**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** These failures could place residents at risk for unassessed changes in conditions that could lead to permanent impairment, including decreased quality of life. Based on interviews and record reviews the facility failed to ensure that residents received treatments and care in accordance with professional standards of practice and the residents' choices for 1 of 1 resident (Resident #1) reviewed for quality of care.Resident #1 had an appointment on or around 4/28/2025, for an MRI (a medical imaging technique that uses a magnetic field and computer-generated radio waves to create detailed images of the organs and tissues in your body) for his prostate, and the facility failed to schedule the appointment and failed to place the necessary preop instructions needed for the procedure in PCC; subsequently Resident #1 missed his appointment twice. There were no adverse reactions from him not attending his appointment. These failures could place residents at risk for unassessed changes in conditions that could lead to permanent impairment, including decreased quality of life. Record review of Resident #1's admission record, dated 8/14/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnosis which included major depressive disorder, recurrent severe without psychotic feature (s characterized by multiple episodes of major depressive disorder that are severe in nature but do not include psychotic symptoms), chronic embolism and thrombosis of unspecified vein (a blood clot in a deep vein that has lasted for at least a month. It can be difficult to treat and can lead to scarring and vein damage), overactive bladder (causes sudden urges to urinate that may be hard to control), and benign prostatic hyperplasia with lower urinary tract symptoms (is a noncancerous enlargement of the prostate gland that can lead to lower urinary tract symptoms, affecting urination and overall quality of life). Record review of Resident #1's quarterly MDS, dated [DATE] reflected a BIMs of 10, which indicated mild cognitive impairment. Record review of Resident #1's physicians order dated 10/31/2024 reflected Resident #1 had a referral to see the urologist upon admission. Original orders from the hospital dated 3/31/2025 revealed the resident had a cystoscopy on 3/26/2024 which identified large bladder capacity. The resident has an overflow incontinence. TRUS not performed. It was recommended a Urolift but the patient canceled. 12/3/24: the resident wen in there of complaints included severe urge incontinence. Overall, he is frustrated with his status. Patient report delayed ejaculation. During an interview on 8/14/2025 at 1:50 PM with Resident #1 revealed he had an MRI that was scheduled that he did not attend. Resident #1 stated he waited a month to get the appointment scheduled, he was advised the facility never received he prep instructions. He stated he gave the instructions to the ADON. He stated he has waited 3 months for the appointment, and it is finally scheduled for 8/15/2025. He stated the DON apologized and assured him it was rescheduled, and he will be prepped the night before and he will be transported to his appointment. He stated he was upset that once he saw the ADON, she did not apologize to hm for the mistake she made. During an interview on 8/14/2025 at 4:20 PM with ADM revealed there was a transportation driver that brings the residents to their appointments if she was informed. He stated if residents had appointments scheduled at the same time, they utilized a ride share company. He stated there was a mix up with the appointment with Resident #1. He stated it was missed once and it was rescheduled. He stated it was an MRI appointment for urology. He stated it was not an appointment that was life threatening. During an interview on 8/14/2025 at 5:08 PM with ADON revealed Resident #1 came from another town hospital and he scheduled his own MRI and set up his own transportation where he attended his appointment in the other town. She stated he came back with no follow-up paperwork. She stated she received a call from the surgical confirming his appointment on or about 3/30/2025. She advised the surgical representative that there will not have anyone medically equipped on the van to handle Resident #1 after the procedure. The next day they called from the same surgical center and stated he cannot get on the van after the procedure. The ADON stated that was why the first appointment was cancelled. She stated Resident #1 then received a referral from the doctor to a local urologist. The ADON stated the appointment was scheduled but never questioned anything regarding preop instructions because she figured he did not need anything for the MRI. Once he arrived at the appointment, he could not be seen because he had not been prepped. The ADON stated they received the orders from the doctors' office, but the orders were not put into PCC so Resident #1 missed that appointment. The ADON stated the orders was now placed into the system and Resident #1 appointment was scheduled and he has started his preop for the procedure that will take place on tomorrow. The ADON stated the was not a life-threatening procedural appointment he missed. During an interview on 8/14/2025 at 5:38 PM with DON revealed it was the ADON or the charge nurse job to make sure appointments and orders are placed in PCC but ultimately it was her responsibility. The DON stated the first time, the surgical center in [NAME] did not communicate the instruction. The second time, it was not entered into PCC. When she learned about it, she scheduled it. She stated the ADON went on vacation, and she did not see the instruction. It was revealed, the instructions were not placed in PCC. She found the instructions and she went over them with Resident #1. She advised him it was scheduled for 8/15/2025 and he was alright with that. A record review of the facility's Abuse Prohibition undated policy revealed, each resident has the right to be free from verbal, sexual, physical and mental abuse, mistreatment, neglect, involuntary seclusion and misappropriation of property. Neglect: Failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. It may include failure to assist in personal hygiene, or in provision of food, clothing, shelter; failure to provide medical care for physical and mental health needs or failure to protect from health and safety hazards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect and promote the resident's right to a dignified existence and self-determination for 1 of 6 residents (Resident #1) reviewed for resident rights, in that: The facility failed to allow Resident #1 to maintain her smoking privileges. This failure could place residents at risk of feelings of poor self-esteem, anxiety, decreased quality of life and loss of dignity.The findings were: Review of resident #1's face sheet dated 7/24/2025 revealed she is a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: Schizoaffective disorder, Bipolar type (mental health conditions involving mood disorders), Epilepsy (seizure disorder) Ulna Fracture (broken bone in forearm), Intellectual Disabilities (limitations in both intellectual functioning and adaptive behavior), Type 2 Diabetes (blood sugar disorder). Dementia with other behavioral disturbance (loss of memory) and Major Depressive Disorder. Face sheet further revealed that a family member was resident #1's Power of Attorney. The face sheet did not identify a responsible party. Review of resident #1's quarterly MDS dated [DATE], revealed a BIMs of 9, suggesting moderate cognitive impairment. In the behavior symptom section, resident #1 was noted to have verbal behaviors directed towards others occurring in 1 to 3 days in the last 7-day lookback period. There was no section in the MDS that addresses smoking. Review of resident #1's progress notes from 6/27/2025 to 7/23/2025 reflected no notes concerning removal of resident #1's smoking privileges. Review of resident #1's smoking assessment dated [DATE] reflected she was safe to smoke but needed supervision. This was the only smoking assessment found in resident #1's EMR Review of resident #1's Smoking Agreement dated 5/29/2025, reflected it was signed by resident #1 on 5/29/2025. In the agreement Resident #1 agreed to abide by the smoking rules which were centered around safe smoking habits. Specifically, #11 stated Failure to adhere to safe smoking practices may result in denial of smoking rights at [the facility]. Family and resident will be kept informed of issues that arise. Review of resident #1's untitled contract dated 6/27/2025 reflected I [resident] entering into this contract with [nursing facility] in the agreement. I will only smoke 3 cigarettes per day at 8:30 am, 1:30 pm and 6:30 pm. I understand if I break this agreement, I may have my smoking privileges taken away. Contract was signed by resident using her first name on 6/27/2025. Review of resident #1's care plan dated 7/24/2025 reflected [resident #1] is a smoker with goal of resident will smoke safely through next review and interventions: complete smoking assessment, if it is determined that resident is safe to smoke, staff will review and explain facility smoking policy and smoking agreement. During an interview on 7/24/2025 at 12:09 pm, the ADON stated on 7/23/2025 herself, the activities person and the ADM were having a meeting in her office and resident #1 came in and talked to the ADM about smoking. She stated resident #1 asked ADM if he would give her one more chance to smoke and ADM stated he didn't think it was a goo idea. She stated resident #1 started crying at that point which was not unusual for her - she would cry a lot when she didn't get her way. She stated the ADM had decided about 3 weeks ago for resident #1 to stop smoking. She stated she did not remember a meeting with resident, family member or IDT to discuss taking away resident #1's smoking privileges. During an interview on 7/24/2025 at 12:53 pm facility SW stated the facility cut out smoking for resident #1 because behaviors would happen around smoking times because resident #1 would get impatient. SW stated resident #1 has not verbalized any desire to smoke since the smoking privileges were taken away. He stated he did not recall their being an IDT meeting with the resident, a family member or the PASSAR case manager to discuss removing resident #1's smoking privileges. He stated resident #1's smoking privileges were taken away about a month ago. SW states smoking is a privilege, not a right. During an interview on 7/24/2025 at 1:30 pm ADM stated smoking at the facility was a resident privilege not a resident right. He stated resident #1's smoking privileges were taken away somewhere around 7/3/2025 because issues with smoking would lead to an escalation of behaviors with resident #1 with verbal and physical aggression incidents directed towards staff and other residents. ADM stated resident #1 did not have another smoking assessment completed when her smoking privileges were revoked because it was not a safe smoking issue, it was a behavior issue. ADM provided the facility policy on smoking, resident #1's smoking agreement and resident #1's cigarette contract for investigator review. During an interview on 7/24/2025 at 2:40 pm, PASARR Case Manger stated she was not aware of resident #1 having smoking restrictions or that her privileges had been revoked. She stated she attended resident #1's initial PASARR meeting on 7/3/2025 and resident #1 was still smoking at that time. She stated at that time no behavioral concerns around smoking were discussed in the meeting. She stated they did discuss resident #1's desire to continue smoking and what the expectations of resident #1 were - being patient, waiting for staff, only smoking when allowed - and resident #1 was in agreement with those expectations at that time. She stated she was not aware until yesterday 7/23/2025, that resident #1 was not allowed to smoke at the facility. When she asked staff why resident #1 was no longer allowed to smoke, she was informed it was because of increased behaviors around the time she was able to smoke, having access to cigarettes and refusing to come back in after smoke break. She could not remember which facility staff had informed her of these behaviors. During an interview on 7/24/2025 at 2:50 pm, resident #1 stated they took my cigarettes away and they wouldn't give them back She stated she didn't think it was right that other residents go out to smoke, and she isn't allowed to go out with them to smoke. She stated she wanted her cigarettes back and she wanted to go out and smoke. During an interview with the ADM on 7/24/2025 at 3:12 pm he stated he had a meeting with the resident regarding her smoking - he thought it had been on 6/30/2025 but it could have been the first or second of July. He staed he knows they had a conversation with her to tell her they were taking away her smoking privileges dur to her behaviors. He stated he could not find where it was documented anywhere in the EMR. He stated, we didn't document anything - how is that possible. During an interview on 7/24/2025 at 3:42 pm, the Medical Director stated he was not aware of resident #1's smoking privileges being revoked. He stated he doesn't necessarily get involved in day-to-day behavior issues and he is okay with not knowing about this issue. He stated resident #1 was being followed by psyche services and the last note on 6/29/2025 did not mention any behavior issues with smoking. MD was informed that resident #1's care plan had not been updated to reflect her smoking privileges being revoked and there being no progress notes or IDT meeting about the revocation. He stated the care plan should have been updated and documentation completed in the EMR. During an interview on 7/24/2025 at 4:12 pm, ADM stated it was his responsibility to follow up and ensure progress notes were completed when they had the conversation with resident #1 about revoking her smoking privileges. He stated he knew they had the conversation; it just wasn't documented. He stated the care plan should have been updated by the MDS coordinator but the MDS coordinator would not have known about the conversation [with resident #1 about revoking smoking privileges] and he [ADM] didn't remember sharing details with the MDS coordinator. ADM was asked who is responsible for doing smoking assessments when there are changes and he stated a re-assessment was not applicable [with resident #1] because resident was able to smoke safely, she just had behaviors around not being able to smoke, when she didn't get her way. Review of undated facility policy Smoking Policy - Residents reflected the following: This facility has established and maintains safe resident smoking policies.8. A resident's ability to smoke safely is re-evaluated quarterly, upon significant change (physical or cognitive0 and as determined by staff. 9. Any smoking related privileges, restrictions, and concerns (for example, need for close monitoring) are noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. 10. The facility may impose smoking restrictions on a resident at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision.

Based on interview and record review, the facility failed to determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 2 of 2 medication carts reviewed for pharmaceutical services. The facility failed to ensure all controlled medications were accurately reconciled at the start and end of each shift. This failure could place residents at risk of drug diversion and could result in diminished health and well-being. Findings include: Record review of the Change of Shift Narcotic Count Sheets for Cart #1 revealed missing documentation for 06/01/2025, 6:00 AM on-coming and 6:00 PM off -going shifts and the 06/04/2025 6:00 PM on-coming and 6:00 AM off-going shifts. Record Review for Cart #2 revealed missing documentation for 06/02/2025 6:00 PM off-going shift, 06/03/2025 6:00 AM on-coming shift, 6:00 PM on-coming, and 6:00 AM off-going shifts, 06/06/2025 6:00 PM on-coming and 6:00 AM off-going, and 06/11/2025 6:00 PM off-going shifts. During an interview with CMA A on 06/18/2025 at 11:37 AM, she stated it was required for the off going and oncoming staff to count narcotic medications and sign the Narcotic Count Sheet. During an interview with LVN A on 06/18/2025 at 11:40 AM, she stated it is required for the off going and oncoming staff to count narcotic med's and signed the Narcotic Count Sheet. During an interview with ADON A on 06/19/2025 at 9:35 AM, she stated it was the expectation the off-going and on-coming shifts count narcotics and signed the Narcotic Count sheet at each shift change. ADON A reported she made rounds every morning and audited the Narcotic Count Sheets. If a deficiency was found, a narcotic count was immediately performed, and the responsible staff were educated. ADON A stated new staff were educated about the change of shift narcotic count expectation during their three-day orientation period. During an interview with the Administrator on 06/19/2025 at 10:10 PM, he stated it was the expectation that the off-going nurse and the on-coming nurse counted the narcotics together at the change of shift. He stated a negative outcome of not consistently following the narcotic count expectations was there was a possibility of drug diversion. Record review of the facility's, undated policy stated Nursing staff must count controlled drugs at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and 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 infections for 2 of 4 residents (Resident #19 and Resident #88) reviewed for infection control. 1. The facility failed to ensure hand hygiene was implemented appropriately when CNA-A provided perineal and catheter care for Resident #19. 2. The facility failed to ensure hand hygiene was implemented appropriately when LVN-B provided wound care to Resident #88. These deficient practices could place residents at-risk of the spread of infection. Findings include: Record review of Resident #19's face sheet, dated 01/06/2025, revealed a [AGE] year-old male who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #19's primary diagnosis included Spinal Stenosis, Cervical Region (a condition where the spinal column narrows, putting pressure on the spinal cord or nerves in the neck area). Record review of Resident #19's Care Plan, last updated 01/16/2025, revealed a Problem which included Resident # 19 requires a foley catheter secondary to Neurogenic Bladder,. This problem area included the following interventions: - Change foley catheter monthly with 18 .F, 10 .CC. - foley catheter care Q shift - Monitor for evidence of blockage, flush catheter per MD order, change catheter as indicated. Record review of Resident #19's Quarterly MDS assessment, dated 06/05/2025, revealed a BIMS score of 15, which indicated intact cognition. Resident #19 was assessed as having an indwelling catheter. Record review of Resident #19's Active Orders, dated 06/18/2025, revealed orders which included: - Foley catheter care every shift start date 06/02/2024. Observation on 06/18/2025 at 01:06 PM revealed there was a sign which indicated Enhanced Barrier Precautions outside the door to Resident #19's room, and there was a supply of PPE available outside the door/room. CNA-B sanitized her hands and donned gloves and gown prior to performing perineal care and foley care for Resident #19. During the care, CNA-B failed to sanitize her hands two of five times she changed from dirty gloves to clean gloves. During these instances, she removed soiled gloves and donned clean gloves after removing a soiled brief and she removed soiled gloves and donned clean gloves after wiping the perineal area of stool. During an interview with CNA-B on 06/18/2025 at 1:30PM, she stated it was an expectation that hand sanitization be performed each time dirty gloves were removed. She stated she may have failed to sanitize her hands in between glove changes as she was nervous. 2. Record review of Resident #88's face sheet, dated 09/17/2024, revealed a [AGE] year-old male with a diagnosis which included Cerebral Infarction (a condition where brain tissue dies due to a lack of blood supply). Record review of Resident #88's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 00, which indicated severe cognitive impairment. Record review of Resident #88's Care Plan and Orders, of 06/18/2025, revealed Resident #88 was assessed as having a skin tear wound to the left anterior superior leg. The orders stated Cleanse with NS, pat dry, apply Alginate Calcium with silver daily. Observation on 06/18/2025 at 12:52 AM of wound care treatment to Resident #88 by LVN B revealed LVN B changed gloves multiple times while care was provided which included after moving from dirty to clean areas and after touching the outside environmental object but did not sanitize her hands in between one glove change after LVN B removed the soiled dressing and donned clean gloves to cleanse the wound. During an interview with LVN B on 06/18/2025 at 1:10 PM, LVN B stated she did not sanitize her hands after each glove change while providing wound care to Resident #88 because she was nervous, but also stated she should have. During an interview with the DON on 06/19/2025 at 8:57 AM, she stated it was the policy to perform hand sanitization before donning gloves and when there was a change from dirty to clean gloves, and then when the procedure was completed. The DON stated staff were trained on hand hygiene expectations during their three-day orientation period and frequently thereafter. The DON reported the Infection Control Practitioner and herself performed random rounds and observations to ensure compliance with hand hygiene. The DON stated failure to perform hand hygiene could result in the spread of bacteria. During an interview with the Infection Control Practitioner on 06/19/2025 at 9:34 AM, she stated staff were expected to perform hand hygiene anytime there was a transition from dirty to clean. She stated staff were educated during their three-day orientation period and periodically during the year on the hand hygiene policy. The Infection Control Practitioner stated she performed monitoring of six instances of hand hygiene every two weeks. During an interview with the Administrator on 06/18/2025 at 10:10 AM, he stated it was his expectation that hand hygiene be performed each time soiled gloves were discarded and before clean gloves were donned. The Administrator stated a possible outcome of the failure to perform hand hygiene could result in the spread of infection. During a record review of the hand hygiene policy revealed the following: Purpose: Hand washing with either soap and water or hand sanitizer is one of the best ways to stop the spread of infection. Handling soiled or used linens, dressing, bedpans, catheters, and urinals. Removing gloves or aprons.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 facility kitchen and 3 (nourishment room [ROOM NUMBER], 2, and 3) of 3 nourishment rooms reviewed for food safety and sanitation. 1. The facility failed to conduct temperature checks and/or complete the temperature check logs for refrigerators and freezers in the facility's kitchen and nourishment rooms. 2. The facility failed to conduct temperature checks and/or complete the temperature check log form for the 3-compartment sink in the facility's kitchen. 3. The facility failed to ensure the refrigerators and freezers in the facility's nourishment rooms were cleaned, sanitized, and in proper working condition. 4. The facility failed to ensure food items stored in the nourishment room refrigerators/freezers were labeled and dated. 5. The facility failed to ensure items stored in the nourishment room refrigerators/freezers were restricted to residents' items only. These failures could place residents at risk for foodborne illnesses. Findings include: Observation of the facility's kitchen on 6/17/2025 at 8:37 AM revealed written directives posted on the door of the refrigerator that stated in part: PUT A DATE ON ALL ITEMS IN THE FRIDGE PERSONAL ITEMS ARE NOT ALLOWED IN THE FRIDGE, THERE'S A FRIDGE IN THE BREAKROOM. Observation of the facility's kitchen on 6/17/2025 at 8:48 AM revealed the REFRIGERATOR/FREEZER TEMPERATURE LOG for the month of June 2025 in which staff failed to conduct and/or log temperature checks for the kitchen refrigerators and freezers as follows: 6/13/2025-No morning temperature check logged for refrigerator #2. 6/14/2025-No morning temperature check logged for refrigerator #2. 6/14/2025-No morning temperature check logged for freezer #1. 6/15/2025-No evening temperature check logged for refrigerator #1. 6/15/2025-No evening temperature check logged for refrigerator #2. 6/15/2025-No evening temperature check logged for freezer #1. 6/16/2025-No evening temperature check logged for refrigerator #1. 6/16/2025-No evening temperature check logged for refrigerator #2. 6/16/2025-No evening temperature check logged for freezer #1. Observation of the facility's kitchen on 6/17/2025 at 8:48 AM revealed the 3 Compartment Sink Log for the month of June 2025 in which staff failed to conduct and/or log the water temperature checks and sanitation solution concentration levels following dinner service on 6/15/2025 and 6/16/2025. Observation of the facility's kitchen on 6/17/2025 at 8:49 AM revealed the DAILY/AFTER EACH USE CLEANING SCHEDULE FORM for each week in the month of June 2025. Each form listed all items and areas that required at least daily cleaning and the staff members responsible for completing each task. The items and areas listed included refrigerators, freezers, microwave, food carts, and the janitor's closet, but did not include items or areas with the facility's nourishment rooms. Observation of nourishment room [ROOM NUMBER] (center station) on 6/17/2025 at 8:52 AM, revealed a refrigerator/freezer combination unit operable and in use. Adhered to the front of the unit was a temperature log form for June 2025. The Refrigerator Temperature Log included instructions that stated the following: Monitor Temperatures Closely Record Temps twice each day. Initial after you record the temp. Take action if temp is out of range - above 46'F or below 36'F. The temperature log was observed to be mostly incomplete with temperature checks not conducted and/or logged on any morning shift for the month, and no evening temperature checks conducted or logged on 6/11/2025 and 6/12/2025. Also adhered to the front of the unit were typed signs with directives which read as follows: EMPLOYEE FOOD ITEMS THERE IS A NEW REFRIGERATOR IN THE BREAK ROOM FOR EMPLOYEE FOOD ITEMS. BEGINNING MARCH 16TH, ALL EMPLOYEE FOOD ITEMS THAT ARE STORED IN THE NURSES STATION REFRIGERATORS WILL BE DISPOSED OF EACH DAY. YOU ARE NOT ALLOWED TO COMMINGLE RESIDENT AND STAFF FOOD ITEMS INCLUDING WATER AND SODAS. PLEASE HELP US MEET THE STATE REQUIREMENTS FOR THESE REFRIGERATORS; and Resident Refrigerator Personal Snacks and Supplements No Employee Items Allowed!! Observation of the interior of nourishment room [ROOM NUMBER]'s freezer on 6/17/2025 at 8:52 AM revealed an opened and partially consumed bottle of water, a pint of ice cream wrapped and tied in a plastic grocery bag, evidence of spillage of a red liquid which pooled, dripped and dried within the bottom and sides of the freezer. Stored within the shelves of the freezer door was a large frozen bottle of water, instant ice packs, and various plastic ice packs. None of the items stored within the freezer were labeled with a name or date the products were obtained or stored. The items stored in the freezer door shelves were also soiled and stained red from the evident spillage. Observation of the interior of nourishment room [ROOM NUMBER]'s refrigerator on 6/17/2025 at 8:53 AM revealed evidence of spillage of a red liquid that had dripped down and under the storage compartment drawers. The seal around the refrigerator door was contained red liquid which caused the door to be sticky and hard to open. An opened and partially empty plastic bottle containing red soda was observed within the refrigerator along with an opened can of coffee with a napkin shoved into the opening of the can and opened and unopened beverage jugs, bottles and cans. None of which were labeled with a name or date the products were obtained or stored. Observation of nourishment room [ROOM NUMBER]'s (central east station) refrigerator on 6/17/2025 at 8:54 AM revealed the absence of a temperature check log or documentation which indicated if or when temperature checks were done. Inspection of the interior of the refrigerator revealed the absence of a thermometer, and storage of food and beverage items which were inconsistent with resident type meals or snacks. These items included several plastic grocery bags full of fresh vegetables that appeared to have been brought in from someone's personal garden, partially consumed bottles of water, a can of diet Coke, a bag of chips, leftovers covered and stored in a personal looking storage container, yogurt, and a box of leftover pizza. None of the items were labeled or dated. Observation of nourishment room [ROOM NUMBER]'s (secure unit) refrigerator/freezer unit on 6/17/2025 at 8:59 AM revealed a temperature log form adhered to the front of the freezer door and a temperature log adhered to the front of the refrigerator door. Both forms were dated June 2025. The Refrigerator Temperature Log forms included instructions that stated the following: Monitor Temperatures Closely Record Temps twice each day. Initial after you record the temp. Take action if temp is out of range - above 46'F or below 36'F. The temperature log adhered to the freezer door had the word Freezer handwritten on it. The freezer temperature log was observed to be mostly incomplete with temperature checks not conducted and/or logged on any morning shift for the month of June 2025, and no evening temperature check conducted or logged on 6/14/2025. The temperature log adhered to the refrigerator door was observed to be mostly incomplete with temperature checks not conducted and/or logged on any morning shift for the month of June 2025, and no evening temperature checks conducted or logged on 6/13/2025 and 6/14/2025. Observation of the interior of nourishment room [ROOM NUMBER]'s (secured unit) freezer and refrigerator on 6/17/2025 at 8:59 AM revealed a thick layer of ice and frost build up around all sides of the freezer and the back of the refrigerator. The freezer and refrigerator were observed as not maintaining acceptable temperatures as evidenced by the lack of cold air coming from the unit, condensation droplets from the melting ice build-up, and observation of the refrigerator temperature reading was 60'F on the thermometer placed near the back of the unit. Contained within the freezer were frozen beverage bottles with ice buildup around each and a frozen Magic cup. None of which were labeled or dated. The refrigerator contained an opened gallon of whole milk, several opened containers of pre-thickened water, pudding cups, packets of jalapeno ranch, and a ham, cheddar, and cracker snack pack. In an interview on 6/17/2025 at 8:50 AM, DC A stated the kitchen staff were responsible for cleaning equipment, surfaces, and areas within the facility's kitchen according to the posted cleaning schedule. DC A stated kitchen staff were responsible for conducting and logging temperature checks within the kitchen according to the schedule listed on the various temperature log forms. DC A also stated kitchen staff were responsible for conducting temperature checks and sanitation solution concentration checks for the kitchen's 3-compartment sink and dishwasher and logging such on the forms provided. DC A stated there was a refrigerator/freezer unit in each of the facility's nourishment rooms, but she and the kitchen staff were not responsible for those. In an interview on 6/17/2025 at 8:52 AM, TD A stated each of the facility's nourishment rooms contained a refrigerator/freezer unit which was restricted to resident use only. In an interview on 6/17/2025 at 8:53 AM, TD A stated the nourishment room refrigerators/freezers were supposed to be used to store resident items only. TD A stated he was uncertain as to who was responsible for cleaning the nourishment room refrigerators, or who was responsible for completing and documenting temperature checks of the refrigerators/freezers in the nourishment rooms. In an interview on 6/17/2025 at 8:55 AM, TD A stated the refrigerator in nourishment room [ROOM NUMBER] likely contained staff members' personal food and beverage items because during the facility's recent remodel, that room and refrigerator were not in use for resident items because the residents on this unit were moved elsewhere while construction was going on. TD A stated the renovation was completed several months prior and staff were instructed to use the breakroom refrigerator for storage of personal items. In an interview on 6/19/2025 at 2:19 PM, the HKS stated the housekeeping staff were not typically responsible for the cleaning and upkeep of nourishment room refrigerators, but he stated housekeeping staff would assist if asked. The HKS stated these tasks were the responsibility of the nursing staff, along with conducting and logging refrigerator/freezer temperatures. In an interview on 6/19/2025 at 2:21 PM, the ADM stated the facility had no specific policy regarding refrigerator/freezer tasks, which included which staff were responsible for maintaining them. The ADM stated it was known and understood that nursing staff was responsible for cleaning nourishment room refrigerators/freezers, and logging refrigerator/freezer temperature checks. If the units or thermometers contained therein were not working or malfunctioning, nursing staff should create an electronic work order and route it to the maintenance department, or nursing staff could report the problem directly to the ADM and he would address the issue right away. In an interview on 6/19/2025 at 2:25 PM, CNA A stated she had been employed with the facility for 4 years. CNA A stated it was the responsibility of the nursing staff to log temperature checks for the nourishment room refrigerators. CNA A stated the temperature check logs should be maintained on the outside of each unit. CNA A stated facility staff should never store personal items in the nourishment room refrigerators. These were for resident items only. CNA A stated this was necessary to prevent cross contamination and to prevent the possibility of mistakenly serving a resident a product not intended for them. CNA A stated nursing staff was responsible for cleaning and maintaining the nourishment refrigerators/freezers. In an interview on 6/19/2025 at 2:38 PM, LVN A stated she was a charge nurse who typically worked the dayshift. She stated she had been employed with the facility for 5 years. LVN A stated she's not sure who was responsible for cleaning and maintaining the nourishment room refrigerators. LVN A said the night shift nurse was responsible for completing and logging temperature checks for the nourishment room refrigerators/freezers. LVN A said the ADON was responsible for making sure this got done. LVN A said she did not know who was responsible in the absence of the ADON. LVN A said the facility's policy on was unclear and she's not sure what the policy stated. LVN A said the refrigerator in nourishment room [ROOM NUMBER] (east center station) was reopened about 2 months ago after the remodel of that unit was completed. LVN A said the nourishment room [ROOM NUMBER] (east station) refrigerator had historically been used by staff to store personal items such as coffee creamer. LVN A said the center station nourishment room was used to store resident items because that was where the kitchen staff delivered resident snack items. In an interview on 6/19/2025 at 2:45 PM, the DON said nursing staff was responsible for maintaining the nourishment rooms. The DON said the unit manager was responsible for making sure temperature checks were completed and logged, and the unit was clean and in working order. In an interview on 6/19/2025 at 2:45 PM, the RNC stated the ADM received the policies request. The RNC stated the ADM provided the only policies they had regarding nourishment room temperature check logs and cleaning. Record review of the facility's policy regarding measuring unit refrigerators for safe temperatures, updated January 2023, revealed the following: Refrigerators: All facility refrigerators should have working thermometers to measure and monitor safe temperatures. Freezers should be solid frozen at all times. Leakages in freezers must be reported to the maintenance team immediately. Refrigerator temperatures shall remain at 41 degrees and below at all times. Daily logs: The temperature will be checked and recorded by designated staff. When checking temperature, the doors should have been kept closed for at least 10 minutes prior to evaluation. The reading and time of the reading will be noted, along with the signature of the person checking. Maintain logs per the retention policy and procedure. If the refrigerator/freezer was not maintaining acceptable temperatures the contents will be removed and destroyed Daily record keeping of refrigerator temperature shall be kept near or on the actual refrigerator. Any temperature issues (if below 41 degrees) should be communicated with the maintenance team. De-frosting of the freezers is recommended to be done monthly. During the de-frosting process and while cleaning the refrigerator, all stored items shall be transferred to another refrigerator/freezer and not left out in the open. Review of the U.S. Food and Drug Administration Food Code dated 2022 revealed the following: 3-304.11 Food Contact with Equipment and Utensils. FOOD shall only contact surfaces of: (A) EQUIPMENT and UTENSILS that are cleaned as specified under Part 4-6 of this Code and SANITIZED as specified under Part 4-7 of this Code; P 3-305.11 Food Storage. (B) (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (C) (1) In a clean, dry location; (D) (2) Where it is not exposed to splash, dust, or other contamination 3-307.11 Miscellaneous Sources of Contamination. (E) FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. 4-602.11 Equipment Food-Contact Surfaces and Utensils. (D) Surfaces of UTENSILS and EQUIPMENT contacting TIME/TEMPERATURE CONTROL FOR SAFETY FOOD may be cleaned less frequently than every 4 hours if: (5) EQUIPMENT is used for storage of PACKAGED or unpackaged FOOD such as a reach-in refrigerator and the EQUIPMENT is cleaned at a frequency necessary to preclude accumulation of soil residues.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to protect the residents' right to be free from neglect for 1 (Resident #3) of 6 residents reviewed for neglect. The facility failed to ensure Resident #3's safety and well-being when RN D and CNA E left her in the Shower Room in soiled undergarments unattended for approximately 30 minutes. This failure could result in residents receiving injuries and possible skin breakdown. Noncompliance existed from 02/13/2025 to 02/18/2025, but the facility corrected the noncompliance through inservicing, one on one inservicing and the QAPI process. Therefore, the findings are of past noncompliance. Findings included: Record review of Resident #3's undated admission Record reflected the resident was a [AGE] year-old female admitted to the facility on [DATE] with a diagnoses of Generalized Atherosclerosis (a widespread buildup of plaque in the arteries throughout the body, which can lead to narrowing and blockage of blood vessels), Unspecified Dementia (a decline in cognitive function that cannot be attributed to a specific underlying cause), and Unspecified Abnormalities of Gait and Mobility (difficulty walking or moving without a specific cause). Record review of Resident #1's quarterly MDS, dated [DATE], reflected a BIMS score of 3, indicating she had a significant level of cognitive impairment. Her Functional Status reflected she required partial/moderate assistance with mobility, Supervision or touching assistance with toileting hygiene, and Substantial/maximal assistance with showering. Record review of Resident #3's care plan, initiated on 06/27/2019 and most recently update 02/04/2025, reflected she had an ADL Self Care Performance Deficit related to diagnosis of Dementia/schizoaffective Disorder, and Major Depressive Disorder. Care Planned Interventions include the following: Resident requires staff x 1 for participation with bathing. Resident requires staff x 1 to use toilet. Resident participates in toileting process. Resident requires assist of staff x 1 for transfers. Resident participates in transfer process. Resident requires staff x 1 to choose simple comfortable clothing and for ability to dress self. Resident requires staff xx1 for a sponge bath when a full bath or shower cannot be tolerated. Resident requires staff x 1 for reminding, prompting, cueing, for assistance with eating. Resident requires setup help with meals but can feed self independently. Resident requires staff x 1 to set up or assist with oral care. Check nail length and trim and clean on bath day. Report any changes to the nurse. Praise all efforts at self-care. Record review of the facility's investigation report on 02/26/2025 at 12:21 PM reflected the facility was notified of this event by the outside representative on 02/13/2025 at 11:00 AM. According to the Facility's Investigation Report, RN D walked thru the Dining Room on 02/07/2025 after lunch and the outside representative notified him that Resident #3 needed to be changed as she had urinated on the floor. RN D notified CNA E that the resident needed to be changed. RN D placed Resident #3 in the Shower Room per CNA E's request. CNA E reported to RN D she would finish her round and attend to Resident #3. The outside representative later called Social Worker to report Resident #3 was alone in the shower for approximately 30 minutes unattended. Record review of the Facility follow up included the following: 02/13/2025 RND and CNA E are suspended pending further investigation. 02/13/2025 Ad Hoc QAPI 02/13/2025 and 02/14/2025 Notification of Medical Director 02/13/2025-02/14/2025 All staff inservicing to include Abuse and Neglect, Resident rights/Dignity-Bowel and Bladder, Communication-Clarification of Task Assignment, and Shower Room Monitoring. 02/14/2025 Attempted notification of responsible party. 02/17/2025 Education sent to outside providers regarding reporting of Abuse and Neglect. 02/18/2025 One on One communications with RN D and CNA E to include Communication and Clarification and Shower supervision. Record review of Resident #3's medical record on 02/26/2025 at 11:00 AM ,reflected the Social Worker completed an assessment for injury on 02/13/2026 at 4:45 PM. According to the note, Resident #3 did not demonstrate any signs of a negative outcome from this event. Skin Assessment completed on 02/14/2025 at 1:09 PM is negative for any physical injury. Interview with Resident #3 was conducted on 02/26/2025 at 11:33 AM. Resident #3 stated the staff are good to her and always help her. She has no recollection of being left in the Shower Room unattended. Interview with DON on 02/26/2025 was conducted at 10:26 AM. The DON stated it was her expectation that residents are not to be left alone in the Shower Room even if they can shower themselves. The DON stated the following interventions were implemented. RN D and CNA E were suspended on 02/12/2025 pending investigation. One on one communication with RN D and CNA E for training on staff-to-staff communication was completed on 02/18/2025. One on one training on Shower Supervision was completed with RN D and CNA E on 02/18/2025. The following in-service training was also implemented with direct care staff on 2/13/25 and 2/14/2025: Abuse and Neglect Resident Rights/Dignity related to Bowel and Bladder needs. Communication-Clarification of Task Assignment Shower Room Monitoring Interview conducted with CNA F was conducted on 02/26/2025 at 2:23 PM. She confirmed receiving training as listed above and described that a resident is never to left alone in the shower room. She also stated staff should always communicate clearly with coworkers and nurse to make sure everyone understands what is going on. Interview conducted with Activity Therapy staff G on 2/26/2025 at 2:35 PM. AT staff G confirms having received training as list above. She stated the main theme of the training was regarding monitoring residents in the shower and residents should never be left alone in the shower. Confirms receiving training on clear communication with coworker. Also reported having received training on reporting abuse and/or neglect the facility Administrator. Interview conducted with CNA H on 02/26/2025. CNA H confirms receipt of training as listed above. CNA stated she was trained on the types of abuse and neglect and to whom to report. CNA H verbalized receipt of training on rights and dignity. CNA H stated staff are to be in the shower room with any resident regardless of their mobility status. Interview with LVN I was conducted on 02/26/2025 at 2:51 PM. LVN, I confirmed receipt of training on abuse/neglect/exploitation and Resident Rights. LVN I stated residents are never to left unattended in the shower room for any reason. Interview with the Social Worker on 02/26/2025 at 1:27 PM revealed, he had received information about this event from the outside representative on 02/13/2025 at 11:00 AM. The outside representative reported she thought Resident #3 was in the shower room unattended for approximately 30 minutes. Interview with the outside representative by phone on 02/26/2025 at 2:07 PM was conducted. The outside representative stated she heard CNA E tell RN D to take Resident #3 to the shower and CNA E would be there in a little bit. The outside representative stated she did not know exactly how long Resident #3 was in the Shower Room, but she guessed it was about 30 minutes. The outside representative stated she did not realize Resident #3 was in the Shower Room alone until she heard her yell out. Interview with RN D on 02/26/2025 at 1:55 PM stated Resident #3 was taken to the Shower Room to await CNA E. He stated, I should have just done the hygiene care myself. RN D also reported he will change his practice by not ever leaving anyone in the Shower Room but, rather outside in the hallway. RN D also stated he should have communicated better with CNA E. Interview with CNA E was conducted at 02/26/2025 at 2:01 PM. CNA E stated she and RN D did not communicate regarding how long it was going to take CNA E to get to Resident #3. CNA E stated she should have let RN D know how long it was going to take her to get to Resident #3. Interview with the Administrator was conducted 02/26/2025 at 4:54 PM. The Administrator stated every resident must be supervised while in the Shower Room. If the resident can shower independently, the CNA was to stand outside the door, knock and check on the resident frequently. Additionally, the Administrator was asked about the existence of documentation of notification of the physician and the resident representative regarding the event. The Administrator responded the physician was not notified because there was no injury, and the Resident Representative was not notified because Resident #3 was legally her own representative. A telephone interview was conducted with Resident #3's family member at 5:42 PM. He stated he was pleased with the care and treatment Resident #3 received from the facility and was thankful for the assistance. He stated: they're doing a great job and I'm thankful for that. Review of the facility's Abuse Prohibition policy, dated 12/2019, reflected: Each resident has the right to be free from verbal, sexual, physical and mental abuse, mistreatment, neglect, involuntary seclusion and misappropriate of property.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #13) reviewed for accidents hazards and supervision, in that: On 01/23/2025 Resident #13 was transferred by CNA C using standing pivot transfer x 1 staff instead of a mechanical lift. During transfer Resident #13 pivoted into the chair, her leg did not pivot well, and the knee twisted and popped which later caused swelling and pain to the left knee. This failure could lead to injury or death to residents. Findings include: Record review of Resident #13's face sheet dated 02/11/2025, revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included Multiple Sclerosis (a chronic, autoimmune disease that affects the central nervous system-brain and spinal cord, Muscle Weakness (a lack of muscle strength or the inability to control voluntary muscle force), and Unspecified Abnormalities of Gait and Mobility. Record review of Resident #13's Quarterly MDS assessment, dated 01/30/2025, reflected a BIMS of 15 which suggested the resident's cognition was intact. Section G revealed Resident #13 required extensive assistance with 2 persons for transfers. The prior Quarterly MDS assessment, dated 12/28/2024, in effect at the time of the event, revealed the resident was classified as requiring substantial/maximal assistance-Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. There was no designation for 2 person assist with a mechanical lift. Record review of Resident #1's Care Plan dated 03/27/2015 and revised on 02/03/2025, revealed Resident #13 required a mechanical lift X 2 staff assist for all transfers. The previous Care Plan dated 12/6/24 did not specifically address the resident's transfer needs. Record review of the Provider Investigation Report, dated 02/05/2025, related to the facility's self-report of Resident #13's injury on 01/23/2025, revealed on 01/23/2025 at 5:15 PM, [CNA C] performed a one person standing assist, as the resident pivoted into the chair the leg did not pivot well and the knee twisted and popped. At the time the resident denied any pain. X-ray results received on 01/24/2025 were negative with no acute fractures. On 01/24/2025 the resident did not communicate any pain. On 01/25/2025 the knee was found to be visibly swollen. The resident declined pain medications. An order for prednisone for inflammation was given and referral for an Orthopedic Physician appointment was given. The Orthopedic appointment is scheduled for 2/11/2025. Upon medical record review it was discovered that there was no order for transfer with a lift. At that time an order was placed for two-person mechanical lift device for transfer. The Administrator was informed of the event by Resident #13 on 01/29/2025 and the event was reported to HHSC on 01/29/2025 at 5:44 PM. Record review of the statement from the Director of Therapy reflected he stated he verbally communicated a transfer status change sometime during the dates of 1/20/2025 to 1/24/2025 from one person assist to two person Hoyer lift to another CNA but had not appropriately communicated the transfer status change to clinical leadership. As a result, an appropriate order was not received to officially change the status to a 2 person assist with a mechanical lift. This failure to communicate the resident's transfer status created confusion amongst the front-line staff and led to the injury. On 01/23/2025 when CNA C performed the transfer, Resident #13's order still reflected the need for a one person standing assist. Further record review revealed in-services on Safe Lifting and Movement of Resident and Use of Mechanical Device, Transfer List Communication, and Accessing [NAME] were implemented with the staff. Interview with the Administrator was conducted on 02/11/2025 at 3:00 PM. The Administrator described the facts as disclosed in the Facility Investigation Report. The administrator stated after the investigation was completed, an Ad Hoc QAPI Committee was convened, a Root Cause Analysis was completed, and the Director of Therapy received a corrective action for his failure to communicate. A Performance Improvement Plan was initiated. The Administrator described the current process of monitoring of resident transfer needs. The Administrator stated the transfer needs of each resident is discussed in the facility's morning meeting. On 02/11/2025 Record Review of the Interview with CNA C was conducted. CNA C stated she was not aware Resident #13's transfer status had changed prior to the implementation of the transfer. Record Review of the facility policy titled, Safe Lifting & Movement of Residents policy statement reads, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and moved residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate for 2 of 3 residents (Resident #300 and Resident #301), reviewed for changes made to charges or other items and services. The facility failed to ensure that Resident #300 and Resident #301 were provided a SNF ABN (SNF ABN document that informs a Medicare beneficiary that Medicare will no longer pay for skilled services) when discharged from skilled services at the facility prior to covered days being exhausted. This failure could place residents at risk for not being aware of changes to provided services not covered by Medicare and their financial responsibilities. Findings included: Review of Resident #300's admission MDS assessment dated [DATE], Section A (Identification Information) revealed an [AGE] year-old female admitted to the facility 09/06/23. Section C (Cognitive Patterns) revealed a BIMS score of 8 indicating moderately impaired cognition. Section I (Active Diagnoses) reflected diagnoses including coronary artery disease (disease of the blood vessels of the heart), septicemia (infection in the blood), and cerebrovascular accident (stroke). Review of Resident #300's electronic medical record revealed no SNF ABN form. Review of Resident #301's admission MDS assessment dated [DATE], Section A (Identification Information) revealed a [AGE] year-old female admitted to the facility 11/10/23. Section C (Cognitive Patterns) revealed a BIMS score of 14 indicating intact cognition. Section I (Active Diagnoses) reflected diagnoses including cerebrovascular accident (stroke), encephalopathy unspecified (damage or disease that affects the brain), and urinary tract infection. Review of Resident #301's electronic medical record revealed no SNF ABN form. Review of the Medicare discharge list reflected Resident #300's Medicare benefit days started on 09/06/23 and ended on 11/16/23. Resident #301's Medicare benefit days started on 11/10/23 and ended on 11/25/23. During an interview on 04/30/24 at 2:56 PM, the ADM stated neither Resident #300 nor Resident #301 were provided with an ABN document. The ADM stated they did not have a policy regarding ABN notifications. He stated the facility had recently found the notices were not being provided and the staff were not sure of the process or who was responsible for providing the form to residents. He stated they recently started reviewing and monitoring Medicare days and potential changes in service during their daily meetings. The ADM stated he would be contacting the corporate office regarding a policy. Review of the Medicare Claims Processing Manual accessed at https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c30.pdf, Chapter 30, section 70 reflected in part, If Medicare is expected to deny payment (entirely or in part) on the basis of one of the exclusions listed in §70 of this chapter for extended care items or services that the SNF furnishes to a beneficiary, a SNF ABN must be given to the beneficiary in order to transfer financial liability for the item or service to the beneficiary. The initiation, reduction and termination of such extended care items or services, that Medicare may not pay, are considered triggering events.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents received services within the facility with reasonable accommodation of the residents' needs and preferences for 4 of 12 residents (Resident #23, Resident # 57, Resident #83, and Resident #45) reviewed, in that: The facility failed to: 1) Ensure a call light was within reach for Resident #23 2) Ensure a call light was within reach for Resident #57 3) Ensure a call light was within reach for Resident #83 4) Ensure a call light was within reach for Resident #45 This deficient practice placed residents at risk for delayed care and a decreased quality of life. Findings Include: 1) Review of Resident # 23's quarterly MDS assessment dated [DATE], Section A (Identification Information) reflected a 74- year-old male admitted to the facility on [DATE]. Section C (Cognitive Patterns) Reflected a BIMS score of 15 indicating intact cognition. Section GG (Functional Abilities) reflected he was dependent on staff for personal hygiene, bathing and toileting. Section I (Active Diagnoses) reflects medically complex conditions, Other Hereditary and Idiopathic Neuropathies (a condition that causes gradual muscle weakness), Muscle Wasting and Atrophy (the wasting or thinning of muscle mass), Unspecified Lack of Coordination (a condition that affects balance), Schizophreniform Disorder (a mental health condition that causes hallucinations, delusions and disorganized speech), Spinal Stenosis Spinal Region (where the space inside the backbone is too small placing pressure on the spinal cord), Low Back Pain, Kissing Spine (a condition that causes pain, inflammation and nerve damage), Generalized Muscle Weakness, Abnormalities of Gait and Mobility (problems with walking or standing) and Aphasia (a condition that affects how you communicate with speech). Review of Resident #23's care plan initiated 11/11/22 reflected a focus, Resident is bed bound due to his own decision and refuses to be transferred with a mechanical lift and is unable to move and sit in a wheelchair /geriatric chair. Interventions include, keep call light within reach of resident and keep resident belongings accessible and within reach. An observation and interview on 04/29/2024 at 01:15pm with Resident # 23, resident stated he can't reach call light and will usually ask his roommate for help to call for staff. Resident call light was not visible to surveyor nor to the resident. 2) Review of Resident # 57's quarterly MDS assessment dated [DATE], Section A (Identification Information) reflected a [AGE] year-old female re-admitted to the facility on [DATE]. Section C (Cognitive Patterns) Reflected a BIMS score of 15 indicating intact cognition. Section I (Active Diagnoses) Hypothyroidism (a condition that causes decreased thyroid hormones), Parkinson's Disease (a movement disorder that causes tremors or stiffness), Other Idiopathic Peripheral Autonomic Neuropathy (a condition that causes numbness, pain, and balance issues) and Schizophrenia (a condition causing hallucinations, delusions, confused thoughts and behavior). Review of Resident #57's care plan initiated 11/11/22 reflected a focus, Potential for falls related to Decreased mobility and noncompliance with using walker for ambulation. Resident has had falls due to not using walker. Interventions include, encourage resident to keep belongings within reach, provide a safe environment with floors free from spills, assist with removing room clutter, glare free lighting, reachable call bell etc. An observation and interview on 04/29/2024 at 10:05am with Resident #57, residents call light was not within reach. The call light was between the wall and the bed near the floor. 3) Review of Resident # 83's quarterly MDS assessment dated [DATE], Section A (Identification Information) reflected a [AGE] year-old male admitted to the facility on [DATE] 3. Section C (Cognitive Patterns) Reflected a BIMS score of 14 indicating intact cognition. Section GG (Functional Abilities) reflected resident is independent with activities of daily living. Section I (Active Diagnoses) reflected, Hyperlipidemia (a condition that causes high lipids or fat in the blood), Major Depressive Disorder (a condition that affects mood), Insomnia (a condition that causes trouble falling or staying asleep), Constipation (a condition that causes bowel movements less than three times per week), Hypothyroidism (a condition that causes decreased thyroid hormones), Bipolar II Disorder (also known as manic depression), Schizoaffective Disorder Bipolar Type (a condition causing hallucinations, delusions, confused thoughts and behavior) , Diabetes Mellitus without Complications (a condition that affects the way the body processes blood sugar), Disorder of Muscle and Schizophrenia (a condition causing hallucinations, delusions, confused thoughts and behavior). Review of Resident #83's care plan initiated 12/05/2023 reflected a focus, The resident has an ADL Self Care Performance Deficit. Interventions include, Encourage Resident to use bell to call for assistance before attempting any ADL's that resident cannot do independently. An observation and interview on 04/29/2024 at 10:12am with Resident # 83, the resident stated he can't reach his call light and asks his roommate to press the button for him. Resident call light was not visible to surveyor. When the surveyor asked resident to locate the call light, he could not see nor find the light. 4) Review of Resident #45's quarterly MDS assessment dated [DATE], Section A (Identification Information) reflected a [AGE] year-old female admitted to the facility 03/06/20. Section C (Cognitive Patterns) Reflected a BIMS score of 15 indicating intact cognition. Section GG (Functional Abilities) reflected she was dependent on staff for personal hygiene, bathing and toileting. She required substantial/maximal assistance with upper body dressing. She was dependent on staff and a mechanical lift for transfers to and from bed. Section I (Active Diagnoses) reflected, hemiplegia following cerebral infarct affecting left dominant side (paralysis of the left side of the body due to a stroke), diabetes mellitus (a condition that affects the way the body processes blood sugar), generalized muscle weakness, contracture of hand (permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen), and morbid (severe) obesity. Review of Resident #45's care plan initiated 11/11/22 reflected a focus, Alteration in musculoskeletal status related to contractures to left hand. Interventions included, Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. A focus initiated on 03/06/20 reflected, Resident has the potential for falls related to CVA . An intervention reflected, Place the resident's call light within reach and encourage the resident to use it for assistance as needed. An observation on 04/29/24 at 2:14 PM revealed Resident #45 sitting up in a bariatric wheelchair next to her bed. Her left side, with hemiparesis (a condition that causes weakness or the inability to move on one side of the body) and a hand contracture was closest to the bed. The string for the resident's call light was hanging down from the ceiling. A stuffed animal was tied to the end of the string. The Stuffed animal was hanging several inches above the bed. During an interview on 04/29/24 at 2:15 PM with Resident #45, she stated she wanted to get into bed, but she could not reach her call light, so she had to wait for staff. She stated she sometimes got her roommate to push her call light to get staff to the room. During an interview on 05/01/24 at 2:00 PM, LVN L stated call lights should be in reach, accessible to the residents. She stated if the call light was not within reach, the residents may not be able to get medications, toileted, or have any other needs met. She stated she was not working with Resident #45 today but she would check the call light placement. During an interview on 05/01/2024 at 2:15PM CNA F stated she checks on residents every thirty minutes during her shift, and she thought everyone had a call light string. She said there should not have been anyone that didn't have a string attached to their call light. She said she would notify her charge nurse if a resident didn't have a call light string, or she would go find a longer string herself. During an interview on 05/01/2024 at 2:45PM with DON, she stated nursing staff checked each resident every 2 hours and should have ensured they could reach the call light with a string attached. She said it was unacceptable for any resident to not have independent access to the call light. During an interview on 05/01/2024 at 3:00PM with ADM, he stated that all residents should have a working call light and the CNAs are responsible to ensure the resident can access the call light. He said residents should not have had to ask their roommates for assistance. Review of facilities undated policy titled Answering Call Light, which states: Purpose The purpose of this procedure is to ensure timely responses to the resident's requests and needs. General Guidelines 4. Be sure the call light is plugged in and functioning at all times. 5. Ensure that the call light is accessible to the resident when in bed, from the toilet, the shower and bathing facility and from the floor. 6. Report all defective call lights to the nurse supervisor promptly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to provide a Safe/Clean/Comfortable/Homelike Environment for three of six residents (Resident #57, Resident #23, and Resident #66). The facility failed to ensure a safe/clean/comfortable/ homelike environment for Resident #57, Resident #23 and Resident #66. This failure could affect residents by placing them at risk for diminished quality of life due to the lack of a well-kept environment and placing residents at risk of living in an unsafe, unsanitary, and uncomfortable environment. Findings Include: 1) Review of Resident # 57's quarterly MDS assessment dated [DATE], Section A (Identification Information) reflected a [AGE] year-old female re-admitted to the facility on [DATE]. Section C (Cognitive Patterns) Reflected a BIMS score of 15 indicating intact cognition. Hypothyroidism (a condition that causes decreased thyroid hormones), Parkinson's Disease (a movement disorder that causes tremors or stiffness), Other Idiopathic Peripheral Autonomic Neuropathy (a condition that causes numbness, pain, and balance issues) and Schizophrenia (a condition causing hallucinations, delusions, confused thoughts and behavior). During observation and interview on 04/29/2024 at 10:05AM with Resident #57, the room appeared cluttered with items stacked haphazardly against the wall. Multiple items on the floor which could have been dropped. The residents room appeared messy; bed disheveled and trash can was full. Resident stated housekeeping does not sweep and mop like they should. 2) Review of Resident # 23's quarterly MDS assessment dated [DATE], Section A (Identification Information) reflected a 74- year-old male admitted to the facility on [DATE]. Section C (Cognitive Patterns) Reflected a BIMS score of 15 indicating intact cognition. Section GG (Functional Abilities) reflected he was dependent on staff for personal hygiene, bathing, and toileting. Section I (Active Diagnoses) reflects medically complex conditions, Other Hereditary and Idiopathic Neuropathies (a condition that causes gradual muscle weakness), Muscle Wasting and Atrophy (the wasting or thinning of muscle mass), Unspecified Lack of Coordination (a condition that affects balance), Schizophreniform Disorder (a mental health condition that causes hallucinations, delusions and disorganized speech), Spinal Stenosis Spinal Region (where the space inside the backbone is too small placing pressure on the spinal cord), Low Back Pain, Kissing Spine (a condition that causes pain, inflammation and nerve damage), Generalized Muscle Weakness, Abnormalities of Gait and Mobility (problems with walking or standing) and Aphasia (a condition that affects how you communicate with speech). During observation on 04/29/2024 at 10:12AM with Resident #23, the room appeared cluttered with multiple items stacked high on counters and bedside table. There were personal items and debris on the floor. The bathroom had a walker lying on the shower floor with soiled underwear and socks. 3) Review of Resident #66's MDS assessment dated [DATE] reflected a [AGE] year-old female originally admitted to the facility 09/23/22 with a readmission on [DATE]. Her diagnoses included septicemia (infection in the blood), diabetes mellitus (a condition that affects the way the body processes blood sugar) and chronic obstructive pulmonary disease (a lung disease limiting air flow from the lungs). Her BIMS score was fifteen, indicating intact cognition. During observation on 04/30/2024 at 8:50AM with Resident #66, her room appeared cluttered with multiple boxes stacked and a piece of wood furniture sitting directly in front of the sink. The boxes in front of the sink protruded outward approximately 3-4 feet. There were dirty containers that appeared to have had food in them. On the privacy curtain near the resident's bed, there were different colored marks on the curtain, which appeared to have been drawn with a marker, by the resident. During an interview on 05/01/2024 at 1:52PM with HS , he stated the housekeepers swept and mopped the residents' rooms daily. He said that it was everyone's responsibility to pick up items off the floor when they observed it. He said resident rooms have clutter and that the facility had a deep cleaning scheduled soon. He said the clutter presented challenges for the housekeeping staff, making it difficult to sweep and mop around the items. During an interview on 05/01/2024 at 2:45PM with DON, she stated her expectation was that the resident rooms were swept and mopped daily, by housekeeping. She said excess personal items and boxes piled up in residents' rooms create clutter, a potential fire hazard, and issues with cleanliness. During an interview on 05/01/2024 at 3:00PM with ADM, he stated that he was aware of clutter is resident rooms. He said he had called some of the resident's family members in the past, to come pick up the extra items. He said the clutter caused issues with bugs, mildew, and mold when the boxes became wet, tripping hazards, and a fire hazard. He said the facility had another deep clean/declutter on the upcoming schedule. He acknowledged clutter was an ongoing issue within the resident's rooms. The surveyor requested a policy regarding personal items for residents and the facility did not have one.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments, under proper temperature control and labeled in accordance with currently accepted professional principles for 1 (medication room [ROOM NUMBER]) of 2 medication storage rooms and 1 (medication cart #1) of 4 medication carts reviewed for medication storage that. Medication cart # 1 was left unattended and unlocked. An undated, opened and accessed, vial was stored in the medication room [ROOM NUMBER] refrigerator. The medication room [ROOM NUMBER] refrigerator temperature was not monitored daily. This failure could allow residents unsupervised access to prescription and over the counter medication and can result in the resident receiving ineffective medication due to lack of temperature management or proper labeling. Findings included: Observation on 4/29/2024 at 11:53 am revealed Medication cart # 1 was unlocked and unattended at the nurse's station not visible from the nurses sitting at the desk. Inspections of the contents revealed insulin pens and needles, prescription and over-the-counter medications. No nurses approached during the inspection. After approximately 4 minutes LVN A, who was sitting at the nurse's station, was asked about the cart. LVN A came around the desk and locked the cart. An observation on 05/01/24 at 8:12 AM revealed a multi-dose vial of Influenza Vaccine in the medication room [ROOM NUMBER] refrigerator. The vial which had been opened and accessed, was not labeled with the date the vial was opened. An observation on 05/01/24 at 8:15 AM revealed the medication refrigerator temperature log taped to the front of the refrigerator. The log was dated April 2024. The log did not have any entries for 4/2/24, 4/5/24, 4/6/24, 4/7/24, 4/15/24, 4/16/24, 4/19/24, 4/20/24, and 4/30/24. Interview of LVN A on 4/29/2024 at 12:00 pm stated that she was unaware the cart was unlocked and that it may have been unlocked for about 5 minutes. She stated she did see the surveyor going through the drawers and did not see an issue with it. She stated that if a resident had been opening the drawers she would have intervened. She stated that most of the resident would not be at risk for the cart being unlocked because they were oriented and did not go thru things. Interview with DON on 4/29/2024 at 12:30 pm she stated her expectation was the medication carts be locked when not attended. She stated that residents and visitors could have access to prescription and over-the counter medications and that could put them at risk for possible overdose and medication side effects. During an interview on 05/01/24 at 8:16 AM, the DON stated, anything opened, including multi-dose vials, were dated when opened. She stated the nurse who opened the vial or bottle was responsible for dating the medication. She stated vials were good for 30 days once opened. She stated expired medications may not have been effective and then residents may not receive the desired effect. She stated the medication room refrigerator temperature was supposed to be monitored daily. She stated some medications were stored in the refrigerator to maintain their effectiveness. She stated it did not meet her expectations that 9 of 30 days were not monitored. Record Review of the policy titled Storage of Medications, undated, states 6. Compartments (including, but not limited to, drawers, Cabinets, rooms, refrigerator, carts, and boxes) containing drugs and biological are locked when not in use. Unlocked medications are not left unattended. and 7. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medication is stored separately from food and are labeled accordingly. Record Review of the policy titled Medication, vaccine refrigerator temperature monitoring, updated January 2024, states Daily logs: The temperature will be checked and recorded by designated staff.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food storage and sanitation, in that: 1) The facility failed to ensure the kitchen prep area was free of personal items. 2) The facility failed to ensure food and beverages in refrigerator #1 and #2, and the freezer, were covered, labeled, and dated. These deficient practices could cause cross contamination and place residents at risk of foodborne illness. Findings include: 1.) Observation of the kitchen food prep table #1 on 04/29/2024 at 8:28am revealed a pink travel cup. Observation of the kitchen food prep table #2 on 04/29/2024 at 8:28am revealed car keys on a Miami Beach key chain and a white cell phone charger sitting next to a box of sandwich bags. Observation of kitchen Refrigerator #1 on 04/29/2024 at 8:31am revealed a Styrofoam drink container with a red straw and what appeared to be a red liquid inside the container. The drink container was on the bottom shelf of Refrigerator #1, next to a gallon of milk. Interview with DA #1 on 5/1/2024 at 2:05pm, she stated personal items should be kept in the DM's office. She said it was not okay to have personal drinks in the kitchen refrigerator. Interview with DA #2 on 05/01/2024 at 2:10pm, she stated personal items should be kept in the DM's office and it was not okay for a drink to have been in the refrigerator. Interview with DM on 05/01/2024 at 2:25pm, she stated all personal items should be kept in her office and personal drinks should be kept in the staff refrigerator in her office. Surveyor requested policy for storing personal items and the facility does not have one. 2.) Observation of the kitchen Refrigerator #1 on 04/29/2024 at 8:31am revealed an unsealed and unlabeled storage bag with contents that resembled sliced cheese (yellow/orange squares). Observation of the kitchen Refrigerator #1 on 04/29/2024 at 8:31am revealed an unlabeled storage bag containing an opened, bag of Whipped Topping. Observation of the kitchen Refrigerator #2 on 04/29/2024 at 8:34am revealed with a rolling cart and two gray tubs with small drinking glasses containing a white liquid that resembled milk. The white plastic lids were ajar and not placed securely on the drinking glasses. Observation of the kitchen Refrigerator #1 on 04/29/2024 at 8:35am revealed a white box labeled Peeled and Cooked Eggs. Inside the box were multiple sealed bags of eggs. The box was not labeled with an opened on and use by date. Observation of the kitchen Freezer on 04/29/2024 at 8:37am revealed a blue storage bag tied in a knot. The bag contained what resembled frozen kernels of corn. The bag was not labeled with an opened on and use by date. Interview with DA #1 on 5/1/2024 at 2:05pm, she said all items in the refrigerator and freezer should have been placed in a plastic bag with a label and date. She said this task is the responsibility of all kitchen staff. Interview with ADM On 5/1/2024 at 2:00 Surveyor requested policy for storing personal items and the facility does not have one. Interview with DA #2 on 05/01/2024 at 2:10pm, she stated food in the refrigerator should be labeled and in storage bags. She said the kitchen staff were responsible for the labels and dates and the DM came behind them to ensure it was completed. Interview with DM on 05/01/2024 at 2:25pm, she stated her expectation was for items to be wrapped or placed in a storage bag, labeled with the contents and the date. She said this task was everyone's responsibility and she completes rounds to ensure it was done correctly. Review of facility policy titled Food Receiving and Storage, MED-PASS, Inc. Revised November 2022 states the following: Policy Statement Foods shall be received and stored in a manner that complies with safe food and handling practices. Refrigerated/Frozen Storage 1. All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). 7. Refrigerated foods are labeled, dated and monitored so they are labeled by their use by date, frozen or discarded. Record review of Federal Drug Administration Food Code 2022 indicated [(C) PACKAGED FOOD shall be labeled as specified in LAW, including 21 Code of Regulation 101 FOOD Labeling, 9 Code of Regulation 317 Labeling, Marking Devices, and Containers, and 9 Code of Regulation 381 Subpart N Labeling and Containers, and as specified under § 3-202.18.

Based on observation, record review and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 29 of 29 ( Resident's # 75,70,92,73,8,58,7,60,81,32,59,88,36,80,19,49,10,78,21,34,25,26,43,71,61,2,9,and 43) residents by 5 ( DON,ADON,LVN C, CNA D and CNA E) of 5 staff passing lunch trays that were reviewed for infection control and transmission-based precautions policies and practice, in that: The facility failed to ensure DON, ADON, LVN C, CNA D and CNA E did not grab resident's cups by the rim with bare hands, contaminating the tops of the rims, during the lunch meal serving process. This failure could place residents at risk for infection through cross contaminations of pathogens. Findings include: During the lunch observation on 4/29/2024 at 12:15pm DON, ADON, LVN C, CNA D and CNA E were observed touching the rims of the Resident's cups ( Resident's # 75,70,92,73,8,58,7,60,81,32,59,88,36,80,19,49,10,78,21,34,25,26,43,71,61,2,9,and 43) covered with plastic lids that did not fit properly with bare hands during the meal service. Hand hygeine was preformed between residents, however the lids of the cups were touch once to place on the tray , the tray deliver to the resident then removed from the tray to place in front of the resident. Interview with CNA D on 4/29/2024 at 1:00 pm he stated he did not even realize he was grabbing the cups by the rims and will start grabbing by the sides. He was not sure what harm could come to the resident, but he would not want to drink from a cup someone had grabbed from the rim. Interview with CNA E on 4/29/2024 at 1:05 pm she stated that she was not aware she was supposed to grab the cup from the side, and the way they have them on a tray it is hard to always grab from the side when you are trying to get the residents served their meals. Interview with ADON on 4/29/2024 at 1:15 pm she stated that the cups should be grabbed by the side, but lunch was a little late today and they were in a hurry to get the residents their meal. She stated that grabbing the cups by the rim could potentially cause cross contamination. She also stated employees are encouraged to use hand sanitizer between delivery of resident trays and there is some available in the dining room. Interview with LVN C on 4/29/2024 at 1:25 pm she stated that it is hard to grab the cups by the side for the first several residents as the drinks are pre poured and are on a tray . She stated that after she thought about it, grabbing by the side makes sense to help with cross contamination. Interview with DON on 4/29/2024 at 1:30 pm she stated that she did not realize the lids did not cover the entire drinking area of the cup. She stated that cups should be grabbed by the side of the cups to prevent cross contamination. Interview with ADM on 4/29/2024 at 2:00 pm he stated that his expectation is that the infection control and hand hygiene policies be followed. He stated anytime it is not followed it puts the resident at risk for infection from cross contamination. Record review of the facility's infection prevention and control program policy, undated, stated: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development of transmission of communicable disease and infection as per accepted national standards and guidelines. Record review of the facility's Hand Hygiene policy, undated, stated: Hand washing with either soap and water or hand sanitizer is the best way to stop the spread of infection, Before and after Assisting a resident with meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 3 (Residents #67, #33, #1) 3 residents reviewed for rights. 1. The facility failed to prevent CNA K from calling Resident #67 a feeder on 2 occasions. 2. The facility failed to empty Resident #33's urinal in a timely manner. 3 The facility failed to respect Resident #1's personal property and care wishes. The findings include: Record Review of Resident #1's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, heart failure, pulmonary disease, and cerebrovascular disease. Record review of Resident #1's 03/03/23 MDS revealed a BIMs of 15 which indicated that she was cognitively intact. Record Review of Resident #67's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including metabolic encephalopathy, rheumatoid arthritis, and reflux. Record review of Resident #67's 04/13/23 MDS revealed a blank for the section that provided a BIMs score. Record Review of Resident #33's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including diabetes, pulmonary disease, and cerebral infarction Record review of Resident #33's 02/10/23 MDS revealed a BIMS of 13, which indicated he was cognitively intact. In an observation on 05/17/23 at 2:12 pm CNA K entered the room and called Resident #67 a feeder while speaking to a new staff member. In an interview on 05/17/23 at 2:12 pm with Resident #1 she stated she has heard staff use the term feeder often when referring to her roommate because her roommate, Resident #67 requires assistance with her meals. In an interview and observation on 05/17/23 at 2:13 pm with Resident #67 she was lying in the bed with her eyes closed and she was not interviewable, and not able to verbalize her feelings or thoughts In an observation on 05/17/23 at 2:23 pm in the hall next to the nurses station CNA K was speaking to a new staff member and again used the term feeder while going through a list of residents with the new staff member. In an interview and observation on 05/17/23 at 2:24 pm with CNA K she did not realize the term feeder was disrespectful and should not be used; she was going over required tasks for each resident with a new staff member. In an observation on 05/20/23 at 4:00 pm with Resident #33 in his room the urinal with urine in it was sitting on the table in full view. In an observation on 05/22/23 at 10:20 am of Resident #33 when passing in the hall outside of his room his urinal was 35 - 45 % full and was sitting on his over bed table. In an observation on 05/22/23 at 11:00 am of Resident #33 when passing in the hall outside of his room his urinal was 35 - 45 % full and was sitting on his over bed table. In an interview with Resident #1 on 05/17/23 at 2:12 pm she stated that CNA M had worked for the facility before and Resident #1 had problems with her because she was rude and not polite. CNA M has returned to the facility and and she came into the room and Resident #1 asked her not to use Resident #1's red hairbrush on her roommate (who has a blue brush) and CNA M told her Don't you think I know that, which upset Resident #1. Then CNA M proceeded to use Resident #1's hairbrush on her roommate (Resident #67). The resident ws upset that this staff member was alloweed back at the facility and felt she was disrespectful by using her brush on her roommmate and ignored becuase she had just asked her not to do that. Record review of the undated facility policy titles Statement of Resident Rights revealed .1. All care necessary for you to have the highest possible level of health . 2. Safe, descent and clean conditions . 4. Be treated with courtesy, consideration, and respect

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident had the right to a safe, clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safely for 2 hallways (Secure Hall, and 200 Hall) of 4 hallways observed for environment 1. The facility failed to ensure the rooms and halls were free from offensive odors on the Secure Hall and the 200 Hall. 2. The facility failed to ensure the walls, ledges and windows were free from stains on the Secure Hall and the 200 Hall. These failures placed all residents at risk of living in an unclean, uncomfortable, un-homelike environment. Findings include: In an observation on 05/17/23 at 2:10 pm a strong odor of urine was detected outside of rooms [ROOM NUMBERS]. In an observation on 05/17/23 beginning at 3:52 pm on the secure unit revealed in the end of the hall on the wall to the left of the exit door stains were observed on the blinds; stains on the wall and ledge; and on the wall to the left of the window a drop of red substance and smear of brown substance. In a confidential staff interview, staff member stated that they were understaffed and residents did not always get checked every 2 hours, which led to the smells. In an observation on 05/22/23 at 10:20 am on the secure unit the same issues observed on 05/17/23 at 3:52 pm were still present; the secure unit the wall in the hall by the exit door stains were observed on the blinds; stains on the wall and ledge; and on the wall to the left of the window a drop of blood and smear of dirt. In an observation on 05/21/23 at 10:38 am a strong smell of urine was detected down the 200 Hall off the common area where the residents were gathered sitting in wheelchairs. In an interview with a confidential visitor to the facility, the visitor stated the facility floors were sticky and on several residents the visitor noted dirty and soiled clothing. Record review of an undated facility policy on Resident Rights stated that residents have a right to safe, decent, and clean conditions.

**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 is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for four (Resident #46, #63, #28, and #33) of 4 residents reviewed for ADLs. The facility failed to ensure residents were provided with ADL care when needed for Resident #46, #63, #28 and #33. These failures could place residents at risk of worsening health conditions due to not having their personal hygiene needs addressed. Findings include: In a confidential staff interview, staff member stated that they were understaffed and residents did not always get checked every 2 hours, which led to the smells. In an interview with a confidential visitor to the facility, the visitor stated several residents the visitor noted dirty and soiled clothing. Record Review of Resident #46's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including dementia, depression, anxiety. Record review of Resident #46's 03/17/23 MDS revealed her BIMS was left blank. It further revealed she required extensive assistance for bed mobility, transfer, walking in room, dressing, toilet use, and personal hygiene. In an observation on 05/21/23 at 10:50 am Resident #46 was laying on the left side and observed wearing grey jogging pants that were wet from the top of the pants on down. A brief was be seen at the top. The room smelled of urine. In an interview with a confidential visitor to the facility, the visitor stated several residents the visitor noted dirty and soiled clothing. Record Review of Resident #33's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including diabetes, pulmonary disease, and cerebral infarction (stroke). Record review of Resident #33's 02/10/23 MDS revealed a BIMS of 13, which indicated cognitively intact answers. It further revealed he required extensive assistance with bed mobility, transfers and assistance with toileting and hygiene. In an interview on 05/19/23 at 1:00 pm Resident #33 stated that the normal time it takes for his call light to be answered is 30 minutes, but it can be a lot longer. He stated he often had his urinal left for hours without being emptied. He stated that he was uncomfortable with his full urinal being left unemptied and it was embarassing. Record Review of Resident #63's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including spinal stenosis, pulmonary disease, schizophreniform disorder. Record review of Resident #63's 03/08/23 MDS revealed his BIMS was left blank; it further revealed he was an extensive assist for hygiene, eating, and dressing and for toilet use it was marked as activity did not occur. A record review of a photo dated 04/10/23 at 6:32 pm revealed Resident #63 in a soiled brief with a soiled pad underneath him. Record Review of Resident #28's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including intracerebral hemorrhage (stroke), and schizoaffective disorder (distorted reality). Record review of Resident #28's 04/14/23 MDS revealed a BIMS of 10, which indicated he had moderately impaired cognition. It further revealed that he was an extensive assist with toileting, personal hygiene, and dressing. A record review of a photo dated 04/24/23 at 10:18 am revealed Resident #28 with 2 soiled briefs on and 2 pads under him and all were soaked with urine . Record Review of Resident #35's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including cerebral infarction, schizoaffective disorder (distorted reality), and anxiety. Record review of Resident #35's 04/15/23 MDS revealed a BIMS of 08, which indicated moderatley impaired cognition. Further review revealed he required extensive assistance with toileting, hygiene, dressing, bed mobility, and transfers. A record review of a photo dated 04/24/23 at 4:46 pm revealed Resident #35 in his wheelchair with no socks on, just slip-on shoes and his trousers are covered in yellow stains on both legs, starting in the hip and pelvic area and continuing down his gray sweat pant legs [lunch was served at 12:00 pm]. A record review of the undated facility dining times revealed that breakfast was at 8:00 am, lunch was at 12:00 pm, and dinner was at 5:00 pm. In an interview on 05/19/23 at 10:15 am the DON stated that CNAs are expected to check on residents every 2 hours and as needed and that she had not noticed strong odors. She said residents left soiled could cause infections and skin breakdown. She denied any complaints about urine odors to the best of her knowledge. Record review of an undated facility policy on Resident Rights stated that residents have a right to safe, decent and clean conditions. Record review of the abuse prohibition policy, revised [DATE], revealed each resident has a right to be free from neglect; it further defined neglect as .failure to assist in personal hygiene . failure to provide medical care for physical and mental health needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 25 (Resident #2, #11, #14, #18, #19, #22, #23, #31, #33, #34, #36, #38, #39, #40, #41, #1, #47, #51, #61, #63, #64, #66, #67, #68, and #70) of 72 residents reviewed for missing medication doses, and for 2 of 2 (Center cart log and Center cart #1 log) medication cart logs that were reviewed for pharmacy services. #1 The facility failed to ensure medications were available as ordered by a practitioner for Resident #2, #11, #14, #18, #19, #22, #23, #31, #33, #34, #36, #38, #39, #40, #41, #1, #47, #51, #61, #63, #64, #66, #67, #68, and #70. #2 The facility failed to ensure accurate documentation in narcotic count sheets for 2 of 2 (Center cart log and Center cart #1 log) medication cart logs that were reviewed for pharmacy services: The facility failed to provide a system of medication records that enables periodic accurate reconciliation and accounting for all controlled medications on the medication cart logs that were reviewed for pharmacy services. The facility failed to ensure medications were available as ordered by a practioner. These failures could place the residents at risk for not receiving the therapeutic effects from controlled narcotics due to from controlled narcotics did not being reconcile every shift and at risk for worsening of medical condition due to not having prescribed medications available. The findings included: #1 The facility failed to ensure medications were available as ordered by a practitioner In an interview on 05/17/23 at 4:40 pm with ADON 2 she stated the facility had a new system that started 05/10/23 for pharmacy services that involved a nightly delivery that contained medications for the following day. Record Review of Resident #2's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including diabetes, heart disease, bipolar disorder, hypertension, and schizoaffective disorder. Record review of the progress notes for Resident #2 printed on 05/22/23 at 4:11 pm revealed a progress note dated 05/06/23 at 5:28 am revealed none on cart, med unavail. Didn't come out of passport Facility failed to provide Resident #2's May 23 MAR, which was requested on 3 occasions prior to exit. Record Review of Resident #11's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including crohn's disease, bipolar disorder, depression, anxiety, mood disorder, dementia, and schizoaffective disorder. Record review of Resident #11's May 23 MAR revealed on 05/03/23 at 8:00 pm, for administration of Ingrezza 60 mg, give 1 capsule by mouth at bedtime for tardive diskenesia (uncontrollable movements) related to drug induced subacute dyskinesia , the number 9 was entered which indicated to see the progress notes. Record review of the progress notes for Resident #11 printed on 05/22/23 at 4:11 pm revealed a progress note dated 5/3/23 at 6:44 pm medication on order . Record Review of Resident #14's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including dementia, bipolar disorder, depression, schizoaffective disorder, subdural hemorrage, and anxiety. Record review of Resident #14's progress notes, printed on 05/22/23 revealed a progress note on 5/9/23 at 00:51 am re-ordered oxcarbazepine 75 mg via pcc. Pending RX delivery. 00:51 am med not available. Pending Rx delivery. Record Review of Resident #18's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including syncope & collapse, hypothroidism, and cirrhosis. Record review of Resident #18's progress notes, printed on 05/22/23 revealed a progress notes on the following dates with medications not available: 5/22/23 8:20 am not available, awaiting delivery; another progress not 5/21/23 3:30 pm not available; 10:20 am medication pending to delivery 5/20/23 4:36 pm medication pending to delivery; 09:52 am 5/19/23 3:53 pm awaiting delivery; 10:40 am awaiting delivery; 5/14/23 5:26 am drug unavailable 5/7/23 4:06 am med unavail. None on cart 5/5/23 4:50 am none on cart, med. Unavail. 5/4/23 4:01 am none on cart, med. Unavail. 5/1/23 4:04 am med. Unavail. Facility failed to provide Resident #18's May 23 MAR, which was requested on 3 occasions prior to exit. Record Review of Resident #19's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including diabetes, paraplegia, and spinal stenosis. Record review of Resident #19's progress notes, printed on 05/22/23 revealed a progress notes on the following dates with medications not available: 05/12/23 11:51 pm med not available on cart, need to be ordered Record review of Resident #19's May 23 MAR revealed on 05/13/23 at 12:00 am he did not get his Gabapentin Oral Tablet 600 MG (Gabapentin) Give 1 tablet by mouth every 8 hours for pain. Record Review of Resident #22's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including heart disease, dementia, and schizoaffective disorder. Record review of Resident #22's progress notes, printed on 05/22/23 revealed a progress notes on the following dates with medications not available: 5/20/23 5:11 pm drug unavailable Record review of Resident #22's May 23 MAR revealed 05/20/23 at 5:00 pm she did not get Cyclobenzaprine HCl Tablet 5 MG Give 1 tablet by mouth three times a day for muscle pain. Record Review of Resident #23's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, epilepsy, and hyperlipidemia. Record review of Resident #23's progress notes, printed on 05/22/23 revealed a progress notes on the following dates with medications not available: 05/05/23 4:07 am med unavail none on cart/passport 05/04/23 8:10 am on order; 5:32 am med unavail; none on cart/passport 05/03/23 5:11 pm medication not here; 9:57 am medication not here 05/01/23 4:01 am med unavail Record review of Resident #23's May 23 MAR revealed she did not get the following: 05/05/23 5:00 am Levothyroxine Sodium Tablet 100 MCG Give 1 tablet by mouth in the morning for low thyroid hormone 05/04/23 5:00 am Levothyroxine Sodium Tablet 100 MCG Give 1 tablet by mouth in the morning for low thyroid hormone 05/03/23 4:00 pm Colchicine Oral Tablet 0.6 MG (Colchicine) Give 2 tablet by mouth two times a day for edema to leg for 4 Days 05/01/23 5:00 am Levothyroxine Sodium Tablet 100 MCG Give 1 tablet by mouth in the morning for low thyroid hormone Record Review of Resident #31's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, respiratory failure, and cardiovascular syphilis. Record review of Resident #31's progress notes, printed on 05/22/23 revealed a progress notes on the following dates with medications not available: 5/18 10:22 pm pending delivery; 5:57 pm benztropine blister pack was empty 5/1/23 7:52 pm medication on hold, pending delivery from pharmacy Facility failed to provide Resident #31's May 23 MAR, which was requested on 3 occasions prior to exit. Record Review of Resident #33's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including diabetes, pulmonary disease, and cerebral infarction. Record review of Resident #33's progress notes, printed on 05/22/23 revealed a progress notes on the following dates with medications not available: 5/12/23 11:50 pm med not available on cart, need to be ordered Facility failed to provide Resident #33's May 23 MAR, which was requested on 3 occasions prior to exit. Record Review of Resident #34's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including sepsis, lymphedema, and seizures. Record review of Resident #34's progress notes, printed on 05/22/23 revealed a progress notes on the following dates with medications not available: 5/21/23 4:38 pm not available; 9:00 am not available 5/5/23 8:38 am phenobarbital waiting on pharmacy to deliver 5/4/23 6:39 pm on order Record review of Resident #34's May 23 MAR revealed he did not receive his 05/04/23 4:00 pm PHENobarbital Oral Tablet 97.2 MG (Phenobarbital) Give 1 tablet by mouth two times a day related to OTHER SEIZURES; his 05/05/23 8:00 am PHENobarbital Oral Tablet 97.2 MG (Phenobarbital) Give 1 tablet by mouth two times a day related to OTHER SEIZURES; and on 05/21/23 at 8:00 am Metamucil Oral Powder 28.3 % (Psyllium) Give 1 tsp by mouth two times a day for Constipation. Record Review of Resident #36's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including diabetes, heart failure, depression, and anxiety. Record review of Resident #36's progress notes, printed on 05/22/23 revealed a progress notes on the following dates with medications not available: 05/21/23 11:14 pm pending RX delivery Facility failed to provide Resident #36's May 23 MAR, which was requested on 3 occasions prior to exit. Record Review of Resident #38's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including Alzheimer's disease, bipolar disorder, and pulmonary disease. Record review of Resident #38's progress notes, printed on 05/22/23 revealed a progress notes on the following dates with medications not available: 5/14/23 11:06 am medication is not available, nurse ordered medication at this time awaiting for pharmacy to send Record review of Resident #38's May 23 MAR revealed on 05/14/23 at 8:00 am she did not receive ZyPREXA Tablet 10 MG (OLANZapine) Give 1 tablet by mouth two times a day for Agitation related to SCHIZOPHRENIA. Record Review of Resident #39's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including hypertension, and reflux disease. Record review of Resident #39's progress notes, printed on 05/22/23 revealed progress note(s) on the following dates with medications not available: 5/16/23 1:51 am pending rx delivery Record review of Resident #39's May 23 MAR revealed he did not get: 05/15/23 4:30 pm Apixaban Oral Tablet 5 MG (Apixaban) Give 1 tablet by mouth two times a day for Atrial Fibrillation Not Caused by a Heart Valve Problem 05/16/23 12:00 am Tylenol with Codeine #3 Oral Tablet 300-30 MG (Acetaminophen w/ Codeine) Give 1 tablet orally every 8 hours for pain 05/16/23 8:00 am Tylenol with Codeine #3 Oral Tablet 300-30 MG (Acetaminophen w/ Codeine) Give 1 tablet orally every 8 hours for pain 05/16/23 8:00 am Furosemide Oral Tablet 40 MG (Furosemide) Give 1 tablet by mouth one time a day for diuretic 05/16/23 8:00 am Folic Acid Oral Tablet 1 MG (Folic Acid) Give 1 tablet by mouth one time a day for supplement 05/16/23 8:00 am Levothyroxine Sodium Oral Capsule 75 MCG (Levothyroxine Sodium) Give 1 capsule by mouth one time a day for elevation is TSH. Record Review of Resident #40's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including Huntington's disease, hypertension, reflux, and psychotic disorder. Record review of Resident #40's progress notes, printed on 05/22/23 revealed progress note(s) on the following dates with medications not available: 5/5/23 4:49 am none on cart, med unavail 5/4/23 4:03 am none on cart, med unavail 5/1/23 4:03 am med unavail Recod review of Resident #40's May 23 MAR revealed she did not get: 05/05/23 5:00 am Levothyroxine Sodium Tablet 88 MCG Give 1 tablet by mouth in the morning related to HYPOTHYROIDISM 05/04/23 5:00 am Levothyroxine Sodium Tablet 88 MCG Give 1 tablet by mouth in the morning related to HYPOTHYROIDISM 05/01/23 5:00 am Levothyroxine Sodium Tablet 88 MCG Give 1 tablet by mouth in the morning related to HYPOTHYROIDISM Record Review of Resident #41's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including pulmonary disease, dementia, and Parkinson's disease. Record review of Resident #41's progress notes, printed on 05/22/23 revealed progress note(s) on the following dates with medications not available: 5/13/23 5:00 am med not available on cart need to be ordered 5/5/23 4:48 am med unavail. None on cart/passport 5/4/23 4:03 am med unavail, none on cart 5/1/23 4:02 am med unavail Record review of Resident #41's May 23 MAR revealed she did not get: 05/13/23 5:00 am Levothyroxine Sodium Tablet 25 MCG Give 1 tablet by mouth in the morning related to HYPOTHYROIDISM 05/05/23 5:00 am Levothyroxine Sodium Tablet 25 MCG Give 1 tablet by mouth in the morning related to HYPOTHYROIDISM 05/04/23 5:00 am Levothyroxine Sodium Tablet 25 MCG Give 1 tablet by mouth in the morning related to HYPOTHYROIDISM 05/01/23 5:00 am Levothyroxine Sodium Tablet 25 MCG Give 1 tablet by mouth in the morning related to HYPOTHYROIDISM Record Review of Resident #47's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including atherosclerosis, schizoaffective, depression, and anxiety. Record review of Resident #47's progress notes, printed on 05/22/23 revealed progress note(s) on the following dates with medications not available: 5/22 11:33 am not in stock, pharm will re-order - ingrezza Resident #1 Record Review of Resident #1's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, heart failure, pulmonary disease, and cerebrovascular disease. Record review of the progress notes for Resident #1 printed 05/22/23 revealed a note dated 05/21/23 at 1:35 pm revealed Resident stated that she did not receive her 12:00 am Tizanidine and Gabapentin and she did not receive her 0500 Levothyroxine. Contracted Pharmacy was contacted and it was confirmed that the Levothyroxine was delivered this AM around 0130 and signed by LVN D. Levothyroxine was signed off in the MAR as been being administrated. As for the 12:00 am Tizanidine and gabapentin, both of those needed to be pulled from the Cubex machine because the times were updated and there was no med packs for those. Contracted pharmacist was contacted and it was confirmed that at 12:00 am both of those medications were pulled from the Cubex machine by LVN D and in the MAR both medications were signed off by LVN D as they were administered. Record review of the progress notes for Resident #1 printed on 05/22/23 revealed the following date when medication was not available: 5/15 at 10:16 PM pending rx delivery for 10 medications. Record Review of Resident #51's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, pulmonary disease, heart disease, and hypertension. Record review of Resident #51's progress notes, printed on 05/22/23 revealed progress note(s) on the following dates with medications not available: 05/12/23 7:10 pm pending [NAME] Record review of Resident #51's May 23 MAR revealed on 05/12/23 at 4:00 pm her Haloperidol Tablet 1 MG Give 4 tablet by mouth two times a day related to SCHIZOAFFECTIVE DISORDER was not administered. Record Review of Resident #61's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, cerebral infarction, and dementia. Record review of Resident #61's progress notes, printed on 05/22/23 revealed progress note(s) on the following dates with medications not available: 5/6 9:18 pm Aricept unavailable; 9:04 pm trazadone unavailable; 9:01 pm abilify unavailable; 4;11 am simvastatin, unavailable; 4:11 am trazadone med not available; 4:10 am Remeron - blank note; 4:10 am melatonin blank note; 4:09 aricept med not available; 4:07 am ability not available Record Review of Resident #63's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including spinal stenosis, pulmonary disease, and schizophreniform disorder. Record review of Resident #63's progress notes, printed on 05/22/23 revealed progress note(s) on the following dates with medications not available: 05/12/23 6:23 pm pending [NAME] Record review of Resident #63's May 23 MAR revealed on 05/12/23 at 4:00 pm the following medication was not administered: Systane Ophthalmic Solution 0.4-0.3 % (Polyethylene Glycol-Propylene Glycol (Ophth)) Instill 1 drop in both eyes two times a day related to DRY EYE SYNDROME OF BILATERAL LACRIMAL GLANDS. Record Review of Resident #64's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including dementia, respiratory failure, and schizophrenia. Record review of Resident #64's progress notes, printed on 05/22/23 revealed progress note(s) on the following dates with medications not available: 05/09/23 3:31 am re-ordered trazadone via pcc, pending rx delivery 05/06/23 8:50 pm trazadone 25 mg med unavailable Record Review of Resident #66's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including Alzheimer's, hypertension, reflux, and kidney failure. Record review of Resident #66's MDS dated [DATE] revealed a BIMS of 0 which indicated severely impaired cognition. Record review of Resident #66's progress notes, printed on 05/22/23 revealed progress note(s) on the following dates with medications not available: 05/08/23 2:11 pm ADON 2 Review of Seroquel by NP, at this time no change in dose, not recommended for GDR due to behaviors could worsen. Record Review of Resident #67's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including metabolic encephalopathy, rheumatoid arthritis, and reflux. Record review of Resident #67's MDS dated [DATE] revealed her BIMS section was blank. Record review of Resident #67's progress notes, printed on 05/22/23 revealed progress note(s) on the following dates with medications not available: 05/20/23 10:07 am Spoke with pharmacy regarding antibiotics the packaging is dated for 5/21/2023 no packages were received for 05/20/2023 tech she will add more packages on the run tonight for tomorrows medication pass 05/19/23 Order entered 1:46 pm for pneumonia, first does dose due at 4:00 pm, not in facility Record review of Resident #67's May 23 MAR revealed an order for Doxycycline Hyclate Tablet 100 MG Give 1 tablet by mouth two times a day for pneumonia for 7 Days give 100 mg PO BID for X7 days; which was not administered until 05/20/23 at 8:00 am despite being scheduled for 05/19/23 at 4:00 pm. Record Review of Resident #68's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including osteomyelitis (infection in the bone) of the left ankle and foot, hypothyroidism, bipolar disorder, and depression. Record review of Resident #68's progress notes, printed on 05/22/23 revealed progress note(s) on the following dates with medications not available: 05/19/23 5:21 pm on order 05/17/23 00:22 pending RX delivery; 00:21 pending RX delivery 05/16/23 7:23 pm - all meds NH with 9, no information in progress note, just copied order 05/16/23 5:03 pm on order Record review of Resident #68's May 23 MAR revealed that on 05/16/23 at 4:00 pm he was supposed to have a 10 cc saline flush before and after each dose of ertapenem, but this was on order. On 05/16/23 an order for Ertapenem 1 gram every 8 hours for infection in foot bone was entered with a start date of 05/16/23 4:00 pm, and was discontinued 05/16/23 at 3:25 pm. On 05/16/23 at 7:00 pm his Mirtazapine Oral Tablet 15 MG was not given, his 4:00 pm Bactrim DS Oral Tablet 800-160 MG (Sulfamethoxazole- Trimethoprim) Give 1 tablet by mouth two times a day for bone infection was not given, his 5:00 pm Gabapentin Capsule 400 MG Give 1 capsule by mouth three times a day for pain was not given because they were not available. On 05/17/23, 12:00 am his Ertapenem Sodium Injection Solution Reconstituted 1 GM (Ertapenem Sodium) Use 1 gram intravenously every 8 hours for foot infection for 36 Administrations was not given pending delivery, his 05/17/23 12:00 am 10 cc saline flush before and after each dose of ertapenem was pending delivery, and on 05/19/23 at 4:00 pm his Hydrocortisone External Cream 1 % (Hydrocortisone (Topical)) Apply to left ankle /calf topically two times a day for itching for 7 Days was not given because it was on order. Record Review of Resident #70's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, kidney disease, hepatitis c, and dementia. Record review of Resident #70's progress notes, printed on 05/22/23 revealed progress note(s) on the following dates with medications not available: 05/14/23 11:03 am Medication was not available nurse ordered medication at this time Record review of Resident #70's May 23 MAR revealed on 05/14/23 at 8:00 am she did not get amLODIPine Besylate Tablet 5 MG Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold if HR less than 60 or SBP less than 100. Record Review of Resident #34's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including sepsis, lymphedema, and seizures. Record review of Resident #34's May 23 MAR revealed he did not receive his 05/04/23 4:00 pm phenobarbital 97.2 mg tab for seizures, nor did he receive his 05/05/23 8:00 am dose. Record review of the progress notes for Resident #34 printed 05/22/23 at 4:11 pm revealed a progress note dated 5/4/23 at 6:39 pm on order; a progress note dated 5/5/23 8:38 am waiting on pharmacy to deliver. Record Review of Resident #51's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, pulmonary disease, heart disease, and hypertension. Record review of Resident #51's MDS dated [DATE] revealed a BIMS of 11 which indicated moderately impaired cognition. Record review of Resident #51's May 23 MAR revealed she did not receive her 05/12/23 4:00 pm dose of haloperidol 4 mg dose. Record review of the progress notes for Resident #51 printed 05/22/23 at 4:11 pm revealed a progress note dated 05/12/23 7:10 pm stating pending [NAME] [halodperidol 4 mg]. Record Review of Resident #23's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, epilepsy, and hyperlipidemia. Record review of Resident #23's MDS dated [DATE] revealed a BIMS of 14, which indicated the resident was cognitively intact. Record review of Resident #23's May 23 MAR revealed she did not receive colchicine 1.2 mg on 05/03/23 8:00 am, 05/03/23 4:00 pm, and 05/04/23 at 8:00 am. Record review of the progress notes for Resident #23 printed 05/22/23 at 4:11 pm revealed a progress note dated 05/03/23 9:57 am medication not here; 05/03/23 5:11 pm medication not here; 05/04/23 8:10 am on order. Record review of Resident #23's orders revealed an order for Colchicine Oral Tablet 0.6 MG (Colchicine) Give 2 tablet by mouth two times a day for edema to leg for 4 Days with a start date of 04/30/23 4:00 pm. Record review of the undated facility policy title Administering Oral Medications revealed Steps in the procedure 9. prepare the correct dose for the resident . 10. Confirm the identity of the resident 11. Explain the procedure to the resident 12. Place medications on the bedside tray or table . 14 assist the resident to a sitting position . 15 offer water to assist .21. Remain with the resident until all medications have been taken. Record review of the undated facility policy title Documentation of Medication Administration revealed . 2. Administration of medication must be documented immediately after (never before) it is given . 3. Must include d.date and time administered; e reason(s) why a medication was withheld, not administered, or refused (as applicable) . #2 The facility failed to ensure accurate documentation in narcotic count sheets for 2 of 2 (Center cart log and Center cart #1 log) medication cart logs that were reviewed for pharmacy services: During an observation on 05/17/23 at 2:08 pm an inspection of the medication cart log on Center Hall, revealed a form titled, Controlled Drugs-Count Record (Narcotic count sheet at each change of nursing shift), with missing signatures for the following dates: 05/01/23, 05/02/23, 05/12/23, 05/13/23, 05/14/23, and 05/15/23. In addition, there was already a signature by CMA A in the spot for the 05/17/23 11 pm to 7 am shift in the nurse off signature block. During an observation on 05/17/23 at 2:25 pm an inspection of the medication cart #1 log on Center Hall revealed a form titled, Controlled Drugs-Count Record (Narcotic count sheet at each change of nursing shift), with missing signatures for the following dates: 05/01/23, 05/02/23, 05/10/23, 05/14/23, 05/15/23 and 05/16/23. During an observation on 05/18/23 at 1:32 pm an inspection of of the medication cart log on Center Hall revealed a form titled, Controlled Drugs-Count Record (Narcotic count sheet at each change of nursing shift), revealed a signature by CMA A already present in the spot for the 05/18/23 11 pm to 7 am shift in the nurse off signature block. In an interview on 05/18/23 at 1:40 pm with CMA A she stated that she signed the logs the way she was supposed to, but she had noticed that there were missing signatures . Record review of the CMS form 2567 with an exit date of 03/02/23 revealed the facility was cited for the same deficiency. In the plan of correction the facility stated the DON would monitor the logs for accuracy for 3 months. Record review of the facility's policy titled, Controlled Substances, no date, revealed, .12. At the end of Each shift: a. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. b. Any discrepancies in the controlled substance count are documented and reported to the director of nursing services immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and PRN orders for psychotropic drugs are limited to 14 days for 2 (Resident #68 and #8) of 4 residents reviewed for psychotropic medication errors. The facility failed to ensure psychotropic medications were prescribed for appropriate medical diagnoses for Resident #68 and Resident #8. This failure put all residents at risk of decreased quality of life due to improper use of psychotropic medications. Finding included: Record Review of Resident #68's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including osteomyelitis (infection in the bone) of the left ankle and foot, bipolar disorder, and depression. Record review of Resident #68's May MAR revealed an order for aripiprazole 10 mg, give 1 tablet 1 time per day for behavior. Further record review revealed no diagnosis associated with the medication order. Record Review of Resident #8's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including kidney disease, dementia, depression, anxiety, and adjustment disorder with mixed anxiety and depression. Record review of Resident #8's 04/13/23 MDS revealed her BIMSs was blank. Record review of the progress notes for Resident #8 printed on 05/22/23 at 4:11 pm revealed a progress note dated 05/16/23 at 4:21 pm written by ADON that stated stated spoke with family (RP) about AM and afternoon trazadone being discontinued and he was upset to why that would be the case; notified NP E and resident was placed back on trazadone 100 once in am and in afternoon and 150 mg 2 tab at night before bedtime. RP happy with change. Record review of Progress note dated 05/15/23 at 3:16 pm stated Resident #8 was yelling down the hall and was entered by AD; 5/12/23 at 3:22 pm yells at other residents per LVN N, 5/12/23 3:08 pm combative today hitting other residents and cursing able to redirect by AD Record review of the progress notes for May, printed 05/22/23 at 4:11 pm revealed 05/05/23 at 12:02 pm physician progress note mdd stable but does cry at times per staff; Cymbalta 30 mg hs and trazadone 100 mg po hs vit d3 25 mcg po daily signed by NP E. Record review of Resident #8's May MAR revealed from 05/01/23 - 05/08/23 8:00 pm 100 mg Trazadone, and 12:00 pm 100 mg trazadone; from 05/08/23 - 05/16/23 150 mg trazadone at 8:00 pm; then starting 05/17/23 100 mg trazadone at 8:00 am, 100 mg trazadone at 12:00 pm, and 300 mg trazadone at 8:00 pm. Record review revealed no existing order for trazadone scheduled at 8:00 am prior to 05/17/23. Record review of the manufacturer prescribing information for trazadone, in section 2.1 dosage selection, the dose may be increased by 50 mg/day every 3 to 4 days . The maximum dose for outpatients usually should not exceed 400 mg/day in divided doses. Inpatients (i.e., more severely depressed patients) may be given up to but not in excess of 600 mg/day in divided doses. In an interview on 05/23/23 at 1:28 pm with DON she stated she would review all psychotropic medications and limit PRN orders to 14 days and add diagnoses for medications that were lacking an associated diagnosis. She stated that the consultant pharmacist had recommended a 30 day maximum on PRN psychotropic medications. She stated she was not aware that hospice was required to follow the 14 day PRN guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were free of any significant medication errors for 26 (Resident #1, #7, #9, #12, #14, #15, #20, #22, #23, #25, #28, #30, #31, #33, #38, #45, #46, #47, #50, #54, #56, #62, #64, #65, #68, and #70) of 72 residents reviewed for medication errors. 1. The facility failed to administer medications prescribed by provider(s) for Resident #1, #7, #14, #20, #22, #23, #25, #28, #31, #33, #38, #46, #47, #62, #64, #65, and #70. 2. The facility failed to adhere to the parameters of medication administration as written by the provider(s) for Resident #1, #15, #12, #9 #25, #56, #47, #54, and #45. 3. The facility failed to administer medications in a timely manner, within an hour of the scheduled administration time, and before meals as prescribed for Resident #33. 4. The facility failed to ensure the administration of levothyroxine on 05/21/23 at 5:00 am for 3 of 3 (Resident #1, Resident #50, and Resident #68) residents reviewed for missing levothyroxine complaints on 05/21/23. 5. The facility failed to ensure the administration of medications that have a narrow therapeutic index for Resident #1, #25, and #30. These failures could place resident at the facility and placed each resident at risk of continued serious medication errors that were likely to cause injury, harm, impairment or death, in addition to impairing psychosocial wellbeing. Findings included: #1 The facility failed to administer medications prescribed by provider(s). Record Review of Resident #1's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, heart failure, pulmonary disease, and cerebrovascular disease. In an interview and observation on 05/17/23 at 2:12 pm Resident #1 she did not get her night medicine on 05/12/23, which included medicine for sleep and for pain. She stated that her pain on 05/12/23 was a 10 out of 10 and she couldn't sleep either. She said her pain was relieved sometime after 7:00 am on 05/13/23 when the morning shift arrived. Resident #1 cringed multiple times and grabbed her left leg stump while she spoke. She also grimaced 3 times and then gasped while grabbing her left leg. She became tearful and stated that she has told all of the nurses she was in pain, and it has been for a few weeks; she said she has not been re-evaluated by a doctor after she informed the nurses she was in pain. Resident #1 did not feel the Tylenol #4 PRN was helping. She stated her current pain level was a 10 out of 10. In an interview on 05/17/23 at 2:24 pm with DON this Surveyor informed her of Resident #1 complaining of 10 out of 10 pain. Record review on 05/17/23 revealed that Resident #1's May 2023 MAR was blank on 05/11/23 and 05/12/23 for her 8:00 pm medications which were Melatonin 10 mg, Glucophage 500 mg, Tizanidine 4 mg, gabapentin 800 mg, Aggrenox 25-200, dilantin 200 mg, coreg 50 mg, Cymbalta 60 mg, and trazadone 250 mg. In addition, her 4:00 pm ziprasidone 40 mg was not administered on either date. Interview on 05/17/23 at 2:30 pm with LVN O stated Resident #1 likes meds [enjoys narcotics] and got people fired [complained often about care]; she had never seen the resident grimace. She stated she had a med at 6:45 am and she goes to pain management in Waco and [NAME]. Resident #1 was a drug addict, she knew from back in the day [before the resident admitted to the facility in 2015]. In an interview and observation on 05/17/23 at 4:40 pm with ADON 2 and DON, the DON walked to the medication cart and pulled out medication baggies that had a resident name at the top and a date and time for administration. She stated if the medications were not administered they would be in the cart and no medications were in the cart . In an interview on 05/17/23 at 4:48 pm, while observing a med cart with DON, unprompted CMA A stated that on 05/11/23 before she left for the evening she noted that a few residents, including Resident #1, did not have baggies for their night medications. She stated the new pharmacy company had a rep on site and the rep was informed that residents were missing meds and rep stated she would send an email but it could take a day to get it straightened out. She stated that 05/10/23 was the first day of the new pharmaceutical system using the medications and baggies, so the rep was present. In an observation on 05/17/23 at 4:52 pm with DON she came out of a room behind the nurses station carrying 2 baggies of medications with Resident #1's name and 05/12/23 8:00 pm on the top [the medications that should have been administered to Resident #1 on Friday 05/12/23 at 8:00 pm]. In an interview on 05/17/23 at 5:19 pm with DON she stated she spoke to CMA B on the phone and CMA B stated that Resident #1 refused her medications on 05/12/23. The DON asked if she should enter a progress note at this time reflecting the resident refused her medications. The DON stated that the expectation was that CMA B should have informed the nurse working that night of the refusal, the nurse should have spoken to the resident and offered the medications again. She said medications not being administered was a risk to the resident and the expectation was that medications be administered or the reason be documented in the MAR . In an interview on 05/17/23 at 5:19 pm with the ADON she stated Resident #1 can't be in pain she was outside smoking and smiling just before she claimed to be in pain. In an interview on 05/18/23 at 8:23 am with PHAR P she stated the rep would not call me back, she is her supervisor. She stated the deliveries arriving around midnight tonight would be for the day after tomorrow. The medication carts should have today's medications to be distributed and tomorrow's. She said it was not possible that the medications were not present in the building and that there was a central computer called a cubex that had the common medications so they could be pulled if needed. In an interview on 05/18/23 at 1:27 pm with CMA A she stated she was pretty sure Resident #1, Resident #38 and Resident #50 were was all missing night medications on 05/11/23 and she informed the pharmacy rep of this In an interview and observation on 05/18/23 at 4:50 pm with Resident # 1 she said she saw the pain doctor today, but doesn't think the medications are working. She said she did not get any medications last Thursday (05/11/23) or Friday (05/12/23) which included medications for pain and sleep. She said she did not get sleep on Thursday or Friday, she was in pain and couldn't calm down and she was crying on and off through the night. She stated that hell no I did not refuse my medications, and said she refused a patch that did not help her but other than that she did not refuse her medications ever. She said her left stump pain started around an 8 of 10 and went up to a 10 of 10 on both nights. She told ADON 2 on Tuesday 05/16/23 that she was in pain and she said they would try to fix it, but she told her a few times over the last few weeks and nothing was done about her pain. She was clearly uncomfortable, shifting multiple times, grabbing her left leg stump, and cringing and gasping a few times. In addition, she got emotional several times as we spoke. She said that it was a horrible anxiety and pain that got worse and worse through the night on Thursday and Friday when she did not get her medicine and her roommate was snoring and added to her frustration; she said it was overwhelming to deal with the pain and lack of sleep. In an interview on 05/18/23 at 5:05 pm with DON and ADON 2, ADON 2 she said Resident #1 was a drug addict, and she had failed the screening for a pain pump. The DON and ADON 2 said Resident #1 should have hit her call light and Resident #1 could have called or texted them to get her medicine. In an interview on 05/18/23 at 7:15 pm with LVN C she stated that if the CMA had told her a resident refused medications she would have spoken to the resident, if the resident still refused she would document it in the MAR. She said on 05/12/23 CMA B left at 10:00 pm and the medication delivery came around midnight. She said there were a handful of medication in the corner of the drawer when CMA B left if she recalled correctly . She did not now if the left over meds belonged to Resident #1 and they were in the cart when she signed off the cart in the morning. In an interview on 05/19/23 at 10:13 am the DON stated that the expectation was that the CMA notify the nurse if a medication was refused and the nurse would offer or document. She said without the correct documentation that residents could end up not getting the correct amount of medicine which would harm them. She said she and ADON 1 and ADON 2 run a report to look for blanks in the MAR and address these blanks. She stated the report was supposed to be run daily, but she had not run it this week. She said she did not know why it did not get done. She stated missing medication could harm residents. She was not sure how these were missed and she was not sure why parameters were missing from several orders for blood pressure. She said she would get back to me and left the room. In an interview on 05/19/23 at 11:00 am with Resident #1 she stated she was in about a 3 of 10 pain level and that was comfortable for her [her pain was under control]. In an interview on 05/19/23 at 11:52 am with CMA B she stated she couldn't find Resident #1 on 05/12/23 to give her the medicine she was supposed to administer and when she finally saw the resident around 9:30 pm the resident refused her medication. She said she did not inform anyone working that night;. sShe stated she had the phone number for the DON but did not inform her of the refusal either. She confirmed she should have informed the nurse but forgot and forgot to chart the refusal. Record review of the Medication Admin Audit Report run on 05/17/23 at 4:52 pm for residents who had a blank for medication administration between 05/11/23 - 05/13/23 revealed the following medications were missed in addition to Resident #1 listed above: Resident #7, Center 3 unit, 05/11/23 8:00 pm, melatonin 5 mg Resident #14, Secure unit, 05/13/23 1:00 pm, Depakote sprinkles 125 mg Resident #20, Secure unit, 05/13/23 8:00 am, metoprolol 12.5 mg Resident #22, Center 3 unit, 05/11/23 8:00 pm, Aricept 10 mg, melatonin 5 mg, Xanax .5 mg, trazadone 50 mg, dicyclomine 10 mg Resident #23, Center 3 unit, 05/11/23 8:00 pm, Humalog sliding scale (no blood sugar done) Resident #25, Center 3 unit, 05/11/23 8:00 pm, Novalog sliding scale (no blood sugar done), lantus 30 units 05/12/23 8:00 pm, Novalog sliding scale (no blood sugar done), lantus 30 units Resident #28, Center 3 unit, 05/11/23 8:00 pm, melatonin 5 mg, risperidone 1 mg Resident #29, Center 1 unit, 05/12/23 4:00 pm, combigan ophthalmic solution 1 drop in both eyes, methocarbamol 500 mg 05/12/23 8:00 pm, senna 8.6 mg, latanoprost ophthalmic solution 1 drop in both eyes Resident #31, Center 1 unit, 05/12/23 6:30 am, pantoprazole 40 mg 05/12/23 8:00 am, benztropine .5 mg, baclofen 10 mg, coreg 25 mg, sertraline 100 mg, amlodipine 10 mg, Depakote Sprinkles 500 mg, Vistaril 25 mg 05/12/23 1:00 pm, Vistaril 25 mg Resident #33, Center 1 unit, 05/11/23 8:00 pm, atorvastatin 80 mg, hydromorphone 2 mg, Flomax .4 mg, trazadone 150 mg, novolog sliding scale, Gabapentin 600 mg, lantus 15 units, docusate 100 mg Resident #38, Center 3 unit, 05/13/23 8:00 am, Zyprexa 10 mg Resident #46, Secure unit, 05/13/23 1:00 pm, Depakote sprinkles 125 mg, med pass 2.0 Resident #47, Secure unit, 05/13/23 1:00 pm, lorazepam 1 mg, sodium chloride 1 g Resident #62, Center 1 unit, 05/12/23 7:00 pm, metaxalone 400 mg 05/12/23 8:00 pm, trazadone 50 mg, Aricept 5 mg Resident #64, Center 1 unit, 05/12/23 5:00 am, levothyroxine 05/11/23 4:00 pm, gabapentin 100 mg, risperidone 1 mg, benztropine .5 mg Resident #65, Center 3 unit, 05/11/23 8:00 pm, Advair diskus 1 puff Resident #70, Center 3 unit, 05/11/23 8:00 pm, lantus 15 units, Humalog sliding scale 05/13/23 8:00 am, amlodipine 5 mg Record review of all active orders printed 05/22/23 at 3:58 pm revealed the following orders: Resident #7 had an order Melatonin Tablet 5 MG Give 1 tablet by mouth at bedtime related to INSOMNIA Resident #14 had an order for Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) Give 1 capsule by mouth three times a day related to SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE Resident #20 had an order for Metoprolol Tartrate Oral Tablet 25 MG (Metoprolol Tartrate) Give 0.5 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold if HR <60 or bp <120/60. Resident #22 had the following orders: Aricept Oral Tablet 10 MG (Donepezil Hydrochloride) Give 1 tablet by mouth at bedtime for DEMENTIA; Xanax Oral Tablet 0.5 MG (Alprazolam) Give 1 tablet by mouth at bedtime for anxiety; Melatonin Oral Tablet 5 MG (Melatonin) Give 5 mg by mouth at bedtime for insomnia; traZODone HCl Oral Tablet 50 MG (Trazodone HCl) Give 1 tablet by mouth at bedtime related to MAJOR DEPRESSIVE DISORDER; and Dicyclomine HCl Capsule 10 MG Give 1 capsule by mouth at bedtime for IBS; Resident #23 had an order for tor HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale subcutaneously before meals and at bedtime related to TYPE 2 DIABETES Resident #25 had an order for NovoLOG Injection Solution (Insulin Aspart) Inject as per sliding scale, subcutaneously at bedtime related to TYPE 2 DIABETES MELLITUS; and an order for Lantus Solution 100 UNIT/ML (Insulin Glargine) Inject 30 unit subcutaneously at bedtime related to TYPE 2 DIABETES MELLITUS Resident #28 had an order for Melatonin Tablet 5 MG Give 1 tablet by mouth at bedtime for insomnia; and RisperiDONE Tablet 1 MG Give 1 tablet by mouth at bedtime related to SCHIZOAFFECTIVE DISORDER Resident #29 had an order for Combigan Ophthalmic Solution 0.2-0.5 % (Brimonidine Tartrate-Timolol Maleate) Instill 1 drop in both eyes two times a day related to UNSPECIFIED GLAUCOMA; Methocarbamol Oral Tablet 500 MG (Methocarbamol) Give 1 tablet by mouth two times a day related to UNSPECIFIED OSTEOARTHRITIS; Senna Oral Tablet 8.6 MG (Sennosides) Give 1 tablet by mouth at bedtime for constipation; and Latanoprost Ophthalmic Solution 0.005 % (Latanoprost) Instill 1 drop in both eyes at bedtime for GLACOMA. Resident #31 had an order for Pantoprazole Sodium Oral Tablet Delayed Release 40 MG (Pantoprazole Sodium) Give 40 mg by mouth in the morning related to GASTROESOPHAGEAL REFLUX DISEASE; Benztropine Mesylate Oral Tablet 1 MG (Benztropine Mesylate) Give 0.5 tablet by mouth two times a day for EPS; Baclofen Oral Tablet 10 MG (Baclofen) Give 10 mg by mouth two times a day for muscle spasms; Coreg Oral Tablet 25 MG (Carvedilol) Give 25 mg by mouth two times a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold for BP under 100/60 or HR under 60; Sertraline HCl Oral Tablet 100 MG (Sertraline HCl) Give 100 mg by mouth one time a day for Depression; amLODIPine Besylate Oral Tablet 10 MG (Amlodipine Besylate) Give 10 mg by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold for BP less than 100/60, HR less than 60; Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) Give 4 capsule by mouth two times a day related to GENERALIZED ANXIETY DISORDER; and Vistaril Oral Capsule 25 MG (Hydroxyzine Pamoate) Give 1 capsule by mouth three times a day related to GENERALIZED ANXIETY DISORDER. Resident #33 had an order for Atorvastatin Calcium Tablet 80 MG Give 1 tablet by mouth at bedtime for HLD; HYDROmorphone HCl Tablet 2 MG Give 1 tablet by mouth every 4 hours related to ACQUIRED ABSENCE OF RIGHT LEG BELOW KNEE; Flomax Capsule 0.4 MG (Tamsulosin HCl) Give 1 capsule by mouth at bedtime for benign prostatic hyperplasia; traZODone HCl Oral Tablet 50 MG (Trazodone HCl) Give 1 tablet by mouth at bedtime related to INSOMNIA, UNSPECIFIED (G47.00) administer with 100mg tablet = 150mg; traZODone HCl Tablet 100 MG Give 1 tablet by mouth at bedtime for Insomnia related to INSOMNIA, UNSPECIFIED (G47.00) administer with 50mg tablet = 150mg; NovoLOG Injection Solution 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale, subcutaneously before meals and at bedtime related to TYPE 1 DIABETES; Gabapentin Oral Tablet 600 MG (Gabapentin) Give 1 capsule by mouth every 4 hours for diabetic nerve pain; Lantus SoloStar Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 15 unit subcutaneously at bedtime for diabetes; and Docusate Sodium Capsule 100 MG Give 1 capsule by mouth at bedtime for constipation Resident #38 had an order for ZyPREXA Tablet 10 MG (OLANZapine) Give 1 tablet by mouth two times a day for Agitation related to SCHIZOPHRENIA Resident #46 had an order for Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) Give 1 capsule by mouth three times a day related to ANXIETY DISORDER; and Med Pass 2.0 three times a day for 80cc offer snacks with med pass Resident #47 had an order for LORazepam Tablet 1 MG Give 1 mg by mouth three times a day for ANXIETY DISORDER; and Sodium Chloride Tablet 1 GM Give 1 tablet by mouth three times a day for HYPONATREMIA. Resident #62 had an order for Metaxalone Tablet 400 MG Give 1 tablet by mouth at bedtime for muscle spasm; TraZODone HCl Tablet 50 MG Give 1 tablet by mouth at bedtime for Inability to Sleep related to INSOMNIA; and Aricept Tablet 5 MG (Donepezil HCl) Give 1 tablet by mouth at bedtime for dementia. Resident #64 had an order for Levothyroxine Sodium Tablet 125 MCG Give 1 tablet by mouth in the morning for low thyroid hormone related to HYPOTHYROIDISM, UNSPECIFIED (E03.9) pt requests med be given at 0730; Gabapentin Oral Capsule 100 MG (Gabapentin) Give 1 capsule by mouth two times a day for pain; RisperDAL Oral Tablet 2 MG (Risperidone) Give 1 tablet by mouth two times a day related to PARANOID SCHIZOPHRENIA; and Benztropine Mesylate Oral Tablet 0.5 MG (Benztropine Mesylate) Give 1 tablet by mouth two times a day for . Resident #65 had an order for Advair Diskus Aerosol Powder Breath Activated 250-50 MCG/DOSE (Fluticasone-Salmeterol) 1 puff inhale orally two times a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE. Resident #70 had an order for Lantus 100 UNIT/ML Solution Inject 15 unit subcutaneously at bedtime related to DIABETES; HumaLOG Injection Solution 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale, subcutaneously before meals and at bedtime related to DIABETES MELLITUS, and amLODIPine Besylate Tablet 5 MG Give 1 tablet by mouth one time a day related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) Hold if HR less than 60 or SBP less than 100. Record review of the MAR for the month of April 2023 revealed every resident in the facility had medications that were not administered, with a total of 1239 omissions on the secured unit (Residents #8, #44, #27, #54, #4, #72, #42, #47, #45, #16, #60, #14, #61, #59, #46, and #30) and 255 omissions (Residents #56, #37, #12, #15, #25, #22, #70, #41, #50, #1, #22, #11, and #6) for the center unit. These counts reflected only medication administrations and did not include other orders that were not completed. Record review of the MAR for the month of May (05/01/23 - 05/19/23) revealed 55 omitted medication administrations on the secure unit and 419 omitted medication administration on the center unit. #2 The facility failed to adhere to the parameters of medication administration as written by the provider(s). Record Review of Resident #1's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, heart failure, pulmonary disease (lung disease), and cerebrovascular (blood flow in brain) disease. Record review of Resident #1's 03/03/23 MDS dated revealed a BIMSs of 15, which indicated the resident was cognitively intact. Record review of Resident #1's May 23 MAR revealed on 05/04/23 8:00 pm her Coreg 50 mg (hold for BP less than 100/60 or heart rate less than 60) was held when her blood pressure was 124/60 and heart rate was 76. On 05/03/23 7:00 am her blood pressure was 177/77 and her Cozar 100 mg (hold if blood pressure is under 100 and call MD if over 170) but there was no documentation that the physician was not notified of her 177 systolic blood pressure. In an interview on 05/18/23 at 5:08 pm with ADON 2 she stated that if a physician was notified of anything there should be a progress note on the date and time the notification was made. In addition, she said it should be on the 24-hour report. She denied any notifications of blood pressure out of range being on the 24-hour report in May. Record Review of Resident #15's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, depression, anxiety, and schizoaffective disorder. Record review of Resident #15's 05/08/23 MDS revealed a BIMSs of 13, which indicated the resident was cognitively intact. Record review of Resident #15's May 23 MAR revealed on 05/07/23 at 8:00 am her BP was 174/96 and her metoprolol 50 mg ER (hold for BP under 100 and notify MD if over 170) was administered and MD was not notified;. oOn 05/17/23 at 8:00 am her BP was 175/89 and her metoprolol was administered, and the MD was not notified. Record Review of Resident #12's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, lung disease, and low thyroid. Record review of Resident #12's 03/24/23 MDS revealed a BIMSs of 15, which indicated the resident was cognitively intact. Record review of Resident #12's May 23 MAR revealed on 05/01/23 at 8:00 am her BP was 107/42 and heart rate was 79, and her metoprolol 50 mg was administered. On 05/02/23 at 8:00 am her BP was 110/53 and heart rate was 80 and her metoprolol was administered. The medication required measuring BP and heart rate but had no hold parameters. On 05/02/23 at 8:00 am her BP was 110/53 and HR was 80 and her lisinopril 20 mg (hold if BP less than 100/60) was administered by CMA B. Record Review of Resident #9's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including diabetes, cerebral infarction (stroke), and hyperlipidemia (high cholesterol). Record review of Resident #9's 03/15/23 MDS revealed a BIMSs of 6, which indicated severely impaired cognition. Record review of Resident #9's May 23 MAR revealed on 05/05/23 at 8:00 am his BP was 106/68 and his lisinopril 20 mg (hold if BP is less than 100/60) was marked as held by CMA B per parameters but the parameters were safe to administer his medication. Record Review of Resident #25's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, pulmonary disease, Alzheimer's, and bipolar disorder. Record review of Resident #25's 05/08/23 MDS revealed a BIMSs of 2, which indicated a severely impaired cognitive function. Record review of Resident #25's May 23 MAR revealed the following orders: Humalog sliding scale before meals and bedtime Humalog inject 8 units before meals (no parameters) Lantus inject 32 units one time per day (7:00 am, no parameters) Lantus inject 30 units at bedtime (no parameters) On 05/13/23 at 8:00 pm her Lantus 30 units at bedtime was held with a note BS=199 by LVN J. On 05/03/23 at 7:00 am her lantus 32 units was held with a note glucose 111 held by LVN G. On 05/03/23 at 7:00 am her Humalog 8 units was held with a note 111 by LVN G. On 05/04/23 at 7:00 am her Lantus 32 units was held with a note 107 by LVN G. On 05/04/23 at 7:00 am her Humalog 8 units was held with a note 107 by LVN G . Record Review of Resident #56's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including metabolic encephalopathy (mental confusion), and hypertension (high BP) . Record review of Resident #56's 05/10/23 MDS revealed a BIMSs of 0, indicating the resident was not able to complete the test. Resident review of Resident #56's May 23 MAR revealed an order for metoprolol 25 mg give 1 tablet via PEG-tube two times a day related to essential (primary) hypertension, hold if SBP under 100, DBP under 60 or HR under 55; there are no blood pressures or heartrates associated with administration and no boxes to enter the information. Record Review of Resident #47's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including atherosclerosis (blocked vessels), depression, and anxiety. Record review of Resident #47's 03/01/23 MDS dated [DATE] revealed it had a blank for the BIMSs score. Record review of Resident #47's May 23 MAR revealed an order for lisinopril 5 mg (hold if BP less than 100/60), and on 05/04/23 at 8:00 am her BP was 96/50 and her lisinopril was administered by LVN N. Record Review of Resident #54's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, Alzheimer's disease, and hypertension. Record review of Resident #54's 04/21/23 MDS dated revealed a blank for the BIMSs score. Record review of Resident #54's May 23 MAR revealed an order for a Lidoderm 5% patch, apply to neck topically; apply for 12 hours in a 24 hour period; the record showed the patch was applied at 8:00 am daily and removed the following day at 7:59 am, then a new patch was applied at 8:00 am . The patch was documented as applied on the following dates: 5/1, 5/2, 5/3, 5/4, 5/8, 5/9, 5/10, 5/11, 5/12, 5/13, 5/14, 5/15, 5/16, 5/17, 5/18 and 5/19 at 8:00 am. The patch was documented as removed at 7:59 am on the following dates: 5/1, 5/2, 5/3, 5/4, 5/8, 5/9, 5/10, 5/11, 5/12, 5/13, 5/14, 5/15, 5/16, 5/17, 5/18 and 5/19. In an interview on 05/23/23 at 1:30 pm with DON and NP E, NP E stated that the order said the patch should be applied for 12 hours out of 24 hours. DON stated that is not what was being done, the patch was applied in the morning and left in place until the next morning. She stated the instructions for the removal of the patch would be updated. Record Review of Resident #45's face sheet dated 05/22/23 revealed an [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, depression, and anxiety. Record review of Resident #45's 05/03/23 MDS dated revealed a BIMSs of 15, which indicated the resident was cognitively intact. Record review of Resident #45's May 23 MAR revealed an order for amlodipine 5 mg with no parameters, on 05/09/23 at 8:00 am her BP was 116/59 and it was marked as held per parameters; on 05/10/23 at 8:00 am her BP was 116/59 and her medicine was administered. In an interview on 05/18/23 at 9:55 am with the Medical Director, he stated that administering BP medications when the resident's blood pressure is below the threshold could cause serious injuries such as heart attack and stroke and could also lead to death. #3 The facility failed to administer medications in a timely manner, within an hour of the scheduled administration time, and before meals as prescribed Record Review of Resident #33's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including diabetes, pulmonary disease, and cerebral infarction. In an observation on 05/18/23 at 1:27 pm CMA A administered the following to Resident #33 creon, pancrealipase, 1 capsule, scheduled at 1:00 pm; hydromorphone, 2 mg, pulled from secure drawer, documented in log, scheduled at 12:00 pm, so administered an hour and a half late, and gabapentin, 600 mg, it was in a baggie, then a blister pack by itself, it was scheduled for 12:00 pm, so it was an hour and a half late, and the order was written as administer every 4 hours. Record review of the Medication Admin Audit Report run on 05/17/23 for Resident #33 revealed on 05/13/23 his novolog sliding scale insulin (ordered before meals and bedtime) scheduled at 7:30 am was administered at 8:39 am; his 11:30 am dose pre-lunch dose on the same day was administered at 2:50 pm. On 05/14/23 his 7:30 am pre-breakfast does was administered at 8:40 am. On 05/01/23 his 8:00 am medications (Plavix 75 mg, pancrelipase 6000 units, rivaroxaban 20 mg) were all administered at 1:10 pm . His 05/02/23 4:30 pm pre-dinner dose was scheduled at 4:30 pm and administered at 5:43 pm; his bedtime dose on 05/07/23 was scheduled for 8:00 pm and was administered at 11:02 pm and the next night (05/08/23) it was administered at 11:06 pm. A record review of the undated facility dining times revealed that breakfast was at 8:00 am, lunch was at 12:00 pm, and dinner was at 5:00 pm. Record review of Resident #33's hospital records obtained 05/22/23 revealed he was admitted to the emergency room [DATE] at 6:53 am. It further revealed that paramedics administered glucose prior to his arrival at the hospital because his blood sugar was 36. #4 The facility failed to ensure the administration of levothyroxine on 05/21/23 at 5:00 am for 3 of 3 (Resident #1, Resident #50, and Resident #68) Record Review of Resident #1's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, heart failure, pulmonary disease, and cerebrovascular disease. Record review of the progress notes for Resident #1 printed 05/22/23 written by ADON 1 revealed a note dated 05/21/23 at 1:35 pm indicated Resident stated she did not receive her 0500 Levothyroxine. Pharmacy was contacted and it was confirmed that the Levothyroxine was delivered this AM around 0130 and signed by LVN D. Levothyroxine was signed off in the MAR as been being administrated Record Review of Resident #68's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including osteomyelitis (infection in the bone) of the left ankle and foot, hypothyroidism, bipolar disorder, and depression. Record review of Resident #68's progress notes, printed on 05/22/23 revealed a note dated 05/21/23 1:44 pm by ADON 1 indicated the Resident stated that he did not receive his Levothyroxine this AM at 0500. Remedi Pharmacy was contacted and it was confirmed that the Levothyroxine was delivered this AM around 0130 and signed by LVN D. Levothyroxine was signed off in the MAR as been being administrated by LVN D. Record Review of Resident #50's face sheet dated 05/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses including diabetes, renal disease, and pulmonary disease. Record review of Resident #50's MDS dated [DATE] revealed a BIMS of 14 which indicated she was cognitively intact. Record review of the progress notes printed on 05/22/23 for Resident #50 revealed a note dated 05/21/23 at 4:59 pm by ADON 2 indicated the Resident reported that she did not get her am synthroid this morning., She was informed her that a an investigation would be made and cameras pulled to verify if medication was administered. About 10 minutes later resident returned with synthroid in her hand and stated, LVN D never misses my medication she must have given it to me and I was still asleep. Provided resident with water and resident took synthroid at this time. Record review of the progress notes printed on 05/22/23 for Resident # 50 revealed a progress note dated 05/21/23 at 1:43 pm by ADON 1 indicated Resident stated that she did not receive her Levothyroxine this AM at 0500. Remedi Pharmacy was contacted and it was confirmed that the Levothyroxine was delivered this AM around 0130 and signed by LVN D. Levothyroxine was signed off in the MAR as been administrated by LVN D. #5 The facility failed[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents for 2 (secure hall and 200 hall) of 2 halls observed for insects. The facility failed to ensure the facility was free from deceased and living insects on the 200 hall and the secure hall. This failure placed all residents at risk of not living in a safe, clean and home-like environment. The findings included: In an observation on 05/17/23 beginning at 3:52 pm on the secure unit revealed in the hall by the exit door was noted to have a deceased insect body on the wall. In an observation on 05/22/23 at 10:20 am on the secure unit the same issues observed on 05/17/23 at 3:52 pm were still present; the secure unit the wall in the hall by the exit door was noted to have a deceased insect body on the wall. In an interview on 05/18/23 at 1:25 pm with CMA A she stated she was aware of roaches in Resident #33's room. Record Review of Resident #33's face sheet dated 05/22/23 revealed a [AGE] year-old male admitted on [DATE] with diagnoses including diabetes, pulmonary disease, and cerebral infarction (stroke). Record review of Resident #33's 02/10/23 MDS revealed a BIMs of 13, which indicated he is cognitively intact. In an observation and interview on 05/20/23 at 4:00 pm with Resident #33 he stated that he saw roaches all of the time on the walls and they are all over the place. A small dead roach was observed by Resident #33's bed and another small dead roach was observed on the roommate's side of the room. In addition, several small gnats were observed. In an interview on 05/20/23 at 12:30 pm MAINT I stated if water bugs are found they are usually dead, but sometimes new residents move in and report seeing roaches. When reports are made, the rooms are inspected to find trash or food that may be the cause of the issues. Pest control was an ongoing monthly service contract to resolve issues . In an interview on 05/20/23 at 12:30 pm MAINT I stated if water bugs are found they are usually dead, but sometimes new residents move in and report seeing roaches. When reports are made, the rooms are inspected to find trash or food that may be the cause of the issues. Pest control was an ongoing monthly service contract to resolve issues In an interview with a confidential visitor to the facility, the visitor stated living insects were present, roaches and gnats and that staff were informed and aware (unknown name of staff). In an observation on 05/22/23 at 6:00 pm a small living cockroach was seen running across the floor in Resident #33's room and under his chest of drawers. Record review of the pest control monthly receipt dated 04/26/23 revealed the provider treated room and hallway for scorpions and roaches and bathroom. This was in addition to the monthly visit dated 04/02/23. Record review of the undated facility policy titled Pest Control Policy stated .ensure that the building is kept free of insects . Record review of an undated facility policy on Resident Rights stated that residents have a right to safe, decent, and clean conditions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate PASARR for 1 of 2 residents (Residents #37) reviewed for PASARR Level 1 screenings. The facility did not send the correct PASARR Level 1 screening to the local authority for Residents #37. This failure could affect residents with mental illness placing them at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings included: Resident #37 Record review of a Face Sheet dated 03/01/23 for Resident #37 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included alcohol abuse with alcohol induced psychotic disorder with hallucinations (a set of psychiatric symptoms that may include hallucinations, delusions, alcoholic paranoia, and generally losing touch with reality), chronic kidney disease stage 3 (gradual loss of kidney function), atrial fibrillation (an abnormal heart rhythm characterized by rapid and irregular beating of the atrial chambers of the heart), and major depressive disorder (a mental disorder characterized by at least 2 weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). Record review of Resident #37's diagnosis report revealed that she was diagnosed with alcohol abuse with alcohol induced psychotic disorder hallucinations on 04/07/22. Record review of Resident #37's Quarterly MDS dated [DATE] revealed a BIMS score of 14 which indicated a cognition level that was intact in section C. Record review of Resident 37's care plan dated 03/01/2023 revealed a focus that Resident #37 required psychotropic drugs r/t to: Depression., psychiatric diagnoses of: (Schizophrenia, Bi-Polar Disorder, Psychosis, etc.) with a goal to have the smallest, most effective dose without side effects through review date. Interventions in place to administer medications as ordered, monitor side effects and report, dose reduction as needed, and psych consult as needed. Record review of Resident #37's PASARR Level 1 Screening dated 08/04/22 indicated resident did not have a Mental Illness, Intellectual Disability, or Developmental Disability in section C. In an interview on 03/02/2023 at 2:43 PM with the ADM, he stated PASARR screenings were usually done prior to a resident admitting to the facility. He stated the MDS Coordinator and Social Worker were responsible for completing PASARR screenings if the PASARR was not done prior to admission, and he believed they should had been formerly trained on PASARR completion. He stated the MDS Coordinator, and the Social Worker were responsible for ensuring the PASARR was completed accurately. He stated if a resident had a diagnosis of a psychological disorder, it should be noted on the PASARR. He stated the PASARR completed on 08/04/22 for Resident # 37 was completed inaccurately. He stated an inaccurate PASARR could result in a resident not receiving services they may need or improper placement of a resident. In an interview on 03/02/2023 at 2:48 PM with MDS coordinator, she stated residents usually come to the facility with a PASARR already complete. She stated if a resident comes from home she usually gets with the resident and family and completes the PASARR herself. She stated the only way a resident would not have had a psychological diagnosis notated on their PASARR would be if the resident had a main diagnosis of Dementia. She stated Resident # 37's PASARR was completed inaccurately, and she felt like the diagnosis of alcohol abuse with alcohol induced psychotic disorder hallucinations was put in Resident # 37's chart inaccurately. She stated if a PASARR was completed inaccurately it could cause a resident to go without desired services that could be offered, or they could not receive the care they needed. She stated she was not sure who entered Resident #37's Diagnoses into the electronic records. In an interview on 03/02/2023 at 2:56 PM with the DON, she stated PASARR screenings should be done prior to admission of a resident. She stated the Social Worker or MDS Coordinator were responsible for completing PASARR screenings if the resident admits without one. She stated she believed the MDS Coordinator was responsible for ensuring the accuracy of PASARR screenings. She stated she thought the diagnosis of alcohol abuse with alcohol induced psychotic disorder hallucinations should have been notated on Resident # 37's PASARR screening. She stated the PASARR screening for Resident # 37 was completed inaccurately. She stated when a PASARR screening was not completed accurately a resident may not receive services that could be offered to them. In an interview on 03/02/2023 at 3:16 PM with the ADON, she stated she does not know much about PASARR screening and how they were done or who does them. She stated she input residents diagnoses in the electronic records when a resident admitted , and she put the diagnosis for alcohol abuse with alcohol induced psychotic disorder hallucinations in Resident #37's electronic record when Resident #37 admitted . She stated she had gotten the diagnoses off of resident #37's admission paperwork the day of admission. She stated she does not know where the diagnosis of alcohol abuse with alcohol induced psychotic disorder hallucinations came from, but that it was possibly added by error. Record review of the policy entitled admission Criteria, dated March 2019 read in part, 9. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a. The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source to determine if the individual meets the criteria for a MD, ID or RD. b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. (1) the admitting nurse notifies the social services department when a resident I identified as having a possible (or evident) MD, ID, o RD. (2) the social worker is responsible for making referrals to the appropriate state-designated authority.) c. Upon completion of the level II evaluation, the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate. d. the state PASARR representative provides a copy of the report to the facility.

Based on interview, observation, and record review the facility failed to assure that menus were developed and prepared to meet resident choices including their nutritional, religious, cultural, and ethnic needs while using established national guidelines for 4 of 8 residents reviewed for specialty diets. - [NAME] A was not following menu and recipes for specialty diets. This failure could prevent 70 residents from receiving their recommended daily nutritional intake. Findings included: In observation on 2/28/23 at 9:50AM, CookA was pouring reduced fat milk from a gallon bottle with best by date of 2/25/23 into a puree cake recipe. In an observation on 2/28/23 from 12:07pm-12:43pm [NAME] A was seen serving puree submarinesandwich meat and cheese with a blue #12 serving spoon (2oz.) until Dietary Manager switched spoon with a white #10 serving spoon (3.2oz). In an interview on 2/28/23 at 12:06PM, the Dietary Manager said the serving spoons were color coded to ensure the residents were receiving the correct amount of food to meet their nutritional needs. In an interview on 3/2/23 at1:53PM, the Dietician said using a smaller serving spoon could cause weight loss and not using the whole milk could prevent weight gain. The Dietician said not following the menu by leaving something out could reduce caloric intake and lead to weight loss. In an interview on 3/2/23 at 1:34PM, the ADON said Dietary Manager was aware of changes such as whole milk being ordered as she was in these meetings and was responsible for updating her dietary system with these changes. Record review of Pureed Sandwich Submarine dated 4/13/22 revealed for Portion: a #10 scoop of puree sandwich filling and 2 #20 scoops of puree bread. Record review of Pureed Peanut butter crumble cake did not indicate which type of milk to use.

FACILITY Medication Storage and Labeling Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. The facility failed to provide a system of medication records that enables periodic accurate reconciliation and accounting for all controlled medications for 2 of 2 medication carts that were reviewed for pharmacy services. This failure could place the residents at risk for not receiving the therapeutic effects from controlled narcotics due to from controlled narcotics did not reconcile every shift. The findings included: During an observation and record review on 3/1/23 at 12:00 p.m., an inspection of the medication cart #1 on Center Hall, revealed a form titled, Controlled Drugs-Count Record (Narcotic count sheet at each change of nursing shift), with missing signatures for the following dates: 2/1/23, 2/7/23 - 2/12/23, 2/16/23, 2/19/23-2/21/23, 2/25/23-2/26/23, and 2/29/23-2/28/23. During an observation and record review on 3/1/23 at 12:30 p.m., an inspection of the medication cart #2 on Center Hall, revealed a form titled, Controlled Drugs-Count Record (Narcotic count sheet at each change of nursing shift), with missing signatures for the following dates: 2/1/23, 2/2/23, 2/5/23, 2/7/23, 2/12/23, 2/18/23-2/20/23, and 2/24/23-2/26/23. During an interview on 3/1/23 at 12:30 p.m., MA A for cart #2 stated she has been aware of the missing signatures and stated that it can be a detriment to the residents by not having professional accountability for the narcotic count each shift. During an interview on 3/1/23 at 12:40 p.m., LVN A stated that it can be a detriment to the residents by not having professional accountability for the narcotic count each shift. During an interview on 3/1/23 12:35 p.m., the ADON stated she has acknowledged the noncompliance and stated that it is not in compliance can be a detriment to the residents. During an interview on 3/1/23 9:00 a.m., the Director of Nursing DON stated she has acknowledged the possible noncompliance and stated that if not in compliance that it can be a detriment to the residents. She has also stated, This is an issue and all the nurses have been consulted about signing the narcotic count sheet at the time of the count. Record review of the facility's policy titled, Controlled Substances, no date, revealed, .12. At the end of Each shift: a. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. b. Any discrepancies in the controlled substance count are documented and reported to the director of nursing services immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchens in the facility in that: 1. Food and beverages present in refrigerator, walk in cooler, freezer, and dry storage were not properly labeled with open date, use by date, and product description. 2. Food and beverages present in refrigerator, walk in cooler, freezer, and dry storage were not properly sealed. Food and beverages present in refrigerator, walk in cooler, freezer, and dry storage were not properly labeled with open date, use by date, and product description. 3. Food and beverages present in refrigerator, walk in cooler, freezer, and dry storage were not discarded by use by/expiration date. 4. One 1-gallon bottle of Reduced Fat Milk past the Best By date was being used by [NAME] A 5. 3 boxes of food inside walk in cooler that were labeled by manufacturer to keep frozen. 6. Food inside of freezer had freezer burn present. 7. 1 tray of baked chicken with internal temp of 100 degrees Fahrenheit was cooled improperly, prepared for dinner meal, and placed inside of refrigerator. 8. 1 box of meat was defrosting over a bowl of cut potatoes. 9. Temperatures of cold lunch were held and served at a temperature above 41 degrees Fahrenheit. This failure could place residents becoming ill from food contamination or bacterial growth. Findings included: In observation on 2/28/23 at 9:50AM, a gallon bag was in the refrigerator containing grated cheese with date 2/21 use by date 3/2, [NAME] with date 2/27/23, burritos dated 2/24, butter dated 2/24, without product description or use by date labeled. In observation on 2/28/23 at 9:50AM, a gallon bag was in the refrigerator labeled sausage dated 2/28/23 and use by date 2/29 was not properly sealed. In observation on 2/28/23 at 9:50AM, located in the refrigerator was an open container of labeled Hormel Thick and Easy clear thickened orange juice 46fl oz dated 2/6, ready care thickened apple juice dated 2/4, and thick and easy clear dated 12/6. In observation on 2/28/23 at 9:50AM, there was 6 individual serving sized covered containers with unknown substance inside that was located in refrigerator without a date or product label. In observation on 2/28/23 at 9:50AM, a metal container with plastic wrap cover was in the refrigerator labeled cherry salad and dated 1/19/23. In observation on 2/28/23 at 9:50AM, a 5-gallon bucket was located under the prep area labeled sugar dated 1/6/23, chicken base dated 1/15/23, rice dated 4/23, beef base dated 1/15/23, and flour dated 1/15, with lid sitting loosely on top and was not secured. In observation on 2/28/23 at 9:50AM, [NAME] A was pouring reduced fat milk from a gallon bottle with best by date of 2/25/23 into a puree cake recipe. In observation on 2/28/23 at 9:50AM, a baking pan with cooked chicken was seen sitting on top of oven with a temperature of 100 degrees Fahrenheit. In an interview on 2/28/23 at 10:02 AM the Dietary manager stated chicken sitting out on top of oven with temperature of 100 degrees Fahrenheit was not ok and needed to be thrown out. In an observation on 2/28/23 at 10:05AM, a box of frozen deli meat was seen on the top shelf of a rolling cart above a bowl with cut potatoes on the bottom shelf. In observation on 2/28/23 at 10:10AM, there was a 5-gallon plastic container located in walk in cooler labeled iced tea and dated 2/23/05 In observation on 2/28/23 at 10:12AM, there was sour cream packets with use by date of 2/27/23 located in walk in cooler. In observation on 2/28/23 at 10:15AM, there was a 5-gallon plastic container located in walk in cooler labeled iced tea and dated 2/23/05 In an observation on 2/28/23 at 10:15AM, there was an open bag of corn tortillas inside walk in cooler that was not properly sealed. In an observation on 2/28/23 at 10:15AM, there was 2 boxes of garlic Texas toast and 1 box of hoagie wheat rolls inside walk in cooler that were labeled by manufacturer to keep frozen. In an observation on 2/28/23 at 10:16AM, inside of the freezer, there was a box of popcorn shrimp filled with ice and inside the bag was shrimp covered with freezer burn. In an observation on 2/28/23 at 10:16AM, there was a box of deli sliced ham and turkey covered with freezer burn. In an observation on 2/28/23 at 10:17AM, there was a box of corn dogs with freezer burn not sealed inside of freezer. In an observation on 2/28/23 at 10:17AM, there was 1 banana cream pie inside freezer not sealed with freezer burn and open date written 1/15/23. In an observation on 2/28/23 at 10:17AM, there was abag of unknown food that was not in manufacturer package unlabeled and covered with freezer burn. In an observation on 2/28/23 at 10:20AM, there was a box of cookie dough not sealed inside of freezer. In an observation on 2/28/23 at 10:25AM, there was 1 box of cocktail sauce package with manufacturer expiration date of 1/26/23. In an observation on 2/28/23 at 10:25AM, there was 1 box of steak sauce package with manufacturer expiration date of 2/22/23. In an observation on 2/28/23 at 10:27AM, there was 1 bag of an unknown food without food description label with date: 10/28 and use by: 3/28. In an observation on 2/28/23 at 10:27AM, there were 3 bags of dry cereal without food description label. In an observation on 2/28/23 at 10:46AM, the chicken that Dietary Manager said needed to be thrown out was seen in a bowl inside of the refrigerator. In an interview on 2/28/23 at 10:46AM, theDietary Manager said I know the chicken needed to be thrown out and it will be thrown out later. In an observation on 2/28/23 at 10:47AM, the ice machine located outside of dining room area had buildup inside of white, brown, pink, and black substance in area where ice trays were located and black substance present on water source that felt ice trays. In an interview on 2/28/23 at 10:48AM, the Dietary Manager said she was responsible for making sure the outside of the machine was clean, but the inside of the ice machine was cleaned yearly by maintenance. She said the white, brown, pink, and black substance could contaminate ice and potentially make residents sick. In an observation on 2/28/23 at 12:05PM, the chicken that was 100 degrees Fahrenheit from 9:50AM and Dietary Manager said would be discarded at 10:46AM was untouched in the refrigerator. In an observation on 2/28/23 at 12:06PM, the cold lunch temperatures were all greater than 40 degrees Fahrenheit. The temperatures were: mustard potato salad 89 degrees Fahrenheit, mechanical soft subway sandwich meat and cheese was 41 degrees Fahrenheit, puree subway sandwich meat and cheese was 55 degrees Fahrenheit and without smooth texture, puree mustard potato salad was 81 degrees Fahrenheit, and pea salad that was not on the menu was 41 degrees Fahrenheit. In an interview on 2/28/23 at 12:06PM, the Dietary Manager said the cold lunch being served should be held and served at less than 41 degrees Fahrenheit. She said she saw what the temperature was on each item when she took the temperatures, and she didn't need it pointed out that all of the cold food was too hot to be served for safety reasons to residents. She said it was her responsibility to oversee everything that went on in the kitchen. She said she had a checklist of tasks for her to complete but could not produce this or kitchen policies. In an observation on 2/28/23 at 12:06PM, the Dietary Manager pulled the puree meat and cheese to reconstitute with reduced fat milk to make a smooth texture. In an observation on 2/28/23 at 12:07PM-12:43PM [NAME] A was seen serving puree subway sandwich meat and cheese with a blue #12 serving spoon (2oz.) until Dietary Manager switched spoon with a white #10 serving spoon (3.2oz) after 3 of 4 puree plates had been served. All plates were served without cooling the food down to less than 41 degrees Fahrenheit. Puree meals consisted of puree meat and cheese, puree mustard potato salad, puree peanut butter crumble cake, and without puree bread or puree replacement for lettuce, tomato, and pickles. Mechanical soft meals consisted of mechanical soft meat and cheese, a whole hoagie roll, mustard potato salad, pea salad, and peanut butter crumble cake. The regular diet plates consisted of a whole hoagie roll, 4 pieces of deli sliced ham, 1 piece of sliced cheese, a scoop of potato salad, a small unmeasured amount of chopped lettuce, 1 thin slice of a small tomato, crumble cake, and no pickles. In an interview on 3/1/23 at 1:08PM with Dietician, she said any item that was labeled with best by date meant it was best to be consumed by the date listed for better quality. She said there was no time frame for when that item should be thrown away but could become problematic for consumer if it were a milk-based product used after best by date. She said juice should be discarded after being open for 3 days and all cooked food should be discarded after 72 hours. She said all items should be properly sealed to prevent contaminants and bacteria growth. She said chicken should be cooled in the refrigerator and not at room temperature. She said any food cooled at room temperature could reach the danger zone of 45-135 degrees Fahrenheit, which could lead to bacteria growth and could cause consumer to become ill. She said food that was meant to be served cool should be maintained below 41 degrees Fahrenheit to prevent bacteria growth that could cause consumer to become ill. She said she provided an in-service to kitchen staff in November 2022, December 2022, and February 2023 regarding following the provided recipes and using a dense liquid for puree food. She said puree food should be smooth and without lumps. She said if puree food was not the correct consistency it could cause the consumer to choke. She said meat should not be stored over potatoes because drippings could cause bacteria growth and contamination could cause consumer to become ill.