**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility documentation review, and interviews, the facility failed to refund 4 Residents (Resident #4, Resident #5, Resident #6, and Resident #8) of 6 residents reviewed, for refunds of resident trust accounts within 30 days of discharge. The facility failed to monitor resident trust fund balances, so no resident goes over the $2000.00 balance limit for 1 (Resident #4) out of 6 discharged residents reviewed for trust fund balances. The findings include: Review of facility policy titled, Resident Trust Fund Refund Accounts Receivable, dated 9/2017, 10/2020, revealed, .The Facility must ensure accurate and timely, refunds within individual state regulations .Resident Trust Fund Refunds are usually issued due to either the resident was discharged .and return is not anticipated, or due to the resident expired. The facility must refund the Resident Trust Fund money of discharged or deceased residents according to the time frames and procedures of the individual state (TN [Tennessee] - within 30 days of discharge or expiration) . Review of facility policy titled, Resident Trust Funds Accounts Receivable, dated 9/2017, 9/2019, 9/2021, revealed, .It is the policy of this facility to ensure that all resident trust accounts are maintained according to state regulations .The facility must refund the resident trust fund money of discharged or deceased residents according to the time frames and procedures of the individual state (TN - within 30 days of discharge or expiration) .Monitor closely that no Medicaid resident goes over their $2,000.00 limit per state guidelines . Review of facility policy titled, Resident trust Fund General Compliance, dated [DATE], revealed, .Resident Trust fund accounts shall be kept separate from the facility's operating accounts .The facility must refund the resident trust fund money of a discharged or deceased resident according with 30 days of discharge or resident death . Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses which included Personal history of Traumatic Brain Injury, Torticollis, Other conduct disorders, and Essential (primary) Hypertension. Resident #4 was discharged from the facility on [DATE]. Review of the Resident Trust Fund Statement, dated [DATE] to [DATE], for Resident #4 revealed: Date: [DATE] Balance: $2,901.00 Date: [DATE] Balance: $2,413.90 Date: [DATE] Balance: $2,984.02 Date: [DATE] Balance: $2,161.06 Date: [DATE] Balance: $3,248.36 Date: [DATE] Balance: $3,437.77 Date: [DATE] Balance: $2,238.89 Date: [DATE] Balance: $3,522.61 Date: [DATE] Balance: $3,476.74 Date: [DATE] Balance: $3,748.89 Date: [DATE] Balance: $3,183.03 (Resident #4 discharged on [DATE]) Date: [DATE] Balance: $475.51 (53 days after Resident #4 discharge date ) Date: [DATE] Balance: $1,266.58 (84 days after Resident #4 discharge date ) Date: [DATE] Balance: $2,068.83 (114 days after Resident #4 discharge date ) Date: [DATE] Balance: $51.91 (145 days after Resident #4 discharge date ) Date: [DATE] Balance: $843.95 (177 days after Resident #4 discharge date ) Date: [DATE] Balance: $10.04 (206 days after Resident #4 discharge date ) Date: [DATE] Balance: $802.44 (210 days after Resident #4 discharge date ) Date: [DATE] Balance: $1,594.44 (241 days after Resident #4 discharge date ) Date: [DATE] Balance: $802.44 (269 days after Resident #4 discharge date ) Date [DATE] Balance: $792.19 (300 days after Resident #4 discharge date ) Date: [DATE] Account Closed - Check 1398 Amount $1,610.19 - Balance $0 The Resident Trust Fund Statement, for Resident #4, dated [DATE] to [DATE], revealed twelve (12) months the trust fund balance exceeded the $2000.00 state guideline limit. The facility did not refund the trust fund balance until 302 days after Resident #4's discharge date of [DATE]. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Other Acute Osteomyelitis, Right Ankle and Foot, Acquired Absence of Right Great Toe, Methicillin Resistant Staphylococcus Aureus Infection causing diseases classified elsewhere, Essential (primary) Hypertension, and Cellulitis, unspecified. Resident #5 was discharged from the facility on [DATE]. Review of the Resident Trust Fund Statement, dated [DATE] to [DATE] for Resident #5 revealed; Date: [DATE] Balance: $558.73 Date: [DATE] Balance: $558.75 (Resident #5 discharged on [DATE]) Date: [DATE] Balance: $404.20 (34 days after Resident #5 discharge date ) Date: [DATE] Balance: $434.06 (73 days after Resident #5 discharge date ) Date: [DATE] Balance: $464.09 (104 days after Resident #5 discharge date ) Date: [DATE] Balance: $526.58 (134 days after Resident #5 discharge date ) Date: [DATE] Balance: $526.61 (165 days after Resident #5 discharge date ) Date: [DATE] Balance: $556.64 (196 days after Resident #5 discharge date ) Date: [DATE] Balance: $616.25 (225 days after Resident #5 discharge date ) Date: [DATE] Balance: $556.65 (230 days after Resident #5 discharge date ) Date: [DATE] Ending Balance: $526.65 (319 days after Resident #5 discharge date ) The facility did not refund the trust fund balance for Resident #5 within the 30 days of discharge date of [DATE]. Resident #4's trust fund still had a balance of $524.18 on [DATE] (342 days after discharge date ). Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction, unspecified, Hemiplegia, unspecified affecting left nondominant side, Secondary Hypertension, and Chronic Ischemic Heart Disease. Resident #6 was discharged from the facility on [DATE]. Review of the Resident Trust Fund Statement, dated [DATE] to [DATE], for Resident #6 revealed; Date: [DATE] Balance: $292.72 Date: [DATE] Deposit $200.00 Balance: $461.50 (Resident #6 discharged on [DATE]) Date: [DATE] Check 1396-: $460.13 - Balance: $1.37 (25 Days after Resident #6 discharge) Date: [DATE] Account Closed - Check 1400 Amount $1.37 - Balance $0 The facility did not refund the trust fund balance until [DATE], 62 days after Resident #6's discharge date of [DATE]. Review of an email from Family Member #1 to facility's Social Services Director (SSD), dated [DATE] at 8:53 AM Eastern Standard Time (EST), revealed, .I need assistance with a few things. Could you [SSD] help me please .I [Family Member #1] sent a $200 check to him [Resident #6] the week before he [Resident #6] was removed from your facility. Can you [SSD] give me [Family Member #1] the status of that check . Review of an email from Family Member #1 to facility's SSD dated [DATE] at 12:58 PM EST revealed, .Please let me [Family Member #1] know about the mo [money] why from dad's account and where his things could have ended up . Review of an email from Family Member #1 to facility's SSD, dated [DATE] at 7:36 PM EST, revealed, .I've [Family Member #1] requested a response regarding my Dad's [Resident #6] money .I [Family Member #1] would appreciate a statement of account showing when the check I [Family member #1] sent for $200 for his [Resident #6] personal expenditures was refunded to him [Resident #6] and where it was mailed. It was mailed to you [facility] the week before he [Resident #6] was kicked out of your facility . Review of an email from facility's SSD to Family Member #1 dated [DATE] at 4:05 PM EST revealed, .I have included with this email a statement from his account. Our business office manager cut a check and gave it to our receptionist who then put it in the mail to the address listed on the statement. The check number was #1396 and it was put in the mail the week of the 8th-12th. I am not sure why you have not received this. We had major snow on Monday the 15th and below average temps in the area, so it is possible that mail was stalled . Review of the medical record revealed, Resident #8 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses which included Sepsis, unspecified organism, Unspecified Dementia, unspecified severity, with behavioral disturbance, Pain, unspecified, Vascular Dementia, unspecified severity, with psychotic disturbance, and Impaired Fasting Glucose. Resident #8 was discharged from the facility on [DATE]. Review of the Resident Trust Fund Statement, dated [DATE] to [DATE], for Resident #8 revealed; Date: [DATE] Balance: $819.73 Date: [DATE] Balance: $1,119.85 (Resident #8 discharged on [DATE]) Date: [DATE] Balance: $0.00 (25 Days after Resident #8 discharge date ) Date: [DATE] Balance: $1,119.85 (176 days after Resident #8 discharge date ) Date: [DATE] Balance: $1,120.08 (181 days after Resident #8 discharge date ) Date: [DATE] Account Closed - check #1399 Amount $1,120.08 - Balance $0.00 The facility did not refund the trust fund balance until [DATE], 185 days after Resident #8's discharge date of [DATE]. Review of the facility's Open Balance Report, dated [DATE], with the Business Office Manager's (BOM) handwritten dispositions of resident's accounts revealed; Resident discharge date Disposition Balance -[DATE] Resident #9 [DATE] Family finding where to send $248.01 Resident #8 [DATE] POA (power of attorney) hasn't processed $1,119.85 Resident #7 [DATE] In Process $42.44 Resident #5 [DATE] Working with SS [Social Security] $524.07 Resident #4 [DATE] Facility hasn't requested change $792.00 Resident #6 [DATE] In Process $460.13 The facility's Open Balance Report, dated [DATE], revealed resident accounts open past 30 days after residents' discharge date s. Review of the facility's Open Balance Report, dated [DATE], revealed; Resident #5 discharge date : [DATE] Balance: $524.18 The facility's Open Balance Report, dated [DATE], revealed Resident #5's trust fund account was open 343 days after Resident #5 was discharged from the facility. During an observation and interview in the BOM's office, on [DATE] at 4:10 PM, the BOM presented a facility document titled, Open Balance Report, dated [DATE], which listed 11 resident trust funds with 6 residents on the report with discharge date s. The BOM was asked to provide dispositions of the 6 discharged residents' trust fund accounts. Observed the BOM writing comments, about the account status, on the Open Balance Report, dated [DATE]. The BOM stated Resident #8's POA hasn't processed the check. The BOM stated Resident #4 was discharged from the facility on [DATE] and admitted to another facility that needs to request the direct deposit from social security be transferred. The BOM stated they can only write and send the checks, they cannot make the family or POA cash them within 30 days of discharge. When residents transfer to another facility it is up to the receiving facility to request the direct deposits be transferred from social security to the receiving facility. The BOM stated trust fund accounts are usually closed and refunds sent within 30 days of a resident's discharge from the facility. The BOM was asked about the balance limits on resident trust funds. The BOM stated Resident Trust Funds have a $2000.00 balance limit per state guideline and facility policy. The BOM stated, .Resident Trust Funds are to be monitored to not exceed $2000.00 . During a telephone interview on [DATE] at 10:55 AM, Family Member #1 stated Resident #6 was her (Family Member #1) father and was discharged from the facility in [DATE] not sure of the exact date. Family Member #1 stated had recently sent emails to the facility Social Services Director requesting a trust fund account statement for Resident #6 and disposition of a $200 check Family Member #1 had sent to the facility a week before Resident #6 was discharged . Family Member #1 stated, I haven't received the trust fund statement or refund from the facility. Family Member #1 checked the mail while on the phone with this surveyor. Family Member #1 stated a letter post marked [DATE], with no return address, was received. Inside the letter was a Resident Trust Fund Statement for Resident #6, dated [DATE] through [DATE], with a discharge date of [DATE], and check #1396 dated [DATE] for the amount $460.13, a refund of the trust fund balance. During an interview on [DATE] at 5:05 PM, the Administrator stated, The policy states the facility must refund the resident trust fund money of a discharged or deceased resident within 30 days in the State of Tennessee. The Administrator and the BOM were shown the Open Balance Report, dated [DATE] and was asked if the residents on the list were refunded in 30 days. The Administrator responded It is a state rule, and the rules are made almost impossible for facilities to meet. There are a lot of factors that we cannot control. The Administrator was shown the email from Family Member #1 dated [DATE] and was asked if she was aware of it. The Administrator stated, Yes that resident was discharged three months ago. The Administrator and the BOM were asked why the trust fund refund check for Resident #6 dated [DATE], had been received by Family Member #1 during a phone interview on [DATE] with the envelope post marked [DATE]. The BOM responded, I originally sent it out in [DATE], and it was just returned a couple weeks ago. I put it in another envelope with the correct address and mailed it I think the second week of [DATE]. The BOM was asked if the original envelope it was mailed in was kept. The BOM stated, No I think I threw it away.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, facility's Grievance Log review, facility email review, and interview, the facility failed to follow the policy to document and investigate a grievance for 1 resident (Resident #6) of 6 residents reviewed for grievances. The findings include: Review of the facility policy titled COMPLAINT MANAGEMENT: OPPORTUNITY FOR IMPROVEMENT, dated 9/1/2017, revealed, .It is the policy of this facility to document and investigate all concerns and complaints .The resident, their representatives, advocates, or interested family members may file a concern or complaint .All reported complaints/concerns will be responded to orally and in writing no longer than 5 working days after being reported .The responsibility for investigating concerns and complaints is assigned to the Social Services department at the facility .Upon receipt of a concern/complaint, the Social Services Director will begin by sending a letter to the person who has reported the complaint or concern acknowledging the receipt of the complaint or concern .Then the Social Services Director will begin by conducting an investigation into the incident. A copy of the report will be given to the department head from which the complaint refers to .The report will include .Date and time report filed, Date, time, and location incident took place, Name of witnesses or others involved, Account by person filing concern/complaint as to what occurred .The resident or person acting on behalf of the resident will be informed of the findings upon completion of the investigation as well as any corrective actions recommended orally and in writing no later than five days after the complaint or concern was made . Review of the medical record revealed, Resident #6 was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction, unspecified, Hemiplegia, unspecified affecting left nondominant side, Secondary Hypertension, and Chronic Ischemic Heart Disease. Resident #6 was discharged from the facility on 11/13/2023. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated moderate cognitive impairment. Review of the facility grievance log dated 9/1/2023 through 1/26/2024 revealed blank pages with .No Complaints . written at the top of 9/2023 through 12/2023 logs and .1/26/2024 No Complaints at this time . written across the top of the January 2024 log. The facility failed to document the specific concern/grievance from Resident #6's Family Member #1 sent to facility by email dated 1/11/2024 per the facility's policy that stated, . the policy of this facility to document and investigate all concerns and complaints . Review of an email from Family Member #1 to facility's Social Services Director (SSD) dated 1/11/2024 at 8:53 AM, Eastern Standard Time (EST), revealed, . I need assistance with a few things. Could you [SSD] help me please .I sent a $200 check to him [Resident #6] the week before he [Resident #6] was removed from your facility. Can you [SSD] give me the status of that check .his [Resident #6] wallet was not returned in the items released to his sister and her friend. Those also should have been released to me and not them. They [Resident #6's sister and friend] are in no way responsible for his [Resident #6] care .there were so many items that I had given to him [Resident #6] that were not returned. I just want you [SSD] to know that there is a very real problem with people taking things that aren't theirs in your facility. Whether it's employees or accidentally given to another patient, it's so unacceptable. Their things are all they have and to lose them so frequently is very heartbreaking .do you [SSD] have his [Resident #6] Choices coordinator information? He [Resident #6] has been accepted in Chattanooga and they need that information .since his [Resident #6] wallet was not returned, he [Resident #6] now has no identification, no SS [Social Security] card and no way of being identified. The new coordinator stated that it is standard procedure for every facility to have copies of those on hand. Could you [SSD] please send me the copies that you have on file? This is the most urgent need we have currently .The behavioral issues dad [Resident #6] was displaying ended up being related to medications he [Resident #6] was on while there. Those have been adjusted to the proper dosage and he [resident #6] hasn't had a single episode since. I just thought someone there should know it was related to medication, not a mental break . The facility did not acknowledge receipt of this complaint to the complainant per facility policy that states .Upon receipt of a concern/complaint, the Social Services Director will begin by sending a letter to the person who has reported the complaint or concern acknowledging the receipt of the complaint or concern . Review of an email from Family Member #1 to facility's SSD dated 1/16/2024 at 12:58 PM EST revealed, .Please let me [Family Member #1] know about the mo [money] why from dad's account and where his things could have ended up . Review of an email from Family Member #1 to facility's SSD dated 1/20/2024 at 7:36 PM EST revealed, . I've [Family Member #1] requested a response regarding my Dad's [Resident #6] money and personal items twice. I understand you [SSD] feel he is no longer your problem, but ignoring this request for information is both unprofessional and disrespectful. If I [Family Member #1] don't hear back within five business days, I'll [Family member #1] be forced to file a complaint with the police and the BBB [Better Business Bureau]. I [Family Member #1] would appreciate a statement of account showing when the check I [Family member #1] sent for $200 for his [Resident #6] personal expenditures was refunded to him [Resident #6] and where it was mailed. It was mailed to you [facility] the week before he [Resident #6] was kicked out of your facility. I [Family member #1] would also like to request that someone explain where all of my dad's [Resident #6] personal items have disappeared to. As well as his [Resident #6] wallet, including his ID, his social security card and health insurance cards. This is so unacceptable and unprofessional. I knew that theft was a regular issue there [the facility] but this is just unbelievable. Additionally, his [Resident #6] items should NEVER have been released to anyone but me [Family member #1] or my brother. His [Resident #6] sister and her friend should not have been allowed to leave with his [Resident #6] personal items. Please respond by Friday . The facility did not acknowledge receipt of this complaint to the complaint per facility policy that stated, . All reported complaints/concerns will be responded to orally and in writing no longer than 5 working days after being reported .The responsibility for investigating concerns and complaints is assigned to the Social Services department at the facility .Upon receipt of a concern/complaint, the Social Services Director will begin by sending a letter to the person who has reported the complaint or concern acknowledging the receipt of the complaint or concern . Review of an email from the facility's SSD to Family Member #1 to Facility SSD dated 1/23/2024 at 4:05 PM EST, revealed, .I have been trying to interview and talk to all the people involved in your dad's belongings and business affairs, I should have sent you an email letting you know that I was trying to find out the answers for you . During an interview in the administration building office with the SSD on 1/5/2024 at 12:15 PM the SSD stated there were no formal complaints, and .everything is logged including any verbal complaints. During a phone interview on 1/26/2024 at 10:15 PM, Family Member #1 stated Resident #6 was her [Family Member #1] father, was admitted in 2022, and had been discharged from the facility in November of 2023. Family Member #1 was unsure of exact discharge date . Family Member #1 stated after Resident #6 was sent to the hospital Family Member #1 called the facility and did not receive a return call. Family Member #1 had concerns about Resident #6's belongings, account balance, and wallet with identification cards and stated she had emailed the SSD on 1/11/2024 and didn't receive a response until 1/23/2024. Family Member #1 stated the SSD still had not resolved the concerns of Resident #6's belongings. During an interview in the office of the Director of Nursing (DON) on 1/30/2024 at 2:30 PM, when asked about the facility's policy on grievances or concerns, the DON stated anyone, staff, resident, or family member can file a grievance. The DON stated if residents are unable to complete the form staff are to assist residents completing the form. The DON stated that some examples of grievances include missing property, being treated unfairly, and lack of care. When asked when a grievance should be documented the DON stated the process is to fill out a grievance form immediately, notify the SSD, and begin investigating the concern. During an observation and interview in room [ROOM NUMBER] with SSD on 1/26/2024 at 2:35 PM, the SSD was asked for the January 2024 Grievance Log. The SSD presented a blank Grievance Log dated January 2024. The SSD was asked if the facility had received any grievances from any family members this month? The SSD stated No. The SSD was asked to note that on the January 2004 Grievance Log. The SSD wrote 1/26/2024- No Complaints at this time. The SSD was asked if a resident/family member stated I can't find mom's sweater what is your process. SSD stated, We all pitch in and find it. Between the laundry, CNAs, and social services we find it. If we don't find the items, then it is put on the grievance log and goes to the Administrator. The Administrator is the head of the grievance committee. A grievance form is then completed and sent to the appropriate department head for resolution. We tell families up front not to bring valuables or family heirlooms or anything of sentimental value due to people coming in you don't have control over. The SSD stated they have a locked drawer in the administration building for resident valuables such as wallets, and jewelry. Upon further interview the SSD stated The minute I get a concern I try to resolve it. If I am unable to resolve it, then I fill out a grievance and depending on the concern I forward it to the appropriate department supervisor. The supervisor then must tell how it will be fixed. During an interview in the Administrator's office with SSD present on 1/30/2024 at 5:00 PM, the Administrator was asked about the facility's Grievance process and policy. The Administrator stated, A lot of the times they [residents/family/advocates] call and are asked if they want to file a formal complaint and decline. The Administrator was asked to provide an example of something that would be entered on the Grievance Log. The Administrator stated, Obviously if complaining if someone was mean to them or if missing items. We [facility staff] usual sweep the building and find the missing item. The Administrator was asked when an item would be replaced the Administrator responded If it is something they are adamant about we replace it. We encourage residents not to bring items of great value or sentiment because they could become misplaced. The Administrator was asked if the facility had received any grievances in person, by phone, or electronic in the past month. The Administrator stated not for a current resident. The Administrator was asked if she [Administrator] was aware of an email from Family Member #1 to the SSD. The Administrator was shown a copy of the email dated 1/11/2024, from Family Member #1 to the SSD. The Administrator stated, That resident had been discharged for more than 3 months ago. The Administrator was asked if the person is no longer a resident do you address grievances or concerns. We have never done a grievance for a former resident. The SSD has been emailing [Family Member #1] to address the issue. The Administrator was asked if the email should have been documented in the Grievance Log and an investigation documented. The Administrator stated Probably. The SSD stated that the concerns in the email were investigated. The SSD was asked for the written investigation report. The SSD stated there was no written investigation report.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to complete a Quarterly Minimum Data Set (MDS) assessment for 2 (Resident #11 and Resident #13) of 22 residents reviewed. The findings include: Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses which included Personal history of Traumatic Brain Injury, Atherosclerotic Heart Disease of Native Coronary Artery, Essential (primary) Hypertension, and Chronic Obstructive Pulmonary Disease. Medical record review revealed Resident #11 had an Annual Minimum Data Set (MDS) assessment dated [DATE]. Further medical record review revealed no Quarterly MDS assessment was completed in November 2023. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Dementia in other diseases classified elsewhere, Encephalopathy, unspecified, Nontoxic Multinodular Goiter, and Neurosyphilis, unspecified. Medial record review revealed Resident #13 had a Quarterly MDS assessment dated [DATE]. Further medical record review revealed no Quarterly MDS assessment was completed in December 2023. During an interview in the Director of Nursing (DON)'s office on 1/30/2024 at 2:30 PM, the DON was asked how often are MDS assessments to be completed for residents. The DON stated MDS assessments are done within 14 days of admission, quarterly every 92 days, when there is a significant change in the resident's condition, and annually. The DON was asked to show the surveyor the most current MDS assessment for Resident #11 in the Electronic Medical Record (EMR). The DON stated Resident #11 had an Annual MDS assessment that was completed on 8/25/2023 and a Quarterly MDS Assessment should have been completed in November 2023. The DON was asked to show the surveyor the most current MDS assessment for Resident #13 in the EMR. The DON stated Resident #13 had a Quarterly MDS assessment that was completed on 9/4/2023 and a Quarterly MDS Assessment should have been completed in December 2023. The DON confirmed the Quarterly MDS Assessments for Resident #11 and Resident #13 were overdue. During a phone interview on 1/30/2024 at 4:01 PM, the MDS Coordinator was asked when MDS assessments are completed. The MDS Coordinator stated admission MDS assessments must be done by the 14th day after admission, Quarterly MDS assessments are completed no later than 92 days after the last MDS Assessment was completed. Annual MDS Assessments are completed annually. During an interview in the Administrator's office on 1/30/2024 at 5:15 PM, the Administrator was asked to show the surveyor the current MDS assessments for Resident #11 and Resident #13 in the EMR. The Administrator stated Resident #11 had an MDS assessment on 8/25/2023 and Resident #13 had an MDS assessment on 9/4/2023. The Administrator was asked if Quarterly MDS Assessments are due every 92 days are Resident #11 and Resident #13 current MDS assessments in compliance. The Administrator stated, I will need to talk with our MDS Coordinator. During a phone interview on 1/30/2024 at 7:20 PM, the MDS Coordinator stated the Administrator had called and stated there was a problem with MDS Assessments. The MDS Coordinator was asked to look up in the EMR the current MDS Assessments for Resident #11 and Resident #13. The MDS Coordinator stated Resident #11 had an Annual MDS assessment dated [DATE] and Resident #13 had a Quarterly MDS assessment dated [DATE]. The MDS Coordinator was asked if Quarterly MDS Assessment are to be completed by 92 days after the last MDS Assessment, was Resident #11 and Resident #13 overdue and out of compliance for Quarterly MDS Assessments. The MDS Coordinator stated Yes, you're right. They are not in compliance.

Based on facility policy review, medical record review, facility investigation, and interview, the facility failed to report an allegation of abuse, within 2 hours of occurrence, to the State Survey Agency, on 1 Facility Reported Incident (FRI) # (number) 2022111110340 reviewed. The findings include: Review of the facility's policy titled, Abuse, Neglect, Misappropriation of Resident Funds, dated 9/1/2017, revealed, .The facility has a zero tolerance policy for abuse, involuntary seclusion, neglect and misappropriation of resident property. The facility will attempt to identify and will investigate any reported violation or allegation of abuse .3. Reports must be within 24 hours (if there is not serious bodily injury) after forming your reasonable suspicion. Within 2 hours (if there is serious bodily injury) after forming your reasonable suspicion .There are two time limits for the reporting of reasonable suspicion of a crime, depending on the seriousness of the event that leads to the reasonable suspicion .1. Serious Bodily Injury-2 hour limit: If the events that cause the reasonable suspicion result in a serious bodily injury to a resident, the facility shall report the suspicion immediately, but not later than 2 hours after forming the suspicion .5. Employees of this facility who have been accused of resident abuse will be suspended from duty until the results of the investigation have been reviewed by the Administrator . Review of the FRI, ID (Identification) # (Number) 2022111110340, for Resident #3, revealed an allegation of employee-to-resident abuse, involving CNA (Certified Nursing Assistant) #2 and Resident #3, occurred on 11/10/2022 at 2:00 AM. The Administrator was immediately notified, and an abuse allegation was reported to the State Agency on 11/11/2022 at 10:34 AM, which was not within 2 hours of the abuse allegation being reported. CNA #2 was immediately suspended pending an investigation. An investigation was initiated. Staff and resident interviews were obtained, and the investigation was completed. The facility was unable to substantiate the abuse allegation. Continued review of the investigation report and employee statements revealed no concerns. During an interview on 12/7/2022 at 4:07 PM, the Administrator stated that she was the Abuse Coordinator. She stated that her expectations were for staff to report any allegations of abuse immediately. The Administrator confirmed that FRI #2022111110340, involving Resident #3, had a date and time of occurrence of 11/10/2022 at 2:00 AM and the date and time reported to the State Agency was 11/11/2022 at 10:34 AM. She stated, I thought it was 24 hours or 1 day, that I had to report it. I didn't realize it was 2 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to revise a care plan for 2 of 6 sampled residents (Resident #5 and Resident #6) reviewed for behaviors. The Findings include: Review of the facility's policy titled, Care Plans - Comprehensive, dated 9/1/2017 revealed, .An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the residents's medical, nursing, mental and psychological needs is developed for each resident .Care plans are revised as changes in the resident's condition dictate. Care plans are reviewed at least quarterly . Review of the facility's policy titled, Behavioral Management Program, dated 9/1/2022, revealed, .The Program is a subcommittee of the Interdisciplinary Care Plan Team established for the facility employees to: Evaluate behaviors .Identify the root cause of the behaviors .Track, trend and analyze negative behaviors for the purpose of appropriate interventions . Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses which included Peripheral Vascular Disease, Depressive Disorders, and Chronic Kidney Disease Stage 3. Review of Resident #5's Psychiatric Evaluation dated 8/31/2022 revealed, .This is a medication check visit with [Named Resident #5]. Duloxetine [Antidepressant] was increased to 40 mg [milligram] daily related to inappropriate sexual behaviors .staff report resident has not displayed any sexual inappropriate behavior and has been around the other resident involved in the incident. Continued review of Resident #5's Psychiatric Evaluation dated 8/24/2022 revealed, .This is a staff requested psychiatric visit with [Named Resident #5] .Staff report resident was caught attempting an inappropriate sexual act with another resident .Recommendations .Increase Duloxetine to 40 mg daily r/t [related to] sexual behaviors to help decrease libdo [libido] . Review of the Quarterly MDS assessment dated [DATE], revealed Resident #5 had a BIMS score of 11 which revealed moderately impaired cognitive abilities. Review of Resident #5's current Care Plan revealed, .At risk for self/social isolation .Depression, memory deficits .mood & behavioral sx [symptoms] . The Care Plan did not address history of inappropriate sexual behaviors. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses which included Traumatic Brain Injury, Dementia, and Major Depressive Disorder. Review of Resident #6's Psychiatric Evaluation dated 8/31/2022 revealed, .Medroxyprogesterone 10 mg twice daily was started at last visit with this provider related to inappropriate sexual behaviors . Continued review of Psychiatric Evaluation dated 8/24/2022 revealed, .This is a staff requested psychiatric visit .Staff report resident was engaged in inappropriate sexual behavior with another resident .staff reports since incident resident has tried to inappropriately touch other female residents at the facility . Review of the Quarterly MDS assessment dated [DATE], revealed Resident #6 had a BIMS score of 8 which revealed moderately impaired cognitive abilities. Review of Resident #6's current Care Plan revealed, .At risk for self/social isolation .cognitive deficits, moods and behavioral sx [symptoms] . The Care Plan did not address Resident #6's history of inappropriate sexual behaviors. During an interview on 12/6/2022 at 4:00 PM, MDS Coordinator and Business Office Manager revealed Resident #5 has history of sexual acts, and her medication was increased. The MDS Coordinator stated, I know [Named Resident #5, Named Resident #6] was touching each other inappropriately in the dining room a couple of months ago. During an interview on 12/6/2022 at 4:13 PM, Social Service Director (SSD) revealed she had been employed at the facility since 7/2020. SSD stated, It was brought to my attention that [Named Resident #5, Named Resident #6] started a relationship and touching each other, he was touching her breast, and she was rubbing him in the dining room. I discussed this episode with them and explained this was something they could not do in public. Both residents were consensual with these actions. I called [Named Resident #6] conservator and the conservator was ok if the resident agreed with the sexual interaction. [Named Resident #5] was also in agreement with the sexual actions from [Named Resident #6]. [Named Resident #5] is responsible for herself and has no family. During an interview on 12/7/2022 at 3:50 PM, the Administrator was asked to review Resident #5 and Resident #6's current Care Plans, and she confirmed that sexual behaviors or a relationship between the two residents were not care planned. During an interview on 12/7/2022 at 4:00 PM, the MDS Coordinator stated, I thought the behaviors were care planned for [Named Resident #5, Named Resident #6], but we changed computer systems and this maybe why it is not there anymore.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observations, and interview, the facility failed to ensure dignity for 2 of 2 sampled residents (Residents #14 and #132) who required an indwelling urinary catheter. The findings include: Review of the facility's policy titled, Resident Rights Under Federal Law, revised January 2014, revealed, .The resident has a right to a dignified existence . Review of the medical record revealed Resident #14 was admitted to the facility on [DATE] with readmission on [DATE] with diagnoses which included Obstructive and Reflux Uropathy. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #14 required an indwelling catheter. Review of the current Physician's Orders, for Resident #14, revealed orders for an indwelling urinary catheter and catheter care. Review of the medical record revealed Resident #132 was admitted to the facility on [DATE] with diagnoses which included Neuromuscular Dysfunction of the Bladder. Review of the admission MDS assessment dated [DATE], revealed Resident #132 required an indwelling catheter. Review of the current Physician's Orders for Resident #132 revealed the resident had an order for a suprapubic catheter. Observation in Resident #14's room on 4/11/2022 at 8:25 AM, revealed the resident's urinary catheter drainage bag was hanging on the side of the bed facing the door, not covered with a privacy cover. Observation in Resident #14's room on 4/12/2022 at 8:25 AM, revealed the resident's urinary catheter drainage bag was hanging on the side of the bed facing the door, not covered with a privacy cover. Observation and interview in Resident #14's room on 4/12/2022 at 8:35 AM, Licensed Practical Nurse (LPN) #2 confirmed Resident #14's urinary catheter drainage bag was not covered with a privacy cover. Observation in the lobby on 4/11/2022 at 8:00 AM, revealed Resident #132 was sitting in a wheelchair with his catheter drainage bag in view not covered with a privacy cover. Observation and interview in the lobby on 4/11/2022 at 8:16 AM, LPN #1 confirmed Resident #132's catheter drainage bag was in view and not covered with a privacy cover.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to maintain patient confidentiality for 1 of 25 sampled residents (Resident #14) reviewed. The findings include: Review of the facility's policy titled, Resident Rights Under Federal Law, revised January 2014, revealed, .The resident has the right to personal privacy and confidentiality of his or her personal and clinical records . Review of the facility's policy titled, Confidentiality and Privacy, dated September 1, 2017, revealed, .It is the policy to treat all resident information as strictly confidential .Access to the resident's clinical records is limited to the staff and consultants providing services to the resident . Review of the medical record revealed Resident #14 was admitted to the facility on [DATE], with readmission on [DATE], with diagnoses which included Type 2 Diabetes Mellitus, Obstructive and Reflux Uropathy, Secondary Hypertension, Anxiety, and Major Depressive Disorder. Observation in the hallway on 4/11/22 at 7:53 AM, revealed Resident #14's identifiable information was on an overbed table in the hallway, viewable to anyone who passed by. Continued observation revealed there were no staff in attendance of the information. The identifiable information revealed, .CNA Care Plan .Resident: [named Resident #14] .Adm. [admit] date: 10-28-21 .Bath M [Monday] SU [Sunday] .shower .assist .day shift .Mobility .Assist x [times] 2 .Transfer .Assist x 2 .Ambulate .W/C [Wheelchair] .Eating .Set-up .Diet: regular .Grooming .Total .[NAME]/Bladder .Incontinent .Foley .Mental Status .Alert .Oriented x 3 .Confused .Vision .Adequate .Teeth .Natural .Hearing .Adequate . Observation and interview in the hallway on 4/11/2022 at 7:56 AM, Certified Nurse Aide (CNA) #2 confirmed Resident #14's CNA care plan was on an overbed table in the hall in view of anyone who walked by. She stated, I have no idea why it's there, but it shouldn't be. During an interview on 4/13/2022 at 8:08 AM, the Director Of Nursing confirmed Resident #14's CNA care plan was to be kept in the resident's closet in his room. She stated, It should not have been on a table in the hallway.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to notify the State Ombudsman Office regarding transfers from the facility for 2 of 2 sampled residents (Resident #18 and #24) reviewed for hospitalization. The findings include: Review of the facility's policy titled, Admitting the Resident, dated 9/1/2017 and updated 4/13/2022, revealed, .When a resident is temporary transferred on an emergency basis to an acute care facility, copies or notices for the emergency transfers must be sent to the ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis . Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with readmission on [DATE] with diagnoses which included Embolism and Thrombosis of Thoracic Aorta, Congestive Heart Failure, and Chronic Pain. Review of the medical record revealed Resident #18 was transferred to an Acute hospital on 1/14/2022. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Type 2 Diabetes Mellitus, Chronic Kidney Disease and Major Depressive Disorder. Review of the medical record revealed Resident #24 was transferred to an Acute hospital on 2/6/2022. During an interview on 4/13/2022 at 10:20 AM, the Administrator confirmed she had not send a resident hospitalization list to the Ombudsman. She stated, We have never sent a list to the Ombudsman. I missed it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to implement a person-centered care plan for 14 of 17 sampled residents (Resident #12, #13, #14, #18, #19, #21, #23, #24, #25, #29, #31, #132, #183, and #184) reviewed. The findings include: Review of the facility's policy titled, Admitting the Resident, dated [DATE], revealed, .An individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident .4. The resident's Comprehensive Care Plan is developed within seven (7) days of the completion of the resident's comprehensive assessment (MDS [Minimum Data Set]) . Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with readmission on [DATE] with diagnoses which included Convulsions, Dementia, and Acute Kidney Failure. Review of the Physician Orders for Scope of Treatment (POST) form dated [DATE], revealed Resident #12's code status was, .Do Not Attempt Resuscitate (DNR) .Comfort Measures . Review of the Care Plan dated [DATE], revealed Resident #12 had no Advance Directive care plan. Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses which included Disorganized Schizophrenia, and Major Depressive Disorder. Review of the POST form dated [DATE], revealed Resident #13's code status was, .Resuscitate (CPR [Cardiopulmonary Resuscitation]) .Full treatment . Review of the Care Plan dated [DATE], revealed Resident #13 had no Advance Directive care plan. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE], with readmission on [DATE], with diagnoses which included Type 2 Diabetes Mellitus, Obstructive and Reflux Uropathy, Secondary Hypertension, Anxiety, and Major Depressive Disorder. Review of the POST form dated [DATE], revealed Resident #14's code status was, .Resuscitate (CPR) .Full Treatment . Review of the Care Plan dated [DATE], revealed Resident #14 had no Advance Directive care plan. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses which included Embolism and Thrombosis of Thoracic Aorta, Major Depressive Disorder, and Gastrointestinal Hemorrhage. Review of the POST form dated [DATE], revealed Resident #18's code status was, .DNR .Limited Additional Interventions . Review of the Care Plan dated [DATE], revealed Resident #18 had no Advance Directive care plan. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses which included Peripheral Vascular Disease, Chronic Kidney Disease, stage 3, Type 2 Diabetes Mellitus with Diabetic Neuropathy, and Depression. Review of the POST form dated [DATE], revealed Resident #19's code status was, .Resuscitate (CPR) .Full treatment . Review of the Care Plan dated [DATE], revealed Resident #19 had no Advance Directive care plan. Review of the medical record revealed Resident #21 was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction, Schizoaffective Disorder, Aphasia, Vascular Dementia, and Major Depressive Disorder. Review of the POST form dated [DATE], revealed Resident #21's code status was, .Resuscitate (CPR) .Full Treatment . Review of the Care Plan dated [DATE], revealed Resident #21 had no Advance Directive care plan. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with readmission on [DATE] with diagnoses which included Hypertension, Diabetes, Chronic Obstructive Pulmonary Disease, and Cerebral Infarction. Review of the POST form dated [DATE] revealed Resident #23's code status was, .Resuscitate (CPR) .Full Treatment . Review of the Care Plan dated [DATE], revealed Resident #23 had no Advance Directive care plan. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with readmission on [DATE] with diagnoses which included Type 2 Diabetes Mellitus, Chronic Kidney Disease and Major Depressive Disorder. Review of the POST form dated [DATE] revealed Resident #24's code status was, .DNR .Limited additional interventions . Review of the Care Plan dated [DATE], revealed Resident #24 had no Advance Directive care plan. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses which included Depressive Disorder, Psychotic Disorder with Delusions and Hypokalemia. Review of the POST form dated [DATE], revealed Resident #25's code status was, .Resuscitate (CPR) .Full treatment . Review of the Care Plan dated [DATE], revealed Resident #25 had no Advance Directive care plan. Review of the medical record revealed Resident #29 was admitted to the facility on [DATE] with diagnoses which included Vascular Dementia with Behavioral Disturbance, and Major Depressive Disorder. Review of the POST form dated [DATE], revealed Resident #29's code status was, .DNR (Allow Natural Death) .Comfort Measures . Review of the Care Plan dated [DATE], revealed Resident #29 had no Advance Directive care plan. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE] with readmission on [DATE] with diagnoses which included Vascular Dementia with Behavioral Disturbance and Psychotic Disorder. Review of the POST form dated [DATE], revealed Resident #31's code status was, .DNR .Limited additional interventions . Review of the Care Plan dated [DATE], revealed Resident #31 had no Advance Directive care plan. Review of the medical record revealed Resident #132 was admitted to the facility on [DATE] with diagnoses which included Bipolar Disorder, Type 2 Diabetes Mellitus, Hypertension, and End Stage Renal Disease. Review of the admission Orders And Plan Of Care for Resident #132 dated [DATE], revealed, .CPR Status .Yes . Review of the Care Plan dated [DATE], revealed Resident #132 had no Advance Directive care plan. Review of the medical record revealed Resident #183 was admitted to the facility on [DATE], with diagnoses which included UTI (Urinary Tract Infection), Osteoarthritis, Dementia with Behavioral Disturbance, and Chronic Kidney Disease. Review of the POST form dated [DATE], revealed Resident #183's code status was, .DNR (Allow Natural Death) .Limited Interventions . Review of the Care Plan dated [DATE], revealed Resident #183 had no Advance Directive care plan. Review of the medical record revealed Resident #184 was admitted to the facility on [DATE], with diagnoses which included Sepsis due to Escherichia Coli, Dementia with Behavioral Disturbance, and Atrial Fibrillation. Review of the POST form dated [DATE], revealed Resident #184's code status was, .Resuscitate (CPR) .Full Treatment . Review of the Care Plan dated [DATE], revealed Resident #184 had no Advance Directive care plan. During an interview on [DATE] at 11:20 AM, Licensed Practical Nurse (LPN) #3 confirmed there was no care plan for Advance Directives for Residents #12, #13, #14, #18, #19, #21, #23, #24, #25, #29, #31, #132, #183, and #184.

Based on observation, test tray temperatures, and interview, the facility failed to serve palatable food at a safe and appetizing temperature during the lunch meal on 4/11/2022. The findings include: Observation in the dining room on 4/11/2022 at 12:37 PM, revealed 2 dining carts arrived in the dining room with 25 trays total (including a test tray). The last resident's meal was delivered at 12:52 PM. Observation in the hall on 4/11/2022 at 12:52 PM, revealed temperatures taken of the test tray by [NAME] #1 as follows: Ham-pureed 80 degrees F (Fahrenheit); Ham-chopped: 100 degrees F; Ham slice-whole: 80 degrees F; mixed vegetables: 110 degrees F; mixed vegetables-pureed: 60 degrees F; pineapple casserole: 85 degrees F; and pineapple casserole pureed: 75 degrees F. During an interview in the hall on 4/11/2022 at 12:56 PM, [NAME] #1 confirmed the food temperatures were not appropriate. She stated, That food should be hotter than that.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, facility documentation review, medical record review, and interview, the facility failed to ensure there was no more than 14 hours between a substantial evening meal and breakfast the following day. The findings include: Review of the facility's policy titled, Frequency of Meals, dated September 1, 2017, revealed, .It is the policy of this facility that each resident shall receive at least three (3) meals daily, as well as an evening or bedtime snack .At least three (3) meals or their equivalent are served daily, at regular times, with not more than a fourteen (14) hour span between the evening meal and breakfast . Review of the undated facility documentation titled, Meal Times, revealed 14.5 hours between the evening meal at 5:00 PM and the breakfast meal at 7:30 AM. Review of the facility documentation titled, Resident Council Meeting Minutes, dated from March 2021 thru March 2022, revealed there was no meeting to extend the mealtimes greater than the regulated 14-hour span between the evening meal and the breakfast meal. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] with readmission on [DATE] with diagnoses which included Major Depressive Disorder. Review of the admission Minimum Data Set assessment dated [DATE], revealed Resident #10 had a Brief Interview for Mental Status score of 14, which indicated no cognitive impairment. Observation in the dining room on 4/11/22 at 7:41 AM, revealed 2 dining room carts arrived to the dining room for staff to serve breakfast to the residents. During an interview in the dietary department on 4/11/2022 at 2:25 PM, [NAME] #1 stated, We serve breakfast at 7:30 AM and supper is served at 5:00 PM. During an interview in the dietary department on 4/11/2022 at 4:00 PM, [NAME] #2 stated breakfast was served to the residents at 7:30 AM and supper was served at 5:00 PM. During an interview in Resident #10's room on 4/12/2022 at 10:19 AM, Resident #10 (President of the Resident Council) stated he attended resident council meetings regularly and the council had not voted to have longer than 14 hours between supper and breakfast the following day. During an interview in the conference room on 4/12/2022 at 8:25 AM, the Dietary Manager confirmed there was 14.5 hours between the supper meal at 5:00 PM and the breakfast meal the following day at 7:30 AM. During an interview in the conference room on 4/12/2022 at 8:16 AM, the Activity Director confirmed they did not have any documentation regarding a resident council meeting to approve for the mealtimes to be longer than 14-hours between supper and breakfast the following day.

Based on facility policy review, observation, and interview, the facility's dietary department failed to maintain dietary equipment in a sanitary manner and failed to ensure food was served under sanitary conditions when a male dietary employee with facial hair was observed working in the kitchen without wearing a hair net or beard net and a Certified Nurse Aide entered the kitchen without wearing a hairnet. Findings include: Review of the facility policy titled, Personnel Standards, Dietary, revised 1/1/2005, revealed, .It is the policy of this facility that dietary personnel shall follow sanitary standards .Hair nets, covering all of the hair, must be worn at all times while on duty . Review of the facility's policy titled, Food Storage, dated September 1, 2017, revealed, .it is the policy of this facility that food storage areas shall be maintained in a clean, safe, and sanitary manner .food storage areas shall be clean at all times . Observation in the dietary department on 4/11/2022 at 7:41 AM revealed the Dietary Manager was working in the kitchen without a hair net or beard net on. Observation in the dietary department on 4/11/2022 at 7:48 AM, revealed a refrigerator contained 2 cups of vegetables and a bowl of soup that were not labeled and were not dated. Continued observation revealed a can opener had a buildup of dried brown debris on the blade, the stove drip pan had an accumulation of black dried debris, the toaster had breadcrumbs on the top of the toaster and had a buildup of a sticky substance on the base, and the microwave had an accumulation of splattered debris on the inside and a buildup of debris on the door. Observation in the dietary department on 4/11/2022 at 8:00 AM, revealed Certified Nurse Aide (CNA) #1 came into the kitchen without wearing a hair net. Observation in the dietary department on 4/11/2022 at 11:24 AM, revealed the can opener continued to have a buildup of dried brown debris on the blade, the toaster continued to have breadcrumbs on the top of the toaster and had a buildup of a sticky substance on the base, and the microwave continued to have an accumulation of splattered debris on the inside and a buildup of debris on the door. During an interview in the dietary department on 4/11/2022 at 7:45 AM, the Dietary Manager confirmed he was not wearing a hair net or beard net. During an interview in the dietary department on 7:48 AM, the Dietary Manager confirmed 2 cups of vegetables and a bowl of soup in the refrigerator was not labeled or dated. Continued interview he confirmed the drip pan needed cleaned. He stated, I cleaned it 3 weeks ago. During an interview in the dietary department on 4/11/2022 at 8:00 AM, CNA #1 confirmed she entered the kitchen without wearing a hair net. During an interview in the dietary department on 4/11/2022 at 11:28 AM, [NAME] #1 confirmed the can opener had a buildup of dried brown debris on the blade, the toaster had breadcrumbs on the top and had a buildup of a sticky substance on the base, and the microwave had an accumulation of splattered debris on the inside and a buildup of debris on the door.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview the facility failed to have a 14 day stop date for a psychotropic PRN (as needed) medication 1 resident (#83) of 5 residents reviewed. The findings include: Review of the facility policy, Psychotropic Medication Use, revised 11/2018 revealed .If psychotropic medications are administered as PRN dosages repeatedly over several days, the Physician should discuss the situation with s staff and evaluate the resident as needed to determine whether the use is appropriate and the symptoms are responding to the medication. PRN doses will require a 14 day script per federal guidelines . Medical record review revealed Resident #83 was admitted to the facility on [DATE] with diagnoses which included Major Depressive Disorder, Anxiety Disorder, and Psychotic Disorder. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #83 had a Brief Interview of Mental Status (BIMS) score of 5 which indicated severe cognitive impairment. Medical record review of the Physician Orders dated 4/2019 and 5/2019 revealed .Trazadone (antidepressant) 25 MG (milligrams) PO (by mouth) BID (twice daily) PRN . Medical record review of the 4/2019 Medication Administration Record (MAR) revealed Resident #83 received Trazadone 25 mg PO PRN for insomnia. Interview with the Nurse Practitioner (NP) on 5/30/19 at 3:09 PM in the conference room revealed, when asked if the resident was ordered Trazadone PRN for depression the NP stated yes. Continued interview with the NP when asked if a stop date was added to an order when a PRN psychotropic medication is ordered confirmed I missed it. Interview with the Director Of Nursing (DON) on 5/30/19 at 4:27 PM in the conference room stated .we generally just call them [providers] if we see any discrepancies . Continued interview confirmed the Trazadone 25 MG PO BID PRN did not have a stop date after 14 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility orientation training, medical record review, observation and interview 1 Certified Nurse Aide (CNA) failed to wear gloves when handling food for 2 (#7 and #27) of 17 residents observed. The findings include: Record review of the Orientation Training Inventory and All Staff In-Service Schedule revealed documentation of teaching infection prevention and food handling to all staff that included wearing gloves when handling food for residents. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses which included Hypertension (HTN), Depression, Gastro-esophageal Reflux, and Psychotic Disorder with Delusions. Medical record review of the Nursing Care Plan revised 5/20/19, revealed Resident #7 needed assistance with set-up for meals but fed herself at times. Medical record review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #7 required set-up assistance and supervision for meals. Medical record review revealed Resident #27 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease, Hypertension, Anxiety Disorder, Type 2 Diabetes Mellitus, Depression, and Pain. Medical record review of the Nursing Care Plan revised 5/23/19 revealed Resident #27 required set-up and cues with meals. Medical record review of the admission MDS dated [DATE] revealed Resident #27 required set-up and supervision for meals. Observation of Resident #7 and Resident #27 on 5/28/19 at 12:42 PM sitting next to each other in the dining room revealed CNA #1 handled the hamburger buns with her bare hands while setting up the meals for Resident #7 and Resident #27. Interview with CNA #1 on 5/28/19 at 12:45 PM in the dining room when asked how food should be handled by staff for residents she replied .1 don't know, with clean hands . Interview with the Director of Nursing (DON) on 5/30/19 at 12:50 PM in her office confirmed . staff cannot directly handle food without gloves . Interview with Assistant Director of Nursing (ADON), also know as the Infection Control Nurse, on 5/30/19 at 1:23 PM in her office confirmed . staff are taught not to touch any of the food with their bare hands . Interview with the Administrator on 5/30/19 at 1:25 PM in her office confirmed .I expect staff to wear gloves when handling residents food .

Based on facility policy review, facility procedure review, observation and interview the facility failed to maintain a clean and sanitary water dispenser and ice scoop container. The findings include: Facility policy review, Ice Machines and Ice Storage Chests, dated 9/1/17, revealed .keep ice scoop on a clean surface when not in use .clean and sanitize the tray and ice scoop daily . Record review of the facility procedure, undated, revealed . Daily: scrub all parts with warm soapy water. Use a good brush and clean thoroughly. Rinse thoroughly with fresh water and invert to air dry. Weekly: During the daily cleaning .dismantle the spout and carefully clean the entire assembly with warm soapy water. Use a good brush to clean all parts thoroughly. Rinse with fresh water and reassemble . Observation on 5/28/19 at 12:40 PM of the water dispenser in !he dining room revealed the water dispenser had a large amount of moist black material around the spigot, concentrated underneath the spigot. Continued observation revealed the drawer on the cart for the ice scoop had gray-brown dried material in the back bottom side of the drawer. Observation on 5/28/19 at 3:50 PM in the dining room revealed the water cart returned from the kitchen with the ice chest and water dispenser. Continued observation revealed moist black material remained around the spigot and gray-brown material remained in the scoop drawer. Interview with the Dietary Manager on 5/28/19 at 3:52 PM in the dining room confirmed . that looks like mold [around spigot] and that looks like scum [in drawer] .housekeeping is responsible for cleaning them .maybe a couple times a week .we don't have a policy . Continued interview with the Dietary Manager revealed the cart was used to pass ice water for residents rooms twice a day in the morning and evening, then stays in the dining room all day for refills as needed. Interview with the Administrator on 5/28/19 at 3:55 PM in the dining room confirmed .that looks like mildew [around spigot] and that looks like dirt [in drawer] .I expect the Dietary department to keep it clean .

Based on facility policy review, observation, and interview, the facility failed to perform hand hygiene for 4 residents (#21, #24, #80, #29) of 20 residents observed on 1 of 2 halls during the dining observation. The findings included: Review of the facility policy Handwashing/Hand Hygiene dated 9/1/17 revealed, .Employees must wash their hands .before and after contact with residents .the preferred method of hand hygiene is with alcohol-based hand rub .before and after direct contact with resident .after contact with objects (e.g. medical equipment) in the immediate vicinity of the resident . Observation of dining and meal tray pass on 4/23/18 from 12:45 PM - 12:55 PM, on the long hall, revealed Certified Nursing Assistant (CNA) #1 delivered Resident #21's tray to the room, set the tray up, placed the resident's shoes in the closet, and moved the resident's wheelchair. CNA #1 exited the room without washing or sanitizing the hands. Continued observation revealed CNA #1 then delivered Resident #25's tray to the room, retrieved a carton of milk from the dining room, and gave the milk to the resident. The CNA exited the room without washing or sanitizing the hands. Further observation revealed CNA #1 then delivered Resident #80's tray to the room, touched/arranged the overbed table, and exited the room without washing or sanitizing the hands. Continued observation revealed CNA #1 then delivered Resident #29's tray to the room, touched/arranged the overbed table, and exited the room without washing or sanitizing the hands. Interview with CNA #1 on 4/23/18 at 12:55pm, in the long hall, confirmed CNA #1 did not wash or sanitize the hands between residents and equipment contact. Interview with the Administrator on 4/23/18 at 1:00 PM, in the Director of Nursing's Office, confirmed staff were expected to sanitize and/or wash hands between residents and equipment contact.