**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #3 revealed an admission date of 11/19/20. Diagnoses included Parkinson's disease and delusional disorders. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had moderate cognitive impairment. Review of the Pre-admission Screening and Resident Review (PASARR) dated 12/17/20 revealed Resident #3 had no diagnoses of any mental disorders indicated under Section D: Indications of Serious Mental Illness, which included Delusional Disorder. Review of the care plan dated 10/14/22 revealed Resident #3 was at risk for mood fluctuation related to a history of delusional disorder and Parkinson's disease. Interview on 11/09/22 at 8:33 A.M. with Admissions Assistant #110 confirmed the diagnoses were not completed correctly for Resident #3 on his PASARR dated 12/17/20. Review of the facility's policy titled HENS (Healthcare Electronic Notification System)/PASARR Policy, dated 01/01/22, revealed no information related to the accuracy of documentation, only addressing the timing and situations under which a PASARR was required. Based on staff interview, review of the facility's policy, and record review, the facility failed to ensure residents were accurately assessed for mental illnesses on Pre-admission Screening and Resident Reviews (PASARR). This affected two (Resident #3 and #8) of three residents reviewed for PASARR. The facility census was 20. Findings include: 1. Review of Resident #8's records revealed an admission date of 07/11/21 with diagnoses including dementia, anxiety disorder, delusional disorders, and vascular dementia with behavioral disturbance. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had severe cognitive impairment. Review of the care plan for behavioral symptoms including packing belongings, misplaces items, and accusing staff of hiding and stealing related to psychotic disorder; psychotropic drug use, psychiatrist/psychologist as needed/ordered, causal factors of behavior, monitor behaviors, disorders, decline in mood, document and notify physician of negative findings. Review of the Pre-admission Screening and Resident Review (PASARR) dated 07/11/21 revealed no diagnoses of any mental disorders indicated under Section D: Indications of Serious Mental Illness. Section D included Delusional Disorder(s) and Panic or other Severe Anxiety Disorder(s). Review of the Nursing History and Physical dated 07/13/21 revealed Resident #8 had a diagnosis of delusional disorders upon admission. Review of the physician orders dated 03/29/22 revealed an orde for Seroquel (antipsychotic) 25 milligrams (mg) by mouth daily for delusional disorders. Interview on 11/09/22 at 8:33 A.M. with Admissions Assistant #110 stated she does the facility's PASSARs upon admission and verified the available PASSAR for Resident #8 was not completed accurately and no mental disorders were noted in Section D.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed routinely assess a resident's dialysis access site for patency or complications. This affected one (Resident #13) of one resident reviewed for dialysis. The facility identified one resident who receives dialysis. The facility census was 20. Findings include: Review of the medical record for Resident #13 revealed the resident was admitted to the facility on [DATE] with diagnoses including end stage renal disease with dependence on renal dialysis. Review of Resident #13's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had no cognitive impairment, required extensive assistance with all Activities of Daily living (ADL). The MDS assessment indicated the resident received dialysis treatments. Review of Resident #13's November 2022 physician orders revealed the resident has orders to receive dialysis treatments weekly on Mondays, Wednesdays, and Fridays. Resident #13 had orders for no blood pressures or blood draws to be obtained from the resident's upper right arm where the dialysis shunt was located. The residents' orders revealed no instructions related to the assessment of the resident's dialysis access site. Further review of Resident #13's medical record revealed no information or documentation the resident's dialysis site was being assessed for patency or complications. Interview on 11/09/22 at 7:55 A.M. with Licensed Practical Nurse (LPN) #107 revealed Resident #13's dialysis access site was assessed weekly during weekly skin assessments. Interview on 11/09/22 with the Director of Nursing (DON) confirmed staff were not assessing Resident #13's dialysis access site. The DON stated Resident #13's dialysis site and shunt should be assessed before and after each dialysis treatment and every shift for patency by auscultating for a bruit and palpating for a thrill.

Based on observations, staff interview, and policy review, the facility failed to ensure storage of food was stored in a safe manner. This had the potential to affect all 20 residents residing in the facility who received food from the kitchen. Findings include: Observations during the initial tour on 11/07/22 from 10:05 A.M. to 10:35 A.M. with Household Coordinator #109 revealed the following: • Observation on 11/07/22 at 10:09 A.M. revealed the Colonial Kitchen refrigerator had two bags of cheddar cheese opened, unlabeled and undated, one container of cantaloupe sealed, but unlabeled and undated, and one container of chicken salad, sealed, but unlabeled and undated. • Observation on 11/07/22 at 10:13 A.M. revealed the Colonial Kitchen freezer revealed one bag of cheese biscuits opened, unlabeled and undated, one bag of frozen peaches opened, unlabeled and undated, one bag of regular biscuits opened, unlabeled and undated. • Observation on 11/07/22 at 10:25 A.M. revealed the Craftsmen Kitchen freezer had two bags of frozen turkey burgers opened, unlabeled and undated, one bag of frozen apples unsealed, unlabeled, and undated, and one bag of frozen eggplant opened, unlabeled and undated Interview on 11/07/22 at 10:35 A.M. with Household Coordinator #109 verified the above findings and discarded those items. Review of the facility's policy titled Storing Leftover Food, dated 11/07/22, revealed leftover food will be stored for up to seven days with the day of preparation being day one. A label will be affixed to the container with the following information: name of the food item, the date food was placed in container, and indicate if contents included a common allergen such as peanuts, tree nuts, or eggs.

Based upon record review and staff interview, the facility failed to accurately assess resident status regarding the provision of hospice services. This affected one (#11) of two residents reviewed for hospice and end of life care. The census was 23. Findings include: Review of record for Resident #11 revealed an admission date of 01/04/18, with diagnoses which included Parkinson's disease and Alzheimer's disease. Review of record for Resident #11 revealed an order dated 04/20/18 for hospice services for end-stage Alzheimer's disease. Review of care plan for Resident #11 revealed a care plan dated 04/20/18 for resident to receive hospice service for end stage Alzheimer's disease. Interventions included the following: activity as tolerated, call hospice with change in condition, hospice nurse to visit one to two times per week, pain management, offer religious support/counseling. Review of Minimum Data Set (MDS) Section O, dated 05/29/19 for Resident #11 revealed resident was coded negative for the provision of hospice services. Interview on 08/21/19 at 2:45 P.M., with the Director of Nursing (DON) confirmed the MDS for Resident #11 dated 05/29/19 was coded incorrectly for the provision of hospice services and confirmed that resident had received hospice services since 04/20/18.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, resident and staff interview, the facility failed to ensure an order was obtained for oxygen. This affected one resident (#20) of the three residents whom the facility identified as being on oxygen. The facility census was 23. Findings included: Review of the medical record for the Resident # 20, revealed an admission date of 07/15/19. Diagnoses included: syncope and collapse major depressive disorder, hypertension, hypothyroidism, acute kidney failure, hypokalemia and heart block. Review of the most recent Minimum Data Set (MDS) assessment, dated 07/29/19 revealed resident was cognitively intact. Resident # 20 had no behaviors, did not reject care, and did not wander. Resident was a one-person physical assist, required extensive or limited assistance for activities of daily living (ADLs). MDS section 0 (special treatments) was silent for Resident #20 being on oxygen Interview with Resident #20 on 08/19/19 at 11:03 A.M., indicated she was started on oxygen when she came back from the hospital on [DATE]. Resident #20 also stated she had never witnessed the staff change her oxygen tubing and nasal cannula. Review of physician orders for August 2019 were silent for any indication oxygen was ordered. Review of medication administration record (MAR) for August 2019 was silent for any indication resident #20 was ordered oxygen. Review of progress notes dated 08/08/19 at 11:02 P.M. indicated Resident #20 was re-admitted to the facility and started on oxygen 2.5 liters per minute (LPM). Interview with Licensed Practical Nurse (LPN) #206 on 08/20/19 at 5:10 P.M. indicated Resident #20 was admitted to hospital on [DATE] and returned on 08/08/19 with diagnosis of pulmonary embolism (PE) and started on oxygen. LPN #206 verified there were no active orders for oxygen. Interview with Director of Nursing (DON) #216 on 08/21/19 at 1:15 P.M. verified there were no orders for oxygen for Resident #20. Review of the policy titled Quality of Care, dated 04/08/11, indicated oxygen therapy will be performed by a licensed nurse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the failed to ensure a residents antipsychotic medication (Risperdal) was limited to 14 days and when given, no careplanned or non-pharmacological approaches were attempted prior to Risperdal being administered. This affected one (#6) of the five residents reviewed for unnecessary medications. The facility census was 23. Findings included: Review of the medical record for the Resident #6, revealed an admission date of 11/08/19. Diagnoses included: Alzheimer's disease, dementia, cataracts, and delusional disorders. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had moderately impaired cognition. Resident #6 had no behaviors, did not want wander but rejected care. MDS section N indicated an antipsychotic was used 7 days. Resident #6 was a one-person physical assist, required extensive assistance or limited assistance for activities of daily living (ADLs). Review of plan of care dated 11/08/18 was silent for any indication Resident was on antipsychotic. Review of physician orders dated 07/19/19, revealed orders for Risperdal (antipsychotic) 0.25 milligrams (mg) one tablet by mouth as needed (PRN) every eight hours for dementia. Physician orders also revealed no stop date. Review of progress notes dated 07/19/19 at 5:10 P.M., revealed resident was having episodes of increased behavioral and was not easily redirected. Notes indicated Licensed Practical Nurse (LPN) #206 notified the physician and received verbal orders to start Risperdal 0.25 mg every eight hours PRN for agitation and psychosis. Review of monthly pharmacy review dated 07/22/19 was silent for any indication the pharmacist reviewed or provided recommendations for the PRN Risperdal ordered on 07/19/19. Review of physician notes/monthly visit dated 07/30/19 indicated there had been no changes, behaviors or pacing issues with Resident #20. Physicians notes were silent for any indication resident was on an antipsychotic. Review of July 2019 medication administration record (MAR) revealed PRN Risperdal 0.25 mg was administered to resident on 07/31/19 by medication aide #215. Review of August MAR revealed PRN Risperdal 0.25 mg was administered to resident on 08/05/19 and 08/16/19 by medication aide #215. Review of progress notes for Resident #6 on 07/31/19, 08/05/19 and 08/16/19 were silent for a clearly documented indication of an PRN antipsychotic medication to be administered. Progress notes were silent for any implemented care planned or non-pharmacological approaches before a PRN antipsychotic was administered. Progress notes were also silent for Resident #20 being assessed by a licensed nurse for need of a PRN antipsychotic when medication aide #215 administered PRN Risperdal. Interview with Director of Nursing (DON) #216 on 08/21/19 at 1:15 P.M. verified the PRN Risperdal 0.25 mg for dementia was ordered on 07/19/19 and contained no stop date. DON #216 also verified resident received the PRN Risperdal on 07/31/19, 08/05/19 and 08/16/19 by medication aide #215.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, observation, resident and staff interview, the facility failed to assist the resident in obtaining timely routine dental care. This affected one (#1) of one residents reviewed for dental concerns. The census was 23. Findings include: Review of record revealed Resident #1 was admitted on [DATE] with a diagnosis of unspecified dementia with behavioral disturbance. Review of Minimum Data Set (MDS) for Resident #1 dated revealed resident was cognitively impaired and was coded as negative for dental concerns. Review of record for Resident #1 revealed resident's representative had signed a consent for resident to receive dental services from the dentist who visited the facility dated 05/31/18. Review of social service progress note for Resident #1 dated 11/26/18 revealed resident's representative inquired about resident's teeth and that arrangements would be made for resident to examined by the the in-house dentist. Review of social service progress note for Resident #1 dated 02/25/19 revealed resident's representative asked about resident's broken and missing teeth and that the household coordinator confirmed the dentist would be at the facility in March 2019, and that the resident's representative gave consent for a dental exam. Further review of the medical record revealed no evidence of the resident seeing a physician in March 2019. Review of oral assessment dated [DATE] for Resident #1 completed by nursing revealed the section of the form that listed the date of the resident's last dental exam was blank. Review of nurse progress note for Resident #1 dated 06/12/19 revealed nurse observed tooth decay and darkening around the resident's gumline and that resident was to be put on the list the see the facility dentist. Observation of Resident #1 on 08/19/19 at 1:36 P. M., revealed resident had multiple missing teeth and several teeth that appeared to be broken and showing signs of decay. Interview with Resident #1 on 08/19/19 at 1:38 P.M., confirmed resident did not have any mouth pain but that she had not seen a dentist since her admission to the facility in February of 2018 and that she was not sure why she had not been seen. Interview with the Administrator on 08/21/19 at 11:00 A. M, confirmed the resident had not been seen by a dentist since her admission to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, observation, staff interview, review of facility policy, review of manufacturer's recommendations, and review of online medication resources, the facility failed to date multi-use containers and vials of medication in order to determine when they should be discarded, failed to discard expired medication, and failed to store medication appropriately by storing oral medications next to externally administered medications. This had the potential to affect 8 (#1, #2, #3, #5, #7, #18, #21, #123) of 23 residents residing in the facility. Findings include: 1. Review of record for Resident #2 revealed an admission date of 11/15/17 with a diagnosis of glaucoma. Review of the record for Resident #2 revealed a revealed an order dated 11/15/17 for dorzolamide eye drops to the right eye three times daily. Review of manufacturer's insert for dorzoloamide revealed no recommendations for when to discard opened medication. Review of for Resident #2 revealed an order dated 06/14/19 for erythromycin ointment to the right eye four times per day for a duration of five days. Review of record for Resident #2 revealed an order for Depakote tablets dated 11/15/17 that had been discontinued. Observation of the medication storage cabinet in Resident #2's room on 08/19/19 at 5:39 P.M. with Licensed Practical Nurse (LPN) #206 revealed an opened container of dorzolamide eye drops that had been delivered to the facility on [DATE], but was not marked with the date the bottle had been opened, and an opened tube of erythromycin opthalmic ointment and a bottle of Depakote tablets. Interview with LPN #206 on 08/19/19 at 5:40 P.M. confirmed that the eye drops should have been dated upon opening and discarded in 28 days and that discontinued medications should be discarded. 2. Review of record for Resident #21 revealed an admission date of 04/22/19 with a diagnosis of Parkinson's disease. Review of record for Resident #21 revealed an order dated 05/20/19 for Thera tears eye drops twice daily. Review of manufacturer's insert for Thera tears eye drops revealed no recommendations for when to discard opened medication. Observation of the medication storage cabinet in Resident #2's room on 08/19/19 at 5:42 P.M. with Licensed Practical Nurse (LPN) #206 revealed an opened bottle of Thera-tears eye drops that had not been dated to indicate when they had been opened. Interview with LPN #206 on 08/19/19 at 5:43 P.M. confirmed that the eye drops should have been dated upon opening and discarded in 28 days. 3. Review of record for Resident #1 revealed an admission date of 02/21/18 with a diagnosis of dementia. Review of record for Resident #1 revealed an order dated 08/02/19 for debrox ear drops to be instilled in both ears twice daily for four days. Review of record for Resident #1 revealed an order dated 02/20/18 for vitamin B12 injection to be given once monthly. Observation of the medication storage cabinet in Resident #1's room on 08/19/19 at 5:45 P.M. with Licensed Practical Nurse (LPN) #206 revealed an opened bottle of debrox ear drops and an opened vial of B12 injectable liquid that had been dispensed on 05/22/19 and not dated when opened. Interview with LPN #206 on 08/19/19 at 5:46 P.M. confirmed that bottles of ear drops and multi-dose vials of injectable medication should be dated when opened. 4. Review of record for Resident #7 revealed an admission date of 08/20/10 with a diagnosis which included dry eye syndrome. Review of record for Resident #7 revealed an order dated 03/19/16 for artificial tears to both eyes four times per day. Review of record Resident #7 revealed an order dated 08/19/17 for latanaprost eye drops to both eyes once daily. Review of record for Resident #7 revealed an order dated 02/27/17 for Robitussin DM cough syrup 10 milliliters every four hours as needed for cough. Observation of the medication storage cabinet in Resident #7's room on 08/19/19 at 5:49 P.M. with Licensed Practical Nurse (LPN) #206 revealed an opened bottle of artificial tears eye drops which had not been dated when opened, an opened bottle of latanoprost eye drops which had not been dated when opened, and an opened bottle of Robitussin DM cough syrup with a manufacturer's expiration date of 12/2018. Interview with LPN #206 on 08/19/19 at 5:52 P.M. confirmed that bottles of eye drops should be dated when opened and discarded in 28 days from opening and that expired medications should be discarded. 5. Review of record for Resident #3 revealed an admission date of 04/26/19 with a diagnosis of unspecified dementia with behavioral disturbance. Review of record for [NAME] Resident #3 revealed an order dated 06/28/19 to cleanse skin tear with normal saline wound cleanser once daily until healed. Review of record for Resident #3 revealed an order dated 04/26/19 for Trazodone 25 milligrams by mouth once daily with a stop date of 06/13/19. Observation of the medication storage cabinet in Resident #3's room on 08/19/19 at 5:53 P.M. with Licensed Practical Nurse (LPN) #206 revealed the residents wound cleanser and oral trazodone tablets were stored together. Interview with LPN #206 on 08/19/19 at 5:54 P.M. confirmed that external medications such as wound cleanser and internal medications such as trazodone tablets should be stored separate from one another. 6. Review of records for the Craftsman Cottage revealed five residents with physician orders for aspirin (Residents #2, #13, #18, #21, #123), one resident with an order for Pepto-Bismol (Resident #5), and one resident with an order for Colace (Resident #123) Observation of medication storage for Craftsman Cottage on 08/19/19 at 5:55 P.M. with LPN #206 revealed an unopened bottle of Pepto Bismol with a manufacturer's expiration date of 07/2019, two bottles of Colace tablets, one opened and one not opened both with a manufacturer's expiration date of 09/18, and an opened bottle of aspirin with a manufacturer's expiration date of 07/2019. Interview with LPN #206 on 08/19/19 at 5:56 P.M. confirmed that expired medications should be discarded. Review of policy titled Medication Storage in the Facility dated January 2019 revealed orally administered medication are kept separate from externally used medications, outdated medications are immediately removed from inventory and discarded, and that when the original seal of a manufacturer's container or vial is broken the vial will be dated. The container or vial will then be dated with an expiration date of 30 days unless the manufacturer recommends another date. Review of The International Pharmacopeia, Seventh Edition, dated 2017, (http://apps.who.int/phint/2017/index.html#d/b.6.2.1.3) revealed multidose ophthalmic drop preparations may be used for up to four weeks/28 days after the container is initially opened.

Based on observation and staff interview, the facility failed to store food in accordance with professional standards by having a hand-held scooper in the bread crumbs container and expired food items in the refrigerators. This had the potential to affect all residents that resided in the facility. The facility census was 23. Findings included: During the initial observation of the Colonial kitchen on 08/19/19 at 8:30 A.M., revealed a container of cottage cheese inside the commercial refrigerator that was undated and expired on 07/31/19. Observations of the Colonial kitchen also revealed a clear plastic hand-held scooper inside the portable bread crumb container. Observations of the Craftsman kitchen on 08/19/19 at 8:35 A.M. revealed two containers of cottage cheese inside the commercial refrigerator that were undated and expired on 07/31/19. Interview with versatile worker (VW) #238 on 08/19/19 at 8:32 A.M. verified the cottage cheese container inside the commercial refrigerator was undated and expired on 07/31/19. VW #238 also verified the clear plastic hand-held scooper inside the portable bread crumb container. Interview with Household Coordinator (HC) #209 on 08/19/19 at 8:40 A.M. verified the two cottage cheese containers inside the commercial refrigerator were undated and expired on 07/31/19. Review of 01/01/19 policy titled Dining Services revealed handing and storage of food delivered to the households will be in accordance with the food code.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to include a resident's medical diagnoses on the comprehensive assessment. This affected one (#4) of 12 residents reviewed for comprehensive assessments. The facility census was 24. Findings include: Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of gastro-esophageal reflux disease (GERD), atherosclerotic heart disease, Parkinson's disease, psychotic disorder with delusions, and anxiety disorder. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #4 had severe impairment of cognitive skills for daily decisions, required extensive assistance with activities of daily living, and had diagnoses to include Non-Alzheimer's dementia, depression, psychotic disorder. The assessment did not include a diagnosis of anxiety. Review of the psychiatry consult notes dated 01/30/18, 02/09/18, 03/19/18, 04/17/18, 04/17/18, and 06/17/18 revealed the resident had a diagnosis of mood disorder, secondary to general medical condition, with anxiety component as well. Interview on 07/10/18 at 4:51 P.M., with Registered Nurse (RN) #60 verified Resident #4 did have the diagnosis of anxiety disorder, and that it was not documented on the comprehensive significant change MDS assessment dated [DATE].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete a Level One, Preadmission Screen and Resident Review (PASARR) for a resident prior to admission to the nursing home. This affected one (#4) of two residents reviewed for PASARR. The facility census was 24. Findings include: Record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses including gastro-esophageal reflux disease (GERD), Parkinson's disease, major depressive disorder with behavioral disturbance, psychotic disorder with delusions, and anxiety disorder. Review of the medical record revealed a Level One PASARR was completed for Resident #4 on 07/09/18. The medical record contained no evidence a Level One PASARR was completed prior to the resident's admission to the nursing home. Interview on 07/10/18 at 11:04 A.M., with the Administrator verified a Level One PASARR was not completed prior to the resident's admission to the facility.