**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to report a change in condition for a resident to the resident's representative for 1 of 6 (Resident #4) sampled residents. The findings include: Review of the facility policy titled, Infection Prevention and Control Program, with revision date 10/24/2022 revealed, .A system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents .visitors .The RNs [Registered Nurse] and LPNs [Licensed Practical Nurse] participate in surveillance through assessment of residents and reporting changes in condition .Residents, family members, and visitors are provided information relative to the rationale for the isolation, behaviors required of them in observing these precautions . Review of the facility policy titled, Notification of Change, with revision date 3/28/2023 revealed, .The purpose of this policy is to ensure the facility promptly informs the resident, consult the resident's physician, and notifies the resident's representative .when there is a change requiring notification .Definitions .Significant alteration of treatment: Examples-A need that occurs due to an adverse consequence of the need to begin a new course of treatment, procedure or therapy .Circumstances that require a need to alter treatment . Review of the facility policy titled, Covid-19 Visitation Policy, with revision dated of 5/12/2023 revealed, .Purpose: To provide guidance on COVID-19 visitation procedures to comply with state, federal, and local guidelines .Procedure .The Infection Preventionist shall monitor the status of the COVID-19 situation through the CDC [Centers for Disease Control and Prevention] website and local/state health department and shall keep facility leadership informed of current directives or recommendations and the need for restricting visitation if indicated . Review of the medical record revealed Resident #4 admitted to the facility on [DATE] with diagnoses which included Metabolic Encephalopathy, Dementia, and Pressure Ulcer of Right Buttock. Review of a Significant Change in Status Minimum Data Set, dated [DATE] revealed Resident #4 had a Brief Interview for Mental Status score of 2 which indicated severe cognitive impairment. Review of the July 2023 Physician Order Sheet revealed, .Order Isolation Precautions .order date 7/13/2023 .Continuous for Eleven Days . Review of the Clinical Notes Report for Resident #4 dated 7/13/2023 revealed .Covid isolation continues with no complications. Continues to remain asymptomatic . During an entrance conference on 7/17/2023 at 1:21 PM, the Administrator stated, We do have COVID positive residents in the facility. During a telephone interview on 7/18/2023 at 1:36 PM, Family Member #4 (Resident #4's responsible party) stated, The facility called me last week, I asked them if my sister had it and they said No. Does she have COVID? [Family Member #4 confirmed no knowledge that Resident #4 had COVID] During an interview on 7/18/2023 at 1:40 PM, the Director of Nursing reviewed Resident #4's progress notes and confirmed no documentation that Resident #4's responsible party was notified of residents positive COVID status. During an interview on 7/18/2023 at 1:55 PM, the Administrator confirmed the facility should call the family or responsible party if their resident tests positive for COVID.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, record review, and interview the facility failed to maintain a qualified Infection Preventionist with specialized training and failed to report an outbreak of COVID to the local health department during July of 2023 for 5 of 6 (Resident #1, 2, 3, 4, and 5) sampled residents, which had the potential to affect all residents in the facility. Census of 62. The finding include: Review of the facility policy titled, Infection Prevention and Control Program, with revision date 10/24/2022 revealed, .It is a policy of this facility to establish and maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines .The designated Infection Preventionist (IP) serves as a consultant to our staff on infectious diseases, resident room placement, implementing of isolation precautions, staff and resident exposures, surveillance, and epidemiological investigations of exposures of infectious diseases .The IP serves as the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility and reports surveillance findings .The Infection Preventionist or designee shall coordinate screening procedures in case of widespread exposure of staff to any infectious disease . Review of the facility policy titled, COVID-19 Prevention, Response, and Reporting, with revision date of 5/12/2023 revealed, .Purpose: To provide guidance and prevent the spread of COVID-19 .This facility shall ensure that appropriate interventions are implemented to prevent the spread of COVID-19 and respond promptly upon suspicion of illness associated with SARS-CoV-2 infection in efforts to identify, treat, and prevent the spread of the virus .The Infection Preventionist shall assess facility risk associated with COVID-19 through surveillance activities of emerging diseases in the community and illnesses present in the facility .Notify the state/local health department promptly about any of the following per state reportable disease list: [greater than or equal to] 1 residents or healthcare personnel (HCP) with suspected or confirmed SARS-CoV-2 infection . Review of the facility policy titled, Covid-19 Visitation Policy, with revision date of 5/12/2023 revealed, .Purpose: To provide guidance on COVID-19 visitation procedures to comply with state, federal, and local guidelines .Procedure .The Infection Preventionist shall monitor the status of the COVID-19 situation through the CDC website and local/state health department and shall keep facility leadership informed of current directives or recommendations and the need for restricting visitation if indicated . Review of the medical record revealed Resident #1 admitted to the facility on [DATE] with diagnoses which included Chronic Diastolic Heart Failure, Type 2 Diabetes Mellitus, and Chronic Kidney Disease. Review of the Clinical Notes Report for Resident #1 revealed .7/8/2023 .Resident positive for Covid isolation precautions placed into affect . Review of the medical record revealed Resident #2 admitted to the facility on [DATE] with diagnoses which included Personal History of Traumatic Brain Injury, Essential Primary Hypertension, and Epilepsy. Review of the Clinical Notes Report for Resident #2 revealed .7/17/2023 .Resident has tested positive for Covid this shift .Covid isolation precautions in place . Review of the medical record revealed Resident #3 admitted to the facility on [DATE] with diagnoses which included Cerebral Vascular Disease, Pneumonia, and Chronic Atrial Fibrillation. Resident #3 was discharged to hospital on 7/10/2023 with an admitting diagnosis of Hypertension. Review of the Clinical Notes Report for Resident #3 revealed .7/10/2023 .Resident on isolation for recent positive Covid test .[Resident #3 was in isolation at the facility prior to being sent to the hospital] . Review of the medical record revealed Resident #4 admitted to the facility on [DATE] with diagnoses which included Metabolic Encephalopathy, Dementia, and Pressure Ulcer of Right Buttock. Review of the Clinical Notes Report for Resident #4 revealed .7/13/2023 .Covid isolation continues with no complications. Continues to remain asymptomatic . Review of the medical record revealed Resident #5 admitted to the facility on [DATE] with diagnoses which included Hemiplegia following Cerebral Infarct, Hypertensive Heart Disease, and Cardiomyopathy. Review of the Clinical Notes Report for Resident #5 revealed .7/10/2023 .Resident on isolation for recent positive Covid test . During an entrance conference on 7/17/2023 at 1:21 PM, the Administrator stated, We do have COVID in the facility. During an interview on 7/17/2023 at 3:00 PM, Assistant Director of Nursing (ADON) (Named Infection Control Preventionist) revealed the facility currently had 5 resident rooms under droplet precautions due to positive COVID status. On 7/17/2023, the ADON was asked to provide this surveyor her certification or specialized training for Infection Preventionist. The ADON was unable to provide her certification or specialized training for the qualification of an Infection Preventionist. During an interview on 7/18/2023 at 12:03 PM, the Administrator stated, The ADON is having trouble finding her training on infection Control. She has emailed someone to find it, but she has been unable to provide it yet. If the ADON had given me a copy, I would have placed it in her employee file. During an interview on 7/18/2023 at 1:45 PM, the ADON stated, The COVID outbreak started on 7/1/2023 when 9 residents tested positive .outbreak testing started for staff 2 times per week on Monday and Thursday .July 5th 5 more residents were positive majority was on the 100 hall with 2 residents on the 200 hall .14 cases .then 1 more case 2 days later a roommate of a positive resident .we had 22 cases .7/13/2023 1 resident positive with 2 staff testing positive .7/17/2023 no positive staff with one positive resident . During a telephone interview on 7/18/2023 at 2:27 PM, Registered Nurse Supervisor with Local Health Department confirmed the facility had not notified the local health department of the COVID outbreak. During an interview on 7/18/2023 at 2:35 PM, the Administrator was asked if the facility notified the local health department related to the recent COVID outbreak. The Administrator stated, We don't have to notify the Health Department any longer, just do the NHSN report weekly. During an interview on 7/18/2023 at 3:20 PM, the Administrator reviewed the facility COVID-19 Prevention, Response, and Reporting, policy and confirmed the policy of the facility was to notify the local Health Department during an outbreak. During an interview on 7/18/2023 at 4:00 PM, the Administrator stated, We were unable to find the Infection Preventionist certification but we have the ADON's transcript, but we were unable to find a passing score for the training. Review of the Transcript for the ADON revealed .Nursing Home Infection Preventionist Training Course .Score 62 .Completion date 5/18/2022 .Status Failed .

**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 baseline care plan for psychotropic medications (antidepressant and antianxiety) for 1 of 19 residents (Resident #185) receiving psychotropic drugs. The findings include: Review of the undated facility policy, Baseline Care Plan, revised 11/2020, showed .The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care .the baseline care plan will include the minimum healthcare information necessary to properly care for a resident including, but not limited to initial goals based on admission orders .physician orders .Interventions shall be initiated that address the resident's current needs . Review of the medical record revealed Resident #185 was admitted to the facility on [DATE] with diagnoses which included Anxiety Disorder and Major Depressive Disorder. Review of the Physician's Orders dated 5/26/2021, showed Resident #185 had admission orders which included the following medications: Diazepam (a medication used to treat anxiety), which had a start date of 5/26/2021, and Duloxetine (a medication used to treat depression), which had a start date 5/26/2021. Review of the Medication Administration Record (MAR) dated May 2021, showed Resident #185 had received Diazepam 5 mg (milligram) tablet two times a day and Duloxetine 60 mg two times a day from 5/26/2021 through 6/9/2021. Review of the Baseline Care Plan dated 5/26/2021, showed Resident #185 was not care planned regarding the use of psychoactive medications and monitoring for behaviors and side effects. During an interview on 6/8/2021 at 3:03 PM, after reviewing Resident #185's baseline care plan, the Director of Nursing confirmed, It (the use of psychoactive medications) should have been on the baseline care plans because it's part of the admission process. I'm not seeing it. There is not a category for psychoactive med use and there should be.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and interview, the facility failed to ensure 1 of 16 (Resident #263) beds were in working order. The findings include: Medical record review revealed Resident #263 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Chronic Pain, Dysphagia, Cerebrovascular Disease, and Chronic Kidney Disease. Observations in Resident #263's room on 6/17/19 at 8:10 AM, revealed the Speech Language Pathologist (SLP) delivered Resident #263's meal tray, and attempted to raise the head of his bed. The head of the bed would not raise. Observations on 6/17/19 at 8:29 AM, on the 100 Hall, revealed Certified Nursing Assistant (CNA) #1 stated to the Maintenance Director, Resident #263's bed won't raise or lower . Interview with the Maintenance Director on 6/18/19 at 7:53 AM, on the 200 Hall, the Maintenance Director was asked if he was aware Resident #263's bed was not working properly. The Maintenance Director stated, .It needs a new .remote. It was in [named another room number], and I took it out. They moved it right down to another room and put a resident in it . Interview with the Maintenance Director on 6/18/19 at 8:37 AM, in Resident #263's room, the Maintenance Director stated, The pins are wore out on the plug . The Maintenance Director pushed the button on the remote to raise the head of the bed, but it did not raise. The Maintenance Director was asked if he knew why the bed had not been replaced out. The Maintenance Director stated, .I can't say exactly what happened. Interview with CNA #2 on 6/18/19 at 8:41 AM, on the 100 Hall, CNA #2 was asked if Resident #263's bed was working properly. CNA #2 stated, .it wouldn't raise . CNA #2 was asked if she had reported that to anyone. CNA #2 stated, .they already knew about it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to ensure psychiatric services were provided for 1 of 6 (Resident #44) sampled residents reviewed for behavioral health issues. The findings include: Medical record review revealed Resident #44 was admitted to the facility on [DATE] with diagnoses of Nontraumatic Subarachnoid Hemorrhage, Cerebral Aneurysm, Vascular Dementia with Behavioral Disturbance, Depression, Anxiety, Insomnia, Cognitive Communication Deficit, and Mood Disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] reviewed a Brief Interview for Mental Status (BIMS) score of 14, which indicated no cognition impairment, a mood severity score of 5, no behaviors, walking did not occur, required extensive staff assistance with all activities of daily living, and received antianxiety and antidepressant medications daily for the past 7 days. The physician's PROGRESS NOTE dated 4/2/19 documented, .Patient has been depressed, sad, withdrawn .Will set up transfer to the psych [Psychiatric] due to the severity of the depression . The hospital admission History and Physical dated 4/3/19 documented, .woman with major depressive disorder and anxiety disorder who was admitted .for worsening depressive symptoms . The hospital PATIENT DISCHARGE SUMMARY REPORT dated 4/12/19 documented, .DISCHARGE INSTRUCTIONS .Discharge to SNF [Skilled Nursing Facility] .Psych and PCP [Primary Care Physician] follow up at facility . Interview with the Director of Nursing (DON) on 6/19/19 at 10:06 AM, in the Conference Room, the DON was asked if the discharge instructions to follow up with psychiatric services had been followed. The DON stated, I'll have to look into it. The facility was unable to provide documentation that psychiatric services had been provided after Resident #44 was readmitted to the facility on [DATE].

Based on policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by dirty floor with debris, improper food storage, opened and undated food stored in the reach in freezer, ice buildup on the chest freezer, and refrigerator temperatures were not documented daily. The facility had a census of 62 residents, with 60 of those residents receiving a tray from the kitchen. The findings include: 1. The facility's .Food Storage . policy revised 11/2017 documented, .Leftover foods are stored in appropriate container so that the interior temperature of the food chills quickly .They are covered, labeled and dated . The Dietary Services Training Manual documented, .Freezer will be clean .Floors .should be swept and mopped after each meal . Observations in the kitchen on 6/17/19 beginning at 5:37 AM, revealed a dirty kitchen floor with scattered pieces of paper lying on the floor and a metal pan in the oven with food inside. Interview with the Certified Dietary Manager (CDM) on 6/17/19 at 6:17 AM, in the Kitchen, the CDM was shown the pan in the oven and was asked what kind of food was inside. The CDM stated, .left over from lunch .beef macaroni . The CDM was asked if food should be stored in the oven. The CDM stated, Should have been thrown out . Observations in the kitchen on 6/17/19 beginning at 9:25 AM, revealed the following: a. 1 bag of carrots in the freezer opened and undated b. 1 bag of hamburger patties in the freezer opened and undated c. 2 bags of French toast in the freezer unlabeled and dated d. 1 bag of egg rolls in the freezer unlabeled and dated e. chest freezer with thick ice buildup around the sides and the bottom of the freezer Interview with the CDM on 6/17/19 at 9:27 AM, the Kitchen, the CDM was asked if there should be an open date on opened foods in the freezer. The CDM stated, Yes, ma'am . The CDM was asked should there be ice build up in the freezer. The CDM stated, No . Observations in the kitchen on 6/18/19 beginning at 11:15 AM, revealed the following: a. a small plastic lid lying on the floor b. pieces of paper scattered on the floor c. a metal lid touching the floor d. a wet oven mitt lying on the floor e. a long metal spoon lying on the floor f. a plastic scraper lying on the floor Observations in the Kitchen on 6/19/19 at 9:32 AM, revealed a metal lid touching the floor. Interview with the CDM on 6/19/19 at 9:35 AM, in the Kitchen, the CDM was asked should the metal lid be touching the floor. The CDM stated, .shouldn't be . Review of the Refrigerator Temperature Log for 100 Hall refrigerator revealed incomplete daily refrigerator temperature documentation on 23 of 31 days on the January 2019 log, 10 of 28 days on the February 2019 log, 11 of 31 days on the March log, 13 of 30 days of the April 2019 log, and 7 of 31 days of the May 2019 log. Interview with the Director of Nursing (DON) on 6/19/19 at 11:20 AM, in the Administrator office the DON was asked how often should the refrigerator temperatures to be done. The DON stated, .night shift is supposed to do it .it didn't get documented .