Based on staff interview and clinical record review, the facility staff failed to provide timely toileting assistance for one of eleven residents in the survey sample (Resident #10). The findings include: Resident #10's request for toileting assistance was delayed until after meal trays were delivered to other residents on the living unit. Resident #10 (R10) was admitted to the facility with diagnoses that included atrial fibrillation, heart failure, morbid obesity, chronic obstructive pulmonary disease, respiratory failure, and dysphagia. The minimum data set (MDS - assessment tool) dated 2/28/24 assessed R10 as cognitively intact and as dependent upon staff assistance for toileting and transfers. R10's closed clinical record documented a nursing note dated 3/12/24 stating, .18:00 [6:00 p.m.] resident turned call light, CNA's [certified nurses' aides] were passing trays. Residents CNA checked to see what was needed resident needed to go to the bathroom. CNA told her [R10] she would be able to after dinner (per facility policy) .Resident has done this several times knowing what the policy for is . (sic) R10's plan of care (initiated 2/21/24) documented the resident had a self-care deficit for activities of daily living (ADLs) including toileting and was at risk of falls. Interventions to maintain ADLs and prevent falls included physical assist as needed .resident requires (limited to extensive assistance by staff for toileting .resident requires limited to extensive assistance by staff to move between surfaces .Be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance . (sic) On 6/24/24 at 2:05 p.m., the licensed practical nurse (LPN #3) that wrote R10's nursing note on 3/12/24 was interviewed. LPN #3 stated she routinely cared for R10 on the evening shift (3:00 p.m. to 11:00 p.m.) at least five days each week during her stay. LPN #3 stated on 3/12/24, toileting assistance for R10 was delayed until after the dinner trays had been delivered and residents were fed. LPN #3 stated staff had been told to check call lights but that if the call light request was not an emergency, to wait until trays were delivered to provide assistance. LPN #3 stated it was not sanitary for staff to go from feeding residents to toileting residents and that her unit had multiple residents requiring feeding assistance. When asked what a resident was to do if they needed to use the bathroom at mealtime, LPN #3 stated that lots of the residents wore incontinence briefs. On 6/24/24 at 2:50 p.m., CNA #5 that routinely cared for R10 was interviewed. CNA #5 stated R10 required two staff members for toileting because she required a mechanical lift. CNA #5 stated R10 was incontinent as times but usually let staff know when she needed to go to the bathroom or be changed. CNA #5 stated staff were expected to respond to call lights even during mealtimes. CNA #5 stated if staff members were feeding residents, other staff members on the unit were expected to respond to call lights. On 6/24/24 at 2:55 p.m., CNA #6 that routinely cared for R10 was interviewed. CNA #6 stated R10 required assistance of two staff members for toileting because she required the sit-to-stand lift. CNA #6 stated she responded to call lights and requests for toileting as soon as possible and was not aware of a facility policy that residents were not to be toileted during mealtime. On 6/24/24 at 3:15 p.m., the director of nursing (DON) was interviewed about R10's delayed toileting assistance on the evening of 3/12/24. The DON stated call bells and requests for toileting assistance should be answered/provided promptly by staff members. The DON stated there was no facility policy to not respond or toilet residents during meals. The DON stated staff members should have provided prompt assistance to toilet R10 when requested. This finding was reviewed with the administrator, director of nursing and regional consultants during a meeting on 6/25/24 at 12:00 p.m. with no further information provided prior to the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, and clinical record review, the facility staff failed to use a meal ticket that accurately reflected food allergies for one of eleven residents in the survey sample (Resident #3). The findings include: Resident #3 (R3) was admitted to the facility with diagnoses that included hypothyroidism, anemia, gastroesophageal reflux disease, venous insufficiency, depression and neuropathy. The minimum data set (MDS) dated [DATE] assessed R3 as cognitively intact. R3's clinical record documented a physician's order dated 7/27/23 for a regular high protein diet. The clinical record documented R3's food allergies of aspartame and food preservatives. On 6/25/24 at 8:12 a.m., R3 was observed eating breakfast. With the resident's permission, the breakfast meal ticket was reviewed. R3's meal ticket matched the food items served but documented no mention of the resident's allergy and/or intolerance of aspartame and food preservatives. R3 was interviewed at this time about her food allergies. R3 stated she was allergic/intolerant of food preservatives and artificial sweeteners like aspartame. R3 stated she was not aware of being served those items but did not know why the allergies were not listed on the meal ticket. On 6/25/24 at 9:05 a.m., the dietary manager (other staff #5) was interviewed about R3's meal ticket. The dietary manager reviewed the ticket system and stated the resident's allergies of aspartame and food preservatives had not made it to the dining side. The dietary manager stated he was not aware that R3's allergies were missing from the meal tickets. The dietary manager stated R3's food allergies were in the clinical record but had not been entered into the meal ticket system. This finding was reviewed with the administrator, director of nursing and regional consultants during a meeting on 6/25/24 at 12:00 p.m. with no further information provided prior to the end of the survey.

Based on staff interview, facility document review, and clinical record review, the facility staff failed to accommodate food allergies for one of eleven residents in the survey sample (Resident #10). The findings include: Resident #10 (R10) was admitted to the facility with diagnoses that included atrial fibrillation, heart failure, morbid obesity, chronic obstructive pulmonary disease, respiratory failure and dysphagia. The minimum data set (MDS- assessment tool) dated 2/28/24 assessed R10 as cognitively intact. R10's clinical record documented a physician's order dated 2/21/24 for a regular textured diet with food allergies listed as broccoli, cauliflower, carrots, yellow dye, and lemonade. R10's diet was changed on 2/22/24 to a 2-gram sodium diet and then on 2/23/24 to a 2-gram sodium dysphagia diet, advanced texture. Facility menus for February 2024 included at least four meals served with mixed vegetables that included broccoli, cauliflower, and/or carrots. On 6/24/24 at 2:25 p.m., the dietary manager (other staff #5) was interviewed about accommodation of food allergies for R10. The dietary manager stated that on several occasions during the first week or two of R10's stay, R10 was served broccoli, cauliflower, carrots or vegetable mix including those foods. The dietary manager stated the allergies were listed on the meal ticket but the ticket system at that time did not allow a substitute to be listed. The dietary manager stated he did not know why kitchen staff plated/served the allergic food items when they were listed on the ticket as foods not to be served. The dietary manager stated R10 made him aware at the time that the vegetables were served, and the resident did not eat the foods. The dietary manager stated to his knowledge, R10 was not served broccoli, cauliflower or carrots after the resident's first week in the facility. R10's plan of care (initiated 2/28/24) documented the resident had nutrition screening that indicated a risk of malnutrition. Interventions to maintain nutrition included, .Honor food preferences as diet allows .Provide modified textured diet/liquids as ordered . The facility's policy titled Food Allergies and Intolerances (10/01/21) documented, Residents with food allergies and/or intolerances are identified upon admission and offered food substitutions of similar appeal and nutritional value. Steps are taken to prevent resident exposure to the allergen(s) . Residents with food intolerances and allergies are offered appropriate substitutions for foods that they cannot eat . This finding was reviewed with the administrator, director of nursing and regional consultants during a meeting on 6/25/24 at 12:00 p.m. with no further information presented prior to the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview and facility document review, the facility staff failed to follow the standards of practice for testing and testing documentation. The facility failed to obtain a physician's order prior to performing a COVID-19 test and then failed to document COVID-19 testing information in the clinical record for one of 5 residents in the survey sample, Resident #1. The facility failed to maintain complete and accurate COVID-19 testing logs for staff, including documentation of each instance of testing with results. Findings include: 1. According to the medical record, Resident #1 was admitted to the facility on [DATE], developed COVID-19, and was discharged to the hospital on [DATE]. A review of Resident #1's clinical documentation revealed the following: A practitioner note dated 11/30/22 documented, .seen today for refusal of care .feeling weak .refused to go to urology appointment this morning because of having diarrhea .signature of NP (Nurse Practitioner). A practitioner note dated 12/01/22 documented, .chief complaint .presenting problem .COVID .being seen today for new diagnosis of COVID .feeling kind of weak .he is complaining of a sore throat and nasal congestion .seems a bit more confused today .COVID + .isolation and supportive care .signature of NP. There was no documentation indicating when the COVID-19 test was performed for Resident #1, only that the resident had a new diagnosis of COVID. There was no documentation regarding who performed the test, the method of testing, nor the testing results. There was no documented record of the testing for this resident of any kind. A review of resident #1's physician's orders was then completed. No physician order to perform a COVID test on resident #1 was found. On 12/06/22 at approximately 1:00 PM, the administrator was asked about the above information. The administrator stated that they (facility) do obtain physician orders to test resident's for COVID-19. The administrator was made aware that a physician order could not be located for Resident #1 regarding COVID-19 testing and that there was no information regarding the testing, other than the resident having a new diagnosis of COVID. The administrator was asked for testing logs and information regarding Resident #1. At approximately 1:30 PM, the administrator stated that the NP had administered the COVID 19 test to the resident. When asked where was the documentation regarding the testing for Resident #1, the administrator stated that she did not know. When asked, the administrator stated that she wasn't sure why the NP did the test and then did not inform staff for COVID-19 tracking. The facility policy titled, COVID-19 Screening/Testing plan for residents and staff documented, .in general testing is not necessary for asymptomatic people .testing will be met through the use of rapid point of care .devices .resident's attending physician/practitioner will be notified of the presence of symptoms and the facility will follow physician /practitioner orders for care .symptomatic individuals identified .residents, regardless of vaccination status, with signs and symptoms must be tested .A physician/practitioner order (standing order is acceptable) will be obtained prior to administration of test .consent for the testing will be maintained and documented for each resident tested .the facility will document resident testing in the medical record in accordance with protected health information .the facility will maintain compliance with testing requirement by documenting the following .date and time of signs/symptoms date of testing date of results .actions taken by facility based on test results .new COVID-19 case-outbreak with resident or staff . At approximately 2:30 PM, the administrator was made aware of concerns regarding Resident #1 not having a physician's order to be tested for COVID-19, as well as the lack of documentation and tracking information regarding testing for this resident. The administrator stated that she did not know why an order was not obtained and why the information was not documented per the facility policy. No further information and/or documentation was presented prior to the exit conference on 12/06/22 at 3:30 PM. 2. The facility failed to document that testing was completed and/or that the subsequent results were recorded. The facility's COVID-19 testing logs for staff were reviewed from September 2022 to present 12/06/22, which included spaces to document the following: staff name, DOB (date of birth ), Date/Time, Result, Lot #/Expiration date, and Completed by. The testing log for September 27, 2022 through October 28, 2022 had 20 staff tests documented. Out of the 20 tests, 13 did not have lot# information or who completed the tests. Three tests did not have a date, only a time stamp. Two tests did not have a date or an actual test result for the test completed. The administrator was asked about the above information and testing logs. The administrator stated that the DON (director of nursing) was out today, and that is who takes care of the tracking information. The administrator stated that she could not answer as to why the COVID-19 testing logs were incomplete and stated that she knew that all of the tests were negative. The facility's policy titled, COVID-19 Screening/Testing plan for residents and staff documented, .the facility will document testing results for staff in a secure manner consistent with requirements specified .the facility will maintain compliance with testing requirement by documenting the following .date and time of signs/symptoms date of testing date of results .actions taken by facility based on test results .new COVID-19 case-outbreak with resident or staff . No further information and/or documentation was presented prior to the exit conference on 12/06/22 at 3:30 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility staff failed to develop a comprehensive care plan for 2 of 25 residents in the survey sample, Resident #103 and Resident #89. Resident #103's care plan did not include focus areas with goals and interventions for the use Insulin and for the use of the antidepressant Venlafaxine (Effexor). Resident #89's care plan did include a focus area with goals and interventions for the use of the diuretic Furosemide (Lasix). The findings include: 1a. Resident #103 was admitted to the facility with diagnoses that included muscle weakness, traumatic brain injury, chronic respiratory failure, COPD, type 2 diabetes, hypokalemia, major depression disorder, sleep apnea, hypothyroidism, obesity, and GERD. The most recent minimum data set (MDS) dated [DATE] was an annual assessment and assessed Resident #103 as moderately impaired for daily decision making with a score of 8 out 15. Resident #103's electronic clinical record (EHR) was reviewed on 06/01/2022. Observed on the order summary report was the following order: Insulin Giargine Solution 100 UNIT/ML. Inject 5 unit subcutaneously at bedtime for diabetes. Order Date: 04/30/2022. Start Date: 04/30/2022. Also observed on the order summary report was the following order: Venlafaxine (Effexor) HCI Tablet 100 mg. Give 1 tablet by mouth a day related to Major Depressive Disorder, Recurrent. Order Date: 04/30/2022. Start Date: 05/01/2022. A review of the medication administration record (MAR) for April 2022 through June 2022 documented Resident #103 received the Insulin and the Venlafaxine (Effexor) as ordered. Resident #103's care plans were reviewed and they did not include a focus area for the use of the Insulin or the use of the Venlafaxine (Effexor). On 06/02/2022 at 9:02 a.m., the unit manager (LPN #1) where Resident #103 resided was interviewed about the above referenced medications and if care plans should have been developed. LPN #1 reviewed Resident #103's EHR and stated the Resident had been on both medications for some time and care plans should have been developed for the use of both medications. LPN #1 advised the MDS coordinators routinely completed the care plans. On 06/02/2022 at 3:21 p.m. the MDS Coordinator (registered nurse - RN #1) was interviewed regarding Resident #103's care plans. RN #1 reviewed Resident #103's EHR and stated care plans should have been developed Resident #103 was diagnosed with diabetes and depression and care plans should have been developed for the use of both the Insulin and Venlafaxine (Effexor). On 06/02/2022 at 4:40 pm., the above findings were reviewed with the administrator, DON and various clinical staff during a meeting. No additional information was received by the survey team prior to exit on 06/02/22 at 6:00 p.m. 2. Resident #89 was admitted to the facility with diagnoses that included palliative care, disorientation, hypo-osmolality, hyponatremia, type 2 diabetes, unilateral inguinal hernia, peripheral vascular disease, hyperlipidemia, stage 3 chronic kidney disease, anemia, adult failure to thrive, and muscle weakness. The most recent minimum data set (MDS) dated [DATE] was a quarterly assessment and assessed Resident #89 as cognitively intact for daily decision making with a score of 15 out of 15. Resident #89's electronic clinical record was reviewed on 06/01/2022. Observed on the order summary report was the following order: Furosemide (Lasix) Tablet 20 mg. Give 1 tablet by mouth in the morning for diuretic. Order Date: 05/23/2022. Start Date: 05/24/2022. A review of the medication administration record (MAR) for May 2022 through June 2022 documented Resident #89 received the Furosemide (Lasix) as ordered. Resident #89's care plans were reviewed and they did not include a focus are for the use of the Furosemide (Lasix). On 06/02/2022 at 9:02 a.m., the unit manager (licensed practical nurse - LPN #1) where Resident #89 resided was interviewed regarding Resident #89's care plans. LPN#1 stated Resident #89 had been experiencing some localized swelling in his right arm and the nurse practitioner had originally thought it was related to gout and ordered Prednisone; however, after additional assessing and monitoring the Furosemide (Lasix) was ordered to reduce the swelling. LPN #1 stated the MDS coordinators routinely completed the care plans. On 06/02/2022 at 3:21 p.m., the MDS Coordinator (RN #1) was interviewed regarding Resident #89's care plans. RN #1 reviewed Resident #89's EHR and stated a care plan should have been developed for the use of the Furosemide (Lasix). On 06/02/2022 at 4:40 pm., the above findings were reviewed with the administrator, DON and various clinical staff during a meeting. No additional information was received by the survey team prior to exit on 06/02/22 at 6:00 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, clinical record review and facility document review, the facility staff failed to ensure a complete and accurate record for for one of 25 residents, Resident #71. Resident #71's advance directives were not included in the EMR (electronic medical record). Findings include: Resident #71 was admitted with diagnoses which included, but were not limited to: diabetes mellitus, chronic kidney disease, vascular dementia, constipation, and osteoarthritis. The resident's most current MDS (minimum data set) was an annual assessment dated [DATE]. This MDS assessed the resident with a cognitive score of 14, indicating the resident was intact for daily decision making skills. On [DATE] at 3:20 PM, Resident #71's clinical EMR were reviewed. The physician's order for the resident included an order for: .DNH (Do Not hospitalize) . The physician's orders did not include an order for full code and/or CPR (cardiopulmonary resuscitation) or DNR (Do Not Resuscitate). On [DATE] at 3:54 PM, the administrative assistant was asked about an advance directive/code status for Resident #71. The administrative assistant stated that the resident should have an order and stated that she would investigate and attempt to find out the resident's code status. The policy titled, Cardiopulmonary Resuscitation (CPR) documented, .CPR .Code Status refers to the level of medical interventions a person wishes to have started in their heart or breathing stops .DNR refers to a medical order issued by a physician .not to administer CPR .Staff will confirm that physician admission and readmission orders address the resident's code status and that the orders conform to the resident's wishes . The administrative assistant stated, The resident is actually a DNR and presented the paper copy of the DDNR (durable do not resuscitate) order and stated that the order should have been in the EMR under the physician's orders and that the DDNR order should have been scanned into the EMR as well. No further information and/or documentation was presented prior to the exit conference.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review and facility document review, the facility staff failed to ensure professional standards of practice by a hospice provider for 1 of 25 residents in the survey sample, Resident #89. Records of weekly hospice visits for Resident #89 were not provided to the facility as required in the hospice services agreement. The findings include: Resident #89 was admitted to the facility with diagnoses that included palliative care, disorientation, hypo-osmolality, hyponatremia, type 2 diabetes, unilateral inguinal hernia, peripheral vascular disease, hyperlipidemia, stage 3 chronic kidney disease, anemai, adult failure to thrive, and muscle weakness. The most recent minimum data set (MDS) dated [DATE] was a quarterly assessment and assessed Resident #89 as cognitively intact for daily decision making with a score of 15 out of 15. Under Section O - Special Treatments, Procedures, and Programs, the MDS assessed Resident #89 has receiving Hospice Services. Resident #89 was interviewed on 06/01/2022 during the initial tour regarding the quality of care and quality of life since being admitted to the facility. Resident #89 stated things were going well and everyone treated him nice. Resident #89 shared he was seen twice weekly by the hospice provider and he looked forward to seeing them for the visits. Resident #89's electronic clinical record (EHR) was reviewed on 06/01/2022. Observed on the order summary report was an order for hospice with an order date of 03/10/2022 and a start dated of 03/11/2022. Observed on the care plans was a focus area including goals and interventions for hospice care related to declining condition. Observed within the miscellaneous section of the EHR was the hospice physician's orders/plan of care dated 03/20/22 to 06/17/22 and the hospice certification statement for 90-day period of 03/20/22 to 06/17/2022. Additional review of the EHR did not provide any hospice visits notes. On 06/02/2022 at 9:02 a.m., the unit manager (LPN #1) was interviewed about the hospice notes. LPN #1 stated the hospice notes were filed in Resident #89's paper/hard chart. A review of this chart documented hospice visits notes with the most recent note dated 04/19/2022. LPN #1 was asked how and when did the facility receive the hospice visits notes. LPN #1 stated the hospice provided the printed notes normally during their visits. LPN #1 was advised the most recent hospice note observed in the paper/hard chart was dated 04/19/2022. LPN #1 stated she was not aware why the notes were not current as hospice visited Resident #89 twice weekly. A review of the Agreement For Provision Of Hospice Services dated February 12, 2004 between the facility and hospice provider documented on page 8 the following: . V. Records: 5.1 Compilation of Records: a. Preparation: The Nursing Facility and Hospice shall each prepare and maintain complete and detailed clinical records concerning each Residential Hospice Patient receiving Nursing Facility Services and Hospice Services under this Agreement in accordance with prudent record-keeping procedures and as required by applicable federal and state law and regulations and application Medicare and Medicaid program guidelines. Each clinical record shall completely, promptly and accurately document all services provided to, and events concerning, each Residential Hospice Patient (including evaluations, treatments, progress notes, authorizations to admissions to Hospice and/or the Nursing Facility and physician orders, entered pursuant to the Agreement). The Nursing Facility and Hospice shall cause each entry made for services provided hereunder to be signed by the person providing the services On 06/02/2022 at 4:40 pm., the above findings were reviewed with the administrator, DON and various clinical staff during a meeting. No additional information was received by the survey team prior to exit on 06/02/22 at 6:00 p.m.

Based on staff interview, record review, and facility document review, the facility failed to ensure drug irregularities were noted in the pharmacy review for one of 25 residents, Resident #42. The pharmacy did not report an ongoing order of an as needed (PRN) anti-psychotic medication for Resident #42. The Findings Include: Resident #42 was admitted with diagnoses which included: Dementia with behaviors, cerebrovascular disease, dysphagia, and hypertension. The most current MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 3/30/22. Resident #42's cognitive score indicated having long and short-term memory problems and severely impaired cognitively. Resident #42's physician orders documented an order dated 2/4/22 that read: Quetiapine (seroquel, antipsychotic) tablet 25 MG (milligrams) Give 1 tablet by mouth every 6 hours as needed for agitation . Review of monthly pharmacy medication record review (MRR) from 2/28/22 through 5/30/22 evidenced that the reviews had been completed, but did not include any recommendations to stop the as needed Seroquel. On 06/02/22 at 11:52 AM, registered nurse (RN #1) reviewed the chart and said she was unable to find pharmacy recommendations regarding discontinuing Seroquel. On 06/02/22 at 12:01 PM, RN #2 stated the process is for the pharmacy to review all orders monthly and make any necessary recommendations. The recommendations are then reviewed by the physician and faxed back to the pharmacy with any necessary changes. RN #2 went onto say, the as needed Seroquel should have been reviewed and a recommendation to discontinue the medication should have been in place by the end of February. Facility policy titled Antipsychotic Medication Use read in part: 15. PRN orders for antipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication. On 06/02/22 at 4:38 PM, the above information was presented to the director of nursing and the administrator. No other information was presented prior to exit conference on 6/2/22.

Based on staff interview, record review, and facility document review, the facility failed to ensure an as needed anti-psychotic medication was limited to 14 days for one of 25 resident's. Resident #42's as needed order for Seroquel was in place for 4 months. The Findings Include: Diagnoses for Resident #42 included: Dementia with behaviors, cerebrovascular disease, dysphagia, and hypertension. The most current MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 3/30/22. Resident #42's cognitive score indicated having long and short-term memory problems and severely impaired cognitively. Resident #42's physician orders documented an order dated 2/4/22 that read: Quetiapine (seroquel, antipsychotic) tablet 25 MG (milligrams) Give 1 tablet by mouth every 6 hours as needed (PRN) for agitation . Review of Resident #42's medication administration record (MAR) evidenced the PRN order for Seroquel was available for distribution, but was not given from he time it was ordered (2/4/22) through 5/31/22. On 06/02/22 at 12:01 PM, RN #2 stated the process is for the pharmacy to review all orders monthly and make any necessary recommendations. The recommendations are then reviewed by the physician and faxed back to the pharmacy with any necessary changes. RN #2 went onto say, the as needed Seroquel should have been reviewed and a recommendation to discontinue the medication should have been in place by the end of February. Facility policy titled Antipsychotic Medication Use read in part: 15. PRN orders for natipsychotic medications will not be renewed beyond 14 days unless the healthcare practitioner has evaluated the resident for the appropriateness of that medication. On 06/02/22 at 4:38 PM, the above information was presented to the director of nursing and the administrator. No other information was presented prior to exit conference on 6/2/22.

Based on observation, staff interview, and facility document review, the facility staff failed to ensure food was properly stored in the main kitchen. Findings were: Initial tour of the kitchen was conducted on 06/01/2022 at approximately 10:40 a.m. with the dietary manager (DM). In the walk in refrigerator was a cart with an opened partial gallon of whole milk. The manufacturer's stamped date on the milk jug was 05/27/2022. On the side of the jug was written, Opened 05/30/2022. He was asked what the dates signified. He stated that date of 05/30/2022 was when the milk had been opened by the dietary staff. He was asked what the manufacturer's stamped date of 05/27/2022 meant. He stated, I am going to throw that out. On a shelf in the refrigerator were three additional gallon jugs of whole milk. All with the manufacturer's stamped date of 05/27/2022. The DM was asked if the manufacturer's date on the milk jugs was a use by date or a sell by date. He stated, I'm not sure, but I will make some calls and find out. Also observed in the walk in refrigerator was an unopened 48 ounce container of ricotta cheese. The manufacturer's stamped date was 05/29/2022. The DM stated, I think that is a use by date on the ricotta cheese, I am throwing it away. The DM was asked who was responsible for checking expiration dates on the items in the refrigerator. He stated, I am, but I haven't done it yet this week. He was asked if the dietary staff should check the dates on items before use. He stated, Yes. Observed in the walk-in freezer on the top shelf was a box of pepperoni. The top and sides of the box were covered in thick white ice. Above the box was a condenser that was also covered in ice. The DM was asked about the thick ice accumulation on the box. He stated, The condenser leaks water down and it freezes, it happens again as soon as we clean it up. He was asked if food should be stored under the leak. He stated he would move the box. On 06/01/2022 at approximately 4:00 p.m., the DM stated, The dates on the milk were a sell by date .they should be used within 3-4 days after the date .the milk should have been used by yesterday at the latest .I threw it all away. He presented documentation from the vendor/manufacturing company of the milk which contained the following: The sell by date represents the last day that the product should be purchased on the market. If the product is purchased on this date and has maintained proper temperature during distribution, the product should be consumable for 3-4 days after this date. No further information was obtained prior to the exit conference on 06/02/2022.

Based on staff interview and facility document review, the facility staff failed to implement an antibiotic stewardship program. The facility's documented program regarding protocols and monitoring of antibiotic use was not implemented. The census in the facility was 111 residents. Findings were: On 06/01/2022 at approximately 1:55 p.m., the interim DON (director of nursing), who also identified herself as the IP (Infection preventionist) was interviewed regarding the antibiotic stewardship program at the facility. She stated, I'm not sure what we have, I will need to look .I've been doing this position less than 24 hours. At approximately 3:00 p.m. she presented a policy and procedure Antibiotic Stewardship Program that contained the following: .The goals of the program include: Ensuring residents .are prescribed the appropriate antibiotic, reducing the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use. The Antibiotic Stewardship team will analyze infection data [including type of infection or symptoms being treated, antibiotic utilization, and adverse outcomes, etc.] monthly and feedback will be provided to the QAPI Committee regarding antibiotic stewardship practices . The policy included specific procedure and guidance to be followed for the antibiotic stewardship program The Interim DON was asked if there was documentation regarding the use of antibiotics. She stated, This policy is all we have .the former DON was doing it. I talked to her and she said there is supposed to be a book for tracking and other information but we don't have one. She was asked if the former DON was onsite for interview. She stated, Yes. At approximately 3:15 p.m., the former DON was interviewed. She stated, The former ADON (assistant director of nursing) was doing it .she went out on FMLA in December and then resigned .I can't find any of her books .I took it over in December and I have some tracking back to then, but we really don't have the information that you are looking for. No further information was obtained prior to the exit conference on 06/02/2022.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and clinical record review, the facility staff failed to review and revise a comprehensive care plan for one of 25 in the survey sample. Resident #42's care plan was not revised to reflect the use of anticoagulant medication. The findings include: Resident #42 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included vascular dementia with behavioral disturbance, heart failure, bilateral osteoarthritis, chronic kidney disease stage 3, hypothyroidism, vitamin d deficiency, and muscle weakness. The most recent minimum data set (MDS) dated [DATE] was an annual assessment, assessed Resident #42 as severely impaired for daily decision making with a score of 5 out of 15. Resident #42's clinical record was reviewed on 03/03/2020. Observed on the current physician order sheet was the following order: Eliquis 5mg tablet (1 tab) TABLET Oral. Two Times Daily Starting 10/09/2019. Order Date: 10/9/2019. Notes: Anticoagulant. A review of Resident 42's comprehensive care plan (CCP) was completed on 03/02/2020. There were no problems, goals, or interventions observed on the care plan to reflect the use of the anticoagulant. On 03/04/2020 at 9:30 a.m., the licensed practical nurse (LPN #1) who provided routine care to Resident #42 was interviewed if Resident #42 was receiving the anticoagulant. LPN #1 stated that yes, Resident #42 continued to receive the medication. On 03/04/2020 at 2:00 p.m., the director of nursing (DON) was interviewed regarding who was responsible for updating the care plans. The DON stated either the MDS coordinator and/or someone in nursing could review and revise the care plans. The DON was interviewed if an anticoagulant medication should be included on the care plans. The DON stated yes, because of concerns with bleeding it should be included on the care plans. The DON stated she would follow-up once she spoke with the MDS coordinator to make sure the care plans were accurate. On 03/04/2020 at 2:16 p.m., the DON returned to the conference room and stated, no the anticoagulant was not put on the care plans and should have been. These findings were reviewed with the interim administrator, director of nursing and assistant director of nursing during a meeting on 03/04/2020 at 2:45 p.m. No additional information was received by the survey team prior to exit on 03/04/2020 at 3:30 p.m.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility staff failed for one of 25 residents in the survey sample (Resident # 24), to develop a plan of care that included the resident's participation in Hospice care. Resident # 24's care plan failed to include a delineation of care functions to be carried out by the facility and by Hospice. The findings were: Resident # 24 in the survey sample, an [AGE] year-old female, was admitted to the facility on [DATE] with diagnoses that included anemia, hyponatremia, osteoporosis, aphasia, cataracts, pressure ulcer, spinal stenosis, weakness, dry eye syndrome, hypocalcemia, and macular degeneration. According to a Significant Change Minimum Data Set (MDS) with an Assessment Reference Date of 10/24/18, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15 out of 15. According to a review of the resident's Electronic Health Record, the resident entered Hospice care on 10/15/18. Further review of the Significant Change MDS at Section O (Special Treatments, Procedures, and Programs) found the resident was assessed at Item O0100 (K), as receiving Hospice care. At approximately 2:00 p.m. on 1/23/19, the surveyor asked the Director of Nursing (DON) for a copy of the resident's current care plan. At approximately 2:45 p.m., the surveyor was given a copy of Resident # 24's care plan. The care plan had an effective date of 9/6/18. A thorough review of the care plan failed to reveal any problem, goals, or interventions related to Hospice care. At about 7:50 a.m. on 1/24/19, the DON was interviewed regarding Resident # 24's care plan. When advised the resident's care plan failed to include any mention the resident was receiving Hospice care, the DON said, Do you think it (Hospice) should be care planned? The surveyor indicated there should be a coordination of care between the facility and the Hospice provider. At approximately 8:45 a.m., the DON provided a copy of a separate care plan from the Hospice provider. The Hospice care plan provided was not a part of the facility's care plan for Resident # 24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility document review, the facility failed to ensure proper hand hygiene was performed during medication pass on one of 4 units. The medication nurse on the [NAME] Run unit did not use hand hygiene between Resident's during medication pass observation. The Findings Include: On 1/23/19 a medication pass and pour was observed from 7:47 AM to 8:10 AM. During the medication pass three Resident's were observed receiving medications from license practical nurse (LPN #1). During the observation LPN #1 was observed touching Resident's, and moving inanimate objects in Resident's rooms on top of the over bed tables. After each medication pass LPN #1 returned back to the medication cart and begin pulling medications for the next Resident without using any hand sanitizing agent or washing hands. At the end of the medication pass observation LPN #1 was interviewed regarding the observation. This surveyor verbalized the observation regarding hand hygiene. LPN #1 agreed but did not offer reasoning. 01/23/19 04:33 PM during a meeting with the director of nursing and administrator the above information was presented. The DON was asked what is expectation regarding hand hygiene between residents. The DON verbalized that the staff should at least use a hand sanitizer between resident's. A facility policy was obtained titled Infection Prevention Hand Hygiene and read in part [ .] Indications for Hand Hygiene [ .] Use an alcohol-based hand sanitizer if hands are not visibly soiled. Before and after each patient contact. After contact with environmental surfaces in the immediate vicinity of patients[ .] No other information was presented prior to exit conference on 1/24/19.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, and clinical record review, facility staff failed to follow physician orders for one of 25 residents in the survey sample, Resident #55. Facility staff failed to obtain physician ordered daily weights from 10/21/2018 through 01/20/19 for Resident #55. Findings included: Resident #55 was admitted to the facility on [DATE] with diagnoses including, but not limited to: Heart Disease, Hypertension, Anxiety, Dementia and Thyrotoxicosis. The most recent MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 11/27/18. Resident #55 was assessed as moderately impaired in her cognitive status with a total cognitive score of nine out of 15. Resident #55's clinical record was reviewed on 01/23/19 at approximately 2:00 p.m. During this review a physician order dated 10/21/18 included, Weights One Time Daily Starting 10/21/2018. Subsequent review of the Resident Weight Report included recorded weights on the following dates: 10/22/18, 10/26/18, 10/30/18, 11/05/18, 11/06/18, 11/26/18, 11/27/18, 12/18/18, 12/27/18, 01/05/19, 01/11/19, 01/21/19, and 01/22/19. The TAR's (treatment administration records) dated October 2018, November 2018, December 2018 and January 2019 included documentation of nurse's initials that weights had been obtained daily from 10/21/18 through 01/22/19, although actual weights were only recorded for the dates listed above. The DON (director of nursing) was interviewed on 01/23/2019 at 4:30 p.m. regarding weight documentation. The DON stated, They would be recorded on the treatment record or they could be recorded on the weight record in the computer. At one time she [Resident #55] had a lot of edema, so daily weights were ordered. I don't know why the weights weren't recorded. Corporate Clinical Support stated at 4:55 p.m., She used to be weighed on first shift. When the order was changed to second shift the physical monitor piece was not ordered in the computer, therefore it did not print on the treatment sheet as a box to record weights. No further information was received by the survey team prior to the exit conference on 01/24/2019.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, and clinical record review, facility staff failed to ensure one of 25 residents in the survey sample received behavioral health services, Resident #55. Facility staff failed to ensure Resident #55 was seen by behavioral health services from October 01, 2018 to currently. Findings included: Resident #55 was admitted to the facility on [DATE] with diagnoses including, but not limited to: Heart Disease, Hypertension, Anxiety, Dementia and Thyrotoxicosis. The most recent MDS (minimum data set) was an annual assessment with an ARD (assessment reference date) of 11/27/18. Resident #55 was assessed as moderately impaired in her cognitive status with a total cognitive score of nine out of 15. Resident #55's clinical record was reviewed on 01/23/19 at approximately 2:00 p.m. During this review clinical notes included the following documentation: 10/1/18 at 11:48 a.m. resident was crying this morning after breakfast. (sic) She stated [Name], my car won't start and I need to get to class, what am I going to do? .Resident continued to cry and be upset for a few minutes but calmed down. 10/3/18 at 1:59 a.m. Resident was noted with behaviors after dinner this evening. Resident noted with crying spell when she was coming back from dinner. Resident saying that she was all alone . 10/4/18 at 5:41 a.m. Resident attempting to get oob [out of bed] at 0100 [1:00 a.m.]--tearful and c/o [complained of] legs hurting .Resident confused and asking staff why we are in her house. Explained she was at [Name Nursing Home]. Resident states Well why does my bedroom look just like my bedroom at home? Begging staff not leave --states I'm scared, please don't leave me here alone . 10/4/18 at 4:56 p.m. The resident started crying in the dining room this morning. She came down the hallway drying (sic) and stated I can't find my purse! Have you seen my purse? It has my keys and my wallet in it. What am I going to do? . 10/5/18 at 6:02 a.m. Resident refusing to get up this morning . 10/6/18 at 10:59 a.m. Resident came out of the dining room this morning crying and stated I can't find my purse. Resident asked several resident's and staff members if they had seen her purse . 10/8/18 at 12:10 a.m. Resident did have a crying spell after dinner time this evening . 10/12/18 at 11:34 a.m. This morning the resident had some behaviors. There was a resident yelling out help me, hey. This resident was also just yelling. [Name] Resident #55 started yelling back at the resident stating Shut up, Don't you have any manners? To this the resident responded You shut up. [Name] Resident #55 continued to yell at her and stated. Didn't they teach you how to talk to an adult? I'm an adult and am older then you so don't talk to me that way! She was also talking about her kids were here and she had to find them .After breakfast, [Name] Resident #55 came out of the dining room crying and stated I can't find my kids. Have you seen them? I have to find them and get home! She started crying and screaming .She later asked this nurse 'What's wrong with me, I've never been like this. I feel like I'm going crazy . (sic) 10/18/18 at 4:23 p.m. Resident went to her appointment this morning at [Name] health center. The address was incorrect. Her appointment was at [Name] Behavior center in [City]. Appointment was cancelled (sic) at the [City] location. transport picked the resident and the CNA [certified nursing assistant] up and brought them back at 1130. Appointment will have to be rescheduled if needed. RP [responsible party] aware. 10/30/18 at 1:24 a.m. Residents noted with some increased behaviors this shift. (sic) Resident stated that she was just mad at everyone . 11/1/18 at 12:35 p.m. Resident came out of the dining room this morning upset and yelling. She was asking people to help her get up so she could go to her car and go home. She stated No one will help me, they don't give a crap about me. I have a car sitting at home. I want to to home.Resident started crying and repeated what she said earlier about no one caring for her . 11/14/18 at 1:26 p.m. Resident came out of the dining room this morning upset. She was yelling about needing to go home. Noted resident has behaviors with other residents. At one point, she was arguing with another resident about yelling .The resident told this nurse If they were stuck here they would feel this way too. Can you take me home on your way home? don't be a hypocrite like everyone else! . 11/15/18 at 12:27 a.m. Resident noted with behaviors this evening before and after dinner. Resident tore her identification bracelet off twice . 11/16/18 at 5:07 p.m. Resident self propelling around unit and yelling out .Resident refused PM medicines after multiple attempts. 11/24/18 at 12:52 a.m. Resident had one teary episode this evening after dinner . 11/29/18 at 11:27 p.m. Resident refused treatment .this shift .Nurse did make several attempts but resident would not comply. 12/14/18 at 2:22 a.m. Resident noted with having some behaviors at HS [bedtime]. 12/31/18 at 12:50 a.m. Resident noted with behaviors most of the shift up until bedtime. Resident had several crying episodes, then wanting to find a ride to her house in [City]. Resident also has several episodes of agitation with fellow residents and then the staff . 01/3/19 at 11:58 p.m. Resident noted with having two episodes of a drying (sic) spell this shift . 01/4/19 at 2:25 p.m. Resident refused treatment and afternoon medication. Resident agitated, and disruptive in dining room during lunch. 01/11/19 at 12:11 a.m. Resident noted screaming at another female resident and calling her names at the nurses station .This resident was still at the nurses station and her behavior changed to crying and stating that she was scared . 01/12/19 at 11:45 p.m. Some behaviors noted from the resident after dinner time . 01/16/19 at 12:19 a.m. Resident had behaviors after dinner this evening. Resident noted with yelling, screaming and cursing at another female resident and also a male resident at the nurses station. Staff attempted to redirect resident but she would not cooperate .Resident continue to scream at nurse and called her Names . (sic) 01/16/19 at 6:23 a.m. resident refusing to get out of bed and changed this shift. (sic) 01/18/19 at 12:20 a.m. Resident had two crying spells this shift . 01/18/19 at 11:31 p.m. Resident noted with behaviors after dinner. Resident was screaming, yelling and cursing two other residents and also staff who intervened. Resident was very difficult to redirect . Review of the POS (physician order sheet) dated January 2019 included: .Venlafaxine ER 150 mg capsule .Please give with 75 mg dose one time daily .starting 04/27/2017, depression .Quetiapine 50 mg tablet .Please give in the AM one time daily .starting 07/25/2018 .Seroquel 25mg .Please give in the evening one time daily .starting 07/25/2018 .Buspirone 7.5 mg tablet .agitation/depression .four times daily .starting 12/18/2018 . Resident #55's Quarterly MDS with an ARD of 09/04/2018 included under Section C, Cognitive Patterns a total summary score of nine out of 15, indicating moderate impairment in her cognitive status. Section D, Mood included a total severity score of four, indicating feeling down, depressed, or hopeless 2-6 days (several days), trouble falling or staying asleep, or sleeping too much 7-11 days (half or more of the days) .moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual 2-6 days (several days) over the last two weeks . Section E, Behavior included Physical behavioral symptoms directed toward others .Verbal behavioral symptoms directed towards others, occurred 1 to 3 days each . Resident #55's Annual MDS with an ARD of 11/27/2018 included under Section C, Cognitive Patterns a total summary score of nine out 15, indicating moderate impairment in her cognitive status. Section D, Mood included a total severity score of three, indicating feeling down, depressed, or hopeless 2-6 days (several days) .feeling tired or having little energy 2-6 days (several days) .moving or speaking so slowly that other people could have noticed. Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual 2-6 days (several days) over the last two weeks . Section E, Behavior included Verbal behavioral symptoms directed towards others, occurred 1 to 3 days .Rejection of Care .occurred 1 to 3 days . The only change in Resident #55's plan of care during the period of 10/01/18 through 01/23/19 was her Buspar frequency was changed to four times a day. Her missed appointment at behavioral health was never rescheduled. The DON (director of nursing) was interviewed on 01/23/19 at 2:00 p.m. regarding an appointment with behavioral health for Resident #55. The DON stated, She currently doesn't have one. We just talked about her in the morning meeting. You have that note already. Said note included: SW [social worker] went to speak with pt [patient] due to depression/behavior note mentioned in morning meeting. SW asked [Name] Resident #55 how she was feeling and she stated she was very tired and didn't feel good. Asked if she was eating her meals and she said she doesn't eat much because she just has no interest. [Name] was very weeping (sic) during the conversation and I stated to her that if she would like to talk to a counselor I would set up an appt. [appointment] She declined services at this time and SW told her that if she changes her mind just let SW know. The Administrator was informed of the above information during an end of the day meeting with the survey team on 01/23/19 at 4:30 p.m. No further information was received prior to the exit conference on 01/24/19.