Based on interview, record review, and facility policy review, the facility failed to ensure a baseline care plan was completed within 48 hours of admission for 1 (Resident #143) of 1 newly admitted resident reviewed. Findings included: A facility policy titled, Care Plans - Baseline, copyright 2001, indicated, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. An admission Record revealed the facility admitted Resident #143 on 07/11/2024. According to the admission Record, the resident had a medical history that included diagnoses of a left femur fracture, type two diabetes mellitus, and stage four chronic kidney disease. As of the time of the survey, Resident #143's admission Minimum Data Set (MDS) assessment was still In Progress. Resident #143's electronic health record (EHR), reviewed on 07/16/2024, revealed the resident's Baseline Care Plan had a status of Errors. The Baseline Care Plan, dated 07/11/2024, was incomplete with no signatures or date and no Lock Date. Resident #143's EHR indicated the resident's Baseline Care Plan was created by Licensed Practical Nurse (LPN) #3 and revised by the MDS Coordinator. During an interview on 07/17/2024 at 10:46 AM, LPN #3 stated she was not sure who was responsible for completing the baseline care plan for new admissions and did not know the time frame for completing the baseline care plan. LPN #3 stated Resident #143 was admitted the week prior, and she initiated the baseline care plan but did not complete it because she was waiting on the Assistant Director of Nursing (ADON) to verify a few things. During an interview on 07/17/2024 at 11:53 AM, the ADON stated the nurse working at the time of a resident's admission was responsible for initiating the baseline care plan, and each department completed their respective sections. The ADON further stated the baseline care plan was to be completed within 48 hours of admission, and the MDS Coordinator was responsible for locking a resident's baseline care plan once it was completed. The ADON stated when a baseline care plan indicated the status was Errors, it either meant the base line care plan was incomplete or it was not yet locked to indicate it was completed. During an interview on 07/17/2024 at 12:41 PM, the MDS Coordinator stated a resident's baseline care plan should be completed within 48 hours of admission, and he was responsible for ensuring they were complete. The MDS Coordinator stated he was behind on completing care plans and indicated the Director of Nursing (DON) was aware. During an interview on 07/17/2024 at 1:53 PM, the DON stated she expected baseline care plans to be completed. The DON stated the admitting nurse started the baseline care plan, and the MDS Coordinator completed it. During an interview on 07/17/2024 at 2:10 PM, the Administrator stated he did not know the required timeframe for baseline care plan completion but expected them to be completed on time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and facility policy review, the facility failed to develop a comprehensive care plan that addressed all triggered care areas from the Minimum Data Set (MDS) for 1 (Resident #4) of 13 sampled residents. Findings included: A facility policy titled, Care Plans, Comprehensive Person-Centered, revised in 03/2022, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. An admission Record revealed the facility admitted Resident #4 on 10/24/2023. According to the admission Record, the resident had a medical history that included diagnoses of major depressive disorder, protein-calorie malnutrition, hemiplegia affecting unspecified side, hypertension, overactive bladder, pain, and osteoarthritis. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/31/2023, revealed Resident # 4 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated the resident had severe cognitive impairment. The MDS indicated Resident #4 required supervision from staff for eating, was dependent on staff for oral hygiene, toileting, showering/bathing, putting on and taking off footwear, and personal hygiene, and required substantial maximal assistance from staff for upper and lower body dressing. The MDS also indicated Resident #4 was frequently incontinent of bladder and was at risk for developing pressure ulcers/injuries. The MDS also indicated Resident #4 received an antidepressant medication during the assessment look-back period. The MDS Care Area Assessment (CAA) Summary revealed the areas of cognitive loss/dementia, communication, urinary incontinence, psychosocial well-being, activities, falls, nutritional status, pressure ulcer, and psychotropic drug use had triggered and would be addressed in the care plan. Resident #4's care plan for their admission on [DATE] included Focus areas that indicated the resident would live at the facility long term, was dependent on staff for activities/recreation therapy, and had potential for nutritional problems. The areas of cognitive loss/dementia, communication, urinary incontinence, falls, pressure ulcer, and psychotropic drug use were not included on the care plan. During an interview on 07/15/2024 at 11:16 AM, Certified Nurse Assistant (CNA) #9 stated she reviewed care plans to know how to take care of the residents. During an interview on 07/17/2024 at 3:41 PM, the MDS Coordinator stated the admission MDS for Resident #4 indicated the areas would be care planned but they had not been care planned. During a follow-up interview on 07/17/2024 at 12:41 PM, the MDS Coordinator stated he was behind on care plans. During an interview on 07/17/2024 at 1:54 PM, the Director of Nursing (DON) stated she was aware of the issue with care plans not being done. The DON said care plans were very important, because they gave staff a sense of what to do for each resident. During an interview on 07/17/2024 at 2:10 PM, the Administrator stated he expected care plans to be completed timely.

2. An admission Record revealed the facility admitted Resident #23 on 10/06/2023. According to the admission Record, the resident had a medical history that included a diagnosis of generalized anxiety disorder. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/14/2024, revealed Resident #23 had a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident had severe cognitive impairment. The MDS also indicated the resident received antianxiety medication during the seven-day assessment look-back period. Resident #23's care plan included a Focus area, initiated on 01/16/2024, that indicated the resident used anti-anxiety medications related to anxiety. Resident #23's Order Summary Report, listing active orders as of 07/17/2024, contained an order started on 05/13/2024 for lorazepam oral concentrate (antianxiety medication) 2 milligrams per milliliter (mg/mL), give 0.5 mL by mouth every four hours as needed for agitation or restlessness related to generalized anxiety disorder. The order did not specify the duration of use or a stop date. The Scheduling Details for Resident #23's lorazepam oral concentrate 2 mg/mL revealed a start date of 05/13/2024 and an end date of Indefinite. Resident #23's Medication Administration Record (MAR) for the timeframe from 07/01/2024 through 07/17/2024 revealed staff had documented administration of the lorazepam once on 07/10/2024. During a telephone interview on 07/17/2024 at 12:15 PM, Pharmacist #5 stated they followed the Centers for Medicare and Medicaid (CMS) guidelines for extending PRN psychotropic use past the allotted 14 days with the physician's documented rationale on a form the facility used. Resident #23's Psychotropic Committee Medication Review form, dated 06/27/2024, for the resident's PRN lorazepam revealed the physician signed and dated the form on 07/09/2024 and agreed to continue the PRN medication; however, there was no documented rationale for extending the use beyond 14 days. Based on interview, record review, and facility document and policy review, the facility failed to ensure as-needed (PRN) orders for psychotropic medications specified the duration of use and the residents' records reflected documentation of the rationale for use beyond 14 days for 2 (Resident #11 and Resident #23) of 5 residents reviewed for unnecessary medications. Findings included: A facility policy titled, Psychotropic Medication Use, revised in July 2022, indicated, 12. Psychotropic medications are not prescribed or given on a PRN basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. a. PRN orders for psychotropic medications are limited to 14 days. (1) For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. 1. An admission Record revealed the facility admitted Resident #11 on 09/27/2022 and readmitted the resident on 06/26/2023. According to the admission Record, the resident had a medical history that included a diagnosis of Alzheimer's disease. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/23/2024, revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS also indicated the resident had active diagnoses of anxiety disorder and depression and had not received an anti-anxiety medication during the seven days prior to assessment. Resident #11's Order Summary Report, listing active orders as of 07/16/2024, contained an order started on 03/05/2024 for lorazepam intensol oral concentrate (antianxiety medication) 2 milligrams per milliliter (mg/mL), give 0.25 mL by mouth every four hours PRN for anxiety/agitation related to generalized anxiety disorder. The order did not specify the duration of use or a stop date. The Scheduling Details for Resident #11's lorazepam intensol oral concentrate 2 mg/mL revealed a start date of 03/05/2024 and an end date of Indefinite. Resident #11's Psychoactive Medication Therapy Informed Consent Form, dated 03/05/2024, indicated Ativan (lorazepam) was being used to treat agitation and anxiety with a proposed course of therapy as prolonged treatment/unknown. Resident #11's Medication Administration Record (MAR) for the timeframe from 07/01/2024 through 07/17/2024 revealed staff had documented the administration of the lorazepam once on 07/01/2024. During a telephone interview on 07/17/2024 at 12:15 PM, Pharmacist #5 stated they followed the Centers for Medicare and Medicaid (CMS) guidelines for extending PRN psychotropic use past the allotted 14 days with the physician's documented rationale on a form the facility used. Resident #11's Psychotropic Committee Medication Review form, dated 06/27/2024, for the resident's PRN Ativan revealed the physician signed and dated the form on 07/16/2024 and agreed to continue the PRN medication; however, there was no documented rationale for extending the use beyond 14 days. During an interview on 07/17/2024 at 11:54 AM, the Assistant Director of Nursing (ADON) stated the facility followed the physician's orders for PRN psychotropic medications and that PRN psychotropic medications should only be used 14 days, unless specified differently by the physician. During an interview on 07/17/2024 at 1:58 PM, the Director of Nursing (DON) stated the facility discussed PRN psychotropic use at their monthly psychotropic medication review meetings. The DON stated Pharmacist #5, the facility's physician, herself, and the ADON attended the meetings, discussed the medications, and made recommendations. The recommendations were then sent to the primary physician to agree or disagree. The DON stated the facility tried to limit PRN psychotropic use to 14 days per the guidelines, but the physicians did not like having to re-order a PRN medication every 14 days.

Based on observation, interview, and review of the United States Food and Drug Administration (FDA) 2022 Food Code, the facility failed to ensure staff wore hair restraints in the dietary department to prevent potential contamination of food and food preparation equipment. This had the potential to affect 42 of 42 residents who received meals from the dietary department. Findings included: The United States FDA 2022 Food Code, dated 01/18/2023, revealed, Chapter 2. Management and Personnel, section 2-4 Hygienic Practices, 2-402 Hair Restraints 2-402.11 Effectiveness specified, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that cover body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. During a tour of the kitchen on 07/15/2024 beginning at 9:08 AM, the Dietary Supervisor (DS) was observed not wearing a hairnet while working with food items. An observation on 07/15/2024 at 9:26 AM, revealed Certified Nurse Assistant (CNA) #11 walked into the kitchen area and did not don a hairnet. She walked past a food preparation area, dishwasher, and the three-compartment sink area. During an interview on 07/15/2024 at 9:28 AM, CNA #11 stated she just came to drop off a diet slip and did not know that she had to wear a hairnet. She said she thought she could enter the kitchen without a hairnet if she did not get close to the stoves. During an interview on 07/15/2024 at 9:34 AM, the DS stated she thought staff could enter the kitchen without a hairnet if they did not come close to the stove. During an interview on 07/17/2024 at 2:10 PM, the Administrator stated he expected staff to wear hairnets when in the food preparation area and when serving food.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined, the facility did not ensure prompt efforts were taken by the facility to resolve grievances the residents may have had. In addition, the facility did not maintain evidence demonstrating the results of all grievances for a period of no less than three years from the issuance of the grievance decision. Specifically, for 1 out of 27 sampled residents, the facility did not document the grievance of a resident who stated an item of her clothing went missing, and a prompt resolution to the grievance was not documented or followed up on by the facility. In addition, there were no grievances documented for the previous year. Resident identifier: 38. Findings included: Resident 38 was admitted on [DATE] with diagnoses that included chronic kidney disease, atherosclerotic heart disease, acute and chronic respiratory failure with hypoxia, hypertension, thrombocytopenia, dysphagia, spondylolysis, asthma, and pain. On 1/23/23 at 2:13 PM, an interview was conducted with resident 38. Resident 38 stated that shortly after she was admitted to the facility on e of her nightgowns went missing. Resident 38 stated she reported the item missing to the Resident Advocate (RA). Resident 38 stated she did not believe there was a name on the nightgown. A review of resident 38's inventory list that was completed on 12/31/22, included two nightgowns. No items were documented as items acquired after original entry. On 1/24/23 at 12:39 PM, an interview was conducted with the RA. The RA presented the grievance binder that had no grievances listed for the previous year. The grievance binder contained a blank grievance form. The RA stated grievances were resolved on the spot if possible. The RA stated if an item of clothing was missing she would look in the laundry, allow a whole cycle of laundry to be completed, and look in the lost and found. The RA stated if a grievance was unable to be resolved on the spot, there was a form that would be filled out, and placed in the grievance binder. The RA stated that when a resident was admitted , an inventory was taken of their personal items within the first 24 hours and placed in the resident's hard chart. The RA stated she did not know why a form was not filled out when resident 38's item was reported missing and was not found. On 1/24/23 at 12:39 PM, an interview was conducted with the Administrator (ADM). The ADM stated he was aware of resident 38's missing item of clothing. The ADM stated staff in the facility had canvassed the rooms several times. The ADM stated that he had not spoken to a family member yet about the item. The ADM stated he had offered to replace the missing item but resident 38 had not made a decision about doing that yet. The ADM stated that he would go and speak with resident 38 about the item. On 1/24/23 at 2:35 PM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated if she was told about a missing item, she would try to help the resident look for it. CNA 2 stated sometimes the missing clothing could still be in the laundry. CNA 2 stated if she was unable to find what was missing, she would report it to the Director of Nursing (DON) or the ADM. CNA 2 stated sometimes a flyer would be put up about the missing item, or it would be discussed in a meeting. CNA 2 stated there should be an inventory of what the resident brought into the facility. CNA 2 stated if something came in later, there should be a record of it. CNA 2 stated other ways of communicating missing items to staff would be at shift change report or it would be written down in the CNA book at the nurses station. CNA 2 stated if the items were not found, the DON or the ADM would know what to do about it. On 1/25/23 at 8:28 AM, an interview was conducted with the Housekeeper (HK). The HK stated sometimes clothing items do not have labels. The HK stated the resident's family was responsible to label clothing that came into the facility. The HK stated if a resident was missing an item of clothing they could look for the item in the lost and found area. The HK stated there was a form that should be filled out when things were missing so there would be documentation. The HK stated if the item was not found it was usually replaced. On 1/25/23 at 3:01 PM, an interview was conducted with the ADM and the RA. The ADM stated he tried to resolve grievances within two business days. The RA stated she had reached out to resident 38's son and he was not aware of the clothing item. The RA stated it was possible that resident 38's neighbor had brought the item in and resident 38's son was checking on that. The RA stated if the resident's family did not label clothing before items were brought in, the facility would label items and put them on the inventory. The RA stated she had completed training about how to handle grievances, and had in-serviced facility staff about grievances. The RA stated, there has been nobody that has wanted to fill out a grievance. A review of the facility policy, Grievances/Complaints, Filing last reviewed on April 2017, revealed in pertinent part: Policy Statement: Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman). The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. Policy interpretation and administration: (number 8) Upon receipt of a grievance and /or complaint, the grievance officer will review and investigate the allegation and submit a written report of such findings to the administrator within five (5) working days of receiving the grievance and/or complaint .(number 12) The resident, or person filing the grievance and/or complaint on behalf of the resident, will be informed (verbally and in writing) of the findings of the investigation and the actions that will be taken to correct any identified problems. (including) a. The administrator, or his or her designee, will make such reports orally within (no designation) working days of the filing of the grievance or complaint with the facility . b. A written summary of the investigation will also be provided to the resident, and a copy will be filed in the business office .(number 14) The results of all grievances files, investigated and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined, the facility did not ensure that each resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrably unavoidable. Specifically, for 1 out of 27 sampled residents, a resident with a hand contracture was not being provided the ordered device to hold in the contracted hand during the day for comfort and prevention. Resident identifier: 10. Findings included: Resident 10 was admitted to the facility initially on 6/5/15 and readmitted on [DATE] with diagnoses that included hemiplegia affecting right nondominant side, cerebrovascular disease, acute kidney failure, bipolar disorder, hypertension, major depressive disorder, history of pulmonary embolism, hypokalemia, and neuromuscular dysfunction of the bladder. On 1/24/23 at 9:58 AM, an interview was conducted with resident 10. Resident 10 was noted to have a contracture of the right hand such that her fingernails were not visible and the hand made a fist. Resident 10 was asked if she used a splint or other device to relieve the contracture to which she replied, I just don't have it. A physician's order dated 1/7/22, included cleanse right hand with ns [normal saline] between fingers and palm, dry thoroughly, dust with baby powder, and place a rolled up wash cloth in hand for comfort. The frequency included every day shift for prevention. A review of the Point of Care documentation revealed that, for the care area related to the restorative splint/brace program, each day was documented not applicable. On 1/24/23 at 1:59 PM, a request was made for any physical therapy notes for resident 10. The Minimum Data Set Coordinator revealed that resident 10 had not received any physical therapy in the past year. On 1/25/23 at 8:33 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1 who served as the CNA Coordinator. CNA 1 stated the facility did not currently have a restorative nursing program. CNA 1 stated that CNAs were helping with the duties of the restorative nursing aide. CNA 1 stated if a CNA noticed a need for a resident, they would suggest therapy or help from a restorative nursing aide. CNA 1 also stated that the physical therapist would sometimes recommend a resident have restorative therapy. CNA 1 stated when restorative therapy was recommended, the task was added in the Point of Care system. CNA 1 stated when not applicable was marked it meant that the task was not completed. CNA 1 also stated that it could also mean that the service was not offered that day. CNA 1 stated that for resident 10, she encouraged other CNAs to ensure the resident's hand was washed and to help with range of motion in that hand. CNA 1 stated if a splint or brace was being utilized, it would be charted. CNA 1 stated resident 10 did not have a brace, but did have a posy. CNA 1 stated staff offered it to the resident for a minimum of one hour per day. When shown resident 10's Point of Care for restorative splint/brace program, CNA 1 stated she needed to educate some of the CNAs about restorative stuff. CNA 1 stated the CNA's needed more training on the charting in Point of Care. On 1/25/23 at 9:30 AM, an interview and observation was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 was observed to be able to open resident 10's right hand enough to view the palm of the hand. The palm of resident 10's hand was pink, and the skin was intact. Resident 10's long fingernails were observed to be pushing into the palm of the hand. LPN 1 stated resident 10 needed her nails to be trimmed, and resident 10 stated she would like to have her nails trimmed. LPN 1 asked resident 10 why she did not have her gray thing in her hand. Resident 10 stated she did not know where it was. LPN 1 stated she would try to find it and looked in the drawers in resident 10's room but was unable to find it. LPN 1 stated there was a restorative nursing aide at the facility who weighed the residents and provided passive range of motion to those residents who needed it. Upon exiting resident 10's room, LPN 1 asked CNA 4 to obtain a washcloth to roll up and place in resident 10's hand. On 1/25/23 at 9:35 AM, CNA 4 notified LPN 1 that he had found the device for resident 10's hand and had placed it appropriately. On 1/25/23 at 3:08 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the CNAs were supposed to make sure the palm posy was in place for residents who used them. The DON stated the facility had to pull back on the restorative program because of short staffing. The DON stated the nurses on the unit should monitor the residents and do weekly skin assessments to ensure there was no skin breakdown.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record the review, it was determined, the facility did not ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 1 out of 27 sampled residents, a resident that had uncontrolled pain was not evaluated for increased pain medication needs by the Medical Director (MD). Resident identifier: 15. Findings included: Resident 15 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, encounter for palliative care, rheumatoid arthritis with rheumatoid factor, anxiety disorder, osteomyelitis, and major depressive disorder. On 1/24/23 at 9:21 AM, an interview was conducted with resident 15. Resident 15 stated that she had pain and she was starting to have some pain as we're speaking. Resident 15 stated that she was unsure when her last dose of pain medication was administered and if she was due for another pain medication she was going to request one. Resident 15's medical record was reviewed on 1/24/23. On 5/25/22, a Nursing Pain Interview was completed. The interview documented that resident 15 had frequent pain over the last five days that made it hard to sleep and had limited day to day activities. Pain intensity was documented as severe. The staff assessment for pain documented non-verbal sounds, vocal complaints of pain, and facial expressions. Resident 15 reported daily indicators of pain and a majority of pain was due to rheumatoid arthritis. [Note: No additional Nursing Pain Interviews were located.] A care plan Focus initiated on 5/25/22, documented Resident has Doctor orders for Hospice cares. A care plan Goal documented Resident will be kept comfortable. Resident will share feelings regarding end-of-life issues and diagnosis if able and as needed. The care plan Interventions included, but were not limited to, Nursing to keep resident comfortable and as pain free as medically possible. An admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 15 had a Brief Interview for Mental Status (BIMS) score of 11. A BIMS score of 8 to 12 indicates moderately impaired cognition. In addition, the MDS assessment documented that resident 15 had been on a scheduled pain medication regimen, had received as needed (PRN) medications, and non-medication interventions for pain were not received. A pain assessment interview was completed and revealed that resident 15 had frequent pain. A care plan Focus initiated on 6/7/22, documented The resident has acute/chronic pain r/t [related to failure to thrive. A care plan Goal documented The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. The care plan Interventions included: a. Initiated on 5/25/22, Per hospice - resident commonly states higher pain levels when questioned, not fully understanding pain control charting; PCP [primary care physician] is aware and does not wish to receive routine reports of increased follow-up pain levels. b. Initiated on 6/7/22, Administer analgesia, as per orders from hospice. c. Initiated on 6/7/22, Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. A quarterly MDS assessment dated [DATE], documented that resident 15 had a BIMS score of 14. A BIMS score of 13 to 15 indicates intact cognition. In addition, the MDS assessment documented that resident 15 had been on a scheduled pain medication regimen, had received PRN medications, and non-medication interventions for pain were not received. A pain assessment interview was not completed. The Staff Assessment for Pain documented non-verbal sounds and vocal complaints of pain. Indicators of pain or possible pain observed daily. The January 2023 Medication Administration Record and Treatment Administration Record were reviewed and the following pain medications were documented: a. On 5/25/22, morphine sulfate Solution 20 milligrams (mg)/milliliter (ml), give 0.5 ml by mouth every hour as needed for pain related to encounter for palliative care and rheumatoid arthritis with rheumatoid factor. [Note: There were no administrations documented for the month of January 2023.] b. On 5/25/22, Tylenol tablet 325 mg, give two tablets by mouth every four hours as needed for pain and or fever. [Note: There were no administrations documented for the month of January 2023.] c. On 7/21/22, methadone tablet 10 mg, give two tablets by mouth two times a day for pain related to encounter for palliative care and rheumatoid arthritis with rheumatoid factor. d. On 8/3/22, oxycodone tablet 20 mg, give one tablet by mouth every two hours as needed for pain. Give one tablet by mouth every two hours as needed for breakthrough pain. Resident 15's average pain score for the month of December 2022 was 8 out of 10. Out of 372 medication opportunities for the month of December 2022, resident 15 requested oxycodone on 206 occasions. Resident 15's average pain score for the month of January 2023 was 8 out of 10. Out of 280 medication opportunities for the month of January 2023, resident 15 requested oxycodone on 159 occasions. The hospice physician notes were reviewed and the following were documented: a. On 6/8/22, . Patient has chronic pain. Since her medications are being managed by the facility, Oxycodone was added for breakthrough pain. She takes Methadone regularly but reports it does not help her pain, oxycodone does. b. On 7/26/22, . Patient has debilitating, chronic pain. Her Methadone with [sic] recently increased from 10mg TID [three times a day] to 20mg BID [two times a day]. She take Oxycodone every 2-3 hours for breakthrough pain. A dilaudid pump was discussed but patient feared it would be too strong for her. c. On 10/7/22, . past medical history of rheumatoid arthritis, chronic pain, and malnutrition ., continues with significant pain complaints in bil [bilateral] knees, hips, and back. Bil hand deformity, ulnar deviation of 2nd - 5th fingers, swan-neck of 2nd-3rd, and interphalangeal joint swelling limits pt's [patient's] dexterity of hands. d. On 11/17/22, . States that she is always in pain, and the pain medications are not helping her pain. Her pain is in all joints, mainly feet/ankles/ and hands. Pt [Patient] is in need for further pain management, as pain is not controlled. The December 2022 Monthly Chart Review conducted by the pharmacist and completed on 12/23/22, documented Finding(s): Patient seems to be in consistent pain based on pain assessments. Recommendation: Recommend an extended release pain medication like fentanyl patches or extended release preparations of oxycodone or morphine to provide increased pain control. The physician had not responded to the recommendation and had not signed or dated the form. On 1/3/23 at 5:15 PM, a Pharmacy Recommendation progress note documented Note Text: Received pharmacy recommendation: Patient seems to be in consistent pain based on pain assessments, recommends an extended-release pain medication like Fentanyl patches or extended-release preparations of oxycodone or morphine to provide increased pain control MD notified will await further orders. On 1/24/23 at 1:36 PM, an interview was conducted with Certified Nursing Assistant (CNA) 3. CNA 3 stated that resident 15 was able to toilet herself and resident 15 had a bedside commode. CNA 3 stated that mornings were the hardest for resident 15 and she would use her call light because she was weaker. CNA 3 stated resident 15 went up and down on her pain levels and there were days resident 15 really needed staff assistance. CNA 3 stated that resident 15 was really good to use the call light when she was in pain and the staff were really quick to respond because they did not want resident 15 to be in any pain. On 1/25/23 at 10:00 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 15 was admitted to the facility on hospice and resident 15 had chronic pain. RN 1 stated that resident 15's pain was mainly from her rheumatoid arthritis and the arthritis had exacerbated over time. RN 1 stated that resident 15 was on scheduled methadone and oxycodone every two hours. RN 1 stated that resident 15 would ask for the oxycodone every three or four hours. RN 1 stated the hospice nurse was always asking the staff about resident 15's pain when the nurse visited. RN 1 stated hospice increased the frequency of the oxycodone and he felt like resident 15's pain was better managed. RN 1 stated that resident 15 had a few evaluations with the hospice physician. RN 1 stated that before the pharmacy reviews were sent to the physician the Director of Nursing (DON) would show the pharmacy recommendations to the floor nurses. RN 1 stated the hospice nurse had mentioned a pain patch for resident 15 but the hospice nurse had not started a pain patch. RN 1 stated as far as nonpharmalogical interventions the staff were spending time with resident 15 and providing reassurance. On 1/25/23 at 12:11 PM, an interview was conducted with the DON. The DON stated the pharmacist would send her a list of all the residents that were reviewed monthly. The DON stated if there were any findings she would make a note in the resident's medical record and would fax the recommendations to the resident's provider. The DON stated she would send the recommendations to the provider the day the recommendations were received from the pharmacy. The DON stated it was a struggle to get the recommendations back from the providers. The DON stated that Transport would go out daily to the offices to pick up the recommendations and the DON stated that she would call the providers daily. The DON stated she had spoken to the providers and the facility MD in person regarding the pharmacy recommendations. The DON stated if the recommendation was not an immediate order the MD wanted to wait for the resident's provider to respond. The DON stated she had gone through the MD and the MD did not want to take over everyone's orders. The DON stated it did not matter when you go into resident 15's room, resident 15 would say her pain was a seven or a five. The DON stated that resident 15 would look at the clock and say she needed a pain pill. The DON stated the hospice nurse did not want to change resident 15's medications and they were not getting the results with resident 15's current medication regimen. The DON stated that resident 15 was getting a lot of the oxydocone. On 1/25/23 at 12:30 PM, an interview was conducted with the Resident Advocate (RA). The RA stated that in an interdisciplinary team (IDT) meeting the hospice nurse came in and discussed resident 15's pain medications with the team. The RA stated that resident 15 had Coronavirus disease 2019 in December 2022. The RA stated the hospice nurse was afraid that resident 15 would come off of hospice and was worried what doctor would follow resident 15 if she came off. The RA stated that resident 15 tried pain patches in the past and they had not helped with her pain. [Note: The last documented IDT meeting was held on 11/15/22. No additional information was provided.] A review of the Pain Management Review Policy and Procedure provided by the facility documented, POLICY: The facility shall provide adequate management of pain to ensure that residents attain or maintain the highest practicable physical, mental, and psychosocial well-being. PROCEDURE: 1. Evaluate the resident for pain upon admission, during periodic scheduled assessments, and with change in condition or status (e.g., after a fall, with change in behavior or mental status). 2. 3. Assessment and evaluation by the appropriate members of the interdisciplinary team may include: a. Asking the patient to rate the intensity of his/her pain using a numerical scale or a verbal or visual descriptor that is appropriate and preferred by the resident. b. Review of the resident's diagnoses or conditions and any additional factor that may be causing or contributing to pain. c. Identifying key characteristics of the pain (Examples: Duration, Frequency, Location, Onset, Pattern and Radiation) d. Obtaining descriptors of the pain (Examples: Aching, Burning, Throbbing, Tingling, Stabbing) e. Determining factors that make the pain better or worse f. Identifying recent exacerbations of chronic pain g. Impact of pain or quality of life h. Current prescribed pain medications, dosage and frequency i. Note all treatments the patient is receiving for pain including nonpharmalogical therapies. j. The resident's goals for pain management and his/her satisfaction with the current level of pain control k. The effectiveness of specific drugs and other treatments used in the past to treat pain. 4. If the resident's pain is not controlled by the current treatment regimen, the practitioner should be notified. 5. The interdisciplinary team and the resident collaborate to arrive at pertinent, realistic and measurable goals for treatment. 6. 7. Non-pharmacological pain management interventions include but are not limited to: a. Adjusting room temperature b. Smoothing linens c. Turning and repositioning to a comfortable position d. Loosen any constrictive bandage or device e. Applying splinting (e.g., pillow or folded blanket) f. Physical modalities (e.g., cold compress, warm shower or bath) g. Exercises to address stiffness h. [sic] Cognitive/behavioral interventions (e.g., music, diversions, pain education) 8. Pharmacological interventions should follow a systematic approach. 9. The interdisciplinary team is responsible for developing a pain management regimen. 10. The following are general principles for prescribing analgesics in the long-term care setting: a. Evaluate the patient's medical condition and current medication regimen to determine the most appropriate therapy for pain b. Consider whether the medical literature contains evidence based recommendations for specific regiments to treat identified causes of pain c. Use the least invasive route of administration possible d. For chronic pain, begin with a low dose and titrate carefully until comfort is achieved e. For acute pain, begin with a low or moderate dose as needed and titrate more rapidly than for chronic pain f. Reassess and adjust the dose to optimize pain relief while monitoring and trying to minimize or manage side effects g. Some clinical conditions may require several analgesics or adjuvant medications, documentation should help clarify the rationale for a treatment regimen and to acknowledge associated risks. 11. Reassess patients with pain regularly based on the facility's established intervals. 12. If when re-evaluated, findings indicate pain is not adequately controlled, revise the pain management regimen and plan of care as indicated. 13.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined, the facility did not ensure that residents were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. Specifically, for 1 out of 27 sampled residents, a resident's physician visits for the first 90 days after admission were not completed timely by the facility Medical Director (MD) or the hospice physician. Resident identifier: 15. Findings included: Resident 15 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, encounter for palliative care, rheumatoid arthritis with rheumatoid factor, anxiety disorder, osteomyelitis, and major depressive disorder. Resident 15's medical record was reviewed on 1/24/23. On 6/8/22, a Face to Face Visit was completed by the hospice Nurse Practitioner (NP). On 7/26/22, a Face to Face Visit was completed by the hospice NP. There were 50 days between the last physician visit. On 10/7/22, a Face to Face Visit was completed by the hospice physician. There were 73 days between the last physician visit. [Note:The facility MD or hospice physician should have seen resident 15 at least once every 30 days for the first 90 days after admission. A physician visit was considered timely if it occurred not later than 10 days after the date the visit was required.] On 1/25/23 at 2:43 PM, an interview was conducted with the Resident Advocate (RA). The RA stated the facility had a house physician and the residents had a choice to see their own physician. The RA stated that Transportation would set up all physician appointments. On 1/25/23 at 2:50 PM, an interview was conducted with the Transportation Manager. The Transportation Manager stated when the facility had a new resident admission, she would get the discharge orders and would schedule the appointments. The Transportation Manager stated she would schedule with the primary care physician a week to two weeks out from admission. The Transportation Manager stated the nurses would let her know if a resident needed to be seen and she would schedule the visits and transport the residents. The Transportation Manager stated that she would schedule the resident physician visits according to the regulation. The Transportation Manager stated she would get the resident scheduled out so she did not forget. The Transportation Manager stated she did not schedule the hospice physician visits. On 1/25/23 at 2:53 PM, an interview was conducted with the Director of Nursing (DON). The DON stated if the resident was not on hospice services the Transportation Manager took care of getting the resident scheduled for the physician visits. The DON stated the Transportation Manager just knew that the visits were a Medicare regulation. The DON stated the Transportation Manager would put the physician visits on her calendar. The DON stated if the resident was on hospice services the hospice physician would come to the facility to see the resident. The DON stated the hospice companies knew the regulations and the frequency of visits was in the policy that the facility had the hospice companies sign. On 1/25/23 at 3:22 PM, an interview was conducted with the Administrator (ADM). The ADM stated the hospice regulations required the hospice physician to visit the resident every eight weeks. The ADM stated the hospice physician was following the hospice regulations.

Based on observation and interview, it was determined, the facility did not have the nurse staffing information posted. The facility must post the following information on a daily basis: Facility name, the current date, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: Registered Nurse (RN), Licensed Practical Nurses (LPN), Certified Nursing Assistants, and the resident census. The facility must post the nurse staffing data on a daily basis at the beginning of each shift and maintain the posted daily nurse staffing data for a minimum of 18 months. Additionally, the information must be displayed in a prominent place readily accessible to residents and visitors. Specifically, the nurse staffing information was not completed and readily accessible to residents and visitors. Findings included: On 1/25/23 at 9:10 AM, an observation was made throughout the facility and the nurse staffing information could not be located. At the nurse's station, a form was observed to be pinned to a bulletin board. The form included areas for information required for the nurse staffing information, but the form had not been completed. On 1/25/23 at 9:19 AM, an interview was conducted with RN 1. RN 1 stated the staff schedule was posted on the wall behind the nurse's station. When observed, the posting RN 1 referred to was the nursing staff schedule for the month. On 1/25/23 at 12:22 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the nighttime nurse was responsible for filling out the nurse staffing information. The DON stated she would call that nurse and see where she had put it. On 1/25/23 at 1:15 PM, an interview was conducted with LPN 1. LPN 1 stated she did not know where the nurse staffing information was. LPN 1 stated she thought the DON was the person who completed the form and posted it. On 1/25/23 at 3:01 PM, a second interview was conducted with the DON. The DON stated she was told by the nighttime nurse that she had not been completing the form. The DON stated the nighttime nurse did not have a reason for not filling out the form. The DON stated, we're going to just have to take the hit on this.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined, the facility did not ensure that the antibiotic stewardship program included antibiotic use protocols and a system to monitor the antibiotic use. Specifically, for 1 out of 27 sampled residents, a resident with a Urinary Tract Infection (UTI) was treated with an antibiotic that was based off of a urinalysis (UA) and culture and sensitivity (C&S) that was collected three months prior. Resident identifier: 1. Findings included: Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, mental disorders due to known physiological condition, bipolar disorder, mood disorder due to known physiological condition, dementia with behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and major depressive disorder. Resident 1's medical record was reviewed on 1/25/23. On 10/7/22 at 3:24 AM, a LABS AND DIAGNOSTICS progress note documented Note Text: Collected UA [urinalysis] per [name of doctor removed], urologist, d/t [due to] increased confusion, aggravation, and agitation. On 10/7/22 at 11:24 PM, a LABS AND DIAGNOSTICS progress note documented Note Text: Received UA results from lab: WBC [white blood cells] > [greater than] 30, and RBC [red blood cells] >30. Called urologist, talked with [name removed] who is on-call this weekend who stated they wanted to wait to give orders until the C&S results came back. Results were faxed to Urologist as well. On 10/9/22 at 8:43 PM, a Nurses Note documented Note Text: UA culture results sent to PCP [primary care physician]. Requested for pain medication refills sent to PCP. On 10/10/22 at 4:00 PM, a LABS AND DIAGNOSTICS progress note documented Note Text: Urinary culture and sensitivity faxed to resident's urologist, [name of doctor removed]. No orders at this time. On 10/10/22 at 10:17 PM, a Nurses Note documented Note Text: [Name of doctor removed] nurse called and said that he does not want resident on an antibiotic. Abnormality in UA culture is d/t having a suprapubic catheter. Watch for s/s [signs and symptoms] of UTI, encourage oral fluids, if any changes to contact his office. On 10/11/22 at 10:58 AM, an Infection Note documented Late Entry: Note Text: Contacted [name of doctor removed] office in regard to UA culture and having 50000 Pseudomonas noted on culture. MD [Medical Doctor] aware and stated does not want to treat with ATB [antibiotic] and to inform him of S/S of UTI. Family notified. On 1/6/23 at 12:59 PM, a Nurses Note documented Note Text: Resident had increased confusion this morning, with speaking with resident's daughter, [name removed], she reports her mom has been more confused the past couple evenings when she has spoken with her. [Name removed] is requesting we do a prn [as needed] IV [intravenous] fluid infusion today. On 1/6/23 at 3:27 PM, a Nurses Note documented Note Text: UA dip D/T increased confusion. 3+ for Leukocytes; 3+ Protein; 3+ Blood. pcp notified via backline, awaiting response. Requested to also do IV fluids per family request. On 1/6/23 at 9:14 PM, an Order Note documented Note Text: The order you have entered Cipro Tablet 500 MG [milligrams] (Ciprofloxacin HCl [hydrochloride]) Give 500 mg by mouth two times a day related to UNSPECIFIED SEVERE PROTEIN-CALORIE MALNUTRITION. A review of the January 2023 Medication Administration Record documented that resident 1 received the Cipro on 1/7/23 through 1/9/23. On 1/9/23 at 10:56 AM, an Order Note documented Note Text: The order you have entered Cipro Tablet 500 MG (Ciprofloxacin HCl) Give 500 mg by mouth two times a day related to URINARY TRACT INFECTION, SITE NOT SPECIFIED . until 01/13/2023 13:00 [1:00 PM]. On 1/10/23 at 1:06 PM, a UA and C&S was faxed to the facility from the laboratory. The report was initialed by facility nursing staff and was noted that the PCP was notified on 1/10/23. It was documented on the UA results that the lab was collected on 10/7/22. [Note: There was no documentation indicating that resident 1 had a UA collected for the signs and symptoms of a UTI on 1/6/23.] On 1/10/23 at 2:37 PM, a LABS AND DIAGNOSTICS progress note documented Note Text: Resident's urinary culture and sensitivity received today. Culture shows the presence of several organisms. PCP, [name removed], notified of results. Awaiting response from PCP if there will be any changes to antibiotic orders. On 1/10/23 at 4:26 PM, a Nurses Note documented Note Text: New antibiotic order to start tonight as per [name of doctor removed]: Macrobid Capsule 100 MG (Nitrofurantoin Monohyd Macro) Give 1 capsule by mouth two times a day related to URINARY TRACT INFECTION, SITE NOT SPECIFIED . for 14 Administrations Start Date:1/10/2023 End Date: 1/17/2023 Resident is now taking two antibiotics for UTI d/t urinary culture showing the presence of several different infectious organisms in urine. Resident's family already notified regarding antibiotic orders. [Note: The antibiotic treatment initiated on 1/10/23, was based off of the UA collected on 10/7/22.] On 1/10/23 at 4:40 PM, a LABS AND DIAGNOSTICS progress note documented Note Text: Reached out to PCP to see if resident needs to be put on contact precautions d/t resident had 5000 pseudomonas as one of the organisms that urine culture came back with. PCP stated he wouldn't recommend putting on contact precautions. On 1/17/23 at 10:33 AM, an Infection Note documented Note Text: Resident took her last antibiotic for UTI this morning, no adverse reactions noted. Vital signs stable, level of consciousness at her baseline. Resident does not complain of any pain at lower abdomen area; urine appears yellow and clear; Resident given sips of water throughout shift to increase hydration; will monitor this shift. On 1/25/23 at 11:06 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated labs would be collected if the resident made a visit to their PCP and returned with orders. RN 1 stated if a resident had a change of condition the nursing staff would contact the Medical Director and would receive orders to collect labs. RN 1 stated the PCP or other specialist would also fax orders for up and coming resident appointments that required labs. RN 1 stated that facility staff would collect the labs. RN 1 stated a complete blood count would be returned within one to two days after collection. RN 1 stated a urine sample for a UA would be returned within a day and a C&S could take three to four days to be returned. RN 1 stated that he would document in a progress note that the lab was received and would fax the results to the Medical Director and would follow up with a phone call to the Medical Directors office. On 1/25/23 at 1:43 PM, an interview was conducted with the Director of Nursing (DON). The DON stated if the nursing staff received a physician's order to collect labs the nurse would put the order in the resident's medical record. The DON stated if the lab was to be collected immediately (STAT) the staff would collect the lab, if the lab was not STAT it would be put off a day or two. The DON stated the nursing staff had a book that stated what labs were out. The DON stated when the lab results were received by the facility the nursing staff would review the lab and send the lab results to the Medical Director for review. On 1/25/23 at 3:33 PM, a follow up interview was conducted with RN 1. RN 1 stated he was not the nurse that originally collected the UA for resident 1. RN 1 stated he had received the lab results and started resident 1 on the antibiotic per the PCP and was waiting on the culture. On 1/25/23 at 3:37 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated the Interim Report date on the lab report indicated when the lab results were requested from the lab. LPN 1 stated that someone had requested resident 1's UA from 10/7/22, be faxed to the facility. On 1/25/23 at 3:57 PM, an interview was conducted with Infection Preventionist (IP). The IP stated the nursing staff were expecting a urine culture back for resident 1 and a urine culture was faxed to the facility on 1/10/23. [Note: The urine culture that was faxed to the facility on 1/10/23, was from the UA collected on 10/7/22.] On 1/25/23 at 4:06 PM, a follow up interview was conducted with the DON. The DON stated that resident 1's urine was dipped on 1/6/23. The DON stated that a UA was not collected for resident 1 in January 2023 and a UA was not sent to the lab.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 27 was admitted on [DATE] and re-admitted on [DATE] with diagnoses that included type 2 diabetes with neuropathic arthropathy, major depressive disorder, anxiety disorder, bipolar disorder, epilepsy, history of poliomyelitis, intellectual disabilities, and gastro-esophageal reflux disease. Resident 27's medical record was reviewed on 1/24/23. A review of resident 27's physician orders revealed the following: a. Probiotic capsule, give 1 capsule by mouth every day and night for GI (gastrointestinal) distress. The order was initiated on 7/13/21. b. Vitamin C tablet, give 1 tablet by mouth every day shift for supplement. The order was initiated on 1/31/22. c. Vitamin supplement E-1000 capsule 450 MG, give 1 capsule by mouth every day shift for supplement. The order was initiated on 1/31/22. d. Cyanocobalamin Tablet 2500 micrograms, give 1 tablet by mouth every day shift for supplement. The order was initiated on 10/9/20. e. Omeprazole Tablet delayed release 20 MG, give 1 tablet by mouth every day shift for GI distress. The order was initiated on 10/9/20. A monthly drug regimen review dated 3/7/22, revealed the pharmacist recommended to d/c (discontinue) Vitamin B 12, Vitamin C, Vitamin E and give daily MVI (multivitamin) if desired. Also evaluate if Melatonin is necessary as well as ongoing omeprazole and probiotic therapy. The physician accepted the recommendations on 4/22/22. On 1/25/23 at 11:39 AM, an interview was conducted with the DON. The DON stated the turn around time for the physician to sign orders depended on the physician. The DON stated one of the house physicians came in every Thursday, and the other one came in frequently. The DON stated they both sign orders. The DON stated that for physicians that were not in the facility, she had a terrible time getting the physicians to sign and return items. The DON stated she had spoken to the physician's offices several times and did not know what more she could do to get the physicians to review and approve or disapprove the pharmacy recommendations and sign the orders. The DON stated she kept a running list of things she was waiting for and marked them off as they came through. Based on interview and record review, it was determined, the facility did not ensure that the drug regimen of each resident was reviewed monthly by a licensed pharmacist and that any identified irregularities were reported to the attending physician and documented what, if any, action had been taken to address it. In addition, the facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps in the process and steps the pharmacist must take when he or she identifies an irregularity that requires urgent action to protect the resident. Specifically, for 3 out of 27 sampled residents, residents that had irregularities identified by the pharmacist were not acted upon by the attending physician in a timely manner. In addition, the Medication Regimen Review facility policy did not include time frames for the different steps in the process. Resident identifiers: 15, 27, and 40. Findings included: 1. Resident 40 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, dissection of aorta, abdominal aortic aneurysm, fatty liver, Alzheimer's disease, dementia, stenosis of cerebral artery, neoplasm of carotid body, hypomagnesemia, and anxiety disorder. On 1/24/23, resident 40's medical record was reviewed. Review of resident 40's physician orders revealed the following: a. Glipizide Extended Release (ER) Tablet 5 milligrams (mg), give 0.5 tablet by mouth every day. The order was initiated on 4/16/21. b. Glipizide ER Tablet 5 mg, give 1 tablet every day. The order was initiated on 7/15/22. c. Glipizide ER Tablet 10 mg, give 1 tablet by mouth every day. The order was initiated on 8/3/22. d. Lantus Solution (Insulin Glargine), Inject 1 unit subcutaneously every evening shift every 2 day(s) related to TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS may give 1 unit every few days until blood glucose is within optimal range. The order was initiated on 1/23/22, and discontinued on 1/17/23. e. If morning fasting glucose is over 120 for 3 consecutive days, increase long acting insulin dose by 2 units. If morning fasting glucose over 250 for 3 consecutive days, increase by 5 units. If morning fasting glucose under 70 for 2 consecutive days, decrease long acting insulin by 1 unit as needed for blood glucose management. The order was initiated on 5/7/21, and discontinued on 1/20/23. Review of the January Medication Administration Record revealed that the Lantus insulin 1 unit was documented as administered every other day, starting on 1/2/23 through 1/16/23. Resident 40's monthly Drug Regimen Reviews revealed the following: a. In May 2022, the pharmacist documented that resident 40 had fasting blood sugar levels trending high. The recommendation was please consider increasing Glipizide ER 5mg to 10 mg daily. The physician accepted the recommendation on 8/2/22. It should be noted that the new order for the increased dosage of Glipizide was initiated on 8/3/22. b. In July 2022, the pharmacist documented that resident 40's blood sugars were consistently elevated. The recommendation was to adjust the insulin. The physician accepted the recommendations with the following changes, please clarify current insulin dose and titration guidelines. The physician accepted the recommendations on 10/19/22. It should be noted that no new orders for insulin dose or titration guidelines were implemented after the recommendations were accepted on 10/19/22. On 1/25/23 at 9:54 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the pharmacist came to the facility at the end of the month to conduct the drug regimen review for all the residents. The DON stated that the pharmacist would then email the results to her and she would fax the recommendations to the physician. The DON stated that she would then implement the changes to the orders when the physician gave a reply. The DON stated that it depended on which physician on how long it took to get a response. The DON stated that they had a physician that they had to send the recommendations 2-3 times, or have had the transportation driver hand deliver the pharmacy recommendations to receive a response. The DON stated that resident 40's physician was who they were having a hard time obtaining a timely response to the pharmacy recommendations. The DON stated that she sent the recommendations to the physician immediately when she received them from the pharmacy. The DON stated that she did not know how to fix the problem. 3. Resident 15 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, encounter for palliative care, rheumatoid arthritis with rheumatoid factor, anxiety disorder, osteomyelitis, and major depressive disorder. Resident 15's medical record was reviewed on 1/24/23. The December 2022 Monthly Chart Review completed by the pharmacist on 12/23/22, documented Finding(s): Patient seems to be in consistent pain based on pain assessments. Recommendation: Recommend an extended release pain medication like fentanyl patches or extended release preparations of oxycodone or morphine to provide increased pain control. The physician had not responded to the recommendation and had not signed or dated the form. On 1/3/23 at 5:15 PM, a Pharmacy Recommendation progress note documented Note Text: Received pharmacy recommendation: Patient seems to be in consistent pain based on pain assessments, recommends an extended-release pain medication like Fentanyl patches or extended-release preparations of oxycodone or morphine to provide increased pain control MD [Medical Director] notified will await further orders. On 1/25/23 at 10:00 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that before the pharmacy reviews were sent to the physician the DON would show the pharmacy recommendations to the floor nurses. On 1/25/23 at 12:11 PM, an interview was conducted with the DON. The DON stated the pharmacist would send her a list of all the residents that were reviewed monthly. The DON stated if there were any findings she would make a note in the resident's medical record and would fax the recommendations to the resident's provider. The DON stated she would send the recommendations to the provider the day the recommendations were received from the pharmacist. The DON stated it was a struggle to get the recommendations back from the providers. The DON stated that Transport would go out daily to the offices to pick up the recommendations and the DON stated that she would call the providers daily. The DON stated she had spoken to the providers and the facility MD in person. The DON stated if the recommendation was not an immediate order the MD wanted to wait for the resident's provider to respond. The DON stated she had gone through the MD and the MD did not want to take over everyone's orders. A review of the Medication Regimen Review policy provided by the facility documented, The consultant pharmacist performs a comprehensive review of each resident's medication regimen at least monthly. The medication regimen review (MRR) includes evaluating the resident's response to medication therapy to determine that the resident maintains the highest practicable level of functioning and preventing or minimizing adverse consequences related to medication therapy. Findings and recommendations are reported to the director of nursing and the attending physician, and if appropriate, the medial director and/or the administrator. The facility policy was not dated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident 27 was admitted on [DATE] and re-admitted on [DATE] with diagnoses that included type 2 diabetes with neuropathic arthropathy, major depressive disorder, anxiety disorder, bipolar disorder, epilepsy, history of poliomyelitis, intellectual disabilities, and gastro-esophageal reflux disease. Resident 27's medical record was reviewed on 1/24/23. A review of resident 27's physician orders revealed the following: a. Effexor extended release (XR) capsule 150 MG, give 1 capsule by mouth every day shift related to major depressive disorder. The order was initiated on 6/4/21. b. Zyprexa tablet 5 MG, give 1 tablet by mouth every day shift related to bipolar disorder. The order was initiated on 2/23/22. A review of the December 2022 and January 2023 MAR and TAR revealed no documentation of behavioral or non-pharmacological interventions for the psychotropic medications Effexor XR and Zyprexa. The Psychotropic Committee Medication Review dated 4/28/22, documented the medication Effexor 150 mg and Zyprexa 5 mg were reviewed. No target behaviors or number of episodes were documented for the past 30 days. The evaluation documented no changes noted. The interdisciplinary team recommendations were to maintain the dose. They physician signed the form on 4/28/22. On 4/28/22 at 11:06 AM, the psychotropic medication review progress note documented Resident is currently taking .Effexor (150 mg, qD [daily], for depression), Zyprexa (5 mg, qD, for bipolar) .Will continue with current dosing. Will continue to monitor behaviors associated with psychotropic medications. MD [Medical Director] present at review. The Psychotropic Committee Medication Review dated 8/4/22, documented the medication Effexor 150 mg and Zyprexa 5 mg were reviewed. No target behaviors or number of episodes were documented for the past 30 days. The evaluation documented no changes noted. The interdisciplinary team recommendations were to maintain the dose. The physician signed the form on 8/4/22. On 8/4/22 at 11:11 AM, the psychotropic medication review progress note documented Resident is currently taking .Zyprexa (5 mg, qD, for bipolar disorder), Effexor (150 MG, qD, for depression) .Will continue with current dosing. Will continue to monitor behaviors associated with psychotropic medications. MD present and aware of findings. On 10/6/22 at 9:43 AM, a physician progress note documented Psychological: No increase in depression, no anxiety .will continue her medical management. The Psychotropic Committee Medication Review dated 10/27/22, documented the medication Effexor 150 mg and Zyprexa 5 mg were reviewed. No target behaviors or number of episodes were documented for the past 30 days. The evaluation documented no changed noted. The interdisciplinary team recommendations were to maintain the dose. The physician signed the form on 10/27/22. On 10/27/22 at 5:55 PM, the psychotropic medication review progress note documented Resident is currently taking .Effexor (150 mg, qD, for depression), Zyprexa (5 mg, qD, for bipolar disorder) .will continue with current dosing. Will continue to monitor behaviors associated with psychotropic medications. MD present at review. On 12/1/22 at 9:35 AM, the psychotropic medication review progress note documented will continue to monitor behaviors associated with psychotropic medications. MD present at review. On 12/29/22 at 10:31 AM, the psychotropic medication review progress note documented will continue to monitor behaviors associated with psychotropic medications. MD present at review. Family informed. The psychotropic medications Effexor XR and Zyprexa were not mentioned. It should be noted that Zyprexa 5 mg once daily had not had a GDR since the medication was initiated on 2/23/22. Effexor XR 150 mg once daily had not had a GDR since the medication was initiated on 6/4/21. No documentation of contraindications to GDR's could be found. On 1/25/23 at 12:50 PM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that none of the physicians associated with the facility were documenting contraindications for medications that were not having a GDR. Based on interview and record review, it was determined, the facility did not ensure that residents who used a psychotropic medication received a gradual dose reduction (GDR), and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Specifically, for 3 out of 27 sampled residents, residents who used a psychotropic medication did not have a GDR or a clinical contraindication to that GDR for the medication. Additionally, residents who used a psychotropic medication did not have any behavioral interventions or non-pharmacological interventions documented. Resident identifiers: 15, 27, and 40. Findings included: 1. Resident 40 was admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus, dissection of aorta, abdominal aortic aneurysm, fatty liver, Alzheimer's disease, dementia, stenosis of cerebral artery, neoplasm of carotid body, hypomagnesemia, and anxiety disorder. On 1/24/23, resident 40's medical record was reviewed. Review of resident 40's physician orders revealed the following: a. Lorazepam Tablet 2 milligrams (mg), give 1 tablet by mouth two times a day for anxiety. The order was initiated on 6/2/21. b. Sertraline Tablet, give 50 mg by mouth every day shift for depression. The order was initiated on 9/16/22. Review of the December 2022 and January 2023 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no documentation of behavioral interventions or non-pharmacological interventions for the psychotropic medications Sertraline and Lorazepam. Review of the Psychotropic Committee Medication Review revealed the following: a. On 6/2/22, the medication Lorazepam 2 mg by mouth two times a day was reviewed. No target behaviors or number of episodes were documented for the past 30 days. The evaluation documented No change noted. The interdisciplinary team recommendations were to maintain the dose. The physician signed the form on 6/8/22. On 6/2/22 at 5:31 PM, the psychotropic med review progress note documented the resident was currently taking Lorazepam 2 mg twice daily for anxiety; will continue with current dosing. Will continue to monitor behaviors associated with psychotropic medications. b. On 9/8/22, the medication Lorazepam 2 mg by mouth two times a day was reviewed. No target behaviors or number of episodes were documented for the past 30 days. The evaluation documented No change noted. The interdisciplinary team recommendations were to maintain the dose. The physician signed the form on 9/14/22. On 9/8/22 at 4:53 PM, the psychotropic med review progress note documented the resident was currently taking Lorazepam 2 mg twice daily for anxiety; will continue with current dosing. Will continue to monitor behaviors associated with psychotropic medications. c. On 12/1/22, the medication Lorazepam 2 mg by mouth two times a day was reviewed. No target behaviors or number of episodes were documented for the past 30 days. The evaluation documented No change noted. The interdisciplinary team recommendations were to maintain the dose. The physician signed the form on 12/15/22. On 12/1/22 at 10:08 AM, the psychotropic med review progress note documented the resident was currently taking Sertraline 50 mg daily and Lorazepam 2 mg twice daily for anxiety; will continue with current dosing. Will continue to monitor behaviors associated with psychotropic medications. It should be noted that the Lorazepam 2 mg by mouth two times a day had not had a GDR since the medication was initiated on 6/2/21. No documentation could be found for a physician rationale for a clinical contraindication to a GDR for the Lorazepam. On 1/24/23 at 2:02 PM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 40's behaviors were exhibited by anxious comments about his family. RN 1 stated that resident 40 would make comments such as how long was he going to be here and when was his family visiting. RN 1 stated that resident 40 did not have any episodes of crying, tearfulness, or statements of sadness. RN 1 stated that resident 40 had scheduled Lorazepam for anxiety and it helped quite a bit. RN 1 stated that the documentation for behaviors would be located on the TAR. RN 1 stated that the Sertraline was normally ordered for depression, but resident 40 had a diagnoses of anxiety. RN 1 stated that the Sertraline was prescribed for resident 40's anxiety disorder. On 1/25/23 at 9:54 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 40 was taking Sertraline for anxiety. The DON stated that resident 40's as needed or PRN dose of Lorazepam was discontinued. The DON stated at the time resident 40 had a Lorazepam order for a scheduled dose two times a day and a PRN dose. The DON stated that the PRN order of Lorazepam was discontinued due to non-use. The DON stated that she would need to check with the Minimum Data Set (MDS) Coordinator to see if resident 40 had a GDR for the scheduled dose of Lorazepam as he was in charge of the psychotropic meetings. The DON stated that the staff were monitoring the resident for episodes of anxiety and how often they occurred, and for any adverse side effects of the medication. The DON stated that they did not document any non-pharmacological interventions for resident 40's episodes of anxiety I know we do it, I just don't think it's part of the documentation. On 1/25/23 at 12:57 PM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated that the physician did not specify a diagnosis for the Sertraline, but the physician did write it for depression and anxiety. The MDS Coordinator stated that the Sertraline was added because the Lorazepam two times daily was not sufficient for resident 40's increased anxiety. The MDS Coordinator stated that they did not have any physicians that documented a clinical contraindication for a GDR and resident 40 did not have a GDR for the scheduled Lorazepam. 2. Resident 15 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, encounter for palliative care, rheumatoid arthritis with rheumatoid factor, anxiety disorder, osteomyelitis, and major depressive disorder. Resident 15's medical record was reviewed on 1/24/23. A physician's order dated 5/26/22, documented DULoxetine HCl [hydrochloride] Capsule Delayed Release Sprinkle 30 MG Give 1 capsule by mouth every day shift related to MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED. The Psychotropic Committee Medication Review dated 6/2/22, documented duloxetine 30 mg daily for major depression. No target behaviors or number of episodes were documented for the past 30 days. No change noted. The interdisciplinary team recommendation was to maintain. The physician signed the form 14 days after the review and did not indicate if they agreed or disagreed with the committee recommendation. On 6/2/22 at 5:45 PM, a Psychotropic med review progress note documented that resident was currently taking duloxetine 30 mg daily for depression and will continue with current dosing. Will continue to monitor behaviors associated with psychotropic medications. The Psychotropic Committee Medication Review dated 9/8/22, documented duloxetine 30 mg daily for major depression. No target behaviors or number of episodes were documented for the past 30 days. No change noted. The interdisciplinary team recommendation was to maintain. The physician signed the form but they did not indicate if they agreed or disagreed with the committee recommendation. On 9/8/22 at 4:31 PM, a Psychotropic med review progress note documented that resident was currently taking duloxetine 30 mg daily for depression and will continue with current dosing. Will continue to monitor behaviors associated with psychotropic medications. The Psychotropic Committee Medication Review dated 12/1/22, documented duloxetine 30 mg daily for major depression. No target behaviors or number of episodes were documented for the past 30 days. No change noted. The interdisciplinary team recommendation was to maintain. The physician signed the form but they did not indicate if they agreed or disagreed with the committee recommendation. On 12/1/22 at 10:15 AM, a Psychotropic med review progress note documented that resident was currently taking duloxetine daily for depression and will continue with current dosing. Will continue to monitor behaviors associated with psychotropic medications. On 12/29/22 at 9:37 AM, a Psychotropic med review progress note documented that resident was currently taking duloxetine 30 mg daily for depression and will continue with current dosing. Will continue to monitor behaviors associated with psychotropic medications. It should be noted that the duloxetine 30 mg daily had not had a GDR since the initiation of the medication on 5/26/22. No documentation could be found for a physician rationale for a clinical contraindication to a GDR for the duloxetine. [Note: Within the first year in which a resident was admitted on a psychotropic medication or after the prescribing practitioner has initiated a psychotropic medication, the facility must attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated.] The January 2023 MAR and TAR was reviewed and revealed no documentation of behavioral interventions or non-pharmacological interventions for the psychotropic medication duloxetine. On 1/25/23 at 10:00 AM, an interview was conducted with RN 1. RN 1 stated that resident 15 was scheduled to take diazepam for anxiety and resident 15 would ask about her family. RN 1 stated as far as non-pharmalogical interventions the staff were spending time with resident 15 and providing reassurance. On 1/25/23 at 12:11 PM, an interview was conducted with the DON. The DON stated if a resident was on a lower dose of a medication the pharmacist would not recommend a GDR. On 1/25/23 at 1:05 PM, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated the facility was not meeting the regulation as far as the rationale for resident 15 not having a GDR on the duloxetine. The MDS Coordinator stated the facility did the psychotropic meetings and shared with the providers, but the providers did not send anything back. No additional information was provided.

Based on interview and record review it was determined, for 1 of 37 sample residents, that the facility did not implement written policies and procedures that prohibited and prevented abuse. Specifically, staff did not investigate or follow up after a resident was yelled at by another resident in the dining room. In addition, the resident hit the table while yelling at the resident. Resident identifier: 30. Findings include: A nursing progress note dated 5/30/2021 at 3:05 PM revealed, During lunch, she yelled at another resident, pounding and hitting the table, telling the other resident to hurry up and eat his food. Resident was asked to leave the dining hall and return to her bedroom to finish her meal. Resident was cooperative and redirected easily. Will continue to monitor this shift. The note was written by Registered Nurse (RN) 1. Resident 30 did not have any care plans regarding behaviors. On 6/14/21 at 5:02 PM, an interview was conducted with RN 1. RN 1 stated that if there was a resident to resident altercation he separated the residents, determined what was going on, de-escalated the situation and reported it to the Director of Nursing (DON). RN 1 stated if it was something that caused injury then would notify DON. RN 1 stated depending on the yelling then might not report the altercation to the DON. RN 1 state that if someone was upset and de-escalated the situation then he reported the situation to the DON. RN 1 stated that resident 30 had yelled out during dining when she had to wait for her food. RN 1 stated that he did not know who the other resident was that resident 30 yelled at on 5/30/21. RN 1 stated he was could not remember the incident. RN 1 stated that he notified the DON. RN 1 stated that the DON developed new interventions for resident 30 after the incident when she yelled at the other resident. RN 1 stated that staff wait to bring resident 30 to the dining room until her food is ready. RN 1 stated I think if there was threatening of safety or harm or danger then it would be abuse. RN 1 stated determining abuse depended on who the other resident was and if they felt threatened. RN 1 stated he should have asked the other resident about how they felt. RN 1 stated that the Resident Advocate (RA) was the abuse coordinator. RN 1 stated that he Feels like (the situation) might need to be looked into more, but it was an instance where she was cooperative and it didn't go past yelling. On 6/14/21 at 5:22 PM, an interview was conducted with the RA. The RA stated that the Director of Nursing, the Administrator and her were the abuse coordinators. The RA stated that any type of abuse needed to be reported including verbal. The RA stated that abuse was reported to the Administrator and he completed an investigation. The RA stated that staff have reported resident to resident allegations. The RA stated that if a resident to resident altercation happened it was reported to the State Survey Agency and the Ombudsman. The RA stated there had not been any resident to resident altercations to report to the State Survey Agency. The RA stated that when there was an resident to resident altercation at the facility there was no abuse. The RA stated that if a resident was really upset and yelled that would be considered verbal abuse. The RA stated that if the staff can calm the situation between the residents then it was not considered abuse. The RA stated that Adult Protective Services (APS) had told the facility staff that, if facility staff can handle the situation on their own, then don't call APS. The RA stated if there was physical or sexual abuse she reported that to APS. The RA stated that if a resident had a threatening manor and was yelling, then that would be reported. The RA stated if a resident was acting differently and not going to activities or not eating then she would report abuse. The RA stated that the facility used the STOP technic. The RA stated it meant Separate, Tell the nurse, Obtain information, P. The RA could not remember what the P was for. The RA stated that the facility staff worked with a lot of dementia and brain injury residents that yelled out and required redirection. The RA stated residents yelled out in the dining room. The RA stated that if a resident was yelled at another resident she asked them if they felt safe, offered hot chocolate or something else to comfort the resident. The RA stated she had not heard of resident 30 yelling directly at another resident and hitting the table. The RA stated that resident 30 yelled out while in the dining room but it was not abuse. The RA stated she had not talked to the other resident about how that resident felt because she did not know about it. On 6/14/21 at 5:41 PM, an interview was conducted with the DON. The DON stated that the RA was the abuse coordinator. The DON stated that any type of abuse would be investigated. The DON stated that she expected staff to contact management with any type of abuse. The DON stated she would find out who the residents were and look into things. The DON stated that resident 30 came to the dining room and scream out if she did not get food right away. The DON stated that resident 30 was asked to calm down. The DON stated that staff were to bring her to the dining room when her food was ready. The DON stated that she looked for physical abuse rather than verbal with dementia residents. The DON stated If (staff were) unable to re-direct, a resident was attacking another resident, then I would expect to be notified. On 06/15/21 at 11:26 AM, a follow up interview was conducted with the RA. The RA stated resident 30 hollered out when she was hungry. The RA stated that resident 30's brain and personality was what was causing her to yell out. The RA stated that resident 30 was becoming more demanding with her personality. The RA stated she remembered that In a case like this, with another resident being yelled at. A text was sent to her and she called RN 1 back. The RA further stated RN 1 told her that resident 30 was yelling in the dining room, re-directed her and had her go to her room to finish her meal. The RA stated that RN 1 did not tell her who the other resident was. The RA stated she would expect staff to talk with other resident. The RA stated that if resident 30 repeatedly yelled at the same resident, then she would look into it. The RA stated that if it was a willful act then would have gotten more information and more would have been done at that moment. The RA stated I would have made the decision to come in and contacted the DON and Administrator, if I felt there was a threat of some kind. The RA stated that she was sure RN 1 would have done more if there was more of a willful attack than an outburst. The RA stated she did not document or investigate to determine if the act was willful. On 6/15/21 at 12:20 PM, an interview was conducted with the DON. The DON stated resident 30 came to her office and asked for food regularly and did not feel abused by resident 30. The DON stated that resident 30 did not direct her yelling at anyone. The DON stated that her nurse should have documented the incident differently. The DON stated that if it was abuse it would be a personal attack. The DON stated she did not investigate to determine if it was a personal attack on the other resident. The facility Abuse policy and procedures titled Recognizing Signs and Symptoms of Abuse/Neglect revealed the definition of abuse was .a willful infliction of injury,.intimidation, or punishment with resulting physical harm, pain or mental anguish. Another section of the Abuse policy and procedure was titled Abuse Investigations. The Policy stated was All reports of resident abuse, neglect, and injuries of unknown source shall be promptly and thoroughly investigated by facility management. An additional section titled Reporting Abuse to Facility Management revealed It is the responsibility of our employees, .to promptly report an incident or suspected incident of neglect or resident abuse.to facility management. The Policy Interpretation and Implementation revealed that 2. To help with recognition of incidents of abuse, the following definitions of abuse are provided: a. b. 'Verbal abuse' is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents.or within hearing distance, to describe residents, regardless of their, age, ability to comprehend or disability. 3. All personnel.are encourage to report incidents of resident abuse or suspected incidents of abuse. Such reports may be made without fear of retaliation from the facility or its staff. 5. Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Administrator or Director of Nursing Services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 1 of 37 sample residents, that the facility did not coordinate assessments with the pre-admission screening and resident review (PASARR) program. Including referring all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment. Specifically, after a resident was diagnosed with a mental illness there was no referral for a level II. Resident identifier: 36. Findings include: Resident 36 was admitted to the facility on [DATE] with diagnoses which included chronic kidney disease, pain, visual loss, and hypertension. A diagnosis anxiety was added on 2/23/21. Resident 36's medical record was reviewed on 6/14/2021. A review of resident 36's Pre-admission screening Application/Resident Review (PASRR) dated 7/9/2019 revealed there was no serious mental illness diagnoses. According to the form if any diagnoses where checked resident 36 needed a Level II PASRR evaluation. One of the diagnoses on the form was generalized anxiety disorder. The box was not checked. On 6/14/21 at 4:35 PM, an interview was conducted with the Resident Advocate (RA). The RA stated when the doctor diagnosed resident 36 with anxiety 2/23/21. The RA stated that the PASARR was filled out prior to admission and the nurses filled in the diagnoses after the physician provided diagnoses. The RA stated that when there was a new diagnosis regarding mental illness the nurses notified her and she made a referral for a Level II evaluation. The RA stated that she had not provided the information to the PASARR so that resident 36 was re-evaluated.

Based on observation, interview and record review it was determined that the facility did not post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility. Specifically, the full survey results were not available to residents. Findings include: On 6/13/21, an observation was made of a binder at the front of the building. The binder was labeled Survey results. The binder was observed to be missing pages for each deficiency cited for the survey dated 4/11/2019. On 6/15/21 at 10:29 AM, resident council was conducted. The members of resident council meeting stated that the survey results were not available. On 6/14/21, an interview was conducted with the Administrator. The Administrator stated that he would have to get a bigger binder for all the pages of the survey results for the recertification survey for 2019. The Administrator stated that he placed the pages of the survey results that contained the plan of correct because I felt that was the most important part. The Administrator stated that there was more than half of the survey results missing from the binder.

Based on interview and record review it was determined that the facility did not employ a clinically qualified full-time dietitian or other clinically qualified nutrition professional to serve as the director of food and nutrition services. Specifically, the facility the director of food services was did not meet the requirements to serve as the director of food and nutrition services. Findings include: On 6/15/21 at 7:55 AM, an interview was conducted with the Dietary Manager (DM). The DM stated that she was taking the courses to become a Certified Dietary Manager(CDM). The DM stated that she had been taking the courses for 2 months. The DM stated that she was previously certified by another certifying body, but the certification expired about a year ago. The DM stated that the RD came to the facility twice per month. The DM stated that the RD was available by phone if she had any problems.

Based on observation and interview it was determined, for 4 of 37 sample residents, that the facility did not provide each resident with food and drink that was palatable, attractive, and at a safe and appetizing temperature. Specifically, residents complained that the food was not palatable and the test tray was not visibly attractive or palatable. Resident identifiers: 8, 33, 35 and 41. Findings include: On 6/13/21 at 4:43 PM, an interview was conducted with resident 8. Resident 8 stated that the food was not very good. Resident 8 that the eggs at breakfast were too hard. On 6/14/21 at 8:20 AM, an interview was conducted with resident 35. Resident 35 stated that the chicken sandwich was not good. Resident 35 stated that the facility served beets a lot and the same vegetables. Resident 35 stated that the food did not taste good all the time. Resident 35 stated that the food was very bland and was sometimes served cold. On 6/14/21 at 8:43 AM, and interview was conducted with resident 33. Resident 33 stated the food was just OK. Resident 33 stated that When you're used to home cooked food, nothing tastes that good. On 6/13/21 at 4:32 PM, an interview was conducted with resident 41. Resident 41 stated that the food was not very good. Resident 41 stated that the eggs are very hard, need a little milk or cream. Resident 41 stated that the food was comparable to army food. On 6/15/21 at 11:58 PM, the lunch meal was brought out to the serving cart and three hall carts were prepared. At 12:02 PM cart 1 went out of the kitchen to the hallway for residents eating in their rooms. At 12:08 PM cart 2 went out of the kitchen, and at 12:16 PM cart 3 was taken to the last resident hallway. On 6/15/21 at approximately 12:20 PM, a test tray was taken off of hall cart 3 after all residents were served. Temperatures were taken on each item on the meal tray and the food was sampled. Results were as follows: [Note: All temperatures were in degrees Fahrenheit.] a. Water in a small cup was 60.0 degrees. The water was warm to the taste. b. Milk in a small cup was 50.0 degrees. c. Orange punch in a small cup was 49.2 degrees. d. Fried chicken was 78.7 degrees. The chicken was cold to the taste. e. Mashed potatoes with chicken gravy was 78.7 degrees. The mashed potatoes were cold to the taste, bland, gravy was thick with a strong taste of corn starch. f. Broccoli was 75.2 degrees. The broccoli was dull in color with a mushy texture. The broccoli was also cold to the taste. g. [NAME] salad was 61.7 degrees. The lettuce had a brown tint. h. Dinner roll with butter was cold to the taste. I. Vanilla ice cream was 31 degrees. The tray was observed to be all brown and yellowish foods with a pale green from the broccoli.