**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to resubmit a Pre-admission Screening and Resident Review (PASARR) timely after a new mental health diagnosis for 3 residents (Residents #43, #47, and #69) of 11 residents reviewed for PASARR. The findings include: Review of the facility's policy titled, Pre-admission Screening and Resident Review (PASRR), revised on 11/2016, revealed .Center should refer any patient for Level II resident review upon a significant change in status/ condition such as newly evident or possible serious mental disorder, intellectual disability or a related condition . Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with diagnoses including Dementia, Right Leg Fracture, and Insomnia. Review of a PASARR Level 1 screen outcome for Resident #43 dated 7/14/2023, revealed the resident had 1 mental health diagnosis which included Adjustment Disorder. Review of the medical record revealed Resident #43 was diagnosed with a new mental health condition of Delusional Disorder on 4/16/2024. Review of a quarterly Minimum Data Set (MDS) assessment for dated 9/3/2024, revealed Resident #43 scored a 5 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Further review of the quarterly MDS assessment revealed Resident #43 had psychiatric and mood conditions which included Anxiety Disorder, Depression, and Psychotic Disorder. Review of the medical record revealed Resident #43 was diagnosed with a new mental health condition of Major Depressive Disorder on 12/3/2024. Review of the medical record revealed Resident #43 was diagnosed with a new mental health condition of General Anxiety Disorder on 1/24/2025. Review of a Psychiatric Nurse Practitioner note for Resident #43 dated 1/24/2025, revealed the resident was seen for management of mental health conditions which included Anxiety, Depression, and Delusional Disorder. Review of the medical record revealed a new PASARR for Resident #43 was not submitted after the mental health diagnosses of Delusional Disorder, Major Depressive Disorder, Generalized Anxiety Disorder, or Psychotic Disorder was added. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE] with diagnoses including Dementia, Rib Fractures, Falls, and Heart Disease. Review of a PASARR Level 1 screen outcome for Resident #47 dated 3/24/2023, revealed the resident did not have a substance related abuse or dependency disorder. Review of a quarterly MDS assessment dated [DATE], revealed Resident #47 scored a 5 on the BIMS assessment which indicated the resident had severe cognitive impairment. Further review of the quarterly MDS assessment revealed the resident received medications of high-risk drug classes which included Antipsychotic, Antidepressant, and Opioid. Review of the medical record revealed Resident #47 was diagnosed with 2 new mental health conditions of Psychoactive Substance Dependency and Opioid Dependency on 1/7/2025. Review of a Nurse Practitioner Note for Resident #47 dated 1/7/2025, revealed the resident was seen for management of mental health conditions which included Psychoactive Substance Dependency and Opioid Dependency. Review of the medical record revealed a new PASARR for Resident #47 was not submitted after the new mental health conditions of Psychoactive Substance Dependency and Opiod Dependency was added. Review of the medical record revealed Resident #69 was admitted to the facility on [DATE] with diagnoses including Dementia, Senile Degeneration, Adult Failure to Thrive, and Kidney Disease. Review of a PASARR Level 1 screen outcome for Resident #69 dated 11/4/2022, revealed the resident did not have a mental health condition. Further review of the PASARR Level 1 screen outcome revealed the resident did not have a substance related abuse or dependency disorder. Review of the medical record revealed Resident #69 was diagnosed with a new mental health condition of Adjustment Disorder on 1/16/2023. Review of the medical record revealed Resident #69 was diagnosed with a new mental health condition of Delusional Disorder on 10/5/2023. Review of the medical record revealed Resident #69 was diagnosed with 2 new mental health conditions of Psychoactive Substance Dependency and Opioid Dependency on 8/6/2024. Review of a significant change MDS assessment dated [DATE], revealed Resident #69 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. Further review of the significant change MDS revealed the resident had psychiatric and mood disorders which included Anxiety Disorder and Psychotic Disorder. The significant change MDS also revealed the resident received medications of high-risk drug classes which included Antianxiety and Opioid medications. Review of the medical record revealed Resident #69 was diagnosed with a new mental health condition of General Anxiety Disorder on 1/21/2025. Review of the medical record revealed a new PASARR for Resident #69 was not submitted after the new mental health diagnoses of Generalized Anxiety Disorder, Delusional Disorder, Psychoactive Substance Dependency, and Opiod Dependency was added. Review of a Nurse Practitioner Note for Resident #69 dated 1/25/2025, revealed the resident was seen for management of mental health conditions which included Adjustment Disorder, Delusional Disorder, Psychoactive Substance Dependency, Opioid Dependency, and General Anxiety Disorder. During a record review and interview on 2/11/2025 at 2:40 PM the Assistant Director of Nursing (ADON) stated the Level 1 screen outcomes which included Resident #43 dated 7/14/2023, Resident #47 dated 3/24/2023, and Resident #69 dated 11/14/2023 were the most recent referrals to the state designated PASARR agency. During further interview the ADON confirmed the facility failed to refer Resident #43, Resident #47, and Resident #69 to the state designated agency for PASARRS after identifying new mental health conditions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observations, and interviews, the facility failed to develop a person-centered comprehensive care plan related to hospice services for 1 resident (Resident #75) and for dental issues for 1 resident (Resident #85) of 19 residents reviewed for care plans. The findings include: Review of the facility's policy titled, SECTION VII: PATIENT CARE PLANS, dated 11/2023, revealed .services outlined in the comprehensive care plan meet .standards of quality .Problems are patient conditions .Care plans are updated as needed .New problems are handled as they arise .are to be added to the current care plan . Review of the medical record revealed Resident #75 was admitted to the facility on [DATE] with diagnoses including Heart Failure, Atrial Fibrillation, and Chronic Kidney Disease. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #75 scored an 11 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Review of the comprehensive care plan for Resident #75 initiated 1/1/2025, revealed the resident did not have a care plan for hospice services. Review of the Physician's Order Summary Report for Resident #75 dated 2/7/2025, revealed .HOSPICE TO EVAL AND TREAT . Review of a facility document titled, Hospice Plan of Care, for Resident #75 dated 2/8/2025, revealed .HOSPICE .CERTIFY THAT THE PATIENT HAS A TERMINAL DIAGNOSIS .PROGNOSIS IS SIX MONTHS OR LESS . Review of a Nurse's Note for Resident #75 dated 2/10/2025, revealed .Sig [significant] change MDS [assessment] set up for admit to hospice services . Review of the medical record revealed Resident #85 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Heart Failure, and Diabetes. Review of the comprehensive care plan for Resident #85 initiated on 8/30/2024, revealed the resident did not have a care plan for dental issues related to broken and missing teeth. Review of a quarterly MDS assessment dated [DATE], revealed Resident #85 scored a 13 on the BIMS assessment which indicated that the resident was cognitively intact. Review of the Physician's Order Summary Report for Resident #85 dated 2/10/2025, revealed .Penicillin [antibiotic medication] 500 mg [milligram] r/t [related to] broken tooth .Four Times A Day .Tramadol [pain relieving medication] .50 mg .Three Times A Day .PRN [as needed] . During an interview on 2/10/2025 at 11:16 AM, Resident #85 stated .I was eating breakfast this morning and tooth broke off and came out . Resident #85 stated .do not have any pain at present . During an interview on 2/11/2025 at 7:45 AM, Resident #85 stated .they are giving her some antibiotics and she has Tramadol for pain and is not in pain at this time . During an interview on 2/12/2025 at 7:30 AM, the Director of Nursing revealed the dentist was coming to the facility to evaluate Resident #85 on 2/13/2025. During an interview on 2/12/2025 at 9:25 AM, the Assistant Director of Nursing (ADON) revealed she was responsible for updating the residents' care plans. The ADON confirmed the care plan had not been developed to include hospice services for Resident #75 and dental issues to include broken with missing teeth for Resident #85.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, and interviews, the facility failed to properly store refrigerated food items for 1 Resident (Resident #5) of 19 residents observed for a homelike environment related to food storage. The findings include: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Stroke, Difficulty Swallowing, Kidney Disease, and Falls. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 scored a 15 on the Brief Interview for Mental Status assessment which indicated the resident was cognitively intact. Further review of the annual MDS assessment revealed Resident #5 was able to feed herself with staff set up and staff clean up assistance. During an observation on 2/10/2025 at 11:20 AM, revealed Resident #5 was resting in her bed with her eyes closed. Further observation revealed two 4-ounce yogurts which were room temperature and unopened and located on the overbed table. During an interview on 2/10/2025 at 2:37 PM, Certified Nursing Assistant A stated Resident #5 was able to feed herself and open tray items independently which included yogurt containers. During an observation on 2/11/2025 at 7:30 AM, revealed Resident #5 was resting in her bed with her eyes open. Further observation revealed two 4-ounce yogurts which were room temperature and unopened and located on the overbed table. During an interview on 2/11/2025 at 7:35 AM, Resident #5 stated the two 4-ounce yogurts were safe to consume. During an observation and interview on 2/11/2025 at 7:40 AM, in Resident #5's room, Registered Nurse (RN) Supervisor confirmed the two 4-ounce yogurts were .expired . and available for resident use. During an interview on 2/11/2025 at 7:50 AM, the Certified Dietary Manager (CDM) stated the 2 room temperature yogurts would not have hurt the resident if they were consumed. The CDM further stated the yogurt if left unrefrigerated may have a bad taste but would not have likely caused an upset stomach.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review, observation, and interview the facility failed to follow infection control practices for 2 residents (#34 and #125) of 3 residents in isolation precautions of 18 sampled residents. The findings include: Review of the facility policy Transmission-Based Procedures revised date 11-2019 showed .Enhanced Barrier Precautions .In addition to Standard Precautions, use Enhanced Barrier Precautions (EBP) during high-contact patient care activities .EBP expands the use of PPE (personal protective equipment) beyond situations in which exposure to blood and body fluids is anticipated .Equipment .Appropriate Contact Precautions sign on door . Record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including Urinary Tract Infection, Chronic Kidney Disease, Alzheimer's Disease, Delusional Disorder, Dementia, and Hypertension. Review of the resident plan of care dated 1/31/2020 showed .enhanced barrier percation [precaution] in place . Review of the physician's order dated 2/1/2020 showed .enhanced barrier precautions r/t [related to] ESBL [Extended Spectrum Beta-Lactamase] in the urine . Observation on 2/3/2020 at 11:40 AM, on the 400 hall, showed no isolation sign on Resident #34's door to indicate the resident was in isolation. Interview with Licensed Practical Nurse (LPN) #2 on 2/3/2020 at 11:40 AM, on the 400 hall, confirmed that Resident #34 was on enhanced barrier precautions for ESBL in the urine and an isolation sign had not been posted on the resident's door. Record review revealed Resident #125 was admitted to the facility on [DATE] with diagnoses including Spinal Stenosis, Chronic Kidney Disease, and Heart Disease. Review of the resident plan of care revised date 2/3/2020 showed .pt [patient] on enhanced barrier precautions related to lice on scalp . Observation on 2/3/2020 at 9:30 AM, on the 100 hall, showed no isolation sign on Resident #125's door to indicate the resident was in isolation. This surveyor entered the resident's room and was thereafter verbally informed by a staff member that an isolation room had been entered. Interview with LPN #1 on 2/3/2020 at 11:35 AM, on the 100 hall, confirmed the resident was on isolation for head lice and an isolation sign had not been posted on Resident #125's door. Interview with the Director of Nursing on 2/4/2020 at 3:05 PM, in the conference room, confirmed the facility had not posted isolation signs for Residents #34 and #125.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to provide a rationale in response to pharmacy recommendations for 1 resident (#53) of 5 residents reviewed for unnecessary medications, of 36 sampled residents. The findings include: Review of the facility policy Consultant Pharmacist Reports, dated 6/2016, revealed .Recommendations are acted upon and documented by .the prescriber. 1) Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing . Medical record review revealed Resident #53 was admitted on [DATE] with diagnoses including Pneumonia, Unspecified Atrial Fibrillation, Congestive Heart Failure, Presence of Aortocoronary Bypass Graft, and Atherosclerotic Heart Disease. Medical record review of Resident #53's quarterly Minimum Data Set, dated [DATE] revealed Resident #53 had a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. Medical record review of a Note to Attending Physician/Prescriber from the Consultant Pharmacist dated 7/23/18 revealed .Patient has continued on current dose of clorazepate [a medication used to treat anxiety] since 4/2018. Please evaluate risks vs [versus] benefits of current dose and consider reduction. If a reduction is not indicated, please document reasoning below .Recommend: Discontinue clorazepate 7.5 mg [milligrams] bid [twice daily]. Start clorazepate 3.75 mg po [by mouth] qam [every morning] and 7.5 mg po qpm [every evening] . Continued review of the document revealed the Physician signed the recommendation with the box indicating disagree checked. The line for the Physician's rationale read .DO NOT D/C [discontinue] . Medical record review of a Note to Attending Physician/Prescriber from the Consultant Pharmacist dated 8/17/18 revealed .Consider drawling labs to evaluate benefits vs risks of Lipitor [a medication used to treat high cholestral] in this patient .Recommend: Order lipid panel and liver function tests . Continued review of the document revealed the Physician signed the recommendation with the box indicating disagree checked. The line for the Physician's rationale was left blank. Interview with Assistant Director of Nursing on 2/06/19 at 7:35 AM, in the conference room, confirmed .They don't always fill out the form . Continued interview confirmed the facility failed to obtain a Physician's rationale in response to the Pharmacist's recommendations dated 7/23/18 and 8/17/18.

Based on review of facility policy, observation, and interview the facility failed to maintain a sanitary kitchen evidenced by improperly storing the flour scoop, undated food items in dry food storage, and open to air items in 1 of 1 walk in freezers, potentially affecting 85 residents. The findings include: Review of the facility policy Dry Storage, revised 11/2017, revealed .Scoops should be stored in a sanitary method with handles of scoops not contacting food . Review of the facility policy Refrigerator and Freezer Storage, revised 11/2017, revealed .Refrigerated and frozen foods will be stored properly for optimal product safety . Observation and interview with the Director of Dietary Services (DDS) on 2/4/19 at 10:05 AM, of the flour bin, in the kitchen, revealed the flour scoop improperly stored with the scoop placed inside the bin and resting on top of the flour. Continued interview confirmed .it was touching the flour . Further interview confirmed the facility failed to properly store the flour scoop. Observation and interview with the DDS on 2/4/19 at 11:20 AM, of the dry storage, in the kitchen, revealed an undated 21lb. (pound) bag of corn flakes, half used, an undated 21 lb. bag of bran flakes, half used, an undated 21 lb. bag of fruit wheels, a quarter used, an undated 21 lb. bag of frosted flakes, three-quarters used, and an undated 32 ounce bag of flake coconut, half used. Continued interview confirmed the facility failed to properly store dry food items available for resident consumption. Observation and interview with the DDS on 2/4/19 at 11:31 AM, of the walk in freezer, outside the kitchen, revealed an undated 30 lb. bag of winter vegetables, in a large plastic bag inside a cardboard box, open to air. Further observation revealed an undated 30 lb. bag of vegetable stew, in a large plastic bag inside a cardboard box, open to air. Continued interview confirmed the facility failed to properly store frozen food items available for resident use.