**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review; it was determined the facility failed to ensure that in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete, accurately documented, and readily accessible for 1 of 6 residents reviewed for clinical records (Resident #1) in that: The facility failed to conduct a fall risk assessment for Resident #1. This failure could place residents at risk of increased falls. The findings included: Record review of Resident #1's Face sheet, dated 02/13/2025, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included, but were not limited to, Hemiplegia and hemiparesis (weakness in one leg, arm or side) the left dominant side following cerebrovascular disease (stroke), anemia and hypertension. Record review of Resident #1's quarterly MDS assessment, dated 02/04/2025, revealed he had a BIMS of 12 out of 15, which indicated he had mild cognitive impairment. Resident #1 needed maximal assistance for sit to stand and chair to bed transfer. Resident #1 needed moderate assistance for toilet transfer. Resident #1's assessment also revealed he had fallen since admission to the facility. Record review of Resident #1's care plan, updated on 02/04/2025, revealed the following: Resident #1 is a high risk for falls related to CVA with interventions anticipating and meeting resident's needs. Record review of Resident #1's clinical record relating to Fall Risk Assessment revealed the last Fall Assessment conducted for Resident #1 was on 11/18/2023 as a post fall assessment, which indicated he was a moderate risk for falls. There was no documentation relating to quarterly fall assessments in Resident #1's clinical record . In an interview and observation on 2/13/2025 at 4:35 PM, revealed Resident #1 was sitting in his wheelchair eating dinner, Resident #1 stated he had not fallen in a while and had no concerns. In an interview on 02/13/2025 at 7:09 PM, the DON stated she could not find any quarterly fall risk assessments for Resident #1. The DON stated Resident #1's fall risk assessments were overlooked because the EHR system did not trigger the assessment because he had been a resident for some time. The DON stated fall risk assessments were only triggered at admission or after a fall. The DON stated she was responsible for ensuring charge nurses completed admission, quarterly and as needed Fall Risk Assessments on each resident and a possible negative outcome for not completing one would be a resident could get hurt . In an interview on 02/13/2025 at 7:14 PM, RN A stated charge nurses were responsible for ensuring fall risk assessments were completed on residents. RN A was unsure when the assessments were to be completed. RN A stated a possible negative outcome for not doing an assessment would be a resident could get hurt. In an interview on 02/13/2025 at 7:20 PM, LVN B stated a possible negative outcome for not doing a risk assessment for falls would be a resident could get hurt if there were no interventions. LVN B did not know when fall risk assessments were to be completed. In an interview on 02/13/2025 at 7:40 PM, the ADM stated charge nurses were the ones responsible for completing fall risk assessments, but she was the one ultimately responsible for ensuring the documentation was completed. The ADM stated a possible negative outcome for not having the fall risk assessments completed would be a resident could be overlooked as a fall risk. Record review of the facility's, undated, Fall and Post Fall Management Policy revealed the following: Each resident must be assessed on admission, quarterly and any change in condition for potential risk for falls in order to take a preventative approach for resident as well as staff safety. Fall Risk Assessment: .The interdisciplinary team will complete the following: 1. Complete a Fall Risk Assessment a. Upon admission b. Following any significant change of status of fall c. Quarterly documentation assessment

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide pharmaceutical services to include the accurate dispensing and administering of drugs to meet the needs for 1 of 5 residents (Resident #1) reviewed for physician orders. The facility failed to accurately enter physician orders for Seroquel(anti-psychotic medication) and Trazodone(insomnia medication) for Resident #1. The deficient practice could place residents at risk of not receiving medications as prescribed and/or deterioration in their condition. Findings included: Record review of Resident #1's face sheet dated 08/28/24 revealed an [AGE] year old male was originally admitted to the facility on [DATE] and was sent to the hospital and readmitted on [DATE] with diagnoses to include but not limited to Alzheimer's disease(memory loss), atherosclerotic heart disease of native coronary artery(narrowing of arteries), vascular dementia, unspecified severity, without behavioral disturbance(breakdown of thought process), psychotic disturbance, mood disturbance and anxiety, delusional disorder, psychotic disorder with delusions due to known physiological condition, mood disorder due to know physiological condition with major depressive like episode and Vascular dementia, unspecified severity, with other behavioral disturbance(breakdown of thought process causing disruptive behavior). Record review of Resident #1's last completed Quarterly MDS dated [DATE] revealed Resident #1 had a BIMS score of 03 out of 15 indicating that he had severe impairment. Resident #1's functionality was independent from sitting to lying down, sitting to standing and chair/bed transfer with setup assistance with eating, oral hygiene, and upper and lower body dressing. Resident #1 had occasional bowel and urinary incontinence. Record review of Resident #1's care plan start date 08/08/2022 revised on 08/20/2024 revealed that Resident #1 had a history of depression and took antidepressants with interventions to encourage and assist resident to attend activities and provide medication as ordered. Care plan also indicated Resident #1 had a diagnosis of Alzheimer's/Dementia with interventions to encourage and allow resident to verbalize needs and concerns and provide medications as ordered. The care plan did not address Resident #1's insomnia or antipsychotic medication. Record review of Resident #1's discharge orders from the Rehab Hospital dated 08/15/2024, indicated Resident #1 was admitted on [DATE] and released back to the facility on [DATE] and revealed the following orders: Quetiapine ER (Seroquel XR) Give 100 mg (2tablets) by mouth at bedtime DO NOT CRUSH. Start date/Time: 07/31/2024 at 9:00 PM and Stop Date/Time: 09/28/2024 9:00 PM Active Days: 16 Trazodone (Desyrel) Give 50 mg (1 tablet) by mouth at bedtime PRN for Insomnia Start date/Time: 07/31/2024 at 9:02 PM and Stop Date/Time: 09/28/2024 9:02 PM Active Days: 16 Record review of Resident #1's orders listed as Discontinued Orders entered on 08/15/2024 and discontinued on 08/18/2024 revealed the following: Seroquel Oral Tablet 50 MG-Give 2 tablet by mouth two times a day related to psychotic disorder with delusions due to known physiological condition. Trazodone HCI Oral Tablet 50 mg-Give 1 tablet by mouth at bedtime for Insomnia. Record review of Resident #1's orders listed as Active Orders entered on 08/18/2024 revealed the following: Seroquel XR Oral Tablet Extended Release 24-hour 50 mg (Quetiapine Fumarate) Give 2 tablet by mouth at bedtime related to Psychotic disorder with delusions due to known physiological condition. Trazodone HCI Oral Tablet 50 mg (Trazodone HCI) Give 1 tablet by mouth every 23 hours as needed for insomnia (Use only at bedtime). Record review of the MAR dated August 2024 revealed that Resident #1 took Seroquel Oral Tablet 50 mg (Quetiapine fumarate) Give 2 tablet by mouth two times a day. Resident #1 was given the medication on 08/15 at 8:00 PM, 08/16 and 08/17 at 8:00 AM and 8:00 PM, and 08/18 at 8:00 AM. The MAR also revealed that Resident #1 was given Trazodone HCI Oral Tablet 50mg-Give 1 tablet by mouth at bedtime for insomnia on 08/15, 8/16, and 08/17/2024. Interview on 08/28/2024 at 11:45 AM, Resident #1 stated that he was doing well and that they fixed his medications. Resident #1 stated he did not know what medications he was taking but he did not feel drunk anymore. Interview on 08/28/2024 at 12:45 PM, LVN C stated the nurses were responsible for putting in the orders when a new admission was admitted to the facility. LVN C stated that she was told that when Resident #1 was sent to the hospital that they were looking at lowering his medication and was wondering about the medications. LVN C stated she looked at the discharge orders from the Rehab hospital from [DATE] and noticed that the orders that were put in the system did not match the discharge orders from the Rehab Hospital. LVN C stated she contacted her DON immediately and put the correct orders in the system on 08/18/2024. LVN C stated that the LVN that put the orders in wrong was no longer employed at the facility. LVN C stated that a possible negative outcome for not having the correct orders would be that it could cause the resident harm. Interview on 08/28/2024 at 1:38 PM, LVN A stated that the nurse on duty at the time of a resident's admission was responsible for entering the orders from the doctor/hospital. LVN A stated that a possible negative outcome for putting orders in wrong would be that a death could occur if too much medication was given. Interview and observation on 08/28/2024 at 1:51 PM, LVN B opened the medication cart where Resident #1's medication was stored. LVN B stated that when the new medications that were ordered were the same medication but a different dose, a label was put on the blister pack that identified the new order in the system. LVN B pulled out the labels that were used to put on the blister packs that identified new orders. LVN B stated that a possible negative outcome for putting orders in wrong would be that a resident's side effects could get worse, or they could become lethargic and hurt themselves. Interview on 08/28/2024 at 2:45 PM, the DON stated that Resident #1 was already taking Seroquel and Trazodone so when he returned to the facility, they were able to use the medication on hand. The DON stated that a possible negative outcome for not having correct documentation for orders would be that a resident could die or become injured due to confusion. Record Review of Medication Administration Policy (no date) revealed the following: . Follow the six rights of medication administration(Right Patient, Right Drug, Right Dose, Right Route, Right Time, Right Documentation) . . Read the label 3 times as your prepare a medication, carefully checking the drug label against the Medication Administration Record (MAR, med card or physician orders) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to conduct a comprehensive and accurate assessment of each resident using the resident assessment instrument (RAI) specified by CMS for 1 of 14 residents (Resident #31) whose records were reviewed for assessments. Resident #31 was on CPAP therapy while in the facility and it was not addressed in his MDS. This failure to ensure comprehensive and accurate assessments could affect residents by placing them at risk for not receiving correct care and services. Finding include: Record review of Resident #31's face sheet dated 8-12-2024 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interferes with daily functioning), atrial fibrillation(an irregular, often rapid heart rate that commonly causes poor blood flow), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), obstructive sleep apnea (a sleep disorder that involves cessation or significant decrease in airflow in the presence of breathing effort), and venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes). Record review of Resident #31's admission MDS completed 6-24-2024 listed him with a BIMS of 15 indicating he was cognitively intact, and he had a functionality from being independent with some of his activities of daily living to requiring substantial/maximal assistance with his activities of daily living. Section O Special Treatment, Procedures, and Programs: -Respiratory Treatments G-Non-Invasive Mechanical Ventilator (BiPAP/CPAP)- neither while not a resident or while a resident is mark as the resident having either one of these therapies. Record review of Resident #31's care plan with admission date 6-17-2024 revealed the following: Focus: The resident has COPD and uses O2 PRN and should use CPAP at night. Date initiated 7-1-2024. Record review of Resident #31's order summary report with active orders as of 8-12-2024 revealed the following order: CPAP to be worn at HS, every night shift. Active Date - 6-19-2024 Record review of Resident #31's TAR (Treatment Administration Record) for 6-2024 revealed that Resident #31 received CPAP therapy nightly from 6-19-2024 through 6-24-2024, 6 days prior to the 6-24-2024 admission MDS assessment. During an observation and interview on 08-12-2024 at 10:52 AM Resident #31 was noted to have a CPAP machine on his bedside dresser that Resident #31 reported he had for years and he used daily. Resident #31 reported that the facility helped him with all his needs to include the CPAP and the care of the CPAP equipment such as cleaning, adding water, replacing the tubing. During an interview on 08-13-2024 at 01:45 PM the DON reported that the facility was currently completing all MDS's offsite due to the sudden loss of their ADON/MDS nurse. They both confirmed that in the meantime they have been having to scramble to cover the MDS's and care plans. During an interview on 08-13-2024 at 01:56 PM the DON reported that if a resident does not have their CPAP addressed on the MDS she would not know if it would affect the resident in any way because she does not know enough about the MDS's to answer any questions. During an interview on 08-13-2024 at 02:06 PM the CMDS Coordinator reported that she had not dealt with Resident #31's MDS when the CPAP therapy was missed, that that was completed by the facility's ADON/MDS Coordinator of which she (the CMDS Coordinator) did not know why the ADON/MDS Coordinator missed the CPAP. The CMDS Coordinator did report that the CPAP should have been addressed on the admission MDS if the CPAP was documented in Resident #31's chart. The CMDS Coordinator reported that the MDS affects the care plan and that if the MDS was not accurate then the care plan will not be accurate and the care plan drives the resident's care. The CMDS Coordinator reported that the policy followed for the MDS was the RAI manual. Record review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17, dated October 2019 revealed the following: Section O0100 Special Treatment, Procedures, and Programs- o O0100G, Non-invasive Mechanical Ventilator (BiPAP/CPAP) Code any type of CPAP or BiPAP respiratory support devices that prevent airways from closing by delivering slightly pressurized air through a mask or other device continuously or via electronic cycling throughout the breathing cycle. The BiPAP/CPAP mask/device enables the individual to support his or her own spontaneous respiration by providing enough pressure when the individual inhales to keep his or her airways open, unlike ventilators that breathe for the individual. If a ventilator or respirator is being used as a substitute for BiPAP/CPAP, code here. This item may be coded if the resident places or removes his/her own BiPAP/CPAP mask/device.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to perform preadmission screening for individuals with a mental disorder and individuals with intellectual disability prior to admission for 2 (Resident #18 and #20) of 16 residents reviewed for preadmission screenings. A. The facility failed to perform a PASRR for Resident #18 until 4 months after admission. B. The facility failed to perform a PASRR for Resident #20 until 2 months after admission. This failure could place residents at risk of receiving inadequate care. Findings Included: Record review of Resident #18's admission record dated 08/13/24 revealed Resident #18 was an 81year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to dementia ( a group of thinking and social symptoms that interferes with daily functioning), anxiety ( a feeling of worry, nervousness or unease), depression (a mood disorder that affects how a person thinks feels and acts) and anemia( a condition in which the blood does not have enough healthy red blood cells and hemoglobin) Record review of Resident #18's MDS completed 04/29/24 section C revealed a BIMS score of 8 indicating cognition was moderately impaired. Section E revealed Resident #18 had no behaviors. Record review of Resident #18's care plan completed on 04/22/24 revealed Resident #18 used a wheelchair for mobility and was incontinent. Record review of Resident #18's PASRR Level 1 Screening revealed it was completed on 08/13/24. Record review of Resident #20's admission record dated 8/13/24 revealed Resident #20 was a 64-y o male admitted to the facility on [DATE] with diagnoses of diabetes (a group of diseases that result in too much sugar in the blood), anemia ( a condition in which the blood does not have enough healthy red blood cells and hemoglobin) and (hypertension ( a condition where the pressure in your blood vessels is consistently higher than normal). Record review of Resident #20's quarterly MDS completed 06/30/24 section C revealed a BIMS score of 9 indicating cognition was moderately impaired. Section E revealed Resident # 20 had no behaviors. Record review of Resident #20's care plan completed on 03/25/24 revealed Resident #20 used a walker for mobility, was hard of hearing and at risk of depression due to his situation. Record review of Resident #20's PASRR Level 1 Screening revealed it was completed on 06/24/24. During an interview on 08/13/24 at 9:26 am, the ADM stated she was responsible for ensuring PASRRs on new admits were completed. She stated PASSR's were to be done immediately at admission or before admission. She stated both Resident #18 and Resident #20 came from the community and not from a hospital setting when admitted . She stated the PASSR's were done late. She stated a possible negative outcome of not having PASSRs completed prior to or at admission could result in not getting needed services. Record review of the undated facility policy titled Preadmission Screening and Resident Review revealed the policy of this facility is to ensure all residents are screened and appropriately addressed via the PASSR process as outlines by regulations. The facility designated staff will review all potential admission for possible positive PASSR conditions and ensure that CMS Preadmission guidelines are followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 (Resident #31) of 14 Residents reviewed for comprehensive care plans. -The facility failed to include a care plan for Resident #31's smoking. This failure could affect residents in the facility receiving care per comprehensive person-centered care plans resulting in resident not being able to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Finding include: Record review of Resident #31's face sheet dated 8-12-2024 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interferes with daily functioning), atrial fibrillation(an irregular, often rapid heart rate that commonly causes poor blood flow), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), obstructive sleep apnea (a sleep disorder that involves cessation or significant decrease in airflow in the presence of breathing effort), and venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes). Record review of Resident #31's admission MDS completed 6-24-2024 listed him with a BIMS score of 15 indicating he was cognitively intact, and he had a functionality from being independent with some of his activities of daily living to requiring substantial/maximal assistance with his activities of daily living. Record review of Resident #31's care plan with admission date 6-17-2024 revealed no care plan for smoking. Record review of Resident #31's Smoking Assessment completed 6-17-2024 revealed the following: D. Frequency 4. How often does the resident smoke per day? 2-5 times During an interview on 08-12-2024 at 10:52 AM Resident #31 confirmed that he was a smoker. During an interview on 08-13-2024 at 01:45 PM the DON reported that the facility was currently completing all MDS's offsite and that she (the DON) has been attempting to complete care plans due to the sudden loss of their ADON/MDS nurse. They both confirmed that in the meantime they have been having to scramble to cover the MDS's and care plans. The Administrator reviewed Resident #31's chart and confirmed that he had no care plan for smoking. The DON reported that she has been learning how to complete the care plans since July 4th, 2024, with no training and reported that it probably was her fault that the smoking care plan was missed. The DON confirmed that smoking should be in a resident's care plan, that missing this smoking care plan would not be an issue due to this resident was independent and does not need any help. The DON reported that if the smoking is not addressed in the care plan, then direct care staff will not know how to address the resident's needs. The DON reported that if a resident wishes to smoke and the facility wishes to keep that resident safe then the facility needs to address that need on that resident's care plan. During an interview on 08-13-2024 at 01:58 PM the Administrator reported that since Resident #31 was an independent person not addressing his smoking on his care plan really was not a problem but if the resident was not independent then it would be a problem and that could affect a resident negatively if they did not receive the proper care. Record review of the facility provided policy titled Comprehensive Care Plans undated, revealed the following: 2. The comprehensive care plan will describe the following: a. The services that are to be furnished to attain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on observation, interview, and record review; the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles when applicable on 1 (Hall 100 and half of Hall 300) of 2 medication carts reviewed. Two Loose pills found in the medication drawers of the medication cart for Hall 100 and half of Hall 300. This failure could result in residents not receiving an accurate dose of medication as well as not being maintained at their best therapeutic level. Findings include: Observation and interview on 08/12/24 at 11:07 AM revealed 2 loose pills in the bottom of medication drawer in medication cart for Hall 100 and half of Hall 300. LVN B was able to identify the pills, the red pill was identified as Plavix. The yellow pill was identified as Bethanechol Chloride unsure who the medications belonged to. Interview on 08/12/24 at 11:16 AM with LVN B revealed that a negative outcome for having lose medications in the medication carts would be that the medication could be mistaken for something else. Interview on 08/14/24 at 03:09 PM with DON revealed that a negative outcome for having lose medications in the medication carts would be that staff could assume what they are and give to a resident, and they are no longer clean. DON stated that she was aware of the loose medications and a in-service/training has been provided to the staff. Record review of facility policy titled, Storage of Medications , undated, states the following, but not limited to: Purpose: Ensure that medications are stored in a safe, secure, and orderly manner. Procedure: 1. Medications are stored in the containers in which they are received. .3. No discontinued, outdated, or deteriorated medications are available for use in this facility. All such medications are destroyed.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection in 1 of 1 dining rooms. -CNA C failed to perform hand hygiene before assisting Resident #32 with eating. This failure had the potential to affects residents in the facility by exposing them to care that could lead to the spread of viral infections, secondary infections, communicable diseases, and feelings of isolation related to poor hygiene. Findings include: Observation on 08/12/24 at 12:18 PM revealed CNA C playing with hair while waiting on Residents food to be delivered to table in the dining room. Observation on 08/12/24 at 12:24pm revealed CNA C playing with hair again and no hand hygiene was performed before touching Resident #32's napkin or silverware to assist Resident #32 with eating her lunch meal. Interview on 08/12/24 at 02:40 PM CNA C revealed that a negative outcome from playing with hair and then feeding a resident could lead to germs being transferred to the Resident. Interview on 08/14/24 at 03:09 PM with DON revealed that a negative outcome for not performing hand hygiene before assisting residents to eat could contaminate the resident's food. Record review of facility policy titled, Hand washing , undated, stated the following, but not limited to: Purpose: Hand washing will be regarded by this facility as the single most important means of preventing the spread of infections. Procedure: 1. All personnel will follow the facility's established handwashing procedures to prevent the spread of infection and disease to other personnel, residents, and visitors. 2. Hands should be washed 20 seconds under the following conditions: . .i. After using the toilet, blowing or wiping the nose, smoking, combing the hair, etc.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to conduct a periodic comprehensive assessment of each resident's functional capacity for 3 of 14 residents (Residents #7, #9, and #20) whose records were reviewed for assessments. The facility failed to complete a comprehensive assessments for Resident #7, #9, and #20 every 3 months. This failure could place residents at risk for not getting an accurate assessment and could result in lack of care. Findings include: Resident #7 Record review of Resident #7 face sheet dated 8-13-2024 revealed she was admitted on [DATE] with diagnoses to include Alzheimer's (a progressive disease that destroys memory and other important mental functions), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), convulsions (a sudden, violent, irregular movement of a limb or of the body caused by involuntary contraction of the muscles and associated especially with brain disorders such as epilepsy), hypertension (a condition in which the force of the blood against the artery walls is too high), diabetes(a chronic condition that affects the way the body processes blood sugar (glucose), and malnutrition (lack of proper nutrition). Record review of Resident #7's last completed MDS dated [DATE] listed her with a BIMS score of 00 indicating she was severely cognitively impaired, and she had a functionality of being dependent on staff for all her activities of daily living. Record review of Resident #7's MDS tracking record revealed the last completed MDS was a quarterly completed on 4-26-2024. The next MDS listed was a quarterly 7-27-2024 that was in progress and listed as 3 days overdue. Resident #9 Record review of Resident #9's face sheet dated 8-12-2024 revealed she was admitted [DATE] with diagnoses to include chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), osteoporosis (a medical condition in which the bones become brittle and fragile from loss of tissue, typically as a result of hormonal changes or deficiency of calcium of vitamin D), hypertension (a condition in which the force of the blood against the artery walls is too high), and malnutrition (a condition in which the force of the blood against the artery walls is too high). Record review of Resident #9's last completed MDS dated [DATE] listed her with a BIMS score of 12 indicating she was moderately cognitively impaired, and she had a functionality of requiring supervision/touching assistance with most of her activities of daily living. Record review of Resident #9's MDS tracking record revealed the last completed MDS was a quarterly completed 3-20-2024. The next MDS listed was a quarterly 6-20-2024 that was in progress and listed as 40 days overdue. Resident #20 Record review of Resident #20 face sheet dated 8-14-2024 revealed he was admitted to the facility originally on 4-4-2023 and readmitted on [DATE] with diagnoses to include diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), hypertension (a condition in which the force of the blood against the artery walls is too high), peripheral vascular disease (a circulatory condition in which narrowed blood vessels recue blood flow to the limbs), malnutrition(lack of proper nutrition), and intermittent explosive disorder(a behavioral disorder characterized by explosive outburst of anger and/or violence, often to the point of rage that are disproportionate to the situation at hand),. Record review of Resident #20's last completed MDS dated [DATE] listed him with a BIMS score of 9 indicating he was moderately cognitively impaired, and he had a functionality of requiring supervision/touching assistance with most of his activities of daily living. Record review of Resident #20's MDS tracking record revealed the last completed MDS was an admission completed 3-31-2024. The next MDS listed was a quarterly 6-30-2024 that was in progress and listed as 30 days overdue. During an interview on 08-13-2024 01:45 PM the DON reported that the facility was currently completing all MDS offsite due to the sudden loss of their ADON/MDS nurse. They both confirmed that in the meantime they have been having to scramble to cover the MDS's and care plans. During an interview on 08-132024 at 02:14 PM the CMDS Coordinator reported that all late MDS assessments were currently due to the situation with the ADON/MDS Coordinator which resulted in the facility contacting her facility to ask for assistance with MDS coordination, that any late MDS is currently due to her facility waiting on additional information from this facility such as therapy notes for a resident so they can finish the MDS and submit it. The CMDS Coordinator reported that all the late MDS's will result in issues such as late plans of care, late care plans, and will result in delay of facility reimbursement. The CMDS Coordinator reported that she does not feel this will affect the residents care because she personally knows the two owners of this facility and they would not let the resident do without what they need because of the delayed reimbursements. During an interview on 08-13-2024 at 02:06 PM the CMDS Coordinator reported that the policy followed to complete the MDS to include timing for the MDS to be completed was the RAI manual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to review the risks and benefits of bed rails with the resident or resident's representative and obtain informed consent prior to installation of bed rails for 4 (Residents #5, #13, #24, and #25) of 14 residents reviewed for bedrails. The facility failed to inform Residents #5, #13, #24, and #25 or their representatives of the use of bed rails and obtain consent for the use of bed rails. This failure could place all residents with bed rails at risk for injuries such as abrasion, fractures, and entrapment. Finding include: Resident #5 Record review of Resident #5's clinical record revealed an [AGE] year-old female admitted to the facility originally on 6-8-2022 and readmitted on [DATE] with diagnoses to include atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), polyosteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), chronic respiratory failure (a long-term condition that occurs when the body's respiratory system cant exchange oxygen and carbon dioxide properly), muscles spasms(an involuntary and forceful contraction of a muscle or group of muscles that can't relax), muscle weakness (a lack of muscle strength), and pain in shoulder. Record review of Resident #5's clinical record revealed her last MDS was a quarterly completed 6-25-2024 which indicated her BIMS score was 10 indicating she was moderately cognitively impaired, and she had a functionality of requiring set-up/clean-up with most activities of daily living. Record review of Resident #5's order summary report with active orders as of 8-13-2024 revealed the following order: May have a grab-bar for bed mobility. - Active 08-12-2024 Record review of Resident #5's care plan with date of admission 2-15-2023 revealed the following: Focus: Resident uses a positioning bar on the right side of her bed for increased bed mobility and positioning. Date initiated 10-26-2022. Intervention: Ensure consent is on chart prior to initiating . During an observation on 08-12-2024 at 10:50am Resident #5 was not present. Noted a bed rail on the right side of Resident #5's bed. During an interview on 08-12-2024 at 02:23 PM Resident #5 stated that she was able to get in bed with the assistance of her bed rail but has gotten weaker since the last CHF flare up. Resident #13 Record review of Resident #13's clinical record revealed a [AGE] year-old male admitted to the facility originally on 4-18-2023 and readmitted on [DATE] with diagnoses to include displaced fracture (a type of complete fracture that occurs when the ends of a broken bone are out of alignment), osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), intermittent explosive disorder (a behavioral disorder characterized by explosive outburst of anger and/or violence, often to the point of rage that are disproportionate to the situation at hand), muscle wasting (the loss of muscle mass and strength due to disease, injury, or lack of use), and muscle weakness (a lack of muscle strength). Record review of Resident #13's clinical record revealed his last MDS was a quarterly completed 6-25-2024 which indicated his BIMS score was 12 indicating he was moderately cognitively impaired, and he had a functionality of requiring partial/moderate assistance with most activities of daily living. Record review of Resident #13's order summary report with active orders as of 8-13-2024 revealed the following order: May have a grab-bar for bed mobility. - Active 08-12-2024 Record review of Resident #13's care plan with date of admission 8-1-2024 revealed the following: Focus: May have grab bars on bed to promote independence with bed mobility as needed. Date initiated 8-12-2024. During an observation on 08-12-2024 at 10:52 AM Resident #13 was lying in his bed. Resident #13 had bedrails on the side of his bed. During an interview on 08-13-2024 at 09:39 AM Resident #13 revealed that he used his bedrails to help himself turn over. Resident #13 stated that he does need assistance transferring into his w/c from staff. Resident #24 Record review of Resident #24's clinical record revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include dementia (a group of thinking and social symptoms that interferes with daily functioning), osteoarthritis (a type of arthritis that occurs when flexible tissue at the ends of bones wears down), history of fractures, fall history, and hypertension (a condition in which the force of the blood against the artery walls is too high). Record review of Resident #24's clinical record revealed his last MDS was a quarterly completed 6-3-2024 which indicated his BIMS score was 04 indicating he was severely cognitively impaired, and he had a functionality of requiring supervision/touching assistance to partial/moderate assistance with most activities of daily living. Record review of Resident #24's order summary report with active orders as of 8-13-2024 revealed the following order: May have a grab-bar for bed mobility. - Active 08-12-2024 Record review of Resident #24's care plan with date of admission 9-19-2022 revealed the following: Focus: May have grab bars on bed to promote independence with bed mobility as needed. Date initiated 8-12-2024. During an observation and interview on 08-12-2024 at 10:51 AM Resident #24 sat up in his bed with the assistance of a bedrail on the side of his bed. Resident #13 did not voice any concerns and stated, I'm fine, and did not need anything at this time. Resident #25 Record review of Resident #25's clinical record revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include hemiplegia (partial paralysis), diabetes (a chronic condition that affects the way the body processes blood sugar (glucose), morbid obesity (a disorder involving excessive body fat that increase the risk of health problems), cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), and hypertension, (a condition in which the force of the blood against the artery walls is too high). Record review of Resident #25's clinical record revealed her last MDS was a quarterly completed 6-20-2024 which indicated her BIMS score was 15 indicating she was cognitively intact, and she had a functionality of requiring partial/moderate assistance with most activities of daily living. Record review of Resident #25's order summary report with active orders as of 8-13-2024 revealed the following order: May have a grab-bar for bed mobility. - Active 08-12-2024 Record review of Resident #25's care plan with date of admission [DATE] revealed the following: Focus: May have grab-bars on bed to promote independence with bed mobility as needed. Date initiated 8-12-2024. During an observation and interview completed on 08-12-2024 at 10:31 AM Resident #25 was in her room in her bathroom in her wheelchair initially. Resident #25's bed was made with bilateral 1/8 bedrails up and locked in place. Resident #25 reported that she used her bedrails to steady herself in bed and that she had been trained on the use of the bedrails. During an interview on 08-14-2024 at 08:27 AM the administrator reported that the facility did not have the proper consent forms for the four residents reviewed for bedrails. The administrator verified that they did have orders for the bedrails, ongoing monitoring for the bedrails via care plans and review at each care plan meeting but that the consents were not completed prior to installation or the resident moving to a bed with bedrails. The Administrator reported that residents or resident representatives who were not educated on the risks and given the opportunity to consent would be at risk for injuries and harm. During an interview on 08-14-2024 at 08:58 AM the DON verified that all 4 residents did not have a consent for the use of a bedrail and reported that a resident could be affected negatively and have an injury especially if they were not educated on the risk and use of a bedrail. Record review of the facility provided polity titled Bed Rails undated, revealed the following: Procedures: 2. Review the risk and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation.

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 18 days out of 31 (05/28/23, 06/03/23, 06/04/23, 06/10/23, 06/11/23, 06/17/23, 06/18/23,06/24/23) 07/6/24, 07/13/24, 07/20/24, 07/21/24, 08/03/24, 8/10/24 and 8/11/24 ) 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: 05/4/24, 05/5/24, 05/11/24, 05/18/24, 05/19/24, 05/25/24, 05/26/24, 06/23/24, 06/29/24, 06/30/24, 07/04/24, 07/6/24, 07/13/24, 07/20/24, 07/21/24, 08/03/24, 8/10/24 and 8/11/24. This failure could place residents at risk for inconsistency in care and services. Findings include: Record review of the facility's employee roster undated revealed there were five RN's employed at the facility. Record Review of time sheet provided by the Administrator for the time period 05/01/24-08/11/24 revealed the following dates did not have RN coverage for at least 8 hours a day for the following days: 05/4/24, 05/5/24, 05/11/24, 05/18/24, 05/19/24, 05/25/24, 05/26/24. 06/23/24, 06/29/24, 06/30/24, 07/04/24, 07/6/24, 07/13/24, 07/20/24, 07/21/24, 08/03/24, 8/10/24 and 8/11/24. During an interview on 08/12/24 at 3:45 pm, the DON stated the administrator and DON were responsible for RN coverage. She stated she only clocks in for her shift and does not clock out. She stated she cannot prove that she was in the facility for 8 hours each day she clocked in. She stated the consequences of not having an RN in the building could cause poor care for the residents. During an interview on 08/13/24 at 1:55 pm, the Administrator stated the DON only clocks in for accountability to the owner. She stated she could not prove the DON was in the facility for 8 consecutive hours or more on the days she just clocked in. A policy was requested from the ADM but never furnished.

Based on interview and record review, the facility failed to employ sufficient staff with appropriate competencies and skill sets to carry out the functions of the food and nutrition service for the facility's only kitchen reviewed for dietary services. The facility failed to ensure the designated Dietary Manager completed the required dietary managers certification course or had any other qualifying credentials. This failure could place residents at risk for the spread of foodborne illness and residents not having their nutritional needs met. The findings include: Record review of the personnel file for the Dietary Manager revealed she was hired on 10/31/23 as a cook. There was no documentation in the personnel file that indicated that she had completed the required training for Dietary Manager and was a Certified Dietary Manager. Record review of the facility's Dietician documentation revealed that the Dietician was contracted and not full-time. In an interview on 8/12/24 at 10:15 am, the DM stated she was hired as a cook in the kitchen and had been the DM for about 2 months. She stated her duties as dietary manager were to supervise the kitchen staff and ensure all dietary functions were carried out. tShe stated she was not working on her certification for the DM as she cannot afford to pay for it and the owner will not pay for it. She stated she has never been employed as a DM before and does not have a degree in food service. In an interview on 8/12/24 at 12:40 pm the RD stated the owner has a DM certificate. She stated she had never been in the building. She further stated she had never seen the owner in the kitchen. In an interview on 8/12/24 at 1:45 pm, the RD stated she is only allowed by the owner to provide 20 hours a week of dietary consultation. In an interview on 8/13/24 at 9:40 am the ADM stated the Dietary Manager was not a certified DM and had not taken the required DM course. The ADM stated the DM must pay for the certification herself and she does not have the money to do it. She stated the owner will allow the staff to do it at their expense. The ADM stated the owner's wife is a DM. When asked if the owner's wife was in the kitchen supervising the kitchen, she said no. She stated she expected the Dietary Manager to become certified. The ADM stated she expected the DM to be certified to manage the kitchen effectively. The ADM stated the consequences of not being certified could be poor resident satisfaction with meals and not being knowledgeable about important dietary issues. In an interview on 8/13/24 at 9:55 am, the DM stated she had never met the owner's wife who had a DM certificate. She stated the owner's wife had never been in the kitchen or trained staff. The DM stated the owner's wife orders coffee for the facility and reviews the kitchen budget. In an interview on 8/14/24 at 8:28 am Dietary Aide B stated she had never seen the owner's wife in the kitchen and the DM runs the kitchen. In an interview on 8/14/24 at 8:30 am CNA C stated she had never seen the owner's wife in the kitchen and the DM runs the kitchen. Record Review of the undated facility policy titled Dietary Service revealed if a qualified dietician is not employed full time the facility will designate a person to serve as a Director of Food Service. The director of food service must be at least a person who has completed a state agency approved 90 hour course in food service supervision.

Based on observation, interview, and record review, the facility failed to ensure the meals served reflected the nutritional needs of residents in accordance with established national guidelines for all residents when the facility failed to ensure menus were followed all residents for 1 of 2 meals observed. 1. The facility did not serve a biscuit or any bread products to any residents for the lunch meal on 8/12/24 as directed by the menu. These failures could place all residents who received food from the kitchen, at risk for decreased meal satisfaction, potential weight loss due to poor meal intake, not having their nutritional needs met, and a decline in health status, Findings included: Record review of the diet spreadsheet, approved by the facility Dietitian, for Lunch- Monday 8/12/24, Week 1, revealed residents were to receive: honey garlic chicken thighs, cheesy rice, steamed broccoli, strawberry shortcake and 1 biscuit. In an observation on 8/12/24 at 11:55 am, [NAME] A was observed plating and serving lunch. There were no rolls or biscuits on the serving line and no biscuits were served to any residents on any of the noon meal trays prepared for lunch. During an observation on 8/12/24 at 12:20 p.m., of the lunch meal in the dining room and residents who ate in their rooms revealed none of the residents received a biscuit or any bread for the lunch meal as listed on the menu. During an interview on 8/12/24 at 12:40 pm, the RD stated if a food item was on the menu, it should have been served. She stated she expects that if a food is listed on the menu it is served. She stated she has trained the DM for kitchen practices. She stated the consequences of residents not getting what is listed on the menu could be weight loss and lack of nutrients in their diet. During an interview on 8/12/24 at 1:40 pm, the DM stated she was aware that none of the residents received a biscuit for the lunch meal and they should have gotten a biscuit for lunch. She stated she did not know why a biscuit or bread was not served. She stated the consequences of not having all the food items listed on the menu could lead to weight loss and hunger. In an interview on 8/12/24 at 1:45 pm, the RD stated she was aware that there was no biscuit served for the noon meal. The RD stated there should have been a biscuit served at the noon meal. During an interview on 8/12/24 at 1:55 pm, [NAME] A stated none of the residents received a biscuit for the lunch meal and they should have gotten a biscuit for lunch. She stated she just forgot to make the biscuits and did not put bread on the trays. She stated the consequences for the residents could be hunger at the end of the meal. [NAME] A stated she had been trained by the DM for work in the kitchen. Record Review of the undated facility policy titled, Dietary Services revealed the facility menu will meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council Record Review of the undated facility policy titled, Food Service revealed the facility menu will meet the nutritional needs of each resident; provide a well-balanced, flavorful, and varied food service program. All meals will meet USDA guidelines for the major food groups using the nutritional pyramid. Record Review of the undated facility policy titled ' Menus' documented menus will be prepared in advance, be nourishing, palatable, well balanced and will meet the daily nutritional dietary needs of the residents, If the meal service varies from the planned menu, the change and the reason for the change will be noted in the record used solely for recording such changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen when they failed to: A. Ensure stored food was properly labeled, dated, and contained. B. Ensure general cleanliness was maintained. C. Ensure all food service staff used proper hand hygiene and use of gloves during meal preparation. D. Ensure temperatures were taken at the beginning of the meal service. E. Ensure substitution list, cleaning list and temperature logs were utilized. These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings include: Observations on 8/12/24 at 10:25 am, on initial kitchen rounds of the pantry revealed: 1. Crumbs in the bin holding chips 2. 5 bags of cereal, no label or date, not in original box. 3. A bin holding powdered milk was sticky and grimy to the touch. The lid was not secured. 4. Trash, food packets and crumbs were observed in the floor of the pantry Observations on 8/12/24 at 10:30 am, on initial kitchen rounds of the walk-in freezer revealed: 1. A bag of frozen biscuits was unsecured, unlabeled, undated, not in the original box and open to air. 2. A box of chocolate chip cookie dough was unsecured and open to air. 3. A box of rolled dough was unsecured and open to air. 4. A box of breadstick dough was unsecured and open to air. 5. A box of meat patties was unsecured and open to air. 6. Trash, food packets and food particles in the floor of the walk- in freezer. Observations on 8/12/24 at 10:35 am, revealed the walk-in cooler had trash, food packets and food particles in the floor of the cooler. Observations on 8/12/24 at 10:40 am, of the main kitchen prep area revealed walk-in freezer revealed: the white plastic bins holding thickener, flour, rice and sugar were sticky and grimy to the touch. There was a brown grimy film surrounding the lips of each bin. The sides and tops of each bin were sticky to the touch and food particles were stuck to the tops of each bin. The lids for each bin were not tight fitting and did not seal. The sugar had brown spots inside the bin on the top of the sugar. In an observation and interview on 8/12/24 at 11:40 am, [NAME] A washed her hands, plugged the blender into the electrical outlet and picked up the canister for the mixer. [NAME] A then put gloves on her hands. [NAME] A picked up a bowl and tongs and walked to the food steam table. [NAME] A used the tongs to put the chicken into the bowl. [NAME] A scooped 2 lades of sauce into chicken and walked to the prep table. [NAME] A pureed the chicken then took the lid off the blender with her gloved hands and set the lid on the counter. [NAME] A walked across the kitchen, picked up the loaf of bread and carried it to the prep table where she was blending the chicken. [NAME] A opened the bread wrapper, and pulled out a piece of bread with her gloved hand. [NAME] A put the piece of bread into the blender with her gloved hand. [NAME] A then put the lid on the blender and pureed the chicken. [NAME] A then took off the lid of the blender and pulled out another piece of bread, tore the bread in half with her gloved hands and added a half slice of bread to the blender. [NAME] A blended the chicken. [NAME] A then picked up the other half of the bread with her gloved hand and added it to the blender. [NAME] A did not wash her hands or change her gloves. [NAME] A stated she did not realize she touched the bread with her contaminated hands. She stated she had gloves on. She stated she did not realize she touched other surfaces in the kitchen. She stated she should have changed her gloves. When asked about the consequences to the residents she stated she did not know. In an observation on 8/12/24 at 11:55 am, [NAME] A was observed serving lunch. The temperatures of the foods on the steam table were not taken prior to the first plate being served. In an interview on 8/12/24 at 12:50 pm, [NAME] A stated she did not take temperatures of the food before serving. She stated she takes the temperatures as she cooks. [NAME] A was asked about the biscuits not being served at the noon meal. She stated she forgot. She stated she did not put any bread on anyone's tray. She stated the DM had trained her for her kitchen duties. [NAME] A stated residents would be hungry if they did not get all the menu items listed. In an interview on 8/12/24 at 1:40 pm, the DM stated she was aware that there was no biscuit served for the noon meal. The DM stated there should have been a biscuit served at the noon meal. She stated the consequences of residents not getting a bread at lunch was not enough to eat. In an interview on 8/12/24 at 1:45 pm, the RD stated she was aware that there was no biscuit served for the noon meal. The RD stated there should have been a biscuit served at the noon meal. She stated the kitchen does not have a substitution list or a cleaning schedule. The RD stated she is only allowed to provide 15 hours of service a month and she trains when she is in the facility. She stated she looks at cleanliness when she is in the facility. She stated some of the things she looks at was whether the floor and countertops were sticky, whether the shelf holding spices was clean and the spices were closed. She stated she also looks at the hood vent and whether the top of the dishwasher was clean. She stated she was aware there was no substitution list or cleaning list. The RD stated she was aware the kitchen staff had not been taking food temperatures and she had discussed this with the DM. In an observation on 8/13/24 at 9:55 am, the kitchen revealed the same cleanliness conditions in the kitchen and the same food storage issues in the pantry floor, pantry storage Items in the walk-in freezer were still opened to air. There was still trash and food particles in the floor of the walk-in freezer and walk in cooler. The plastic bins holding thickener, rice and sugar still had grime and crumbs on the containers. [NAME] spots were observed in the sugar. In an interview on 8/13/24 at 10:10 AM, the DM stated she did not have a cleaning schedule or a substitution list. She stated she expected staff to clean as they go. She stated right now she is the one cleaning. When told about [NAME] A using her hands to touch the bread while pureeing the chicken, she nodded her head OK. The DM stated she expected all kitchen staff to use tongs and proper hand washing. In a walk-through of the kitchen with the DM, on 8/13/24 at 8:30 am, cleanliness issues were pointed out and observed to still be an issue. Record Review of the undated facility policy titled ' Dry Storage and Supplies ' documented all facility storage areas will be maintained in an orderly manner [NAME] preserves the condition of the food and supplies. We will ensure storage areas are clean, organized, dry, and protected from vermin and insects. Dry bulk food (flour, sugar) is stored in seamless metal or plastic containers with tight covers or bins which are easily sanitized. Containers are cleaned regularly. Opened packages of food are stored in closed containers with tight covers and dated as to when opened. Storeroom floors should be swept and mopped to be maintained in a sanitary manner. Record Review of the undated facility policy titled ' Cleaning ' documented all equipment, food contact surfaces and utensils shall be cleaned whenever contamination may have occurred. Record Review of the undated facility policy titled ' Storage Refrigerators' documented food must be covered when stored, with a date, and label identifying what is in the container. Record Review of the undated facility policy titled ' Daily Food Temperature Control' documented prior to meal service, the cook shall take the temperature of all hot and cold food. Temperatures are recorded on the temperature log form. Record Review of the undated facility policy titled ' Menus' documented menus will be prepared in advance, be nourishing, palatable, well balanced and will meet the daily nutritional dietary needs of the residents, If the meal service varies from the planned menu, the change and the reason for the change will be noted in the record used solely for recording such changes. Record Review of the undated facility policy titled ' Storage of Food in Refrigeration' documented food items that remain sealed from the supplier may be held until the expiration date if unopened. Food returning to storage after cooking or preparing must be covered. Record Review of the undated facility policy titled ' Food Safety' documented all staff will be aware of proper food handling and storage procedures. Food will be served in such a way as to prevent growth of bacteria. All food service staff will wash their hands when moving from one food prep area to another. Temperatures of food will be monitored at each meal. Use sanitized utensils and avoid hand contact. Avoid cross contamination of foods. Food must be covered when stored, with a date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 3 of 13 residents (Residents #3, #7, and #18) reviewed for advanced directives, in that: Residents #3, #7 and #18 were listed as a DNR but had a OOH-DNR forms that were incorrectly filled out or missing required information. These failures could place residents at risk for not having their end of life wishes honored and incomplete records. Findings included: Resident #3 Record review of Resident #3's face sheet, dated [DATE], revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include diabetes (high blood sugar), hypertension (high blood pressure), and cerebral palsy (affects a person's ability to move, maintain balance and posture). The face sheet also revealed under the advance directive section - ADC: Do not resuscitate - DNR. Record review of Resident #3's physician's order summary dated [DATE] revealed the following order: ADC: Do Not Resuscitate - DNR dated [DATE]. Record review of Resident #3's care plan, dated [DATE], revealed a care plan for DNR. Record review of Resident #3's Out of Hospital Do Not Resuscitate form dated [DATE] revealed under the physician's statement that the date and license number were blank. Resident #7 Record review of Resident #7's face sheet, dated [DATE], revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnosis to include diabetes (high blood sugar), atrial fibrillation (irregular heart beat), major depressive disorder, and dementia (loss of cognitive functioning). The face sheet also revealed under the advance directive section - ADC: Do not resuscitate - DNR. Record review of Resident #7's physician's order summary dated [DATE] revealed the following order: ADC: Do Not Resuscitate - DNR dated [DATE]. Record review of Resident #7's care plan, dated [DATE], revealed a care plan for DNR. Record review of Resident #7's Out of Hospital Do Not Resuscitate form dated [DATE] revealed under section b unchecked boxes that should have indicated the legal guardian, agent or proxy on the behalf of an adult person and under the witness's section revealed no witnesses. Resident #18 Record review of Resident #18's face sheet, dated [DATE], revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (loss of cognitive function), congestive heart failure (fluid around heart), and anxiety. The face sheet also revealed under the advance directive section - ADC: Do not resuscitate - DNR. Record review of Resident #18's physician order summary dated [DATE] revealed the following order: ADC: Do Not Resuscitate - DNR dated [DATE]. Record review of Resident #18's care plan, dated [DATE], revealed a care plan for DNR. Record review of Resident #18's Out of Hospital Do Not Resuscitate form dated [DATE] revealed under the physician statement the date, license # and printed name were blank. During an interview on [DATE] at 09:00 AM with the ADON/MDS Nurse, she stated the admitting nurse was responsible to check the DNR form for accuracy. She verified that Residents #3, #7 and #18 had DNR orders in the EMR and verified missing information on the OOH DNR's. She stated she had been trained on how to complete a DNR form. She stated an incomplete DNR was not valid. She stated her expectations were for the DNR to be filled out completely and accurate. She stated, These DNR's was brought in by the family and could have been completed when the doctor was in facility. She stated the potential negative outcome could be having to perform CPR and go against residents wishes. During an interview on [DATE] at 12:30 PM with the Administrator, she stated the DON was responsible to check the DNR form for accuracy. She verified that Residents #3, #7 and #18 had DNR orders and verified missing information on the OOH DNRs for Residents #3, #7 and #18. She stated an incomplete DNR was not valid. She stated her expectations were for the DNR to be complete. She stated the potential negative outcome could be the resident would need to be resuscitated if the Resident's DNR was not complete. During an interview on [DATE] at 12:50 PM with LVN B, she stated a DNR form was an order to not resuscitate the resident if their heart had stopped beating. She stated when the resident was admitted to the nursing home if they came in with a DNR they check it to make sure it was complete. If they do not have a DNR and wish to be a DNR they will complete the form when the doctor was in house. She stated the resident's DNR was kept in the resident's paper chart, in the EMR and in the front of the narcotic book on the medication cart. She stated she had been trained on how to properly complete a DRN form. She stated an incomplete DNR form was not vailed. She stated if the form was incomplete, they would start CPR and that would be going against the residents wishes. During an interview on [DATE] at 01:45 PM with the DON, he stated the charge nurse, DON or person who initiated the DNR was responsible to check the form for accuracy. He stated the DNR was a do not resuscitate order based on the resident's wishes. He verified that Residents #3, #7 and #18 had DNR orders. He verified missing information on the OOH DNR's for Residents #3, #7 and #18. He stated there was currently no system in place to monitor DNR's for accuracy. He stated all staff had been trained on how to complete a DNR. He stated an incomplete DNR was not valid. He stated his expectations were for the DNR's to be complete and accurate. He stated the potential negative outcome could be having to go against residents wishes. Record review of the facility's policy, DNR No Extraordinary Life-Saving Measures, undated, revealed: No guidance regarding the instructions in completing the DNR form within the policy. Record Review of the Instructions for Issuing An OOH-DNR Order (undated) revealed the following: INSTRUCTIONS FOR ISSUING AN OOH-DNR ORDER PURPOSE IMPLEMENTATION: A competent adult person, at least [AGE] years of age, or the person's authorized representative or qualified relative may execute or issue an OOH-DNR Order. The person's attending physician will document existence of the Order in the person's permanent medical record. The OOH-DNR Order may be executed as follows: Section B - If an adult person is incompetent or otherwise mentally or physically incapable of communication and has either a legal guardian, agent in a medical power of attorney, or proxy in a directive to physicians, the guardian, agent, or proxy may execute the OOH-DNR Order by signing and dating it in Section B. Section C - If the adult person is incompetent or otherwise mentally or physically incapable of communication and does not have a guardian, agent, or proxy, then a qualified relative may execute the OOH-DNR Order by signing and dating it in Section C . In addition, the OOH-DNR Order must be signed and dated by two competent adult witnesses, who have witnessed either the competent adult person making his/her signature in section A, or authorized declarant making his/her signature in either sections B, C, or E, and if applicable, have witnessed a competent adult person making an OOH-DNR Order by nonwritten communication to the attending physician, who must sign in Section D and also the physician's statement section. Optionally, a competent adult person or authorized declarant may sign the OOH-DNR Order in the presence of a notary public. However, a notary cannot acknowledge witnessing the issuance of an OOH-DNR in a nonwritten manner, which must be observed and only can be acknowledged by two qualified witnesses. Witness or notary signatures are not required when two physicians execute the OOH-DNR Order in section F. The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professionals.

**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 1 of 13 residents (Residents #19) reviewed for care plans as follows: Resident #19 did not have a care plan for ADL Functional/Rehabilitation Potential. These failures could place residents at risk of not receiving the care required to meet their Individualized needs. Findings include: Record review of Resident #19's face sheet, dated 06/25/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoseis to include atrial fibrillation (irregular heart beat), hypertension (high blood pressure), atherosclerotic heart disease (narrowing of the arteries), muscle weakness, difficulty walking, and repeated falls. Record review of Resident #19's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 14, which indicated the Resident #19's cognition was not impaired. Section V CAA summary revealed ADL Functional/Rehabilitation Potential triggered and was marked yes to be included in the care plan . Section G Functional status revealed Resident #19 required extensive assistance with one person assist for bed mobility and personal hygiene. Resident #19 requires extensive assistance with two persons assist for transfers, dressing, and toilet use. Resident #19 was not steady, only able to stabilize with staff assistance when moving from seated to standing position, walking, turning around, moving on and off toilet, and surface to surface transfer. Resident #19 requires a wheelchair for mobility. Record review of Resident #19's care plan, dated 03/13/23, revealed no care plan for ADL Functional/Rehabilitation Potential. During an interview on 06/27/23 at 09:00 AM with the ADON/MDS Nurse, she stated she was responsible for care plans. She stated the care plan was developed based off triggered CAA's. She stated there was no reason a triggered care area should not be care planned. She stated the care plan was to guide and direct staff. She stated the care plan was used by all staff. She stated Resident #19 did not have a care plan for activities of daily living . She stated she started working on a care plan for ADL's and then went to another area. She stated, Some of the ADL care area was combined with other care areas but it does not address everything. She stated there was not a system in place to follow up on care plans. She stated her expectations of what should be included in the care plan was much as possible and more. She stated she had been trained on how to develop care plans. She stated the potential negative outcome could be missing information or safety for the resident. During an interview on 06/27/23 at 12:30 PM with the Administrator, she stated the MDS nurse and DON were responsible for care plans. She stated she plays no role in the development of the care plans. She stated she can make suggestions. She stated the care should be resident centered. She stated she does not know about triggered care areas. She stated the care plan was used to provide care the residents need safely. She stated the nurses and MDS use the care plan. She stated there was no system in place to follow up on care plans. She stated she does not know why the triggered care area was not care planned. She stated she expectations was for the care plan to be accurate. She stated the staff have been trained on care plans. She stated the potential negative outcome could be incorrectly caring for the resident or miss something important related to the care of the resident. During an interview on 06/27/23 at 12:50 PM with LVN B she stated the care plan was the overall plan, goals and how to care for each resident. She stated care planned ADL's show how each staff member care for the resident. She stated, It tells us if the resident was a 2 person assist or 1 person assist. She stated, The care plan had goals which lets us know if the resident was declining or not. She stated she had been trained on care plans. She stated the potential negative outcome for missing care areas could be not caring for the resident appropriately, not meeting their needs and not being able to tell if they were adjusting as needed . During an interview on 06/27/23 at 01:45 PM with the DON, he stated the ADON/MDS nurse and DON were responsible for care plans. He stated his role was developing and implementing the care plan. He stated the care plan was developed using the admitting diagnoseis and ADL's. He stated all triggered care areas should be care planned. He stated, The care plan was used to make sure we our caring for the resident they we are supposed to. He stated information that should be included in the care plan was admitting diagnoseis, behaviors, triggered care areas, certain medications and the resident's wishes. He stated the potential negative outcome could be not knowing a decline. He stated there was a system to follow up on care plans. He stated he was trained on how to develop care plans. Record review of the facility's policy, Comprehensive Care Plans, undated, revealed: Procedures: 1. The facility will develop and implement a comprehensive person centered care plan for each resident, consistent with the resident rights that includes measurable objectives and the timeframes to meet a residents medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment. 2. The comprehensive care plan will describe the following: a. The services that are to be furnished to attain the residents highest practicable physical, mental, and psychosocial well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident who was incontinent of bladder, received appropriate treatment and services to prevent urinary tract infections for 1 of 1 resident with a urinary catheter (Resident #27); in that: The facility failed to ensure catheter related physician's orders were followed and failed to position the catheter drainage bag and tubing in a manner that promoted gravity flow and prevented infections. These failures could place residents at risk for urinary tract infections. The findings include: Record review of the Order Summary Report dated 6/25/23 for female Resident #27 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of obstructive and reflux uropathy (obstruction of urine flow disorder), chronic pulmonary embolism (lung clotting disorder), Alzheimer's disease, unspecified (mental disorder), and aphasia following cerebral infarction (communication disorder following a stroke). Record review of the Order Summary Reports for Resident #27 dated 6/25/23 revealed the following order: Monitor for potential complications of indwelling urinary catheter use such as redness, irritation, signs/symptoms of infection, obstruction, urethral erosion, bladder spasms, hematuria (blood in urine), or leakage around the catheter every shift. Order status - Active. Order date - 3/11/23. Start date - 3/11/23. Record review of the Order Summary Reports for Resident #27 dated 6/25/23 revealed the following order, Use catheter securing device to reduce excessive tension on the tubing and facilitate urine flow. Rotate sites of securement daily, and PRN every shift. Order status - Active. Order date 3/11/23. Start date 3/11/23. Record review of the significant change MDS assessment for Resident #27 dated 4/5/23 reflected the resident had an indwelling catheter. The resident had no BIMS score and was documented as cognitively severely impaired. Record review of the current care plan for Resident #27 reflected a Focus of, The resident has indwelling catheter: related to infection, obstructive uropathy, poor fluid intake, pressure sore. Date initiated: 3/22/23. Revision on: 3/22/23. Interventions included, Monitor for signs and symptoms of discomfort on urination and frequency. Date initiated: 3/22/23 . Monitor/document for pain/discomfort due to catheter. Date initiated: 3/22/23. Record review of the April 2023 MAR for Resident #27 revealed there was an order for Bactrim DS oral tablet 800-160 mg. Give One tablet by mouth two times a day suspected UTI for five days. Start date 4/17/23. Further record review of the MAR revealed that the medication was given from 4/17/23 through 4/22/23. Record review of the Progress Notes for Resident #27 dated 4/20/23 at 10:15 PM, Nursing Note. Note text: 16 French Foley catheter inserted per (physician) order for prolonged urinary retention . Catheter tubing secured to left upper thigh with Stat Lock (securing device). Drainage bag, attached, tubing, coiled loosely with no kinks and bag is below the bladder level on the bed frame with 100 cc light yellow immediate return noted, resident tolerated without complaint. Record review of the facility document titled Case Detail - Quick View revealed the following documentation regarding Resident #27, infection details, Onset date 4/17/23. Infection type. Bacterial. Infection - unknown. Infection site - urinary tract. Signs and symptoms - urinary complaints. Create date - 4/17/23 . Associated documentation. Record type - pharmacy order. Description - Bactrim DS oral tablet 800-160 mg. On 6/26/23 at 9:01 AM Resident #27 was observed in bed and the bed was in a low position. The catheter drainage bag was attached to the bed and the tubing was looped and was not positioned for gravity drainage/flow. During an observation on 06/26/23 09:28 AM revealed CNA A provided catheter care to Resident #27. Resident #27 had a catheter in place attached to a closed drainage bag. The tubing was not attached to the resident's leg. The tubing and catheter tubing laid over the left leg and was not secured. The tubing laid on the bed and the closed drainage bag hung on side of bed. On 6/26/23 at 1:06 PM Resident #27 was observed in a low positioned bed. Her catheter drainage bag and tubing were contacting the floor. Her urine was slightly cloudy and contained sediment. The tubing was looped low, below the drainage bag inlet and not in a position for gravity flow. The resident had a slight urine odor. On 6/26/23 at 4:30 PM an observation was made of Resident #27 in her low positioned bed. The catheter drainage bag and tubing were contacting the floor. The tubing was also looped in a manner that would not provide for gravity flow. On 6/26/23 at 4:33 PM an observation and interview were conducted with CNA A regarding Resident #27's catheter drainage bag and tubing. Observation of the resident revealed she was in a low positioned bed, and there was no evidence of any device attached to the resident to prevent the tubing from moving. At that time the CNA stated, to secure/stabilize the tubing, staff twisted the tubing connector and attach the tubing to the bed and clip it on the sheet. She stated the resident moved around in bed and that was the reason the resident's tubing was not being secured as ordered. She stated Resident #27 had the securing leg straps but tore them off. She added she only used the clip on the sheet to keep the tubing in place. She further stated staff lowered the resident's bed to prevent falls and had noticed that this caused the catheter drainage bag to contact the floor at times. She added that staff had not asked the DON for guidance for the issue of the drainage bag contacting the floor. Regarding what could happen if the catheter drainage bag and tubing contacted the floor, she stated residents could get infections. On 6/26/23 at 4:45 PM an interview was conducted with the DON regarding Resident #27's catheter. The DON stated if the drainage bag and tubing were touching the floor, there should have been a barrier between them and the floor; the bag and tubing should now be changed out. Regarding what could result from the tubing and catheter drainage bag contact in the floor, he stated, microorganisms could get in the tubing and in the bag. He added, staff would use a strap to secure the tubing as ordered. He added that the resident used to pull on the catheter tubing. He stated he was not aware of the bag and tubing contacting the floor and was not aware that the resident did not have the stabilizing/securing strap/device as ordered. On 6/27/23. 10:46 AM an interview was conducted with the DON related to catheter care and services. Regarding if Resident #27 had had any UTIs, he stated not lately, but staff had noticed sediment in her urine when they changed her catheter yesterday (6/26/23), so they got a UA. He added Resident #27 had a UTI in April 2023, which was her first one. Regarding if he had conducted any training or in-services with staff regarding catheter care, he stated, he was going to do one, but had not prior to the survey. Regarding why he felt the catheter issues occurred, he stated, it was just an education thing; staff not educated properly. He added, he was aware of the order for the strap device and had initiated the order because he was told the resident tugged at the tubing. He stated the resident had not had any issues with the strap since it was reapplied. Regarding whom was responsible for ensuring that catheter care was conducted as ordered and correctly, he stated, the charge nurse, and himself/DON. He stated he expected the CNAs to report issues and would expect, if issues were found, to do a UA and change the bag. Regarding what could result from the catheter issues observed, he stated, UTIs, septicemia (bacterial infection), resulting in dehydration. Without wearing the strap, it could have caused the tubing/catheter to become dislodged, and the resident could sustain trauma. He added it would be hard to keep a catheter in place in the future. On 6/27/23 at 1:06 PM an interview was conducted with the Administrator regarding issues found in the facility. Regarding catheter care, she stated the DON was responsible. She stated she expected staff to make sure the catheter care was conducted correctly. She added the issues could result in the resident experiencing UTIs. Record review of the facility's current undated policy, titled Anchoring Catheter, Section 16 - Nursing, revealed the following documentation, Policy: Anchoring - Catheter Bags. To ensure that all catheter bags are anchored appropriately, they do not touch the ground and, as much as possible, remain out of plain, sight for dignity purposes. Procedure: When in bed: hang on the opposite side of the bed outside of a clear line of sight when possible. When in wheelchair: to be placed in privacy bag, that should be attached to the wheelchair. If there is no privacy bag, please let the DON or ADON know so that we can order one and ensure it is in place. This is imperative for infection, control purposes, and to maintain resident dignity at all times .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to offer, based on a resident's comprehensive assessment, a therapeutic diet when there was a nutritional problem, and the health care provider ordered a therapeutic diet for 1 of 1 resident (Residents #5) on a therapeutic diet, in that: The facility failed to provide Residents #5 with her physician ordered 2g sodium therapeutic diet for 3 of 3 meals (6/25/23 Supper and 6/26/23 - Lunch and Supper). The Dietary staff were not aware of the diet and were serving the resident foods that were high in sodium. This failure could place residents at risk for hunger, weight loss, and chemical imbalances. The findings include: Record review of the Order Summary Report dated 6/25/23, for female Resident #5 revealed the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of, essential, primary hypertension (high blood pressure), edema (fluid retention), unspecified, unspecified systolic (congestive), heart failure (heart disorder), acute, pulmonary edema (lung fluid retention), nonrheumatic, aortic, (valve) stenosis (heart disorder), hypoosmolality and hyponatremia (disorder of fluid and electrolyte balance), chronic respiratory failure (breathing disorder). Record review of the Order Summary Report for Resident #5 revealed a diet order of, 2 g sodium diet. Regular texture, regular/thin consistency, for 2 g sodium/2 L fluid restriction. Order status - active. Order date - 2/16/23. Start date - 2/16/23. Record review of the Order Summary Report for Resident #5 revealed an order for, Daily weight, and notify MD if greater than 7 pounds fluid gain/24 hours every day shift. Order status - active. Order date - 3/20/23. Start date - 3/21/23. Record review of the quarterly MDS assessment dated [DATE] for Resident #5 revealed no documentation of the resident having a therapeutic diet. Active diagnoses listed were heart failure, hypertension, and hyponatremia. The resident had a BIMS score of nine indicating moderate cognitive impairment. Record review the current care plan for Resident #5 revealed a care plan Focus of Diet: HSG, regular diet, HSG, regular texture, regular consistency. Date initiated 6/14/22. There was no current care plan, addressing the resident's 2g sodium diet. Record review of the Nutrition Status Review for Resident #5 dated 6/21/23 revealed the resident was on a low sodium/regular texture and fluids 2200 ml fluid restriction diet. The report further reflected there were no current labs available, and orders meet estimated needs overall. Continue current diet orders. On 6/25/23 at 4:38 PM an interview was conducted with the Administrator. At that time, she presented the facility diet spreadsheets (with diet extensions) that were requested for Sunday thru Tuesday (6/25/23 - 6/27/23). She stated, those were the only diets the facility served. Record review of the diets listed on the presented spreadsheet (with extensions)on 6/25/23 revealed only regular, mechanical soft, and purée diets were documented. There was no guidance or listing for a 2g sodium diet. The following observations and interviews were made, and interviews conducted during a kitchen tour on 6/25/23 that began at 4:43 PM and concluded at 5:06 PM: On 6/25/23 at 4:51 PM, an interview was conducted with Dietary Staff B regarding the meal she was serving. She stated she just made it up because they did not have the items on the menu. She stated the combination/casserole dish contained cheese, onions, potato tots, and hamburger meat. She added it was made with 5 pounds of hamburger, onions, a can of cream of chicken soup, small cream of mushroom soup, a bag of tater tots, shredded cheese and diced potatoes. On 6/25/23 at 5:02 PM, Dietary staff B was observed preparing a meal tray for Resident #5 which included corn, stewed tomatoes, tater tot casserole, tea and water. On 6/25/23 at 5:46 PM an interview and observation were conducted with Dietary Staff B regarding how she made the foods that she served. She stated for the casserole she added salt, pepper, garlic, and onion powder and she added a couple of tablespoons of sugar. Also, for the corn, she added butter and 3 tablespoons of sugar. She stated the tater tots came in a generic and label bag, which was observed in the walk-in freezer. She stated for her meal she had not checked the sodium levels/content for the meal that she prepared. Record review of the Memorial [NAME] Cancer Center document titled Patient and Caregiver Education, 2 G Sodium Diet, last updated on January 23, 2023, revealed salt, canned soup and cheese were high sodium items to limit or avoid. On 6/26/23 at 12:13 PM an observation was made of the Dietary Manager preparing Resident #5's tray. The resident was served corn bread, cabbage, macaroni & cheese, and sausage and peppers. The tray card reflected, Regular diet. On 6/26/23 at 12:17 PM Resident #5 was observed seated in the dining room and was served the meal tray with water and tea. The resident was obese, on oxygen, wore glasses, fed herself and used a wheelchair. On 6/26/23 at 12:19 PM an interview was conducted with the Dietary Manager regarding what she used to make the food for the noon meal. She stated the sausage and peppers include Polish sausage, salt, creole seasoning, beef broth, onions, peppers; the macaroni and cheese was prepared in water using salt, noodles, cheese sauce, parsley, salt and pepper; and the cabbage included cabbage, onions, bacon, salt, pepper, garlic powder. Record review and observation (6/26/23 at 12:19 PM ) of the creole seasoning labeled [NAME] More Spice Creole Seasoning revealed that the seasoning had 290 mg of sodium in a 1/4 of a teaspoon. Record review of the Memorial [NAME] Cancer Center document titled Patient and Caregiver Education, 2 G Sodium Diet, last updated on January 23, 2023, revealed sausage, salt, cheese, bacon and broth were high sodium items to limit or avoid. Interview on 6/26/23 at 8:11 AM, the Dietary Manager stated she had not conducted any in-service for the dietary staff since taking the position approximately 2 months ago. On 6/26/23 at 12:19 PM an Interview was conducted with the Dietary Manager. She stated she met the Dietitian briefly a week ago. She added communication was not that great, and she hoped to make it better. Regarding the diet spreadsheets she stated she had never seen them. She further stated staff were going by the Week At a Glance Menus which did not contain any guidance for special diets. Regarding the diet manual which would offer guidance for therapeutic diets, she stated she thought she would learn about the manual when she started her Dietary Manager course. No Diet Manual was found by the Dietary Manager. Record review of the facility's Week At a Glance menus titled, Menu: Copy of Homestyle 5 PB S/S 2023 menus for Week 1, Week 2, Week 3, and Week 4 (June 2023) revealed the following documentation, The meal item shown are those served on a regular diet. If your physician has ordered for you a therapeutic or texture altered diet, you may be served a different menu item, a different portion of the menu item or the item may be eliminated entirely in order to comply with your current diet order Record review of the undated Diet Order Book for the dietary department revealed no documentation for diets for Resident #5. On 6/26/23 at 4:45 PM an interview was conducted with the DON regarding why Resident #5 was on a low sodium diet. He stated she was on absolute restrictions (fluid). The low sodium diet was to prevent fluid buildup. He added the resident had lots of CHF and COPD. On 6/26/23 at 4:55 PM an observation was made of Resident #5's meal tray on the hall tray cart. The resident received strawberry ice cream, two soft tacos, corn with cheese and a sour cream packet. Record review of the supper tray card for Resident #5 dated 6/26/23, revealed the following: Diet: regular. Diet texture: regular. Beverages: water - 8 fluid ounces; coffee, 8 fluid ounces; sweet tea - 8 fluid ounces On 6/26/23 at 5:03 PM an interview was conducted with the Dietary Manager as to what she used to make the meal foods. She stated the soft taco included salt, pepper, garlic, and hamburger; and the corn included bell pepper, corn and butter. Record review of the Memorial [NAME] Cancer Center document titled Patient and Caregiver Education. 2 G Sodium Diet last updated on January 23, 2023, revealed salt was a high sodium items to limit or avoid. On 6/27/23 at 9:30 AM observations and interviews were conducted with the Dietary Manager regarding issues found in the dietary department. Regarding therapeutic diets the Dietary Manager stated she was not aware that Resident #5 had a 2g sodium diet. She stated dietary staff printed the tickets/tray cards, and the diets were automatically in the computer system. Regarding how she was made aware of diet changes she stated it was by word of mouth. Observations of the dietary computer display for Resident #5's diet and record review on 6/27/23 at 10:25 AM revealed Resident #5 was documented as being on a regular diet. She added she did not know who input the diet information; Dietary staff D or nursing staff. She stated she was not aware of Resident #5's fluid issues. Regarding if she had any documentation of any guidance on a 2 g sodium diet, she stated as of right now no. She added she never found the diet manual and had no access to know where it was. Regarding what could result from residents not receiving the appropriate 2g sodium therapeutic diet, she stated swelling and decreased circulation; not good for the heart. Regarding whom was responsible for ensuring that therapeutic diets were served correctly, she stated herself with the help of nursing and therapy. Regarding why the issue happened, she stated just being unaware; thinking all residents were on regular diets; shorthanded and not aware. On 6/27/23 at 11:06 AM the DON was interviewed regarding dietary order changes and how the information was communicated. Regarding Resident #5, he stated, she was still on fluid restrictions and it was lifted some. He added she was weighed daily and any increases in weight, edema, and crackles (lung sounds) was reported to the physician. Regarding how the facility communicated diet changes, he stated if there was a change, nursing staff reported it to dietary staff. Nursing also printed out the order and took it to dietary. Regarding who input the data for diet orders changes, he stated nursing. Dietary should be able to pull up the diet order report in the dietary department since they printed diet cards. He added he assumed the diet information transferred over to the dietary computer system. Regarding what could result from the resident not receiving the appropriate 2g sodium diet, he state, she would retain fluid; fluid overload, exacerbation of COPD and CHF. On 6/27/23 at 1:06 PM an interview was conducted with the Administrator regarding issues found in the facility. Regarding therapeutic diets, she stated the DON and Dietary Manager were responsible. She stated she expected staff to follow the diet ordered. Regarding the result of the issue, she stated residents could experience a clinical decline. Record review of the Memorial [NAME] Cancer Center document titled Patient and Caregiver Education, 2 G Sodium Diet, last updated on January 23, 2023, revealed the following documentation, This information explains what you can eat while you're following a 2g sodium diet. About the 2 g sodium diet. Sodium is a mineral that helps balance fluids in your body. It's found in almost all foods. On this diet, you limit the total amount of sodium you eat or drink to 2 g, or 2000 mg daily. 1 teaspoon of salt contains 2300 mg of sodium, so you'll need to take in less than this amount per day. The diet can be used to manage: heart disease, high blood pressure, kidney disease, poor liver function, weight gain from water retention, (such as swelling in your legs) . High Sodium Foods. The following is a list of high sodium foods. Limit these foods while following your diet. When reading the nutrition facts labels, you'll be surprised how much sodium is in them. Many of these products are available in a low sodium version, so try to use those. Food Group. Dairy - High sodium item to limit or avoid - Cheeses:. Food Group - Meats, and fish. High sodium items to limit or avoid - Smoked, cured, dried, pickled, canned, and frozen processed meats. Deli meats, such as corn beef, salami, ham, bologna, frankfurters, sausage, bacon, chipped beef, and regular roasted turkey. Food Group - Vegetables and vegetable juice. High sodium item to limit or avoid - Canned or jarred, vegetables and vegetable juices. Canned and instant soups . Frozen vegetables in butter sauces. Broth or bullion. Food group - condiments, High sodium items to limit or avoid - Onion salt, garlic salt, and other seasonings containing salt Record review of the facility's undated policy titled Special Diets. Section 9 - Dietary/Food Services, revealed the following documentation, Policy: Special Diets. Procedures: 1. Special diets are prepared as ordered by the physician 3. All meals will be prepared by good nutritional standards, according to the food pyramid, and the USDA guidelines, which include: . c. Limited use of salt.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure, based on a comprehensive assessment, that PRN orders for psychotropic drugs were limited to 14 days and could not be renewed, unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of the medication for blank of blank residents on psychoactive medication's (Resident #1), in that: The facility failed to ensure that Resident #1 had orders for psychotropic medications (lorazepam (brand name Ativan)) that did not contain PRN orders beyond 14 days without a start date and reassessment. This failure could place residents at risk for receiving unnecessary medications and adverse drug reactions. The findings include: Resident #1 Record review of the Order Summary Report for female Resident #1 dated 6/25/23 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of heart failure (heart disorder), generalized anxiety disorder (mental disorder), obsessive compulsive disorder (mental disorder) unspecified, unspecified dysphagia, oropharyngeal phase unspecified (swallowing disorder), and macular degeneration (vision disorder). Record review of the quarterly MDS assessment for Resident #1 dated 4/1/23 revealed no documentation of the resident receiving an anti-anxiety medication in the last seven days. The residents BIMS score was 15 indicating the resident was cognitively intact. Record review of the current care plan for Resident #1 revealed the care plan addressed Celexa, anti-depressant, but there was no documentation that the Ativan was addressed. Record review of the Order Summary Report for Resident #1 dated 6/25/23 revealed the following physician orders, Lorazepam Intensol - oral concentrate, 2 mg/milliliter (lorazepam) give 0.25 ml by mouth every two hours as needed for restlessness, anxiety/ Dyspnea. Order status - active. Order date - 5/22/23. Start date - 5/22/23. Record review of the Consultation Report from the current Pharmacy Consultant dated 5/1/23 through 5/31/23 revealed the following documentation, The following residents were reviewed, and based upon the information available at the time of the review, and assuming the accuracy and completeness of such information, it is my professional judgment, that at such time, the residents medication regimens contain no new irregularities, (As defined in 42 CFR 483, Subject part B - Requirements For Long-Term Care Facilities) . [Resident #1]. Reviewed 5/8/23 . Record review of the Gradual Dose Reduction Tracking Report dated 5/8/23 by the pharmacy consultant revealed the following documentation, . Resident #1. Medication lorazepam (Ativan) . Therapy start - 6/29/22. Routine order? No. PRN order? Yes. Last GDR request 10/10/22 . Record review of the Progress Notes for Resident #1 revealed that the resident was administered PRN lorazepam on the following days and times between 6/1/23 and 6/24/23: 6/3/23 (2 times), 6/4/23 (2 times), 6/6/23 (2 times), 6/9/23 (one time), 6/10/23 (2 times), 6/11/23 (2 times), 6/14/23 (2 times), 6/16/23 (1 time), 6/17/23 (3 times), 6/19/23 (2 times) and 6/24/23 (1 time). The resident was administered lorazepam 20 times on 11 days. Further record review of the Progress Notes revealed no documentation of reassessment for the PRN lorazepam ordered by the physician. Additional record review of the Progress Note dated 6/18/23 at 10:06 revealed the following documentation, .Note text: . She takes her pills whole and takes PRN Ativan due to hallucinations There was no other documentation noted related to the Ativan. On 6/27/23 at 11:06 AM an interview was conducted with the DON. Regarding the PRN psychoactive medication orders, he stated, PRN Psychotropic medications should be reviewed every 14 days. Staff would review and call the hospice doctor. Typically, it was not used very often. Regarding what could result from the resident using the PRN psychotropic medication past the 14 days without review, he stated if used on a regular basis, the resident could experience extrapyramidal symptoms (movement dysfunction), psychotropic medication adverse reactions, and psychological issues. Regarding whom was responsible for ensuring that psychotropic medications were not used PRN without review in 14 days, he stated, the charge nurse should review every 14 days. The doctor should be called if there were issues. Regarding why the residents order for psychotropic medications PRN was more than 14 days, he stated, staff missed the issue and if staff reviewed the issue, it was not charted. He felt this was the norm of staff not documenting reviews of medications. Regarding if he conducted any reviews of physician orders, he stated, staff do reviews with the pharmacy consultant and look at them together. He added staff should have caught this issue. On 6/27/23 at 1:06 PM an interview was conducted with the Administrator regarding issues found in the facility. Regarding PRN Psychoactive medications ordered more than 14 days and not reviewed, she stated the DON was responsible to ensure psychoactive medications were not given PRN without being reviewed. She stated she expected staff to give medications correctly. She further stated residents could experience negative effects of the medication as a result of this issue. Record review of the facility's current undated policy, titled Psychotropic Drugs, revealed the following documentation, Policy: Psychotropic Drugs. It is the policy of this facility to appropriately utilize and monitor the use of psychotropic drugs throughout the tenure of a residents stay. To accomplish the successful implementation of this policy, the facility will use its established Quality Assurance Performance Improvement, (QAPI) program to monitor their use. Procedures: the facility will ensure, through a comprehensive assessment of a resident, the following: . 4. PRN orders for psychotropic drugs will be limited to 14 days unless the prescriber believes that the medication should be extended past 14 days and has documented their rationale in the medical record including the duration for the PRN order .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure each resident received, and the facility provided food prepared in a form designed to meet individual needs for 2 of 2 meals observe for 2 of 2 residents with orders for puréed diet (Residents #1 and 24); in that: The facility failed to provide food that was in a form to meet resident needs, 2 of 2 meals observed (6/26/23 - Lunch and Supper) for 2 of 2 residents with the orders for puréed diets (Residents #1 and 24). This failure could place residence at risk of decreased food intake and choking. The findings include: Resident #1 Record review of the Order Summary Report for female Resident #1 dated 6/25/23 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of heart failure, unspecified, dysphasia, oropharyngeal phase, unspecified (swallowing disorder), macular degeneration (vision deficit), and moderate protein-calorie malnutrition (Protein deficient nutrition disorder). Further record review of the Order Summary Report dated 6/25/23 revealed a diet order of, regular diet. Puréed texture, regular/thin consistency, fortified foods with meals times 30 days or 10/7/22 for hospice. Order status - Active. Order date - 8/15/22. Start date - 8/15/22. Record review of the quarterly MDS assessment dated [DATE] documented under Swallowing Disorder that the resident experienced coughing or choking during meals or when swallowing medications. The residents BIMS score was 15 indicating the resident was cognitively intact. Record review of the current undated care plan for Resident #1 revealed the following Focus, I have a puréed diet, but eat what I choose, despite what's recommended. I enjoy eating, but my son brings to eat, and I enjoy, snacking throughout the night on foods that my son brings me. Date initiated: 5/2/19. Created on: 5/2/18. Created by DON. Revision on: 4/12/23. Revision by: ADON . Record review of the Nutrition Status Review for Resident #1, dated 3/20/23, revealed that the resident was ordered a regular diet/purée texture, regular consistency. Further record review of the document revealed the following, continue current diet orders. Record review of the Diet Type Report dated 6/25/23 documented that Resident #1 had a Diet Type - regular, Diet Texture - puréed and Fluid Consistency - regular/thin . Resident #24 Record review of the Order Summary Report for female Resident #24 dated 6/27/23 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of Alzheimer's disease, unspecified (cognitive disorder). Further record review of the Order Summary Report revealed a diet order, of HSG puréed diet regular texture, regular/thin consistency, may have regular snacks, if requested for EDENTULOUS. Order status - Active. Order date - 5/12/22. Start date - 5/12/22. Record review of the quarterly MDS for Resident #24 dated 3/20/23 revealed no documentation of dental issues. The residents BIMS score was 8 indicating the resident had moderate cognitive impairment. Record review of the current care plan for Resident #24 revealed a Focus that stated, Diet: regular purée with regular liquids. Date initiated: 5/12/22. Created on: 5/12/22. Interventions included the following alternate choices will be given. Date initiated: 5/12/22. Created on: 5/12/22. Revision on: 7/15/22. Further record review of the current care plan revealed a care plan Focus of, The resident has no teeth and is satisfied without teeth. Date initiated: 12/28/22. Created on: 12/28/22 . Record review of the Dietitian's Progress Note dated 5/15/23 revealed the following documentation, Note Text: current diet is regular diet. Diet texture of puréed diet. Fluid consistency is regular/thin. No signs/symptoms of dehydration. Current diet is appropriate. Recommendations/interventions. Continue current diet orders. Record review of the Diet Type Report dated 6/25/23 revealed that Resident #24 had a Diet Type - HSG purée, Diet Texture - regular, Fluid consistency - regular/thin. On 6/26/23 at 8:11 AM, an interview was conducted with the Dietary Manager. She stated that she had not conducted any in-service for the dietary staff since taking the position of Dietary Manager. The following observations were made, and interviews conducted during a kitchen tour on 6/26/23 that began at 11:53 AM and concluded at 12:35 PM: On 6/26/23 at 11:53 AM the service line was observed: Puréed, macaroni and cheese stored in a bowl on the service line. Puréed sausage in a bowl on the service line and it appeared very coarse in texture. Puréed cabbage stored in a bowl on the service line. Observation on 6/26/23 at 12:05 PM revealed pureed meal trays for Residents #1 and #24 were observed served by the Dietary Manager. The foods were placed in divided plates for both residents. The pureed sausage was very coarse on both trays. The surveyor requested to test a sample of the purée. The results of the test were as follows: Puréed cabbage - no issue Purée macaroni & cheese - still had some whole pieces of pasta. Puréed sausage - very coarse and grainy with gristle. An interview was conducted with the Dietary Manager on 6/26/23 at 12:19 PM regarding purée training, she stated she had met the Dietitian briefly a week ago. She added she had been trained related to purées, but not at this facility. She stated that a purée should have a pudding-like consistency. Regarding the diet manual, which would have guidance regarding puree diets, the Dietary Manager stated she thought she would learn about it when she started her Dietary Manager course. No Diet Manual was located by the Dietary Manager. On 6/26/23 at 1:12 PM, an interview was conducted with the DON as to why Residents #1 and #24, were on puréed diets. He stated, Residents #24 was edentulous (no teeth). Resident #1 was on hospice and had been on puréed foods and had swallowing difficulty. He added even her medications were crushed. On 6/26/23 at 4:59 PM, an observation was made of the kitchen. The Dietary Manager had prepared two servings of puréed foods, one each for Resident #1 and Resident #24. The puréed taco looked very coarse on the service line. Surveyor requested to test the puréed foods. The results of the test were as follows: Puréed soft taco (beef and flour tortilla) - very coarse with bits of gristle Purée corn - contained skins and hulls. On 6/27/23 at 9:30 AM, an interview was conducted with a Dietary Manager regarding puréed foods. Regarding what could result from foods not being puréed appropriately, she stated choking, asphyxiation. She stated when puréeing foods, she needed to check the blades too. Regarding if she had talked to the Dietitian about purees, she stated no. Regarding who was responsible for ensuring that foods were in the appropriate puréed form, she stated, the cook, and the person above the cook, the Dietary Manager. Regarding why she felt these issues occurred, she stated, human error; not vigilant enough; assuming the consistency was okay. She added she received puree training other places. She further stated there were posted guidelines for puréeing at the kitchen processor area, which she had not noticed until a couple of weeks ago. Observation of the processor area revealed that there were two documents posted related to pureeing foods. On 6/27/23 at 1:06 PM, an interview was conducted with the Administrator regarding issues found in the facility. Regarding food form, she stated that the Dietary Manager and the Administrator were responsible. She stated she expected the purée to be produced correctly. She stated the result of these issues could cause the resident to have trouble swallowing. Record review of the posted guidance for purées revealed the following documentation on one posting, Hints for Pureeing Foods. 3. Avoid pureeing the original food with too much liquid. Puréed foods should be the consistency of applesauce to mashed potatoes, unless there is tolerance for something thinner. 5. Bread may be added to other food items to include nutrients from this food group, however, it will dilute the flavor of original food items. Serving sizes must be increased when bread is added to food items in order to preserve nutritional content of the meal. Record review of the second posted guidance related to purées revealed the following documentation, Purée, consistency. Guidelines for texture modification: puréed foods. Pureed foods must be soft, smooth, and be of a pudding or mousse like texture, (no water separation liquids can be added back if the finished purée is not the correct consistency) . Chop or dice larger pieces of food, such as meat, before placing into the food processor. Blend food item until fine and smooth. If the food item is not smoothing out or appears to dry, add back reserved liquid 1 tablespoon at a time until desired. Mousse-like texture is achieved. Where applicable, followed recipe instructions for purée if, mixed dishes, such as casseroles. Record review of the facility provided document current undated, titled Puréed Food Guideline revealed the following documentation, Instructions for Preparing Puréed Foods: . 3. Add appropriate liquid, (example: reserved liquid, broth, juice, milk), if needed to assist with purée. Purée with a blender or food processor until smooth. 5. Puréed foods should be a smooth consistency. The food should appear smooth like pudding or mashed potatoes. There should be no lumps or particles. Note: it is not recommended to purée the following items. Tough skins or casings. Corn* . *Commercially made products are available. For more information, contact your sales representative. Record review of the facility's current undated policy titled Special Diets. Section 9 - Dietary/Food Services, revealed the following documentation, Policy: Special Diets. Procedures: 1. Special diets are prepared as ordered by the physician. 2. Special diets available include. e. Mechanically altered .

Based on record review and interview, the facility failed to ensure residents had the right to send and receive mail promptly on Saturdays, in that: Resident mail was delivered and available at the facility's US Post Office mailbox on Saturday's but was not delivered to residents until Monday. This failure could place residents at risk for a decline in their psychosocial well-being and not receiving important mail in a timely manner. The findings include: During a confidential Resident Council meeting interviews, 8 of 8 residents stated they had not seen any mail deliveries on Saturday's. One resident stated the staff go to the post office and pick up mail. On 6/26/23 at 3:58 PM an interview was conducted with the Administrator regarding mail delivery in the facility. She stated the DON picked up the mail every weekday from the US post office and passes it out. The post office building is open on Saturday, but the window service was not. The mailboxes were accessible, and the facility had a mailbox there. She added that if items were delivered to the physical address, the staff get it and give it to the residents. No one goes to the PO Box on Saturday. Staff pass out the mail once it is at the facility and that was for all days. She further stated residents do receive mail through the facility's PO Box. She stated if resident mail was received at the PO Box on Saturday, they would not get it until Monday. On 6/27/23 at 2:58 PM an interview was conducted with the Administrator regarding mail delivery in the facility. She stated the individual responsible for ensuring residents received their mail was the Administrator. Her expectation was that she expected residents to get their mail daily. Regarding what could result from residents not receiving their mail in a timely manner, she stated a decline in quality of life. Record review of the current website for the local post office US Postal Service - (https://tools.usps.com/find-location.htm?location=1372122) revealed the following documentation, .Hours .Last Collection Hours - Mon-Fri 4:00 pm, Sat 8:45 am . Lobby Hours - Mon-Fri 12:01 am-11:59 pm, Sat 12:01 am-11:59 pm . PO Box Access Hours - Mon-Fri 12:01 am-11:59 pm, Sat - 12:01 am-11:59 pm Record review of the facility's current undated policy titled Resident Mail. Section 8 - Activity Department, Policy: Resident Mail, revealed the following documentation, The healthcare center will develop a system to deliver and distribute resident mail in accordance with privacy and confidentiality regulations. Procedure: . 2. All resident mail is delivered to residents unopened on the day it is delivered to the facility

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, 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 4 of 13 residents (Residents #4, #6, #7, #13) reviewed for PASRR screening, in that: Resident #4 did not have an accurate PASRR Level 1 assessment when she had a diagnosis of unspecified psychosis. Resident #6 did not have an accurate PASRR Level 1 assessment when she had a diagnosis of major depressive disorder. Resident #7 did not have an accurate PASRR Level 1 assessment when she had a diagnosis of major depressive disorder. Resident #13 did not have an accurate PASRR Level 1 assessment when she had a diagnosis of major depressive 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 #4 Record review of the Order Summary Report dated 6/25/23 for Resident #4 revealed she was admitted to the facility on [DATE] and was [AGE] years old with the following diagnoses of unspecified, psychosis, not due to a substance or non-physiological condition, mild cognitive impairment of uncertain or unknown ideology, and psychotic disorder, with delusions, due to non-physiological condition. Further record review of the Order Summary Report revealed the resident had no orders for psychoactive medications and no primary diagnosis of Alzhimer's/Dementia. Record review of the PASRR Level 1 Screening for Resident #4 with an assessment date of 2/4/20 revealed that Section C0100. Mental illness documented, Is there evidence or an indicator this is an individual that has a mental illness? The response document it was no. Record review of the significant change MDS assessment for Resident. #4, dated 3/17/23 revealed in section A1500 that the resident had not been evaluated by level II PASRR and determined to have a serious mental illness and/or mental retardation or a related condition. Further record review revealed that the resident had a BIMS score of four indicating cognitive impairment. The active diagnoses listed reflected the resident had a psychotic disorder (other than schizophrenia). Record review of the current care plan for Resident #4 revealed a Focus Resident #4 has potential for mood problem related to diagnoses of psychotic disorder with delusions and delirium, due to known physiological condition; benign neoplasm of the brain, and as a specified psychosis. Date initiated 2/11/20. Revision on: 2/27/23. Resident #6 Review of Resident #6's face sheet dated 6/25/23 revealed an [AGE] year-old-female with an admission date of 07/21/21 with primary admitting diagnosis dated 07/21/21 to include major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life) and no primary diagnosis of Alzhimer's/Dementia. Review of Resident #6's PASRR assessment Level 1 Screening dated 07/21/21, under Section C0100 revealed documentation indicating Resident #6 did not have a mental illness. The PASRR Level I screening was also certified by the Assessor on 07/21/21 indicating the information was true and accurate. Record review of Resident #6's Quarterly MDS assessment, dated 03/21/23, revealed Resident #6 had a BIMS score of 02, which indicated the resident's cognition was severely impaired. Section I (Active Diagnoses revealed a diagnosis of depression. Review of Resident #6's Annual MDS assessment dated [DATE], revealed in section A1500 revealed the resident was not currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition. Record review of Resident #6's care plan revealed a focus: [Resident #6] has a major depressive disorder diagnosis date initiated 08/03/21. Record of Resident #6's physician's orders dated 06/25/23 revealed a diagnosis of major depression disorder. The orders reflected the resident was prescribed Lexapro 10mg by mouth in the afternoon, dated 4/26/23. Record review of Resident #6's physician's progress noted dated 4/3/23 revealed resident problems to include major depression disorder. Resident #7 Record review Resident #7's Order Summary Report dated 6/25/23 revealed that Resident #7 was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of, major depressive disorder, psychotic disturbance, mood, disturbance, and anxiety . Further record review of the Order Summary Report revealed an order for antidepressant Venlafaxine ER oral tablet extended release 24-hour 150 mg (Venlafaxine, HCl) give one tablet by mouth one time a day for anxiety. Order dated 6/15/23 and start date 6/16/23. The Order Summary Report further revealed no primary diagnosis of A;zhimer's/Dementia. Record review of the PASRR Level 1 Screening for Resident #7 revealed an assessment date of 3/22/21. Further record review revealed that under Section C0100. Mental illness it documented, Is there evidence or an indicator this is an individual that has a mental illness? The response document it was no. Record review of the admission MDS assessment dated [DATE] for Resident #7 revealed in section A1500 that the resident had not been evaluated by level II PASRR and determined to have a serious mental illness and/or mental retardation or a related condition. The resident had a BIMS score of 6, which indicated cognitive impairment. Under active diagnoses the resident was documented as having depression (other than bipolar). Record review of the current care plan for Resident #7 revealed a Focus: Resident #7 receives anti-depressant venlafaxine HCL ER. Date initiated: 10/25/19. Created on: 10/25/19. Further record review revealed a Focus: Resident #7 has a diagnosis of major depressive disorder, recurrent, moderate. Prescription for venlafaxine HCL ER 150 mg Q a.m. Date initiated 7/31/19. Revision on: 11/12/19. An additional Focus reflected: Resident #7 receives anti-depressant medication (Effexor) related to depression. Date initiated 8/9/19. Revision on: 8/9/19. Resident #13 Record review of Resident #13's Order Summary Report dated 6/25/23 revealed Resident #13 was admitted to the facility on [DATE] and was [AGE] years old with the following diagnoses of unspecified mood (affective) disorder, major depressive disorder, single episode, in partial remission, other specified depressive episodes, major depressive disorder, recurrent unspecified, anxiety disorder, unspecified . Further record review of the Order Summary Report revealed the resident had orders for the following medications: - Anti-anxiety/ Anxiolytic Buspirone HCl oral tablet 10 mg (Buspirone HCl). Give one tablet by mouth two times a day for anxiety disorder. Ordered 84/18/23. Start date 4/18/23. - Depakote oral tablet delayed release 125 mg (divalproex sodium). Give one tablet by mouth two times a day for mood disorder. Ordered date 4/18/23. Start date 4/18/23. - Antidepressant Duloxetine HCl oral capsule delay release sprinkle 40 mg (duloxetine HCl) give one tablet by mouth one time a day for major depressive disorder. Order date 4/18/23. Start date 4/19/23. Further reveiw of the Order Summary Report revealed resident no primary diagnosis of Alzhimer's/Dementia. Record review of the PASRR Level 1 Screening for Resident #13 had an assessment date 04/18/23. Further record review of Section C0100. Mental illness revealed the following, Is there evidence or an indicator this is an individual that has a mental illness? The response document it was no. Record review of the admission MDS assessment for Resident #13, dated 4/25/23 revealed in section A1500 that the resident had not been evaluated by a level II PASRR and determined to have a serious mental illness and/or mental retardation or a related condition. The resident had a BMS score of 15 which indicated cognition is intact. Under active diagnosis the resident was listed as having anxiety disorder and depression, (other than bipolar). Record review of the current care plan for Resident #13 revealed a Focus: the resident uses anti-anxiety medication's related to anxiety disorder. Date initiated: 4/27/23. Created on: 4/27/23. The resident's current care plan had another Focus: the resident uses anti-depressant medication related to depression. Date initiated: 4/27/23. Created on: 4/27/23. During an interview on 06/27/23 at 09:00 AM with the ADON/MDS Nurse, she stated she was responsible for PASRR accuracy. She stated she was not aware that major depressive disorder was a qualifying diagnosis to trigger a positive PL1. She verified Resident #6 was admitted on [DATE] with a diagnosis of major depressive disorder. She verified Resident #6's PL1 was negative and dated 07/21/21. She stated she was responsible for PL1 corrections. She stated her expectations was for the PL1 to be accurate. She stated, Ttraining is available but whether I made it or not is not confirmed. She stated the potential negative outcome could be lack of services and not knowing how to treat residents correctly. On 6/27/23 at 2:03 PM an interview was conducted with the ADON/MDS Nurse regarding the inaccurate PASRR PL 1's conducted for Residents #4, #7, and #13 when they had mental illness diagnoses. She stated, she did not realize that the residents should have been documented as positive PL 1 due to their mental illness diagnosis. During an interview on 06/27/23 at 12:30 PM with the Administrator, she stated the ADON/MDS nurse was responsible for the PL1 on admission and corrections. She stated the ASDON/MDS Nurse hads been trained on PASRR. She stated she was not aware major depressive disorder was a qualifying diagnosis. She stated the potential negative outcome could be the resident not receiving services they wereare entitled to receive from PASRR. During an interview on 06/27/23 at 01:45 PM with the DON, he stated the ADON/MDS nurse was responsible for the PL1. He stated he has had training on PASRR. He stated the potential negative outcome could be not being able to treat residents properly. Record review of the facility policy titled Preadmission Screening and Resident Review (PASRR), undated, revealed the following: It is the policy of the facility to ensure the all residents are screen and appropriately addressed via the PASRR process as outlines by regulations. The results of this process will be used to develop, review and revise the residents care plan. This facility will not admit any new residents with: 1. A mental disorder unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission, a. that, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and b. If the individual requires such level of services, whether the individual requires specialized services; or Coordination of the results and recommendations of the PASRR screen into a resident's assessment, care planning, and transitions of care will be performed to achieve the resident's highest practicable level of well-being. Procedure: 1. The facilities designated staff will review all potential admission for the possible positive PASRR conditions and ensure that CMS Preadmission guidelines are followed. Record review Detailed Item by Item Guide for Referring Entities to Complete the PASRR Level Screening Form, dated June 2023 from Texas HHS website https://www.hhs.texas.gov/sites/default/files/documents/doing-business-with-hhs/providers/resources/pasrr/pasrr-item-by-item-guide-pl1-form.pdf revealed the following: Section C: PASRR Screening Items C0090 through C0300 Page 14 Examples of MI diagnoses are: Mood Disorder (Bipolar Disorder, Major Depressive Disorder, or other mood disorder)

Based on observation, interview, and record review, the facility failed to ensure that the menu was followed and reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy for residents, for (Residents #5, 12, 17 and 26), in that: 1. The facility failed to ensure residents received consistent serving sizes as called for on the menu and approved by the Dietician during 2 meal observations. 2. The facility failed to ensure diet guidance for all diets ordered was represented on the diet spreadsheet and had Dietician approval. These failures could place residents at risk for unwanted weight loss, hunger, unwanted weight gain, and metabolic imbalances. The findings include: During the confidential Resident Council Meeting interviews, three of eight residents voiced concerns related to the menus. Residents stated that the menus that were posted were not always what they were served. During individual confidential interviews, one of seven residents voice concerns with the menu. The resident stated that sometimes the dietary staff could not get organized and get their act together (organized) regarding what foods were served. The resident voiced dissatisfaction with the meal selections and stated that on Father's Day they received a ham sandwich meal. During the entrance conference on 6/25/23 at 10:47 AM, copies of all current menus including therapeutic menus were requested for all days of the survey. Initially, the facility presented Week At A Glance menus which listed only regular diets and did not include other diets served as with a therapeutic spreadsheet. On 6/25/23 at 4:38 PM, an interview was conducted with the Administrator. At that time, she delivered the facility's dietary spreadsheets that were requested. She stated, they were the only diets the facility had or served (regular, mechanical soft, and puree). Record review of the Diet Type Report dated 6/25/23 documented that there were residents with other special diets beyond what was listed on the diet spreadsheets - 2 gram sodium (Resident #5), CCD (carbohydrate counting diet - Residents #12 and #17), and LCS (low concentrated sweets - Resident #26). Record review of the diets listed on the presented facility diet spreadsheets revealed only regular, mechanical, soft, and purée were documented and there was no listed guidance for the 2 gram sodium, carbohydrate counting diet, or low concentrated sweets diets. Record review of the Diet Spreadsheet, Menu: Copy of Homestyle 4 PB S/S2023 Week 3 (Day 15) Lunch (6/25/23) menu revealed the following: Regular diet: parmesan crusted chicken 3 oz, roasted potatoes 4 ounces spoodle, green bean casserole 4 oz spoodle. Mechanical soft diet: ground parmesan crusted chicken with gravy #8 scoop, mashed potatoes with gravy #8 scoop/2 ounce gravy, chopped soft green bean casserole 4 ounce spoodle. Record review of the Week at a Glance, Menu: Copy of Copy of Homestyle 5PB S/S2023. Week 3 (Day 15) Lunch, reveal the following: Smothered chicken, roasted potatoes, green bean casserole and roll. - The following observations were made during a kitchen tour on 6/25/23 that began at 11:22 AM and concluded at 12:35 PM: Observation of the service line at 12:07 PM revealed the following: Sliced Baked Chicken served with a 4 ounce ladle (Regular diet) Mashed potatoes served with a #8 scoop (Regular diet and Mechanical Soft Diet) Green beans (regular not a casserole) served with a 6 ounce (3/4 cup) ladle (Regular diet and Mechanical Soft Diet) White gravy - served with a #10 scoop. Mechanically altered chicken served with a #6 scoop (5/8 cup) (Mechanical Soft Diet). Bite-size chicken served with the #6 scoop (5/8 cup). No roasted potatoes, parmesan chicken or smothered chicken, or green bean casserole were present as call for on the either the Diet Spreadsheet Menu or Week At A Glance Menu. The Dietary Manager served the meal, and the meal portions were one scoop of each. Incorrect size servings were given - residents should have received a 4 ounce serving of green beans instead of 6 ounces, residents should have received 4 ounces of mechanically altered chicken instead of a #6 scoop which was 5/8 cup. Residents being served Bite sized chicken should have received a 4 ounce serving instead of a 5/8 cup serving. Record review of the Diet Type Report dated 6/25/23 revealed that there were no residents with orders for large or double portions. Record review of Diet Spreadsheet, Menu: Copy of Homestyle 4 PB S/S2023 Week 3 (Day 15) Supper (6/25/23), revealed the following: Regular diet: beef and macaroni #6 (5/8 cup) spoodle, tossed salad 8 ounce spoodle/2 tablespoons dressing, buttered peas 4 oz spoodle. Mechanical soft diet: Beef and macaroni #6 scoop, chopped soft cooked vegetable 4 ounce spoodle, buttered peas 4 ounce spoodle Record review of Week at a Glance, Menu: Copy of Copy of Homestyle 5PB S/S2023. Week 3 (Day 15) Supper revealed the following: cheese tortellini and red sauce, Italian blend vegetables, garlic bread - The following observations were made, and interviews conducted during a kitchen tour on 6/25/23 that began at 4:43 PM and concluded at 5:06 PM. An observation and interview were conducted on 6/25/23 at 4:51 PM with Dietary staff B. Regarding the meal she was serving, she stated, she just made it up because they didn't have anything. Meaning the foods were not present for the items on the menu. Observation of the service line revealed that there was soup present, and there was a combination dish that she stated had cheese, onions, potato tots, and hamburger meat. She stated that the casserole was made with 5 pounds of hamburger, onions, a can of cream of chicken, soup, small cream of mushroom soup, bag of tater tots, shredded cheese and diced potatoes. Also on the service line was ham and cheese sandwiches, corn served with a 2 ounce ladle, and stewed tomatoes served with a 2 ounce ladle. No beef and macaroni, tossed salad with dressing, buttered peas, cheese tortellini and red sauce, Italian blend vegetables, and garlic bread were present as called for on the either the Diet Spreadsheet Menu or Week At A Glance Menu. Dietary staff B served the meal, and the meal portions were one scoop of each. There was no documentation available as to the appropriate/correct serving sizes for the meal served. An interview was conducted on 6/25/23 at 4:57 PM with Dietary staff B. Regarding how long the facility had been serving foods that were not on the menu and had to use other foods, she stated that it was quite often but did not specify a length of time. She added, she was the make up menu woman meaning she could make up a menu from a variety of foods quickly. Regarding if she had seen the diet spreadsheet, she stated had never seen them. She further stated that the Week at A Glance menu was the main menu used for this evening. On 6/25/23 at 5:25 PM, an observation and record review of the posted Lunch Menu Sunday, June 25 was baked chicken, cornbread stuffing, green beans, dinner roll, cobbler. The posted Dinner Menu Sunday, June 25 was tater tot casserole, corn, stewed, tomatoes, sherbet. On 6/26/23 at 8:11 AM, the Dietary Manager at that time, stated that she had not conducted any in-service for the dietary staff since taking the position (approximately 2 months). Record review Diet Spreadsheet, Menu: Copy of Homestyle 4 PB S/S2023 Week 3 (Day 16)(6/26/23) Lunch revealed the following: Regular diet: Sliced smoked sausage 3 ounce, macaroni and cheese 4 ounce spoodle, buttered cabbage 4 ounce spoodle. Mechanical soft diet: ground sausage cuts with sauce #8 scoop, macaroni and cheese 4 oz spoodle, soft buttered cabbage 4 ounce spoodle. Week at a Glance, Menu: Copy of Copy of Homestyle 5PB S/S2023. Week 3 (Day 16) (6/26/23) Lunch, Polish sausage with Peppers and onions, macaroni and cheese, seasoned cabbage. On 6/26/23 at 11:22 AM, an observation of the posted menu revealed the following: (6/26/23) Lunch Polish sausage with pepper and onions, macaroni and cheese, seasoned cabbage, cornbread, and frosted cake. Dinner: soft taco with lettuce, tomato and cheese, fiesta corn, and strawberry ice cream. - The following observations were made during a kitchen tour on 6/26/23 that began at 11:53 AM and concluded at 12:19 PM. On 6/26/23 at 11:53 AM an observation was made of the service line: Cabbage served with a 4 ounce ladle. Macaroni and cheese served with a #10 scoop (3/8 cup) and then midway of meal service, the dietary manager changed to the #6 scoop (5/8 cup). Sausage and peppers served with a 3 ounce ladle and then midway of meal service the Dietary Manager changed it to an 8 ounce ladle. Corn bread Ground sausage served with a 4 ounce ladle Mashed potatoes no utensil present Cake at least a 2 inch square Gravy served with a 2 ounce ladle The Dietary Manager served the meal, and the meal portions were one scoop of each. Incorrect/inconsistent sized servings were given - residents should have received a 4 ounce serving of macaroni and cheese instead of a 3/8 cup then a 5/8 cup. Residents should have received an 3 ounce serving of sausage for the meal, but later in the meal, residents received 8 ounce servings. Record review of the Diet Type Report dated 6/25/23 reveal that there were no residents with orders for large or double portions. During an tnterview and record review were conducted with the Dietary Manager on 6/26/23 at 12:19 PM, she stated she met the Dietitian briefly a week ago. Regarding why she had changed scoop sizes in the middle of the meal, she stated, she eyeballed it. She stated residents did not like big portions on their plates and she knew resident preferences. She added, communication was not that great and hoped to make it better. Regarding the diet spreadsheets, she stated, she had never seen them. This was after the surveyor has shown her the diet spreadsheet. She further stated that staff were going by the Week At A Glance Menus which did not contain any guidance for serving sizes or special diets. Regarding substitutions, she stated there was no substitutions list. She stated that she had not contacted the Dietitian for guidance with menu substitutes, or when substitutes were made. Record review of the one substitution documentation that she had revealed that it was on 6/15/23. She stated there were no other pages with any substitution documentation. She further stated that the Dietitian had not gone over substitution system/guidelines. On 6/27/23 at 9:30 AM observations and interviews were conducted with a Dietary Manager regarding issues found in the dietary department. Regarding following the menus and menu issues, she stated staff were going by the Week At A Glance menu, without scoop sizes documented. She added she was told by Dietary Staff D these menus were what they always had, and she had been employed in dietary for 2 years. She further stated that staff did not always have the foods that were listed on the menu. She stated in the past month they had done better getting what was needed. She added the issue was the budget and that was why dietary did not have the ingredients for the casserole. She stated a lot of time, ordered foods did not get sent and items were removed to save money. On the Week 2's menu, she substituted okra for other food items because they had a lot of okra. She further stated she was told by Dietary Staff D that lots of things are marked out on the Week 2 menu because they did not have it. She stated roasted potatoes were on the menu for Sunday Week 3 and were removed by management. Regarding the two different Menus At A Glance, one was Homestyle 5 PB and the other Homestyle 4 PB, which the spreadsheets were derived from, she stated, she had never seen the diet spreadsheets. She further stated that she did not know she had to check with the dietitian for substitutes and meal changes. Regarding if she had checked the recipes for guidance, she stated she had not followed the recipes and had just gone by memory. She stated she had gone by what she had known. Regarding therapeutic diets the Dietary Manager stated that she was not aware that Resident #5 had a 2gram sodium diet. Regarding why staff were unable to follow the menu, she stated circumstances, lack of proper leadership, dietary accreditation (Dietary Manager certification). Regarding what could result from not following the menu, she stated, it could make residents sick by getting the wrong foods. Regarding whom was responsible for ensuring that the menu was followed, she stated, the Dietary Manager with proper communication with nursing. On 6/27/23 at 1:06 PM, an interview was conducted with the Administrator regarding issues found in the facility. Regarding following the menu, she stated that those responsible were the Dietary Manager and then Administrator. She stated she expected the staff to follow the menu. Regarding what could result from this issue, she stated the residents may not get the nutritional servings that they require. On 6/27/23 at 3:05 PM, an interview was conducted with the Consultant Dietitian for the facility. She stated that the last visit was the first time she had seen the Dietary Manager. She planned to go out the following month. She was asked if dietary staff were reporting that menu changes to her. She stated, dietary staff asked her about some menu changes. She added dietary staff had not informed her in the past of food changes. She further stated dietary department had a program with all of this (menu) information and the problem was organization and guidance. Record review of the document titled Resource: Menu Substitution Form, revealed that on 6/15/23, the schedule food item was stewed tomatoes, and it was substituted with corn. Reason for substitution, Corn goes better with chicken. Cooks choice. Employees who initialed the documentation was CH. There was no Registered Dietitian signature. The area was blank for the signature. There was no further documentation of any other substitution or menu changes other than the one on 6/15/23. Record review of the Dietitian Consultant Report dated 6/21/23, documented the following comment . Menu planning/alternates/recipes . Comments. Any changes to menu to be reviewed/signed by RD . Record review of the Dietitian Consultant Report dated 5/15/23 revealed the following documentation, . Other concerns. Noted new menus with no diet extensions, when asked - a.m. cook was unaware of extensions existed. Facility in open window for their annual state survey, recommend for owner, who change the menus, to print out extensions as they required RD approval/signature. Also recommend to have Diet manual updated with signature along with menus and extensions . Signed Consultant Dietitian. 5/31/23. Record review of the facility undated policy titled Menus, . Section 9 - Dietary/Food Services, revealed the following documentation, Policy: Menus. Purpose: menus will be prepared in advance, be nourishing, palatable, well balanced, and will meet the daily nutritional and special dietary needs of the residents. Procedure: 1. The Dietitian will approve all menus. 3. If any meal served varies from the planned menu, the change and the reason for the change will be noted on the posted menu in the kitchen and/or in the record used solely for recording such changes. 4. Menus will provide a variety of foods and indicate standard portions at each meal. Menus will be varied for the same day of consecutive weeks. When a cycle menu is used, the cycle will be of no less than three weeks duration and revised quarterly. 6. Menus will be prepared in advance.

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 8 out of 30 (05/28/23, 06/03/23, 06/04/23, 06/10/23, 06/11/23, 06/17/23, 06/18/23, and 06/24/23) 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: 05/28/23, 06/03/23, 06/04/23, 06/10/23, 06/11/23, 06/17/23, 06/18/23, and 06/24/23 This failure could place residents at risk for inconsistency in care and services. Findings include: Record review of the facility's employee roster undated revealed there were three RN's employed at the facility. Record Review of time sheet provided by the Administrator for the time period 05/28/23-06/25/23 revealed the following dates did not have RN coverage for at least 8 hours a day for the following days: 05/28/23, 06/03/23, 06/04/23, 06/10/23, 06/11/23, 06/17/23, 06/18/23, and 06/24/23. During an interview on 06/27/23 at 12:30 PM with the Administrator, she stated the DON and Administrator were responsible for RN coverage. She stated if there was not an RN available, the staff was to contact the administrator or DON. She stated the facility's policy on RN coverage was to have a RN 8 hours every day. She stated the importance to have an RN on duty was because there was thing in their scope of practice that LVN's cannot do. She stated the potential negative outcome could be if there was something they needed and the LVN cannot do, it would affect them in that way. She stated they have advertising on Facebook and indeed. She stated they could use agency if needed. She stated her expectations was to have an RN in the building every day . She stated there was no system in place to monitor RN coverage. She stated the scope of the nurse was different between the RN and LVN . She stated the DON's working hours was Monday through Friday 8am-5pm, but that was subject to change if he was needed to work the floor. During an interview on 06/27/23 at 12:50 PM with LVN B, she stated if there is not a RN in the building, she would call the DON for any needs. She stated the scope of practice is different between the RN and LVN. She stated she is not able to do higher-level assessments, IV's or pronounce residents. She stated most of the time, they call the hospice nurse to pronounce if there is not an RN in the building. During an interview on 06/27/23 at 01:45 PM with the DON, he stated the administrator and DON were responsible for RN coverage. He stated he could not find any days he worked on the weekend. He stated he does not have a RN that works the weekend. He stated he knew the requirement was to have an RN 8 hours every day but was told him being on call was enough. He stated the importance of an RN was for assessments that LVN's was not allowed to do, wound staging, and higher-level assessments. He stated the potential negative outcome could be residents not receiving the proper treatment. He stated they have not had been advertising for a RN weekend nurse, but were now . He stated an ad for weekend RN was put on Facebook and Indeed on 6/27/23. He stated they used agency in the past but have not used them since he started in February. He stated his expectations was to have an RN 8 hours a day. He stated his working hours are 8-5 or 9-5 Monday through Friday. Record review of RN job posting on indeed.com (undated) did not specify the facility was seeking a weekend RN. The Job posting specifically stated they were seeking a full time RN charge nurse. Record review of the facility's policy, RN Coverage, undated, revealed: The facility will ensure there is registered nurse coverage at least eight(8) hours per day, seven (7) days per week.

Based on interview and record review, the facility failed to employ sufficient staff with appropriate competencies and skill sets to carry out the functions of the food and nutrition service for thefacility's only kitchen reviewed for dietary services. The facility failed to ensure the designated Dietary Manager completed the required dietary managers certification course or had any other qualifying credentials. This failure could place residents at risk for the spread of foodborne illness and residents not having their nutritional needs met. The findings include: Record review of the personnel file for the Dietary Manager revealed a document titled Change In Status. The document stated, Date of change, 5/29/23 and stated that the Dietary Manager's position in housekeeping had now been changed to the Dietary Supervisor. The document was signed 5/30/23 by the Dietary Manager. Further record review of the personnel file for the Dietary Manager revealed a listing of education. There was nothing listed in the area titled Vocational or trade training. The Former Employers listed revealed that in 2022 the Dietary Manager had worked as a chef from 2/2022 through 3/2023 and 3/2021 through 3/2022. There was no documentation in the personnel file that indicated that she had completed the required training for Dietary Manager and was a Certified Dietary Manager. Record review of the facility's Dietician documentation revealed that the Dietician was contracted and not full-time. Record review of the Food Handlers documentation/certification revealed that the Dietary Manager had completed the Food Handlers of Texas Food Handlers Program successfully on 7/28/22; date of expiration 7/28/24. On 6/25/23 at 4:38 PM, an interview was conducted with the Administrator regarding the Dietary Manager qualifications. She stated, the Dietary Manager had not taken the required DM course. She stated she started in the housekeeping department. On 6/26/23 at 8:15 AM, an interview was conducted with the Dietary Manager. Regarding the status of her Dietary Manager course, she stated, she had not completed payment for the course and had been Dietary Manager approximately two months. On 6/27/23 at 1:06 PM, an interview was conducted with the Administrator regarding issues found in the facility. Regarding the Dietary Manager qualifications, she stated the person responsible was the Administrator. She stated she expected the Dietary Manager to become certified. As far as the result of this issue affecting residents, she said the Dietary Manager not being as knowledgeable about important dietary issues. Record review of the undated facility document titled Job Description. Dietary Service Manager, revealed the following documentation, The following is a non-exhaustive criteria that relates to the job of a dietary service manager, and it is consistent with the business needs of the facility. These are legitimate measures of the qualifications for Dietary Service Manager, and or related to the functions that are essential to the job of a Dietary Service Manager. Basic knowledge: current Certified Dietary Managers license. Statement: this position reports directly to the Administrator .

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 in 1 of 1 kitchen reviewed for dietary services, in that: 1) The facility failed to ensure Dietary staff used pasteurized eggs in under cooked egg dishes (soft cooked/sunny side up/over easy eggs), 2) The facility failed to ensure Dietary staff stored foods in a manner to prevent contamination, 3) The facility failed to ensure Dietary staff maintained adequate chlorine sanitizer levels in the low temperature dish machine. 4) The facility failed to ensure Dietary staff ensured food contact surfaces were clean, 5) The facility failed to ensure Dietary staff performed sanitary handwashing between the handling of soiled and clean food equipment during dishwashing, 6) The facility failed to ensure Dietary staff used good hygienic practices (personal foods in food storage and prep areas), 7) The facility failed to ensure Dietary staff stored personal items in a manner to prevent contamination of food contact equipment. 8) The facility failed to ensure Dietary staff ensured that foods were not held past the manufacturers recommended expiration date. These failures could place residents at risk for food contamination and foodborne illness. The findings include: - The following observations were made, and interviews conducted during a kitchen tour on 6/25/23 that began at 11:22 AM and concluded at 12:35 PM: There were three flies, crawling on the toaster oven while the fly zapper/electronic extermination unit was on. Dietary Staff A was washing her hands. She turned off the water with her bare hands, then dried her contaminated hands on a paper towel and donned on a pair of gloves. She then poured coffee and handled sugar packets. The Dietary Manager was observed washing her hands and she turned off the water with a paper towel, but then she dried her hands and arms with the soiled paper towel. During an observation and interview on 6/25/23 at 11:32 AM. The Dietary Manager tested the dishwasher and she attempted to test the dishwasher sanitizing rinse with a quaternary sanitizer test strip. At the time, the Dietary Manager was not aware that the dishwasher was a low temperature chlorine sanitizing dish machine until the surveyor pointed out that the sanitizer container label documented that it was a chlorine sanitizer. The Dietary Manager stated that the sanitizer for the dishwasher was quaternary sanitizer. She then stated this sanitizer was not the same as at another facility. She then looked at the quaternary test strips and asked, What are these used for? This was after the surveyor told her that there were different (chlorine) test strips for the dishwasher. The dishwasher was then tested by the dietary manager a third time with chlorine test strips and the temperature was 110°F and the level of chlorine sanitizer rinse was 200 ppm which was a toxic level of chlorine. During an interview with the Dietary Manager on 6/25/23 at 11:37 AM, she stated she had not seen the dishwasher being serviced in the last two months that she had been there. Record review of the dishwasher test log revealed the last time the dishwasher was tested was 6/22/23. The Dietary Manager again washed her hands, turned off the sink with a paper towel and then dried her hands and arms with the soiled paper towel. Observation of the walk-in freezer revealed that there were 12 bags of ice on the floor and there was available shelf space to place these bags of ice on a shelf. Observation of the walk-in refrigerator revealed that there was a pan containing large tubes of raw hamburger that were thawing. There was pooling blood in the pan. The pan was stored above bottles of drinking water that were stored on the floor. There was room available to move these bottles of water away from the pan of thawing meat. There was a personal drink on an upper walk-in rack with bread that was labeled with [Dietary Staff D]. name. There was a buildup of dirt on the underside of the racks in the walk-in refrigerator. In the walk-in refrigerator, there was half a case of Sysco Strawberry Banana Shakes that had a date on the box of 4/6/23. There was also a full case of Sysco Strawberry Shakes that was dated 4/20/23. There was a case of Sysco Chocolate Shakes label 4/6/23 also present. The underside of the upper shelf of the stove had dried spills. On 6/25/23 at 11:58 AM, an interview was conducted with the Dietary Manager. Regarding the flies in the kitchen, she stated the flies increased in the past month. Regarding what caused the fly increase, she stated, the big back door was open at times and then there were a lot of donations coming in due to the tornado. There were 4 flies crawling on a prep table and the fly zapper in the kitchen and at the back door entrance in the auxiliary hall were on. While taking temperatures on the service line, the Dietary Manager took temperatures of the chicken and bite-size chicken by picking up the individual pieces with her gloved hands then placed it back in the pan to be served. - The following observations were made, and interviews conducted during a kitchen tour on 6/25/23 that began at 4:43 PM and concluded at 5:06 PM: One of two drink guns was submerged in a liquid in a red bucket. During an interview on 6/25/23 at 5:04 PM, Dietary staff A was asked what was in the red bucket. She stated, it was just water. There was an accumulation of dry spills on the underside of the steam table top. - The following observations were made, and interviews conducted during a kitchen tour on 6/26/23 that began at 8:05 AM and concluded at 8:40 AM: During an interview and observation on 6/26/23 and 8:09 AM, the Dietary Manager stated that the Maintenance Supervisor had placed a call to the dishwasher machine repairman about the chlorine level of the dishwasher. She further stated, the cook had checked the level last week and stated it was OK. A large bowl and a pan had been washed in the dishwasher. The level was tested and 200 ppm chlorine. During an interview on 6/26/23 at 8:11 AM, the Dietary Manager stated she was not aware that the bowl and pan had been washed in the dishwasher that morning. She further stated that she had not conducted any in-service for the dietary staff since taking the position as Dietary Manager. The Dietary Manager was observed walking in the stove area, drinking a bottle of water. She placed the bottle on a dirty dish cart at the three-compartment sink and then started doing the dishes. Observation of the walk-in refrigerator revealed that the pan with thawing, bloody hamburger meat was still stored above bottles of water and there was even more blood in the pan. Observation in the walk-in refrigerator revealed a case of raw eggs present was not pasteurized eggs. During an interview on 6/26/23 at 8:20 AM, the Dietary Manager stated she used the raw eggs to prepare over easy eggs every morning for Resident #17. During an interview on 6/26/23 at 8:22 AM, the Dietary Manager stated she thought the eggs she received were pasteurized. On 6/25/23 at 8:25 AM, the Dietary Manager stated the dishwasher sanitizer level should be 50 to 100 ppm chlorine. She stated that she was not aware that 200 ppm Chlorine was a toxic level. On 6/26/23 at 8:30 AM, an interview was conducted with the Dietary Manager. Regarding the dates on the boxes of shakes, she stated the dates were the time that the shakes came in and were placed in the walk-in. She stated that the two resident who used the shakes did not drink them. She further stated she was not aware of the labeling on the shakes that documented once thawed the shakes should be used within 14 days per manufacture instructions. - The following observations were made, and interviews conducted during a kitchen tour on 6/26/23 that began at 11:53 AM and concluded at 12:19 PM: There was a personal drink in a red cup, covered with a small Styrofoam plate. The cup was located on a lower shelf of a food preparation table and next to bags of potato chips and corn chips. There were flies landing on food equipment. - The following observations were made, and interviews conducted during a kitchen tour on 6/27/23 that began at 9:26 AM and concluded at 9:30 AM: There was a cell phone lying on the prep table and leaning against a bag of pasta. There was a fly crawling on the sugar bin and another one flying around in the kitchen. There was a personal drink on the lower shelf of a preparation table at the service line and covered with a small Styrofoam plate. On 6/27/23 at 9:30 AM interviews and observations were conducted with a Dietary Manager regarding issues found in the dietary department. Regarding pasteurized eggs, she stated pasteurized eggs were expensive, and the facility only had one person eating them. She was then explained that the nursing home had a highly susceptible population and that raw eggs cannot be used for sunny side up type dishes. She stated, Sunday was the last time Resident #17 received over easy eggs. Regarding the last time that the walk-in refrigerator racks were cleaned, she stated staff had not cleaned them in the last two months. She added, she was in the middle of creating a chores chart and the cleaning of the racks was not on it. Regarding the shakes and the expiration on them, she stated she was not aware of the 14-day limit. She further stated that she had not trained any new employees yet. Regarding the flies, she stated, the flies had been at this level for the two months she had been here. She added then the tornado came the facility had people bringing in donations, and the problem worsened. At that time, the dishwasher was tested, and it dispensed 50 ppm chlorine and the temperature was 110°F. Observation of the gauge/temperature label documented, Wash/rinse 120°F minimum. The Dietary Manager stated that she was not aware that the hot water needed to be 120°F. Regarding how the issues in the dietary department could affect residents, she stated, unhygienic practices and germs. The dishwasher not working could spread germs around; residents could get sick. Regarding whom was responsible for ensuring that dietary duties were conducted correctly, she stated, herself and staff. She added that she had not taken the required Dietary Manager course. Regarding why she felt these issues happened, she stated, leadership, and not staying on top of things. On 6/27/23 at 1:06 PM an interview was conducted with the Administrator regarding issues found in the facility. Regarding dietary sanitation, she stated that the Dietary Manager and Administrator were responsible. She stated she expected staff to know the correct dietary procedures. She also stated that nursing home residents were highly susceptible and could be affected from those issues related to dietary sanitation in the dietary department. Record review of the Dish Machine Log for June 2023 revealed that the last time the dishwasher was checked was on 6/22/23 dinner meal where the wash was 120°F. The rinse was 120°F and the parts per million chlorine was 100. Further record review of this document revealed the following, .Standards . Chemical sanitizing low temp: Wash: 120 to 140°F. Rinse: 120 to 140°F . Manufacture recommended PPM: (blank). No documentation in this area. The document further stated, . Always defer to manufactures guidelines regarding temperature and correct chemical concentration for use . Record review of the Code Of Federal Regulation, Title, 21, Volume 3, CITE: 21, CFR 178.1010, TITLE 21 - FOOD AND DRUGS, CHAPTER 1 - FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES, SUBCHAPTER, B - FOOD FOR HUMAN CONSUMPTION (CONTINUE), PART 178 - INDIRECT FOOD ADDITIVES: ADJUVANTS, PRODUCTION AIDS, AND SANITIZERS, Subpart B - Substances Utilize To Control The Growth Of Microorganisms, SCC. 178.1010 Sanitizing Solutions, current as of 7/06/23, revealed the following documentation, .Sanitizing solutions may be safely used on food-processing equipment and utensils, and on other food-contact articles as specified in this section, within the following prescribed conditions: (a) Such sanitizing solutions are used, followed by adequate draining, before contact with food. (b) The solutions consist of one of the following, to which may be added components generally recognized as safe and components which are permitted by prior sanction or approval. (1) An aqueous solution containing potassium, sodium, or calcium hypochlorite, with or without the bromides of potassium, sodium, or calcium . c)The solutions identified in paragraph (b) of this section will not exceed the following concentrations: (1) Solutions identified in paragraph (b)(1) of this section will provide not more than 200 parts per million of available halogen determined as available chlorine. Record review of the Sysco shakes cartons revealed the following documentation, Handling instructions: store frozen. Thaw under refrigeration, (40°F or below). Shake well before using. Open top, then pour and serve. After thawing, keep refrigerated. Use within 14 days after thawing. Record review of the website document, Food Safety in Nursing Homes: A Beginner's Guide (https://foodsafepal.com/food-safety-nursing-homes/) . January 30, 2023, revealed the following documentation, . Guidelines for Food Safety in Nursing Homes. Regardless of the population you serve, following safe food handling practices is essential. However, because nursing home residents are considered a highly susceptible population, there are additional food safety precautions you must take to reduce the risk of foodborne illnesses . Raw and undercooked eggs, meats, and seafood. Eggs have the potential to carry Salmonella, which can survive if they are not cooked through. For this reason, you cannot serve eggs where the yolk is runny like over-easy or sunny-side-up eggs to nursing home residents. However, you can make them using pasteurized eggs, which are heat-treated to kill off Salmonella and other bacteria that may be present . Record review of the current undated policy titled Employee Hygiene. Section 9 - Dietary/Food Services, revealed the following documentation, Policy: Employee Hygiene. Procedure: 1. Employees must keep their hands, arms and fingernails clean. 5. Employees may not eat, drink or use tobacco in any area where food preparation is occurring. Employees may drink from a closed container if the closed container prevents contamination. Record review of the undated facility policy, titled Storage of Food and Refrigeration, . Section 9 - Dietary/Food Services, revealed of the following documentation, Policy: Storage of Food and Refrigeration. Procedure: 1. 2. Store raw meats on the bottom shelf to prevent contamination of other perishable items. 4. All containers must be labeled with the contents and the date food item was placed in storage. 6. Food items that remain sealed from the supplier may be held until the expiration date if unopened . Record review of the undated facility policy, titled Thawing Food. Section 9 - Dietary/Food Services, revealed the following documentation, Policy: Thawing Food. Procedures: food that is frozen, should be thawed in such a manner as to prevent the temperature of the food from rising above 41°F. Method for thawing food. 1. Under for refrigeration. b. Meats to be thawed must be placed on the lower shelf in the refrigerator to prevent contamination of other foods with meat juices . Record review of the undated facility policy, titled Section 9 - Dietary and Food Service, revealed the following documentation, Policy: Equipment Sanitation. We will provide clean and sanitized equipment for food preparation. Facility will clean all food service equipment in a sanitary manner. Procedure: 1. Equipment must be thoroughly sanitized between using different food preparation task (E. G. Salad, preparation, raw meat, cutting and cooked meat cutting). 6. Pots and pans. f. All equipment and utensils shall be sanitized by one of the following methods: . h. Immersion for a period of at least one minute in a sanitizing solution containing: at least 50 ppm of available chlorine at temperature not less than 75°F . 7. Facilities should use an approved test kit to measure the parts per million of the chemical solutions in a pot sink on a daily basis. Records of test results shall be kept on the temperature/chemical log. Any abnormal test results shall be reported to the dietary service manager, and the solution shall not be used until at the correct ppm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area from each resident's bedside for 4 of 14 resident rooms (102, 205, 207, and 301); in that: 1. The facility failed to ensure that the resident call system at bedside could not be cancelled from the nurse's station (Rooms 102, 205, 207, and 301). 2. The facility further failed to ensure that the call system accurately indicated the location of the registered call (rooms [ROOM NUMBERS]). These failures could place residents at risk of not receiving needed services. The findings include: On 6/26/23 at 9:10 AM, an observation was made in room [ROOM NUMBER]. The call system at the B bed was activated (dome light illuminated and audible sound emitted) and a voice came over the call system intercom and stated that someone would come to the room shortly. After this response, the call was canceled and the dome light above the room went out and there was no sound. The call had not been cancelled by anyone in the room. On 6/26/23 at 9:19 AM, an observation was made in room [ROOM NUMBER]. The call system was activated in the bedroom and a voice came over the call system intercom (LVN B) and stated, someone would come to the room shortly. At that time the call was canceled from the nurse's station and the dome light went out and there was no sound. During an interview with LVN B, at this time (6/26/23 at 9:19 AM), she stated, staff could shut the call system off in the room and from the nurse's station. She added, staff must pick up the receiver, say something, then staff hang up receiver and the system shuts off. She further stated that the call system had worked that way since her employment in 2019. On 6/26/23 at 9:22 AM, an interview was conducted with LVN A. She stated, regarding the call system, the bathroom call systems could not be reset/cancelled from the nurse station. She added staff could pick up the nurse station call system receiver, put it down, and this would shut off the resident room dome light and sound. On 6/26/23 at 9:44 AM, an observation was made in room [ROOM NUMBER]. The call system was tested and like rooms [ROOM NUMBERS], the call in the bedroom could be cancelled from the nurse's station. The dome light stopped illuminating and there was no audible sound after being cancelled from the nurse's station by LVN B. Also, at that time, the call display at the nurse station displayed 8306-1 (room [ROOM NUMBER]) on the monitor when the call was registered from room [ROOM NUMBER]. During an interview with LVN B, at this time (6/26/23 at 9:44 AM), she stated, some numbers on the display monitor did not match the rooms after there was a power outage in the past. Staff now physically look for the room dome call light in the halls to verify the correct room. On 6/26/23 at 9:47 AM an observation was made in room [ROOM NUMBER]. The call system was tested. When a call was registered from the bedroom, the call system monitor at the nurse's station displayed 8104-1 (room [ROOM NUMBER]), Routine, and the time display was 6:55. During an Interview with LVN B, at this time (6/26/23 at 9:47 AM), she stated, the facility had tried to fix the display issue. Observation at this time revealed that the call registered from room [ROOM NUMBER]. LVN B picked up the receiver, then hung up and at that time this cancelled the sound, and the dome light and the call was canceled. During additional interview at this time, LVN B stated the last repairman who came, checked the call system recently, said that the facility needed a whole new call system. She further stated staff used to be able to hear the resident's response through the intercom but now that portion of the call system does not work. On 6/27/23 at 12:21 AM, an interview was conducted with the Maintenance Supervisor regarding the call system. He stated that he was not aware of the regulation that the call system could not be canceled at the nurse's station. He added the call system could not be cancelled at a bath. Regarding the room number inaccuracy on the nurse station display, he stated the call system was out of date and obsolete and that the main control was replaced during a lightning storm years ago. He added currently the main control did not relay properly to the system. Regarding what could result from the call system not operating properly and capable of being canceled at the nurse's station, he stated residents in distress would not get services. Regarding who was responsible for ensuring that the call system operated correctly, he stated, the fire protection people. Regarding if he made rounds and checked the call systems in the facility, he stated he rounds 1 to 2 times a month. He added, he knew the importance of the call system. Regarding why this issue happened with the call system, he stated, it was the way the system was installed in 2006 where the call system could be canceled at the nurse station. He added the new call systems could not be canceled from the nurse station. On 6/27/23 at 1:06 PM, an interview was conducted with the Administrator regarding issues found in the facility. Regarding the call system, she stated that the responsible individuals were the Administrator and Maintenance Supervisor. She stated she expected staff to answer calls. She stated that she did not know or was aware of these call system issues. The result of these issues could be unanswered calls and residents not receiving services. Record review of the facility's undated policy, titled Operational/Resident Care Policies, XRV .3, revealed the following documentation, . Resident Call Systems: The nurse's station is equipped to receive resident calls through a communication system from resident rooms at each resident's bedside and at toilet, shower, and bathing facilities. The call system in resident rooms will be accessible to alert, confined residents and confused residents and the residents will be instructed as to its availability and location .

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 of 2 carts (medication cart 1) reviewed for storage: The facility failed to ensure medication cart 1 was locked when unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversions. Findings included: During an observation and interview on 4/28/23 at 10:44 a.m. revealed an unsupervised medication cart 1against the wall and observed the lock not pushed in. LVN C stated LVN E was assigned to the unlocked medication cart, and she does not see her in the area. LVN C walked to the medication cart and pushed in the lock on the unsupervised medication cart. LVN C stated that the cart should have been locked and residents could get into the unlocked medication cart and get medications and take them. LVN C stated that there is a risk of residents taking medications that are not theirs and it could cause them to have potential side effects to the medications and cause them to become sick and require hospitalization. The LVN C stated that an unlocked medication cart can also lead to missing medications and medication errors. LVN C stated that all nurses are trained to keep medication carts locked at all times when they are not standing in front of them. LVN C stated that LVN E walked out of the area and was taking medications to a resident. During an observation and interview on 4/28/23 at 10:55 a.m. with LVN E who was walking out of the dining room towards the nursing station with empty medication dispensing cups in her hand. LVN E stated that she is assigned to the medication cart and did not realize that she left it unlocked. LVN E stated there was no issue with the locking mechanism and there was no excuse for leaving her cart unlocked. The LVN E stated that she has worked at the facility for 2 years and was trained to keep the medication cart locked. The LVN E stated that a resident could be at harm if they took medications that were not theirs or took too many of their own medications. The LVN E stated that the risk of residents having access to an unlocked and unsupervised medication cart and taking medications would be the resident overdosing, ingesting chemicals, medication side effects and death. The LVN E stated that she knew better and was in the dining room giving a resident medication and failed to lock the medication cart when she left the area. During an interview on 4/28/23 at 11:35 a.m. with the ADON/MDS; stated that she was notified by LVN E that LVN E left her assigned medication cart unlocked. The ADON/MDS stated that the medication cart should be locked at all times and the nurse should lock it after getting into the cart. The ADON/MDS stated that the LVN E assigned to the cart was responsible for keeping the cart secure. The ADON/MDS stated that the LVN E has been trained on drug diversion and keeping the medication cart secured and the LVN E had been an ADON before and knows the risks of leaving a cart unlocked. The ADON/MDS stated that the risk of a medication cart being unlocked would be multiple residents getting into the cart and medications. The ADON/MDS stated that a resident could take a medication. When asked by the HHSC Investigator the risk associated with a resident taking medications from an unlocked cart the ADON/MDS replied, I know where you are going with this, so I don't want to say. It should have been locked. Review of the facility provided, undated policy titled Pharmacy Services reflected the following: Policy statement: The facility will provide routine and emergency drugs and biologicals to our residents. Storage of Drugs and Biological: -In accordance with state and federals laws, the facility will store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to keys. Drug Security: -When not in use, a medication cart will be secured in a designated area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food safety for the facility's refrigerator used by the activity department and residents. The facility failed to ensure that food items were dated and labeled in the dining room refrigerator/freezer. These failures could place residents at risk for foodborne illness. Findings include: During an interview on 4/27/23 at 4:26 p.m. with the ADM; stated that dietary was in charge of the resident refrigerator/freezer in the dining room, and it is their job to ensure items are labeled with the resident name and date. The ADM stated the date on the item was the date the item was placed in the refrigerator. The ADM stated that any staff could have monitored the refrigerator including herself, dietary, activities or nursing to make sure the refrigerator was cleaned, and old items were tossed. During an observation and interview on 4/27/23 at 4:44 p.m. with the Dietary Supervisor of the refrigerator and freezer located in the dining room; stated that she did not know that she was in charge of making sure that this refrigerator/freezer contained labeled and dated food items. The Dietary Supervisor stated that she did not know who was in charge of this refrigerator/freezer. The Dietary Supervisor stated that she has been trained on food storage and knows that all items should be labeled and dated to ensure that food items are safe to eat. -The Dietary Supervisor pulled the following items undated items from the dining room refrigerator: 2 Styrofoam cups with a whipped cream fruit salad; 7 chocolate, 2 orange juice, 7 strawberry banana and 1 strawberry shake cartons from a metal serving bowl; 1 chocolate and 1 vanilla four pack of pudding; Open chocolate shake; 1 sandwich wrapped in plastic wrap; Plastic container of pineapple chunks; clear plastic container of pimento cheese; container of sour cream containing peanut butter; 2 20 oz opened Dr. Pepper sodas; opened [NAME] Honey BBQ sauce; Lemonade bottle ½ full; Pace Taco Sauce; Sweet Relish; Yellow Mustard; Tostitos Chunky salsa; 44 oz container of ½ full Heinz ketchup. The Dietary Supervisor pulled the following undated items from the dining room freezer: Frozen cups of green, red, orange substance; Breyers opened vanilla ice cream; Cow Bell opened vanilla ice cream; cup of yellow residue; medical glove filled with frozen liquid; Frozen water bottle; [NAME] Dean Delights Bowl; One gallon of opened rainbow sherbet; One-gallon vanilla ice cream ¾ full; Clear plastic container of plastic reusable ice cubes. During an observation and interview on 4/27/23 at 4:46 p.m. with the ADM; stated that all items in the dining room refrigerator/freezer should be dated with names on the items. The ADM stated that this refridgerator/freezer is used by the Activity department and residents also use it. The ADM stood next to HHSC Investigator, and the Dietary Supervisor as the Dietary Supervisor removed items from the freezer and refrigerator. The ADM took items and threw all of the undated items into the trash can and advised the Dietary Supervisor that it was her responsibility to ensure only dated/labeled items were stored in the refrigerator/freezer. Record review of the facility provided, undated, Storage of Food in Refrigeration policy, indicated All containers must be labeled with the contents and date food item was placed in storage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and the public for 1 of 1 facility reviewed for environment. The facility failed to ensure staff dogs were leashed at all times and failed to prevent staff dogs from being in the dining room and resident rooms during meal service and during resident incontinent care. These failures could affect residents placing them at risk of living in an unsafe, uncomfortable environment, infection and disease, and decreased quality of life due to exposure to animals during incontinent and meal service in the facility. Findings includes: During an interview on 4/27/23 at 1:30 p.m. with the Administrator; stated there was one facility staff who had their dog in the facility right now, the BOM. The ADM stated the BOM was allowed to bring her dog into the building and the dog stayed in the BOM office unless it went outside to use the restroom. The ADM stated the BOM had provided proof that the dog was vaccinated. The ADM stated staff are permitted to bring their dog to work if they present a vaccination record, keep the dog on a leash and ask permission first. During an interview on 4/27/23 at 1:57 p.m. with the Activity Director, stated there are 2 dogs are typically in the facility owned by CNA A and the BOM. The Activity Director stated the BOM keeps her dog in her office and CNA A takes her dog around the facility to resident rooms on a leash. The Activity Director stated that CNA A had her dog in the dining room during mealtimes on at least one occasion. The Activity Director stated only one resident has complained about the dog, but she cannot remember the specifics about the complaint. During an interview and observation on 4/27/23 at 2:39 p.m. with the BOM and a small Australian shepherd puppy in the BOM office; BOM stated her dog has had all vaccines based on his age of 2.5 months old. The puppy was observed moving around the office unleashed with the office door opened. The BOM stated she has a copy of the vaccinations in her office and has provided it to the facility. The BOM stated she does not keep the dog on a leash in her office or when she takes him outside to use the restroom. The BOM stated the puppy moves freely around her office and stands in the office doorway when it wants to go outside and then it walks off leash outside the doors where the smoking area is. The BOM stated she is not sure what the pet policy is for staff. The BOM stated she had not thought the puppy could pose a safety or fall hazard to residents if the puppy got between a resident's legs or in front of a resident walking. The BOM stated she did get permission from the facility to bring her dog to work. Stated she does not bring the puppy into the dining room. The BOM stated there is a CNA (CNA A) who brings her dog to work but it is not at the facility the entire shift. The BOM stated CNA A keeps her dog on a leash and the dog goes with her around the facility. During an interview on 4/27/23 at 2:45 p.m. with Resident # 1 , stated that CNA A brings her dog to work a lot and so does the BOM. Resident #1 stated that CNA A lets the dog run around in the dining room during mealtime and the dog runs by his feet. Stated that he is worried that a resident will fall when the dog runs around and does not want the dog in the dining room at all. Stated that the dog should always be on a leash and CNA A should hold the leash but does not always hold it and lets the dog drag it. Resident #1 stated that the BOM brings her dog to work and keeps it inside her office unless it goes outside. Resident #1 stated the BOM's dog is not leashed when it goes from her office to the outside and the dog barks a lot, and he does not think residents should have to listen to a dog barking in the facility. During an interview on 4/27/23 2:50 p.m. with CNA B; stated that there are 2 dogs that staff bring to the facility. CNA B stated the BOM has a puppy that she keeps in her office unless the BOM is taking the dog outside. Stated the BOM puppy is not on a leash when it goes from the BOM office to the outside area to use the restroom. CNA B stated that CNA A brings her dog, and her dog is on a leash most of the time. Stated that the CNA A does bring her dog into resident rooms and into the dining room. During an interview on 4/27/23 at 2:58 p.m. with Resident # 2 , stated that the BOM has a puppy in her office, and she did not mind the puppy because it stays in the office unless it goes outside. Resident #2 stated that CNA A brings her dog every time she works usually in the afternoon. Resident # 2 stated that CNA A's dog is on a leash but is in the dining room during meals and she does not like it. Resident # 2 feels that the dog in the dining room during mealtimes is not sanitary and should not be allowed. During an interview on 4/27/23 at 3:02 p.m. with a visiting community member; stated that she visits the facility often because many of the residents she has known for years. The community member stated that she has observed the dogs in the facility and has an issue with the dogs being here. The community member stated she also hears the BOM's barking in her office when she is visiting friends. The community member stated that the dogs run around wild and not always on a leash. The community member stated that she has observed CNA A's dog in the dining room during mealtime and think that it is disgusting, and the dog could be spreading germs. During a phone interview on 4/27/23 at 4:06 p.m. with CNA A; stated that she has a male [NAME] mixed dog that weighs approximately 7 pounds and is 1.5 years old. CNA A stated that her dog is fully vaccinated but she does not have a copy of the vaccinations and has not provided them to the facility. CNA A stated that the activity director requested the vaccination records, but no other staff had. CNA A stated that she started bringing her dog to work when he had escaped from home, and she found him on her way to work. Stated she did not ask permission and she would bring her dog in the afternoon to the facility. CNA A stated that the dog is always on a leash and always with her, or with someone at the nurses station. CNA A admitted that she does not always have control of the leash or have it attached to her body. CNA A stated the dog goes into resident rooms but stated she had never asked a resident permission before bringing the dog into their room. Stated that the dog only comes in the evening hours. CNA A stated that the dog has been in the dining room during meal service. CNA A stated the dog has accompanied her to residents who eat in their rooms. CNA A stated that when she delivered meals to resident rooms, she would set the dog leash on the ground outside the resident room, pick up the food tray and deliver it into the resident room. CNA A stated she would then exit the room, pick up the dog leash and move to the next room where she would set down the dog leash and grab the next food tray. CNA A stated she did not sanitize her hands after touching the dog leash off the floor or before grabbing the resident food tray. CNA A stated her dog is at the facility several times a week when she worked, and she did not ask permission. CNA A stated that she has brought her dog into a resident room when she performed incontinence care and the dog laid on the floor during resident care. CNA A stated that she did not know the rules about bringing her dog into the facility and stated she thought it was okay because no one had ever told her not to. During an interview on 4/27/23 at 4:26 p.m. with the ADM; stated that all dogs must be with their owner or a designated staff member at all times. The ADM provided the HHSC Investigator a policy regarding dogs and stated this is what the facility is following regarding facility staff and resident dogs. The ADM stated that dogs should not be in resident rooms or in the dining room during meal service. The ADM stated staff must ask resident permission before bringing a dog into a resident room. The ADM stated that she is aware of the Food Code by the Food and Drug Administration that prohibits dogs in the dining room. The ADM stated that dietary staff have Food Handler certificates and would know that dogs are prohibited from the dining room. The ADM stated that if dietary observed a dog in the dining room, they should have had the dog removed and notified her that a dog had been permitted in the dining room. The ADM stated that all staff had a responsibility to notify her that CNA A had allowed her dog in the dining room, and during meal service. The ADM stated that she was not aware that CNA A brought her dog into resident rooms during incontinence care and that it is not permitted. The ADM stated that I am in the dark and did not know this was going on. The ADM stated that had staff notified her that CNA A's dog was in the dining room, in resident rooms during incontinence care or off leash, she would have addressed it. The ADM stated that she was not aware that the BOM and CNA A took their dogs outside without a leash or let the dogs roam in the resident smoking areas off leash. During an interview on 4/27/23 at 5:14 p.m. with Dietary Supervisor; stated that she has previously informed the ADM that the CNA had her dog in the dining room during dinner meal service on more than one occasion. The Dietary Supervisor stated that she is certified in food handling but does not know the rules pertaining to dogs in the dining food. The Dietary Supervisor stated that she believes that having a dog in the dining room during meal service is unsanitary and should not happen. During an interview on 4/27/23 at 5:45 p.m. with the ADM; stated that the dietary supervisor never informed her that CNA A brought her dog into the dining room during resident meal service. The ADM stated she had found on a policy that the facility is following regarding dogs in the facility. The ADM stated that all dogs must be vaccinated, on a leash at all times and prohibited in the dining room or around food service. The ADM stated that CNA A never provided her with her dog's vaccination records and the BOM has her puppy's vaccination record in her office. During an interview on 4/27/23 at 6:13 p.m. with the Dietary aide; stated that he has seen CNA A's dog roam in and out of the dining room and has seen the dog in the dining room during meal service at least once. The Dietary aide stated that he has told staff to get the dog out of the dining room but had not informed the Administrator about the dog. The Dietary aide stated that Food safety training instructs them that dogs are not allowed in the dining room. The Dietary aide stated that he believes that by the dog being in the dining room it could be an infection control issue and if the dog has fleas or ticks it could cause health concerns. The Dietary aide stated that dogs carry germs, and it is unsanitary for dogs to be in the dining room, regardless of if it is mealtime or not. During an interview on 4/27/23 at 6:38 p.m. with Resident # 3; stated that there are two dogs that staff bring to the facility. Resident #3 stated that the BOM has a cute mini aussie that she keeps in her office and CNA A has a mixed breed dog. Stated that the dogs go outside in the smoking area and are not on a leash when the dogs use the restroom outside on the grass in the smoking area. Resident #3 stated he is concerned that someone will fall from the dogs running around the facility. During an interview on 4/27/23 at 6:42 p.m. with Resident #4; stated that CNA brings her dog to work, and she has brought the dog into her room. Resident #4 stated that the CNA does not always ask before bringing the dog into her room. Resident #4 stated that the dog has a retractable leash that the CNA A puts the handle into her pocket but stated that sometimes the dog's leash handle is on the ground following on the floor behind the dog. Resident # 4 stated that sometimes the dog is in the dining room and begs for food from the residents. During an interview on 4/27/23 at 6:46 p.m. with Resident #5; stated that there are two staff owned dogs that come into the facility. Resident #5 stated that the BOM's dog is a small puppy, and it stays in the BOM's office unless the BOM takes it outside. Resident #5 stated that he is concerned of the dogs getting under foot and causing a fall. Resident # 5 stated that CNA A brings her dog into his room, and he does not mind that because the dog is smaller and not aggressive. Resident # 5 stated he does have a problem with mealtimes in the dining room because CNA A has brought her dog into the dining room during meal service on at least two occasions. Resident #5 stated that the dog will come under their feet and beg for food and some resident's do feed the dog during meal service. During an interview on 4/27/23 at 6:55 p.m. with Resident # 6 ; stated that CNA A has brought her dog into her room once and the dog came and jumped on her bed. Stated CNA A has brought the dog into the dining room at least once during mealtime. During an interview on 4/28/23 at 10:44 a.m. with LVN C; stated that she has observed CNA A bring her dog to work several times during the week. LVN C stated that CNA A keeps her dog on a leash and tries to keep the dog out of the dining room. LVN C stated that she has observed CNA A's dog in the dining room a few times during dinner meal service. LVN C stated she has not told the ADM about the dog being in the dining room. LVN C stated that CNA A's dog follows her around the facility on a leash. During an interview on 4/28/23 at 11:07 a.m. with CNA D; stated that she has seen the BOM and CNA A's dog in the facility and has only seen CNA A's dog in the dining room during mealtime with residents. CNA D stated she never told the ADM that CNA A permitted her dog in the dining room. Review of the undated, provided facility policy on Pets-Allowed indicated that: -Procedure: We recognize that pets can be beneficial to the psychosocial well-being of our residents, therefore: Pets are permitted at this facility with prior approval of the Administrator. Pets must be kept on a leash when outside the room and their owners must clean up after them. Pets are not permitted in the common areas. Noisy pets are not acceptable. Must present documentation of pet immunizations. Review of the FDA (Food and Drug Administration) U.S. Health and Human Services, Food Code, dated 2017; revealed that: -Section: 6-501.115 Prohibiting Animals. (A) Except as specified in (B) and (C) of this section, live animals may not be allowed on the premises of a food establishment. (B) Live animals may be allowed in the following situations if the contamination of food; clean equipment, utensils, and linens; and unwrapped single-service and single use articles cannot result: (4) Pets in the common dining areas of institutional care facilities such as nursing homes, assisted living facilities, group homes, or residential care facilities at times other than during meals if: (a) Effective partitioning and self-closing doors separate the common dining areas from food storage or food preparation areas, (b) Condiments, equipment, and utensils are stored in enclosed cabinets or removed from the common dining areas when pets are present, and (c) Dining areas including tables, countertops, and similar surfaces are effectively cleaned before the next meal service. -Salmonella lives in the intestines of animals or humans. It can be found in water, food, soil, or surfaces that have been contaminated with the feces of infected animals or humans. People can become infected with Salmonella by: o Contacting farm animals or pets (including reptiles, amphibians, chicks, and ducklings), animal feces, or animal environments. o Touching contaminated surfaces or objects and then touching ones mouth or putting a contaminated object into ones mouth.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure any drug regimen irregularities reported by the Pharmacist Consultant were acted upon, for 4 of 14 residents (Residents #1, #6 #20, and #26 ) reviewed for medication regimen. The facility did not communicate the Pharmacist Consultant's recommendations to physician for Residents #1 for January 2022. The facility did not communicate the Pharmacist Consultant's recommendations to physician for Residents #1, # 6, #20, and #26 for February 2022. These failures could place all residents receiving medication, who required monthly Medication Regimen Reviews (MRR) at risk for medication errors, unnecessary medications, and incorrect medication administration. The findings included: Resident #1 Record review of Resident #1's admission record, dated 04/25/22, revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include diabetes (high blood sugar), Hypertension (high blood pressure), cerebral palsy, and post-polio syndrome. Record review of Resident #1's Annual Minimum Data Set, dated [DATE] revealed Section I I3300. Hyperlipidemia. Record review of the resident's care plan dated 01/31/22 did not address hyperlipidemia or simvastatin. Record review of Pharmacist Consultation Report dated January 1, 2022 through January 31, 2022 revealed a recommendation letter for Resident #1, To: MD C, from: Consultant Pharmacist, recommendation date 01/31/2022 addressed the following: Comment: Resident #1 receives simvastatin 80 mg daily. Recommendation: Please discontinue simvastatin, change to atorvastatin 40 mg daily, and monitor a fasting lipid panel in 4 weeks and every 12 months thereafter. Additionally, the facility interdisciplinary team should ensure ongoing monitoring for symptoms of myopathy (e.g., muscle pain, muscle weakness, fatigue, decreased reflexes). Physician's Response: No response noted on form and physician signature blank. Record review of Pharmacist Consultation Report dated February 3, 2022 through February 7, 2022 revealed a recommendation letter for Resident #1, To: MD C From: Consultant Pharmacist, recommendation date 02/03/2022 addressed the following: Comment: Resident #1 receives simvastatin 80 mg daily and experienced a fall on 1/21/22. Recommendation: If muscle weakness is a concern, please consider changing to Atorvastatin 40 mg daily. Rationale for recommendation: The use of simvastatin 80 mg should be reserved for individuals who have been receiving this dose for 12 months or more without symptoms of myopathy. Reference: Stone NJ et al. 1013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014; 129(25):S1-S45. Physician's Response: No response noted on form and physician signature blank. Record review of Resident #1's Physician Orders dated 4/25/22 revealed an order for Simvastatin 80mg daily started on 01/11/22. Review of Resident #1's MAR/TAR (medication administration record/ treatment administration record) dated 05/03/22 for April 2022 revealed resident received Simvastatin 80mg. Resident #6 Record review of Resident #6's Face Sheet dated04/25/22, revealed an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include anemia, hypo-osmolality (low level of proteins and nutrients in the blood), hyponatremia (low sodium level), weakness, and lack of coordination. Record review of Resident #6's admission Minimum Data Set, dated [DATE] revealed: Section J Pain Management indicated the resident received scheduled pain medication regimen. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered) No CAA triggered associated with pain. Record review of the resident #6's care plan dated 02/01/22 did not address the meloxicam or the pain associated with the arthritis. Record review of Pharmacist Consultation Report dated February 3, 2022 through February 7, 2022 revealed a recommendation letter for Resident #6, To: MD C From: Consultant Pharmacist, recommendation date 02/04/2022 addressed the following: Comment: Resident #6 continues on meloxicam 15 mg daily for arthritis. Recommendation: Please consider changing Meloxicam to alternative analgesia (e.g. acetaminophen 650 mg topical Diclofenac three times daily) or whether dose could be decreased to Meloxicam 7.5 mg once daily. Rationale for Recommendation: Routine NSAID use is associated with increased risk for gastrointestinal bleeding especially in high risk groups (e.g. age greater than 75 years, residents receiving oral or IV corticosteroids, anticoagulants, or antiplatelets). Additionally, this medication increases the risk for renal failure, hypertension, stroke, myocardial infarction, and heart failure requiring hospital admission. References: 1.) American Geriatrics Society 2019 updated AGS Beers Criteria. JAGS. 2019. 2)[NAME] DE et al. The risk and benefits of long-term use of proton pump inhibitors: Expert review and best practice advice from the American Gastroenterological Association. Gastroenterology. 2017; 152 (4):706-715. 3) [NAME] JT et al. Alternative medications for medications in the use of high-risk medications in the elderly and potentially harmful drug-disease interactions in the elderly quality measures. J AM Geriatr Soc. 2015; 63 (12): e8-18. 3)Prescribing information obtained from Daily Med. Physician's Response: No response noted on form and physician signature blank. Record review of Resident# 6's Physician Orders dated 4/25/22 revealed the resident takes Meloxicam 15 MG with an order date of 10/29/21 and a start date of 10/30/21. Review of Resident #6's MAR/TAR dated 05/02/22 for April 2022 revealed Resident #6 was receiving the Meloxicam daily. Resident #20 Record Review of Resident #20's admission record dated 04/27/22 revealed a [AGE] year-old male original admitted on [DATE] and readmitted on [DATE] with diagnosis to include cerebral palsy, major depressive disorder, and heart failure. Record review of Resident#20's admission Minimum Data Set (MDS) assessment, dated 01/24/22, revealed: Section D Mood indicated a mood interview be conducted and when conducted the Resident's score was a 3 indicating she was classified mild for depression. Section I Psychiatric/ Mood Disorder indicated the resident has a diagnosis of depression. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered) 17. Psychotropic drug use care area triggered, and care planning decision was indicated by a checkmark in the box. Record review of the resident #20 care plan dated 02/21/22 revealed the resident receives an antipsychotic (Abilify) because he has a psychotic condition that causes the resident to act ways that are inappropriate for the setting and situation such as yelling at staff and cursing. Resident #20 had an additional care plan addressing antidepressant medication (Wellbutrin and Abilify) for his diagnosis of depression. Resident #20 had a care plan that addresses the prescribed medication, furosemide, for hypotension and is at risk for fluid deficit. Interventions include taking the prescribed medications as the doctor ordered and to observe for side effects and effectiveness. Record review of Pharmacist Consultation Report dated February 3, 2022 through February 7, 2022 revealed a recommendation letter for Resident #20, To: MD C, From: Consultant Pharmacist, recommendation date 02/03/2022 addressed the following: Comment: Resident #20 was started on a new order for Furosemide 40 mg daily on 01/22/22 and does not receive a potassium supplement. Recommendation: Please ensure BMP labs have been assessed for hypokalemia. References: [NAME] PK et al. ACC/AHA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2018; 71:e127-e248. Rationale for Recommendation: CMS requires that antipsychotics, used to treat an enduring condition other than dementia, be evaluated at least quarterly with documentation regarding continued clinical appropriateness. A dose reduction should be attempted at least annually unless clinically contra-indicated. If this therapy is to continue, it is recommended that a) prescriber document an assessment of risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual, b) the record contains documentation of the dose reduction history, specific target behavior(s), desired outcome(s), and the effectiveness of individualized non-pharmacological interventions; and c) the facility interdisciplinary team ensures ongoing monitoring for effectiveness and potential adverse consequences (e.g., orthostasis, uncontrollable movements). Physician's Response: No response noted on form and physician signature blank. Record review of Pharmacist Consultation Report dated February 3, 2022 through February 7, 2022 revealed a recommendation letter for Resident #20, To: MD C, From: Consultant Pharmacist, recommendation date 02/03/2022 addressed the following: Comment: Resident #20 has a PRN order for Loratadine 10 mg every six hours and PRN Fluticasone nasal spray 2 sprays in each nostril every 4 hours, which is above maximum recommended dose. Recommendation: Please clarify if directions for Loratadine should be once daily if needed for allergy symptoms and if Fluticasone nasal spray should be given2 sprays inn each nostril once daily for allergy symptoms. Physician's Response: No response noted on form and physician signature blank. Record review of Pharmacist Consultation Report dated February 3, 2022 through February 7, 2022 revealed a recommendation letter for Resident #20, To: MD C, From: Consultant Pharmacist, recommendation date 02/03/2022 addressed the following: Comment: Resident #20 has had some incidents of hypotension with systolic less than 90 and continues on Tamsulosin .4 mg two capsules daily for prostate since his admission on [DATE]. He also receives Ditiazem ER 120 mg daily and metoprolol 12.5 mg twice daily with Furosemide 40 mg daily, which are necessary for tachycardia and heart failure. Recommendation: Please consider if bladder flow could be controlled with Tamsulosin .4 mg daily, which may decrease risk of hypotension. Rationale for Recommendation: The recommended dosage is .4 mg PO once daily, 30 minutes following a meal and given at approximately the same time each day. In patients who fail to respond to this dose after 2 to 4 weeks of therapy, the dose can be increased to .8 mg PO once daily. Even though tamsulosin causes less hypotension than other alpha-blockers, signs and symptoms of orthostasis were reported during two US short-term, placebo-controlled trials conducted in 1487 men. The most common symptoms included dizziness, syncope, symptomatic orthostatic, hypotension, and vertigo. Physician's Response: No response noted on form and physician signature blank. Record review of Resident# 20's Physician Orders dated 04/27/22 revealed Resident #20 was prescribed Abilify tablet 2 MG with a start date 01/22/22 and revision date 01/21/22. Resident # 20 was prescribed Wellbutrin SR tablet extended release 12-hour 100 mg with a start of 01/22/22 and revision date of 02/26/22. There was no order for BMP labs to be drawn. The resident was prescribed Furosemide tablet 40 mg. and Fluticasone PRN. The resident was prescribed Tamsulosin .4 mg and prescribed 120 mg of diltiazem extended release. Review of Resident #20's MAR/TAR dated 04/7/22 for April 2022 revealed Resident #20 received his Abilify and Wellbutrin. There were no labs for BMP drawn according to the MAR/TAR reviewed. The resident received his Furosemide 40 mg., but no Fluticasone was given during this time period. The resident received his Tamsulosin and Diltiazem during the time period. Resident #26 Record review of Resident #26's admission record dated 04/25/22, revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include respiratory failure, Alzheimer's dementia, anxiety, depression, arthritis, and Parkinson's disease. Record review of resident #26's Annual Minimum Data Set, dated [DATE] revealed Section I: I5300. Parkinson's Disease in not checked. Record review Resident #26 care plan dated 10/11/21 revealed care plan for Parkinson's. Record review of Pharmacist Consultation Report dated February 3, 2022 through February 7, 2022 revealed a recommendation letter for Resident #26, To: MD C, From: Consultant Pharmacist, recommendation date 02/04/2022 addressed the following: Comment: Resident #26 has had recent falls and continues on a low dose of Carbidopa-Levodopa 10-100 mg twice daily for Parkinson's disease. Recommendation: Please consider if Parkinson's treatment should be adjusted, such as by increasing to carbidopa/levodopa 25/100 three times daily. Rationale for Recommendation: A minimum bioavailable carbidopa daily dose of 70 mg up to a maximum of 200 mg is needed to inhibit the peripheral metabolism of levodopa. References: 1) [NAME] MJ et al. Diagnosis and treatment of Parkinson disease: A review. [NAME]. 2020;323(6):548-560. 2) Prescribing information obtained from Daily Med. Physician's Response: No response noted on form and physician signature blank. Record review of Resident #26's Physician Orders dated 4/25/22 revealed an order for Carbidopa-Levodopa Tablet Disintegrating 10-100MG Give 1 tablet by mouth two times a day started on 10/11/21. Review of Resident #26's MAR/TAR (medication administration record/ treatment administration record) dated 05/03/22 for April 2022 revealed resident received Carbidopa-Levodopa Tablet Disintegrating 10-100MG. During an interview with DON on 04/27/22 at 10:30 AM, he stated pharmacy recommendations were sent to the clinic or MD email. He stated he sometimes does them verbally and makes any changes the MD verbally stated by putting an order in the EMR along with a progress note. He stated he has not sent the April 2022 recommendations to the MD. He stated the pharmacy recommendations just got overlooked. During an interview with MD C on 04/27/2022 at 11:08 AM, he stated as it relates to recommendations, he receives these either via fax, verbal, delivered in person, or via email. He said he reviews the recommendation, and he will sign the document and indicate his choice to approve, deny or modify the recommendation. He stated there was no reason he would not sign the recommendation. In particular, he said regarding pharmacy, he will not always approve it but that he will write modifications. He stated if the recommendation does not have a signature, this most likely means he has not seen it, and the resident orders should not be modified. He stated that he receives documents from the facility at least monthly, but he does not have any record of what he has seen to verify. He said if there were absolutely no recommendations with his signature in the facility, this may be incorrect because he has signed some of the facility's recommendations. During an interview with the District Director of Clinical Services on 04/27/2022 at 11:08 AM, he stated regarding pharmacy recommendations, he was aware that the system was not working and some of the recommendations fell through the cracks. He said that he expected the physician reviews all recommendations. If the physician does not respond, the staff should follow up until the physician acknowledges the recommendation. If the physician verbally acknowledges it was his expectation for a progress note to be entered. He stated failure to ensure that recommendations were acknowledged places the resident at risk because the assessment to ensure the medicine is beneficial or effective was not being done and could harm the resident. During an interview with the Administrator on 04/27/2022 at 12:54 PM, he stated his expectation for pharmacy reviews from the pharmacy was for the recommendations to be reviewed by the physician. He said that if there was no response from the physician, he expects his staff to follow up. He stated when a recommendation is submitted, the indication that it has been reviewed is a signature. If the recommendation does not have a signature, then this indicates that it was incomplete. He stated he expects that a note of some kind is placed in the resident's chart if a verbal order is received. He stated this was the responsibility of his DON. He stated this lack of oversight in this area could negatively affect the residents because the residents could be on medication such as antipsychotics for long periods, which could harm them. During an interview with the pharmacy consultant on 04/27/22 at 01:00 PM she stated, I will email the reports to the DON and Administrator and they are responsible for sending them out the doctor. She stated, I do follow up the next month to make sure recommendations have been addressed. She stated I just can't let things go. If no follow up has been done I will redo the recommendation letter. She stated, there was some problems in the past due to COVID and different pharmacist, but I think there has been lots of good changes lately. Record review policy provided by facility titled: 9.1 Medication Regimen Review, revision date 03/03/20. Applicability: This policy 9.1 sets forth procedures relating to the medication regimen review (MRR). Procedure: 6. The pharmacist will address copies of the residents' MRRs to the director of nursing and/or the attending physician and to the medical director. Facility staff should ensure that the attending physician, medical director, and director of nursing are provided with copies of the MRRs. 7. Facility Should encourage physicians/prescriber or other responsible parties receiving the MRR and the director of nursing to act upon the recommendations contained in the MRR. 7.1 For those issues that require physician/prescriber intervention, facility should encourage physician/prescribers to either accept or act upon the recommendations contained within the MRR or reject all or some of the recommendations contained in the MRR and provide an explanation as to why the recommendation was rejected. 7.2 The attending physician should document in the residents' health record that the identified irregularity has been reviewed and what, if any, action has been taken to address it. 7.2.1 If the attending physician has decided to make no change in the medication, the attending physician should document the rationale in the residence health record. 8. Facility should alert the medical director where MMRs are not addressed by the attending physician in a timely manner. During exit conference on 04/27/22 at 01:15 PM the administrator and DON stated they had no additional documentation to provide.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 6 of 14 residents (Residents #1, #8, #14, #22, #24, and #26) reviewed for advanced directives. Residents #1, #8, #14, #22, #24, and #26 were listed as a DNR (Do Not Resuscitate) but had Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms that were incorrectly filled out or missing required information. This failure could place residents at risk for not having their end of life wishes honored and incomplete records. Findings included: Resident #1 Record review of Resident #1's admission record, dated 04/25/22, revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include diabetes (high blood sugar), Hypertension (high blood pressure), cerebral palsy, and post-polio syndrome. Advance Directive section revealed ADC: Do Not Resuscitate - DNR. Record review of Resident #1's physician order summary dated 04/25/22 revealed an order ADC: Do Not Resuscitate - DNR dated 01/11/22. Record review of Resident #1's care plan, dated 01/31/22, revealed care plan for DNR. Record review of Resident #1's Out of Hospital Do Not Resuscitate form dated 07/16/21 revealed under Physician's Statement revealed no license number or printed name. Resident #8 Record review of Resident #8's admission record dated 04/25/22, revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include dementia, COPD (breathing disease), CHF (fluid around heart), anxiety and heart disease. Advance Directive section revealed ADC: Do Not Resuscitate - DNR. Record review of Resident #8's physician order summary dated 04/25/22 revealed an order ADC: Do Not Resuscitate - DNR dated 04/11/22. Record review of Resident #8's care plan, dated 03/29/21, revealed care plan for DNR. Record review of Resident #24's Out of Hospital Do Not Resuscitate form dated 04/10/22 revealed under the Physician's statement no date, license number or printed name. Resident #14 Record review of Resident #14's admission record dated 04/25/22, revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include benign neoplasm of brain, cerebral infarction (stroke), breast cancer, mild cognitive impairment, and blindness in right eye. Advance Directive section revealed ADC: Do Not Resuscitate - DNR. Record review of Resident #14's physician order summary dated 04/25/22 revealed an order ADC: Do Not Resuscitate - DNR dated 02/04/20. Record review of Resident #14's care plan, dated 02/28/22, revealed care plan for DNR. Record review of Resident #14's Out of Hospital Do Not Resuscitate form dated 5/29/19 revealed under the final section All persons who have signed above, must sign below acknowledging that this document had been properly completed, revealed no signature of Person's signature. Resident #22 Record review of Resident #22's admission record dated 04/25/22, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include COPD (breathing disease), Hypertension (high blood pressure), dementia, and depression. Advance Directive section revealed ADC: Do Not Resuscitate - DNR. Record review of Resident #22's physician order summary dated 04/25/22 revealed an order ADC: Do Not Resuscitate - DNR dated 06/22/21. Record review of Resident #22's care plan, dated 03/24/22, revealed care plan for DNR. Record review of Resident #22's Out of Hospital Do Not Resuscitate form dated 06/14/21 revealed under the final section All persons who have signed above, must sign below acknowledging that this document had been properly completed, revealed no signature from A, B or C. Resident #24 Record review of Resident #24's admission record dated 04/25/22, revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include chronic kidney disease, cardiac murmur, urinary tract infection, hyperglycemia (high blood glucose) and hyperlipidemia (high fat content/ cholesterol in the blood). Advance Directive section revealed ADC: Do Not Resuscitate - DNR. Record review of Resident #24's physician order summary dated 04/25/22 revealed an order ADC: Do Not Resuscitate - DNR dated 03/03/22. Record review of Resident #22's care plan, dated 03/25/22, revealed care plan for DNR. Record review of Resident #24's Out of Hospital Do Not Resuscitate form dated 03/02/22 revealed under the Physician's statement no Physician's signature, date, license number or printed name and under the final section All persons who have signed above, must sign below acknowledging that this document had been properly completed, revealed no attending physician signature. Resident #26 Record review of Resident #26's admission record dated 04/25/22, revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include respiratory failure, Alzheimer's dementia, anxiety, depression, arthritis and Parkinson's disease. Advance Directive section revealed ADC: Do Not Resuscitate - DNR. Record review of Resident #26's physician order summary dated 04/25/22 revealed an order ADC: Do Not Resuscitate - DNR dated 10/11/21. Record review of Resident #26's care plan, dated 02/21/22, revealed care plan for DNR. Record review of Resident #26's Out of Hospital Do Not Resuscitate form dated 10/10/21 revealed under the final section All persons who have signed above, must sign below acknowledging that this document had been properly completed, revealed no signature for witness 1 or witness 2. During an interview on 04/27/22 at 09:00 AM with LVN B, she stated she looks at the resident's electronic medical record (EMR) to determine the residents code status. She stated she can also look at the paper copy of the OOH DNR (Out of Hospital Do Not Resuscitate) in the resident's paper chart. She stated the OOH DNR was not valid if not completely filled out. She stated they were still considered a full code until it was complete. She stated the residents code status was determined on admission and everyone was responsible for completing the OOH DNR. She stated the order for OOH DNR was not written until the OOH DNR was complete. She stated whoever gets the completed OOH DNR was responsible for making sure it was completely filled out and change the code status in the resident's EMR. She stated the negative consequences of an incomplete OOH DNR could be residents receiving life saving measures against their wishes. During an interview on 04/27/22 at 09:15 AM with LVN A, she stated an OOH DNR is not valid if not completely filled out. She stated she will make sure the OOH DNR is complete at the time it is being initiated. She stated the OOH DNR is checked for accuracy by the person who initiated, the DON and the doctor as he is the last one to sign it. She stated she determines the residents code status by looking at the residents EMR and the best place is the paper copy of OOH DNR in the resident's paper chart. She stated the negative consequences if the OOH DNR is not complete the resident has to be a full code and this would go against the residents wishes. During a record review and interview on 04/27/22 at 10:00 AM with DON, he verified Residents #1, #8, #14, #22, #24, and #26 OOH DNR were incomplete. He stated the OOH DNR is not valid if not completely filled out. He stated nursing services or whoever is completing the form is responsible for completing the OOH DNR and putting the order in the EMR. He stated the person putting in the code status in the EMR is the one responsible for checking the OOH DNR for accuracy. He stated the resident code status is determined by looking in the resident EMR and checking the paper copy in the resident's paper chart. He stated the negative consequences would be going against residents wishes. During an interview on 04/27/22 at 12:17 PM Administrator stated he does not know about OOH DNR process. He stated it would be nursing services responsibility to complete the OOH DNR. He stated the only policy he can find is the policy on advanced directives. He stated, We do not have a specific policy on completing the OOH DNR, I assume they use the instructions on the back of the form to complete the OOH DNR. Record review on 04/27/22 policy provided by facility titled Advanced Directives with a revision date February 2017 revealed no information related to OOH DNR. During exit conference on 04/27/22 at 01:15 PM the administrator and DON stated they had no additional documentation to provide.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet residents highest practicable physical, mental, and psychosocial needs for 10 of 16 residents (Residents #1, #2, #6, #7, #14, #17, #22, #24, #26, and #27) reviewed for care plans. Resident #1 did not have a care plan for communication or dental care. Resident #2 did not have a care plan for dehydration. Resident #6 did not have a care plan for dehydration. Resident #7 did not have a care plan for pressure ulcers. Resident #14 did not have a care plan for communication. Resident #17 did not have a care plan for cognitive loss and communication. Resident #22 did not have a care plan for communication and urinary. Resident #24 did not have a care plan for dehydration and urinary. Resident #26 did not have a care plan for activities. Resident #27 did not have a care plan for behavior. These failures 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 #1 Record review of Resident #1's admission record, dated 04/25/22, revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include diabetes (high blood sugar), Hypertension (high blood pressure), cerebral palsy, and post-polio syndrome. Record review of Resident #1's Annual Minimum Data Set, dated [DATE] revealed: Section C Brief Interview for Mental Status (BIMS) score reflected as 11, 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) 4. Communication 15. Dental Care Record review of Resident #1's care plan, dated 01/31/22, revealed no care plan for communication or dental care. During an interview with the MDS Coordinator on 04/27/2022 at 9:15 AM, she stated that according to the Annual MDS dated [DATE], she completed Resident #1 triggered for the following care areas: communication, dental care. She said that those triggered areas were not care planned after looking at the most recent comprehensive MDS and the latest care plan located in the electronic medical record. She stated that she and the Director of Nursing (DON) are responsible for the care plans for all the residents in the facility. She said her role is to complete the MDS and identify the care area assessments (CAA). She and the DON both share the duty of completing the resident's care plans. She states she has been trained. She said there is no reason why a triggered care area would not be care planned. She stated everyone uses the care plan, but the certified nurse's aides do not use it as much. She said; that ideally, the nurses should be utilizing the care plan daily. She stated the care plan is used to guide the whole team toward taking care of the resident. In addition, she said the care plan educates the team, residents, and their family the plan of care and what risks a resident may have. She stated that she knows what to put in the care plan from the triggered CAAs, orders, family members, and learning the resident. She reported the care plan is individualized to the resident. She stated she is unsure why and how she missed the missing care plans but attributed this to distractions. She said she may have stepped away from the care plan and failed to enter those missing care plans when she returned. She stated she could not think of any other reason why the missing care plans were not there. Specifically, regarding Resident #1, she said the failure to care plan the dental care might affect them negatively because the resident does not like to wear his teeth but has dentures, and staff may try to get him to wear his teeth. This would go against the resident's preference of not wearing dentures. Staff who do not know him may schedule dental appointments not needed. She stated the failure to care plan communication may affect this resident and other resident's because staff may not be able to communicate with the resident. She said communication allows the staff to assess them and determine their needs, whether for pain or just for their overall care. She stated staff might not be able to decide on this for the resident without the care plan for communication. Resident #2: Record review of Resident #2's Face Sheet, dated 04/25/22, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include morbid obesity, secondary thrombocytopenia (low blood pressure/low platelet count), hypo-osmolality (low level of proteins and nutrients in the blood), hyponatremia (low sodium level) Record review of Resident #2's admission Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status (BIMS) score was reflected as 14, which indicated the resident's cognition was intact. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered) 14. Dehydration care area triggered, and care planning decision was indicated by a checkmark in the box. Record review of Resident #2's care plan, dated 02/01/22, revealed no care plan for dehydration. During an interview with the MDS Coordinator on 04/27/2022 at 9:15 AM, she stated according to the admission MDS dated [DATE] that she completed, Resident #2 triggered the following care areas: dehydration. She said that those triggered areas were not care planned after looking at the most recent comprehensive MDS and the latest care plan located in the electronic medical record. She stated that when the resident was admitted into the facility, she came from the hospital and had IV fluids. Her diagnosis of thrombocytopenia (low blood pressure/low platelet count) was the reason this care area triggered. She said without the dehydration care plan, staff may not know her past and may not understand fluids were a need in the past before admission but now, not hydrating appropriately may lower her sodium. She stated that decreased sodium could cause seizures, cramping, and physical ailments. Resident #6: Record review of Resident #6's Face Sheet, dated 04/25/22, revealed an [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include anemia, hypo-osmolality (low level of proteins and nutrients in the blood), hyponatremia ( low sodium level), weakness, and lack of coordination. Record review of Resident #6's admission Minimum Data Set, dated [DATE] revealed: Section C Brief Interview for Mental Status (BIMS) score was reflected as 1, which indicated the resident had severely impaired cognition. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered) 1. Dehydration care area triggered, and care planning decision was indicated by a checkmark in the box. Record review of Resident #6's care plan, dated 02/21/22, revealed no care plan for dehydration. During an interview with the MDS Coordinator on 04/27/2022 at 9:15 AM, she stated according to the admission MDS dated [DATE] that she completed, Resident #6 triggered for the following care areas: dehydration. She said that those triggered areas were not care planned after looking at the most recent comprehensive MDS and the latest care plan located in the electronic medical record. She stated the resident was triggered for this because she had had a UTI within the past 30 days. She said while in the hospital, she had IV fluids. She stated the lack of a care plan for dehydration could cause this resident to have continuous UTIs, inability to flush her bladder appropriately, and weakness. Resident #7: Record review of Resident #7's admission record, dated 04/25/22, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include type 2 diabetes mellitus and anemia. Record review of Resident #7's admission Minimum Data Set, dated [DATE] revealed: Section C Brief Interview for Mental Status (BIMS) score was reflected as 10, which indicated the resident's cognition was moderately intact. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered) 16. Pressure Ulcer care area triggered, and care planning decision was indicated by a checkmark in the box. Record review of Resident #7's care plan, dated 02/21/22, revealed no care plan for pressure ulcers. During an interview with the MDS Coordinator on 04/27/2022 at 9:15 AM, she stated that according to the admission MDS dated [DATE], she completed Resident #7 triggered for the following care areas: pressure ulcers. She said that those triggered areas were not care planned after looking at the most recent comprehensive MDS and the latest care plan located in the electronic medical record. She stated the lack of a care plan for pressure ulcers could compromise the skin integrity of this resident. She said in his case specifically, he could develop a pressure ulcer, which could be at risk of worsening. Resident #14 Record review of Resident #14's admission record dated 04/25/22 revealed an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include benign neoplasm of the brain, cerebral infarction (stroke), breast cancer, mild cognitive impairment, and blindness in the right eye. Record review of Resident #14's Annual Minimum Data Set, dated [DATE] revealed: Section C Brief Interview for Mental Status (BIMS) score was reflected as 10, 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) 4. Communication Record review of Resident #14's care plan, dated 02/28/22, revealed no care plan for communication. During an interview with the MDS Coordinator on 04/27/2022 at 9:15 AM, she stated that according to the Annual MDS dated [DATE], she completed Resident #14 triggered for the following care areas: Communication. She said that those triggered areas were not care planned after looking at the most recent comprehensive MDS and the latest care plan located in the electronic medical record. Resident #17 Record review of Resident #17 admission record dated 04/25/22 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include atrial fibrillation (irregular heartbeat), hypertension (high blood pressure), and osteoarthritis. Record review of Resident #17's Annual Minimum Data Set, dated [DATE] revealed: Section C Brief Interview for Mental Status (BIMS) score was reflected as 10, 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) 2. Cognitive Loss/Dementia 4. Communication Record review of Resident #17's care plan, dated 02/21/22, revealed no care plan for cognitive loss/dementia or communication. During an interview with the MDS Coordinator on 04/27/2022 at 9:15 AM, she stated that according to the Annual MDS dated [DATE], she completed Resident #17 triggered for the following care areas: cognitive loss and communication. She said that those triggered areas were not care planned after looking at the most recent comprehensive MDS and the latest care plan located in the electronic medical record. Resident #22 Record review of Resident #22's admission record dated 04/25/22 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of COPD (breathing disease), Hypertension (high blood pressure), dementia, and depression. Record review of Resident #22's Annual Minimum Data Set, dated [DATE] revealed: Section C Brief Interview for Mental Status (BIMS) score was reflected as 01, 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) 4. Communication 6. Urinary Record review of Resident #22's care plan, dated 03/24/22, revealed no care plan for communication or urinary. During an interview with the MDS Coordinator on 04/27/2022 at 9:15 AM, she stated that according to the Annual MDS dated [DATE], she completed Resident #22 triggered for the following care areas: communication and urinary. She said that those triggered areas were not care planned after looking at the most recent comprehensive MDS and the latest care plan located in the electronic medical record. Resident #24: Record review of Resident #24's admission record, dated 04/25/22, revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include chronic kidney disease, cardiac murmur, urinary tract infection, hyperglycemia (high blood glucose) and hyperlipidemia (high-fat content/ cholesterol in the blood). Record review of Resident #24's admission Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status (BIMS) score was reflected as 11, which indicated the resident's cognition was moderately impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered) 1. Urinary area triggered, and care planning decision was indicated by a checkmark in the box. 14. Dehydration care area triggered, and care planning decision was indicated by a checkmark in the box. Record review of Resident #24's care plan, dated 03/25/22, revealed no care plan for dehydration and urinary. During an interview with the MDS Coordinator on 04/27/2022 at 9:15 AM, she stated that according to the admission MDS dated [DATE], she completed Resident #24 triggered for the following care areas: dehydration and urinary. She said that those triggered areas were not care planned after looking at the most recent comprehensive MDS and the latest care plan located in the electronic medical record. She stated the resident triggered for dehydration because of her history of UTIs and urinary because of her incontinence. She reported that failure to manage plan dehydration places her at risk for this resident to have continuous UTIs, inability to flush her bladder appropriately, and weakness. Additionally, she stated the failure to care plan urinary for this resident places her at risk for skin issues and can also contribute to the resident's dignity if the staff does not know the resident is incontinent. Resident #26 Record review of Resident #26's admission record dated 04/25/22 revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include respiratory failure, Alzheimer's dementia, anxiety, depression, arthritis, and Parkinson's disease. Record review of Resident #26's Annual Minimum Data Set, dated [DATE] revealed: Section C Brief Interview for Mental Status (BIMS) score was reflected as 04, 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) 10. Activities Record review of Resident #26's care plan, dated 02/21/22, revealed no care plan for activities. During an interview with the MDS Coordinator on 04/27/2022 at 9:15 AM, she stated that according to the Annual MDS dated [DATE], she completed Resident #26 triggered for the following care areas: activities. She said that those triggered areas were not care planned after looking at the most recent comprehensive MDS and the latest care plan located in the electronic medical record. Resident #27: Record review of Resident #27's admission record, dated 04/25/22, revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include low back pain, type II diabetes, and hemiplegia (paralysis to one side of the body), pain to the right knee, and depression. Record review of Resident #27's admission Minimum Data Set, dated [DATE] revealed: Section C Brief Interview for Mental Status (BIMS) score was reflected as 11, 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) 1. Behavior care area triggered, and care planning decision was indicated by a checkmark in the box. Record review of Resident #27's care plan, dated 04/18/22, revealed no care plan for behavior. During an interview on 04/27/22 at 09:00 AM, LVN B stated she often does not use the care plan. She said the residents could receive the wrong care if the care plan was incorrect. During an interview with the MDS Coordinator on 04/27/2022 at 9:15 AM, she stated that according to the admission MDS dated [DATE], she completed Resident #27 triggered for the following care areas: behavior. She said that those triggered areas were not care planned after looking at the most recent comprehensive MDS and the latest care plan located in the electronic medical record. She stated the resident displays behavior of yelling and screaming. She said the failure to care plan the resident's behavior could affect the resident negatively because staff may not know how to address the resident's needs. She stated that staff might not be able to decipher if it is a part of the behavior or if the resident is in pain, or if the resident is confused. She stated that he also has difficulty hearing, which may be another reason the resident is yelling. During an interview on 04/27/22 at 09:15 AM LVN, A stated she uses the care plan daily to provide resident care. She said if the resident's care plan is not correct, they would not be providing the care the resident needs. During an interview with the DON on 04/27/2022 at 11:37 AM, he said himself and the MDS coordinator were responsible for the care plans. He stated that nursing services utilize the care plan to track the residents and see if they are getting better. He said if the care plan is inaccurate or missing information, the residents could be affected negatively. He stated that the care plan should include the CAAs triggered from the MDS and things that help the resident's hygiene. He said this is his expectation of taking care of the residents. He said he had had the training to complete care plans. During an interview with the District Director of Clinical Services on 04/27/2022 at 11:08 AM, he stated that he does not have a direct role in the care planning process for the facility. However, he said he expects that the facility's care plan should include all pertinent information related to the resident, such as medications, code status preference, acute changes, falls, and anything triggered from the MDS. He said if the care plan is not accurate, this could negatively affect the resident plan of care; for example, if the code status was not correct, the resident's end-of-life decisions may not be carried out. During an interview with the Administrator on 04/27/2022 at 12:54 AM, he said he did not have any role related to the care plan. However, he stated he expects that policy is followed. He said the care plan paints an overall picture of the resident's needs. He stated if the care plan is accurate, then the comprehensive plan of care for the resident can be affected negatively, and residents may not get what they need. He stated the facility DON and MDS coordinator is responsible for the development of care plans. Record review of the facility policy Care Plans, Comprehensive Person-Centered, revised May 2021, revealed the following documentation: Policy Statement The center will develop a comprehensive person-centered care plan that identifies each resident's, medical, nursing, mental, and psychosocial needs within seven days after completion of the comprehensive assessment. The care plan is developed with the resident or resident's representative and reflects the resident's goals, wishes and preferences. The plan includes measurable objectives and timetables agreed to by the resident to meet such objectives. Procedure: #2. The comprehensive Care Planning process includes: 1. An assessment of the resident's strength and needs; 2. A functional comprehensive assessment of the resident using the Minimum Data Set (MDS); #4. Care Plans must be fully developed within 7 days after completing the comprehensive assessment ( MDS) and must include: 1. Interventions to meet both short and long term resident goals, to prevent avoidable decline in function or functional level, and to attempt to manage risk factors; 2. A functional comprehensive assessment of the resident using the Minimum Data Set (MDS);