**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to incorporate recommendations from a PASRR evaluation report into a resident assessment, care planning, and transition of care for 1 (Resident #1) of 2 residents reviewed for PASRR services. The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within 20 days after the IDT meeting. This failure could place residents who were PASRR positive at risk of not getting the PASARR services for a better quality of life and could lead to a decline in health. Findings included: Record review of Resident #1's face sheet dated 06/16/2025 revealed a [AGE] year-old male, admitted to the facility on [DATE]. He had the following diagnoses: muscle weakness (decreased strength), muscle wasting and atrophy (loss of strength), unspecified lack of coordination (unable to control movement), osteoarthritis (tissue wears down), genetic related intellectual disabilities (abnormalities in genes or chromosomes), obesity (excessive body fat). Record review of Resident #1's MDS annual assessment dated [DATE] revealed a BIMS score of 15 meaning intact cognitive response. Record review of Resident #1's care plan dated revision date 12/10/2024 revealed Resident #1 is PASRR positive, will participate in quarterly care plan meetings with PASRR representative/social worker, Coordination of PASRR services and Individual Service Plan developed by PASRR representative/social worker. Record review of Resident #1's PCSP dated 12/19/2024 revealed IDT meeting was held on 12/19/2024. Attendees included the resident, the PASRR habilitation coordinator, the Social Worker, MDS RN, and Resident #1. The following NFSS were identified and confirmed: Customized Manual Wheelchair - 3 indicated on-going. During an interview on 06/16/2025 at 9:40 AM, the ADM stated he became aware of a concern with Resident #1's CMWC recently around the end of May 2025. He stated the MDS nurse, and the DOR advised him they were having a hard time getting paperwork completed for Resident #1 for a new customized manual wheelchair. He stated he looked into their concerns and realized they were needing to have the resident assessed for possibly a new wheelchair. He stated the customized manual wheelchair Resident #1 had, was two years old. He stated he was told a recommendation was made during an IDT meeting for a new CMWC. He stated he reached out to the DME company for them to evaluate Resident #1 and the CMWC he currently had. He stated Resident #1 was evaluated by the DME Rehab Tech and Resident #1 did not qualify for a new CMWC. He stated Resident #1 did not have a significant medical change of condition that would qualify for a new CMWC. He stated he sent out an email to the DON, MDS nurse, DOR, SW and BOM about the process for completing information and submitting NFSS forms on 05/30/2025. He stated he did go into the LTC portal and fill out the forms to see the process, but he did not submit the form. He stated the facility did not complete the NFSS form in the LTC portal within the 20 days. During an interview on 06/16/2025 at 10:15 AM, the SW stated she did attend an IDT PASRR meeting for Resident #1 in December 2025 and it was mentioned during the meeting that Resident #1 might benefit from a new CMWC. During an interview on 06/16/2025 at 10:30 AM, the MDS nurse stated it would have been in November or December of 2025 that she attended a PASRR meeting for Resident #1. That during the meeting it was mentioned that therapy would need to start the process for the CMWC for Resident #1 and coordinate with MDS on that process. She stated the DOR was working on a form for the process and he realized he was not qualified to sign the form and that was when they went to the ADM and asked for assistance. During an interview on 06/16/2025 at 12:12 PM, the DOR stated he did not attend the PASRR meeting in December 2025 with Resident #1. He stated he was not familiar with the PASRR process and reached out to colleagues for assistance. He stated he was not qualified to make assessments for CMWC and could not sign the form for the CMWC. He stated the facility did have the DME company evaluate Resident #1 for a new CMWC and at that time the DME company said repairs were needed to the CMWC and once the repairs were made, they would re-evaluate Resident #1 to see if a new CMWC was needed. During an interview on 06/16/2025 at 12:40PM, Resident #1 stated that his wheelchair worked just fine and was comfortable for him. Record review of the email from the ADM dated 05/30/2025 sent to DON, DOR, SW, MDS and BOM for training purposes for PASRR recommendations revealed the following: 3. NFSS Form Completion: The nursing facility provider must complete the NFSS form, including all required information, such. as the resident's demographics, the therapist's assessment findings, and the physician's order. For customized manual wheelchairs, the NFSS form needs to be completed by a licensed therapist. - Worksheet is to be completed by Therapy and that information is to be imputed into SlmplelTC by MDS - MDS will upload the following forms into SimpletlTC - 1. CMWC Signature page - Therapist, Physician and Administrator signature page 2. PT or OT Evaluation or Cert/progress notes signed by physician out of PCC (Therapy to provide) 3. Supplier Acknowledgement page - Rehab Engineer 4. Manufacturers page - Estimate of cost 5. QRP - Rehab Engineer Certificate 6. Once this is completed, we submit forms and wait for response from THHS. Once we have approval for order, it is the facility responsibility to pay for wheelchair upfront and then request for reimbursement - 7. Receipt - CMWC - To be signed by therapist and Administrator after wheelchair is received and both agree that it meets the resident's needs. The completed NFSS form is submitted through the Texas Medicaid and Healthcare Partnership's LTC Online Portal. 5. Authorization and Payment: The NFSS request is reviewed by Texas Health and Human Services and, if approved, the requested wheelchair is authorized, and the nursing facility can proceed with purchasing it. 6. Provider Action Required: If any rejection error messages occur during the workflow process, the provider must take action to correct the request and resubmit it. Record review of the facility policy: Resident Assessment - Coordination with PASRR Program Policy: The facility coordinates assessments with the preadmission screening and resident review PASRR program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. Policy Explanation and Compliance Guidance: 7. Recommendations, such as any specialized services, from a PASRR level II determination and/or PASRR evaluation report will be incorporated into the resident's assessment, care planning, and transactions of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure in accordance with accepted professional standards and practices, medical records maintained on each resident were accurately documented for 1 of 17 (Resident #47) residents reviewed for accuracy of records. 1. The facility failed to document communication between staff and the MD when Resident #47 was attempting to elope from the facility on 8/30/24. 2. The facility failed to record verbal orders in the EHR when the MD ordered Resident #47 be moved to the secured unit. These failures could place residents at risk for not receiving needed care or treatment after an incident occurred. Findings Included: Record review of Resident #47's undated face sheet reflected Resident #47 was an [AGE] year-old female whose admission date to the facility was on 6/17/24. Resident #47 had the following diagnoses: Neurocognitive disorder with Lewy bodies (memory loss); psychotic disorder with delusions due to known physiological condition (mental health condition with false beliefs); restlessness and agitation (inability to relax and be still); dementia in other diseases classified elsewhere, unspecified severity, with mood disturbance (memory loss and a mental health condition that affects the emotional state); major depressive disorder, recurrent severe without psychotic features (mental health condition); dementia in other diseases classified elsewhere, severe, with behavior disturbance (memory loss and disruptive behaviors); hallucinations (false perceptions that were not true); and chronic obstructive pulmonary disease (airflow blockage and breathing-related problems). Record review of Resident #47's Care plan dated 6/28/24 revealed Resident #47 was an elopement risk related to being in a disoriented place and impaired safety awareness. The goal was that Resident #47's safety will be maintained through the review date. Interventions were to distract Resident #47 from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. Also, to provide Resident #47 with structured activities for toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Record Review of Situation, Background, Assessment Recommendation (SBAR) Communication form and Progress Note for RN's/Licensed Practical Nurses (LPN)/LVN's dated 8/31/24 revealed Resident #47's mental status evaluation (compared to baseline) had an altered level of consciousness, increased confusion or disorientation, new or worsened delusions or hallucinations, and other symptoms or signs of delirium. Additionally, the behavioral evaluation revealed Resident #47 was a danger to self or others, had verbal aggression, physical aggression, a personality change, and had signs and symptoms of agitation. Record review of Resident #47's EHR physician orders dated 9/25/24, revealed there was no order of the verbal orders made by the physician to move Resident #47 to the secured unit on 8/30/24. Record review of Resident #47's progress notes dated 8/26/24 - 9/26/24, revealed no documentation by LVN A of the communication between she and the physician regarding Resident #47's elopement behaviors that occurred on 8/30/24. During an interview on 9/25/24 at 5:58 PM, Family Member #1 stated she received a call from the facility several weeks ago requesting permission to move Resident #47 to the secured unit due to behaviors, and she consented due to Resident #47's behaviors and exit seeking. During an interview on 9/27/24 at 11:50 AM, the SW stated Resident #47 admitted to the facility into a regular room, however, she was recently moved to the secured unit when she began exit seeking. She stated Resident #47 was never able to successfully elope from the facility. She stated Resident #47 was hitting staff, pushing trash barrels at staff, she was agitated, and she threw a water pitcher. She stated Resident #47 pushed her roommate's wheelchair in the hallway into other resident's doorways. She stated Resident #47 was hallucinating and told her she knew she was seeing things that were not real. She stated Resident #47 was moved to the secured unit before she went to the behavior hospital. She stated she contacted Resident #47's family member on 8/30/24 who consented to moving her to the secured unit. The SW stated the facility tried to implement other avenues, such as a wander guard to ensure Resident #47's safety was least restrictive; however, they could no longer do it and it was decided she be moved to the secured unit to ensure her safety. She stated Resident #47 went to the behavior hospital for assessment and returned on 9/18/24. When she returned, she started having behaviors immediately throwing things, crawling on the floor, and undressing. She said they contacted the behavior hospital and were told there was nothing they could do for her due to her diagnosis of Lewy body dementia. She stated she contacted another behavior hospital who also denied her due to the acuity on their unit. She stated the nurse was responsible to contact the physician for orders. She stated nursing staff decided when to place a resident on the secured unit, so she had not received training on what all was needed to place a resident on the secured unit. She stated the department heads trained staff. She stated she did not know what a potential negative outcome could be to the resident for not having written orders before placing a resident on the secured unit. During an interview on 9/27/24 at 11:55 AM, the ADM stated the facility obtained verbal orders from the MD prior to moving Resident #47 to the secured unit but the staff member did not document it in the EHR due to the behaviors that were going on at the time they were speaking to the physician. The ADM stated he was trying to determine which nurse obtained the verbal orders from the physician. The ADM stated the facility did not have a written order, but he was trying to get it and would enter it into the EHR. During an interview on 9/27/24 at 12:01 PM, the MD stated Resident #47 had Lewy body dementia, threw coffee on people, and she was very aggressive. He stated she was sent to a behavior hospital for assessment and returned to the facility after she was discharged . He stated she needed to be on the secured unit because she was very aggressive. He stated he was notified by the nurse and gave verbal orders prior to her being moved to the secured unit. He stated usually the facility sent him the written orders and he signed and returned them. During an interview on 9/27/24 at 1:35 PM, LVN A stated facility policy to place a resident on the secured unit were that they must call the physician to get direction when there were concerns about a resident, the resident must show signs of being an elopement risk, and they must notify the family and ask for permission. LVN A stated this all must be done before the resident was moved to the secured unit. She stated she was the CN on 8/30/24 and she was responsible to call the physician and make notifications for any concerns about residents. She stated the SW could help make notifications. She stated she called the physician on 8/30/24 to talk to him about how Resident #47 was constantly exit seeking as well as her behaviors. She stated the physician gave her verbal orders to move Resident #47 to the secured unit as he felt it was necessary. She stated the SW called the family and told them the physician ordered the resident to move to the secured unit and she asked them for permission, and they consented. She stated she was responsible to transcribe orders on the same day, as well as document her conversation with the physician in the EHR since she was the staff that spoke with him. She stated she was trained to transcribe orders and document all conversations leading up to the order request immediately as soon as they had time when things were settled down and the resident was safe. She stated she believed she failed to do those things because of how hectic things were with Resident #47 during that time. She stated she was trained by the ADON and the DON. She stated she was trained during orientation to document everything as well as the importance of documentation. She stated documentation was also discussed monthly during staff meetings. She stated she had received training on documentation at least five times that year. She stated she was not aware she did not put the order in the EHR until that day. She stated a possible negative outcome was that the physician would not be aware the resident was on the secured unit. She stated being on the secured unit could cause residents to have depression and feel isolated, so it was important for there to be a physician order. During an interview on 9/27/24 at 1:55 PM, the ADON stated in order to place a resident on the secured unit, the facility must complete an assessment on the resident, the resident must be exit seeking or they must be a danger to themselves or others. She stated initially Resident #47 had a wander guard (a sensor placed on the wrist that activates an alarm when exiting the facility) when she was on the regular unit, but her exit seeking got progressively worse where she was trying to find her way out of every exit in the facility by slamming her walker against the exit doors. She stated it was no longer safe for Resident #47 to be on the regular unit. She stated staff must get verbal orders from a physician to place a resident on the secured unit. She stated CNs were responsible to communicate with physicians or she could, if needed. She stated all physician orders go into the EHR. She stated the nurse that got the order must enter it into the EHR as soon as the resident was safe or at least before they leave their shift that day. She stated there must be documentation in the EHR showing information that led up to the order request. She stated all written orders must be scanned and uploaded into the EHR. She stated she and the DON were responsible for training staff on documentation requirements. She stated in-services were done with staff often and this was also discussed during their monthly meetings. She stated they also complete in-services with staff immediately for concerns that needed to be addressed immediately. She stated she expected staff to document any concerns, observations, issues, and orders in the EHR. She stated a negative outcome was that the resident could miss care, medications, or necessary treatment when pertinent information was missing from their EHR. During an interview on 9/27/24 at 2:25 PM, the DON stated facility policy to place residents on the secured unit was that residents must be exit seeking, the facility must complete an assessment, and the facility must get orders from the physician and approval from the family prior to placing the resident on that unit. The DON stated the CN was responsible to obtain verbal orders from the physician and then write the order in the EHR as soon as they get the verbal order from the physician. The DON stated the EHR was the only place to find the orders. The DON stated verbal orders were received for Resident #47 prior to moving her on the secured unit. The DON stated the CN was supposed to document the reasons for the request for the move in the progress notes. She stated herself and the ADON trained staff to document orders and progress notes during monthly meetings and during daily meetings to go over what was missed or was needed. She stated she expected staff to document accurately, timely, and precisely in the EHR because it did not happen if it was not charted. She stated she was not aware the facility did not have signed physician orders for Resident #47 to be moved to the secured unit. She stated Resident #47 went to a behavior hospital and returned on 9/18/24. She stated Resident #47 had Lewy body dementia and was cognitively intact when she admitted on [DATE]. The DON stated she used a walker, she was friendly, and she played bingo. She stated Resident #47 became paranoid within 2 months and she hallucinated. She said Resident #47 got worse, and started going in other resident's rooms, her verbal and physical aggression increased, and then she began trying to elope from the facility. She stated Resident #47 told staff she was going to leave. She stated Resident #47 had a wander guard, but it was determined this was not enough to keep her safe and the facility felt she needed to be moved to the secured unit. The DON stated staff spoke to the family who approved it. The DON stated since then, Resident #47 went to the behavior hospital for assessment and treatment. The DON stated a negative outcome of placing a resident on the secured unit inappropriately was it would isolate the resident and could cause depression due to having less stimuli. The DON stated the facility could face legal issues placing restrictions on residents without physician orders. During an interview on 9/27/24 at 2:41 PM, the ADM stated for a resident to be placed on the secured unit, the facility must determine if the secured unit would create a better well-being for the resident, they must discuss and obtain permission from family, and they must discuss and obtain an order from the physician prior to placing a resident on the secured unit. The ADM stated the facility must try all other least restrictive interventions prior to placing a resident on the secured unit. The ADM stated the CN nurse on duty was responsible to obtain orders from the physician, document the orders, and document the reason for obtaining the order in progress notes in the EHR. The ADM stated then the CN should write and send them out to the physician for a signature. The ADM stated all documentation and orders should be written timely or preferably before they leave for their shift that day. The ADM stated the facility tried to send orders to the physician weekly for signatures. The ADM stated Resident #47 was admitted to the facility on [DATE] and at that time she was cognitively intact, and they had good conversations. He stated within a couple of months, she began making false accusations, she became paranoid, and her aggressive behaviors at night increased. He stated Resident #47 also made comments and attempted to leave the facility. He stated resident #47 had a wander guard (a sensor placed on the wrist that activates an alarm when exiting the facility). He stated the facility determined that due to Resident #47's behaviors and the facility's numerous exits that she be placed on the secured unit to better ensure her safety. He stated Resident #47 was moved to the secured unit on 8/30/24. He stated Resident #47 went to a behavior hospital from [DATE] and returned on 9/18/24. The ADM stated he was not aware the facility did not have signed written orders for Resident #47 to be placed on the secured unit. He stated staff were trained to document reasons for obtaining orders, and all communication with physicians. He stated the ADON and the DON were responsible to train staff. He stated the DON and ADON completed documentation training regarding when to document and how to document on a monthly basis with staff. He stated he expected staff to document behaviors, interventions, responses, and contact with family and the physician in the EHR. He stated not having the signed written orders did not have a negative effect on the resident. He stated written orders showed they had actions in place for the resident and provided greater information from staff to staff. He stated having the written order was a paper compliance that they were required to have because the State said they have to. He stated he did not think there was a negative outcome to the resident if they were properly placed there whether the facility had an order or not. Record review of the facility policy, Memory Care admission Policy (undated), revealed in part the following: admission Policy for Secured Memory Care Unit Purpose: This policy outlines the criteria and procedures for admitting residents to the secured memory care unit, ensuring a safe and supportive environment for individuals with cognitive impairments. Scope: This policy applies to all admissions to the secured memory care unit of [facility]. admission Criteria: 4. admission Order: 1. admission to the secured unit must be made by a licensed provider. Record review of the facility policy, Charting and Documentation (revised July 2017), revealed in part the following: Policy Statement All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation 7. Documentation of procedures and treatments will include care-specific details, including: a. the date and time the procedure/treatment was provided; b. the name and title of the individual(s) who provided the care; c. the assessment data and/or any unusual findings obtained during the procedure/treatment; d. how the resident tolerated the procedure/treatment; e. whether the resident refused the procedure/treatment; f. notification of family, physician or other staff, if indicated; and g. the signature and title of the individual documenting. Record review of the facility policy, Telephone Orders (revised February 2014), revealed in part the following: Policy Statement Verbal telephone orders may be accepted from each resident's Attending Physician. Policy Interpretation and Implementation 1. Verbal telephone orders may only be received by licensed personnel (e.g., RN, LPN/[NAME], pharmacist, physician, etc.). Orders must be reduced to writing, by the person receiving the order, and recorded in the resident's medical record. 2. The entry must contain the instructions from the physician, date, time, and the signature and title of the person transcribing the information. Telephone orders must be countersigned by the physician during his or her next visit. Record review of the facility policy, Verbal Orders (revised February 2014), revealed in part the following: Policy Interpretation and Implementation 4. The individual receiving the verbal order must write it on the physician's order sheet as ''v.o. (verbal order) or t.o. (telephone order). 5. The individual receiving the verbal order will: a. read the order back to the practitioner to ensure that the information is clearly understood and correctly transcribed; b. record the ordering practitioner's last name and his or her credentials (MD, NP, PA, etc.); and c. record the date and time of the order. 6. The practitioner will review and countersign verbal orders during his or her next visit Record review of the facility policy, Medication and Treatment Orders (revised July 2016), revealed in part the following: Policy Statement Orders for medications and treatments will be consistent with principles of safe and effective order writing. Policy Interpretation and Implementation 7. Verbal orders must be recorded immediately in the resident's chart by the person receiving the order and must include prescriber's last name, credentials, the date and the time of the order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure each resident's drug regimen was free of unnecessary medication for 1 of 17 residents reviewed for adequate monitoring of unnecessary medication (Resident #9). The facility did not monitor Resident #9 for side effects of the anti-anxiety medication Lorazepam (an anxiety medication). This failure could place the residents at risk for adverse consequences of medication. Findings included: Record review of Resident #1's face sheet, dated 08/08/23, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis to include Alzheimer's disease (cognitive loss). Record review of Resident #9's Comprehensive Minimum Data Set, dated [DATE], revealed Resident #9 had a BIMS score of 03, which indicated the resident's cognition was severely impaired. Record review of the physician orders dated 08/08/23 indicated Resident #9 was prescribed Lorazepam (an anti-anxiety medication) 0.25 ml every 4 hours as needed for pain related to Alzheimer's disease with a start dated of 07/30/23. The orders did not address monitoring the anti-anxiety medication. Record review of a care plan revised 07/12/23 did not indicate Resident #9 received antianxiety therapy. Record review of MAR undated indicated Resident #9 received Lorazepam 0.25ml every 4 hours as needed on 08/7/23 and 08/08/23 as ordered. Record review of the electronic record for Resident #9 did not reveal the nurses documented on monitoring of side effects of antianxiety daily with medication administration. During an interview with the DON on 08/10/23 at 11:53 AM, she stated anti-anxiety medications need daily monitoring for side effects. She stated monitoring for behaviors should be documented on the treatment administration record or medication administration record. She stated the nurses were responsible for putting in the monitoring order when the medication was ordered, and she followed up to make sure it was done. She stated monitoring of anti-anxiety medication monitoring should start with the first dose. She stated nursing staff had been trained to add the monitoring to anti-anxiety medications. She stated she does not know why it was not done. She stated when asked what the potential negative outcome could be I don't feel comfortable answering that question. That's like making me guess. During an interview with the ADM on 08/10/23 at 12:53 PM, he stated anti-anxiety medications need monitoring for side effects and appropriate effectiveness. He stated monitoring should be documented on the treatment administration record. He stated the DON was responsible for making sure anti-anxiety medications were being monitored for side effects and benefits. He stated anti-anxiety medication monitoring should start on initial dose of medication. He stated he was not aware monitoring of the medication was not being done. He stated the potential negative outcome could be not noticing a reaction or the effectiveness of the medication. During an interview with LVN C on 08/10/23 at 01:10 PM, she stated anti-anxiety medication required monitoring for side effects, adverse reactions and effectiveness. She stated monitoring was documented on the treatment administration record. She stated she was not sure who was responsible for adding the monitoring to the treatment administration record, but it should be added at the time the order for the medication was received. She stated monitoring started with the initial dose. She stated the potential negative outcome could be not being aware of reactions or side effects. Record review of the facility's policy titled Psychotropic Medication Use; revision date July 2022 revealed: Policy Statement: Residents will not receive medications that are not clinically indicated to treat a specific condition. Policy Interpretation and Implementation 2. Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: c. Anti-anxiety medications . 12. Residents receiving psychotropic medications are monitored for adverse consequences.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure the residents had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 4 of 17 residents ( Resident #40, #45, #46, and #47) reviewed for resident rights . The facility failed to obtain a signed informed consent from responsible party based on information of the benefits, risks, and options available from for Residents #40, #45, #46, and #47 prior to administering melatonin (sleep aide). These failures could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party. Findings included: Resident #40 Record review of Resident #40's face sheet, dated 08/08/23, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (cognitive loss), insomnia (sleep disorder), depression (sadness or loneliness), and hypertension (high blood pressure). Record review of comprehensive MDS assessment dated [DATE] revealed Resident #40 was understood (clear comprehension). The MDS revealed Resident #40 had a BIMS of 02 which indicated the resident's cognition was severely impaired. Record review of a care plan for Resident #40 dated 07/12/23 revealed no care plan for use of melatonin or insomnia. Record review of Resident #40's order summary report dated 08/08/23 revealed the following orders: Melatonin 10mg at bedtime related to insomnia dated 5/31/23. Record review of Resident #40's medication administration record undated for the month of August 2023 revealed resident received Melatonin 10 mg orally at bedtime from August 1st through August 9th. Record review of Resident #40 electronic medical record revealed no consent for melatonin. Resident #45 Record review of Resident #45's face sheet, dated 08/08/23, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include insomnia (sleep disorder), muscle weakness, and hypertension (high blood pressure). Record review of comprehensive MDS assessment dated [DATE] revealed Resident #45 was understood (clear comprehension). The MDS revealed Resident #45 had a BIMS of 00 which indicated the resident's cognition was severely impaired. Record review of a care plan for Resident #45 dated 07/26/23 revealed no care plan for use of hypnotic or insomnia. Record review of Resident #45's order summary report dated 08/09/23 revealed the following orders: Melatonin 10mg at bedtime related to insomnia dated 05/30/23. Record review of Resident #45's medication administration record undated for the month of August 2023 revealed resident received Melatonin 10 mg orally at bedtime August 1st through August 9th. Record review of Resident #45 electronic medical record revealed no consent for melatonin. Resident #46 Record review of Resident #46's face sheet, dated 08/08/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include diabetes (high blood sugar), Alzheimer's disease (cognitive loss), insomnia (sleep disorder), depression (sadness and loneliness), muscle weakness, and hypertension (high blood pressure). Record review of comprehensive MDS assessment dated [DATE] revealed Resident #46 was understood (clear comprehension). The MDS revealed Resident #46 had a BIMS of 99 which indicated the resident's cognition was severely impaired. Record review of a care plan for Resident #46 dated 07/05/23 revealed no care plan for melatoin or insomnia. Record review of Resident #46's order summary report dated 08/08/23 revealed the following orders: Melatonin 10mg at bedtime related to other insomnia dated 5/24/23. Record review of Resident #46's medication administration record undated for the month of August 2023 revealed resident received Melatonin 10 mg orally at bedtime August 1st through August 9th. Record review of Resident #46 electronic medical record revealed no consent for melatonin. Resident #47 Record review of Resident #47's face sheet, dated 08/08/23, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include anxiety (feeling of fear and worry), dementia (cognitive loss), depression (sadness and loneliness), muscle weakness, and hypertension (high blood pressure). Record review of comprehensive MDS assessment dated [DATE] revealed Resident #47 was understood (clear comprehension). The MDS revealed Resident #47 had a BIMS of 03 which indicated the resident's cognition was severely impaired. Record review of a care plan for Resident #47 dated 07/13/23 revealed no care plan for melatonin. Record review of Resident #47's order summary report dated 08/08/23 revealed the following orders: Melatonin 3mg at bedtime related to restlessness and agitation dated 06/02/23 . Record review of Resident #47's medication administration record undated for the month of August 2023 revealed resident received Melatonin 3 mg orally at bedtime August 1st through August 9th. Record review of Resident #47 electronic medical record revealed no consent for melatonin. During an interview on 08/09/23 at 02:38 PM, the Regional Nurse Consultant stated melatonin was a dietary supplement and does not require a consent per CMS and psychotropic list they were following. During an interview on 08/10/23 at 11:53 AM, the DON stated the nurses were responsible for obtaining the consent for psychotropic medications when they receive the order and then she will follow up. She stated consents were obtained when the order was given. She stated Residents #40, #45, #46 and #47 were taking melatonin for sleep aide. She stated consents were not obtained because it was not on the psychotropic list. During an interview on 08/10/23 at 12:53 PM, the ADM stated the floor nurses were responsible for obtaining consents and the DON follows up. He stated consents should be obtained prior to the first dose. He stated the consents for Residents #40, #45, #46 and #47 were not obtained because he thought melatonin had been removed from the psychotropic list. He stated melatonin was used for a sleep aide. He stated the potential negative outcome would be not providing residents and family member the risk and benefits information. During an interview on 08/08/23 at 01:05 PM with LVN C, she stated melatonin did require a consent. She stated consents were obtained the day of the order. She stated melatonin was used as a sleep aide. She stated potential negative outcome of not obtaining a consent would be family upset because they have not received information about the medication or the possible side effects. She stated she had been trained on obtaining consents. Record review of the facility's Classes of Medications Frequently Used for Psychiatric Indications dated [DATE] revealed: Consent is required for any medication that is used in the treatment of a psychiatric diagnosis or symptom, whether or not the medication is included in this list. Refer to physician order for determination of indication for use. The classification of psychotropic medication is fairly standard, but medications can be used for treatment of illnesses that would be considered listed under a different classification. For example, some medications listed under antipsychotics maybe used as a mood stabilizer . Record review of the facility's policy titled Use of Psychotropic Medication, undated revealed: Policy: Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Policy Explanation and Compliance Guidelines: 1. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include but are not limited to the following categories: antipsychotics, antidepressants, anti-anxiety, and hypnotics . 4. b. iii. Consent will be obtained from the resident or resident's representative prior to initiation of medication. 5. Residents and/or representatives shall be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments/non-pharmacological interventions . Record review List of Psychotropic Medication and Side Effects, dated 4/2023 (Revised) from Texas Health and Human Services (hhs.texas.gov) revealed the following: Medication: Melatonin Side Effects: Common - Headache, dizziness, shaking, nausea, or abdominal cramps may occur. Serious but Rare - Mental or mood changes (e.g., depression, confusion). Very Serious but Very Rare - Serious allergic reaction is rare but can occur rash, itching or swelling (especially of the face, tongue or throat), severe dizziness, trouble breathing).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment for 2 of 24 residents (Residents #15 and 35) reviewed for PASRR screening, in that: Residents #15 and #35 did not have an accurate PASRR Level 1 assessments when they had a diagnosis of major depressive disorder or schizoaffective disorder. These failures could place residents with an inaccurate PASRR Level 1 evaluation at risk for not receiving care and services to meet their needs. The findings were: Resident #15 Record review of Resident #15 electronic face sheet revealed a [AGE] year-old male most recently admitted to the facility on [DATE]. The face sheet listed under Diagnoses Information, schizoaffective disorder, depressive type. Record review of Resident #15's Quarterly MDS dated [DATE], revealed under section I Active Diagnoses, a diagnosis of schizoaffective disorder. Additionally, under Section C Cognitive Patterns, the MDS revealed a BIMS of 13 indicating the resident was cognitively intact. Record review of Resident #15 most recent care plan, undated, revealed a focus area and diagnosis of schizoaffective disorder, this problem started 09/11/2020. Resident #15 was prescribed Sertraline HCL 100mg to assist with this area of need. Record review of Physician progress notes for Resident #15 dated 08/08/2023 revealed under current medications, Resident # 15 prescribed Sertraline HCL 100mg one tablet once a day for schizoaffective disorder. Record review of Resident #15's Preadmission Screening and Resident Review Level One (PL1) form dated 11/08/2022 revealed under section C0100 Mental Illness an answer of No, indicating the resident did not have a mental illness. Resident #35: Record review of Resident #35's electronic face sheet revealed an [AGE] year-old male most recently admitted to the facility on [DATE]. The face sheet listed under Diagnosis Information a diagnosis of Major Depressive Disorder, recurrent and severe. Record review of Resident #35's Quarterly MDS dated [DATE], revealed under section I Active Diagnoses, a diagnosis of Major Depressive Disorder, recurrent and severe. Additionally, under Section C Cognitive Patterns, the MDS revealed a BIMS of 11 indicating the resident cognition was moderately impaired. Record review of Resident #35's most recent care plan, undated, revealed a focus area and diagnosis of Major Depressive Disorder, recurrent and severe, this problem started 03/02/2022. Record review of Physician progress notes for Resident #35 dated 08/08/2023 revealed under Current Diagnosis, diagnosis of Major Depressive Disorder, recurrent and severe. Record review of Resident #35's Preadmission Screening and Resident Review Level One (PL1) form dated 3/2/2022 revealed under section C0100 Mental Illness an answer of No, indicating the resident did not have a mental illness. During an interview on 08/10/23 at 01:00PM with the Administrator, he stated Residents #15 and #35 did not have PL2 evaluations as all their PL1s were negative. The ADM said the purpose of the PL1 screening was to identify if someone needs extra services. He said if it was positive then it gets put into an online system and they reach out to the necessary people to ensure a level two evaluation was done. He said the ADON was responsible for entering the PL1 into the system. He said he thought there have been recent changes with PASRR but was not sure if they changed what diagnoses qualified as a mental illness and said she would have to check. The ADM stated there was potential harm if a resident with a diagnosis of a mental illness who had a negative PL1 and no subsequent level two evaluation as they could potentially go without services. During an interview with the ADON on 08/10/23 at 10:40AM, she stated Residents #15 and #35 did not have PL2 evaluations as all their PL1s were negative. The ADON stated it was her responsibility to ensure every resident admitted to the facility has a PL1. The ADON also stated it was her responsibility to ensure PL1s are completed accurately by comparing them to Resident medical records. The ADON stated there was not a procedure in place to update a PL1 if a resident was diagnosed with a new diagnosis after being admitted to the facility. The ADON stated she did not know a diagnosis of MDD would warrant a positive PL1. The ADON stated she was aware Resident #35 did have a diagnosis of MDD. The ADON also stated she knew Resident #15 had a diagnosis of schizoaffective disorder. The ADON stated the potential harm to a resident without a subsequent PL2 evaluation was the residents will not receive the services they need. During an interview with the DON on 8/10/23 at 11:20am, she stated Residents #15 and #35 did not have PL2 evaluations as all their PL1s were negative. The DON stated it was the ADONs' responsibility to ensure every resident entering the facility had a completed and accurate PL1. The DON also stated it was the ADONs' responsibility to ensure any new mental health diagnosis added after entry to the facility that warrant a new PL1 are completed. The DON stated she was not aware a diagnosis of PTSD or MDD warranted a positive PL1. The DON stated she did not know why Resident 15s' PL1 was not positive due to his diagnosis of schizoaffective disorder. The DON stated the potential negative outcome for residents not having an accurate PL1 and subsequent PL2 are the residents may not be offered the services they may need for their diagnosis. The facility policy for PASARR states all applicants to a Medicaid-certified nursing facility are evaluated for mental health prior to admissions and offered the most appropriate setting for their needs. If the PASARR level one screening indicated the individual may have an Intellectual Disability or a Mental Illness diagnosis the facility will confer with local mental health providers to complete a PASARR level two screening. Following the completion of the level two screening a care plan will be developed by the facility in order to meet the needs of a resident with an Intellectual Disability or a Mental Illness diagnosis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for 14 of 17 residents (Residents #2,#4, #5, #7, #9, #14, #17,#27, #29, #33, #46, #47, #48, and #53) reviewed for care plans as follows: Resident #2 did not have a care plan for visual, behavior, nutritional and pressure ulcer. Resident #4 did not have a care plan for visual, psychosocial wellbeing, falls and psychotropic drug use Resident #5 did not have a care plan for visual function, communication, urinary incontinence, behavior, and dental care. Resident #7 did not have a care plan for visual function, communication, urinary incontinence, and nutritional status. Resident #9 did not have a care plan for urinary incontinence, pressure ulcer and psychotropic drug use. Resident #14 did not have a care plan for visual function, urinary incontinence, nutritional status and pressure ulcer. Resident #17 did not have a care plan for cognitive loss, visual, communication and pressure ulcer. Resident #27 did not have a care plan for cognitive loss, visual function, communication, urinary incontinence, nutritional status and pressure ulcer. Resident #29 did not have a care plan for cognitive loss, visual function, communication, urinary incontinence, psychosocial wellbeing, or falls. Resident #33 did not have a care plan for visual, communication, mood, behavior, falls, nutritional, pressure ulcer. Resident #46 did not have a care plan for visual, communication, urinary, psychosocial wellbeing, activities, pressure ulcer, psychotropic drug use. Resident #47 did not have a care plan for visual and falls Resident #48 did not have a care plan for cognitive loss, urinary, nutritional and pressure ulcer. Resident #53 did not have a care plan for urinary, dehydration and psychotropic drug use. These failures could place residents at risk of not receiving the care required to meet their Individualized needs. Findings include: RESIDENT #2 Record review of Resident #2's face sheet, dated 08/09/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include Alzheimer's, urinary tract infection, dementia and mood disorder. Record review of Resident #2's Order Summary report, dated 08/08/23 revealed the following: Regular diet Mechanical Soft texture, Regular/Thin consistency, super cereal with breakfast; house shake with noon/evening meal. Record review of Resident #2's Comprehensive Minimum Data Set, dated [DATE], revealed: -Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. -Section E : No significant data was entered for behavior -Section K: No significant data was entered for nutrition. -Section M Skin Conditions M0150. Risk of pressure ulcers/injuries Is this resident at risk of developing pressure ulcers/injuries? Coded 1 = Yes -Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual Function 09. Behavior 12. Nutrition 16. Pressure Ulcer Record review of Resident #2's care plan, dated 07/11/23, revealed no care plan for vision, behavior, nutritional and pressure ulcer. RESIDENT #4 Record review of Resident #4's face sheet, dated 08/08/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Alzheimer's, major depressive disorder and gout. Record review of Resident #4's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. Section B 1000. Vision Enter Code: 2 - Impaired - sees large print, but not regular print in newspapers/books. Section D Mood: Although the MDS indicated a mood assessment should be conducted the resident was unable to participate in the interview. Section J: Although there was no significant data in the MDS Resident #4 did trigger for falls. Section N Medications N0410. Medication Received B. Antianxiety coded 7 days C. Antidepressant coded 7 days Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual Function 07. Psychosocial Wellbeing 11. Falls 17. Psychotropic Drug Use Record review of Resident #4s Order Summary report, dated 08/08/23 revealed the following medications: -Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) Give 1 capsule by mouth two times a day related to anxiety disorder. Order date 06/02/23 -Buspirone Oral Tablet 5 MG Give 1 tablet by mouth three times a day related to dementia. Order date 06/16/23 Record review of Resident #4's care plan, dated 07/06/23, revealed no care plan for visual, psychosocial wellbeing, falls and psychotropic drug use RESIDENT #5 Record review of Resident #5's face sheet, dated 08/08/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include anxiety, cognitive communication deficit (impaired thought process that allow humans to function successfully and interact meaningfully with each other) and hypertension (high blood pressure). Record review of Resident #5's Comprehensive Minimum Data Set, dated [DATE], revealed: -Section C Brief Interview for Mental Status score revealed a score of 12, which indicated the resident's cognition was moderately impaired. -Section B1000. Vision - coded 2 = Moderately impaired - limited vision; not able to see newspaper headlines but can identify objects. -Section E0800. Rejection of Care-Presence and Frequency revealed behavior occurred 1 to 3 days out of the past 7 days. -Section G0100. Activities of Daily Living (ADL) Assistance revealed bed mobility, transfer, and dressing was all coded 3 = Extensive assistance - resident involved in activity, staff provide weight bearing support and 2 plus person physical assist. Toilet use and personal hygiene was coded 7 = activity occurred only once or twice with one-person assist. -Section G0300. Balance During Transitions and Walking revealed moving from seated to standing position, walking (with assistive device if used), turning around and facing the opposite direction while walking, moving on and off toilet and surface to surface transfer (transfer between bed and chair or wheelchair) was all coded 2 = not steady, only able to stabilize with staff assistance. -Section L Oral/Dental Status revealed mouth or facial pain, discomfort or difficulty with chewing. -Section M Skin Conditions M0150. Risk of pressure ulcers/injuries Is this resident at risk of developing pressure ulcers/injuries? Coded 1 = Yes -Section N Medications N0410. Medication Received C. Antidepressant coded 7 days -Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual Function 04. Communication 06. Urinary Incontinence 09. Behavioral Symptoms 15. Dental Care Record review of Resident #5's care plan, dated 07/10/23, revealed no care plan for visual function, communication, urinary incontinence, behavior or dental care. RESIDENT #7 Record review of Resident #7's face sheet, dated 08/08/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (lung disease), depression (sadness or loneliness), anxiety (feeling of fear, dread and uneasiness), and muscle weakness. Record review of Resident #7's Comprehensive Minimum Data Set, dated [DATE], revealed: -Section C Brief Interview for Mental Status score revealed a score of 09, which indicated the resident's cognition was moderately impaired. -Section B1000. Vision revealed vision impaired - sees large print, but not regular print in newspapers/books. -Section G0100. Activities of Daily Living (ADL) Assistance revealed bed mobility, transfer, walk in room, dressing, eating, and personal hygiene was all coded 3 = Extensive assistance - resident involved in activity, staff provide weight bearing support and 2 plus person physical assist. Toilet use was coded 8 = activity did not occur in the last 7 days. -Section G0120. Bathing revealed physical help in part of bathing activity and coded 4 = total dependence. -Section G0300. Balance During Transitions and Walking revealed moving from seated to standing position, walking (with assistive device if used), turning around and facing the opposite direction while walking, moving on and off toilet and surface to surface transfer (transfer between bed and chair or wheelchair) was all coded 2 = not steady, only able to stabilize with staff assistance. -Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual function 04. Communication 06. Urinary Incontinence 12. Nutritional Status Record review of Resident #7's care plan, dated 07/10/23, revealed no care plan for visual function, communication, urinary incontinence and nutritional status. RESIDENT #9 Record review of Resident #9's face sheet, dated 08/08/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease (cognitive loss), hypertension (high blood pressure) and muscle weakness. Record review of Resident #9's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 06. Urinary Incontinence 16. Pressure Ulcer 17. Psychotropic Drug Use Section G0100. Activities of Daily Living (ADL) Assistance revealed bed mobility, transfer, dressing, eating, and personal hygiene was all coded 3 = Extensive assistance - resident involved in activity, staff provide weight bearing support and 2 plus person physical assist. Toilet use was coded 2 = limited assistance - resident highly involved in activity, staff provide guided maneuvering of limbs or other non-weight bearing assistance and one-person physical assist. Section G0120. Bathing revealed physical help in part of bathing activity and coded 4 = total dependence. Section G0300. Balance During Transitions and Walking revealed moving from seated to standing position, walking (with assistive device if used), turning around and facing the opposite direction while walking, moving on and off toilet and surface to surface transfer (transfer between bed and chair or wheelchair) was all coded 2 = not steady, only able to stabilize with staff assistance. Section M Skin Conditions M0150. Risk of pressure ulcers/injuries Is this resident at risk of developing pressure ulcers/injuries? Coded 1 = Yes Section N Medications N0410. Medication Received C. Antidepressant coded 7 days Record review of Resident #9's care plan, dated 08/04/23, revealed no care plan for urinary incontinence pressure ulcer risk and psychotropic drug use. RESIDENT #14 Record review of Resident #14's face sheet, dated 08/08/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include schizoaffective disorder (mental illness), anxiety (feeling of fear, dread and uneasiness), depression (sadness or loneliness), epilepsy (seizure disorder) and muscle weakness. Record review of Resident #14's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 13, which indicated the resident's cognition was minimally impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual function 06. Urinary Incontinence 12. Nutritional Status 16. Pressure ulcer Section B1000. Vision revealed vision impaired - sees large print, but not regular print in newspapers/books. Section G0100. Activities of Daily Living (ADL) Assistance revealed bed mobility, transfer, walk in room dressing and personal hygiene was all coded 3 = Extensive assistance - resident involved in activity, staff provide weight bearing support and one-person physical assist. Eating and toilet use was coded 7 = activity occurred only once or twice in the last 7 days with one-person physical assist. Section G0300. Balance During Transitions and Walking revealed moving from seated to standing position, walking (with assistive device if used), turning around and facing the opposite direction while walking, moving on and off toilet and surface to surface transfer (transfer between bed and chair or wheelchair) was all coded 2 = not steady, only able to stabilize with staff assistance. Section M0150. Risk of Pressure Ulcer/Injuries revealed resident #14 was at risk for pressure ulcer. Record review of Resident #14's care plan, dated 07/06/23, revealed no care plan for visual function, urinary incontinence, nutritional status and pressure ulcer. RESIDENT #17 Record review of Resident #17's face sheet, dated 08/09/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include Alzheimer's, diarrhea, dementia and mood and anxiety disorder. Record review of Resident #17's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 00, which indicated the resident was unable to complete the interview. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 02. Cognitive Loss 03. Visual 04. Communication 16. Pressure Ulcer Section B 1000. Speech & Vision Enter Code (Speech clarity):1-Unclear speech- slurred or mumble words Enter Code (Makes Self Understood): 3-Rarely/never understands Enter Code (Ability to Understand others): 3-Rarely/never understands Enter Code (Vision): 3 - Highly Impaired - Object identification in question, but eyes appear to follow objects. Section M Skin Conditions M0150. Risk of pressure ulcers/injuries Is this resident at risk of developing pressure ulcers/injuries? Coded 1 = Yes Record review of Resident #17's care plan, dated 07/11/23, revealed no care plan for cognitive loss, visual, communication and pressure ulcer. RESIDENT #27 Record review of Resident #27's face sheet, dated 08/08/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (cognitive loss), depression (sadness or loneliness), hypertension (high blood pressure) and muscle weakness. Record review of Resident #27's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 08, which indicated the resident's cognition was moderately impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 02. Cognitive loss 03. Visual function 04. Communication 06. Urinary Incontinence 12. Nutritional Status 16. Pressure Ulcer Section B1000. Vision revealed vision impaired - sees large print, but not regular print in newspapers/books. Section G0100. Activities of Daily Living (ADL) Assistance revealed bed mobility, transfer, dressing, toilet use, and personal hygiene was all coded 3 = Extensive assistance - resident involved in activity, staff provide weight bearing support and 2 plus person physical assist. Section G0300. Balance During Transitions and Walking revealed moving from seated to standing position, walking (with assistive device if used), turning around and facing the opposite direction while walking, moving on and off toilet and surface to surface transfer (transfer between bed and chair or wheelchair) was all coded 2 = not steady, only able to stabilize with staff assistance. Section K0100. Swallowing disorder revealed Resident #27 had coughing or choking during meals or when swallowing medications in the last 7 days. Section M0150. Risk of Pressure Ulcer/Injuries revealed resident #27 was at risk for pressure ulcer. Record review of Resident #27's care plan, dated 07/10/23, revealed no care plan for cognitive loss, visual function, communication, urinary incontinence, nutritional status and pressure ulcer. RESIDENT #29 Record review of Resident #29's face sheet, dated 08/08/23, revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include dementia (cognitive loss), atrial fibrillation (irregular heartbeat), hypertension (high blood pressure), falls and weakness. Record review of Resident #29's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 02, which indicated the resident's cognition was severely impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 02. Cognitive loss 03. Visual function 04. Communication 06. Urinary Incontinence 07. Psychosocial Well-being 11. Falls Section B1000. Vision revealed vision moderately impaired - limited vision; not able to see newspaper headlines but can identify objects. Section G0100. Activities of Daily Living (ADL) Assistance revealed bed mobility, transfer, dressing, and personal hygiene was all coded 3 = Extensive assistance - resident involved in activity, staff provide weight bearing support and 2 plus person physical assist. Toilet use was coded 2 = limited assistance - Resident highly involved in activity staff provide guided maneuvering of limbs or other non-weight bearing assistance with one-person physical assist. Section G0300. Balance During Transitions and Walking revealed moving from seated to standing position, walking (with assistive device if used), turning around and facing the opposite direction while walking, moving on and off toilet and surface to surface transfer (transfer between bed and chair or wheelchair) was all coded 2 = not steady, only able to stabilize with staff assistance. Section G0120. Bathing was coded 3 = Physical help in part of bathing activity with one-person physical assist. Section J1700. Fall risk revealed Resident #29 was at risk for falls and had falls within the last 6 months. Record review of Resident #29's care plan, dated 07/11/23, revealed no care plan for cognitive loss, visual function, communication, urinary incontinence, psychosocial well-being, and falls. RESIDENT #33 Record review of Resident #33's face sheet, dated 08/08/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include Alzheimer's, repeated falls, abnormal weight loss and psychotic disorder with hallucinations. Record review of Resident #33's Order Summary, dated 08/08/23, revealed: Regular diet Mechanical Soft texture, Regular/Thin consistency, super cereal with breakfast. Record review of Resident #33's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 99, which indicated the resident was unable to complete the interview. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual Function 04. Communication 08. Mood 09. Behavior 11. Falls 12. Nutritional 16. Pressure Ulcer Section B 1000. Speech & Vision Enter Code (Make Self Understood): 2-Sometime understands Enter Code (Ability to Understand Others): 2- Sometime understands Enter Code (Vison): 3 - Highly Impaired - object identification in question, but eyes appear to follow objects. Section D Mood: although the MDS did not reflect significant data Resident #33 triggered for mood in Section V. Section E: Behavior 1. Physical behavioral symptoms directed towards others (hitting, kicking, pushing, scratching and grabbing). As indicted by the MDS these behaviors impacted others by putting them at risk for physical injury. Section J: Falls: Although no significant data reflected in the MDS Resident #33 triggered for falls in Section V. Section K: Nutritional: Resident is on a mechanically altered diet Section M Skin Conditions Resident #33 had a pressure reducing device for chair Record review of Resident #33's care plan, dated 07/10/23, revealed no care plan for visual, communication, mood, behavior, falls, nutritional, pressure ulcer. RESIDENT #46 Record review of Resident #46's face sheet, dated 08/23/23, revealed a [AGE] year-old-female was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include diabetes, cognitive communication deficit, major depressive disorder, Alzheimer's, and depression. Record review of Resident #46's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 99, which indicated the resident was unable to complete the interview. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual Function 04. Communication 06. Urinary 07. Psychosocial Wellbeing 10. Activities 16. Pressure Ulcer 17. Psychotropic Drug Use Section B 1000. Speech & Vision Enter Code (Make Self Understood): 2 - Sometimes Understood Enter Code (Ability to Understand Others): 2 - Sometimes Understood Enter Code (Vison): 3 - Highly Impaired - Object identification in question, but eye appear to follow objects Enter Code (Corrective Lenses): 1 - Yes Section H: Bowel and Bladder Enter Code (Urinary Continence): 2 - Frequently incontinent Enter Code (Bowel continence): 1- occasionally incontinent Section D: Mood: Although no significant data in this section Resident #46 did trigger in section V. Section F: Preferences for Customary Routine and Activities Resident prefers: d. shower g. snacks between meals i. family involvement in care discussions. m. listening to music p. doing things with groups of people. Section M Skin Conditions M0150. Risk of pressure ulcers/injuries Is this resident at risk of developing pressure ulcers/injuries? Coded 1 = Yes Section N Medications N0410. Medication Received A. Antipsychotic coded 7 days Record review of Resident #46 Order Summary, dated 08/08/23, revealed that she took the following medications: VENLAFAXINE 75 MG CAP Give 75 mg by mouth one time a day related to major depressive dis order. Order date 05/30/23. Melatonin Oral Tablet 10 MG (Melatonin) Give 10 mg by mouth in the evening related to insomnia. Record review of Resident #46's care plan, dated 07/11/23, revealed no care plan for visual, communication, urinary, psychosocial wellbeing, activities, pressure ulcer, psychotropic drug use. RESIDENT #47 Record review of Resident #47's face sheet, dated 08/08/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include Alzheimer's, psychotic disorder with delusions, dementia, restlessness and agitation. Record review of Resident #47's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 03. Visual Function 11. Falls Section B 1000. Vision Enter Code: 1 - Impaired - sees large print, but not regular print in newspapers/books. Section J: Falls: Although there was no significant data reflected in the MDS Resident #47 triggered for Falls in Section V. Record review of Resident #47's care plan, dated 07/11/23, revealed no care plan for visual and falls RESIDENT #48 Record review of Resident #48's face sheet, dated 08/08/23, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include type 2 diabetes, anxiety disorder, slowness and poor responsiveness, and dementia. Record review of Resident #48's Order Summary, dated 08/08/23, revealed she took the following medications: Probiotic Oral Capsule (Saccharomyces boulardii) Give 1 capsule by mouth one time a day related to urinary tract infection. Order date 07/05/23. Paxil Oral Tablet (Paroxetine HCl) Give 10 mg by mouth at bedtime related to mood disorder. Order date 07/09/23. Record review of Resident 48's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 03, which indicated the resident's cognition was severely impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 02. Cognitive loss 06. Urinary 12. Nutritional 16. Pressure Ulcer Section H Bladder and Bowel Enter Code (Urinary Continence): 1 - Occasionally incontinent Enter Code (Bowel continence): 2- Frequently incontinent Section K Nutrition: Although there was no significant data in the MDS Resident #48 triggered for nutrition in Section V. (Please not record review of the order summary did not reflect an altered diet,) Section M Skin Conditions M0150. Risk of pressure ulcers/injuries Is this resident at risk of developing pressure ulcers/injuries? Coded 1 = Yes Record review of Resident #48's care plan, dated 07/12/23, revealed no care plan for cognitive loss, urinary, nutritional and pressure ulcer. RESIDENT #53 Record review of Resident 53's face sheet, dated 08/08/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia, urinary [NAME] infection, mood disorder and anxiety. Record review of Resident #53's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 02, which indicated the resident's cognition was severely impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 06. Urinary 14. Dehydration 17. Psychotropic Drug Use Section H Bladder and Bowel Enter Code (Urinary Continence): 1 - Occasionally incontinent Enter Code (Bowel continence): 9- Not rated because the resident did not have a bowel movement within the 7 day time period. Section K: Although there was no significant data in this are please not the resident did trigger for dehydration in section V. Section N Medications N0410. Medication Received B. Antianxiety coded 3 days C. Antidepressant coded 4 days Record review of Resident 48's care plan, dated 07/12/23 revealed no care plan for urinary, dehydration and psychotropic drug use. During an interview on 08/09/23 at 08:28 AM, the ADM said that the most recent and updated information should be in EMR A. He said they transitioned to EMR A on 06/01/23 He said they did have a binder with old care plans from EMR B, but if the care plan was in EMR A then that was the most updated one and the one that staff should be using. When asked if there was a list of care plans that had not been updated, he said the MDS Coordinator may have one. During an interview on 08/09/23 at 09:37 AM, the MDS coordinator said if the care plan was in EMR A, it was the most updated one and the one the staff should be using. She said that she had a list of residents' care plans that were not complete. She said all of [NAME] Hall was not complete, and three residents of Ritz Hall were not complete. She said all other care plans for the other residents in the remaining halls were complete. She said once the care plan was completed in EMR A, then the care plan in EMR B was no longer valid. During an interview and record reviews on 08/09/23 at 02:34 PM, the MDS Coordinator said she was responsible for care plans, but other departments entered information into resident care plans. She said all the staff (nurses and CNAs) use the care plans. She said the care plan was how you take care of your resident. She said a care plan included the diagnosis and any assistive devices the resident may use. She said she includes ADLs. She said she does use the MDS and the triggered CAAs. She said if it was triggered in (Section V). said that she tried to avoid duplication when she did care plans, so some of the care plans may include two or more triggered areas of concern. She said no system was in place to help monitor the care plans. She said that after she completed them, no one checked them. She said she did have help with the care plans at one point but would take full responsibility for the care plans. She went over the following residents' care plans in the presence of the surveyor. She said she was unsure why all the care plans were missing. Resident #4 She confirmed the following did trigger in the most recent comprehensive assessment and that they were not care planned (visual, psychosocial wellbeing, falls, and psychotropic drug use). Resident #48: She confirmed the following did trigger in the most recent comprehensive assessment and that they were not care planned (Cognitive loss, Urinary, nutritional, and pressure ulcer). Resident #2: She confirmed the following did trigger in the most recent comprehensive assessment and that they were not care planned (Visual, behavior, nutrition, and pressure ulcer). Resident #46: She confirmed the following did trigger in the most recent comprehensive assessment and that they were not care planned (Visual, communication, psychosocial wellbeing, activities, pressure ulcer, and psychotropic drug use). Resident #53: She confirmed the following did trigger in the most recent comprehensive assessment and that they were not care planned (Urinary, dehydration, and psychotropic drug use). Resident #33: She confirmed the following did trigger in the most recent comprehensive assessment and that they were not care planned (visual, communication, mood, behavior, falls, nutritional and pressure ulcer). Resident #17: She confirmed the following did trigger in the most recent comprehensive assessment and that they were not care planned (cognitive loss, visual, communication, and pressure ulcer) During an interview and record review on 08/10/23 at 12:28 PM the MDS coordinator said the facility had used EMR A since 06/01/23 She said the potential negative outcome of incomplete care plans would have been that staff would not know how to care for the residents properly. She said the missing care plans could affect the resident's communication ability, nutrition, and the necessary daily items, such as glasses. She said there was no reason why the care plans were missed. She said she had been trained on how to do care plans. She said she had worked hard on the care plans in EMR B. She stated that EMR A contained the most recent care plans that staff would have used. She went over the following remaining residents' care plans in the presence

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation, in that: 1) Dietary staff (Dietary Worker A, B and the DM) failed to store, serve or process foods in a manner to prevent contamination, 2) Dietary staff (CNA I, Alternative Dining Worker A, & B) failed to properly wear hair restraints while in the food preparation area, 3) Dietary Staff (Dietary A) failed to exhibit proper handwashing after removal of gloves. These failures could place residents at risk for food contamination and foodborne illness. The findings include: On 08/08/23 at 09:50 AM, an observation revealed a dented can of green beans dated 08/07/23 and a dented can of blueberry filling dated 07/03/23. On 08/08/23 at 10:02 AM, an observation revealed 15 crème pies in a tray. The crème pies were not labeled with a date or a discard date. On 08/08/23 at 10:22 AM, an observation revealed Alternative Dining Worker A and Alternative Dining Worker B, with hair restraints worn improperly. Hair was sticking out along both sides of their face. Alternative Dining Workers A and Alternative Dining Worker B were assisting in plating food to take outside the facility. Alternative Dining Worker A exited the kitchen at 10:24 AM while the DM corrected the Alternative Dining Worker B at 10:25 AM. During an interview on 08/08/23 at 10:15 AM, the DM said all dented cans should be placed in her office. She said she was responsible for ensuring the dented cans were not in the pantry. She said when she received a dented can, she stores them in her office, contacts the vendor, and waits for a refund or the vendor to replace the dented item. She said she must have missed the dented cans when putting the items up from the vendor. She stated the crème pies in the freezer and said those items should have been labeled. On 08/08/23 at 11:26 AM, an observation revealed CNA I entered the kitchen. She did not wash her hands. She had on a hairnet, but all of her hair was not properly restrained. There was hair along the left side of her face that was not restrained with the hair restraint. She enetered the kitchen and obtained juice from the refrigerator. She exited the kitchen after obtaining the juice. On 08/08/23 at 11:35 AM, an observation revealed two trays of cookies stacked on each other. Both trays of cookies were not covered. Half of the bottom tray of cookies was exposed to the bottom of the pan. On 08/08/23 at 11:36 AM, observation revealed that Dietary Worker A shifted the top tray of cookies to the other half of the exposed cookies. On 08/08/23 at 11:39 AM, observation revealed that Dietary Worker A touched the cookies with her bare hand before putting her gloves on. On 08/08/23 at 11:43 AM, observation revealed that Dietary Worker A removed her gloves and did not wash her hands. She walked over to the oven, placed on oven mitts, pulled the pan out of the oven, took the temperature of the food, and placed the food back in the oven. She returned to the workstation with the cookies and placed another pair of gloves on without washing her hands. During an interview on 08/08/23 at 12:19 PM, CNA I said that she had been trained not to enter the kitchen. She said she entered the kitchen because the other workers appeared busy. She stated she did not wash her hands when she entered the kitchen but said she washed her hands before entering the kitchen. She said she was unaware pieces of her hair were sticking out. She said she had been trained to ensure all of her hair was in the hair net. She stated that pieces of her hair were sticking out. During an interview on 08/09/23 at 02:03 PM, the DM said she was responsible for ensuring that hairnets were worn properly. She said the Meals on Wheels staff are trained wherever they come from. She said she did not notice the hair hanging out on both staff. In regard to labeling the food in the fridge, she said the worker that made and or plated the food item would have been responsible for labeling. However, as the DM, she ensured that all food in the fridge and freezers were labeled properly. She said Dietary Worker B was responsible for making the crème pies that were not labeled. In regard to the stacked exposed cookies, she said it was customary that before stacking and pans, the food was not exposed and covered with a liner of some sort. She said she did not notice that those cookies were stacked. She said she had been trained to wash her hands after removing gloves, and her staff had also been trained. She said it was also the facility policy for kitchen staff to wash their hands once they entered the kitchen. She said she did not see the staff touch the cookies with her bare hands or remove her gloves and not wash her hands. She said she did not see the non-kitchen staff enter the kitchen area and retrieve the juice from the fridge. She said the potential negative outcome of unrestrained hair was hair could fall into the food. She said this could affect the resident because it would not be good, and the residents could get sick. She said touching food with bare hands could cause contamination, and the residents could get sick. She said failure to wash hands could cause contamination of the food and could make the residents sick. She said not correctly labeling the Creme pies, staff may not know when the food item was made. She said not knowing when food is made risks the resident getting sick because staff would not know when items were made and if the food item needed to be thrown away. She said she was the only one that received the items from the delivery truck and placed the items in the pantry. She said there were no other systems in place to check for the deficient practice identified outside of her as the DM observed and corrected them as she saw them. During an interview on 08/09/23 at 02:15 PM, Dietary Worker A said she had been trained to wash after she removed her gloves. She said she knew she had not washed her hands but forgot. She knew she had to wash before and after, but she said she was nervous. In regard to touching the cookies with her bare hands, she said she could not remember if she had done that, but it might have happened. She said it was never ok because it was contamination of the food and could get residents sick. Regarding the exposed cookies stacked on each other, she said she was waiting for the cookies to cool down. She said she did not cover them because the paper would stick to the cookies when they were hot. After the incident, she could see what the issue was, but when she did it, she did not think about the cookies on the bottom being exposed to the bottom of the other pan. She said non-kitchen staff was not supposed to come into the kitchen. She said she did not see the non-kitchen staff come into the kitchen. She said the facility process was for the kitchen staff to provide non-kitchen staff with what they need. She said it was the facility process that when entering the kitchen, they should wash their hands first so staff do not risk contamination. During an interview on 08/09/23 at 02:24 PM, Dietary worker B asked about the pies, and she said she believed the label must have fallen off because she remembered that she did label the pies. She said maybe she did not stick it on correctly. She said she had been trained to label all the food in the fridge or the freezer. When asked what the potential negative outcome was, she said labeling the food was to identify what the food was and when it was made. She said that not having the food labeled, staff would notnow what and when to serve. She said if they do not know when the food was placed in the fridge, it could make the residents sick. During an interview on 08/10/23 at 01:26 PM, the ADM revealed he expected anyone within the food service area to have a hair net on and all their hair restrained. He said all dented cans would be inspected upon delivery or before opening. He said the dented cans should be stored separately from the other canned items for resident consumption. He said the location was in the DM office but that he intended to change this location. He was not aware of any issues with hairnets or dented cans. He said handwashing was ongoing. It was never brought to his attention that staff had entered the kitchen area. He said he expected everyone should wash their hands when they enter the kitchen and that a hair net should be properly placed. When asked if there was a system to monitor the kitchen activities, he said he would conduct random checks in the kitchen. He said he usually verified there was a hairnet in place but had never checked to see if any excess hair was hanging out. He said the DM was responsible. He said he could not think of a potential negative outcome for dented cans. He said he also could see a specific negative outcome for the residents for the hair nets, but that hand hygiene was important because that prevented food-borne precautions. He said he did not have a potentially negative outcome for non-kitchen staff entering the food service area because this had never been an issue. He said he expected that non-kitchen staff should ask the kitchen staff what they need in the kitchen. Record review of facility policy titled Food Preparation and Service dated November 2022 (revised), revealed the following: Policy Statement Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices. Food Distribution and Service Food and nutrition services staff, including nursing services personnel, wash their hands before serving food to residents. Employees also wash their hands after collecting soiled plates and food waste prior to handling food trays. Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves are single-use items and are discarded after each use. Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) in food preparation area so that hair does not contact food. Record review of facility policy titled Food Receiving and Storage dated November 2022 (revised), revealed the following: Policy Statement Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation (5) When food is delivered to the facility it is inspected for safe transport and quality before being accepted. Cans are inspected prior to use to verify they are not dented. Dented cans will not be used, but will be placed on return shelf for return to food vendor. Refrigerated/Frozen Storage All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded. Record review of facility policy titled Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices dated November 2022 (revised), revealed the following: Policy Statement Food and nutrition services employees follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Policy Interpretation and Implementation 1. All employees who handle, prepare or serve food are trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents. Hand Washing/Hand Hygiene 2. Employees must wash their hands: a. after personal body functions (i.e., toileting, blowing/wiping nose, coughing, sneezing, etc.); b. after using tobacco, eating or drinking; c. whenever entering or re-entering the kitchen; d. before coming in contact with any food surfaces; e. after handling raw meat, poultry or fish and when switching between working with raw food and working with ready-to-eat food; f. after handling soiled equipment or utensils; g. during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and/or h. after engaging in other activities that contaminate the hands. 3. Gloves and Direct Food Contact 4. Contact between food and bare (ungloved) hands is prohibited. 5. Gloves are considered single-use items and must be discarded after completing the task for which they are used. Gloves are removed, hands are washed and gloves are replaced: a. after direct contact with residents; b. after assisting with medical treatments; c. between handling raw meats and ready-to-eat foods; and d. between handling soiled and clean dishes. 6. The use of disposable gloves does not substitute for proper handwashing. 7. Gloves are worn when directly touching ready-to-eat foods. 8. Gloves are used when serving residents who are on transmission-based precautions. 9. Gloves are not required when distributing foods to residents at the dining tables or when assisting residents to eat, unless touching ready-to-eat food. 10. Food service employees are trained in the proper use of utensils such as tongs, gloves, deli paper and spatulas as tools to prevent foodborne illness. Hair Nets 11. Hair nets or caps and/or beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens. 12. Hair nets are not required when distributing foods to residents at the dining tables or when assisting residents to dine.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, and psychosocial needs for 1 of 15 residents (Residents #28) reviewed for care plans as follows: The facility failed to develop a care plan for visual and communication for Resident #28 This failure could place residents at risk of not receiving the care required to meet their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: Resident #28 Record review of Resident 28's face sheet (undated) documented a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: dysphagia ( difficulty swallowing), generalized anxiety disorder and adjustment disorder (emotional or behavioral reaction to a stressful event or change) with depressed mood. Record Review of Resident #28's comprehensive admission MDS (Minimum Data Set) assessment dated [DATE] documented the following: Section B - Hearing, Speech, and Vision B1200. Corrective Lenses No B0200. Hearing 2. Moderate Difficulty- Speaker has to increase volume and speak distinctly B1000. Vision 1. Impaired- sees large print, but not regular print in newspapers/books Section C - Cognitive Patterns - C0500. BIMS (Brief Interview for Mental Status) Summary Score = 10 moderately impaired cognitively (Alert and Oriented x time, place, person). Section I Active Diagnosis Vision I6500 Cataracts, Glaucoma, or Macular Degeneration ( Not marked or checked) (Orders did not reflect these diagnoses) Section Q Participation in Assessment and Goal Setting Q0100 Participation in Assessment A. Resident Participated in assessment 1 Yes Section V - Care Area Assessment Summary (3) Visual (4) Communication Record Review of Resident #28's admission Report dated 05/19/22 revealed the following: Hearing: Minimal difficulty- difficulty in some environments Vision: Impaired Sees large print, but not regular print in newspapers Corrective lenses: Yes Record Review of Resident #28's Care Plan (undated) did not reveal a care plan that included measurable objectives, interventions and time frames for visual and communication. Record Review of Resident #28's Care Plan (undated) specifically, the altered mental status care plan did not include any goals, interventions or measurable objectives specific to how to communicate with Resident #28. Record Review of Resident #28's Care Plan dated (undated) did not reveal any data that suggest the resident has any visual impairments. On 06/29/22 at 11:55 AM, an observation was made of an HGTV magazine (regular print) on Resident #28 bedside table. During an interview with Resident #28 on 06/29/22 at 1:29 PM, she said she has a hard time seeing but has glasses. She said that she had not worn them in a while. She did not have a reason why she had not used her glasses but pointed in the direction where she thought her glasses were. She said she could communicate and hoped the staff could understand her. The interview was cut short as the resident stated that she was uncomfortable and in pain. The interview stopped so staff could provide care. During the interview it was difficult to hear the resident. Surveyor had to get close to understand Resident #28. During an interview with the Confidential Staff B on 06/29/22 at 12:03 PM, she stated that she has worked with Resident #28 and has observed her doing puzzles. She stated the resident said that she could barely see. She stated the resident does wear glasses. She stated the resident has not been wearing them because she wears oxygen. She stated she knows a care plan but has never looked at it and does not know where they are located. She said that she gets her information verbally from other staff. She stated that she has worked with the resident long but that communication could be difficult if you do not know her. She stated that the resident speaks very low. You have to get really close to her to hear what her needs are. During an interview with the Confidential Staff C on 06/29/22 at 1:31 PM, she stated she does not know what a care plan is. She stated she had not used a care plan. She said she knows what care the resident needs because she is verbally told by other staff. She said Resident #28 talks really low, and you must pay close attention to her to know she is speaking to you and what she is saying. She stated the resident does wear glasses. She said she has not received specific training on Resident #28 but has worked with her and has gotten to know her. During an interview with the Confidential Staff D on 06/29/22 at 1:33 PM, she said she works with Resident #28. She said the resident does not have a visual impairment that she knows of. She said the resident has changed in and appears to talk more softly, making it difficult to hear her. She said the resident seemed more sleepy. She said that the resident is not communicating as much. She said that she knows a care plan but has never seen one. She said she gets a verbal report from staff about residents. During an interview with the Confidential Staff A on 06/29/22 at 1:38 PM, she said she was the one who gave the resident the HGTV magazine (with regular print) to the resident. She said she has worked with Resident #28 and that the resident has difficulty hearing and speaks very softly. She said Resident #28 could speak for herself and understands, but if you don't know her, you may not know she is talking. She said she was unaware of Resident #28 visual impairment. She said she had not been trained regarding Resident #28 particular need for large print items. During an interview with the Nurse Consultant on 06/28/2022 at 2:58 PM revealed that the facility used MDS consultants to complete the MDS Assessments and the care plans. She reported that she was ultimately responsible for care plans while the new DON was being trained for her new position. During this interview, she did not see a visual care plan for Resident #28. She stated that a negative outcome for a resident that triggered for visual and was not care planned might be that the resident may not recognize who is coming in the room or may not recognize their surroundings. During this interview, she confirmed after looking at the care plan for the resident that a communication care plan had not been completed. She stated that failure to care plan for communication for a resident that triggered would make it difficult for the resident to request their preferences. She reported the care plan is a plan that communicates the plan of care for the resident. She stated that all direct care, such as the nurses, utilize the plan. She said that the nurse completing the care plan decides if care plans can be combined, meaning that more than one care plan can be listed within one individual care plan. She said she is sure this is in their facility policy. She stated she had been trained on care plans. She said she needed more time to review the file. When questioned about the accuracy of the MDS assessment, she said the MDS should be correct to her knowledge. She confirmed that the triggered areas from the MDS would have been accurate based on the MDS assessment to her knowledge. During an interview with the DON on 06/28/22 at 3:22 PM, she stated she had not been in her role very long. She stated a care plan is a plan that includes goals and outcomes for the resident. She said that if a triggered care plan is not addressed, then things can slip through the cracks. During an interview with the Administrator on 06/29/22 at 10:21 AM, he said the care plan is a 1st person's perspective of how to care for a resident. He stated that all staff utilizes the care plan to provide care for the resident. He said that the Nursing Consultant is responsible for care plans. He stated that care plans had been discussed in their weekly stand-up meetings due to a previous survey a month ago. He said he believed they were halfway through checking the residents care plans in the facility. After consulting with the DON, he could not verbally tell the surveyor which resident they were on. He stated that this had been cited a month ago, and as a response to this deficient practice, they conducted an audit (weekly) and an internal audit using consultants monthly. He stated that care plans should be individualized and tailored to the resident. He did not provide an answer specifically to the negative outcome regarding communication stating it depended on the severity of the communication issue. He said regarding Resident #28 visual care plan that if she is supposed to receive large-print reading material, this could inconvenience the resident. When asked if this was important, even though it has nothing to do with nursing directly, he stated this inconvenience is significant because the facility is their home and should not be inconvenienced. He said he expects the care plan fits the resident's needs. During an interview with the Nurse Consultant on 06/29/22 at 10:00 AM, she said she reviewed the file. She said that the resident was able to communicate and understands people. She stated that she was unsure why this was triggered. She stated that the resident was triggered for visual because of cataracts, eye pain, and decreased visual acuity. She said she could not attest to the MDS assessment's accuracy as someone else completed it. She stated the resident reads large print. She stated the resident no longer wears her glasses. She stated that the course nurses' aids take teaches them basic care of residents. When asked if providing large print to all residents was a part of the training, she stated the staff would be able to care for the resident's communication and visual needs. She stated she does not feel that there is a negative outcome for the resident at this time. She said that just because the information is not in the care plan does not mean the resident's needs will not be met. When asked what could be the negative outcome for a resident that triggered communication or visual care areas, the nurse consultant responded, I will not talk about hypothetical. She stated that she could not state why the care plans were not done. She stated her expectation for care plans is that all required portions are completed. She said that she expected section v of the MDS, known as the care area assessment, to be addressed in the care plan. At 10:32 AM, she stated in response to the Administrator and DON searching for documentation that reflected the status of the care plan audits, that all care plans had been reviewed and addressed. During an interview with the Co-founder on 06/29/22 at 10:56 AM, he said he was responsible for overseeing all operations. He stated he did not have any additional information regarding care plans because when the facility was first cited, he was out of town. However, he stated that the facility did hire consultants due to being cited on care plans prior to the full book survey. He said as a part of the plan of action, all care plans should have been reviewed, audits should have been completed, and all care plans should have been revised by 06/15/22. When asked about the status of the revision of the care plans and if by the standard of the facility recent action plan, was Resident #28's reviewed and revised, he explained that the definition of revised is edit. He said he could not attest that Resident #28's care plan had been edited or not. During an interview with the MDS Clinical Director on 06/29/22 at 10:58 AM, she stated she is responsible for completing the care plans for the facility at this time. She said that she had personally completed the care plan for Resident #28. She stated a care plan should give staff an idea of the resident's current status. She said that she compares the MDS assessment to the care plan so that she can create the care plan. She said that she recently updated Resident #28 care plan on 06/27/22. She said that if the care area is triggered in the MDS, there is usually a care plan created associated with the triggered care area. She stated if a person triggers for a care area and it was not care planned, staff would not be able to address that area effectively. When asked specifically about adverse outcomes for the resident, she said that she did not feel the resident's care was being affected at the time. She stated she feels the resident communication was addressed under altered mental status. She said that she did not complete a vision care plan. No reason was provided as to why this care plan had not been completed. When asked why a care plan was not completed even though the MDS stated a care plan had been completed, no specific answer was provided. During an interview with the MDS Clinical Director Supervisor on 06/29/22 at 10:58 AM, she said the care plan is based on the MDS. She said that care plans could be combined. She interjected while the interview was being conducted with the MDS Clinical Director and stated that the MDS Clinical Director is trying to say that care plans can be included in other areas if the triggered care area is not a critical need. During an interview with the DON on 06/29/22 at 11:56 AM, she stated she was unsure who left the HGTV magazine (regular print) on Resident #28 bedside table. She said it may have been one of her family members. Record review of the facility policy Care Plans, Comprehensive Person-Centered, (Revised March 2022), revealed the following documentation: Policy Statement: A comprehensive, person centered care plan that includes measurable objectives and timetables to meet the residents physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation (3) The care plan interventions are derived from a thorough analysis of the information gathered as apart of the comprehensive assessment. (6) The comprehensive, person-centered care plan: a. Measurable objectives and timeframes b. Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . c. Build on resident's strengths; and d. Reflects currently recognized standards of practice for problem areas and conditions

Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 2 out of 23 days reviewed for RN coverage. The facility failed to ensure they had RN coverage 8 hours a day, 7 days a week for the following days: 06/04/22 and 06/05/22 This failure could place residents at risk for inconsistency in care and services. Findings include: Record review of Employee Roster 06/27/22 revealed five registered nurses. Record review of Registered Nurse B's Payroll Detail dated 06/27/22 for time period 05/27/22 through 06/26/22 revealed the following: 06/03/22: 06:18 PM Clock IN and 06:49 AM Clock OUT on 06/04/22 (6hrs 49 min worked on 6/4/22) 06/04/22: 06:00 PM Clock IN and 07:02 AM Clock OUT on 06/05/22 (7hrs 02 min worked on 6/5/22) During an interview on 06/29/22 at 09:55 AM the Nurse Consultant stated they have always used the RN on the night shift for RN coverage. She stated the DON and ADON's were responsible for scheduling RN coverage. She stated they were supposed to call agency or nurse consultant if they do not have RN coverage. She stated the RN requirement was 8 hours a day. She stated they ensured RN coverage by looking at the schedule. When asked why it was important to have an RN on duty, she stated Beats me, because it's required. When asked what the potential negative outcome for no RN coverage was, she stated, None in my opinion. During an interview on 06/29/22 at 10:16 AM the Administrator stated it is the DON's responsibility to schedule RN coverage. He stated the DON is new and still in training and the June schedule was already made by the former DON. He stated if no RN coverage is scheduled, they are to find coverage using staffing agency or the multiple RN employees. He stated the RN requirement is eight consecutive hours within a 24-hour period. He stated they ensure RN coverage in morning standup meetings. He stated it is important to have RN coverage to ensure you have skills necessary to care for residents and pronounce at times when needed. When asked what the potential negative outcome for no RN coverage could be, he stated I am having a hard time thinking due to other nurses in the building and RN accessibility out in the community. Record review of the provided facility policy labeled Director of Nursing Services, RN Coverage revised August 2006 revealed, Policy Statement: The Nursing Services department is under the direct supervision of a Registered Nurse. Policy Interpretation and Implementation 3. Every 24-hour period will have 8 consecutive hours of coverage by a Registered Nurse.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for residents who consumed food from 1 of 1 facility kitchen in that: 1) Food was not dated properly in the refrigerator. 2) A grey fuzzy substance was clinging to the top shelf in the walk-in refrigerator. 3) Glasses were found in the drying area upside down on top of trays with moisture trapped in the glasses. 4) Bowls were found stored upside down on trays on a shelf under a prep table with moisture trapped inside the bowls. 5) Two kitchen staff members, Dietary Aide A and Dietary Aide B, failed to perform correct hand hygiene. 6 One single serve ice cream container was on the floor of the walk-in freezer underneath a shelving unit. 7) The temperature of the juice dispenser refrigerated compartment was too hot. 8) Dry goods were improperly stored and unsealed. 9) Food prep tables were grimy on the undersides of the edges. 10) Sanitizing solution in 1 of 2 buckets did not meet the minimum ppm required by manufacturer, according to test strip color. These failures could place residents at risk of foodborne illnesses and cross contamination. The findings included: The following observations were made in the kitchen on 6/27/22 between 10:00 AM and 11:10 AM: In an observation made on 06/27/22 at 10:03 AM, Dietary Aide B was observed performing hand washing at the sink near the dishwasher. She did not perform proper hand washing as she touched the automatic paper towel dispenser twice instead of waving her hand in front of the dispenser, thus contaminating the cleaned hand. In an observation made on 06/27/22 at 10:05 AM, the sanitizing solution in the red bucket for wiping down tables was observed to be cloudy. The kitchen staff tested the solution using test strips. The test strip indicated the solution was below the required ppm ratio. The strip remained the original orange in color, which indicated 0 - 100 ppm of quaternary solution (150 - 200 ppm required by the manufacturer guideline and facility policy Sanitization). In an observation made on 06/27/22 between 10:07 AM - 10:16 AM of the walk-in refrigerator, a grey fuzzy substance was observed clinging to the front and top of the shelving unit to the left of the door when entering. Three improperly dated foods were in the walk-in refrigerator. The first was a cheese liquid in a steam table pan. It was dated with only one date, 6/22/22, in marker on the plastic wrap covering. There was no indication of what this date meant, if it was a made on, use by, or expires by date. At least 5 individual, still sealed packages of whipped topping were piled in a large plastic tub which had a date of 6/13/22 affixed to the tub. Again, there was no indication of whether this was a use by or expires by date. No manufacturer expiration date could be found on the individual packaging. A large block of opened cream cheese was in a zipped bag with a single handwritten date of 06/13/22 as the date opened, but no expiration date was visible on the zip locked bag. In an observation made on 06/27/22 at 11:05 AM, one single serve container of ice cream was observed on the floor of the walk-in freezer under the shelving unit and was not stored on a shelf off the floor as required. During an interview on 06/27/22 at 11:02 with the Dietary Manager, regarding the grey fuzzy substance clinging to a top shelf in the walk-in refrigerator, she said, Well to me it looks like mold. When asked about the items in the walk-in refrigerator that lacked an expiration date, she said that having one date on the items was confusing and made it difficult to determine when an item should be discarded. She then discarded the items in the walk-in fridge that lacked an expiration date. The following observations were made in the kitchen on 6/29/22 between 10:35 AM and 11:20 AM: In an observation made on 06/29/22 at 10:40 AM, three trays of upside-down glasses were observed in the dish drying area. 3 of 3 trays had glasses with moisture trapped inside. The trapped moisture was visible as the glasses were made of clear patterned plastic, the bottom tray had 18 containers, the top two trays had approximately 16 containers each. In an observation made on 06/29/22 between 10:45 AM and 10:50 AM, the curve under edges of all prep tables in the kitchen area were found to be grimy, as measured by running fingers along the inside of the curve. Inside the edges of 4 of the 4 prep tables, there was grime. On 2 of the 4 tables, crumbs were also present on the curved edges on the underside of the preparation tables. A sticky paper with food residue was removed from one table and was visibly soiled. In an observation made on 06/29/22 at 11:00 AM, an open, unsealed bag of chocolate chips was found in the drawer of the baking prep table. In an observation made on 06/29/22 at 11:06 AM, the juice dispenser did not have a thermometer inside of the refrigerated portion. Dietary Manager took a thermometer from one of the refrigerators and placed it in the refrigerated portion of the juice dispenser. An observation on 6/29/22 at 12:00 PM showed the temperature being taken of the juice was 48.3. According to the thermometer, the air inside the refrigerated portion of the juice dispenser was 70 degrees. As a result of the juice being held at a temperature above 41 degrees, the juice was discarded by the Dietary Manager per facility policy Food Service and Preparation. In an observation made on 06/29/22 at 11:12 AM, two trays of small plastic serving bowls were observed stored upside-down on a shelf under a prep table. 2 of the 2 trays of bowls had moisture in the bowls and on the trays. In an observation made on 6/29/22 at 11:15 AM, Dietary Aide A was observed having entered the kitchen from the dining room and, without washing her hands, pick up a steam table container and continue to work on preparing food until corrected by the Dietary Manager and told to wash her hands. During an interview on 6/29/22 at 10:43 AM, the Dietary Manager was asked about glasses that were upside-down on a plastic tray and had moisture trapped inside. She stated that this could cause contamination and that the items should be allowed to drip dry with air flow beneath for proper cleaning and to prevent contamination. During an interview on 6/29/22 at 10:50 AM the Dietary Manager was asked about the cleaning of the underside of preparation tables, and the Dietary Manager stated the cleaning of all surfaces of the preparation tables is a scheduled cleaning task. She stated that lack of cleaning could cause illness in a resident. During an interview on 06/29/22 at 11:00 AM when shown the open, unsealed chocolate chips in the drawer of the baking prep table, the Dietary Manager acknowledged that it was unsealed and improperly stored and took the bag and threw it away. She noted it should be sealed with a use by date for proper storage. During an interview on 06/29/22 at 11:18 AM, the Dietary Manager provided a copy of the walk-in refrigerator cleaning schedule. She said the walk-in refrigerator was cleaned with the sanitizing solution in the red buckets using a white cloth. Referring to the possible negative outcome of mold in the walk-in refrigerator, Dietary Manager stated, Oh, that is no good, somebody could get sick from that and it could just build up in other food. During an interview on 06/29/22 at 11:27 AM when the Administrator was asked about his expectations of the cleanliness of the walk-in he said, Simple answer, it should be clean. He stated dietary management was responsible for the cleanliness of the walk-in refrigerator. When asked about disposal of expired food or improperly dated food in the walk-in, he stated that the primary responsibility resides with dietary management. He said his expectation regarding dates on food items was that a label gun was used on all pantry items and dated plastic wrap or stickers are used for cold items showing the dates received, opened, and expired. During an interview on 6/29/22 at 1:50 PM with the Dietary Manager, when asked what a negative outcome could be for food/drink stored at incorrect temperatures could be, the Dietary Manager stated that food or drink stored at incorrect temperature could lead to foodborne illness. She acknowledged that the expired and improperly dated food found in the walk-in refrigerator on Monday 6/27/22 could lead to illness in residents. She further stated it is the responsibility of dietary staff to ensure correct temperatures and proper labeling and dating of food. When asked about hand hygiene of kitchen staff she said it is a requirement for proper hand hygiene to be performed by every person entering the kitchen from any other room to minimize contamination. She further explained that improper cleaning of the hands could lead to illness for a resident. She stated they do monthly refreshers on hand hygiene, so staff do not become complacent. Record review of the facility policy dated 2008 and titled, Sanitization reflected the following; The food service area shall be maintained in a clean and sanitary manner. 1. All kitchens, kitchen areas and dining areas shall be kept clean, free from litter and rubbish and protected from rodents, roaches, flies, and other insects. 4. Sanitizing of environmental surfaces will be performed with one of the following solutions: b. 150-200 ppm quaternary ammonium compound (QAC) 9. Food preparation equipment and utensils that are manually washed will be allowed to air dry whenever practical. 13. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. 14. The food services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas . Record review of the facility policy dated 2019 and titled, Food Preparation and Service Food and nutrition services employees prepare and serve food in a manner that complies with safe food handling practices. Food Preparation Area . 4. Appropriate measures are used to prevent cross-contamination. These include: c. Sanitizing towels and cloths used for wiping surfaces in containers filled with approved sanitizing solution (at concentrations specified by the manufacturer of the solution used); and d. Cleaning and sanitizing work surfaces (including cutting boards) and food-contact equipment between uses, following food code guidelines. 5. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of food-borne illness. Food Preparation, Cooking and Holding Time/Temperatures 1. The 'danger zone' for food temperatures is between 41 degrees F and 134 degrees F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. Food Service/Distribution 1. Proper hot and cold temperatures are maintained during food service. Foods that are held in the temperature 'danger zone' are discarded after 4 hours. Record review of the facility policy dated 2017 and titled, Food Receiving and Storage Foods shall be received and stored in a manner that complies with safe food handling and practices. 1. Food Services, or other designated staff, will maintain clean food storage areas at all times. 5. Non-refrigerated foods, disposable dishware and napkins will be stored in a designated dry storage unit which is temperature and humidity controlled, free of insects and rodents and kept clean. 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Such foods will be rotated using a first in - first out system. 9. Refrigerated foods must be stored below 41 degrees F unless otherwise specified by law. 12. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the food and nutrition services manager or designee and documented according to state-specific requirements. Record review of the kitchen cleaning schedule dated June 2022 and provided by Dietary Manager Review of this schedule indicates that the last time the walk-in refrigerator was cleaned was 06/27/22. The previous documented cleaning was 06/09/22. In addition, all surfaces of the preparation tables were assigned to be cleaned 6/17/22. The facility was asked to provide a copy of hand hygiene requirements in the kitchen but failed to produce any guidelines and informed surveyors no such policy exists. An additional opportunity to provide further evidence was given at the exit conference, the facility declined to provide any further documentation at that time.