Based on record review and interview, the facility failed to ensure resident assessments were accurate for one (#74) of six sampled residents whose assessments were reviewed for accuracy. The DON identified 76 residents who resided in the facility. Findings: The facility had no policies regarding resident assessments. Res #74 had diagnoses which included anxiety. Res #74's progress notes on 07/17/24, 07/19/24, 07/21/24, 07/22/24, 07/24/24, 07/25/24, 07/26/24, 07/30/24, 07/31/24, and 08/02/24 documented behaviors for Res #74 of yelling and screaming. Progress noted, dated 07/18/24, documented Res #74 had a fall and sustained a laceration above their left eye which resulted in the resident being transferred to the local hospital emergency department where they received seven sutured to the laceration. An admission resident assessment, dated 07/22/24, did not document any behaviors or a fall with injury for Res #74. On 08/02/24 at 2:00 p.m., the administrator reported they had no policies regarding resident assessments and use the RAI Manual as guidance. On 08/02/24 at 3:45 p.m., the MDS Coordinator reported they should have documented the fall for Res #74 as a fall with injury. On 08/02/24 at 3:53 p.m., the social services director reported they were not aware the resident had any behaviors of yelling and screaming. The social services director reported had they known about the yelling and screaming, they would have documented behaviors for Res #74 on their resident assessment.

Based on observation, record review, and interview, the facility failed to care plan behaviors for one (#74) of six sampled residents whose care plans were reviewed for accuracy. The DON identified 76 residents who resided in the facility. Findings: Res #74 had diagnoses which included anxiety. Res #74's progress notes on 07/17/24, 07/19/24, 07/21/24, 07/22/24, 07/24/24, 07/25/24, 07/26/24, 07/30/24, 07/31/24, and 08/02/24 documented behaviors for Res #74 of yelling and screaming. Res #74's comprehensive care plan did not have a care plan for behaviors. On 07/31/24 between 9:00 a.m. and 10:45 a.m., observed Res #74 yelling loudly the same phrases repeatedly. The resident was also observed to be yelling profanity very frequently. The yelling was continual for approximately 1 hour and 45 minutes. On 08/02/24 at 11:15 a.m., Res #74 was observed to be yelling loudly the same phrases repeatedly for approximately 5 minutes. On 08/02/24 at 4:20 p.m., the MDS Coordinator reported the behaviors for Res #74 should have been care planned.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure residents were provided with a comfortable, homelike environment for two (#60 and #75) of six sampled residents who were reviewed for noise level/comfortable, homelike environment. The DON identified 76 residents who resided in the facility. Findings: Res #74 had diagnoses which included anxiety. Res #74's progress notes on 07/17/24, 07/19/24, 07/21/24, 07/22/24, 07/24/24, 07/25/24, 07/26/24, 07/30/24, 07/31/24, and 08/02/24 documented behaviors for Res #74 of yelling and screaming. On 07/30/24 between 9:00 a.m. and 10:45 a.m., observed Res #74 yelling loudly the same phrases repeatedly. The resident was also observed to be yelling profanity very frequently. The yelling was continual for approximately 1 hour and 45 minutes. On 08/02/24 at 11:15 a.m., Res #74 was observed to be yelling loudly the same phrases repeatedly for approximately 5 minutes. On 07/30/24 at 10:30 a.m. Res #60 reported they couldn't eat breakfast this am due to Res #74 yelling. Reports the yelling is non-stop all day and night. Res #60 stated, Res #74's yelling is so upsetting to me. Reports they can hear Res #74 yelling even with door closed. Res #60 reported they had a terrible night's sleep. I only slept a few hours and it wasn't quality sleep. Res #60 reported they are catholic and need peace and quiet to pray and does not feel at peace spiritually due to the constant yelling and cursing. During the interview, the door was shut and Res #74 who is on the opposite side of the hall three doors down could be heard clearly yelling and cursing. On 07/30/24 at 10:40 a.m. Res #75's husband was at bedside. Both reported Res #74's (who is next door) screaming keeps Res #75 up at night. The husband stated, it's very disruptive. Res #75 reported the yelling/screaming was non-stop, day and night and has been going on since their admission [DATE]). Res #75's husband reported they have mentioned the yelling to the staff and stated, they have been very 'apologetic' but have not done anything about it. On 08/01/24 at 9:36 a.m., LPN #2 reported it's normal for Res #74 to yell/scream constantly LPN #2 stated, Other residents can't sleep because of Res #74's yelling.

Based on record review and interview, the facility failed to ensure physician's orders were documented properly for one (#49) of six residents whose physician's orders were reviewed for accuracy. The DON identified four residents who had tube feedings Findings: Res #49 had diagnoses which included cerebral infarction and dysphagia. A physician's order, dated 03/29/24, documented Res #49 is to receive Jevity 1.5, 250ml via peg tube every 6 hours. A physician's order, dated 06/12/24, documented Res #49 is to receive Jevity 1.5, 350ml via peg tube every 6 hours. The July and medication administration record documented both feedings were administered each time the resident was administered a feeding. The August medication administration record documented both feedings were administered each time the resident was administered a feeding. On 08/02/24 at 3:32 p.m., the DON reported they aren't sure why there are two physician's orders for Res #49's feeding. On 08/02/24 at 4:05 p.m., the DON reported they wrote a new physician's order to clarify the feeding and reported the nurses were giving one feeding, and if the resident was still hungry, they gave the other feeding. DON reported when the new order was written in June, the old order from March should have been discontinued. On 08/02/24 at 5:51 p.m., LPN #1 reported they were giving Res #49 both feedings. LPN #1 was reported they thought both feedings were to be given because the resident had lost weight. LPN #1 reported they would give one feeding and ask the resident if they were still hungry and give the additional feeding if they were. LPN #1 reported the physician's orders did not document an order to give both feedings if Res #49 was still hungry. LPN #1 reported they now wish they had gotten clarification of the orders because they are confusing and they didn't know what to do.

Based on observation and interview, the facility failed to ensure the kitchen was maintained in good repair. The administrator identified 73 residents received services from the kitchen. Three residents received nutrition and hydration solely through a feeding tube. Findings: On 08/01/24 at 8:30 a.m., a tour of the kitchen was conducted. The following observations were made. a. the wall was not finished and base boards were missing in the ice machine area, b. ceiling lights were burned out and/or not working and not shielded, c. base boards were missing in the dish wash area. There were gaps between the wall and the floor, d. the gasket on the walk in cooler door was split on the bottom of the door, e. the metal threshold on the door opening to the walk in cooler was not secure to the floor, f. the metal floor in the walk in cooler was raised and not level. There was brown residue and standing water on the floor, and g. there was an accumulation of ice on the walk in freezer door. On 08/01/24 at 11:02 a.m., the DM was how staff ensure the kitchen was maintained in good repair. They stated they reported to maintenance. They were shown the above observations.

Based on record review and interview, the facility failed to conduct a significant change assessment after the resident was admitted to hospice services for one (#116) of 26 sampled residents whose assessments were reviewed. The Resident Census and Conditions of Residents form documented 65 residents who resided in the facility. Findings: Res #116 had diagnoses which included emphysema and protein-calorie malnutrition. A physician order dated, 05/30/23, documented to admit Res #116 to hospice care. The resident's medical record was reviewed and did not document a significant change assessment had been completed within the required timeframe. On 06/20/23 at 2:59 p.m., the MDS coordinator was asked if the facility had completed and submitted a significant change assessment for Res #116 upon their admission to hospice services. The MDS coordinator stated they had overlooked it and a significant change related to admission to hospice had not been completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop and implement interventions to prevent falls for one (#168) of five residents sampled for accident hazards and falls. Res #168 was admitted to the facility on [DATE] for skilled nursing and therapy related to a fall at home which had resulted in a right hip fracture. The resident had a fall in the facility on 03/14/22 which resulted in a second broken right hip that required another surgery. No interventions were in place to prevent falls from the resident's admit until the fall on 03/14/22. The Resident Census and Conditions of Residents form documented 65 residents resided in the facility. Findings: 1. Res #168 was admitted to the facility on [DATE] and had diagnoses which included fracture of right leg, polyneuropathy, Alzheimer's disease, chronic pain, insomnia, and scoliosis. A nurse practitioner progress note, dated 02/15/22 at 8:59 a.m., documented Res #168 was admitted to the facility after a recent hospitalization due to a right hip fracture sustained at home resulting in surgery. An incident report, dated 03/14/22 at 4:40 p.m., documented Res #168 had an unwitnessed fall in his room. The report documented the resident was found sitting in the floor in front of his w/c with no notable injuries. The report documented the resident stated, I was wiggling around to straighten up my pants and slid out of my chair. An x-ray report, dated 03/15/22, documented an x-ray of Res #168's right leg was performed. The x-ray report documented no fracture or displacement. A nurse note, dated 03/19/22 at 2:45 p.m., documented Res #168 was transferred to the hospital ER due to complaints of increased pain, swelling, and redness to the right hip. A nurse note, dated 03/19/22 at 8:53 p.m., documented the hospital ER nurse notified the facility that Res #168's right hip was shattered and the resident would require another surgery. The resident did not return to the facility. On 06/22/23 at 10:03 a.m., the MDS coordinator was asked if a fall care plan with interventions was in place prior to Res #168's fall on 03/14/22. They stated there was not a care plan to address the resident's fall risk. On 06/22/23 at 10:14 a.m., the DON was asked if a fall care plan with interventions was in place prior to the resident's fall. The DON stated Res #168 did not have a fall care plan or interventions to prevent falls.

Based on record review and interview, the facility failed to ensure the physician and/or NP responded in the proper time frame to a pharmacist MRR for two (#7 and #32) of five sampled for unnecessary medications and failed to ensure the MRR policy documented the required components. The Residents Census and Conditions Of Residents form Documented 54 receiving psychoactive medications resided in the facility. Findings: A Monthly Drug Regimen Review Policy, Rev 11-22-16 read in part .The facility will ensure that the Consultant Pharmacist will review each Resident's drug regimen monthly and address issues identified promptly. Procedure 1. The Pharmacist shall submit a written report at least monthly to the Administrator/designee which shall be a summary of thee duties performed by the consultant pharmacist any error or problems found in the facility, delivery of pharmaceutical services and a detailed listing of any discrepancies and/or irregularities noted by the pharmacist during his drug regimen reviews. 2. Upon identification of an irregularity that would require urgent action the Consultant Pharmacist will immediately notify the Director of Nursing/designee. 3. The Director of Nursing/designee will then notify the residents's physician for further orders. 4. The Director of Nursing upon receipt of Pharmacist monthly report will review and follow up on the recommendations within 5 business days . The policy did not document the time frames for the response of the physician or NP or what steps the facility would take if the physician or NP did not respond within the required time frame. 1. Res #7 had diagnoses which include schizoaffective disorder, depressive type, anxiety, and depressive disorder. A Quarterly Assessment, dated 06/20/23, documented the resident was intact with cognition and required supervision to limited assistance with most ADLs. The assessment documented the resident had taken an antipsychotic and antidepressant medication during the look back period. The assessment documented antipsychotics were received on a routine basis. The assessment documented no behaviors. An MRR, dated 04/19/23, documented Res #7 had received citalopram and duloxetine for schizoaffective disorder, depressive type as a reminder that even with this diagnosis the facility needed current documentation of schizophrenia/harmful behavior and effectiveness to justify the continuation. The MRR documented CMS required the facility identified target behaviors which citalopram and duloxetine were added to treat and document the effectiveness for treatment of those behaviors. The MRR documented Res #7 had two documented falls within the previous month that may have been attributed to medications. On 06/15/23 the NP documented they disagreed to the recommendation related to the resident refusing medication, resisting care, and increased anger. On 06/20/23 at 3:53 p.m., the DON stated the time frame for the NP to have responded to the 04/19/23 MRR was not an appropriate time frame. The DON confirmed the policy did not contain the time frame for a physician response. The DON stated the MRR had asked for the diagnosis to be addressed and it was not according to the current orders which still had the previous diagnosis. The DON stated when they reviewed the MRR on 06/19/23 they did not notice it was asking about the diagnoses for the antidepressant medication. 2. Res #32 had diagnoses which included depressive disorders, anxiety disorders, and dementia without behaviors. A quarterly assessment, dated 05/14/23, documented the resident was severely impaired with cognition and required extensive assistance with most activities of daily living. The assessment documented the resident received an antipsychotic and antidepressant medication six days of the seven day look back period. The assessment documented antipsychotics were received on a routine basis. An MRR, dated 03/23/23, documented the resident received Lexapro 10mg tablet once a day, Risperidone 0.25mg every 12 hours, as well as Remeron. The MRR documented the resident had experienced multiple falls and asked the provider to consider a reduction or GDR of one of these medications. On 04/18/23 the NP responded and the DON did not respond to the MRR until 05/03/23 which was greater than five days referred to in the policy. On 06/19/23 at 12:21 p.m., the administrator confirmed the monthly drug regimen review was the facility's only policy for MRRs. On 06/20/23 at 9:50 a.m., the DON stated the diagnoses of dementia was not an appropriate diagnosis for the Risperdal and the facility was working on decreasing antipsychotic usage for the residents who resided in the facility. The DON stated the nurses sometimes did not receive correct diagnoses with the medication orders. The DON confirmed they did not always note the MRR responses within five days.

Based on record review and interview, the facility failed to ensure ordered medications documented an appropriate diagnosis for one (#32) of five residents reviewed for unnecessary medications. The Residents Census and Conditions Of Residents form Documented 54 receiving psychoactive medications resided in the facility. Findings: Res #32 had diagnoses which included depressive disorders, anxiety disorders, and dementia without behaviors. A physician order, dated 05/09/23, documented risperidone (an antipsychotic medication) was ordered to treat dementia without behaviors. A quarterly assessment, dated 05/14/23, documented the resident was severely impaired with cognition and required extensive assistance with most activities of daily living. The assessment documented the resident received an antipsychotic and antidepressant medication six days of the seven day assessment period. The assessment documented antipsychotics were received on a routine basis. On 06/20/23 at 9:50 a.m., the DON stated the diagnosis of dementia was not an appropriate diagnosis for the risperidone. The DON stated they were working on decreasing the antipsychotic usage in the facility. The DON stated the nurses were not always provided with the correct diagnosis with medication orders.

Based on observation, record review, and interview, the facility failed to ensure assessments accurately reflected the residents' status for three (#32, 53, and #60) of 26 residents whose assessments were reviewed. The Residents Census and Conditions Of Residents form Documented 65 residents resided in the facility. Findings: 1. Res #60 had diagnoses which included atherosclerotic heart disease of native coronary artery without angina pectoris. A physician order, dated 05/06/23, documented the facility was to administer Eliquis (an anticoagulant medication) once daily for a diagnosis of atherosclerotic heart disease. An admission Assessment, dated 05/12/23, documented the resident was intact with cognition and required extensive assistance with most ADLs. The assessment did not documented the resident was on an anticoagulant medication. A physician order, dated 05/26/23, documented the facility was to administer Eliquis two times a day related to atherosclerotic heart disease. On 06/16/23 at 09:30 a.m., Res #60 was observed in her bed. Res #60 stated they were taking the blood thinner Eliquis daily. On 06/20/23 at 10:06 a.m., the MDS coordinator stated she had never captured the Eliquis on the MDS because they did not monitor for it. She stated she did not know she was supposed to capture it as an anticoagulant medication. 2. Res #53 had diagnoses which included acute embolism and thrombosis of unspecified deep veins of left lower extremity. A physician order, dated 08/24/22, documented Eliquis one tablet two times daily related to acute embolism and thrombosis of unspecified deep veins of left lower extremity. A quarterly assessment, dated 05/17/23, did not document the resident was on an anticoagulant medication. On 06/15/23 at 4:06 p.m., Res # 53 stated they thought they took and anticoagulant medication. On 06/20/23 at 10:07 a.m., the MDS coordinator stated she had never captured the Eliquis on the MDS because they did not monitor for it. She stated she did not know she was supposed to capture it as an anticoagulant medication. 3. Res #32 had diagnoses which included other recurrent depressive disorders and anxiety. A pharmacist MRR, dated 01/17/23, documented Risperdal (an antipsychotic medication) 0.25 mg one tab two times a day related to other recurrent depressive disorder. An admission assessment, dated 01/30/23, did not document the resident received and antispychotic medication. A physician order, dated 05/09/23, documented the facility was to administer Risperdal one time a day related to unspecified dementia, unspecified severity, without behavioral disturbances, psychotic disturbances, mood disturbances, and anxiety. On 06/20/23 at 10:04 a.m., the MDS coordinator stated the antipsychotic medication was not captured on the admission assessment. The MDS coordinator stated the resident was taking the Risperdal when they admitted to the facility.

4. Res #65 had diagnoses which included dementia, arthritis, displaced fracture of the left shoulder and elbow, rheumatoid arthritis, and disc degeneration. An incident report, dated 03/27/23 at 7:54 a.m., documented Res #65 had an unwitnessed fall without injury. The incident report documented an intervention to prevent the reoccurrence of falls was to place a digital clock at Res # 65's bedside. An incident report, dated 03/29/23 at 1:34 a.m., documented Res #65 had an unwitnessed fall without injury. The report documented an intervention to prevent the reoccurrence of falls was to place a winged mattress on Res #65's bed. An admission assessment, dated 03/31/23, documented Res #65 had severely impaired cognition, required extensive assistance with ADLs, and in the last six months prior to admission had falls with one fall resulting in a fracture. The assessment documented the resident had two or more falls since admission. An incident report, dated 04/01/23 at 8:59 a.m., documented Res #65 had an unwitnessed fall without injury. The report documented an intervention to prevent the reoccurrence of falls was to place fall mats on the floor at Res #65's bedside. An incident report, dated 04/04/23 at 7:14 a.m., documented Res #65 had an unwitnessed fall resulting in bruising to their left knee and toes. The report documented an intervention to prevent the reoccurrence of falls was to move the resident to a room closer to the nurse station. A nurse note, dated 04/06/23, documented Res #65 discharged from the facility to another nursing home. The resident's care plan did not address falls or interventions to prevent reoccurrence. On 06/22/23 at 4:06 p.m., the MDS coordinator was asked if a fall care plan with interventions was in place prior to Res #65's falls. The MDS coordinator stated the facility did not develop a fall care plan for Res #65 before or after any falls. On 06/22/23 at 4:28 p.m., the DON was asked if a fall care plan with interventions was in place prior to Res #65's falls. The DON reviewed the resident's care plan and confirmed it did not document a fall care plan. Based on observation, interview, and record review, it was determined the facility failed to ensure a comprehensive care plan was developed to meet the residents' medical and nursing needs for four (#7, 13, 32, and #65) of 26 sampled residents whose care plans were reviewed. The facility failed to develop a care plan related to: a. the use of diuretics for Res #13. b. diuretic and opioid use for Res #7. c. the use of antipsychotic medications for Res #32. d. falls for Res #65. The Resident Census and Conditions of Residents form documented 65 residents resided in the facility. Findings: 1. Res #13 had diagnoses which included generalized edema and cellulitis of other sites. On 10/17/22, a physician order documented torsemide (a diuretic medication) tablet 20 mg one time a day related to generalized edema. A care plan, dated 03/20/23, did not document a plan of care regarding the resident's use of diuretics. A significant change assessment, dated 04/01/23, documented the resident was cognitively intact and required moderate to total assistance with most ADLs. The assessment documented a diuretic was taken for seven days of the seven day assessment period. On 06/15/23 at 8:15 a.m., Res #13 was observed sitting in a wheelchair in their room and edema and red scaly skin was observed in their lower extremities. At that time Res #13 stated they have had red swollen lower extremities for the past two years. On 06/21/23 at 1:44 p.m., the MDS Coordinator stated there was not a care plan for edema or diuretic use. 2. Res #7 had diagnoses which included heart failure, COPD and lower back pain. A physician order, dated 06/10/22, documented the facility was to administer furosemide (a diuretic medication) one time a day for edema related to heart failure. A physician order, dated 08/13/22, documented the facility was to administer tramadol (an opioid medication used for pain) two times a day for pain related to lower back pain. A physician order, dated 02/19/23, documented the facility was to administer Norco (a pain medication) every eight hours as needed for pain. A quarterly assessment, dated 06/20/23, documented the resident was intact with cognition and required supervision to limited assistance with most ADLs. The assessment documented the resident used diuretic and opioid medications. Res #7's care plan was reviewed and did not observe a care plan for diuretic or opioid use. On 06/20/23 at 4:36 p.m., the MDS coordinator stated they did not develop a care plan for the use of diuretic or opioid medications for Res #7. 3. Res #32 had diagnoses which included other recurrent depressive disorders, anxiety disorder, and dementia without behavioral disturbances. A physician order, dated 05/09/23, documented the facility was to administer Risperdal (an antipsychotic medication) one time a day related to dementia without behavioral disturbances. A quarterly assessment, dated 05/14/23, documented the resident was severely impaired with cognition and required extensive assistance with most activities of daily living. The assessment documented the resident received antipsychotic medication on a routine basis. A review of the resident's care plan did not document a plan of care for the use of antipsychotic medications. On 06/20/23 at 10:44 a.m., the MDS coordinator stated antipsychotic use for Res #32 was not currently on the resident's care plan.

Based on interview and record review, it was determined the facility failed to conduct annual CNA competencies for three of five employee records reviewed. The Resident Census and Conditions of Residents form documented 65 residents resided in the facility. Findings: On 06/23/23, the facility was asked for the CNA performance reviews for CNAs who had been employed at the facility for more than a year. The facility was unable to provide documentation of annual skill competencies for three CNAs whose records were provided for review. On 06/23/23 at 11:30 a.m., the DON stated they were not able to locate the competency documents for the CNAs.

Based on observation, record review, and interview, the facility failed to ensure the blood pressure and heart rate were monitored before holding a medication as ordered by the physician for two (#32 and #48) of five sampled residents whose medications were reviewed for unnecessary medications. The Residents Census and Conditions Of Residents form Documented 65 residents resided in the facility. Findings: 1. Res #32 had diagnoses which included HTN , myocardial infarction, and atherosclerosis of the aorta. A physician order, dated 05/08/23, documented losartan (an anti hypertensive medication) administer two times a day related to HTN, no parameters for holding the medication were documented. A quarterly assessment, dated 05/14/23, documented the resident was severely impaired with cognition. A care plan, last reviewed 05/30/23, documented the resident had hypertension. The care plan documented to give the anti hypertensive medications as ordered and to monitor for side effects such as orthostatic hypotension, increased heart rate, and effectiveness. The May 2023 MAR had areas to document the BP and HR for the resident. The May MAR documented losartan was held on the 9th, 17th, and 24th with no vital signs documented and a notation the vital signs were outside of parameter for administration. The MAR documented the medication was held on the 10th, 15th, and 19th, with blood pressures documented, and the medication was held. The MAR documented the medication was administered on the 8th with a blood pressure documented of 79/47 and pulse of 74. The June 2023 MAR did not document a blood pressure and pulse for the 5th and the medication was held with a notation of for vital signs outside of parameters for administration. On 06/19/23 at 8:02 a.m., the resident was observed in the dining room for breakfast. Res #32 was being assisted and encouraged to eat by a staff member. On 06/20/23 at 3:53 p.m., the DON stated the blood pressure should have been documented on the MAR for the losartan. The DON stated there were not blood pressure parameters on the order. The DON stated when the staff obtained a low blood pressure reading they should have informed the nurse and the nurse should have contacted the physician and documented the physicians response. On 06/21/23 at 9:27 a.m., CMA #1 stated it was the practice of the facility to use universal parameters for blood pressure and notify the nurse if the blood pressure was low. CMA #1 stated the losartan order did not have perimeters for blood pressure documented. On 06/21/23 at 9:34 AM LPN #1 stated she did not think there were blood pressure parameters for the losartan order for Res #32. LPN #1 stated the facility had not obtained parameter orders from the physician for the medication. The LPN stated the CMAs reported a low blood pressure and most generally and the nurse would have re-checked the blood pressure with a cuff machine to make sure both readings were low. The LPN stated she had not contacted the physician about Res #32's blood pressure readings since the resident returned to the facility. 2. Res #48 had diagnoses which included HTN, hypertensive heart, and chronic kidney disease. A physician order, dated 03/16/23, documented the facility was to administer amlodipine (a calcium channel blocker) one time a day related to hypertensive heart and chronic kidney disease and to hold the medication if systolic blood pressure was less than 100 or diastolic less than 80. A quarterly assessment, dated 04/25/23, documented the resident was moderately impaired with cognition. The May 2023 MAR documented 22 days the medication was held without a blood pressure reading documented on the MAR. On 06/22/23 at 4:00 p.m., the DON stated the blood pressure should have been be documented when giving or holding the medication. The DON stated the facility would call someone and find out about that function on the MAR. On 06/22/23 at 4:35 p.m., the DON stated they had asked about documenting the blood pressure on the MAR and the blood pressure had to be entered before the medication was marked held or not given as the system would not allow a staff to enter the blood pressure after you mark not given. The DON stated blood pressures had intermittently been recorded in the vital sign area of the EHR but not with every dose missed.

Based on observation and interview, the facility failed to ensure the kitchen was maintained in good repair. The Residents Census and Conditions Of Residents form documented 65 residents resided in the facility. Findings: On 06/15/23 at 6:40 a.m., an initial tour of the kitchen was conducted. On 06/15/23/ at 6:50 a.m., the walk-in refrigerator and walk-in freezer was observed to have ice build-up around the door of the freezer section which would not allow the door to the freezer to close completely. Water from the ice buildup around the door of the walk-in freezer was observed to have melted and was present on the floor of the walk-in refrigerator. On 06/15/23 at 6:52 a.m., the DM stated even when the ice was removed around the door of the walk-in freezer and with the door shut completely the ice would build up again and cause the same issue. The DM stated they were approved for a kitchen remodel and the freezer was supposed to be on the list but did not know when the remodel was going to happen. On 06/15/23 at 7:17 a.m., the wall behind the dish machine was observed to have missing tiles. The wall had missing drywall with a small piece on the floor and the wall studs and insulation were able to be viewed. A black substance was observed on the wood and drywall. A large hole was observed where the drain for the dish machine went through the wall. On 06/15/23 at 11:28 a.m., the DM stated the wall behind the dish machine had been that way a long time.