to deprive the resident of their right to determine their life status. Findings include: Resident #67 (R67) R67 was admitted to the facility on [DATE], with diagnoses including diffuse traumatic brain injury, bipolar disorder, anxiety disorder, and unspecified dementia. R67 had a Brief Interview for Mental Status (BIMS) score of three indicating severe cognitive impairment. A resident document titled Resident Face Sheet documented the resident was the responsible party and the daughter, sister, and brother-in-law were the emergency contacts. The facility was not able to provide any advanced directive documents such as: Power of Attorney paperwork, Guardian paperwork, a Physician Order for Life-Sustaining Treatment (POLST) form, or any other Advanced Directive paperwork for R67. The physician wrote an open-ended order dated 04/24/2023 with the description: Code Status: Full. On 06/10/2025 in the afternoon, an interview with R67 revealed the resident seemed confused. The resident thought was living in the Falls Housing Community off interstate five in California. On 06/11/2025 in the afternoon, the Director of Social Services (DSS) stated was not sure why the physician wrote an order for a full code for the resident when a full code is the default designation when no advanced directive is in place. The DSS affirmed a physician order is not considered a valid advanced directive. The DSS acknowledged since the resident had a low cognition (BIMS of three), there was no discussion with the resident on advanced directives since the resident lacked decisional capacity. This also meant the resident did not have the capacity to fill out the POLST form. The facility policy titled, Advance Directives, revised 06/09/2023, documented upon admission to the facility, the facility designee will determine the resident's decision-making capacity and identify the resident's primary decision maker and review the resident's existing choices with the resident or legal representative. The facility designee will also develop a care plan for all advanced directives; identifying, clarifying, and periodically reviewing, as part of the comprehensive care planning process, the existing care instructions and whether the resident or resident representative wishes to change or continue these instructions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure a resident's yelling and disruptive behaviors were addressed for 1 of 26 sampled residents (Resident 55). The deficient practice deprived other residents of the right to live in a peaceful environment with comfortable noise levels permitting for a restful night's sleep. Findings include: Resident 55 (R55) R55 was admitted on [DATE] and readmitted on [DATE], with diagnoses including insomnia, anxiety disorder and major depressive disorder. On 06/10/2025 at 9:45 AM, R55 was overheard from the hallway yelling, help! help! help! A Licensed Practical Nurse (LPN1) entered R55's room. Upon leaving R55's room, the LPN indicated R55 yelled all the time. On 06/10/2025 at 9:52 AM, R55 was seated in wheelchair and reported being unhappy in the facility due to not getting along with roommate and expressed was upset over being transported to the main dining room where R55 remained all night accompanied by a nurse. R55 indicated the nurse removed the resident from the unit to allow other residents to sleep because the resident yelled constantly. R55 acknowledged yelling constantly because the resident had difficulty sleeping and did not want to take any medications for sleep. On 06/10/2025 at 10:00 AM, R55's roommate Resident 109 (R109) sat in motorized wheelchair and indicated R55 yelled constantly day and night and cussed at staff which was disturbing to R109. On 06/12/2025 in the afternoon, R55 was observed asleep and unarousable in wheelchair by the front desk. On 06/13/2025 at 9:50 AM, R109 indicated R55 yelled day and night which disrupted R109's normal sleep patterns and R109 was able to sleep yesterday afternoon because staff brought R55 to the receptionist to allow R109 to rest. R109 confirmed the nurse had to bring R55 to the main dining room on the evening of 06/09/2025 to allow other residents in the unit to sleep. R109 indicated staff were fully aware of R55's behaviors but had run out of moves because nothing worked for R55. On 06/13/2025 at 11:06 AM, Resident 58 (R58) whose room was next to R55's room indicated being bothered by R55's constant yelling and stated, I am lucky to get three hours of sleep. On 06/13/2024 at 2:33 PM, Resident 122 (R122) who resided in the room directly across from R55's, was seated in walker on the front patio. R122 indicated being bothered by R55's constant yelling and had expressed this with the staff but the resident did not know what was being done for R55. On 06/13/25 at 10:29 AM, LPN2 indicated being familiar with R55 and R109 who did not get along mostly due to R55's behaviors. According to LPN2, R109 was protective of staff and did not like it whenever R55 became verbally abusive towards staff. LPN2 indicated being aware Residents 109, 58 and 122 had expressed being bothered by R55's constant yelling and LPN2 was informed R55 needed to be removed from the room just to allow R109 to get some sleep. LPN2 indicated reporting R55's behaviors to the Assistant Director of Nursing (ADON1) and the DON but LPN2 was not aware of the leadership's plans for R55. LPN2 indicated all residents had the right to exist in a peaceful, homelike environment free from disruptive noise and R55's constant yelling was depriving other residents of peace and sleep. Review of medical record revealed R55's yelling behaviors were identified and documented by nursing staff almost daily. The medical record lacked documented evidence R55's yelling and disruptive behaviors were communicated to the psychiatric provider. On 06/13/2025 at 11:12 AM, ADON1 indicated being aware of R55's yelling behaviors which occurred frequently. ADON1 indicated being informed R55 had to be transported to the main dining room on the evening of 06/09/2025 to allow other residents to sleep. The ADON explained the facility tried room changes and one-on-one conversations but did not know what else could be done for the resident. The ADON indicated residents had the right to live in a peaceful homelike environment free from disruptive noise. On 06/13/25 at 11:32 AM, the Administrator indicated being aware of R55's yelling behaviors which affected other residents as evidenced by the night nurse needing to remove the resident from the unit on the evening of 06/09/2025 to allow other residents to sleep. According to the Administrator, the facility had tried room changes and separating R55 from other residents, but nothing seemed to work. The Administrator indicated residents had the right to live in a peaceful homelike environment free from disruptive noise. On 06/13/25 at 11:56 AM, the DON indicated being aware R55 had psychiatric diagnoses including major depressive disorder, insomnia and anxiety disorder and confirmed R55 was not on any psychotropic medications. The DON was familiar with R55's yelling and disruptive behaviors and was made aware R55's behaviors were affecting other residents particularly those who were near R55's room. The DON indicated all residents had the right to live in a peaceful, homelike environment free from disruptive noise and the DON acknowledged R55's behaviors were depriving other residents of peace and sleep. The Resident's Rights policy (undated) documented each resident had the right to a homelike atmosphere which is safe, clean with comfortable noise levels.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to review and follow up on a Preadmission Screening and Resident Review (PASRR) level 2, following a resident's psychiatric hospitalization for 1 of 26 sampled residents (Resident #57), and failed to ensure referrals for PASRR level 2 screening were completed for 4 of 26 sampled residents (Residents #121, 64, 55, and 67). The deficient practice had the potential to delay necessary specialized services and interventions for the residents, and could have impacted their placement, overall care and well-being.Findings include:A Preadmission Screening and Resident Review (PASRR) is a federally mandated process that ensures individuals with mental disorders or intellectual and developmental disabilities are not inappropriately placed in nursing facilities for long-term care, and it helps determine the most suitable and least restrictive setting, ensuring access to necessary services and supports. The facility's PASRR documentation policy dated 06/09/2023, indicated referrals were required for Level II residents or individuals with newly identified mental health or intellectual disabilities following a significant change in status. The policy documented the facility was expected to promptly notify the state-designated authority in such cases. Residents readmitted after psychiatric hospitalization or displaying new behavioral symptoms were to be referred for evaluation. Resident #57 (R57)R57 was originally admitted on [DATE], and re-admitted on [DATE], with diagnoses including intraparenchymal hemorrhage, status post craniotomy, anxiety, depression and agitation.The Minimum Data Set (MDS) quarterly assessment (MDS is a standardized assessment tool used in nursing homes and skilled nursing facilities to collect comprehensive information about residents' health and functional status) dated 02/04/2025, revealed neurological diagnoses included hemiplegia and seizure disorder, and psychiatric diagnoses included anxiety and bipolar disorder.In the MDS discharge assessment dated [DATE], neurological diagnoses included hemiplegia and seizure disorder, and psychiatric diagnoses included anxiety and bipolar disorder.A nursing progress note dated 04/08/2025, revealed R57 expressed feelings of depression, citing not seeing their children and their recent birthday as contributing factors. R57 communicated a desire to harm themself, which was reaffirmed upon subsequent assessment and redirection efforts were unsuccessful, leading to arrangements for hospital evaluation and treatment via legal hold (a situation where an individual is placed under involuntary psychiatric care due to concerns about their safety) for medical and psychiatric clearance.A hospital admission document dated 04/16/2024, revealed R57 was admitted to emergency department (ED) complaining of being suicidal with a plan to cut the wrists. Working diagnosis included suicidal ideation and schizoaffective disorder. The criteria for admission revealed behavioral health condition, symptom or finding for which observation care had failed, or was not considered appropriate. The hospital Discharge summary dated [DATE], documented R57's admission following an acute bipolar exacerbation, characterized by severe mood disturbances, suicidal ideation, and emotional distress. Prior to hospitalization, R57 reported feelings of hopelessness, expressed a plan for self-harm, and experienced worsening symptoms despite attempts at coping. The discharge summary indicated that due to the severity of their condition, R57 was medically cleared, placed on a legal hold, and admitted to the psychiatric unit for further treatment. Upon discharge, diagnoses included post-traumatic stress disorder. R57 was re-admitted to the facility on [DATE] at 11:30 PM, following hospitalization for an acute exacerbation of bipolar disorder and post-traumatic stress disorder, marked by suicidal ideation, depressed mood, racing thoughts, and flight of ideas. A Psychiatric evaluation dated 04/18/2025, documented R57 was recently hospitalized due to moderately worsening symptoms of severe depression and suicidal ideation with plan to self-inflict injuries. Baseline care plan dated 04/20/2025, documented R57 was re-admitted following an acute hospitalization due to depressed mood and suicidal ideation, resulting in a legal hold. Care approaches included implementation of PASRR recommendations to address mental health needs.The medical record lacked documented evidence a PASRR Level 2 evaluation was conducted after R57's return to the facility, despite R57's acute change in condition. The previous PASSR Level 1 screening dated 05/03/2021, determined R57 had no mental illness, intellectual disability, or related condition. This PASRRA 1 screening was no longer an accurate assessment for R57's current mental health conditions given their recent psychiatric hospitalization and legal hold. On 06/12/2025 at 1:00 PM, the MDS Coordinator explained the diagnoses documented in the MDS assessment were derived not only from the discharge summary but also from the attending physician's history, physical examination, medication administration records, and progress notes. The MDS Coordinator acknowledged unfamiliarity with the criteria for PASRR Level 2 screening, stating that such inquiries would typically be addressed by the Social Worker who was recently hired and may not be aware of the screening process for PASRR level 2. The MDS Coordinator confirmed the last quarterly MDS assessment did not include the new diagnoses of PTSD documented in the hospital discharge summary and the severe depression documented in the post hospitalization psychiatric evaluation conducted on 04/18/2025.Following a review of the agency's website responsible for conducting PASRR screenings, the MDS Coordinator identified a PASRR Level 2 determination dated 04/23/2025. Upon verification, the MDS Coordinator confirmed this screening result was not incorporated into R57's medical records and affected the accuracy of the last MDS assessment, preventing the development of a comprehensive care plan to address R57's updated conditions.The PASRR screening level 2 dated 04/23/2025, which had been referred by the hospital on [DATE], revealed R57 met the criteria to be admitted in a nursing facility level of service and may be admitted if the facility was able to provide or arrange specialized services including individual and family psychotherapy, psychiatric follow ups, monitoring and advocacy services.Resident #121 (R121)Resident #121 was admitted on [DATE] with diagnoses including anxiety.The MDS initial assessment indicated R121 had psychiatric diagnoses including anxiety, depression, and bipolar disorder.The history and physical dated 03/31/2025 documented only anxiety as a psychiatric diagnosis.The hospital Discharge summary dated [DATE] listed anxiety as one of the discharge diagnoses, with no mention of other psychiatric conditions.A psychiatric evaluation dated 04/03/2025 identified bipolar disorder, which was not present at the time of admission.R121's medical record lacked documented evidence that a PASRR Level 2 evaluation was conducted upon the emergence of the new psychiatric diagnosis.On 06/12/2025 at 2:32 PM, the facility's Administrator explained the former Social Worker retired in February 2025, and the substitute was on leave. As a result, the facility hired a new Social Worker, who was still undergoing training and was not familiar with the PASRR screening process. The Administrator acknowledged gaps in Social Worker services may have impacted the PASRR process and care planning, potentially affecting timely assessments and specialized service coordination. Resident 64 (R64)R64 was admitted on [DATE], with diagnoses including schizoaffective disorder.A PASRR Level One dated 08/20/2025 documented no mental illness, no intellectual disability, no related condition, and no dementia.The Quarterly Minimum Data Set, dated [DATE], documented R64 had active diagnoses including anxiety disorder and schizophrenia.R64's medical record lacked documented evidence R64 was referred for a new level of care (LOC) assessment after being admitted with diagnoses including schizoaffective disorder.On 06/13/2025 at 8:40 AM, the Assistant Director of Nursing (ADON) confirmed R64's diagnosis of schizoaffective disorder and use of psychotropic medications; however, no PASRR Level Two or referral was in place. The ADON explained responsibility for PASRR belonged to Social Services, but the department head was unavailable due to a family emergency.On 06/13/2025 at 8:45 AM, the Social Services Assistant indicated the Social Services Director was responsible for PASRR, expressed no knowledge of the process, and confirmed no PASRR Level Two or referral was in place. Resident 55 (R55)R55 was admitted on [DATE] and readmitted on [DATE], with diagnoses including insomnia, anxiety disorder and major depressive disorder. R55's PASRR level one dated 04/26/2022, revealed R55 did not have mental illness, mental retardation, related condition or dementia. The medical record lacked documented evidence R55 was referred for a new level of care (LOC) assessment after being admitted with diagnoses including major depressive disorder, anxiety disorder and insomnia. On 06/13/2025 in the afternoon, the DON reviewed R55's PASSR level one and indicated R55 should have been referred for a new LOC assessment or a PASSR level two due to psychiatric diagnoses being identified after completion of PASSR level one on 04/26/2022. Resident 67 (R67)R67 was admitted to the facility on [DATE], with diagnoses including diffuse traumatic brain injury, bipolar disorder, anxiety disorder, and unspecified dementia. R67 had a Brief Interview for Mental Status (BIMS) score of three indicating severe cognitive impairment.On 06/10/2025 in the afternoon, R67 stated had been at the facility for four days. The resident felt the facility overall was a decent place to reside. Although, the resident seemed confused as the resident thought were living in the Falls Housing Community off interstate five in California. A PASARR level one document dated 10/28/2021, revealed R67 did not have dementia, mental illness (MI), intellectual disability (ID), mental retardation (MR), or any related condition (RC) and was deemed appropriate for nursing facility placement. R67's medical record revealed traumatic brain injury was diagnosed on [DATE], bipolar disorder was diagnosed on [DATE], anxiety disorder was diagnosed on [DATE], and R67's unspecified dementia was diagnosed on [DATE].The medical record lacked documented evidence R67 was referred for a PASARR level two screening. On 06/11/2025 in the afternoon, the Medical Records Staff, Minimum Data Set (MDS) Staff, and Social Services staff indicated there were no other PASSAR information available for R67 which indicated a PASSAR II referral had been sent since the resident's original admission of 04/24/2023.The facility's policy titled PASARR Documentation Policy, documented any resident with newly evident or possible serious mental disorder, intellectual disorder, or a related condition must be referred by the facility to the appropriate state-designated mental health or intellectual disability authority for review.The Division of Health Care Financing and Policy- Medicaid Services Manual- for Nursing Facilities Policy dated 05/01/2015, documented when an individual has been identified with possible indicators of mental illness, intellectual disabilities or related condition, a PASARR Level II screening must be completed to evaluate the individual and determine if nursing facility services and/or specialized services are needed and can be provided in the nursing facility. Examples include: a resident who exhibits behavioral, psychiatric, or mood related symptoms suggesting a presence of a mental disorder (where dementia is not the primary diagnoses), or an intellectual disability or related condition was not previously identified and evaluated through PASARR. Social services would be responsible for keeping track of each resident's PASARR screening status and referring to appropriate authority.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and document review, the facility failed to develop and implement a comprehensive care for post-traumatic stress disorder (PTSD) reflecting a resident's new mental health conditions and following a new Preadmission Screening and Resident Review (PASRR) Level 2 screening determination for 1 of 26 sampled residents (Resident #57). The deficient practice had the potential to compromise the resident's mental health management, leading to inadequate treatment, delayed interventions, and a lack of necessary support services. Findings include: A Preadmission Screening and Resident Review (PASRR) is a federally mandated process that ensures individuals with mental disorders or intellectual and developmental disabilities are not inappropriately placed in nursing facilities for long-term care, and it helps determine the most suitable and least restrictive setting, ensuring access to necessary services and supports. Resident #57 (R57) R57 was originally admitted on [DATE], and re-admitted on [DATE], with diagnoses including intraparenchymal hemorrhage, status post craniotomy, anxiety, depression and agitation. The Minimum Data Set (MDS) quarterly assessment (MDS is a standardized assessment tool used in nursing homes and skilled nursing facilities to collect comprehensive information about residents' health and functional status) dated 02/04/2025, revealed neurological diagnoses included hemiplegia and seizure disorder, and psychiatric diagnoses included anxiety and bipolar disorder. A nursing progress note dated 04/08/2025, revealed R57 expressed feelings of depression, citing not seeing their children and their recent birthday as contributing factors. R57 communicated a desire to harm themself, which was reaffirmed upon subsequent assessment and redirection efforts were unsuccessful, leading to arrangements for hospital evaluation and treatment via legal hold (a situation where an individual is placed under involuntary psychiatric care due to concerns about their safety) for medical and psychiatric clearance. In the MDS discharge assessment dated [DATE], neurological diagnoses included hemiplegia and seizure disorder, and psychiatric diagnoses included anxiety and bipolar disorder. A hospital admission document dated 04/16/2024, revealed R57 was admitted to emergency department (ED) complaining of being suicidal with a plan to cut the wrists. Working diagnosis included suicidal ideation and schizoaffective disorder. The criteria for admission revealed behavioral health condition, symptom, or finding for which observation care had failed, or was not considered appropriate. The hospital Discharge summary dated [DATE], documented R57's admission following an acute bipolar exacerbation, characterized by severe mood disturbances, suicidal ideation, and emotional distress. Prior to hospitalization, R57 reported feelings of hopelessness, expressed a plan for self-harm, and experienced worsening symptoms despite attempts at coping. The discharge summary indicated that due to the severity of their condition, R57 was medically cleared, placed on a legal hold, and admitted to the psychiatric unit for further treatment. Upon discharge, diagnoses included post-traumatic stress disorder (PTSD). R57 was re-admitted to the facility on [DATE] at 11:30 PM, following hospitalization for an acute exacerbation of bipolar disorder and post-traumatic stress disorder, marked by suicidal ideation, depressed mood, racing thoughts, and flight of ideas. A Psychiatric evaluation dated 04/18/2025, R57 was recently hospitalized due to moderately worsening symptoms of severe depression and suicidal ideation with plan to self-inflict injuries. Baseline care plan dated 04/20/2025, documented R57 was re-admitted following an acute hospitalization due to depressed mood and suicidal ideation, resulting in a legal hold. Care approaches included implementation of PASRR recommendations to address mental health needs. The medical record lacked documented evidence a comprehensive care plan to manage and care for PTSD was developed and implemented. The medical record lacked documented evidence a PASRR Level 2 evaluation was conducted after their return to the facility, despite R57's acute change in condition. The previous PASSR Level 1 screening dated 05/03/2021, determined R57 had no mental illness, intellectual disability, or related condition. This PASRRA 1 screening was no longer an accurate assessment for R57 current mental health conditions given their recent psychiatric hospitalization and legal hold. On 06/12/2025 at 1:00 PM, the MDS Coordinator explained the diagnoses documented in the MDS assessment were derived not only from the discharge summary but also from the attending physician's history, physical examination, medication administration records, and progress notes. The MDS Coordinator acknowledged unfamiliarity with the criteria for PASRR Level 2 screening, stating that such inquiries would typically be addressed by the Social Worker who was recently hired and could probably not be aware of the screening process for PASRR level 2. The MDS Coordinator confirmed the last quarterly MDS assessment did not include the new diagnoses of PTSD documented in the hospital discharge summary and the severe depression documented in the post hospitalization psychiatric evaluation conducted on 04/18/2025. Following a review of the agency's website responsible for conducting PASRR screenings, the MDS Coordinator identified a PASRR Level 2 determination dated 04/23/2025, which had been referred by the hospital on [DATE]. Upon verification, the MDS Coordinator confirmed this screening result was not incorporated into R57's medical records and affected the accuracy of the last MDS assessment, preventing the development of a comprehensive care plan to address R57's updated conditions. The PASRR screening level 2 dated 04/23/2025, revealed R57 met the criteria to be admitted in a nursing facility level of service and may be admitted if the facility was able to provide or arrange specialized services including individual and family psychotherapy, psychiatric follow ups, monitoring and advocacy services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure a new skin impairment was communicated to the wound care team in accordance with facility protocol for 1 of 26 sampled residents (Resident 118). This deficiency placed the resident at risk for wound complication. Findings include: Resident 118 (R118) R118 was admitted to the facility on [DATE], with diagnoses including acute and chronic respiratory failure with hypercapnia and ingrown nail. On 06/10/2025 at 8:38 AM, R118 laid in bed with feet exposed. A blackened area was observed on the tip of R118's right great toe. R118 explained the podiatrist had tried to remove R118's ingrown nail on 06/03/2025 but had to stop when R118 complained of pain. R118 indicated not knowing what the blackened area on the toe was and had communicated the concern to multiple staff but the resident had not heard back from anyone. A physician's order dated 03/28/2025 documented a consultation with Podiatry. A podiatry consult dated 06/03/2025, revealed R118 was seen by the podiatrist and was treated for thick, yellow toenails. Treatment included mycotic toenail debridement, trimming of long, thin, colorless nails, and simple nail trimming. On 06/12/2025 at 01:07 PM, the Wound Care Nurse reported being aware the podiatrist had attempted to remove the ingrown nail on the right great toe on 06/03/2025, but the provider had to stop when R118 expressed pain. The Wound Care Nurse reported evaluating R118's right great toe and described the blackened area as dried blood versus necrotic tissue which was painful when touched. The wound care nurse confirmed being told by R118 the concern had been communicated to multiple staff however no one had reported the skin issue to the wound care team. On 06/12/25 at 01:28 PM, R118 laid in bed with feet exposed. The Wound Care Nurse was present when R118 repeated having told multiple staff of the toe discoloration and pain, but no one had gotten back to R118 regarding the concern. The Wound Care Nurse indicated the toe discoloration and pain were considered abnormal findings and expected nursing staff to notify the wound care team of new skin impairment or complication immediately. On 06/12/2025 at 01:28 PM, the Certified Nursing Assistant (CNA) verbalized being assigned to R118 on 06/11/2025 and 06/12/2025. The CNA indicated noticing the blackened area on the right toe 06/11/2025 and reported it to the licensed Practical Nurse (LPN) on duty who said would check on it, but the CNA did not know if the LPN had done so. The CNA indicated expecting the nurse to contact the physician or the wound care team if R118 had a skin impairment. On 06/12/2025 at 01:31 PM, the (LPN) indicated having been assigned to R118 last week, but LPN did not notice R118's discolored toe until today. The LPN reported attempting to apply socks on R118's right foot this morning, but R118 refused, stating the toes were tender. The LPN indicated the LPN to whom the CNAs reported the discolored toe on 06/11/2025 should have reported it to the wound care team. On 06/12/25 at 01:43 PM, the Wound Care Nurse indicated expecting nurses to report skin impairments immediately to avoid delays in appropriate interventions. The Wound Care Nurse stated it was difficult to determine how long the delay in reporting was and stated delay in communication meant a delay in proper interventions which placed R118 at risk for infection and worsening pain. On 06/12/25 at 01:49 PM, the Assistant Director of Nursing (ADON) indicated the CNAs' form called STOP and WATCH, the CNAs filled out whenever a change in condition was identified. According to the ADON, the purpose of the form was so CNAs could protect themselves in case the nurse they reported the abnormal finding to, forgot to address the reported change of condition. The ADON confirmed the CNA who identified R118's discolored toe with pain on 06/11/2025, failed to complete a Stop and Watch form for R118. The ADON indicated expecting CNAs to inform nurses of new skin impairments immediately, and nurses were expected to communicate with the wound care team for timely interventions. The ADON stated delays in communication translate to delays in intervention, which place the resident at risk for infection and pain. On 06/13/2025 at 10:39 AM, the wound care physician was inside R118's room and described the blackened area on R118's right great toe as hyper-granulation tissue or a scab and not dried blood. The physician indicated being aware the podiatrist performed an ingrown nail removal on 06/03/2025 wherein only a portion of the ingrown nail was removed due to R118's complaints of pain. The physician reported the wound care team was informed of R118's discoloration of the toe and reports of pain on 06/12/2025 and indicated expecting nurses to notify the wound care team sooner to prevent wound complications. The physician indicated after the wound care team was notified of R118's skin issues, infectious disease was involved, and prophylactic antibiotic had been ordered. The wound physician verbalized a delay in communication meant a delay in proper interventions and placed the resident at risk for complications such as infection and worsening pain. The facility policy titled Wound Care: Skin Checks, revised July 1, 2015, documented CNA would perform skin checks daily, as this allows for earlier identification and intervention. The facility policy titled Wound Care, Licensed Nurse Skin Checks, revised July 1, 2015, documented all residents will have a thorough weekly skin evaluation performed by a licensed nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure interventions were implemented to identify hazards and risks associated with smoking, and residents who smoked were adequately monitored or supervised for 2 of 16 sampled residents (Residents 91 and 99), and 1 unsampled resident (Resident 97), identified as smokers. This deficient practice had the potential to result in fire hazards and compromise the safety and well-being of the residents, staff, and others in the facility.Findings include:A facility policy titled Smoking Regulation, revised 11/01/2017, documented the facility was highly encouraged to maintain a smoke-free environment. If the facility chose not to remain smoke-free, facility leadership was required to establish an appropriate and safe environment for smoking to reduce the risk to residents who smoked, minimize exposure to secondhand smoke for others, and reduce the risk of fire. Smoking without direct supervision was not permitted. Possession of smoking materials (lighters, matches, cigarettes, etc.) in resident rooms or on the person was prohibited. When smoking was permitted during a resident stay, facility staff were required to receive and safeguard all smoking materials.Resident 91 (R91)R91 was admitted on [DATE], with diagnoses including chronic obstructive pulmonary disease and heart failure.On 06/10/2025 at 3:00 PM, R91 reported being a smoker and acknowledged keeping a lighter in a pants pocket while the roommate's Oxygen (O2) was on, in close proximity. R91 indicated being wheelchair-bound, able to propel self, smoked outside near a tree within the facility premises, did not require staff assistance, and was not supervised during smoking. R91 reported running out of cigarettes for a few days and indicated a sister would be bringing more.The Observation Detail List report dated 05/12/2025, documented R91 as a chain smoker.A document titled Smoking Residents, listed R91 as a smoker.A final written warning for violation of the no-smoking policy dated 05/202/2025, documented it was acknowledged and signed by R91.On 06/10/2025 at 3:15 PM, the Assistant Director of Nursing (DON) indicated R91 was alert, oriented, and identified as a smoker. The Assistant Director of Nursing (ADON) confirmed possession of a lighter in R91's pants pocket. The ADON retrieved the lighter and provided education regarding the non-smoking policy. The ADON indicated a smoking assessment was completed and a care plan developed. On 06/12/2025 at 11:01 AM, a Licensed Practical Nurse (LPN) explained a smoking assessment and inventory of smoking materials were completed upon admission of residents who smoked. The LPN was uncertain about the current smoking policy but indicated a transition was underway toward establishing a designated smoking area with assigned staff. The LPN acknowledged inconsistent enforcement of the non-smoking policy and indicated R91 was non-compliant despite repeated counseling. The LPN had not personally observed R91 smoking but confirmed frequent smoking behavior. The LPN expressed the physician notification and education attempts were made but hindered by unclear enforcement protocols regarding smoking.On 06/12/2025 at 11:20 AM, the ADON indicated assessments and inventories were completed at admission. The ADON indicated facility was identified as non-smoking, with plans to establish a designated smoking area and staff monitoring. The ADON reported R91 was non-compliant, continued smoking, and refused nicotine patches. The ADON indicated the physician and social services were aware, but discharge was delayed due to social worker turnover. The ADON explained the issue had been ongoing since having been discussed during Quality Assurance and Performance Improvement (QAPI) meetings and thirty-day discharge notices had been issued to non-compliant residents. The ADON indicated despite confiscation efforts, residents continued obtaining smoking supplies. The ADON described the issue as a daily challenge with ineffective interventions and inconsistent enforcement. The ADON confirmed the residents who smoked outside were not monitored.On 06/12/2025 at 11:39 AM, the Social Services Assistant (SSA) confirmed no active discharge plan for R91 related to non-compliance with smoking. The SSA indicated R91 had signed a no-smoking agreement upon admission and the leadership had discussed transitioning R91 to a smoking-permitted facility. The SSA explained additional personnel were assigned to redirect smokers, but monitoring and education efforts had not resolved the issue. The SSA indicated the residents were frequently observed smoking at the entrance with approximately 10 smokers daily on different times. The SSA indicated the issue had persisted since the previous year, and family members had voiced concerns regarding secondhand smoke exposure at the entrance. The SSA indicated despite consistent confiscation and patch offerings, residents refused interventions. On 06/12/2025 in the afternoon, a Certified Nursing Assistant (CNA) in Unit 2 indicated the facility was a non-smoking facility. The CNA indicated the residents continued to smoke near the entrance and in the parking area and were not monitored. The CNA indicated smoking materials were confiscated during the week of survey.On 06/13/2025 at 7:32 AM, another CNA indicated R91 was non-compliant and had previously stored smoking supplies in the bedside drawer. During inspection, no smoking supplies were found, however a cigarette butt was observed on the bedside table. The CNA confirmed the observation.On 06/13/2025 at 8:05 AM, the ADON inspected R91's wheelchair at the facility front entrance and found three lighters and four packages of matchsticks. R91 became visibly upset, denied having cigarettes, and propelled the wheelchair toward the tree.R15 was admitted on [DATE] and readmitted on [DATE], with diagnoses including chronic kidney disease, diabetes mellitus, and muscle weakness.On 06/13/2025 at 7:40 AM, R15, who was R91's roommate, was alert, oriented, and verbally responsive. R15 confirmed R91 was a known smoker with supplies brought in by family. R15 indicated smoking did not occur inside the room, but cigarettes were finished near the facility entrance. R15 reported the outdoor patio had been closed four to five months earlier due to suspected inappropriate activity.Resident 97 (R97)R97 was admitted on [DATE], with diagnoses including nicotine dependence, cognitive communication deficit, Parkinson's disease, bipolar disorder with psychotic features, and hypertension.On 06/13/2025 at 7:15 AM, R97 and another resident were observed smoking in the parking lot without staff supervision. No staff were present in proximity.On 06/13/2025 at 7:25 AM, a Hospitality Aide (HA) assisted R97 back into the facility and confirmed R97 had been smoking earlier. The HA explained two HAs were assigned to monitor smoking supplies and inspect rooms of known smokers. The HA reported families brought smoking materials to the residents. An inspection of R97's room found no lighters or cigarettes.On 06/13/2025 at 7:30 AM, R97 was seated in a wheelchair at the room door and confirmed smoking in the parking lot. R97 reported receiving the cigarette from a friend and had no smoking supplies. R97's breath smelled of smoke.On 06/13/2025 at 7:32 AM, the CNA assigned to R97 indicated the facility transitioned from smoking to non-smoking status in recent years. The CNA indicated the residents were not permitted to keep smoking supplies. The CNA indicated the leadership had conducted inspections earlier in the week, but families continued to bring supplies. The CNA reported R97 borrowed cigarettes. On 06/13/2025 at 8:00 AM, the ADON and HA accompanied the surveyor to the front of the facility. The HA confirmed observing R97 smoking in the parking lot, approximately 25 feet from the entrance. The ADON explained the residents were not allowed to smoke on facility's premises. The ADON explained smoking commonly occurred near a tree 50 to 60 feet from the entrance, outside facility property. The ADON confirmed R97 violated rules by smoking within the parking lot.On 06/11/2025 in the morning, four residents attended the resident council meeting. Residents indicated awareness the facility was a non-smoking facility but reported the presence of active smokers.Resident 29, who served as the Resident Council President, indicated the side yard patio near the activities room had restricted access due to previous misuse for smoking, despite the facility-wide smoking prohibition. The patio was locked by 7:30 PM. Resident 29 stated staff had explained supervision could not be provided for residents who insisted on smoking outside facility premises, but the no-smoking rule could be enforced within the premises. Residents reported awareness active smokers smoked outside the front entrance of the facility. Residents recalled the January Resident Council meeting during which non-smoking residents complained about the inability to get fresh air due to the presence of smokers.Resident 32 indicated daily walks were taken around the building for exercise and reported continued exposure to cigarette smoke near the front entrance, expressing dislike for the smell. Resident 61 reported going outside twice daily for fresh air and noted the persistent presence of cigarette smoke. Resident 99 (R99)R99 was admitted [DATE], with diagnosis including other specified depressive episodes, bipolar disorder current episode hypomanic, and anxiety disorder due to known physiological condition. A document titled Horizon Health and Rehabilitation Center (HHRC) Smoking Residents, listed R99 as a smoker.A final written warning of non-compliance in regard to the facility's No-Smoking Policy was signed by R99 and dated 05/20/2025. Care Plan dated 06/20/2024, documented R99 was a non-complaint smoker, did not follow facility's nonsmoking policy.R99's Smoking Risk (Acuity) Review dated 05/19/2025, documented smoking materials as cigarettes, carried matches/lighter, frequency of use was every few hours, and listed smoked in unauthorized areas as a severe problem.On 06/13/2025 at 8:57 AM, R99 was observed walking continuously back and forth in the hallways. R99 was dressed in street clothes and wore a purse over the shoulder. R99 reported was a smoker and had cigarettes and a lighter in the purse, while pointed to the purse hanging on the shoulder. R99 explained would go outside the facility to smoke. R99 acknowledged was aware it was a nonsmoking facility. R99's facial expression changed with noticeable flushing, stopped speaking, and abruptly ended the interaction by walking away.On 06/13/2025 at 9:30 AM, the Assistant Director of Nursing (ADON), reported R99 had been educated many times about the nonsmoking policy. R99 became very agitated when smoking paraphernalia was confiscated and shortly after would obtain more smoking paraphernalia. The ADON reported had been unable to determine how R99 would obtain more smoking paraphernalia.On 06/13/2025 at 12:10 PM, a Certified Nursing Assistant (CNA), reported lighters and cigarettes were confiscated, and residents were educated and reminded continuously it was a nonsmoking facility. The CNA reported was unsure of how residents obtained more smoking paraphernalia after the items were confiscated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure the Foley catheter was assessed timely, the physician was notified of foul-smelling urine, the change in condition was documented, and the urinary drainage bag was changed as ordered for 1 of 26 sampled residents (Resident 104). This deficient practice had the potential to contribute to urinary tract infection, compromised skin integrity, and overall health status. Findings include: Resident 104 (R104) R104 was admitted on [DATE], with diagnoses including neoplasm of the kidney and obstructive and reflux uropathy. A Physician order dated 08/21/2024, documented to change Foley drainage bag weekly on Sunday. A Physician order dated 10/16/2024, documented an indwelling Foley catheter, 16 French, inflated with 10 cubic centimeters (cc), for benign prostatic hyperplasia (BPH). The order indicated the Foley catheter may be changed as needed for obstruction or dislodgement. A Physician order dated 10/16/2024, documented may irrigate Foley catheter with 60 cc sterile water as needed for sediments/obstruction as needed. A Care Plan dated 10/15/2024, documented R104 had an indwelling catheter related to BPH and recurrent urinary tract infections. Interventions included providing catheter care as ordered, monitor and document urinary output. The goal was for R104 to remain free from urinary tract infections for 90 days. On 06/10/25, at 9:59 AM, R104 was observed in bed with eyes closed. A urinary drainage bag, undated and in place, contained approximately 450 cc of dark yellow to amber-colored urine with visible sediment. On 06/11/25, at 1:49 PM, R104 was observed in bed, awake and verbally responsive. R104 verbalized the Foley catheter and urinary drainage bag had not been changed. R104 verbalized the diaper had been soaking wet and staff attributed the moisture to leakage from the insertion site, but the Foley had not been changed in over a month. R104 indicated had frequent urinary tract infections. On 06/11/25 at 1:51 PM, a Licensed Practical Nurse (LPN) verified the Foley catheter in place was a 16 French with a 10-cc water balloon. The LPN confirmed the urinary tubing contained sediment build-up, the urinary bag appeared old and discolored, and the urine was cloudy with a foul odor. The LPN indicated the Foley catheter should have been changed if leaking, the urinary bag should have been replaced as needed, and a physician's order should have been implemented and documented. R104's medical record lacked documented evidence the Foley catheter was assessed timely, the physician was notified of foul-smelling urine, the change in condition was documented, and the urinary drainage bag was changed as ordered. On 06/11/25 at 2:05 PM, the Assistant Director of Nursing (ADON) indicated a physician's order was required for residents with an indwelling Foley catheter, including justification, management, and ongoing assessment. Staff were expected to follow physician orders. The ADON confirmed R104 had concentrated amber-colored urine with a foul odor at the time of the catheter change, indicating a change in condition that should have been reported, with a Situation-Background-Assessment-Recommendation (SBAR) initiated and documented. No documentation was found of leakage, urinary tract infection symptoms, or SBAR initiation. The ADON stated the order directed weekly catheter changes, documented in the Treatment Administration Record (TAR); however, although recorded as changed on June 1 and 8, 2025, the catheter was not changed. The ADON explained changes were performed as needed, but the active order specified weekly changes and should have been clarified. The ADON confirmed the presence of foul-smelling urine, a tarnished and discolored drainage bag, and visible sediment. The urinary bag appeared old, and a reported change in condition should have prompted assessment and catheter replacement. The ADON indicated nursing staff were expected to notify the physician and document the change; however, this was not completed. On 06/12/25 at 11:31 AM, the Director of Nursing (DON) indicated residents with Foley catheters had diagnoses supporting continued use. Physician orders were required for catheter care, including maintaining cleanliness and discontinuing use when appropriate. Some residents had indwelling catheters due to underlying medical conditions. The DON stated the Foley catheter should have been flushed if occluded and changed if leaking. If foul-smelling urine was present, prompt assessment and physician notification were expected to obtain an order for urine collection, catheter change, and documentation. A facility policy titled Catheter-Urinary Catheter Cleaning and Maintenance - Lippincott Nursing Procedures, 9th Ed., pages 432-435, revised 05/05/2023, directed staff to monitor intake and output as ordered, observe for changes in urine volume and color, and notify the practitioner of abnormal findings. A facility policy titled Physician and Other Communication/Change of Condition, revised 05/05/2023, directed staff to complete a resident assessment, including any interventions provided. Staff were to complete a Situation-Background-Assessment-Recommendation (SBAR), notify the physician, and document all assessments and changes in the resident ' s condition in the medical record. Changes and new interventions were to be reflected in the individualized care plan. All attempts to notify physicians and family members or legal representatives were to be thoroughly documented in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure enteral feeding orders administered through the gastrostomy tube were followed as ordered, and total volume delivered was monitored and documented for 1 of 26 sampled residents (Resident 34). This deficient practice had the potential to result in inadequate nutritional and fluid intake, leading to malnutrition, dehydration, electrolyte imbalances, impaired wound healing and increased susceptibility to infections. Findings include: Resident 34 (R34) R34 was admitted on [DATE], with diagnoses including risk for malnutrition due to impaired food and fluid intake, diabetes mellitus, dementia and gastrostomy. On 06/10/2025 at 10:10 AM, R34 was observed in bed with the head of bed elevated 30 to 45 degrees. Nepro 1.8 (a liquid therapeutic nutritional supplement specifically designed to help meet nutritional needs) was hung on a pole, with the tube feeding (TF) bag approximately full at 1000 milliliters (mL). The bag was labeled 06/10/2025 at 4:40 AM, with an indicated rate of 35 mL/hour. The water bag was at approximately 1000 mL, labeled with the resident's name, but lacked an infusion rate and staff initials. TF was not flowing at the time of observation. A physician order dated 02/14/2025 documented Nepro 1.8 at 35 mL/hour for 15 hours daily or until a total volume of 525 mL was infused. Date and label each tubing, monitor for tolerance. On 06/10/2025 at 11:33 AM, TF remained connected to R34 but was not flowing at the time of observation. On 06/13/2025 in the morning, TF via enteral pump was observed turned off. A Licensed Practical Nurse (LPN) explained R34 was dependent on enteral feedings due to dysphagia (difficulty swallowing) and was receiving hospice services. The LPN indicated TF started at 2:00 PM and ended at 5:00 AM. The LPN confirmed the enteral feeding pump history showed a total feed volume of 1,452 mL over three days, reflecting a deficit of 123 mL. The 30-day total was 13,823 mL, reflecting a cumulative deficit of 1,927 mL. On 06/13/2025 at 10:13 AM, the Assistant Director of Nursing (ADON) explained if TF was initiated at 2:00 PM, it should have been administered for the prescribed duration or until the ordered volume was completed. The ADON clarified the ordered volume must be administered in full, regardless of interruptions. The ADON indicated inadequate delivery placed the resident at risk for weight loss and stated the current weight remained stable. A review of the June Medication Administration Record (MAR) revealed lacked documented evidence the total TF volume was consistently monitored or recorded. On 06/13/2025 at 10:00 AM, the Registered Dietitian (RD) explained R34 was entirely dependent on tube feeding, with no oral intake. The current TF order was 35 mL per hour over 15 hours daily, totaling 525 mL/day or 15,750 mL over 30 days. The actual administered volume was 13,823 mL, reflecting a 1,927 mL deficit. The RD confirmed the deficit was clinically significant, particularly for a resident with no oral intake. The RD indicated the TF provided complete nutrition, including essential fatty acids, vitamins, and minerals. The RD indicated failure to deliver the full ordered volume placed the resident at risk for weight loss and nutritional deficiencies. The RD reported R34's TF met approximately 88.9% of daily caloric needs and 72.8% of protein needs. The RD identified protein intake as suboptimal and below the recommended goal. The RD recalled a request to nursing staff to begin documenting total volume delivered was made in November 2024, shortly after hire, but had not been implemented. The RD confirmed TF volume was not consistently monitored or documented in the MAR and expressed this failure placed the resident at risk for unintentional weight loss and unmet nutritional needs. On 06/13/2025 at 1:34 PM, the physician indicated it was essential to maintain nutritional status through consistent enteral feeding as ordered to support metabolic balance and reduce the risk of skin breakdown. The physician confirmed staff were expected to follow TF orders as prescribed. A facility policy titled Enteral Feeding - Documentation, revised 06/20/2023, documented licensed nursing staff would monitor residents receiving enteral nutrition daily and document according to facility guidelines, including recording intake and output amounts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure 1) a resident's yelling and disruptive behaviors were communicated to the psychiatric provider and 2) the resident was referred to the behavioral services provider for psychotherapy services for 1 of 26 sampled residents (Resident 55). The deficient practice potentially had a negative impact on the resident of concern's overall well-being and deprived other residents of the right to live in a peaceful environment free from disruptive noise. Findings include: Resident 55 (R55) R55 was admitted on [DATE] and readmitted on [DATE], with diagnoses including insomnia, anxiety disorder and major depressive disorder. Psychiatric provider not informed On 06/10/2025 at 9:45 AM, R55 was overheard from the hallway yelling, help! help! help! A Licensed Practical Nurse (LPN1) entered R55's room. Upon leaving R55's room, the LPN indicated R55 yelled all the time. On 06/10/2025 at 9:52 AM, R55 was seated in wheelchair and reported being unhappy in the facility due to not getting along with roommate and expressed was upset over being transported to the main dining room where R55 remained all night accompanied by a nurse. R55 indicated the nurse removed the resident from the unit to allow other residents to sleep because the resident yelled constantly. R55 acknowledged yelling constantly because the resident had difficulty sleeping and did not take any medications for sleep. On 06/10/2025 at 10:00 AM, R55's roommate Resident 109 (R109), sat in motorized wheelchair and indicated R55 yelled constantly day and night and was verbally abusive towards staff which R109 found disturbing. On 06/12/2025 in the afternoon, R55 was observed asleep and unarousable in wheelchair in the lobby by the front desk. On 06/13/2025 at 9:50 AM, R109 indicated R55 yelled day and night which disrupted R109's normal sleep patterns. R109 reported being able to nap yesterday afternoon because staff brought R55 to the receptionist to allow R109 to rest. R109 confirmed the nurse had to bring R55 to the main dining room on the evening of 06/09/2025 to allow other residents in the unit to sleep. R109 indicated staff were fully aware of R55's behaviors but had run out of moves because nothing worked for R55. On 06/13/2025 at 11:06 AM, Resident 58 (R58) whose room was next to R55's room indicated being bothered by R55's constant yelling and stated, I am lucky to get three hours of sleep. On 06/13/2024 at 2:33 PM, Resident 122 (R122) who resided in the room directly across from R55's, was seated in walker on the front patio. R122 indicated being bothered by R55's constant yelling and had expressed this with the staff but the resident did not know what was being done for R55. On 06/13/25 at 10:29 AM, LPN2 indicated being familiar with R55 and R109 who did not get along mostly due to R55's behaviors. According to LPN2, R109 was protective of staff and did not like it whenever R55 became verbally abusive. LPN2 indicated being aware Residents 109, 58 and 122 had expressed being bothered by R55's constant yelling and LPN2 was informed R55 needed to be removed from the room just to allow R109 to get some sleep. LPN2 indicated reporting R55's behaviors to the Assistant Director of Nursing (ADON1) and the DON but LPN2 was not aware of the leadership's plans for R55. LPN2 indicated all residents had the right to exist in a peaceful, homelike environment free from disruptive noise and R55's constant yelling was depriving other residents of peace and sleep. A psychiatric consult report dated 12/17/2024, revealed R55 was seen by psychiatric provider due to refusing to go to dialysis treatments. The report documented R55 was currently not on any psychotropic medications and nursing was instructed to monitor R55's mood changes and consult psychiatry for any concerns. Review of medical record revealed R55's yelling behaviors were identified and documented by nursing staff almost daily. The medical record lacked documented evidence R55's yelling and disruptive behaviors were communicated to the psychiatric provider. On 06/13/2025 at 11:12 AM, ADON1 indicated being aware of R55's yelling behaviors which occurred frequently. ADON1 indicated being informed R55 had to be transported to the main dining room on the evening of 06/09/2025 to allow other residents to sleep. The ADON explained the facility tried room changes and one-on-one conversations but did not know what else could be done for the resident. On 06/13/25 at 11:32 AM, the Administrator indicated being aware of R55's yelling behaviors which affected other residents as evidenced by the night nurse needing to remove the resident from the unit on the evening of 06/09/2025 to allow other residents to sleep. According to the Administrator, the facility had tried non-pharmacological interventions such as room changes, separating R55 from other residents but the Administrator deferred to the DON regarding pharmacological interventions. On 06/13/2025 at 11:59 AM, the psychiatric nurse practitioner (NP) confirmed R55 was a patient whom the NP saw only one time on 12/17/2024 when R55 refused to go to dialysis treatments. The NP indicated not being aware of R55's yelling and disruptive behaviors since no one from the facility had communicated R55's behaviors with the NP. The provider indicated whenever mood or behavior changes were identified, the facility must request a psychiatric consult to allow the NP to re-evaluate R55 and provide education regarding appropriate interventions such as medications. On 06/13/25 at 11:56 AM, the DON indicated being aware R55 had psychiatric diagnoses including major depressive disorder, insomnia and anxiety disorder and confirmed R55 was not on any psychotropic medications. The DON was familiar with R55's yelling and disruptive behaviors and was made aware the night nurse had to take R55 to main dining room on the evening of 06/09/2025 so the other residents could sleep. The DON acknowledged non-pharmacological interventions which included room changes and separating R55 from other residents were ineffective. The DON indicated facility staff were fully aware of R55's disruptive behaviors and how it had negatively impacted other residents, but no one thought to refer R55 for a psychiatric consult which would have given the psychiatric provider the chance to discuss appropriate interventions sooner. Referral for Psychotherapy Services On 06/13/25 at 1:43 PM, ADON2 indicated R55 was a Tier one resident which were residents with yelling and disruptive behaviors. According to ADON2, the facility had contracted with a private vendor who had a government contract with Medicaid. The Behavioral Health Services (BHS) provider would place behavior residents in Tiers (one, two or three) based on review of facility documentation and inter-disciplinary team (IDT) reports. Once a resident was identified to benefit from bedside psychotherapy services, the vendor would obtain Medicaid approval and if approved the resident would receive bedside psychotherapy services. ADON2 indicated R55 should have been identified by the IDT for BHS referral to be able to be considered for psychotherapy services. The DON reviewed medical record and confirmed R55 had not been seen by BHS nor referred by the IDT for psychotherapy services and should have been. The Behavioral Health Services policy revised 06/09/2023, documented each resident must receive and the facility must provide necessary behavioral health care and services to attain and maintain the highest practicable physical, mental and psycho-social well-being. Provided services and attempts to provide services would be documented in the resident's medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, document review, and record review, the facility failed to ensure target behaviors were monitored for a resident receiving medication to treat Post Traumatic Stress Disorder (PTSD) for 1 of 26 sampled residents (Resident #26). This deficient practice had the potential to cause the residents to use unnecessary medication, which may result in possible adverse effects. Findings include: Resident 26 (R26) R26 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including chronic respiratory failure with hypercapnia and post-traumatic stress disorder (PTSD). A physician's order dated 04/02/2025 documented Prazosin capsule two milligrams (mg) by mouth every 12 hours for PTSD, target behaviors: night terrors. The psychotropic consult report dated 01/20/2019 documented R26 had a history of being abused as a child and witnessing a violent crime. R26 experienced night terrors related to the incident and had trouble sleeping. R26's medical record lacked documented evidence target behaviors were being monitored for R26 related to the medication Prazosin. On 06/12/25 at 12:05 PM, the Assistant Director of Nursing (ADON) indicated being familiar with R26. The ADON confirmed R26 had been on Prazosin for PTSD for many years, with target behaviors of night terrors. The ADON explained Prazosin was not a psychotropic medication but was ordered for off-label use to address R26's PTSD. The ADON indicated if a medication was used to treat a psychiatric diagnosis such as PTSD, target behaviors must still be monitored. The ADON confirmed R26's night terrors were not being monitored per the physician's order. The ADON indicated the purpose of monitoring Prazosin medication was to identify adverse effects and to determine if the medication was effective. On 06/12/25 at 12:06 PM, the Director of Nursing (DON) explained that Prazosin was an alpha-blocker (a cardiovascular drug) which could be used to improve sleep quality and reduce nightmares. The DON corroborated the ADON's interview, stating medications used for psychotropic diagnoses even if used off-label, must be monitored for target behaviors. The DON indicated monitoring psychotropic medications ensured adverse effects were identified and the medication is effective, particularly in this case for night terrors. The Psychotropic Drugs policy, revised 04/17/2024, documented the facility would monitor and document the resident's response to psychotropic medications for efficacy and adverse consequences. Symptoms, behaviors, and side effects were to be monitored.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, document review, and record review, the facility failed to ensure a medication error rate of less than 5% was obtained during medication pass. There were 31 opportunities observed, which revealed three errors. The medication error rate was 9.68%. Failure to follow physician orders during medication administration had the potential to cause harm or injury to residents. Findings include: Resident 82 (R82) R82 was admitted on [DATE], with diagnosis including hemiplegia affecting left nondominant side, major depressive disorder recurrent severe without psychotic features, and generalized anxiety disorder. On 06/12/2025 at 7:17 AM, a Licensed Practical Nurse (LPN) prepared and administered R82 six medications including Aspirin 81 milligrams (mg) one tablet by mouth and Vistaril (hydroxyzine pamoate) 25 mg (a medication used to treat anxiety), one capsule by mouth. R82's medical record lacked a physician order for Aspirin 81 mg one tablet by mouth. A Physician order dated 11/15/2024, documented Multivitamin (multivitamin-minerals (min)-iron-folic acid (fa)-vit K) tablet, 18 mg, iron-400 micrograms (mcg) oral, once a day at 9:00 AM. A Physician order dated 11/20/2024, documented Vistaril (hydroxyzine pamoate) capsule, 25 mg, amount 1, oral. Special instructions documented for anxiety and poor sleep, do not change the time, twice a day at 9:00 AM and 9:00 PM. A Care Plan edited 05/31/2025, documented R82 had potential for complications related to blood thinning medication and anticoagulant use. R82 had restlessness related to anxiety. Approach included to administer medication as ordered. On 06/12/2025 at 9:23 AM, the LPN, confirmed had administered R82 Aspirin 81 mg one tablet. The LPN acknowledged R82 did not have a physician order for Aspirin 81 mg, and it was administered in error. The LPN acknowledged did not administer the Multivitamin 18 mg, iron-400 mcg tablet. The LPN explained mistook the Aspirin bottle for the Multivitamin bottle, the Aspirin was given to R82 in error and the Multivitamin was not administered as ordered. The LPN confirmed the physician order for Vistaril (hydroxyzine pamoate) 25 mg 1 capsule included specific instruction not to change the time of administration. The LPN acknowledged the Vistaril (hydroxyzine pamoate) 25 mg 1 capsule should have been administered at 9:00 AM as ordered and it was administered at 7:17 AM in error. The LPN acknowledged medication should have been administered as ordered by the physician. On 06/12/2025 at 9:32 AM, the Assistant Director of Nursing (ADON), confirmed R82 did not have a physician order for Aspirin, and it was administered in error. The ADON explained R82 had a physician order for Multivitamin which was not administered and should have been administered instead of the Aspirin. The ADON reported Vistaril (hydroxyzine pamoate) 25 mg had physician instructions not to change the time of administration of 9:00 AM and confirmed it was administered too early at 7:17 AM, outside of the time ordered by the physician. The ADON reported medication had to be administered as ordered. On 06/13/2025 at 10:58 AM, the Pharmacist Consultant, during a phone interview, explained was concerned R82 was administered Aspirin instead of a Multivitamin due to the resident already taking another anticoagulant. The Pharmacist Consultant explained the Aspirin had the potential to cause bleeding. The Pharmacist Consultant reported the expectation was for staff to follow orders and administer the correct medication at the appropriate time as specified by the physician. On 06/13/2025 at 11:24 AM, the Nurse Practitioner (NP), during a phone interview, acknowledged was the prescriber of R82's Vistaril (hydroxyzine pamoate) 25 mg order. The NP explained ordered the medication to be given at 9:00 AM and 9:00 PM, with instructions not to change the time, due to the resident experiencing consistent episodes of anxiety in the morning and to help with sleep in the evenings. The NP reported the expectation was for the medication to be administered as ordered. A facility policy titled Nursing Policies and Procedures, Medication Management Program revised 05/05/2023, documented preparing for the medication pass included staff understanding the eight medication rights including the right drug and the right time.

Based on interview and document review, the facility failed to ensure a Quality Assurance Performance Improvement (QAPI) plan was in place. This deficient practice has the potential to negatively affect the outcomes of resident care and the quality of each resident's life. Findings include: On 06/13/2025 at 1:20 PM, the Administrator acknowledged the facility did not have a specific QAPI plan in place. The Administrator explained the facility was using their QAPI policy as their plan. A facility policy titled, Quality Assurance and Performance Improvement Program Committee Guidelines, revised on 12/03/2019, did not identify the requirement of developing a QAPI Plan containing the processes that will guide the nursing home's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved. However, it did document the QAPI Plan is used to guide the organizational and facility performance improvement efforts. According to the state operations manual, the facility is required to develop a QAPI plan and present its plan to federal and state surveyors at each annual recertification survey and upon request during any other survey, and to CMS upon request. The QAPI plan should describe the process for identifying and correcting quality deficiencies. Key components of the process include tracking and measuring performance; establishing goals and thresholds for performance measurement; identifying and prioritizing quality deficiencies; systematically analyzing underlying causes of systemic quality deficiencies; developing and implementing corrective action or performance improvement activities; and monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. On 06/13/2025 in the afternoon, the Administrator confirmed the facility did not have a specific QAPI plan in place. The Administrator provided Quality Assurance & Performance Improvement continuing education course materials which documented the QAPI Plan should have a vision statement, mission statement, purpose statement, and guiding principles individualized for the facility. It also stated the program plan can serve as a guide for the program. The Administrator conceded the QAPI policy should be part of the plan, but the plan should be tailored to reflect the specific units, programs, departments, and unique population the facility serves, as identified in the facility assessment.

Based on observation, interview, and document review, the facility failed to maintain proper food storage practices in the dry storage area, and temperature control in the refrigerators. The deficient practice had the potential to compromise food safety and increase the risk of foodborne illness among residents. Findings include: On 06/10/2025 at 8:40 AM, a kitchen inspection was conducted alongside a cook, during which the following deficiencies were identified: - A refrigerator used for storing tray line salads, ham, salami, shredded and sliced cheese displayed a temperature of 42°F on its thermometer screen. However, an internal check showed temperatures ranging between 45-50°F. A bag of shredded cheese registered 50°F, while a packet of salami held at 45°F. The temperature log for June 2025 did not document any readings above 40°F, and the refrigerator lacked an internal thermometer for verification. The Kitchen Manager confirmed the recorded food temperatures. - A second refrigerator in the tray line used for storing beverages, including dairy products, displayed a temperature of 42°F, while an internal thermometer measured 50°F. A one quarter liter of whole milk recorded 42°F. This observation was confirmed by the Kitchen Manager, who also observed ice covering the condenser, acknowledging that the refrigerator required defrosting. - In the dry storage, several expired food items were found, including: A baker lane container with sugar had expiration date 02/02/2025. A baker lane container with oatmeal had expiration date 07/05/2024. A baker lane container with white rice had expiration date 08/12/2024. A baker lane container with flour had expiration date 08/12/2024. A baker lane container with brown rice did not document expiration date. On 06/10/2025 at 11:00 AM, the Kitchen Manager stated staff should have been regularly inspecting and labeling food items to ensure expired products were identified and removed in a timely manner. The facility's Food Services Plan, effective from 01/01/2022 to 01/01/2027, outlined requirements for maintaining refrigerator temperatures at 40°F, ensuring that refrigerator thermometers are functional and properly calibrated, and regularly monitoring temperatures. Additionally, the policy specified that food items must not exceed the manufacturer's use-by date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure the signs and symptoms (s/s) of bleeding for a resident on anticoagulants were monitored for 1 of 25 sampled residents (Resident 2). This deficient practice had the potential to result in hemorrhage, an increased risk of severe anemia, and harm to the resident. Findings include: Resident 2 (R2) R2 was admitted on [DATE], with diagnoses including anoxic brain damage and iron deficiency anemia. A physician order dated 06/10/2024, documented Heparin Solution 5,000 units/milliliters (ml) to be administered subcutaneously every 12 hours for deep vein prophylaxis. The Medication Administration Record (MAR) from June to July 2024, documented the Heparin solution injections were administered as ordered. R2's medical records lacked documented evidence the s/s for bleeding were monitored until 07/11/2024. On 07/09/2024 at 9:34 AM, R2 was in bed, awake, non-verbal and obtunded. The family was at the bedside. A Licensed Practical Nurse (LPN) indicated R2 was bed-bound and totally dependent in activities of daily living. On 07/11/2024 at 3:12 PM, R2 was lying in bed, and the lower quadrant of the abdomen had minimal bleeding and bruising. The LPN confirmed there was minimal bleeding in the lower abdomen. The LPN confirmed R2 was taking an anticoagulant. On 07/11/2024 at 3:15 PM, the Assistant Director of Nursing (ADON) explained the resident who was receiving anticoagulant medication should have been monitored for bruising, hematuria (blood in urine), bloody stool, nausea and vomiting, and coffee ground emesis. The ADON indicated the monitoring would be incorporated with the order to give prompts to the Licensed Nurses or ensure continuity of care. The ADON explained the admission nurse or the Licensed Nurses were responsible for obtaining and transcribing the monitoring orders, and the ADONs would review the chart following the resident's admission. The ADON confirmed monitoring orders had not been obtained and transcribed until 07/11/2024. On 07/12/2024 at 1:07 PM, the Director of Nursing (DON) indicated the residents receiving anticoagulant medications should have been monitored for signs and symptoms of bleeding, and an order should have been required. A facility policy titled Anticoagulation Monitoring Program revised May 5, 2024, documented the anticoagulant administration was based on an individualized management program to reduce the likelihood of harm. Steps to minimize adverse effects included improving communication, implementing close prescriber oversight, and enhancing resident and family education.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to provide care to prevent a stage 4 pressure ulcer for 1 of 25 sampled residents (Resident 72). The deficient practice caused a wound to develop and not be identified until it had progressed into a stage 4 pressure ulcer. Findings include: Resident 72 (R72) R72 was admitted on [DATE], and readmitted on [DATE], with diagnosis including unspecified injury level of cervical spinal cord, paraplegia, muscle wasting and atrophy. Braden Scale for Predicting Pressure Sore Risk dated 01/15/2024, documented total Braden Scale score of 15, which determined R72 was at risk for pressure ulcers. A Skin Risk Analysis and Interventions dated 01/15/2024, documented skin was to be inspected daily, especially bony prominences, repositioned at least every hour and increased frequency of turning. A Wound Information Observation History dated 02/27/2024, documented an unstageable (the stage of the wound was unclear) right buttock ulcer was identified on 02/27/2024, not present on admission/re-entry. An Observation Report dated 01/26/2024, documented weekly skin observation was completed by a nurse. Observation details included no alterations in skin. The medical record lacked documented evidence skin evaluations by nursing were completed from 01/27/2024 until the wound was identified on 02/27/2024. A Point of Care History Report dated 01/20/2024 to 02/19/2024, documented turning/repositioning was done for R72 until 02/13/2024. The medical record lacked documented evidence R72 was assisted with turning/repositioning from 02/14/2024 until the wound was identified on 02/27/2024. On 07/11/2024 at 02:45 PM, The Director of Nursing (DON) reported Certified Nursing Assistants (CNAs) were to check skin daily and report to the nurses any changes or concerns. Nurses were to do weekly skin checks. On 07/11/2024 at 11:19 AM, the Wound Care Nurse, confirmed the facility acquired wound was identified during bedside care on 02/27/2024. The pressure ulcer was unstageable when identified and later staged as a stage 4 pressure ulcer. The Wound Nurse explained nursing staff was supposed to perform weekly skin assessments and well as skin checks with bedside care and stated skin assessments must have included a visual of the site. The Wound Nurse acknowledged if the wound would have been found earlier, more appropriate healing time would have been achieved, the wound would have been smaller and easier to have worked with. On 07/12/2024 at 09:42 AM, a Licensed Practical Nurse (LPN) reported scheduled weekly head to toe skin checks were to be done and also while repositioning R72. The LPN acknowledged the benefits of identifying the wound early included reduced pain and risk of sepsis and R72 would have resumed regular activities quicker. On 07/12/2024 at 09:56 AM, the Wound Care Nurse reported R72's wound was avoidable if the processes in place would have been followed. On 07/12/2024 at 09:57 AM, a CNA explained CNAs were to check resident's skin, chart in the system when completed and report any findings to a nurse. On 07/12/2024 at 12:00 PM, the Wound Physician confirmed R72 had a facility acquired, stage 4 sacral pressure sore. The Wound Physician explained due to R72's medical conditions, lack of feeling in the area and nutritional status, R72 could have developed the wound in a very short period of time, even 24 hours. The Wound Physician explained the wound was unavoidable based on R72's condition, however, the Wound Physician acknowledged R72's wound may have been avoided if the process of turning R72 was followed as well as skin checks done. On 07/12/2024 at 12:28 PM, the DON explained nursing skin assessments were to be done weekly and repositioning R72 was supposed to happen or be offered assistance with repositioning, every two hours. On 07/12/2024 at 02:36 PM, the DON reported repositioning was an expectation that should have been done as standards of practice. The DON explained the Point of Care (POC) system where CNAs charted, did not display the option of repositioning after 02/13/2024 and reported not knowing how the option dropped off the POC system. The DON explained staff should have continued repositioning R72 even though the POC system did not show it as an option and acknowledged the medical record lacked documented evidence repositioning was done from 02/14/2024 until the wound was identified on 02/27/2024. The DON further acknowledged the medical record lacked documented evidence nursing skin assessments were done from 01/27/2024 until the wound was identified on 02/27/2024. The DON reported the nurse assigned to the side of the building where R72 resided, admitted had not performed skin assessments due to not knowing skin assessments needed to be done for residents. A policy titled Wound Care Policies and Procedures revised 06/01/2015, documented weekly skin checks should have been performed and documented by licensed staff on all patients/residents. Assessment of a resident's skin condition helped define prevention strategies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure a physician order for splint application was obtained and implemented to treat a resident's contracture for 2 of 35 sampled residents (Residents 2 and R77), and the care plan was updated following the resident's readmission for 1 of 35 sampled resident (Resident 77). The deficient practice could potentially lead to worsening contractures, decreased mobility, increased pain, and a reduced quality of life for the affected residents. Findings include: R2 was admitted on [DATE], with diagnoses including contracture of the left and right hands and atrophy. The Joint Mobility Screen dated 06/10/2024, documented the inability of R2 to flex and extend the fingers. The Restorative Nursing Care Plan dated 06/10/2024, documented R2's goal of maintaining the current level of function with the use of bilateral upper extremities palm protection or a hand roll for 3-6 hours per day. The Minimum Data Set with R2's functional status dated 06/24/2024, documented R2's upper and lower extremities were impaired. A Care Plan revised 06/24/2024, documented R2 was receiving splinting due to an increased risk of contracture in both upper extremities. The approach involved using palm protector splint/rolls on both hands to prevent contracture. R2's medical records lacked documented evidence a physician order for R2's palm protector splint or hand roll to manage R2's contracture was obtained and implemented. On 07/09/2024 at 9:38 AM, R2 was in bed, obtunded, and contracted in all four extremities. R2's fingers were digging into the palms. R2's family was at the bedside, and applied rolled towels to both hands. When interviewed, R2's family could not communicate in the common language. On 07/11/2024 at 3:15 PM, the Director of Rehabilitation Services (DORS) indicated a screening performed on 06/10/2024, showed no recent changes from the previous admission, and R2 remained totally dependent in all care. The DORS explained R2 was referred to restorative nursing for range of motion exercises. The recommendation was for both upper and lower extremities to receive passive range of motion exercises. The DORS explained for upper extremity contractures, hand rolls or palm protectors were recommended to prevent further contractures. The DORS indicated the nursing staff were responsible for obtaining physician orders, transcribing, and implementing the splint. On 07/11/2024 at 4:16 PM, the lead Restorative Nursing Assistant (RNA) indicated after R2 was screened, the Restorative Nursing Care Plan (RNCP) would be formulated and endorsed by the rehabilitation department to the RNA department. The lead RNA indicated after receiving the RNCP, the recommendations would be reviewed and endorsed to the nursing department for order transcription. The lead RNA explained the paperwork for splinting should have been processed within 24 hours on weekdays, and, if received on weekends, by the following Monday. The lead RNA explained the ADONs were responsible for obtaining and transcribing the order, while the RNA was responsible for implementing the splinting. The lead RNA acknowledged obtaining and transcribing orders in a timely manner was challenging, which led to delayed implementation. On 07/12/2024 at 1:32 PM, the Assistant Director of Nursing (ADON) confirmed the order had not been obtained and transcribed per recommendation. The ADON explained following the resident's readmission, the care plan should have been updated, and there should have been an order to treat the resident's contractures. Resident 77 (R77) R77 was admitted on [DATE], with diagnoses including hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) affecting the right dominant side, muscle weakness, and right hand contracture. On 07/09/2024 at 9:22 AM, R77 was in bed, awake and verbally responsive. R77 had a contracture on the right arm with a closed fist. No splint was in place. R77 indicated had right-sided weakness and could not lift the arm or open the fingers. R77 indicated had not been on rehabilitation services. On 07/11/2024 at 3:25 PM, the DORS indicated the most recent screening recommended rehabilitation services for R77's reduced upper and lower extremity functioning. The DORS indicated the services had ended on 06/20/2024, for a two-week maintenance therapy. The DORS indicated the evaluation included a right-hand splint for 4-6 hours, and R2 was expected to wear a resting hand splint for 4-6 hours following the transition. The DORS confirmed the implementation of the splinting was delayed. On 07/12/2024 at 1:32 PM, the ADON confirmed there was no updated care plan for R77's contractures and there was a delay in order transcription. The ADON verbalized the importance of having an order in place and ensuring timely implementation of splinting to manage R77's contracture. On 07/12/2024 at 2:20 PM, the Director of Nursing (DON) indicated the staff were expected to have better communication to ensure the prompt implementation of the resident's splinting to prevent further contracture or injury. A facility policy titled Joint Mobility/Range of Motion Program and Splinting revised 02/29/2024, documented a restorative program would be implemented through the care plan to increase, maintain or prevent deterioration of joint mobility, to maximize physical function when referral to therapy was not indicated or upon transition, and assistive devices would be provided if indicated. A facility policy titled Restorative Nursing dated 02/29/2024, documented the facility was committed to providing quality care and services to all residents. The restorative program, an integral component of nursing practice, contributed to achieving this goal. The plan of care included the program's approaches and interventions, and documented the interventions and results.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure: 1) the nutritional assessment for a resident on percutaneous endoscopic gastrostomy (PEG) was completed upon readmission per policy for 1 of 25 sampled residents (Resident 2), and 2) care orders to manage the PEG tube were obtained and transcribed for 1 of 25 sampled residents (Resident 2). The deficient practice could have the potential to compromise resident safety and well-being, leading to inadequate nutritional support and an increased risk of complications related to PEG tube management. Findings include: Resident 2 (R2) R2 was admitted on [DATE] and readmitted on [DATE], with diagnoses including anoxic brain injury, dysphagia (difficulty swallowing) and gastrostomy. 1) On 07/09/2024 at 9:34 AM, R2 was in bed, awake, non-verbal, and obtunded. Tube feeding (TF) Jevity 1.2 was hanging by the bedside and not infusing. The label on the TF bag dated 07/08/2024, indicated a flow rate of 70 milliliters per hour (ml/hr.). The water bag's label indicated a flow rate of 70 ml/hr. R2's medical records lacked documented evidence the nutritional assessment was completed following R2's readmission. On 07/10/2024 at 3:44 PM, a Licensed Practical Nurse (LPN) indicated R2 was PEG tube dependent, was discharged and readmitted on [DATE]. The Licensed Practical Nurse (LPN) verified and confirmed the incompleteness of the nutritional assessment for R2's PEG tube. The LPN indicated the assessment should have been completed upon the resident's admission or readmission by the Registered Dietitian. The LPN indicated the nutritional assessment in the medical record was outdated from R2's previous stay. The Observation Detail List Report completed on 07/11/2024, documented R2 was nothing per Orem (NPO) or nothing by mouth, as per information obtained from medical record review. R2 received Jevity 1.2 at 65 ml/hr. for 18 hours, with a weight of 146.2 kilograms. The intervention plan included continuing Jevity 1.2 at 65 ml/hr. for 18 hours and continuing water flushing at 125 ml every 6 hours. On 07/11/2024 in the afternoon, the Assistant Director (ADON) confirmed the nutritional assessment had not been completed in a timely manner, and indicated the Registered Dietitian (RD) was responsible for completing it upon R2's admission. The ADON verbalized the importance of the nutritional assessment in meeting the nutritional needs of residents receiving nutrition through a PEG tube. On 07/11/2024 at 2:22 PM, the Registered Dietitian (RD) confirmed the nutritional assessment had not been completed upon R2's admission until 07/11/2024. The RD explained the standard process was to complete the resident's assessment following admission or readmission and annually thereafter, or as needed in case of a change in condition. The RD explained there had been no significant weight change for R2, and the goal was to maintain the current weight. A facility policy titled Nutritional Assessment/Evaluation, revised on June 20, 2024, documented the RD would complete a comprehensive assessment upon the resident's admission, annually, and whenever a significant change in status occurred. The medical record retained the original nutritional assessments until its closure. A new nutritional assessment should have been completed upon the resident's readmission. 2) The hospital transfer summary dated 06/08/2024, documented R2 presented to the emergency department from the facility with symptoms including bilious emesis and fever. R2's course was complicated by a clogged PEG tube, which was resolved with flushing. The Minimum Data Set, dated [DATE], documented R2 had a PEG tube. On 07/09/2024 at 9:34 AM, R2 was in bed, awake, non-verbal, and obtunded. TF Jevity 1.2 was hanging by the bedside and not infusing. The label for the TF bag dated 07/08/2024, with a flow rate of 70 ml/hr. The water bag was not infusing and labeled a flow rate of 70 ml/hour. R2's family was at bedside and showed R2's bloated stomach and tapped the abdomen with fingers, creating a dull sound. R2's medical records lacked documented evidence the care orders to manage R2's PEG tube were obtained and transcribed, such as verification of PEG tube placement, elevating the head of the bed and monitoring, changing the PEG tube when obstructed or dislodged, and water flushing before and after medications. On 07/10/2024 at 3:22 PM, the Wound Care Certified Nurse (WCCN) indicated the care orders should have been obtained. Normal saline to cleanse the PEG tube insertion area and gauze application for which the wound team was responsible, and the care orders such as feeding, flushing, changing the PEG tube for obstruction or dislodgement, placement verification, and monitoring would have been obtained and implemented by the assigned Licensed Nurses. During verification at bedside, the WCCN confirmed R2 was bloated and should have R2's normal state documented and indicated the Licensed Nurses were responsible for the assessment and monitoring. On 07/10/2024 at 3:44 PM, a Licensed Practical Nurse (LPN) indicated the admission nurse or the assigned licensed nurse should have completed the PEG tube assessment upon R2's readmission and transcribed the care orders. The LPN indicated was familiar with the care of R2, as resident had been PEG tube dependent for a long time. The LPN verbalized care orders to manage R2's PEG tube should have been obtained and transcribed upon readmission. On 07/10/2024 at 4:03 PM, the Director of Nursing (DON) indicated, on admission the Licensed Nurses or admission nurses, were responsible for obtaining and transcribing the orders. The DON indicated the care orders should have been in place upon R2's readmission. The DON indicated it was the staff's responsibility to obtain and transcribe the care orders to manage residents' PEG tubes. A facility policy titled Enteral and Parenteral Feedings, revised on June 20, 2024, documented physician orders were to be obtained for all enteral feedings. Problems and complications, such as gastric distention and aspiration, were monitored and reported to the physician and nutrition services.

Based on observation, interview, and document review the facility failed to post daily staffing information in a place accessible to residents and visitors. The deficient practice had the potential to result in a lack of awareness for residents and visitors regarding the type and number of staff on duty on any given day. Findings include: On 07/12/2024 at 8:10 AM, a tour of the facility was conducted with the Director of Nursing (DON). Licensed nurses and Certified Nurse Assistant assignments were posted on an 8 and 1/2 by 11-inch sized paper near each of the two nursing stations, affixed to the corridor wall about four or five feet above floor level. The posting verbiage was in approximately size-14 font, difficult to read unless close up, and room assignments were hand-written. The staffing documents lacked the total Patient Per Day (PPD) hours information for the facility. The DON verbalized the staffing posting as observed was what the facility customarily posted daily. On 07/12/2024 at 8:20 AM, the Administrator, verbalized knowledge of the requirement to post daily staffing information in a prominent place accessible to residents and visitors. The Administrator verbalized the staffing posting should have been in the front lobby areas of the facility. The Administrator verbalized the document should have been in a fairly large font for ease of review. The Administrator verbalized the PPD information should have been included in the staffing posting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure their medication error rate was below five (5) percent (%) when two errors were identified with 30 opportunities observed, calculating an error rate of 6.67%. Failure to follow physician orders and timely administer medications posed a potential risk of injury or harm to the resident. Findings include: Resident 55 (R55) R55 was admitted on [DATE], with diagnoses including muscle weakness and spasms. On 07/11/2024 at 8:26 AM, a Licensed Practical Nurse (LPN) prepared R55's eight medications except B12 and the Refresh eye drop. A Physician order dated 04/19/2024, documented B12 tablets, chewable daily, at 9:00 AM. A Physician order dated 05/13/2024, documented Refresh Classic, one drop in both eyes four times daily. The Medication Administration Record (MAR) dated 07/11/2024, documented R55 refused the B12 and the eye drops. On 07/12/2024 at 11:26 PM, R55 indicated the vitamin B12 and the eye drops had not been refused on 07/11/2024, and the LPN did not explain or ask R55 as to why the medications were not administered. R55 expressed a desire to receive the medications as ordered, particularly the eye drops to ease eye dryness. On 07/12/2024 at 11:28 AM, the LPN confirmed the vitamin B12 and eye drops had not been administered. The LPN indicated the medications were missed and documented R55 as having been refused. The LPN confirmed R55 had not been asked nor refused the medication. The LPN explained if a resident refused medication, it would be reoffered, and the physician would be notified and the refusal documented. The LPN confirmed the physician had not been notified, and there was no documentation of R55's refusal. The LPN indicated the medications were missed and not administered within the time frame as ordered. On 07/12/2024 at 11:40 AM, the Director of Nursing (DON) indicated the staff were expected to accurately document if the medications were administered, missed, or had an actual refusal. A facility policy titled Medication Management revised 04/17/2024, documented medication error rates were not five percent or greater. The staff and practitioners should strive to minimize the potential for medication error by following eight (8) rights for administering medication, including the right time and right charting.

Based on observation, interview, and document review, the facility failed to 1) procure a clean food preparation environment and 2) ensure food products that needed to be refrigerated were kept in a safe temperature range by accurately monitoring the temperature of the walk-in refrigerator. The deficient practice could potentially expose residents to foodborne illnesses. Findings included: On 07/09/24 in the morning, an inspection was conducted with the kitchen manager in the kitchen area. The following issues were identified: 1) Cleanliness: - The exhaust hood over the stove was greasy and visibly dusty outside. - The oven was visibly soiled with greasy matter and dust outside and greasy with food debris inside. - Food debris was observed on the floor behind the oven, stove, and pressure cook. - The floor in the room preparation area was visibly soiled with food debris. A fan was on the floor, blowing air to the table where hamburger patties were being prepared. - The air conditioning (AC) vents were visibly dusty. - An AC vent in the dishwashing area was visibly corroded, with the paint peeling apart. On 07/09/2024 at 9:30 AM, the kitchen manager indicated the oven and the exhaust hood were cleaned monthly but should be cleaned more often. The kitchen manager acknowledged that fans could not be used in the kitchen, and food exposed to the air blown by the fan would be discarded. 2) Walk-in Refrigerator: At 9:40 AM, the temperature reading in the external thermometer of the walk-in refrigerator indicated 44 degrees Fahrenheit (°F). The temperature log located at the door of the walk-in refrigerator documented a temperature of 40 °F was obtained in the morning. The two thermometers situated inside the refrigerator read 58 °F each. The kitchen manager indicated that the door of the walk-in refrigerator was opened several times during meal preparation, which could be the reason the temperature dropped. It was suggested the temperature be checked in one hour. On 07/09/2024 at 11:09 AM, the temperature of the walk-in refrigerator was rechecked. The two internal thermometers read 54 °F. The kitchen manager confirmed the observation and verbalized the temperature should have been between 38 and 40 °F and the food products should have been relocated to another refrigerator. The kitchen manager stated a report would be submitted to the maintenance department. On 07/09/2024 at 12:30 PM, the walk-in refrigerator was checked again. The temperature in the internal thermometers continued at 54 °F. Temperatures were obtained from food products, including a milk carton and a bag of smoked sausages. The temperature was 56 °F, confirmed by the kitchen manager, who indicated the food products would be relocated to another refrigerator. The kitchen manager indicated some products were received in the morning such as the orange juice that needed to be keep frozen and dairy products including milk. On 07/10/2024 at 7:35 AM, a follow-up inspection of the walk-in refrigerator was performed. The temperature in the internal thermometers continued at 56 °F. The temperature was 56 F. There were food products at dangerous temperatures, including three boxes of oranges with labels indicating to keep them frozen. The orange juices in the boxes were not frozen. Additionally, some condiments needed to be refrigerated, including mayonnaise, cheese, two boxes of buttery spread, vegetables, a soy sauce container, whipped topping, sandwiches, sliced ham, sliced turkey, health shake, raw and boiled egg, yogurt, sour cream, and some vegetables. The kitchen manager disposed of the items and acknowledged that the food was in a dangerous zone temperature. The kitchen manager indicated staff did not check the two thermometers inside the refrigerators; instead had used the outside thermometer and documented that temperature. The facility policy titled Food Safety in Receiving and Storage, dated 06/20/2023, documented a thermometer should be kept in each refrigerator and that the refrigerator's ambient temperature should be maintained between 34 and 40 °F.

Based on observation, interview, and document review, the facility failed to ensure a walk-in refrigerator was maintained in working condition to keep refrigerated food products in a safe range of temperature. The deficient practice could potentially endanger the safety of the food, exposing residents to foodborne illnesses. Findings included: On 07/09/24 at 9:40 AM, the temperature reading in the external thermometer of the walk-in refrigerator indicated 44 degrees Fahrenheit (°F). The temperature log located at the door of the walk-in refrigerator documented a temperature of 40 °F was obtained in the morning. The two thermometers situated inside the refrigerator read 58 °F each. The kitchen manager indicated that the door of the walk-in refrigerator was opened several times during meal preparation, which could be the reason the temperature dropped. It was suggested the temperature be checked in one hour. On 07/09/2024 at 11:09 AM, the temperature of the walk-in refrigerator was rechecked. The two internal thermometers read 54 °F. The kitchen manager confirmed the observation and verbalized the temperature should have been between 38 and 40 °F and the food products should have been relocated to another refrigerator. The kitchen manager stated a report would be submitted to the maintenance department. On 07/09/2024 at 12:30 PM, the walk-in refrigerator was checked again. The temperature in the internal thermometers continued at 54 °F. Temperatures were obtained from food products, including a milk carton and a bag of smoked sausages. The temperatures were 56 °F, confirmed by the kitchen manager, who indicated the food products would be relocated to another refrigerator. The kitchen manager indicated some products were received in the morning such as the orange juice that needed to be keep frozen and dairy products including milk. On 07/10/2024 at 7:35 AM, a follow-up inspection of the walk-in refrigerator was performed. The temperature in the internal thermometers continued at 56 °F. The temperature was 56 F. There were food products at dangerous temperatures, including three boxes of oranges with labels indicating to keep them frozen. The orange juices in the boxes were not frozen. Additionally, some condiments needed to be refrigerated, including mayonnaise, cheese, two boxes of buttery spread, vegetables, a soy sauce container, whipped topping, sandwiches, sliced ham, sliced turkey, health shake, raw and boiled egg, yogurt, sour cream, and some vegetables. The kitchen manager disposed of the items and acknowledged that the food was in a dangerous zone temperature. On 07/10/2024 in the morning, the Maintenance Director explained they had not received a report the walk-in refrigerator was malfunctioning, and the last report received from the kitchen happened on 07/08/2024 for an unrelated issue. A facility's form titled Engineering Repair Request lacked documented evidence of the kitchen staff reported the concerns related to the walk-in refrigerator on 07/09/2024. The maintenance records revealed the last monthly preventive maintenance of the walking refrigerator was performed on 07/08/2024 and no issues were identified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review, the facility failed to complete a comprehensive assessment in a timely manner for 1 of 25 sampled residents (Resident 3). The deficient practice placed the resident at risk for receiving inappropriate care. Findings include: Resident 3 (R3) R3 was admitted on [DATE] with diagnoses to include anoxic brain damage and muscular dystrophy (group of diseases that cause progressive weakness and loss of muscle mass). R3's medical record revealed the last annual Minimum Data Set (MDS) assessment was dated 07/19/2022. On 08/04/2023 in the afternoon, two MDS Coordinators explained an annual MDS assessment should be conducted a year following the last annual date, with a grace period of seven days. The two MDS Coordinators confirmed R3's medical record lacked an annual MDS assessment for July 2023 due to an oversight. The Centers for Medicare & Medicaid Service Resident Assessment Instrument (version 3.0 manual; dated October 2019) documented an annual assessment was a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 7 (R7) R7 was admitted on [DATE] with diagnoses including cognitive communication deficit, anorexia, and dysphagia (swallowing difficulties). A Nutrition care plan initiated on 06/26/2017, revealed R7 was at risk for weight loss due to current body weight, disease state, advanced age, and increased needs due to therapy and healing. Interventions included offering snacks twice a day. On 08/02/2023 at 12:12 PM, three Certified Nursing Assistants (CNA) verbalized R7 ate snacks brought in by a family member. On 08/03/2023 at 09:10 AM, a CNA indicated R7 had a snack drawer which R7 could access when they wanted a snack. The CNA indicated the snacks in R7 snack drawer was provided from a family member and not by the facility. The CNA noted R7 did not like the sandwiches the facility provided for a snack. On 08/03/2023 at 09:24 AM, with permission, the same CNA opened R7's snack drawer and a couple of cookies, an individual pudding, and a banana on top of the drawer, were observed. The CNA informed they did not offer R7 snacks. On 08/04/2023 at 9:53 AM, the Registered Dietician (RD) confirmed R7's care plan documented snacks should be offered twice a day and indicated the nursing staff were responsible for offering snacks to residents that can be obtained from the nourishment rooms. The RD explained staff documented a resident's name and what snack was provided to the resident from the nourishment room on a form. The RD reviewed the form and confirmed R7 was not listed on the form. The Person-Centered Care Plan Process policy revised 05/05/2023, documented the facility will develop and implement a baseline and comprehensive care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident. Based on observation, interview, record review and document review, the facility failed to 1) develop a care plan for a resident who was newly diagnosed with end stage renal disease (ESRD) for 1 of 25 sampled residents (Resident 45) and 2) implement interventions in the resident's nutrition care plan for 1 of 25 sampled residents (Resident 7). The deficient practice placed Resident 45 at risk for catheter-related complications which included infection, sepsis up to and including death, and placed Resident 7 at risk for malnutrition. Findings include: Resident 45 (R45) R45 was admitted on [DATE] with diagnoses including diabetes mellitus, osteomyelitis, and hyperkalemia. A Nursing note dated 11/03/2022, revealed R45 was found unresponsive to verbal or tactile stimuli and was transferred to the hospital. Review of medical record revealed R45 was readmitted on [DATE], with a new diagnoses of end stage renal disease and acute kidney failure. R45 returned to the facility with a right chest central venous catheter (CVC) and was scheduled to receive dialysis (renal replacement therapy) at an outpatient dialysis provider. The Annual Minimum Data Set (MDS) dated [DATE], revealed R45 had a new diagnosis of renal insufficiency and required renal dialysis. The medical record lacked documented evidence an ESRD care plan was developed when R45 was newly diagnosed with ESRD and started receiving dialysis treatments. On 08/04/2023 at 8:30 AM, the Assistant Director of Nursing (ADON) reviewed the resident's medical record and confirmed the resident's care plan was not updated when the resident's care changed to ESRD status requiring dialysis. The ADON indicated interventions in an ESRD care plan typically included interventions such as assessment of the dialysis access, following dietary orders, carrying out laboratory orders and communicating with the dialysis provider. On 08/04/2023 at 8:35 AM, the ADON verbalized when R45 returned to the facility with a right CVC related to kidney failure and started to refuse dialysis treatments, the facility missed multiple crucial steps, namely: 1) obtaining care orders for R45's right CVC during non-use, 2) conveying R45's response when the physician assistant (PA) discussed the consequences of missing dialysis treatments with R45, 3) involving the nephrologist and dialysis care team with regards to providing patient education related to R45's refusal to continue with dialysis which included necessary next steps and, 4) responding to the dialysis provider's multiple requests to submit the consent to withdraw from dialysis form. The ADON indicated the facility had failed on multiple levels regarding the care required for R45 as a dialysis patient. On 08/04/2023 at 9:49 AM, the minimum data set (MDS) Coordinator indicated there were no ESRD interventions in the resident's baseline care plan initiated on 01/16/2020 because the resident had not been diagnosed with ESRD at the time of first admission. The MDS Coordinator indicated R45 returned from the hospital on [DATE] with an ESRD diagnosis and receiving dialysis which was reflected in the resident's annual comprehensive assessment, completed on 12/16/2023. The MDS Coordinator confirmed R45's care plan was not updated to incorporate appropriate interventions for R45's ESRD and dialysis status. The MDS Coordinator verbalized being uncertain who was responsible for developing the resident's ESRD care plan. The Person-Centered Care Plan Process policy revised 05/05/2023, documented the inter-disciplinary team (IDT) would review and revise the resident's care plan through ongoing assessment when the resident's clinical status changes. The care plan must include date, problem, goals, interventions, and refusal of services or treatments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a psychiatry evaluation was provided per the physician's order for 1 of 25 sampled residents (Resident 31). The deficient practice had the potential for the facility not providing the appropriate care and services to the resident. Findings include: Resident 31 (R31) R31 was admitted on [DATE], with diagnoses including post-traumatic stress disorder, major depressive disorder, unspecified mood (affective) disorder, insomnia due to medical condition, and anxiety disorder. The physician's order dated 04/17/2023, documented consult: psychiatry evaluation and treat. R31's Quarterly Minimum Data Set (MDS) dated [DATE], documented psychological therapy (by any licensed mental health professional) was not administered to the resident for at least 15 minutes a day in the last seven days. The physician's order dated 07/31/2023, documented psychiatry consult for refusal of wound care due to depression. R31's Wound Treatment Administration History for July 2023 and August 2023, documented the resident refused the daily wound treatment to bilateral buttocks on the following dates: - 07/18/2023 - 07/19/2023 - 07/25/2023 - 07/26/2023 - 07/30/2023 - 07/31/2023 - 08/01/2023 - 08/03/2023 R31's medical record lacked documented evidence a psychiatry evaluation was provided to the resident per the physician's orders. On 08/04/2023 at 9:03 AM, the Assistant Director of Nursing (ADON) confirmed the findings and revealed the only psychiatry evaluation provided to R31 was on 01/22/2023 during the resident's previous admission to the facility. The ADON explained the nurses would have notified the ADON when the physician ordered for a psychiatry consult. The ADON would have contacted the psychiatrist for the consultation as ordered. The ADON acknowledged there was no psychiatry evaluation provided to R31 as ordered. On 08/04/2023 at 12:42 PM, the Treatment Nurse confirmed R31 was still refusing wound treatment on the buttocks. On 08/04/2023 at 1:27 PM, a Licensed Practical Nurse (LPN) indicated a copy of the physician's order for a psychiatry evaluation would have been given to the ADON as soon as the nurse received the order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident 68 (R68) R68 was admitted on [DATE] with diagnoses including malignant neoplasm of lower-outer quadrant of right breast and age-related osteoporosis. R68 had a BIMS (brief interview for mental status) score of 15, indicating R68 was cognitively intact. On 08/02/2023 at 12:50 PM, R68 was seated in wheelchair outside the facility to the left of the front entrance. R68 was smoking a cigarette. The resident indicated there was no designated smoking area, no smoking schedule and verbalized being aware the facility no longer allowed smoking and stated Hey, no one has said anything about it to me. On 08/02/2023 at 12:52 PM, The Activities Director was walking towards the front entrance, went outside, looked to left side and confirmed R68 was smoking a cigarette. The Activities Director indicated this was a non-smoking facility but occasionally a few residents had tried to go outside and smoke without the facility staff member's knowledge. 08/03/23 02:30 PM, the Administrator indicated the facility was a non-smoking facility. The administrator verbalized when residents were admitted they would be given a smoking assessment and if the resident was a smoker, they would be offered a nicotine patch. The administrator revealed any residents observed smoking would be reminded of rules at facility and if they were not willing to follow the no smoking rule they would be discharged . The administrator verbalized if they were aware of any resident smoking, they would keep the cigarettes and lighter locked up in the social services office and be given to resident upon discharge. The administrator indicated they were not familiar with any residents in the facility going outside to smoke, explaining the residents do go outside however the facility staff was not aware of any smoking. The administrator verbalized the person working at the reception desk would be able to see any residents going outside to sit under the canopy on the benches and they were not aware of any reports from staff or other residents regarding smoking. The facility's Smoking Policy dated 11/01/2018, documented employees who witnessed violations of the facility's smoking policies by residents, visitors or staff must have promptly intervened and ensure smoking materials were immediately extinguished in the designated ashtrays and further safeguarded with facility staff. All violations must have been promptly reported to the Unit Supervisor and/or Facility Administrator. Based on observation, interview, record review and document review, the facility failed to ensure a pack of cigarettes and lighter were not kept inside a resident's room for 1 of 25 sampled residents (Resident 221); and failed to monitor the residents who were smoking for 1 of 25 sampled residents (Resident 221) and one unsampled resident (Resident 68). The deficient practice had the potential for the residents, and the facility in general, to be at risk for accidents. Findings include: Resident 221 (R221) R221 was admitted on [DATE], with diagnoses including restlessness and agitation, traumatic subdural hemorrhage without loss of consciousness, and acute pain due to trauma. The Focused Observation form dated 07/29/2023, documented R221 was alert and oriented to person, place, time, and situation. On 08/02/2023 at 9:04 AM, R221 was not inside the resident's room. There was a pack of cigarettes observed on top of the resident's bedside table. On 08/02/2023 at 9:58 AM, R221 confirmed keeping the cigarettes and lighter inside the resident's room. The resident revealed putting the lighter inside the pack of cigarettes. The resident indicated not being aware of the location of the smoking area and nobody from the facility had informed the resident about it. On 08/02/2023 at 2:02 PM, a Certified Nursing Assistant (CNA) assigned to R221 revealed the resident was a heavy smoker who smoked cigarettes three to four times daily during day shift. The CNA indicated R221 smoked by the parking lot near the front entrance of the facility. The CNA confirmed R221 kept the cigarettes on top of the bedside table inside the resident's room. The CNA explained the facility had no designated smoking area. The CNA revealed having seen R221 smoking at 5:30 AM on 08/02/2023 by the parking lot. The CNA had also seen the resident smoking by the parking lot on 07/31/2023 and 08/01/2023. The CNA confirmed not reporting to the supervisor when the CNA witnessed R221 smoking because everyone could have seen the resident smoking by the parking lot which was near the facility entrance. The CNA acknowledged it was not safe for the resident to keep the cigarettes and lighter inside the room due to safety risk and accident hazards. On 08/02/2023 at 2:24 PM, the Assistant Director of Nursing (ADON) explained if a resident wanted to smoke, the staff would have explained to the resident about the facility being a non-smoking facility. The physician would have been notified to obtain an order for a Nicotine Patch. A smoking risk assessment would have been completed for each resident upon admission then quarterly. The ADON indicated the residents were not allowed to keep the cigarettes and lighter inside their room due to safety risk. The staff were expected to report to the ADON or the social workers if a resident was seen smoking or kept cigarettes and lighter inside the resident's room. The ADON revealed R221's admission smoking risk assessment dated [DATE] did not identify the resident as a smoker and there were no smoking materials such as cigarettes and lighter in the resident's possession. The ADON indicated R221 was sneaking the cigarettes and the resident's family could have brought the cigarettes to the facility. The ADON explained another smoking risk assessment was completed for R221 on 08/02/2023 at 10:31 AM. The ADON provided a copy of the assessment which documented the following: - Resident had cigarettes and carried matches/lighter. - The frequency of use was every few hours. - Smokes in Unauthorized Areas - Severe Problem. - General Awareness and Orientation - Including Ability to Understand the Facility Safe Smoking Policy - Severe Problem. - Smoking Risk Total: Score = 10.0 (Potentially Unsafe Smoker) On 08/03/2023 at 7:30 AM, R221 was observed seating in a wheelchair on the left side of the facility's front entrance. The resident was smoking a cigarette with the left hand and a pack of cigarettes was observed on the resident's lap. On 08/03/2023 at 7:40 AM, a Receptionist confirmed by direct observation R221 was smoking a cigarette right outside the front entrance of the facility. The Receptionist verbalized the facility was a non-smoking facility and was not aware who was responsible for enforcing this. On 08/03/2023 at 10:37 AM, a Licensed Practical Nurse (LPN) indicated the facility was a non-smoking facility and had no designated smoking area. If a resident wanted to smoke, the physician would have been notified to obtain an order for a Nicotine Patch. The LPN explained the staff would have informed the house supervisor or social worker when a resident was caught smoking or kept cigarettes inside the resident's room. The house supervisor or the social worker would have explained to the resident about the facility's smoking policy. The LPN acknowledged the resident should have not kept the cigarettes and lighter on bedside because of safety risk and accident hazards. On 08/03/2023 at 10:41 AM, the Director of Social Services confirmed becoming aware about R221 smoking on 08/02/2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to 1) provide three fortified meals a day as ordered and offer snacks as care planned for 1 of 25 sampled residents (Resident 7) and 2) obtain weights per facility policy for 1 of 25 sampled residents (Resident 3). The deficient practice placed the residents at risk for malnutrition. Findings include: Resident 7 (R7) R7 was admitted on [DATE] with diagnoses including cognitive communication deficit, anorexia, and dysphagia (swallowing difficulties). The quarterly Minimum Data Set (MDS) dated [DATE], documented the Brief Interview for Mental Status (BIMS) score as 99 (unable to complete the interview) and required supervision with set up assistance for eating. A physician's order dated 07/03/2017, documented to give fortified food, one serving with meals three times a day. A physician's order dated 07/11/2023, documented to give Super soup (fortified) once a day at 9 AM, to provide extra nutrients to compensate for low food intake (less than 50%) and to help prevent further weight loss. On 08/03/2023 at 07:56 AM, R7 was observed feeding themselves breakfast. There was no Super soup observed on the meal tray. On 08/03/2023 in the morning, R7's meal ticket for lunch on 08/03/2023 documented one cup of gelatein plus. On 08/04/2023 at 8:02 AM, R7 was observed feeding themselves breakfast. There was no Super soup observed on R7's meal tray and R7's meal ticket did not include Super soup. R7's bedside tray table and surrounding areas were observed again at 8:21 AM, 8:38 AM, and 8:43 AM, and there was no Super soup observed. On 08/04/2023 at 9:53 AM, the Registered Dietician (RD) explained gelatein was ordered as an option to fortify foods due to R7's intolerance to lactose and the gelatein was mixed in with the jello dessert. The RD revealed the facility has not had a gelatein supply due to the gelatein being backordered. R7 was then started on fortified soup (Super soup), which the RD indicated unflavored protein powder would be mixed in with oatmeal or soup. The RD reviewed R7's lunch meal ticket for 08/04/2023 which documented one cup of gelatein plus and reiterated the facility did not have gelatein in stock to provide for R7. The RD reviewed R7's dinner meal ticket for 08/04/2023 which documented Super soup. The RD confirmed R7's order for a serving of fortified food with three meals a day, but R7 was only receiving one serving of fortified food a day, which was at dinner time per the resident's preference. The RD confirmed R7's order for Super soup once a day at 9 AM and indicated should have checked in with a physician to have the order changed to dinner time per the resident's preference. On 08/02/2023 at 12:12 PM, three Certified Nursing Assistants (CNA) verbalized R7 ate snacks brought in by a family member. On 08/03/2023 at 09:10 AM, a CNA indicated R7 had a snack drawer which R7 could access when the resident wanted a snack. The CNA indicated the snacks in R7 snack drawer was provided from a family member and not by the facility. The CNA noted R7 did not like the sandwiches the facility provided for a snack. On 08/03/2023 at 09:24 AM, with permission, the same CNA opened R7's snack drawer and a couple of cookies and an individual pudding, along with a banana on top of the drawer, were observed. The CNA informed they did not offer R7 snacks. On 08/04/2023 at 9:53 AM, the Registered Dietician (RD) confirmed R7's care plan documented snacks should be offered twice a day and indicated the nursing staff were responsible for offering snacks to residents that can be obtained from the nourishment rooms. The RD explained staff documented a resident's name and what snack was provided to the resident from the nourishment room on a form. The RD reviewed the form and confirmed R7 was not listed on the form. Resident 3 (R3) R3 was admitted on [DATE] with diagnoses to include anoxic brain damage and muscular dystrophy (group of diseases that cause progressive weakness and loss of muscle mass). R3's medical record indicated R3 was sent to the hospital on [DATE] and returned to the facility on [DATE]. R3's recorded weights were as follows: -07/08/2023- 143 pounds (lbs.) -07/17/2023- 143.5 lbs. -08/01/2023- 146.8 lbs. The medical record lacked documented evidence the resident was weighed on 07/09/2023, 07/10/2023, 07/24/2023, and 07/31/2023 in accordance with facility policy. On 08/03/2023 at 2:54 PM, a Restorative Nursing Aide explained weights were taken daily for three consecutive days, weekly for 3-4 weeks, and then monthly, unless there was a specified order, for readmitted residents. On 08/04/2023 at 9:53 AM, the Registered Dietician (RD) explained weights should be taken daily for three consecutive days, weekly for three weeks, and then monthly. The RD confirmed R3's weights were not collected according to the facility's policy. The Weighing the Resident policy revised 05/05/23, documented the weight will be obtained daily for three days, then weekly for three weeks, and then monthly and/or per physician's orders, for a resident who was re-admitted .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** gastrostomy tube (G-tube) feeding and water flush bag were labeled with the name of the resident, room number, infusion rate, and date and time the feeding and water flushes started; the correct amount of G-tube water flush was provided, and G-tube placement was verified prior to starting the feeding for 1 of 6 sampled residents (Resident 222). The deficient practice had the potential for the resident receiving expired or incorrect G-tube feeding, inaccurate rate of feeding and water flushes, and develop complications from incorrect amount of water flush and incorrect placement of the G-tube. Findings include: Resident 222 (R222) R222 was admitted on [DATE], with diagnoses including hypo-osmolality and hyponatremia, nausea with vomiting, and cognitive communication deficit. The physician's order dated [DATE], documented check feeding tube placement per facility policy. The physician's order dated [DATE], documented Jevity 1.2 at 85 milliliters (ml) per hour for 18 hours (2:00 PM - 8:00 AM) or until full volume (1530 ml). On [DATE] at 9:27 AM, R222 was lying in bed. There were a G-tube feeding and a water flush bag connected to the resident's G-tube through a feeding pump (enteral pump). The feeding pump was on. The stickers attached to the G-tube feeding and the water flush bag were not filled-out with the name of the resident, room number, rate of the feeding and flushes, and date and time the feeding and water flushes started. On [DATE] at 9:35 AM, a Licensed Practical Nurse (LPN) confirmed the findings and acknowledged R222's G-tube feeding, and water flush bag should have been labeled with the name of the resident, room number, infusion rate for both feeding and flushes, and date and time the feeding and flushes started. The LPN explained complete labeling of feeding and water flush bag was necessary to make sure the resident was getting the correct feeding, rate, and flushes. On [DATE] at 2:30 PM, the LPN was observed starting a G-tube feeding for R222. The LPN flushed the G-tube with 65 ml of water and did not verify the G-tube placement and gastric residual prior to starting the feeding. The LPN confirmed the observations and indicated not being sure about the correct amount of water flush prior to starting the tube feeding. On [DATE] at 2:56 PM, the Charge Nurse explained the G-tube placement should have been verified through auscultation and gastric residual should have been checked prior to starting the tube feeding. On [DATE] at 3:00 PM, the LPN acknowledged the G-tube placement should have been verified and gastric residual should have been checked prior to starting the feeding for R222. The LPN confirmed R222's G-tube was flushed with 65 ml of water prior to feeding. The LPN indicated the water flush should have been 95 ml of water prior to feeding. On [DATE] at 1:23 PM, another LPN revealed the G-tube placement should have been verified through auscultation, gastric residual should have been checked, and flushed G-tube with 30 ml of water prior to starting a tube feeding. On [DATE] at 1:37 PM, the Assistant Director of Nursing (ADON) explained the nurses were expected to verify the G-tube placement through auscultation, check gastric residual, and flush the G-tube with 30 ml of water prior to starting the feeding. The ADON indicated the nurses should have labeled the G-tube feeding and the water flush bag with the resident's name, room number, name of the feeding formula, rate, date, and time started, and nurse's initials. The facility's policy titled Gastrostomy Tube Flush/Irrigation dated [DATE], documented the nursing staff would take measures to maintain or establish patency of the gastrostomy tube. Flushing of the tube with 30 ml of water would be performed before and after each intermittent feeding. Check for residual. Verify correct tube placement at least every eight hours and prior to beginning a feeding/flushing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and document review, the facility failed to ensure there was proper coordination of care with the dialysis provider regarding the resident's persistent refusal of dialysis treatments and care of the resident's central venous catheter (CVC) during non-use for 1 of 25 sampled residents (Resident 45). The deficient practice placed the resident at risk for a CVC infection, sepsis up to and including death. Findings include: R45 was admitted on [DATE] and readmitted on [DATE], with diagnoses including diabetes mellitus, end stage renal disease and acute kidney failure. On 08/02/2023 at 10:23 AM, R45 laid in bed while having casual conversation with roommate. The resident's gown was slightly pulled down which revealed a right CVC with an exposed insertion site. The resident indicated the CVC was for the dialysis clinic's use. On 08/03/2023 at 12:26 PM, a Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN) were in R45's room when R45 pulled down frontal right side of gown. The right chest CVC's insertion site was exposed, not covered with gauze or any type of dressing and was stabilized by black suture on the wings. R45's CVC had two flexible lumens, one with a blue port at the tip and one with a red port at the tip. The blue (venous) lumen was marked 1.6 milliliters (ml) (reflects priming or lock solution volume) and was filled with black fluid. The red (arterial) lumen which read 1.6 ml was filled with brown fluid. The CNA and LPN confirmed the description of R45's CVC by direct observation. On 08/03/2023 at 12:28 PM, the CNA and LPN were present when R45 stated it was the resident's personal decision to discontinue dialysis treatments since April 2023. R45 indicated being fully aware of the risks and consequences of stopping dialysis which included death. R45 tapped on right chest and indicated the CVC which was used for dialysis was causing the resident discomfort but none of the providers or staff from the facility had communicated plans to remove the CVC. The resident indicated facility staff do not touch, cleanse, or dress the CVC. On 08/03/2023 at 12:30 PM, the LPN indicated the black and brown fluid inside the lumens appeared to be old blood. The LPN verbalized the resident's CVC did not look good and could end up getting infected resulting in sepsis and death. The medical record lacked documented evidence 1) the provider or nursing staff members coordinated with the dialysis provider in addressing the resident's persistent refusal to go to dialysis treatments, 2) the facility involved the nephrologist and the dialysis care team in providing education to R45 regarding R45's decision to discontinue dialysis which included necessary next steps, 3) the facility obtained or clarified if there were any laboratory orders from the nephrologist and 4) the facility obtained and carried out care orders for R45's CVC during non-use. On 08/03/2023 at 12:33 PM, the Assistant Director of Nursing (ADON) indicated R45 had been refusing to go to dialysis treatments since April 2023 despite multiple reminders by the physician assistant (PA) regarding consequences of missing dialysis treatments. According to the ADON, a Hospice recommendation was presented to R45 who refused to be on Hospice and wanted to remain a full code. On 08/03/2023 at 12:47 PM, the charge nurse at R45's dialysis clinic indicated R45's first dialysis treatment was on 12/06/2022, with a prescription time of three hours and 30 minutes, three times a week on Tuesdays, Thursdays, and Saturdays using right chest CVC. The charge nurse explained R45 was being monitored as an acute kidney injury patient, meaning R45 may have residual or recovering kidney function, but it was also possible R45 would be dialysis-dependent for life. According to the charge nurse, R45's last dialysis treatment was on 04/18/2023. On 08/03/2023 at 12:50 PM, the dialysis charge nurse indicated the nephrologist was made aware of R45's refusal to come for dialysis treatments and the physician wanted a laboratory order done, specifically, a glomerular filtration rate (GFR - measure of kidney function) prior to ordering the removal of the CVC. The charge nurse indicated the dialysis provider made multiple attempts to contact the facility's Director of Nursing (DON) and social services department regarding R45's laboratory order, but getting someone to respond became challenging and attempts were unsuccessful. On 08/03/2023 at 1:44 PM, the dialysis charge nurse indicated if the facility discussed risks and consequences to stopping dialysis with R45, this discussion was not conveyed to the dialysis provider and the lack of communication deprived the dialysis charge nurse and/or nephrologist from providing patient education regarding consequences of withdrawal from dialysis treatments. According to the charge nurse, R45 had the right to refuse any laboratory orders and the dialysis treatment itself, but the dialysis provider must follow its discontinuation protocol for patients who opt to discontinue dialysis treatments which required completion of a form titled, Consent to Withdraw from Dialysis. The charge nurse indicated when it became apparent R45 was not returning to the dialysis clinic, the form was faxed to the skilled nursing facility multiple times and on 07/21/2023, the charge nurse finally touched based with someone from social services who agreed to assist with the form, but the dialysis provider had yet to receive the form. On 08/04/2023 in the morning, the ADON indicated it was possible messages were being left for the former DON who resigned from the facility in June 2023. The ADON could not speak to the former DON's correspondence with the dialysis provider. On 08/04/2023 in the morning, the Social Services Director (SSD) indicated being new to the facility and had not received any calls or facsimiles from the dialysis provider, but could not speak to voice messages or any correspondence which may have been addressed to the former SSD. On 08/04/2023 in the morning, the Social Services Assistant (SSA) recalled receiving a phone call from the dialysis provider on 07/21/2023 where the dialysis provider requested assistance with R45's consent form. The SSA indicated obtaining R45's signature and then faxed the form to the dialysis provider on the same day. The SSA indicated assuming the facsimile was successful and the SSA did not find it was necessary to phone the dialysis provider whether the form was received without issues. The SSA indicated not keeping proof of successful facsimile transmittals. On 08/04/2023 in the morning, the ADON verbalized when R45 returned to the facility with a right central venous catheter (CVC) related to kidney failure and started to refuse dialysis treatments, the facility missed multiple crucial steps, namely: 1) obtaining care orders for R45's right CVC during non-use, 2) conveying R45's response when the physician assistant (PA) discussed the consequences of missing dialysis treatments with R45, 3) involving the nephrologist and dialysis care team with regards to providing patient education regarding R45's refusal to continue with dialysis which included necessary next steps and, 4) responding to the dialysis provider's multiple requests for laboratory work and/or submission of a consent to withdraw from dialysis form. The ADON indicated the facility had failed on multiple levels regarding the care required for R45 as a dialysis patient. The dialysis agreement signed 10/18/2018, documented to deliver appropriate care to its residents, the facility and provider shall exchange all necessary information useful and necessary for the care of the residents. At the facility's request, the dialysis provider shall coordinate and provide instruction in areas including but not limited to the resident's dialysis access and other guidelines of care for the dialysis patient. Facility nursing staff would be responsible for resident care at all times while in the facility. The Dialysis/Hemodialysis policy dated 07/01/2016, documented facility staff will participate in ongoing communication with the dialysis center.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and document review, the facility failed to ensure an unnecessary medication (duplicative anti-psychotic order) was discontinued per the physician orders for 1 of 25 sampled residents (Resident 79) and an Abnormal Involuntary Movement Scale (AIMS) was completed on admission for a resident who was receiving anti-psychotic medication (R31). The deficient practice had the potential to result in adverse consequences for the resident's health and well-being. Findings include: Resident 79 (R79) R79 was admitted on [DATE] with diagnoses including schizoaffective disorder, bipolar type, and post-traumatic stress disorder. The medical record revealed an after-visit note from a specialty clinic on 07/14/2023, documented to discontinue the bedtime dose of Nuplazid (20mg) after one more dose. A prescription order from the specialty clinic dated 07/14/2023, documented Nuplazid 10 mg tablets, give 2 tablets at bedtime for one dose and discontinue medication. The medical record indicated R79 was receiving 30 mg of Nuplazid during the day and an additional 20 mg at bedtime as of 08/03/2023. The medication administration record revealed R79 received the 20 mg bedtime dose on the following dates: 07/16/2023-07/18/2023 07/20/2023-08/02/2023 On 08/04/2023 at 8:00 AM, a Registered Nurse (RN) verbalized the medication Nuplazid was prescribed by neurologist at a specialty clinic and orders were generally carried out by visit notes and prescription would be faxed over to facility. The RN confirmed the resident was receiving 30 mg during day and 20 mg at night for visual disturbances and hallucinations. On 08/04/2023 at 8:23 AM, Assistant Director of Nursing (ADON1) indicated the information sent from the specialists were only recommendations and the final decision was determined by the primary physician. If the physician does not agree with recommendation, they should write a note or provide some form of documentation as to why the facility was not following the recommendations. On 08/04/23 at 10:19 AM, ADON2 indicated recommendations from the specialty clinic on 07/14/2023 included changing day time dose to 34 mg when available. To discontinue bedtime dose after one more dose. ADON2 confirmed the last dose for Nuplazid at bedtime should have been on 07/15/2023 and resident was still receiving dose. ADON2 explained once recommendations and scripts were sent to facility they would be ordered unless there was a conflict with psychiatric services or primary physician. ADON2 revealed there was a progress note from psychiatric services to follow the recommendations of the specialty clinic. ADON2 confirmed the resident was still currently receiving 30 mg during day and 20 mg at night. Resident 31 (R31) R31 was admitted on [DATE], with diagnoses including post-traumatic stress disorder, major depressive disorder, unspecified mood (affective) disorder, insomnia due to medical condition, and anxiety disorder. The physician's order dated 04/17/2023, documented Aripiprazole (Abilify/an antipsychotic medication) 5 milligrams one tablet by mouth daily. R31's medical record lacked documented evidence an Abnormal Involuntary Movement Scale was completed on admission per the facility's policy (AIMS/a rating scale designed to measure involuntary movements known as tardive dyskinesia which could develop as a side-effect of an antipsychotic medication). On 08/04/2023 at 12:15 PM, the Assistant Director of Nursing (ADON) explained an AIMS assessment should have been completed for R31 upon admission, quarterly, annually, and if there was a change in the medication. The ADON indicated R31 was receiving Abilify which was an antipsychotic medication, and an AIMS assessment was required. On 08/04/2023 at 12:35 PM, the ADON confirmed there was no AIMS assessment completed for R31 upon the resident's admission on [DATE]. The ADON indicated the Charge Nurse was expected to complete the AIMS assessment on admission for residents who were receiving an antipsychotic medication. The ADON explained an AIMS assessment was required to make sure a resident who was receiving an antipsychotic medication was not having side-effects from the medication such as extrapyramidal symptoms (EPS/drug-induced movement disorders). On 08/04/2023 at 1:30 PM, a Licensed Practical Nurse (LPN) indicated an AIMS assessment was completed upon admission for residents who were receiving an antipsychotic medication such as Abilify. The assessment could have identified whether the resident had side-effects from the medication such as EPS. The facility's policy titled Psychotropic Drugs - Use of dated 04/20/2022, documented the facility would monitor and document the resident's response to psychotropic medication, including antipsychotic, for efficacy and adverse consequences. AIMS testing should be completed as a baseline on admission or readmission with an enduring antipsychotic medication, on initiation of an antipsychotic medication and at least every six months and with dosage changes.

Based on observation, interview, and document review, the facility failed to ensure 1) the walk-in freezer was free from ice build-up, 2) rotten vegetables were discarded, 3) opened food items were labeled and dated, 4) kitchen equipment was in working condition, 5) food preparation area and equipment were maintained in a sanitary manner and 6) the sanitation compartment of the three-compartment sink was not too hot. The deficient practice had the potential to serve foods to residents at an increased risk of food safety. Findings include: On 08/02/2023 at 8:20 AM, an initial tour of the kitchen revealed the following: 1) Walk-in freezer had significant ice build-up -freezer pipes were covered in ice -frozen ice covered the door frame and strip curtains from inside the freezer -heavy ice buildup on freezer floor and on top of boxes containing food items 2) Rotten vegetables were discarded -a box filled with rotten cucumbers approximately 25 pieces or more were in the walk-in refrigerator 3) Opened food items were dated and labeled -an opened container of salsa was one-third full and was not labeled and dated 4) Kitchen equipment was in working condition -seven out of ten stove top knobs were missing from the stove top regulator -walk-in freezer door was broken and failed to create a good seal -a reach-in refrigerator located on the left side of the tray line was non-operational - the wind curtain located by the kitchen entrance which prevented insects from flying into the kitchen was non-functional 5) Food preparation area and equipment not maintained in a sanitary manner -food particles and debris build-up under the workstations in the food preparation area -portable toaster had heavy breadcrumb collection inside and around the equipment 6) The solution in the sanitation compartment of the three-compartment sink was too hot. -a signage on top of the three-compartment sink indicated solution inside the sanitation compartment (compartment #3) was to be maintained between 65 degrees Fahrenheit to 75 degrees Fahrenheit. The actual temperature at the time of observation was 113 degrees Fahrenheit. On 08/02/2023 at 8:45 AM, the Kitchen Manager acknowledged the missing stove top knobs, broken wind curtain, reach-in refrigerator and freezer door had been broken since the Kitchen Manager's start of employment three months ago. The Kitchen Manager explained the purpose of the wind curtain was to prevent bugs and insects from entering the kitchen area. The Kitchen Manager deferred to the Director of Maintenance for status of broken equipment. On 08/02/2023 at 9:00 AM, the Kitchen Manager confirmed the rotten vegetables should have been discarded and the opened jar of salsa should have been dated to ensure food safety. The Kitchen Manager confirmed the food preparation area under the tray line and in and around the toaster should be cleaned after each meal service. The Kitchen Manager confirmed the sanitation solution which was too hot could compromise the effectiveness of the chemical used for dish and tray sanitation. On 08/02/2023 at 9:10 AM, the Kitchen Manager indicated being new to the facility and had not had the chance to create a process to ensure all kitchen tasks were assigned and completed. On 08/02/2023 at 3:51 PM, the Director of Maintenance indicated the stove top knobs had been missing for six to eight months, the reach-in refrigerator had been broken for three weeks, the freezer door had failed to create a good seal in the last two and one-half months, and the wind curtain had been broken for six years. On 08/03/2023 at 9:20 AM, the Registered Dietitian (RD) indicated kitchen tasks were assigned verbally in an informal manner which may be the reason some kitchen tasks were missed. The RD confirmed the facility currently did not utilize a cleaning schedule or a kitchen task log to ensure kitchen tasks were assigned and completed through accountability. On 08/03/23 at 9:25 AM, the RD explained when the freezer door does not seal well, air which enters the freezer turns into ice buildup. The ice buildup around food items inside the freezer could compromise food quality specifically the texture through freezer burns. The Manual Cleaning and Sanitizing Stationary Equipment and Work Surfaces policy revised 06/20/2023, documented equipment and work surfaces should be cleaned and sanitized appropriately before use, in between uses, and after use. The Food Storage policy revised 07/21/2023, documented to label and date new food items removed from original containers. Check for signs of spoilage and discard foods which have unusual color and odor. The Cleaning the Freezer policy revised 06/20/2023, documented freezers should be cleaned and free of odors. The walls and shelves should be washed with freezer cleaner.

Based on interview, and document review, the facility failed to ensure the facility had a Director of Nursing (DON) in accordance with the facility assessment. The deficient practice had the potential to compromise supervision of nursing care and oversight. Findings include: The Facility Assessment tool reviewed on 01/18/2023, described staffing resources needed to provide care to the population based on care analysis would include one Director of Nursing, two Assistant Directors of Nursing (ADONs) and one Infection Preventionist/Director of Staff Development. The Facility Assessment tool was re-reviewed on 07/10/2023, which revealed the facility did not have a DON and the DON position had not been filled. On 08/04/2023 at 12:29 PM, the Human Resources (HR) Director explained the DON resigned on 06/02/2023 and the facility had been unsuccessful at hiring a new DON. The HR Director indicated the two ADONs who were Licensed Practical Nurses and the Infection Preventionist who was a Registered Nurse worked their best to perform the DON's duties but collectively, the three employees were not sufficient replacement for the DON because they were busy enough with own duties in their current job roles. On 08/04/2023 at 12:32 PM, the HR Director reviewed the facility assessment and acknowledged the facility required a DON apart from two ADONs and the Infection Preventionist. According to the HR Director, the DON was required to be a Registered Nurse and was responsible for overall nursing supervision and oversight. The DON job description revised November 2016, revealed the DON would be responsible for overall management of the nursing department and coordinated with other disciplines to provide quality care to all residents. The DON must have three to five years of nursing experience with prior management experience. The job description for the Registered Nurse is the basis for this job description and must be followed. On 08/04/23 at 1:17 PM, the Clinical Services Director confirmed the facility had not had a DON since 06/02/2023 in accordance with the facility assessment. The Clinical Services Director indicated even if the two ADONs and the Infection Preventionist worked their best to perform DON duties, it was still not sufficient replacement to meet the demands of the DON duties and expectations.