**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to maintain resident room doorways and hallways in good repair and a homelike environment for 4 resident rooms (#205, #207, #209, #210) of 24 rooms observed for homelike environment on 2 of 5 hallways observed. The findings include: During an environment tour of 5 Halls and 24 rooms on 11/14/2023, starting at 10:00 AM and ending at 10:30 AM, the following concerns were observed: room [ROOM NUMBER] was observed to have scratched/gouged (hole)/scuffed door jamb with missing paint. room [ROOM NUMBER] was observed to have scratched/gouged/scuffed doorjamb with missing paint. In the hallway between rooms [ROOM NUMBERS] showed the bottom portion of the wallpaper had gouged/ripped areas. room [ROOM NUMBER] was observed to have scratched/gouged/scuffed door jamb with missing paint. room [ROOM NUMBER] was observed to have scratched/gouged/scuffed door jamb with missing paint. In the hallway to the left of room [ROOM NUMBER] (exiting room [ROOM NUMBER]) showed 3 holes on the upper portion of the wall. On the 200 hallway near the clean linen room, 12 floor tiles were cracked and deteriorated. On the 300 hallway near the beauty salon, the wallpaper was peeling from the wall along both sides of the seams from trim to handrail. During an observation tour and interview on 11/14/2023 at 10:23 AM, the Maintenance Director confirmed the 200 and 300 hallway areas were in disrepair and those conditions were not a home like environment. During an observation tour and interview on 11/14/2023 at 10:35 AM, the Administrator confirmed the 200 and 300 hallway areas were in disrepair.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, observations, and interviews the facility failed to develop a baseline care plan to include an indwelling urinary catheter (a tube inserted into the bladder to drain urine) for 1 resident (Resident #214) of 18 new admissions reviewed for baseline care plans. The findings include: Review of the facility policy titled, Care Plans-Baseline, undated, .A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of admission .The Interdisciplinary Team will review the healthcare practitioner's orders .and implement a baseline care plan to meet the resident's immediate needs including .Physician orders . Resident #214 was admitted to the facility on [DATE] with diagnoses including Neoplasm of Right Lung, Benign Prostatic Hyperplasia, and End Stage Renal Disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was a new admit and the MDS had not been completed. Review of the Physician's Orders dated 11/7/2023, showed .16 FR [French] with 10cc [unit of measurement] indwelling catheter care each shift, change foley cath [catheter] daily as needed, irrigate every 8 hours with sterile water as needed. Review of #214's baseline care plan dated 11/7/2023, showed a section titled Foley Cath which was unchecked and not addressed on the care plan. During an observation on 11/12/2023 at 11:10 AM showed Resident #214 laying in bed with indwelling urinary catheter covered with dingnity bag hanging on bed rails below the bladder level. During an interview on 11/13/2023 at 3:55 AM, the Director of Nursing (DON) confirmed the facility failed to include the indwelling urinary catheter on the baseline care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, observation, and interview the facility failed to ensure expired supplies were not available for resident use in 1 of 2 medications storage rooms observed. The findings include: Review of the facility policy titled Storage of Medications, revised 4/2019, showed .The facility stores all .biologicals in a safe, secure, and orderly manner .outdated .biologicals are .to be .destroyed . During an observation and interview on [DATE] at 9:32 AM, in the Station 2 Medication Storage room with Registered Nurse (RN) #1 showed: (2) gray top vacuette tubes (tubes used to collect blood for laboratory values) with an expired date of [DATE]; (2) IV start kits with an expired dated of [DATE]; (1) IV start kit with an expired date of [DATE]; and (7) Invervenous (IV) start kits (a kit used to prepare the arm for IV-a small tube inserted into the vein to administer medications or fluids) insertion with an expired date of [DATE]. RN #1 confirmed the supplies were expired and available for resident use. The medication storage rooms are to be checked once a month by the central supply person, nursing, and pharmacy for expired supplies. During an interview on [DATE] at 9:59 AM, the Director of Nursing confirmed the vacuette tubes and the IV start kits were expired and were available for resident use. It was her expectation that expired supplies to be disposed of when found, and the medication storage rooms are to be checked monthly for expired supplies by the supply stock person, nursing, and pharmacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, and interview the facility failed to develop a comprehensive care plan to address anticoagulant (medication used to prevent strokes and blood clots) for 2 residents (#36 and #61) of 6 residents reviewed for unnecessary medications of 17 residents sampled. The findings include: Review of facility policy Care Planning-Interdisciplinary Team revised 2013 revealed .Our facilities Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident . Medical record review revealed Resident #36 was admitted to the facility on [DATE] with diagnoses including Dementia with Behavioral Disturbance, Anxiety Disorder, Atrial Fibrillation, and Metabolic Encephalopathy. Medical record review of Resident #36's Care Plan, dated 10/17/18 revealed the care plan did not address the resident's use of anticoagulant medication. Medical record review of the Physician's Recapitulation Orders for the month of March 2019 revealed .10/17/18 .XARELTO [a blood thinner used to prevent blood clotting] .20mg [milligram] TABLET. GIVE 1 TAB [tablet] EVERY NIGHT. Medical record review revealed Resident #61 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Hypertension, Hypothyroidism, and Heart Failure. Medical record review of Resident #61's Care Plan, dated 2/7/19 revealed the care plan did not address the resident's use of anticoagulant medication. Medical record review of the Physician's Recapitulation Orders for the month of March 2019 revealed .2/7/19 .ELIQUIS 2.5MG TABLET TAKE 1 TABLET BY MOUTH TWICE DAILY . Interview with Minimum Data Set (MDS) Coordinator #2 on 3/5/19 at 1:23 PM, in the MDS office, confirmed a care plan to address the use of an anticoagulant medication had not been developed for Resident #61. Interview with the Director of Nursing (DON) on 3/5/19 at 1:23 PM, in the MDS office, revealed the anticoagulant had not been addressed on Resident #61's care plan. Interview with MDS Coordinator #2 on 3/6/19 at 2:38 PM, in the MDS office, confirmed a care plan had not been developed to address the use of anticoagulant medication for Resident #36. Interview with the DON on 3/6/19 at 3:25 PM, in the DON's office, confirmed the care plan for Resident #36 did not reflect the use of anticoagulant medication. Continued interview confirmed the facility failed to follow the Care Planning/Interdisciplinary Team policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, and interview the facility failed to ensure Physician Orders Life Sustaining Treatment (POLST) forms were completed for 2 residents (#18 and #324) of 17 residents reviewed. The findings include: Review of the facility policy Do Not Resuscitate Order, revised 4/2017, revealed, .A Do Not Resuscitate (DNR) order form must be completed and signed by the Attending Physician and resident (or resident's legal surrogate, as permitted by state law) and placed in the front of the resident's medical record . Medical record review revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Abnormalities of Gait and Mobility, Cellulitis of Right Lower Limb, Hypertension, and Fracture of Lumbar Vertebra. Medical record review of the POLST form dated 3/24/17 revealed the Physician had not signed and dated Resident #18's POLST form. Medical record review revealed Resident #324 was admitted to the facility on [DATE] with diagnoses including Hypertension, Diabetes Mellitus, Neoplasm of the Brain, and Cognitive Communication Deficit. Medical record review of the POLST form dated 2/19/19 revealed the Physician had not signed and dated Resident #324's POLST form. Interview with the Director of Nursing (DON) on 3/5/19 at 2:28 PM, in the conference room, confirmed the POLST form was incomplete for Resident #324. Continued interview confirmed a POLST form must be signed by the Physician to be valid. Interview with the DON on 3/6/19 at 3:25 PM, in the DON's office, confirmed the POLST form was incomplete for Resident #18. Continued interview confirmed the facility failed to follow the do not resuscitate order policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Resident Assessment Instrument (RAI) Manual Version 3.0, review of the Minimum Data Set (MDS), review of Physician Orders, review of Medication Administration Record (MAR), and interview the facility failed to accurately assess 1 resident (#11) for antipsychotic use and 3 residents (#22, #36 and #61) for anticoagulant (medication used to prevent strokes and blood clots) use of 8 residents reviewed for unnecessary medications of 17 sampled residents. The findings include: Review of the RAI Manual Version 3.0 section N: Medications revealed .Coding instructions .N0410A, Antipsychotic: Record the number of days an antipsychotic medication was received by the resident at any time during the 7-day look-back period .N0410E, Anticoagulant (e.g., [example] warfarin, heparin, or low-molecular weight heparin) .Record the number of days an anticoagulant medication was received by the resident at any time during the 7-day look-back period .code medications according to a drug's pharmacological classification . Medical record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including Bipolar Disorder, Post-Traumatic Stress Syndrome and Borderline Personality Disorder. Medical record review of an annual MDS assessment with an Assessment Reference Date (ARD) date of 12/4/18 revealed .Section N - Medications .N0410A: Medication received: Days: antipsychotic 0 . Medical record review of Resident #11's Physician Recapitulation Orders for the month of November 2018 revealed .OLANZEPINE [antipsychotic medication to treat Bipolar Disorder] 15 MG [milligram] TABLET BY MOUTH AT BEDTIME . Medical record review revealed Physician Recapitulation Orders for December 2018 revealed .OLANZEPINE 15 MG TABLET BY MOUTH AT BEDTIME . Medical record review of Resident #11's November 2018 MAR revealed the resident had received an antipsychotic medication on the following dates: 11/2818 - 11/30/18. Medical record review of Resident #11's December 2018 MAR revealed the resident had received an antipsychotic medication on the following dates: 12/1/18 - 12/4/18. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses including Cerebrovascular Disease, Coronary Artery Disease, and Type 2 Diabetes. Medical record review of a quarterly MDS assessment with an ARD date of 12/6/18 revealed .Section N - Medications .N0410E: Medication received: Days: anticoagulant 0 . Medical record review of the November 2018 Physician Recapitulation Orders for November 2018 revealed .XARELTO [medication to treat blood clots] 15 MG TABLET BY MOUTH AT BEDTIME FOR HEART DISEASE . Medical record review of the December 2018 Physician Recapitulation Orders revealed .XARELTO 15 MG TABLET BY MOUTH AT BEDTIME FOR HEART DISEASE . Review of Resident #22's November 2018 MAR revealed the resident had received an anticoagulant medication on the following date 11/30/18. Review of Resident #22's December 2018 MAR revealed the resident had received an anticoagulant medication on the following dates: 12/1/18 - 12/6/18. Medical record review revealed Resident #36 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Anxiety Disorder, and History of TIA (mini stroke). Medical record review of a quarterly MDS assessment with an ARD date of 1/18/19 revealed .Section N - Medications .N0410E: Medication received: Days: anticoagulant 0 . Medical record review of the March 2019 Physician Recapitulation Orders revealed .XARELTO 20 MG TABLET. GIVE 1 TAB [tablet] EVERY NIGHT with a start date of 10/17/18. Medical record review of Resident #36's January 2019 MAR revealed the resident had received an anticoagulant on the following dates: 1/12/19 - 1/18/19. Medical record review revealed Resident #61 was admitted to the facility on [DATE] with diagnoses including Atrial Fibrillation, Hypertension, Hypothyroidism, and Heart Failure. Medical record review of an admission MDS assessment with an ARD date of 2/13/19 revealed .Section N - Medications .N0410E: Medication received: Days: anticoagulant 0 . Medical record review of Resident #61's Physician Recapitulation Orders for the month of March 2019 revealed .ELIQUIS 2.5MG TAKE 1 TABLET BY MOUTH TWICE DAILY . Medical record review of the February 2019 MAR revealed the resident had received an anticoagulation medication on the following dates: 2/7/19 - 2/13/19. Interview with MDS Coordinator #2 on 3/5/19 at 12:58 PM, in the MDS office, confirmed the facility failed to document the resident had received an antipsychotic medication during the 7 day look back period for the 12/4/18 assessment. Interview with MDS Coordinators (#1, #2) on 3/5/19 at 12:58 PM, in the MDS office, confirmed .we are not coding Eliquis or Xarelto as anticoagulants . Interview with MDS Coordinator #2 on 3/6/19 at 2:02 PM, in the MDS office, confirmed the MDS for Resident #36 dated 1/18/19 on the 7 day look back period revealed no anticoagulant use. Interview with MDS Coordinator #2 on 3/6/19 at 2:28 PM, in the MDS office, confirmed Eliquis and Xarelto are anticoagulant medications and the assessments for Resident #22 and #61 had not been coded for anticoagulant use.

Based on observation and interview, the facility failed to properly label and date foods available for resident consumption in 2 of 2 nourishment refrigerators, potentially affecting 65 of 65 residents in the facility. The findings include: Observation and interview with the Dietary Manager (DM) on 3/6/19 at 10:11 AM, in the upstairs nourishment room, revealed: 1 open and unlabeled pint frozen dessert 1 open and unlabeled 15 ounce French onion dip Interview with the DM on 3/6/19 at 10:16 AM, in the upstairs nourishment room, confirmed unlabeled items were available for resident use. Observation and interview with the DM on 3/6/19 at 10:20 AM, in the country kitchen nourishment room (downstairs), revealed: 13 unlabeled 16.9 ounce sodas 7 unlabeled 16.9 ounce flavored waters 1 open, undated, and unlabeled frozen dessert 1 open and unlabeled quart of frozen dessert 2 unlabeled 4 ounce frozen cookies 3 undated and unlabeled freezer pops 4 unlabeled 7 ounce breakfast bowls 1 unlabeled 17 ounce box of breakfast biscuits Interview with the DM on 3/6/19 at 10:32 AM, in the country kitchen nourishment room (downstairs), confirmed undated and unlabeled items were available for resident use. Interview with the Director of Nursing (DON) on 3/6/19 at 2:11 PM, in the DON's office, confirmed the facility failed to properly store foods available for resident consumption.