**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy, observations, record reviews, interviews and the manufacturer's FDA (Food & Drug Administration) approved package insert, the facility failed to ensure that a resident (R)106, was free of an unnecessary psychotropic drug for 1 of 5 residents reviewed for unnecessary medications. Findings include: A review of the facility's policy titled, PHARMACY SERVICES POLICIES AND PROCEDURES: SECTION 6- MEDICATION MANAGEMENT, SUBJECT: 6.8 UNNECESSARY DRUGS revised 4/17/2024 revealed 3. Unnecessary drugs are defined as any drug when used: .D. Without adequate indication for its use. A review of the FDA approved manufacturer package insert guidelines for the use of for Seroquel (quetiapine) revised October 2013 revealed, Indications and Usage: Seroquel is an atypical antipsychotic indicated for the treatment of: Schizophrenia, Bipolar I disorder manic episodes, and Bipolar disorder, depressive episodes. R106 was originally admitted to the facility on [DATE] from a local hospital with an order for Quetiapine 100 mg (milligram) + 50 mg hs (bedtime) and was readmitted to the facility on [DATE] after a shoulder aspiration with diagnoses including, but not limited to vascular dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. A review of the Electronic Medical Record (EMR) Quarterly Minimum Data Set (MDS) for R106 with an Assessment Reference Date (ARD) of 03/21/25 revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicates moderate cognitive impairment and that R106 had received antipsychotic medications on a routine basis with the last Gradual Dose Reduction (GDR) documented by the physician on 03/26/2024, as being clinically contraindicated. On 06/9/25 at approximately 11:00 AM, a review of the June 2025 EMR physician orders for R106 revealed: -Seroquel 100 mg with a 50 mg tablet (total 150 mg) HS for vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety ordered 5/15/24 and discontinued 1/16/25. -Seroquel 100 mg administer with a 25 mg tablet (125 mg total) HS for vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety ordered 1/16/25 as open ended (until discontinued). -Trazodone 50 mg HS - insomnia ordered 5/15/24 and discontinued 2/24/25. On 06/09/25 at approximately 2:00 PM, a review of the medication administration records (MARS) since 05/15/24 revealed that all doses for Seroquel and Trazodone had been administered as prescribed. On 06/09/25 at approximately 4:45 PM, review of a pharmacist GDR recommendation to the attending physician/prescriber, dated 03/19/24, revealed that R106 was receiving Quetiapine 150 mg at bedtime and the prescriber on 03/26/24 had indicated MEDICATION CONTINUATION: Psychotropic medication is controlling and improving target symptoms. Continue until next review and further review of a GDR recommendation, dated 2/20/25, whereby the physician accepted a Trazodone GDR recommendation and wrote a new order Trazodone 25 mg q (every) HS x 1 wk (week), then D/C (discontinue). On 06/10/25 at approximately 11:00 AM, further review of the EMR revealed that on 09/16/24, a physician progress note indicated recurrent major depressive disorder in remission. did not tolerate GDR of Seroquel Spring 2023. Psych is following and on 5/28/25 Major Depression/Mood Disorder: Chronic, stable moods on Seroquel GDR done [DATE] w/o (without) apparent worsening. On traz (Trazodone) prev (previously) by dc' d (discontinued) Mar (March) 2025. During an interview with the Administrator and Director of Nursing (DON) on 06/10/25 at approximately 11:45 AM, the Administrator stated in response to being asked How do you ensure that the attending physician's supervise the medical care of residents with dementia and their use of antipsychotic medications? The Administrator stated, This is overseen by the Medical Director. On 06/10/25 at approximately 12:30 PM, the Administrator stated that the Medical Director cannot be reached because she is out of the country and provided a telephone number for the Physician Assistant. On 06/10/25 at approximately 12:35 PM and 12:43 PM, the Surveyor tried to contact the Physician's Assistant, but the phone was busy and mailbox was full, being unable to leave a message. These calls were not returned. On 06/10/25 at approximately 2:30 PM, the DON provided documentation that the spouse of R106 had consented to a request for mental health services on 04/23/23 and that R106 had refused psych services on 04/26/23 with a physician signature dated 04/27/23 and stated to her knowledge the resident had never received psychiatric services.

Based on review of the facility policy, observations, and interviews, the facility failed to assure that medications were properly stored according to manufacturer labeling in 1 of 3 treatment carts. Findings include: Review of the facility's Policy and Procedures entitled GENERAL GUIDELINES FOR STORAGE OF MEDICATION AND BIOLOGICALS revised 4/17/2024 states 1. Medications and biologicals are stored safely, securely and properly following manufacturer's recommendations or those of the supplier . On 06/09/25 at approximately 11:30 AM, inspection of the Indigo treatment cart revealed: one opened TheraHoney Gel 1.5 ounce tube dated 06/02/25 by Medline labeled Sterile in unopened, undamaged package. Single Use Only and one opened Plain Packing Strip 1/4 inch x 5 yards by Curad labeled Sterile in unopened undamaged package. Single Use Only. On 06/09/25 at approximately 11:35 AM, these findings were reviewed and verified by Licensed Practical Nurse (LPN)1, who stated she was unfamiliar with the manufacturer labeling. On 06/10/25 at approximately 11:50 AM, the Director of Nursing (DON) stated she was aware of this finding, but was unaware of the manufacturing labeling related to these products being single use only.

Based on review of the facility policy, observations and interviews, the facility failed to ensure foods, prepared and frozen, were stored properly. The facility further failed to ensure the dry storage room was kept clean and free from spillage and debris in one of one main kitchen. Findings include: Review of the facility policy titled, Food Safety in Receiving and Storage, with a complete revision date of 06/20/23 states Policy: Food will be received and stored by methods to minimize contamination and bacterial growth. Under General Food Storage Guidelines it states, 3. Place food that is repackaged in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight fitting lid. Label both the container and its lid with the common name of the contents, the date it was transferred to the new container, and the discard date. It is recommended that food stored in bins (e.g. flour or sugar) be removed from its original packaging. Under Refrigerated Storage Guidelines it states, 12. Refrigerated, ready to eat Time/Temperature Control for Safety Foods (TCS) are properly covered, labeled, dated with a use-by date, and refrigerated immediately. [NAME] them clearly to indicate the date by which the food shall be consumed or discarded. The day of preparation or day original container is opened shall be considered day 1. Follow USDA guidelines for food storage. An observation on 06/08/25 at 10:20 AM of the main kitchen revealed: Walk in cooler contained: -Seven salads, previously made, and placed in carry-out containers with no date and no expiration date. Walk in freezer contained: -Two bags of breaded chicken filets opened and repackaged in a plastic bag with no open date and no expiration date. -One bag of sliced garlic bread, repackaged with no label, no open date. -One partially used bag of chocolate chip cookie dough, open with no dates. -One large box of fish filets, opened and not sealed, with no dates. -One bag of chicken parts, repackaged with no label and no open nor expiration date. -A plastic bag with 2 pieces of fish, partially used with no dates. -One bag of Zucchini partially used, with no open date and no expiration date. -A large bag of mixed veggies partially used with no dates. -A large cardboard box of sausage, opened, partially used, and not resealed, with no open date. The sausage was dried out and dark in color. Outside Freezer: -One bag of frozen cookies opened, partially used, and contained no dates. During an interview with the [NAME] on 06/08/25 at 10:40 AM, she confirmed the findings and removed the salads from the cooler, and the unlabeled items from the freezers. Review of the Cleaning Schedule, dated 06/01/25-06/07/25 revealed the Storeroom Clean and Date, that was signed off by dietary staff as cleaned. An observation on 06/08/25 at 10:45 AM of the dry storage room, revealed dirt, food, and debris on the floor. There was spillage on the floor along with debris under the bottom shelf that was covered by plastic containers. The plastic containers were outlined along the outer edges by the dirt and debris. On one shelf, was a crushed, single serving of pancake syrup that was dry on the shelf with a cardboard box stuck to it. During the observation of the dry storage room with the [NAME] on 06/08/25, she confirmed the findings and stated that the dry storage room is cleaned every other day and mopped daily. On 06/10/25 at an unspecified time, during a conversation with the Certified Dietary Manager (CDM), she stated the staff clean the dry storage regularly and provided the cleaning schedule. She stated that the dry storage room was cleaned on 06/07/25 and was signed off by staff.

Based on review of the facility policy, observations and interviews, the facility failed to ensure the refuse dumpsters were not overfilled and closed with tight fitting lids for 2 of 2 dumpsters observed outside of the kitchen, in a newly paved area. Findings include: Review of the facility policy titled, Waste Disposal with a revision date of 06/20/23, states, Waste will be disposed of in a manner to prevent transmission of disease, nuisance or breeding place for insects and feeding places for rodents and other mammals. Procedures: 1. Waste is not disposed of by garbage disposal. It is kept in leak proof non-absorbent containers with close fitting lids. 2. Dispose of waste in closed trash bags. 3. Cover waste containers in transport to dumpsters. 4. Remove trash frequently enough to prevent overflow. 5. Always cover waste containers and close dumpsters. 6. Keep waste containers clean, odor free and without cracks. 7. Keep area around refuse dumpsters clean, odor and rodent free. An observation on 06/08/25 at 10:50 AM of the outside dumpsters revealed, 2 large dumpsters overfilled, and the lids were unclosed due to the overflow of trash and refuse. During an interview with the [NAME] on 06/08/25 at 10:50 AM, she confirmed that the 2 dumpsters were overfilled and the lids were not closed. During an interview with the Certified Dietary Manager (CDM) on 06/09/25 at approximately 10:15 AM, she stated that the dumpsters normally do not get that full and if they have an excess of trash then it is carried to another dumpster else where on the property. She also confirmed that the lids should be closed at all times.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews the facility failed to provide the necessary services to a dependent resident who was not able to carry out Activities of Daily Living (ADLs) for one (1) of two (2) residents reviewed for ADL care. Specifically, the facility failed to ensure the resident received personal hygiene daily to include combing and removing foreign debris from the resident's hair. (Resident #101) Findings include: Review of the Nursing Policies and Procedures with the subject of Activities of Daily Living, Optimal Function revised 5/5/23 read: The Definition of ADLs refers to tasks related to personal care including, grooming, dressing, oral hygiene . The Facility provides necessary care to all residents that are unable to carry out activities of daily living on their own to ensure they maintain proper nutrition, grooming, and hygiene. Record review revealed Resident #101 was readmitted to the facility on [DATE] with diagnoses that included: Acute Osteomyelitis on the right ankle and foot, Direct Infection of the right ankle and foot, and Infectious and Parasitic diseases. Review of the Annual Minimum Data Set (MDS) assessment, dated 12/29/22, revealed resident's Brief Interview for Mental Status (BIMS) score of 12 out of 15, indicating he/she had moderately impaired cognition. The resident's daily preferences were assessed to be very important in relation to the resident choices which included: what clothes to wear, taking care of personal belongings or things, choose between a tub bath, shower, bed bath, or sponge bath. The Resident's Functional status for personal hygiene was extensive with one (1) person assist and bathing was total dependence with one (1) person assist. Review of the Care Plan, which was revised on 10/3/23, identified that Resident #101 had mobility and visual impairments that affected his/her ability to perform ADL tasks and required staff assistance with ADL needs. The approaches included, staff was to assist or provide ADL care needs for Resident #101 routinely, as needed and as tolerated. Review of the Physician Orders included: Start date 4/13/21, bathing assist with one [1] staff. Start date 4/13/21, dressing and grooming assist with one [1] staff. Review of the progress notes from 7/1/23 to 10/5/23 did not reveal any resident refusals for care and assistance with daily personal hygiene to include combing his/her hair. During an observation on 10/3/23 at 10:39 a.m., Resident #101 was waiting to go to Dialysis. His/her hair was disheveled and contained copious amounts foreign debris that appeared to be lint balls. During an interview and observation on 10/5/23 at 9:27 a.m. The resident stated he/she cared about his/her presentation. He/she stated that the staff did not assist with combing his/her hair and was not aware of the lint balls in hair, because he/she had trouble seeing. During an interview on 10/6/23 at 9:36 a.m., Certified Nurse Aide (CNA) #1 stated he/she assisted residents with completing ADL tasks that residents were unable to complete themselves. CNA #1 stated they tried to encourage independence and some residents could not comb their hair or wash areas they could not reach. CNA #1 stated the resident sometimes refused ADL care. He/she didn't think the resident's hair was too bad. During an observation with CNA #1, he/she looked at Resident 101's hair and stated there was lint in the resident's hair in multiple areas. During an interview on 10/6/23 at 9:45 a.m., the Licensed Practical Nurse/Unit Manager (LPN) #4 stated ADL care included washing residents' hair, brushing their teeth, and washing their face. He/she stated, basically head to toe care, including getting dressed and equipping glasses and hearing aids. LPN #4 stated, that if the resident refused; the CNA would tell the nurse, the nurse would ask the resident, if still refused then reapproached later. The LPN said, the resident had multiple personalities and the surveyor may not have been talking to the right person. LPN #4 stated he/she did not know if Resident #101 had lint balls in their hair. He/she stated the resident was able to comb their hair. LPN #4 said, I have not seen lint in the resident's hair. LPN #4 stated he/she did not look at the resident because he/she was too busy passing medication. LPN #4 did not complete an observation with the surveyor because he/she was passing medication. During an interview on 10/6/23 at 10:25 a.m., the Director of Nursing (DON) said ADL care included showers/baths, brush teeth, brushing hair, and added the resident's hair was combed daily unless they refused. The DON observed Resident 101's hair and stated the staff should have assisted with removing lint balls from his/her hair. The DON stated it was important to comb and provide care to residents to prevent sores in the resident's head and to keep the resident's hair from being matted together.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and clinical record review, the facility failed to ensure bilateral hearing aids were applied in accordance with a nursing order; and failed to identify hearing aids were lost/missing for one (1) of 28 sampled residents (Resident #47). The findings include: In an attempted interview during initial tour on 10/3/23 at 10:01 a.m., Resident #47 did not respond to questions asked by this Surveyor. Resident #47 stated he/she could not hear. Review of the Resident #47's clinical record revealed an admission date of 8/26/2020, with diagnoses including Unspecified Dementia and Bilateral Acute Otitis Media. Resident #47's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate difficulty hearing and utilized hearing aids. According to the assessment, the resident was moderately cognitively impaired having scored 11 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. Resident #47 did not receive any therapy services during this assessment period. Review of Resident #47's Communication Care Plan initiated on 9/4/2020 and last reviewed on 10/3/23 revealed the following: Problem: [Resident] is hearing impaired in both ears. Goal: [Resident] will hear and understand communication appropriately through next review. Approach: Utilize dry erase board for communication as tolerated; Obtain resident's attention before speaking; Face the resident when speaking; Repeat phrases as needed; Rephrase if necessary; Speak clearly and adjust tone as needed; If refuses to wear hearing aid, explore reason for refusal (9/22/21). Goal: [Resident] will hear and understand communication through next review. Approach: [Resident] to wear bilateral hearing aids/amplifier as tolerated (9/4/2020); Referrals to audiologist as needed; Provide quiet, non-hurried environment, free of background noises and distractions; Place in front of room during group activities; Obtain resident's attention before speaking; Face the resident when speaking; Repeat phrases as needed. Rephrase if necessary; Speak clearly and adjust tone as needed; If refuses to wear hearing aids, explore reason for refusal (9/4/2020); Check that hearing aid(s) is clean, functioning and properly placed into___ (left, right, both) ear(s) (9/4/2020). Review of Resident #47's Nursing Orders, revealed an order for bilateral hearing aids was initiated on 8/26/2020 by a facility Licensed Practical Nurse (LPN) and noted the use of the hearing aids was to be listed in the resident's Activities of Daily Living (ADL) Flow Sheet. Continued review revealed this order was discontinued on 10/5/23 at 12:31 p.m. by the Unit Manager (UM) and noted the resident's [Responsible Party/adult child] picked up hearing aids last time [he/she] came. Review of Resident #47's Nursing Progress Notes revealed the following: 8/26/2020 - Resident admitted to [facility from hospital]. Arrived at 6pm and admitted to room [ROOM NUMBER]. Report given from [Registered Nurse] RN. Resident [was] alert and oriented with some intermittent confusion. Resident [was] pleasant and cooperative with care. Resident [could] not hear well despite having bilateral hearing aids. Able to read lips. 9/4/2020 - Body Audit: Resident alert and able to make needs known to staff, wearing bilateral hearing aids, no drainage noted from eyes, ears, or nose, partial upper denture and natural teeth on bottom . 10/5/23 at 12:34 p.m. - Resident's hearing aids not in room or on resident. RP [Responsible Party] [adult child] inform[ed] staff that [he/she] retrieved the hearing aids on [his/her] last visit. Order discontinued. An interview on 10/5/23 at 11:55 a.m. with the resident's Unit Manager (UM), an LPN, revealed the resident did not consistently or regularly wear his/her hearing aids. The UM stated that, Resident #47 started off the day wearing the hearing aids and then independently removed them from his/her ears during the day. The UM stated that, Resident #47 knew how to store the hearing aids and put them away correctly. Observation and interview with the resident on 10/5/23 at 12:10 p.m. revealed the resident self-propelled down the hallway in a manual wheelchair. The resident was not observed wearing hearing aids. When asked about his/her hearing aids, Resident #47 responded and said, I can't hear but I can see. The resident continued and said, I don't wear hearing aids. An interview on 10/5/23 at 12:10 p.m. with Certified Nursing Aide (CNA) #2, revealed the aide had been employed by the facility for years. The aide said he/she was not aware that Resident #47 wore hearing aids. CNA #2 said he/she had not seen [Resident #47] with any [hearing aids]. An interview on 10/5/23 at 12:20 p.m. with the Activities Director (AD), revealed the staff was not aware the resident wore hearing aids. The AD said that the resident's RP may have taken the hearing aids on his/her last visit around the first of September 2023. An observation in Resident #47's room at 12:20 p.m. on 10/5/23, revealed the resident's UM searched the resident's room (including the roommate's side of the room) in search of the resident's hearing aids. The UM could not find the hearing aids. He/she said the hearing aids should have been locked in the nurses' cart. An interview on 10/5/23 at 12:32 p.m. with the Assistant Business Office Manager (ABOM), revealed the staff called the resident's RP, and the RP reported that he/she had taken the hearing aids away some time ago because his/her mother could not hear with or without them. The ABOM stated the UM was currently discontinuing the resident's order for the bilateral hearing aids. In a follow-up interview on 10/5/23 at 2:50 p.m., the UM revealed he/she discontinued the hearing aids after the ABOM told him/her the RP had taken the hearing aids with him/her. The UM stated the use of the hearing aids was initiated as a nursing order and did not require physician involvement to discontinue the order. An interview with Resident #47's RP on 10/5/23 at 3:03 p.m. revealed he/she had spoken with an employee from the facility earlier in the day. The RP said that he/she told the facility staff that when Resident #47 initially received the hearing aids, the doctor informed the RP that the resident may not be able to hear even with the hearing aids because his/her hearing was so bad. The RP said that he/she did not have the hearing aids and did not take them away from the resident on his/her last visit. The RP also said that he/she did not tell the facility's employee (ABOM) that he/she had taken the hearing aids away. The RP said that he/she would prefer that Resident #47 received another set of hearing aids if it would not be too costly. An interview on 10/5/23 at 3:37 p.m. with the facility's Director of Nursing (DON) revealed the UM informed him/her earlier in the day that the resident's RP had taken the hearing aids on his/her last visit and that the assistive devices were discontinued. He/she said that the hearing aids were a Nursing Order which did not require physician involvement to discontinue the devices. When informed that the resident's RP said that he/she did not retrieve the hearing aids, the DON said that the expectation would now be for the UM to set up an audiology appointment and if the hearing aids were lost on behalf of the facility then the facility would replace the hearing aids. The DON said that staff should have discovered that the hearing aides were missing before Surveyor intervention. The DON said that nursing aides were made aware that Resident #47 required the use of hearing aids because that information appeared in the electronic kiosk/cardex system that the nurse aides accessed to review residents' ADL assistance requirements. The DON said nursing aides were not required to sign off that they assisted with placing the hearing aids on Resident #47. In an interview on 10/5/23 at 5:15 p.m., the DON revealed he/she had a follow up call with the resident's RP. The DON said the RP informed him/her that he/she told the ABOM that Resident #47 left the hearing aids at their last placement before being admitted into the current facility.

Based on observations, interviews, and facility policy, the facility failed to follow the facility infection control protocol to hand sanitize prior to entering resident rooms to provide medication administration in order to prevent cross-contamination for residents on Enhanced Barrier Precautions. This failure affected five (5) of five (5) sampled residents (Residents #3, 46, 91, 96 and 337). The findings include: Review of a facility policy titled Infection Prevention and Control Policies and Procedures revised date, 5/15/23, documented the following: SUBJECT: Transmission Based/Standard Precautions, and Enhanced Barrier Precautions (Continued) PROCEDURES: Enhanced Barrier Precautions (EBP) The facility will provide access to hand hygiene supplies prior to entering and exiting the resident's room. 5. Fundamentals of Precautions A. Hand Hygiene/Hand washing and Gloving 1) Hand Hygiene/Hand washing is the single most important measure to reduce the risks of transmitting microorganisms from one person to another or from one site to another on the same patient/resident. Review of the information of a sign posted on above resident rooms indicated: STOP Enhanced Barrier Precautions - Everyone Must: Clean their hands, including before entering and when leaving the room. On 10/3/23 at 8:10 a.m., Registered Nurse (RN) #1 prepared medications to be administered to Resident #337. A sign on Resident #337's door stated the resident was on Enhanced Barrier Precautions. The RN entered the resident's room with the medications and failed to sanitize/wash his/her hands before they entered the room. On 10/3/23 at 8:20 a.m., Licensed Practical Nurse (LPN) #2 prepared medications to be administered to Resident #91. A sign on Resident #91's door stated the resident was on Enhanced Barrier Precautions. The LPN entered the resident's room with the medications and failed to sanitize/wash his/her hands before he/she entered the room. On 10/3/23 at 8:32 a.m., LPN #2 prepared medications to be administered to Resident #3. A sign on Resident #3's door stated the resident was on Enhanced Barrier Precautions. The LPN entered the resident's room with the medications and failed to sanitize/wash his/her hands before he/she entered the room. On 10/3/23 at 8:47 a.m., LPN #2 prepared medications to be administered to Resident #46. A sign on Resident #46's door stated the resident was on Enhanced Barrier Precautions. The LPN entered the resident's room with the medications and failed to sanitize/wash his/her hands before they entered the room. On 10/3/23 at 9:07 a.m., LPN #3 prepared medications to be administered to Resident #96. A sign on Resident #96's door stated the resident was on Enhanced Barrier Precautions. The LPN entered the resident's room with the medications and failed to sanitize/wash his/her hands before she entered the room and prior to exiting the room. On 10/5/23 at 9:30 a.m., the Infection Control (IC) Nurse stated nurses were to sanitize his/her hands immediately before entering and prior to exiting a resident room to provide care. On 10/5/23 at 9:40 p.m., the Director of Nursing (DON) stated the nurse must hand sanitize their hands before they entered a room and prior to leaving the room.

Based on observation, interview and review of maintenance logs, the facility failed to ensure three (3) of three (3) dryers in the facility's laundry room were free of lint build-up on the dryer vent hose and wall behind the dryers. The findings include: An observation in the facility's laundry room with the facility's Assistant Director of Nursing (ADON) present on 10/6/23 at 11:40 a.m., revealed the dryer vent hose attached and extending from the back of three (3) commercial size dryers were covered with a layer of lint. On one (1) of the hoses was an old fabric softener sheet. Continued observation revealed there was lint build-up on the lower part of the wall behind the three (3) dryers, as well. During an interview at this time, the ADON confirmed the observation of the lint build-up and fabric softener sheet on the hose and wall behind the dryers. In an interview on 10/6/23 at 11:46 a.m., Laundry Staff revealed laundry staff was responsible for cleaning the lint from the front compartments of the dryers and maintenance staff were responsible for cleaning the lint that accumulated behind the dryers. An interview on 10/6/23 at 11:57 a.m. with the facility's Maintenance Director confirmed laundry staff were responsible for removing lint from the front of the dryers in between loads and maintenance staff were responsible for removing lint from the back of the dryer once per month. The Maintenance Director stated, it's coming due again. Continued interview revealed that this cleaning was documented and kept in a logbook. The Maintenance Director said that the lint accumulated quickly on the outside of the dryer vent hose and wall behind the dryers. He/she said maintenance was mostly concerned about lint accumulating on the inside of the vent hose. An observation on 10/6/23 at 12:05 p.m. with the Maintenance Director present was made in the laundry room. The Maintenance Director confirmed there was lint build-up behind the dryers on the hose and wall. He/she stated he/she had seen it worse than that. With his/her right hand index finger and thumb, the Maintenance Director picked up a small clump of lint from the hose behind the dryer, and picked up the fabric softener dryer sheet that was on the hose as well. When the surveyor touched the fabric softener sheet, it was warm and hard. At 12:10 pm on 10/6/23, the Maintenance Director provided documentation for the last monthly log check for the dryers and stated, it's time for a check again. Review of Monthly, Check dryer form dated 9/8/23 revealed Dryers #1, #2 and #3 were last checked and cleaned on 9/8/23.

Based on interview, record review, and review of facility policy and procedure, the facility failed to ensure one (Resident (R) 343) of three resident representative was provided the right to participate in treatment care. This failure had the potential to prevent the resident representative from the ability to consent or decline treatment options for R 343's treatment plan. Findings include: Review of facility policy titled, Psychotropic Drugs-Use Of dated 11/1/17 revealed, . 6. A consent form will be completed for each psychotropic medication prescribed. Documentation should include if the intended or actual benefit is understood by the resident and, if appropriate, his/her family and/or representative(s) and is sufficient to justify the potential risk(s) or adverse consequences associated with the selected medication, dose, and duration. Consents can be obtained in two ways: A, Resident/patient or their legal representative's given written consent, which includes provision of risk and benefits information and signature on the facility approved consent form. This form will be kept in the resident's/patient's chart. B. Telephone consents are acceptable when the required information was discussed with the resident/patient or legal representative and documented in the chart. If telephone consent is received, it required the signature of two witnesses .7. D. When psychopharmacological medications are used as an emergency measure, adjunctive approaches, such as individualized, non-pharmacological approaches and techniques must be implemented . Review of R 343's electronic medical record (EMR) Face Sheet dated 11/18/20 revealed the following diagnoses: metabolic encephalopathy, cognitive communication deficit, hypovolemia, type 2 diabetes mellitus, and hypertension. Review of R 343's EMR Care Plan dated 11/18/2020 revealed, Resident/responsible party will be informed of any changes in residents condition and benefits, risk and possible choices of treatment. Review of R 343's EMR Physician Orders dated 12/23/2020 revealed R 343 was administered Diphenhydramine 25 mg (milligram) x (time) 1 dose for agitation. Review of EMR nursing Resident Progress Notes dated 12/23/20 at 1:39 AM, revealed, Resident O2 (oxygen) at 79 without ordered 4L (liters) NC (nasal cannula) on. 11:40 PM res (resident) noted to remove IV (intravenous) and NC (nasal cannula). Sats (saturation) read at 82% (percent) RA (room air). MD (medical doctor) notified and ordered 25 mg (milligram) of Benadryl PO (by mouth) x 1 dose for agitation. Benadryl was administered with effective results. Res (resident) rested with cannula in place with sats at 96 4L NC . Review of R 343's EMR Care Plan revealed R 343 was not care planned for a psychotropic medication. During an interview with the Unit Manager (UM) on 08/17/21 at 3:35 PM, s/he stated that medication changes of a resident is relayed to the representative by the nurse. They will get the order, put the order in the computer, and then call the representative and let them know. The nurses are to document that they contacted the representative. If I don ' t see the documentation, then I will call the representative the next day personally and make them aware. Psychotropic medications are the only medications requiring a resident or resident representative consent for the meds. Reglan, Benadryl, and Melatonin also require consents prior to administration. During a telephone interview with the complainant/resident representative on 08/17/21 at 7:14 PM, s/he stated that they never told me about any changes and what was going on. Nearly everyone staff and patients had Covid during the time that my mom was there. Once he/she got Covid they said someone would call often and let me know how he/she was doing. They would have a different person everyday taking care of him/her. I think the changes in his/her medications is ultimately what caused him/her to have the issues he/she did at the end.

Based on interview, record review, and review of facility policy and procedure, the facility failed to ensure that two (Residents (R) 109 and 114) of five residents reviewed for care planning involved the Interdisciplinary team members. Subsequently, there was no documentation of involvement and/or approval of the care plan by the medical director. This failure had the potential to prevent the residents from experiencing their highest practicable physical, mental, and psychosocial well-being. Findings include: Review of facility policy, Person Centered Care Plan Process dated 07/01/16 revealed, .8. The IDT (Interdisciplinary) includes but is not limited to: A. A registered nurse with responsibility for the resident. B. A nurse aide with responsibility for the resident. C. A member of food and nutrition services staff. D. The attending physician E. Other appropriate staff or professional in disciplines as determined by the resident's needs or as requested by the resident . 1. Review of R 109's Electronic Medical Record (EMR) Face Sheet dated 06/19/21 revealed R 109 was admitted to the facility with the following diagnoses: metabolic encephalopathy, severe sepsis, urinary tract infection, shortness of breath. Review of R 109's EMR Care Plan Conference Summary dated 07/27/21 revealed R 109's participants consisted of a licensed practical nurse (LPN), resident representative, resident, certified nursing assistant (CNA), DSS (Department of Social Services) representative, registered nurse, clinical data manager, and certified physician assistant. Review of R 109's EMR Physician's Orders revealed no acknowledgement by the Medical Director for approval of R 109's care plan dated 07/27/21. 2. Review of R 114's EMR Face Sheet dated 05/29/20 revealed R 114 was admitted to the facility with the following diagnoses: anxiety disorder, chronic pulmonary edema, unspecified systolic (congestive) heart failure, and dehydration. Review of R 114's EMR Care Plan Conference Summary dated 07/27/21 revealed R 114's participants consisted of a LPN, resident representative, CNA, DSS representative, registered nurse, clinical data manager, and certified physician assistant. Review of R 114's EMR Physician Orders revealed no acknowledgement by the Medical Director for approval of R 114's care plan dated 07/27/21. On 08/16/21at 2:13 PM in an interview with the Minimum Data Set Coordinator revealed I normally write up the conference summary sheet post the assessment of the resident. I send a letter to the resident representative and hospice (if involved) via mail. We give the resident an invite. Social services calls the family to contact them prior to the meetings as a 2nd layer of communication. Usually Social services, dietary, activity director, MDS coordinator, resident representative if available will attend. The MD will sign the care plan sheet once reviewed . We put it in the doctor's book for them to look at and sign. Once signed I check it off and give to the medical records person to scan in the chart. On 08/18/21 at 11:34 AM in an interview with the Certified Physician Assistant revealed during the care plan meetings I go over meds (medications), recent labs, therapy goals and answer any questions they may have. The Medical Director sees long term care once every other month and if there are any concerns, then s/he will come once a week and I will review any changes with him/her. I usually sign off on the care plans.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record keeping, interviews and the 2017 ISMP (Institute for Safe Medication Practices) Guidelines for Optimizing Safe Subcutaneous Insulin in Adults the facility failed to coordinate FSBS (finger stick blood sugar) glucose monitoring with meal deliveries and the administration of rapid-acting insulin (Humalog) for 1 (Resident # 47) of 5 residents reviewed for unnecessary medications. The findings include: -On 8/16/21 dinner on a red tray was observed to be delivered to Resident # 47 at approximately 6:30 PM, on 8/16/21 and 8/17/21 lunch was delivered at approximately 1:20-1:25 PM and on 8/17/21 breakfast was delivered at approximately 9:05 AM. On 8/17/21 Registered Nurse (RN) # 1 was observed entering the room of Resident # 47 at approximately 11:10 AM to perform FSBS (finger stick blood sugar) glucose monitoring on Resident # 47. Resident # 47 had been readmitted to the facility on [DATE] and placed on contact precautions on the Indigo Front Hall, with diagnoses including, but not limited to diabetic mellitus with diabetic neuropathy. -On 8/17/21 at approximately 10:20 AM a medical record review for Resident # 47, Indigo Front Hall, revealed an open ended physician order dated 8/10/2021 which stated Humalog Kwikpen (insulin lispro) Per Sliding Scale three times a day before meals with times of 6:00 AM, 11:00 AM and 4:00 PM. Review of the medication administration record for Resident # 47 revealed that FSBS glucose monitoring was being performed according the physician orders at 6:00 AM, 11:00 AM and 4:00 PM. Further review of the of the facility's Meal Cart Times Revised 6/24/2021 revealed scheduled deliveries for the Indigo 1st Cart at breakfast was 9:19 (AM), Lunch 1:15 (AM) and Dinner 6:15 (PM). -On 8/17/21 at approximately 12:20 PM, the DON (Director of Nursing) acknowledged the findings and stated that insulin should be administered 15-30 minutes before meals and concurred that there is too much time between finger stick blood sugar checks being done, Novolog insulin being administered if needed and meals being served and that the physician's order needs to be adjusted to relate to actual meal service times. The 2017 ISMP Guidelines for Optimizing Safe Subcutaneous Insulin Use in Adults states in 3.1: Organizations should develop a coordinated process to ensure timely blood glucose checks and administration of NUTRITIONAL INSULIN (Humalog (insulin lispro) and Novolog (insulin aspart) in conjunction with meal delivery. A lack of coordination between meals, glucose checks, and insulin administration can have a significant impact on the effectiveness of diabetes management and the prevention of hyper- and hypoglycemia. Variability in the timing of any of these segments of care can lead to harmful outcomes for the patient. Clear organizational guidance and standardization is the key to success in this practice.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of the facility policy titled, Nutrition Policies And Procedures. the facility failed to ensure residents were served meals sequentially during 2 of 2 meal observations on 3 of 3 Units. The findings include: An observation on 8/15/2021 at 5:21 PM of the dinner meal on the Palmetto Unit revealed 4 residents sitting at one table. One resident was served dinner and began eating. The three other residents were not served for over 10 minutes when the second meal cart was brought to the Palmetto Unit. The resident that had received his/her tray first was finished eating before the other 3 residents received their dinner trays. An observation on 08/15/21 at 6:40 PM revealed supper trays were delivered to Hall 100 by the dietary staff. An observation on 08/15/21 at 6:50 PM revealed the resident in room [ROOM NUMBER] A received his/her supper tray and the resident in 118 B was not served a tray. An observation on 08/15/21 at 7:00 PM revealed Resident 118 B did not have a supper tray when the surveyor left the floor. An observation on 08/16/21 at 9:06 AM revealed Resident 118 A with a breakfast tray and Resident 118 B with no breakfast tray. An observation on 08/16/21 at 9:21 AM revealed Resident 118 B with a breakfast tray. On 08/16/21 at 11:50 AM in an interview with Certified Nursing Assistant (CNA) 4 revealed that We normally pass trays out from one end of the hall to the other. We try to pass them out from one room to the next. The feeder trays (those we feed) we leave them on the cart and go back and feed them. A second observation on 8/17/2021 at 12:45 PM of the lunch meal service on the Palmetto Unit revealed table with 2 or more residents were being served at random times while the residents left without a tray at the same table were observing the residents eat that had already received their trays. The tables were not served sequentially for residents awaiting lunch trays with residents that had already received their lunch trays. An interview on 8/17/2021 at approximately 1:05 PM with the Licensed Practical Nurse (LPN) Unit Manager on the Palmetto Unit, confirmed that lunch trays were randomly served to residents at tables with 2 or more residents that were awaiting trays and watched other residents at the same table eat lunch. Review on 8/17/2021 at approximately 2:00 PM of the facility policy titled, Nutrition Policies and Procedures, under, Meal Delivery, Procedures: Number 16 states, Serve patients/residents seated together their meal at the same time.

Based on observations, record reviews and interviews the facility failed to assure the proper medfication storage and removal of expired medications in 2 of 3 medication rooms. The findings include: -On 8/15/21 at approximately 3:49 PM inspection of the Indigo Medication Room Refrigerator revealed two reconstituted bottles of First - Omeprazole 2 mg (milligram)/ml (milliliter) Oral Suspension belonging to Resident # 61. Bottle # 1 with lot number 21013 was approximately 2/3 full and dated by the facility to expire on 7/26/21 and Bottle # 2 with lot number 21013 was approximately 1/10 full and was not dated by the facility as to expiration date. This finding was verified by LPN (Licensed Practical Nurse) # 1 -On 8/15/21 at approximately 4:11 PM inspection of the Palmetto Medication Room Refrigerator revealed one opened and reconstituted 100 ml bottle of E.E.S. (Erythromycin Ethylsuccinate) Oral Suspension 200 mg/5 ml with pink dried substance around bottle cap and down sides of the bottle This finding was verified by LPN # 2 who proceeded to clean the exterior of the bottle.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and facility policies and procedures reviewed, the facility failed to ensure that the meals served were palliative, offered at an acceptable temperature, and delivered in a timely manner. Specifically, the facility was serving residents food that was not appetizing, cold in temperature, and given after the times that meals were supposed to be offered. There were also residents that received their meals long after other residents that reside in the same room as well as in the dining hall. Findings include: 1. According to the Assistant Certified Dietary Manager (CDM), the mealtimes for each unit in the facility are as follows: Breakfast: Palmetto First Cart 8:00 AM Palmetto Second Cart 8:20 AM Magnolia Dining Room Cart 8:35 AM Magnolia Middle Cart 8:50 AM Magnolia Back Cark 9:05 AM Indigo First Cart 9:15 AM Indigo Second Cart 9:35 AM Lunch: Palmetto First Cart 12:00 PM Palmetto Second Cart 12:20 PM Magnolia Dining Room Cart 12:35 Magnolia Middle Cart 12:50 PM Magnolia Back Cart 1:05 PM Indigo First Cart 1:15 PM Indigo Second Cart 1:35 PM Dinner: Palmetto First Cart 5:00 PM Palmetto Second Cart 5:20 PM Magnolia Dining Room Cart 5:35 PM Magnolia Middle Cart 5:50 PM Magnolia Back Cart 6:05 PM Indigo First Cart 6:15 PM Indigo Second Cart 6:35 PM Dinner was observed being served to the residents on the Magnolia unit on 08/15/2021. The first tray in the Magnolia dining room was delivered at 5:59 PM, first tray to be delivered on the unit (room [ROOM NUMBER]) was at 5:58 PM, room [ROOM NUMBER] received their tray at 6:09 PM, and the last room on the unit received their tray at 6:27 PM. A test tray of both a regular lunch meal and a pureed lunch meal was given to the survey team on 08/17/2021 at 1:48 PM. The menu consisted of for the pureed tray, mashed potatoes with gravy, pureed vegetables, pureed chicken, lime fat free sherbet, tea, and water with a salt and pepper packet included. The regular meal tray consisted of teriyaki chicken, mixed vegetables, white rice, lime fat free sherbet, tea, and water along with a salt and pepper packet included. The food on the pureed tray was barely warm, the vegetables tasted like it was only pureed carrots, the mashed potatoes were barely warm as well, pureed chicken tasted like fried chicken. The regular meal tray was a little warmer than the pureed tray, but both trays were not at a temperature that a resident could enjoy the food. There was no seasoning on the pureed foods, but the regular meal did have a little seasoning. Overall both test trays were not at a desirable temperature and quality was poor. There had been many complaints in regard to the quality of the food and the food being cold. An interview was conducted with Facility Administrator, and the Director of Nursing (DON) on 08/18/2021 at 9:15 AM about the expectations on meal service and meal service times. The Administrator stated that he/she does allow a ten-to-fifteen-minute leeway time for the CNA's or other staff to get the food trays to the residents' rooms. All the CNAs are supposed to have walkie talkies so that they will know when the food carts are being brought out by the kitchen staff to the specified units announced over the walkie talkie system. DON stated that independent residents get their food trays first, then the staff comes back to the food carts and start to hand out the residents that are dependent and need to be fed after all the other residents' trays have been passed out. The CDM stated that the trays are different colors (pink, red, and yellow) in order to let the staff know whether or not the resident will need assistance with eating their meals. Pink is for residents that can eat by themselves, red is for residents that are Feeders ( need to be fed by staff), and yellow is for residents that need assistance (open milk, cut up food, get out the straw, etc.) Review of the facility's policy and procedure titled, Nutrition Policies and Procedures with the subject of Meal Delivery, last revised on 10/07/2017 states that Nursing and Culinary staff will work together to enhance the quality of the dining experience. Satisfaction with the dining experience leads to improved appetite and can enhance quality of life. Room trays will be delivered promptly to maintain food temperatures. According to the policy the following procedures are not being followed: #2 Make every effort to deliver the trays at the same time each day so patients/residents and nursing staff can anticipate the approximate arrival time. #4 Schedule staff mealtimes around the patient/resident mealtime so that an adequate amount of nursing staff is present and available to assist patients/residents. This will ensure that the food is delivered to the patient/resident at the proper temperature and that there is enough monitoring of those residents who require assistance, reminders, and/or direction. #8 Pull trays from the cart in the order they are set up; staff is discouraged from hunting for a tray. Nursing unit manager and Nutrition/Culinary Services Director develop a list for proper tray delivery order that nutrition services use to set up the carts. #10 Pass meals promptly upon tray cart's delivery to the nursing unit. #16 Serve patients/residents seated together their meal at the same time. In a review of R38's admission Minimum Data Set (MDS), with an assessment reference date (ARD) of 06/02/21, revealed R38 was admitted on [DATE] with diagnoses including but not limited to, acute and chronic respiratory failure with hypoxia, gastroesophageal reflux disease, adult failure to thrive, and major depressive disorder. The resident's Brief Interview for Mental Status (BIMS) was 15, indicating cognitively intact. An interview with R38 on 08/15/21 at 05:03 PM, revealed his/her food is often cold and he/she asks to get the food warmed up. In an observation on 08/17/21 at 09:28 AM, R38 received his breakfast in a Styrofoam container. He was given two sausage links, scrambled eggs, grits and toast. When the Styrofoam container was opened R38 proceeded to touch his/her grits with his/her finger and take a bite of his/her sausage. He/she then asked the nurse's assistant to heat up the meal. R38 stated the food was cold. In an observation on 08/18/21 R38 food arrived in the cart on the unit at 09:07 AM. He/she received his/her tray at 09:32 AM. The food was in a Styrofoam container. His/her breakfast consisted of two sausage links, scrambled eggs, grits and toast. R38 took a bite of one sausage link and eggs and proceeded to ask for the food to be warmed up. In a review of R65's quarterly MDS, with an ARD of 06/16/21, revealed R65 was admitted on [DATE] with diagnosis including but not limited to, acute chronic heart failure, end stage renal disease, and pulmonary hypertension. The resident's BIMS was 13, indicating cognitively intact. An interview with R65 on 08/16/21 at 10:27 AM, revealed his/her food is always lukewarm adding it was as if the food was sitting on the plate for a while before he/she received it. On 08/17/21 at 09:32 AM, R65 revealed his/her breakfast was was not hot and was not cold. He/she stated he/she would prefer the food to be warmer. On 08/18/21 at 09:52 AM, R65 stated his/her food was lukewarm again. In an interview with Unit Manager (UM) #1 revealed R38 often complains of getting cold food and needs to get it warmed up. UM #1 added R65 often complains of the food temperature as well.