Based on observation, record review, and interview, the facility failed to ensure a care plan was updated to include an order for oxygen for one (#5) of one sampled residents reviewed for oxygen. The corporate nurse consultant identified two residents required oxygen. Findings: 1. Res #5 had diagnoses which included COPD. A physician order, dated 08/15/24, documented Res #5 was to receive oxygen at two to three liters per minute via nasal cannula to maintain oxygen saturation above 90%. On 10/21/24 at 9:57 a.m., Res #5 was observed in bed in their room. The oxygen concentrator was observed at bedside delivering oxygen at two liters per minute via nasal cannula. Res #5's care plan did not document they received oxygen. On 10/24/24 at 10:40 a.m., the MDS coordinator stated oxygen should be on the care plan. Upon review of Res #5's care plan they stated the oxygen was not documented, but should have been.

Based on observation, record review, and interview, the facility failed to ensure informed consent was obtained prior to the utilization of bed rails for one (#32) of one sampled resident reviewed for bed rails. The administrator identified four residents whose beds were equipped with a bed rail of any type. Findings: A Proper Use of Side Rails policy, revised December 2016, read in part, .Consent for side rail use will be obtained from the resident . Res #32 had diagnoses which included fusion of the cervical spine, central cord syndrome, and muscle weakness. An admission assessment, dated 09/26/22, documented the resident was cognitively intact, required extensive assistance with bed mobility, and had one fall without injury. A physician order, dated 06/28/23, documented the resident could have half rails to their bed for repositioning purposes. A care plan, dated 09/28/23, documented the resident was able to use side rails for repositioning and rolling in bed. On 10/21/24 at 9:56 a.m., Res #32 was observed lying in bed. Bilateral half bed rails were observed on the upper half of the bed in the up position. Res #32 stated the bed rails were used to aide in turning and repositioning. There was no documentation of informed consent for bed rails found in the medical record. On 10/22/24 at 2:00 p.m., the corporate nurse consultant stated informed consent was not obtained prior to use of bedrails.

Based on record review and interview, the facility failed to administer medication as ordered for one (#3) of six sampled residents whose medication records were reviewed. The BOM identified 38 residents who resided in the facility. Findings: Res #3 had diagnoses which included schizophrenia, auditory hallucinations, and bipolar disorder. A Release of Responsibility for Medication record, dated 12/11/23, documented the facility received 125 tablets of clozapine (antipsychotic medication) 100 mg upon Res #3's admission. A physician order, dated 12/11/23, documented to administer two tablets of clozapine 100 mg at bedtime for schizophrenia. A physician order, dated 12/11/23, documented to administer one tablet of clozapine 100 mg twice daily for schizophrenia. A care plan, dated 12/14/23, documented Res #3 received psychotropic medication for schizophrenia and to administer clozapine 100 mg at 8:00 a.m. and 4:00 p.m. The care plan documented to administer clozapine 200 mg at bedtime. A December 2023 MAR documented Res #3 received a total of 83 tablets of clozapine 100 mg. A pharmacy log, dated 01/26/24, documented the facility received 56 tablets of clozapine 100 mg for Res #3. A January 2024 MAR documented Res #3 received a total of 124 tablets of clozapine 100 mg for the entire month. A pharmacy log, dated 02/19/24, documented receipt of 56 tablets of clozapine 100 mg for Res #3. A February 2024 MAR documented Res #3 received a total of 116 tablets of clozapine 100 mg for the entire month. Pharmacy record review documented the facility had received a total of 237 tablets of clozapine 100 mg for Res #3 during the months of December 2023, January 2024, and February 2024. Res #3's medication records documented the resident had received 323 tablets of clozapine 100 mg during the months of December 2023, January 2024, and February 2024. On 10/24/24 at 10:23 a.m., CMA #1 was asked about the discrepancy in the number of clozapine tablets available in relation to the number of tablets documented as given for Res #3. CMA #1 stated Res #3 had received a total of 4 tablets of clozapine 100 mg daily during the months of December 2023 through February 2024. They stated having only been responsible for administering one of the three tablets during their shift. CMA #1 stated CMA #2 would have been responsible for administering the other three tablets in the afternoon and at bedtime. They stated CMA #2 may have been administering a discharged resident's leftover clozapine after Res #3's supply of tablets ran out. CMA #1 stated giving Res #3 some other resident's medication was against the rules and should not have happened. On 10/24/24 at 10:40 a.m., the BOM stated CMA #2 was unavailable for interview due to a medical leave absence. Attempts to interview CMA #2 via phone call were made with no success. On 10/24/24 at 11:27 a.m., the administrator was made aware of the medication count discrepancy for Res #3. The administrator stated the concern was never brought to their attention by staff. They stated staff should not have borrowed medications from another resident and there was no way to prove Res #3 had received the medication according to physician orders. On 10/24/24 at 11:43 a.m., the corporate nurse consultant stated Res #3's clozapine had not been administered per physician order.

Based on record review and interview, the facility failed to ensure the physician responded to a pharmacist MRR and failed to ensure physician rationale was documented related to a declination of a GDR for two (#6 and #26) of five sampled residents reviewed for unnecessary medications. The BOM identified 38 residents who resided in the facility. Findings: A Drug Regimen Review policy, dated 2020, read in parts, .The consultant pharmacist drug regimen reviews are processed as follows: The physician provides a written response of the report to the facility within one month after the report is sent . 1. Res #6 had diagnoses which included dementia, schizophrenia, unspecified psychosis, and insomnia. A physician order, dated 06/08/23, documented to administer ramelteon (hypnotic medication) 8 mg at bedtime for insomnia. A physician order, dated 06/21/23, documented to administer Trintellix (antidepressant medication) 20 mg in the morning for depressive disorders. A physician order, dated 06/21/23, documented to administer desvenlafaxine (antidepressant medication) 100 mg in the morning for depressive disorders. A physician order, dated 07/27/23, documented to administer Vraylar (antipsychotic medication) 6 mg daily for schizophrenia. A physician order, dated 11/10/23, documented to administer olanzapine (antipsychotic medication) 10 mg at bedtime for schizophrenia. An annual assessment, dated 04/01/24, documented the resident was moderately cognitively impaired, had no depression symptoms, had no behaviors, and received hypnotic, antidepressant, and antipsychotic medication. A MRR report, dated 05/07/24, documented the resident was due for consideration of a gradual dose reduction of Trintellix, ramelteon, Vraylar, olanzapine, and desvenlafaxine. There was no documented response from the physician on the MRR report. On 10/24/24 at 9:15 a.m., the DON stated they did not have anything to do with the MRR process and was not familiar with the policy. The DON stated the MDS coordinator was responsible for this task. On 10/24/24 at 9:20 a.m., the MDS coordinator stated the physician had not responded to the pharmacist's request for a gradual dose reduction for Res #6's medication. 2. Res #26 was admitted with diagnoses which included dementia, depression, and insomnia. A physician order, dated 02/02/22, documented to administer trazadone (antidepressant medication) 150 mg at bedtime for insomnia. A physician order, dated 06/20/23, documented to administer Lexapro (antidepressant medication) 20 mg daily for depression. A physician order, dated 06/20/23, documented to administer Remeron (antidepressant medication)15 mg daily for depression. A physician order, dated 06/21/23, documented to administer lamotrigine (anticonvulsant medication) 150 mg twice daily for physical debility. A physician order, dated 08/08/23, documented to administer Invega (antipsychotic medication) 234 mg intramuscularly every 21 days for unspecified dementia. An annual assessment, dated 01/11/24, documented the resident was severely cognitively impaired, had no depression symptoms, had no behaviors, and received antipsychotic and antidepressant medication. A MRR report, dated 01/12/24, documented the resident was due for consideration of a GDR for Lexapro, lamotrigine, Remeron, Invega, and trazadone. The physician documented they disagreed with the request. There was no physician documented rationale for the declination of the GDR request on the MRR report. On 10/24/24 at 9:30 a.m., the MDS coordinator stated the physician should have documented a rationale for the declination of a GDR request for Res #26. On 10/24/24 at 11:45 a.m., the corporate nurse consultant stated the physician did not provide rationale for the declination of a GDR request for Res #26, but should have.

Based on record review and interview, the facility failed to ensure a resident who received psychotropic medications had an acceptable diagnosis/indication for the use of an antipsychotic medication for one (#26) of five sampled residents reviewed for unnecessary medications. The corporate nurse consultant identified 16 residents who received antipsychotic medications. Findings: Res #26 was admitted with diagnoses which included dementia and depression. A physician order, dated 06/20/23, documented to administer cariprazine (antipsychotic medication) 3 mg once daily for unspecified dementia without psychotic or behavioral disturbance. A physician order, dated 08/08/23, documented to administer Invega (antipsychotic medication) 234 mg intramuscularly every 21 days for unspecified dementia. An annual assessment, dated 01/11/24, documented the resident was severely cognitively impaired, had no depression symptoms, had no behaviors, and received antipsychotic medication. On 10/24/24 at 9:30 a.m., the MDS coordinator stated Res #26 should not have antipsychotic medications ordered for a diagnosis of dementia. On 10/24/24 at 11:45 a.m., the corporate nurse consultant stated dementia was not an appropriate diagnosis for the use of antipsychotic medications.

Based on observation and interview, the facility failed to ensure food was stored in accordance with professional standards for food service safety. The BOM identified 38 residents resided in the facility. Findings: On 10/21/24 at 8:12 a.m., the initial tour of the kitchen was conducted. The following was observed: a. in the two door silver refrigerator a clear gallon bag containing six raw, pre-formed, hamburger patties was observed in a white plastic tote on top of a clear gallon bag containing pre-cooked and sliced sandwich meat labeled Ranch Packs dated 10/03/24, b. in the two door silver refrigerator a clear gallon bag labeled deli-sliced ham was on top of the bag containing raw hamburger patties, c. in the two door silver refrigerator a gallon pour top jug containing a brown liquid was not dated or labeled, d. in the two door silver refrigerator a gallon pour top jug containing an orange liquid was not dated or labeled, e. in the dry storage area an undated and unlabeled blue bag was observed with the top tied in a knot, the staff identified the contents as raisins, f. in the white Frigidaire refrigerator zucchini was observed to have a grey and white fuzzy substance covering the surface of the vegetables, and g. the floor in the kitchen had debris and food particles. On 10/21/24 at 8:16 a.m., [NAME] #1 stated the raw meat should not have been stored with the cooked meat. They stated food should be labeled and dated when they were prepared, stored, or opened. On 10/21/24 at 8:46 a.m., the DM was made aware of the above observations.

Based on observation, record review, and interview, the facility failed to conduct regular inspections of all bed frames, mattresses, and bed rails as part of a regular maintenance program to identify areas of possible entrapment for one (#32) of one sampled resident reviewed for bed rails. The corporate nurse consultant identified four residents whose beds were equipped with a bed rail of any type. Findings: An undated Maintenance policy, read in part, .This facility will conduct preventative maintenance checks periodically and as needed for facility equipment and facility property. This facility will maintain preventative maintenance records pertaining to equipment and facility property . Res #32 had diagnoses which included fusion of the cervical spine, central cord syndrome, and muscle weakness. An admission assessment, dated 09/26/22, documented the resident was cognitively intact, required extensive assistance with bed mobility, and had one fall without injury. A physician order, dated 06/28/23, documented the resident could have half rails to their bed for repositioning purposes. A care plan, dated 09/28/23, documented the resident was able to use side rails for repositioning and rolling in bed. On 10/21/24 at 9:56 a.m., Res #32 was observed lying in bed. Bilateral half bed rails were observed on the upper half of the bed in the up position. Res #32 stated the bed rails were used to aide in turning and repositioning. On 10/22/24 at 1:35 p.m., the administrator was asked to provide documentation of regular bed rail inspections for Res #32. On 10/22/24 at 2:05 p.m., the administrator stated maintenance routinely checked bed rails, but had not maintained records of the inspections.

Based on record review and interview, the facility failed to ensure resident medical records were complete and readily accessible for one (#1) of three residents whose records were reviewed. The Resident Census and Conditions of Residents form documented 41 resident resided in the facility. Findings: Res #1 had diagnoses which included diabetes mellitus, hyperlipidemia, and HTN. On 02/24/23, at approximately 1:00 p.m., the corporate nurse stated she did not have the MDS assessments for the closed records. The MDS for resident #1 was not available during the survey. On 02/27/23 at 3:15 p.m., the administrator stated she had requested the MDS assessments for Res #1 but had not received them.

Based on record review and interview, the facility failed to ensure the resident's treatment and care was in accordance with professional standards and the person centered care plan for one (#1) of three resident reviewed for neglect. The Resident Census and Conditions of Residents form documented 41 resident resided in the facility. Findings: Res #1 had diagnoses which included diabetes mellitus, hyperlipidemia, and HTN. A physician order, dated 09/01/21, documented to administer Cozaar (an antihypertensive every day for HTN. A care plan, edited 12/20/21, documented the resident was at risk for impaired cardiac status related to anemia, HTN, history of COVID 19, and hyperlipidemia. The care plan documented to obtain blood pressure prior to administering medication. A physician order, dated 01/20/22, documented to administer amlodipine (a calcium channel blocker) one every HS for HTN. A MAR, dated March 2022, revealed the resident's blood pressure had not been documented prior to the administration of Cozaar one time March 19th, 2022 and six times for the amlodipine on March 11th, 13th, 14th, 16th, 18th, and 19th of 2022. On 02/27/23 at 12:25 p.m., CMA #1 stated the system the facility is currently using will not let you proceed if you do not enter the blood pressure. She stated she thought the old system was also that way. She stated she normally worked the days shift and would give the medication between 7:00 a.m. to 9:00 a.m. She stated she had worked one night the blood pressure had not been documented on the MAR. On 02/27/23 at 2:21 p.m., RN #1 stated the blood pressure should have been obtained before blood pressure medication was administered. The RN was asked about the days on the MAR without documentation of blood pressures. RN #1 stated looks like the staff had not documented the blood pressures.

Based on record review and interview, the facility failed to ensure a surety bond with adequate coverage for resident funds, which had been deposited in the account, was purchased. The facility administrator reported 34 residents had funds in the trust fund account. Findings: A Surety Bond, dated 02/20/11 and a renewal date of 02/08/23, documented a sum of 18,000 dollars. On 09/29/22, ''Elmwood Manor Nursing Home PO and Trust Balance Sheet'' were reviewed and documented a total balance for trust as of 09/29/22: 30,706.34 dollars, which included foster home sale proceeds of 14,086.32 dollars and vending money balance of 73.96 dollars. On 09/29/22 at 12:33 p.m., the administrator stated a resident who had previously passed away had deposited the funds from a sale of the family home into the trust fund. The administrator stated she did not know what to do with the extra funds due to issues with the CARES Act. She was shown the Trust account balance from the trust account information provided as of 09/29/22. She was asked if 30,706.34 dollars was the correct balance in the account. The administrator stated it was close enough. She was shown the Surety bond where the amount indicated the amount was 18,000 dollars. She stated the Surety bond was not enough.

Based on observation, record review, and interview, the facility failed to conduct a significant change assessment to reflect the resident's current status for one (#8) of 19 residents whose assessments were reviewed. The Resident Census and Conditions of Residents form documented 38 residents resided in the facility. Findings: Res #8 had diagnoses which included transient ischemic attack, diabetes, vascular dementia with behavioral disturbance, and depression. An admission assessment, dated 04/07/22, documented Res #8 was moderately impaired in daily decision making, physical behaviors directed toward others, rejection of care, and required limited assistance of one or two staff with ADLs and did not walk. A quarterly assessment, dated 07/06/22, documented Res #8 was severely impaired in cognition, had physical and verbal behaviors directed toward others, and required supervision to total assistance with ADLs. On 09/29/22 at 10:43 a.m., the MDS coordinator stated she had been told significant change assessments were to be done with hospice admissions. She stated she was not aware a significant change assessment had to be done when there were changes in two or more areas of the assessment as well.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure all residents with newly evident or possible serious mental disorder, were referred to OHCA for evaluation of need for a level II PASRR for one (#33) of one resident reviewed for PASRR. The Resident Census and Conditions of Residents form documented 21 residents had psychiatric diagnoses excluding dementia and depression. Findings: Resident #33 had diagnoses which included unspecified psychosis, recurrent depressive disorders, anxiety disorder, and unspecified dementia. A PASRR prescreening assessment, dated 03/11/14, documented Res #33 had no serious mental illness. An annual assessment, dated 03/09/22 documented the preadmission screening did not identify serious mental illness. The assessment documented Res #33 was moderately impaired in cognition, had no behaviors, required extensive to total assistance with most ADLs, and did not walk. A quarterly assessment dated [DATE], documented Res #33 was moderately impaired in cognition required extensive to total assistance with ADLs and received antipsychotic, antianxiety, antidepressant, and hypnotic medications during the assessment period. On 09/27/22 at 3:26 p.m., corporate nurse stated Res #33 should have had a PASRR II assessment and could not say if it had been done or if OHCA had been notified when she received the new diagnoses. On 09/28/22 at 8:28 a.m., the corporate nurse stated she was unable to tell when Res #33 received the new psychiatric diagnoses as they were unable to get into the EHR system they used before. She stated she could not tell if OCHA had been notified when the diagnoses were received.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a baseline care plan which included physician orders for psychotropic medications for one (#20) of five residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 28 residents were prescribed psychotropic medications. Findings: Res #20 had diagnoses which included generalized anxiety disorder and depression. A baseline care plan, dated 03/30/22, did not document the resident's medications including psychotropic medications. An admission MDS, dated [DATE], documented the resident was cognitively intact and received anti-anxiety and antidepressant medications seven out of seven days during the review period. A quarterly MDS, dated [DATE], documented the resident was cognitively intact, had minimal depression, and received anti-anxiety and antidepressant medications every day of the review period. The physician orders prior to April 2022 were unable to be viewed. On 09/29/22 at 11:29 a.m., the MDS coordinator stated the resident's psychotropic medications were not on his baseline care plan. She reviewed his admission orders and stated since he was on those medications at admission they should have been included on the baseline care plan.

Based on observation, record review, and interview, the facility failed to ensure ADLs cares were provided for dependent residents for one (#84) of one resident reviewed for ADL care. The Resident Census and Conditions of Residents form documented 38 residents resided in the facility. Findings: Res #84 had diagnoses which included infective bursitis, psychiatric and behavioral factors associated with discord, and Lewy body dementia. The facility was not able to provide comprehensive or quarterly assessments for this resident. The ADL sheets were reviewed and documented Res #88 toileted either herself or with staff assist ranging from independent to total assist, often in the same day. There were several shifts from June 5, 2021 through June 26, 2021, the records did not document ADL cares were provided. On 09/30/22 at 08:17 a.m., the corporate nurse reviewed the ADL records for June 2021 and stated the facility was in outbreak with COVID-19 at the time. She stated there had been an issue with ADL documentation on the second and third shift. The corporate nurse stated she was not sure of what happened as the resident had been discharged for some time. On 09/30/22 at 8:44 a.m., the MDS coordinator reviewed the ADL sheets and stated if was not documented then she would have to assume the ADL was not done. She stated she remembered the resident was occasionally incontinent and needed more help to get to the bedside commode toward the end of her stay.

Based on observation, record review, and record review, the facility failed to ensure the resident's treatment and care was in accordance with the person centered care plan and in accordance with professional standards for one (#4) of one resident reviewed for hospice. The Resident Census and Conditions of Residents form documented one resident was receiving hospice services. Findings: Res #4 had diagnoses which included alcoholic cirrhosis of the liver with ascites, end stage renal failure, and diabetes. A care plan, dated 06/20/22, documented Res #4 was a long term care resident. The care plan documented problems including dental/oral care, cardiac output, gastrointestinal function, hypothyroidism, and end stage renal disease. A significant change assessment, dated 06/28/22, documented Res #4 was cognitively intact and required supervision to limited assistance with ADLs. The assessment documented Res #4 had a life expectancy of less than six months and was receiving hospice services. On 09/26/22 at 11:21 a.m., Res #4 was observed in her room lying on her bed. She showed the surveyor a intra-abdominal drain she stated she had placed a few months ago to drain her abdominal fluid. She stated she was receiving hospice care. Res #4's comprehensive care plan was reviewed and did not document a plan of care for end of life, or hospice. On 09/28/22 at 1:39 p.m., the BOM stated the facility did not have a contract in the facility for [name deleted] hospice. The BOM stated he was trying to get one sent over and had left two messages. On 09/28/22 at 2:22 p.m., the MDS coordinator stated she did not do a care plan for end of life and hospice. She stated the care plans were not up to date. On 09/28/22 the resident's hospice clinical records were reviewed. The clinical hospice records did not contain any information after 07/08/22. Missing documentation included the hospice election of benefits form and the physician certification of terminal illness. On 09/28/22 at 3:53 p.m., the administrator confirmed the required hospice documentation had not been available to review until the facility requested and had it sent over. The administrator stated the facility did not provide in-services to the hospice staff.

Based on observation, record review, and interview, the facility failed to ensure pain was assessed consistent with professional standards of practice for one (#33) of one resident reviewed for pain. The Resident Census and Conditions of Residents form documented 12 residents who resided in the facility were on a pain management program. Findings: Res #33 had diagnoses which included polyneuropathy, muscle spasm, radiculopathy, idiopathic scoliosis, low back pain, and chronic pain syndrome. Physician orders, dated 04/25/22, documented the facility was to administer Mobic, hydrocodone-acetaminophen, fentanyl, clonazepam, Baclofen, acetaminophen, and Senna Plus to Res #33. A quarterly MDS assessment, dated 06/07/22, documented Res #33 was moderately impaired in cognition, and required supervision to total assistance with ADLs. The assessment documented the resident frequently complained of pain they rated at a six out of a one to ten scale with ten being the most severe pain. A physician order, dated 06/29/22, documented the facility was to administer Narcan 4 mg nasal spray as needed every two the three minutes for opioid induced respiratory depression. A care plan, dated 09/03/22, documented Res #33 had a potential for discomfort/pain due to chronic pain history. The care plan documented the facility was to interview the resident monthly for pain and to complete monthly pain assessments. A quarterly MDS assessment, dated 09/07/22, documented Res #33 was moderately impaired in cognition, and required supervision to total assistance with ADLs. The assessment documented the resident frequently complained of pain they rated at a six out of a one to ten scale with ten being the most severe pain. The assessment documented the resident received an opioid for seven days of the seven day assessment period. On 09/26/22 at 11:03 a.m., Res #33 was observed in her room sitting in a geri-chair. She stated she had back and neck and pain and took medications for the pain which did not help. On 09/28/22, Res #33's EHR was reviewed and documented only monthly pain assessments. On 09/27/22 at 3:30 p.m., the corporate nurse confirmed the EHR did not document daily pain assessments. She stated the EHR only contained monthly assessments. She stated the pain assessments should have been every shift and as needed.

Based on observation, record review, and record review, the facility failed to ensure the resident's treatment and care was in accordance with the person centered care plan for one (#4) of one resident reviewed for hospice. The Resident Census and Conditions of Residents form documented one resident was receiving hospice services. Findings: Res #4 had diagnoses which included alcoholic cirrhosis of the liver with ascites, end stage renal failure, and diabetes. A care plan, dated 06/20/22, documented Res #4 was a long term care resident. The care plan documented problems including dental/oral care, cardiac output, gastrointestinal function, hypothyroidism, and end stage renal disease. A significant change assessment, dated 06/28/22, documented Res #4 was cognitively intact and required supervision to limited assistance with ADLs. The assessment documented Res #4 had a life expectancy of less than six months and was receiving hospice services. On 09/26/22 at 11:21 a.m., Res #4 was observed in her room lying on her bed. She showed the surveyor a intra-abdominal drain she stated she had placed a few months ago to drain her abdominal fluid. She stated she was receiving hospice care. Res #4's comprehensive care plan was reviewed and did not document a plan of care for end of life, or hospice. On 09/28/22 at 1:39 p.m., the BOM stated the facility did not have a contract in the facility for [name deleted] hospice. The BOM stated he was trying to get one sent over and had left two messages. On 09/28/22 at 2:22 p.m., the MDS coordinator stated she did not do a care plan for end of life and hospice. She stated the care plans were not up to date. On 09/28/22 the resident's hospice clinical records were reviewed. The clinical hospice records did not contain any information after 07/08/22. Missing documentation included the hospice election of benefits form and the physician certification of terminal illness. On 09/28/22 at 3:53 p.m., the administrator confirmed the required hospice documentation had not been available to review until the facility requested and had it sent over. The administrator stated the facility did not provide in-services to the hospice staff. The administrator reviewed the current hospice contract and stated it did not document the facility or hospices responsibility as related to suspician of abuse. A hospice coordinator from the hospice provider stated when their company took over the facility and the hospice maintained the same contract. She stated she would provide a new contract with the appropriate verbage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to maintain hand hygiene practices during wound care for one (#20) of two residents reviewed for pressure ulcers. The Resident Census and Conditions of Residents form documented four residents with pressure ulcers resided in the facility. Findings: Resident #20 had diagnoses which included Pressure ulcer of sacral region stage IV, paraplegia and diabetes. A quarterly MDS, dated [DATE], documented the resident was cognitively intact, required minimal assistance with ADLs, used a wheelchair, had an indwelling catheter, had a stage IV pressure ulcer present on admission and a deep tissue pressure injury not present on admission. A physician order, dated 08/31/22, documented nursing staff were to cleanse right heel with dermal wound cleanser, pat dry, apply betadine and wrap with Kerlix daily. A physician order, dated 09/20/22, documented nursing staff were to cleanse sacral area with dermal wound cleanser, pat dry, sprinkle collagen powder to wound bed and cover with hydrofera then cover with dressing, change every three days until resolved. On 09/29/22 10:18 AM LPN #1 was observed performing wound care on Res #20's foot wound. The LPN washed her hands prior to collecting supplies. LPN #1 donned a pair of gloves, removed the resident's sock, opened a trash bag, and then used scissors to remove the dressing on the resident's foot. LPN #1 then cleaned the wound with wound wash and gauze. The LPN was then observed to remove her gloves. No hand hygiene was observed after the LPN removed her dirty gloves. The LPN then donned a new pair of gloves, applied betadine to the wound and removed her gloves. No hand hygiene was observed after the LPN removed her gloves. The LPN donned a pair of gloves and was observed applying gauze and gauze roll to the wound. She then removed her gloves. No hand hygiene was observed after the LPN removed her gloves. She then donned new gloves and used tape to secure the dressing, labeled the dressing and removed her gloves. No hand hygiene was observed after she removed her gloves. The LPN then assisted the resident to put a sock on his foot. No hand hygiene was observed after the LPN assisted with the sock. On 09/09/22 at 10:38 a.m., LPN #1 was observed performing wound care on Res #20's sacral wound. The LPN was not observed performing hand hygiene prior to donning a pair of gloves. The LPN removed the dressing from the wound and then removed her gloves. No hand hygiene was observed after she removed her gloves. She then donned a pair of gloves, cleaned the wound with wound wash, applied collagen powder and a purple disk identified by the nurse as hydrofera. She then applied a dressing to cover the wound and dated the dressing. The LPN removed her gloves and was not observed performing hand hygiene. The LPN donned a pair of gloves, gathered the trash and supplies and disposed of them. The LPN was observed washing her hands after disposing of the trash and supplies. On 09/29/22 at 3:20 p.m., LPN #1 stated the protocol for hand hygiene during wound care was to wash hands before and after care. She stated she did not cleanse her hands between dirty and clean while doing wound care for Res #20 but should have. On 09/29/22 at 3:22 p.m. the corporate nurse stated staff were instructed to sanitize their hands between glove changes, before, and after care.

Based on observation and interview, the facility failed to ensure a a safe, clean, comfortable, and homelike environment for residents, visitors, and staff. The Resident Census and Conditions of Residents form documented 38 residents resided in the facility. Findings: On 09/29/22 at 2:01 p.m., a tour of the laundry room was conducted. Water was observed leaking from the piping below the hand sink and standing water was observed in containers below the sink. A accumulation of lint and dust was observed on the washer and dryer. A plastic/material was observed peeling off the walls. Dirt and other debris was observed on the floor around the equipments and along the baseboards. On 09/29/22 at 2:15 p.m., a laundry staff #1 stated they cleaned the physical environment and equipment when they had a chance. The laundry staff stated the leak below the sink and the material peeling off the walls had been like that since they had worked at the facility. On 09/29/22 at 2:20 p.m., Res #7's wheelchair was observed to have brown residue on the chair tag and on the metal areas on the frame of the wheelchair. At that time, the resident was asked how often their wheelchair was cleaned. Res #7 stated it used to be cleaned every two weeks but not so often anymore. The resident stated they would like to have their wheelchair cleaned. The wood flooring at the threshold of the resident's room was observed to be broken, missing a section, and not secured to the floor. On 09/29/22 at 2:23 p.m., a gap and daylight was visible around the window air unit in Res #20's room. The resident stated bugs came in the gap. On 09/29/22 at 2:55 p.m., RN #1 and CNA #1 stated maintenance were responsible to clean the wheelchairs at least once a week and the CNAs cleaned them as needed. They Res #7 was out of the building the last time the wheelchairs were cleaned and had let them know they needed their wheelchair cleaned. On 09/29/22 at 3:00 p.m., RN #1 stated if there was a maintenance issue they verbally reported the issue to maintenance or there was a book to document the issue in. On 09/29/22 at 3:02 p.m., the maintenance supervision and administrator were asked about the threshold of Res #7's room. They stated they were working on getting materials which would be sturdy but allow easy access for the residents into their rooms. They were asked about the gaps around the window air units and stated they would be replacing the areas with wood around the windows. They were made aware of the gap where daylight was visible around the window unit in Res #20's room. They stated they were aware of the above findings in the laundry room.

Based on record review, observation, and interview, the facility failed to ensure residents were free from abuse for three (#1, 12, and #18) of three residents reviewed for abuse. The Resident Census and Conditions of Residents form documented 38 residents resided in the facility. Findings: An Abuse Policy and Procedures, dated 2019, read in parts, .Each resident shall be free from abuse, neglect, mistreatment, exploitation and misappropriation of property . Abuse shall include physical harm, pain, mental anguish, verbal abuse derogatory terms, sexual abuse, photographs and/or videos, or involuntary seclusion from any source . Resident care and treatment shall be monitored by all staff on an ongoing basis to assure residents are free from abuse, neglect, or mistreatment . It is the responsibility of all staff to provide a safe environment for the residents . The director of nursing or designee will complete an assessment of the resident or residents involved and document finding in the medical record and interdisciplinary care plan as needed. 1. Res #12 had diagnoses which included chronic viral hepatitis C and psychoactive substance abuse in remission. An admission assessment, dated 05/11/22, documented the resident was cognitively intact and was independent with most activities of daily living. Res #19's quarterly assessment, dated 07/08/22, documented the resident was cognitively intact and was independent with most activities of daily living. The assessment documented the resident had diagnoses which included hypertension, depression, and anxiety disorder. An incident report, dated 09/20/22 at 7:15 p.m., read in parts, .This adm was notified by the nurse around 5:45 p.m. that an altercation occurred between these two residents. (Res #12 name deleted) removed another resident's hall tray out of the hot cart. The tray was for a resident that refused the meal .A verbal altercation that also included a scratch on (Res #12's name deleted) arm. (Res #12 name deleted) has double portions and can request more food as desired but has been homeless so they may explain the getting the tray out of the hot cart .Residents on 30 min monitoring 72 hrs. (Res #12 name deleted) was assessed and the area cleaned. Residents were spoken to by staff about behaviors. (Res #12 name deleted) diet order will be changed to triple portions & (Res #12 and Res #19 name deleted) reminded this is not acceptable behavior. A nurse note, dated 09/20/22 at 11:47 p.m., read in part, .1725 nurse noticed (Res #12 name deleted) took untouchable tray from cart to eat & another (Res #19 name deleted) was there & ordered this (Res #12 name deleted) to place this food back. This (Res #12 name deleted) didn't listen then another (Res #19 name deleted) hit this (Res #12 name deleted) on his R forearm scratched till blood. They started loud with each other try to hit. Nurse & CNA barely separated (Res #12 and Res #19 name deleted) from each other. (Res #12 and Res #19 name deleted) placed on Q 30 minute observation during 72H. DON, ADM, and (physician name deleted) notified. (Res #12 name deleted) has been told if this accident will be repeated nurse will call to police. 09/26/22 at 12:58 p.m., Res #12 was observed sitting outside in smoking area smoking a cigarette. Res #12 reported an altercation with another resident about a week ago resulting in a scratch on the right forearm. A reddened scabbed area approximately two inches in length was observed on res #12's right forearm. On 09/26/22 at 4:00 p.m., Res #19 was observed propelling down hall in wheel chair towards smoking area exit door. Res #19 stated he stayed to himself most of the time and avoided Res #12. Res #19 denied further incident with Res #12 since the incident in question. On 09/27/22 at 2:37 p.m., Res #12 was observed sitting in a chair in the common area hallway. Res #12 stated he avoided Res #19 most of the time. Res #12 denied additional altercation with res #19 since the incident in question. On 09/28/22 at 3:55 p.m. through 4:30 p.m., five staff members which included a LPN, housekeeper, and three CNAs were asked if additional abuse prevention training occurred after an incident of abuse in the facility. All staff members denied additional in-services or training after an incident of abuse. On 09/28/22 at 3:56 p.m., LPN #1 stated any incident of abuse should have been reported to the charge nurse immediately. She stated residents were separated immediately, assessed for injuries, and the administrator, physician, and family were notified. LPN #1 stated the incident was documented in the progress notes and an incident report was completed. She stated this incident should have been documented in the progress notes of the medical record. On 09/29/22 at 10:20 a.m., the administrator stated a facility incident report and state reportable incident report was completed. The administrator stated that both residents were educated to never touch another resident and to always remove themselves from any situation that might result in harm or abuse in the future. She stated verbal and physical abuse occurred and assessment of the resident or residents involved was not documented in the medical record or interdisciplinary care plan but should have been according to the policy. On 09/29/22 at 10:25 a.m., the corporate nurse stated the plan of care was not revised with interventions to prevent abuse. On 09/29/22 at 2:03 p.m., CNA #2 stated that after an abuse incident occurred no additional training was provided to staff. 2. Res #18 was admitted with diagnoses which included hypertension and specified depressive episodes. An admission assessment, dated 07/13/22, documented the resident was cognitively intact and independent with most activities of daily living. An incident report, dated 09/12/22, read in parts, .It was reported to this administrator on 09/12 at 7:10 p.m., by the corp. nurse. She reported that (Res #18 name deleted) came to her office and reported what (staff member name deleted) said while she was assisting in weighing residents fat ass. (Res #18 name deleted) stated he was tired of her saying things like this to him .(Staff member name deleted) was suspended pending an investigation .The investigation is completed and in the opinion of (facility name deleted) the allegations of inappropriate language and inappropriate comment verbal abuse was substantiated . No documentation of the alteration was found in the progress notes or interdisciplinary care plan. On 09/28/22 at 8:50 a.m., Res #18 was observed sitting on the bed in room. Res #18 stated the staff member who committed the verbal abuse was lazy, rude, and never responded to needs in a timely manner. The resident stated that the staff member was fired immediately after the incident and felt the situation was handled appropriately by administration. On 09/28/22 at 3:20 p.m., the administrator stated the incident was reported within two hours and was investigated. She was asked why the staff member who witnessed the event did not come forward and report it to administration. The administrator stated that the witness stated at the time when the incident occurred she thought it did not upset the resident because he is very blunt and sarcastic and always joked and spoke to the staff in a harsh way. The witness stated she realized the resident was upset when she was brought in for the investigation. The administrator stated no in-service or training was provided to the staff after the incident occurred because the staff should have known better and not let it happen in the first place. On 09/28/22 at 3:30 p.m., the corporate nurse stated any allegations brought to her attention were immediately sent to the administrator. She denied additional abuse training for staff or revision of resident care plans after incidents of abuse occurred. On 09/28/22 at 3:50 p.m., the DON stated she did not complete documentation of interventions or implementation of additional safety interventions on the plan of care after incidents of abuse in the facility. 3. Res #1 had diagnoses which included Alzheimer's disease, recurrent depressive disorders, and cerebral infarction. An incident report, dated 03/04/22, documented Res #23 swatted at Res #1 while they were in the lobby and Res #1 kicked back at Res #23. The incident report documented the residents were separated by the administrator and the corporate nurse and were placed on 30 minute monitoring for 72 hours. The incident report documented staff were made aware. No other steps to prevent recurrence of resident to resident altercations was documented on the incident report. An incident report, dated 05/26/22, Res #1 observed an unidentified resident, who was no longer in the facility, while the unidentified resident was striking and yelling at staff members. The incident report documented Res #1 attempted to strike the unidentified resident who then spit in Res #1's face. The incident report documented Res #1 then spit back at the unidentified resident and attempted to hit her. The incident report documented four staff members held the residents apart while Res #1 was taken to the break room then to his room. The incident report documented Res #1 sustained a skin tear to his hand and a small abrasion to the left side of the face. No steps to prevent recurrence was documented. An annual MDS assessment, dated 06/22/22, documented Res #1 was moderately impaired in daily decision making, had no behaviors, and required supervision to limited assistance with ADLs. An incident report, dated 08/15/22, documented Res #1 entered another a second unidentified resident's room and struck the unidentified resident in the stomach. The incident report documented neither resident was injured and both were place on 72 hour monitoring. The incident report did not document any other interventions to prevent the recurrence of Res #1 from striking other residents. A care plan for Res #1, dated 09/07/22, documented the resident had an alteration in coping, mood, or behavior related to insomnia, depression. The care plan documented a goal of Res #1 would have no increase or change in behaviors. The care plan documented the resident had harmful behaviors to others with a goal to remain free from accidents. Interventions included to assess the resident's behavior pattern daily, to implement behavior modification activities, and gently redirect as necessary. The care plan did not document the resident's previous altercations or steps to prevent recurrence for each incident. A quarterly assessment, dated 09/22/22, documented Res #1 was moderately impaired in daily decision making, had no behaviors, and required supervision to limited assistance with ADLs. On 09/29/22 at 4:39 p.m., the administrator was asked about intervention to prevent recurrence for the 03/04/22 incident. The administrator stated Res #23 was experiencing a manic episode, was running into things, and was not easy to redirect. She stated Res #23 was sent to a geriatric psychiatric hospital for evaluation and treatment and she was not like that anymore. On 09/29/22 at 4:44 p.m., the administrator was asked about interventions to prevent recurrence for the 05/26/22 incident. The administrator stated she had been told Res #1 had been in the military and she felt the resident was trying to protect the staff members from the unidentified resident. She stated the unidentified resident was the aggressor in this incident and she subsequently went home with family. On 09/29/22 at 4:47 p.m., the administrator was asked what steps were put in place to prevent Res #1 from entering another residents' room and striking them. She stated there were no other interventions put in place for Res #1 other than 72 hour monitoring. The administrator was asked if an investigation had been conducted to ascertain what may have precipitated the event, she stated she did not document an investigation. She stated Res #1 had walked into the second unidentified resident's room through the adjoining bathroom. The administrator stated they placed a lock on the unidentified resident's bathroom so it could be secured to prevent a resident from entering from the adjoining room. On 09/29/22 at 4:54 p.m., the administrator was asked if the facility had put any new interventions in place to prevent Res #1 from becoming aggressive with other residents or to prevent him from becoming a target for aggression. She stated other than putting a new doorknob with a lock and the resident in the second incident leaving the facility she did not put any new interventions in place to prevent resident to resident abuse for Res #1.

Based on observation, record review, and interview, the facility failed to implement their abuse policy for abuse prevention for three (#1, 12, and #18) of three residents reviewed for abuse. The Resident Census and Conditions of Residents form documented 38 residents resided in the facility. Findings: An Abuse Policy and Procedures, dated 2019, read in parts, .Each resident shall be free from abuse, neglect, mistreatment, exploitation and misappropriation of property . Abuse shall include physical harm, pain, mental anguish, verbal abuse derogatory terms, sexual abuse, photographs and/or videos, or involuntary seclusion from any source . Resident care and treatment shall be monitored by all staff on an ongoing basis to assure residents are free from abuse, neglect, or mistreatment . It is the responsibility of all staff to provide a safe environment for the residents . The director of nursing or designee will complete an assessment of the resident or residents involved and document finding in the medical record and interdisciplinary care plan as needed. 1. Res #12 had diagnoses which included chronic viral hepatitis C and psychoactive substance abuse in remission. An admission assessment, dated 05/11/22, documented the resident was cognitively intact and was independent with most activities of daily living. An incident report, dated 09/20/22 at 7:15 p.m., read in parts, .This adm was notified by the nurse around 5:45 p that an altercation occurred between these two residents. (Res #12 name deleted) removed another resident's hall tray out of the hot cart. The tray was for a resident that refused the meal . A verbal altercation that also included a scratch on (Res #12's name deleted) arm. (Res #12 name deleted) has double portions and can request more food as desired but has been homeless so they may explain the getting the tray out of the hot cart . Residents on 30 min monitoring 72 hrs. (Res #12 name deleted) was assessed and the area cleaned. Residents were spoken to by staff about behaviors. (Res #12 name deleted) diet order will be changed to triple portions & (Res #12 and Res #19 name deleted) reminded this is not acceptable behavior. A nurse note, dated 09/20/22 at 11:47 p.m., read in part, .1725 nurse noticed (Res #12 name deleted) took untouchable tray from cart to eat & another (Res #19 name deleted) was there & ordered this (Res #12 name deleted) to place this food back. This (Res #12 name deleted) didn't listen then another (Res #19 name deleted) hit this (Res #12 name deleted) on his R forearm scratched till blood. They started loud with each other try to hit. Nurse & CNA barely separated (Res #12 and Res #19 name deleted) from each other. (Res #12 and Res #19 name deleted) placed on Q 30 minute observation during 72H. DON, ADM, and (physician name deleted) notified. (Res #12 name deleted) has been told if this accident will be repeated nurse will call to police. 09/26/22 at 12:58 p.m., res #12 was observed sitting outside in smoking area smoking a cigarette. Res #12 reported an altercation with another resident about a week ago resulting in a scratch on the right forearm. A reddened scabbed area approximately two inches in length was observed on res #12's right forearm. On 09/26/22 at 4:00 p.m., res #19 was observed propelling down hall in wheel chair towards smoking area exit door. Res #19 stated he stayed to himself most of the time and avoided res #12. Res #19 denied further incident with res #12 since the incident in question. On 09/27/22 at 2:37 p.m., res #12 was observed sitting in a chair in the common area hallway. Res #12 stated he avoided res #19 most of the time. Res #12 denied additional altercation with res #19 since the incident in question. 09/29/22 at 10:20 a.m., the administrator was provided a copy of the abuse policy and procedure and asked if all components were implemented. She stated verbal and physical abuse occurred and assessment of the resident or residents involved was not documented in the medical record or interdisciplinary care plan but should have been according to the policy. The administrator stated It's my fault for not following up. On 09/29/22 at 10:25 a.m., the corporate nurse stated the plan of care was not revised with interventions to prevent abuse. On 09/29/22 at 2:03 p.m., CNA #2 stated that after an abuse incident occurred no additional training was provided to staff. 09/29/22 at 2:37 p.m., the DON stated the care plan and medical record should have documentation related to the incident and the injury that occurred per the abuse policy but it does not. 2. Res #18 was admitted with diagnoses which included hypertension and specified depressive episodes. An admission assessment, dated 07/13/22, documented the resident was cognitively intact and independent with most activities of daily living. An incident report, dated 09/12/22, read in parts, .It was reported to this administrator on 09/12 at 7:10 p.m., by the corp. nurse. She reported that (Res #18 name deleted) came to her office and reported what (staff member name deleted) said while she was assisting in weighing residents fat ass. (Res #18 name deleted) stated he was tired of her saying things like this to him . (Staff member name deleted) was suspended pending an investigation . The investigation is completed and in the opinion of (facility name deleted) the allegations of inappropriate language and inappropriate comment verbal abuse was substantiated . On 09/28/22 at 8:50 a.m., res #18 was observed sitting on the bed in room. Res #18 stated the staff member who committed the verbal abuse was lazy, rude, and never responded to needs in a timely manner. The resident stated that the staff member was fired immediately after the incident and felt the situation was handled appropriately by administration. On 09/28/22 at 3:15 p.m., the DON was provided with abuse policy and asked if all components were implemented for incident in question and all other abuse allegations. She stated she was never told by administration to complete an assessment of the resident involved and document the findings in the medical record and interdisciplinary care plan. On 09/28/22 at 3:17 p.m., the MDS coordinator was provided with abuse policy and asked if the care plan was revised after the incident in question and all other abuse allegations. She stated she does not revise the care plan after an incident and she had never saw that component of the abuse policy before now. On 09/28/22 at 3:20 p.m., the administrator was provided with abuse policy and asked if an assessment was completed and documented in the medical record and the care plan was revised after the incident in question and all other abuse allegations. She stated these components were not completed after incidents of abuse. She confirmed this allegation of abuse was substantiated and the staff member was terminated and placed on the do not rehire list. The administrator denied additional abuse prevention training was provided to staff after incidents or allegations of abuse occurred.3. Res #1 had diagnoses which included Alzheimer's Disease, recurrent depressive disorders, and cerebral infarction. An incident report, dated 03/04/22, documented Res #23 swatted at Res #1 while they were in the lobby and Res #1 kicked back at Res #23. The incident report documented the residents were separated by the administrator and the corporate nurse and were placed on 30 minute monitoring for 72 hours. The incident report documented staff were made aware. No other steps to prevent recurrence of resident to resident altercations was documented on the incident report. An incident report, dated 05/26/22, Res #1 observed an unidentified resident, who was no longer in the facility, while they had been striking and yelling at the staff members. The incident report documented Res #1 attempted to strike the unidentified resident who then spit in Res #1's face. The incident report documented Res #1 then spit back at the unidentified resident and attempted to hit her. The incident report documented four staff members held the residents apart while Res #1 was taken to the break room then to his room. The incident report documented Res #1 sustained a skin tear to his hand and a small abrasion to the left side of the face. No steps to prevent recurrence was documented. An annual MDS assessment, dated 06/22/22, documented Res #1 was moderately impaired in daily decision making, had no behaviors, and required supervision to limited assistance with ADLs. An incident report, dated 08/15/22, documented Res #1 entered another a second unidentified resident's room and struck the unidentified resident in the stomach. The incident report documented neither resident was injured and both were place on 72 hour monitoring. The incident report did not document any other interventions for to prevent the recurrence of Res #1 from striking other residents. A care plan for Res #1, dated 09/07/22, documented the resident had an alteration in coping, mood, or behavior related to insomnia, depression. The care plan documented a goal of Res #1 would have no increase or change in behaviors. The care plan documented the resident had harmful behaviors to others with a goal to remain free from accidents. Interventions included to assess the resident's behavior pattern daily and to implement behavior modification activities and gently redirect as necessary. The care plan did not document the resident's previous altercations or steps to prevent recurrence for each incident. A quarterly assessment, dated 09/22/22, documented Res #1 was moderately impaired in daily decision making, had no behaviors, and required supervision to limited assistance with ADLs. On 09/29/22 at 4:39 p.m., the administrator was asked about intervention to prevent recurrence for the 03/04/22 incident. The administrator stated Res #23 was experiencing a manic episode, was running into things, and was not easy to redirect. She stated Res #23 was sent to a geriatric psychiatric hospital for evaluation and treatment and she was not like that anymore. On 09/29/22 at 4:44 p.m., the administrator was asked about interventions to prevent recurrence for the 05/26/22 incident. The administrator stated she had been told Res #1 had been in the military and she felt the resident was trying to protect the staff members from the unidentified resident. She stated the unidentified resident was the aggressor in this incident and she subsequently went home with family. On 09/29/22 at 4:47 p.m., the administrator was asked what steps were put in place to prevent Res #1 from entering another residents' room and striking them. She stated there were no other interventions put in place for Res #1 other than 72 hour monitoring. The administrator was asked if an investigation had been conducted to ascertain what may have precipitated the event, she stated she did not document an investigation. She stated Res #1 had walked into the second unidentified resident's room through the adjoining bathroom. The administrator stated they placed a lock on the unidentified resident's bathroom so it could be secured to prevent a resident from entering from the adjoining room. On 09/29/22 at 4:54 p.m., the administrator was asked if the facility had put any new interventions in place to prevent Res #1 from becoming aggressive with other residents or to prevent him from becoming a target for aggression. She stated other than putting a new doorknob with a lock and the resident in the second incident leaving the facility she did not put any new interventions in place to prevent resident to resident abuse for Res #1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Res #7 had diagnoses which included COPD, schizophrenia, depression, disorders of bladder, urinary retention, convulsions, and dementia. A quarterly MDS, dated [DATE], documented the resident was cognitively intact, required minimal assistance with ADLs, used a wheelchair, had an indwelling catheter, required a therapeutic diet, and received antipsychotic and antidepressant medications seven out of seven days during the review period. During record review it was determined the resident did not have a care plan in the EHR. On 09/27/22 at 3:25 p.m., the MDS coordinator stated the resident did not have a care plan in the EHR because she was behind. She stated the resident should have a comprehensive care plan. On 09/27/22 at 03:34 p.m., the DON was presented with a Care Plan Conference Summary document, dated 07/18/22, for review. She stated she did not review the care plan with the resident during the care conferences. She was unaware the resident did not have a care plan in the EHR. 6. Res #20 had diagnoses which included generalized anxiety disorder and depression. A baseline care plan, dated 03/30/22, did not document the resident received psychotropic medications. An admission MDS, dated [DATE], documented the resident was cognitively intact, had no depression, and received anti-anxiety and antidepressant medications seven out of seven days during the review period. Physician orders, dated 04/24/22, documented the facility was to administer duloxetine 20 mg daily related to depression and sertraline 100 mg daily related to depression. A physician order, dated 05/15/22, documented the facility was to administer buspirone 20 mg daily related to generalized anxiety disorder. A quarterly MDS, dated [DATE], documented the resident was cognitively intact, had minimal depression, and received anti-anxiety and antidepressant medications every day of the review period. A physician order, dated 07/22/22, documented the facility was to administer hydroxyzine 25 mg three times daily related to generalized anxiety disorder. On 09/29/22 at 11:29 a.m., the MDS coordinator stated the resident's psychotropic medications were not on his care plan but should have been included. 7. Res #86 had diagnoses which included Down syndrome, hydronephrosis with ureteropelvic junction obstruction, pressure ulcer of sacral region stage IV, and hypothyroidism. A quarterly MDS, dated [DATE], documented the resident was moderately impaired in cognition, required limited to total assistance with ADLs, had an indwelling catheter and was always incontinent of bowel. The assessment documented the resident had one stage IV pressure ulcer present on admission and received antipsychotic medication seven out of seven days during the review period. A care plan, dated 09/26/22, documented a focus of nephrostomy tube care related to temporary nephrostomy until nephrectomy. There were no other care areas documented on the care plan. On 09/29/22 at 12:57 p.m., the MDS coordinator stated Res #86's comprehensive care plan was never put in the EHR. On 09/29/22 at 1:16 p.m., the corporate nurse stated the resident should have had a lot more documented in the care plan because the resident had a lot of medical issues. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan which reflected the resident status for seven (#4, 7, 8, 16, 20, 35, and #86) of 20 residents whose records were reviewed. The Resident Census and Conditions of Residents form documented 38 residents resided in the facility. Findings: 1. Res #4 had diagnoses which included alcoholic cirrhosis of the liver with ascites, end stage renal failure, and diabetes. Physician orders, dated 06/06/22, documented the facility was to administer amlodipine (for high blood pressure), sertraline (for depression), ferrous sulfate (for anemia), propranolol, and spironolactone and Lasix (for edema). A physician orders, dated 06/17/22, documented the facility was to administer Novolog Flexpen (for diabetes) by sliding scale four times a day. An admission assessment, dated 06/19/22, documented Res #4 was cognitively intact and required supervision to limited assistance with ADLs. A care plan, dated 06/20/22, documented Res #4 was a long term care resident. The care plan documented problems including dental/oral care, cardiac output, gastrointestinal function, hypothyroidism, and end stage renal disease. A significant change assessment, dated 06/28/22, documented Res #4 was cognitively intact and required supervision to limited assistance with ADLs. The assessment documented Res #4 had a life expectancy of less than six months and was receiving hospice services. A physician order, dated 07/08/22, documented the facility was to administer lactulose (a medication used for liver failure) twice daily. Physician orders, dated 08/03/22, documented the facility was to administer Levemir insulin 5 units in the morning and Ozempic once weekly for diabetes. A physician order, dated 08/25/22, documented the facility was to administer trazodone (an antidepressant medication) at bedtime. On 09/26/22 at 11:21 a.m., Res #4 was observed in her room lying on her bed. She showed the surveyor a intra-abdominal drain she stated she had placed a few months ago to drain her abdominal fluid. Res #4's care plan did not document a plan of care for the resident's psychotropic medications or for the intra-abdominal drain system. On 09/28/22 at 2:22 p.m., the MDS coordinator stated she did not do a plan of care related to the resident's intra-abdominal drain system or for her psychotropic medications. She stated the care plans were not up to date. 2. Res #8 had diagnoses which included transient ischemic attack, COPD, vascular dementia, diabetes, mood disorder, and depression. An admission assessment, dated 04/07/22, documented Res #8 was moderately impaired in cognition, had physical behaviors directed toward others, rejection of care, and required limited assistance of one to two staff members with ADLs. The assessment documented the resident received insulin and an anticoagulant daily during the assessment period. A quarterly assessment, dated 07/06/22, documented Res #8 was severely impaired in cognition, had physical and verbal behaviors directed toward others, and required supervision to total assistance with ADLs. The assessment documented the resident received insulin, antipsychotic, antidepressant, and anticoagulant medications daily during the assessment period. Dietitian recommendation dated 08/23/22 documented an acknowledgement Res #8 had experienced a weight loss and was to have swallow study and PEG placement. The dietitian recommended the resident received shakes until he had the placement and after tube placement recommended Jevity. April 2022 physician orders, documented the facility was to administer apixaban (an anticoagulant), atorvastatin (a medication to control cholesterol), budesonide /foromoterol inhaler (for COPD), famotidine (a medication to treat GERD), and glargine insulin. A physician order, dated 05/27/22, documented to administer cariprazine (an antipsychotic), donepezil (a medication used to treat dementia), escitalopram (an antidepressant), Novolog Flexpen insulin, lamotrigine (an anticonvulsant medication), and metoprolol (a medication used to treat high blood pressure). A physician order, dated 07/01/22, documented to administer riluzole (a medication used to treat amyotrophic lateral sclerosis). A physician order, dated 08/26/22, documented to administer risperidone (an antipsychotic medication). A physician order, dated 09/09/22, documented to administer quetiapine (an antipsychotic medication). A care plan for Res #8, reviewed on 08/26/22, did not document a plan of care related to the resident's use of psychotropic medications, weight loss, or dementia care. On 09/29/22 at 10:43 a.m., the MDS coordinator stated the care plan was incomplete. 3. Res #16 had diagnoses which included anoxic brain damage, cerebral palsy, and contracture of unspecified joint. An annual assessment, dated 07/07/22, documented Res #16 was severely impaired in cognition, was totally dependent for all ADL cares, and had limited range of motion of both sides in the upper and lower extremities. On 09/26/22 at 4:00 p.m., Res #16 was observed lying in his bed. His hands were observed to be turned completely laterally to his wrists. The resident was observed to not have splints or hand rolls. On 09/29/22 at 08:44 a.m., the MDS coordinator confirmed Res #16's care plan did not document a plan of care related to restorative care or range of motion. 4. Res #35 had diagnoses which included diabetes, dementia, and atherosclerotic heart disease. An admission assessment, dated 06/22/22, documented Res #35 was severely impaired with daily decision making and required extensive to total assistance with ADLs. Res #35's EHR did not document a comprehensive care plan. On 09/29/22 at 1:14 p.m., the corporate nurse stated Res #35's records did not document a comprehensive care plan. She stated she told the MDS coordinator the care plan should have been completed within 10 days of completion of the admission assessment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure the resident was given an opportunity to participate in the development, review, and revision of his/her care plan for one (#7) of 13 residents whose care plans were reviewed. The Resident Census and Conditions of Residents form documented 38 residents resided in the facility. Findings: Res #7 had diagnoses which included COPD, schizophrenia, depression, disorders of bladder, urinary retention, convulsions, and dementia. A quarterly MDS, dated [DATE], documented the resident was cognitively intact, required minimal assistance with ADLs, used a wheelchair, had an indwelling catheter, required a therapeutic diet, and received antipsychotic and antidepressant medications. On 09/27/22 at 3:25 p.m., the MDS coordinator stated the resident did not have a care plan in the EHR because she was behind. She stated the resident should have a comprehensive care plan. On 09/27/22 at 03:34 p.m., the DON was presented with the Care Plan Conference Summary documents dated 01/10/22, 03/28/22, and 07/18/22 for review. She stated she did not review the care plan with the resident during the care conferences. She stated during the meetings she asked the resident if there were any issues at the time and filled out the care conference summary form afterwards so it could be signed. She stated she does not make a copy of the care plan available for the resident to review because she was not instructed to do so. She was unaware the resident did not have a care plan in the EHR. On 09/27/22 at 3:52 p.m., Res #7 was observed in her room seated in her wheelchair. She stated she was not given an opportunity to review and contribute to her care plan during the conferences. She stated the conference consisted of being informed there were no changes to her care plan from the prior meeting and then the provided her with a form to sign. She stated she would like to receive a copy of her care plan to review to ensure her restrictions from the physician were included. She stated she would like to make sure her care plan is updated with physician instructions.

Based on observation, record review, and interview, the facility failed to assess, develop, and implement a care plan which ensured the resident received the appropriate treatment and services to attain the highest practicable well-being for one (#8) of three residents sampled for dementia care. The Resident Census and Conditions of Residents form documented 11 residents who resided in the facility had a diagnosis of dementia. Findings: Res #8 had diagnoses which included transient ischemic attack, vascular dementia with behavioral disturbance, and unspecified mood disorder. An admission assessment, dated 04/07/22, documented Res #8 was moderately impaired in daily decision making, physical behaviors directed toward others, rejection of care, and required limited assistance of one or two staff with ADLs and did not walk. A quarterly assessment, dated 07/06/22, documented Res #8 was severely impaired in cognition, had physical and verbal behaviors directed toward others, and required supervision to total assistance with ADLs. The assessment documented the resident had dementia. The assessment documented the resident's behaviors, such as rejection of care which may have been necessary to achieve the resident's goals, for one to three days during the seven day assessment period. Res #8's plan of care did not document a plan for dementia care. On 09/26/22 at 2:45 p.m., Res #8 was observed sitting on a chair in the main lobby. He was not able to be interviewed. On 09/29/22 at 12:50 p.m., the restorative aide stated he did not have many outbursts any more other than shouting. She stated if he starts to shout she would back off and give him time to compose himself. On 09/28/22 at 9:51 a.m., the MDS coordinator reviewed Res #8's care plan and confirmed it did not have a plan of care related to dementia. She stated the facility should have formulated one to include non pharmacological measures.

Based on observation, record review, and interview, the facility failed to ensure consultant pharmacist GDR requests were acted on by the physician for two (#21 and #33) of six residents whose medications were reviewed. The Resident Census and Conditions of Residents form documented 38 residents resided in the facility. Findings: 1. Res #21 was admitted with diagnoses which included unspecified dementia with behavioral disturbance and alcohol dependence in remission. A physician order, dated 04/23/22, documented trazadone (antidepressant medication) 150 mg daily at 8:00 p.m. An annual assessment, dated 07/12/22, documented res #21 had moderate cognitive impairment and was independent with most activities of daily living. A care plan, dated 07/12/22, documented psychotropic drug use with the potential for adverse drug reaction related to dementia with behaviors and insomnia as evidenced by agitation, delusional behavior, disrobing, pacing, and sleeplessness. The goal for res #21 was reduced incident of mood or behavior change by using approaches which included assessment of behavior pattern daily and observation for any signs of decline in functional or cognitive status. A physician order, dated 08/04/22, documented Remeron (atypical antidepressant medication) 7.5 mg at bedtime. A physician order, dated 08/26/22, documented Rozerem (sedative medication) 8 mg at bedtime. A MRR, dated 08/11/22, read in part, .The resident was recently started on Remeron at bedtime, in addition to trazadone and Rozerem. Please advise if all three are needed to maintain sleep pattern or if a decrease in therapy might be tolerated. The physician documented disagreement with the request and provided no clinical rationale for the disagreement. On 09/28/22 at 9:12 a.m., the MDS coordinator was asked about the physician response to the 8/9/22 GDR request. She stated it was difficult to contact the physician to request additional documentation and that she was not aware of the requirement for clinical rationale upon disagreement. On 09/28/22 at 9:30 a.m., the corporate nurse stated that the physician did not provide clinical rationale for disagreement with the GDR request but should have. She stated it should have been followed up on by the nursing staff.2. Res #33 had diagnoses which included polyneuropathy, muscle spasm, radiculopathy, idiopathic scoliosis, low back pain, and chronic pain syndrome. The MRR, dated 08/11/21, documented the consultant pharmacist requested the physician consider a reduction for the medication Risperdal 1.0 mg BID. There was no physician response documented in the resident's clinical record. The MRR, dated 11/03/21, documented the consultant pharmacist requested a GDR of either Cymbalta 60 mg or Zoloft 150 mg daily. The physician documented a response to continue the current dose and did not document a clinical rational for not attempting a GDR. The MRR, dated 01/06/22, documented the consultant pharmacist requested a GDR for clonazepam 0.5 mg daily and 1 mg at bedtime, or Ambien 5 mg at bedtime. The physician documented resident stable and did not provide a clinical rational for not attempting a GDR. Physician orders, dated 04/25/22, documented the facility was to administer the following medications: sertraline, 50 mg, take one tablet with a 100 mg tablet to equal 150 mg daily, sertraline, 100 mg, take one tablet with a 50 mg tablet to equal 150 mg daily, clonazepam, 1 mg, take 1 mg daily, clonazepam, 0.5 mg, take one tablet daily. These physician orders were generated when the facility EHR system was transferred to a new EHR documentation system. The facility was unable to provide documentation of the original order date. A quarterly MDS assessment, dated 06/07/22, documented Res #33 was moderately impaired in cognition, and required supervision to total assistance with ADLs. The assessment documented the resident frequently complained of pain they rated at a six out of a one to ten scale with ten being the most severe pain. A physician order, dated 06/29/22, documented the facility was to administer Narcan 4 mg nasal spray as needed every two to three minutes for opioid induced respiratory depression. A quarterly assessment, dated 06/07/22, documented Res #33 was moderately impaired in cognition and required supervision to total assistance with ADLs. The assessment documented the resident had no behaviors and received antipsychotic, antianxiety, antidepressant, and hypnotic medications. The assessment documented the resident frequently complained of pain they rated at a six out of a one to ten scale with ten being the most severe pain. A physician order, dated 07/14/22, documented the facility was to administer risperdone, 2 mg, take 1 tablet at bedtime and risperidone, 1 mg, take one tablet daily. The MRR, dated 07/19/22, read in part, .recent increase in bedtime dose of Risperdal to 2 mg. She is also on clonazepam 1 mg at bedtime. Do you feel that she would tolerate a decrease in clonazepam to 0.5 mg not that she is on the higher dose of Risperdal? . The physician documented a response of continue current doses without providing a clinical rational to not attempt a GDR. A physician order, dated 08/19/22, documented the facility was to administer duloxetine (Cymbalta) 60 mg, take one capsule at bedtime. A quarterly MDS assessment, dated 09/07/22, documented Res #33 was moderately impaired in cognition and required supervision to total assistance with ADLs. The assessment documented the resident frequently complained of pain they rated at a six out of a one to ten scale with ten being the most severe pain. The assessment documented the resident received antipsychotic, antianxiety, antidepressant, and opioid medications daily during the assessment period. On 09/26/22 at 11:03 a.m., Res #33 was observed in her room sitting in a geri-chair. She stated she had back and neck and pain and took medications for the pain which did not help. On 09/27/22 at 4:15 p.m., the MDS coordinator stated the physician did not provide a response to the 08/11/21 GDR request. On 09/27/22 at 3:30 p.m., the corporate nurse was asked about the MRR requests. She stated the physician responses should have documented a clinical rational to disagreeing with the GDR requests.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Res #5 was admitted with diagnoses which included nightmare disorder, adjustment insomnia, and restlessness and agitation. A physician order, dated 06/15/22, documented bupropion HCL (atypical antidepressant medication) 150 milligrams daily and mirtazapine (atypical antidepressant medication) 45 milligrams at bedtime. An admission assessment, dated 06/29/22, documented res #5 was cognitively intact and independent with bed mobility and transfer. Res #5 exhibited verbal behavioral symptoms directed toward others, exhibited other behavioral symptoms not directed toward others, and rejected evaluation or care one to three days of the seven day assessment period. A physician order, dated 07/01/22, documented Ramelteon (hypnotic medication) 8 milligrams at bedtime for insomnia. A care plan, dated 07/11/22, documented a potential for alteration in mood due to depression with a goal that res #5 will be free from symptoms of depression. Approaches to meet this goal included encouragement to participate in activities with other residents for socialization and monitoring for signs and symptoms of depression such as crying, mood, refusing to eat, and anger or sadness. Psychotropic drug use behaviors or side effect monitoring was not documented in the plan of care. No documentation of psychotropic drug use behavior or side effect monitoring was found within Res #5 EHR or paper chart. On 09/27/22 at 3:30 p.m., the corporate nurse stated psychotropic medication monitoring should be documented in the EHR but was unable to locate the documentation upon request. She stated this documentation used to be completed on the TAR in the facility's prior EHR system but the new system does not have an area to complete this documentation. The corporate nurse stated behavior and side effect monitoring should have been completed but it has not been done since May 2022. On 09/28/22 at 9:10 a.m., the DON stated documentation of abnormal behavior is only completed monthly and denied awareness that psychotropic drug use behaviors or side effect monitoring needed to be completed or documented within resident medical record. On 09/28/22 at 9:20 a.m., LPN #1 stated floor nurses have not documented daily on target behaviors or side effects of psychotropic drugs received by residents. She stated documentation was only completed if an incident occurred. 4. Res #20 had diagnoses which included generalized anxiety disorder and depression. Physician orders, dated 04/24/22, documented the facility was to administer duloxetine 20 mg daily related to depression and sertraline 100 mg daily related to depression. A physician order, dated 05/15/22, documented the facility was to administer buspirone 20 mg daily related to generalized anxiety disorder. A quarterly MDS, dated [DATE], documented the resident was cognitively intact, had minimal depression, and received anti-anxiety and antidepressant medications seven out of seven days during the review period. A physician order, dated 07/22/22, documented the facility was to administer hydroxyzine 25 mg three times daily related to generalized anxiety disorder. On 09/29/22 at 11:29 a.m., the MDS coordinator stated the resident had no monitoring for psychotropic medications. Based on observation, record review, and interview, the facility failed to monitor for target behaviors and side effects associated with psychotropic medication and failed to consistently document diagnoses for the use of psychotropic medications for five (#4, 5, 8, 20, and #33) of six residents reviewed for unnecessary medications. The Resident Census and Conditions of Residents form documented 28 residents received psychoactive medications. Findings: 1. Res #4 had diagnoses which included alcoholic cirrhosis of liver with ascites, depression, unspecified, and end stage renal disease. A physician order, dated 06/06/22, documented the facility was to administer sertraline (an antidepressant medication) 50 mg daily for depression. An admission assessment, dated 06/19/22, documented Res #4 was intact in cognition and required supervision to limited assistance with ADLs. The assessment documented the resident received antidepressant and hypnotic medications daily during the assessment period. A baseline care plan, dated 06/20/22, documented the facility was to administer medications as ordered and monitor the therapeutic effects of medications. The care plan documented the facility was to monitor the adverse side effects of medications and report findings to the medical provider. A significant change assessment, dated 06/28/22, documented Res #4 was intact in cognition, required supervision to limited assistance with ADLs, and received antidepressant and hypnotic medications daily during the assessment period. The assessment documented the resident was receiving hospice services. A physician order, dated 08/25/22, documented the facility was to administer trazodone (an antidepressant medication) 50 mg daily at bedtime. On 09/26/22 at 11:22 a.m., Res #4 was observed in her room lying in her bed. During her interview she was observed to repeatedly smack her lips. On 09/28/22 at 2:22 p.m., the MDS coordinator stated the resident was admitted with the lip smacking movement. She stated the facility did not do an AIMs assessment on the resident because AIMs were only done if a resident was on an antipsychotic medications. She reviewed the resident's EHR and confirmed the facility was not monitoring for side effects or target behaviors. 2. Res #8 had diagnoses which included transient ischemic attack, unspecified mood [affective] disorder, vascular dementia with behavioral disturbance, and depression. An admission assessment, dated 04/07/22, documented Res #8 was moderately impaired in cognition, had physical behaviors directed toward others, and rejection of care. The assessment documented the resident required limited assistance of one or two staff members and did not walk. The assessment documented the resident received insulin and an anticoagulant daily during the assessment period. Physician orders, dated 05/27/22, documented the facility was to administer escitalopram, (an antidepressant medication) 20 mg, daily for a diagnosis of mood. The orders documented the facility was to administer Vraylar (an antipsychotic medication) 3 mg daily for a diagnosis of mood. The orders documented to administer lamotrigine (an antiseizure medication) 25 mg, take two tablets twice daily for an indication of mood. A physician order, dated 07/01/22, documented the facility was to administer riluzole (a medication used for amyotropic lateral sclerosis) 50 mg three times daily for an indication of mood. A quarterly assessment, dated 07/06/22, documented Res #8 was severely impaired in cognition and had physical and verbal behaviors directed toward others. The assessment documented the resident had rejection of care for one to three days during the assessment period. The assessment documented documented the resident required supervision to total assistance with ADLs. The assessment documented the resident received antipsychotic and antidepressant medications daily during the assessment period. On 08/13/22, a consultant pharmacist documented a request for the physician to document a diagnosis for the use of Vrylar and Risperdal. The request also documented Res #8 needed an AIMs test. The physician responded by documenting atypical psychosis. A physician order, dated 08/26/22, documented the facility was to administer risperdone (an antipsychotic medication) 0.25 mg twice daily. No diagnosis was documented for the use of this medications. A physician order, dated 09/09/22, documented the facility was to administer quetiapine (an antipsychotic medication) 50 mg daily at bedtime. No diagnosis was documented for this medication's use. The resident's care plan was reviewed and did not document the facility staff should monitor for side effects or described what target behaviors were for this resident. On 09/29/22 at 10:43 a.m., the MDS coordinator stated there was no care plan regarding the resident's medications and the facility did not monitor for side effects. She stated there was no routine behavior monitoring other than what was documented in the nursing notes. 3. Res #33 had diagnosis which included unspecified psychosis, recurrent depressive disorders, and dementia. Physician orders, dated 04/25/22, documented the facility was to administer 150 mg of sertraline daily and did not document a diagnosis. The orders documented the facility was to administer hydrocodone/acetaminophen (a pain medication) 10/325 one tablet twice daily and did not document a diagnosis for its use. The orders documented the facility was to administer fentanyl (a pain medication) 25 mcg/hour, one patch every 72 hours with no diagnosis documented. The orders documented to administer clonazepam (an antiseizure medication) 1.5 mg daily and did not document a diagnosis for it's use. The orders documented the facility was to administer buspirone, (an antianxiety medication) 5 mg three times daily and did not document a diagnosis for it's use. A quarterly MDS assessment, dated 06/07/22, documented Res #33 was moderately impaired in cognition and required extensive to total assistance with most ADLs. The assessment documented the resident received antispsychotic, antianxiety, antidepressant, and hypnotic medications daily during the assessment period. A physician order, dated 07/14/22, documented the facility was to administer risperidone, one mg daily and 2 mg at bedtime and did not document a diagnosis for it's use. A physician order, dated 08/19/22, documented the facility was to administer duloxetine (a medication used for depression and anxiety) 60 mg at bedtime and did not document a diagnosis for it's use. A quarterly assessment, dated 09/07/22, documented Res #33 was moderately impaired in cognition, required extensive to total assistance with ADLs, and received antipsychotic, antianxiety, antidepressant, and hypnotics medications daily during the assessment period. A care plan, dated 09/16/22, related to the use of psychotropic medication use, documented to assess Res #33's behavior pattern daily, to assess the effectiveness of medications, and to monitor for side effects of medication use. On 09/27/22 at 2:44 p.m., during an interview with the MDS coordinator and the corporate nurse, they stated behavioral monitoring would only be charted by exception and she did not know if the facility had identified target behaviors for this resident. The corporate nurse stated they were not monitoring for side effects of medications.

Based on observation and interview, the facility failed to ensure the dietary manager received certified dietary manager certification within one year of employment. The Resident Census and Conditions of Residents documented 36 residents were served meals from the kitchen. Findings: On 09/26/22 at 9:10 a.m., the cook was observed in the kitchen preparing the lunch meal. The cook identified herself as the dietary manager. She stated having attended dietary manager classes some time during a past 12 year in length employment with the facility prior to 2017 but was not sure if she was certified. She stated she had not received any training with present employment beginning in 2018. A copy of her certification was requested. On 09/27/22 at 11:53 a.m., the administrator stated the cook was not certified as a dietary manger but the facility's corporate nurse was certified and monitored the daily kitchen activities. On 09/27/22 at 12:00 p.m., the corporate nurse stated she completed pre-certification training for dietary management in 2017 but never completed the certification test. She stated no one was currently certified as a dietary manager in this facility but someone should have been. On 09/29/22 at 3:12 p.m., the cook was observed in the kitchen preparing food. The cook was asked if she had completed a test for certification in dietary management. She stated she is not certified as a dietary manager and intended on retiring from the position in one week. On 09/29/22 at 4:00 p.m., the administrator stated she thought that the corporate nurse was a certified dietary manager but that was incorrect. She confirmed the facility did not have a certified dietary manager at this time.

Based on observation, record review, and interview, the facility failed to ensure food was prepared, stored, and served in a sanitary manner. The Resident Census and Conditions of Residents documented 36 residents were served food prepared in the kitchen. Findings: On 09/26/22 at 9:10 a.m., an initial tour of the kitchen was conducted. Two large ice chests were observed sitting on the floor adjacent to the steam table. The cook stated the refrigerator in the kitchen had quit working two days ago and the items from within the refrigerator were now being kept in ice chests. The ice chests were observed full of ice and food/drink items. A reclosable plastic bag of cheese and a reclosable plastic bag of butter was observed without date or time documented on the outside of the bags. The cook stated the bags should have had date and time documented on each of them. On 09/26/22 at 9:15 a.m., twenty cockroaches, both dead and alive, were observed stuck to a glueboard trap underneath a wire shelf housing dishes adjacent to the cook stove in the facility's kitchen. The cook stated the facility had roaches for a while and she observed a mouse stuck on a glueboard last week. On 09/26/22 at 9:30 a.m., the refrigerator adjacent to the laundry room containing food items for resident consumption was observed to have an internal temperature of 48 degrees Fahrenheit. The cook stated the temperature in the refrigerator should have been 41 degrees Fahrenheit or less and that this refrigerator was not cool enough. On 09/26/22 at 9:35 a.m., a tray containing two bags of turkey breast thigh roasts and two 5 pound rolls of hamburger meat were observed thawing on the middle rack of the refrigerator. Blood was observed dripping down into the bottom of the refrigerator onto a cardboard box of scrambled egg mix. The cook stated the meat should not have been thawing on the middle rack and should have been on the bottom rack of the refrigerator. On 09/26/22 at 10:15 a.m., the ice machine was observed. A medium amount of black residue was removed with a white towel from the inner lid and the inside of the machine. The housekeeping manager was asked who is responsible for cleaning the ice machine. She stated it was the maintenance man's responsibility. On 09/26/22 at 10:20 a.m., the maintenance man stated he has only worked for the facility for two months and did not know that cleaning the ice machine was his responsibility. On 09/26/22 at 10:25 a.m., the housekeeping manager stated she had forgotten to inform the maintenance man of this responsibility upon hire and the ice machine had not been cleaned in at least two months. On 9/27/22 at 11:05 a.m., the cook was observed preparing residents' pureed diets. During preparation, the cook had a surgical mask pulled down past her nose and mouth around her chin. The cook removed the inner mixer blade and laid it on the counter beside the mixer and placed the mixer lid clean side down on the counter. The cook stirred the contents of the mixer several times with a plastic spoon and then placed the spoon down on the bare counter between use. The cook was observed to have touched a light switch, oven knob, and steam tray lids while preparing food without washing her hands before resuming food preparation. The cook was observed placing her face, without a mask, down into the blender pitcher six times to see if the food was blended to proper consistency. The cook was asked if a mask should be worn to prevent respiratory or droplet contamination while placing her face so close to the food. The cook stated she had never thought about the risk and probably should wear a mask during preparation of food. The cook was asked about the lack of hand washing after touching dirty surfaces during the preparation process. The cook stated she should have washed her hands but did not. On 09/27/22 at 11:43 a.m., two live roaches were observed crawling under the wire rack in the dry goods closet. Ten dead roaches were observed stuck to the glueboard under this same rack. On 09/27/22 at 11:45 a.m., the cook stated the roach problem had been worse over the last few months. She stated pest control sprayed monthly but the roaches have persisted. She stated some of the kitchen staff do not clean like they should and it has added to the problem. On 09/27/22 at 11:53 a.m., the administrator stated she was not aware of roaches in the kitchen. She confirmed roaches have been a problem in the past but she thought it was improved because pest control sprayed monthly. On 09/29/22 at 10:50 a.m., pest control records for July, August, and September of 2022 were reviewed. The records documented a pest control company provided glueboards and a liquid application last on 09/08/22. A pest control receipt dated 08/11/22 documented roaches in the kitchen and in one other room were observed during liquid application. On 09/29/22 at 10:45 a.m., the administrator stated the maintenance man should have been told to clean the machine but it had not happened. She stated the kitchen staff should have known proper infection control practices related to sanitary practices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Res #7 had diagnoses which included COPD, schizophrenia, depression, disorders of bladder, urinary retention, convulsions, and dementia. Physician orders, dated 04/24/22, documented to administer ondansetron four mg every four hours as needed and Milk of Magnesia 400 mg every 24 hours as needed. There were no diagnoses documented for the orders. A physician order, dated 05/11/22, documented to administer calcium antacid one tablet every four hours as needed. There was no diagnosis documented on the order. Physician orders, dated 06/16/22, documented to administer vitamin D3 50 MCG daily and gabapentin 100 mg three times daily. There were no diagnoses documented on the orders. A physician order, dated 07/01/22, documented to administer quetiapine 50 mg daily. There was no diagnosis documented on the order. A quarterly MDS, dated [DATE], documented the resident was cognitively intact, required minimal assistance with ADLs, used a wheelchair, had an indwelling catheter, required a therapeutic diet, and received antipsychotic and antidepressant medications seven out of seven days during the review period. A physician order, dated 08/25/22, documented to administer propranolol 20 mg twice daily. There was no diagnosis documented on the order. Physician orders, dated 09/09/22, documented to administer Lexapro 10 mg daily and Ramelteon eight mg at bedtime. There were no diagnoses documented on the orders. A physician order, dated 09/20/22, documented to administer Lantus 75 units twice daily. There was no diagnosis documented on the order. A physician order, dated 09/22/22, documented to administer torsemide 10 mg daily. There was no diagnosis documented on the order. 5. Res #20 had diagnoses which included paraplegia and diabetes. A physician order, dated 05/11/22, documented to administer Novolog twice daily according to sliding scale for diabetes mellitus. A quarterly MDS, dated [DATE], documented the resident was cognitively intact, had minimal depression, and received anti-anxiety and antidepressant medications seven out of seven days during the review period. A physician order, dated 07/22/22, documented to administer Crestor 10 mg daily. There was no diagnosis documented on this order. A MAR for September 2022, did not document the amount of Novolog administered for the a.m. dose on 09/02/22, 09/06/22, 09/07/22, 09/11/22, 09/12/22, and 09/13/22. The amount of insulin given was not documented for the p.m. dose on 09/07/22, 09/09/22, and 09/12/22. A physician order, dated 09/14/22, documented to administer Humalog twice daily according to sliding scale for diabetes mellitus. A MAR for September 2022 did not document the amount of Humalog administered for the a.m. dose on 09/19/22, 09/20/22, 09/21/22, 09/25/22, 09/27/22 and 09/28/22. The amount of insulin given was not documented for the p.m. dose on 09/14/22, 09/15/22, 09/16/22, 09/19/22, 09/20/22, 09/22/22, 09/23/22, 09/26/22, and 09/27/22. On 09/28/22 at 4:05 p.m., LPN #1 stated the EHR system did not populate how many units of insulin were administered according to the FSBS so she had to put it in the comments. She stated it was the responsibility of the nurse to remember to put the units administered in the comments. She stated there was no way to tell how many units of insulin were given after the fact if it was not put in the comments. On 09/28/22 at 4:08 p.m., LPN #2 stated she would put the number of units and location of insulin administered for sliding scale insulin under the comments On 09/29/22 at 11:17 a.m., the corporate nurse stated the staff should type in how many units are given in the notes. She stated it was an issue that the IT department of the EHR had been contacted to resolve but had not been fixed yet. 6. Res #86 had diagnoses which included Down syndrome, hydronephrosis with ureteropelvic junction obstruction, pressure ulcer of sacral region stage IV, and hypothyroidism. A quarterly MDS, dated [DATE], documented the resident required limited to total assistance with ADLs, had an indwelling catheter and was always incontinent of bowel. The assessment documented the resident had one stage IV pressure ulcer present on admission and received antipsychotics seven out of seven days during the review period, and opioids three out of seven days during the review period. A physician order, dated 04/24/22, documented to administer vitamin C 500 mg twice daily. There was no diagnosis documented on the order. A physician order, dated 07/08/22, documented to administer Arginaid one powder pack daily. There was no diagnosis documented on the order. Physician orders, dated 09/26/22, documented to administer vitamin D3 25 mcg daily; cyanocobalamin/folic ac/vit B6 one tablet daily; ferrous sulfate 325 mg twice daily; hydrocortisone 20 mg twice daily; levothyroxine sodium 100 mcg daily; midodrine 10 mg three times daily; Miralax 17 gram daily before meals; Riluzole 50 mg every 12 hours; sennosides 8.6 mg daily, two tablets daily; thiamine HCL 100 mg daily; and valproic acid 250 mg/5 ml, 5 ml twice daily. There were no diagnoses documented on the orders. A physician order, dated 09/29/22, documented to administer Zosyn 3.375 gram, infuse 3.375 gm IV every eight hours via PICC line for 14 days, infuse over 30 minutes with a running rate at 200 ml per hour, flush with 10 ml of normal saline before and after administration. There was no diagnosis documented on the order. On 09/27/22 at 1:50 p.m., during an interview with the corporate nurse, she stated they know about medications being in the order set without diagnosis documented. Stated they have contacted the company about diagnosis showing up on the order set. Stated sometimes they show up and sometimes they did not. Based on record review and interview, the facility failed to ensure resident medical records were complete, readily accessible, and systematically organized for six, (#8, 7, 20, 33, 84, and #86) of twenty residents whose records were reviewed. The Resident Census and Conditions of Residents form documented 38 resident resided in the facility. Findings: 1. Resident #33 had diagnoses which included unspecified psychosis, recurrent depressive disorders, anxiety disorder, and unspecified dementia. A PASRR prescreening assessment, dated 03/11/14, documented Res #33 had no serious mental illness. A quarterly assessment dated [DATE], documented Res #33 was moderately impaired in cognition required extensive to total assistance with ADLs and received antipsychotic, antianxiety, antidepressant, and hypnotic medications during the assessment period. On 09/28/22 at 8:28 a.m., the corporate nurse stated the facility could not identify when the resident received the new mental illness diagnosis as they could not get into the old documentation system. She stated the facility changed EHR systems in the last part of April 2022 and the first part of May 2022. 2. Res #8 had diagnoses which included transient ischemic attack, diabetes, vascular dementia with behavioral disturbance, and depression. An admission assessment, dated 04/07/22, documented Res #8 was moderately impaired in daily decision making, physical behaviors directed toward others, rejection of care, and required limited assistance of one or two staff with ADLs and did not walk. A quarterly assessment, dated 07/06/22, documented Res #8 was severely impaired in cognition, had physical and verbal behaviors directed toward others, and required supervision to total assistance with ADLs. On 09/29/22 at 10:43 a.m., the MDS coordinator verified she did not compare the April 2022 and the June 2022 assessment to see if the resident required a significant change assessment. She stated she was unable to see the previous MDS system as they did not have access to the old system anymore. 3. Res #84 had diagnoses which included infective bursitis, psychiatric and behavioral factors associated with discord, and Lewy body dementia. The facility was not able to provide comprehensive or quarterly assessments for this resident as her records were in the previous EHR system. The ADL sheets were reviewed and documented Res #88 toileted either herself or with staff assist ranging from independent to total assist, often in the same day. There were several shifts from June 5, 2021 through June 26, 2021, the records did not document ADL cares were provided. On 09/30/22 at 08:17 a.m., the corporate nurse stated she was not sure of what happened as the resident had been discharged for some time and the facility had to contact the EHR company to have them copy and send the records and this was all they had for now.

Based on observation, record review, and interview the facility failed to maintain an effective pest control program. The Resident Census and Conditions of Residents documented 38 residents resided in the facility. Findings: On 09/26/22 at 9:15 a.m., twenty cockroaches, both dead and alive, were observed stuck to a glueboard trap underneath a wire shelf housing dishes adjacent to the cook stove in the facility's kitchen. On 09/26/22 at 9:16 a.m., the cook stated the facility has had roaches for a while and that she observed a mouse stuck on a glueboard last week. On 09/27/22 at 11:43 a.m., two live roaches were observed crawling under the wire rack in the dry goods closet. Ten dead roaches were observed stuck to the glueboard under this same rack. On 09/27/22 at 11:45 a.m., the cook stated the roach problem had been worse over the last few months. She stated pest control sprayed monthly but the roaches have persisted. She stated some of the kitchen staff do not clean like they should and it has added to the problem. On 09/27/22 at 11:53 a.m., the administrator stated she was not aware of roaches in the kitchen. She confirmed roaches have been a problem in the past but she thought it was improved because pest control sprayed monthly. On 09/29/22 at 10:50 a.m., pest control records for July, August, and September of 2022 were reviewed. The records documented a pest control company provided glueboards and a liquid application last on 09/08/22. A pest control receipt dated 08/11/22 documented roaches in the kitchen and in one other room were observed during liquid application.