Based on observation and interview, the facility failed to treat residents with respect and dignity for 2 (R #10 and R # 31) of (R #10 and R # 31) residents randomly identified when the staff failed to knock on the resident's bedroom door before they entered the resident's room. This deficient practice could likely result in residents feeling unimportant and not having privacy. The findings are: A. On 07/09/24 at 12:37 pm, during an observation of staff interaction, Registered Nurse (RN) #1 entered R #10's room, RN did not knock on R #10's door prior to entering the room. R #10 was asleep on his bed. B. On 07/09/24, at 12:38 pm, during an observation of staff interaction, RN #1 entered multiple empty room (residents were in the recreation room socializing), without knocking, . RN #1 found Certified Medical Assistant (CMA) #1 and asked for help. Both staff proceeded back into the R #10 room again without knocking. C. On 07/09/24 at 12:40 pm, during an observation of staff interaction, RN #1 entered R # 31's room without knocking to perform personal care. D. On 07/09/24 at 12:41 pm, during an interview, CMA #1 stated that it is call light policy for staff to knock on the residents' door and announce why staff are entering the room. CMA #1 stated that they were in a hurry looking for wipes for another resident.

Based on observation and interview, the facility failed to maintain infection control practices for 1 (R #31) of 1 (R #31) residents reviewed for catheter care (the practice of properly utilizing a Foley catheter and catheter bag. The Foley catheter is a tube that is inserted into a patient's bladder to remove urine. The catheter bag is where the urine is drained into). This deficient practice could likely result in the resident being susceptible to infection. A. On 07/08/24 at 10:55 am, during an observation, R #31 was resting in bed, with the bed in the lowest position. R #31's urine catheter bag was attached to the bottom rail of his bed. Due to the position of the bed, the catheter bag was resting on the floor. B. On 07/09/24 at 2:10 pm, during an observation, R #31 was resting in bed, with the bed in the lowest position. R #31's urine catheter bag was attached to the bottom rail of his bed. Due to the position of the bed, the catheter bag was resting on the floor. C. On 07/09/24 at 2:12 pm, during an interview with Registered Nurse (RN) #1, she confirmed the catheter bag was on the floor. She also confirmed that the catheter bag should not be resting on the floor.

Based on record review, observation, and interview, the facility failed to provide reasonable accommodations of resident needs for 1 (R #10) of 1 (R #10) resident reviewed for care when the facility failed to ensure that the resident call light was within the resident's reach and signs were in the preferred language (Navajo-Dine). This deficient practice could likely result in the residents' needs not being met, leaving them at risk of accidents and falls. The findings are: A. During observations of R #10 the following was revealed: 1. On 07/08/24 at 10:24 am, R #10 laid in bed and the call light was under the bed. 2. On 07/08/24 at 12:15 pm, R #10 laid in bed and the call light was under the bed. 3. On 07/09/24 at 09:13 am, R #10 laid in bed and the call light was under the bed. 4. On 07/09/24 at 12:30 pm, R #10 laid in bed and the call light was under the bed. B. On 07/09/24 at 12:36 pm, during an interview with Certified Medical Assistant (CMA) #1, she confirmed the following: 1. R #10 does need occasional assistance getting out of bed. 2. R #10 does need to have his call light within reach due to having multiple falls in the past. C. Record review of R #10's care plan revised on 11/27/23, revealed that the call bell and personal items are within resident's reach. Encourage resident to use the call bell to request assistance PRN (as needed). Record Review of the care plan for R # 10, revised 11/27/23, revealed place a chair at the nurses' station with signage in English and Navajo with a picture of a person sitting. Add signage to the chair in 400 hall lounges. Upon observation there was no signage anywhere on the 400 hall that was in Navajo/Dine', so the residents that speak or read Navajo/Dine'. D. On 07/12/24 at 11:32 am, during an interview with Social Services, she confirmed that the sign should be on the 400 hall.

Based on observation and interview, the facility failed to provide a comfortable and home-like environment for all 33 residents (residents were identified by the census provided by the Administrator on 07/08/24) when they failed to clean mice dropping on the floor in multiple areas of the facility. This deficient practice could likely cause residents to feel like they are not living in a comfortable, home-like environment and are not valued. The findings are: A. On 07/08/24 at 11:30 am, during an observation of the main conference room, mice dropping were along the walls and behind the trash can. B. On 07/09/24 at 1:22 pm, during an observation of the main dining area, mice droppings were along the walls and behind the door that enters the dining area. C. On 07/09/24 at 1:32 pm, during an observation of the secondary dining area, mice droppings were along the walls and behind the bookshelf. D. On 07/11/24 at 11:30 am, during an observation of multiple rooms in the 400 halls the following were revealed: 1. Room # 410- mice dropping on the north wall floor under the window along the wall. 2. Room # 402- mice dropping on the north wall floor under the window where the fall pad was located. 3. Room # 401- mice dropping on the north wall under the window along the wall. E. On 07/12/24 at 11:30 am, during an interview, Certified Medical Assistant (CMA) #1 stated, staff have seen mice in the dining area and the rooms. She stated that she and other staff, along with housekeeping, had let the management know. F. On 07/15/24 at 12:13 pm, during an interview with the Administrator, he stated that the main conference room was used for the resident council meetings and the Care Plan meeting. He stated that housekeeping cleans the conference room daily Admin confirmed that the mice issue was being addressed with maintenance. G. On 07/15/24 at 12:22 pm, during an interview with the housekeeper, she stated that she sees mice dropping around the building but does her best to sweep and mop daily. She states that the housekeeping does deep cleaning when they have extra time.

Based on observation and interview the facility failed to ensure essential equipment was in safe operating condition by not replacing a broken plastic light covering for a light located directly over the cooking area of the stove. This deficient practice has the potential to affect all 33 residents on the facility census that was provided by the administrator on 07/08/24. The findings are: A. On 07/08/24 at 10:13 am during the initial tour of the kitchen, there was a light in the stove hood that had a broken plastic light cover which had tape holding part of the cover together. Pieces of tape hung off of the cover; and a piece of the plastic cover was completely missing. B. On 07/11/24 at 11:07 an during an interview, the dietary manager stated that the light cover on the oven hood had been broken since he started working at the facility in September of 2023. He also stated that he had not put in a paper work order to repair or replace the light cover but that he has verbally requested this to be fixed. He further stated that he was unsure as to if or when this light cover will be repaired and confirmed that there was loose and old/dirty tape used to hold the light cover together that was hanging loosely off of the light cover.

Based on record review and interview, the facility failed to provide a Facility Initiated Report (mandatory self-initiated facility report of an incident) within 24 hours from the date of the incident to the State Survey Agency, for 1 (R #1) of 3 (R #1, R #2, R #3) residents reviewed for incidents. If the facility fails to provide a Facility Initiated Report to the State Agency then the State Agency will be unable to assure residents are safe and have a hazard free environment. The findings are: A. Record review of New Mexico Health Facility Licensing and Certification (NMHFL&C) report revealed the facility did not successfully send a Facility Initiated Report to the state reporting system within 24 hours of a resident elopement (when a resident leaves the facility without the knowledge of the staff) that occurred on 01/17/24. B. On 01/24/24 at 9:45 am, during an interview with the Director of Nursing (DON), she stated the facility administrator sent the Facility Initiated Report on 01/17/24 but said they received an error message when it was sent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to update a resident's care plan with a focus (problem), goal, or intervention related to behaviors of refusing care and depression for 1 (R #18) of 2 (R #14 and R #18) residents reviewed for activities of daily living. This deficient practice could likely result in residents not receiving personalized care according to their individual and behavioral needs. The findings are: A. Record review of the facility policy Comprehensive Care Plan and Care Conferences- Rehab/Skilled, last revised 10/21/22, revealed the following Purpose To provide an ongoing method of assessing, implementing, evaluating and updating the resident's care plan to help maintain the resident's highest practicable level of function, including culturally competent and trauma informed care. Further review revealed Formulating the care plan: a. The care plan is driven by identified resident issues/conditions and their unique characteristics, strengths and needs. When implemented in accordance with standards of good clinical practice, the care plan becomes a powerful, practical tool representing the best approach to providing quality of care and quality of life . f. If a resident has specific behavioral interventions, they need to be reflected in the care plan. g. The interdisciplinary team will ensure that the care plan is comprehensive by incorporating the following: - Any services that are not provided due to the resident exercising his or her right to refuse treatment. B. Record review of R #18's face sheet reveled that R #18 was admitted to the facility on [DATE] with the following pertinent diagnosis: previous fall with traumatic subarachnoid hemorrhage (bleeding within the spaces of the brain, resulting in a traumatic brain injury), Parkinson's disease (brain disorder that causes unintended or uncontrollable movements), and dysphagia, unspecified (swallowing difficulties). C. On 02/21/23 at 4:30 pm, during an interview with Certified Nurse Assistant( CNA) #2, when asked to explain R #18's needs and compliance with care, he stated He was very rebellious. He was a very light speaker when it came to asking for help. He would refuse meals, medicines, weights, vitals, it was frustrating because we were trying to get the best and it was a struggle for him. When asked what type of assistance he needed during meal times, he explained He was set up only [meals are to be prepared and presented to the resident for easy consumption]. Then, one day, he just didn't want to eat. It was hard to watch this because I knew his capabilities. I think he missed his wife and being outside. He wasn't a guy to speak on his feelings but I could see it in him. When asked how long he was refusing meals, he explained It had been a while since he was refusing meals, like a month. There were times when he would eat then the next day not eat. It was like the same for getting out of bed and getting to the restroom and showers . We would present stuff to him and he would just refuse. He was set up [level of assistance] until about a month ago. I don't know if he went on the list for needing assistance for eating but we let the nurse know. D. On 02/22/23 at 8:44 am, during an interview with Registered Nurse (RN) #2, when asked to explain what he can remember about R #18's needs, he explained that he needed assistance with His medications, vitals, pain, and his food. He can't swallow. I was monitoring if he was eating or not. Every week when I was here I would ask him and the CNA if he was eating. He refused his meds. Usually, I talk to [name of physician], I tell him that this resident was refusing his meds. We encouraged him and I spoke to the DON [Director of Nursing] about it. I let the family know. [Name of physician] suggested I ask him [R #18] why and if he want to change or crush his medications but he said he didn't want to take it at all even if we crushed it. Sometimes he took it from me. We would double check his mental status for dementia. We tried to change his food texture orders but he refused. We told [name of physician] about hospice. He then explained On my shift, last week, he was not on oxygen, he was alert and oriented but not eating or taking his medications. I asked him why he doesn't want to eat- he just said 'I don't want to'. Last week I didn't see any abnormalities just his refusals to eat and take meds. He didn't want to get out of bed. I encouraged him and he said he was not interested. I didn't feel like he was in a bad situation. His mentality was not changing. I didn't see any abnormalities. E. On 02/22/23 at 10:52 pm, during an interview with RN #4, when asked to explain R #18, she stated He was not compliant with his medications. He would refuse them. I would try to coax [persuade] him to take them but then he would get very adamant that he wasn't going to take them. One night he would take them and the other night he wouldn't. F. On 02/22/23 at 10:18 am, during an interview with CNA #1, when asked to explain R #18 and his needs, he stated When I first got here, he would get out of bed and go to the bathroom by himself. He would do better when his wife was here and then if his wife wasn't here, he wouldn't want to get out of bed or get a shower. He wouldn't eat unless his wife was here. The last couple weeks he didn't want to eat or drink at all. When his wife was here, she would say that he barely ate for her too. He started being incontinent like, 2-3 weeks back. When asked to explain how he would assist during meal times, CNA #1 stated I would cut it for him put it on his fork and encourage him then try to give him some bites. He didn't like it. He would ask for fruits that he had. I would try to encourage him then I fed him like a full assist. The encouragement started about 4-6 weeks ago. The full assist was like 2 weeks ago. Towards the end he was full assist for eating. That was also the time he really almost refused to eat anything. So we were giving him more and more encouragement. G. On 02/22/23 at 1:44 pm, during an interview with the DON, when asked to explain R #18's needs and care, she stated, He was refusing medications and food. It was tough, he came in and was doing ok. He was very dependant on his wife. He always refused the food. Then his wife would come less and he seemed to be angry and depressed. Then he got COVID [an infectious disease that causes a respiratory illness and in some cases can lead to death] and I think it made him more depressed. He was refusing everything. He pushed things away. His decline started before COVID, he was refusing before COVID. H. On 03/15/23 at 3:46 pm, during an interview with the Director of Therapy, she explained that R #18 began to express signs of failure to thrive after he was placed in isolation and unable to have regular visitations from his wife. His desire to participate in therapy decreased more and more which caused him to become weaker along with his poor meal intake. She then explained that before COVID, he didn't have coordination for fine motor skills but he was able to get out of bed with stand-by assistance/contact guard (the resident would be able to stand without hands-on assistance but staff would be next to him to ensure safe movement). After COVID, he was minimal assistance and sometimes moderate assistance. I. Record review of R #18's Medication Administration Records (MARs) revealed the following medication refusals: October 2022- R #18 refused medication 40 times out of 279 opportunities to receive medications. November 2022- R #18 refused medication 43 times out of 330 opportunities to receive medications. December 2022- R #18 refused medication 45 times out of 341 opportunities to receive medications. January 2023- R #18 refused medication 52 times out of 372 opportunities to receive medications. February 2023- R #18 refused medication 90 times out of 190 opportunities to receive medications. J. Record review of physician orders revealed that R #18 did not have orders for an antidepressant or a psychiatric referral. K. Record review of R #18's care plan, revealed an entry with a focus initiated on 06/14/2022, and revised on 02/20/2023 Potential for Dehydration/Inadequate Nutrition R/T [related to] Dysphagia, Cognitive/Communication Deficit, Parkinson's Disease, HTN [hypertension], Hyperlipidemia, Constipation and Dependence on Staff to Provide Food/Fluids. Further review revealed the goal to read [Name of R #18] will consume an average greater than 50% of meals through the review date. Date Initiated: 09/08/2022. Revised on 02/20/2023 Target date: 03/07/2023. [Name of R #18] will receive adequate nutrition/hydration as evidence by stable weight and moist mucosa, through next review. Date initiated: 11/22/22, Revision date: 02/20/2023, Target date: 03/07/2023. Review of the intervention revealed the following: Regular diet, regular texture with thin liquids and house supplements 2.0 90 mL [milliliters] TID [Three Times a Day], 02/20/2023 Offer resident foods within the current diet order and encourage fluids with meals, between meals, and when providing care [not dated] Avoid lying down for at least 1 hour after eating. Keep head of bead elevated. Encourage to stand/sit upright after meals. Date initiated: 09/08/2022 Resident has order for soft bite sized texture modified diet. Date initiated: 06/14/2022 Talk with resident/family and provide information pertaining to the current therapeutic diet. Offer [name of R #18] sandwiches that he prefers like grilled cheese or fried bologna when he does not like the menu options. Send ice cream and fruit with lunch and dinner. Date initiated: 01/13/2023. Further review revealed that R #18 did not have any entries related to medication refusals or depression. L. On 02/23/23 at 2:02 pm, during an interview with the DON, when asked if the resident's refusals of medication and meals, dependence on wife, and increased depression should have been care planned, she confirmed yes.

Based on observation, record review and interview, the facility failed to maintain oxygen equipment according to professional standards for 2 (R #18 and R #24) of 3 (R #14, R #18, and R #24) residents reviewed for respiratory care. This deficient practice could likely result in oxygen tubing not being changed according to the date of install or previous replacement and using humidifier bottles without physician instruction. A. Record review of the facility policy Oxygen Administration, Safety, Mask types- R/S [repiratory system], LTC, [Long Term Care] Therapy & Rehab, last reviewed 06/29/22, revealed Disposable equipment [pieces or parts that are intended to use for a short amount of time and may be easily replaced] should be changed weekly or according to manufacturer's instruction and marked with date and initials. Findings for R #24 B. On 02/19/23 at 11:32 am, during an observation of R #24's oxygen concentrator, the humidifier bottle was observed to be empty. C. Record review of physician orders for R #24 revealed the following orders related to oxygen use: Physician order, dated 10/24/22, Oxygen via nasal cannula 2 liters per minute cont [continuous] via n/c [nasal cannula]. Every shift for COPD [Chronic Obstructive Pulmonary Disease- a group of diseases that cause airflow blockage and breathing-related problems] Physician order, dated 12/28/22, Change oxygen tubing and clean concentrator filter weekly. One time a day every Wed [Wednesday] for SOB [Shortness of Breath] Findings for R #18 D. On 02/19/23 at 2:03 pm, during an observation of R #18's oxygen tubing, it was noted that the oxygen tubing was not labeled as to the date when it was changed or installed. E. Record review of physician orders for R #18 revealed that R #18 did not have supplemental oxygen ordered. F. On 02/22/23 at 3:06 pm, during an interview with Certified Medical Assistant(CMA) #2, when asked to explain the process of maintaining oxygen equipment, she stated I change the tubing out every week. Its usually on Wednesday. I wipe down the concentrator [a device that concentrates the oxygen from a gas supply] to make sure its not clogged. I change the water pack [humidifier bottle] and date the tubing. I make sure everything is working ok. I get the oxygen orders and do the paper work for all the DME [Durable Medical Equipment] When asked if R #24 should have water for her concentrator, she explained that R #24 likes to use the humidifier and sometimes turns up the oxygen flow rate without telling staff. She then explained Sometimes the water bottles last a week but sometimes they run out. If the CNA's (Certified Nursing Assistants) see that it is empty, they should change it too. When asked if R #18 uses oxygen regularly, she explained that he doesn't normally use oxygen and they placed him on oxygen over the weekend while she was off. When asked if the staff who were on shift should have dated his oxygen tubing, she confirmed yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to document a resident's change in condition for 1 (R #18) of 1 (R #18) residents reviewed for a change in condition. This deficient practice could likely result in a negatively impacted continuum of care by nursing staff. A. Record review of the facility's policy titled Charting and Documentation, last reviewed 01/05/2022, revealed the following: Purpose: All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record. All observations, medications administered, services performed, etc., must be documented in the resident's clinical records. All incidents, accidents, or changes in the resident's condition must be recorded Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: a. The date and time the procedure/treatment was provided; b. The name and title of the individual(s) who provided the care; c. The assessment data and/or any unusual findings .; d. How the resident tolerated the procedure/treatment; e. Whether the resident refused the procedure/treatment; f. Notification of family, physician or other staff, if indicated; . B. Record review of R #18's face sheet revealed that R #18 was admitted to the facility on [DATE] with the following pertinent diagnoses: previous fall with traumatic subarachnoid hemorrhage (bleeding within the spaces of the brain, resulting in a traumatic brain injury), Parkinson's disease (brain disorder that causes unintended or uncontrollable movements), and dysphasia, unspecified (swallowing difficulties). C. On 02/19/23 at 2:03 pm, during an observation of R #18, R #18 was observed sleeping in bed with his oxygen cannula (tubing that sits within the nostrils to deliver supplemental oxygen) resting on his chest. His respirations (breaths) were noted to be labored [difficulties while breathing] with a crackle sound accompanied by occasional coughing. D. On 02/19/23 at 2:03 pm, during an interview with Med Tech #1 when asked to measure R #18's oxygen saturation (the amount of oxygen in blood-the normal range is 95%-100%), R #18's oxygen saturation was found to be 77%. E. Record review of Physician orders revealed that R #18 did not have an order for oxygen. F. Record review of R #18's progress notes revealed that no entries were documented related to his recent need for oxygen or change in condition. G. On 02/22/23 at 10:52 pm, during an interview with Registered Nurse (RN) #4, when asked what prompted her to apply oxygen, she explained, That night [02/18/22] I worked and his oxygen saturation dropped so we put him on oxygen, his oxygen saturation was 85. We put him on 2 liters and he (his oxygen saturation level) went up to 92. H. On 02/23/23 at 11:46 am, during an interview with the facility's physician, when asked if he would expect R #18's need for oxygen to be documented in his chart, he replied I would expect that they document the need for oxygen in his chart. It's a change in condition that should be documented. I. On 03/16/23 at 2:14 pm, during an interview with the DON, when asked if the nurse who initially applied oxygen should have documented this occurrence, the DON confirmed yes. When asked if the nurse should have created a Change In Condition assessment when he initially needed oxygen, she confirmed yes. She also explained that a Change In Condition should have been documented and an assessment should have been completed which would allow the nurse to provide an update for the doctor. When asked if she would expect the nurse on the shift of 02/19/23 to notify the doctor when she became aware that R #18 recently needed oxygen, she confirmed yes. When asked if additional monitoring should have occurred, she confirmed yes and explained that if the Change In Condition assessment was initiated, then it would have prompted the nurses to continue to monitor him closely.

Based on interview, observation, and record review, the facility failed to meet professional standards of quality for 1 (R #26) of 2 (R #14 and 26) resident reviewed for resident preferences. This deficient practice could likely result in residents not receiving the option and ability they desire to self treat for mild symptoms. The findings are: A. On 02/20/23 at 12:31 pm, during an interview with R #26, he explained I have this cream [Aspercreme- a pain relief product/rub], I keep it in my bed and I ask the staff to put it between my toes and they refuse, they say I don't have an order for it. When asked how he obtained the cream, he stated My daughter brought it to me. B. On 02/20/23 at 12:31 pm, during an observation of R #26, it was noted that he had a tube of Aspercreme in his bed. C. Record review of R #26's physician orders revealed that he does not have an order for Aspercreme. D. On 02/23/23 at 2:50 pm, during an interview with the Director of Nursing (DON), when asked if he should have an order to keep Aspercreme at bedside, she explained Yes, he should of had an order for it (the Aspercreme) to be at bedside.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to measure, stage (staging helps determine what treatment is best) and document appearance of pressure wounds ulcer (areas of damaged skin caused by pressure, shear or friction) for 2 (R #26, 28) of 2 (R #'s 26, and 28) residents reviewed for pressure ulcers. This deficient practice could likely result in nursing staff being unaware if the wound is healing and if the course of treatment is appropriate causing wounds to worsen. The findings are: Resident #26 A. Record review of the face sheet indicated that R #26 was admitted on [DATE]. Right Heel Wound: B. Record review of the Wound Data Collection dated 11/14/22 indicated the following: Right heel wound Length (L) 4 centimeters (cm), Width (W) 5 cm and Depth (D) 0 and wound bed (describes the wound) was 100% eschar (necrotic tissue that appears black or brown), with minimum, serous drainage (a thin, watery and clear substance exiting the wound). No staging (pressure wounds are divided into 4 stages, from least severe stage 1 to most severe stage 4. A wound is not assigned a stage when there is full-thickness tissue loss and the base of the ulcer is covered by slough or eschar is found in the wound bed) of the wound or was noted to be unstageable (the base of the ulcer needs to be visible in order to properly stage). C. Record review of the Wound Data Collection dated 12/02/22 indicated the following: Right heel wound L 5 centimeters, W 5 cm and D 0.5 cm and the wound bed was 50% granulation tissue (is a pink, fleshy tissue that forms in wounds and helps them heal) and 50% slough (tissue that is yellow or white and can be stringy with thick clumps. It is noted as having heavy, purulent drainage (can be shades of green, yellow or gray, and tend to be rather thick in consistency but can also be thin. This type of drainage often indicates infection of the wound) with moderate brown drainage. The wound assessment did not have any staging or was noted to be unstageable. D. Record review of the Wound Data Collection dated 12/09/22 and 12/25/22 indicated the following: Right heel wound had 0 measurements, 0 documentation for wound bed and no staging. E. Record review of the Wound Data Collection dated 01/07/23, 01/14/23, 01/21/23 and 01/29/23 indicated the following: Right heel wound had 0 measurements, 0 documentation for wound bed and no staging. F. Record review of the Wound Data Collection dated 02/05/23 and 02/12/23 indicated the following: Right heel wound had 0 measurements, 0 documentation for wound bed and no staging. Left Heel Wound: G. Record review of the Wound Data Collection dated 11/14/22 indicated the following: Left heel wound L 3 cm, W 3 cm and D is 0 100% eschar. No staging for the wound or was noted to be unstageable. H. Record review of the Wound Data Collection dated: 12/02/22 indicated the following: Left heel wound L 2 cm, W 3 cm and D 0, wound bed was 100% eschar. 12/10/22 indicated the following: Left heel wound L 2.2 cm, W 2.5 cm and D 0, wound bed was 100% eschar. 12/05/22, 12/12/22 and 12/29/22 indicated the following: Left heel wound had 0 measurements, 0 documentation for wound bed and there was no staging or was noted to be unstageable for any of the above assessments. Vertebrae Wound: I. Record review of the Wound Data Collection dated 11/14/22 indicated the following: Vertebrae (upper mid) L 2.7 cm W 1.5 and D .1 and the wound bed was 100% slough. No staging was noted for the wound or was noted to be unstageable. J. Record review of the Wound Data Collection dated: 11/22/22 indicated the following: Vertebrae (upper mid) dated 11/22/22 noted L 8 cm W 2.5 and D 0. Nothing was noted for the wound bed or what stage the wound was. 11/28/22 the wound was noted as L 4 cm, W 3 cm and D1, it was 10% epithelialized (new or pink tissue) 10% granulation and 80% slough minimum, serosanguineous drainage (It is thin, watery and tends to be pink in color, but can also be shades of darker red). No staging was noted for the wound or was noted to be unstageable. K. Record review of the Wound Data Collection dated: 12/04/22 indicated the following: Vertebrae (upper mid) L 5 cm W 3 and D 0 and the wound bed was 100% slough but there was no staging. 12/14/22 and 12/25/22 there was 0 documentation for wound measurements no wound bed description or staging. 12/29/22 the Vertebrae was noted as L 5.3 cm, W 1.8 and D is 0 and nothing noted for the wound bed or staging or was noted to be unstageable. Sacrum Wound: L. Record review of the Wound Data Collection dated: 11/14/22 indicated the following: Sacrum wound L 3 cm, W 1.7 cm and D 0.5 cm 100% slough with heavy purulent drainage. 11/28/22 L 5.0 cm W 7.5 cm and D 0 nothing is noted for the wound bed and no staging of the wound or was noted to be unstageable. M. Record review of the Wound Data Collection dated: 12/04/22 indicated the following: Sacrum wound L 2 cm, W 3 cm and D 0 cm and the wound bed was 100% slough. 12/14/22 and 12/25/22 did not have measurements and nothing noted for the wound bed. 12/29/22 the Sacrum wound was noted to be L 2 cm, W 1.8 cm and D 0, nothing noted for the wound bed. None of the above assessments had the wound staging or was noted to be unstageable. N. Record review of the Wound Data Collection dated 01/07/23, 01/14/23 and 01/21/23 indicated the following: there were no measurements and nothing noted for the wound bed or staging. Resident #28 O. Record review of the face sheet indicated that on 01/25/23 re-admission from the hospital R #28 had a pressure wound on his left heel that was documented to be a stage II (the sore area of your skin has broken through the top layer of skin and some of the layer below). P. Record review of the Wound Data assessment dated [DATE] indicated that for the left heel wound there are no measurements and nothing documented for the wound bed or staging. Q. Record review of the Wound Data Assessment on 02/11/23, 02/18/23, 02/21/23 indicated that for the left heel there were no measurements and nothing documented for the wound bed or staging. R. On 02/22/23 at 9:16 am, during an interview with Registered Nurse (RN) #1, she stated that she was unaware until today (02/22/23) that there was a wound assessment she was supposed to be filling out. She stated that the wound assessment should be done with measurements every time you look at it. S. On 02/23/23 at 12:00 pm, during an interview with the Director of Nursing (DON) she stated that she checked into the wound documentation and realized that the documentation wasn't getting done for the wounds and it should be. She stated that she spoke with one of the nurses and she was told that the previous DON was doing all of the wound care and measurements and staging so the nurses weren't doing that piece of it that is why it hasn't been getting done. T. On 02/23/23 at 12:11 pm, during an interview with Licensed Practical Nurse (LPN) #1 she stated that she is not allowed to stage wounds only an RN can stage. She stated that the previous DON told them not to do measurements and staging, so they didn't. She agreed that wounds should be measured weekly. When asked about the staging of R #26's wounds it wasn't clear, but documentation indicated that the right heel is still being treated as a stage 4. Left heel is still being treated but is almost healed. The Sacrum wound is healed and there was no information presented about the Vertebrae wound. U. Record Review of [NAME] Policy for Pressure Ulcer/Wound Care dated 05/26/22 indicated in the forms section Wound Data Collection UDA is required for documenting daily monitoring, at least weekly when skin integrity is impaired or open area is present (i.e., pressure ulcer, surgical wound, venous ulcer) and is required to be used daily and with every treatment for documenting observations of skilled service for Medicare or other third-party payer's reimbursement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to document in a manner that would demonstrate the physician's decisions about a resident's course of treatment for 3 (R #'s 14, 18, and 20) of 3 (R #'s 14, 18, and 20) residents reviewed for physician services. This deficient practice could likely result in residents receiving unnecessary medication and/or not receiving the appropriate care to meet the residents needs. The findings are: A. Record review of the facility policy titled Physician Visits, last reviewed 12/30/20, revealed At the time of the physician's visit, the physician must review the resident's total program of care, including medications and treatments, and also write, sign and date the progress notes and review, sign and date all orders. Findings for R #20: B. Record review of R #20's order recap report (summary of all diagnosis, medications that were orders, medications that were discontinued and shows any monitoring that has occurred) dated 02/23/23 revealed she (R #20) was admitted to the facility on [DATE] with multiple diagnosis including, but this is not an all-inclusive list; Altered mental status, unspecified (An altered mental status isn't a specific disease. It's a change in mental function that stems from illnesses, disorders and injuries affecting your brain. It leads to changes in awareness, movement, and behaviors), unspecified dementia, unspecified severity (A condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems. Symptoms may also include personality changes and emotional problems). C. Record Review of R #20's Order recap Report revealed: -Physician's order, dated 09/16/22 for Haloperidol tablet 5 mg (milligrams), give 5 mg by mouth every 4 hours as needed for anxiety/agitation, discontinued on 11/29/22 -Physician's order, dated 12/06/22 for Haloperidol tablet 5 mg (milligrams), give 1 tablet by mouth every 4 hours as needed for anxiety and agitation . discontinued on 01/22/23 -Physician's order, dated 01/22/23 for Haloperidol oral tablet 5 mg (milligrams), give 1 tablet by mouth every 4 hours as needed for agitation/anxiety, discontinued on 02/11/23 -Physician's order, dated 02/11/23 for Haloperidol oral tablet 5 mg (milligrams), give 1 tablet by mouth every 4 hours as needed for agitation/anxiety for 14 days, discontinued on 02/25/23 D. Record Review of the EMAR/ETAR (Electronic Medication Administration Record/Treatment medication administration) on 02/21/23 revealed R #20 was not being monitored by the staff for any behaviors, or side effects Haloperidol might have cause. E. Record review of R #20's provider notes revealed the following: Physician note, dated 12/21/22, revealed the following: Chief Complaint/Nature of presenting Problem: UTI (Urinary Tract Infection), History of Present Illness: advanced dementia- no new issues, settled in- no new concerns or behaviors . Diagnosis, Assessment and Plan: no entries were documented related to how the physician plans to treat each diagnosis, concern, or need for Haloperidol. Physician note, dated 02/20/23, revealed the following: Chief Complaint/Nature of presenting Problem: UTI, History of Present Illness: advanced dementia- no new issues, settled in- no new concerns or behaviors . Diagnosis, Assessment and Plan: no entries were documented related to how the physician plans to treat each diagnosis, concern, or need for Haloperidol. Findings for R #14: F. Record review of a nursing progress note dated 01/24/23 revealed a note indicating a behavior that Resident was very paranoid and asked this nurse to retake her COVID test because she wants to see that she is positive and that we are lying (meaning that R #14 didn't believe that she had tested positive for COVID and wanted to see the test and felt that staff were lying to her). This note indicated that this behavior supported the need for Seroquel [antipsychotic medication used to treat certain mental/mood conditions like schizophrenia, bipolar disorder, and depression] G. Record review of R #14's Order Recap Report revealed the following: -Physician order, dated 11/28/22, for Seroquel tablet 25 MG give 12.5 mg by mouth at bedtime for mood disorder, discontinued on 02/11/23 -Physician order, dated 02/11/23, for Seroquel tablet 25 MG give 12.5 mg by mouth at bedtime for Schizo-Affective disorder [Schizo-affective disorder is a rare and complex mental illness that combines schizophrenia and a mood disorder] H. Record Review of providers progress notes, hospital history, and diagnoses revealed that R#14 did not have documentation to support the diagnosis for Schizo-Affective disorder. I. Record review of the pharmacy recommendation, dated 02/13/23, revealed This resident is receiving the antipsychotic Seroquel. An antipsychotic medication should only be used for the following conditions/diagnosis. Please check the appropriate indication for this resident The Medical Director/Physician's response was Schizo- Affective disorder accompanied by a hand-written note Med records/HIM [Health Information Management] needs to add DX [diagnosis] J. Record review of physician notes for R #14 revealed the following: Physician note, dated 12/21/22, revealed the following: Chief Complaint/Nature of presenting Problem: LTC [Long-Term Care], History of Present Illness: doing well- ltc- no new complaints- mood stable- resigned to stay . Diagnosis, Assessment and Plan: no entries were documented related to how the physician plans to treat each diagnosis, concern, or the need for Seroquel. Physician note, dated 02/20/23, revealed the following: Chief Complaint/Nature of presenting Problem: ltc, History of Present Illness: no new issues . Diagnosis, Assessment and Plan: no entries were documented related to how the physician plans to treat each diagnosis, concern, or the need for Seroquel K. On 02/23/23 at 3:08 pm, during an interview, the Director of Nursing (DON) was asked if it was appropriate to give Seroquel for a resident who made a comment to a nurse that she wanted to see her COVID test so she would know if nursing staff was lying. DON stated it would depend on who the resident was, and what their diagnosis was. I wouldn't give them a PRN for that, no. DON didn't state that R#14 had any other behaviors. Findings for R #18: L. Record review of R #18's face sheet revealed that R #18 was admitted to the facility on [DATE] with the following pertinent diagnosis: previous fall with traumatic subarachnoid hemorrhage (bleeding within the spaces of the brain, resulting in a traumatic brain injury), Parkinson's disease (brain disorder that causes unintended or uncontrollable movements), and dysphagia, unspecified (swallowing difficulties). M. Record review of R #18's Medication Administration Records (MARs) revealed the following: -In October of 2022, R #18 was prescribed the following medications: Carbidopa/levodopa for Parkinson's, Lisinopril for hypertension, Prazosin for night terrors, Senna tablet for constipation, and House supplement 2.0 for weight stabilization. Further review of the October MAR revealed that R #18 refused medication 40 times out of 279 opportunities to receive medications. -In November of 2022, R #18's prescriptions did not change. Further review of the November MAR revealed that R #18 refused medication 43 times out of 330 opportunities to receive medications. -In December 2022, R #18's prescriptions did not change. Further review of the December MAR revealed that R #18 refused medication 45 times out of 341 opportunities to receive medications. -In January 2023, R #18 continued to receive Carbidopa/levodopa, Lisinopril, Prazosin, and Senna. He was no longer ordered to receive the House supplement 2.0. Further review revealed that R #18 received a new order for Lactulose for constipation and Pepcid for GERD (Gastroesophageal reflux disease- when stomach acid repeatedly flows back into the esophagus). Further review of the January MAR revealed that R #18 refused medication 52 times out of 372 opportunities to receive medications. -In February 2023, R #18 continued to receive Carbidopa/levodopa, Lisinopril, Prazosin, Lactulose, Pepcid and [NAME]. Further review of the February MAR revealed that R #18 refused medication 90 times out of 190 opportunities to receive medications. N. Record review of nutritional documentation revealed the following: 06/15/22- (as documented by the dietitian) At risk for malnutrition. Inadequate nutrient intake: calorie, fluid, and protein. PO [meal intake by mouth] intake 25-20% CBW [Current Body Weight]: 143. Nutrition Interventions: . Food preferences addressed and PO is encouraged. Nursing is monitoring tissue integrity. Will continue and proceed as physician directs. Rec [recommend]: Medpass 2.0 @ 60 ml [milliliter] TID [three times a day] to provide 360 kcal [calorie] and 15 gram protein. 08/31/22- (as documented by the dietitian) PO intake 25-50% CBW: 144.6.Food preferences addressed and PO is encouraged. Nursing is monitoring tissue integrity. Will continue and proceed as physician directs. 10/19/22- (as documented by the dietitian) PO intake 25-50% CB: 128.2.Nursing also reports that resident is eating meals brought in from spouse. Reweigh is requested . Recd: House supplement 2.0 @ 90 ml TID to provide 540 kcal and 22 gram protein. [If on 08/31/22, the resident weighed 144.6 pounds and on 10/19/22, the resident weighed 128.2 pounds, this is a weight loss of 11.34 %- resulting in a significant weight change] 11/9/22- (as documented by the dietitian) PO intake 25-50% CBW: 168.2.Food preferences addressed and PO is encouraged. Nursing is monitoring tissue integrity. Nursing also reports that resident is eating meals brought in from spouse. Reweigh is requested. Will continue and proceed as physician directs. [On 10/19/2022, the resident weighed 128.2 lbs. On 11/09/2022, the resident weighed 168.2 pounds which is a 31.20 % gain- resulting in a significant weight change] 12/07/22- (as documented by the dietitian) PO intake 25-50% CBW: 131.4. Weight fluctuations are questionable. Supplement is in place. Reweigh is requested . [On 11/08/2022, the resident weighed 168.2 lbs. On 12/07/2022, the resident weighed 131.4 pounds which is a -21.88 % Loss- resulting in a significant weight change] 02/09/23- (as documented by dietary staff) . Dietary staff have been directed to send extra servings of ice cream and fruit at meals. They also offer [name of R #18] the choices of grilled cheese or bologna sandwiches if he does not like either selection offered as these are food items that he does prefer O. Record review of R #18's EHR (Electronic Health Record) revealed his weight to be: 06/10/22- 143.0 pounds (weighed with a wheel chair) 08/13/22- 144.6 pounds (weighed with a wheel chair) 09/14/22- 149 pounds (not indicated if wheel chair was present or not) 10/11/22- 128.2 pounds (not indicated if wheel chair was present or not) 11/09/22- 168 pounds (not indicated if wheel chair was present or not) 12/14/22- 131 pounds (not indicated if wheel chair was present or not) 01/03/23- 123.8 pounds (weighed with a wheel chair) P. Record review of nursing notes revealed that R #18 tested positive for COVID (a highly contagious disease that causes illnesses such as the common cold and severe acute respiratory syndrome) on 01/25/23. Further review revealed that no significant signs or symptoms were documented while he was COVID (+). Q. Record review of physician notes for R #18 revealed the following: Physician visit, dated 06/22/23, Chief complaint/Nature of presenting problem- ams [Altered Mental Status] . Diagnosis, Assessment and Plan: no entries were documented related to how the physician plans to treat each diagnosis or concern. Physician visit, dated 07/25/22, Chief complaint/Nature of presenting problem- ams . Diagnosis, Assessment and Plan: no entries were documented related to how the physician plans to treat each diagnosis or concern. Physician visit, dated 09/07/22, Chief complaint/Nature of presenting problem- ams . History of Present Illness: tbi/sah [traumatic brain injury/subarachnoid hemorrhage]- still weak and confused- can't answer questions . Diagnosis, Assessment and Plan: no entries were documented related to how the physician plans to treat each diagnosis or concern. Physician visit, dated 10/03/22, Chief complaint/Nature of presenting problem- LTC [Long-Term Care] . History of Present Illness: refuses care frequently, family aware . Diagnosis, Assessment and Plan: no entries were documented related to how the physician plans to treat each diagnosis or concern. Physician visit, dated 11/17/22, Chief complaint/Nature of presenting problem- ams . Diagnosis, Assessment and Plan: no entries were documented related to how the physician plans to treat each diagnosis or concern. Physician visit, dated 01/10/23, Chief complaint/Nature of presenting problem- ams . Diagnosis, Assessment and Plan: no entries were documented related to how the physician plans to treat each diagnosis or concern. R. On 03/20/23 at 2:56 pm, during an interview with the DON, she explained the following for R #20, R #14 and R #49: When asked if the physician progress notes for R #20 should have information regarding the need for antipsychotic medications, she explained For verbal orders, I don't know if he makes notes for everything especially if its a verbal. I would expect it [notes explaining the need for an antipsychotic] from the nurses but I don't see those type of notes from the physician. I don't know if he writes a note on everything they call him for. When asked if R #14 has a diagnosis of Schizo-Affective disorder, she confirmed no. When asked why R #14 has an order of Seroquel for Schizo-Affective disorder, she explained that she wasn't sure why that diagnosis would be tied to that order. When asked if the physician documented in his physician notes why R #14 would have this medication, she confirmed no. She then explained that the physician will ask Medical Records to add a diagnosis to the residents chart [as noted in the pharmacy recommendation]. When asked if this was the appropriate process to diagnose a resident with a mental health condition, she explained I don't know if its a good process but its what has been taking place. I know that that's how he has done it. When asked if R #18 should have physician notes related to his weight loss, she explained It surprises me [that lack of detail] because we had a big discussion about his weight loss. I don't know why he doesn't do his notes to reflect that [resident status] or what he feels is appropriate. I know he goes through hospital H&P and he will sign off on things but I don't know what constitutes his notes. When asked if R #18 should have additional detail of depression and refusals in his physician notes, she explained, I would of liked to see those notes but I don't know his typical practice. As nurses, I will document to ensure the quality of my work and responsibility. My expectations is that the nurses document as well. I would love to see more notes from the physician. When asked if the physician's notes demonstrate information of his thought process and rational for the course of a residents treatment, she confirmed no.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide behavioral health services for 2 (R #14 and R #18) of 2 (R #14 and R #18) residents reviewed for behavioral health and the use of antipsychotic medications. This deficient practice could likely result in residents not receiving person centered care to evaluate, diagnose, and treat signs or symptoms of depression and/or other mental health conditions. The findings are: Findings for R #18: A. Record review of R #18's face sheet reveled that R #18 was admitted to the facility on [DATE] with the following pertinent diagnosis: previous fall with traumatic subarachnoid hemorrhage (bleeding within the spaces of the brain, resulting in a traumatic brain injury), Parkinson's disease (brain disorder that causes unintended or uncontrollable movements), and dysphagia, unspecified (swallowing difficulties). B. On 02/21/23 at 4:30 pm, during an interview with Certified Nurse Assistant (CNA) #2, when asked to explain R #18's needs and compliance with care, he stated He was very rebellious. He was a very light speaker when it came to asking for help. He would refuse meals, medicines, weights, vitals, it was frustrating because we were trying to get the best and it was a struggle for him. When asked what type of assistance he needed during meal times, he explained He was set up only [meals are to be prepared and presented to the resident for easy consumption]. Then, one day, he just didn't want to eat. It was hard to watch this because I knew his capabilities. I think he missed his wife and being outside. He wasn't a guy to speak on his feelings but I could see it in him. When asked how long he was refusing meals, he explained It had been a while since he was refusing meals, like a month. There were times when he would eat then the next day not eat. It was like the same for getting out of bed and getting to the restroom and showers . We would present stuff to him and he would just refuse. He was set up [level of assistance] until about a month ago. I don't know if he went on the list for needing assistance for eating but we let the nurse know. C. On 02/22/23 at 8:44 am, during an interview with Registered Nurse (RN) #2, when asked to explain what he can remember about R #18's needs, he explained that he needed assistance with His medications, vitals, pain, and his food. He cant swallow. I was monitoring if he was eating or not. Every week when I was here I would ask him and the CNA if he was eating. He refused his meds. Usually, I talk to [name of physician], I tell him that this resident was refusing his meds. We encouraged him and I spoke to the DON [Director of Nursing] about it. I let the family know. [Name of physician] suggested I ask him [R #18] why and if he want to change or crush his medications but he said he didn't want to take it at all even if we crushed it. Sometimes he took it from me. We would double check his mental status for dementia. We tried to change his food texture orders but he refused. We told [name of physician] about hospice. He then explained On my shift, last week, he was not on oxygen, he was alert and oriented but not eating or taking his medications. I asked him why he doesn't want to eat- he just said 'I don't want to'. Last week I didn't see any abnormalities just his refusals to eat and take meds. He didn't want to get out of bed. I encouraged him and he said he was not interested. I didn't feel like he was in a bad situation. his mentality was not changing. I didn't see any abnormalities. D. On 02/22/23 at 10:52 pm, during an interview with RN #4, when asked to explain R #18, she stated He was not compliant with his medications. He would refuse them. I would try to coax [persuade] him to take them but then he would get very adamant that he wasn't going to take them. One night he would take them and the other night he wouldn't. E. On 02/22/23 at 10:18 am, during an interview with CNA #1, when asked to explain R #18 and his needs, he stated When I first got here, he would get out of bed and go to the bathroom by himself. He would do better when his wife was here and then if his wife wasn't here, he wouldn't want to get out of bed or get a shower. He wouldn't eat unless his wife was here. The last couple weeks he didn't want to eat or drink at all. When his wife was here, she would say that he barely ate for her too. He started being incontinent like, 2-3 weeks back. When asked to explain how he would assist during meal times, CNA #1 stated I would cut it for him put it on his fork and encourage him then try to give him some bites. He didn't like it. He would ask for fruits that he had. I would try to encourage him then I fed him like a full assist. The encouragement started about 4-6 weeks ago. The full assist was like 2 weeks ago. Towards the end he was full assist for eating. That was also the time he really almost refused to eat anything. So we were giving him more and more encouragement. F. Record review of physician orders revealed that R #18 did not have orders for an antidepressant or a psychiatric referral. G. Record review of R #18's Medication Administration Records (MARs) revealed the following medication refusals: October 2022- R #18 refused medication 40 times out of 279 opportunities to receive medications. November 2022- R #18 refused medication 43 times out of 330 opportunities to receive medications. December 2022- R #18 refused medication 45 times out of 341 opportunities to receive medications. January 2023- R #18 refused medication 52 times out of 372 opportunities to receive medications. February 2023- R #18 refused medication 90 times out of 190 opportunities to receive medications. H. Record review of R #18's EHR (Electronic Health Record) revealed his weight to be: 06/10/22- 143.0 pounds (weighed with a wheel chair) 08/13/22- 144.6 pounds (weighed with a wheel chair) 09/14/22- 149 pounds (not indicated if wheel chair was present or not) 12/14/22- 131 pounds (not indicated if wheel chair was present or not) 01/03/23- 123.8 pounds (weighed with a wheel chair) I. Record review of R #18's care plan revealed that resident's refusals of medication and meals, dependence on wife, and increased depression were not mentioned in his care plan. J. Record review of care conference notes revealed the following: Care conference note dated 09/28/22, revealed Resident spoke and stated that he had a terrible night last night, felt like he could not breath . It was also noted by MDS (Minimum Data Set) that resident's anti-Parkinson's medication is known for causing vivid dreams and nightmares. Resident expressed his desire to live a long life . K. On 02/22/23 at 1:44 pm, during an interview with the Director of Nursing(DON), when asked to explain R #18's needs and care, she stated, He was refusing medications and food. It was tough, he came in and was doing ok. He was very dependant on his wife. He always refused the food. Then his wife would come less and he seemed to be angry and depressed. Then he got COVID [an infectious disease that causes a respiratory illness and in some cases can lead to death] and I think it made him more depressed. He was refusing everything. He pushed things away. His decline started before COVID, he was refusing before COVID. When asked why his symptoms of depression were not addressed she explained that, that decision is up to the doctor. L. On 02/23/23 at 11:46 am, during an interview with the facility's physician, when asked why R #18 was not being treated for depression, he explained He [R #18] was demented and had a head injury. I considered it [prescribing an antidepressant] and it didn't seem beneficial, especially if he was noncompliant [refusing medications], it wouldn't work. M. On 02/23/23 at 2:02 pm, during an interview with the DON, when asked if the resident's refusals of medication and meals, dependence on wife, and increased depression should have been care planned, she confirmed yes. N. On 02/28/23 at 10:35 am, during an interview with R #18's wife, when asked if she wanted R #18 to go to the hospital on [DATE], she explained No, he was already down low [depressed] and he couldn't talk. He told me that he was ready to go . He couldn't hold up anymore. He was very down, he would just bow his head . He told me 'it was time for me, just let me be', he just went down so fast. He wanted to go, he didn't want to suffer anymore, what he was going through with his Parkinson's. O. On 03/15/23 at 3:46 pm, during an interview with the Director of Therapy, she explained that R #18 began to express signs of failure to thrive after he was placed in isolation and unable to have regular visitations from his wife. His desire to participate in therapy decreased more and more which caused him to become weaker along with his poor meal intake. She then explained that before COVID, he didn't have coordination for fine motor skills but he was able to get out of bed with stand-by assistance/contact guard (the resident would be able to stand without hands-on assistance but staff would be next to him to ensure safe movement). After COVID, he was minimal assistance and sometimes moderate assistance. Findings for R #14: P. Record review of a nursing progress note dated 01/24/23 revealed a note indicating a behavior that Resident was very paranoid and asked this nurse to retake her COVID test because she wants to see that she is positive and that we are lying (meaning that R #14 didn't believe that she had tested positive for COVID and wanted to see the test and felt that staff were lying to her). This note indicated that this behavior supported the need for Seroquel [antipsychotic medication used to treat certain mental/mood conditions like schizophrenia, bipolar disorder, and depression] Q. Record review of R #14's Order Recap Report revealed the following: -Physician order, dated 11/28/22, for Seroquel tablet 25 MG give 12.5 mg by mouth at bedtime for mood disorder, discontinued on 02/11/23 -Physician order, dated 02/11/23, for Seroquel tablet 25 MG give 12.5 mg by mouth at bedtime for Schizo-Affective disorder [Schizo-affective disorder is a rare and complex mental illness that combines schizophrenia and a mood disorder] R. Record Review of providers progress notes, hospital history, and diagnoses revealed that R#14 did not have documentation to support the diagnosis for Schizo-Affective disorder. S. Record review of the pharmacy recommendation, dated 02/13/23, revealed This resident is receiving the antipsychotic Seroquel. An antipsychotic medication should only be used for the following conditions/diagnosis. Please check the appropriate indication for this resident The Medical Director/Physician's response was Schizo- Affective disorder accompanied by a hand-written note Med records/HIM [Health Information Management] needs to add DX [diagnosis] T. On 02/23/23 at 3:08 pm, during an interview, the DON was asked if it was appropriate to give Seroquel for a resident who made a comment to a nurse that she wanted to see her COVID test so she would know if nursing staff was lying. The DON stated it would depend on who the resident was, and what their diagnosis was. I wouldn't give them a PRN for that, no. The DON did not state that R#14 had any other behaviors. U. On 03/20/23 at 2:56 pm, during an interview with the DON, she explained the following: When asked if R #14 has a diagnosis of Schizo-Affective disorder, she confirmed no. When asked why R #14 has an order of Seroquel for Schizo-Affective disorder, she explained that she wasn't sure why that diagnosis would be tied to that order. When asked if the physician documented in his physician notes why R #14 would have this medication, she confirmed no. She then explained that the physician will ask Medical Records to add a diagnosis to the residents chart [as noted in the pharmacy recommendation]. When asked if this was the appropriate process to diagnose a resident with a mental health condition, she explained I don't know if its a good process but its what has been taking place. I know that that's how he has done it. When asked if R #14 and 18 were referred to psych services to be evaluated for depression or Schizo-Affective disorder, she explained We don't have psych services here. I don't know why. I think our administrator is trying to arrange for psych services via telehealth

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Findings for R #20: F. Record review of R #20's order recap report (summary of all diagnosis, medications that were orders, medications that were discontinued and shows any monitoring that has occurred) dated 02/23/23 revealed she was admitted to the facility on [DATE] with multiple diagnosis including, but this is not an all-inclusive list; Altered mental status, unspecified (An altered mental status isn't a specific disease. It's a change in mental function that stems from illnesses, disorders and injuries affecting your brain. It leads to changes in awareness, movement, and behaviors), unspecified dementia, unspecified severity (A condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems. Symptoms may also include personality changes and emotional problems). G. Record review of the facility policy titled Psychotropic Medications-Rehab/Skilled, dated 12/09/22. Policy states Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record (each resident's drug therapy must be free from unnecessary drugs. This includes drugs used in excessive doses, excessive durations, without adequate monitoring, without the right indications for use, in the presence of adverse consequences or any combination of these). PRN orders for psychotropic drugs are limited to 14 days. H. Record review of R #20's physician orders dated 02/11/23 revealed an order for the administration of Haloperidol (medication prescribed to treat certain mental/health disorders) oral tablet 5 MG every 4 hours PRN [as needed] for agitation/anxiety. This order had an end date of 02/25/23. I. Record review of R #20's provider notes dated 12/21/22 revealed that the Medical Director/Physician did not assess R #20 for the use of Haloperidol, which was prescribed for 14 days from 02/11/23. Nurse #1 stated in the record it was a verbal order she was given by the Medical Director/Physician dated for 02/11/23. J. Record Review of the EMAR/ETAR (Electronic Medication Administration Record/Treatment medication administration) on 02/21/23 revealed R #20 was not being monitored by the staff for any behaviors, or side effects Haloperidol might have cause. Findings for R #8: K. Record review of R #8 order recap report dated 02/23/23 revealed R #8 was admitted to the facility on [DATE] with multiple diagnoses including (not an all-inclusive list); anxiety disorder, unspecified (anxiety or phobias that don't meet the exact criteria for any other anxiety disorders but are significant enough to be distressing and disruptive) and restlessness and agitation (can be a normal physiological process related to specific situations, but it can also entail an underlying disease). L. Record review of R #8's physicians orders dated 02/12/23 revealed a verbal PRN order for Lorazepam [a benzodiazepine used to treat anxiety agent] tablet 0.5 mg give 1 tablet by mouth every 6 hours as needed for Restlessness and Agitation for 30 days, review in 30 days. M. Record review of R #8 order recap dated 02/23/23 at 2:51 pm revealed resident is taking Seroquel (a medication used to treat mental disorders such as depression-a mood disorder that causes a persistent feeling of sadness and loss of interest and schizophrenia-a serious mental disorder in which people interpret reality abnormally) 25 mg by mouth at bedtime for Schizo-Affective (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations-an experience in which you see, hear, feel, or smell something that does not exist or delusions-a false belief that conflicts with reality, and mood disorder symptoms, such as depression). R #8 had no supporting diagnoses in her Electronic Medical Record (EMR). N. Record review of policy and procedure titled, Psychotropic Medications dated 12/09/22 stated to obtain an order for an appropriate medication, in an appropriate dose and corresponding diagnosis, as well as medical symptoms from the Medical Director/Physician. Policy states Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record (each resident's drug therapy must be free from unnecessary drugs. This includes drugs used in excessive doses, excessive durations, without adequate monitoring, without the right indications for use, in the presence of adverse consequences or any combination of these). O. Record review of R #8's Pharmacists Consultation Report dated 02/22/23 revealed: Comment (Name of R #8) has a PRN order for a Lorazepam 0.5 mg PRN for restlessness, an anxiolytic (a medication used to reduce anxiety), which has been in place for greater than 14 days with a stop date greater than 14 days. Recommendation: If the medication cannot be discontinued at this time, current recommendations require that the prescriber (medical provider/physician) document the indication for use, the intended duration of the therapy, and the rationale for the extended time frame. Rational for recommendation: (Initials of federal regulatory agency) requires that PRN orders for non-antipsychotic drugs be limited to 14 days unless the prescriber documents the diagnosed specific condition being treated, the rational for the extended time frame and the duration for the PRN order. P. Record review of R #8's EMARS/ETARS (Electronic Medication Administration Record/Treatment Electronic Medication Record) dated 02/23/23 revealed no documentation of observations of mood, symptoms or behaviors that might cause the resident distress or endanger the resident or others in response to interventions used when taking Lorazepam. Q. On 02/23/23 at 3:08 pm, during an interview, the DON was interviewed about the antipsychotic medication (lorazapam) that was being given PRN, when asked would you look at the orders for this medication? When would this medication be reviewed? DON stated, Our Doc would give a look at the recommendation and order it again. DON stated, They are made PRN for 14 days unless there's an exclusion of some sort. When DON was asked if the physician came and physically laid eyes on the resident before any changes or adjustments were made. DON answered, (Name of Physician) will review the pharmacy recommendations and the nurses will let him know about behaviors. We will adjust after that. DON was asked if it was okay to get a verbal on any of the pharmacy recommendations for an antipsychotic that is PRN? DON answered, No. (Name of Physician) comes in every Tuesday or at least weekly to go over the medical recommendations. During the interview the DON was asked if monitoring behaviors, or any side effects while on an antipsychotic was expected? DON answered that they put them in MDS (Minimum Data Set), and didn't specify what they should be monitoring for. She also stated, The care plans show if the medication is effective or not. Nothing was noted in the order set regarding monitoring for behaviors or side effects, for R #8 DON was asked if a resident should be treated for a diagnosis that is not confirmed or has no history of having. She stated, No. R. On 02/23/23 at 3:08 pm, during an interview, with LPN (Licence Practical Nurse) #1 she was questioned on what an exclusion (the process or state of excluding or being excluded) would consist of. Her statement was If it was stated in the pharmacy recommendation or the Doctor put down no changes would be an exclusion. this was asked because the medication being given (lorazapam) was ordered for 30 days instead of 14 days for an as needed order. Findings for R #14 S. Record review of the physician order dated 02/11/23 revealed resident is taking the medication Seroquel [medication used to treat certain mental/mood conditions] 25 MG (milligrams) tablet by mouth at bedtimes. The diagnosis for this medication is Schizo-Affective disorder [Schizo-affective disorder is a rare and complex mental illness that combines schizophrenia and a mood disorder] which was on the physician order. T. Record Review of providers progress notes, hospital history, and diagnoses R#14 had no documentation to support the diagnosis for Schizo-Affective disorder. U. Record review of the pharmacy recommendation dated 02/13/23 made by the pharmacist to the facility asked the provider what the choice of diagnosis was to be attached to the order. Medical Director/Physician checked the box Schizo- Affective disorder. On 02/11/23, Medical Director/Physician gave a verbal order to change the diagnosis, and to order the PRN (as needed) medication V. Record review of a nursing progress note dated 01/24/23 revealed a note indicating a behavior that Resident was very paranoid and asked this nurse to retake her COVID test because she wants to see that she is positive and that we are lying (meaning that R #14 didn't believe that she had tested positive for COVID and wanted to see the test and felt that staff were lying to her). This note indicated that this behavior supported the need for Seroquel. W. Record review of the EMAR/ETAR revealed R #14 was not being monitored for behaviors. X. On 02/23/23 at 3:08 pm, during an interview, the DON was asked if it was appropriate to give Seroquel for a resident who made a comment to a nurse that she wanted to see her COVID test so she would know if nursing staff was lying. DON stated it would depend on who the resident was, and what their diagnosis was. I wouldn't give them a PRN for that, no. DON didn't state that R #14 had any other behaviors. Based on record review and interview, the facility failed to maintain a process to monitor resident behavior after prescribing a psychotropic medication (a medication that alters the chemical makeup of the brain and nervous system) to determine effectiveness for 4 (R #8, R #14, R #20 and R #22) of 7 (R #5, R #8, R #14, R #20, R #22, R #24, and R #134) residents reviewed for unnecessary medications. This deficient practice could likely result in residents being administered psychotropic medications they do not need, experience potential unnecessary drug interactions and/or adverse side effects. The findings are: A. Record review of the facility's policy Psychotropic Drug Monitoring, Antipsychotic, LTC (Long Term Care)- Hillsbor, last reviewed 12/13/22, revealed: Procedure: . 6. When antipsychotic therapy is initiated, the resident is monitored to determine the effectiveness of the medication and the presence of adverse reactions . 8. Residents being monitored by the Psychiatric consult will be seen at appropriately scheduled intervals to monitor the effectiveness of medication regimen, change in behavior, and benefits/risks associated with medication use. 9. Licensed nursing staff will be responsible for monitoring for side effects of medications and updating the provider and/or Psychiatric consult as appropriate. 10. Target behaviors will be monitored on a Behavior Log as appropriate, for resident's receiving psychotropic medications. a) Behavior Logs are reviewed by the psychiatric service consult and PRN (as needed) by licensed staff. Further review revealed: Duration of use for a PRN non-antipsychotic medication will be no greater than 14-days, unless otherwise specified by the attending physician or other prescriber. The attending physician or other prescriber may extend the PRN non-antipsychotic psychotic order beyond 14-days if they believe it is medically necessary and document their clinical rationale in the resident's medical record. Resident symptoms and therapeutic goals must be identified and documented. Medical record must clearly document that a resident distress persists and their quality of life is negatively impacted. Facility staff will contact prescriber to obtain a 14-day stop if: The duration of use for the PRN non- antipsychotic psychotropic medication is extended beyond 14-days with no clinical rationale. Duration of use for an antipsychotic psychotropic medication will be no greater than 14-days regardless if specified otherwise by the attending physician or other prescriber. The PRN antipsychotic psychotropic medication may only be reordered after clinical assessment by the attending physician or other provider. Findings for R #22 B. Record review of R #22's face sheet revealed that R #22 was admitted to the facility on [DATE] with a diagnosis of anxiety disorder, unspecified (having feelings of distress, fear, and worry) C. Record review of R #22's physician orders revealed the following: * Physician order dated 01/26/23, Lexapro Oral (Escitalopram Oxalate) [an antidepressant medication]- Tablet 20 MG (Milligram)- Give 1 tablet by mouth one time a day for anxiety. * Physician order dated 02/14/23, Ativan [a controlled substance that can be used to treat anxiety] Tablet 1 MG- Give 1 tablet by mouth every 6 hours as needed for Anxiety for 30 Days review for need in 30 days * Physician order dated 02/14/23, Ativan(LORazepam)Tablet 0.5 MG, Give 1 tablet by mouth every 6 hours as needed for Severe anxiety related to anxiety disorder, unspecified, for 30 Days review for need in 30 days AND Give 2 tablet by mouth every 6 hours as needed for Severe anxiety for 30 Days. Physician order dated 02/15/23, LORazepam Oral Tablet 1 MG (C)- Give 1 tablet by mouth at bedtime for anxiety agents * Further review of the physician orders revealed that an order to monitor R #22 for behaviors was not written. D. On 02/23/23 at 11:46 am, during an interview with the facility's physician, when asked how residents are evaluated to determine the effectiveness of their PRN psychotropic medications, he explained that he depends on nursing staff to notify him of irregular resident behavior and if the medication should be evaluated. When asked if an antipsychotic medication order should have accompanying order to monitor for behaviors, he confirmed Yes, that's part of the order set. Its part of being on an antipsychotic medication. E. On 02/23/23 at 1:35 pm, during an interview with the Director of Nursing (DON), when asked why R #22 had multiple PRN orders for anxiety and a 30 day PRN order, she explained that R #22 was a hospice resident and hospice residents normally receive anti-anxiety orders as they are expected to pass. When asked to explain the process of how residents are evaluated to determine the effectiveness of their PRN psychotropic medications, she confirmed that she did not have a process of evaluation.

Based on observation, interviews, and record review, the facility failed to ensure the medication error rate did not exceed 5% by performing 2 medication errors out of 20 opportunities for 2 (R #14 and R #83) of 16 (R# 5, 8, 11, 13, 14, 15, 16, 19, 20, 22, 23, 24, 26, 30, 82, 132, and 134) residents reviewed during medication administration. This likely resulted in a medication error rate of 10%. If medications are not administered as ordered, residents are likely to experience an exacerbation [sudden worsening] or lack of relief from symptoms that the medication was ordered to prevent or manage not allowing residents to experience the maximum benefit intended. The findings are: Findings for R #83: A. On 02/22/23 at 3:06 pm, during observation of medication administration to R #83 by Certified Medication Assistant [CMA] #1 of the prescribed medication, Combivent Respimat [brand name] Albuterol [medication to expand the airways in the lungs, allowing more air flow] per metered inhaler [device that holds the medication under pressure and allows one dose per actuation {puff}] 1 puff, CMA #1 gave the inhaler to the resident to self-administer (give to self), giving no direction to the resident on how to use the inhaler. CMA #1 also did not instruct R #83 on how to rinse his mouth after the medication was administered. B. Record review of the facility's policy titled administration of an inhaled dose medication dated October 2022, stated that the staff should explain the steps involved for administering medication to the resident via inhaler. The policy read to ask resident to exhale fully, shake unit to disperse medication, place mouthpiece in front of the mouth or in mouth according to manufacturer's recommendations. Direct mouthpiece to back of throat, while inhaling slowly and deeply through the mouth, depress medication canister fully. Instruct resident to hold breath for 10 seconds or as long as possible or according to the manufacturer's recommendations. Wait approximately 1 minute between puffs or as ordered by physician or per recommendations. Rinse mouth with warm water and then spit out after each use. Findings for R #14 C. On 02/23/23 at 11:40 am, during an observation of medication administration to R #14 by CMA #1 of the prescribed medication, Ventolin [brand name] Albuterol HFA (stands for Hydrofluoroalkane, which is the propellant in the inhaler) per metered inhaler 2 puffs, CMA #1 gave the inhaler to the resident to self-administer and instructed R #14 to take a breath. R #14 put the inhaler in her mouth and took a breath in and gave one puff and exhaled after approximately 3 seconds. A significant amount of the aerosol [the Albuterol medication exhaled as a fine spray] came out of R #14's mouth and into the room when she exhaled [breathing out]. CMA #1 gave R #14 a second dose approximately one minute after the first dose instructing R #14 to take a breath. R #14 didn't inhale the second dose and likely received no medication. CMA #1 did not instruct R #14 on how to properly take in a full breath, exhale and then breathe in while pressing the inhaler holding breath for 10 seconds or however long the resident could hold her breath. D. On 02/23/23 at 11:43 am, during an interview with CMA #1 revealed I follow policy and procedure when I am passing medication to the residents. I have been doing this a while. I have been here 4 to 5 years. I have worked as a CNA (Certified Nursing Assistant), but I mostly work as a CMA. E. On 02/23/23 at 3:08 pm, during an interview, the DON was asked if it was her expectation that when passing medications, and inhalers to be exact would she expect CMA's and Nurses to follow policy and procedure. DON said, Yes, I do expect them to follow policy and procedure. There's an outline for it that you have.

Based on record review, observation, and interview, the facility failed to: 1. Discard refrigerated food when it met its 7-day shelf life; 2. Date refrigerated food; and 3. Discard dented cans These deficient practices are likely to affect all 30 residents listed on the census provided by the Director of Nursing (DON) on 02/20/23 and could likely lead to foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins) in residents if food is not being stored properly and safe food handling practices are not adhered to. The findings are: A. Record review of facility policy Date Marking- Food and Nutrition, last revised 05/03/22, revealed the following: Leftovers- Food items prepared for service that were not served and subsequently stored for use within seven days per food code . a. Ready-to-eat TCS [Time/temperature control for safety foods- a food that requires time/temperature control to limit pathogenic microorganism growth or toxin formation] foods prepared at the location and held in refrigeration for more that 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. Employees: 2) Count the day of preparation as day 1. At no time can a TCS prepared food be held more than seven days in a non-frozen state. B. On 02/19/23 at 10:08 am, during an observation of the dry food storage, the following canned food items were noted to be dented: 1. Blueberry pie filing 2. Apple sauce 3. Seasoned beef stalk C. On 02/19/23 at 10:11 am, during an observation of the walk-in refrigerator, the following food items were noted to be on the shelf: 1. A bag of cilantro, dated 2/2 [02/02/23], opened 2. A bag of diced red potatoes, undated and opened 3. A bag of leaf lettuce, undated and opened 4. A bag of Diced tomatoes, dated 2/9 [02/09/23] with a use by date of 2/17 [02/17/23] D. On 02/19/23 at 10:15 am, during an interview with the Dietary Manager, when asked how food is stored in the walk-in fridge (refrigerator), she explained We keep open produce on the shelf for less than a week. We come in on Wednesdays and clean it out. The food should be dated when we received it and it should have a use by date. When asked if the bag of cilantro, and tomatoes should remain on the shelf, she confirmed no. When asked if the potatoes and leaf lettuce should be dated, she confirmed yes. When asked how she stores canned food, she explained We date them and file fill the shelves [older cans are placed in the front to be used sooner]. When asked what is done with a dented can, she explained We just toss them. If someone dropped a can and doesn't say something, I may not be aware of the dented can on the shelf. She then confirmed that the 3 observed dented cans should be disposed of.

Based on observation and interview, the facility failed to follow infection control practices by; 1. Not doffing (removing personal protection equipment) gloves prior to exiting a room that was occupied by a resident on Transmission Based Precautions (infection control practices that help to stop the spread of germs); 2. Not washing or sanitizing hands in-between assisting residents; 3. Not developing a comprehensive surveillance plan (a plan and process to identify whether staff comply with established prevention and infection control procedures to prevent and reduce the spread of infection) These deficient practices could likely effect all 30 residents in the facility as identified on the census provided by the Director of Nursing (DON) on 02/20/23, Failure to plan, implement and monitor an infection control program could likely result in the spread of infections and illness to residents and staff within the facility. The findings are: A. On 02/19/23 at 11:53 am, during an observation of Certified Nursing Assistant (CNA) #1 while exiting R #26's room that was on contact Transmission Based Precautions for MRSA (Methicillin-resistant Staphylococcus aureus-a difficult to treat type of bacteria). It was observed that he removed his gloves after exiting the room. B. On 02/19/23 at 3:03 pm, during an observation of the Certified Medical Assistant (CMA) #1 while administering medications, it was noted that she did not wash her hands in between assisting residents. She prepared a medication to administer, adjusted the oxygen cannula (a device that sits on a resident's nostrils and is used to deliver supplemental oxygen) on a different resident, then proceeded to administer the medication without sanitizing or washing her hands after adjusting the nasal cannula. C. On 02/19/23 at 3:06 pm, during an interview with CMA #1, when asked how often hand washing should occur, she explained that you should wash or sanitize in between helping patients. When asked if she washed her hands or sanitized her hands in between adjusting the oxygen cannula for unknown and administering a medication to unknown resident she confirmed No I didn't, I didn't stop to wash my hands [between residents]. I probably was just thinking about getting the oxygen on the patient. There are some [residents] who remove their oxygen and its a force of habit [for me] to put the oxygen on. D. On 02/21/23 at 3:40 pm, during an interview with the DON, when asked if staff should remove their gloves before exiting a room on Transmission Based Precautions, she confirmed yes. When asked if staff should wash their hands or sanitize in-between helping residents, she confirmed yes. E. On 02/23/23 at 2:27 pm, during an interview with the DON, when asked if she had a comprehensive surveillance plan in place, she explained that she does surveillance everyday as she is working however; a formal surveillance plan has not been established and the only results form her daily surveillance was a training on hand hygiene that occurred in January of 2023. When asked if she has a checklist of observations to make that are included in her surveillance, she confirmed no. When asked if she documents her daily surveillance, she confirmed no. F. Record review of the facility policy Surveillance, AL [Assisted Living], Rehab/Skilled, Home Health, Hospice- Enterprise, last revised 03/30/22, revealed the following: Surveillance is an activity that a healthcare institution employs to find, analyze, control and prevent nosocomial [infection that occurs within 48 hours after admission] infections. It's definition can further include; collection, collation, analysis of data and passing of information to those who need to know and take action. Once a baseline is established, it can then be determined where control is needed. Components of surveillance are the following: -Definitions of infections -Data collection procedures -Forms and reports -Analysis by using cultures, changes in prevalent organisms and increase in rates - Results, which are given to appropriate persons Uses of the surveillance data may be the following: -Establish baseline -Identify problems -Evaluate control measures -Evaluate policies and procedures

Based on interview, the facility failed to ensure staff implemented a comprehensive antibiotic stewardship program (a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use). This deficient practice has the potential to effect any of the 30 residents identified on the census provided by the Director of Nursing (DON) on 02/20/23 who might be placed on antibiotics and could result in the inappropriate use of antibiotics that can lead to resistance of multi-drug resistant organisms. The findings are: A. On 02/23/23 at 2:27 pm, during an interview with the DON, when asked if there was a binder that would contain tracking and trending information related to the antibiotic stewardship program, she explained that she began working in the facility in December of 2022 as the DON and since she has taken on this role, she will now also be the Infection Preventionist but currently does not have an antibiotic stewardship binder. When asked if the previous Infection Preventionist left a binder she explained I'm not familiar with what was happening before I came in. There was not a binder. When asked when the previous Infection Preventionist was working in the facility, she stated He left in October or November [of 2022]. He worked as the MDS [Minimum Data Set- a collection of resident information that explains the resident's abilities and needs] nurse and had other roles. She then explained that her current MDS nurse creates a list of residents who are currently on antibiotic medications and those residents get reviewed for additional cultures or direction from the doctor. When asked if she tracks and trends the infections and antibiotic use, she confirmed no. When asked if she had a comprehensive antibiotic stewardship program, she confirmed no.

Based on interview the facility failed to have a qualified, trained or Certified Infection Preventionist. This deficient practice could likely to affect all 30 residents identified on the census provided by the Director of Nursing (DON) on 02/20/23. This deficient practice could likely result in residents being at greater risk of infectious disease. The findings are: A. On 02/21/23 at 3:40 pm, during an interview with the DON, when asked who the Infection Preventionist for the facility was, she explained that she will be enrolling in the course to become certified as the Infection Preventionist. She then explained that she began working in the facility, training in October and then stepped into the DON role in December of 2022. B. On 02/23/23 at 2:27 pm, during an interview with the DON, when asked if the previous Infection Preventionist left a binder she explained I'm not familiar with what was happening before I came in. There was not a binder. When asked when the previous Infection Preventionist was working in the facility, she stated He left in October or November [of 2022]. He worked as the MDS [Minimum Data Set- a collection of resident information that explains the resident's abilities and needs] nurse and had other roles as well.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This is a repeat deficiency from a recertification survey that was conducted on 12/03/20. Based on observation, interview and record review, the facility failed to follow proper sanitation and safe food handling practices by not: 1. testing sanitizing solution (sanitizing solution-a chemical and water mixture used for cleaning to reduce or eliminate disease causing agents,such as bacteria, on the surfaces of objects) 2. maintaining documentation of regular (regular-a reoccurring or repeating timeframe as determined by the manufacturer's recommendations, institutional best practice standards, or facility's policy, i.e, daily, 2x per shift, etc.) testing of sanitizing solution, and 3. having adequate (satisfactory or acceptable in quality or quantity) equipment (the necessary items for a particular purpose) to ensure adequate washing and sufficient concentration (strength) of sanitizing solution present to effectively clean and sanitize dishware, kitchen equipment, and kitchen surfaces. The testing strips on hand at the facility were expired or did not have an expiration or open date on the packaging making it not possible to determine if the tests results read were accurate or valid. These deficient practices could likely affect all 26 residents listed on the resident census list provided by the Administrator on 02/21/22, by leading to foodborne illnesses if correct sanitizing practices in the kitchen are not adhered to. The findings are: A. On 02/24/22 at 2:15 pm, during an observation and interview, the Dietary Aide (DA) was asked to demonstrate how the Multi-Quat Sanitizing Solution (Quat is the common name/abbreviation for quaternary ammonium chloride compounds which are chemical compounds that are effective at killing germs; Multi-more than one quaternary compound is used in the solution) Sanitizer Solution from the dispenser station (a device that premixes flowing water and the sanitizing chemical to the correct chemical to water concentration/ratio when needed from the dispenser; the solution is used to disinfect hard, non-porous food contact surfaces such as tables, counters, and food processing equipment located at the kitchen's main sink) was tested by staff to ensure it is at the correct concentration to sanitize properly. DA located testing strips and tested the running water from the sink and not the multi-quat sanitizing solution. The strips were observed to be water hardness test strips, which are not the correct strips for testing the multi-quat sanitizing solution. DA explained she was confused and did not know how to test the sanitizing solution because the cooks do the testing. DA confirmed there were no logs documenting testing of the sanitizing solution. B. On 02/24/22 at 2:25 pm, during an observation and interview, Certified Dietary Manager (CDM) tested the solution in the Multi-Quat Sanitizer Solution station at the sink, using testing strips stored on the windowsill, which were exposed to sunlight. She tested the solution and the strip read 50 ppm (parts per million). CDM repeated the test several times using different strips from different vials of test strips and got the same low readings. It was observed the vials were chlorine test strips and not the correct test strips for testing quaternary compounds. The vial labels were faded and difficult to read. There were no expiration or manufacture dates on the vials. One bag of Quick Response QAC Test strip (Quaternary Ammonium Compounds) was found and the CDM tested the multi-quat solution using the correct test strips. The multi-quat solution dispensed directly from the dispenser was tested twice at 100 ppm (parts per million), using 2 separate test strips. 150-200 ppm is the correct ratio for a sanitizing solution if there are no manufacturer instructions for chemical sanitizing. It was unknown if the test readings were valid because there was no expiration date, manufacture date, or opened date on the QAC test strip packaging. The test strips were stored on the windowsill along with the chlorine test strips, exposed to sunlight. CDM confirmed there were no logs or documentation of testing of the multi-quat solution. She said the reason for not testing the solution and maintaining a log of the regular testing of the solution is because the pots and pans were being sanitized in the high temp dishwasher (a dishwasher that operates at over 150 degrees Fahrenheit to sanitize dishes). The CDM reported that the facility had been using bleach solution to disinfect the kitchen and confirmed there are also no logs for the bleach solution. She said the facility was now using the quat solution to disinfect and clean the kitchen and not the bleach. C. On 02/24/22 at 3:14 pm, during an interview, ECOLAB (a company that specializes in providing water, hygiene, and infection prevention products and services) representative (ER) reported that prior to the last few months, the facility had been using bleach to disinfect the kitchen. He did not review or see any facility logs for testing of the multi-quat solution located at the kitchen sink, during his last 2 visits to the facility on [DATE] and 01/27/22. ER reported he goes to the facility monthly to service the ECOLAB equipment and he serviced the multi-quat dispenser. According to ER, the recommended range for the multi-quat solution concentration is 200 ppm-350 ppm for the correct sanitization. The recommended testing for the quat solution is daily to ensure the solution is dispensing the correct concentration of sanitizing product to disinfect properly. When ER tested the multi-quat solution, it tested at 250 ppm. This means the dispenser is dispensing properly. ER used Hydrion QT (product brand name) - 40 test strips. He did not use the test strips on hand at the facility. He has not provided the facility with any test strips. D. Record review of the manufacturer's Quick Response QAC Test Strip Precision Laboratory Product Technical Fact Sheet (undated) found on the Precision Laboratories current product website, indicated the storage recommendations are Store in original packaging in a cool (20-30C), dry, place out of direct sunlight, and the shelf-life is Two years from date of manufacture when stored properly in original packaging. E. Record review of the facility policy titled Sanford Policy Enterprise Ware Washing- Mechanical and Manual-Food and Nutrition Policy dated 04/28/21, the facility policy under Manual Ware Washing - Chemical Treatment indicated: 3) Use proper test strips to ensure accurate results for the chemical in use. 4) Manufacturer's instructions are always followed. 5) If information is not available from manufacturer: Chlorine (a poisonous gas, one of the chemical elements, used especially to make water safe for drinking and swimming): 50 - 100 parts per million (ppm) minimum 10 second contact time or per manufacturer's instructions. Iodine (a chemical element used to purify water): 12.5 -25 ppm with minimum 30 second contact time or per manufacturer's instructions. QAC space (quaternary): 150 - 200 ppm with concentration and contact time per manufacturer's instructions (Ammonium Compound). F. Record review of the facility's policy titled Sanford Policy Enterprise Ware Washing-Mechanical and Manual-Food and Nutrition Policy dated 04/28/21, under Manual Ware Washing - Temperature and chemical concentration revealed: Proper test strips and thermometers are available. Temperatures and/or chemical concentration will be recorded on either Chemical Sanitizing Log (GSS #454) or Pot/Pan Hot Water Sanitizing Log (GSS #465). G. Record review of the Oasis (product brand name) 146 Multi-Quat Sanitizer product feature, found on the ECOLAB product website, indicated that it is effective at sanitizing at 150 ppm- 400 ppm for Escherichia coli (germ found in the environment, foods, and intestines of people and animals) and Staphylococcus aureus (a type of germ that about 30% of people carry in their noses or skin). At 200 ppm-400 ppm, the sanitizer is effective against 8 additional germs. H. On 02/25/22 at 11:21 am, during an interview, Dietary [NAME] (DC) stated there were no bleach or quat logs documenting regular testing of the sanitizing solutions. According to DC, the Registered Dietician has never said anything to the kitchen staff about using logs or documenting testing of sanitizing solution. She said the kitchen staff had been using bleach solution for disinfecting the kitchen, prior to using the multi-quat solution, because the multi-quat solution was not being ordered for the dispenser. I. On 02/25/22 at 11:49 am, during an interview, the Registered Dietician (RD) confirmed there should be regular testing whenever a chemical sanitizer is used regardless of the chemical used, hypochlorite (bleach) or quat and there should also be a ppm log. The log should read at the correct ppm necessary to disinfectant kitchen items and surfaces. He was not aware if the testing strips used at the facility are testing accurately because he takes his own testing supplies to each facility due to the amount of time it takes staff to locate supplies. On 02/23/2022, he tested the solution in the sanitizing bucket in the sink and it was the right ratio that day for the multi-quat solution. He used his own testing strips and not the facility's test strips. The RD reported that the previous dietary manager used bleach for disinfection.