**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure residents were offered the choice to formulate advanced directives for seven (#7, 10, 20, 21, 24, 26, and #30) of 12 sampled residents reviewed for advanced directives. The Director of Nursing identified 35 residents resided in the facility. Findings: 1. Resident #7 was admitted on [DATE]. Code Status: DNR 2. Resident #10 was admitted on [DATE]. Code Status: DNR 3. Resident #20 was admitted on [DATE]. Code Status: Resuscitate 4. Resident #21 was admitted on [DATE]. Code Status: Resuscitate 5. Resident #24 was admitted on [DATE]. Code Status: Resuscitate 6. Resident #26 was admitted on [DATE]. Code Status: Resuscitate 7. Resident #30 was admitted on [DATE]. Code Status: Resuscitate The clinical records for Resident #7, #10, #20, #21, #24, #26, and #30 did not document the residents and/or their representatives had or were offered the choice to formulate an advanced directive on admission nor thereafter. On 07/23/24 at 1:23 p.m., the DON acknowledged Resident #7, 10, 20, 21, 24, 26, and #30 did not have an established advanced directive nor did they have a signed acknowledgement saying it had been offered.

Based on record review, observation, and interview, the facility failed to ensure a means to accurately measure and verify the amount of a liquid controlled drug on hand for four (#6, 15, 27, and #29) of six residents receiving a liquid controlled drug. The Director of Nursing identified 35 residents resided in the facility. There were six residents in the facility receiving a liquid controlled drug. Findings: A 'Controlled Substances' policy, effective date July 2015, read in part, .E. Accurate accountability of the inventory of all controlled drugs is maintained at all times . A 'Controlled Drug Receipt Record/Disposition Form' for Resident #15, read in parts, .Lorazepam Con 2mg/ml .Date Received 04/25/24 .Quantity Received 30.00 of 30.00 .Date 07/23/24 .Amount Left 29.25 . A 'Controlled Drug Receipt Record/Disposition Form' for Resident #27, read in parts, .Lorazepam Con 2mg/ml .Date Received 01/15/24 .Quantity Received 30.00 of 30.00 .Date 04/03/24 .Amount Left 29.25 . A 'Controlled Drug Receipt Record/Disposition Form' for Resident #6, read in parts, .Lorazepam Con 2mg/ml .Date Received 05/21/24 .Quantity Received 30.00 of 30.00 .Date 05/22/24 .Amount Left 29.25 . A 'Controlled Drug Receipt Record/Disposition Form' for Resident #29, read in parts, .Lorazepam Con 2mg/ml .Date Received 06/26/24 .Quantity Received 30.00 of 30.00 .Date 07/20/24 .Amount Left 27ml . On 07/24/24 at 11:20 a.m., this surveyor observed there were no markings on the 30ml Lorazepam Con 2mg/ml bottles to measure the amount of medication that exceeded 22mls. CMA #1 was asked to look at the medication bottles and confirm the amount of liquid Lorazepam Con 2mg/ml remaining in the bottles for Resident #6, #15, #27, and #29, without referring to the controlled drug sheet. They stated they could not. On 07/24/24 at 12:37 p.m., the DON was asked how the count for liquid narcotics was verified as accurate since there were no markings on the medication bottles between 22mls and 30mls. The DON acknowledged they could not verify the accuracy of the count and stated, The pharmacy would need to dispense it differently.

Based on observation, record review, and interview, the facility failed to ensure: a. food items were labeled, dated and stored according to facility policy, b. proper freezer cleaning practices were followed to prevent the outbreak of foodborne illness, c. using adequate utensils for portion sizes for meals, d. maintain proper dishwasher temperature, and e, maintain infection control during wrapping of silverware. Findings: The DON reported all 35 residents that resided in the facility also received services from the kitchen. The facility's Food Receiving and Storage policy, dated 12/2008, read in part, Foods shall be received and stored in a manner that complied with safe food handling practices. The policy also read, Food Services, or other designated staff, will maintain clean food storage areas at all times. The policy also read, All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). The facility's Cleaning Freezer document, undated, read in part, Remove all food from freezer to be defrosted and place in another freezer. The policy also read, Repeat this procedure as often as necessary. The facility's Kitchen Weights and Measures policy, dated 12/2008, read in part, Food Services staff will be trained in proper use of cooking ans serving measurements to maintain portion control. The policy also read, Cooks and Food Services staff will be trained in weights and measures, volume and weights, appropriate utensil use, and food can sizes. The policy also read, Serving utensils used. Staff will be trained in the appropriate measurement and type of serving utensil to use for each food. Signs or posters explaining coded measurement indicators (e.g., color-coded) on utensils will be prominently displayed for reference. The facility's Washing Dishes document, undated, read in part, Dishwasher .(Wash 120 degrees F, Rinse 120 degrees F). On 07/22/24 at 3:15 p.m., during the initial tour of the kitchen the following observations were made: In refrigerator/freezer #2: a. one clear plastic container with yellow hinges with cheddar cheese inside with no date on the container. The cheese was not in its original container. b. two opened gallons of milk with no opened date. c. one opened half gallon of chocolate milk with no opened date. In refrigerator/freezer #1: a. one Ziploc bag of sliced cheese with no label or opened date. In refrigerator/freezer #3: a. one large pan of rice crispy bars covered with foil with no date or label. b. one pound cake in a plastic bag with no label or opened date. In the freezer in the dry storage area: a. two bags of opened frozen cookies with no label or opened date. b. observation of dietary aide #1 wrapping silverware on top of the deep freezer. The utensils were touching the surface of the freezer top with no barrier underneath. The freezer had debris on it. In freezer #5 observation made of the bottom of the freezer to be covered with ice and frozen red liquid underneath a shelf of frozen meat. On 07/22/24 at 3:34 p.m., the DM was asked what the policy and procedure was for refrigerator storage. They went to look. On 07/22/24 at 3:36 p.m., the DM stated the dishwasher temperature should reach 120 degrees. The DM stated it read 100 degrees and should be 120 degrees, then walked away. On 07/22/24 at 3:37 p.m., the dietary aide #1 stated if the dishwasher did not meat the right temperature then they would run it again. The dietary aide was observed to remove the dishes from the dishwasher and proceed to put them away. It was a large pot and two cups. On 07/22/24 at 3:39 p.m. the dietary aide #1 stated they could not say why they put the dishes up that were washed when the dishwasher was not at the correct temperature. On 07/22/24 at 3:41 p.m., the dishwasher temperature log was observed to have no temperatures documented for 7/20, 7/21, nor 7/22/2024. The dietary aide #1 stated the temperature log should be completed three times a day. They stated after looking at the log on the wall that the last date documented was the 19th. On 07/22/24 at 3:43 p.m., the DM ran the dishwasher again. The temperature reading was 105 and 100 degrees. On 07/22/24 at 3:44 p.m., the CDM informed staff to use paper until the dishwasher was fixed. On 07/22/24 at 3:45 p.m. the DM stated to use the 3 compartment sink for pots and pans. On 07/22/24 at 3:46 p.m., the CDM stated they were to check the dishwasher temperatures three times a day and the last date on the log was the 19th. On 07/22/24 at 3:48 p.m., the CDM stated the following of the identified concerns: a. the cheese had no date and the three milks had no date when opened. b. the pound cake had no date and stated the rice crispies had just been made that day but had no date or label. c. the wrapping of the cutlery should have been done on a clean surface and done in the dining room normally. d. no knowledge of when the cookies were place as there was no date. On 07/22/24 at 3:53 p.m., the CDM stated the freezers were to be cleansed once a month. They looked inside the freezer #5 and was asked if the freezer had been cleaned recently. They stated, No! They were asked if the policy and procedure were being followed. The CDM stated, no. On 07/22/24 at 4:07 p.m. the DM stated if dishes were washed in an under temp dishwasher, the staff were to re-wash them. On 07/22/24 at 4:10 p.m., there was a purple spoon/spatula in appearance, in the pureed main entree of shepherds pie. They had already served from the pan. On 07/22/24 at 4:12 p.m., the DM stated it was a one tablespoon. The removed it and stated should be a #12 which was a 1 1/2 cup and they did not have that so they were using a 1.5 scoop. On 07/22/24 at 4:15 p.m., the DM acknowledged the puree had already been served. On 07/22/24 at 4:41 p.m., the DON stated the portion sizes were on the wall and they did not have a policy. They were informed of the kitchen concerns.

Based on record review and interview, the facility failed to provide a binding arbitration agreement that contained an acknowledgement the resident or their representative understood the agreement they were signing for sixteen (#6, 7, 10, 11, 13, 15, 20, 21, 23, 24, 26, 28, 29, 30, 32, and #34) of twenty-six residents with signed binding arbitration agreements. The DON identified 35 residents resided in the facility. There were 26 residents who had signed a binding arbitration agreement. Findings: The binding arbitration documentation did not contain an acknowledgement that the resident or their representative understoon the agreement for the following Residents #6, 7, 10, 11, 13, 15, 20, 21, 23, 24, 26, 28, 29, 30, 32, and #34. On 07/25/24 at 3:54 p.m., the Administrator was asked to identify where in the binding arbitration agreement for Residents #6, 7, 10, 11, 13, 15, 20, 21, 23, 24, 26, 28, 29, 30, 32, and #34 did it state the resident or their representative understood the agreement they were signing. The Administrator reviewed the agreements and acknowledged they did not contain that necessary information

Based on record review and interview, the facility failed to provide a binding arbitration agreement that informed the resident or their representative of their right to have the arbitration held at a venue that is convenient to both parties for sixteen (#6, 7, 10, 11, 13, 15, 20, 21, 23, 24, 26, 28, 29, 30, 32, and #34) of twenty-six residents with signed binding arbitration agreements. The DON identified 35 residents resided in the facility. There were 26 residents who had signed a binding arbitration agreement. Findings: The binding arbitration agreement did not contain a statement informing the resident or their representative of their right to have the arbitration at a neutral site that is convenient for both parties for Residents #6, 7, 10, 11, 13, 15, 20, 21, 23, 24, 26, 28, 29, 30, 32, and #34. On 07/25/24 at 3:54 p.m., the Administrator was asked to identify where in the binding arbitration agreement for Residents #6, 7, 10, 11, 13, 15, 20, 21, 23, 24, 26, 28, 29, 30, 32, and #34 did it state the resident or their representative had the right to have the arbitration held at a venue that was convenient to both parties. The Administrator reviewed the agreements and acknowledged they did not contain that necessary information.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to have a water management program in place to minimize the risk of Legionella and other opportunistic pathogens in building water systems reviewed for infection control. This had the potential to affect all residents. The DON identified 35 residents resided in the facility. A Legionnaires' Disease policy, dated 9/2019, read in part, Develop a water management strategies to reduce the risk of the growth and spread of Legionella if a risk assessment determines the facility to be at risk. 1. Complete a facility risk assessment of the water system. A map/diagram will be developed which will map out how the water enters and travels through the building. 2. Develop water management strategies for the facility's hot and cold water distribution system. 3. Document the water management program. Maintain record of the facility's activities and strategy to manage and maintain an efficient water system. 4. Prepare a facility description. A facility description should be written and include: location, age, uses/function, occupant population, visitor population. 5. Describe the facility's water system. The description should be written and include: general summary (how water enters and flows through the facility), uses of water, aerosol-generated devices, process flow diagram. The building diagram provided attached to the policy was blank and did not identify water flow. An Identifying Buildings at Increased Risk form, undated, documented if the answer to questions 1-4 were yes, then there should be a water management program for that building's hot and cold water distribution system. An X mark next to Yes for question#1 that stated Is your building a healthcare facility where patients stay overnight or does your building house or treat people who have chronic and acute medical problems or weakened immune systems. There was also a yes marked for question #2 for Does your building primarily house people older than 65 years (like a retirement [NAME] or assisted-living facility). An email, dated 11/02/2022 from CMS DNH Triage Team to a facility corporate representative per the DON. The email documented, Facilities must be able to demonstrate measures to minimize the risk of Legionella and other opportunistic pathogens in building water systems such as having a documented water management program. It also documented, Facilities must also have an assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread to prevent the growth of opportunistic waterborne pathogens (also known as control measures), and how to monitor them. It also documented, Your water management program must at a minimum meet federal guidelines and any additional state requirements if applicable. On 07/24/24 at 8:52 a.m., the DON stated they were the IP for the facility. They stated they had not had any Legionellosis in the facility. The DON stated they needed to ask the administrator about the Legionella policy. They were asked if the maintenance would do it and they further stated would ask the administrator. On 07/24/24 at 10:30 a.m., the DON stated they did not follow the policy and procedure for Legionella but they were doing what was instructed and approved per their corporate which was who the email was sent to and who sent the documents to the facility. The DON verbalized they did not follow the policy they provided the survey team.

Based on record review and interview, the facility failed to submit accurate Registered Nurse staffing data to CMS for FY Quarter 2 2024. The DON identified 35 residents resided in the facility. Findings: A PBJ Staffing Data Report, for January 1, 2024 - March 31, 2024, documented the facility did not have RN hours for 01/02; 01/03; 01/04; 01/05; 01/08; 01/09; 01/09; 01/10; 01/11; 01/12; 01/15; 01/16; 01/17; 01/18; 01/19; 01/22; 01/23; 01/24; 01/25; 01/26; 01/29; 01/30; 01/31; 02/01; 02/02; 02/05; 02/06; 02/07; 02/08; 02/09; 02/12; 02/13; 02/14; 02/15; 02/16; 02/18; 02/19; 02/20; 02/21; 02/22; 02/23; 02/26; 02/27; 02/28; 02/29; 03/01; 03/04; 03/05; 03/06; 03/07; 03/08; 03/11; 03/12; 03/13; 03/14; 03/15; 03/16; 03/17; 03/18; 03/19; 03/20; 03/21; 03/22; 03/23; 03/24; 03/25; 03/26; 03/27; 03/28; and 03/29. On 07/23/24 at 3:48 p.m., the DON was asked if the facility had RN coverage on the days outlined on the PBJ Staffing Data Report. They stated all of the days listed for missing RN coverage were days the DON had worked, and the previous business office person failed to manually input them into the system before submitting the information to the state. The DON provided copies of the updated time reports. RN coverage was noted for each day designated on the [NAME] report. The DON was asked if accurate information had initially been submitted to the state? They stated no it was not.

Based on record review and interview, the facility failed to revise a care plan related to behaviors for one (#28) of one sampled resident reviewed for behaviors. The MDS coordinator identified 10 residents who refused medication and care. The Resident Census and Conditions of Residents, dated 07/03/23, documented a census of 39 residents. Findings: Res #28 was admitted with diagnoses which included depression, dementia, bipolar, delusional disorder and anxiety. A review of the nursing notes, dated 06/01/23 to 07/07/23, documented Res #28 refused medications 26 times, refused showers four times, and refused skin treatments twice. A Behavioral and Mental Health care plan, dated 03/08/22, did not document the resident's refusal of medications, showers and treatments. On 07/06/23 at 1:36 p.m., the MDS coordinator reported Res #28's behaviors of refusing medications, showers and treatments 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 care plans were developed and implemented for three (#8, 14 and #23) of three sampled residents with orders for a diuretic, opioid pain medications, anti-depressants, and anticoagulants. The MDS Coordinator identified three residents with orders for diuretics, eight residents with orders for opioid pain medications, 30 residents with orders for antidepressants, and six with orders for anticoagulants. Findings: 1. Res #8 was admitted with diagnoses which included chronic pain syndrome and depression. A care plan, last updated 12/13/22, did not contain documentation of Res #8's opioid pain medication or anti-depressant. A physician order, dated 03/01/23, documented to administer Cymbalta (an antidepressant) 30 mg daily. A physician's order, dated 05/08/23, documented to administer Oxycodone (an opioid pain medication) 5 mg twice daily. A quarterly assessment, dated 06/12/23, documented Res #8 had received the anti-depressant and pain medication for seven days of the seven day look back period. On 07/06/23 at 8:10 a.m., Res #8 was observed receiving the Cymbalta and Oxycodone. On 07/06/23 at 1:45 p.m., the MDS coordinator reported the anti-depressant and pain medication for Res #8 should have been care planned. 2. Res #14 was admitted with diagnoses which included hypertension and edema. A physician order, dated 03/23/23, documented to administer Lasix (a diuretic medication) 20 mg daily in the morning. A care plan, last updated 06/08/23, did not contain documentation of the diuretic/Lasix. A quarterly assessment, dated 06/29/23, documented Res #14 had received a diuretic for seven days of the seven day look back period. On 07/06/23 at 8:15 a.m., Res #14 was observed receiving Lasix 20 mg. On 07/06/23 at 1:45 p.m., the MDS coordinator reported the diuretic for Res #14 should have been care planned. 3. Res #23 was admitted to the facility on [DATE] with diagnoses which included atrial fibrillation and CVA. A physician order, dated 04/05/23, documented to administer warfarin (an anticoagulant) 4 mg daily. An admission assessment was completed on 04/12/23. A comprehensive care plan for Res #23 was not developed until 06/06/23. The care plan, dated 06/06/23, did not include a care plan for anticoagulant therapy. On 07/06/23 at 1:35 p.m., the MDS Coordinator reported there should have been a care plan for Res #23's anticoagulant therapy because warfarin use required monitoring. They stated the care plan for Res #23 was not developed in a timely manner.

Based on record review, observation, and interview, the facility failed to ensure residents were free of accident hazards for one (#1) of three residents reviewed for transporting while in reclining wheelchairs. The Administrator reported five residents utilized reclining wheelchairs. Findings: An untitled and undated policy, read in parts, .To ensure that all residents are safe during transportation of using facility vehicle .All residents will be secured in their seats . On 03/14/23 at 2:20 p.m., Res #1 reported the brakes on their reclining wheelchair were broken. Res #1 reported when being transported in the facility van the reclining wheelchair was not secured. On 03/14/23 at 2:25 p.m., Res #1's reclining wheelchair was observed with the right brake missing and the left brake was broken. On 03/14/23 at 2:30 p.m., CNA #1 reported they had transported Res #1 to an appointment and the reclining wheelchair brakes were broken at the time. On 03/14/23 at 3:10 p.m., the Administrator observed Res #1's reclining wheelchair and reported the brakes were broken . The Administrator reported Res #1 should not have been transported with the broken brakes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure an admission assessment accurately reflected the resident's status for one (#26) of one resident whose admission assessment was reviewed. The Resident Census and Conditions of Residents documented 31 residents resided in the facility. Findings: Res #26 was admitted on [DATE]. An untitled, undated document, read in parts, .Active Diagnosis .Pressure ulcer of sacral region, Stage 4 .Current diagnosis date 02/04/22 . An admission assessment completed on 02/10/22 documented there were no unhealed pressure ulcers for Res #26. On 06/01/22 at 3:53 p.m., the MDS Coordinator confirmed Res #26 was admitted with a stage 4 pressure ulcer of the sacral region. The MDS Coordinator also reported she had not documented the pressure ulcer correctly on the admission assessment.

Based on record review and interview, the facility failed to review and revise a care plan for one (#26) of one resident whose care plan was reviewed. The Resident Census and Conditions of Residents documented 31 residents resided in the facility. Findings: Res #26 was admitted with diagnoses which included Stage 4 pressure ulcer to sacrum. A care plan dated, 02/04/22, read in parts, .New admit to nursing facility for the DX of .stage three pressure area of coccyx . A TAR dated 05/01/22 through 05/31/22, documented Res #26's wound was resolved on 05/19/22. The Wound Evaluation & Management Summary, dated, 05/19/22, read in parts, .Stage 4 pressure wound sacrum resolved on 5/19/2022. On 06/01/22 at 3:53 p.m., the MDS Coordinator reported she was behind on care plans and should have revised the care plan regarding the pressure ulcer for Res #26. The MDS Coordinator reported care plans should have been updated at least quarterly. On 06/01/22 at 4:00 p.m., LPN #2 reported the pressure ulcer for Res #26 was healed and should have been taken off the care plan.

Based on record review and interview, the facility failed to ensure: a. annual skills competencies were completed for two (CNA #3 and LPN #2) of six employees whose personnel files were reviewed. b. skills competencies for new hires were completed for two (LPN #1 and RN #1) of six employees whose personnel files were reviewed. Findings: A CNA checklist for CNA #3, dated 01/06/21, was blank. A Nurse checklist for LPN #2, dated 03/19/21, was blank. A Nurse checklist for LPN #1, dated 05/01/22, was blank. On 06/02/22 at 10:30 a.m., the administrator verified the skills competencies were blank and reported they should have been completed upon hire and annually.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to maintain an effective pest control program. The Resident Census and Conditions of Residents documented 31 residents received meals from the kitchen. Findings: On 05/31/22 at 9:10 a.m., during the intital tour of the kitchen, mouse droppings were observed: a. in the doorway between the kitchen and dining room. b. in the general storage room underneath a storage rack. c. in the corner of the chemical storage room. On 06/01/22 at 1:27 p.m., during a walk through of the kitchen, mouse droppings were observed: a. in the doorway between the kitchen and dining room. b. in the general storage room underneath a storage rack. c. on the floor of the chemical storage room. d. on the floor beside the food preparation table. e. behind the faucet in the janitor closet. f. on the floor of the broom closet. A Pro-[NAME] Pest Control invoice dated, 09/28/21, was provided by the facility. On 06/01/22 at 2:25 p.m., the administrator stated she had not allowed the pest control company inside the building due to Covid.